The practice of osteopathy

By J. Deason

Diseases of the Ear

Methods and Technic of Examination.—The external ear may be examined by direct inspection with or without the aid of artificial light. The external auditory meatus may be examined by means of a simple conical ear speculum and reflected light from a head mirror. This method requires considerable practice but efficiency can and should be attained because it can be used under all conditions and therefore is a reliable method.

The Holmes electric auroscope which we use and recommend for examining the meatus and ear drum, is very efficient but like other electrical equipment is not always dependable. There are many electrical equipments for examining the ear, but so far I have found none other than the one above mentioned that is worth space in an instrument cabinet.

To examine the meatus, grasp the pinna and draw it firmly upward and backward. This tends to straighten the canal so that the aural speculum may be inserted well into the external canal. It must be remembered that the auditory canal is always sensitive and while there is really little danger of doing any harm by exercising ordinary care, the patient is always afraid of being hurt and one can accomplish better results by practicing careful technic.

If the electric auroscope is used, the eye should be placed very close to the lens and every part of the canal, walls and drum membrane carefully examined. The Holmes auroscope has a small tube and bulb, pressure upon which will vary the air pressure in the meatus and cause the drum to move. This must be done very carefully because in very thin, atrophic membranes there is some danger of rupturing the drum.

Diseases of the Auditory Meatus

Inspissated Cerumen, or hardened ear wax is one of the most common affections of the meatus. The cause in some cases can be traced to lesions of the mandible, but in many cases the cause is unknown.

Treatment.—Protect the clothing by means of a towel or rubber neck piece. By means of a soft rubber ear syringe, wash the canal thoroughly by forcing warm soap solution into it. I prefer concentrated liquid castile soap (any good soap will do) diluted about one to four in water as warm as the patient can bear it. The soap solution is contained in a pus bowl held tightly against the neck under the ear. There is little danger of using too much force with the soft rubber syringe.

In most cases the hardened cerumen will be dislodged by the syringing only. If this cannot be done, it may be well to discontinue the treatment until the following day. The solvent action of the soap solution will further reduce the hardened mass and it usually can be removed by syringing the following day. This method is preferable in many cases because patients dislike the pain which usually accompanies the use of a curet.

The dull loop curet is the most efficient and safest instrument for removing hardened cerumen that the syringe may fail to dislodge. This instrument must be used with great care because the membranes, long protected by the covering of cerumen are hypersensitive and bleed easily.

After removing the cerumen, the canal should be thoroughly dried and lubricated with some non-irritating lubricant. It is also well to place a small pledget of absorbent cotton into the external opening to protect the sensitive membranes from the cold, air and dust.

In drying the canal I prefer to use a small aluminum applicator, twisting a small piece of absorbent cotton on the end in such a way as to cover the tip well, thus making any injury from its use impossible.

Atrophic Meatus

Sensitive or itching ears as the patient commonly describes it, is a very common disease caused by any atrophic condition of the membranes of the auditory meati and frequently found in common with auditory or other cranial nerve deficiency or degeneration. The direct cause of the irritation is the collection of particles of dry cerumen.

Treatment.—The local treatment consists of syringing with warm (118° to 120°F) soap solution until all of the scaly cerumen has been removed. The canal is then dried and lubricated as described above. Several such treatments may be required after which I prefer the use of the continuous irrigating ear cup, using salt mixture instead of the soap. The same salt mixture as is recommended for nose and throat irrigation is satisfactory. After such irrigations the application of phenol-glycerine (10% phenol in glycerine) seems to be an efficient treatment.

The local treatment must, of course, be accompanied by corrective treatment to the mandible and upper cervicals.

Furunculosis

There are three acute affections of the ear which may usually be diagnosed from their points of tenderness or pain. Pain upon moving the lobe or pinna indicates furunculosis. Pain on pressure posterior to the angle of the jaw or externally in front of the ear indicates middle ear infection and pain on pressure over the mastoid region suggests mastoiditis.

Probably the most common of the painful diseases of the external meatus is furunculosis, which is a subcutaneous infection of the lining membrane of the meatus. The point of swelling may usually be seen but in some cases the entire canal is closed.

Treatment.—In all cases of occluded pus, drainage must be obtained, but in the early stages of furunculosis, it is not always possible to determine the place of “pointing” or the most desirable point to lance. As soon as the place of “pointing” can be located it is advisable to lance deeply by means of a curved paracentesis knife. The parts are thoroughly cleansed and anesthetized by applying phenol and neutralizing with alcohol. The external parts are first painted with alcohol to prevent “burning” from any phenol which may be dropped upon them. A small cotton applicator is used, applying the concentrated solution of phenol or the crystals (using only a small amount of phenol) to the affected parts and immediately neutralizing with alcohol. Care must be observed not to apply any phenol to the drum membrane and the operator must be sure that the action of the carbolic acid is completely neutralized by a liberal application of alcohol.

The knife blade is placed beyond the furuncle, its curved point turned outward and quickly drawn forward through the furuncle, cutting deeply. The canal is then packed with a pledget of cotton dipped into phenol-glycerine.

If the place of pointing cannot be seen, palliative treatment may be applied by thoroughly cleaning the meatus, drying and applying a phenol-glycerine pack. Heat may be applied by means of a therapeutic lamp. Any electric light bulb or the dry electric pack will do. The external parts are well lubricated with paraffin oil and the heat applied continuously or intermittently until the pain is relieved.

Infection of the Meatus

Infections of the meatus are frequently secondary to, or accompanied by furunculosis. The treatment, therefore, is similar to that of furunculosis.

Always try to locate the point of infection, lance or curet, apply phenol or other chemical germicide, neutralize, dry and pack with phenol-glycerine. After the point of infection has been thoroughly drained, cleanliness and protection from dust or further infection is all that is necessary.

In all cases of infection of the external meatus, suspect middle ear abscess as a cause. There may be a pin-point opening through the drum, from which the infection has originated and is being maintained.

Otomycosis or fungus infection of the auditory meatus is rare. It usually resembles other infections symptomatically, but often without pus. A microscopic examination will serve to diagnose the condition.

The treatment consists of thorough cleansing, drying and the free application of alcohol. Alcohol is dropped into the ear until the canal is full and a pledget of cotton applied to retain it. Usually two or three applications are sufficient to effect a cure.

