easily neglected unless it be kept in mind, that everything that enters the room of one sick with contagious disease, must remain there until measures are taken to disinfect them. As the contagion of some of these diseases may be carried in the clothing or hair, precaution must be taken by any one leaving the room

The physician should wear an outside protection to his clothing, when in the room, and must not sit down in the room, or touch the patient more than necessary. He should hold his breath when examining throats, and if the patient coughs, keep out of the way of the breath, as particles of infection may be thrown from the throat upon him. Domestic animals may carry contagion. In sweeping the room, I would suggest the use of damp, carbolized saw-dust to avoid the danger of spreading into other rooms dried particles of infectious material contained in the dust from the floor.

Patients should spit only on rags, which should be burned, or if spit-cups are used, they should contain a strong disinfectant solution. All excrement from the patient should be disinfected and buried. Washings should be disinfected, also all books, papers, dishes, children's playthings, brooms, brushes, clothing, bedding, and in fact, every surface which has been exposed to the atmosphere of the room used for patients with infectious diseases. In diseases in which the infectious agent is given off from all parts of the body, occasional ablutions of olive oil will prevent the spread of contagion by desquamation.

Other members of the family, and all inmates of the house who might have been exposed, should be kept at home, and watched for the early symptoms of the disease until the period of incubation is passed.

It should not surprise us if many of these precautions seem unreasonable to ignorant people, and we will often meet with opposition among the better classes, where we would expect better judgment and more respect for the opinions of our profession. We, however, should not resent it, for the first passengers over a new road must expect a jolting.

It will be necessary to explain to the people in a manner to suit their intellects, the theory which demands these measures, and expect to meet with trying ridicule, but if all physicians would endeavor to strictly follow the plan, the public would soon find it necessary to follow directions, and consider our demands of more importance; and while others who have the opportunity, are trying to develop practical theories by means of which the human system may be rendered insusceptible to contagious diseases, we in our sphere of usefulness, may be contributing our share to preventive medicine by devising means for the successful application of our present knowledge, to the requirements of fellow beings in our own localities.

If our predecessors had known the value, and persevered in the

practice of even the few suggestions I have brought to your notice, they would have saved more lives than they ever did with their drugs, and this remark will apply to the present generation of doctors as well.

The improper use, or neglect, of the general adoption of a good practice, is proof to me, that there is a lack of knowledge, either of the theory or the means of applying it practically; and that the practice of preventive medicine is sadly neglected by many of our physicians today, I know to be a fact.

Not only this, but I have known members of our Society even, who professed better things, to not only neglect proper precautions, but to put little obstacles in the way of others who were trying to do right.

We sometimes forget, in our own active competition, to have charity for other doctors who may have thought best in some case to isolate a patient, because his symptoms simulate those of some contagious disease, and we perhaps may offer some cutting, sarcastic remark, with our opinion of the "useless practice," just to gratify a jealous feeling which should not be humored. This is encouraging ridicule which should, and probably would, reflect upon our own practice when similarly perplexed, and desiring to do our duty. We are all at times uncertain in our diagnosis of disease, which may be complicated with other troubles, and it would be much better never to encourage a neighbor to scoff at your competitors' diagnosis, but always encourage respect for your profession.

It is too much the practice for opposing physicians, as well as people of other professions, to hold up the stumblings of medicine to the public gaze, and invoke ridicule and censure; but if the faults and defects of the public officers-if the deficiencies and errors of the other departments of professional labor, were sifted with as invidious and jealous an activity, there would be few left to smile without wincing at their own uncovered sores.

ACUTE INFLAMMATION OF THE MIDDLE EAR.

By J. N. JENNE, M. D., ST. ALBANS, VT.

Mr. President and Gentlemen:

In calling the attention of the Society to this disease, I do so, not with the expectation of imparting new facts or information concerning it, but with a hope that a healthful discussion and renewed interest may be aroused in a subject which from indifference on the part of the profession and ignorance on the part of parents and guardians has led to many serious results.

Most cases of acute inflammation of the middle ear will recover uninfluenced by medical treatment, without doing appreciable damage to the affected ear, but a small number, however, leave behind them as legacies, a chronic, purulent and offensive discharge, diseases of adjacent organs, which will in a few instances destroy life, after months perhaps, by involving the meninges or the brain.

This need not be so; there is scarcely a disease in the whole category which responds more promptly or surely to well directed treatment than acute catarrhal and purulent inflammation of the middle ear, if seen early.

It is then, plainly the duty of the physician to teach the public that there is but one safe course to pursue in all these cases, and that is to consult a physician when threatening symptoms arise, and see to it that he is not guilty of the charge of neglect; these cases, with very few exceptions, should recover completely under proper management.

Causes. Under the head of causes may be mentioned exposure to cold and wet, acute or chronic pharyngeal and nasal catarrh, allowing cold water to run into the ear, the nasal douche, constitutional diseases, such as scarlatina, measles, small pox and syphilis. It may be said the disease originates in the fauceal end of the Eustachean tube, rarely in the external auditory canal.

