Incipient Inflammations of the 
Ear in Early Life, and their 
Sequelae. 
BY 
S. MaoCUEN smith, m. d., 
Clinical Professor of Otology in Jefferson Medical College; 
Surgeon in Charge of Ear and Throat Department of 
Germantown Hospital, Philadelphia. 
REPRINTED FROM THE 
Neto Yorft f&eWcal Journal 
for July 21, 1894■ Reprinted from the New York Medical Journal 
for July 21, 1891f. 
INCIPIENT INFLAMMATIONS 
OF THE EAR IN EARLY LIFE, 
AND THEIR SEQUELAE.* 
By S. MacCUEN SMITH, M. D., 
CLINICAL PROFESSOR OF OTOLOGY IN JEFFERSON MEDICAL COLLEGE ; 
SURGEON IN CHARGE OF 
EAR AND THROAT DEPARTMENT OF GERMANTOWN HOSPITAL, PHILADELPHIA. 
It is the object of this paper to present to you a few 
suggestions for the purpose of stimulating a more general 
interest in the primary aural inflammations that must neces- 
sarily first come under the care of the general physician. 
The prevention of diseases of the ear and the subsequent 
deafness, rather than the frequently futile efforts to relieve 
conditions that could and should have been prevented, must 
be the aim of all true physicians. The evident lack of interest 
and information concerning diseases of the ear doubtless 
arises in great part from the fact that until recently this 
subject has received little or no recognition from our medi- 
cal colleges. Furthermore, the demands of an active prac- 
tice will allow the busy physician but little time to devote 
to the study of otology, and therefore he has frequently 
* Read before the Pennsylvania State Medical Society, May 16, 1894.,. 
COPYKIGHT 1894, BY D. APPLETON AND COMPANY. 2 
INCIPIENT INFLAMMATIONS OF 
felt impelled to use palliative measures when more radical 
treatment was demanded. 
It has been estimated that from eighteen to twenty-two 
per cent, of school children are unable to write dictations 
correctly when the teacher speaks in a high tone of voice 
at a distance of twenty to twenty-five feet. If these de- 
ductions are even approximately correct, it reveals an in- 
creasing and alarming affliction among our young popula- 
tion, to which neither our profession nor the public have 
given due and serious consideration. Now, as the great 
majority of ear diseases (excepting traumatism) have their 
incipiency in infancy and early childhood, and, as the prac- 
titioner of general medicine is always, and very properly, 
the first to he consulted in all that pertains to the health 
and physical care of his patient, he must, therefore, to a 
great extent he morally responsible for the proper manage- 
ment of these incipient ear troubles and for the prevention 
of the possible serious sequelae. 
He who would not promptly care for and protect the 
eyes of the newborn infant would indeed be regarded as very 
remiss and negligent in the performance of his professional 
duties. If this be true in regard to the eyes, why should not 
the health of the ears he of equal importance ? Within the 
past three years it has fallen to my lot to see six infants 
die from disease of the middle ear, and, unfortunately, in 
every case the trouble had not been recognized until within 
a few hours of their death. Four of these patients were 
thought to have been suffering from “ brain fever ” and 
two from “ meningitis.” We should not hastily conclude 
that a child is “ horn with a temper ” simply because its 
youthful being is disposed to resent suffering, and so re- 
sorts to crying as its only means of expression. When a 
child frets and cries persistently, and the cause can not 
be otherwise located, an examination of the ears will fre- THE EAR IN EARLY LIFE. 
3 
quently reveal the difficulty and suggest prompt means of 
relief. 
In years past the belief prevailed that there was some- 
thing mysterious, or at least most intricate, connected with 
morbid conditions of the ear and their treatment. While 
this curious impression is still somewhat in vogue, it is 
nevertheless gratifying to note the gradual disappearance of 
the gross ignorance and empiricism that divided all diseases 
of the ear into two great classes, “ wax and no wax,” “ wax 
curable and wax incurable.” Likewise, the charlatan, whose 
prosperity is usually notable hut brief, has been compelled 
to seek other fields of operation, where he can astonish 
another credulous community with some startling wonder. 
