pected whenever granulations or polypi exist. While many attacks may appear to get well, as long as the diseased condition remains just so long recurring attacks will succeed each other A slight exciting cause sets up another exacerbation of the existing inflammation. Mastoid suppuration is an offspring of

middle ear inflammation.

Treatment. The first object in treatment is absolute cleanliness. This is best accomplished by syringing with at least a quart of fluid; sterile water or a weak bichloride solution of about 1-6,000 answers very well. The fluid should be used warm and with as much force as can be comfortably borne, especially at the first cleansing, in order to remove all the discharges from the ear. Dry with cotton and dust gently with a powder blower a thin coating of boric acid or aristol. Later the dry treatment may be employed omitting the syringing, but absorbing the discharge with pellets of absorbent cotton. Where the odor of the discharge indicates dead bone, iodoform in fine powder often gives good results. Peroxide of hydrogen was very extensively employed, but the danger of mastoid complications is a serious objection to its use. Bishop's ear aspirator, resembling a double syringe, answers a useful purpose in aspirating the discharges from the middle ear. Alcohol, either alone or in combination with boric acid, may be employed in some cases with marked advantage.

Cases. The following brief reports represent different types of the disease.

1.-J. A., aged 10, was examined January 30, 1902. Patient had experienced slight pains in both ears for one or two days. Left ear had been very painful since morning. Inspection of right membrane showed some redness. The left was red and slightly swollen. Did a paracentesis of this membrane under cocaine anaesthesia. There was free hemorrhage, apparently free from pus. The ear improved rapidly with little or no complaint of patient afterward. Five days later was called to see patient at his house. He was suffering severe pain in right ear. Examination was not quite as satisfactory as at office on account of character of light; membrane was somewhat red, but could detect no swelling. A swelling of the posterior superior wall of canal, near the membrane, pointed to involvement of the mastoid. There was considerable tenderness over the bone with a very little oedema. Temperature 103 2-3°. Applied antiphlogistine over mastoid and ichthyol in meatus.

Symptoms gradually improved and patient was comparatively comfortable, with a normal temperature, two or three days later. February 12, one week from time of mastoid involvement, the tenderness was disappearing from mastoid.

2.-M. A., age 9, consulted me April 15, 1901. Complained of severe pain in left ear of two days' standing. Examination showed lumen of canal filled with impacted cerumen. Tenderness over the mastoid. The ear was syringed with sterile water, and part of the cerumen removed; the remainder was removed the following day. The membrane was red and swollen. An incision gave vent to a little pus and blood. The usual remedies were employed, and after six weeks' time the patient was discharged cured, with very little impairment of hearing.

3.-R. H., aged 30, consulted me April 22, 1901. Patient's family history good. He had recently returned from the Southern states where he suffered with malaria, had lost weight and was rather anaemic. Had subacute pharyngitis and suppuration of right and middle ears of several days' duration. Was some tenderness over left mastoid. Patient's hearing had been failing for the past three weeks. Made an incision in the left membrane, as the perforation gave insufficient drainage. Patient was treated on general principles; was given tonics in addition to the local treatment of his ear. He improved very much. Owing to a death in the family, patient returned to his home in Idaho the last of May. He reported that he was still improving a few days later. June 14 I received word that the patient had suffered a relapse, and concluded from symptoms given that he had facial paralysis with a serious involvement of the mastoid. Examination of the patient on the 21st found the above opinion correct. He had lost flesh very rapidly, and it was found that the patient was suffering with an active tubercular involvement of the lungs, also a tubercular laryngitis. The ear and mastoid complication was probably of the same origin. I hesitated to do a mastoid operation, as the lung complication pointed to a fatal termination at a comparatively early date. The temperature reached 1041⁄2 with symptoms of infection on the 23d, and on the following morning I operated on the mastoid. The antrum and cells were filled with pus, and a large amount of diseased bone, extending to the mastoid tip, was removed. The patient stood the operation well, improved rapidly and left for home eleven days after the operation. The wound was healing rapidly when I received the last report some days after his

arrival home. I learned that the patient subsequently died from the tubercular involvement of the lungs.

4.-G. R. S., aged 24, was referred to me September 10, 1901. Patient was here for his health. Tubercle was suspected, but its presence was not proven. Patient complained of discharge from left ear, more or less constant since infancy. For the last three years there had been an offensive odor to the discharge. Examination showed a perforation in the posterior part of the membrane, involving about one-sixth of that structure. Abundant granulation tissue could be seen through the perforation. The ear was cleansed frequently, the granulations cauterized a number of times, and treated on general principles. The discharge slowly but gradually lessened and in two months it had almost ceased. Patient is rather susceptible to climatic changes, and upon taking cold he still has a slight irritation of the ear, with a very little moisture in the middle ear. While the case appears to be practically cured, the tissues still remaining in a susceptible condition, however, such that they might easily become inflamed, yet a positive opinion as to cure or resolution could only be given after the lapse of a considerable time.

