tutional symptoms; while smallpox is a systemic disease, and does produce constitutional symptoms.

Both diseases are contagious. Pemphigus is inoculable in person affected. That is, by rupturing a vesicle and inoculating an unaffected area in saine person, identical lesions will be produced in from 8 to 24 hours. Smallpox is not inoculable in person affected. Incubation period in pemphigus is from eight hours to few days; in smallpox, from to 17 days, or possibly 21 days.

9

Dr. John S. Windesch (Journ. A. M. A., Jan. 13, 1900), in his study of pemphigus as it occurred in soldiers of the Spanish-American war says: "There was no fever that could be attributed to the disease." Dr. Ross says there is no secondary fever, yet in his report of the affection in a lady, he shows that she had temperature 103, pulse 105, and general condition unsatisfactory, etc., one week after the onset. I don't see how he accounts for this fever and the general conditions, unless he accept his predecessor's diagnosis of grip, and considers the eruption and fever as distinct and separate affections.

Dr. Ross does not give exact dates, but it seems to me that the incubation period (two weeks) from time his first patient came from Medina to Cato, is too long for pemphigus. His wife could have taken the disease from him at any time thereafter, as, also, could baby have taken it from either of them at any time, but the incubation period being about two weeks in each case, is very suggestiv of smallpox. Also the invasion by grip symptoms, followed by eruption in about four days, with decline of temperature and general improvement, and relapse in about one week from onset. However, I do not presume to change his diagnosis in cases that he has made a study of.

He says he vaccinated two cases after onset, but did not influence the disease. According to German authorities, which are the best we have on vaccination, a successful vaccination on or before the third day after exposure will prevent smallpox; on the fourth day, will favorably influence it; on the fifth day, or thereafter, will not influence the disease.

So far as I know, umbilication is always present in smallpox when vesicles and pustules rupture and dry up; but it might be concealed by dried crusts.

Very few cases of smallpox are followed by pitting. Remember Sydenham's statement: "It is very rarely the case that distinct smallpox leaves its mark." We have had several cases of smallpox here in the last three years, and the origin of every case could be traced to some "socalled smallpox" in some other local

ity, that had not been quarantined. It makes no difference what name we call the disease, the condition remains the same. It is a loathsome, contagious disease, and should be quarantined. If it is smallpox, the law says to quarantine it. If it is pemphigus, the health laws should be made to cover it, and every case quarantined. The most severe case of smallpox I ever saw was contracted from a man that had it in such light form that he did not quit work. H. M ARTHUR. Hazleton, Ind.

Inflammation of Ear as a Result of Measles.

Editor MEDICAL WORLD:-Having recently passed thru the most extensiv and severe epidemic of measles we have ever seen, and having had a large number of cases of middle ear inflammation as a complication, I thought perhaps a few words on that subject might interest the family.

These complications are usually light and progress to a perfect recovery; but some of them become serious, and either produce death or leave very serious defects.

Acute otitis media, either catarrhal or purulent, may occur at any time during the course of an attack of measles, but generally during the febril stage. The catarrhal form usually occurs with light attacks, but the reverse may be true. The discharge is usually turbid from the presence of epithelial cells, and viscid from the admixture of mucus.

The purulent form is generally more severe, and often results in the destruction of the ossicles and tympanic walls.

The catarrhal cases are characterized by pain, varying in character from a dull ache to one that is sharp and lancinating; little or no rise in temperature; the power of hearing is diminisht.

In purulent cases the pain is more intense, often excruciating in character; temperature rises to 103° or 104°; vertigo, tinnitus, headache and anorexia. This continues until the appearance of the discharge, when the above symptoms abate and the patient falls into a quiet sleep.

In severe cases the inflammation may extend into the mastoid, filling the antrum with pus, and causing bone destruction from caries. The temperature in these cases shows some increase, and the pain becomes more severe and more generally distributed over that side of the head. The discharge diminishes in quantity; there is tenderness over the antrum; that is, at the attachment of the auricle close to the superior wall of the external auditory canal. If there is a perforation of the mastoid cortex there is fluctuation. There is invariably pres

ent a markt swelling or bulging of the posterior canal wall.

