BOOK REVIEWS

THE DIETARY COMPUTER. (By AмY ELIZABETH POPE, Formerly Instructor in the School of Nursing, Presbyterian Hospital; Instructor in the School of Nursing, St. Luke's Hospital, San Francisco, Cal. Published by G. P. Putnam's Sons, New York and London, The Knickerbocker Press, 1917. Price, $1.25.)

This small volume is composed mainly of lists of foods, their percentage composition and caloric values. The essentials of a diet, the proportion of protein, fat and carbohydrate, and the estimations of the approximate number of calories required by a human being as determined by various international authorities are all given.

This book should be of definite practical value to the housewife at a time like the present, as well as to the professional dietitian.

CANCER, Its Cause and Treatment. (By L. DUNCAN
BULKLEY, A. M., M. D., Senior Physician to the
New York Skin and Cancer Hospital, etc. Volume
II. Published by Paul B. Hoeber, New York, 1917.
Price $1.50.)

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The chief value of this book lies in its pointing out that we do not know the cause of cancer as yet. The author has added nothing to our knowledge of the subject. In fact, a book of this sort warning the profession against early surgery and strongly advocating medical treatment of cancer is dangerous in its influence. Until the author's medical treatment consisting mainly of a meat, alcohol, and coffee free diet, moderate in amount with a potassium salt in some form added thereto shows a higher percentage of cures in cases proved by the microscope than surgery does, the medical profession will not be justified in substituting this line of treatment for surgery. The reviewer cannot agree in every case with the conclusions drawn from statistics quoted in this work.

C. B. DRAKE.

C. B. DRAKE.

Vol. I

ORIGINAL ARTICLES

THE CONSERVATION OF HEARING.*

HORACE NEWHART, A. B., M. D., F. A. C. S., Minneapolis, Minn.

Diseases of the ear are far more prevalent than is generally supposed. The figures of the federal census for 1900, which returned a total of 89,287 deaf persons in the United States, including 51,870 who were deaf from childhood, and 51,861 who were only partially deaf, represent but a very small proportion of our population who are afflicted with some impairment of hearing. In the outpatient department of the University of Minnesota Hospital with an annual attendance of practically fifty-six thousand, during the past three years between 82 per cent and 10 per cent have been in the otological clinic.

It is conservatively estimated that in the United States there are not less than 3,000,000 persons who are appreciably hard of hearing. These figures are substantiated by the reports of medical inspection in our public schools, where the examinations are of necessity very superficial. From two to six per cent of all school children are reported as having defective hearing. McCallie and Cornell, as the result of more accurate tests made in Philadelphia in 1910 and 1911, report defects of hearing in no less than 14 per cent of the series of 530 ears examined.

2

Von Troeltsch, on the basis of careful physiological tests has stated that in persons over

*Presented before the Southern Minn. Medical Assoc. Mankato, Minn., Nov. 27, 1917

No. 5

twenty years of age3 one out of every three has some impairment of hearing.

The wide prevalence and serious significance of aural diseases is even more strikingly suggested by our mortality statistics. The records of Guy's Hospital show that disease of the ear was the cause of death in one out of every 158 deaths. In the Vienna General Hospital the ratio was one to every 232, and in Copenhagen one to every 303. Dr. Koerner, of Rostock, reviewing the carefully kept vital statistics of Prussia, has stated that no less than 4 per cent of all deaths occurring under thirty years of age are due to diseases of the ears. In this rather surprising statement he is upheld by Prof. Bezold, of Munich.

Otology is one of the youngest of the surgical specialties. As such it has made equally rapid progress with other departments of medicine. Through its achievements in surgical diagnosis and in the surgical care of middle ear suppurations, labyrinthine affections and intracranial complications, it has already accomplished much in the saving of life and in the conservation of hearing.

Unfortunately the fact remains that during the past twenty years little advancement has been made in the treatment of those cases of progressive deafness due to chronic non-suppurative disease which constitute so large a proportion of those who are hard of hearing.

Thus the medical profession is confronted by the large problem of preventing the vast amount of economic inefficiency and loss, social embarrassment and isolation and its consequent mental depression, all resulting from avoidable causes. Already there has been successfully established a worldwide movement for the prevention of blindness and for the care and edu

cation of the blind. In consequence, many of our states have responded with beneficent laws which, backed by public sentiment, are well en forced. Up to the present time comparatively little interest has been manifested in the prevention of deafness, though much has been accomplished in the interest of the totally deaf.

