The Window Operation: Hope through Surgery

By Jaipreet Virdi-Dhesi

[Dr. Lempert] reached not quite as high as my shoulder. We liked each other on sight. He had read Cotton in My Ears and enjoyed it, he told me, as we stood talking when the meeting was over. “You tried them all,” he remarked, referring to my lifelong search for a cure for deafness. His unspoken question “Why not me?” was in the air between us; in the lift of his shoulders, in the quizzical cock of his eyebrows as he clanked sidewise at me.[1]

 A 44 year-old female patient, nearly stone-deaf for half her life, laid upon the operating table. Two dental drills covered with sterile linen sleeves hung over the table, prepared and ready. The surgeon, a wispy, small man with a bushy pompadour underneath his surgeon’s cap, signaled to the anesthetist that the procedure was about to begin. Turning on his headlamp, the surgeon focused a powerful, pencil-thin stream of illumination on the patient’s right ear. Then he began the first incision on her outer ear, creating an opening the size of a small coin. Taking one of the drills, the surgeon devoured the tough mastoid bone, slowly proceeding for half an hour until he was able to expose the bony labyrinth of the inner ear. This was to be the new window that would, hopefully, restore sound vibrations and enable the patient to hear.[2]

Virdi-Dhesi_Image 1 Movie still

Still from video “Lempert Fenestra Nov-Ovalis: A New Oval Window for the Restoration of Practical Hearing in Clinical Otosclerosis.” New York, Lempert Institute of Otology, 1947.

The three-hour operation was a bold innovation, perfected by New York otologist Dr. Julius Lempert (1890-1968) to treat otosclerosis, a hereditary condition causing progressive hearing loss. It occurs when sponge-like bone tissue grows around the ossicles—the three bones of the middle ear, the malleus, incus, and stapes—effectively immobilizing them (especially the stapes) and preventing proper sound vibrations necessary for hearing. Prior to the 1930s, the condition was deemed incurable and it was believed only a hearing aid could assist in amplifying hearing in partially deaf patients. Yet this did not stop numerous attempts to offer “cures,” many of which came from “quack” practitioners promoting their procedures through advertisements and mail-order flyers. As surgeon Howard P. House (1908-2003), founder of the House Ear Institute in Los Angles, expressed,

Perhaps no other group of individuals has been subjected to more treatment without benefit than has the unfortunate patient with otosclerosis. Repeated Eustachian tube inflations, nose treatments, nose and throat surgery, ear drum massage, various diets, endocrines, vitamins and minerals all have been put through their paces without noticeable benefit. When benefit has been derived, one is lead to believe the diagnosis of otosclerosis was in error, for it is difficult when one visualizes the underlying pathology to understand how such therapy could have much reward. [3]

The nineteenth century was a period of experimental surgery for ear diseases and deafness, as medical practitioners began to identify causes of deafness associated with particular disease etiology and pathology. In 1841, the British aural surgeon Joseph Toynbee (1815-1866) was among the first to associate otosclerosis with deafness. Through a series of dissections on temporal bones of the ear, he discovered that when the stapes was immobile, deafness was usually the result. Otologists thus began a search for removing the obstruction to sound vibrations by devising maneuvers for remobilizing the stapes. By making a new window into the labyrinth, it was possible to restore vibration. Early operations yielded a substantial restoration of hearing immediately after the surgery, but produced disappointing and disastrous long-term results.[4] In a few weeks or months, often the bony growth returned, or patients died from secondary infections. The threat to patient health for a “possible” cure was so damaging, that in 1894 at the International Congress of Medicine in Rome, leading otologists Adam Politzer (1835-1920), E.J. Moure, and Vincenzo Cozzolino condemned all surgical attempts at otosclerosis. The condemnation continued at the next international congress, in 1900, when otologists rejected all forms of invasive surgery for deafness. For the time being, deafened persons were protected against dangerous procedures promising ill-fated “cures” for hearing loss. At the same time, the period also saw a tremendous rise of patent medicines and innovative devices directed towards securing sales from desperate consumers by promising immediate results.

