SOME PREVENTABLE AURAL CONDITIONS*

BY F. W. COLBURN, M. D., BOSTON, MASS.

A paper upon the topic assigned me by your Chairman, who specified that it should be for the benefit of the general practitioner, may not be out of place at this time.

The old adage, "An ounce of prevention is worth a pound of cure," is still true, and especially so when we are considering the organ of hearing.

The object of the writer in preparing this brief paper is not so much to present something new, as to reiterate and emphasize a few points for the especial benefit of those who are called upon to treat cases before they come to the hands of the aurist, and to urge upon them the necessity of recognizing and attending to conditions which are of vital importance to the growing youth.

In a measure the work of the aurist is upon results, many of which might have been averted had appropriate treatment been given at the proper time.

The writer does not wish to be misunderstood when he offers "Preventable Aural Conditions" as a topic for discussion.

We may ask: What are "preventable aural conditions”? Preventable conditions of the ear are those which, had appropriate treatment been given preëxisting condition, the existing aural disease might have been averted.

What aural conditions then are preventable? You will agree with me that in children we have a great many cases of catarrhal or suppurative inflammation of the middle ear; the latter usually dependent upon the former. You will also agree that an acute or chronic mastoiditis, with all its attending dangers is not infrequently. the sequel of the middle-ear condition.

In adults we find the same condition perhaps to a less frequent degree. Now are these conditions preventable? Not in all cases by any means, but undoubtedly many might have been averted had the primary causes been removed.

Upon what preexisting conditions then are these so-called preventable conditions dependent? Let us for a moment consider a type of cases which frequently comes to us with a history of slight or marked impairment of hearing which the parents have attributed to inattention, thus allowing the patient to go on until permanent damage has been done. We see at a glance that the child is a mouthbreather, has snuffles, or has some obvious obstruction in the upper respiratory tract. On examination we may find enlarged faucial tonsils or adenoids in the naso-pharynx, or both. The nose may be obstructed by a deviated septum, spurs or ridges on the septum, hypertrophied turbinals, or polypi.

*Read before the Massachusetts Homeopathic Medical Society, Worcester, October 13, 1909.

Now undoubtedly some of these conditions are preëxistent in a large majority of the catarrhal affections of the tympanum. Dench says that one-half of the pathological lesions of the tympanum are caused by the presence of adenoids in the naso-pharynx. This is unquestionably true, especially in the case of children. The hypertrophied faucial tonsil may by pressure upon the surrounding structures cause at least a temporary stenosis of the eustachian tube with a resulting congestion of the tympanum. Intra-nasal obstructions in proportion to their degree cause, during the act of swallowing, a more or less complete vacuum in the naso-pharynx with a resulting hyperemia of the part. Any suppurative process in the adjacent cells or cavities of the nose may cause infection, by extension along the continuous ciliated columnar epithelium of the mucous membrane through the eustachian tube to the tympanum.

Now in order to prevent in some degree these catarrhal and suppurative middle ears, it behooves us to be on the watch for contributing causes and then remove them in so far as is in our power.

If then post-nasal adenoids are present have them removed before they have produced any tympanic complication. I would say the same of tonsils that are enlarged; I would not, however, go as far as some whe claim that all tonsils that can be seen are abnormal and therefore should be removed. Nasal irregularities should be corrected so that the patient may have unobstructed breathing space.

Of all our sense organs that of hearing is one we can ill afford to lose. How much of life is dependent upon good hearing and how many there are whose ears are defective. Upon this faculty depends not only much of the social and intellectual enjoyment of life, but also in these days of automobiles, trolley-cars and other modes of rapid transit, our safety.

Accident insurance companies recognize this fact, and refuse to take risks on a person whose hearing is much impaired. Suppurating middle-ear disease will debar one from taking out a policy in most of the first-rate life insurance companies.