Eczema of the auricle and meatus is of two types, the squamous or scaly form and the sclerotic form. Both forms are chronic and may be readily diagnosed by the appearance.

Treatment.—Some cases are very difficult to cure but we have had excellent results with the following treatment: Careful adjustment of cervical and mandibular lesions; thorough treatment of any local infections of head or neck; direct application of phenol-glycerine, local cleanliness and protection from irritation.

Diseases of the Middle Ear

Clinically the middle ear consists of the tympanic cavity and its contents, the Eustachian tube and the mastoid cells.

Acute Suppurative Otitis Media

Acute infections of the middle ear result from acute nasopharyngeal affections such as colds, influenza, measles, mumps, whooping cough, etc. Bathing in contaminated water often results in infection to the middle ear through the Eustachian tube.

Diagnosis.—Earache, pain on pressure under the angle of the jaw and sudden deafness are the symptoms. (There are also the common febrile symptoms.) The chief physical signs are: redness and bulging of drum membrane, and contraction and tenderness of upper cervical muscles.

Treatment.—If the patient is seen before the drum has ruptured it is seldom necessary to lance the drum if the proper treatment is given promptly.

Drainage must be obtained and maintained by catheter aspiration through the tube irrigation of the nasopharyngeal cavity, irrigation of the meatus by means of the continuous ear irrigator and application of dry heat over the affected part. Heat is best applied by means of a therapeutic lamp. (Any lamp with reflector that will furnish proper heat is efficient as there is no virtue in colored light.) The skin surface over the ear, side of face and mastoid region is first well lubricated with some mineral oil to prevent blistering and the heat is applied either constantly or intermittently. A pledget of absorbent cotton dipped into phenol-glycerine is placed in the meatus and forced loosely against the drum. This should be removed every few hours and a fresh pledget put in.

The neck and upper dorsal muscles should be kept relaxed and adjustive treatment given frequently.

Under this treatment the pain should be relieved and the bulging of the drum should disappear in from two to twelve hours. If this is not accomplished or if the condition grows worse, the drum should be lanced. See some text on otology for technique. In my experience, very few cases have required paracentesis.

It must be remembered that treatment should be continued regularly and for some time after the pain and other symptoms have been relieved or a recurrence is probable. Patients should have daily treatment until the physician is sure that no complication or recurrence is likely to result.

If the patient is not seen until after the drum has ruptured, the same treatment may be applied except the irrigation or syringing of the meatus. This, in case of ruptured drum, may force pus into the mastoid cells resulting in mastoiditis. Instead of syringing, the auditory meatus is cleaned by means of a cotton applicator or by aspirating with a catheter. At all times drainage through the meatus must be maintained until the drum begins to heal.

Acute Mastoiditis

Acute mastoiditis results from acute or chronic otitis media. In some cases the otitis media may have been only a mild attack.

Diagnosis.—There is no one symptom that is positively diagnostic but a number of signs and symptoms must be considered as follows:

1. Always suspect mastoid complications in acute otitis media and watch for this complication daily. Most cases have some mastoid inflammation.

2. Pain or swelling over mastoid. Pain may not be present, but usually is, sometimes radiating over temples and eye on affected side.

3. Tenderness on pressure not always present. May be very marked. Tenderness extending to tip or above ear means extension of infection. If persistent tenderness over tips with marked swelling and discoloration—operation is indicated.

4. Swelling, not always present, but sometimes very marked. If extreme swelling and bluish discoloration—usually means operation.

5. Temperature varies from normal to 104° or 105° F. Temperature of more than one or two degrees means systemic absorption and suggests surgical drainage. Streptococcus or staphylococcus infections cause higher temperatures and require drainage earlier than other infections.

6. Transillumination not positive, but of some value. Like X-ray, usually shows dark, because of inflammation, but must rely upon symptoms, as above.

7. Microscopic.—Stain for pus, bacteria and bone debris. Hematoxylin stain shows dark bone particles if there is bone disintegration.

8. Blood Count.—If absorption, there will be some variation in proportions of leucocytes. Any high leucocytosis shows systemic absorption and the natural attempt to overcome the infection.

Non-Surgical Treatment.—1. Drainage must be maintained from middle ear through tube or drum or both. Catheter aspiration through tube. Sometimes gentle inflation to clear the tube, followed by aspiration is effective.

2. If drum is ruptured, aspirate middle ear by catheter or by Moore’s method or both. This is very important. If no aspirating machine, use syringe and pump meatus and tube persistently. Dry meatus and keep well open.

3. Patient should be kept in bed if symptoms are marked, with light diet and bowels well open.

4. Heat.—Apply oil or other lubricant over whole side of face and head and apply heat by means of “therapeutic” lamp intermittently. Thirty minutes light on and fifteen minutes light off. The light-heat (any electric lamp with reflecting shade will do) is much better than hot water bottle or electric pad or sand bag. The heat must be kept going day and night if symptoms are marked until the pain has entirely subsided. Heat is most efficient in the early stages. After symptoms are well marked, the ice pack is more desirable.

5. If drum is not ruptured, heat may be applied by means of Deason’s continuous irrigating cup. Start at 116° F. and gradually increase to 123° F. if patient can bear it.

Surgical.—If drum has not ruptured and symptoms continue, it is best to make free incision of drum,—keep open and apply (2) above.

Indications for Mastoid Operation.—There are no definite signs, symptoms or tests that will determine positively when operation should be done. If the above non-surgical methods are practiced, few cases will require operation, but many will develop into chronic mastoiditis and so it is very difficult to decide whether a mastoid operation should or should not be done. It is best to explain thoroughly the possible complications to the patient and relatives and request them to assume responsibility. Mastoid operations are attended by very little danger when properly done.

Signs and Symptoms Suggesting Operation.—Acute otitis media with mastoiditis.

(1) Persistent pain and swelling not relieved by non-surgical treatment.

(2) Marked protruding of posterior wall or meatus.

(3) Marked tenderness, swelling and discoloration above ear or over tip of mastoid.

These with temperature of more than 102° usually are enough to demand immediate drainage.

(4) Any evidence of extension of pus under skin of neck below tip. A positive indication for drainage.

(5) Any indications of brain or meningeal involvement such as very marked and persistent headache, partial or total loss of consciousness, etc.

(6) Indications of labyrinthine involvement such as marked vertigo, etc.

