CHAPTER X.

COLLAPSE AND RIGIDITY OF THE MEMBRANE: ADHESIONS:

ANCHYLOSIS OF STAPES.

AMONG the effects of chronic inflammation of the tympanum, a very frequent one is a thinning and degeneration of the entire membrane, which leads to its falling in upon, and becoming adherent to, the inner wall of the tympanum. In extreme cases of this kind the appearance is almost entirely the same as if the membrane were wanting, but the surface is smooth and shining, and no margin of the membrane is to be seen. Polypi not unfrequently coexist with this condition, and when they have been cured, the surface that remains visible is that of the tympanum covered as with a layer of gold-beater's skin. The malleus may be completely or partly wanting, and generally the head of stapes stands prominently out. Here again the remarkable fact is that the hearing may be very good indeed, even while the collapse is extreme. A girl, aged 16, was brought to me for discharge and deafness lasting since scarlatina at 3. A polypus existed on both sides, which was eradicated on the right only after enlarging the orifice in the membrane and thoro❜ly evacuating the tympanum. On the left side, a large

polypus occupied almost the whole meatus, and was found, after removal, to have apparently grown from the lower part of the tympanic wall, which was red and fleshy. After a few weeks' treatment, however, it was seen that there was no free margin of membrane, but that the whole internal wall of the tympanum assumed a white and glazy appearance; all its contour could be distinctly traced, but there was no sign of any breach of continuity in the membrane, which could be seen falling inwards from its margin to the promontory. The malleus was much drawn back, and seemed shortened, and the stapes stood out behind it. Air blown thro' the Eustachian tube entered the tympanum, but did not escape, and by repeated inflation, by Politzer's bag and the catheter, the thinned membrane was blown off from the lower and anterior part of the tympanic wall, and she could herself make it bulge into a bladder. The hearing greatly improved, and became quite sufficient for all practical purposes. A whisper was heard at ten feet.* In all such cases, if the hearing does not otherwise return, the artificial membrane should be tried; and if that does not succeed, a small curved knife may be introduced very carefully behind the adherent handle of the malleus, and it may be gently raised from its bound-down position; or the stapes (which is generally plainly to be seen) may have slight incisions carefully made around it, and even very gentle pressure applied to it, to restore its mobility, * See Atlas, Plate III., fig. 6.

precautions being taken to prevent any risk of sudden movements. I have known measures of this kind render the cotton wool fairly effective in cases in which it was previously of no avail. But all such means would perhaps be avoided or carried out with excessive care if the other ear were lost; or, if the nervous power were destroyed, of course they would be futile.

A slightly different condition is when a part of the membrane has been destroyed and the edges have become adherent to the tympanic wall.* In these cases, if other means are unavailing, cutting round the adherent part with a small sharp knife, and so setting the membrane free, has sometimes had a very good effect. In other instances suction on the meatus-best exerted by the mouth-will, for the time at least, restore the hearing. So that the resources in such cases are: powerful inflation; suction; the artificial membrane; cutting around. the scar; and, finally, cautiously endeavouring to liberate the malleus and restore mobility to the stapes. Also the possibility of the presence of old viscid secretion gluing the parts together should not be overlooked, nor an urgent case abandoned (if the nerve-power is good) without a fair attempt being made thoro❜ly to clear out the tympanum.

In milder degrees of indrawing of the membrane, when tho' it can be restored to its place by inflation, and temporary improvement follows, it soon falls back again,

* See Atlas, Plate XX., fig. 4.

Politzer introduced, and still speaks highly of, the plan of keeping up an air-tight closure of the meatus. Having well inflated the tympanum, he takes some cotton wool rolled up into a small ball with wax, or ointment, and with it closes the orifice of the meatus; he thus takes off the pressure of the external air, and even turns to account the absorption of air in the meatus, making it tend to draw the membrane outwards, care being always taken to see that the Eustachian tube is free. The ball may be worn for several consecutive nights, and then omitted for a time. When the membrane is atrophied, however, this plan does not succeed. But then excision of the relaxed part, whether it be a scar or a part otherwise thinned, will sometimes be of use. Or if the relaxation has advanced only to a less degree, and the membrane simply lacks the proper tension, simple incisions into the most relaxed part of the membrane help towards a restoration of the normal tension; apparently thro' the contraction that attends their healing. The incisions may be frequently repeated, and at short intervals. But in this climate, and with the kind of patient we usually see, I should prefer always to let fourteen days elapse.

A similar treatment has been found useful also for an opposite condition: namely, for increased tension and rigidity of the membrane, indicated by abnormal prominence of the folds that run anteriorly and posteriorly from the short process to the margin of the membrane. Re

peated incision of these folds, especially the posterior one, is said to have often a permanent good effect.*

Also in scars, or slight adhesions, of the membrane it has often been found that a rupture produced by forcible inflation of the drum has permanently improved the hearing.

In some cases of relaxed membrane, with more or less loss of the ossicula, the hearing is improved by the membrane being forced outwards, in others by its being gently pressed inwards. Varying relations between the membrane and the stapes may account for this difference. In one case, in which, on dissection, the incus was wanting, and the thinned membrane lay in contact with the stapes, the hearing had been fairly good.

Very frequently the hearing is at once and greatly improved by mere incision of the membrane, as if it took off a tension or load from the ossicula; but the improvement is lost again as soon as the membrane heals. And this may recur several times. Accordingly every contrivance has been used for keeping incisions in the membrane permanently open, but none of them have succeeded; not even Dr. Wreden's method of cutting away at once the chief part of the membrane and of the handle of the malleus. Politzer, in view of these facts, constructed a small ring of hard rubber, with a slight groove

*In the Atlas, Plate XIX., fig. 2, is shown a case, in which the membrane is seen gaping after incision. The hearing was greatly improved, but for a time only.