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contents, and the special funotion restored, COLLABORATORS.
with all the joy and advantage that attend the ALBERT ABRAMS, M. D., San Francisco. M. V. BALL, M. D., Warren, Pa.
recovery of serviceable hearing;—these give FRANK BILLINGS, M. D., Chicago, Ill.
the matter an importance that may arouse, on CHARLES W. BURR, M. D., Philadelphia. C. G. CHADDOCK, M. D., St. Louis, Mo.
the part of the progressive readers of THE 8. SOLIS COHEN, M. D., Philadelphia, Pa. ARCHIBALD CHURCH, M. D., Chicago.
MEDICAL FORTNIGHTLY, quick interest in a N. S. DAVIS, M. D., Chicago.
brief description of a simple method of acARTHUR REDWARDS, M. D., Chicago, Ill. FRANK R. FRY, M. D., St. Louis.
complishing these ends, if supplemented Mr. REGINALD HARRISON, London, England. RICHARD T. HEWLETT, M. D., London, England.
with a short dewoustration of its efficiency J. N. HALL, M. D., Denver.
in clinical experience.
Although not new, the method which we are
about to consider is one, not generally familiar E. E. MONTGOMERY, M. D., Philadelphia.
to physioians; and, even amongst specialists, NICHOLAS SENN, M. D., Chicago. FERD C. VALENTINE, M. D., New York.
it seems to have failed of due appreciation. It. EDWIN WALKER. M. D.. Evansville, Ind. REYNOLD WEBB WILCOX, M.D., LL.D., New York wa
was first publicly suggested to the medical H. M. WHELPLEY, M. D., St. Touis.
profession by Dr. Clarence J. Blake of Bos. WM. H. WILDER, M. D., Chicago, Ill.
ton, Mass., at the First Congress of the In
ternational Otological Suciety, which met in LEADING ARTICLES the City of New York in 1876. You will
find a description of the method, made at
that time, in the Transactions of that Society, INTERESTING PROBLEMS IN EAR, NOSE
published, in 1877, by D. Appleton & Co., AND THROAT PRACTICE.
of New York; and a more recent and exhaust
ive treatment of the subject, in the conjoined ROBERT BARCLAY, A. M., M. D.
treatise of Dr. Blake and Dr. Reik, just issued
by the same publishers, under the title of SAINT LOUIS.
"OPERATIVE OTOLOGY, SURGICAL PATHOLOGY, Fellow of the American Otological Society; formerly Assistant Aural Surgeon, New York Eye and Ear Infirmary,
AND TREATMENT OF DISEASES OF THE EAR." New York: Aural Surgeon, Missouri Pacific Railway
I beg to remark, in passing, that this work Hospital, St. Louis Baptist Hospital, M. K. & T. Railway Hospital (Sedalia, Mo.), Passavant
specifies several additional indications for the Memorial Hospital (Jacksonville, Ill.); etc.
application of this method other tban that for I. TO HEAL PERSISTENT PERFORATIONS OF
the bealing of perforations of the drum-head, THE DRUM-HEAD.
thus enlarging its field of usefulness in the
hands of those familiar with all advantages. ALTHOUGH not frequent, as a rule, in gen. The wethod of Blake consists essentially in eral practice, the occasions are nevertheless applying to the perforation, a moistened disc urgent, where it becomes necessary for the of sized writing paper, a trifle larger than the physician to have at band some simple, yet perforation. This is effected by cutting out reliable method of healing perforations of the of such paper, a disc sufficiently large to overdrum-head, persistent without attendant dis. lap the entire edge of the perforation; moischarge of secretions. For, not only does he tening it upon both sides with sterilized water meet this condition shortly after the patient or normal saline solution; carrying it to the has sustained an injury, but, less frequently, perforation, upon the tip of a wet cotton wool. perhaps, in cases where an active suppurative brush; applying it to the perforation, conprocess has entirely ceased, leaving a persist. centrically; pressing it snugly into apposi-ent and dry perforation, the cure of which tion with a broad, flat, dry cotton wool brush; appears, practically, an exceedingly interest and having the patient abstain from tympanic ing clinical problem.
