DEAFNESS BY PNEUMO-MASSAGE AND

PHONO-MASSAGE.

BY C. JAY SELTZER, M.D.,

OF PHILADELPHIA;

AURIST AND LARYNGOLOGIST TO THE PHILADELPHIA HOSPITAL.

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5

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18.2

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76

83.3

Diphtheric with coccus
Diphtheric with streptococci 25

or staphylococci

DEAFNESS due to catarrhal inflammation comes on so insidiously that the impairment of hearing is not noticed in most cases until the conduction of sound is greatly impaired in one ear, if not in both ears. A desire to secure relief without resort to surgery calls for many efforts to devise some form of mechanism by means of which the delicate membranes and bony arches may be restored to their normal condition of elasticity and mobility. This can be best accomplished by a process of exercise or massage, associated with constitutional and local medication.

ever, have but little significance, so far as the proof of the relation of the Loeffler bacillus to diphtheria is concerned, and I shall, therefore, avoid their dis

cussion.

Summarizing briefly the leading points brought out in this paper, it will be seen, first, that the Loeffler bacillus is present in much more than 73 per cent. of real clinical diphtherias; second, that pure cultures introduced into animals reproduce false membranes, paralyses, and other ill-effects observed in diphtheria; third, that the chemic products of the bacillus produce paralyses, diarrhea, intoxication, and death, completing the resemblance to the natural disease; fourth, that the mortality is vastly greater in those cases in which the Loeffler bacillus is present than in those from which it is absent; fifth, that the antitoxic serum, which possesses a specific action toward the Loeffler bacillus and its poison, reduces the mortality in those cases in which the Loeffler bacillus is present and is without effect in those from which it is absent.

It is this overwhelming evidence that fully justifies us in stating that whenever the Loeffler bacillus is found in a disease it is diphtheria. It was with genuine pleasure that Loeffler could make the definite announcement at Budapest last year, ten years after his pioneer work of 1884, that "The cause of diphtheria is the diphtheria-bacillus.'

HYGIENIC LABORATORY, UNIVERSITY OF MICHIGAN.

of the membrana tympani and associated ossicles in the middle ear, thus breaking up some of the adhesions due to deposits of plastic material and inspissated mucus. This movement generally relaxes, and if sufficiently long continued permanently lessens the tension caused by such adhesions, and at the same time frees the drum of the inspissated mucus which mechanically interferes with sound-conduction. This continued action upon the drum, moreover, tends to stimulate the normal secretion of mucus, and thus slowly softens the inspissated masses, which may be dislodged and expelled into the upper pharynx. At the same time it admits of freer ventilation of the middle ear, and consequent equalization of air-pressure inside and outside of the drum, thereby removing one source of tinnitus.

The vibrophone does not possess sufficient force to produce more than very mild impacts, and is, therefore, much inferior to the vibrometer or the phonograph. The vibrometer has one advantage over other instruments in that the vibrations produced by one or the other of the banjo-strings possess a pitch and tone that are agreeable to the patient and sufficiently mild to admit of long sittings. The best instrument for the purpose, however, is the phonograph, which, with the proper diaphragm attached, possesses the maximum of force with the minimum of sound. Such a diaphragm, with the attachment for the stylus, was devised some four years since, and although very delicate in construction, makes a

sufficiently strong attachment for use on the grooved wax-cylinders ordinarily used on the phonograph.'

With this diaphragm, and the cylinders grooved as the operator may desire, very forcible impacts with greatly reduced noise can be produced, and can be easily regulated to suit the conditions in each case. This is accomplished with comfort and safety for the patient owing to the movement of the diaphragm which causes the drum to retract, thereby producing, or tending to produce, a partial vacuum by first drawing out the membrana tympani and relieving the internal ear from pressure, and then alternating the pressure as the diaphragm returns to its original position, thus rapidly and continuously putting in motion the membrana tympani and the ossicles, without increasing the pressure on the oval window, and without possible harm to the internal ear.

