a number of cases where the drum-head and two of the larger ossicles were absent, and the hearing in the affected ear was rather above the average, both for conversation and the tick of a watch. The absence of the drum-head, however, does render such an ear more liable to recurrent attacks of catarrhal inflammation of the exposed mucous membrane; which at any time may become purulent in character and extend to all portions of the middle ear, and finally involve the intracranial structures with fatal result.

Among the more common cases that prevent the cure of chronic otorrhea should be enumerated first of all, absence of the drum-head. When in any other portion of the body mucous membrane is exposed for a long time to the air, it ceases to be a secreting surface and becomes covered with epithelium resembling that of the surrounding skin. This same process occurs in the ear when its mucous membrane is exposed; but the process of epidermization is rarely complete enough to cover the entire middle ear with epidermis, and as the result of the irritation caused by moisture supplied by surrounding mucous surfaces or from other causes, the epidermis lining the middle ear exfoliates somewhat rapidly and little balls of epidermal scales collect, which from time to time require removal in order to prevent a recurrence of the discharge. Cleansing of the middle ear from epidermal scales and other accumulations may not be necessary more frequently than once in two or three years; but when necessary it should be done thoroly and by an expert. If cleansing of the ear is not done from time to time, the accumulation will sooner or later become sufficiently irritating to set up a discharge which will continue until the accumulation is washed away, after which the discharge may or may not cease spontaneously. The condition of the ear described above is by no means uncommon, and may be considered as a not unfavorable termination of the disease. With no more care than is commonly given to the teeth after a dentist has put the mouth in good condition, the ear can be maintained in a fairly good condition during a person's lifetime. But in such cases eternal vigilance is the price of safety, and the individual may pay for neglect with his life. It is for this reason that life insurance companies hesitate to insure an individual who has ever had a discharge from his ear.

When epidermal scales accumulate in the attic of the tympanum, if the remains

of the ossicles are present, the mass cannot be washed away by discharges, nor can it always easily be detected and removed by the surgeon. Under such circumstances the mass becomes saturated with decomposing pus and the discharge is sometimes extremely fetid. Growing larger constantly, the pressure of such a mass produces caries and absorption of the surrounding bony walls until the entire temporal bone may be converted into a shell containing the accumulation. Such masses were referred to by the earlier writers on diseases of the ear as "pearly tumors; but are now called cholesteatoma, from the fact that the mass contains cholesterine crystals. A large portion of the temporal bone may be occupied by such an accumulation without producing any symptoms except continued otorrhea, which remains horribly fetid in spite of the removal of polypi and thoro cleansing. In a young girl, 17 years of age, the entire mastoid bone was found to be occupied by such a mass, the only symptom of which was a fetid discharge which had continued since her second year. In this case a radical mastoid operation was done, simply because the discharge from the ear remained fetid after four weeks of faithful treatment. The opera

tion resulted in a cessation of the discharge, and hearing that was in all respects nearly normal-a result that could not have been accomplished by simply remov. ing the larger ossicles or even by the Wolfe operation.

The middle ear consists of a chain of five cavities, the first of which is the Eustachian tube. Pus generally accumulates in the tympanic extremity of the tube and should be blown into the atrium by means of the Bolitzer air douch before an attempt is made to cleanse the middle ear by the syringing. The second of the middle ear cavities is the lower part of the tympanum or atrium. Above the atrium and extending outward over the bony roof of the external auditory meatus is the third of the middle ear cavities, the attic. Between the attic and the meatus, forming the floor of the former and the roof of the latter is a triangular ledge of bone, which, because it slopes somewhat sharply downward and inward toward the tympanum, has been named by Leidy the scute or toboggan slide. Upon the scute within the attic lie the head of the malleus and the body of the incus. From the head of the malleus, the handle of this bonelet projects downward to be inserted into the drum