(7) Sudden cessation of discharge means obstructed drainage from middle ear or from mastoid into middle ear and if drainage cannot be restored by aspiration, this means operation.

(8) The whole clinical picture must be carefully considered at all times. Take no chances. Advise operation before someone else finds it too late.

Chronic Mastoiditis

Cause.—Always from unsuccessfully treated acute form or from chronic suppurative otitis media.

Non-surgical treatment.—See chronic suppurative otitis media. We have had a few cases that were seemingly permanently cured by non-surgical treatment, but believe they are rare.

Indications for Operation.—1. Recurrent exacerbation of acute or chronic otitis media.

2. Constant discharge which resists treatment for chronic suppurative otitis media.

3. Continued pain or recurrent pain and swelling following acute otitis media.

4. Open sinus into mastoid either external or through meatus.

5. Cholesteatoma.

6. Symptoms of labyrinthine or brain involvement following acute otitis media.

7. Definite evidence of bone disintegration in mastoid.

As stated above, none of these are definite indications. The whole group of signs and symptoms are to be considered.

Chronic Suppurative Otitis Media

Etiology.—Chronic suppurative otitis media usually results from an unsuccessfully treated acute otitis media. If in acute otitis media there has been bone erosion or extensive destruction of the mucous membrane by a virulent infection, chronic suppuration is likely to result. A persistent mastoid infection following otitis media is likely to result in chronic otitis media and this is strong argument for early mastoid operation.

1. Otitis media resulting from some virulent infection such as the recent influenza pandemic or scarlet fever is always more likely to result in mastoiditis and chronic suppuration of the middle ear.

2. Such infectious agents as streptococcus, staphylococcus, long-chain pneumococcus or bacillus influenzæ are likely to result in chronic suppurations.

3. Lowered vitality from any cause.

4. Inefficient drainage from failure to aspirate the Eustachian tube, delayed perforation or failure to lance drum sufficiently early.

5. Mastoid necrosis, which maintains drainage into the tympanic cavity.

6. Abnormal granulations, polypi, etc. in tympanic cavity.

7. Chronic inflammation with suppuration of the epipharynx or Eustachian tubes.

8. Cholesteatoma resulting from perforated drum and growths of epithelium extending into the middle ear cavity.

Diagnosis.—The diagnosis is easy because nearly every case of discharging ear without pain is chronic suppurative otitis media. The determination of the exact nature of the condition present is not only very important but very difficult.

Differential diagnosis consists in determining the nature of the infecting organism and the nature and extent of the pathology.

1. Direct examination of the external meatus after drying with cotton applicator usually determines the location and extent of perforation of the drum and the general nature of the discharge, whether purulent or mucopurulent. Very rarely one finds a serious discharge which means a very slight infection or discharge from non-infective inflammation. The presence of whitish or greyish pus, mucoid and stringy, usually means pneumococcus infection. Greyish, purulent non-mucoid discharge usually indicates streptococcus or bacillus influenzæ infection. Yellow, purulent discharge suggests staphylococcus infection. The general appearance of the discharge, however, cannot be considered of important diagnostic value because most chronic suppurations are mixed infections, because of long exposure to external contamination.

2. After cleaning the meatus, several smears should be made directly from the opening in the drum. By staining with methylin blue or gentian violet, the nature of the bacterial infection can be determined and this is very important.

By staining another smear with hematoxylin and washing in water, any dark irregular particles, bone debris, may be found, which means bone disintegration. This too, is very important.

3. Transillumination is sometimes of value. The mastoid may be transilluminated by placing a good rubber covered transilluminating lamp over the mastoid and observing the external meatus through an aural speculum. If the mastoid is free from infection the light will pass through and illuminate the meatus.

4. The X-ray plate is, of course, the best means of determining the nature and extent of mastoid involvement.

Treatment.—This is certainly one of the most difficult diseases of the ear that one is ever called upon to treat and the physician should be cautioned against offering a favorable prognosis. Perhaps the most difficult thing about its treatment that the doctor has to learn is that practically none of the so-called antiseptic washes do any good, but on the other hand they often do harm. Certain general principles are important and the treatment must depend upon the nature and extent of the infection and pathology present in each case.

The constitutional treatment consists of everything that will increase the patient’s general resistance and certainly all lesions of the cervical, upper dorsal and mandibles must be properly adjusted, but this is not enough. All spinal lesions that may exert an influence on metabolism and elimination are of important consideration. The diet, habits and environment of the patient must be considered.

A careful examination of the nasopharyngeal tract may reveal some other focal infection, such as chronic tonsillitis, pharyngitis or sinuitis, which is maintaining the infection through the Eustachian tube. There may be a focal or general infection of some other part of the body, which is reducing resistance or causing a hematogenous infection of the tympanic cavity or mastoid cells.

Drainage must be maintained in all cases, both through the Eustachian tube by catheter aspiration and through the drum by aspirating and drying. If the perforation in the drum is small or in the middle or upper part, it should be opened down to the floor so that the contents may be more easily removed and better drainage established. It is well first to thoroughly cleanse the meatus and tympanic cavity by syringing with salt mixture (salt 3 parts, borax 2 parts and soda 1 part, a teaspoonful to a half pus bowl of water) at from 116° to 118° F. After syringing, the meatus is carefully dried, and the middle ear cavity aspirated through the tube and drum opening. The advantage of this simple treatment is thorough cleanliness and drainage with the minimum of irritation. This treatment given daily or thrice weekly will often cure the case.

Staphylococcus and streptococcus infections usually respond to the following treatment: After thoroughly cleansing as above, the meatus and tympanic cavity is syringed with a one to four or one to five dilution of Dakin-Carrel solution (Hyclorite may be used instead) followed by aspiration, the fluid being drawn through the tube, thus preventing reinfection from that source.

Pneumococcus infections do not respond to either of these methods of treatment. The pneumococcus, because of its capsule, is not affected by antiseptics, but on the other hand the irritation of the tissues caused by their use, only gives the infective agent a better opportunity for growth.

In pneumococcus infections we have found the following method efficient: Thoroughly cleanse the meatus and middle ear cavity by salt mixture syringing, aspiration and drying. The meatus and tympanic cavity is then filled with a neutral mineral oil. The oil is also pumped through the Eustachian tube. It is the purpose to fill the entire cavity and its openings so thoroughly that no air can enter. In some cases we have used bismuth paste after the oiling with excellent results. The pneumococcus is aerobic and if all air can be kept away for a considerable time, it furnishes an unfavorable culture environment with little irritation to the membranes.

