There is a distinction to be made between douching an ear and syringing an ear. Douching means the application of the fluids to the meatus and drum membrane for a certain length of time in order to derive thermal effects. Syringing means cleansing by the aid of the one or other fluid. For many cases the rubber bulb syringe with soft rubber tip, advised by me, is useful.

We should keep in mind WILDE's words: "So long as otorrhea is present we can never tell how, when, or where it will end, or where it may lead to." In a chronic suppuration of the middle ear when success does not accompany peaceful treatment radical interference becomes indicated.

A

Cotton should not remain unchanged in a discharging ear for a great length of time. The patient should always be directed not to put the cotton inside of the ear any considerable distance. I had opportunity to see, by courtesy, a child which was admitted to a general hospital. correct diagnosis could not be made and an examination of the meatus showed a foreign body deep in the meatus which I removed and which proved to be cotton soaked with discharge. It could not be ascertained how long the cotton had remained in the ear. I am rather inclined to think that the child died in consequence of a retention of pus as an early operation by one of the foremost European aural surgeons revealed practically nothing locally.

The over-treatment of the ear by the Politzer air douche or by massage, is a common occurrence. Continually repeated hearing tests must. guide us in choosing the manner of treatment. The final word concerning rapid massage has not yet been spoken. Before treating an ear the mobility of the sound conducting apparatus should be ascertained by the use of Siegle's speculum or any of its modifications.

Patients with so-called sclerosis of the ear need careful attention as to special and general treatment. "Nihil nocere" should be the watchword in these cases. POLITZER, SIEBENMANN, PANSE, HARTMANN, KATZ and others have called our attention to changes in the osseous structures which may take place in cases of this character. While the pathology of the process may explain, in many cases, the unsuccessful results of any routine procedures, we should carefully individualize and base our special and general therapeutic efforts on a repeated conscientious examination of the hearing organ and adjacent parts and on a thorough consideration of the general condition of the patient.

Like in other cases, rest amounts to a great deal in acute ear diseases. We should keep the patient in bed, or in the house as long as necessary. Acute cases should not be treated in dispensaries but at home or in the hospital.

In conclusion I should like to call attention to the influence which a middle ear suppuration may exercise on the digestive tract and thus on

the whole system. If there is pus in the tympanic cavity it is very probable, especially in children, that it wanders through the Eustachian tube and is swallowed. This must be of consequence for the health of the patient. I think that this circumstance should be watched and perhaps added to those which formn the indications for surgical interference in middle ear suppuration.

REFERENCES.

(1) DOCTOR ADAM POLITZER: "Lehrbuch der Ohrenheilkunde," Stuttgart, Verlag FERDINAND ENKE, 1901, pages 193 and 194.

(2) Loco citato, page 141.

(3) "Die Fremd Koerper in Nase und Ohr," VON DOCTOR EMANUEL FINK, Hamburg, Verlag VON GUSTAV FISCHER, Jena, 1897, page 283.

(4) See (1), page 192.

(5) WALB: "Schwartze Handbuch der Ohrenheilkunde," Volume II, pages 231 and 232.

(6) HERMANN: "Schwartze Handbuch der Ohrenheilkunde," Volume II, page 791.

270 WOODWAD AVENUE.

THE RESTRICTION OF SCARLET FEVER.*

BY GUY L. KIEFER, A. B., M. D., DETROIT, MICHIGAN.

LECTURER ON HYGIENE IN THE DETROIT COLLEGE OF MEDICINE; HEALTH OFFICER OF DETROIT.

THE restriction of scarlet fever is a subject which, it seems to me, deserves special attention at a convention of this nature. In the first place the mortality from scarlet fever ranks high in this State; in the second place, the permanent after effects in the form of chronic kidney disease, chronic deafness or something equally serious are not uncommon. Again, the infection of scarlet fever, whatever it may be, is one of the most tenacious with which we come in contact. You all have read many reports in various text-books and medical journals of epidemics of scarlet fever traceable to clothing of persons who had had the disease years previously and had carried it for miles to some relative. Again, other epidemics have been traced to milk, years after scarlet fever had been seen in the family of the particular milkman.

If it were possible in public health work in a large city to carry out to the letter the resolutions as laid down by organizations of health officers in their meetings, the fight against this disease would be considerably less difficult. At a meeting of State and Provincial Boards of Health of North America, the following resolution was adopted in regard to the restriction of scarlet fever:

"Resolved, That the isolation of the person or persons afflicted with smallpox (varioloid) or scarlet fever (scarlatina or scarlet rash), and of the * Read at the Sanitary Convention held at Ludington, September 5, 1901.

nurse or nurses attending upon such person or persons, shall be absolute. That such isolation shall continue for a period of not less than four weeks from the first appearance of the eruption, and as much longer as may be necessary to secure complete desquamation, the necessary period to be determined by the health officer in charge, or his assistant.'

Now let us add to this, a resolution for thorough disinfection with formaldehyd after the disease has run its course and we have an ideal manner to prevent the spread of this formidable enemy to human life. But what are some of the difficulties we encounter in endeavoring to carry out such rigid regulations and what is the remedy in each case?

If we can answer these questions properly and satisfactorily, we have established a method for the restriction of scarlet fever which can be carried out and which will be more effective than a more rigid method not properly enforced.

