CHAPTER XII. CHRONIC NON-SUPPURATIVE INFLAMMATION OP THE (Part 4)

Ohrenkrankheiten. PATHOLOGY. 283 5. The stapes bone completely and firmly anchylosed to the margin of the fenestra ovalis. 6. An exostosis on the inner surface of the neck of the malleus. 7. Malleus and incus anchylosed together. 8. Firm bands of adhesions in the mastoid cells. 9. False membrane on the tendon of the tensor tympani muscle. 10. Partial obliteration of the cavity of the tympanum from adhesions of the membrana tympani to the labyrinth wall. 11. Hyperostosis of the petrous bone, and anchylosis of both stapes. 12. Atrophy and fatty degeneration of the tensor tympani. These are actual appearances, of individual cases taken from Toynbee's catalogue and from the writings of the other authorities whom I have mentioned ; some of them are per- haps consequences of suppurative inflammation, although I have been careful to exclude all cases in which there was loss of the membrana tympani, or other positive evidence of a sup- purative process. Gruber's* account of the pathology of otitis media hyper- trophica is, that, " from some cause or other, there is first a great hyperemia with distention of the membrane, and in part the new formation of blood-vessels, and increase of the inter- cellular fluid. The connective-tissue corpuscles are increased. The tissue of the inflamed mucous membrane is less moist than in the catarrhal form. The new formations or new ele- mentary formations go on to a higher development. The most various adhesions may occur, or a soft connective sub- stance appears which is either evenly spread over the whole portion that was originally inflamed, and thus leads to hyper- trophy of the mucous membrane, or it may go on to granular formation. Many of these new formations may also undergo regressive metamorphosis — they may undergo molecular dis- integration, become fatty, and be absorbed." * Lehrbucli der Olirenheilkunde, S. 516. Wien, 1870. 284 CAUSES OF INFLAMMATION OF THE MIDDLE EAB. CAUSES. I have endeavored, in recording the histories of about fifteen hundred cases of aural disease observed in private practice, to give the probable remote and proximate causes. These are only to be obtained by a strictly-observed system of cross-questioning, since, by far the greater number of patients ascribe their disease to causes which are certainly very remote if not doubtful, and to others which have cer- tainly had no influence. Thus patients will assert that their loss of hearing results from cold, when they cannot remember that they ever had a severe cold affecting the ears, but they conclude that it must have been a cold ; others, again, declare that their throats have always been well, that they seldom require to use a handkerchief, and yet an examination will reveal a bad condition of the naso-pharyngeal mucous mem- brane. Judging as well as I am able, from my experience in public as well as private practice, I am disposed to consider the following as among the most probable causes of chronic non- suppurating inflammation of the middle ear : Remote. — 1. A feeble state of the system, due, for exam- ple, to inherited or acquired syphilis, phthisis pulmonalis, etc. 2. Defective hygienic management, e. g., neglect of bathing, want of exercise in the open air, lack of proper food, etc. Proximate. — 1. Repeated attacks of acute catarrh of the pharynx and middle ear, a disease popularly known as ear- ache. 2. Naso-pharyngeal inflammation. 3. Diseases of the lungs and bronchial tubes. These proximate causes are chiefly to be made out in the catarrhal form of chronic inflammation, while in the prolifer- ous form, the practitioner is often greatly in doubt, as to what may have been the origin or exciting cause of the insidious affection which goes on so steadily to change of structure and loss of function. Indeed, we are often obliged to be content to acknowledge the fact of change of structure without being able to definitely assign a cause for it. Why the changes that make up a true case of proliferous inflammation, or one of a CAUSES OP INFLAMMATION OF THE MTDDLE EAR. 285 bastard form in which the proliferous element predominates, continue to advance in spite of treatment and of proper hygienic management, is one of the most disheartening pro- blems that a practitioner who treats aural disease attempts to solve. It is not strange, that cases of insidiously advancing impairment of hearing, dependent upon illy defined, but posi- tive causes, have excited the minds of physicians to adopt even what may appear to be fanciful means for their cure. The history of coryzas and ear-aches, and of chronic sore- throats, is usually distinct enough in chronic catarrhal inflam- mation, and even if there be no such history, then the appear- ances of the pharynx, and the results of tactile investigation of the tubes, are sufficient to allow us to determine just what kind of a process has been going on. It would be interesting to accurately trace the origin of these proximate causes. We should find, I think, that the most of them were due to neglect, or improper management ; for exam- ple, the heads of some children are oftentimes vigorously washed without being thoroughly dried ; they are allowed to remain in water unduly long ; their legs and chests are left uncovered in weather in which strong men are clad in beaver-cloth, and women in furs ; they play about the streets, and sit down, when tired and warm, on the damp and cold stone steps of city-houses ; they are held thoughtlessly by an open window on a cold day ; they are warmly clad by day but insufficiently covered at night ; in short, the temperature of the body is not properly regulated, and a pharyngeal catarrh passes in an instant to the tympanic cavity, where it is an acute catarrh. If the acute catarrh does not go on to suppuration, it is half recovered from under the use of anodynes applied to the outer surface of the drum-membrane ; in which a thickening is left which forms a good basis for a case of gradual and mysterious middle-ear trouble, and with no known cause. In large towns where the system of drainage or sewerage is sometimes im- perfect, foul air may be forced back through the water-pipes, and becomes a cause, often unsuspected, of catarrhs of the worst type. With older people a slight and neglected corjTza or pharyn- gitis is followed by a fulness in the ears, that "will wear 286 CAUSES OF INFLAMMATION OF THE MIDDLE EAR. away," and which does wear away in part ; but if it occurs in persons who have no good hygienic habits in such matters as bathing, temperance, and so forth, it leaves behind a residuum of hypersecretion or proliferation, which, as has been said, is the foundation for repeated attacks, and, finally, of permanent thickening. The syphilitic catarrh, of infants and young persons, is the frequent cause of an affection of the middle ear, which, unlike its frequent companion, interstitial keratitis, is one of the worst forms of disease in the obstinacy with which it resists all treatment. The eyes may, and generally do, get well ; but, if once the tympanic cavities be attacked, intra-auricular adhe- sions occur, the membrana tympani is drawn inward, the nerve is secondarily involved, and the loss of hearing often becomes almost complete. There are no peculiar aural symptoms by which we may positively distinguish a case of chronic disease of the middle ear that was caused by syphilis, from one occurring in a non- syphilitic patient. Yet we may say in general, that a syphi- litic diathesis seems to cause the proliferation of tissue to be more rapid and less amenable to treatment. Schwartze be- lieves that the pathological change in these syphilitic cases is a periostitis, and this view seems to be correct. Just how it is, that pregnant women are so often affected by a proliferous inflammation of the middle ear, I am unable to say ; but it is a fact, that many women have told me, that they traced their impairment of hearing to their first preg- nancy, and that they became worse at the birth of each child. I am now in the habit of warning such patients that great attention should be paid to their throat and ears, by means of gargles and Politzer's method, during the period of utero-ges- tation. It is the proliferous form of inflammation, and not the catarrhal, which I have usually observed during such cases. The causes given by patients themselves, taken from my note-book, are as follows : " Stuffy sensations in the head ;" " going in the water very frequently ; " " severe colds in the head ; " " when a child, the ears would stop up, and, would not hear well for a few days." The first manifestation was " a roaring noise heard at night ; " " chronic sore-throat ; " " great CAUSES OF INFLAMMATION OF THE. MIDDLE EAPw. 287 deal of ear-ache ; " " all the colds from which I suffer are in the head;" " excessive grief ; " " a sound like that of locusts was the first indication of trouble ; " " by accident I discovered that I could not hear from one ear ; " "I have always had a great deal of sore-throat;" "diphtheria;" "typhoid fever." One patient gave a graphic account of a gradual loss of hearing from proliferous inflammation, in the following words : " Ten years ago I observed that I could not hear the church- bells, and in four or five years it began to be difficult for me to hear conversation." Another ludicrously attributed his chronic catarrh to exercise upon a gymnastic pole. Another was quite sure that it resulted from great mental anxiety. These are fair specimens of the causes assigned by the patients or their friends for cases of the variety of aural disease now under consideration. Some of them are far from being true causes, although the most of them may be admitted as having at least placed the system in such a con- dition that catarrhal disease or proliferation of tissue was likely to result. It is undoubtedly true, that any great mental depression may cause an attack of pharyngitis in a person disposed to it, and that such a long-continued state of mind will make such an affection incurable. We may, perhaps, sum up our knowledge of the causes of chronic non-suppurative disease of the middle ear, by stating that they are such as dispose to inflammation of mucous mem- brane. Our increased knowledge of the pathology of this tissue, will serve us in good stead in investigating the affec= tions of a part which is thoroughly lined by it.