boracic acid. In a case in which the teeth may be the exciting cause of antrum inflammation, a combined operation may be indicated, that is, opening through the alveolar process and intranasal wall.

The Jansen operation is primarily the same as the Kuster, with the addition that the middle and superior turbinal, operative treatment of frontal sinuses is only to be resorted to when nasal treatment, removal of obstructions, probing and irrigation have proven a failure. The frontal cells, on account of the position of the ostia at its most dependent position, drain most naturally. In consequence, it takes more than ordinary inflammation to close the natural opening. It may be for this reason that chronic purulent inflammation of the frontal cells is the most difficult to

cure.

In the beginning it is hardly necessary for me to reiterate a proven fact, that nothing but a free exposure of the sinuses should be undertaken if an operation is at all indicated. There are many methods of operative procedure, notable among which are those suggested by Bryan, Hajek, Killian and Ogston-Luc. All these operations advocate, practically, the enlargement of the nasofrontal duct and obliteration of the anterior ethmoid cells so as to secure practical permanent drainage. The disposition of the external wall varies, according to the operation. Some operators advocate complete closure of the external wound, others partial closure, allowing a strip of gauze to pass from the external surface to the nasal cavity. The amount of deformity necessarily depends upon the amount of frontal plates removed and whether or not primary union of the edges of the superficial tissue takes place. With this in view, Czerny, Kuster, Lathrop and others have recommended osteoplastic operations.

The operation designed by Killian and known to the world as the Killian operation, consists in first making an incision under chloroform narcosis and rigid antiseptic precautions, from the temporal extension of the eyebrows to the middle of the base of the nose down to and through the peritoneum. The sinus is perforated with a chisel, care being taken not to wound the

mucous membrane. With a blunt curved probe separating the mucosa from the frontal plate, the vertical extension of the cell is discovered, and from this point a second incision is made in the median line down to and joining the primary incision at the base of the nose. The flap is dissected upward. The frontal wall as outlined is chiseled away, followed by curetment of the entire diseased mucosa. The ethmoid and even the sphenoid cells may now be opened. The floor of the sinus at its nasal portion is chiseled away and nasal cavity entered with sharp bistoury, the nasal mucous membrane is brought forward and stretched to the wound facing the nasal cavity. The flap of skin and tissue is now stretched into place.

The patient is instructed not to blow his nose but to suck all secretion back into the pharynx. The depression produced by the removal of the frontal wall according to Killian, is filled up by granulations and but little scar results. During the removal of the upper wall of the orbit in this operation, there is great danger of injuring the eye.

Opening the Ethmoid Cells.-Under strong illumination from. head mirror and cocain anesthesia, the ethmoid cells can be opened by removal of the middle turbinal. The best way of accomplishing this is by cutting the anterior attachment of the turbinal with a curved Holme's scissors and snaring away with a cold snare. After the anterior portion of the middle turbinal is detached, the removal of the entire middle turbinal is comparatively easy. With a long curet and Miles' cutting forceps the ethmoidal cells are easily cureted and cleansed of any accumulation. The superior turbinal can be easily bitten away, thus expiring in the posterior cells. With the aid of adrenalin this operation is a bloodless one, comparatively speaking.

There is danger of the external and upper walls of the cells having become necrotic. In cureting the cavity, we must avoid passing directly into the orbital or into the brain cavity.

The subsequent treatment is directed to daily irrigation with a warm alkaline antiseptic wash.

The sphenoidal cells are more difficult of entrance and require

a fuller display of dexterity. After the middle turbinal is removed, the ostium sphenoidal is not so difficult to find. With a strong curet or Grünwald punch forceps, the anterior wall may be entirely removed. After the cavity has been completely opened, it may be swabbed with pure carbolic acid.

Irrigation previous to operation usually accomplishes very little. The pain is severe, which is, to say the least, very distasteful to the patient, who usually objects to a repetition.

Recovery after the radical operation, is, as a rule, from three to five weeks.

FOOTWEAR AND ITS INFLUENCE ON FLAT-FOOT.

BY E. D. CLARK, M. D., INDIANAPOLIS, IND.

It is a lamentable fact that the human race, whether civilized or savage, attempt to change or alter the body to accord with their ideas of beauty. As a result, it is well nigh impossible to find a normal foot in an adult. The use of shoes and stockings that to a greater or lesser degree interfere with the full function of the foot is practically universal. I will in this paper endeavor to bring to the attention of the society some of the abuses in footwear that are so common, and show how they may act as a strong contributing cause of flat-foot.

In studying the feet of children and nonshoe wearing people, we are impressed with the fact that the race has not inherited the deformities that are almost always present. The foot of an infant is practically normal. Upon inspection it appears flatter than it should. Dane has shown that this is due to a pad of fat which acts as a brace to the long arch until the foot becomes stronger. To make it easy to follow what I have to say, I will use Sampson's division of the foot into arches.

First, an outer one which is low and only slightly yielding. Second, an inner one which is higher and much more elastic. The latter is the one usually spoken of as the long arch.

Both arches are permanent. The inner one is lowered and raised by movements of the foot when the outer one is very slightly effected by any movement of the foot. In the passive support of the arches, the ligaments bear the greater part of the burden, but during active motion the arches are relieved from much of the strain by the muscles of the leg.

The third is not a permanent one and is known as the transverse arch. When the body weight is thrown forward, it is flattened out, thereby widening the foot, giving the individual surer sup

port. It is lessened by dorsal flexion and increased by plantar flexion.

The function of these arches is to impart ease and elasticity to the movements of the foot and to take away the jar of walking. It has been proven in studving skeletons so articulated that where the normal motion of the mediotarsal joint has been maintained, that in adduction the scaphoid slides under the astragalus and lifts it up thus raising the long or inner arch, and that in abduction it is pushed down.

One can easily prove this by assuming these positions. In the adduction position the greater part of the body weight is thrown on the outer part of the long arch, that part of which is strongest and best adapted to receive it. The position is one of strength and muscular support. On the other hand, if one assumes the abducted position, the greatest weight is thrown on the inner side of the arch, causing the foot to be rolled over inward into a position of weakness and legamentous support. Both positions are physiologic. Such positions must be assumed to enable one to walk comfortably over uneven ground. The position of abduction with promotion is the one assumed when the body weight is thrown on one foot or both in such a manner that equilibrium is maintained without muscular exertion. This position becomes pathologic however when excessive or used in other or all attitudes.

The big toe acts as a support to the long arch, owing to its ability to be adducted and in preventing the rolling inward which occurs in the pronated foot.

The point I wish especially to emphasize is that the abducted position of the foot is the natural means of supporting the long arch, and also that adduction of the big toe is an aid. Anything that will interfere with this natural position of adduction will weaken and lower the arches and is, in my judgment, one of the potent causes of flat-foot. Unfortunately almost all modern footwear tends to the abducted position, thereby throwing the weight of the body on this elastic long arch.

The muscular power of the foot is a strong factor in maintain