One of the first and most constant difficulties that we encounter is the

poverty of the family in which the case occurs. Poverty brings with it the

inconvenience to the sanitarian of a small house and the small house in turn means that isolation of the patient is next to impossible. On the other hand the head of the family must be isolated so that he may earn a livelihood for himself and the sick ones. Why not send him out of the house to some relative and keep him there during the course of the disease? That is a good solution, but having been in the infected house for a number of hours he himself and the clothes that he takes from the house must be thoroughly disinfected. This again is difficult because of the lack of room. It is advisable, therefore, in a case of this kind, for the health officer to go to the house as soon as the case has been reported, look over the situation and formulate his plans. The mere placing of a placard on the house does not quarantine. The reasons for all our actions must be explained to the people, they are inconvenienced by our quarantine and are entitled to some enlightenment regarding the situation.

Having established a quarantine in this manner, the next difficulty we encounter is that the quarantined persons will not obey the rules as laid down; they will break quarantine. What is the remedy? I have heard the suggestion, "Prosecute the offenders." This cannot be done until after the disease has run its course and in the meantime we run the risk of infecting the entire neighborhood. There is only one remedy-guards. When people will not obey the law, they must be watched. There must be a guard stationed at the infected house constantly during the twentyfour hours of each day to see to it that no one either leaves or enters the house.

Most people will submit to a short period of confinement, but the longer the period, the more difficult it is to maintain quarantine. Not only is this true, but the longer the period of quarantine, the more difficult is it to learn of the existence of the disease. The laity do not object

so seriously to our regulations regarding diphtheria, because the period of confinement is usually short; but when the physician diagnoses scarlet fever and the family knows that this means that they are to be locked up for at least four weeks and probably much longer, they begin to plead with the family doctor to suppress the case. The firm, upright physician will not yield, but the weaker members of the profession fearing lest they may lose the fee attending this case and subsequent patronage from the family are tempted and sometimes, shameful though it may sound to say it, suppress mild cases. And these suppressed cases are the causes very often of epidemics; the causes sometimes of a number of deaths.

The physician is not prosecuted because he is not discovered, but the lives of the little ones, through his criminal suppression of a very mild case, are sacrificed. This is indeed a serious difficulty and how are we to meet it? We cannot promise a shorter quarantine than the duration of the disease will permit, but we can promise to make it as short as each individual case will allow. In other words, we will gain the good will of the laity and the profession, and these we must have to be successful in our work, by promising them in each case to raise the quarantine as soon as the particular case has recovered, regardless of any time limit. What does this mean in regard to the period of quarantine for scarlet fever cases? It means that in the vast majority of cases the quarantine will continue at least four weeks, and in a considerable number of cases a much longer time, but it also means that in some few exceptional cases the quarantine may be raised in less than twenty-eight days, say as early as twenty-one days. There are cases of scarlet fever, exceptional to be sure, that complete desquamation in this brief period, and by yielding this point we obtain the great advantage of locating a large number of cases which would otherwise escape detection. I wish to add this precaution: no case should ever be disinfected until after it has been examined by the health authorities and pronounced recovered.

One of the most trying situations that confronts the health officer is when death makes its grim appearance in a quarantined house. The body of the dear little one is to be carried out, the usual coterie of friends are not allowed to come in and sympathize, but the bereaved mother, and often the older sister or brother, plead that they may accompany the dear one to its last resting place. Whenever this is permitted, the disinfection. of the persons who are allowed to go and their clothes must be thorough. It is best, perhaps, to have all the clothes to be worn on this sad occasion put in a room the night before the funeral, there to be disinfected by being exposed to the disinfectant all night in the room which had been previously sealed. The next day the persons who are allowed to go, should be ordered to bathe, go immediately into the disinfected room (which has now been aired), there don the disinfected clothes, and if possible leave the house from this room.

In cities where we have access to large hospitals, and especially in cities where the municipality itself controls a city hospital, it is advisable to transfer all cases of scarlet fever, as soon as we know of their existence, to the city hospital. But even in this instance we meet with a difficulty. For example, a case of scarlet fever is reported in a house where there are five other children. The patient is at once removed to the hospital. But what about the other children? They have all been exposed and should be quarantined for at least two weeks-the maximum period of incubation of the disease—until we are certain that they are not coming down. But is this method practicable? Certain it is that after the sick child has been removed from the house, the others will not stay in unless the house is guarded; and will the average city allow the health authorities money for guards under such circumstances? No, it will not. Consequently the practical thing to do is to disinfect at once the house from which the patient has been taken and then examine the other inmates daily for possible additional cases of the disease.

All of the foregoing precautions must be observed during the entire year to prevent the spread of scarlet fever, but during that part of year in which the schools are in session new troubles begin. The health authorities in a given city may succeed in keeping down the number of cases of scarlet fever during the summer months, but when the children begin to return to school the number of cases of scarlet fever begins to run up. Is there a remedy for this difficulty? Yes, a very certain one, and one that should be applied in every city, village and township. Medical inspection of the schools daily under the supervision of the board of health will do much to restrict scarlet fever. Many cases will be recognized that would otherwise have gone unnoticed and would have infected others. In Chicago the medical inspection of schools was introduced a few years ago. During the first four months of last year 76,805 school children were examined and 4.539 were excluded from school on account of contagious diseases. This remarkable result was obtained in spite of the fact that the number of inspectors was inadequate for the work according to report submitted by the superintendent in charge. The particular method of school inspection depends upon the local authorities. Reforms of this nature are slow and must be worked out gradually. In Detroit there has been no inspection of schools up to the present time, but it is a reform that should be introduced and I am now conferring with members of the board of education with reference to inaugurating some such system during the next few weeks. In my opinion, a daily examination of school children is one of the most important steps to be observed in guarding against the spread of scarlet fever.

After the case has run its course and the health authorities have determined to raise the quarantine, it is time for disinfection. This process should be very thorough. Burning a bit of sulphur in the infected house