Dr. Stapler, closing the discussion: In reply to the question as to how one arrives at the diagnosis of whether a child is a deaf-mute or not, I would say that it is well understood that if a child does not respond to certain noises or calls, or show some sign of hearing, and also does not speak at the age when a normal child does speak, it is usually considered that he is deaf and mute. Before the eighteenth month, it would not be proper to diagnose him as a deaf-mute. After the eighteenth month, we make this diagnosis by the fact that we cannot demonstrate any practical degree of hearing and cannot get any response in words.

As to the labyrinthitis, I was basing that statement on the generally accepted idea given by the textbooks that had gone into the autopsies of these cases. In these autopsies, the claim is that there was a labyrinthitis in eighty-five per cent. That is my standard. The textbooks claim that eighty-five per cent. of the cases of deafs are caused by a labyrinthitis. That is the foundation upon which I base my claim that eighty-five per cent. are caused by labyrinthitis; because we know that ordinary Faid the middle ear does not shut a child off and show such a pronounced effect as that shown in a deaf-mute. WEIBRARY child for two years, and, all of a sudden, he stops speaking; yet the middle ear is normal. You cannot get him to speak the words that he has been speaking. These cases usually shut off pretty suddenly. For that reason, I think that it is labyrinthitis; because we see no evidence of middle-ear trouble in these cases when they first begin. Of course, we cannot be certain that it is a labyrinthitis; because you cannot get, in a deaf-mute child, thus afflicted, whose other faculties are usually below the normal, the signs that we get in a grown person-nystagmus and other things. These children will not respond to these tests, unless you have been able to get them into school and train them. I have not been so fortunate as to get them into school. I had the Legislature provide a place; and when I tried to get it, somebody else stepped in and took the place; and they turned around and fought me without saying why they were fighting. Therefore, I have been in for all that sort of thing, and have not had a chance to test the matter out so thoroughly as I

should have done. I bring the patient before you, in order to show that something can be done in these cases. This is not a selected case. I have some patients that are better than this

one

Chronic Nasal Diphtheria. Dr. Clifton M. Miller, Richmond, Va.: Primary nasal diphtheria, essentially chronic in type, has been recognized for thirty years; but the textbooks that devote much space to diphtheria and those on the subject of public health do not lay sufficient emphasis upon the existence of this condition, which is probably the cause of many of the epidemics that have been observed. The diagnosis of this condition is fraught with some difficulties, and cannot be positively made without careful rhinological examination and the taking of a culture. It is usually found in children under the age of seven. The prognosis is good, death rarely occurring and paralysis being almost unknown. I have seen six cases of this condition. The diagnosis in all of these was confirmed by a bacteriological examination. It is my opinion that the examination of all dispensary patients presenting a long continued nasal discharge would bring to light many more such cases, and it seems probable that many of our epidemics of diphtheria would be prevented by such care.

Dr. J. W. Jervey, Greenville, S. C.-The question of chronic nasal diphtheria is, I think, one that has been recognized only in recent years to any extent. About fourteen years ago, when on service in the China Dispensary (?) at Charleston, a negro woman of thirty years presented herself to me for treatment, with almost a typical diphtheria covering the right surface of the nares. I was just out of my student days, had very little experience, and had no idea of what I was up against; but after seeing her three times, I had a bacteriological examination made. The Klebs-Loeffler Bacillus was found, and I made a diagnosis of chronic nasal diphtheria. My old preceptor at Charleston looked at me and said that there was no such thing as chronic nasal diphtheria, as diphtheria was an acute infectious disease. Naturally, I was not in a position to argue the matter out with him; but I stuck to the diagnosis, and sent the patient away to a city physician for anti-diphtheritic treatment. This she received, and

recovered from the condition promptly. I was delighted, a year or two afterwards, to run across, in the English Journal of Laryngology, a report of some cases of chronic nasal diphtheria, made by some Englishman-Grant or Turner, or someone; and I sent this article to by former preceptor, to show him that there were some authorities who had recognized chronic nasal diphtheria.

