THE IMPORTANCE 
OF 
EARLY RECOGNITION OF 
EAR DISEASE. TIIE IMPORTANCE 
OF 
EARLY RECOGNITION OF 
EAR DISEASE. 
By J. ORNE GREEN, M.D. 
AURAL SURGEON BOSTON CITY HOSPITAL; CLINICAL INSTRUCTOR IN 
OTOLOGY IN HARVARD UNIVERSITY. 
Read at the Annual Meeting of the Massachusetts Medical Society, 
June 9, 1880, 
BOSTON: 
DAVID CLAPP & SON, PRINTERS. 
1880. IMPORTANCE OF EARLY RECOGNITION 
OF EAR DISEASE. 
Although the term modern may be with justice applied 
to almost the whole of otir pathological knowledge, it is still 
more applicable to our acquaintance with the changes pro- 
duced by diseases in the ear, for before the time of Toynbee 
(1840—1866) but few attempts had been made to determine 
anatomically the variations in the tissues which resulted from 
aural disease. Since that time, however, great progress 
can be claimed not only in the grosser pathological anatomy, 
but also in the pathological histology of the tympanum and 
its conducting apparatus, and this, with our increased ap- 
preciation of the physiological functions of the different 
parts of the ear, and improved methods of examination, 
gives a basis for the clinical study and treatment of the 
diseases of that organ which compare favorably with that 
used for almost any other organ. The cloud of mystery 
which formerly involved the diseases of the ear is rapidly 
dissolving, and deafness can no longer be spoken of as a 
disease, but merely as a symptom capable of explanation 
from pathological tissue changes which interfere with well- 
known and well-established physiological and physical laws. 
Notwithstanding the very decided advance in our know- 
ledge of the normal and pathological physiology and of the 
pathological histology of the tympanum, the fact, however, 
remains that many diseases of the ear and of the tympanum 
itself, as they are presented to the practitioner, are either 4 
THE IMPORTANCE OF 
irremediable or capable of but partial improvement, and to 
some of the reasons for this intractability attention is asked 
in a general way in this paper. 
According to our present knowledge, the tympanum, in- 
cluding the drum membrane, the chain of ossicles, the cavity 
itself, and the secondary membranes leading to the labyrinth, 
with their muscular and nervous adjuncts, are the most fre- 
quent seat of disease, and the majority of the pathological 
changes which have been found on dissection as occurring in 
these parts may be classified under the three heads of hyper- 
trophic, adhesive, and destructive processes. Of hypertrophic 
and adhesive processes in general it may be said that from 
their very nature they require time, and usually a longtime, 
for their development; although the same remark is not so 
strictly applicable to the destructive processes, as it is well 
established that rapid ulceration and destruction may occur, 
still, the viability of tissues, and especially of tissues having 
an important physiological function to perform, like those of 
the tympanum, is so great that even these may be considered 
relatively slow, although they take place much more rapidly 
often, than either of the other two changes. Of all these 
processes it may be said that they are secondary to some 
variety of inflammation, and are rather the results of disease 
than the disease itself. Clinical investigation may fairly 
claim to have traced these pathological changes to their 
origin, and to have established the fact in regard to the ear 
which general pathology has established in regard to such 
processes in general, namely, that they are the result, as 
lias just been stated, of inflammation in the tissue in which 
they are found. , 
All of these inflammations are varieties of inflammation 
of the mucous membrane of the tympanum, and the majority 
of them are either serous, mucous, or purulent catarrh of 
that membrane. The serous variety is characterized by 
hyperaemia, serous effusion, and oedema of the subepithelial 5 
EARLY RECOGNITION OF EAR DISEASE. 
connective tissue, ending in perfect resolution and absorption, 
or else in general hypertrophy of the mucous membrane, or 
in adhesive inflammation, which is a very common result of 
this disease. In 1013 diseased ears Toynbee found adhe- 
sive inflammation in 202, or twenty per cent. The adhesion 
is brought about in the following way : by a change of 
position in the tissues, due either to swelling or to collapse 
of the drum membrame from closure of Eustachian tube, 
two epithelial surfaces are brought in contact; from the 
pressure the epithelium is destroyed, and the tissue becomes 
changed to granulation tissue, and by proliferation from the 
protuberances adhesion takes place, and the new tissue then 
undergoes cicatricial contraction. In this way broad or 
narrow synechia? are formed, which, if they involve the im- 
portant parts of the conducting mechanism, most seriously 
impair the hearing. AYitli the general hypertrophy of the 
mucous membrane the conducting mechanism must be more 
or less involved, as it is every where covered with the mucous 
membrane. 