Symptoms.-The familiar picture of ear-ache in childhood, pain, tinnitus, crackling noises in the affected ear, unpleasant resonance of one's own voice, impairment of the hearing, redness, swelling and bulging outward of the membrana tympani, catarrh of the pharynx, fever, and in some instances, delirium.

If pus form within the tympanum, another symptom usually presents itself, namely, a bleb or sac containing a colorless blood-stained serum

appearing in the vicinity of the short process of the malleus or in Shrapnell's membrane. It may form at any portion of the periphery of the membrana tympani, but is usually found at the point indicated; it is caused by the effusion of serum from the over-distended blood-vessels at this point, and varies greatly in size. It is usually the size of a pin head, and is tolerably constant in the variety of acute inflammation of the middle ear which terminates by ulceration and perforation of the drum membrane. It is seen occasionally in the simpler forms of the disease. It is at this period of the disease, or a little later, that a slight moisture will be noticed in the external auditory canal, an exudation from the inflamed membrane; the dermoid layer of this membrane is macerated from the presence of this moisture, giving it a whitish or opaque apearance, well calculated to mislead one into thinking he is looking at a normal, or at least uninflamed membrane. With a probe, armed with a little cotton, one can easily satisfy himself that beneath this whitish substance the membrane is intensely inflamed; but it is not possible in most instances to determine whether the inflammation will terminate by resolution and absorption of the effused mucus or serum within the tympanum, or that pus may not form and perforation occur.

Perforation occurs, of course, from the pressure of the fluid within the tympanum and from necrotic effect of the inflammatory stasis in the vessels of the drum membrane, and is usually attended by relief from the more active symptoms, pain, fever or delirium, if present, unless it is already complicated by mastoid or meningeal mischief.

The pain is usually intense, beating or puffing in character, and occasionally it is intermittent. The hearing may not be greatly disturbed during the first twenty-four or forty-eight hours, it may, in fact, be more acute than normal during the stage of pain. Buiging outward of the membrane usually occurs during the first two or three days, but may not be noticed until several days have elapsed.

The two main divisions of the acute disease of the middle ear, therefore, present the same train of symptoms until the pressure of the accumulated fluids within the tympanum reaches a certain point when rupture takes place and the distinguishing features of the purulent variety manifest themselves.

Diagnosis.—Enough already has been said under the head of symptomatlogy to render it unnecessary to pursue the matter further here. Acute inflammation of the middle ear is easily recognized; whether it is of the purulent or catarrhal variety, it matters little, so far as treatment is concerned, in the early stage.

Prognosis. The large majority of the cases of acute diseases of the tympanic cavity recover spontaneously without perceptible disturbance of the general health cr impairment of hearing, but in a small minority of instances in the purulent type of the disease, it produces serious damage.

It may impair or destroy the hearing of the affected ear, inflict a life-long purulent discharge upon the sufferer, or, in a few instances, terminate fatally by meningitis or abscess of the brain.

Treatment. The treatment of the acute catarrhal and purulent varieties of the disease until perforation has occurred, or paracentesis done, is practically the same, and should be varied with the severity of the attack.

If there is severe pain and considerable constitutional reaction it should be prompt, anti-phlogistics and sedatives should be administered. Leeches should be applied to the tragus or to the mastoid process Warm water with a little laudanum added poured into the car, and allowed to remain for a minute or two, will often give relief. The warm douche continued for several minutes during each hour. Blowing tobacco smoke into, and steaming the ear have given ease from pain. Poultices should be rarely used, only when other means of relief have failed; they are dangerous to the integrity of the drum membrane. Oils should never be used either in the acute or chronic inflammations of the ear.

Paracentesis should be done when there is bulging of the membrane, except in the mild attack when absorption of the effused mucus or serum may be hoped for. The incised opening heals much more readily than the perforation by ulceration.

Inflations by Politzer's or Valsalvas' methods should be practiced daily after the acute symptoms have subsided, to ventilate the tympanum and blow out any remaining pus or mucus, and also to prevent adhesions. During the period of the discharge, daily syringing of the ear with water that has been boiled, or some antiseptic solution, such as the 1 to 3000 or 4000 solution bichloride of mercury, should be practiced.

The duration of an attack of acute purulent otitis media of ordinary severity is ten days to two weeks.

No treatment would be complete without due attention being paid to the condition of the naso-pharyngeal membrane As has been said before, an inflammation of the middle ear almost invariably arises from a similar condition of the mucous membrane in the neighborhood of the fauceal end of the Eustachean tube. Obviously it would be unscientific to treat simply the effect without removing the cause. Polypi, adenoid vegetations, hypertrophied tonsils, etc., should be looked for, particularly in the recurrent and sub-acute cases, and should be properly attended to before the patient is dismissed.

Discussion-Dr. Woodward. Dr. Jenne has favored us with a very admirable discussion of two very important affections. There are more cases that do not completely recover than one would be allowed to suppose from what Dr. Jenne has said Although the majority of cases may recover spontaneously, there is a very fair percentage of cases that