Aretæus, the renowned Greek author who throat. As to the histology of this pseudo lived during the first century, A. D., was the membrane, the microscope reveals its strucfirst to give an accurate and definite descrip- ture as composed of rod shaped bacteria, pus tion of this dreadful malady, under the name and epithelial cells, and red blood corpuscles, of "Syriac ulcer." During the years of 1821- incorporated in a reticulum of fibrillated fib25-26, Bretoneau of France contributed valu- rin. The changes which produce this exudaable papers to the medical world concerning tion commence close to the blood vessels and this disease, and named it diphtherite, because beneath the epithelium of the mucous memof the membrane found in the throat. In the brane. year 1855, and the nine succeeding years, it prevailed as an epidemic in various sections of the United States. It has since then been classed among the commonly occurring dis

eases.

For the sake of brevity, we shall not halt to consider the anatomical appearances, clinical history, nor symptomatology.

ETIOLOGY.

Gentlemen, we all know well enough that the ordinary forms of inflammation attacking mucous membranes do not destroy the epithelial cells, and that they are followed by a mucous, or muco-purulent discharge, while to the contrary the inflammation which accompanies diphtheria, and attacks the mucous membrane, does destroy the epithelium, and is characterized by a membranous exudation. Is this not sufficient to show a specific inflammation?

Season and climate appear to have no effect in producing or destroying the germ of diphtheria. Although it has been observed to folThe pathognomonic character which distinlow an exceedingly dry, hot season, conse- guishes the diphtheritic membrane from other quently we may infer that the germ being pseudo membranes is, that when found adherpresent, such a season may favor the developing to mucous membranes which are covered ment of the disease. Filth and unsanitary by pavement epithelium, it infiltrates the surroundings cannot spontaneously produce membrane and cannot be removed without the germs of infection, but may, by sheltering tearing the tissues and leaving a bleeding surand warding off the sunlight and oxidizing face. But when found adhering to mucous. influences of the air, act as a "hot-bed" where membranes which are covered either by colthe germs may multiply and develop into lumnar or ciliated epithelium, it can readily activity.

be removed without damage to the underlying structures. This readily explains why it clings so tenaciously to the tonsils, pharynx, vocal cords, &c., and why it can be so easily removed from the larynx. Albumen in the urine is not altogether dependent on changes in the blood, but chiefly upon morbid processes in the kidneys. Disturbed vision occurs from the loss of adjusting powers caused by paralysis of the ciliary muscles. First and last the poison attacks and expends its force upon the nervous system.

DIAGNOSIS.

Diphtheria can, as a general rule, be readily recognized by inspecting the throat. If the membrane be not present, the glistening mottled appearance of the mucous membrane, which is more strongly marked on one side of the pharynx than the other, is evidence enough to the experienced. The enlarged lymphatic glands, pain at the angle of the

jaws, dizziness, augmented temperature, great My limited experience has been such as to systemic prostration, and lastly, the closely adherent nature of false membrane, leave no room for doubt as to nature of disease.

PROGNOSIS.

cause me to place tinct. chloride of iron at the head of the list of medicines, as I have in several severe cases seen the exudation, swelling and pain disappear in the course of twelve No case however mild is to be considered a or fifteen hours by administering one drachm trivial affection. If the pulse is rapid and of tinct. of iron, largely diluted with water, weak at the onset the prognosis is very grave. every second hour. Chlorate potash is beneThe amount of exudation, so long as confined ficial, in so far as it relieves pharyngitis, and to the pharynx, has nothing to do with prog- stomatitis. Turpentine is much lauded by nosis. It may be abundant in mild cases, or some, but never having used it cannot recomvery sparse in severe ones. Should it extend mend it. Mercurials should never be given, into the larynx, or invade the nares, recovery and purgatives only under the most guarded is very doubtful. Patients seldom survive the circumstances. Astringents prove of little or disease if the false membrane presents a brown no benefit. Acidulous drinks should be used or dark rusty color, or if there be copious or freely. Quinia, in the majority of cases, proves frequently recurring hemorrhages. Pyrexia advantageous. Pyrexia can best be governed has no bearing on prognosis, as I have seen by sponging the body, if not contra-indicated. patients start out with a temperature of 105° Should larynx and trachea become involved, F., and easily pass through all the stages of tracheotomy should unhesitatingly be resortthe disease, and conversely. I have seen se-ed to as soon as conditions require it. Paravere and malignant attacks where the tem-lysis recovers under the use of strychnia and perature never to my knowledge exceeded the galvanic battery.

