CHAPTER III. THE EXAMINATION OP AURAL PATIENTS. (Part 1)

CHAPTER III. THE EXAMINATION OP AURAL PATIENTS. It is a self-evident proposition, that in order to intelli- gently treat any disease, we must carefully and thoroughly examine the parts involved. This is certainly as true of the affections of the ear as it is of those of any other organ. In making such an examination a definite plan should be followed, even in the seemingly simple cases, until at last a large experience enables the practitioner to omit or hurry over some of the details which were necessary in the begin- ning of his practice. In the examination of an aural patient, the following method is the one that I have found very useful : — I usually keep a record of the cases ; a plan which the young, and con- sequently not very busy, practitioner will find extremely valu- able. The name, age, and occupation of the patient are noted. The history should then be given. This history should include a pretty full statement of the general condition, the diseases from which the patient has suffered, the number of times he has had what is called " ear-ache," the medication to which he has been subjected, and so on, from his earliest recollec- tions until the date of his coming under observation as an aural patient. By no other means than by eliciting such a history, can the practitioner get the essential knowledge for a thorough understanding of the subjective manifestations of the affec- tion of the ear. It is very important to ascertain when the troublesome symptoms were first observed. Sometimes sev- eral minutes will be consumed in obtaining an answer to this question. The first reply will be, perhaps, "A few months ago," or, " A year or two." If this response be followed by 68 EXAMINATION OF AURAL PATIENTS. the inquiry, " Before that time were your ears perfectly well ? " in many instances the patient will state, " Well, no. I have had a little dulness of hearing on one side, for ten or twelve years, or for a good while" (which proves to be a number of years) ; or perhaps he says, " There has been a little discharge from that ear, ' which didn't amount to much,' ever since I had the scarlet fever or the measles." As illustrative of this point, I may mention a case which lately came to my clinic ; the patient, an old man, gave the following history : "While sitting quietly by the fire, blood began to run from his ears, until he had lost quite an amount ; he stated positively that this was the first time in all his long life that he had ever had any kind of an affection of the ear, and that he could imagine no cause for it. On close examination in the man- ner of questioning above indicated, he admitted that he had suffered from a "slight running from the ears, which didn't sig- nify, ever since he was a child." An inspection of the organs showed that both inembranse tympani were removed by ulceration, and that exuberant granulations existed, which ac- counted for this seemingly mysterious hemorrhage, to which the patient could assign no cause. It is well in obtaining the history to allow the patient to tell his own story, occasionally interrupting him, as may be necessary, in order to keep him to the matter in hand. After having thus obtained as accurate an account as possible, the next step is to test the amount of hearing. We have three tests for the hearing power : 1. Ordinary conversation. 2. The tick of a watch. 3. The tuning-fork. The first of these tests, the power of hearing conversa- tion, perhaps tells the most about a person's practical hearing power, and yet it is the one that is carried out with most diffi- culty. There are many persons who can hear the tick of an ordinary watch but a short distance, say six inches, and yet are able to hear ordinary conversation with some ease ; and on the other hand, there are others who can hear the same watch twice as far, but who are utterly unable to enjoy con- versation carried on in an ordinary tone. About the best test THE WATCH AS A TEST OP HEARING. 69 of the hearing power that we have, is the one which shows the patient's capability for hearing what is said in social inter- course, at the table, in the drawing-room, and so on. Inas- much, however, as practitioners, especially those who live in large cities or towns, have not always, or even usually, the opportunity of making such a test of their patient's hearing capabilities, and since the amount of this power, although it may be appreciated by the observer himself, cannot be made clear to one who simply reads the case, we are obliged, in recording the histories of patients, to be content with a state- ment as to how far an ordinary ticking watch may be heard, or at what distance words can be understood when they are directed to the person observed, with his face so placed that he cannot see the mouth of the speaker. This latter pre- caution is an essential one, since all persons with impaired hearing soon learn to watch the lips of the speaker, in order to compensate for their loss of hearing power. In testing the hearing by means of the watch, it should be first placed at a distance at which its ticking cannot be heard by the patient, and then gradually approached to a situation where the ticks can be accurately counted. The latter may fairly be considered as the farthest point of distinct hearing. The ear which is not being tested should be closed during the examination by the hand. It is hard to state the distance at which a watch should be heard by a healthy