PAPERS for the Original department should be in hand one month in advance, and contributed to THE MEDICAL FORTNIGHTLY exclusively. A liberal number of extra copies will be furnished authors, and reprints may be ottained at reasonable rates, it request accompanies the manuscript. Engravings from photographs furnished free. Contributions, books and exchanges should be sent to the Managing Editor, Century Building, St. Louis. Signature of contributor, for reproduction, should be sent with every article, on a separate slip; use heavy Ink, and allow autograph to dry without applying blotter. COLLABORATORS. LEWIS H. ADLER, Jr., M. D., Philadelphia. CHARLES W. BURR, M. D., Philadel- DİLLON BROWN, M. D., New York. J. N. HALL, M. D., Denver. HOBART A. HARE, M. D., Philadelphia. CHAS. O. JEWETT, M. D., Brooklyn. FRANKLIN H. MARTIN, M. D., Chi- J. M. MATHEWS, M. D., Louisville. ERNEST SANGREE, M. D., Nashville. EDWIN WALKER, M. D., Evansville. W. E. WIRT, M. D., Cleveland. Clinical Lecture Regulation of Diet in Diabetes Mellitus. BY JAMES C. WILSON, M. D., PHILADELPHIA. E have for our consideration a German of forty-five, with a good fam six glasses of beer a day. The present trouble began four or five years ago, when the patient began experiencing great thirst, and also noticed that micturition was more frequent. Two years ago he had severe pains across the back and loins, which lasted for five minutes. Since then the urine has been still further increased in amount. It now is about five quarts in twenty-four hours. The man is very hungry. The urine is acid; contains no albumen; has a specific gravity of 1039, and contains thirty-five grains of sugar to the fluid ounce. It is hardly necessary to say that we have here a typical case of diabetes mellitus. One point about the case is, that there is no pruritis accompanying it. This is very often an annoying symptom. It is especially prevalent in the pudenda of elderly females, and is the most common cause of such patients seeking medical advice. Diabetes should be thought of at once when a person comes to a physician for this reason, as it will occasion distress, and relief will be sought, when, perhaps, the increased thirst and frequent micturition have not been noticed. SPECIALLY REPORTED FOR THE MEDICAL FORTNIGHTLY. Business trouble or shock of some kind is often the cause of this disease, which is, as a general rule, vague in its etiology. You noticed this man flushed very decidedly as I asked him if he had had any trouble, and he admitted that there had been a severe ordeal of this sort some years ago. I have in mind the case of a woman who, for other reasons, was under observation, and the urine was known to be free from sugar. Her only daughter at home died after a short illness, and the mother was inconsolable. In a few weeks diabetes developed, and finally went on to a fatal termination. The liability of this disease to develop is greater in certain families. This man has been under observation only a short time. A hurried examination of the eyes shows fatty degeneration of the retina in the left eye, and beginning diabetic cataract of both eyes. This makes the case much graver. The stools will be examined for fat, in order to determine if the pancreas is affected. As to the diet in these cases a careful study of each individual case should be made. Perhaps the best way is to give diet containing no sugar, or even potential sugar for some time, say two weeks. The effect of this should be carefully noted, both as to the amount and the quality of the urine excreted, as a result of such diet. If this is effective in decreasing the amount, and especially in reducing the sugar, of the urine, one may know that the case is of such a degree that it may be largely controlled by diet. Then the diet may be added to slowly, and varied in different ways, until a point is reached where it may be maintained with comparative safety. This may need to be continued for the rest of the patient's life, and if rightly explained to an intelligent person it will generally be followed. Indeed the patient himself largely regulates this if he understands the matter, as he can detect an increased flow of urine when he overindulges, as well as feel the effects otherwise. I believe that such patients do better, and are less apt to fool the doctor, and to a greater degree, of course, fool themselves, if at certain times they be allowed to eat a full, big meal. For instance, at holidays, or when the family all be gathered for some reason or other, it lessens the patient's sense of deprivation if he be allowed to sit down and eat with the others in a true sense, that is to just eat of everything on the table, and eat until he is satisfied. Or if a stranger was in, and it was not wished to have the patient's dieting made the subject of inquiry, he might eat as the others. Of course this will cause reviving of the symptoms for a time again, and the patient will not feel so well for a few days, but he knows this before he