LARYNGOLOGY, OTOLOGY, AND RHINOLOGY.

737 needle carrying the depressed lifted upwards and forwards, thus rectifying the deformity. Some local swelling of the parts resulted but no constitutional disturbance. The child, who was a good little patient, suffered no after-pain and appeared quite happy and contented during the ten days in which the needles remained in situ. On removing the needles it was seen that small pressure ulcers had formed at the sides of the nose where the tightened gauze had been in contact with the skin; these, however, healed in a few days. Six months had elapsed since the operation and the nose so far had maintained its shape. Whether the nose would continue to grow in the way that it should grow was, however, a question which only the future could determine. The reason of the failure in the previous cases was due to inability to maintain the corrected position of the parts until fixed by the process of healing. FRIDAY, JULY 31ST.

tightening the strips the lower

structures before

it,

was

Dr. STCLAIR THOMSON

The Methods

opened a discussion on of Dealing with Suppuration in the Maxillary Sinus,

with a paper of which the following is an abstract. The methods available are: (1) spontaneous resolution, aided by general hygiene, the administration of drugs, topical applications, and the extraction of teeth ; (2) nasal lavage (a) through the ostium maxillare, or (b) through the antro-nasal wall ; (3) buccal lavage (a) through the canine fossa, or (b) through a tooth socket ; and (4) operations through the antral walls (a) by an opening through the canine fossa only (Desault’s or Kiister’s operation), (b) by an opening through the canine fossa and a second opening through the antro-nasal wall (Caldwell-Luc operation), (c) the Caldwell-Luc operation, as modified by Denker and by Boenninghaus, and (d) by an opening through the antronasal wall only (proposed by Mikulicz and Krause, and The further developed by Claoue, Rethi, and others). selection of the most suitable method will depend on whether the suppuration is (1) acute and recent ; (2) uncomplicated and chronic; or (3) complicated with suppuration in other cavities. 1. An acute sinusitis may Or last several weeks and resolve without operation. it may become subacute and take six months before without surgical interference. 2. As regards an uncomplicated, chronic, maxillary sinusitis, it will have to be considered whether the classification of Lermoyez into (a) chronic empyema, and (b) chronic sinusitis, is always available and how it influences treatment. Mahu’s method of gauging the capacity of the affected sinus and thus forming a conclusion as to the condition of its mucosa might also be debated. 3. When complicated with suppuration in other cavities, the first point to be decided, if possible, is whether the maxillary sinus is simply a receptacle for pus secreted elsewhere. The next point is the order in which the sinuses should be operated on when they cannot all be treated at one sitting. Conclusions : 1. In cases which come under observation while in the acute or subacute stage, spontaneous resolution may be expected. If cure is delayed puncture and lavage through the antro-nasal wall are indicated. If a suitable tooth socket is available, lavage through the alveolar border might be employed instead. All suspected teeth should be removed. 2. In chronic, uncomplicated maxillary sinusitis the best hope of complete cure is effected by the Caldwell-Luc operation. The intra-nasal route requires full consideration and discussion is invited on its indications, methods, and results. Permanent lavage through the alveolus is reserved for patients where more radical measures are objected to and when age or health does not permit them. The drawbacks of this method must not be forgotten. 3. In complicated cases a complete diagnosis should be formed before starting surgical measures. Alveolar drainage, when available, should first be instituted, both to facilitate diagnosis and to diminish the septic intensity of the retained contents. The ethmoid next demands treatment and the sphenoidal orifice should be enlarged. A frontal sinus operation should take precedence of the maxillary. If the latter is being drained througha tooth socket the radical operation can be deferred

disappearing

until

(by progress) it is

determined that the antrum is

really

diseased and not simply a reservoir. If alveolar drainage is not available then an intra-nasal opening should be made at the time of the frontal operation. A sound tooth should

be sacrificed, as the curative effect of alveolar drainage is uncertain. Free drainage being of prime importance plugs should be avoided. Dr. LOGAN TURNER submitted the following proposition for consideration. Could any assistance regarding the best method of procedure be derived from a study of any one or any combination of the following points : (1) the age of the patient ; (2) the duration of the discharge from the sinus ; (3) the presence or absence of nasal polypi ; (4) the etiology of the condition, nasal or dental infection; (5) transillumination of the sinuses ; (6) cytology of the discharge ; and (7) the bacteriology of the discharge. If treatment by lavage were decided upon did the nasal or buccal route give the better result? Dr. Turner then considered in detail the foregoing points. 1. As regards age, the older cases were cured just as well as the younger by lavage. Age made no difference but lavage was preferred in old people. 2. Recent cases he regarded as those under one year’s standing and 84 per cent. of the cases in his series had been cured by lavage. Cases in which the discharge from the sinus had extended over one year he regarded as chronic. 8 per cent. of the latter cases that had come under his care had been cured by lavage. 3. As regards the presence or absence of nasal polypi, out of 180 cases only 18 had polypi; of these 18, 15 were treated by lavage and 10 were cured. In 19 cases with no polypi lavage had failed to effect a cure. The presence of polypi was generally evidence of some other sinus being affected. 4. As regards the etiology of the condition, out of 180 cases the etiology was definite in 117. As regards the question of nasal or dental infection, bad teeth were not to be readily accepted as the cause. Passing to the cytology and the bacteriology of the discharge, the pus was examined cytologically in 25 cases and bacteriologically in 62. In recent and cases staphylococci were found in 72 per cent. streptococci in 21 per cent. In chronic cases lymphocytes and myelocytes were looked for; the latter were not found, probably on account of there being not much bone affection. The more advanced changes in the epithelium lining the antrum occurred in the lower part, the ciliated epithelium might still be present in the upper part, as was found in a case after six years’ duration of the discharge. The presence of streptococci and squamous cells indicated that the radical operation was called for, whilst the presence of staphylococci indicated that lavage might