ear, for the simple reason that different watches may be heard at different distances, so varying is the distinctness of the tick. It may be approximately stated, however, that an ordinary ticking watch should be heard, by a person with average hearing power, at least four feet. To this rule there are, however, exceptions. For instance, I know a medical gentleman in this city, who, as tested by the ordinary transac- tions of professional and social life, is not at all hard of heai> ing, who cannot hear a watch of common tone more than six inches. Exact examination would undoubtedly show that this gentleman's hearing is defective with regard to all tones like those of a watch. In testing the hearing power by means of a watch, it is well to remember, as Von Troltsch suggests, that all watches are 70 EEGISTER OF HEARING POWER. heard better immediately after they are wound, and also that the intensity of their sound is increased by holding them so that the surgeon's hand covers the back, or when they are held by the patient's own hand. In the two latter instances the cause of the increased clearness of the tick is, in the one case, the retardation of the reflection of sonorous waves from the watch, and in the other, the conducting power of the patient's own arm as it is stretched out. The use of a tape or other measurer, to note the number of inches at which the watch is heard, is indispensable for an accurate record of a case. The measure should not be used, however, until the distance has been ascertained without it. When the patient cannot hear the watch at any distance from the ear, it should be laid or pressed upon the auricle, mastoid process, or forehead. Before using a watch for the purpose of testing the hearing power of diseased ears we should carefully ascertain how far it may be heard by persons whose hearing is unimpaired. My friend Dr. J. S. Prout, Surgeon to the Brooklyn Eye and Ear Hospital, has greatly facilitated our means of record- ing the hearing power, by a simple method, which is some- what analogous to that used in estimating the acuteness of vision ; but, as Dr. Prout says,* " the accuracy with which we measure the visual power by Snellen's test types, and record the results obtained, cannot be arrived at by means of any of the usual sound-makers (sonofactors) ; nor will it be until an instrument can be made which shall always produce uniform tones." Dr. Prout recommends a formula for registering the hearing power, which he describes as follows : " For nearly three years I have recorded the hearing power as a fraction, the numerator of which is the distance at which the particular sound is heard, the denominator the distance at which it should be heard by an ear of good average hearing power. This denominator must vary according to the sonofactor used, and should generally be expressed in inches. " For still further simplification, and that the method may be adapted to international use, I suggest the following abbre- viations : A. D., auris dextra, instead of right ear, or B. E. ; * Boston Medical and Surgical Journal, Feb. 29, 1872. EEGISTEE OF HEAEING POWEE. 71 A. $., auris sinistra; P. A., P. aud., potentia auditus, hearing power ; V., vox, the spoken voice ; V. S., vox susurrata, whis- pered voice — or simply S., susurrus, a whisper ; H., horolo- gium, the watch. " If this system should become general, then the formula P A, A D, H, = ||, would to all otologists represent the fact that a watch that should be heard at 36 inches was heard by the right ear of the patient at a distance of 12 inches ; the formula P A, A S, V S, =3%, would mean that the whispered voice was heard by the left ear at 6 inches that should have been heard at 36 inches." I have employed Dr. Prout's method (more or less) for some years. My own watch can be heard by a person with good hearing power, at least 48 inches. It will be seen that if I wish to express the hearing power of a person who hears that watch one inch, I would use the fraction ¥, and so on. If the patient only hears the watch when brought in contact with the ear, we may employ the formula ?qa ; if only on pres- sure, -£% ; if not at all, ¥°¥. THE TUNING-FORK. The tuning-fork is of value in determining if any disease of the auditory nerve exists, and if so, whether its lesion pre- dominate over the affection of the outer parts of the ear. As is well known, if we close our ears, and speak, the sound of the voice seems to be confined to the head, as it were ; its reflection being to a certain extent prevented by the closure of the external auditory canal. If now the auditory nerve be sound, and there be impacted wax in one auditory canal, or a thickening of the mucous membrane lining the cavity of the tympanum, the state of things will be similar to that when the external meatus of a healthy ear is closed by the finger, or by some similar means, and the vibration of the tuning-fork will be heard more distinctly by an ear thus affected than by the sound one. If the ears are equally affected, it will be, of course, more difficult to come to a con- clusion. If the nerve be seriously impaired, either primarily or secondarily, by disease which has extended from the mid- 72 VALUE OF THE TUNING-FOEK. die ear, no such marked difference will be noticed when the external meatus is closed. Again, when the tick of a watch cannot be heard at all, if the auditory nerve be not seriously impaired, the vibrations of the tuning-fork, when its handle is placed on the teeth, fore- head, or