102° F. Paralysis generally proves harmless unless intercostal muscles become involved.

TREATMENT.

Aural Sequella of the Eruptive Revers.

Diphtheria requires both general and local BY GRANT CULLIMORE, M. D., OF ATCHISON. treatment. The general therapeutical indica

of recent experiences I am about as well prepared to speak upon as any I might choose, and which also has the recommendation of being practical for the general physician. I shall not burden you with statistics or special theories, but my endeavor will be to emphasize the importance of a subject intimately connected with the general practice but much neglected in the works of general practice.

tions are of paramount importance through- Mr. President and Members of the Society :out. Inasmuch as we possess no specific I have selected a subject which by reason remedy, the main object in treatment should be to sustain the vital powers, and withstand the encroachment of the disease. A cool and well ventilated room, with perfect quietude of mind and body are essential. Alcoholic stimulants are indicated throughout. Supporting the system with food is one of the most important points to be gained. Pieces of ice held in the mouth often prove most soothing to the inflamed parts. Caustics, or irritating medicines should never be used locally. The less the throat is interfered with the better. Violent efforts to dislodge bits of false membrane by coughing should be forbidden. The infected tissues should be frequently and thoroughly sprayed with some antiseptic solution. Tilden's bromo-chlor. alum proves as efficient as any. From time to time a vast number of drugs have been recommended and highly extolled, but all have signally failed to prove the specific value claimed for them.

We all know how frequently the mucous membrane inflammations of the exanthematous fevers extends into the nasal cavities and on through the eustachian tubes to the middle ear; the consequent otitis being accompanied by severe pain and perforation of the drum membrane. Of course the latter does not always occur, but the cases in which perforation occurs are the more frequent, and these cases of perforation especially demand our attention. For although suppuration may occur and extend to the mastoid cell and inner

tissues, yet the drum membrane is the first tissue which we recognize as affected by necrosis.

the practioner understand that it does not require complicated instruments, nor even reflected light. The end of the small Von The statistics of Belgium show that out of Græfe cataract knife may be wrapped with 1892 cases of deafness, 216 followed scarlet thread so as to leave bare about inch of the fever. Another observer found 144 out of point. The lowest point of the membrana 400 cases due to the same cause. How many tympana can then be perforated without dancases of chronic otorrhoea with impaired hear-ger of injuring the tissues of the middle ear. ing does every practitioner see? These may I think pus rarely forms if this puncture is all or very nearly all be traced to scarlet fever, measles or diphtheria.

But it is not alone these conditions which impair the hearing and render the patient a disagreeable companion in consequence of offensive otorrhoea that attract our attention, but there occur cases of middle ear and mastoid disease which endanger the life of the patient. I would like systematically to call attention to these aural sequella of the eruptive fevers under the following heads:

made in time, and repeated if necessary. The instillation of hot water serves as an anodyne, and hot water compresses may be applied with good effect to the entire pinna and mastoid region.

2.

Full Developed Suppurative Otitis Media.-Pus having once developed, it does not follow that the 'structures of the middle ear will necessarily be much impaired. If the pus has a continual exit through a small perforation, and if cleansing and antiseptics are 1. Simple inflammation of the middle ear resorted to, the chances of a speedy drying up during the febrile attack.

2. Full developed suppurative otitis media. 3. The development of mastoid disease from this suppurative otitis.

of the pus are very considerable. In the cleansing I would deprecate the use of the syringe, because the force of this instrument tends to drive the fluid pus into and among

4. Mastoid disease proper with its compli- the cells of the mastoid, and the pain of the cations and accidents. operation is objectionable.

5. Operative procedures.

We have in the agent peroxide of hydrogen the most valuable of cleansers for small pus cavities, and no where is its value better illustrated than in suppuration of the middle ear.