The phonograph has an additional advantage in that the confusion sometimes complained of when long-continued applications of massage have been made is nicely relieved by substituting a musical cylinder, which is both entertaining and soothing, especially stringed-instrument records, such as of the banjo. The vocal cylinders can be used to determine the quality of sound-conduction as well as the hearing-value, and the orchestral musical cylinders in determining the pitch and kind of instruments best heard and recognized. We may also note the degree of improvement as shown by the additional words and tones recognized and repeated from time to time. The phonograph is, therefore, decidedly the best and neatest instrument for producing what is called pneumo-massage and phono-massage, with the single exception of certain gentle musical vibrations which can be best obtained from the banjostrings of the vibrometer.

The cases should first be carefully examined, to determine as nearly as possible the seat of pathologic change, the character of deafness as regards the quality of sound, and the sensitiveness both to pain and sounds caused by the instrument in producing vibrations. The instrument is then started at a low speed, which is increased until discomfort or a tendency to vertigo is felt, at which point the maximum limit is reached. The speed is then reduced to a velocity at which comfort is expressed, and retained at that point for several sittings, but may be gradually increased at subsequent sittings. The sittings should be regulated in length of time by the sensations of the patient, so as to avoid mental and physical discomfort (usually from ten to twenty-five minutes), and end by an agreeable musical cylinder, thus diverting attention to pleasant sensations, and at the same time securing mild auditory exercise.

1 Messrs. Hawthorne & Sheble, the Edison phonograph agents of Philadelphia, 604 and 606 Chestnut Street, have been preparing these cylinders and diaphragms for this purpose after the original model made by Mr. Leeds.

The results of this method, in conjunction with proper alteratives and tonics, and local treatment consisting of applications of tannic acid and glycerol, or weak silver-solutions to the naso-pharynx, antipyrin, and compound tincture of benzoin to the nose (especially over the lower turbinated bone), followed by camphor and menthol in liquid vaselin, and when stenosis from engorgement exists the galvano-cautery applied, will result in marked improvement in many cases of deafness in which the loss of delicacy in motion of the conducting bony chain is caused by pathologic changes not destructive to the continuity of soft or bony tissue. A thorough trial of this method in a large series of cases covering a period of twelve months has convinced me that an absolute cure or return of normal hearing-power in a large proportion of these cases may not be possible, but a considerable number will show the most marked improvement, while in the remaining cases an arrest of progress may at least be expected. Associated tinnitus is likewise relieved or cured in many cases, but a few will yield in neither deafness nor tinnitus in the period mentioned.

The disadvantages of this method are the length of time required and the number of applications necessary to accomplish the desired result; but, notwithstanding these faults, it promises at present the greatest degree of success with the least amount of injurious effects of any method yet proposed, and is altogether our surest method of relief when used in connection with the proper inflation of the middle ear and the necessary local and constitutional treatment.

ORIGINAL ADDRESS.

ADDRESS IN MENTAL DISORDERS.1

BY F. X. DERCUM, M.D.,

CLINICAL PROFESSOR OF NERVOUS DISEASES, JEFFERSON MEDICAL COLLEGE; NEUROLOGIST TO PHILADELPHIA HOSPITAL; CONSULTING PHYSICIAN TO THE HOSPITAL FOR THE CHRONIC INSANE AT WERNERSVILLE, PENNA.

FOR many years the public mind in dealing with the problem of insanity has approached it almost exclusively from a practical and utilitarian point of view. The reasons are obvious. The position that insanity and all that pertains to it has occupied in the past has been most peculiar. For ages the insane had been treated as a class that required not only the isolation of the leper, but also the punitive treatment of the evil-doer. In the lay mind insanity involuntarily excited abhorrence and disgust, and was closely associated with ideas of blame and punishment. Indeed, in this day it is by most people regarded as a disgrace if one of their relatives become insane, and often the fact is as much as possible kept concealed. By some unaccountable action of the human mind this peculiarity attaches to no other class of diseases;