mastoid process, will be distinctly heard ; while if the nerve be the seat of serious lesion, so that absolute deaf- ness exists, these vibrations will not be at all perceived in the head. Some deaf-mutes, who were born deaf, and proba- bly with a disease of the central apparatus, have assured me that they always felt the sound of the tuning-fork passing to the region of the diaphragm or stomach, and they would in- voluntarily place their hand there when the vibration began. The large tuning-forks of the note C are to be preferred to the smaller ones. There is one source of error in the use of the tuning-fork that cannot be fully avoided. Patients who do not have fair habits of observation will say that they hear the tuning-fork better from the better ear, because they think that they ought to do so. A little care in urging such persons to notice the sound carefully will usually cause a correct answer to be given. Its chief value is, however, among persons who can be taught to observe what they actually hear, and who will allow their theoretical notions to remain in abeyance for a time. As Dr. Prout intimates, the great desideratum is an instrument which will give the same number of vibrations, of the same pitch and tone under the same conditions. It should also be a portable instrument, and which can be multiplied with accu- racy to any number that may be wanted by those who test hearing power. An interesting case occurred hi my practice last spring, which shows the value of the tuning-fork in cases of slight impairment of hearing, and also exhibits the inadequacy of the watch as a test of hearing power. Dr. W., set. 33, consulted me March 12, 1872, in regard to an uncomfortable, " stuffy " sensation in the right ear, attended by a slight impairment of hear- ing. His history was that he had had nasal catarrh for some months ; for two days he has observed the aural trouble. On testing the hearing power by the watch, it was found to be normal, or ff on both sides ; but the tuning-fork teas heard better on the affected side, and the patient, a busy physician and an exact VALUE OF THE TUNING-FORK. 73 observer, was sure that his hearing power was somewhat impaired upon the right side, although the watch did not detect it. The membrana tympani was slightly injected along the handle of the malleus. I diagnosticated the affection as sab-acute inflammation of the middle ear of the right side, and treated it by the use of the Eustachian catheter, Polit- zer's method, and a gargle, as well as by the application of a leech to. the tragus. After the first use of the catheter and Politzer's method, the tuning- fork was heard with equal distinctness on both sides, thus confirming the diagnosis and illustrating the value of the test. The patient recovered per- fectly in a few days ; but at each visit before the ear was inflated until his ear was fully restored to the normal condition, the tuning-fork was heard more distinctly on the affected side. According to Politzer,* E. H. Weber was the first to show the facts that have been stated with regard to the increase in intensity of the sound of a tuning-fork, on the side of the meatus that is closed by the finger. MaeJi, quoted by Politzer, explained this fact by the theory that the reflections of the waves of sound from the ear was prevented by this closure of the auditory canal. Politzer concludes, as the result of experiments, which may be found in detail in the first vol- ume of the Archiv fur Ohrenheilkunde, that the increased per- ception of sound that is felt in one ear depends upon two causes : 1. The waves of sound that have been carried from the bones of the skull to the air of the external auditory canal are reflected back on the membrana tympani and ossicula auditus. 2. In accordance with Mach's theory, the passing out of the waves of sound which have reached the labyrinth and cavity of the tympanum, through the bones of the head,t is prevented by the obstacle they meet in the closed ear. It will thus be seen that Mach and Politzer explain the phenomenon of increased perception of sounds conveyed through the skull, in an ear whose peripheric portions are obstructed by disease, or by some mechanical cause, entirely by the theories that the loss of sound is prevented by the obstruction to its reflection from the auditory canal, and that the force of the waves is also intensified by their being thrown back upon the nerve. * Reprint from Wiener Medizinischen Wochenschrift. t Archiv fur Ohrenheilkunde, B. I., p. 321, 1868. Politzer, 1. c. 74 VALUE OP THE TUNING-FORK. Erliard" believes that the increased intensity of the sound in an ear whose outer opening is closed, is due to the fact that J the force or impression of sounds that otherwise disturb and distract the mind, is diminished by the closure of the meatus. This reasoning seems to me plainly fallacious. Cases of disease of the middle ear that are connected with disease of the labyrinth, or cases in which the middle ear is sound on one side, while the nerve is affected, and just the opposite state of things exists on the other side — that is, the middle ear is diseased and the nerve sound — will of course ren- der the value of the tuning-fork less positive, and a differen- tial diagnosis difficult. Dr. Politzerf attempted to make the tuning-fork test more objective, that is to say, less dependent upon the statement of the patient, by the use of a diagnostic tube with three arms. The patient has one in each ear, while the surgeon