In one infant under my observation the pus made its way thru the Rivinian segment and gave rise to a post auricular swelling, making the ear project out more prominently.

A perforation may take place on the internal surface of the mastoid, and a swelling extend along the sterno-cleido-mastoid muscle. the pus may pass to the cerebrum or cerebellum, and meningitis result.

Or

In examining an adult I pull the auricle upward, backward, and outward, in order to straighten the canal. In children the canal is already straight, and the drum membrane is easily inspected.

There is almost always in otitis media a congested condition of the membrana tympani, but we must not be deceived if the membrane is a dead white color, due to a necrosis of the superficial epithelium. This may be wiped away with a cotton swab, when the redness will appear.

The relief of pain is a very important part of the treatment of such cases, for which try the milder remedies, such as dry, hot applications, phenacetin and codein, or acetanilid. Glycerin, with 5 to 10 percent carbolic acid, applied on cotton to the drum membrane, will often afford a very great amount of relief. All this failing, I resort to hypodermic use of the king of all pain conquerors, morphin. Watery solutions of cocain, morphin, and atropin are worthless, and oily mixtures cannot be too strongly condemned.

If the attack is not aborted, and the hyperemia increases, the membrane loses its luster and bulging of the membrane takes place. It should not be allowed to rupture spontaneously, but should be incised without delay. The canal should be rendered thoroly antiseptic by irrigation with bichlorid solution, I to 5,000, or by mopping well with peroxid of hydrogen. Then, with a good light and a straight, narrow knife, incise thru the bulging portion. The knife should be very sharp, and should pass thru the membrane by its own weight. At the same time the mucous mem brane of the internal tympanic wall should be freely incised, for its depleting effect.

If the membrane has ruptured spontaneously and the opening is not sufficient to allow free drainage, it should be freely incised. Cocain anesthesia is unsatisfactory; a general anesthetic should be used. After the operation, irrigate, pack lightly with steril gauze, put pad of cotton over ear, and leave alone for twentyfour hours, letting the patient lie on the affected side. Then remove, irrigate, and repack, repeating each day until it heals, which will generally be only a few days.

The discharge, which is usually serous at first, may become purulent, when the process above outlined should be repeated every four hours, and a saturated solution of boric acid, or 1 to 5,000 or 1 to 10,000 bichlorid solution, should take the place of the steril water.

When the painful symptoms have stopt, inflation after the Politzer method should be practised to get rid of pus and prevent adhe

sions.

When the discharge becomes slight, the use of powders, such as boric acid, iodoform, etc., may be used to good advantage. If the condition become chronic, employ astringents, with a swab, or in the form of drops. Cauterize granulations, remove polypi, and the case will get well. D. C. SUMMERS, M.D.

Elm Springs, Ark.

[The proof of this article was submitted to the eminent aurist, Dr. E. B. Gleason, of this city, who says that the advice to pack the auditory canal is dangerous, as it frequently is packt too tightly, daming the discharges back, which may cause mastoiditis. He sometimes

packs the auditory canal, loosely, but in consultation he never recommends it any more, as his experience has been that the ear sooner or later will be packt too tightly, by an inexperienced operator, and mischief is done. He has had several instances of this, in spite of the most careful and painstaking explanation as to the proper method of packing.-ED.]

Should Doctors Charge Clergymen ?

Editor MEDICAL WORLD:-Upon no rational ground can it be affirmed that doctors should not charge clergymen, except that of expediency, in the hope of obtaining their influence in their congregations. Clergymen know this and trade upon it, and most doctors do not charge them for this very reason; for if they did, in most cases, one way or another, that influence would be used against them. With church as a profession, often a refuge for the exceptions of course, clergymen are in the destitute, and are just as keen after the dollar or in taking opportunities of obtaining what they want without paying, as other people; and it is certain that in many cases they do take advantage of their "cloth" to accomplish this, of which I have seen instances characterized by an amount of cheek which might stagger the proverbial army mule. They are no more entitled to our gratuitous services than other persons, to whom, when worthy of our charity, they are given.