With the mucous catarrh there is a universal hyperaemia 
of the mucous membrane, with a serous and cellular infil- 
tration of the subepithelial connective tissue ; the epithelium 
is retained ; as the result of hypersecretion of the tubular 
and racemose glands of the tympanum, there is more or less 
free mucus mixed with triple phosphates and other crystals 
in the cavity. This condition is capable of complete retro- 
gression, the membrane returning to its normally delicate 
and clastic condition ; but when it passes into chronic ca- 
tarrhal inflammation the cellular infiltration becomes organ- 
ized ; the membrane looks bluish-gray or white, is much 
firmer, stronger, and more vascular, from a varicose con- 
dition of the blood-vessels, and we have the thickening 
which, if it involves the conducting mechanism, very serious- 
ly impairs its functions. 
The purulent catarrh is characterized by hyperannia, enor- 6 
TIIE IMPORTANCE OF 
mous swelling, and oedema of the mucous membrane, with 
a secretion of pus cells, granular corpuscles, granules, epi- 
thelium, and detritus. The swelling is due to enlargement 
of the blood-vessels, with cellular and serous infiltration of 
the connective-tissue stroma; the epithelium is destroyed. 
The disease is distinctly ulcerative, and may result in great 
destruction of tissue. It also is capable of complete retro- 
gression, but it may result in hyperplastic processes, forming 
nodules, villi, and papillary growths ; the abundant infil- 
tration of round cells in the middle of the mucosa may be- 
come organized, or calcifications may occur. In addition to 
these tissue changes, irreparable destruction of important 
parts may take place, or caries or necrosis be produced in 
the bone. 
Besides these pathological conditions from the three varie- 
ties of inflammation, still other tissue changes are described 
by Schwartze, which may result from these inflammations 
when chronic. In a small proportion of cases there is found 
a distinct connective-tissue sclerosis of the deep periosteal 
layer of the mucous membrane, showing tendinous bundles 
of homogeneous, brittle, opaque fibres in the deeper layer, 
while the subepithelial connective tissue remains normal. 
In still a larger proportion of cases the deep periosteal layer 
is impregnated with finely granular lime salts, and with 
spots of ossifying periostitis. 
The influence of these tissue changes may be understood 
when it is remembered that the drum membrane, the chain 
of ossicles, and the secondary membranes constitute the 
connecting apparatus of the ear, and must necessarily he 
capable of the most delicate pendulum vibrations. If hyper- 
trophy of the tissues covering this minute apparatus exists, 
the vibration previously able to cause a certain displacement 
of the conducting apparatus is no longer capable of producing 
the same effect; the pendulum adapted to tick half seconds 
cannot be increased in weight without changing the character 
O Do EARLY RECOGNITION OF EAR DISEASE. 
7 
ofits work. If adhesive inflammation has occurred, by which 
new hands and threads of tissues are formed between different 
portions of this same conducting apparatus, its vibratory 
power is interfered with. If destruction has taken place, 
the capability of vibration is much reduced. 
Of hypertrophic and adhesive processes it may be said in 
general that, once thoroughly established, they cannot, as a 
rule, be removed—that is, if true hypertrophy has occurred 
and new fibres of tissues have formed, these new fibres re- 
main as a part of the body ; if true adhesion has taken 
place between two surfaces, those surfaces remain adherent. 
Certain it is that in the tympanum this is the rule ; but in 
this small cavity, when either of these pathological processes 
occurs upon parts or the whole of the conducting apparatus, 
there is more to be feared than the simple weighing or bind- 
ing down of the vibrating pendulum which results from the 
increased tissue or the adhesive bands. It is a characteristic 
of both these processes that they very frequently undergo 
gradual changes after the hypertrophy or adhesion lias taken 
place ; that the new tissue and the adhesions become firmer 
with age, undergoing what may be compared to cicatricial 
contraction, the result of which in the tympanum is a much 
greater interference with the vibratory power of the con- 
ducting apparatus than would be at first suspected from the 
mere increase in the tissue growth. 
