There are several reasons why the diagnosis and treatment of acute purulent otitis media is of interest and importance to every practicing physician. The disease is a very common one. Its spontaneous recovery without loss of tissue and serious impairment of function is rare. The most important reason, though, is the tendency of the disease to develop as a complication of other serious disorders. In the second week of measles, scarlatina, bronchitis or of pneumonia, or in the third week of typhoid fever, a purulent inflammation of the middle ear is common. Occurring as a primary disorder, this disease is always severe, one which produces grave systemic disturbances and leaves the patient greatly weakened. Occurring as a complication in a patient already exhausted by disease, it may be the factor which determines a fatal result. It generally begins in the upper part of the tympanic cavity, in immediate relation with the porous tegmen tympani, through which transmission to the brain is easy. Post-mortem examinations would probably show that in many cases of typhoid or of scarlatina the real cause of death has been an unsuspected purulent inflammation in the middle ear, with an extension to the mininges or to the sinuses of the brain. Read before the Ohio State Medical Society, May 28, 1896. Whole Volume LXXVI. Where the attack begins as a primary disorder, the first symptom to attract attention is pain. This will begin as a severe earache, but the pain soon extends to the whole side of the head. Fever begins almost as soon as the pain, the temperature often reaching 1020-30. Deafness is also an early symptom, but if the attack is unilateral, as it generally is, may not be noticed unless the direct test is made. The deafness is accompanied by more or less tinnitus. In some cases vertigo is very marked. In children, especially badly nourished children, the attack may begin with convulsions. These are apt to be followed by more or less delirium. Direct examination of the ear in the early stages would show intense congestion of the drum membrane above the short process of the malleus and the anterior and posterior folds. Two or three days after the beginning of the attack this portion of the membrane may be so distended as to overlap the membrana vibrans. By this time a general congestion of the drum may be present. When filled with pus the membrane becomes yellow in color, and the epithelium has lost its lustre. In some cases necrosed epithelium overlies the membrane, and the dead white appearance of this covering may deceive the observer as to the presence of inflammation in the tympanic cavity until the dead epithelium is brushed away by a cotton-tipped probe. The functional test, if made, will show a lowering of the upper tone limit and an elevation of the lower tone limit. On account of the pain excited, though, the functional tests are rarely made, and are of little value except in cases where the labyrinth is also involved. In these cases the almost total loss of hearing by bone conduction, in addition to the constitu tional symptoms, will show the gravity | fevers cleansing of the nose and nasoof the disease. pharynx several times daily with a mild with a weak spray of menthol and camphor in one of the petroleum oils, is the most efficient preventive treatment. In patients without notable lesions in the nose or naso-pharynx, but where exposure to cold lights up an inflammation in the ear, cold sponge-baths daily are most efficient in preventing attacks. Where the otitis develops as a secon-alkaline lotion, following this cleansing dary disorder, in conscious patients, the diagnostic symptoms will be the same as those already given. In unconscious or delirious patients the onset of this disease will be marked by increased fever, more active delirium, restlessness and the appearance of great suffering. The constitutional condition, too, will show by the marked depression of the patient that some added burden has been laid on the system already weak-middle ear is common, daily inspection ened by disease. In unconscious or delirious patients, in diseases where suppuration in the of the ears should be made in order that the first symptoms of otitis should be seen and abortive treatment be begun at once. If seen sufficiently early suppuration can be prevented in many cases. Opiates to relieve the pain should be freely given. The local abstraction of blood from in front of the tragus is an old and efficient remedy. With our modern knowledge of asepsis, I do not think it is advisable or necessary to extract the blood by such an indirect route as either the natural or artificial leech in front of the tragus. With the external meatus carefully cleansed and with sterilized instruments, the local depletion can be ac When the mastoid cells become seriously involved in the purulent processes, in either the primary or secondary disease, this extension of the inflammation is attended by increased pain, increased fever, and by greater constitutional depression. Locally there will be tenderness and swelling over the mastoid process. Usually, too, there will be some enlargement of the cervical lymphatic glands below the mastoid. Where the process extends, as it so often does, to the cranial cavity, the temperature may reach 104°-50-6°. There will be intense headache, accompanied frequently by violent delirium. There will be local convulsive move-complished and much better results ments, followed by paralysis of the areas that were formerly involved in the convulsions. The delirium may be followed by stupor, deepening into coma, ending in death in a short time. Where the cerebral sinuses become infected in addition to the local symptoms, we have those of pyemia supervening. There will be sudden extreme rises of temperature, followed in a few hours by profuse perspiration, and the temperature sinking to or below the normal range. This subsidence will be followed in a few hours by a fresh attack of hyperpyrexia. obtained by making direct incision into the congested folds of membrane in the upper part of the tympanic cavity. This should be done in all cases as soon as the degree of pain and fever, and the intense congestion above the short process