J. FITZ-MATHEW, M.D.
West Sound, Washington.

A poultice of grated, cold, raw potato, frequently changed, is of pronounced benefit in quinsy.

Let the Preachers Pay. DEAR "JIM":-In reply to your letter on page 143, April WORLD, I would say that your idea of getting at least half price from the clergy is right, and I hope that this discussion may arouse our overworkt and underpaid brethren to the importance of this subject. What earthly right has a man who gets $1,800 to $3,000 per annum (and usually his home free) to expect a physician to do his work free? Why does this foolish custom prevail? Who started it? Where is the common sense or justice in it? Let's quit such nonsense. In the first place, it is not best for the preacher; it certainly does not increase his self respect. It is not fair to our other patients. It is not fair to our families. Let us quit in the interest of all parties concerned. The best preachers I have known in the past have paid their doctor's bills. "May their tribe increase." Of course there are some men in the ministry who can not pay a physician. They are preaching for poor country churches, or perhaps doing missionary work. They may always count on us to do anything possible for them. But the well paid, well fed, well housed preacher should pay just like other men. Why not? We all like the good men who devote their lives to the ministry. They are usually very lovable characters. We honor them very much, and believe in paying them (also believe they should pay us). J. CALHOUN WHITE. Atlanta, Ga.

Should Clergymen and Their Families be

Treated Free of Charge?

Editor MEDICAL WORLD:-It has been the custom, I think, in this country, from the earliest times to within recent years, not to charge clergymen for professional services rendered themselves or their immediate families, and it can be readily seen, I think, how the

custom came.

The clergymen of the early settlement had no luxuriant church in which to preach, he had no steam-heated house in which to live, no railroad, or trolley, or auto to take him from place to place. He could not afford to travel from Boston to San Francisco to attend a conference; but usually he was an earnest Christian, a faithful, humble worker, who did his best with means at hand. His salary was nil; but his work was large and constantly toward the end that his fellows might be bettered. Altho his salary was lacking in money, his wants were freely and cheerfully supplied, each giving of his store. The physician, having but little more, gave his services.

These conditions were being constantly repeated wherever a new settlement was started as the frontier advanced into the West. And

the custom thus begun has been kept up, partly because it was custom, and partly because the clergyman and physician being so often thrown together in charity work, this part of the clergyman's work was seen and appreciated by the physician, and vice versa, the clergymen admiring and appreciating the work of the physician in behalf of charity, the two very often becoming firm friends.

However, the conditions now are much different. The clergymen and physician meet less and less often in the work of charity, as that branch of church work is more under the charge of societies organized for that purpose. The clergyman is not now dependent upon the charity of the people for his living, but receives a stated salary, which is often larger than the income of the physician who is giving him his services. He pays for everything else which he gets at the same rate as any other citizen, with the possible exception of railroad fare, which is given him yet by most railroads at half rate, but the sentiment is growing in railway circles that this half fare should be abolisht. Clergymen are recognizing the fact that under present conditions the receiving of these things puts them in a false position, and are asking to be relieved from it.

I shall always remember an instance which happened when I first began the practise of medicin. I was treating the family of a clergyman who has an international reputation, not only as a clergyman, but also as a teacher and lecturer. He came into my office one day and askt the amount of his bill. I told him it was customary in our profession to give our services to members of his profession. He said: "Doctor, I have always received my salary and paid my bills, and please God, I always will. I want to live on the same business level with my fellows, and then I believe I can do better work among them. Now, Doctor, do not pauperize the clergy. You will find that we do not like it and do not want it. Charge us the same as you do anyone." And he insisted upon paying me for my services at my regular rate. I have since talkt with a good many clergymen on this subject, and find a growing sentiment of this kind among them. Therefore, I believe that in time this question will solve itself in the right way, and to the satisfaction of both professions.