1 Read before the Medical Society of the State of Pennsylvania, at Chambersburg, May, 1895.

at least not in the same degree. It is not strange in view of these facts that the first attempts at the management of the insane in bulk consisted mainly in their housing, and made no other provision for their welfare. Even in these days, when the insane are placed under the care of physicians, the latter are assigned rather the duties of housekeepers, stewards, and executive officers than those of medical attendants. When we consider the attitude of the public mind that obtains more or less to this day, and when we consider the inherent difficulties of the subject, we can readily understand why the science of insanity, especially its pathology, has remained a veritable Africa to medical men.

We must, however, frankly admit that in the practical care of the insane an enormous advance has been made —an advance that has continued unceasingly ever since the days of Pinel, of Tuke, and of Rush. We, too, often look with eyes of reproach upon the science and forget the great practical good that has been accomplished in other directions. Surely the pathway through the jungle had first to be cleared, a semblance of order had first to be established, a knowledge of clinical forms had first to be acquired, before the explorers of this dark continent could devote their time to purely scientific study. In this struggle, in this gigantic task, the alienist is still engaged.

We cannot be surprised that more has not been accomplished when we reflect that the asylum of to-day is only the refined madhouse of former times, and that in it but few opportunities for scientific research are to be found; and, further, to repeat, that the physicians are burdened with executive duties such as should not come within the province of medical men, and of which medicine as a science can take no cognizance.

For this condition of affairs medical men are not to be held strictly accountable. The insane-hospital is for the most part a public institution, and its organization, the plan upon which it is conducted, the financial system upon which it is based, is a reflection of public opinion. The practical politician fails to see the advantages resulting from purely abstract scientific investigation, and yet it is very probable that an increased knowledge of the pathology of insanity will diminish not only the cost of maintaining the insane, but also the actual number to be maintained.

Another and still more serious obstacle has confronted the student of psychiatry, indeed the greatest obstacle of all, and that is the inherent difficulty of the subject. The alienist has been in the unfortunate position of being able to observe surface-indications only, while of the actual underlying principles he could of necessity have no knowledge, inasmuch as both the structure and the function of the gray cortex, except in their grossest relations, were unknown. As a consequence, metaphysical reasoning and vague speculation for a long time took the place of fact and scientific observation.

At last the difficulty promises to be removed; the dawn of a better day is at hand; the marvellous methods of research of Golgi and of Ramon y Cajal, in the hands of such men as Lloyd Andriezen,' are revealing the actual, the detailed structure of the human cortex. The beginning has been made of associating structure with

mind-action, and the recognition of the fact that mindaction cannot be separated from ordinary brain-action must henceforth be accepted as an indisputable fact. Doubt, prejudice, preconceived notions of all kinds must yield to scientific truth.

Andriezen has analyzed and separated the various elements of which the gray cortex is composed, and the relations of the structures to each other are such that their function seems evident. The incoming, the aferent, fibers, which bring information to this vast expanse of ganglionic matter, the gray cortex, terminate not in ganglion-cells, but in the uppermost layer, the molecular layer, of the cortex. Here their minute divisions come in contact with the minute branches and delicate tufts of the various cortical cells. Significant is it, too, that the insulating material that encircles this afferent fiber is lost when the fiber enters the cortex, so that there is no interference with the proper diffusion, either by contact or induction, of the current which it conveys to surrounding structures. The current, whatever its mode of motion may be, is transferred from cellprocess to cell-body and thence perhaps to afferent fibers, or more frequently to countless numbers of other cells-cells whose business it is to associate, to combine, to separate, and to store up impressions.

