Syphilitic Invasions of the Ear

The Chirurgeon’s Apprentice has a wonderful post on Georgian prostitution and syphilis, which inspired me to dig up my research notebooks and uncover what nineteenth-century aurists wrote about syphilis and deafness. Syphilis is a fascinating topic. In nineteenth-century London, people were quite aware of the gruesome and devastating aspects of the disease. The memoirs of Reverend Frederick Gilby (1865-1949), for instance, documented a “tragic case” of a poor deaf and dumb child at the Bow and Bromley Workhouse Infirmary who began to develop syphilitic symptoms.

Aurists were aware that syphilitic invasions of the ear were not uncommon occurrences. Most of them agreed on the symptoms of syphilitic deafness, though they may have disagreed on the stages of the disease or which part(s) of the ear the disease was presented. Matthew Berkeley Hill (1834-1892), for instance, argued deafness in syphilis occurred at the late stages of the disease and presented in the tiny bones of the ear.[1] By the 1870s, it was agreed that syphilitic deafness included symptoms of: damage to the eighth cranial nerve, tinnitus, a gradual loss of hearing, with periods of remission, and evidence of damage in the tympanic cavity.[2]

John Cunningham Saunders (1773-1810), founder of the London Infirmary for Eye and Ear Diseases, believed that proximate causes of syphilis and nervous deafness (hearing loss due to defective or damaged nervous system) were the same.  “Constitutional deafness” (selective, temporary deafness) also included deafness caused by syphilis. The Irish aurist William Wilde (1815-1878) defined syphilitic deafness as “syphilitic myringitis.” He described the disease as being rooted in the tympanum (bony cavity of the middle ear, behind the eardrum):

[T]he deafness which sometimes accompanies the secondary form of syphilis is generally believed to be caused by inflammation, and ulceration extending from the throat through the Eustachian trumpet [tube] into the middle ear.[3]

The aurist Joseph Toynbee (1815-1866) also discussed deafness arising from syphilis, though he didn’t go into much detail on its root causes. In The Diseases of the Ear (1860), he outlined a case of 28 year old “H.L.” who came to see him on June 25, 1853 for treatment of deafness and afflicted symptoms arising from syphilis:

[He has] suffered for several months from sore throat, consequent upon an attack of secondary syphilis: for two months has complained of deafness in both ears, so as not to hear any except a loud voice. The deafness is accompanied by constant singing [tinnitus], which is increased when the head is on the pillow, and it varies much…The treatment pursued was the use of the nitrate of silver to the fauces, and the administration of steel wine. On July 2d he told me that three or four days previously he heard quite well in the morning, and the improvement lasted for two days, since which he has been gradually getting deaf again. By perseverance in the treatment for a month he perfectly recovered.[4]

James Hinton (1822-1875), aural surgeon at Guy’s Hospital, also noted that 1 in 20 of his patients manifested symptoms of syphilitic deafness. Hinton also assisted in the research of English surgeon Jonathan Hutchinson (1828-1913), who was collecting data on inherited syphilis.

L0008502 Portrait of Sir J. Hutchinson.
Jonathan Hutchinson

Hutchinson studied at St. Bartholomew’s Hospital and was a member and fellow of the Royal College of Surgeons; his remarkable surgical career led to appointments in several of London’s hospitals, including the Lock Hospital, the London Hospital, and Blackfriars Hospital for Diseases of the Skin. His work on syphilis was the first to connect various symptoms to form diagnosis—what’s now called the Hutchinson Triad, in which symptoms of notched teeth, interstitial keratitis, and deafness, could provide a firm diagnosis of congenital syphilis.

photo 2
Types of interstitial keratitis, from Hutchinson’s A Clinical Memoir
L0021139 "Syphilitic malformations of the permanent teeth".
Types of notched teeth, from Hutchinson’s A Clinical Memoir

In A Clinical Memoir of Certain Diseases of the Eye and Ear as a Consequent of Inherited Syphilis (1863), Hutchinson states that deafness frequently follows the presence of keratitis and in the majority of cases, the deafness was complete and permanent. He found syphilitic deafness occurred in cases of diseases of the cranial bones extending towards the internal and middle ears; of these cases, otorrhoea (inflammation of the ear with excessive discharge) was an invariable symptom.