inflation of any kind or degree, for from To deal with the former, in such a way as twenty-four to forty-eight hours afterwards. to induce healing rapidly, while averting the Amongst the principal advantages of Dr. evils attending prolonged exposure of the Blake's method, may be mentioned: that it oloses the perforation in such a way that the allowed to remain until it had passed clear drum-head is at ouce perfected as a sound. outward to the inner edge of the wall of the sail; the tympanum is kept filled normally auditory canal, just at its junction with the with warm, moist air; the growth of new imaginary line marking the division of the membrane is stimulated, at the edge of the upper and lower posterior quadrants of the perforation; a splint, or plane, correspond. drum-head; the perforation having bealed ing with the circumference of the perforation, over during its passage. This was now the is supplied, upon which, without the other. thirty-seventh day since the disc bad been wise unavoidable variable stress or flapping, originally applied. It was forthwith removed the growth of new membrane across the per- from the canal wall with a Jack's stapedeoforation, takes place steadily, and upon the tomy-hook; and there is now no evidence normal plane of the drum-head; and the discs whatever to indicate the site of the original serves also as a local stimulant, support, and perforation, tightener, in like manner, to loose or flapping parts of the drum-head, even where no perfor. CASE II.- Drum-head ruptured by blow ation of the structure exists.
of a sand-bag. L. L, K., aged 39 years, was As evidence of the wide range of its appli. struck a severe blow, upon the left side of cation, in cases of perforated drum-head, I his face and head, with a sand-bag, in the would state, in passing, that this method has hands of an enraged discharged employe. availed me, to secure union by first intention, Six days later, on examination, a dried, cir. in a case where the entire antero-superior cular perforation of the left drum-bead, onequadrant had been detaobed by a blow of the eighth an inch in diameter, was found, close fist upon the ear. After replacing the detached to and bebind the umbo, or lower extremity flap, it was held in place by a Blake-disc; of the handle of the malleus. and after healing, thus, and subsequent re- A forty-eight-inch watch could be heard moval of the diso, no evidence whatsoever of with this left ear at a distance of but five previous injury to the parts was recognizable. inches; his own watoh, at eight. The lower
I have employed this method, also, much to tone-limit for the tuning-fork was sixty-four the astonishment of a brother-practitioner, in vibrations a second, an elevation of one octave healing a perforation of his own drom-head, from the normal. Hearing by bone-conducwhich had previously persisted for fully tion was better than that by air-conduction, thirty-five years.
from the fork of thirty-two, to that of two. The advantages of this ready wethod are thousand-and-forty-eight vibrations & second beautifully illustrated in the following cases: -the entire normal tuning-fork range.
After the application of the Blake-paperCASE 1. – Drum-head ruptured while diso, of circular form, three-sixteenths of an wrestling. G. S. R., aged 22 years, while inch in diameter, the forty-eight-inob watch wrestling, had his head suddenly and tightly was audible, with this ear, at eighteen inches compressed, from side to side, between the arm distance-showing increased hearing power, and body of his antagonist, attempting a for this watch-tick, -over one-thousand perstrangle-hold. After the bout, his left ear felt cent greater than before. He could now hear numb and deaf; and besides a constant bis own watch at twenty-four inches distance ringing in it, be heard an unnatural echo of showing an increase of over eight-hundred his own voice upon that side.
per cent in hearing power, for this sound; Nine days later, on examination, a small and he could hear a low whisper at thirteen crust, elliptical in shape, abuut oneeighth of feet distance,—the limit of capacity of the an inch in its longest diameter, was found testing-room. upon the left drum-head, just behind and be. The diso remaining in situ until the sixth low the umbo, or lower extremity of the day, he was permitted to absent himself from handle of the malleus. This was carefully observation for a considerable period of time. removed; and, near it, was found, a small, On the twenty-sixth day after the diso bad dry, slit-like perforation, about one-sixteenth been applied to the perforation, it was found of an inoh in its longest diameter. This, ex. at the junction of the drum-head with the amined with the utmost care, and with mag. canal-wall, at the level of the imaginary line nifying-glasses, proved to be prefectly dry of demarcation between the postero-superior and quiescent, and presumably persistent. and postero-inferior quadrants of the drum. No further abnormal feature could be noted head. From this point, it was readily rein the affected drum-bead.
moved with a Jaok's stapedectomy-hook, and The Blake-paper-diso was then applied; a Dench-MoKay forceps. and its progress from the site of its original No trace whatever of the perforation was application toward the periphery of the drum. now visible; and the hearing was found nor. head was noted, from time to time. It was mal; whereupon, he was discharged cured; and there has since been no evidence what. METABOLIC ASPECTS OF OVER-FEEDING ever that any injury had ever been done to
AND OF UNDER-FEEDING.* the ear.
