There are two very good reasons why the suppurative variety of inflammation should be so prevalent after scarlet fever. (1) The usually debilitated condition of the patient which would favor a suppurative process. (2) The severity of the inflammation both in the throat and in the middle ear.

The conditions found in acute suppurative inflammation of the middle ear up to the stage when pus begins to form in the tympanic cavity, are identical with those of the non-suppurative variety, but the onset of the disease is more pronounced, the course more rapid, and of greater intensity. The mucous membrane is swollen at times to such an extent as to almost obliterate the tympanic cavity, the tubular and racemose glands, are in a state of active hyperemia pouring forth large quantities of mucus, and becoming cystic at their orifices. The epithelium is macerated by long contact with the retained discharge which has now assumed a decidedly pus-like character. Great pressure is brought to bear upon all sides of the tympanic cavity, the drum membrane being the weakest point, bulges, and ulcerating at one point ruptures and gives vent to the retained discharge. These at first are serum, blood, pus, mucus and epithelial debris. As time goes on they assume more and more a pus-like character.

All the symptoms enumerated under the non-suppurative variety are intensified here, especially the pain, which is agonizing, and will make the bravest quail. Upon inspection the drum is found to be a dark purple red, and to be bulging quite distinctly. Just before rupture the point at which the drum is to give way is marked by a yellow point.

Upon comparing the pathological conditions found in these affections with the symptoms it will be found that the latter are easily explained by the former.

The fullness, by the swelling of the mucous membrane and by the distended state of the blood-vessels; the tinnita, by the rush of blood through the distended vessels, and by the moisture of air and fluid in the tympanic cavity; and the loss of hearing, by the impaired conduction power from swelling of the mucous membrane.

The pain, which is usually severe in the non-suppuration variety, and very intense, the suppurative form of middle ear inflammation, may be explained by the intimate relation which the mucous membrane bears to the periosteum in this region, and by the rich supply of nerves distributed to the tympanic cavity.

After rupture of the membrane has taken place, and free discharge is established, an amelioration in the symptoms is observed. It is probably this fact which has led some of our predecessors, and even some in our own day, to follow the fallacious teaching, that suppuration should be encouraged in all cases of inflammation of the middle ear. I may here speak of a symptom, or rather a complication of this disease, which has received little attention, but which does sometimes occur, namely, spasms. I have now in my mind the case of a little boy, who, afflicted with this aural affection, had during its course many spasms. He had not had spasms before, nor has he had them since the time he was affected with his ear.

Acute suppurative inflammation of the middle ear is often complicated and a grave complicate it is-by serious involvement of the mastoid process in the inflammation. This involvement is indicated, (1) by general systemic disturbances, chills, fever, etc., (2) by incurred pain, (3) by tenderness over the mastoid, (4) by redness and by swelling of the soft tissues over the mastoid. This inflammation may be present, (1) as mastoid periostitis with abscess, (2) mastoid abscess with or without periostitis. If you will glance for one moment at the anatomy of the part, it will be easily seen why the mastoid process should become involved in this inflammation. The mucous membrane lining the mastoid cells is in direct communication with that lining the middle ear, through the mastoid antrum, and it is through this communication that the inflammation travels by direct continuity of tissue.

It is in this affection also that we most dread an extension of the inflammation to the meninges of the brain. The roof of the tympanic cavity which is the bony partition between the cranial and tympanic cavities, is at best very thin, it is often cribriform, and there is a direct vascular communication through it; little wonder is there then that this inflammation often spreads to the meninges and results in the death of our patient. There are no doubt many cases of meningitis due to this course, whose true origin in an aural affection is never suspected.

Many of us will remember, and all who do will regret, the lamentable case of the late Dr. Farrand in this connection. Paralysis of the facial nerve has been observed in some very few cases; it is more common in the chronic variety of middle ear disease attended with suppuration. In outlining the treatment which has been found most efficacious in these affections, we will look at it under three distinct heads:

I. That which should be employed in acute non-suppurative cases, and the early stages of the suppurative variety.

II. That which will be found most applicable when suppuration has supervened and rupture of the drum membrane taken place.

III. That which is indicated when the mastoid process is involved.

I am well aware of the fact that there are many who consider the obstacles in the way of efficiently treating these aural complications of scarlet fever as well nigh insurmountable, but gentlemen, are we to allow our patient to run all the risks and dangers of abscess of the mastoid process, of mastoid periostitis, of cerebral meningitis, or of cerebral abscess, or endure all the horrors of chronic suppuration from the middle ear with its appalling compliment of caries, polypi, disgusting and offensive discharge, or of pyæmia, while we sit quietly by with folded. hands? No! most decidedly, no! We must therefore do all in our power to limit the disease and prevent its complications. This affection is from the start an inflammatory one of the severest type, and very vigorous antiphlogistic treatment must be employed if any good is to be accomplished.

