The Insane ear
No …The above title is not the name of a Public house that serves fine ales and good home cooking.
The title refers to/ or is a derivative of haematoma auris and its prevalence in Asylums and institutions housing the mentally ill and people with learning disabilities.
Today, in the lay and vernacular term, we know haematoma auris as “Cauliflower ear”.
It can be described as: an ear, permanently deformed by repeated trauma, force or friction, which ultimately results in an irregular thickening of scar tissue and formation of blood due to rupture of the blood vessels.
I first read about the insane ear in a book in the 1990's. My first visual sighting of the condition was probably around 1972/73…although at the time I didn’t know what it was …but I definitely saw the swollen deformed ears of several men during an open day at the local hospital/ Institution.
In 1986, I commenced as a student Nurse at that same hospital…I spotted older males residing in the same institution with such ear deformities.
One does not have to look too far and wide to see examples of cauliflower ears. Lovers of art and history can see such ears preserved in Greek and Roman male sculpture.
Pankration was an empty-hand submission sport with minimal rules that was introduced into the Greek Olympic games in 684 BC. Boxing and wrestling techniques were used, but also holds, locks and chokes on the ground. Olympic athletes would have been idolised as demi-gods, so you can see why they were celebrated and honoured…in all of their glory and …swellings.
Examples of such art can be found in both Greek and Roman collections in the National Museums in Athens, Rome, London, Berlin and Paris.
There is also evidence of cauliflower ears in 18th century Japanese prints portraying Sumo wrestlers with cauliflower ears.
Contemporary examples would be Mixed martial artists and Rugby Union/league players
Art and ears ...a chap called Vincent chopped off one of his ears, and just like the insane ear, there are several theories as to why he did so.
I digress…..So, why was it labelled the insane ear? A theme from the aforementioned above offers us clues.
Ubiquitously and colloquially known as the “insane ear” by esteemed physicians and clinicians who had noticed such a condition within the people who resided in asylums and institutions in the 1800's. Research shows that it mainly males who had this condition and that the left ear was often the most affected.
The earliest article or mention I can find of the insane ear was by M. Ferrus, in France, and Bird, in Germany, in around 1838.
Dr. Franz Fisher, wrote a lengthy article on the insane ear in 1848 when he was a physician at the Illenau Asylum.
Edward Reynolds Hun, wrote an article (American Journal of Insanity; vol. xxvii, July, 1870) that was edited by medical officers from the New York State Lunatic Asylum.
Hun reported on twenty-four cases of a condition that nineteenth century physicians referred to as "insane ear, an endemia of the lunatic wards’.
One third of Hun's subjects suffered from general paresis, most likely complications of neurosyphilis. Ten patients in total were infected in both ears, indicating a systemic disease that could be associated with their madness.
It was noted that Hun wrote “several pages of rebuttal to the charge that "insane ear" is nothing more exotic than the result of two inmates getting into a brawl, and the fact that 23 of his cases are men, doesn't help his position”
The theory of no trauma being involved is probably best described by Pietersen in 1892 who defined it as:
"an effusion of blood or of bloody serum between the cartilage of the ear and its perichondrium, occurring in certain forms of insanity and sometimes…. among the sane.
"generally, the left ear was larger than the right and linked with bruised ribs.”
Pietersen described a Prodromal period during which local “turgescence and swelling appeared”.
Onset was sudden: “as a rule, a patient goes to bed with ears perfectly normal, and have a fully developed othamatoma in the morning. The condition was worse in those forms of insanity in which the mental excitement runs high for any length of time”
Some stated that the patients were hitting themselves repeatedly around the right ear only. One does wonder if any root cause was explored if this was witnessed by staff?
There were other theories of the condition found on those living in Institutions. The hardness of the pillows that patients slept on was one. Some Psychiatrists cited advanced theories linking it to abnormalities of bone, blood, or brain in the insane.
One article I found (un-named/cited) discussed that the condition was noted in the Insane with particular frequency in Germany, and that in certain cases in which no history of trauma could be obtained had led to the belief that a certain number of cases occur spontaneously. A link was made between the Haemotama auris and the frequency agitated behaviour of these patients.