never

suffice. Mr. HERBERT TILLEY (London) said that lavage in the acute stage relieved the pain and the case got better more quickly. He advocated the removal of the anterior third of the inferior turbinate body in the radical operation. Mr. C. A. PARKER (London) was in favour of the performance of the intra-nasal operation in the first instance. It was free from the slight risk of the Caldwell-Luc operation, and if it did not suffice then the latter could be proceeded with. Mr. R. H. WOODS (Dublin) considered that the inferior turbinate body of the nose was treated with too little respect in operations for the relief of suppuration in the antrum ; it was removed too often. Dr. DAN MACKENZIE (London) was against alveolar puncture and was in favour of the intra-nasal operation and of the use of a larger intra-nasal tube. Dr. WATSON WILLIAMS spoke in favour of the CaldwellLuc operation through the canine fossa as more reliable than the intra-nasal methods. Dr. N. C. HARING (Manchester) remarked that the latent cases were dark to transillumination after the operation. He was against the intra-nasal operation. Mr. STUART-Low spoke of the regeneration of the mucous membrane lining the antrum. Mr. GEORGE JACKSON (Plymouth) referred to the presence of polypi and the importance of treating caries of the ethmoid. If omitted, recurrence was liable to take place. Dr. JOBSON HORNE (London) attributed the divergence of opinions as to lines of treatment to a lack of knowledge of the etiology. He expressed his thanks to Dr. Logan Turner for his paper which had gone in the right direction to supply that knowledge. Dr. Horne referred to some researches which he made into the bacteriology of the disease some ten years previously, the results of which practically coincided with those of Dr. Logan Turner. Incidentally he mentioned that some of the organisms referred to were not uncommonly

738 normal antrum, and one had to discriminate case of purulent rhinitis ought to be regarded as one of pathogenic and a non-pathogenic role. He was sinusitis till the contrary was proved. The folly of paraffin opposed to packing the antrum after the first 24 hours injection before diseased tissues had been treated was obvious. Mentioning the benefits to be got from cleansing, following the radical operation. The PRESIDENT of the section summed up the discussion packing, and the use of the sucker, as also the imand the openers replied. provement often got after the treatment of sinusitis, he Dr. STCLAIR THOMSON agreed that the antrum was dark referred to the following three points. 1. Paraffin injections to transillumination at times after a cure had been effected. gave good results when there was no sinusitis, when. the The wound in the canine fossa made in the radical operation membrane was not too thin to hold the paraffin ; they should required no stitches; the parts falling naturally into apposition be preceded by massage to strengthen and stimulate the memit closed up of itself. brane ; should be done with solid rather than with liquid Dr. LOGAN TURNER was also of the opinion that the paraffin, though he had known both cause thrombosis, and lines of treatment should be put upon a scientific basis, and though solid paraffin often came out as fast as injected. By he was not in favour of opening an antrum for the purposes slowing evaporation and preventing crusting it sometimes of diagnosis. He also had found that the chronic cases con- got rid of the need for douching ; by helping to obliterate tinued to be opaque to transillumination after treatment and the glands it aided nature’s method of cure. He had had when there ceased to be evidence of discharge. fair or good results in only four cases, for he had been experiMr. CHARLES A. PARKER (London) read a paper on menting lately with ionisation. 2. The recesses of the fossae were packed with strips of gauze or cotton soaked Accesory Air Cells in the Septum Nast, an Utau.scc.al Develop- nasal in a 10 per cent. watery solution of argyrol or a 1 to 2 per ment of the Sphenoidal Sinzeses. cent. zinc sulphanilate. One or two thin zinc rods similarly He exhibited some skulls and diagrams demonstrating the covered were placed amidst the packing and connected to the presence of the cells referred to in the paper. pole, the negative being on the neck, the vestibule positive Dr. WALKER DOWNIE read a paper entitled insulated with gutta-percha tissue; 10 to 20 milliamperes were passed for from 10 to 20 minutes, repeated once °‘ On the Permanence of the Improvement in the Shape of the in five or seven days. This after two or three months gave Nose obtained by the Subcutaneous Iojection of Molten based an Two on over Paraffin, good results in two or three not very advanced cases ; experience of

found in between

a

a

’