Deafness in greater or less degree is frequent in the subjects of inherited syphilis. In some instances it advances to the almost total abolition of the perception of sound. These extreme cases are however exceptional, and more commonly only the hearing is only partially lost.[5]

Symptoms of syphilitic deafness were indicative of the progressive nature of the disease. As Hutchinson explained, deafness is usually symmetrical, in that it appears in both ears at the same time. In none of his cases did he find any changes in the tympanic membrane (eardrum), although the membrane was often abnormal in some way. The stages of hearing loss are rapidly passed through; a patient’s hearing could drastically diminish in six months from perfect hearing, to totally deaf, without any marked degree of pain. In cases of inherited syphilitic deafness, Hutchinson observed that deafness usually appears in five years either before or after puberty.

“Herdito-syphilitic deafness,” Hutchinson declared, had a poor prognosis. Its progressive nature meant there was little chance of permanent improvement, even in spite of the “cautious use” of specific remedies prescribed from the onset of symptoms. Six months to a year was the usual time “for the completion of the process and the entire abolition of the function.”[6]

NOTES

[1] Matthew Berkeley Hill, Syphilis and Local Contagious Disorders (1868).

[2] Deborah Hayden, Pox: Genius, Madness, and the Mysteries of Syphilis (2003), p.80.

[3] William Wilde, Practical Observations on Aural Surgery (1853), p.252.

[4] Joseph Toynbee, The Diseases of the Ear: Their Nature, Diagnosis, and Treatment (1860), p.235.

[5] Jonathan Hutchinson, A Clinical Memoir of Certain Diseases of the Eye and Ear as a Consequent of Inherited Syphilis (London: 1863), p.174.

[6] Hutchinson, p.183.

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Cures of all Kinds

Breathing into the ear to relieve deafness (19th Century)
From: The Magnetic and Botanic Family Physician.
By: D Younger
Published: E. W. Allen.London 1887
An ear cleaner at work; by an unnamed Dehli painter, commissioned by Colonel
James Skinner. Watercolour 1825 (Delhi)
The surgeon Capiomont stitching the ear of general Oudinot at the battle of Wagram, 1809. Watercolour by F. Pils.
An operator making an incision behind the ear of a seated patient, two assistants restraining the patient, and six other people in the room. Oil painting attributed to Joachim van den Heuvel.
An operator extracting “pierres de tête” from behind a man’s ear, with four other people in attendance. Oil painting by a follower of Pieter Jansz. Quast.

All images from Wellcome Collection.

What do you do when you’re sick?

I like to ask my students this question at the beginning of the term to help them get a mindset of what disease and illness was like in the early modern period and medieval ages. When confronted with the inevitable reality of disease, how did people of the Middle Ages react? Of the different forms of healing available, what factors determined which ones they turned to? Availability was one such factor, but we must also consider other factors such as the cost of services and treatment, the healer’s reputation, their suitability to treating the disease as well as explaining its underlying causation, as well as the past experience of the sick themselves, their family, and friends. More importantly, reliability was an ideal attribute to be found in practitioners.

Patients consulted astrologers, empirics, wise-women, midwives, nuns or priests known for their magical or miraculous healing powers, knowledgeable friends, as well as physicians or surgeons. They sought out healers and choose the one that most pleased them.

Physicians were, of course, expensive—but money was not the only consideration. Medical decision-making was a complex process. Medieval and early Renaissance patients were medically promiscuous. They often and perhaps even always consulted several different types of practitioners at the same time, or one after the other. This was true of both the rich and poor; the rich did not rely exclusively on physicians. To a large extent, patients perceived no firm cultural barrier between different medical practitioners, and behaved accordingly.

Moreover, as Gianna Pomata writes in Contracting a Cure: Patients, Healers, and the Law in Early Modern Bologna (1998), the transaction between healer and patient was regulated by a business-like arrangement, known as the healing contract that dates back to the thirteenth century. Here’s an example of a contract from Bologna outlined in Pomata’s book, undersigned in 1244 by Rogerio de Bruch of Bergamo and Bosco the wool carder in Genoa:

          “In the name of the Lord, amen.