During intra-uterine life there'is an accumulation of a 
semifluid substance within the tympanic cavity known as 
Wharton’s jelly. At about the time of birth this fluid is 
usually absorbed through the physiological changes that 
take place in the tympanum, and by means of which air is 
admitted into the middle-ear cavity immediately following 
the first cry of the infant. The external auditory meatus 
is sometimes obstructed by the “ cheesy varnish ” (vernix 
caseosa) covering the surface of the foetus. The presence 
of this material may cause inflammation of both the drum- 
head and the meatus itself. We are at times confronted 
with the statement that “the child was born with a dis- 
charging ear.” This, however, is not likely to he the fact, 
for such a discharge in all probability has been caused by 
the presence of some unabsorbed Wharton’s jelly acting as 
an irritant and exciting a suppurative inflammation of the 
tympanic cavity. It is well, therefore, to examine the ex- 
ternal auditory canal of the newborn child, and if it he 
free from accumulated material and the membrana tympani 
is found to he congested, the tympanic cavity should be in- 
flated by Politzer’s method. If, however, this fails to re- 4 
INCIPIENT INFLAMMATIONS OF 
lieve the symptoms, the drumhead should be carefully 
punctured and inflation again used, when the relief will be 
almost immediate. 
The treatment of so-called “ earache,” when due to an 
inflammation in a previously healthy middle ear, becomes 
an important matter, not only for the purpose of giving re- 
lief .from the suffering that is at times most intense, but an 
urgent interest in such cases is especially required from 
the fact that their prompt and proper treatment is fre- 
quently of vital importance to the patient. It is now gen- 
erally accepted that brain and mastoid complications re- 
sult from the acute suppurative inflammation of the mid- 
dle ear, as well as from the chronic form. Having had 
the misfortune to see a considerable number of these seri- 
ous complications, the writer must express the belief that 
they are in many cases preventable, and therefore we must 
consider it the imperative duty of every practitioner of 
medicine to he able to promptly recognize and immediately 
care for an acute suppurative inflammation (abscess) of 
the tympanic cavity. 
It is necessary that we should recognize two forms of 
acute inflammation of the middle ear, the one caused by 
exposure to dampness, sea-bathing, the careless use of the 
nasal douche, dental irritation from decayed teeth or dur- 
ing dentition, or through continuity we may have an exten- 
sion of some existing catarrhal condition of the throat or 
nasopharynx; the other form is that which occurs during 
the course of one of the infectious fevers, and is usually 
purulent in character. The post-nasal space will always 
hear inspection, especially if the child is a mouth-breather. 
However, from whatever cause the acute inflammation 
may arise, the inflammatory product will undergo fatty de- 
generation, unless the Eustachian tube is sufficiently patu- 
lous to drain the middle-ear cavity, or unless the fluid finds THE EAR IN EARLY LIFE. 
5 
egress through an opening made by puncturing the drum- 
head. 