Surgical treatment.—The presence of bone debris indicates bone disintegration in the tympanic cavity or mastoid cells. If the mastoid cells are thus involved there is little chance for direct treatment. If such cases do not respond in a short time to any of the above methods of local treatment, ossiculectomy or mastoid operation may be necessary. Some specialist surgeons claim from 80% to 90% favorable results from mastoid operation in such cases.

Non-Suppurative Otitis Media—Catarrhal Deafness

Deafness is any impairment of normal hearing and is that symptom next to pain and chronic discharge that causes the patient to visit the doctor. If acute diseases of the ear, nose and throat could always be successfully treated, there would be little trouble from the symptoms of chronic pathology. It must be understood that catarrhal deafness is a symptom of chronic otitis media and is, therefore, seldom of recent origin.

Etiology.—Chronic otitis media is nearly always the result of the extension of infection through the Eustachian tube and has come from some acute or chronic nasopharyngeal infection. Chronic colds, pharyngitis, tonsillitis, sinuitis, etc., resulting in acute or chronic otitis media either with or without suppuration, constitutes the beginning of catarrhal deafness.

Symptoms.—There is seldom any pain with this disease. Some cases have an occasional acute attack with pain and other symptoms of acute otitis media.

Deafness, varying with the progress of the pathologic changes, is always present. The patient in the early stages will seldom admit that he suffers from deafness and often he is honest because he may not realize that he cannot hear normally until his otitis media has progressed to the second or third stage. Most patients, in fact, do not become alarmed about their hearing until it is too late to restore normal hearing. For this reason, physicians should be on the lookout for such conditions and should advise special treatment early.

The human species in its present environment, depends much less upon the organs of special sensation than do the animals of the wild, and they may therefore be very deficient in sight, hearing, smell, etc. without actually realizing this loss.

In addition to deafness there are other symptoms such as occasional or constant fullness or feeling of “stuffiness” as the patients express it, due to partial or complete occlusion of the Eustachian tubes. Tinnitus aurium or head noises is very common and often the most annoying symptom. Autophony, or the loud sound of the patient’s voice to himself, which often causes him to speak low and indistinctly, occurs in the later stages. Presbyacusia, or the inability to adjust the hearing apparatus to variations in pitch, commonly occurs in the second stage and is evidenced by the fact that the patient does not hear when more than one person is talking. Paracousis or perverted phenomena of hearing, such as the better hearing of some persons in a noisy environment, is a symptom of the third stage of otitis media and often means an unfavorable prognosis, so far as marked improvement in hearing is concerned.

Pathologic Stages.—For convenience of discussion we may consider chronic otitis media in three stages.

The First Stage.—The active pathology is limited to the pharyngeal portion of the Eustachian tube with some inflammation of the membranes of the tympanic cavity. Closure of the tube followed by absorption of the oxygen causes a decreased pressure in the tympanic cavity and thus a retraction of the drum, decreased movement of the ossicles and a general decrease in function of all tympanic structures. Deafness in this stage may be very marked, especially if the Eustachian occlusion has occurred from some nasopharyngeal acute inflammation. There may be pain but there is always a characteristic “fullness” and sometimes dizziness. Deafness in these cases varies with weather changes. If proper treatment is had in time, the progress of the pathology can be stopped and every case can be restored to normal hearing.

The Second Stage.—The active pathology has extended throughout the Eustachian tube causing marked occlusion and some stenosis. There is further inflammation of the tympanic structures with an increase in the symptoms of the first stage. The drum membrane is less movable but there is no fixation of the ossicles. Pressure upon the bulb of the auroscope causes movement of that part of the drum to which the malleus is attached. The drum is thicker, more retracted, and less movable than in the first stage. Presbyacusia is common and often marked, but there is no paracousis. More than 90% of these cases can be materially improved and many can be made to hear normally if proper treatment is given in due time.

The Third Stage.—The active pathology in the third stage consists of an involvement of the entire mucous membrane lining the Eustachian tube and tympanic cavity. These membranes are all chronically hypertrophied. The Eustachian tube, however, is sometimes fairly well open, but the ossicular attachments are more or less fixed by hypertrophied tissue and adhesions and the drum is markedly retracted, thickened and usually very immovable. The deafness is usually quite marked, head noises are commonly present and often very annoying. Patients usually do not notice a variation in their hearing from weather changes. Presbyacusia is present in 80% of cases and their hearing for low tones is much reduced.

Unless there is a complicating nerve affection these cases hear well by telephone, which means that they can also use an electric hearing instrument to advantage. These cases can never be restored to normal hearing, but many of them (30% of my cases) can have some improvement and in most cases I believe the progress of the pathology can be stopped, and this is always well worth while because their hearing is likely to be entirely lost if something is not done.

Psychologic Stages.—There are three rather distinct psychologic stages in catarrhal deafness. The first, the period in which most patients refuse absolutely to admit that they are deaf even to the aurist upon whom they call for treatment. They insist that they hear perfectly if people would only speak distinctly. This is partially true, because up to the third stage of deafness the voice can be fairly well heard if people would only articulate clearly. In the second stage patients admit that they don’t hear well, but insist that they are going to recover normal hearing and often resort to various kinds of injurious treatment. In the third stage they give up all hope of ever regaining their hearing, become morose, and avoid company. These psychic stages do not always correspond with the pathologic stages given above.

Diagnosis.—The external auditory meatus, drum membrane and ossicular chain, constitute the apparatus whose function is that of conduction of sound waves to the perception apparatus of the inner ear. The function of the conduction apparatus varies inversely with the progress of pathologic change in these structures. The perception apparatus, the structures of the inner ear, are not necessarily affected by middle ear pathology, but on the other hand, sounds transmitted by bone conduction not only seem louder but they last longer because the “escape of the excess” of sound thus transmitted is hindered by deficient conductive mechanism. This explains why such persons hear well by telephone and why the tuning fork, whose base is held to the mastoid (provided there is no nerve affection) may be heard for a greater time than normal. Likewise the prong of the vibrating tuning fork when held near the concha is heard for a shorter time than normal, because of the deficient function of the conduction mechanism.