head while from the body of the incus its descending process extends downward into the atrium to articulate with the stapes. From the anatomical arrangement described above it will be observed that the cavity of the attic is almost completely shut off from the cavity of the atrium by the presence of the larger ossicles; and hence when the attic is suppurating the products of inflammation more readily find their way backward, upwards and outward into the mastoid antrum than downward into the atrium. The anatomical condition is somewhat alleviated by the presence of the descending process of the incus which acts as a sort of drainage tube upon the surface of which pus flows from the attic into the atrium. Hence, somewhat early in cases of suppuration of the attic the descending process of the incus is ordinarily destroyed by caries, thus setting the stapes free from the disastrous effects upon the hearing of ankylosis of the malleus and incus, which is a somewhat common result of intra-tympanic inflammations of all kinds. The comparatively good hearing observed in nearly all patients when there is a large destruction of the drum-head, which forms such a vivid contrast to the greatly impaired hearing in the so-called cases of dry catarrh, where the drum-head is invariably present, is due largely to the fact that the stapes is thus early set free in most cases of suppuration of the middle ear.

Above, posterior and more external than the attic is the fifth of the middle ear cavities, the mastoid antrum. It is surrounded except above and medianly by the mastoid cells. The somewhat narrow neck of the antrum or additus ad antrum connecting the attic with the antrum is the fourth of the middle ear cavities. It chiefly is of interest to the surgeon because in its hard, bony floor the facial nerve lies so superficially that it might readily be wounded by a careless or ignorant operator.

Besides the accumulation of cholesteatomatous masses and other products of inflammation, the presence of polypi and necrosis, or rather caries of the ossicles are common causes of long-continued suppuration of the middle ear. Both of these conditions are ordinarily the result of imperfect drainage from the attic, and more rarely from the mastoid antrum well.

ав

When suppuration of the atrium alone exists, the simple removal of a polypus and thoro cleansing of the parts is sufficient to

bring about a speedy and brilliant cure of a chronic suppuration that may have existed for many years; but in most instances successful treatment of chronic otorrhea resolves itself into some surgical procedure for facilitating the removal of the products of inflammation from time to time as required, and keeping the parts dry. Of all antiseptics, lack of moisture is probably the most effectual. Frequent dusting of the parts with an absorbent powder, preferably boric acid, is somewhat effectual in securing the necessary dryness of the parts; but all measures that tend to prevent free access of air and rapid evaporation should be carefully avoided. Wearing absorbent cotton inside the meatus is capable of keeping up a discharge from the ear for years which otherwise would speedily cease.

The simplest operation for improving drainage from the attic is removal of the remains of the two larger ossicles and the drum-head, as well as all granulation tissue and debris that can be reached by instruments. As very little space is gained for drainage and access to the parts, the operation is unfortunately often a failure. An improvement on this simple procedure is the removal of the scute in addition to the ossicles. This is the so-called Wolfe operation, and is effectual when simply the atrium and attic are involved in the chronic suppuration, which, unfortunately, is only the case in a somewhat large proportion of cases. The operation which almost invariably yields satisfactory results is the radical mastoid, or Stacké operation. The auricle and cartilaginous meatus is detached from the side of the skull behind and held forward by an assistant. remains of the two larger ossicles, the drum-head, the scute, and also the posterior bony wall of the meatus is removed in such a manner that when the auricle is replaced the whole of the cavities of the middle ear shall have been converted into one, all parts of which remain permanently open to inspection and cleansing. In many instances this operation, which in skillful hands is comparatively free from risk, affords the only method of bringing about a cure of chronic otorrhea. patient's hearing is not impaired by the operation, and in most instances is decidedly improved, reaching in some instances as in the case cited above almost the normal. E. B. GLEASON, M.D. Clin. Prof. Otology, Medico-Chirurgical College. No. 41 South Nineteenth St., Philadelphia.

The

The

The Lancet in Opium Poisoning. Editor MEDICAL WORLD:-In a case of hysterical pain in the stomach where judgment was overbalanced by pity, I suddenly found my patient narcotized with the accumulative action of the morphin I had given; face fairly black and respirations not over ten a minute.

Immediate consciousness was brought about by drawing blood from the arm, the patient demanding to know "what was the trouble?" before four ounces had been drawn. Don't forget the lancet in opium poison. It not only relieves pressure on the brain, but eliminates just so much of the opium from the system.

Danielson, Conn. W. H. JUDSON, M.D.

Dr. Holden's Case of Irritable Urethra. Editor MEDICAL WORLD:-I am with you all the way round. Your efforts in spelling reform are what I have been advocating for years.