The treatment of an acute inflammation of the tym- 
panic cavity will largely depend on the extent and sever- 
ity of the attack. If the patient receives treatment during 
the stage of hypersemia and consequent hypersecretion of 
the mucous lining of the Eustachian tube, tympanum, and 
mastoid cells, the inflammation will have been arrested and 
confined to the sero mucous or catarrhal stage. If, how- 
ever, this early care has not been given, the case will pro- 
gress to the stage of suppuration and subsequent rupture 
of the membrana tympani. As soon as pain of any charac- 
ter is complained of, bloodletting in front of the tragus is 
of the first importance. This may be accomplished by 
applying three to six Swedish leeches, or by the use of 
the artificial leech * devised by Dr. Gorham Bacon, of New 
York. There are some advantages in the use of the arti- 
ficial leech as a means of extracting blood. The difficulty 
of using the natural leech is overcome in many cases, and 
especially in children ; bleeding from the natural leech is 
much more difficult to arrest; its bite is painful, and may 
give rise to an erysipelatous inflammation ; natural leeches 
are not always to be had and are expensive, whereas the 
artificial leech is always ready for use and inexpensive. In 
very young children, or in any case where bloodletting is 
not advisable, a blister in front of the tragus will answer 
the same purpose, unless the case is a severe one. Infla- 
tion of the tympanic cavity is an important part of the 
treatment in the majority of cases. This is readily accom- 
plished in children by attaching a piece of soft rubber tub- 
ing to a Politzer’s air bag and inserting this into the nos- 
tril ; the spasmodic crying of the child naturally prevents 
* This artificial leech can be obtained from the W. F. Ford Surgi- 
cal Instrument Company, of New York. 6 
INCIPIENT INFLAMMATIONS OF 
the air from entering the throat, and it is thus gently 
forced through the tube into the middle ear. A continu- 
ous stream of a mild carbolic-acid or boric-acid solution 
—properly heated—should be carefully directed into the 
external meatus; the bowels must be thoroughly opened 
and the patient kept quiet. The mastoid is usually some- 
what involved, hut when promptly treated by running hot 
or cold water through a Leiter coil, bloodletting or blis- 
tering, the slight inflammation will quickly subside. 
When this treatment fails to relieve the symptoms, it is 
safe to assume that an abscess of the tympanic cavity is 
forming, and no time should he lost in puncturing the 
drumhead at the most dependent point. It is not well in 
all cases to wait until there is bulging of the drumhead, as 
this will not occur in every case, and there is danger of 
spontaneous rupture if we delay too long. When there is 
discharge it is best treated by inflating the cavity twice per 
week and the daily injection of a warm solution composed 
of sodii biborat., 3 j; acid, boric., 3 ij; alcoholis, f 3 iij ; 
aq. dest., q. s. ad f § viij. 
Yon Troltsch has wisely observed : “The moral and in- 
tellectual future of a child stands in direct relation to the 
functional activity of the ear.” This forcibly emphasizes 
the necessity of good hearing power as a prerequisite 
to the proper development of the intellectual faculties. 
How very common it is to have parents and teachers de- 
clare children dull in intellect, stupid, absent-minded, and 
lazy, for one or all of which severe punishment may he in- 
flicted, when the real cause of their apparent stupidity is 
their inability to hear correctly ! A few years ago a boy, 
nine years of age, came under the writer’s notice. Ilis 
parents informed me that he had “ always been stupid, due 
to a defective intellect,” and, following the advice of friends, 
they had subjected him to several methods of , “ mental THE EAR IN EARLY LIFE. 
7 
training,” including some punishment, hut that his condi- 
tion continued to grow worse, and they now regarded him 
as “going into a hopeless state of idiocy.” I regret to 
say that this gloomy prognosis was also the opinion of 
their medical adviser. An examination revealed some post- 
nasal adenoid vegetations which entirely occluded the Eu- 
stachian tubes and post-nasal space. The irritation of these 
growths induced an inflammation of the tubes, which ex- 
tended into the middle ear and thereby caused a purulent 
discharge which had persisted ever since. Such an exhi- 
bition of careless indifference on the part of a physician is 
unpardonable. Moreover, it is difficult to explain why 
many of these patients do not die from a brain or mastoid 
complication long before they receive intelligent care. The 
treatment required in this case was simply the removal of 
the adenoid growths, the use of an antiseptic wash in the 
external meatus, and inflation of the cavity by Politzer’s 
method. The case recovered completely and permanently 
in less than two months, some slight impairment of hearing 
alone remaining. 