Almost without the sensation of contact to sensitive and young patients, this agent, peroxide of hydrogen takes hold of pus and brings it to the surface, its action being the liberation of oxygen which unites with the excessive hydro

being attended by a mild explosion, the debris and pus is forced to the surface.

Of the Middle Ear.-During the period of the most intense inflammation the mucous membrane of the nose and throat in the course of an eruptive fever it is common for the little sufferers to have ear ache, and sometimes this becomes intense and prolonged. When this occurs, the utmost attention from the practitioner is required to prevent, if possible, the development of suppuration with the conse- gen of decomposition and the new development quent destruction of the middle ear tissues. In the few experiences I have had at the bedside of children afflicted with scarlet fever, I have learned to await this critical period with a delicate lance-a small Von Græfe cataract knife. When pain is prolonged, I most strongly urge the practitioner to puncture the drum membrane. If pus is present a way out is thus made, and if pus is not yet developed, the depletive hemorrhage that results from this procedure may prevent pus formation. It certainly in most cases instantly relieves the pain, and in no case have I seen harm result.

In the use of hydrogen peroxide it is well to remember its decided acid character. While I formerly used it full strength, I now dilute so as to make a 25% solution. Pain often follows the use of full strength solution, and the strong acid is destructive to the delicate bony portions of the partitions of the cells.

It frequently occurs that the pus does not bubble to the surface, and we then know that it has assumed a plastic, cheesy nature, and acts as a blockade to natural outflow. Instead

I would simplify the procedure and have of congratulating ourselves that the suppura

tive process has stopped, it is better to be this account against mastoid involvement. guarded and examine for the presence of On the other hand I think the danger from strings of sticky pus and debris. Especially this complication greater, even though the disshould we endeavor to keep the way open, if charge of pus from the external meatus is with the stoppage of the flow of pus the child free. The pus of the acute stage is the laudcomplains of pain. able pus of the writers of but a few years ago. The pus of the chronic stage with its offensive odor is more destructive of tissue. Knapp, Ernst, and others say that all pus is the result of bacteric action. They also agree that bad smelling pus is laudable pus acted upon by still another specie of bacteria-the bacterium

Pain with cessation of pus-flow means pressure from increasing pus unable to find its way out.

These details of suppurative otitis media may seem unnecessary to many practitioners who have seen cases of suppuration of the middle ear progress to apparent recovery or saprogenes-and this organism is more poisonto chronic otitis media without experiencing ous in its effects upon tissue and the blood. mastoid complications. But if these cases are followed up, those in which apparent recovery takes place may, at some future time, be found breaking forth like the eruptions of a volcano which has long been quiet. A severe cold is usually the exciting cause of these eruptions.

The tendency for pus formation has never ceased. The parts have never been thoroughly cleansed of bacteria which remain in necrotic tissue, to development of further suppuration when favorable circumstances pre

I take from my case book an example of chronic suppurative otitis developing mastoid disease. Miss Nora L, age 17, has had ear ache at times for four or five years, with continual discharge of pus. Origin, scarlet fever. One month or six weeks previous to my first observation of the case the patient began to suffer pain in the ear. She has been feeling drowsy, and pain has extended over mastoid and temporal regions. There is now considerable swelling behind the ear which seems to be mainly subtegumental though no fluctuation is discovered. An incision over Every case of suppurative otitis cannot be the mastoid-Wilde's incision-no pus obprevented from terminating in chronic otor- tained. Another and wider incision was subrhoea, but the conduct of the practitioner dur- sequently made and the point of a heavy ing the active suppuration will have much to knife cautiously worked into the bone subdo with the patient's future condition, and stance. Fully two tablespoonfuls of offensive with a more thorough knowledge of these pus followed the opening of the bone, and reconditions and careful treatment offensive lief from all cerebral symptoms was immediotorrhoea will be a rare sequellæ of the eruptive ate. Here is a case developing a serious masfevers. toid disease after a course of four years of middle ear suppuration.

sent.