It is, then, our duty as physicians to prevent these conditions just so far as lies in our power. To prevent them is to anticipate them by removing all conditions which tend to bring on middle-ear disease, and by so doing the cases of catarrhal deafness and of "running ears" will be materially reduced.

As was said at the outset this brief paper is intended merely to emphasize the necessity of using all the means at our disposal to preserve the God-given sense of hearing to the growing generation.

COLLEGE FOR DR. WORCESTER.-It is stated that a movement is in progress for the collection of $1,000,000 to found an institution where students of medicine, theology, and sociology may come together and study what is generally known as the "Emmanuel Movement".

THE REMOTER MANIFESTATIONS OF GONORRHEA AND THEIR INTEREST FOR THE GENERAL PRACTITIONER*

BY ORREN B. SANDERS, M. D., BOSTON, MASS.

Once upon a time, and that time not so far distance, gonorrhea was a disease regarded even by the profession as chiefly local in its development, and temporary in its character. It was an incident, unpleasant but comparatively unimportant, in the experience of the majority of men who sought sexual pleasure.

This was the general attitude of the profession. It would be gratifying if we could confidently assert that it had been wholly superseded by an equally general knowledge of what a formidable. disease gonorrhea really is, and an equally general recognition that the limitation of disastrous results, and eventually of the number of cases, rests primarily more with the general practitioner than with the specialist.

Unfortunately, facts do not make possible any such assertion. As long as the lowest estimate of gonorrhea among men in the United States is 60 per cent., as long as 45 per cent. of sterile marriages are attributed to the gonococcus, as long as 75 per cent. of pelvic operations in women are necessitated by this infection, and of all cases of blindness 10 to 30 per cent. are due to this cause, just so long have we a terrible menace in our midst to the health and moral standards of our country. And more than this, somebody or something not a hundred miles distant from the home or office of each one of us is responsible in this enlightened era, besides that convenient factor long entitled "original sin."

Original sin we have with us and always shall have, but also original virtue, theologians to the contrary. Acquired sin we have and always shall have, but also, and increasingly, acquired virtue. And when it comes to the lessening and the control of the former, and the increasing and direction of the latter, the particular field being that of the sexual life, the medical profession in its ability to control the situation is second to none, and in its responsibilities is preeminently first.

Because to intelligent men and women like yourselves this must be a self-evident proposition, and because its importance, equally obvious, requires equal and repeated emphasis, I will ask your kind indulgence for my rehearsal of some extremely pertinent facts, which, familiar or unfamiliar, should command our serious attention.

In the beginning of its infection it is not difficult to follow the invasion of the gonococcus. From the free surface of the urethral mucous membrane in man, the gonococci rapidly penetrate between the epithelial cells, and even to the submucous connective tissue.

*Read before the Massachusetts Homœopathic Medical Society, Worcester. October 13, 1909.

They increase and multiply in colonies, and by their toxic action. cause engorgement of the blood vessels and the discharge of serum and leucocytes. The desquamation of epithelial cells caused by the flow of serum, results in erosions of the epithelial surface.

Phagocytosis actively takes place, the gonococci being removed from the tissues by being taken into the pus-cells. Thus when the normal course is run, the second or third week sees the practical disappearance of the gonococci from submucous connective tissue and the deeper layers of the mucous membrane. After this ascending stage of phagocytosis comes the stage of decline, the repair of erosions, the disposal by desquamation of epithelial cells of the gonococci removed from the deeper tissues. By the fifth or sixth week, then, in favorable cases the urethra is free from gonococci and inflammation ceases.

