child? Why is the layman called upon to give force and effectiveness in the warfare of moral prophylaxis?

And then the public, growing more exacting and more critical day by day in the increase of its medical knowledge, will write the third section of the medical code, and that section will deal with the relation

ship of the doctor to the public-the part which the doctor must play in the insistent programme of the brotherhood of man.

While it is true that medical men have been associated with and have furnished the technical knowledge for every successful crusade against disease and against any of the faulty social conditions, it has almost invariably happened that laymen have been the active workers-have been the ones who have studied the actual conditions, and who have applied the technical knowledge to the relief or prevention of the conditions. Hence it is true that we find intelligent laymen being quoted as authorities on tuberculosis, sanitation, housing, eugenics, the physical development of the young, heredity, venereal disease and sane and rational living; and we find the rapidly growing work of medical sociology presided over and resting upon non-medical men.

But could not medical men do many of these things better than they are now being done by laymen? Certainly they are better qualified in technical knowledge, and all doctors should be sociologists, although, unfortunately, the vast majority of them are not. However, it is safe to say that medical men with sociologic training should meet medical-sociologic problems more intelligently and more satisfactorily than any other class of men, provided they are able

to do away with certain professional eccentricities which seem to interfere with the doctor's entering upon what is known as team work.

These interesting and important branches of medical sociology belong naturally to the medical profession; but we have always regarded the field as barren and unproductive until laymen have come and preempted it and have irrigated and fertilized it. And now that we see it flourish like the green bay tree under this intelligent husbandry, we want it back and, what is more, we are going to have it back.

Within the next decade, the biggest, broadest, most important part of our professional work will be found in the medical side of public affairs. Preventive medicine will come into its own, not as a matter of mere laboratory science, but as a generally applied art, engaging the attention of the brightest minds of our guild and of many of them. The biggest doctor of them all will be the one who can heal the sores of a mighty people and prevent the disease and inefficiency of a race unborn. The coming age, however, will be one of prevention, not of cure; of how to live and not merely how to heal the bruises and ulcers due to our ignorance, stupidity and folly.

And it is the relationship of the doctor to the public in this coming era of intelli-. gence which will be dealt with in the third section of the code of ethics which the people are preparing to write for our guidance. In the readjustment of the attitude of the medical profession to the public, we will merely take our natural place in the field of medical sociology.

ing their patients' noses and throats with pleasantly aromatic and astringent solutions, many of them in the enjoyment of the fond delusion that they were curing catarrh. Meanwhile, adenoids went for the most part unrecognized, and suppurative

disease of the nasal accessory sinuses was generally attributed to disease of the nasal mucosa, unless ethmoiditis or frontal sinusitis involved the orbit and the oculist discovered a fistula leading into one of those cavities, or some dentist found a connection between a diseased tooth socket and a leaking antrum.

Even as good a man as Bosworth, in the edition of his book published in 1889, spoke at length of the purulent rhinitis of children, without the slightest intimation that it might have any connection with the nasal sinuses. In fact, he speaks of the frequency of the occurrence of purulent rhinitis and the infrequency of accessory sinus disease. During that same year, I spent my time in the clinics of New York and Berlin, and saw only a handful of cases frankly recognized as accessory sinus disease. Only a few years ago, less than ten, I think, Dr. J. A. Stucky, of Lexington, Kentucky, read an interesting paper before one of the national societies devoted to oto-laryngology, in which he reported seven operations for accessory sinus disease in children. I was greatly surprised at the ensuing discussion, which indicated that the New York men, in particular, seldom met such cases, at least those requiring operation.

