later in the disease. More mastoid complications are apt to occur in diphtheria than in the other two conditions, but the symptoms may be less typical. One peculiarity in the otitic infection of all these diseases is the lack of pain in the majority of cases. The most characteristic discharge is seen in measles and the thickest and scantiest discharge discharge in diphtheria. Where the discharge is a brownishwhite fluid with few pus cells, due to bone destruction, and the drum perforation is becoming larger, a mastoid operation should be done without delay in order to save the hearing. The author has obtained good results in performing adenectomy during the course of both measles and scarlet fever, but would couneli against it during the course of diphtheria. Sudden rise in temperature during the course of exanthemata without apparent cause is usually due to aural involvement.

the following

"In conclusion, the points are emphasized:

(1) In scarlet fever, children are liable to middle ear inflammation, which may or may not involve mastoid cells.

Adults rarely have mastoiditis. (2) In measles, both adults and children are very susceptible to middle ear involvement, and adults especially to mastoiditis.

(3) In cases where a profuse discharge is present for more than two or three weeks, the mastoid operation should be considered as a means of drainage.

(4) If after ruling out all other conditions by exclusion in difficult cases and the mastoid condition is doubtful, operate.

(5) In profuse nasal discharge following measles and scarlet fever, examine for adenoids and operate if they are found. This procedure is question. able in diphtheria.

garded as a menace to hearing, and occasionally to life, and not allowed to go untreated."

I would like to add to these conclusions, this: In nasal discharges from la grippe or even an ordinary (cold) infection, treatment should be instituted at the very beginning of the attack, to lessen the amount of germladen mucus and prevent the inflammatory action extending. Infection readily travels to the sinuses of the nasal compartments and the eustachian tubes.

To illustrate this, I give the two following case histories: "Mrs. B., aged 70, was seized with la grippe; was profoundly infected and in bed. two weeks. Nasal discharge was of enormous quantities. No treatment for this was given. She fully recovered with exception of the nasal trouble. Four months following the attach, she came to me for relief from the stinking pus discharge from the nose. An examination confirmed my fears of sinus trouble. She will never be well without a serious operation, which she hesitates. to take.

"Miss M., aged 17, was infected two weeks previous to the time of her visit. to me. Her physician diagnosed the case as pharyngitis, laryngitis and bronchitis, and gave her appropriate treatment for these conditions. She had at the same time, however, a phinitis with rather copious flow of mucus, which early took on a yellowish color and showed a rather severe infection. No attention was given this nasal trouble by her physician, although she told him of the deafness and ringing sound in the ears and of headaches. The day before her visit to me she had twinges in right ear, which as evening came on grew more frequent and severe and she spent a miserable night. I told her she had pus in middle ear and that the ear drum should be opened to allow drainage. This she

would not consent to, so I gave her the best treatment I could. The following evening the other ear became involved, and with both ears affected she spent a horrible night. On her On her second visit the following day, she consented to a double paracentesis, with complete relief of pain. Pus discharge was nil after four days. Nasal treatment was instituted and the deafness and ringing disappeared rapidily." In this case needless pain and serious complications might have been prevented by prompt treatment of the nasal trouble.

Report of Cases.

Case No. 1.-"Lillian R., aged 15, had earache for 6 days, with fever following a chill. Then rupture of membrane with a profuse discharge occurred. I was now consulted, for the parents were somewhat alarmed by the pus. I found temperature of 101 degrees. She was weak, pale and profoundly septic. The following day, she had pain in the other ear. I found an intensely congested membrane with yellowish cast to lower half. I advised and did paracentesis at once. The discharge of pus was slight and lessened each day. Temperature was normal the second day following. Healing complete in 17 days. The ear which had ruptured was discharging and lessening slightly each day but it was four weeks before healing was complete. Hearing much more acute on side of paracentesis."

The lesson here is obvious. How fortunate was she, that the rupture took place and that she was saved the graver peril of mastoid involvement!