I, Rogerio de Bruch of Bergamo, promise and agree with you, Bosco the wool carder, to return you to health and to make you improve from the illness that you have in your person, that is in your hand, foot, and mouth, in good faith, with the help of God, within the next month and a half, in such a way that you will be able to feed yourself with your hand and cut bread and wear shoes and walk and speak much better than you do now. I shall take care of all the expenses that will be necessary for this; and at the time, you shall pay me seven Genoese lire; and you shall not eat any fruit, beef, pasta—whether boiled or dry—or cabbage. If I do not keep my promises to you, you will not have to give me anything. And I, the aforementioned Bosco, promise to you, Rogerio, to pay you seven Genoese lire within three days after my recovery and improvement.”

The promise of a cure is obviously a key feature in the agreement between healer and patient. To the patient, it was valuable because it outlined exactly what was to be expected from the healer and that payment was to be dismissed if cure was not provided—it was a legal binding document that could protect him from fraud as well. To the healer, it served to win the trust of potential clients, to showcase his learned medicine and prognosis. In addition, to those patients seeking out self-help, practitioners would actually build their authority on the difficulty of treatment and the dangers of treating selves without proper medical knowledge.

The Catheter

Valsalva’s De aure remained one of the standard treatises on the ear and the Valsalva maneuver gained popularity among physicians and surgeons for diagnosing sources of blockages in the ear. The maneuver, however, contained little therapeutic benefits for cases in which there weren’t blockages in the tube or associated parts of the ear; moreover, it could hardly detect causes for the majority of cases of deafness. In 1724, Valsalva’s method was modified by the use of a catheter. In order to relieve his deafness, Edmé-Gilles Guyot, a postmaster at Versailles, constructed an angular tube of pewter and put it through his mouth into the opening of the Eustachian tube. The instrument was then attached to a leather tube connected to two small pumps that forced fluid into the mouth of his Eustachian tube and essentially, “washed” out his deafness. Excited with the success of his instrument, Guyot presented his apparatus to the Académie Royale des Sciences des Paris.[1] However, the instrument received little attention or excitement, in part since anatomists did not think the entire tube could be reached via insertion, and partly since the technique was believed to be cumbersome for regular treatments.[2]

In 1741, unaware of Guyot’s instrument, Archibald Cleland (1700-1771), a Scottish military surgeon, published a paper with engravings of several instruments for surgery, including a catheter meant for Eustachian tube catheterization.[3] His instrument and purpose was significantly different than Guyot’s: Cleland used a flexible silver tube instead of a pewter one, “to admit of bending them, as occasion offers.”

Cleland’s Instruments

Additionally, Cleland recommended catheterization only upon occasion in which drainage of ear wax or removal of obstructions with a forceps, failed to remedy the patient from deafness:

If, upon Trial, [the Eustachian tube] should be found to be obstructed, the Passage is to be lubricated by throwing a little warm Water into it by a Syringe joined to a flexible silver Tube, which is introduced through the Nose into the oval Opening of the Duct at the posterior Opening of the Nares, towards the Arch of the Palate. The Pipes of the Syringe are made small, of Silver, to admit of bending them, as occasion offers; and, for the most part, resemble a small Catheters: They are mounted with a Sheep’s Ureter; the other End of which is fixed into an Ivory Pipe; which is fitted to a Syringe, whereby warm Water may be injected: or they will admit to blow into the Eustachian tube, and so force Air into the Barrel of the Ear, and dilate the Tube sufficiently for the Discharge of the excrrementitious Matter that may be lodged there.[4]

Cleland’s procedure also differed significantly from that of Guyot’s with the insertion of the catheter; Cleland favored insertion though the nasal cavity, which allowed better access to the Eustachian tube, whereas Guyot’s method relied on the catheter being inserted through the mouth. It’s important to note that Cleland did not view the procedure solely as a remedy for deafness, but rather as a means to “dilate the Tube” sufficiently for drainage, and attached a syringe as part of the procedure.