But conditions have changed. Specialists, as well as some general practitioners, have learned to make a diagnosis of adenoids and also of sinus disease, and many of the specialists have been spending most of their time the past few years in either removing the walls of the accessory sinuses of the nose or devising methods of doing the work more thoroughly. The net result has been some very beautiful and highly scientific and technical, as well as complete, operative procedures, a large number of sunken and otherwise disfigured countenances, and a much larger number of deaths probably than would have resulted from the disease alone. But it is impossible to speak dogmatically of the statistics. Doubtless many lives have been saved, and such cases are generally reported, while the fatalities are most often concealed in the

same way as our other professional misfortunes. Our foreign brethren have had the advantage of us in this radical sinus work, both by reason of their surgical material being more docile and less sensitive to personal appearance, and, at the same time, less addicted to the malpractice suit habit. It required a long period of time for the gynecologists to learn that they could not remove even diseased ovaries in toto, to say nothing of healthy ones, with impunity. It may not require a longer period for nose and throat specialists to learn that the various accessory sinuses, even when the subjects of more or less discharge, may possibly be more comfortable possessions than air passages so dispossessed of their secreting surfaces as to be as dry as a basket of chips. Instead of there being but few cases, comparatively, of suppurative disease of the nasal sinuses, there are a very great many, and this is true even of children, in whom much of the discharge, formerly mentioned by Bosworth as coming from the adenoids, and Thornwaldt's bursa, without much doubt comes from the sin

It is hardly a thinkable proposition that all or most of these should be operated. There would not be enough surgeons to go around. Most of them go through life more or less annoyed by a purulent leak from somewhere, and especially at such times as they have an acute cold. Do not let me be misunderstood as wishing to underrate these sinus troubles. They are certainly serious enough in the aggregate, and it is of the greatest importance to prevent their occurrence, and where that is not possible, to minimize to the utmost their evil effects. Many a frontal, occipital and vertical headache is the result of pressure in the sinuses, and it has happened to me, as well as to other oculists, to prescribe glasses for some such patients, and finally afford them the first relief by giving vent to some obstructed outlet. The passing of a probe into the frontal or sphenoid sinus, or even the contraction of the swollen tissues about the ostium with cocaine or holocain and adrenalin, will often give prompt

relief. The removal of a too large middle turbinal body in sufficient extent to permit drainage is even more effective. There is not the slightest doubt in my mind that these sinus diseases, as well as suppurations in the tonsils, adenoids and teeth, may be the cause of rheumatism, septic endocarditis, nephritis and perhaps other bacterial infections through the blood current, as well as infections of the brain and meninges through more immediate influence. Such facts have seemed to afford sufficient ground for radical and thoroughgoing work in clearing out the diseased foci, and in some cases it must be done on the ground that the disease is far more dangerous than the required operation. Unfortunately, sinus disease is a very complicated piece of business. The various diagnostic measures may utterly fail to determine the extent of the disease, and if it should be determined that there is pansinusitis present, and the effort be made to eradicate the entire diseased area, it would probably fail unless the most radical and extreme methods were invoked. erations, even in the hands of greatly skilled and experienced men, are attended with such danger as to render them a questionable procedure, except in comparatively rare cases. The variable and in any given case unknown ramifications of the ethmoids and frontals render any operation on these cavities, especially the ethmoids, somewhat of an excursion in the dark, and the occasional close juxtaposition of the walls of the sphenoids to the optic nerves and internal carotids sometimes renders rash work in that region peculiarly unfortunate.

Such op

Within two or three years an eminent New York surgeon, in a paper discussing general surgical principles, alluded to the varying eras of surgery and described the present as the antiseptic and aseptic era, while he said the coming era would be that of physiological surgery. In the present era we aim not only to practice the most rigid aseptic technic, but to religiously remove all vestiges of septic or diseased tissues from operative wounds and regions. In

