interesting attempts to identify the colon bacillus and the bacillus that Eberth pointed out, but I believe the colon bacillus cannot be held accountable for the continued fever of typhoid, as we recognize it.

Vaughn, of Ann Arbor, Mich, in the Journal of American Medical Association of April 19, says: "From time to time atypical forms of the Eberth bacillus, differing from the standard sufficiently to be classed as varieties, have been obtained from persons dead or sick with typhoid fever. Babes was probably the first to report on these atypical forms, all of which were obtained from the organs of typhoid cadavers; but three of the varieties, or very similar bacteria, were also found elsewhere. It is undoubtedly true that the typhoid bacillus, when growing outside the body, as, for instance, in drinking water, departs more or less markedly from the type of this germ as found in the spleen and mesenteric glands after death."

Vaughn has been making a great number of analyses of drinking water from a varied source, and says he has never seen a typical Eberth bacillus in drinking water. A great number of these waters have contained the typical colon bacillus, but not a single epidemic of typhoid has followed where this water was contaminated with the colon bacilli. The colon bacilli and bacilli of Eberth are often found together, and where a micro-organism is found that little resembles the colon and much resembles the typhoid organism, the chances are very much in favor of typhoid.

The typhoid germ is carried by so many different means that it is very hard sometimes to trace the means of infection. In a very large number of cases the infection comes through the food supply, and generally through the water, not through the drinking water, but through the water that is used either in the cooking or mixing of food preparatory to serving. In so many of the cases traceable to milk the bacilli is bound to be introduced in the water,

either the water that the milk is diluted with or that used to wash the milk cans or bottles.

There are a great number of ways to carry the typhoid bacilli, and a great number of carriers, it is hardly worth the while to more than mention them. The infection is given off especially by the bowel, and frequently when a patient may be depositing the organism in each defecation for several says be. fore a diagnosis has been made, or a physician even called, and no precaution being observed as to where or how these stools are taken care of, it is very easy to see how hard it is to prevent the spread of such an infection.

The urine also often contains the bacillus, though not likely to contain it so early in the disease. There are sometimes slight changes in the kidneys; occasionally of a serious nature. There have been a few cases, I think, where the typhoid bacillus were found in the sweat, though these are not well authenticated. There has been a number of reports of the typhoid bacillus being found in the gall-bladder, but just how they get there has been rather a mystery to me. The bacillus has been demonstrated in the blood, especially in the veins.

The absolute identification of the bacilli is not of any especial importance, I take it, clinically, but where there is an atypical case of continued fever, with doubt attached, the finding of the Eberth bacilli would clear up the diagnosis. It is usually very difficult to identify, being surrounded by other bacteria very similar.

Age seems to be a predisposing factor; that is, the extremes of life are seldom attacked. It may be partly because the chances of infection are so limited. We certainly know that infants in arms and very small children have a very limited diet, and their moving about is also very limited; therefore they cannot be exposed as an adult is, who is drinking and eating in many different places where there can be many chances of infection.

In the middle of life, when people are going from place to place, frequently the chances of infection are greater. The same thing applies in later life, when persons get beyond middle life they are more content not to roam about, thus lessening the opportunity for infection. Young adults seem to be the ones who are more frequently attacked. Sex seems to play but little part, maybe the male is more often the subject of typhoid, and again the same reason might apply. The male gets his eat and drink in so many more places than the female. The typhoid bacilli may be carried hundreds and thousands of miles. Cold has but little, if any, inhibiting powers on the life of typhoid bacilli. The period of incubation is from eight to fourteen days as a rule, though some cases are much longer. Cold, fatigue, previous illness, especially debilitating disease, seem to be thought by some as predisposing causes. The invasion is generally slow, usually a period of a week previous to taking to bed the patient complains of being tired, weak, aching in head and back, with often chilly sensations, may be constipated, or diarrhea be present.

Typhoid is not at all frequent during the puerperal state or during lactation, though it is not unheard of, as I will report in this paper a young lady nursing a baby 7 weeks old who was the subject of typhoid.

Mrs. B., aet. 22. Primapara. Is a well-nourished young woman who had given birth to a well-developed, fat girl baby, December 30, 1901. She convalesced rapidly and was up in three weeks. On February 20 she was taken. with a chill and temperature of 104 followed at night. She was advised to go to bed, and was given a mercurial purge, with salol and quinine following. No reduction of temperature followed. On the second day following, the temperature still remaining high, I gave quinine until intense ringing of the ears was produced. Still very little, if any, lessening of the temperature. There

was no medicine given the following day, and the fever went as high as 105. The tongue had become dry and brown, the lips were cracked and sore, sordes were beginning to form on the teeth.