RALPH W. WEBSTER, M. D., PH. D. CASE III. – One drun-head ruptured
CHICAGO, ILL. while sliding to base;" the other, by former inflammation of middle-ear. W.E.W., aged In these days, in which we have so much 26 years, wbile “sliding for Third," in a to do with the various disorders arising, di. base-ball game, struok bis left ear against rectly or indirectly, from the use and abuse the opposing base-man's knee. Immediately of our diet, it seems fitting to ask ourselves afterward, and up to the time of consulting whether we are justified in ordering a certain me, he found this ear practically deafened; diet in one case and a definite diet in an. he had a continuous buzzing in it, and an other. It is not my intention, in this paper, annoying echo whenever he used his voice.
to outline what, to my mind, seems the proper The night following the accident, he suffered dietary in various ailments and diseases with from frontal head-ache.
which we are all confronted, but, rather, to Tbree days later, on my first examination, discuss, briefly, certain phases of the subject a dried, circular perforation of the left drum. of over-feeding and of under-feeding. head, three-thirty-seconds of an inch in diam. eter, was found, half way between the umbo, or lower extremity of the handle of the mal. leus, and the postero-inferior edge of the membrane. No signs of activity were recog. nizable about it.
A large perforation of the antero-inferior quadrant of the right drum-head, five thirty seconds of an inch in diameter was found; around which, and in the oul-de-sac of the canal, was found some muco-purulent secre. tion.
The patient stated, that he used to have discharge from the right ear for years; and that this right ear was 'now' his "bad ear.”
A Blake-paper-disc was applied to the left perforation at once; and bebaved as usual in such cases. As soon as the right ear seemed to have become quieted, and no discharge had been noted for several days, a Blake-disc was applied tentatively; but this had to be removed, a couple of days later, on account of excess of discharge within the tympanum,
RALPH W. WEBSTER, M. D. which oozed out beneath the edge of the disc. After the diso had been removed, it was no.
NORMAL STANDARDS. ticed, that the edge of the perforation had be.
Before proceeding with such a discussion come raw; and the perforation bad begun to heal. Treatment was then instituted, to place
it is imperative that we fix clearly in mind
just what we are to regard as the normal die. the tympanic contents in a more bealthy con
tary standard for a person in good health and dition; when the Blake-paper-disc was once
physioal condition. At the outset we must more applied. Eighteen days after the application of the
remember that certain factors, such as age, Blake-diso to the perforation of the left drum
sex, ocoupation, climate, external surroundhead, it was removed with a Jack's stapedec.
ings, etc., have a great influence in determin. tomy-hook, the perforation having healed,
ing the amount of food necessary to maintain
one in a condition of healthy equilibrium. with normal hearing; and no trace or sign of
Hence, in speaking of a normal standard the perforation remains to mark its former
diet, I will refer, later, to the diet of a site. After a brief period of time, not acourately
healthy adult male doing a moderate amount
of work. recorded, the disc was removed, in the usual
As we all know the standard diet of Carl manner, from the right drum-head also; the
Voit has long been accepted, more or less old perforation having finally healed.
generally, as representing the needs of the (To be continued.)