indulges, and expects to suffer the consequences of satisfying his appetite. But they are grateful for this permission once in awhile, and will not be so apt to abuse it, as perhaps they would all the time if it were not given. And it makes life more bearable and lessens the severity of the treatment, and in every way seems to be a satisfying point in the management of these cases. Diseases of the Eustachian Tube. BY DUDLEY S. REYNOLDS, A. M., M. D., LOUISVILLE, KY. Professor of Ophthalmology, Otology, and Medical Jurisprudence, in the Hospital College of Medicine, Medical Department of the Central University of Kentucky; Surgeon to the Eye and Ear Department of the Louisville City Hospital, and the Gray Street Infirmary, etc. Read before the Mitchell District Medical Society, at New Albany, Ind., December 29th, 1898. NA BRIEF consideration of some of the common affections of the Eustachian tube, and the symptoms by which they are to be recognized, no attempt at anatomic description is called for. From Val Salva in 1735, to Gorham Bacon in 1898, no treatise on diseases of the ear has appeared without elaborate reference to the Eustachian tube. Many of them have descanted learnedly upon the subject, and many have written volumes designed to particularize the conditions of this tube which called for invasion of it by instrumental agencies at the hands of the surgeon. The late Mr. Peter Allen, of London, presented in a handsome volume, a series of clinical essays on what he was pleased to designate "Catarrhal Deafness," meaning by that term to include all those inflammatory changes in the pharynx which are accompanied by disturbances of hearing. Many voluminous works on diseases of the nose and throat have, in recent years, presented elaborate accounts of the important changes which various forms of pharyngitis produce in the structure and functions of the Eustachian tube. It is remarkable how little attention has been given to the actual relations of tinnitus to abnormal conditions of the tube. In the normal state of the pharynx, the Eustachian orifice is closed, excepting when the levatores palati muscles contract. If the atmospheric pressure upon the outer surface of the membrana tympani is greater than that within the cavity of the tympanum, the contraction of the levator muscles of the palate opens the orifice of the Eustachian tube, allowing the air to rush in, and this gives rise to a peculiar sound, not unlike the movement of wrinkled paper suddenly made tense. In cases where swelling of the tonsils, or of the membrane lining the pharynx, stiffens the structures surrounding the orifice of the Eustachian tubes, holding the nose firmly with the thumb and finger, keeping the mouth shut, and blowing forcibly a la ValSalva, produces not only an unpleasant sound in the ear, but is followed by a sense of more or less painful tension. If there be, at the same time, any fluid in the tube, such as accumulations of mucous or serous exudate, and this be blown into the cavity of the tympanum, the hearing is at once greatly impaired. In cases where hyperplasiæ results from the long-continued presence of irritating matters in contact with the pharyngeal membrane, the orifice of the Eustachian tube being greatly narrowed, finally reaches a state where ValSalvan inflation is difficult, or even impossible. Tinnitus gradually increases in such cases, and at the same time great changes in the activity of the cerumenous glands may be observed. In the very beginning when the first disturbances in the circulation of the blood-current, through the walls of the Eustachian tube takes place, hyper-activity brings forth a profuse discharge of cerumen; this is soon followed by gradually diminishing activity, until finally no more wax is secreted. By the time this stage has been reached, an accumulation, of more or less hardness, has been formed by the intermingling of atmospheric dusts with the outer surface of the mass of cerumen. Presently the ear presents a sense of dryness and itching, the tinnitus is nearly constant, and quite annoying. The person thrusts the end of the little finger into the external canal, dislodging a mass of inspissated matter, and forcing it into contact with the membrana tympani, the hearing is at once nearly suppressed. The tinnitus is changed in character, and the act of deglutition produces a sensation at once disagreeable and confusing. It has been compared to the friction of a cotton wool mop rotated in the external auditory canal so deeply as to touch the drum membrane. Now if, as is too frequently the case, the surgeon who is consulted at this stage of the affection employs a stream of warm water for washing out the plug, he may succeed in removing an accumulation of foreign matter, but adds to the depression of the drum membrane, with the effect to greatly increase the discomfort of the patient. In cases of this kind where the membrane is suddenly forced back by pressure on the tragus by the finger, or the forcible impaction