There was a little cough, the abdomen was quite distended; some tenderness, especially over the lower part. On the following day there appeared a great number of rose-colored spots over the abdomen and quite a number on the chest. The baby was taken away and put on artificial food. This patient was put on small continued doses of calomel and naphthaline until free catharsis was produced. The diet consisted of sweet milk alone for the first week, when the patient grew so tired of it that it was difficult to get her to take it. Milk was given diluted with vichy. This patient was then put on panopeptone alternately with buttermilk, when we could get fresh buttermilk. The medication during this time was salol gr. 5 and strychnia gr. 1-20, as her pulse had persisted at about 130. This patient was sponged with water direct from the faucet, with alcohol added, and she drank large amounts of water. She never became delirious, though when she was convalescent she was the subject of hallucinations a number of times. She made a complete recovery in a month and was able to be out on the street in that time. She never had any bed sores. This patient developed an adenitis of the submaxillary glands, but disapappeared rapidly.

CASE II. Dr. H., veterinary surgeon, syphilitic, with open sores on both shins. Had been treated at Hot Springs, Ark.; had great bone ache at nights, slept poorly and was very melancholy. He was morose, disagreeable to his underlings without any cause and generally very reticent. Could seldom be engaged in

conversation. To those that he knew well he was always bemoaning his fate and blasting the world generally.

Was taken with typhoid fever and removed to St. Mary's Hospital; temperature 104 at first. Soon became delirious

and was a very troublesome patient to nurse. Had incontinence of feces and retention of urine. Had to be catheterized for a number of days. On about the twentieth day he had a severe hemorrhage, but without much shock. About the 25th day his temperature became normal and convalescence was thought to be established. About the twenty-eighth day his temperature arose again rapidly and went as high as 106.

In two or three days after this his temperature dropped from 104° to 96°, with cold, profuse perspiration and what appeared to be complete collapse. With artificial heat applied, atropia, nitro-glycerine and whisky he was revived to have the same condition return in about forty-eight hours. He was kept well stimulated in the meantime, with pulse ranging from 120 to 160. Temperature about normal, or a little below. The third or fourth day after this last fall in temperature he began to improve and made a rapid recovery. He gained flesh rapidly, the sores on his legs were well, with most of the pigmentation gone. He became He became well, his disposition improved and he seemed to be entirely transformed. He grew stout, and has enjoyed good health ever since. This was four years ago.

CASE III. Miss D., aet. 15. April 9. Had always been a strong, robust girl. About ten days before the mother had called me up by telephone and said her little girl had mumps, but was not suffering much, only seemed tired and disinclined to move about any, and without appetite. In a few days was called up again and asked if I thought a ride would hurt the patient. I said, "Not if she was kept warm. On the next day I was called to see the young lady and found her with a fever of 101 in the forenoon. There was no swelling on either side of the jaws that I could make out, though some tenderness on one side. The breast on the same side was enlarged, though there was no pain

or

tenderness. Temperature continued, tongue coated, but moist, some

soreness all over with continued chilliness, but little abdominal tenderness. Had given a purge without any remission in fever. I then gave a colon douche without any impression on the temperature.

On the 13th inst. she had considerable nose bleeding, with recurrence again on the next day. In a day or two a number of rose-colored spots appeared on her abdomen. She had great stupor, but when aroused was fully conscious. This patient had no food whatever from the 12th to the 20th, then only panopeptone. She had very little abdominal distention; was able to control her bowels. On the 17th or 18th she became so restless that she could not be kept at all quiet; would throw herself from side to side, cry out, and kick her feet up and down with constant moving of hands. Was given 1-12 gr. morphine. She rested well five or six hours: afterwards became restless again and the nurse thought perhaps she wanted to urinate; gave her the bedpan, but after making several efforts failed to pass her urine. She was catheterized and about one pint of urine was drawn; after that was able to void her urine. I found chloretone after this, used in 5 gr. doses to control the nervousness, produced a very satisfactory hypnotic effect, when desired. This patient had bed sores, in spite of the care of a good nurse; the first I have ever seen in typhoid. Patient is now convalescent.

I have written this short and incomplete paper to obtain a discussion as to management of cases of typhoid. I have treated many cases very differently with about the same result. I would like to hear the older practitioners discuss the management of typhoid especially.

INJURIES OF THE MEMBRANA

TYMPANI.*

BY SAMUEL G. DABNEY, M.D., Professor of Ophthalmology and Clinical Professor of Otology and Laryngology in Hospital College of Medicine.

LOUISVILLE, KY.

Hevell states that injuries of the drum membrane occur about seven times in a thousand cases of ear disease. Chemani, an Austrian brigade surgeon, found 54 cases of rupture of the membrana tympani in 5,041 aural patients. Such injuries, then, appear to constitute about 1% of all ear affections, and are, therefore, rather rare. causes may be either direct or indirect.