of the malleus, show that you are dealing with an infective process—one which will result in purulent otitis if left to run its natural course. The incision should be made in the upper posterior quadrant, and should be carried deeply into the tympanic cavity, so as to incise the folds of membrane present in this region. The bleeding should be The preventive treatment of puru- encouraged by gently syringing with lent otitis media means treatment of any warm sterilized water. A powder of obstructive disease in the nose or naso- boracic acid may next be blown into pharynx. In adults this includes treat- the ear gently to maintain asepsis, and ment of hypertrophic rhinitis, deformed dry heat be applied. This course will, septa or polypi. In children the re- in the majority of cases, prevent suppumoval of adenoid vegetations or hyper-ration. The wound in the drum will heal trophied tonsils is the most effective in two or three days, and there will be prophylactic measure. In infective little impairment of functional power. ment here indicated we can usually secure a cure of the acute suppuration in a comparatively short time, and prevent a chronic suppurative process fol C. W. O., physician, aged thirtyseven years, was seen by me in October, 1895, after considerable exposure at night in attendance on obstetric cases. There was intense pain in the right ear.lowing the acute. We have no known He had been treating it by hot douches and codeine internally. Temperature 101°. Examination showed intense congestion of Shrapnell's membrane. Dry heat locally and morphine internally were suggested for treatment that night. The next morning he reported that he had only slept a short time after two hypodermic injections, grain morphine each. Pain still intense, temperature 102°. Free paracentesis was made and the bleeding encouraged by warm douches. Following this a little boracic acid was blown into the ear. The pain and fever both subsided rapidly, and the patient resumed work that afternoon. No pus was seen in the ear at any time, and convalescence was complete in four days. Where suppuration has begun before the case is recognized, or where abortive measures have failed, the pus should be liberated from the tympanic cavity by the free incision of the drum. This incision should be carried through the posterior half of the drum membrane from near the tympanic ring below to the upper posterior portion of Shrapnell's membrane. In this way free drainage of the pus, which has usually burrowed down along the handle of the malleus until it has reached the atrium, will be accomplished. After the pus and blood which has escaped into the external meatus has been carefully mopped out with sterilized cotton, the meatus should be lightly packed with iodoform gauze. This gauze may be allowed to remain for twenty-four hours, when it should be changed by the physician, and not by the patient. Usually the pain and fever and all the graver symptoms will subside within two or three hours after the establishment of free drainage. The presence of the gauze in the external meatus does not prevent the escape of pus, but it does prevent reinfection of the tympanic cavity. Chronic suppuration does not arise from one infection, but from repeated infections. By the line of treat means of disinfecting living tissues. Any agent which will destroy the germs of suppuration is even more destructive to the white blood cells, nature's agents for the limitation and cure of the suppurative process. The long line of douches and powders that have been used with a fair degree of success in the treatment of acute purulent otitis are objectionable in that their continued use by either physician or patient is liable to result in a reinfection. Packing with antiseptic gauze, with aseptic precautions, overcomes this objection and aids in the most efficient way the natural processes of cure. M. R., aged twenty, referred to me February 24, 1896, by Dr. L. S. Colter. The attack began five days previously, with pain in the ear so intense the patient had not slept for three days. He had been treated by dry heat locally and opiates internally. On the fourth day his physician opened a small furuncle in the external meatus. At this time his temperature was 102°, and there was marked tenderness over the mastoid. The case was sent to me the next morning. There was great bulging of the membrana flaccida, which was yellow in color. There was induration of the soft parts immediately below the mastoid. The drum was freely incised and the blood and pus washed out with warm sterile water. The external meatus was then packed with iodoform gauze. The patient was relieved entirely from the pain within three hours, and slept most of the time for the next fifteen hours. The fever had disappeared when he returned to my office the next day. The discharge of pus was very free for the next five days. The treatment was daily packing with iodoform gauze until he was able to resume his work. After that he was given peroxide of hydrogen with which to cleanse the ear twice daily. Convalescence was complete in ten days. Where, in the ordinary case, symptoms of mastoid involvement become evident, it is not advisable to continue | done is to briefly and somewhat dogmatically state the application of the principles of general surgery to suppurations in the middle ear. opiates for the relief of pain. They mask the symptoms and prevent our gaining precise information as to the extent of the trouble. We should depend rather on ice applications over the mastoid process and on free drainage through the tympanic cavity. In addition to these measures, if the symptoms of mastoiditis are well marked, local depletion can be best obtained by free incision along the posterior wall of the external bony meatus. The communication of the veins of this region and of the mastoid cells is much more intimate than between those of the mastoid and the integument, and we can get a greater result from the local depletion in this region than from the classical Wilde's incision. Should these measures fail to prevent the extension of the process in the mastoid cells, nothing should delay the operation of opening the antrum and establishing free drainage through that cavity and through the tympanum. and external meatus. The Forms of Diabetes. Dr. George Harley gives the following classification of diabetes: 1. Hepatic diabetes-including the gouty variety. 