I reported the man showed some evidence of mental weakness for months before he died. The last time I saw him he was not himself. I learned at the time of his death that he was practically in a delirious condition, and had been for some little time. I believe the mental condition is associated with great weakness.

As regards Dr. Lattimore's remarks, sprue following dysentery, one of the recognized authorities on sprue (Manson), in his book, particularly refers to the fact that there is such a distinct form, and that it is a different type of infection.

Since this paper was prepared, within the last week, I have seen a case which began as dysentery, and has continued since. The man had dysentery some four months ago, and since that time the dysentery was quickly recovered from. It was the ordinary variety of it. He got entirely well, apparently, of the bloody flux. The bowels were loose afterwards, and have continued so up to the present time, showing the typical peculiarities of sprue. There is no doubt at all the disease follows dysentery occasionally.

With regard to the remarks of Dr. Walker, it is rather difficult for me to answer his question. I do not know what to say about it. There is one question I would like to ask him, and that is, if he noted a particular relationship between the changes in the patient's skin and mouth and bowels? Did they get worse together?

Dr. Walker: I did not note the relation in that respect at all.

Dr. Harris: In some of these cases the bowels are in a disturbed condition for years.

Dr. Walker: In the last case I had the bowels were disturbed for two weeks or more, and the mouth condition. was such that it kept up.

Dr. Harris: We have to question these patients closely,

because the disease will appear and progress for a time, and then the patient apparently will get well. In the third or fourth cases of mine this thing happened a number of times. The patient took the waters at the springs; then came home and thought he was well, but in something like a year or more thereafter the trouble began again. We should question the patient closely as to whether he suffered from diarrhea for some time preceding the condition. It is rather difficult in my class of cases to get a history of that sort.

As regards Dr. Vaughan's question concerning the skin lesions, I know so little about diseases of the skin that it is rather an embarrassing question for me to an swer. The only thing I can say about it is that the skin gets quite red and minute blisters form in the beginning, which reminds one very much of a beginning erysipelas. The skin becomes quite red and remains so for a time, but as the patient improves the skin trouble likewise improves, and the skin finally scales off. I should imagine it would be called a simple inflammation of the skin. I do not know enough about skin lesions to give it a definite

name.

Concerning the case with mucus in the stools, it occurs to me it is very likely any case that presents a great quantity of mucus in the stools would not be sprue. The stools show comparatively little mucus in sprue. It is possible that this case might be one of amebic dysentery, and if there is mucus in great quantity, I should strongly suspect it.

In conclusion, since coming to this meeting, I have heard of a number of cases of sprue. One or two gentlemen in talking to me have casually mentioned that they have had cases which they thought were intestinal tuberculosis; the patients had sores in their mouths, but which they now believed to be sprue. I am quite sure

that there are hundreds of cases in the State of this kind, and if this matter receives the earnest consideration of our Georgia physicians, and thes: patients are treated in the early stages, we can certainly accomplish a great deal of good.

THE CAUSATIVE FACTOR IN THE PRODUCTION OF OTITIS MEDIA IN ATLANTA.

BY CLAUDE A. SMITH, M.D., ATLANTA.

About six years ago the writer began a series of examinations of cases of otitis media in Grady Hospital, and found in every instance that the condition was apparently due to a streptococcic infection. The first microscopical examinations indicated that the infective organism was an intracellular diplococcus. However, upon careful examination it was found that occasionally the organism would appear in chains of four or more cocci.

Growth upon culture media showed a typical streptococcus in each instance. The cases coming into the hospital were never seen before the drum membrane was ruptured, and it was therefore not possible to secure cultures before this rupture had occurred and the pus had become contaminated with the other organisms present in the external auditory canal. Therefore, the first examination of the pus always showed quite a variety of bacteria.

At this time Dr. Roy was using 1-5000 bichloride of mercury solution for irrigation in these cases and it was found that after irrigating the ear every two or three hours for a day or so, that all organisms would disappear from the pus with the exception of this streptococcus which was usually found inside the pus-cells and in pairs with an occasional short chain formation. There were about eight cases of middle-ear suppuration in the hospital at this time, and after irrigation with the bichloride

this streptococcus was present in each case in pure culture.

These cases appeared in January and February, and in a few weeks all had cleared up. The following winter at about the same time cases of middle-ear suppuration again appeared in the hospital, and under the same procedure the same organism was isolated in each case. Since that time cases of middle-ear suppuration have appeared in the hospital every winter, and in every case this organism has been isolated.

The infection is peculiar in that it almost invariably appears about the same time each year. Some years there have been not more than half a dozen cases in the hospital during the entire winter, and then again there have been as many as fifteen cases in the hospital at one time. Occasionally cases are seen at other seasons of the year, but this is the exception.

The disease appears to be mildly contagious. During one winter one of the nurses who had been nursing several of these cases developed a suppuration of the middleear and examination showed the same organism which was present in the cases which she had been nursing.

The attack is usually preceded by a cold or sore throat, but as the disease appears at the time of year when colds and sore throats are very common, this symptom is of uncertain significance. One of the first cases examined complained of slight tenderness about the joints, but this cleared up in a day or so, while the discharge from the ear continued for several days.

The amount of pain accompanying the conditions is variable. Some complain of excruciating earache before the rupture of the drum, while others give a history of very little trouble.

When the drum first ruptures there is a profuse discharge, pale mucoid pus, which gradually decreases in