CHAPTER VIII.

RESULTS OF CATARRH OF THE TYMPANUM.

Perforation of the Membrana Tympani.

By classing perforations of the membrane as a result of tympanic catarrh, it is not meant to imply that this disease is their sole cause; but the proportion of cases in which it is so appears to be so large as to make this arrangement practically true. Of course, the inflammation of the tympanum which occurs in scarlatina and the other exanthemata-by far the most frequent cause of chronic perforations-is included under the term catarrh. The immediate cause of the ulceration of the membrane, however, is by no means to be assumed to be the mere presence, or pressure, of the fluid contained within the drum. Much more probably, not only in the specific fevers, but also in the simplest inflammatory affections, the membrane yields only thro' its own structure partaking in the morbid process.

Perforations of the membrane, occurring with discharge from the tympanum, may be of any extent, except that they are never absolutely complete. They vary from the size of a minute pinhole, up to the entire absence of all but a narrow fringe around the border; this latter con

dition being attended after a time with a partial wasting away of the denuded malleus. But there seems to be no destruction of the membrane so extensive as entirely to put aside the possibility of repair. I have only once, however, witnessed its commencement in a case of almost total loss. The case was that of a girl aged 9,* who had been subject to discharge from the left ear since the age of 3, ascribed to cold after chicken-pox, a not very unfrequent cause of perforation if the statements of patients are to be relied on. Twelve months before I saw her the discharge had ceased for a time (under treatment of Dr. Turnbull in Paris), but had recurred, and was very profuse and offensive. There was removed from the ear a quantity of black grumous matter, evidently deposited in consequence of the use of a lotion of green tea which had been carried on for several months. Of the membrane only a narrow rim was left; the malleus, however, was entire and in contact with the promontory. The mucous membrane of the tympanum was of a livid red, thick and spongy, the niche for the fenestra rotunda not distinguishable, the head of the stapes just appearing, the incus was apparently lost. The local treatment consisted in the application of finely powdered talc, mixed with a small quantity of morphia, which was gently blown into the ear, to cover all the exposed portion, every third day for three weeks, the powder being carefully removed by inflation and syringing before being re-applied. Iodine

*See Atlas, Plate VII., figs. 1 and 2.

was applied externally, and the ear was occasionally washed out by a solution of zinci sulph. or nitrate of silver. The spongy mucous membrane assumed a healthy appearance, pale and dry, and the discharge quite ceased. The hearing continued about as at first (), but the "cotton wool" greatly improved it. Three years subsequently I saw the patient again; the handle of the malleus had partly disappeared; but there was a distinct formation of new membrane posteriorly and below, equalling fully half of the lost portion. It was thin and of a bluish hue; and the mucous membrane still exposed was pale and healthy. The next year the repair did not seem to have advanced farther.

But a still more complete healing of a wholly destroyed membrane may take place. Moos* affirms that he has twice seen the whole membrane destroyed, except the part immediately attached to the handle of the malleus, and that from this the whole aperture has been closed with new tissue. A case that I examined in 1865 appeared to be one of complete formation of a substitute for the membrane.

G. F., æt 52, a healthy man of dark complexion. When a child, deafness and an eruption on the scalp alternated with each other. Remembers that when the head was better he was more deaf. No discharge for several years; not much tinnitus. About fourteen years ago, after looking over some business papers, he became all at once as deaf as a post. This happens often." At first my watch was not heard on either side, but on his pushing the right tragus in a peculiar manner

* "Klinik der Ohrenkrankheiten," p. 133.

66

somewhat upwards and backwards, it was heard on that side at two inches. He can almost always produce temporary improvement in this way. The right membrane was irregularly thinned in various parts, giving the appearance of numerous small depressions, which bulged out on inflating the tympanum and fell back on swallowing. It was also a good deal fallen inwards, and the short process of the malleus projected much. A hard accumulation of epidermis was removed from the roof of the meatus, and the tympanum freely inflated, by which the hearing was much improved, varying from six to sixteen inches. From the left meatus a great accumulation of soft but adherent epidermis was removed, a pale irregular polypoid growth was then seen anteriorly, touching and partly hiding the membrane, which appeared white, of a soft thick look and irregular surface. The tympanum could not be inflated without the catheter, from which air entered it with a loud harsh blowing sound; afterwards a watch was heard one inch, and he could inflate the ear. The improvement continued the next day. The polypus was then removed by Wilde's snare, when it appeared that in the membranous septum which occupied the position of the membrana tympani there was a small orifice, like a pin-hole, previously closed by the polypus; for now when he inflated the ear the air passed out of this small aperture with a whistling sound, whereas, before, the membrane had bulged before it. The polypus itself appeared to have been developed from, or around, a small projecting spicula of bone, which yielded to a slight pressure and came away. On exploring farther, none of the ossicula could be discerned, but in the position usually occupied by the short process of the malleus the probe came in contact with a flattened bony surface. In contact with this was the thick white membrane (covered in parts with flakes of epidermis) which I had taken for the altered membrana tympani, but which on further examination appeared to have a different character. For around the inferior twothirds of the meatus, in the usual position of the membrana tympani, and just in front of the white septum referred to, there was perceived a rim of thick tough membrane, resembling soaked chamois leather. This membranous rim was about two lines in width, it was firmly attached externally to the meatus, and its inner margin was free. On applying traction to a part of it by the forceps, the patient complained that I seemed to be "pulling away a part of the real organ," different from

the pain given by the removal of the polypus or the adherent epidermis. In short, this membranous rim answered, in all respects, to a remnant of the natural membrane attached to the cartilaginous ring, which was plainly visible. But the septum which closed the meatus appeared to be quite disconnected with this. It was attached, inferiorly, evidently within the position occupied by the remnant of the membrane, with which it had no visible connection. It appeared like an entirely new formation of thick, strong, though flabby tissue. The next day the small perforation noticed was no more to be seen, the septum bulged on inflation, which slightly improved the hearing, but pressure on the tragus improved it more, raising the hearing distance for the watch to twelve inches. This action made no visible change in the ear, but the effect seemed to depend, in part, on the closure of the meatus, since the presence of even the smallest speculum entirely prevented it. The vapour of acetic ether was passed warm into the right tympanum with improvement of the hearing, and the patient left me with each ear performing its function moderately well. Tonics, with astringents to the throat, and a lotion of carbolic acid to the left ear were advised, but the hearing again diminished, and in five weeks he returned. Watch, right, left 2. The left ear had altered considerably; deep in on the floor of the meatus was seen a small polypus, which fell off without bleeding on being touched by a probe. There was a slight milky discharge, on removing which the portions of membrane before described were seen to have become continuous, forming a white soft septum ; no orifice existed. Inflation of each tympanum again restored the hearing; right to fifteen, and left to twenty inches. This was repeated for three days with the injection of acetic ether vapour by the catheter. At the end of this time all trace of the polypus was gone, and the ears appeared in a healthy condition. The septum above described had evidently grown into one with the circumferential remnants of the membrana tympani, forming a complete membranous layer occupying nearly the ordinary position. The line of junction was visible as a slight ridge. The membrane was of an opaque white, soft-looking, but smooth and bright, and fell slightly into vertical folds, especially at the upper part. It was quite insensitive when touched, and fell inwards towards the promontory, which was easily felt by the probe. There was no trace of malleus or the other ossicula.

N