For catarrhal otitis media diaphoresis is to be produced by hot drinks or sodium sal:cylate, 0.25-2.0 Gm. (4-30 gr.), aspirin, 0.15 0.5 Gm. (2-7 gr.) at a dose are recommended, possibly warm solu tions of dilute acetic acid to the affected ear may hasten the absorption of the exudate. In this as in the purulent form, the severe pain will be alleviated by the instillation of 5 per cent. carbol-glycerin. In case, however, this does not suffice it is necessary on account of persistent high fever and the accumulation of pus to puncture the drum-head. In very young children (nursing infants) this may be delayed, as the pus readily escapes spontaneously, and moreover the field of operation is small and unfavorable. The purulent discharge from the car is best combated by the use of peroxide of hydrogen and distilled water equal parts, and if the pus be very offensive and thick, careful irrigation with a weak solution of potassium permanganate, creolin, or boracic acid is permissible. If the radical operation is necessary, let it be done early, as soon as the purulent. process extends to the mastoid antrum. The after-treatment is tedious but it gives excellent results.
The care of the mouth as already mentioned requires special atten tion. The troublesome dryness of the mouth in young children may be overcome by frequently giving boiled water, tea, etc., or by carefully spraying the mouth with water. In older children gargling with refresh ing washes relieves this dryness, or when greater pain is present with marshmallow or sage tea. The development of aphthde is treated by a carefully arranged nonirritating diet, also by frequent painting with a solution of 1-3 per cent. aneson, or a solution of copper sulphate, and eventually by touching the lesions with a bluestone pencil. Internally one may prescribe silver nitrate (1 to 1000) a teaspoonful at a time in !severe and uncontrollable cases (for instance in the case of small unman ageable children) (metal spoons must not be used). A 1 per cent. solu tion of potassium chlorate may be used with success as a gargle in .aphthous stomatitis (this may be used internally in a solution of 2 to 5 grains to the ounce of water).
Noma, which is rare, should be removed by the cautery or sion. The frightful odor emanating from it can be controlled most readily by dusting pure wood charcoal powder over the gangrenous parts, this may be used alone, or combined with equal parts of dermatol with the addition of five or six drops of oil of cade. An application or wash with a 2 per cent. solution of antinosin is also recommended. Should diphtheritic deposits appear in the mouth, antitoxin should be administered as speedily as possible; the same applies of course in a still greater degree if the process extend to the larynx. As before stated,
one must constantly keep in mind the fact of the greater predisposition to diphtheria exhibited by those who have suffered from measles, the particularly great loss of antibodies to diphtheria demands a more liberal administration of antitoxin, 5000 to 6000 units is to be the initial close in undoubted diphtheritic croup, energetic treatment it is true. but nevertheless correct. As a further therapeutic procedure we think that the immunization of all the measles patients in the hospital (by the injection of 200 or 300 units of antitoxin) is to be recommended, the danger of infection in such patients lasts for several weeks, and it is indeed a great one, so that possibly the immunization may be repeated at intervals of say 14 days in spite of the unpleasant effects that may arise from such reinoculation. The treatment of diphtheria with measles differs from that generally followed in that it must be remembered that diphtheritic croup in the first place gives rise more readily to the de velopment of foci of pneumonia, and in the second place that it much more frequently extends far downwards as a descending croup. Heart tonics, above all infusion of digitalis, 0.15-0.5 Gm. to 70.0 Gm. (2-7 gr. to 21 oz.), caffeine sodium benzoate, 0.1-0.3 Gm. (11-41- gr.) given daily internally or subcutaneously as well as the usual expectorants will often overcome the first-named danger. As to the operative treat ment of diphtheria with measles, in opposition to the usual course, I would give preference to primary tracheotomy, and only in the very lightest cases of croup, would when necessary, suggest intubation, the frequent simultaneous pneumonic complications, the tendency of the croup to descend, and the greater vulnerability of the mucous mem brane, and, as a result the greater danger of ulceration are my main reasons for this.
Subglottic laryngitis or pseudocroup in the prodromal stage of measles presents no difficulty in the treatment, as it usually disappears spontaneously after the outbreak of the rash, moderate diaphoresis, fre quent administration of warm drinks (tea, lemonade), inhalations with steam atomizers, expectorants, very hot poultices over the throat, or the inunction of mercurial ointment suffice. Counterirritants such as mustard, or one or two leeches over the larynx may be used in the more severe forms, such as may come on in the exanthem or convalescent stages. In psendocroup also, in spite of all, the question of trache otomy or intubation must be discussed and the decision as to which is preferable has to be made. Usually here incubation is to be preferred particularly in view of the brevity of the affection.