SINCE presenting my paper before the American Institute, in June of last year on “Vibratory Motion as a Method of Massage in Aural Diseases,” I have been using an instrument specially devised for that purpose called the “vibrometer.” This instrument is in shape like a banjo, and has four strings stretched across its length resting on a bridge, which sets upon a diaphragm. On each side, elevated above the diaphragm and supported by posts, are two horizontal bars, which support the mechanical appliances used for producing the various vibratory motions. This consists in what is called a yoke, in which revolves a shaft connected with the electro-motor by pulley-wheels and a belt.
Behind the diaphragm is a shallow air-tight compartment, leading from which are rubber tubes that are inserted in the external auditory canal during treatment, consequently any vibratory motion of the diaphragm, which must necessarily be an inward and a corresponding outward movement, would be exactly reproduced upon the membrana tympani, as the confined air, not being able to escape, will undergo an alternate condensation and rarefication in the external auditory canal.
Every vibratory movement of the strings of the instrument is communicated to the diaphragm by means of the bridge upon which it rests. These strings by varying their tension and length can be regulated to give a high or low rate of vibration as desired, for instance, the heaviest string left at its original length adjusted to a slight tension may make about fifty vibratory motions to the second, while the highest string on the instrument adjusted to a high tension and clamped down to one-fourth its original length would probably make three thousand vibratory motions to the second.
In the centre of the diaphragm is an attachment which works on a lever, and when hit by the cam on the revolving shaft lifts the diaphragm to a considerable extent, causing a powerful effect on the membrana tympani. This attachment can be adjusted at four different leverages, which causes a modification or increase of its intensity and can be regulated at from one to twenty-five vibratory movements to the second. This is only used in very bad cases and for not more than five minutes continuously.
The instrument which I have been describing in an improvement on the first manufactured, and as far as I know, is the only one which offers the same facilities for applying this method of massage. The class of patients in my experience who are generally benefited from the first, are those in which the mucous membrane lining the tympanic cavity and Eustachian tubes is in a hypertrophic condition. The membrana tympani are depressed, opaque, and thickened. They usually complain of a stiffed sensation in the ears, with a great deal of tinnitus aurium, and that their hearing is worse during a cold.
In cases where the mucous membranes are atrophied with a large external auditory canal perfectly dry and Eustachian tubes patulous, and generally very little tinnitus, this or no other treatment has done very much good in the majority of cases, and in looking ever my records I find that only about five per cent. have been relieved, while in the before-mentioned cases the good results reach at least seventy-five per cent. In treating persons, I always select the rate of vibration which corresponds in pitch, if possible, to that caused by the diseased condition of the ears.
If there is no tinnitus to guide me, I find whether the patient can hear a high or low sound better; if it is a low sound, a high rate of vibration is used in treatment, and vice versa, A point which I would like to explain here is this: It is not necessary that the sound from the instrument should be of the same quality of the tinnitus experienced by the patient, but merely the same pitch. for instance, if a banjo, where one of the strings was adjusted when sounded to produce a certain note, and a musical instrument of any other kind, whose quality of tone was entirely different, was made to sound the same note in a room, the string on the banjo would vibrate in sympathy, which has been proven by experiment, any other note, no matter how loud, would have no effect.
Another point is in the way the strings of the vibrometer are set in motion. On the revolving shaft is a wheel projecting from which are metallic picks which hit the string it is adjusted over. It does not make any difference in the number of vibratory motions per second, whether the string is hit fast or slow, but at the time the string is first hit the intensity is greater than it is just before being hit again, and as the motion of the wheel is perfectly rhythmic, revolving so many times to the second, it has just as good an effect as if the intensity during the fraction of a second did not vary at all.
The idea of using vibratory motion, as I have said before, originated within my mind some years ago, and later put into practical operation, and as far as I know, was the first to lay before the profession in a scientific manner, this method of massage.
I have found that when two of the strings upon the vibrometer were regulated in such a way that when both were set in vibration at the same time, producing the sensation of a harmonious sound, the effect in some cases on the tinnitus was especially beneficial, relieving, where the various kinds of vibrations produced by a single string failed. Sub-acute cases of deafness, accompanied by tinnitus aurium, are quickly relieved, as the following case will illustrate:.