* Read before the Mississippi Valley Medical Association, 3894 Washington Boulevard.
body under normal conditions of life. He necessarily, imperilled by a strict adherence considers that a person of 70–75 kilos weight to the Voit standard. As Magnus-Levy raquiros 118 grams of proteid (of which 105 puts it, "Is it actually the case that life is grams must be absorbable), 56 grams of fat, constantly endangered, hovering as it is beand 500 grams of carbohydrate. This stand- tween the Scylla of toxins and the Charybdis ard of Voit represents, therefore, a calorie of metabolic end-products?”. value of 3055.6 or 43.65 calories per kilo of The question might be asked at this junc. body weight.
ture, why do we consider the proteid content The standards of Ranke, Atwater, Schmidt, of a dietary ae so much more important tbau Gautier, and others are approximately the the fat or carbohydrate values ? If these same, although they differ somewhat in the latter constituents are utilized at all, they are relations of the different constituents. Von oxidized to simple products, wbich are easily Noorden states that 1.3-1.5 grams of proteid exoreted and, hence, cause no undue strain on per body-kilo are necessary to maintain the the assimilative and excretory organs. Of body in nitrogenous equilibrium, while it is course before being oxidized, a portion of immaterial whether the requisite calorie value both of these is stored up in a passive form (35–50 calories per kilo depending on the subjeot to furthor orders from the system in amount of work done) is brought up by fat general. I have, naturally, no reference, bere, or carbohydrate.
to the effect of an excessive fat or carboby. Recently Chittenden, in an elaborate study drate diet, which is a factor in the production of the proteid requirements and metabolism of obesity or of diabetes. of different classes (teacbers, professional With the proteids, however, a somewhat men, soldiers, and athletes), has shown that different course of events is observed. To nitrogenous equilibrium may be satisfactorily be utilized by the system proteid must be maintained with about 1-1 of the proteid built up into its constituent protoplasm. standard of Voit. This work is of exceed. We are all familiar with the differentiation ing importance as it proves, beyond a doubt, of proteid as organized or unorganized, stable that the proteid need, as indicated by the or, labile, tissue or reserve, etc. It is unmaintenance of nitrogenous equilibrium, is necessary for me to do more than call at. far below our generally followed standard of tention to the conception of “reserve proVoit. As Ohittenden's experimental subjeots teid" as being entirely analagous to reserve were in excellent condition, both physically fat or carbohydrate. The proteids, on oxi. and mentally after a period of several months dation, are spilt up into various nitrogenous on such low proteid diet, it is very apropos to produots, some of which may exert, if pres. ask, “Is there any real scientifio ground for ent in sufficient quantity, or if acting over the assumption that the average individual, long periods of time, untoward effects predoing an average amount of work, requires ceding and during their excretion. These any such quantity of proteid or of total nu. metabolic end-products, or toxins as they trients as the ordinary dietetic standards call have been styled, may cause some specifio or for? "While it is true that this lowered local disturbance, which calls for their speedy standard of Chittenden may maintain the removal. In the elimination of such prodvarious individuals studied in nitrogenous ucts through the kidneys, definite lesions or equilibrium, it does not do so without an. at least functional insufficiency may arise. swering the total caloric need of the individ. Moreorer, the other organs of the body, ual, as evidenced by the fact that all of the ' which have to do with the further elaboration subjects showed a calorie consumption of of these products, may suffer functional im30—40 calories per body-kilo: Chittenden pairment in their attempt to keep pace with says, “It is self-evident that the smallest the excessive supply of elaborative material. amount of food, that will serve to keep the Our knowledge regarding the formation and body in a state of bigh efficiency, is physio. excretion of these nitrogenous end-products is logically the most economical, and hence the too meager to permit us to say whether inbest adapted for the needs of the organism. creased formation is accompanied by inAny excess over and above what is really creased excretion of each product or whether, needed is not only uneoonomical but may be on a diet rich in proteids, tbese substances directly injurious.” Although it is doubt. are retained to a greater extent than on a diet less true that the unnecessary overloading of such as is advocated by Chittenden. On the the system with excessive produots of pro- solution of this point depends, it seems to me, teid metabolism, may, in time, weaken the the decision whether the Voit standard is a digestive, absorptive, assimilative, and ex- dangerous one. Naturally tbe excretion of an cretory functions, yet we are not warranted, increased amount of these end-products might it seems to me, in assuming that the life influence the secretory organs, but it remains and happiness of a normal being are, to be proven whether the kidney, in health, is or is not capable of excreting the products the other, of a series of peouliar derange. of metabolism of the proteid standard of ments, pointing to a condition of under un. Voit, without suffering undue strain.
trition. I need only refer to the obese, dia. Folin, in his careful work on proteid utili.