ETHICS.*

Ethics Treats of Right Conduct and Character. Medical Ethics Treats of the Physician's Duty to His Patients, the Public and Himself.

By W. J. ROTHWELL, M.D.,

Professor of Medicine, Gross Medical College,
Denver, Colorado.

The statement is often made that gentlemen do not need a code of ethics for their guidance, since every real gentleman adopts the golden rule as the measure and guide of his conduct. But human judgment is fallible, and, therefore, the inherent right of private opinion free from the restraint of some generally accepted authority cannot be maintained either in public or private life. Two persons may differ in opinion upon any debatable question, but neither has the right to use phy

*Read before the Graduating Class of Gross Medical College, May 15, 1902.

sical force in the maintenance of his opinion. How can the dispute be amicably settled except by an appeal to some well recognized standard of authority governing such a case?

For this very reason society, whether social, political, scientific, military or ecclesiastic has its code or body of rules for the regulation of its conduct.

Our Code of Ethics was adopted at Philadelphia, in 1847, by a body of men now known as the American Medical Association. It has been accepted by all regular physicians as the common basis and guide of good conduct.

It enjoins upon every member of the profession of medicine "to exert his best ability to maintain the dignity and honor of the profession, to exalt its standing, and to extend the bounds of its usefulness."

I hope that without wearying you or the audience I may be permitted to call your attention to a few of its important precepts. Here is a gem of rare beauty. Listen! "No scientific attainment can compensate for the want of correct moral principles." You, as You, as physicians, are familiar with many forms of compensatory action in the organism, but for this moral defect our Code knows no means of compensation. The highest scientific acquirements are no substitute for real moral worth. When combined, they constitute the ideal physician of our Code.

In continuation of this thought, the following may be quoted: "Medicine is a liberal profession, and those admitted into its ranks should found their expectations of success upon the extent of their qualifications, not on intrigues or artifice."

Whoever finds his inclinations running counter to these principles is out of harmony with the spirit of our profession. The statement rather suggests that intrigue and artifice may be made stepping-stones to success, but they are denounced as unfit agents to be employed by members of a liberal profession.

The duties of physicians to the public are strongly emphasized. We, as good ctitzens, are to instruct the public in all that pertains to sanitation, to protect them against infectious diseases, and to guard them against medical impostors. There is no other class of citizens who honestly and persistently work against their own financial interests as we do.

We fight epidemics with Pauline zeal, bottle up contagion, the best friend of our depleted pocket-books, and would gladly legislate our friends, the microbes, out of existence. When all these things are accomplished physicians will be ready to ex

claim: "Now let they servants depart in peace, for our eyes have seen thy salvation."

How well we have performed this part of our duty is shown by the great decrease in the number and violence of epidemic diseases. Small-pox, diphtheria and typhoid fever are being slowly strangled by the giant sanitation, and even the dread yellow fever of Havana has slunk away to its native jungles under the enlightened sway of American physicians.

And, yet, in the face of these results there are many who would have us return to mediaeval conditions, deny the necessity and efficiency of public hygiene, deny the very existence of disease and death and ignore the learning and experience of the ages. Is it possible that the highest wisdom is after all but a negative?

In no part of our duty to the public have we encountered so much opposition, and been so grossly misunderstood as in our efforts to regulate the practice of medicine. We fully endorse the following extract from the Code:

"In no trade or occupation do mankind rely on the skill of an untaught artist; and in medicine, confessedly the most intricate of the sciences, the world ought not to suppose that knowledge is intuitive."

Yet, I am sure you will find this belief very common among certain classes. That a man is not permitted to shoe a horse without first satisfying the authorities of his ability to do so in a fairly skillful manner, and yet that one entirely ignorant of the diseases of mankind may still be allowed to treat human ills is, to say the least, paradoxical.

When we enter the halls of legislature to prevent this danger to the public welfare we are coolly received.

We are told that our aims are selfish, that we wish to form a medical trust. Now everyone knows that a trust is organized for the express purpose of abolishing competition. To form a real medical trust we need but to close the doors of our medical colleges except to a very limited number of students, and to lower the standard of medical education so that the few who may be permitted to graduate shall possess but a minimum of knowledge and skill. This would exclude successful competition, enable us to exact extortionate fees for our services and place us on an equal footing with the genuine commercial trusts. With pocket-books well lined with gold, we might then be classed