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In spite of the fact that otology holds a place of ever-increasing importance in medical education, there are still in the profession a large number of excellent general practitioners who, to quote Dr. W. Sohier Bryant, look upon diseases of the ear as divided into two classes: "First, those that would get well without treatment, and second, those that would not get well with any treatment." This attitude, because of the admitted failure of the profession to be able to restore hearing to the deaf has become widely prevalent and is deeply fixed among the general public.

This almost universal apathy towards diseases of the ear probably does not find its counterpart in any other field of medicine. The reason for this lies in the fact that no other important organ can undergo so great a degree of deterioration without the knowledge of the individual. Originally man is endowed with a far greater acuteness of hearing than he requires in his civilized surroundings. Usually he is not aroused to a realization of his deficiency until he has actually lost from seventy-five to ninetyfive per cent of his hearing power. It should be recalled that the acuteness of hearing is quantitatively determined not by the distance, but by the square of the distance at which sounds are perceived.

Without fear of denial it can be stated that over 90 per cent of all cases of deafness are preventable. Pathology teaches that loss of hearing is due to disturbances within the temporal bone causing destructive deterioration of the special sense organ. Generally speaking, the possibility for restoration of function to even an approximation of the normal is in inverse ratio to the time the causal factors have been at work.

With these principles in mind it is plain that our chief efforts in the conservation of hearing must lie in the field of prophylaxis, through the early diagnosis and treatment of every possible etiological factor. The early detection of con

ditions leading to incipient disturbances of hearing can be assured only by systematic, periodic examinations of every individual.

At the present time the one most effective factor in the prevention of deafness is the medical examination of school children. In the public schools of Minneapolis since the introduction of medical inspection in 1910, Dr. Keene reports the percentage of children with defective hearing has been reduced from 3.7 to 2.1 per cent. Other communities can show equally good results. This rapid diminution in the number of ear defects must be ascribed in part to the decrease in scarlet fever and measles, through early exclusion from the classroom of all suspected cases.

The hearing tests as ordinarily carried out are necessarily hurriedly made, the purpose being to determine the status of the child's hearing as regards his immediate educational needs. As ordinarily made they are not sufficiently comprehensive to safeguard his future hearing by the early detection of the beginning stages of impairment.

In the tuning-fork tests of Weber and Rinne we have a simple means of revealing pathological changes in the ears, long before they would be disclosed by the usual tests with the watch and voice.

The fork tests are rarely made either by the school examiner or by the general practitioner. This is extremely unfortunate, inasmuch as the technic requires but a few moments for each case, and is so simple that the tests can be made by the school nurse or the teacher. The detection of any departure from the normal standard calls for further investigation by the trained physician who must make a complete examination to ascertain the exact nature of the lesion and of every possible contributing cause.

In children under school age the family physician and the pediatrician must assume all the responsibility, for in children under 6 years of age the functional tests are not reliable. Every case of mouth-breathing, every acute pharyngitis, every unusual discharge from the nares or external ear, and the presence of enlarged cervical glands, should be looked upon as the possible symptom of a condition which, neglected, may lead to ultimate deafness.

The contagious diseases of childhood call for

special vigilance. A large proportion of the cases of deafness originating in early life are due to scarlet fever and measles. During their course frequent inspections of the tympanic membrane should be made and on the slightest indication the medical attendant must be ready to incise freely the reddened or bulging drumhead; for in these cases the infection within the tympanic cavity is especially virulent and rapidly destructive. Should involvement of the mastoid cells occur, immediate posterior drainage of the antrum is the safest procedure, and is the best insurance against a later radical mastoid operation."

The ears of all school children should be examined by the medical inspector at least once a year, more frequently if they are found defective on admission; also after every acute illness involving the upper respiratory tract.

Where medical inspection is not provided, many cases might be detected in their incipiency by the school nurse, or in rural communities by the interested school teacher. It is to be hoped that our normal schools will soon demand of their graduates a sufficient knowledge of school hygiene to enable them to intelligently make such examinations as are necessary to safeguard the special senses of their pupils.

Fig. 1.

The urgent need of medical inspection in our rural schools is strikingly illustrated by the photograph here shown, which was not taken for clinical purposes.

While aural examinations at frequent intervals are especially important during the growing period, the proper conservation of hearing demands that the ears of all members of the community should be periodically examined.

Such a procedure can be advantageously carried out in all of our institutions of higher education, in all places where labor is employed on a large scale, by social service workers and by our accident, health and life insurance companies.

In the case of the majority of adults, it is the family physician to whom we must naturally look for the regular examination of the ears. This responsibility he has taken too lightly in the past.