The importance of these inflammations of the ear has a 
renewed and increasing interest when we consider the 
multitude of deaf-mutes that are directly traceable to a 
discharging ear as a consequence of one of the exanthem- 
ata. Contrary to general belief, deaf-mutism is not a 
distinct disease in itself, any more than pain or a rise of 
temperature could be regarded as an entirely separate ail- 
ment. Very properly, therefore, deaf-mutism must be ac- 
cepted as a symptom or, still better, as a sequela of an 
existing disease. Moreover, as the organs of phonation 
and articulation are perfectly normal in deaf-mutes, their 
inability to speak is usually the result of deafness. Deaf- 
mutes, however, can be taught to speak and enter into 
conversation by what is known as the German system of 8 
INCIPIENT INFLAMMATIONS OF 
instruction. From the foregoing it will be seen that the 
loss of speech in this class of cases is almost invariably 
due to deafness, and that deafness is always the result of 
either a diseased condition of the ear after birth, or, as 
is frequently the case, a congenital defect, such as an ar- 
rest of development of the internal ear. When the 
deafness is caused by a congenital arrest of develop- 
ment, there is no probability of the case ever being im- 
proved ; but when the deafness and subsequent loss of 
speech have been acquired after birth, such an affliction 
can frequently be remedied when promptly recognized and 
treated. 
What a sad experience it is to have the parents of an 
otherwise healthy child apply for treatment with the hope 
of having both hearing and speech restored, when neither 
can be improved ! The history of these patients is usually 
that the child had never been ill, that it could talk, and 
was bright and cheerful until two years of age or older, at 
which time it contracted one of the so-called children’s dis- 
eases. An extension of this disease, which always affects 
the throat, developed an “ earache ” and abscess in the 
middle ear. This, however, was regarded as a natural, 
even a necessary consequence, and of little importance; 
therefore this grave complication was neglected, and, as 
frequently occurs, terminated in increasing deafness. In a 
short time the family noticed the child growing progress- 
ively less talkative, but were satisfied with the explanation 
that it was due “ to its increasing backwardness and 
changed disposition.” However, as its articulation became 
more and more indistinct, other advice was obtained, which 
developed the fact that the child was quite deaf, and to all 
practical purposes dumb. 
It is sometimes difficult to determine the degree of 
deafness in early life. It is well, therefore, to caution the THE EAR IN EARLY LIFE. 
9 
parents not to be deceived or to indulge the vain hope 
that because a child can repeat the words “ papa ” and 
“ mamma,” or other words of few syllables, it can really 
hear, for these are acquired by merely watching the move- 
ments of the lips. Again, it must be remembered that 
deaf-mutes are strangely susceptible to vibrations, and will 
for this reason have their attention called to and promptly 
turn in the direction of one entering the room, shutting a 
door, or when the atmosphere is disturbed by an effort to 
attract attention to some noise. Dalby has shown that a 
child of four or five years of age who has been brought up 
in India with a native nurse and taught as a first language 
Ilindustanee, will have completely forgotten it in six 
months if it is brought to England and does not hear this 
language spoken. As Bonnafont has well said: “The 
mind of the deaf remains in a perpetual sleep. The blind 
man is a stranger in the physical world, and the deaf man 
is a stranger in the moral world. The deaf will overcome 
natural difficulties more easily than the blind. But in re- 
lation to moral difficulties the blind will play a better part 
than the deaf. The one, like Alexander, will cut the Gor- 
dian knot; the other will vanquish the sphinx and solve 
the riddle.” 
We are all familiar with a large number of blind people 
who have distinguished themselves in science, art, and 
literature, but we are able to record only one congenital 
deaf-mute, J. F. Berthier, of Paris, who has gained any 
prominence for his literary attainments. It is, indeed, not 
without cause that the deaf are more sad, morose, and 
cheerless than the blind. All that is glorious and beautiful 
in the external world is hidden from the blind man ; but the 
deaf are deprived of that still greater charm, the enjoyment 
of social life with their fellow-men. It is a pleasure to see 
the bright, intellectual and happy expression that crowns 10 
INCIPIENT INFLAMMATIONS OF 
the blind man’s countenance when he enters into conversa- 
tion, for he then forgets his defect; whereas the deaf, 
under similar circumstances, are only reminded of their in- 
firmity, and really feel downcast wThen any one addresses 
them. 