The limits of the time at my disposal will not permit me to enter into a more detailed statement of these discoveries, but their significance is redoubled when we learn that Andriezen obtained the most interesting results when he directed his attention to one of the simpler forms of insanity, namely, one in which the cause is definitely known, and in which the symptoms are well established and relatively simple in character: I refer to alcoholic insanity. Andriezen found, first of all, that the neurons showed changes in the cell-bodies and in the nuclei. There were swelling and indistinct staining of the intercellular chromatin-rods. There were also coarseness and increased staining of the nucleus, changes that indicate that in alcoholic insanity the cellprotoplasm and cell-nuclei are the seat of serious nutritive disturbances. Especially, however, did Andriezen note alteration and destruction of the fine naked collaterals and nerve-terminals of the molecular layers of the cortex-the very layer in which afferent impressions are first communicated to the nerve-cells of the cortex. There were also swelling and softening of the very minute protoplasmic granules attached to the special processes in the superficial quarter of the cortex. changes, "dynamical changes," as Andriezen calls them, doubtless explain the diminished sensitiveness and alertness of the alcoholic to incoming sensory impressions, and similarly a diminution of the spread of the excitation from one area to associated areas. these changes and to the changes in the cell-body are also to be relegated the amnesia of the alcoholic state. We have here the first instance in the history of insanity in which it has been possible to correlate closely cause, structural change, and symptom. Surely a beginning has been made in this brilliant research that augurs well for the future.

These

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It is to be hoped that these results will everywhere stimulate the foundation of laboratories in hospitals for the insane. To be sure, a few such laboratories already

support both from the Boards of Trustees and from the

medical officers of the institutions. Everyone should realize that there is no longer an excuse for the ignorance that exists in reference to the changes in the cortex of the insane. The methods of Golgi and of Ramon y Cajal, as Andriezen has shown, are capable of revealing the most astounding secrets, and one of the most urgent demands upon the time of the alienist should be histologic and pathologic research.

The story, however, does not end here. A second field of work is beginning to claim attention-a field more wide, more vast even than that which has been opened up by Andriezen. After all, whilst the detailed study of the sane or insane cortex will enable us to correlate structure with function and change of structure with change of function, it cannot, save in special instances, as in the case of alcohol, where the cause is clear and self-evident-it cannot of itself reveal the underlying or initial causes that effect these changes. Even if it be possible to correlate the symptoms in the case of mania or of melancholia with dynamic changes in the cell and its processes, it cannot be expected that the agent which produces these changes can be brought to light by this method. After all, the changes that we see are but effects, and are in many instances purely terminal results.

The conviction is steadily growing in the medical mind that the actual agents which produce tissue-changes are chemic agents, toxic substances of one kind or another, no matter what their origin-in one instance absorbed or ingested from without, in another the poison elaborated by bacteria, and in another the poison of altered tissue-metabolism, of abnormal and deranged visceral function.

Unfortunately, we can to-day say little that is fixed and definite upon this subject, and yet enough is known to indicate that we have here vast fields of undiscovered truth. That toxic substances are formed in the blood, that toxic substances are excreted by the urine is well known. This is true both of substances formed by normal and abnormal tissue-metabolism. We need here only allude to the writings of Bouchard upon this subject to recall how the retention of well-known products may cause such symptoms as asphyxia, uremia, uricemia, cholemia, glycemia, etc. A number of French observers, among them Bouchard, Lépine, and Guerin, have isolated alkaloidal substances from normal urine, while Selmi and others have isolated basic substances from pathologic urine. Griffiths, for instance, has obtained ptomains from the urine of scarlet fever, diphtheria, pneumonia, whooping-cough, measles, glanders, and epilepsy. None of these substances exists in normal urine. Luff has isolated a ptomain from the urine of typhoid fever. Albu has discovered ptomains in various pathologic urines, whilst Ewald isolated ptomains from the urine in cases of carcinoma of the stomach, of uremia, and of Addison's disease. It is also known that the urine in melancholia has an increased toxicity, while in mania the toxicity of the urine is decreased while that of the blood is increased. Enough, therefore, is known to justify us in discussing the probable relation of these toxic substances to the nervous system.

