acute aural catarrh, or after prolonged syringing. In such cases I made Politzer's experiment while the patient was bending his head forward. Some patients, accustomed to use Politzer's bag at home, resorted to the same expedient on their own accord. I have frequently seen mild and temporary symptoms of irritation to follow the entrance of liquid into the ear during the use of the nasal douche, but severe symptoms only in about half a dozen cases. In one case doublesided acute otorrhoea occurred in the course of ophthalmic-blennorrhoea neonati. This coincidence is neither rare nor unknown. I believe that the acute otorrhoea is caused by the cold water running from the iced compresses applied to the eye, over the cheek into the ear. Bearing in mind the injurious effect of cold water running into the ear, I warn, not only the attendants of children, but all patients who apply cold water to the eyes, lest the water run into the ear. Besides this, I recommend them to put some cotton into the ears. We find that in acute purulent otitis media, the perforation of the membrana tympani occurs during the first week of the disease in 82 per cent. of the cases. I am convinced that many a case which runs its course from beginning to end as acute aural catarrh, would manifest itself as acute purulent otitis if puncture of the membrana tympani were made. Severe symptoms of irritation, throbbing in the ear, redness and bulging of the membrane, mucus rales on inflation and the like, are cured in many cases without spontaneous or artificial perforation of the drum head. The recovery in most of these cases is complete, and by no means protracted. Perfect recovery, with good hearing, 118 cases, i. e., 64.83 per cent. Permanent and complete cure is the rule--at least 80 per cent. in primary acute otitis media purulenta. In treating acute otitis purulenta, I have laid greater stress on the necessity of rest to the patient than is commonly done. Rest, if we want to secure perfect restoration, is as indispensable in acute inflammations of small organs as in that of large ones, where, de facto, it is a matter of necessity, not of choice. As I strongly advise patients with acute iritis, or acute ophthalmo-blennorrhoea to remain in bed and take care of nothing but their eyes, in order to receive the full enjoyment of perfect sight, and not expose themselves to the development of permanent synechiæ opacities and even the destruction of the visual organ; in the same way I advise patients suffering from acute otorrhoea to remain in bed and take care of nothing but their ears, in order to reduce the action of the heart to a minimum, keep the whole skin equally, and in an imperceptible, or at times, in a low degree of perceptible perspiration. These conditions I consider essential if we want to cure an inflammatory affection readily, safely, and completely. As robust patients are loth to relinquish their accustomed activity when suffering from inflammatory affections of small organs, it is the duty of the physician to call their attention to the consequences and dangers of an incomplete recovery. The oculist is commonly more readily obeyed than the aurist and the general practitioner. The practitioner, for instance, is, in spite of all admonitions, in many cases unable to keep his gonorrhoea patients at home and in bed, which precaution, I am inclined to think, would obviate gleet and stricture more effectively than all general and topical remedies together. The more extensive my medical experience grows, the more importance attach to the establishment of physiological sanitary conditions in contra-distinction to the remedies of the pharmacy, although I am no nihilist. In many cases of the disease underconsideration, I have most positively observed. of what advantage, rest, of what disadvantage, unrest or imprudence, is. Concerning the dangers of imprudence, I beg to recall the case of the German hotel keeper, who, while convalescent from a severe otitis media

purulenta, by visiting his friends, and taking spirituous liquors,brought about a relapse, which terminated fatally in four days. On the other hand, I found that when the patients remained at home, and took good care of themselves, the perforation of the membrana tympani closed in the shortest time, and complete recovery was obtained. My ophthalmic practice, especially the operative, has forced the conviction upon me that rest in bed is of the greatest advantage in every acute inflammation of some importance. The same principles have guided me in the treatment of acute inflammations of the ear, and I cannot too warmly recommend them. To be sure, acute otorrhoea in otherwise healthy persons may disappear without particular pre. caution, in the same way as I saw a gentleman recover from a pneumonia which he had contracted in a snowstorm while travelling through the Rocky Mountains, but which did not deter him from continuing his four days' journey to New York. It would, however, be unpardonable if a physician were governed in his directions by such exceptional cases. All aurists warn us of the dangers of neglected otorrhoea, but they mostly dwell only on the necessity of local treatment. At the head of the treatment of otitis media purulenta, I would place the advice to consider the disease as an important and dangerous inflammation, and treat it with as much care and strictness as we treat pneumonia, iritis, and other inflammatory diseases. Let us remember only what the usual and less important consequences of neglected otitis are, viz.: chronic otorrhoea, chronic aural catarrh, thickening of the drum-head, adhesions between the different parts contained within the drum cavity—a life-long misery which might have been prevented by one week's rest at home and in bed.