Tuning forks are known by their number of vibrations per second, such as 16, 32, 64, 128, etc. Three or more forks are required to make an accurate measurement of the conduction and perception functions—a low fork about a 32, for the low tones, 128 or a 512 for the medium tones and a 2048 for the high tones.

A good set of forks should be selected and standardized, i. e., the normal bone and air conduction of each fork determined by testing it on a number of persons whose hearing is known to be normal. For the general practitioner who cares only to get a general idea of the extent of the pathology, one fork of medium pitch such as a 128 or 512 will be sufficient.

To measure the function of hearing, the fork is set into maximum vibration, its base held against the mastoid and the patient is asked to state when he no longer hears it. This length of time in seconds is recorded as “bone conduction.” The fork is then held near the concha and the patient again states when he does not hear it. This length of time in seconds is recorded as air conduction.

Normal Hearing

Tuning Fork Test.—The normal time rate in seconds set of forks is as follows:

The tuning fork test, carefully made, is the only known method of measuring the functions of the various structures concerned in audition.

The Whisper Test is made by producing a clear whisper from residual air only, which should be heard about twenty feet by a normal ear.

The Watch Test is made by using some loud ticking watch (I prefer an Ingersoll), holding it first near the ear until the patient recognizes the tone, and then taking it beyond the hearing distance and approaching the ear until it is heard. I prefer also to move away from the ear until the limit is reached and strike an average of this with the above results. The average eighteen size Ingersoll watch can be heard for from 100 to 150 inches by the normal ear.

The practical test for the patient is his hearing from the spoken voice, and is the most reliable so far as permanent results are concerned.

Low Tone Limit.—The lowest limit of hearing is about sixteen double vibrations per second, but the lowest practical limit is about thirty-two. There are few people with normal hearing and with musically trained ears who can recognize a definite tone lower than this, so I consider the thirty-two fork sufficiently low for all practical tests.

Conduction Deafness.—Low tones are lost in tympanic involvement or conduction deafness, and are diagnostic in such cases, but are of no particular value in nerve deafness except when that is complicated by catarrhal deafness.

Practical Hearing Limits.—The human voice varies from about 60 to 150 double vibrations per second, and most sounds that we really need to hear are less than 700 vibrations per second. This is the reason for using the low forks, 64, 128 and 512.

Measurement of Nerve Force.—To measure auditory nerve force, the fork (say the 128, whose normal B. C. is 30 seconds) is set into vibration and held gently and with even pressure against the mastoid and the patient is asked to tell or signal the doctor when he ceases to hear the tone. Two or more tests may be made to determine the patient’s personal equation, but the use of control forks (the 64 and 512) will show any such error. Granting that there is no complicating pathology, tympanic or labyrinthine, the number of seconds of hearing over 30 will be the patient’s auditory nerve force. For example, if he hears the fork 30 seconds his hearing will be thirty-thirtieths or normal. If his hearing is 25, 20, 15 or 10 seconds, his auditory nerve force will be respectively 25-30, 20-30, 15-30 or 10-30.

By means of this method an accurate measurement of the functions of hearing can be made and a definite prognosis can be given. I never use any of the various named qualitative fork tests for hearing, because they have no value to one who employs this system.

Summary of Diagnosis of Different Stages of Catarrhal Deafness

First Stage.

2. The drum is only slightly retracted but freely movable.

3. Whisper heard from five to twenty feet.

4. Ingersoll watch heard from 30 to 150 inches.

Second Stage.

Note that the tone of the 32 fork is heard, the 128 fork has increased in bone conduction and reduced in air conduction but that the bone-air ratio is direct, that is the patient hears longer by air than by bone conduction. Note also that the high fork is still normal.

2. The drum will be found retracted but that part to which the malleus is attached is still movable when tested with the auroscope.

3. The whisper is heard from two to ten feet.

4. The Ingersoll watch is heard from six to sixty inches.

5. Presbyacusia but not paracousia is present.

Third Stage.

The typical diagnostic points in third stage catarrhal deafness are: 1. Tone for the 32 fork is lost. 2. There is an inverted bone-air ratio for the medium fork. The drum is retracted and the malleus fixed. 4. The whisper may be heard at less than one foot or not at all. 5. The Ingersoll watch is heard less than six inches from the mastoid. 6. Paracousis Willisiani is present.

For the general practician this is important because he can make a rather definite prognosis.

Treatment.—The treatment will be given briefly because space would not permit of lengthy discussions of details of methods and technic.

A careful examination should be made for some source of focal infection about the nasopharyngeal tract. Chronic or subacute tonsillitis, pharyngitis or sinuitis or root abscess are often a cause, and not much will be accomplished in improving the otitis media until these focal infections are found and properly treated. The original cause of these focal infections may have been some bony lesion, but to successfully correct such lesion now does not mean that the source of infection will be removed.

Auto-intoxication from gastro-intestinal disease is common. In my cases, 80% of the third stage have chronic constipation or other chronic gastro-intestinal affection.

In many severe acute affections of the nasopharynx the inflammatory process has left the Eustachian tube occluded or stenosed and the pharyngeal fossa filled with adhesive bands. It is not uncommon to find the epipharynx and pharyngeal fossa filled with partially atrophied adenoid tissue or if the curet method has been used for removing adenoids, there is often connective tissue adhesions and any or all of these may prevent the normal ventilation of the tympanic cavity by way of the Eustachian tube.

In such cases surgical removal of these obstructions and dilation of the tube is necessary. My practice has been to give a general anesthetic (nitrous oxide or somnoform will be sufficient in many cases) and by means of an adenotome (La Force or Cradle, I never use a curet) remove all adenoid tissue. Then by means of the finger I carefully remove any adenoid tissue in the posterior nares and pharyngeal fossæ that the adenotome may have failed to get and also dilate the pharyngeal portion of the tube by inserting the finger.

This operation if carefully and thoroughly done and if preceded and followed by the proper surgical cleanliness and supportive treatment, will when indicated, accomplish excellent results. The after treatment is even more important because if this is not well done, no results or even unfavorable results may occur. The after treatment consists of daily irrigations of the nasopharynx, thorough attention to upper thoracic, cervical and mandibular lesions, aspiration of the Eustachian tubes and other local treatment to the nasopharyngeal membranes. After the operation has been done it is best to do no digital manipulation of the pharynx for from three to six days. After this time digital treatment, gentle dilation of the Eustachian orifice to maintain its patency, stretching of the soft palate to reestablish proper nerve function and the application of deep pressure in the pharyngeal fossæ to stimulate the otic ganglion is important. This treatment is not massage in any sense but definite, purposeful, manipulation and if carefully done will be followed by excellent results.

