DEP/DUA/1/13/17 (Normalised version)

Thomas Brown

(1777)

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Thomas Brown.

With regard to immediate nature of the affection to which this patient subjected little difficulty

Disease evidently consists in morbid state of function of hearing.

Here not indeed total abolition of this sense but very evidently & very considerably diminished

This in every nosological¹ system supposed to constitute a particular genus of disease.

With some even diseases so far multiplied that have divided such an effect of sense of hearing even into several different genera.

Hence have employed the different genera terms of Dysecoea, Cophosis, Paracusis Surditas etc.

One characterised by hearing being only impaired

Another by total abolition of sense.

One depending on affections of external ear.

Another on those of internal.

Apprehend however that where symptoms the same varieties either in cause or degree afford no grounds for formation of different genera.

And whichever of generic terms employed may include all the affections under one.

Using then term of Surditas as being most familiar & as comprehending all degrees of dullness of hearing, may give that name to affection to which patient is subjected.

Evident however that although plan of cure not altered by degree must totally depend upon cause.

Necessary therefore to inquire from what circumstance the deafness in instance before us arises.

Apprehend that all causes inducing deafness may with propriety be referred to one of two heads.

Either in diseased condition of nerves communicating impression to sensorium.

Or of organ receiving & modifying impression & again communicating it to nerves.

Here very little hesitation in referring it to last of these causes.

For here from meatus auditorius of both ears a yellow viscid matter continually discharged in great quantity.

From this must necessarily arise obstruction to admission of undulae of air on which suppose sound entirely to depend.

Have little hesitation then in considering this to be cause of deafness here.

But here another question of some importance occurs.

Which if of no effect in cure may at least direct us in prognosis.

Apprehend however that even with respect to former is a matter of some consequence to be ascertained.

Question is what the nature of that matter which is here discharged.

Well known that for useful purpose of oeconomy² particularly for preservation of sense of hearing a secretion constantly goes on by the ear.

This secretion however as well as others may be subjected to diseased states.

And while in some cases may be morbidly diminished in others may be morbidly augmented

This however not to be considered as only source of such an evacuation as present.

Well known that internal ear as well as other parts liable to be affected with suppurations.

And here must be allowed that natural discharge both in point of colour & consistency very much resembles pus.

Fetororosis indeed wanting, which for most part to be ranked among sensible qualities of pus.

But from late observations particularly those both of Mr Gaber & Dr Hardy would appear that this by no means to be considered as an essential characteristic of pus.

A question then not entirely without doubt what nature of this discharge.

Must however own that disposed to consider it rather as an increased discharge of mucus than of pus.

For although in recent cases pus may be without fetororosis yet not probable that this would happen after so long continuation.

Besides the furnishing quantity here discharged would require very large ulceration.

And farther did such ulceration take place could hardly be without pain

From all circumstances taken together then disposed to consider it as depending on augmented secretion of mucus.

And on this score entertain more favourable opinion of termination than should otherwise do.

Ulceration within ear not perhaps a very common occurrence.

Yet several instances on record in which has had favourable termination.

And indeed can hardly subsist for great length of time without affecting bones

When this happens must necessarily make way into brain.

And what must then be conclusion need hardly say.

Although however from considering this to be mucous discharge would represent it as less dangerous yet many reasons which should lead to suspicion that would be obstinate.

Has now subsisted with same degree of severity as at present for space of 9 years

May conclude then that secreting organs have acquired a condition which cannot easily or even with safety be altered.

Should be led also to same suspicion from attending to cause.

Are informed that was an occurrence which took place during fever.

Well known however that fever an affection capable of inducing changes in system to be brought about by no other means.

Am much afraid therefore that what this has affected should hardly by interposition of art be able to remove

At least with safety to patient.

For from use of most powerful means in restraining this discharge much to be apprehended.

Can be little doubt that would give determination to some other part.

And were it landed on brain might even have fatal termination.

Thus then here disposed to dread greater danger from cure than from disease.