A number of patients, on their own accord, or by advice of their physicians, had applied warm fomentations, or poultices, to the ear. I have examined these patients with particular attention, and find, in looking over my notes, that they all stated they obtained relief from such applications; I have not been able to convince myself, in any one of those cases, that the wet and warm applications had caused the suppuration to spread. This is heresy, I know, but fact, as far as it goes.

When the discharge suddenly diminished, and at the same time the pain in the ear and head had returned, I found decided advantage from steaming the ear, either with simple, or, if the patient preferred, with aromatic water. This caused the ear to discharge again, and relieved the pain. I obtained the happiest results from steaming in some cases in which the cerebral symptoms were so marked that an opening of the mastoid process seemed justified, and I have seen so much benefit derived from this popular mode of treatment, that I try it in every case, especially in chronic otorrhoea in which the discharge suddenly ceases, and pain, vertigo, fever and other symptoms, together with local inspection prove that the inflammation has not subsided, but rather become more intense. In the majority of cases steaming brings the discharge on again, sometimes attended with the liberation of copious cheesy, offensive masses. If steam ing and leeching do not reduce the inflammation, operative treatment should not be delayed.

Though I am convinced of the appropriateness of inflation, I find in my statistics, besides many cases in which inflation, according to Politzer, immediately improved the hearing, some cases in which, if employed in the initial stage of the disease, it caused pain and temporary diminution of hearing. It is not impossible that the current of air forces mucus and pus from the tube into the drum, and from the drum into the mastoid cells; I am, therefore, very cautious in inflating the ear during acute stage of inflammation, and always use the catheter first, together with the auscultation tube. I begin the inflation with

slight pressure, increasing it gradually, while I listen through the auscultation tube. By this method one can judge better of the resistance in the tube, and the contents of the drum cavity, than by Politzer's experi ment. It frequently happened that the first puffs of air through the catheter, produced mucus rales, but then the air entered in a clear and unobstructed stream. The improvement of hearing was, in most cases_only moderate, but when, immediately afterward, Politzer's experiment was rigorously performed, the acuteness of hearing was considerably increased.

I have seldom resorted to the paracentesis of the membrana tympani. Though the puncture of the drum-head be a simple and harmless procedure, I use it not without a certain reluctance, probably owing to the poor results commonly obtained by paracentesis of the anterior chamber. I have practiced paracentesis of the drum only when the indications (pain, mucus rales, bulging of the membrane, etc.) were clearly pronounced. It afforded relief only when it liberated pus, and was immediately followed by otorrhea; otherwise it increased the pain, which only subsided when, later on,suppuration set in. Much has been written about the paracentesis of the drum cavity. In the present phase of otology, this operation has become "fashionable," yet there was a time-and it has not long passed by-in which it was declared a sin of omission not to puncture the cornea when hypopyon was present. To-day no oculist performs paracentesis of the anterior chamber for the sake of removing pus, for it is known that pus in the anterior chamber is most rapidly absorbed as soon as its source has been removed. I am loth to apply conclusions by analogy from one organ to the other, but I confess that the present popularity of paracentesis of the drum cavity has not induced me to perform this operation at every opportunity.

Opening of the mastoid process was never resorted to in the series of cases under consideration. Of this operation also I am not a great admirer, and perform it only when the cerebral symptoms are threatening, especially when, at the same time, the secretion has ceased more or less suddenly, and the mastoid region is red, swollen, and tender on pressure; i. e, in cases that show some probability of retention of morbid substances in the cells of the mastoid process. I lay great stress on careful cleansing of the ear. This should be done by syringing with lukewarm water, to which a small quantity of table salt or soda may be added.

Instillations, for instance, nitrate of silver, 25 per cent., without exception, increased the inflammation and the pain.

CLINIQUE.

nine cases out of ten. If we examine our text-books, to go still farther, we are often met by the same response, which, while true to a certain and very limited extent, is misleading to students, and directs the attention of more experienced practitioners from matters of far greater importance.