The reform will be gradual, however, and in the meantime we may each do something, perhaps, to hasten it. My own custom, at present, is to charge the clergy half rates for medical attendance, and for obstetrical and surgical cases full rates, or as we would arrange at the time. When a clergyman employs me for the first time, I have a pleasant, explanatory talk with him on the subject, and if I find that he

has never been in the habit of paying anything for medical services, I explain to him that where I live and do business a physician and his family is not only expected to, but is willing to, contribute liberally to the clergyman's salary, to the support of the church, and to be activ in all church work; (and, by the way, this, all right thinking and right-minded physicians will do); also attend church doings, such as entertainments, socials, etc. (This, of of course, applies more to country and village churches than to those of the city.) Usually, in about fifteen minutes we come to a thoro and friendly understanding; and, I think, if that clergyman is the right kind, he will never after accept free medical services except under most adverse circumstances; and his relations to physicians in the future, in all respects, will be more satisfactory to both, and each will better. appreciate the other.

When the physician gives his services to the clergyman, he does it in great majority of instances grudgingly, and with the feeling that he had thereby put the clergyman under obligation to him, and perhaps he has ; and when he learns in a few days, as he is very apt to do, that Mr. Clergyman has recommended his dearest chronic to try Blank's tonic, or So-and So's cough syrup, he does not feel that the obligation has been discharged, or that the clergyman has even kept faith with him. And the fact remains that the clergyman and his family are very free users and advertisers of patent medicins and secret nostrums; and, indeed, why should they not be, when their publications, the socalled religious press, are filled with such advertisements? Edward Bok says, "there are no papers publisht that are so flagrantly guilty of admitting to their columns the advertisements, not only of alcohol-filled medicins, but preparations and cure alls of the most flagrantly obscene nature. . . Beside me, as I write, lie issues of some twenty different religious' weeklies, the advertising columns of which are a positiv stench in the nostrils of decent, self-respecting people." Strong language, but true.

Finally, in his charges for treating clergymen and their families, each physician must use his own judgment and be governed by circumstances he finds in each case, bending his efforts constantly to the end that sentiment will be aroused or fostered which will in the end tend to overcome the abuses under which we labor, and remembering that, usually, reforms are brought about slowly.

WILBER G. FISH, M.D.

Ludlowville, N. Y.

Copper sulfate, two grains to the ounce of water, cautiously and judiciously increast, is efficient in subacute and chronic gonorrhea.

Charging Clergymen.—Acetanilid Mixture. Editor MEDICAL WORLD:-I see in April WORLD that "Jim" wants to know about charging clergymen and their families for services. Well, there is but one way which is business and at the same time free from suspicion : Charge them just the same as you do others. Then if you want to contribute to the church or the support of the preacher, count your bill in as a part of your contribution.

Looking over the various formulas for acetanilid comp., I will say that they are all very good, but why not make them soluble by adding a little tartaric acid? Allow me to suggest the following formula:

Ammon. Carb. Instead of Ammon. Chlorid, in Acetanilid Mixture.

Editor MEDICAL WORLD:-In May WORLD, page 184, L. C. Laycock, M.D., states that "for ten years I (he) have been using this same combination which you publisht in the March MEDICAL WORLD, page 102," and also that he "first saw the formula in THE MEDICAL WORLD for November, 1893, page 377."

Permit me to call attention to the fact that a close comparison of the formulae will show that they differ somewhat, as his contains chlorid, or muriate of ammonia, whilst that publisht in March has carb. ammon. in place of muriate, and a larger proportion of soda bicarb. The formula in March WORLD is 6 parts acetanilid, 3 of soda bicarb., and 11⁄2 each of carb. ammon., and caffein cit. I also saw, and noted the formula publisht in WORLD for November, 1893, and while I consider it very good, I prefer the one containing the carb. ammon., as it is more of a stimulant, and so would aid the caffein in preventing any depressing effect on the heart that the acetanilid might perhaps cause when given in large doses, or where the dose, tho smaller, is closely repeated, as sometimes is needful.