There are also articles and reference to the condition from institutions in Ireland.
Further reports in the late 1800’s started to question the validity of the condition being symptomatic of the insane.
In 1889, Hoffmann, and Laycock were the leading advocates of the idiopathic theory, BryantI recognised both the idiopathic and traumatic form.
Gudden, Griesinger, and Hammond were strong believers that the condition was caused by trauma.
Bucknill, Blandford, Savage, admitted that haematoma of the ear in the insane was frequently the result of violence, but argued that it is not always the root cause.
Some believed that like belligerent horses, the pulling of the ears was an effective way of controlling agitated patients/inmates. Generally, it became accepted that just like those athletes at early the Olympics games, Sumo wrestlers, and both licensed and unlicensed pugilists, that repetitive and/or blunt force was used in some form.
It was also widely noted that the correlation between the left ear of the patient being the most affected and the male orderly generally being right handed, was the more likely reason for the bruising, swelling and disfigurement.
Such behaviour is probably best described by Russell Bardon in his book “Institutional Neurosis”.
Bardon does not hold back when he writes that the “Insane ear” was “almost certainly traumatic and due to an unwritten tradition amongst certain ignorant attendants that brutality was necessary and justifiable in managing mentally ill people”
He writes; “The usual brutality is slapping a patient’s head or face, punching or assaulting with a stick or wet towel”.
Bardon describes many other common coercive brutal tactics used by staff and makes this comment; “Any Psychiatric service providing care for the complete range of mentally disordered people will occasionally have to resort to some physical contact. However, there is a world of difference between a guiding hand, a forceful grip and a clenched fist”
The article I have found that best sums up the debate of staff inflicted trauma or a genuine symptom on the insane was published in 1889 by The British Medical Journal. Written by a barrister at Law; S. A. K. Strahan, M.D., L.R.C.P. Strahan was obviously an erudite and articulate professional, having articles also published in the Lancet in his day.
He writes:
“Griesinger's theory that the left is the ear which most conveniently lends itself to the right hand of the brutal attendant, is almost the only one which has been advanced, and it certainly is not generally accepted. I agree with Dr. Campbell that the number of " asylum ears" may be greatly reduced by careful nursing and judicious restraint; yet when all is done, I believe there will still appear in every asylum, even in Garlands, a certain number of cases of lhematoma (haematoma) of the ear”
From research, it appears that around the First World War, the topic disappeared from the medical press. This appears to be mainly due to the acceptance of the theory (or fact) that the condition was caused by the right hand of someone exerting control, or more heinous reasons.
This article initially was the piecing together of theories and causes of the insane ear after reading about the condition....but it made me think. I refer back to the day in the early 1970's when I saw middle age(ish) males with a disfigured ear. At the time, I am certain I believed it was part of him being how he was... "thats how they look in the mental hospital". However, I was six years of age, not worldly wide, and the 6 million dollar Man was not yet on the telly.
The physicians and Psychiatrists in the 1880's were eminent and esteemed professionals, yet in depth, they explored the causes of the insane ear and it appears there was comprehensive research undertaken. Yet, the obvious was missed and debated when brought to their attention.
Perhaps the orderlies meting out the "treatment" were clandestine. It may have been the accepted norm. One questions why those researching did not appear to speak to the individuals with the condition.
In the early 1970's, there were people living within Institutions with the classic symptoms and disfigurement. This plainly shows that despite knowing the cause, it was still a form of coercive controlling treatment used many many decades later after it was first explored.
One questions if it was widely known and accepted in the 20th century? Is such despicable behaviour still prevalent today...in other guises?
An endnote:
In my Student Nurse days, I went on many placements that served to build my knowledge and skill base. One day, on an external placement, the penny dropped when a male patient probably in his 50/60's said to me...."You're a big un…I wouldn't like you to take me round the back and warm my ears".
I looked at his left ear as he walked away after receiving his cigarette .
Initially written for LinkedIn :https://www.linkedin.com/pulse/insane-ear-jim-snipe/