Out of fifty-one deaf-mutes that have consulted the 
writer in the past few months, thirty-seven acquired their 
affliction, while the remaining fourteen were congenital. 
Of the acquired ones twen+y-one resulted from scarlet 
fever, nine from diphtheria, five from measles, and four 
from traumatism. Nine were between the ages of one and 
two years, sixteen between two and three years, and twelve 
between three and five years. I think it is safe to assert 
that most of these acquired cases would have been pre- 
vented if the pus in the tympanum had been promptly 
evacuated at the opportune moment, followed by mild anti- 
septic irrigation of the external auditory canal, inflation of 
the tympanic cavity, bloodletting, and proper care of the 
throat. When this line of treatment is properly carried out, 
an acute abscess, from whatever cause, will in most cases 
promptly recover. The relief from suffering is almost im- 
mediate, the discharge will have been arrested in a few 
days, and the hearing is usually restored in two or three 
weeks. 
On the other hand, if this simple but highly important 
care is not taken, the pain increases in proportion to the 
distention of the membrana tympani by the progressive 
accumulation of pus in the tympanum, until finally the 
pressure becomes so great that the tension of the drum is 
overtaxed, and with a report quite audible to the patient it 
ruptures, a copious flow of pus follows, and the suffering is 
relieved. By this time, however, great damage has been 
done both to the membrana tympani and tympanic cavity. 
Instead of the opening in the drumhead quickly repairing, as THE EAR IN EARLY LIFE. 
11 
it will do when incised, its lacerated edges are much slower 
to mend. The injury done to the delicate.mucous lining of 
the tympanic cavity gives rise to a discharge that becomes 
more or less chronic, and this in turn is conducive to one 
or more of the many serious complications that too fre- 
quently follow such a condition. Should this discharge 
continue for any great length of time, caries and necrosis of 
the ossicles, with destruction of the membrana tympani, 
and later the walls of the tympanic cavity, are almost sure 
to occur. Knowing that the bony walls of the tympanum 
are always thin; that the roof in some cases is entirely ab- 
sent ; that the carotid canal, through which passes the 
carotid artery, forms the anterior wall of the tympanic 
cavity ; that the jugular fossa, in which lies the bulb of the 
jugular vein, constitutes the floor of the tympanum ; and 
that the middle and back part of the temporo-sphenoidal 
lobe and the outer and front part of the lateral lobe of the 
cerebellum are in direct contact with the middle ear, it is 
indeed surprising that even a slight necrosis of this organ 
is not productive of more fatal results. It is from these 
neglected cases of either an acute or chronic suppurative 
inflammation of the middle ear that we have deafness and 
deaf-mutism, caries and necrosis, abscess of the brain and 
mastoid, diffuse meningitis, osteo-phlebitis, thrombosis of 
the lateral sinus, pyaemia, and infectious inflammation of the 
liver and other internal organs. 
Therefore, gentlemen, when all this suffering and future 
affliction can be prevented by prompt and judicious treat- 
ment in the incipient stages, we must protest against the 
neglect and indifference that are so manifest in a large num- 
ber of- these cases. Notwithstanding the fact that these 
unfortunate complications usually arise from the chronic 
form of discharge, it must nevertheless be borne in mind 
that if the initial lesion is promptly and properly treated 12 
INFLAMMATIONS OF THE EAR IN EARLY LIFE. 
the disease will be quickly eradicated in the majority of 
cases, thus not only preventing the discharge from becom- 
ing chronic but often aborting the inflammation in its in- 
cipiency, and so preventing its progress to the stage of sup- 
puration. 
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