Since the origin of this method of treatment, there has been much comment on its value and many have tried or at least they thought they tried it with unfavorable results. The causes of failure are, attempting treatment in cases impossible of cure, or poor diagnosis, improper technic of operator or incomplete operative procedure and inefficient supportive treatment.

It must be understood that not all cases of otitis media even in the beginning stages require the above method of treatment or will be benefited by it. Those cases which have resulted from other causes than acute pharyngitis seldom require such radical methods of treatment.

In every case, the cause must be found and consistent treatment given. In my experience, the radical method of treatment has not been found necessary in more than twenty per cent of cases of chronic otitis media. In the other cases the treatment consists of removing sources of focal infection (about forty per cent) and normalizing nasopharyngeal reflexes by osteopathic and local treatment (about forty per cent). In all cases, the treatment must be complete. To remove thoroughly all obstruction from the epipharynx and leave a source of focal infection in the tonsils will accomplish little, or to remove carefully all pharyngeal obstruction and all sources of focal infection will not restore normal functions of the middle ear structures if the osteopathic lesions and gastro-intestinal perversions are neglected. Surgery in itself, even though carefully and thoroughly done, is not efficient treatment and this is why the medical specialists fail in this disease. After the necessary surgery has been done, then normal tone must be restored to the various tissues involved. Normal reflex mechanisms must be reestablished and this can be done by thorough and efficient osteopathic corrective work and the proper local treatment directly to the structures affected.

Meniere’s Symptom Complex

This is a form of catarrhal deafness with all the characteristic pathology of the first or second stage, but in which, due probably to sudden tubal occlusion, there results a marked variation in the intralabyrinthine pressure and there are, therefore, the symptoms of conduction deafness combined with labyrinthine involvement somewhat resembling Meniere’s disease. There is dizziness or even vertigo, with head noises, but not the marked prostration and nausea which characterizes Meniere’s disease.

Treatment.—The treatment is the same as in the first stages of catarrhal deafness and the prognosis is always good. The labyrinthine symptoms are usually completely relieved as soon as the middle ear is ventilated.

Diseases of the Inner Ear

Acute Suppurations.—Acute suppurative diseases of the labyrinth occasionally result from the extension of infection from the tympanum but they are certainly very rare. Such conditions may result from acute suppurative otitis media in which there has been an excessive collection of pus without rupture of the drum or drainage through the tube but this very rarely occurs and after drainage has been established, labyrinthine infection is hardly possible.

Diagnosis.—Labyrinthitis is of several forms but in general, there are the symptoms of labyrinthine involvement such as: nystagmus, vertigo, nausea, vomiting, headache, earache, deafness and febrile symptoms. When labyrinthitis is suspected, an aurist of much experience should be called into consultation at once.

Treatment.—Suppurative labyrinthitis is not in itself a fatal disease but dangerous complications may result because of the close proximity to so many delicate structures. Threatened meningeal infection requires surgical drainage, but unless meningeal infection is imminent, surgery is contraindicated. Since the mortality, considering dangers of complications, is not high (about 10%) and since such operations are very complicated and require great surgical skill, we may conclude that surgery is generally contraindicated.

Non-surgical treatment consists of keeping the patient quiet in bed, liquid diet, and good elimination. Drainage through the middle ear or Eustachian tube must be maintained.

Deep manipulation of the cervical structures will help to maintain lymphatic drainage but any treatment which necessitates much movement of the head should be avoided until the symptoms of vestibular irritation have ceased.

Non-Suppurative Labyrinthine Diseases

Meniere’s Disease.—This disease is caused by hemorrhage into the labyrinth with the following symptoms: There is sudden and intense vestibular irritation such as vertigo, marked tinnitus, nausea, vomiting and complete deafness on the affected side. There may also be cerebral disturbances and loss of consciousness.

The Prognosis depends upon the extent and severity of the pathology. It is probable that those cases in which recovery occurs quickly are not true cases of Meniere’s disease but have some causes other than labyrinthine hemorrhage. Such cases are perhaps Meniere’s Symptom Complex.

The Treatment consists of complete rest in bed, light diet, and good elimination until the marked irritation has passed. It has been my practice to carry out further treatment similar to that of the treatment of nerve deafness to be given later. Many of these cases will make complete recovery.

Nerve Deafness

The term “nerve deafness” is generally used very carelessly to apply to any chronic or non-suppurative process of the labyrinthine structures other than those mentioned above, which cause impaired hearing.

Nerve deafness is not an uncommon disease. In my cases of deafness there has been some involvement of the labyrinthine structures or auditory nerve in 27% of the cases examined. I think the reason for most authors putting the percentage of nerve deafness much lower than this is because of inexact methods of diagnosis. The above percentage is based upon the actual measurement of nerve force. See measurement of nerve force under non-suppurative otitis media above.

A careful study of cases by the method of actual measurement of nerve force, shows that there are two distinct forms of nerve deafness. In one there is only a deficient function of the structures of the labyrinth, due perhaps to some perverted physiologic function, and this form we may call auditory nerve deficiency. The other form of nerve deafness, due probably to an actual degeneration of the nerve or its end organs in the labyrinth, may be properly known as auditory nerve degeneration.

Auditory Nerve Deficiency.—A study of our case reports shows that in 64% of the cases in which the nerve force was 16-30 or higher (more than half) favorable results were obtained, provided that there was no complicating labyrinthine affection. These cases have been classed as “nerve deficiency” and the pathology as functional. A favorable prognosis (64%) may be offered.

In addition to the tuning fork findings the voice and watch test will be reduced to from one-tenth to two-thirds normal. The patient often complains of itching meati and dry nares. There are usually no signs or symptoms of labyrinthine affection.