of an accumulated mass, of which cerumen is the principal ingredient, the mere removal of the foreign matter affords but slight relief. If, per contra, some saline spray be thrown into the nostrils, and the patient be directed to snuff and draw forcibly back into the pharynx, considerable accumulated mucus and other matter may be expectorated, thus uncovering the faucial orifices of the Eustachian tubes, after which ValSalvan inflation may alone be sufficient to restore the equilibrium of atmospheric pressure in the tympanum. This affords momentary relief alike to the tinnitus and impaired hearing, but it fails to reach the primary cause of discomfort in the ear. It is no new observation that of all the sources of irritation known to affect the pharyngeal membrane, not one of them may be found present for any length of time without creating such serious disturbances in the nutrition of the lining of the Eustachian tube as to seriously alter its caliber. In rheumatic and gouty people, as well as in syphilitics, both local and constitutional treatment is demanded. In persons of sedentary habits, and especially those who are the subjects of constipation, great relief often follows the exhibition of a cathartic. For example, the patient who is troubled with tinnitus, and who has long been without visible secretion of cerumen, ValSalvan inflation being impossible, I have frequently delayed other measures for invading the tube until I could secure the full effect of a cathartic dose of Rochelle salt, after which ValSalvan inflation became easy, and in every way entirely satisfactory. In people who breathe babitually through the mouth, the Eustachian tubes are especially liable to be plastered over with a tenacious mass of mucoid matter, and without the previous use of a saline spray for the removal of this accumulation, ValSalvan inflation is impossible. Sir Henry Thompson's injunction about passing instruments into the male urethra, may well be borne in mind by aural surgeons who contemplate invading the Eustachian tubes with instruments. They are necessary evils in many cases; they are never entirely harmless, even in the most skilled hands, unless their use should be restricted to the narrowest limit of necessity. In snuffiing air through the nose, it is the practice of many persons to draw the alae into contact with the septum; this necessarily draws out the air from the tympani, impairing the hearing, and augmenting the discomforts from tinnitus. The mechanical presence of the Eustachian catheter causes so much irritation in the lining of the Eustachian tube that, the effects of it are frequently persistent for hours. Where no perforation in the membrane exists, and if inflation with the Politzer bag, or other means, has clearly restored the membrane to its normal position, the hearing being still impaired, it is the custom of some to introduce the Eustachian catheter and pass the filiform bogie, carrying a modicum of medicated ointment into the tube; and as my friend, Prof. Guye, of Amsterdam, occasionally does, the ointment is passed clear on into the cavity of the tympanum, until by artificial illumination of the external ear, the end of the bogie, with some of the ointment still adhering to it, may be distinctly seen through the translucent membrana tympani. I have myself introduced in this way a small quantum of yellow oxide of mercury ointment, or of iodoform ointment, in cases which had resisted all other means of treatment, and have sometimes been greatly gratified to observe much improvement to the patient's hearing. I quite agree with Dr. Buck upon the unsatisfactory nature of the practice of injecting fluids through the Eustachian tubes into the middle ear, and especially where no perforation of the membrana exists. My friend, Dr. Savage, of Nashville, some years ago, called attention to the facility with which accumulated matters in the tympani may be drawn out through the Eustachian tubes in cases of perforated membranæ. This is done by holding the nose with the thumb and finger, and instead of blowing, as directed by ValSalva, the patient is directed to snuff, when at once the air is drawn through the perforated ear drums, and they are thus easily freed from accumulations. In an intelligent patient this is a desirable method of both freeing the tympanum and Eustachian tube from inflammatory matters, and of directly medicating the tube by drawing the medicament through in the same manner as directed for the removal of morbid accumulations. Now, under those conditions of induration, whether there is stenosis of the lumen of the tube, or merely faucial occlusion, saline aperients and a course of the iodides, or the salicylates, renders the local treatment efficient, which would otherwise prove useless. DISCUSSION. Dr. JOHN HAZLEWOOD, of New Albany. Mr. President: I feel very much. obliged to Dr. Reynolds for his paper, and I was very much interested in his remarks about the use of the syringe for removing foreign bodies from |