We find that nearly all morbid processes, at least most of those which are naturally brought to the attention of the surgeon, are produced or producible through the operation of two sets of causes, viz. the predisposing and the exciting. A moment's consideration will convince the reader that if either class is to take precedence it would naturally be the former. At this time I may simply say that this precedence is established from the fact that they indicate some natural defect or peculiarity, which makes the sufferer or those of his class more liable than others, or a dif ferent class. It seems almost impossible that any should be found denying this precedency, but, either in express terms, or impliedly from their silence, there are not a few. When we look over the literature of the subject of hernia, produced by homoeopathic practitioners, we are astonished to find the predisposing causes are rarely mentioned, and oftentimes completely ignored or overlooked. Franklin, indeed, makes bare mention, but Helmuth, in his otherwise admirable work, unless I have overlooked it, does not give a single line to its consideration. It may be said the writer is equally culpable, and he pleads guilty, but it will be admitted, the edition of his treatise on Surgical Diseases, now deservedly out of print, was as much the production of the times as the author. In the present edition, now in press, this, and many other more glaring sins of omission and commission will be fully atoned for. After this long preamble the kernel of the nut may soon be reached.

In the last (and initiatory) number of an excellent periodical, the Journal of Electrology and Neurology, Dr. Miner tells us how to cure inguinal hernia by the galvano-cautery. One would suppose, unless he knew better, that the production of hernia was entirely dependent upon some injury to the inguinal canal, and that no change in the contents of the abdomen was essential. Now, I am very far from intimating that Dr. Miner is uninformed on this point, for I know that he is not. But either from inattention, or acting on the supposition that his readers are sufficiently informed already, the very material fact that alterations in the mesentery are the prime cause, at least for the continuance of hernia, is not given. Where shall our physicians go for this information, at least in our meagre literature? In fact the larger majority of the common text-books in surgery are equally defective. Now, let me state a fact, emphatically, and one which has been proved such in my own experience, over and over again. An old inguinal hernia can rarely, if ever, be cured by any operation, or the aptwo things are accomplished, viz.: either the use of a plication of any mechanical appliances, unless one of well-fitting truss from the beginning, or a correction of the elongated mesentery, should no truss have been

worn.

If we ask the average practitioner what are the causes of hernia we shall probably be told muscular exertion or trauma of some kind. If we extend our inquiry to many of those eminent in the surgical science, the answer will be practically the same, in

ally hereditary. In either case the effects are the same, and the cavity of the abdomen is not sufficient to contain its contents. The hernia is, therefore, due more to the fact that the viscera are partially augmented in size, and an outlet is sought for their accommodation, than to the existence of an opening.

When a truss has been worn from the commencement, if it be well-fitting, and there is no hereditary tendency to hernia, there may be no elongation of the mesentery. Such is the case usually in cases in which the protrusion has not occurred until after the period of adolescence, and is evidently due to traumatism. Here a truss will naturally be applied early; the her

nia being kept up, there is no traction in the mesentery. The later appearance of the lesion will argue against its being due to hereditary malformation. These conditions are favorable to an attempt to cure by surgical treatment, and, indeed, cannot, I believe, be cured in any other manner.

From this it will be seen that in all the cases of failure, the conditions of failure were fairly to be attributed to changes in the mesentery from traction or heredity, and we are fully warranted in assuming that a failure to recognize that element of correction, will give unsatisfactory results, no matter what the operation is, or how well it may be performed.

METASTASIS TO THE MENINGES.

BY EDGAR V. MOFFAT, M. D.,

Old hernias that have been neglected, or imperfectly retained, or those which, from some local conditions, cannot be retained by a truss, permit mesentery elongation to a degree forbidding any attempt at cure, by operation at least.

Now, we are ready to conceive the conditions of cure, and why operative treatment alone must always fail, or so frequently as to be the rule, when etiology is neglected. To avoid falling into the error attributed to others, we will take nothing for granted, and state that the cause of failure is, that the capacity of the abdomen is inadequate for the accommodation of the hernial mass, and one side being closed up it will appear on the other. An umbilical hernia being "cured," we may look for an inguinal. Here then are the conditions."