betic, and gouty subject on the one side, and zation, through which he was lead to formu.
the neurasthenic, neuralgic, and chlorotio Jate his "Theory of Proteid Metabolism." patient on the other. I shall, therefore, in comes to the conclusion that our proteid die.
this paper, treat of the subject of over-feedtary is much too high. His figures agree
ing, only as a therapeutio measure and not
108, only fairly well with those of Chittenden and are as an elio
bars as an etiological factor in disease. based on determinations of the exogenous and It has been shown by Rubner, Magnusendogenous nitrogen. His work shows us Levy and others, that addition of an excess how futile it is to draw conclusions, regard. of food, in the form of fat or carbohydrate, ing the nitrogenous metabolism, from the exerts, even when given in large amounts only amount of urea excreted. Of much greater a slight increase in the energy relations of importance is the nitrogen partition and, par. the system. This, of course, applies to an ticularly, the amount of creatinin excreted immediate increase in the oxidative processes in twenty-four hours, inasmuch as this nitro.
and not to the later effects of the reserve fat genous constituent is the one nitrogen factor
or carbohydrate. Only a part of such excess uninfluenced by a variation in the meat-free is burned up in the system, the chief part be. proteid diet.
ing stored in the various depositaries subjeot It would seem, therefore, that we must ac- to the checking orders of the system. On adcept the possibility that our proteid intake
dition of fat to the diet almost the total ex. may be diminished to one-third to one-halfcess of energy is turned to the advantage of of the Voit standard without causing any dis.
the body, not in the form of increased enturbance of the nitrogenous equilibrium or ergy, but, ratter, in the form of latent energy of the general health and physical activity. as a deposition of fat. Zuntz has proven. However the writer is inclined to believe, that of 100 grams of fat-increase in the diet, without having definite experimental grounds 97-8 grams were stored up. With the carbo. for his belief, that a diet, which keeps strictly bydrates the relations are not quite so high, within the presoribed standard of Voit, will Å loss of 10%, according to Žuntz, is obwork no lasting ill.effect, unless the system served in the total energy available from an be undermined by disease, which is not trace.
increase of carbohydrate. Moreover, the con. able to errors of diet, and in which no sensi.
version of the carbohydrates into fat is acble physician would order a dietary high in
companied by some loss of heat. proteid until the period of convalescence had been definitely established. It is most cer.
An increase of proteid in the diet raises, on tainly true, that a moderate diminution of
the contrary, the general tissue metabolism, as proteid is less barmful, providing the total evid
evidenced by the increased oxidation, far diet be sufficient, than is an abundant pro.
above the normal standards and far above teid diet with a calorie deficit (von Noorden).
that, which could be traced to the activity of
the bowel. This primary increase in the oxiAccepting, then, that the average diet of a dative processes, which is effected by a meal normal individual should contain from 30-50 rich in proteids, lasts for eigbt to ten hours. calories per body-kilo and that the proteid. This fact may be expressed more briefly in content of the dietary should run between the statement that, every addition of proteid three-fourths and one and one-half grams of
increases the proteid decomposition, the sys. prcteid per kilo, we come to the discussion of tem soon adapting itself to a new equilibThe subject of our paper.
rium. Right here it may be well to point OVER-FEEDING.
out that it is erroneous to refer every loss of
nitrogen to an increased decomposition of By the term over-feeding or forced-feeding body-proteid. There is no reason for supwe mean the giving of an aipount of food,
the, giving of an aidount of food, posing that tissue-proteid is decomposed in which furnishes the body more energy than any different way than is food-proteid. Likeit needs, utterly regardless of whether the wise we are not justified in assuming that addition be in the form of proteid, carbohy- the products of tissue-metabolism are, nordrate, or fat (von Noorden).
mally,or abnormally, any different from those The errors in diet, which most of us, un of food-metabolism under the same condifortunately, commit, are productive on the tions. The point of all this is, that the inone band, of various disorders as a result of creased nitrogen excretion observed under tbe overtaxing of the digestive, absorptive, certain conditions may be referable to the assimilative, or excretory organs with exces. proteids of the food and not to those of the sive products of metabolic activity, and, on tissues.