3. Development of Mastoid Disease from these cases of suppurative otitis is not so in- Before going on to the complications of masfrequent as to merit the neglect of this sub-toiditis which render it fatal, I wish to cite a ject which exists in the ordinary text books. case which illustrates a complication someMany times the practitioner fails to recognize what alarming to the family, but which is the presence of mastoid disease, pains in this temporary if relief is afforded to the mastoid region and drowsiness of the child being at- disease in time. I refer to the complication tributed to neuralgia or some digestive or of facial paralysis. general derangement. If Fordyce Barker Called in consultation to see a little boy aged failed to recognize the difficulty in the case of six years, just recovered from scarlet fever, Conkling, certainly the more ordinary doctor suppurative otitis media having followed. An cannot be censured too much for a tardy diag- abscess over the mastoid was the occasion of nosis, especially under inadequate instruction. my consultation. An incision through the An acute otitis having progressed to a integument and down to the bone evacuated chronic stage, there is no greater security on a quantity of pus and showed the periosteum

to be diseased, the bone being rough. This As to the more serious operation of opening trouble entirely recovered without any delay the mastoid cells, Politzer says that no one or complication. In one month swelling oc- should operate on the living before having curred over the mastoid of the other side, and performed the operation at least forty times an incision was made. No pus obtained. upon the dead subject. When Politzer adSubsequent deeper incisions were made and vised this he had in mind the frequent anomno pus obtained. alous course of the lateral sinus.

The symptoms became alarming, facial paralysis supervening with drowsiness.

The external incision should be commenced a little below the attachment of the linea The side of the face was much swollen, and temporalis and continued close to the attachthe auricle stood at an angle of about 80 deg. ment of the auricle and parallel with the At the end of eight or ten days an anæsthetic mastoid prominence. Another incision may was administered and a very wide incision be made at right angles with this, forming a made over the mastoid. The point of a heavy flap. The periosteum, of course, must be reknife was used in making an opening into the moved from the portion of bone to be perbone, and pus was finally discovered. This forated. Various instruments are used by pus was very offensive and thick. It is need- different operators in opening the cells. A less to say that the child grew better immedi- trephine by some, a chisel by others, and still ately. The facial paralysis disappeared. others use simply a gimlet.

4. Complications of Mastoid Disease.-I will not burden you with anything but mere mention of these with illustration upon the anatomical specimen which I show you.

The most dreaded complications are:

1. Purulent meningitis, or cerebral abscess. 2. Septic phlebitis, thrombosis, embolism, and septicæmia consequent on the extension. of the purulent process to the venous sinus on the petrous bone and the sinus of the jugular vein.

3. Bleeding from the ear, the internal carotid. artery on the anterior section of the temporal bone or the lateral sinus being evaded.

4. General cachexia by the reception into the blood of septic material.

With this list of formidable complications it appears evident that timely operative interference is necessary to save the child's life and our own credit and this leads us to our last heading, viz.:

In children I think a heavy, pointed knife, carefully used, is sufficient to open the porous walls of the mastoid cells. In the adult I prefer the chisel.

The line parallel with the external meatus is the guide for directing the instrument.

Chronic Ovaritis.

Read before the South Kansas Medical Society at Rock, Kansas, November 13, 1889.

BY H. F. HORNADAY, M. D.

I give the early history of this case, as I gathered it from the patient, Mrs. R———, aged 35, married 14 years, has never been pregnant, form well developed, weight in health 135 to 140. She had been, by nature, endowed with a good, strong and vigorous constitution, and 5. Operative Procedures.-Wilde's incision had enjoyed good health until about ten years consists in opening the integument and other ago, when she had a very severe attack of soft tissues down to the mastoid bone, and is peritonitis, or, as the patient expressed it, inrecommended in those cases of inflammation flammation of the bowels, which yielded very After recovery she eneither in the mastoid process or the periosteum slowly to treatment. which cannot be allayed by antiphlogistic joyed her former condition of health to a fair treatment. Pus is not always found by this degree for some six months, when she began incision, but the effect is favorable in deplet- to suffer with acute and very severe pains in

ing the parts and relieving the pain. If pus lies deeper, it may find its way to the surface in a few days and be discharged easily through the opening thus made in the soft parts.

the region of the right oviary; at first, at or near the approach of each menstrual epoch, but after a time the recurrence was more frequent, and according to the history given by