Surgical attempts to restore hearing in cases of otosclerosis continued into the early twentieth century. In 1916, Stockholm otologist Gunnar Holmgren (1875-1954) and his assistant Carl-Olof Nylén (1892-1978) conducted observational trials of deafness caused by otosclerosis and carefully investigated safe techniques for surgery. Aided by Nylén’s creation of a binocular microscope, the team were able to observe the possibilities of treating the condition by fixing the stapes footplate, as a proper light source allowed for delicate microscopic surgery.[5] With Nylén’s microscope, Holmgren observed that even if a new fenestra was created, the bony growth returned, thus effectively closing the window. It was impossible to predict when the growth would return, and in which case(s).[6]

Otologists then attempted new maneuvers as means to prevent this phenomenon. In 1924, Maurice Sourdille (1885-1961) visited Holmgren and was impressed by his work; five years later, he modified Holmgren’s technique, developing a three-stage operation for creating and sealing the new window (fenestra). By 1935, he performed over 150 of these “tympanolabyrinthopexy” operations and demonstrated his technique at the Royal Society of Medicine and New York Academy of Medicine in 1937. A year later, Lempert modified Sourille’s procedure to a single stage and created a larger window by removing the incus in order to secure the fenestra against closure, naming the procedure the Lempert Fenestra Nova-Ovalis Technic, or fenestration operation. Further modifications were done by Lempert’s pupil, George E. Shambaugh Jr. (1903-1999), who introduced suction irrigation to ossify the fenestra and remove all bone dust particles, greatly reducing the likelihood of re-closure.[7]

Cross-section of the inner ear, showing the ossicles--mallelus, incus, and stapes. Illustrated by Henry Vandyke Carter for Henry Gray, "Anatomy of the Human Body " (Philadelphia & New York: Lea & Febiger, 1918), plate 919.

Cross-section of the inner ear, showing the ossicles–mallelus, incus, and stapes. Illustrated by Henry Vandyke Carter for Henry Gray, “Anatomy of the Human Body ” (Philadelphia & New York: Lea & Febiger, 1918), plate 919.

By 1950, over 15,000 fenestration operations were performed in the United States. The procedure was far from bloodless, painless, or without danger. Only patients diagnosed with otosclerosis were recommended for the operation, but diagnosing itself was extremely difficult. The likelihood of misdiagnosis was high, as patients frequently had other associated symptoms, such as trauma, childhood disease, or upper respiratory infection, which was more likely to cause hearing loss than otosclerosis. Furthermore, additional hearing loss was a tremendous risk with the operation; in many cases, hearing was not restored completely but only partially, similar to benefits that were obtainable by a hearing aid. Considerable risk was involved, particularly in children, so otologists advised for best results, patients should be between 15-40 years old—preferably under 25—exhibiting no signs or history of middle-ear disease or nerve deafness. Under these conditions, patients had over 80% of immediate success, as opposed to the standard 50%.[8]

Even if fenestration surgery only benefited between 1.5% and 3% of the hard-of-hearing population in the United States, it was perceived as radical and innovative, for the procedure expanded the possibility of “curing” deafness through surgical intervention.[9] This held tremendous benefits for individuals with hearing loss who had gone through the entire roster of nostrums, emetics, oils, artificial eardrums, vibrating massages, light ray therapy, or even hearing aids, all of which failed to restore hearing, even partially. Yet, unless those patients were properly diagnosed with otosclerosis, the operation would prove fruitless for them. This did not, however, stop these patients from attempting to secure slots on the surgical schedule; George Shambaugh Jr., for instance, wrote of the numerous patients he had to turn away.

Virdi-Dhesi_Image 3 Ads Flyers

Various advertisements and mail-order flyers for deafness “cures.” © National Museum of American History Archives.

After the Second World War, fenestration operation was remarkably popularized. Headlines everywhere proclaimed “NEW HOPE FOR THE DEAF.” The American Medical Association’s magazine Hygeia, for instance, published an article with the same headline, which was later condensed, reprinted and given wider circulation in Reader’s Digest. The article claimed fenestration operation improved hearing in 98% of cases—giving the impression to deafened persons that the operation was a surgical cure-all for all forms of deafness. Leaders of deaf and hard-of-hearing organizations and schools questioned the merits of the article and its propensity for raising false hopes among individuals with hearing loss, their families, and friends. To properly caution interested persons, these organization leaders and deaf educators wrote articles and pamphlets outlining the benefits and dangers of the procedure. Most opinions expressed the refrain for interested deafened persons to seek a respectable ear specialist and to be wary of “quack” institutions that masqueraded themselves as reputable. The January 1946 issue of The Pelican, the magazine of the Louisiana State School for the Deaf, for instance, did not

claim any authority to advise parents of deaf children on the value of the “window” or fenestration operation. To the parents who desire advise on the subject, being anxious to do everything in their power to cure their children’s deafness, we urge: “Go slowly. Go to a reputable ear specialist.” The doctors we have discussed this subject with all advise caution. We have heard of a prominent ear specialist, himself every hard of hearing because of otosclerosis, who preferred not to take a chance on the operation on his own ears.