This is by no means a criticism, but simply calling attention to the error in the Doctor's statement of the facts.

R. B. ELDERDICE, M.D.

McKnightstown, Pa.

Nitrate of silver is the caustic of selection when we wish to remove excessiv granulations, but its superficial action is to be remembered.

Acetanilid.

Editor MEDICAL WORLD:-P. T. Barnum, Lydia Pinkham, or some other wiseacre was authority for the statement, "a sucker is born every minute." Some of us are not only born suckers, but remain suckers most of our lives. After graduating in 1894 I paid one dollar ($1) for one ounce of phenacetin. When that ounce was gone I found I could buy acetanilid for 30 to 40 cents a pound from Robinson, Pettit & Co., Louisville, Ky., wholesale druggists. Have since kept a can in office. It is dangerous. So are all drugs in poisonous doses. I have never had any bad results from its use. I give from two to five grs. dry on tongue, followed with water. Give it in capsule. Give it in combination with other drugs. And the best way to give it, if afraid of its depressing effects on heart, is in whiskey well dissolved. If you ever have a patient susceptible to acetanilid, feet and hands become blue and cold, just try same dose next time in whiskey; you will be surprised.

Now as to antikamnia-just put them out of business. They seem to have tried their best to ruin their closest friends, the doctors. Let's all stand together and refuse to prescribe antikamnia or any other remedy they persist in advertising to the laity.

When you have a case of malaria with chills, try 22 to 3 grs. acetanilid and 22 to 3 grs. quinin every three hours.

Now and then the temperature in influenza is subnormal. In one case the past winter the record was 94°. In this condition, or in any minus temperature, stimulation is indicated.

Good drugs are the cheapest, and when procured from Merck & Co., or Lehn & Fink, they are the best in the market.

Physicians who are dealing out to their patients pills and tablets apt to be inert, instead of the more elegant and potent alkaloidal remedies, are missing much (and their patients more) of the greater good found in the newer school of medicin.

In the line of liquids, the Lloyd specific tinctures are far superior to the ordinary tinct

ures.

The spirit of catholicity pervading THE MEDICAL WORLD is admirable. Harrisburg, Pa. S. M. WHISTler, U. of P., 1866.

Seeking Recovery from Tuberculosis in the West. A Sad Story.

Editor MEDICAL WORLD: I read Dr. Erskine's letter in the May WORLD, page 192, and agree with him in his conclusion that the West as a resort for consumptivs is much over rated. I will leave out of consideration his criticisms of the doctors who advise their patients to go West, for I expect the Doctor has different ideas now than he had before he left Maine. I think I know more about the West than I did a few years ago, and Dr. Taylor, if you think it worth anything to your readers, you may publish it. My experience has been a sad one, and I have not yet reacht the place where I can feel that I am safe.

During the summer of 1898 my son Fred served in the Navy. Returning in the fall, he soon showed signs of tuberculosis. At the suggestion of Dr. Ingals, of Chicago, I sent him, in care of another son, to Phoenix, Arizona. Before they left I instructed them carefully as to how they should live, but when they got to Phoenix they found every place crowded with invalids; and in order to stay there at all, had to occupy the same room and the same bed. They finally rented a house, and conditions for living were somewhat better. From the tone of his letters I judged that the presence of so many "lungers" had a depressing effect on him. He failed rapidly, and when the hot weather came on, and all were leaving Phoenix, in spite of the advice of the "veracious nativ" who said "stay," he came home in June, a mere skeleton of his former self. He lived on until the following January, and then gladly left his suffering frame, and I laid it, together with a large part of my aims and hopes, in the tomb. My son George, who had been at Phoenix,