66

1st. In old hernia; those that cannot be retained, from any cause; congenital hernia, or of any character that necessarily subjects the mesentery to traction; the first indication is to correct this elongation, if possible. The means are two-fold, medicinal and mechanical. (a) Calc., Nux, Sulph., Lycop., Plumb., etc., have all a decided influence in this direction, and our journals, society transactions and text-books are crowded with illustrative cases; none are, therefore, needed here. (b) Relieve traction by the use of easy, well-fitted, light-springed trusses, to be removed at night. In very obstinate old cases it will be safer to wear a truss with a double pad, one on the opposite side to the hernia, to guard against protrusion at a new point. When the tendency to protrusion has been corrected, radical operations to close the outlet may be appropriately made.

2d. In recent hernia, particularly when acquired, and due to traumatic influences, operative measures may be at once resorted to.

3d. In all cases, recent or chronic, guard well, with suitable apparatus, all weak points where hernia might protrude, until all danger has passed.

In closing this desultory and imperfect contribution, let me give the result of fourteen operations for radical cure, in my practice.

House Physician, Homœopathic Hospital, Ward's Island. William Moon, æt. 37, married, English, miner by occupation, admitted Aug. 15, 1879. For the past three weeks patient has been on a heavy debauch, eating little or nothing. In a fight five days ago was kicked in the left eye, rupturing the sclerotica just behind the insertion of the cornea on the outer side of the ball, evacuating the aqueous humor, so that the anterior chamber is collapsed and sight entirely goue. Further details of the lesion we could not ascertain. In this condition he traveled from Philadelphia. Two days previous to his admittance erysipelas appeared about the affected eye. We found him suffering great pain in and around the eye; redness and swelling extended down the cheek, neck, and across to the opposite side of the face, so that both eyes were closed. The entire surface was hard and studded with numerous small bullæ, containing serum.

The pain was sharp, but heat, itching and tension predominated. Patient weak, very restless, and thirsty. Temp. 1053°; pulse 70, full and soft; R. Acon. 1, half-hourly.

In three hours (that is, about 7 P. M ) no abatement of the fever had appeared, and as Verat. vir. seemed contra-indicated by the slow, soft, full pulse, Rhus tox. was administered every two hours, and a lotion of Rhus 3 ij., water 3 xvi., applied to the face.

Aug. 16, 9 A. M. Temp. 103°, pulse 80, pain in the face somewhat better.

Aug 17, Aug. 18.

7 P. M. Temp 105°, pulse 80, R. same.
9 A. M. Temp. 102°, feels easier, R. con
tinued.

General improvement: bullæ fewer and larger; right eye could be opened to its full extent; pains less; R. and application continued.

Aug. 20, A. M. Swelling and redness rapidly dimin ishing; bullæ fast drying up.

P. M. Pain, itching, and swelling continued to disappear. Left eye could be opened wide; bullæ nearly reduced to scabs. Patient yet weak, and appetite poor. While the eyes were open the mind was clear; but on closing them patient imagined he saw people standing by the bed and walking around him. He talked more readily; complained of a profuse, gushing, watery diarrhoea, which was frequent, debilitating, and painless. R.: Podoph. 3x, and lotion discontinued.

Aug. 21. Diarrhoea very much better. Temp. 105°; pulse full and soft at 110. Delirium more pronounced, but still mild and very loquacious. R., Stram.

Aug. 22. General condition about the same; delirium continued, but in a milder form.

P. M. About 3 P. M., patient began to grow excited; believed we were trying to murder him, and cut up his body, and occasionally endeavored to spring out of bed and escape. The delirium increased in violence up to 11 P. M., when it became necessary to have an attendant constantly near, to prevent his

him.

jumping from the window. He seemed at times in an agony of fright, screaming "murder!" at the top of his voice; again, he would whimper and cry, or burst into laughter, The eyes, or rather the right eye, was bright, and the pupil but slightly dilated. He was constantly trying to uncover himself and get up. R.: Hyos. gtt. v., aquæ zjj.; teaspoonful half hourly-which, by 2 A. M., had quieted Aug. 23. Still delirious, but mildly so; he continued in his delusion as to our trying to kill him, but only whimpered and protested, in a more quiet way. He would become rational at intervals, when he complained of pain and dryness in the throat. Right eye injected, face red and hot, though not swollen. R., Aug. 24. Still some delirium, but not so marked. Respiration slow, pulse 55; patient very weak; appetite entirely gone. Erysipelas appeared, returning to the left side of the face. R., Bell. 1 hourly, and R., Spts. frumenti, Aquæ, aa. zj,; S. teaspoonful half-hourly. Aug. 25. Patient almost entirely rational. Erysipelas was more marked, the face being hot, red, and shining. Temp. 105°. pulse feeble and slow. R. and stimulants continued.

