This case teaches us that these discharges from the ear ought not to be looked upon as a light affair.

Dr. R. B. Ridley, Jr., of Atlanta: I would like to say that I have listened to this paper with a great deal of interest, and I find that Dr. Roy has embodied in his paper practically the same ideas as to treatment that I use myself. The longer I am engaged in this practice and see these cases of chronic ear trouble, the more thoroughly am I impressed that the radical operation is the only treatment for chronic suppurative conditions of the middle ear. I believe, however, before we do the radical operation, when we first see the patient, it is our duty to give him every advantage of proper medicinal treatment. In using formalin, as Dr. Roy has said, I have found that in connection or in combination with a weak formalin solution used at the office, twenty-five per cent. argyrol solution given to the patient at home will counteract the inclination of the formalin to produce a dermatitis of the external auditory canal.

I want to say that the dry treatment of insufflation of powders through the external auditory canal and from there into the middle ear, as a practice, should not be countenanced, because the powder in connection with the discharge forms a paste and dams up the opening that is present in the drum and prevents any further drainage. It is liable to dam up the opening, break down the mastoid, and set up more serious trouble.

I was favorably impressed with the paper, and I have gained many ideas from it that will benefit me, and I am sure it will benefit others present.

Dr. L. Amster, of Atlanta: I want to say a few words in regard to prophylaxis in these cases.

So far as the operation is concerned, Dr. Roy is naturally qualified to deal with it; but there is a great

deal of prophylactic work to be done by the physician to prevent from getting these cases when they are chronic. I think in a good many cases the physician is to be censured for not paying attention earlier to these cases, so that they may not develop into chronic middle ear trouble, especially during measles or during an attack of scarlet fever. Personally, I have never considered lightly the fact that a child complains of ear trouble. I believe paracentesis of the drum in these cases will tend to lessen the number of chronic instances. The family physician could exert a beneficial effect on these cases by insisting on the parents letting these children be operated for adenoids; not let them wake up with open mouths, which gives them a stupid appearance, but recognize the condition, have the adenoids removed promptly, so that future troubles may be obviated.

Dr. J. L. Hiers, of Savannah: This paper deals with a line of treatment which I have advocated for many years, consequently it has been of intense interest to me. If there is one thing that is of interest to the aurist and the family physician it is a running ear in a small child. Often the child is allowed to go around in all sorts of weather and is subjected to all sorts of exposure from early childhood, and there may be enlargement of the pharyngeal tonsil, commonly known as the adenoid. The running ear keeps up and becomes chronic, and all sorts of stuff, from castile soap, sweet oil to laudanum, are used by the old granny women, if we may so designate them, and then it is up to the aurist. But there are one or two points I wish to emphasize. Too much care and attention to the post-nasal space can not be given. In every instance in which there is a suppurating ear, as soon as we are through with the examination of the ear, the next thing to be examined should be the post-nasal space,

and not only that, but where there is an enlarged adenoid existing for some time there is hypertrophy of the turbinated bone, which invariably subsides after the removal of the adenoid growth.

I have tried everything possible that has been recommended toward the cure of suppurative otitis media, but I must denounce the insufflation of all powders in the strongest terms. In my hands they have been more harmful than beneficial, and, as Dr. Ridley has suggested, the wet treatment, syringing with strong antiseptic solutions, may be best suited to each individual case, and the use of drops where the wet treatment seems to be contraindicated. I wish to emphasize the importance of using dry treatment, but only in the method of packing the ear lightly with absorbent gauze, preferably bichloride or iodoform gauze. That has been ideal dry treatment in my hands.

I wish to thank Dr. Roy for his valuable paper. I have gained many points from it, and I feel greatly benefited by it.

Dr. Claude A. Smith, of Atlanta: I would like to ask Dr. Roy to tell us what has been his experience with regard to brain abscess following in these cases without mastoid involvement, either of the ethmoid or mastoid cells themselves, and in what proportion of cases it occurs?

Dr. Henry R. Slack, of LaGrange: I wish to thank Dr. Roy for his valuable paper. I do not claim to be an aurist myself, but as I do a general practice and confine it principally to office work, I see a great many ear cases which fall into my hands. I would not attempt the radical operation upon a discharging ear, because I have not had the necessary experience, and I agree with Dr. Roy thoroughly that a physician before attempting to

perform this operation should experiment on a number of cadavers. I have found in my limited experience that the wet treatment is decidedly the best, especially if we have to entrust it, as we often do, to the members of the family. If you give any member of the family directions how to` pack the ear they will produce no discharge, and instead of going forward the pus will burrow backward. I do not believe it is wise to trust to members of the family to treat the ear at all, but often we have to do so, and when we do mild antiseptic solutions are the best. In getting rid of granular conditions of the ear, I have found fre quently nitrate of silver has been efficacious.

Dr. Roy (closing the discussion): In answer to the question of Dr. Smith, I will say that I do not know what the proportion of abscesses in the brain is.

Dr. Smith: I find from statistics that probably what occurs in one section of the country, or in Europe, for instance, does not apply to our section. I simply wanted Dr. Roy to give us his experience.

Dr. Roy: Involvement of the mastoid in these cases is less frequent in the South than it is up North. Physicians see many more cases in the North than we do in the South. In my experience the mastoid is involved first, and then there is extension to the brain. In some cases the disease seems to go through the top of the tympanic cavity into the brain substance, forming a subdural abscess, or it involves the brain substance.

There are one or two points to which I desire to call attention. First, it is the prophylactic treatment that I especially wish to impress upon those who have listened to me this morning. It is a fact that a large proportion, if not all, of these cases of chronic trouble come from an acute affection which existed before. The acute attack develops into a chronic one, and in the majority of

cases of running ears the mastoid is involved at the time of the acute attack. The chronic discharge which follows is simply from a diseased antrum or mastoid, and that is simply like a bucket-filled up with water and emptying itself through the auditory canal and tympanic cavity. In these acute cases you can easily tell whether the mastoid is involved or not. If it is involved, and you make the mastoid operation, establishing thorough drainage from the mastoid antrum through the middle ear, and let the case heal up, you will not have any running ears. The trouble is that these ears are not attended to during the acute attack, and if you will consider that one point there will be a much less number of running ears. I want to call your attention to the fact that in these cases of acute inflammation of the middle ear, whether it is pus or mucus, if the discharge keeps up for a long time, three or four weeks without cessation, it shows absolutely that the discharge is coming from the mastoid, and unless you open the mastoid, establish free drainage, open all the cells and destroy them, you are going to have discharging

ears.

My paper dealt not only with the treatment when these cases come to you, and which you have not seen previously, but it was to direct your attention to the acute cases when the mastoid is involved, and if you will go into the mastoid and secure free drainage, you will have no chronic cases to treat. It is necessary to have edema, swelling, with the ear sticking out, so to speak, in order for the mastoid to be involved. It is very essential for those symptoms to occur, and you can tell from the character of the discharge and the length of time it keeps up, and when it keeps up for three or four weeks without cessation, shows mastoid involvement, and if you break up the mastoid cells, and establish free drainage, then you will not have chronic trouble to deal with.