that has been tried and given good results, or any other that might appeal to your judgment, should be faithfully and persistently carried out, then when there is failure, the Otologist should be consulted for advice, or to perform the radical mastoid operation.

833 Candler Building.

DISCUSSION

Dr. H. R. Slack, LaGrange: I have listened with great interest and profit to the paper just read by Dr. Calhoun, and I agree with him in the main line of the treatment outlined. In my personal experience, however, at least sixty-six per cent. of the discharging ears that I have come in contact with could be traced to the presence of adenoids and diseased tonsils; so soon as the adenoids and diseased tonsils were removed, if done thoroughly, the ears would be able to take care of themselves unless

some complication arose. I have in mind now a young man who was brought to my office; he was an engineer, a sufferer from rheumatism; he had an otorrhoea and had great difficulty in deglutition. A careful examination. showed that he had very much inflamed and enlarged tonsils and the ears were discharging a purulent material. He had a high fever. He had also an infection of the right knee. I performed a complete tonsillectomy, removed the adenoids, and syringed the ears well. In a very few days he was entirely cured of his trouble. I have had a large number of such cases where, after the removal of the adenoids or diseased tonsils, the ears have ceased discharging, and cure has taken place in, as I have just stated, at least sixty-six per cent. of the cases. As a result I recommend that all persons who have an otorrhoea should be carefully examined to see if there are present adenoids or enlarged and diseased tonsils.

Dr. Hugh M. Lokey, Atlanta: Cases of chronic suppurating ear troubles occurring in children are very often found associated with adenoids and diseased tonsils. In

principles. One of two operations are usually performed in the treatment of the condition under consideration: The first is for the relief of the discharging ears alone, and this is accomplished by the conversion of the antrum of the mastoid and the middle ear into one large cavity, by lowering the posterior wall. It is really a delicate operation, as many important structures like the facial nerve, the meninges, the semicircular canals, the lateral sinus and carotid artery are constantly before the operator. This operation means the residence of the patient in a hospital for at least ten to fourteen days, and dressing and attention by the surgeon for many weeks afterwards. A permanent cure is brought about in about 60% of the cases. This operation is commonly known as the Stacke operation.

The second operation, the so-called Schwartze-Stacke operation, combines two features viz., the operation for an acute mastoiditis-a curettment of the mastoid cells (the Schwartze operation) and the relief for a chronic discharging ear-the method just described (the Stacke operation). The operation is never done by preference, as is the Stacke operation, but always from necessity, and residence is required in a hospital for several weeks, and nothwithstanding the seriousness of the case, the percentage of cures is larger and the time shorter than the Stacke operation.

I have purposely left to the last, the condition known as cholesteatoma of the middle ear, and its subsequent mastoid involvement. It is a collection of desquamated epitheial cells in the middle ear, brought about oroginally by a perforation of the drum membrane and a secondary infection, and from what might be called pressure necrosis, the middle ear and mastoid are usually involved. An operation is usually indicated and one never knows until the mastoid has been opened, the extent of the destruction.

The method of treatment that T

sted, one

value in the treatment of these cases. This latter is of great value but it is very mussy, makes the part look as if an ink well had been upset; it gives the part a very unsightly appearance. I agree with what Dr. Calhoun said in regard to the use of peroxide of hydrogen; although it will destroy the pus producing bacteria, yet by means of its effervescence it will cause some of the pus to enter the Eustachian tube, or the mastoid antrum, and may cause inflammation and a mastoiditis.

Dr. St. J. B. Graham, Ellijay: There is quite a difference in the treatment of ear diseses at the sea level and in high altitudes; at the sea level there is a pressure exerted upon the ear drum of 14.99, or fifteen pounds to the square inch. If the Eustachian tube be closed or occluded the pressure is greater and might cause it to be broken in. The Eustachian tube is dry; therefore, the drum membrane becomes dry and the pressure, as a consequence, is less.

Tuberculosis is a disease which we should more often take into consideration, because of the fact that the disease gains an entrance through the cripts of the tonsils. Among the large number of cases of otorrhoea seen years ago, about eighty per cent were said to be scrofulous in nature; the disease then was supposed to be simply scrofula, a disease which is now recognized by us all as being tuberculous. Therefore, there were many cases of otorrhoea which resulted from a tuberculous condition of the ear.. Whether the tubercle bacilli enter through the cripts of the tonsils or not I do not know, but this we do know, that dryness of the ear resulting from living at high altitudes frequently result in cure of the condition without further remedies.

Dr. R. R. Daly, Atlanta: I agree with what has been stated in regard to the use of peroxide of hydrogen in the treatment of discharging ears; its value is not very great; it does not kill many germs. It will, however,

shove the pus around, getting it into places that we do not want and may produce very disastrous effects.

With regard to chronic discharging ears, all are agreed as to the kind of operation to be performed when certain indications are present. But the great thing for us to consider is prophylaxis. The operation of myringotomy should be more often taken into consideration. The general practitioner is the one who is consulted so frequently because the patient has an ear ache; and such ear aches can very often be cured by the proper performance of myringotomy, thus getting rid of the pus in the canal. I have in mind now a patient, twenty-two years old. In fact, I have in mind two such cases. One had a purulent discharge from the middle ear which had lasted for some time. This patient was anaesthetized, a myringotomy performed, the pus allowed to escape, and the man was discharged cured in ten days.

Only last Saturday a patient, twenty-eight years old, came to me complaining of ear ache. A myringotomy was promptly performed and the patient was discharged cured on the Monday following.

To me prophylaxis is of the greatest importance. Patients should be taught to pay more attention to ear aches. The membrana tympani should be more often gotten at and opened.

Dr. F. P. Calhoun, Atlanta: (closing discussion): I agree with Dr. Daly in what he has stated about incising the drum membrane when patients come to you complaining of pain in the ear. It is very important and very essential that every general practitioner, who is the person usually first called in to see such cases, when he sees the drum membrane is reddened, to know when and where to open it.

I am glad so many of us are agreed and have the same belief in regard to the use of peroxide of hydrogen in the ear. Since the sad experience I have had with it, I do not see how it is possible for me to again use it.

ELIMINATION, OUR SAFEGUARD.

B. P. Oliveros, M.D., Savannah, Ga.

The old humoral idea of a materies morbi being the ground work for certain diseases and that this same materies morbi could be eliminated from the blood, is not so far from the truth as would at first appear. There may be a decided lack of demonstration, but it is a well known fact that noxious materials can be expelled from the system, this we see verified in the use ef a certain class of drugs known as diuretics and diaphoretics.

Modern Science seems to point out clearly that this class of drugs may aid in separating from the blood retained secretions and may to some extent replace the action of the kidneys when these organs are disabled by disease.

The action of any medicine can be followed from the time it enters the stomach, to the time it makes its exit through the excretory organs. Some medicines chiefly influence the primary assimilation, others again, attack and change the process of assimilation, probably aiding a new growth of tissue or a distictive metamorphosis. After all, the application thereapeutically, of any remedy, is governed altogether by the conception of its physiological action.

The eliminating action of certain drugs is among the most assured of clinical facts, as is also the treatment of many diseases, by the application of certain well known remedies. The few specifics that we have do not always cure or give us even the results to be expected, nevertheless, they are potent factors in our fight with disease.

Dr. Jacobi, in an address before the State Society of