This is what may be called the ideally favorable case where inflammation affects the anterior urethra only, and resistance and repair follow on the heels of infection. This is the ideally favorable. course of the disease, proceeding in ordered sequence, and apparently devoid of direful results. It also looks extremely well on paper, and would incline the average practitioner to continue to say "only a clap," and when the specific urethritis reaches his waitingroom in the shape of an acute case to casually, and more as a matter of form and to satisfy the patient, hand out a prescription for an astringent injection, another for some stomach-insulting balsamic mixture, and with a few desultory injunctions dismiss a case undesired, yet not so undesired, be it remarked, as to be turned over to the specialist. Here is a disease theoretically self-limited, dependent for even a relatively favorable course to limitation to the anterior urethra, abstention from sexual excitement as well as intercourse, from alcoholic beverages, and from freedom from reinfection. Dependent also upon intelligent treatment, upon rest, upon the absence of constitutional conditions such as gout or tuberculosis.

Self-limited as it may be, specialists will bear feeling witness to the intractable nature of these cases so far as a radical and demonstrable cure is concerned, and to the preponderating percentage of stubborn chronic cases which come to them or are referred to them, and which demand all their resources as well as their ability to secure the necessary coöperation of the patient. Also, however self-limited in medical parlance, it has to be borne in mind that the most favorable course of the disease shows no interim when protection from extension of infection to another is assured in sexual intercourse or by some other form of contact.

Eliminating the uncomplicated anterior urethritis-a possible 20 per cent. of all cases we see the gonococcus pass beyond the cutoff muscle, and infect the posterior urethra. Nor is it the treatment alone, as the superficial observer might infer, which progressively taxes the physician; it is also to a mystifying extent the question of diagnosis, for it is oftentimes exceedingly difficult to determine without some special knowledge of and training in the work, what

tissues and organs are involved; a mild posterior urethritis, for instance, being easily overlooked, with disastrous consequences.

The list of the complications of gonorrhea is of formidable length and constantly increasing. Those that first suggest themselves to one, especially those of the acute stage, balanitis, phimosis, paraphimosis, folliculitis, Cowperitis, inguinal adenitis, chordee, etc., we may pass by as too immediate to detain us; but a word concerning epididymitis should not be omitted.

Although this condition is not a metastasis through the bloodvessels or lymph channels, yet it is one of the remoter manifestations of the migratory power of the gonococci which pass onward from the posterior urethra to the epididymis by way of the seminal vesicles and vas deferens, set up inflammation, produce inflammatory products which, if not absorbed may plug up the efferent duct thus causing sterility or, in other ways may bring about the same condition. Sterility as a result of gonorrheal infection is in fact now recognized as an actual and by no means infrequent condition in men as well as in women, although the latter are more often deprived of their reproductive powers.

Let us now turn our attention to the prostate. While stricture of the urethra, with its attendant bladder disturbances, is an old story in the history of gonorrhea, it is felt that the last word has yet to be said on the far-reaching effects of involvement of the prostate.

Morton' considers chronic prostatitis as "perhaps the most important complication of gonorrhea," his reason being included in the following comment on the frequency of its occurrence: "In nearly every case of a post-urethritis developing in the course of a gonorrhea, rectal examination will show that the prostate is more or less affected, and after the inflammation has disappeared from the posterior urethra, foci of disease remain in the prostate, causing exacerbations of the gonorrhea and sexual neurasthenia.

And Boogher of St. Louis in the August "Medical Brief," commenting on the cases of gonorrhea discharged as cured by the general practitioner after the acute stage has been controlled, says: “After the acute stage has disappeared, it is estimated that about 90 per cent. of them become prostatic, the glands in the prostate most frequently retaining infectious tissue for many years."

So also Rathbun and Dexter" of Brooklyn, in an able contribution to the "New York Medical Journal" of last July on "The Bacteriology of Gonorrhea," carry conviction when they affirm that "the number of cases of uncured and incurable gonorrheal prostatitis is far in excess of what most clinicians are ready to believe." This as a result of actual work and investigation, as also the alarming statement that "at present we have no means at our disposal by which we can positively assure a patient that he is cured of gonorrheal prostatitis."

Many cases of enlarged prostate are now being referred to what Trenwith of New York describes as "the long-continued irritating effect of a chronically inflamed prostatic urethra or in