2. Cerebral diabetes-including all cases of saccharine urine arising from nerve derangements. 3. Pancreatic diabetes-the most deadly form of the disease. 4. Hereditary diabetes-a form by no means uncommon, and one, too, where both brothers and sisters may labor under the disease without either their maternal or paternal parent having been affected by diabetes, though more distant members of the family may have suffered from it. 5. Food diabetes-including all forms of saccharine urine arising from the ingestion of unwholesome substances. The Use of Menthol in Coryza. Where symptoms of suppuration in the cranial cavity become marked, if the patient's life is to be preserved opera- In the matter of treatment, besides tion must not be delayed. Where the diet and opium or codeine, Dr. Harley operation is made sufficiently early the reccomends croton chloral, strychnine, abscess may be found between the teg-phosphoric acid for thirst, and an absomen tympani and the dura mater. If lute prohibition of alcohol.-Indian the mastoid is at the same time involved Lancet. an extension of the ordinary bony incision upward will liberate the pus in the extra-dural abscess, and usually result in a rapid recovery. Later in the case, where the temporo-sphenoidal convolution or the cerebellum is involved, an extension of the incision upward or backward, or, better still, trephining over the affected area, must be the measure employed. The only chance of recovery in these cases is the opening and thorough drainage of the abscess. Where infection with thrombosis of the lateral sinus has occurred, the internal jugular vein must be ligated, the sinus incised and thoroughly cleansed and packed with gauze. The details of the operative treatment required in purulent otitis media and its complications would make this paper far exceed the limit set by the rules of the society. All that can be Wunche (Journal de Médecine de Paris, March 1, 1896), of Dresden, has employed inhalations of menthol-chloroform in the strength of 5 or 10 per cent. for the purpose of aborting acute coryza. A few drops of this mixture are placed upon a handkerchief, and five or six deep inspirations are taken. By this means the nasal secretion is augmented at first, but afterwards diminished, and the sore throat and laryngeal symptoms which are frequently found associated with a cold in the head are relieved. The following nasal spray may also be employed after the inhalations are taken: REPORT OF A CASE OF PER NICIOUS ANEMIA. BY MARK MILLIKIN, M.D., HAMILTON, 0. In July, 1895, M. B., a young woman, twenty-two and a half years of age, came under my care. Her previous history, rather imperfectly given here, was as follows: She had been unhappily married two years before, living only a few weeks with her husband. She then went to live with a wealthy family two miles from Hamilton, acting in the capacity of nurse and servant. Her duties in this household were light. She soon made herself indispensable, and was held in high esteem by all members of the family. Though she was more content here than at home, where not the greatest conceivable domestic tranquility prevailed, she seemed, according to her employer, always under a cloud. About a year ago she began running down in general health, complaining of great weakness, loss of appetite, scanty menstruation, etc., etc. When I first saw her (July, 1895) she presented the characteristic symptoms of one suffering from anemia. I wished at that time to make a blood examination, but she refused to undergo the trivial operation. My diagnosis was pernicious anemia, though without a blood examination I was not justified in it. Under arsenic, iron, and occasionally strychnine, she rapidly improved. In about six weeks she decided to stop taking medicine, in spite of my advice to continue. At this time she still seemed very anemic. I did not see her again until March of this year. A blood examination convinced me that she was suffering from pernicious anemia. The following table is of interest: From May 21 to June 3 there were no examinations made. Under the microscope were seen normal red corpuscles, microcytes, macrocytes, poikilocytes, nucleated red corpuscles, and polynuclear neutrophiles. The diagnosis of pernicious anemia was made because of the large number of poikilocytes and the relatively high per cent. of hemoglobin. Arsenic, iron, and strychnine were given. The patient improved slightly, then said she felt worse. For one week during April she took Armour's "Glycerine Extract of Red Bone Marrow," but there was no improvement. Arsenic was again given in increasing doses until she took 10 minims of Fowler's solution three times a day. Considering her low body weight I thought this dose very large, and did not push it further. May 4 to May II she was taking 1/50 gr. cupri arsenitis four times a day. This change was made in the hope that some intestinal antiseptic might have a favorable effect on her. No improvement followed. She now complained of nausea or vomiting. Her appetite was poor. Sometimes only sweet foods, again only sour foods, were tolerated. Meats, eggs, and nitrogenous foods in general she could not bear. The mere thought of food sometimes caused disgust. She was urged to try eating raw marrow spread on bread, but, as might have been anticipated, that proved too loathsome a dish. On May 30, I was called to see her, this being my first visit at her house. She was in bed, where she had been for about a week. She was entirely devoid of sanguineous color; indeed, she looked as though made of cacao butter. Yet there was as much if not more plumpness than two months previous. She vomited nearly everything eaten. Twice during the remaining four days of her life she called for smoked herrings and retained them. Pine-apple sherbet and ice-cream also agreed, but eggnog, blancmange, corn-starch pudding and predigested foods seldom staid down. Rectal feeding was resorted to. Sometimes she retained a six-ounce predigested mix |