That the nervous system is markedly influenced by the presence of toxic substances in the blood is, of course, well known. It remains only to outline a classification of these agents. To begin, certain toxic substances are

It

normal constituents of the blood and urine, and only under certain circumstances are present in excess, when they assert their toxic action. Thus Mosso demonstrated the toxicity of the blood of fatigued animals, while Arbelous demonstrated the same fact not only as regards the blood, but also as regards the muscles of fatigued animals. Lepicque and Marette demonstrated in addition that fatigue increased the toxicity of the urine. is probable that in these facts is to be sought a partial explanation of some of the phenomena of neurasthenia and of those graver forms of nervous exhaustion that eventuate in insanity. In other words, we have an intoxication of the nervous system in such cases from the mere accumulation of tissue-waste; or, to put it in scientific language, the products of excessive tissuemetabolism.

Closely allied to these substances are those that are present in the various diathetic insanities in which toxins are present, some of which may in smaller quantity be normal to the urine, while others are new and foreign. Thus in the insanity of gout we have doubtless to deal with uric acid, a substance normally present in the blood in small proportion, whilst in rheumatism we deal with a substance new and foreign. This is also true of the toxins of diabetic and of carcinomatous insanity. Regarding carcinoma, it may be stated that the toxicity of the urine is always in excess of the normal, proving thus the presence of some poisonous substance.

Next in order come the various toxic insanities due to disordered visceral action. Regarding these we have but little information. Enough is, however, known regarding the diseases of the kidneys and of the liver to indicate that the insanities associated with these affections are in all probability the result of autointoxication, the poisons being generated in consequence of the disordered action of the viscera. It is not at all improbable that disease of other viscera-probably of all of the viscera-is attended with the elaboration of substances that have a toxic action upon the nervous system, ie., autotoxins.

Next we should consider the introduction of toxic substances from without, and for the present we shall exclude all poisons ingested as such. From much that we know, we have reason to infer that under certain pathologic conditions poisons are formed in the stomach and intestines which act profoundly upon the nervous system. Massetti, who has especially studied this subject, comes to the following conclusions: First, that if there be a change in the process of gastric digestion by which, as a result of abnormal fermentation, noxious substances are produced, these when absorbed may in a predisposed individual cause disturbance of function of the nervecenters. Secondly, disturbance of the gastric function secondary to disturbance of the nervous centers may in certain cases lead to the absorption of abnormal materials from the gastro-intestinal tube, which may aggravate a pre-existing mental malady and may retard recovery. Thirdly, the stomach, like the rest of the digestive tube, is, among other things, an organ for the elimination of a toxic principle pre-formed and circulating in the blood. Unfortunately, here, as elsewhere, our knowledge is as yet too indefinite to enable us to speak with precision, and yet the occurrence of intoxication from the intestinal contents is of itself not open to question.

We have still to consider briefly the toxic conditions resulting from infection: for example, influenza, typhoid fever, the eruptive fevers, erysipelas, septicemia, etc. Here the action of the toxic agents resolves itself, as Regis points out, into two separate conditions, depending entirely on the period at which the symptoms of intoxication make their appearance. If these appear during the acute febrile state, they assume ordinarily the form of acute delirium; whilst when they occur during the post-febrile period they produce a mental condition in which confusion, stupidity, stupor, and psychic asthenia are the prominent symptoms. It is not improbable that the symptoms occurring both during the acute febrile period and during the post-febrile state are due to the toxins elaborated by the bacteria of the disease, and are in a sense comparable, the first to the stage of acute alcoholic intoxication, the second to the mental impairment and asthenia of the chronic alcoholic period.

It appears that the various intoxications of the nervous system resolve themselves into two great groups-first, the autointoxications, properly speaking, which embrace, first, the substances normal to the blood and secretions, but present in excess; secondly, those substances due to the general disturbance of tissue-change met with in diathetic conditions; and, thirdly, the poisons formed by the disturbed action of special viscera.