Dr. U. S. Bird, Tampa, Fla.-My experience with diphtheria lately has been almost wholly confined to that class of cases. The general practitioner gets almost all the ordinary cases of diphtheria; and unless they require instrumental work, or special treatment, we seldom see them. I have, however, seen so many of the nasal kind that I nose with bloody crusts, I consider practically distinctive of nasal diphtheria. My experience is that it is not entirely so mild a condition as Dr. Miller stated at first; because I recall a case that I saw in the office, in which the child had been suffering with nasal discharge for nearly a month. I told her people what was the matter; and, as the child was not very sick, l suggested that we get a bacteriological report before administering antitoxin. I was careful, however, to warn them that the child was liable to have a violent attack of ordinary diphtheria at any time. That night, this happened. The condition extended to the pharynx, and I was unable to reach the house; so someone else was called in. The patient had a severe attack of ordinary pharyngeal diphtheria, and was in extremis for almost a week I have always taken the precaution, in making a diagnosis of that kind, to guard myself and also try to protect the patient by informing the parents that the child is liable to become seriously sick without any warning; but I have usually made a bacteriological examination before administering antitoxin, as the patients do not often seem sick. I have yet to see a case that I have diagnosed clinically as nasal diphtheria that has not been proved to be diphtheria by the bacteriological report.

Dr Homer Dupuy, New Orleans, La.-About ten years ago, I commenced to carry on a series of investigations covering four or five years. These must have included certainly as many many as fifty cases of what we diagnosed

simply as membranous rhinitis, the question being to prove from the microscope only whether or not the case was one of diphtheria Out of fifty cases, forty were positively diphtheritic according to the microscope.

As regards the mortality, I recall a death in the Charity Hospital, of an infant nine months old, the death being apparently due, according to the student's statement, to heartfailure. Ten years ago, associated with a pathologist of New Orleans, I conducted an experiment with a family in which six children presented nasal diphtheria, as proved by the microscope, the question being to determine how long the discharge would extend, and what time the microscope would give us the evidence of a negative result. It took these children six weeks. During the interval, we made weekly examinations, and cultures of one, two, three, four, five and six weeks. These remained positive up to the fifth and sixth week. This will give you some idea of the chronicity of a nasal diphtheria. In New Orleans, the recent outbreak of diphtheria has simply served to corroborate what we have been proving in recent years, since the institution of our examinations of school children: that nasal diphtheria is a most potent cause of obscure outbreaks of diphtheria in schools. In one school, the Howard, an outbreak of diphtheria compelled us to undertake an investigation in that school; and we found forty children with nasal diphtheria who were associating with the other children. Therefore, it is a great question; and we, as rhino-laryngologists, can certainly do an enormous amount of missionary work along these lines. We have become so impressed in New Orleans with the seriousness of these cases as being the innocent carriers of infection that the city Board of Health, through its Secretary, has recently assurred me that they are going to require two control cultures from the physician in charge of a case of diphtheria-one from the throat, and one from the nose. They contend that it is only in that way that we can hope to cut down these outbreaks of diphtheria, which are usually traceable to the obscure innocent nasal-diphtheria carrier.

Dr. A. W. Stirling, Atlanta, Ga.-I agree with what the previous speakers have said with regard to the seriousness of obscure nasal diphtheria as a possible

source of infection. There is only one point that I think one ought to bear in mind from the standpoint of pathology. It seems to me that it is hardly proved that every case in which one may find diphtheria bacilli is necessarily a case of diphtheria; because, in the presence of an epidemic of diphtheria, it is highly probable that a large number of individuals will have such germs in the nose, seeing that the air is full of them and one draws this air in at every breath. They pass through the nose, and are probably filtered out there; so that the germs would be caught in the nose, if they were in the air. The clinical symptoms of this common form of diphtheria are, however, so comparatively mild that they are likely to pass unnoted. Every case of this kind, while dangerous and a possible source of infection to others, is yet not a case of what one would call true diphtheria of the nose. It would be interesting to distinguish these two classes of cases pathologically from each other. In a case requiring antitoxin, if there was no membrane, one would be justified in saying that the nose had bacilli in it, without being actually on it.

Diphtheria Carriers. Dr. S. S. Ledbetter, Birmingham, Ala. I have seen quite a number of cases of diphtheria of the nose, nasal diphtheria; but it is only within the last few years that we have recognized the chronicity of diphtheria at all. For that reason, I have kept no records, and have no way of getting at these cases. I should like, however, to report a couple of cases that I have seen recently which, I suppose, according to Dr. Miller's idea, would be classed as chronic. Before doing that, I should like to say that I think that diphtheria carriers should be classed as entirely a different type from cases of chronic diphtheria, for this reason: a diphtheria carrier may have the germs in the tonsils and their crypts for an indefinite period. I have seen cases that for months would respond to the test, and yet the children would be well and going to school. Some of these cases were discovered in school. Without having any fever, sore-throat, or any other symptom, they were found to have the bacillus in the tonsils. I have treated a number of these children with a view to curing them, and have finally had to remove the tonsils. I did not class these cases as chronic diphtheria, but as diphtheria carriers.