A very considerable number of those seeking medical aid for impaired hearing do so not until after they have themselves discovered their deficiency, when much of their hearing power is irreparably lost. Patients of this class have not received the sympathy and attention they deserve. The busy practitioner, priding himself upon his honesty, too frequently tells such a patient with a frankness which is almost brutal, that he cannot be helped. The result is only to discourage the patient from making any further effort.

If the physician wishes to avoid personally discouraging his patient by giving him an unfavorable opinion, occasionally he transfers the responsibility to a specialist. The latter with equal regard for the truth, but with more tact, will tell the patient that he has probably come too late to hope for any great improvement in hearing, but that with proper treatment, based upon the results of a thorough examination, he may hope for some improvement; but that his chief endeavor must be to preserve his present hearing.

The prognosis is admittedly not good. However, in many such cases much can yet be done to arrest the progress of the degenerative changes, if we but look deeply enough for all the causal factors, some of which may still be at work.

It is in order to specifically consider some of these factors.

Any appreciable hindrance to the free ventilation of the Eustachian tube because of nasal insufficiency should be removed regardless of the age of the patient. The nasopharynx in such cases is usually free, but there may be persistent remnants of old inflammatory processes in the form of adhesions or hypertrophy of the tubal lymph-adenoid tissue. The tubes them

selves may be non-patent from swelling or cicatricial tissue. They should receive appropriate local treatment, which includes far more than the usual course of inflation and massage.

Very frequently the patient affirms that he has had no disturbance of his tonsils. Careful inspection will often reveal small or submerged tonsils, or hypertrophied stumps remaining after a supposed tonsillectomy, harboring in the crypts and in the supra-tonsillar space an incredible amount of purulent debris laden with pathogenic organisms. Any opinion regarding the condition of a submerged tonsil based upon the ordinary casual examination of the fauces without an instrumental retraction of the pillars and exploration of the crypts, is dangerous. A simple retractor, like the one here shown, we have used for years and have come to regard as indispensable. Its only merit lies in its simplicity and in the fact that with it one can retract the pillars, explore the crypts and supratonsillar space, and exert sufficient pressure to evacuate the crypts, all without special discomfort to the patient.

Fig. 2.

Author's retractor for examining tonsils.

Recent teaching in regard to focal infections should cause the otologist to be especially suspicious of all tonsils, however innocent they may appear on the surface.

Though pathological proof is lacking, clinical experience in many cases has convinced us that impaired hearing and labyrinthine irritation manifesting itself in tinnitus and vestibular symptoms, are frequently the effects of toxins originating in submerged, suppurating tonsils, in the blind abscesses of devitalized or diseased teeth, and in smouldering chronic infections of the accessory sinuses of the nose. Whether the toxic products find their way to the delicate nerve endings of the organ of hearing by way of the lymphatics, or are carried by the blood current, has not been proven. Nevertheless, it is a fact that in many cases after the usual forms of treatment have failed, we see an amelioration of the ear symptoms following the removal of the focal infection.

To substantiate this theory, we need only point out the large number of intra-ocular diseases which we now know have their origin in similar focal infections.

In many of our cases of non-suppurative ear disease, in addition to local causes, there are also general systemic disorders at work contributing to the deterioration of the hearing as well as of other bodily functions. Among such may be mentioned diseases of the ductless glands, anaemia, diabetes, acidosis, constipation, and post-syphilitic manifestations such as tabes. Their treatment belongs primarily to the field of the internist, but whoever attempts to diagnose and treat aural diseases must be alert to the recognition of all bodily conditions which may affect unfavorably the course of the ear affection. The etiology of that most unsatisfactorily treated disease known as otosclerosis, is doubtless to be found in some systemic disorder, of which the bony changes within the labyrinthine capsule are but an occasional localized manifestation.

Syphilis, congenital and acquired, is not an infrequent cause of nerve deafness. When it occurs in conjunction with other more apparent causes of the deafness, it may lead rapidly to serious loss of hearing before it is discovered. After several embarrassing experiences, when we failed to secure the expected improvement by the usual treatment, the Wassermann test has saved the situation. This test should be promptly made in all doubtful cases.

Chronic middle ear suppuration exists in from one per cent. to two per cent. of our school children, being more frequent in the lower grades and among children from poorer homes. Every case of chronic otorrhoea, be it in the child or adult, which does not yield in a reasonable time to careful treatment, calls emphatically for the radical mastoid operation. It should be urged not only for the sake of insuring the patient against the ever present possibility of death from an intracranial complication, but also to preserve to the patient whatever residuum of hearing he may possess. the public and many of the medical profession need to be educated away from the now obsolete view that the mastoid operation is dangerous to life and is likely to cause increased deafness. The mortality attached to the radical

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