the future, this surgeon thought, the surgeon would leave something for nature to do. The first mastoid operation I ever did, some 22 years ago, was a very poor one, from the scientific standpoint, but the man got well in a surprisingly short time, with good hearing, and no trouble since. I made a short incision through the skin, removed enough of the cortex to uncover the brokendown cells in the bone, smoothed the edges a little, inserted a few stitches in the incision and a lead nail in the bone for drainage, with a simple dressing. After my second visit, the patient, a husky and wellto-do farmer, refused to let me come to the house any more unless I would come for the same fee as his family doctor charged. On my refusal he called in his doctor, who cared for him a few days till he felt like coming to the office. Nowadays, I should not dare to do such an operation. He would now have a beautifully cleaned-out mastoid, exenterated is the word, would have had much more ether and suffered much more shock, and as the family doctor would not dare meddle with the case, it would cost him a good deal more money, and nobody would be any better off, except the surgeon. And perhaps in the long run he would not be. If all mastoids were done as that was, there would very likely be more secondaries than now, and in an occasional case there would be a death as the result of an insufficient operation, just as there is at present from too long delay or neglect to operate. On the whole, however, may it not be that there might be even less deaths, less cases of facial paralysis, nephritis and other results of prolonged and thoroughgoing operations?

The Wild incision has been mentioned for many years, only to be condemned as a treatment of acute mastoiditis. Within comparatively few years the procedure has been again urged as the most effective agency for the abortive treatment of mastoiditis, and during the past winter I ventured to employ it in what seemed an appropriate case. Mrs. R., 38 years old, a large, strong woman, was brought to St.

Barnabas Hospital, December 29 last, by her physician, Dr. Mitchell, of Grand Meadow. She had been having pain from before Christmas and severe since that date. Did a washing the 26th, had pain of severe character and temperature 103 F. the 27th. After purgation, temperature the 28th was nearly normal, but in the afternoon there was throbbing pain and dizziness, and she was started for the hospital. I found, at my visit at hospital at 11 a.m., slight pain, considerable tenderness over mastoid tip, with slight congestion, the mt. moderately congested, mem. flac. in folds, pulse 80 and temperature 99. She had had attacks of pain and discharge of the same ear in previous years. I freely opened the drum posteriorly, including the mem. flac., and evacuated a small amount of thick pus with the exhaust. I then made an incision one inch long over the mastoid to the bone. The profuse venous hemorrhage required application of hemostats, but was soon controlled and the wound packed with gauze soaked in 10 per cent. carbol-glycerine. Ear healed, and whisper heard at twenty feet in eight days. Free drainage is the essential element in the cure of infections of the ear, mastoid and nasal sinuses, and if that can be assured by a minimum amount of surgery, it is very questionable if more is justifiable in the great majority of cases. What does that mean? In the case of acute otitis media, unless the pain and fever are promptly and permanently relieved by hot syringing and a cathartic, there should be a free posterior incision (not a puncture) of the drum membrane, with appropriate after treat

ment.

In the case of mastoiditis not promptly relieved by drainage through the ear, it means a free opening through the mastoid cortex at the earliest possible moment, when the drainage secured by that simple means will probably be sufficient without the necessity of opening the antrum or exenterating the mastoid. A case of mastoiditis, however, which resulted from a suppuration of the ear, which had been neglected or inefficiently treated, could not

safely be operated in that way. But the responsibility for the more severe operation would rest upon the persons responsible for the neglect or delay. The same principles apply to the treatment of the accessory sinuses of the nose. Drainage must be secured, whether by shrinking up or removing tissues in the nose itself, or by negative pressure and must be determined in each case by the surgeon and his patient; but it must not be assumed as a foregone conclusion that in every case the attempt must be made to cut out all the affected sinuses. There has been altogether too much of that work done in the past. I have had the privilege of removing middle turbinals for two of my distinguished specialist brethren, but neither of them has urged me to curette his ethmoids. I also have troubles of my own, and the necessity for further operative work may arise; till then I will try to bear the ills I have.