Mrs. M. Young, married lady, aet. 26, called at my office, April 1, 1893, complaining of partial deafness and tinnitus aurium. She had a stuffed sensation, or as if cotton had been packed in the external auditory canal. She says the tinnitus was so annoying as to prevent sleep. On examination, found considerable retraction of the membrana tympani, and hearing for the watch, on the right side five inches, on the left, seven inches. The Eustachian tube were partially closed, which made inflation somewhat difficult, giving slight relief. I used several of the vibrations on the different strings without immediate benefit.
April 4th.-She came again, and reported that no improvement had taken place. I again inflated her ears, after which she sat down to the vibrometer. The central attachment was used with considerable force continuously for four minutes, after which she declared that the tinnitus had entirely ceased in the right ear, and greatly modified in the left; the hearing for the watch had increased for both ears to fourteen inches, and the stuffed sensation had almost entirely disappeared.
On inspection of the membrana tympani, found them comparatively very slightly retracted. On April 8th, found improvement had continued, when the same treatment was used for three minutes; after which she declared herself completely relieved of the tinnitus and stuffed sensation, with hearing powerfully restored. Saw her again on April 13th, when she declared the good results from last treatment to have still continued.
I find that in the majority of cases, when the strings of the instrument are used it is only necessary to strike them lightly with the friction wheel. In vibrating the heavy string, I generally set the bridge back behind the central attachment, and adjusting the motor in such way that the belt is at a considerable tension, so that the pulley-wheel revolves slowly. I also generally use this adjustment when setting in motion two strings at one time.
The principle of this method of treatment embraces two essential features which to my mind makes this system of massage the only scientific one applicable to the membrana tympani and its associate sound-conducting parts. Message is the application of motion to disease, and its scientific administration consists of its application in a systematic manner. In applying massage in aural diseases, it is necessary to produce a to-and-fro movement of the membrana tympani, and, if possible, by a force which is harmless and at the same time effective. The vibrometer fulfils these conditions.
Any of the strings on the instrument that may be set in motion by the friction-wheel, will produce a certain number of vibratory movements to the second of time, and the movements of the central attachment are also measured. What could be more systematic than this? The motions of the membrana tympani were intended by nature to its vibratory, and as the vibrometer generates measured motion, and these motions are vibratory, theoretically we have a scientific and effective method of massage in aural diseases; and, as demonstrated practically by the use of the vibrometer, we have in fact a great scientific advance over all previous methods.
Since the introduction of this treatment in aural diseases, it makes possible a more or less benefit in cases of deafness heretofore considered hopeless, and has opened up the field for the treatment of aural diseases to such an extent that the number of deaf patients seeking relief at the aurist’s hands will at least double itself.
H.C. HOUGHTON, M.D.: Dr. Garey’s admirable paper gives us the description of the vibrometer, an instrument devised under his personal direction and inspection, for the purpose of applying massage to the ear. It is the only instrument of the kind on the market, so far as I am aware, and after a somewhat prolonged use of it, I am prepared to recommend the latest production of the vibrometer company.
This instrument is a decided improvement over the instrument first sent out, and is capable of producing a most profound effect upon the drum-head and ossicula; indeed, upon the entire auditory apparatus. I am able to confirm Dr. Garey’s statement of the effect of high and low vibrations us regards treatment.
I have also been very much interested in the use of stringed or reed instruments for diagnosis, and find that we can detect any abnormal sensitiveness of the auditory nerve to high or low tones. Some patients are extremely sensitive to all tones, high or low; others to high tones and not to low tones; others, conversely. Again, in some instances, there is a peculiar sensitiveness to single tones or to discords produced by sounding the note and half-note at the same time.
Under the action of the central attachment of the vibrometer this sensitiveness is modified, the sensitiveness to high tones disappearing and being replaced by a low tone or, conversely, under treatment, a low tone disappears and a high tone is established, temporarily, at least. Again, in cases of recent origin, treatment will substitute an undefined rushing sound for a definite musical tone, either high or low, and later, the treatment will abolish this, the patient being relieved of this intensely annoying symptom. In some cases, with this relief, there is an improvement in the audition; in other cases, no improvement follows.