Cleland’s procedure was further described in detail by the surgeon Jonathan Wathen, although Wathen ceased to mention Cleland’s work or might have not been aware of it. In 1755, he wrote “[w]hatever obstructs the passage leading from the ear into the nose, called tuba Eustachiana, so as to hinder the ingress of air through it into the cavity of the tympanum, is, I believe, universally esteemed destructive to the sense of hearing.”[5] Like his predecessors, Wathen argued the Eustachian tube played an important avenue for maintaining air pressure through its “free communication with the atmosphere,” and he describes in detail how he first examined the tube and found catheterization as a valuable mode for treating deafness arising from blockages. One of his patient, thirty-five year old Richard Evans, was deaf in both ears thought there was no visible evidence of any disorder in the external ear. Acknowledging the cause to a cold that subsisted for several years, Evans could not find any treatment sufficient to relieve him. After his death from small-pox, Wathen took the opportunity to conduct an autopsy to examine the Eustachian tubes, and found “them both stuffed quite full of congealed mucus, which was observed by two gentlemen of the profession present. This was the only visible cause of his deafness, the other parts appearing in their natural state.”[6]

Wathen’s observations led him to “make trial” of the operation proposed by Guyot, but “having never practiced it, he wanted the recommendation of facts to support and enforce it; [Wathen] therefore rejected [the procedure] as impracticable.”[7] However, after observing a demonstration by the anatomist John Douglas (d.1743), who, following the work of French surgeon Jean-Louis Petit (1674-1750), inserted a probe through the mouth (as opposed to the nose), Wathen perceived the procedure in a different light. It is to Douglas, Wathen claims, that he “freely acknowlege [sic] myself indebted for the hint, by which I was inclined to make trial on the living, of an operation of so much importance to mankind.”[8] He refined his skills by practicing catheterization on dead subjects, and having done so, he “did the same on a person that was very deaf, and on whom all other means had proven ineffectual: no sooner had I withdrawn the probe, that he said, he could hear better.”[9] Using a silver catheter fixed to an ivory syringe full of liquor (mel rosarum in warm water), Wathen treated several patients with various symptoms and cases of deafness, describing the use of the procedure on six of his patients; he thus is among the first to publish case studies of Eustachian tube catheterization as a remedy for deafness.

Instance of Eustachian Tube Catheterization by Wathen
(volume 49 (1755-6) of Philosophical Transactions; Science Photo Library)

He also acknowledges the difficulty of diagnosing obstructions in the tube:

I have endeavoured to ascertain the symptoms that indicate an obstructed tube, but have not been able to do it with any degree of certainty; nor can I see the great utility of it, could it be done; for the only disorders of the ear, that at present admit of chirurgical helps, are those of the external meatus, ulcerated and swell’d tonsils, &c., all of which are generally visible; and when they are not the cause of deafness, little or nothing is ever attempted, the patient being left to shift for himself.[10]

He does, however, note that Eustachian tube catheterization provided “another probable chance” for the “unhappy sufferer,” being the only procedure that can treat “corroborating symptoms.” The operation, Wathen declares, “is not all dangerous, it neither has, nor will, I believe, be thought painful by those who desire to recover their hearing.” [11]


NOTES

[1] “Machines ou Inventions Approvees par l’Academie en M.DCCXX,” Histoires de l’Académie Royale des Sciences (1720), 114:

‘Une Machine à scier de M. Guyot. Quoi-qu’elle foit conftruite fur le même principe que cells qui font en usage, & que le Vent ou l’Eau font agir, elle a quell-que chose de particulier & d’ingenieux. Elle a fur cells qui font à Vent ou à Eau l’avantage de pouvoir être transportée. Il n’est besoin d’acune adresse pour la faire travailler, & les plus mal adroit peuvent par son moyen équarrer & scier parsaitement des Planches, & tout cela peut dédommager de la petre des foces cause par les srottements inévitables dans toute Machine.”

[2] Neil Weir, Otolaryngology: An Illustrated History (London: Butterworths, 1990), 45.

[3] Archibald Cleland, “A Description of Needles made for Operations on the Eyes, and of Some Instruments for the Ears,” Philosophical Transactions 41 (1741): 847-851.

[4] Cleland, “A Description of Needles,” 849.

[5] Jonathan Wathen, “A Method Proposed to Restore Hearing when Injured from an Obstruction of the Tuba Eustachiana,” Philosophical Transactions of the Royal Society, 49 (1756): 213222; 213.

[6] Wathen, “A Method Proposed to Restore Hearing,” 215.

[7] Wathen, “A Method Proposed to Restore Hearing,” 215.