I think the case Dr. Holden reports in his Jewish patient in the June WORLD is a stricture of large caliber, probably near the end of the penis. Use Otis bulb sounds and locate it, and if near the end divide with probe-pointed, curved bistoury. If deeper use the Otis dilating urethrotome. This treatment will cure him. Albany, Vt.

J. C. CAMPBELL, M.D.

Infantile Summer Diseases. Editor MEDICAL WORLD:-The stomach of a child differs from that of an adult in the following respects: Its size, relative to that of the body, is only one-half as compared with that of adult life; in consequence of having no muscular walls, there is but little churning process during digestion, and the dilated portion at the cardiac end is absent. The stomach lies perpendicularly rather than horizontally, as in the adult, the cardiac end being more open, hence regurgitation of milk can be induced by merely placing the child on its back; food passes thru the stomach much more rapidly than in the adult; the intestines are comparatively short; the pancreas is but little developed, and but little pancreatic juice is secreted, thus the digestion of fat is difficult; the folds of the intestinal wall are but imperfectly formed, and the cecum is small.

Infants should be fed only on milk, and the mother, if possible, should nurse her child. Nursing infants who receive no other food but mother's milk up to twentyfour months are seldom attacked with

cholera infantum. Children who are spoon-fed in part are prone to suffer from the disease before dentition. Those who are altogether spoon-fed are almost sure to be attacked, and of these about 75 per cent. die. The children of the poor are more subject to this disease than the middle or richer classes, owing to ignorance of the laws of hygiene.

All milk on entering the stomach is acted upon by the gastric juice, and the casein is curdled, afterwards being redissolved by the same agent. When the casein is not redissolved by the digestive juices, it ferments and acidifies, producing a caustic kind of fluid, which therefore when vomited has a sour smell. Whereever there is acidity of vomited matter fermentation is present. Cow's milk, on account of containing more casein, is more difficult of digestion than breast milk.

In diarrheal disorders of children we have either fermentation of the casein or its collection in lumps, causing pain. Indigestion either produces diarrhea from the caustic action of its contents in the intestines or constipation. This latter condition of affairs is apt to occur when cow's milk is used, for it takes twice as long to digest cow's milk as it does breast milk.

Again, the intestines are shorter and the peristaltic action much more rapid in the child than an adult. Therefore a baby should have three passages a day up to six months of age. After that it should have

two. The color of these stools should be a deep yellow, of the consistence of thick gruel, of slight odor, much resembling mustard as prepared for table use.

A child under two months should be fed on an average every two hours, day and night; at three months, five times a day; at six months, four times. The infant should take from two to three ounces at each meal, increasing to one-half pint at six months of age when bottle-feeding is necessary. Never give a pint to a child under a year old. We have often seen the ill effect of a mother permitting her infant to sleep on her breast with the nipple in the child's mouth, sipping and sipping, thereby keeping the stomach of the child in constant action and impairing its digestion.

Having told of the peculiarities of the alimentary tract, etc., we pass on to our treatment of

Gastritis.

In moderately severe attacks it is frequently found that simply diminishing the

food, and doing little or nothing else for twenty-four hours, will be all that is required. In severe cases, where there is high fever, place the child in a hot bath for a few minutes and then wrap it in a hot blanket. To control the persistent vomiting, if the infant is brought up on the bottle or nursing, in either case give from three to six grains of bicarbonate of soda in four ounces of sweet cream, to which an equal amount of water has been added, giving in teaspoonful doses rather infrequently.

Ol. ricini

Aq. cinnamomi

M. Sig. Take at once.

dr. j dr. ss

This is to rid the patient of the irritating substance in the intestines. Then irrigate the colon every two hours as in diarrhea, and, where the parents of the child don't object, wash the stomach out. It is very seldom that it will be found necessary to repeat the operation, the vomiting ceasing, as a rule, after the first washing. In cases where the disease is a protracted

one, with chronic rectal cataarh, where prolapsus occurs after each defecation, and the mucous membrane is swollen with more or less hypertrophy of the part, call into service this prescription: B

In this disease the intestines do not permit anything to remain in them, and consequently this progressive strain produces starvation, the condition being due to the nervous state extant between the lower bowel and the pyloric end of the stomach. So soon as food enters the stomach the rectum expels its contents; hence it is best to stop all milk for a while and substitute raw meat prepared thus: Take a piece of meat and scrape it into fine pulp, leaving no fiber, fat, etc. Salt it slightly and administer a teaspoonful every two hours. Relieve the reflex irritability with bromid of potassium. After, this, irrigate for diarrheal symptoms, using the same antisepsis previous to giving the meat diet.