The

Under the former head we find injuries from foreign bodies, and especially from injudicious efforts at their removal; such cases are common in the experience of every otologist; from chemical agents put into the auditory canal; from fracture of the adjacent bones; from surf bathing; from objects used to scratch the auditory meatus-toothpick, hairpin, ear-spoon, etc.; rarely from clumsy use of eustachian bougie, and equally rarely, perhaps, from a thorn passing into the canal and piercing

the drum membrane; one such case has occurred in my own experience—a man riding through the woods was struck in the ear by the twig of a tree; he felt severe pain from a sharp prick and observed a little bleeding and found that his ear had been stuck by a thorn. He consulted me soon afterward, and examination showed a perforating wound of the drum membrane in its lower posterior portion. Bacon reported a

caisson has been known to rupture the tube. To prevent this and other injurious effects on the ear, it is recommended that the patient should occasionally practice inflation by the Valsalva method. Of Chimani's 54 cases 38 of rupture above referred to, were caused by boxes on the ear; 6 by falls on the head, 3 by a kick on the head from a horse, 2 by the report of a loud gun near by, 2 by blows on the head with a club, 2 by playing of brass instruments, and 1 by a fall in the water. The large proportion from boxes on the ear accords with general experience and is especially noteworthy. Two such cases, both due to a box received in sparring, have been recently in my hands, and I have seen several others. A rather odd case seen a few months ago was due to a kick on the ear from a companion while diving under the water. I have seen three cases caused by falls, two in children who fell as they were sliding down the banisters, and one in a man thrown from a buggy in a runaway accident. In both the children there was also a

slight fracture of the bone adjacent to the drum membrane in the upper part of the auditory canal.

Superficial injuries of the membrana tympani are usually mild and require nothing more than cleansing, a soothing application of powder or ear drops. and an antiseptic dressing. The symptoms of rupture due to a box or fall are sudden pain, sometimes a loud report in the ear, dizziness, tinnitus, and, some authors say, hemorrhage. In the cases I have seen this was not observed

Society in 1888.

The severer injuries are more frequently due to indirect causes, such as falls on the head and blows on the ear. Forcible inflation, and even sneezing and coughing have been known to rupture the drum, but in such cases there is reason to believe that there was preexisting disease which had lessened its strength. The condensed air of a

Read before the Louisville Surgical Society, January 20, 1902.

of Chimani's patients. The later symptoms depend on the management of the case; deafness and some tinnitus, however, are likely to continue for some weeks. If seen soon after the injury the appearance is very characteristic. The rupture is usually single, but occasionally multiple. It is said to be either a narrow slit, difficult to discern, or a well-marked opening with gaping edges and usually with blood-stained

To

borders; on inflation the escaping air drum, when the patient had inflammation or obstruction of the eustachian makes a deep, prolonged sound, unlike the perforation whistle in disease. In medico-legal cases it is of the greatest importance to make an early examination, as, if suppuration has occurred, these typical symptoms are lost. illustrate this I may cite the following case: I was called to see a youth of about 16 who was suffering with acute purulent otitis media. I found him with high fever, tenderness about the ear and profuse discharge therefrom. In an altercation with a man three or four days previously he had received a severe box on this ear; he had felt instant acute pain, some dizziness and deafness. More or less pain continued; a day or two later fever set in and discharge began. A suit for damages was brought, though I informed the family that from the appearance of the ear alone, without the patient's statements, it would not be possible for me to state that the drum had been ruptured. Under the usual treatment the case progressed well and made a good recovery. The law suit was compromised, the young man receiving quite a considerable sum.

The prognosis of ruptures, provided the labyrinth has not been injured, is good. Repair takes place usually in two or three weeks or sooner, with restoration of good hearing; when the injury involves the labyrinth the prognosis is guarded-perfected hearing is not likely to be recovered; the diagnosis of this complication will depend chiefly on the intensity of the deafness and on the tuning-fork tests. The treatment of ruptures of the drum membrane is simple. The wisdom required is mostly the wisdom of what not to do. The auditory canal and the surface of the membrane should be gently and aseptically wiped clean with a little absorbent cotton or a probe; blood clots should be removed and a little sterilized gauze put lightly into the ear. Hevell advises the use of a bandage, but it seems

to me unnecessary. If pain is severe, leeches should be applied in front of the tragus. The commonest error is to syringe the ear or to instill some oily substance; it is exactly by these means that severe and often purulent inflammation is set up. It is well to direct the patient, so far as he can, to avoid sneezing and violent blowing of the nose.

Rupture of the membrana tympani accompanying fracture of the temporal bone or of the base of the skull is of course of less importance than the injury it complicates. The chief symptoms in such a case are hemorrhage from the ear, or more or less serous discharge. Hevell says: "When the injury is immediately followed by the escape of clear slightly albuminous fluid from the meatus, there is reason to suspect fracture of the petrous portion of the temporal bone, involving the roof of the tympanum, and the osseous part of the external meatus with laceration of the central membranes and rupture of the membrana tympani. If the discharge first appear twenty-four hours or more after the injury it is in all probability not cerebro-spinal fluid, but inflammatory exudation produced within the tympania.

2.

From this brief review of the subject, the following conclusions may be drawn: 1. As the majority of ruptures of the drum membrane are due to a box on the ear, blows of this kind should be avoided, both in punishing children and in sparring contests. Injudicious efforts at removing a foreign body from the auditory meatus are more dangerous than the foreign body itself. Generally syringing is the safest and best means of expulsion; instruments should only be used under careful illumination with the head mirror. 3. Persons with diseased eustachian tubes run some risk in working in caissons; the risk may be lessened by frequent inflation of the ears. 4. In case of injury to the ear, careful examination should be made before using the syringe or instilling medicineotherwise a simple and easily cured