Treatment.—The treatment consists of local treatment to the nasopharynx, tubes and meati as described under the treatment of chronic otitis media. Everything should be done to build up the patient’s general health and improve the local nutrition. It is highly essential to search the entire system for sources of focal and general infection. Auto-intoxication from chronic gastro-intestinal disease was found in 90% of our cases. Any treatment therefore that will restore normal gastro-intestinal function is indicated. Recently we have had some excellent results from colonic irrigation and the proper adjustment of diet in such cases. Any source of focal infection must of course receive proper attention.

The osteopathic corrective treatment consists largely of careful attention to lesions of the splanchnic area because of the importance of normal digestion, metabolism and elimination. This is certainly a most important part of the treatment and should never be neglected. Upper cervical and mandibular lesions have much to do with the local nutrition to the ear structures and these must not be neglected. The fact that we almost constantly find evidence of deficient nutrition to the meati and drums in this disease together with lesions of the mandible, suggests a local osteopathic cause.

Auditory Nerve Degeneration.—In those cases in which there is a measurable deficiency of nerve function of less than half the normal we have found that very few respond to treatment. (See table above.) The cause has therefore been attributed to a structural pathology and the condition called auditory degeneration.

There is usually very marked impairment of hearing for voice and all other sounds. The Ingersoll watch may be heard five or ten inches, but usually not at all, and the whispered voice heard only a few inches or not at all. There are nearly always signs and symptoms of labyrinthine deafness and evidence of tone islands. The deafness in these cases is usually progressive regardless of any treatment.

In this disease there is nearly always an associated affection of the labyrinth as shown by the high forks. The fractions represented by the high forks will agree in proportion provided there is no labyrinthine involvement.

Our results in auditory nerve degeneration have been measurable improvement in only 2% of the cases treated. The prognosis is therefore very poor and I believe we should always tell our patients frankly that there is almost no chance for improving their hearing in such cases. The treatment is the same as that given for nerve deficiency and because of the general good that may be had from treatment, that is, the improvement of the general resistance, it is often well for the patient to have such treatment to stop the progress of further special sensory degeneration.

It should always be our purpose to treat the patient rather than to treat some particular organ only and if this method is followed, our general results will surely be much higher.

Diseases of the Nose

Method of Examination.—For use in nasal examinations and treatment, a suitable chair with adjustable headrest is of much value because if the patient is not comfortable and in a convenient position, the work is very difficult. A few instruments, such as the following, are very essential: A sterilizer for instruments, head mirror and reflecting lamp, nasal speculum, tongue depressor, tonsil pillar-retractor, a nasal packing forceps and a few aluminum cotton applicators. These instruments are few and comparatively inexpensive, but are of more practical value than a lifetime collection of electrical apparatus. Any physician can readily learn the use of these instruments and the methods of examination by attending the clinical sessions of our conventions. Methods and technic of treatment, however, require much practice and experience to develop efficiency.

Acute Rhinitis

This disease, commonly known as a “cold in the head” is one of the most common, and because of the complications which so commonly result, a disease which really requires careful consideration.

Etiology.—The predisposing cause is reduced resistance and individual susceptibility to air-borne irritants and infective organisms.

Direct exposure of some insufficiently protected part of the body such as the feet in cold, damp weather, exposure of some unprotected part of the body to draughts or exposure of the whole body to slightly reduced temperature for a considerable time, are the common causes. In cold weather, it is very important that the proper indoor humidity be maintained, because the drying of the mucous membranes renders them susceptible to infection. This disease is not only contagious at times but may even become endemic from some specific and virulent organism.

The complications which may and often do follow such infections are laryngitis, bronchitis, pneumonia, etc. and any one or more of the focal infections, such as sinuitis, tonsillitis, or middle ear infection. A focal infection thus caused may become chronic and render the patient constantly susceptible to head colds. In fact in those persons who suffer from chronic head colds, there may nearly always be found some focal infection, such as the above named, and it is often impossible to get permanent relief until such sources of focal infection have been properly treated.

The influence of gross structural lesions, osteopathic lesions of the cervical and upper thoracic region, vertebræ and ribs must not be overlooked because they exert a powerful influence upon the blood supply, particularly the venous and lymphatic drainage and upon the autonomic nervous mechanism, which regulates the physiologic control of such functions.

Gross structural abnormalities of the intranasal chambers, such as deflected septum, enlarged turbinates or cellular turbinates, which cause deficient or abnormal breathing space, may cause and maintain head colds.

Diagnosis.—The diagnosis is usually easy. Nasal congestion with the usual “stuffy” feeling of the head, sneezing, headache, etc. are well known symptoms. On direct examination the nares are congested, there is a watery discharge and all of the membranes of the nasopharyngeal tract are congested.

Treatment.—If there is ever a demand for good, thorough and specific osteopathic work, certainly it is demanded in such cases. I am an advocate of thorough, deep relaxing treatment followed by specific adjustment in such cases.

Complete rest in bed with light diet and careful attention to the elimination are very essential. Perhaps the most difficult problem is to convince the patient that a head cold is really a serious disease and demands thorough and prompt treatment. Every ear, nose and throat specialist has had ample opportunity to know that most of the really serious complications of the head and neck result from the lack of prompt and proper attention to head colds.

The local treatment consists of irrigation of the nasopharynx followed by oil spray to protect from further irritation and the maintenance of proper drainage from the sinuses and middle ears. I am not an advocate of the so-called “antiseptic sprays” because they neither destroy bacteria sufficiently to be effective nor do they maintain drainage.

In all cases, the physician should be ever watchful for the complications and should not hesitate to call consultation of a specialist when such symptoms develop.

Purulent Rhinitis

Persistent inflammations of the nasal membranes are usually of a purulent nature or at least have had such a cause in the beginning.

Etiology.—Purulent rhinitis may be a result of an unsuccessfully treated infection of the nose or throat following some disease of childhood or early life. It may be due to infection at birth. Commonly there is a subacute or chronic sinus infection that maintains the infection of the nasal mucosa. Polyps, enlarged or cellular turbinates, adenoids or adhesions in the epipharynx, often retain the secretions and cause chronic rhinitis. In many cases I have found that osteopathic lesions of the cervical or upper thoracic region are effective causes of chronic rhinitis.

The Pathology consists of hyperemia, hypertrophy and exfoliation of the cellular membrane. The turbinates and all membranes become enlarged and thickened and the breathing space is usually greatly decreased.

The Symptoms are nasal obstruction, and mucous or mucopurulent discharge with usually hypersensitiveness, which causes sneezing and other symptoms common to “head colds.”