Bell.

Aug. 26. Temp 103°. Face appeared about the same, appetite improving, the mind entirely clear. Aug. 27. The erysipelas improving, patient much stronger. R. same.

Aug. 28. Face was not so red, but considerable ædema appeared beneath the affected eye, with stinging pains in the cheek. Patient was thirstless and drowsy. R., Apis, and discontinued stimulants.

Aug. 29. Erysipelas better. R., same. Aug. 30th. General improvement, the inflammation had nearly disappeared. R. continued. Sept. 1. Appetite good, bowels regular, felt much stronger.

Sept. 4. The erysipelas has completely subsided. There was a good deal of pain and lachrymation in the injured eye, which was atrophied. Pain and irritation were becoming slightly manifest in the sound eye when he was transferred to the Ophthalmic Ward. Sept. 5. Patient remained one night in the Ward, and in the morning suddenly determined to go to New Haven. Argument, protest, and a fair warning of the dangers of sympathetic opthal mia, were all useless, and he left the Hospital, cured at least of his erysipelas.

In this case it is interesting to note the concurrence of a temperature of 105 3-5°, with a soft pulse of 70, and we would suggest the query: Is it possible that a lotion of the apparently homeopathic remedy, so dilute as 1.64, could so suppress the disease as to produce the metastasis, especially as the medicine was at the same time administered internally?.

FOREIGN BODY IN THE EAR. REPORTED BY C. L. BAGG, M.D., HOUSE PHYSICIAN,

HOMEOPATHIC HOSPITAL, W. I.

Mary B., aged 48, while on night duty, September 3d, at about 3 A. M.. felt something like an insect enter her right ear, which caused a great deal of uneasiness and pain. She attempted to remove it with a long hairpin, but being unsuccessful came to the doctor about 9 A. M., when a mixture of ether and olive oil was dropped into the ear in the hope of killing any living thing that might be in the ear, and also of relieving the pain, which at times was very severe. She

returned again in the afternoon, saying she was no better, and that she could still feel something moving, the pain having in the meanwhile increased. Upon examination with the otoscope, the meatus auditorius externus seemed perfectly clean and sound; the membrana tympani could be distinctly seen beyond, clear and bright, nothing intervening between it and the eye of the observer. At the lower portion of the membrane there seemed to be a small bright clot of blood. As the woman had been using a hairpin in the ear, it was concluded that this must be a clot resulting from some abrasion. Syringing out the ear carefully, and again examining it, the same appearance was presented, and we began to think the presence of an insect to be out of the question; but the patient was constantly saying "I feel it moving," at which times the pain seemed to be increased. We therefore concluded to make one more attempt before leaving it.

Pulling up the pinna of the ear so as to straighten the canal, a stream of water was thrown forcibly upward and backward, so that it would turn and wash out on the floor of the passage. To our surprise and satisfaction we washed out a black beetle one quarter of an inch long and still alive! Again looking into the and thorax of the beetle, which was very black ear, the clot had vanished, evidently being the head and shining, and by reflected light assumed the ap pearance of blood. The query was, Where could little depression at the base of the membrana tympani the rest of the body have been, unless it lay in the in such a way as to conceal all but its head, which lay up against the membrane?

The pain was at once relieved, but for a day or two afterward a feeling of soreness remained, which was removed by Arnica 3c.

Absorbent Botton is cheap and clean from the beginning. When the sponge is filled with sand, which, if not thoroughly removed before using, may, in case of clean cut wounds or injuries, when," with proper dressing they will heal by the first intention, prevent their so doing by depositing sand in them. It need not be used a second time, and it fills and expands readily in water.

MALT EXTRACTS have become a most important article in the diet of the sick, and physicians have come to regard them as almost indispensable in cases in which malassimilation predominates. Messrs. Fairchild Bros. have succeeded in making a "Jelly" containing over ninety per cent. of the extract, which they supply either simple or in combination with cod liver oil, etc., which has the advantage of not being sweet and syrupy, as is the case with other preparations of malt, thus overcoming an objection which has prohibited their use in cases in which sweets disagree. We have prescribed this preparation in a great number of cases of nervous prostration, inanition, etc, with decided benefit, and we consider it a great addition to our dietary armamentarium, especially as it covers those cases which otherwise would be compelled to do without malt.