Constitutionally, aconite is probably the best remedy we have. Small doses should be given, frequently repeated for its quieting effect upon the head, and its lowering effect on the fever. Quinine is contraindicated because of its well-known physiological effect upon the ear.

It is, however, from local treatment that we expect to derive the most benefit, and at the head of the list we would put local blood-letting by means of leeches. The point at which they should be applied is the tragus, for here the vascular supply of the tympanic membrane and cavity is most easily tapped, here thin blood-vessels inosculate. From one to six leeches may be employed according to the severity of the case, and the age and the condition of the patient.

Next in order of importance, we would place the local application of hot water in the form of the hot ear douche. This should be applied thoroughly for twenty or thirty minutes, the longer the better, every two, three or four hours, according to the severity of the pain. The water will have to be used moderately warm at first, and gradually increased in warmth until it is as warm as the patient will allow. A good and efficient ear douche may be improvised from two or three feet of rubber tubing and a basin of hot water.

The ear should be thoroughly but gently inflated by Politzer's method, once or twice daily, thus cleaning out the tympanic cavity and Eustachian tube, and keeping the middle ear well ventilated. It may be found necessary to use an anodyne, but usually the above line of treatment will be found sufficient for the case in hand.

Poultices of various kinds should not be used, and while sweet oil, London molasses, onions and various other domestic remedies are not likely to do much harm, they should not be allowed to take the place of remedies which will accomplish some good.

Ether, chloroform, and other stimulating applications should not be allowed under any consideration. When it is found impossible to get leeches, a fly blister may be applied to the tragus if the patient be not too young. In severe and stubborn cases, and when the drum membrane is greatly thickened by chronic catarrh, paracentesis may be found necessary, but these cases will be rare.

If, however, we do not see our case until suppuration has been established and rupture of the drum membrane taken place, our treatment must be somewhat varied from that outlined above.

The prime object now is to secure perfect cleanliness and allow and assist nature to repair the damage done.

The ear must be kept thoroughly clean and perfectly free from all discharge, by frequent syringing with some warm antiseptic solution two, three or four times daily, according to the amount of discharge. Various antiseptics may be employed. A weak solution of carbolic acid, or a still weaker solution of bichloride of mercury, sulpho-carbolate of zinc, or soda, or a solution of boric acid.

For all purposes a warm solution of boric acid is probably the most convenient and the most suitable. After thoroughly syringing the ear it should be well dried, and inflated by Politzer's method and some warm mildly astringent drops instilled into the ear. Sulphate of zinc, two grains to the ounce, will be found suitable, or a weak solution of chloride of zinc may be used. Cocaine may be found of some value in allaying the pain of the affection. It must be used in a very strong solution and instilled into the ear after rupture of the drum if any good is to be expected from it. If the case be still further advanced and show any signs of persistence, the mucosa of the middle ear and the margins of the perforation may be touched

by some more stimulating application such as argentum nitricum, ten grains or twenty grains to the ounce, applied carefully on a cotton mop. During all this time the nose, the pharynx, and the naso-pharynx should be thoroughly and systematically cleansed and any catarrhal complication treated as thoroughly as circumstance will admit, with sprays and gargles.

If the mastoid process become involved and there is pain or tenderness on pressure, and redness of the skin over the process, constant application of sponges wrung out of hot water will be found necessary, also the application of from three to six leeches over the mastoid process, and if the skin and other soft tissues become puffy and oedematous, pitting on pressure or showing fluctuation, a full incision must be made down onto the bone through the parietes. If pus collects in the mastoid cells and the substance of the bone, no outlet being found through the middle ear, the mastoid must be chiseled or trephined, the pent up pus liberated and any dead bone removed.

In conclusion, I would say that it is not by the employment of any one of these means alone that we arrive at our best results, but by the judicious combination of the means so easily at hand. In the milder cases of the non-suppurative variety, the hot douche and Politzer's inflation thoroughly and systematically applied may be all that is required, while in the more acute and severer cases we may in addition to these remedies find it necessary to employ leeches and parecentesis of the

membrane.

SCARLATINAL RHEUMATISM.*

BY R. A. JAMIESON, M. D., DETROIT, MICHIGAN.

Scarlatinal rheumatism is a condition or sequel often following the acute stages of scarlet fever, and is observed frequently at the beginning of the third week, sometimes much earlier, or just as desquamation is beginning. It is accompanied when severe by a considerable increase of fever, and with more or less pain and swelling of the joints, with or without redness of the skin.

The smaller joints are particularly prone to be affected, but it is observed in the knee, hip, shoulder, elbow, and occasionally in the sterno-clavicular, infra-maxillary and vertebral articulations (rarely instead of the usual acute and intense synovitis with serous effusions, the disease results in suppurative inflam* Read before the Detroit Medical and Library Association.