Treatment.—The same treatment as given above for acute rhinitis applies here. A thorough examination should be made for all of the various causes given above and the proper corrective treatment given for any or all such causes.

Chronic Hypertrophic Rhinitis

Etiology.—Chronic rhinitis is usually a result of an infective rhinitis and has for its cause any one or more of the various causes given above under purulent rhinitis.

Pathology.—The pathology in chronic rhinitis varies with the cause, but is usually characterized by a series of changes beginning with infection and hyperemia and followed by an actual and usually marked hypertrophy of the interstitial tissue. The posterior ends of the inferior or, less often, the middle turbinates are usually enlarged and extend backward into the pharynx.

The Symptoms are much the same as in purulent rhinitis, except that the purulent discharge is often not present. These cases usually suffer from chronic head colds, headaches and persistent nasal obstruction. The senses of smell and taste are usually impaired and there is a nasal twang to the voice.

Treatment.—In these cases, it is common to find osteopathic causes which prevent proper drainage from the head and neck and this is important because, if all the local causes are properly corrected, this is not sufficient to effect a cure.

Surgical treatment for the removal of polyps, synechia, adenoids, adhesions, correction of septum, or hypertrophied or cellular middle turbinates is often essential and certainly infected sinuses must be properly drained. We have had cases in which root abscesses seemed to be active causes, but it must not be thought that surgery and surgery alone is likely to cure chronic rhinitis, and I want to caution against the wholesale removal of turbinates for such conditions. The mere fact that the turbinates are enlarged is not sufficient reason for their removal. There has been a cause for this enlargement and turbinotomy or turbinectomy does not remove this cause. Cautery is worse, because it seldom accomplishes more than very temporary results and often leaves the membranes worse than before. Cautery destroys mucous membrane, leaving a dry and easily irritated surface which is often impossible to normalize.

The proper surgery, carefully done, followed by efficient osteopathic corrective work and thorough irrigation of the nasopharyngeal tract with the necessary oil spray protection after irrigation, will constitute efficient treatment. Treatment, thorough and long continued, will in due time restore nutrition, drainage and normal reflex nerve control to the tissues. Treatment after surgery is essential.

Intranasal Treatment.—Many cases are caused by the retention of secretions under the turbinates and in the superior vault. In all cases, therefore, it is essential to thoroughly free all possible retention cavities by means of a small cotton-wound probe before irrigation. The intranasal membranes are adrenalized and anesthetized and a thorough examination is made using a good reflecting lamp, nasal speculum and cotton tipped probe. Every part of the intranasal region is inspected for sources of purulent discharge, mucus collections, synechia and for hypersensitive areas. The probe is curved at the end and passed under each turbinate and drawn forward and backward with considerable pressure to insure that any collection of foreign matter is thoroughly removed. Every part of the intranasal region should be thoroughly treated in this way. The hiatus semilunaris must be kept well open to permit free antrum drainage and all other sinus openings should be kept free from any obstruction that may block the drainage. This particular technic requires great care and practice, but it is very effective and so commonly we have found that this work thoroughly done will reduce much and in some cases all of the turbinate hypertrophy rendering surgery unnecessary.

Atrophic Rhinitis

As the term suggests, this disease is just the opposite from hypertrophic rhinitis in that the membranes are shrunken, the nares are wide open and usually the membranes are coated with a mucopurulent discharge, accompanied by a bad odor. It is a chronic disease and progressive in nature.

Etiology.—Deficient nutrition, systemic or local, or some degenerative infective process constitutes the cause. Some cases may be traced to syphilis, but this is certainly not always the cause. Chronic sinuitis, the cause of which is some virulent infection, is often the cause. Too much or incorrect surgery and cautery is certainly a cause in many cases.

Pathology.—The marked atrophic appearance, the retracted turbinates, the excessive purulent or mucopurulent foul discharge are characteristic and diagnostic.

The tissues underlying the mucous membranes are shrunken, and atrophic and this tissue has usually been replaced, sometimes almost completely, by connective tissue, and thus the blood supply is markedly deficient.

Treatment.—In chronic cases, those in which the atrophy is well progressed, there is no hope of restoration to normal conditions, but I believe that the progress of practically every case can be stopped and that, in most cases, a permanent cure can be effected under proper treatment.

Every possible source of focal infection, such as sinuitis, pharyngitis, tonsillitis, etc. should receive proper attention promptly. After this has been done and sufficient time allowed for normalization, a blood count may reveal some other source of focal or general infection, which may be reducing the general resistance.

Auto-intoxication from some gastro-intestinal affection is commonly a cause and must receive proper attention. The general health of the patient must be restored and maintained.

Thorough osteopathic treatment must be given for any cause of lowered nutrition, local or general. The failure, I believe, in medical practice (They admit failure in this disease) is due to the lack of attention to the restoration of normal nutrition. Why drain a sinus and leave an atlas or upper thoracic lesion which decreases the local nutrition and leaves these membranes susceptible to further infection?

Before and after surgical drainage, irrigation of the nasopharyngeal tract. Thorough irrigation to cleanse every part. Hot irrigation (one gallon of salt mixture solution, salt 3 parts, borax 2 parts, and soda 1 part, a tablespoonful to the gallon at 118°F. to 123°F.) to cleanse, to free all parts from infection and to restore blood supply to the affected parts. Frequent irrigation, daily for a sufficient time to thoroughly sterilize and restore circulation. After each irrigation, an oil spray (any non-irritating petroleum oil) is applied freely to protect the membranes from irritation and further infection.

Before each irrigation a thorough probe treatment, as described under hypertrophic rhinitis, should be given that the membranes may be thoroughly freed from all retained secretions.

After the membranes are once clean, the sinuses free from infection and the blood supply reestablished, the treatment may be reduced in frequency to three times weekly, but the treatment must be continued for months or even years to effect a permanent cure. The patient can be taught to do his own irrigation after the disease is well under control. All irritating sprays, chemical cauteries, etc. must be avoided. The so-called “antiseptic sprays” do harm by irritating the membranes and certainly do no good, because they do not cleanse the parts. They only serve to deodorize, but actually accomplish nothing in the way of cure. It has been my experience that iodine and the silver salts in any of their various preparations are not efficient but that they actually do harm. My experience indicates that practically every case can be cured if the proper treatment is given for sufficient time.