As the advance in our therapeutics has not kept pace with 
our pathological knowledge in regard to the tympanum (and 
the same may be said of almost every region of the body), 
the study of the earlier diseases which produce these tissue 
changes becomes of the greatest importance ; for if the various 
forms of inflammation which precede and cause these hyper- 
trophies, adhesions, and destructions of the conducting 
mechanism of the tympanum are as rebellious to treatment 
as these changes in the tissues are when they have once 
formed, but comparatively little can be expected, at least at 8 
THE IMPORTANCE OF 
present, for the relief of many of the pathological conditions 
of the ear. Fortunately, however, such is not the case; 
the earlier and more acute forms of tympanic disease are as 
amenable to treatment as are similar diseases in other organs, 
and the principles of rational medicine can be as well ap- 
plied here as elsewhere. Nature herself, in the way she 
cures innumerable ear-diseases, and without whose aid it is 
safe to say three fourths of the human race would still be 
suffering from imperfect tympana, has pointed out a method 
by which a cure can be effected ; and in large numbers of 
cases where she herself is unable to relieve, assistance from 
art in the direction she has pointed out in other more fortu- 
nate cases is sufficient to restore the parts to their normal 
condition. To accomplish this, however, it is necessary to 
watch the course of the disease in its earlier stages, prepared 
to assist nature by art if necessary, and it is imperatively 
demanded that such assistance should be rendered before the 
irremediable tissue changes, already described, have taken 
place. The natural history of the various forms of tympanic 
inflammation thus becomes an all-important factor in the 
study and treatment of these diseases. 
Unfortunately, many of the primary inflammations of the 
tympanum come on so insidiously and with so little incon- 
venience to the patient that the very slight symptoms which 
exist are ignored or soon forgotten, from the patient becoming 
accustomed to them, and it is only months or years even 
afterwards, when the tissue changes have made considerable 
progress and the interference with the functions of the ear 
has become so great as to produce inconvenience in the ordi- 
nary affairs of life, that relief is sought. 
This ignoring of the earlier symptoms of tympanic disease, 
and the consequent neglect of treatment at the time when it 
could be of value, is one of the most prolific causes for the 
numerous unfavorable prognoses which must be given when 
the sufferer applies for relief. Not infrequently it happens EARLY RECOGNITION OF EAR DISEASE. 
9 
that the patient denies absolutely that any symptoms have 
preceded the existing deafness, but in so many cases close 
questioning will develop the existence of this or that symp- 
tom, often so long before as to have been forgotten entirely, 
that it seems probable that in almost all cases there were 
originally some antecedent warnings. The following could 
be taken as a very common example : the patient gives a 
history of gradual deafness, without subjective noises, of six 
months’ duration, and denies absolutely any preceding disease 
in the ears. Examination shows a drum membrane generally 
opaque from thickening in its mucous layer, very considera- 
bly retracted and immovable, the Eustachian tube closed 
tightly. Inquiry elicits the fact that three years before he 
does remember that, with a very severe cold, the ears felt 
tight and full, and there were for a time violent subjective 
noises which ceased gradually ; that he regarded it as "noth- 
ing but a cold now that you ask him, however, he remem- 
bers this or that circumstance when he suspected a little 
deafness much longer ago than he had at first stated. The 
facts evidently are that three years before, with an acute 
catarrhal inflammation of the naso-pharynx, the mucous 
membrane of the Eustachian tubes and tympanum was also 
inflamed; the trouble of the naso-pharynx passed off, but 
the mucous membrane of the tympanum remained congested 
and swollen ; as the result of this continuous inflammation 
hypertrophy of the membrane has occurred and increased, 
till it has most seriously impaired the hearing. 
Or, again, another very common history is that the patient 
has been subject to slight deafness with each cold in the head 
for a number of years, till finally the deafness has become 
so marked as to be a serious inconvenience. Then, and not 
till then, relief is sought, and examination showing very 
decided tissue changes, the prognosis is necessarily much 
less favorable than it would have been in the preliminary 10 
THE IMPORTANCE OF 
stages of inflammation. In children it frequently occurs 
that examination shows the drum membrane completely col- 
lapsed against the inner tympanic wall, and firmly adherent 
to this wall, so that it cannot be separated ; or else it is 
retained in its abnormal position by inflammatory retraction 
of the tensor tympani muscle and of the hypertrophied tis- 
sues, a condition originally produced by closure of the 
Eustachian tube, and which would in all probability have 
been removed by any of the simple methods of opening that 
tube, or even by a little judicious blowing of the nose, 
which, by relieving the obstruction of the blood-vessels and 
the consequent congestion, would have allowed nature to 
clear up the pathological products and would have restored 
the parts to their natural condition. 