I confess to the domination of the material over my mind in my earlier experience with massage, and I think the inclination of operators will be to use a far greater degree of power than is necessary. I therefore notice with great satisfaction Professor Garey’s remark that “the object should be to produce a to-and-fro motion to the membrana tympani, and, if possible, by a force which is harmless and at the same time effective.” I would hardly say “to-and-fro motion of the drum-head,” because I think that the expression is liable to perpetuate the motion which is fixed in the minds of most physiologists, that the drum-head moves as a whole, with a to-and-fro motion.”
That is true under the influence of the Politzer, Siegle’s otoscope and similar instruments; but it certainly does not so move in the ordinary function of audition, but stands as the iris does in the eye, as an adjustor, a regulator of sound-force; in some sense as the iris does in its relation with the lens, to adjust, regulate and direct the essential force, and the vibration of the drum-head is at every node; every portion receives impressions that are converted into molecular disturbances of varying lengths, according as they are produced upon the stiff and unyielding portions of the drum-head at the periphery, along the manubrium, or in the more attenuated and easily-yielding portions which the between these two areas.
Not only so, but these impulses are communicated to the contained air of the tympanum, and make their impression upon the acoustic nerve through the round window synchronously with the impression made through the ossicula.
This whole subject widens before my mind in such a way that one might wish himself twenty years and at liberty to devote himself to a term of research in acoustics, such as is offered only in the technical schools of the continent of Europe.
WM. R. KING, M.D.: In discussing Dr. Garey’s paper I shall begin by saying that his methods have been closely followed by me since the beginning of his experiments, owing to the fact that I have been greatly interested in the treatment of deafness and tinnitus by means of sound waves or by aural massage since 1887, and have experimented and treated many cases by this method since then, though with crude and unsatisfactory instruments. Since using the vibrometer-which, after much study and experimentation, is now presented to the profession in practical shape-I have undoubtedly increased my percentage of good results.
I don’t believe I am over-sanguine or carried away by interest in this method, and believe I can rightly appreciate that this does not offer us a panacea or cure-all for auditory ailments, and hope I may always be ready to see the failures and to strive to find methods or remedies to reach some of them.
In speaking of the application of the instrument, I wish to call attention to the central attachment or post foe vibrations. Dr. Garey has not given it as much attention in the paper as it deserves. It is very useful as a general means of aural massage, rougher in nature and more general in application than the strings which help to make up the instrument. I often use it before applying the “similar found” to a given case, as a species of gymnastics, to stimulate secretion and motion in the conducting apparatus of the ear, viz., membrana tympani and ossicles. In most cases-in fact, in all-where tinnitus is present, I follow this up immediately by the nearest approach to the similar pitch obtainable.
I agree thoroughly with Dr. Garey, that the best results are achieved in cases accompanying hypertrophic catarrh, and that the least benefit is apparent in cases of atrophic nature.
Regarding the method of treatment in the absence of tinnitus, my experience the does not coincide with that of the author of the paper entirely; I do not feel that as yet we have any safe rule to guide us. My method has been to try the numerous sounds and variations the of until I find the one that seems to give the best immediate results, or that the patient himself will speak of as very penetrating and powerful )though not necessarily loud and heavy).
It seems almost impossible at present to simulate all the qualities of tone as they occur in the ears of those suffering with tinnitus; in fact, it would appear to be unnecessary. However, it seems advantageous and quite necessary to secure the closest simulation of pitch, thus in many cases soon obliterating annoying tinnitus and improving hearing powers.
The arrangement permitting of the picking of two strings simultaneously adds decidedly the usefulness of the instrument, as it increases the range of pitch as well as varying the quality of tones procurable, thereby decidedly enlarging our field of application.
The force used for creating the message or gymnastics of the membrana tympani and the ossicles-viz, vibratory force or sound- carefully and scientifically applied, is nature’s remedy, because it is adapted by nature, and is the only force which can rightly or safely be applied to these delicate portions of this complex organ of hearing.
A startling commentary on this subject is the array of cases benefited who have been relegated to the shelf by ancient and modern otology; cases declared unhelpable have been vastly improved. Pray, make no mistake; I did not say all cases.