Hundred Cases." considered: (1) Was the

whether the results would continue to be worth the trouble

questions were paraffin after remained to be seen ; one case had relapsed after a severe being injected into the nose affected in any way by the cold. After the best results by any method such mucous external temperature ? and (2) Was the result obtained from membranes remain very vulnerable and readily take on its introduction permanent ?2 In regard to the first question, purulent inflammation on slight provocation. 3. Dionisio Dr. Downie’s experience went to prove that climate exercised claimed good results with light treatment ; the tediousness of the method caused Dr. Adam to try the x rays in two no effect whatever on the paraffin lying in the subcutaneous tissues, nor did exposure to a high temperature, such as was cases ; this failed, as it could hardly help failing, for want necessary in the pursuit of certain occupations, affect it in of a proper tube which was now being made. The proceedings closed with a cordial vote of thanks to the any way. In regard to the second question, he held that if President of the section. of from to 1100 F. were 1080 paraffin having a melting-point used, if it were injected in the molten state, and if the PHYSIOLOGY. necessary precautions were taken to prevent it spreading the did not the WEDNESDAY, JULY 29TH. beyond depressed area, paraffin subsequently Two

____

wanderand it did not become absorbed, but that it remained permanently in the position which it occupied when it became solidified in the tissue. Dr. JAMES ADAM (Hamilton) read a paper entitled "Remarks on the Pathology and Treatment of Atrophic "

.Rhinitis. " The paper was based upon the work of the last two years and was limited to 29 cases because on these alone Dr. Adam had had the chance of making a thorough examination. In his introductory remarks he acknowledged his indebtedness for much laborious and careful histological work to Dr. John Anderson, the pathologist to the Victoria Infirmary, Glasgow; for bacteriological observations to Dr. R. M. Buchanan, city bacteriologist, Glasgow ; for preparing vaccines from Abel’s bacillus to Dr. Ian Struthers Stewart of Edinburgh ; and for treating two cases with x rays to Dr. William Allen of Glasgow. Dr. Adam had arrived at the following conclusions : 1. There were two types of atrophic rhinitis, that with and that without sinusitis; they might be the same diseases histologically but clinically and for treatment they were not. In treatment until the rhinologist had found sinusitis he ought to be always ready to revise his diagnosis. and where the pharyngeal condition predominated to sphenoid disease. 2. Atrophic rhinitis was the end stage oj a purulent hyperplastic rhinitis, involving first the membrane, then in more than half the cases the sinuses ; they by :a vicious circle reacted on the membrane. 3. This puruleni rhinitis resulted from microbic action and was most likely t( occur in persons who were more than usually liable t( mucous inflammation or who had structural peculiarities o: their sinuses. Crusting and foetor were favoured by widtl of nostril and by the presence of Abel’s bacillus, the toxin: from which might also accelerate atrophy, but foetor was no a necessary accompaniment, and therefore" ozæna," the name of the symptom, ought to be abandoned as th name of a disease and Gottstein’s definition shortene! The treatment of the con to rhinitis atrophicans. dition was its treatment in the hyperplastic stage. Al purulent rhinitis in children, especially a sequela o eruptic fevers, ought to be persistently dealt with. Ever

suspect

, .

This section met under the presidency of Professor E. H. STARLING (London). Dr. J. B. LEATHES (London) opened a discussion on The Physiology of Purin Metabolism. He reviewed some of the different opinions held upon this subject up to the present time and proceeded to state the conclusions to which his own experiments had led him. He did not consider it possible to lay down any fixed rule regarding the purin metabolism of any individual in identical conditions. He had found with regard to the secretion of endogenous uric acid that it was markedly increased by fever and exposure to cold and after severe exertions. The increased output coincided and terminated with the febrile rise of temperature, coincided with and outlasted by many hours the exposure to cold, followed the exertions and lasted for many hours after them. It was suggested that in all these three conditions the uric acid had its origin in metabolic processes occurring principally in the voluntary muscles and not immediately related to voluntary contractions and work. The daily tide in uric acid excretion, high output in the morning, the maximum being attained about 10 A.M., and low output at night, was not due to retention of uric acid formed during the night ; nor was it due to the fact that the digestive organs were inactive during the night, if that were a fact, with the last meal taken at 9 or 10 P.M., as in most of their experiments. It was rather due to the quickened activity of all functions, especially those of the voluntary muscles, which resulted from the rest of sleep. Generally speaking, he considered that the more lively the performance of the functions of the body as a whole, the greater the amount of uric acid produced would tend to be. The endogenous uric acid tide was independent of food. He did not believe in the retention of uric acid in the system, for the kidneys always got rid of it. The exogenous secretion of uric acid was, on the other hand, affected by foods, but a given food might increase its elimination without in itself containing any purin bodies. Dr. D. CHALMERS WATSON (Edinburgh) dealt with the clinical aspect of the subject. He referred to the results of his, earlier observations on the excretion of uric acid in gout,