fact when do we consider it wise, and if we can give reasons why we attempt it. I think we should ask them the object for which they seek such interference, and should not hesitate to talk to them candidly. These questions and conditions often come before us as medical men, and if we do not answer with candor, and we think that there are conditions present that the bearing of children is unwise, we should give them the benefit of our opinion; and in such cases as were referred to by Dr. Paschal they should be made to feel ashamed of the enormity to contemplate any such conduct. It is perhaps right that this question should be carried out a little further than it was by Dr. Keiller. But the questions that should be discussed by the medical men of this country are whether people, in view of the question as presented by Dr. Paschal, should be thoroughly informed as to the condition to be visited upon our Union. That they should not shirk the duty for which they were created; we should educate the people along these lines; we should treat the questions with candor and fairness as they present themselves. We should not shirk our duty. These are questions which come before us as medical men, and the American people have the right to our intelligent advice and to know that we will not give them wrong ideas of duty. I am heartily glad that Dr. Bell has called the attention of the profession to this question as a medical question, in the light of what Dr. Paschal has said that is threatening our national integrity.

DR. G. H. MOODY, San Antonio: We are sometimes justified in advising prevention of conception, e. g., when there is a well-marked neurotic tendency, because we want the procreation of strong men and women.

We often see married people who have no children, where it seems to be the result of nature's effort toward final elimination of that line of tendencies, which, if allowed to continue, would lead to a degeneracy that would leave to posterity many unfortunates.

Society tries sometimes to establish standards of its own, which would not be good for the human family. As physicians, we should raise our voices against standards out of harmony with nature. Some churches prohibit the granting of divorces. People are often fortunate who get divorced; the earlier they do so the better. Sometimes their union is unfortunate, and to bind them for life is irrational. In such cases there ought to be means to get divorces, and get them early. The time is coming when there will be legal steps to prevent plainly unwise marriages.

DR. BELL, in closing, said: I wish to say that I realized what I was going to hear when I prepared this paper, and have presented it solely with a view of having just what we have had here-the pro and con of this question. The only point that I wish to make is in replying to the different doctors who took part in the discussion.

I believe the question as Dr. Paine puts it as being a moral one and then leaves it is a mistake. I believe that the proposition that this is a question which should be left to the laity to decide is an erroneous one, and this question is not wholly a moral one. I think in what Dr. Paschal said, if I am not mistaken, he spoke along that line.

Gentlemen, I take it that these are physical questions that devolve on us to decide. This question concerns the family; we must face it; we can not push it aside and say the question is settled; we must settle these matters.

No man on this floor is more unwilling than I am to violate the laws of my fellowman or my God or moral or physical law. The question is, whether it is our duty, as physicians, to advise individuals, under certain circumstances or conditions, to prevent conception; and as the gentleman has suggested, it is not wholly a moral question when a case comes before us to decide or advise under what conditions the woman may prevent it. It is not how it should be done that is entirely outside of this question— and, as Dr. Keiller has said, I hope some doctor will in future discuss it as to the question of how to prevent conception—if we have a right to interfere or to advise interference; how and what are the best means, the most harmless means by which to have it done. I live in a local option county. If a man should come into my office and say, "Doctor, I want a prescription for whisky," I say I can not give it to you; but when a man comes to me and says: "My wife is sick," and gives certain symptoms that impress me that he needs it, I give the prescription; and if a man comes to me and says: "My wife and I have enough children; give her something to prevent conception," I can not do it; or if a man comes to me to prevent his wife from having children, that, to my mind, is a moral question, and I have no right to interfere when it is only a question as to how many children they have. I never shall forget the poor little woman who came to me and said the history of her family was tubercular and did not want to conceive again, and because I did not advise her how to prevent conception, I think I did an irreparable injury to that woman and one that I shall regret the rest of my life; it will stay in my mind as a wrong that I have done to that good woman.

OTITIS MEDIA FROM THE STANDPOINT OF THE GEN

ERAL PRACTITIONER.

E. E. GUINN, M. D.,
JACKSONVILLE, TEXAS.

It is not my intention to make it appear that there is a difference of opinion between the general practitioner and the specialist in regard to the etiology, pathology, diagnosis, treatment and prognosis of middle ear disease, except it be that the general practitioner, according to my observation, does not appreciate the gravity of the situation as does the specialist. Therefore, the object of this paper is not to instruct the general profession in the management of this malady, but to impress upon them the importance of looking upon earache as being far more serious than is generally supposed. In fact, an acute naso-pharyngitis should be a note of warning to the family physician; and, in fact, all acute pathological conditions that are prone to result in middle ear disease.