Case No. 2.-"Carrie D., aged 6, subject of scarlet fever. One week following onset, pain in ear developed and two days thereafter. rupture occurred. The rash disappeared in proper time but the temperature with pus discharge continued. Albumin found in urine. Two weeks after rash

disappeared, I was consulted. Temperature 103 degrees. Tenderness with faint blush was found over mastoid. I advised immediate operation. Operation was performed by another surgeon who was consulted. Brain found affected and patient died.”

Here the gravity of the symptoms were not noticed early enough by the physician in charge, and a life was sacrificed.

Case No. 3.-"John W., aged 55, laborer, had earache for a few days. Treated at a dispensary for a week. Purulent discharge commenced. He then went to a general practitioner who, recognizing the danger, kept a careful watch of the symptoms and when tenderness, edema and pain in the mastoid came on, I was called in consultation. I advised immediate operation. Mastoid cells involved. Con

ditions were such that I did the radical operation. Recovered with complete healing in three weeks."

The chances here for meningeal involvement were great, and if the dangers had not been recognized by his physician here might have been a death certificate to sign.

Case No. 4.-"Alice B., aged 19, office girl, had a purulent otitis media. with rupture of the drum head, following treatment, given by a quack, for catarrh. The family physician attended to it and advised her in its treatment for four or five weeks. The discharge became profuse with pain in and around ear about a week prior to my seeing her. On examination I found a very profuse, foul smelling discharge from external canal and a large, tense, fluctuating swelling over the mastoid. Temperature, 101 degrees. Pale and weak. I advised immediate radical operation. Following the incision from one to two ounces of pus gushed forth. Necrosis of the mastoid cells and internal wall with thrombosis of sigmoid sinus had oc

curred. After several weeks she fully recovered."

Death certainly would have followed very shortly had no operation been performed.

Case No. 5.-"William P., aged 39, laborer, had not been feeling well for a few weeks. Had irregular pains about ear for some days previous to seeing his physician, he having had a slight chill and fever but no prominent symptoms about ear and he complained but little. Symptoms of typhoid were most prominent features at this time. The ear symptoms becoming more prominent, an ear specialist was called in. He found inflammation of membrane, but symptoms involving the mastoid portion could not be discovered. His fever increased and he complained of pain and soreness of neck and back and a convergent squint and delirium came on. Recognizing the seriousness of these symp. toms involving the meninges, his physicians had him transferred to the hospital, where I saw him. With an increased fever, delirium, squint, retraction of head, pain around ear and inflammation of the membrane, we made a diagnosis of meningitis from purulent otitis media. Case being considered hopeless, I advised no operation. Patient died in about 24 hours."

This case was one in which the ear symptoms were not prominent and in which the involvment of the mastoid could not be determined by external signs and in which the involvement of the meninges was only determined by the squint, delirium and pain in the movement of the head.

In such errors we can put it, as Robinson does, "Now we can but pray to our Billikens; solace may we seek, but not the restitution of lost opportunities."

D. Braden Kyle, M.D., has recently presented to the profession two articles, "Nasal and Naso-Pharyngeal Conditions as Causative Factors in Aural Diseases," and "Taking Cold,” which are worthy of time in reading. No doubt he would be glad to send reprints to any one interested.

1. Quotation from a former paper by the author, American Medicine, Nov., 1908.

2. Critic and Guide, Jan., 1910.

3. Charles R. C. Borden, "Aural Complications in the Exanthemata.' (Annals of Otology, Rhinology and Laryngology, September, 1909, p. 565.)

4. Critic and Guide, Jan., 1910. 5. Laryngoscope, Oct., 1909. 6. Annals of Otology, Rhinology and Laryngology, Sept., 1909.

The neglect of leucorrhoea is a grave and unfortunately a common error, that is unpardonable because it involves the health, happiness and often the life of the patient. The character and source of a vaginal discharge should always be investigated by the physician who encounters it, and the patient should never be dis

missed with a prescription for a vaginal wash to be used unintelligently and indifferently because the true sig

*Author's abstract from a paper presented by invitation at the Richmond meeting of the Tri-State Medical Association of the Carolinas and Virginia, Feb. 15 to 17, 1910, to appear in the Medical Record.

nificance of the discharge is not appreciated.