Much brilliant work has been done the past dozen years in perfecting radical operative procedures for the cure of antral disease, and it has not infrequently been found, after the completion of such a cure, that the real seat of trouble was higher up in the ethmoids and frontals, and that the antrum had only served as a reservoir. Most of these radical attacks upon the antrum have involved the removal of the anterior half of the inferior turbinal, and some of them the removal of a considerable part of the anterior wall of the antrum, with more or less facial deformity, and the not inconsiderable risk of such interference with the nerve supply of the region as to make the victims very uncomfortable. One of the leading Boston specialists, in expressing his approval of my conservative position as regards antral operations, remarked that one of his patients had made life a burden to him by her complaints of the dryness of her nose and the numbness of her face.

There is no doubt in my mind that there has been a considerable excess of enthusiasm among rhinologists the world over as regards radical surgical procedures, and some of the best men, as well as most of

the other kind, have been sinners. In the future there will be not only less useless, if not dishonest, spraying and destructive cauterizing, but there will be more preventive work in the way of early removal of adenoids and correction of contracted jaws, which will greatly lessen the demand and necessity for the submucous septal resections, which have so great a vogue at present. It is too early to say much about this operation, but it is to be feared that sunken bridges, sooner or later, may be unpleasant evidences of our excess of zeal. And now, what shall be said of adenoids and tonsils? Both should be removed, in my opinion, if the cause of symptoms, and the former before they have caused symptoms. Conservatism in this field means early, skilful, complete and harmless operation, rather than delayed and incomplete operation. This present week I have removed three tonsils which had supposedly been enucleated by other specialists. One of the patients, a slight, delicate girl of fifteen. years, with good family history, came to me a year ago, referred by a local physician, with the history of naso-pharyngeal discharge during the winter. She had had her tonsils and adenoids removed two years before by a local specialist. The operation had been protracted and very bloody, the tonsils being friable and difficult. I found rather large tonsillar stumps, the crypts of which were more or less filled with cheesy, foul-smelling debris, and some adenoid remains, especially filling the fossæ of Rosenmüller. The lower turbinals being swollen, they were touched lightly, posteriorly, with a bead of chromic acid. Thereupon the sinuses of both sides lighted. up, and we had a profuse discharge, which speedily disappeared under the use of hexamethylenamin. The heads of both middle turbinals, which were crowded, were removed, as well as the adenoid remains. The girl returned to her home in a Wisconsin city, apparently improved, but had more or less discharge during the winter. A few weeks ago she came back, with some whitish naso-pharyngeal discharge and one

enlarged gland at the angle of the jaw. The discharge quickly improved under the use of iodo-glycerine, but as she had an occasional temperature of 99.5, and because of the enlarged gland, the removal of the tonsils was advised. A von Pirquet tuberculin test was negative. The tonsils were removed with an interval of two days.

One-half hour before operation, she was given eight drops of a 1⁄2 grain to the ounce solution of scopolamin, the tonsil was painted once with 1-1000 epinephrin, 20 per cent. cocain and 1 per cent. holocain solution. One grain of quinine hydrochloride and three drops of epinephrin solution were boiled in about one dram of distilled water and injected in the pillars and deeper peritonsillar tissues ten minutes before operation. The pillars were separated by sharp and blunt dissectors, and with only slight difficulty the tonsil was removed intact in its capsule, the final step by snare. Neither the child nor the doctor were excited, there was no pain, no hemorrhage worth mention, and no shock, and in three days the other tonsil was removed in like manner. I have no wish to criticise the previous operator. I have done work far more deserving of criticism myself. But I do criticise the method, as I have done before, of removing tonsils and adenoids as a single, complete operation for all three glands and under ether. Adenoids can be removed with anesthetic technic, corresponding to what I have described for tonsils, and in a large proportion of cases with a single sweep of the currette or adenotome, and if the case require other anæsthetics, two or three drams of ether by the drop method, or the so-called "ether rausch" method, will be sufficient. The contrast between such an operation and one under the full surgical anesthesia, the surgeon working more or less in the dark, the mouth and throat full of blood and stomach contents, which often pour forth in volume to strike terror to the heart of a novice or an observing relative, would seem to leave little room for question as to which is the humane, the surgical, the conservative method of