It really seems to me that middle ear disease should be regarded as symptomatic and not a disease itself, because it invariably follows some acute or chronic disease, unless it be congenital, which is the exception and not the rule. With proper attention from the family physician to these acute and chronic conditions a great majority of mastoid abscesses, permanent deafness, idiotic expressions of the face, chronic catarrhal troubles, and a great chain of symptoms and conditions, so often observed in youths and adults, who have in their childhood suffered from middle ear disease, could be prevented.

It, therefore, appears to me that if the family physician is not competent to treat these conditions, he should at least be able to recognize and refer them to some competent specialist or general practitioner who can treat them; if not he is certainly responsible for the condition which follows. And, by the way, this does not only

apply to the ear, but to the nose, throat and eye as well; and it would be wise also to include surgical troubles.

It is the duty of every physician, if he is not competent himself to treat a special condition, to refer said patient to some one who is; if not, this physician is surely responsible for the result. There should be a warmer fraternal tie between the real physician and real specialist, for certainly we can not all be real specialists, and some are not real physicians. And the people and the real physician and specialist should unite and eradicate from the State every vestige of the quacks and charlatans, whose mission it is to propagate poverty, false teachings, human suffering and destruction of life. And this condition does not prevail only amongst the ignorant and poor, but in the homes of the rich and the educated. For proof of this assertion, permit me to call your attention to the action of the Twenty-eighth Legislature on the so-called "Drugless Doctor Bill."

Otitis media is due to many causes, perhaps the most frequent being naso-pharyngitis generally an acute cold. The naso-pharynx is highly vascular and contains much glandular tissue, lying between the pharyngeal mouths of the two eustachian tubes. The pharyngeal tonsil, as you know, is there situated. During an acute coryza and other throat troubles these tissues become engorged, congested and inflamed, and all become abnormally active under these conditions, and from the pressure exerted by these tissues the eustachian tube or tubes are closed. Aeration of the drum cavity is interrupted, a vacuum is formed, an exudation of serum takes place, pressure in the tympanic cavity follows with bulging of the membranic tympani and earache; but before this condition of bulging of the drum membrane takes place it first retracts, by the vacuum of the drum cavity and the external air pressure upon the drum; hence we may have earache. If left alone, or improperly treated with oils and various other harmful agents (which is usually the case), then the bulging comes on, and if the drum does not spontaneously rupture, cell proliferation takes place, followed by microbic infection; and pus formation, eventually the process of

necrosis, comes on, followed by sloughing and evacuation, and a chronic otitis media, and perhaps permanent deafness.

Otitis media from other causes generally goes through the same process, except perhaps it be in the cases due to specific and direct infections, such as scarlet fever, diphtheria, etc.

The diagnosis is generally easy; most every mother has made a diagonsis of earache before the physician has been called. If an exudation in the drum cavity has taken place it is said that a correct diagnosis is easily made by allowing the child to become quiet, and then with your finger's tip make pressure upon the tragus. If the child is suffering from earache it will cry. This, however, I do not consider pathognomonic, as most children have a mortal fear of the physician, and will cry out if you touch them anywhere; therefore, it is best to carefully get a history of the case, the probable exposure to cold, or dampness, whether it has an acute cold or sore throat. If the child is picking at its ear, this will strengthen your diagnosis; however, it may be necessary, in some cases, to search closely for symptoms before a definite diagnosis can be made. You may resort to an inspection of the drum membrane, which is difficult in many cases. After the diagnosis has been made we begin our treatment.

First the pain should be relieved. If in the acute stage of effusion, this can usually be accomplished in twenty to thirty minutes by the instillation into the ear of five or six drops of carbolized gylcerine (one-half per cent); if not relieved within this time (twenty or thirty minutes) it should be repeated; or, better still. use a properly made tampon of absorbent cotton or wool, saturated in the above solution. This tampon should be gently, but surely, placed against the drum, and renewed as required; but in this stage, with proper treatment to the pharynx and eustachian tubes, this condition rarely calls for a repetition of the tampon. The initial tampon should be left over night or day, as the case may be. The glycerine removes the effusion and the carbolic acid has an anesthetic and antiseptic influence.