nasal wall, mucous or pus is naturally retained in the cavity.

There are several methods of diagnosing and treating diseases of this cavity. Tenderness on pressure over the antrum, and pain, infraorbital, and across the nose, and sensitiveness of the bicuspid and first molar teeth, indicate antral disease. Transillumination with a complete shadow above the alveolar margin is a good though not positive evidence.

The removal of the second bicuspid or first molar tooth, and by drilling with a dental burr into the cavity will be a source of positive diagnosis, and also serves as an avenue for the drainage, or by puncturing the lateral nasal wall beneath the anterior end of the inferior turbinate, about one inch from the meatus with a canular trochar and irrigating with normal saline solution, you can confirm your diagnosis, and also relieve the cavity of retained secretions. If pus is found, and several irrigations in this manner do not relieve, an opening should be made with a Myles punch large enough to afford constant drainage. This can be better accomplished by the removal of the anterior one third of inferior turbinate. Where accumulations of polyps exist within, the more radical procedures are required-opening and curetting.

The frontal sinus has the best natural drainage of all the accessory sinuses; but if there are granulations or polyps about the opening of the naso-frontal duct, either at the nasal or sinus end, or if the middle turbinate is engorged or hypertrophic, you have a damming up of the secretions and consequent pain.

The simplest relief to these cases is to remove with the snare, scissors or forceps, the anterior end of the middle turbinate, and if granulations or polyps are present in the hiatus semilunaries, to remove them with curette and forceps, and unless you have an advanced case, the free drain

age thus secured is in a large per cent. of cases all of the operating necessary.

The anterior ethmoidal cells are frequently involved, and are relieved by the same operative procedure. However, if granulations or polyps exist in these cells, they should be broken down and curetted out.

R. F. R., aged forty-nine, March 16, 1908. Right supraorbital, neuralgia one week. Begins at inner angle of eye and bridge of nose; begins early in the morning and growing more severe toward noon-lessens at evening. Refraction-Takes R plus .75; L plus 3. Distance. Fullness in nose-septum very thick-turbinates on right side swollen. He had nearly all upper teeth extracted for neuralgia. Prescribed glasses, and gave adrenalin and alkaline spray. Quinine and aspirin.

March 20. Pain severe in right ant. ethmoidal region. March 22. Transillumination shows fluid in right maxillary antrum. Tenderness over antrum, some discharge from beneath the middle turbinate. Puncture with canular trochar; irrigation, quantity of thick pus. This was repeated through same opening daily for several dayspus diminishing until on the sixth day water came through clear and pain entirely relieved.

Mrs. T., aged thirty-four: Complains of headache and pain in and above eyes. Refraction under hematropine Co. Hm. Ast. Prescribed glasses, headache relieved; but one month later returned complaining of neuralgia in left eye and both supraorbital regions. Examination of nose shows both middle turbinates swollen, extending low down, ant. ends cystic, and very soggy, pressing firmly against septum. Prescribed adrenalin and camphor menthol spray. Advised removal of ant. ends of turbinates if not relieved by local applications.

Miss A. R., aged forty; actress. Had severe cold three weeks ago. Been suffering for ten days with violent

pain in left eye and supraorbital region. Has consulted three physicians—all have given something to relieve pain. Has had several hypo's of morphia, but no relief. Pain in eye caused her to go to an optician who suggested that the pupil had slipped out of place, and advised her to consult an oculist. Fullness of nose, left upper lid and inner angle of eye swollen, lid drooped. Very tender over left ethmoids, inner angle of eye and sup. orbital region. Exam. eye negative.

L. mid. turbinate very much swollen, soggy, very little secretion. Septum swollen. Mucous membrane of nose unusually sensitive. I snipped the mucous membrane of the turbinate with scissors and used alkaline and adrenalin spray, with hot applications to face and free purge. Patient slept with nothing more than aspirin and codein in average doses internally.

This was a clear case of ant. ethmoiditis, and I advised operation after the acute symptoms had subsided. As she left with the company the next day, I can't say what the results were.

DISCUSSION ON DR. LOKEY'S PAPER.

Dr. R. M. Harbin, Rome: I wish, from the standpoint of the general practitioner, to commend some of the points the doctor has made. Many of these papers written by the specialist are of great value to the general practitioner. One practical point that appeals to me is the significance of supraorbital pain. It has been my practice to regard these cases as neuralgia, or, as some people call it, "sun pain," and I have often treated these cases with quinine, sometimes with success, but usually with failure. The general practitioner sees these cases first, and it is very important that he should be able to recognize them. I have in mind a case of a patient who has

had severe headaches for some years. She was referred to an oculist, but nothing found.

I gave a test meal

and found hyperacidity, but the cure of that did not relieve her headaches. I next curetted her and adjusted a pessary, but she is still not relieved. I think my next move must be to have her consult a rhinologist.

Dr. A. W. Stirling, Atlanta: The subject is one of great importance to the general practitioner. I believe that inflammation of the sinuses instead of being a rare disease is one of the most common. I rather fancy that if we investigate thoroughly the nose in cases of acute coryza we will frequently find that one or the other of the sinuses is involved. It is especially common for the maxillary antrum to be inflamed in an ordinary coryza. It is not very difficult for the practitioner to diagnose these cases. Frequently, after a day or two, there is a one-sided discharge, and when that is the case it points to involvement of one of the sinuses, particularly the antrum. These acute cases generally do not need to go to operation. If the small duct from the sinuses into the nose can be kept open the acute condition will get well and we should endeavor to cure these cases before they become chronic. A weak solution of cocaine (the only condition in which I prescribe cocaine) with menthol will frequently abort these cases; even the menthol alone very efficient in the acute cases.

is

GASTRO-ENTEROSTOMY-REPORT OF CASES.

BY EDWARD G. JONES, M.D., ATLANTA.

Case 1. Chronic Gastric Ulcer.-Male, age twenty-six. Patient had suffered from indigestion for seven years. Nearly three years ago he began to experience tenderness in the epigastrium with somewhat frequent attacks of nausea and vomiting. At times he suffered distinct epigastric pain, which pain, however, at that time, could not be said to have any reference to meals. Weight was gradually lost.

For six months prior to operation the above symptoms increased in severity. He constantly waked at night very thirsty, and drank much water which was usually rejected by the stomach. Regurgitation of sour fluid was very common, the patient often waking with his mouth full of this material. About June, 1907, blood was vomited. Slight hematemesis continued for a week. No blood apppeared to be in the stools, though no microscopical examination was made. From this time on constant epigastric tenderness and frequent actual pain were the most prominent and annoying symptoms. About December 20, 1907, slight but distinct hematemesis recurred, and the patient's pain increased to such an extent that he was compelled to abandon his work. Solid food, and even water, increased the pain, and were persistently vomited. The vomitus showed hyperacidity. The stomach was only slightly dilated, the greater curvature reaching the umbilicus.