Education of patients to an appreciation of the possible significance of leucorrhoea in childhood before puberty; in young women before marriage; in married women; and in women past the monopause is particularly insisted

upon.

The danger to woman in after life of disregarding or neglecting a vulvovaginitis of childhood that may be derived from infection of a serious character is forcibly emphasized, as is also the necessity of investigating the leucorrhoea of young girls after puberty and before marriage. These latter are the cases most often neglected because of false modesty on the part of both the mother and daughter, shared only too often by the physician. It too often happens that the unsuspecting mother and physician permit neglect of a vulvo-vaginitis of gonorrhoeal origin because a proper examination is not insisted upon.

The leucorrhoea of recently married woman, as is pointed out, is often the result of infection from the husband who has a gleet or chronic prostatitis, at the time of marriage, and if it is neglected may lead to serious consequences. It is unfortunate that leucorrhoea of married women is so often regarded only as a necessary incon

Conservative Treatment of Prostatic Hypertrophy. Sturgis (February Medical Era) advises in the first two stages (softening and engorgement, preceding fibroid hardening) of the disease the following measures and precautions: Avoidance of taking cold; light woolen underclothing; avoidance of straining and horseback and bicycle riding; open bowels; hot baths for not more than ten minutes, and hot injections; light, nutritious diet, with much water, avoiding

highly seasoned foods, coffee and alcoholics; hexamethylentetramin to clear up a turbid urine; tincture of iodin, 15 minims to one dram, to diminish the size of the prostate;

venience. Its possible character and the probable outcome if disregarded should be impressed upon every

woman.

The danger to the young wife is so great that special examination of the prospective husband who has once had gonorrhoea should always be insisted upon before marriage is consented to.

Vaginal discharge in women past the menopause is often disregarded because of the popular belief that women at this period of life are exempt from disease of the generative apparatus.

The most frequent causes of vaginal discharge at this period are senile en

dometritis and cancer of the uterus. Both of these conditions are important; senile endometritis because it leads to constant ill health or chronic invalidism and premature aging; and cancer because it endangers the life of the patient. Hence at no period of a woman's life is investigation of a vaginal discharge more important than after the menopause.

It is unfortunate that the term leucorrhoea is so indiscriminately used to designate any and all forms of discharge from the female genitalia. It is so frequently given as a symptom by the patient who consults the physician that it has come to be regarded as natural, and its actual character is seldom noted.

Single Copies, 20 cents

PHYSICIANS.

The yearly celebration of the ever glorious Fourth of July costs a greater American loss in lives and wounds than did the battle of Bunker Hill. Most of the mortality, perhaps, may be ascribed to tetanus following slight wounds from the use of the toy pistol, the cannon cracker and other war-like noise-makers. Until the American public becomes sufficiently civilized to have a safe, sane celebration of Independence Day, these sad fatalities will occur. After trauma results, however, the danger to life can be obviated in great measure by early and thorough cleansing of the wound, followed at once by the injection of tetanus antitoxin. Physicians and surgeons should bear in mind that the prophylactic value of this serum is very much greater than its curative effect upon the established disease.

DENVER LYING-IN HOSPITALS.

Since the adoption of a scientific method of collecting vital statistics by the State Board of Health of this state, the board has come to a realization of the great and unnecessary waste of infantile life, as well as the high mortality rate among the lying-in.

The Bureau of Child and Animal Protection has also been cognizant of the conditions existing in the state, especially Denver, relative to lying-in homes conducted by midwives and irresponsible so-called hospitals, the traffic in babies having been practically uncontrolled until the past year.

During the last session of the legis lature, both the State Board of Health and the Bureau of Child and Animal Protection had a bill looking to the regulation of such homes and institutions and the legal protection of chil