It may be interesting to hear the latest regarding the instrument which was first invented for the application of this method of aural massage Mr. E.J. Godman, the inventor and patentee, is constantly on the lookout, and always striving for improvements to his machine. He has made many that you all know of. Permit me to report a few so recent they have not yet left the factory.
First.-The machine has been taken from its case, and is now mounted on a solid stand or table of oak, being set below the level, or so that the face of the instrument is just level with the face of the table. This is all supported by rigid, solid metal legs, which absolutely prevent foreign vibrations.
Second.-The motor has been removed from its little shelf and relegated below the table. I t can be placed upon a box on the floor, a shelf against the wall, or, better yet, a shelf solidly attached to the metal supports of the table. A belt goes up through an aperture to a wheel on a shaft, the other extremity of which carries a wheel with a rubber tire (a friction wheel), which in its revolution, being in contact with a larger flat- surfaced wheel on the main shaft of the instrument, turns this in harmony with itself.
This arrangement does away with the necessity of shifting the motor each time you wish to shift the carriage from one string to another- a consummation to be devoutly thankful for. The removal of the motor from the instrument as at present attached will recommend itself to all who have used the vibrometer, a great amount of undesirable jar being thus avoided.
Third.-Ratchet keys capable of very fine adjustment of tension of strings are now provided for the instrument.
Fourth.-A rheostadt or resistance-coil is now to be placed beneath the table between the storage battery and the switch, by this means enabling us to control the speed and number of revolutions to a nicety.
Other, though comparatively minor, improvements are being made, and others are contemplated, as, for instance, the substitution of a roughly corrugated rubber band for the picker on the wheel, thereby getting rid of the metallic sound of the picker on the wire strings.
I have experimented with a number of appliance for the production of the sounds and pitches that I have required, but I always fall back on the vibrometer, especially as at present constructed, for satisfactory work and results.
This instrument may be, and probably is, as yet, in its infancy. It, and the method it applies, can only be perfected by constant work and experimentation both on the part of the profession and of the manufacturers. Each improvement we can suggest, if it only should serve as a means of helping one solitary case, would be well worth our while.
The experiments being made by different methods for treating deafness by sound waves is indicative of the interest the profession has taken in the matter. It is indicative of a lack of something in our usual armamentarium which is greatly longed for by patient and doctor; that is, the means for making the deaf hear and for relieving distressing tinnitus. There has been a dearth in this direction, and perhaps there still is, but I believe fully that we have in aural massage by vibratory force a decided acquisition at our hands.
E. H. LINNELL., M.D.: I would simply like to ask Dr. King how long he uses the instrument, and whether he uses it according to the deafness.
DR. KING: Yes, decidedly. In an intense case of deafness I would have to use it a great deal longer. The central attachment I never carry over three or five minutes, and the whole treatment I don’t think is over carried over twenty or twenty-five minutes in one case, and usually averages from ten to fifteen.
HAROLD WILSON, M.D.: I have only to suggest, what I have elsewhere called attention to, the possibility of another mechanical device for securing vibratory motion. It is well known that in the make and break of a current of electricity, in the circuit of which there is a telephone, we get an influence upon the make and break of the current in the telephone. Now, it is a simple matter with which these makes and breaks are made as to obtaining any number of vibration that you wish. You may, by a mechanical device of some rotary motion, if you choose, make and break the current as rapidly as you please until you have reached several thousand vibrations a second, or you may even make the vibrations so slow us to be easily counted.
The application of this suggestion has been put in force in my own practice, more or less, in the use of the telephone as connected with the induction-coil ordinary battery. The more intense the current, the more intense the sound. You can easily see that it is mere question of mechanics to secure these two sounds-intensity of vibration and rapidity of vibration. I will say, furthermore, that it has this advantage. There is no noise in the office, which I think is not altogether true of the vibrometer. I would suggest that so far as the vibrometer is concerned, if it could be made to be noiseless to anybody but the patient, it would be a decided improvement. In that respect the telephone is a decided improvement, because there is no noise except to the patient, because the noise is right at the ear of the patient.