In the second group we have, first, those substances absorbed from the intestinal tract, some of which are produced, as we have seen, by disordered chemic action and morbid fermentation of its contents, and others normally excreted by the intestinal tract, but under abnormal conditions reabsorbed; secondly, we have the poisons that are the direct results or accompaniments of infection.

While we know comparatively little of the detailed chemistry of these poisons, we are justified in stating the following proposition, namely: that the most diverse agents may produce the same or at least similar clinical phenomena. For instance, the toxic action of alcohol resembles very closely the toxic action of the poison of an infection. The delirium of the febrile period of an infection may closely resemble alcoholic delirium. Again, the insanities coming on in the post-febrile or convalescent period, the so-called asthenic forms of insanity, in which weakness, stupor, and depression are the cardinal features, so closely resemble each other as to be practically indistinguishable. Nevertheless they may result from widely differing infections.

The determination of the toxicity of the urine, of the blood, or of other tissues and secretions implies of necessity experiment upon animals. If an alkaloidal substance be isolated from the urine, its toxicity can alone be demonstrated by experiment. The toxicity of the blood can only be proved by its injection into the veins or into the peritoneal cavity of some animal-a mouse or a guinea-pig. It is to be feared that attempts in this country to prosecute such lines of research may meet with opposition. "Public opinion," which too often is synonymous with public ignorance and public prejudice, may for a time prevent the establishment of experimental laboratories in hospitals for the insane. But perhaps at no very distant day, when it becomes clear that the pecuniary outlay demanded of the State for the care of its insane will eventually be diminished by the prosecution of just such researches, the opposition may

be withdrawn. As a matter of fact, every asylum, every hospital for the insane should have attached to it not only a laboratory for the study of the microscopic changes in insanity-changes that by the improved methods now at hand, notably those of Golgi and Ramon y Cajal, promise to yield great results, but also for the determination of the various toxic substances, their origin, their chemistry, and their mode of action upon the nervous centers. As we have already stated, the microscope can at best reveal only the wreckage in the path of the storm, whilst the chemistry of the tissues and of the excretions and experiments upon living animals will enable us to determine the actual causes and the actual sequence of the changes.

That consideration of the pathology of insanity from the standpoint here taken has a practical bearing there can, I think, be no doubt. If it be true that certain of the psychoses are due to intoxication through the stomach, certainly one of the first indications is lavage and other local treatment of the stomach. Indeed, to my mind, it seems good therapeutics to practise lavage in the majority of cases of the depressive forms of insanity, for instance in melancholia and in the various stuporous forms of insanity, not because we believe at this day that these insanities are due to the direct absorption of substances formed by abnormal chemic changes in the stomach, but because it is exceedingly probable that toxic substances even normally excreted by the stomach may, in these conditions, be reabsorbed. Again, if it be true that the psychoses are so largely due to the action of toxins, certainly hydrotherapy, so grossly neglected, acquires a value altogether unexpected. Its application should embrace not only the stimulation of the skin by baths and douches, but also the ingestion of large quantities of diuretic waters. Finally, if the psychoses are due to the action of toxic substances, we shall be in a better position to treat these affections when the action of these toxic agents is known-we shall be in a better position to suggest the proper remedial agents.

CLINICAL MEMORANDUM.

COMPOUND FRACTURE OF THE SKULL, WITH SEVERE LACERATION OF THE BRAIN, IN AN INFANT TWO MONTHS OLD, WITH RECOVERY.

BY CLAUDIUS H. MASTIN, M.D., LL.D. UNIV. PENNA.,

OF MOBILE, ALA.

THE following interesting case of severe injury to the brain of an infant, less than two months of age, is not without interest, but is worthy of record in the archives of surgical literature. It shows the tolerance of very young children to severe wounds, even when such injuries implicate vital organs. Although familiar with the histories of very many severe injuries to the skull and the brain itself, I am not able to find among surgical records a single case in which so young a child has met with so severe an injury and made so rapid a recovery-if indeed there has been recovery after such an injury.

The following notes, carefully and correctly taken at the time of the injury, will suffice to lay the case before the profession.