The popularization of fenestration surgery as “NEW HOPE FOR THE DEAF” was hardly a new phenomenon. In the history of deafness and aural surgery, nearly all successful medical treatments and surgical attempts were heralded as the greatest cure-all for hearing loss, even as medical practitioners and ear specialists continuously insisted a particular treatment was only for specific cases of hearing loss. This provides us with insight into the nature of deafness as a stigmatized condition: any cure is better than no cure.

Patients with otosclerosis in the late 1940s and early 1950s were given two options by otologists: fenestration operation, which had great advances but risked nerve degeneration after a certain age (and thus risking permanent deafness), or a hearing aid. Unlike heavy mechanical carbon aids of the 1920s, thanks to miniaturization of vacuum-tubes, hearing aids of the 1940s were remarkably smaller with greater amplification powers and portability.[10] Despite this, patients were more likely to choose the surgical avenue, rather than wear a hearing aid, even if the hearing aid provided a markedly different quality of sound. As Leland Watson and Thomas Tolan noted in their 1948 survey of fenestration operations, while the success of such operations would “reduce the previously exaggerated hearing aid market in the U.S., the psychology of the deafened is such that most hard of hearing individuals, if a choice is available to them, will prefer a fenestration operation to a hearing aid.”[11] So even if hearing aids were being made lighter, smaller, and more convenient, they still carried a social stigma of disability that deafened persons did not want to associate with.

Fenestration operations ceased to be the primary surgical avenue for otosclerosis in the 1950s, when it became possible to remove the stapes and replace it with prostheses (stapedectomy). The operation’s history, however, and especially its promotion in the popular press during the 1930s and 1940s, demonstrates the importance of telling the histories of medicine/surgery and disability together. Such narratives reveal how even if surgical operations were highly risky, the risk, for the most part, was considered necessary, given the alternative—even if the alternative, in this case, was simply to wear a hearing aid.

 

Jaipreet Virdi-Dhesi is a historian of medicine and SSHRC Postdoctoral fellow in the Department of History at Brock University, where she is working on a project on the material culture of disability in the Canadian experience. She is also working on a monograph, tentatively titled ‘Hearing Happiness: Fakes and Fads in Deafness Cures, 1850-1950,’ which examines the history of “quack cures” for deafness. Some of these cures are explored on her blog, From the Hands of Quacks. You can find her on Twitter as @jaivirdi.

 

[1] Frances Warfield, Keep Listening (New York: Viking Press, 1957), 113.

[2] J.D. Radcliffe, “A Window for Deaf Ears,” Hearing Dealer 2.8 (August 1952): 8-9.

[3] Howard P. House. “What can be done for the Deafened Today?” California and Western Medicine 63.3 (September 1945): 130-132; 131.

[4] Neil Weir, Otolaryngology: An Illustrated History (Butterworths: 1990), 203.

[5] Gösta F. Dohlman, “Carl Olof Nylén and the Birth of the Otomicroscope and Microsurgery,” Archives of Otolaryngology 90.6 (1969): 813-817.

[6] Julius Lempert, “An Analytical Study of the Evolutionary Development of the Fenestration Operation,” Annals of Otology, Rhinology and Laryngology 40-40 (1951): 123-151; 122.

[7] Dragan Dankuc, “History of the Surgery for Otosclerosis and Cochlear Implants,” Medicinski Pregled 5-6 (2015): 151-155; 151.

[8] I. Simson Hall, “The Fenestration Operation for Otosclerosis,” The British Medical Journal 2 no.4478 (November 2, 1946): 647-649; 648. Hall added in patients over 40 years, there was a higher risk of nerve degeneration that would prevent hearing improvement after the operation.

[9] George Shambaugh Jr. noted that “[s]ince the proportion of otosclerosis to the total number of hard of hearing has…been estimated at from 5% to 10% this would indicate that only 1.5% to 3% of the hard of hearing population would be good candidates for the fenestration operation.” George Shambaugh Jr. quoted in Leland A. Watson and Thomas Tolan, Hearing Tests and Hearing Instruments (Baltimore: Williams & Wilkins, Co., 1949), 428.

[10] Mara Mills, “Hearing Aids and the History of Electronics Miniaturization,” IEEE Annals of the History of Computing 11 (2011): 24-44.

[11] Watson and Tolan, Hearing Tests and Hearing Instruments, 429.

3 comments

  1. Pingback: [My Guest Post] The Window Operation: Hope Through Surgery | From the Hands of Quacks

  2. Pingback: Whewell’s Gazette: Year 2, Vol. #12 | Whewell's Ghost

  3. Pingback: Hearing Happiness: Fakes, Frauds, and Fakes in Deafness Cures | From the Hands of Quacks

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