Apply cod-liver oil by inunction on the abdomen and back; it is taken up by the capillary circulation and carried thru the glandular system. Its beneficial effects are seen in a short period.

The febrile symptoms of these diseases may be controlled with alcoholic sponge baths and tincture of aconite, allowing the infant ice, if old enough to suck.

Combat convulsions and collapse with nitrite of amyl, m iij, dropped on a cloth and held for the child to inhale.

J. J. S. DOHERTY, M.D.

9 Sylvan Ave., New Haven, Conn.

Summer Complaint and its Treatment.

Editor MEDICAL WORLD:-Every year

as the summer comes around we see the question of "summer complaint" agitated in the various medical journals, and wonderful theories as to the etiology enunciated, and wonderful and complex cures prescribed. It is for this reason that I take

the liberty of recalling here, in your widely circulated journal, my own contributions to this subject.

In a lengthy study of this disease' (New York Medical Journal, 1892), based on nearly 800 personal observations, with a study of the writings and teachings of others, the conclusion was arrived at that the etiologic factors were two; namely, a direct and an indirect one.

The direct, the atmospheric heat.

The indirect (indirect because a consequence of the first), an inhibition of the hydrochloric acid constituent of the gastric juice-a dyspepsia.

The proofs, demonstrations and arguments therefor have been fully set forth there in detail, and cannot be again repeated here. It would take too much space. This, however, I would say, that tho much has since been written upon this subject by eminent men, I have as yet read nothing to invalidate in any way the teachings of said study, either as to etiology, pathology or treatment.

To effect a cure we must naturally obviate the two factors: i. e., banish the heat and restore the acid to the gastric juice. It is a very easy matter to accomplish all this if your little patients have wealthy parents, so that, as the text books say, all you need do is to recommend reremoval to the mountains or to the seashore; but it becomes a more difficult

1. Summer Complaint: A clinical contribution to the Etiology, Pathology and Treatment of the Disease, by H. Illoway, M. D. Professor of Diseases of Children, &c., &c.

question to solve in the case of the middle class and of the poor who cannot get away. This difficulty is readily overcome, as was demonstrated by me so early as 1877, by the cold wet pack. Summing up, the treatment as I practised it is as follows:

1. Remove the heat by the cold wet pack (a sheet wrung out of cool water, 75° F. to 80° F.), and the naked child wrapped therein. wrapped therein. A dry sheet is laid over it. As soon as the wet sheet has become warm it is replaced by another, applied for two hours in the morning and two hours in the afternoon, and if the night happens to be very hot, for two hours again at ing and diarrhea. night. This will at once arrest the vomit

2. For the next few hours (6 to 8) give no food. Bridge over this interval with very small doses (15 to 25 drops) of liquid peptonoids or hemaboloids.

3. Administer dilute hydrochloric acid, as a tonic to the stomach and as an anti

septic for the bowels. A pleasant formula is something like this:

M. Sig. Teaspoonful every three hours. I sometimes prescribe in place of the syr. zing. the syr. rhei aromat., same quantity.

When the attack is over, and it usually is in the course of some hours, then, to keep the child well, I administer a cold bath every morning about 10 a.m., and if the weather or apartment be very hot, another in the evening, allowing the child to play around in the tub and splash about, which they usually like to do. It may be said here that accustoming the children to the cold bath is the best prophylactic against summer complaint.

I continue the administration of the acid for a few days and then stop it, as the cold water very soon effects a restoration of this natural constituent of the gastric secretion and renders the administration of the artificial acid unnecessary. I feed the child and tho it may appear strange, I must acknowledge I have not yet found anything better for summer feeding, either

condensed milk with the addition of barley juice, (as recommended by that Nestor of American pediatrics, Jacobi,) or malted milk.

It is necessary to differentiate between