[8] Wathen, “A Method Proposed to Restore Hearing,” 216.

[9] Wathen, “A Method Proposed to Restore Hearing,” 216.

[10] Wathen, “A Method Proposed to Restore Hearing,” 220.

[11] Wathen, “A Method Proposed to Restore Hearing,” 220.

Quack Curers for the Deaf

During the 1830s, Alexander Turnbull (c.1794-1881), advertised a remedy he conjured, which he professed was capable of curing any cases of deafness not arising from organic disease. In particular, he advocated the use of veratria, a poisonous alkaloid obtained from the hellebore root, as an ointment applied to the external ear; the same treatment, along with other alkaloids from the Ranunculaceæ were also amongst several of his treatment options for deafness, gout, dropsy, rheumatism, and affections of the heart.[1] Six pages of Turnbull’s 1837 A Treatise on Painful and Nervous Affections, and a New Mode of Treatment for Diseases of the Ear were devoted to the application of veratria to the external ear and parts joining the auricle. Terming his treatment as “electro-stimulation,” Turnbull claims

Feeling satisfied that I had in my possession means decidedly effective in promoting absorption through the medium of the nerves, and knowing that deafness often arose from the Eustachian tube being obstructed by enlarged tonsil glands, I applied veratria externally over these glands, and found it frequently succeed in removing their enlargement and restoring the hearing.[2]

Signing off with the initials “J.T.,” on 5 April 1839, Joseph Toynbee (1815-1866) wrote to the Lancet warning readers of “quack curers for the deaf” that were printed in London’s daily newspapers that week.[3] Toynbee’s issue with the advertisement was not whether Turnbull could differentiate between organic and non-organic causes of deafness—a claim that Toynbee doubted merited any truth—but rather, on Turnbull’s public declaration of his expertise through advertisement. “[H]e sends his advertisement to the public papers,” Toynbee wrote, “for an enormous payment gets it inserted as a paragraph…[and] by the aid of the circulation of this puff…deaf people consult Dr. Turnbull; he makes his application, and takes his fee.”[4] Toynbee insisted this was a disgraceful and underhanded maneuver directed towards drawing in patients, who were left vulnerable to potentially dangerous treatments: “Sir, almost every medical man must have heard of the most horrible effects sometimes produced by the application Dr. Turnbull uses…It must be apparent that Dr. Turnbull has no greater knowledge upon the diseases of the ear, than the ignorant whom I have before exposed by means of your pages.”[5]

Moreover, Toynbee argued if Turnbull was truly anxious with “relieving suffering humanity” as he professed in his advertisements, then why didn’t he “devote care, time, and trouble to the study of diseases of the ear? By this mean only can a man obtain information, and practising without that information must make a man appear, what he really is, a noxious hypocrite.”[6] By emphasizing a practitioner’s altruistic nature, advertisements proliferated by newspapers only disguised the skills of a practitioner, and in so doing, “tend to mislead and cheat the public;” thus,

as long as the public is as unwise as it now is, it is to be feared that there will be found Turnbulls, with applications; Cronins, Curtises, and hosts of others with ear drops; Blairs, with gout drops; Holloways, with double universal ointments; St. John Longs, with killing frictions; and all of them will gain their end by getting a living.[7]

NOTES


[1] Alexander Turnbull, On the Medical Properties of the Natural Order Ranunculaceæ: and more particularly on the uses of sabadilla seeds, delphinium staphisagria, and aconitum napellus, and their alcaloids veratria, sabadilline, delphinia, and aconitine (London: Longman, Rees, Orme, Brown, Greene, & Longman, 1835).

[2] Quoted in William Wilde, Practical Observations on Aural Surgery and the Nature and Treatment of Diseases of the Ear (London: John Churchill, 1853), 44.

[3] “Quack Curers for the Deaf,” The Lancet 32 (April 1839): 112-113.

[4] “Quack Curers for the Deaf,” The Lancet 32 (April 1839): 113.

[5] “Quack Curers for the Deaf,” The Lancet 32 (April 1839): 113.

[6] “Quack Curers for the Deaf,” The Lancet 32 (April 1839): 113.

[7] “Quack Curers for the Deaf,” The Lancet 32 (April 1839): 113.