Another very common reason for ignoring the earlier 
symptoms of tympanic disease, even when they are very marked 
or possibly severe, is the slight improvement which often oc- 
curs spontaneously after a time, and which leads the patient 
to think that all trouble has been averted,—an improvement 
which is quite often fallacious in that it deceives the patient 
into a sense of perfect security, whereas it is simply a tran- 
sition from the acute into the chronic inflammation. Such 
an improvement is seen often with acute catarrhs of the 
tympanum : the subjective noises and the pain cease after a 
time ; the sense of fulness in the ear the patient becomes 
accustomed to, and it is forgotten ; the obstruction of the 
Eustachian tube with the congestion and swelling of the 
tympanic mucous membrane, however, remain, and grad- 
ually produce the hypertrophy which months or even years 
after leads the patient to apply for relief from what has be- 
come, with the lapse of time, an incurable deafness. 
Instances might be multiplied almost indefinitely of simple 
and remediable diseases becoming hopeless from these 
changes in the tissues, which have come on gradually as the 
result of preceding inflammation. EARLY RKCOCNITION OF EAR DISEASE. 
11 
That the interference with the functions of the ear, the 
deafness, which appears as a rule gradually as the tissues 
become hardened and retracted, is not more frequently recog- 
nized in its incipiency can only be referred to a want of 
appreciation of what deafness is. Nothing is more com- 
mon than to hear a patient or his friends say that he is not 
deaf, because he can hear what is said to him across a moder- 
ately sized room ; they being apparently wholly ignorant of 
the fact that deafness consists in the inability to hear a sound 
of a given intensity or loudness at as great a distance as 
normal, and that, although he may hear a loud voice at a 
distance of twenty feet, he should, in a normal condition, 
hear the same voice at one hundred feet, in reality four 
fifths of his hearing for that particular sound being lost. 
The extreme limit of hearing power is but seldom used in 
the ordinary affairs of life, and as far as our daily business 
life is concerned we may each be said to be endowed with a 
large amount of superfluous hearing, which may be lost 
with scarcely any inconvenience to ourselves. 
Again, the merciful provision of nature, which has en- 
dowed each of us with two independent organs of hearing, 
is often lost sight of in estimating degrees of deafness, it 
being forgotten that a person may be very deaf with one 
ear, and yet hear so perfectly with the other that the defect 
is not noticed. Indeed, the records of the consulting room 
show large numbers of cases where increasing trouble in 
the good ear is the cause of the patient first applying to the 
physician ; and he is astonished, and often incredulous, at 
being informed that one ear has evidently been practically 
useless for a long time, and that the inconvenience he has 
been experiencing is due to more recent disease in the other 
ear. 
It will be asked, What is the remedy for all this? How 
are these very serious results to be guarded against? The 
only answer is that, as the histological changes are, in the 12 
THE IMPORTANCE OF 
majority of cases, irremediable in themselves, and as they 
are secondary to and the direct result of other diseases, the 
primary disease, for which treatment is often of great value, 
requires very careful attention. Symptoms, however slight, 
should not be neglected ; the natural course of the disease, 
whatever its variety, should be understood, and its course 
watched; if necessary, local or general treatment should be 
used to assist nature ; and, finally, the case should remain 
under observation till recovery is perfect, or as nearly so as 
the particular disease will admit. This latter point, the in- 
surance of perfect recovery, is all-important, for a little 
remaining disease may be sufficient to produce the hyper- 
trophy of the mucous membrane, which will go on insid- 
iously for a long time before it is noticed by the patient. 