This last however shall be our endeavour to avoid.

And on this ground am inclined to believe that while complaint of patient will not be aggravated under our hands shall probably dismiss him pretty nearly in same situation in which found him.

While however continues to attend us may at least give trial to some measures.

And avoiding what any chance of proving dangerous may yet use some measures with prospect of success.

Shall then briefly state principles on which practice has hitherto proceeded & on which future attempts to cure may be conducted.

Here however to be observed that attempts to cure alone without regard to consequences would lead to trial of measures which shall not probably venture to employ.

On idea given of the disease greatest objective in cure must be the restoration of secretion by ear to natural state.

This to be affected on one of two principles.

1 By restraining discharge in consequence of immediate action on secreting vessels.

2. By diminishing flow of blood to the part affected in consequence of determination to other parts.

First of these ends to be affected.

1 By astringents strictly so called applied to secreting vessels.

2 By tonics which while restore vigour to whole system will at same time have tendency to brace up parts here principally affected.

Diminishing of flow of blood to the ear or of pebul. furnished for secretion of fluids here may also be effected on two principles.

Either by diminishing impetus of circulation in general.

Or by changing mode of circulation in neighbourhood of parts here principally affected

First to be effected by evacuation from mass of fluids

Second by drains in neighbourhood of ear.

All these measures calculated for removal of what consider to be cause of affection.

But without removal of cause probable that complaint may be somewhat alleviated on another footing.

By removal viz of consequences which may have induced.

Not to be expected that with such discharge sensibility of nerves would remain untended

From augmenting sensibility then may conclude that though cause of obstruction remains impression will have more effect than formerly.

These then general principles on which imagine that complaint either to be removed or alleviated.

And from these will appear that practice already employed by no means what to be considered as most effective.

Have however selected them as being safest.

And what at least on that account derived first trial.

While determination to a neighbouring part might diminish flow of blood to ear was a means from which nothing to be apprehended.

And from drain behind ear by blister & epispastic ointment running was sometimes diminished

As this however did not seem to give proper restoration of hearing led to attempted augmentation of sensibility by electricity.

These the practices to which have hitherto chiefly trusted.

Have besides this indeed ordered introduction of Camphorated oil into meatus auditorius.

Principally with view of trying what effect gentle stimulation may have as augmenting tone.

From prosecution of these measures although entertain no sanguine hopes yet not entirely without prospect of success.

And could patient be induced to continue them should wish to persist in use for some length of time.

Or to substitute for issue behind ear a seton in the neck

To all troublesome & painful measures of this kind however patient himself expresses an aversion.

And am even doubtful how far shall be able to prevail upon him to continue the present.

Nor do I imagine that can have proper substitution to it from use of general evacuation.

For although these also tendency to diminish supply of [ pebul.] for secretion yet more immediately act as evacuant from system

In this way might not only do [illegible] in other respects but even, as diminishing general tone, take off from that of parts here morbidly affected.

While little prospect of benefit therefore might do much mischief.

Same also I apprehend to be dreaded from immediate action of astringent on ear.

As from suppressing discharge here would necessarily occasion determination to some other part

Yet from these cannot help thinking that greatest chance of curing affection

While from combination with proper drain might perhaps be used without prejudice.

And in hands of bold practitioner might be means of affecting cure.

If however shall venture upon any such will be of most gentle kind.

And not till have first tried what affect may be reaped from tonics, to system in general.

Apprehend that here as in Gonorrhoea some chance of restraining discharge by means of Peruvian Bark or cold bathing.

And should present measures prove ineffective before any other trials would recommend these.

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Explanatory notes:

1) Nosology is the branch of medical science dealing with the classification of diseases. Individuals referred to in the case notes as nosologists were commonly those who had published nosological, or classificatory, medical texts.

2) Oeconomy is an archaic spelling of economy. In the context of medicine, the term animal oeconomy refers to the living system and its management. In these case notes all but one of the cases where this term is used are female.