To recognize and fully appreciate all of the minute changes 
which can be seen by the otoscope is undoubtedly a task re- 
quiring much time and practice; but the clinical histories 
and rational signs of the various diseases are well described 
in the numerous books on the ear; and in the tests of the 
hearing we have a very useful means, although not infallible, 
of judging how the disease is progressing. If more atten- 
tion was paid to the degree of deafness, or perhaps it would 
be better to say of hearing, in the earlier stages of tympanic 
disease, there would be much less of the incurable secondary 
processes. By occasional careful testing, the gradual loss 
of hearing would be noticed almost as soon as it began, and 
the improvement which often follows well-marked acute 
disease would be by this means early discovered to be merely 
fallacious. The importance and the methods of applying 
simple tests for the hearing should be known to every prac- 
titioner. I have already called attention to the fact that a 
person may be extremely deaf in one ear, and yet with the 
remaining good ear hear so well that no defect is noticed ; 
but I have known physicians themselves to say of such a 
case that they did not believe there could be any deafness, 13 
EARLY RECOGNITION OF EAR DISEASE. 
simply because they had never tested the hearing of the two 
ears separately. It would seem superfluous to notice, hut 
experience shows, that the failure to close one ear when 
testing the other, is a very common source of error. The 
first step in testing, then, should he the closure of the op- 
posite car with one finger. 
Having done this, the open ear should he tested for the 
distance at which both the watch and the voice can he heard ; 
not whether they can he heard at all, hut whether they can 
he distinguished as far as normal. In regard to the watch, 
it should he remembered that the intensity of the ticking 
varies in different watches, and for comparative tests the same 
watch should always be used, and the normal distance 
established by tests on normal ears. It should also he 
borne in mind that the normal hearing distance for the ticking 
of a watch varies with age, being very much less in old 
persons than in children. With the voice the hearing dis- 
tance should he established in the same way ; hut as it is 
generally impossible to get space enough to thoroughly test 
a clear, distinct tone, that is, as it is impossible, for want 
of space, to reach anything like the normal distance for that 
tone in ordinary houses, it is necessary to lower the intensity 
of the tone to make the normal hearing distance for that 
tone correspond, approximately at least, with the size of the 
room in which the test is made. Having done this, words 
or short sentences should he used, and the patient required 
to repeat them; for if this repetition is not insisted upon, 
many patients will assert positively that they understood, 
when they have merely heard the sound of the voice, hut 
have been wholly unable to distinguish the words. It is 
also well to use a number of different words or sentences, as 
certain letters of the alphabet have much less distinctive 
sounds and are much less readily heard than others. If 
this caution of employing several sentences is used, how- 14 
TIIE IMPORTANCE OF 
ever, it cun scarcely occur that in each of them these difficult 
letters and sounds should predominate. 
Having determined the distance at which both voice and 
I 
watch can be actually heard, and knowing the distance at 
which they should be normally heard, the hearing for that 
case can be well expressed for practical purposes as a frac- 
tion, the numerator of which is the actual distance, and the 
denominator the normal distance. The necessity of testing 
for both watch and voice depends upon the fact that the 
hearing for the two is by no means always proportionally 
the same ; while it may be very good for one, it may be very 
bad for the other. This is seen especially in the class of 
cases where the degree of hearing enables us to judge very 
fairly how the case is progressing, and whether any treat- 
ment for the restoration of the functions of the ear is abso- 
lutely necessary ; these cases are those of acute tympanic 
inflammation, where, as the inflammation subsides, the hear- 
ing slowly returns, but much more rapidly, as a rule, for 
the voice than for the watch, so that it is found when the 
hearing for the watch is only perhaps B'0, that for the voice 
will be 
In children the test for the watch is often uncertain, from 
fright, mischievousness, or lack of intelligence on the part 
of the patient, but that for the voice can generally be made 
effectual by a little ingenuity on the part of the physician in 
asking questions on subjects in which the child takes an in- 
terest, the answers to which will show that the question was 
well understood. 
In all testing great care should be taken to exclude the 
imagination, which is not infrequently both active and in- 
genious in deaf persons. If such tests were in common use, 
it would often be found that the cessation of pain, discharge, 
and other well-marked symptoms did not necessarily imply 
a restoration of the ear to its normal condition ; any deaf- 
ness would be by this means discovered early, long before it EARLY RECOGNITION OF EAR DISEASE. 
15 
had begun to inconvenience the patient, and the question of 
treatment could he determined before the serious and 
irremediable tissue changes had come on, at a time when 
treatment is, in a large number of cases, of real positive 
value.