impossibility of reaching any definite conclusions or results thus far obtained.

The announcement of the sale of Dr. Friedmann's vaccine will naturally cause prompt cessation of the tests being made in public institutions and under Government surveillance. The U. S. Public Health Service cannot, of course, be placed in the position of officially testing a commercial product. It is a matter for regret that the tests undertaken with such confidence and promise by Dr. Friedmann should hold no further interest for him, for there are many who would like to know just what the turtle vaccine will or will not accomplish. In some respects it is inconceivable that a man with his reputation at stake as Dr. Friedmann's has been, could be so absolutely and completely blind to his opportunities. If he had accomplished what he said he could, he only needed to demonstrate it conclusively to win not only one of the greatest names in history but all the wealth that he ever would need. That Dr. Friedmann showed such indifference to the outcome of his tests, yet made such mad haste to consummate the sale of his remedy justifies but one-ugly-conclusion.

With this confronting us, it is too bad. that a reputable firm, one known so well and favorably as the reputed purchaser of the turtle vaccine should have become associated with a project that starts out with such a handicap of suspicion, doubt and professional antagonism. The reported plan to establish "institutes"-whatever these may be-in thirty-six states and restrict use of the vaccine to only such physicians as will be licensed to administer it, will be watched with interest. Some doubt of the success of the plan may reasonably be expected, for no monopoly in medicine has ever succeeded in America up to now. It can hardly be expected, moreover, that the best men in each community will have anything to do with a remedy the use of which entails a special license. In fact we doubt very much, in the event of its ever being shown to possess specific curative or prophylactic properties, if the Government would permit such a monopoly, for it would be contrary to public policy. The more we consider the "grand finale" of the Friedmann dramawe refrain from referring to it as a

comedy-the more we can appreciate Dr. Friedmann's talents. It was certainly a stroke of genius to consummate the sale of his remedy before its efficacy was established, but the real hand of the artist was shown in collecting $125,000 cash on delivery. Our only hope is that those who bought what Dr. Friedmann had to sell will find that it can stand the acid test. But like the canny Scot "we hae our doots, we hae our doots."

The dangers of being fifty years old have been investigated by Dr. Andrews, pathologist to St. Bartholomew's Hospital in London, because he too had noticed the increasing mortality of men over 55 as contrasted with the vast improvement in the death rates of all ages less than 45. According to press reports he does not seem to think it perfectly natural, that if modern sanitation saves us in youth it merely prolongs our lives to swell the rates later. Nevertheless his work has elicited some very sensible remarks about putting on the brakes at 45. brakes at 45. We really should begin to slow down at 40 for the experience of ages proves that the physique is designed for only 35 or 40 years of strenuous use, after which some competitor usually laid us low. Now that civilization preserves us to wear out, we must not wear our prematurely. After 40 we instinctively avoid the physical activities in which we took keen childish delight, but we have not realized that the other strains were harmful. It is now known that nervous and mental labor must be progressively lessened and performed at lower pressure. At forty it may be possible to work hard ten hours a day but at fifty only seven are safe and even then there must be no extraordinary efforts either mental or physical. Exceptional men can work longer hours, but as far as we know it is always at low pressure and with an even temper-never a rush and never to exhaustion. There is no question that we live too fast at all ages but that those over 50 must go slow, eat, drink and smoke less, and get more fun out of what life is left to them. Why not teach elderly men how to play? and tell mature men not to forget their childish games? It will save doctor's bills later.

, 1913

, Vol. VIII

ORIGINAL ARTICLES.

PATHOLOGICAL SIGNIFICANCE OF CHRONIC SUPPURATION OF THE NOSE, THROAT AND EAR; WITH DEMONSTRATION

OF SPECIMENS.1

BY

JOSEPH C. BECK, M. D.,

Chicago, Illinois. Chronic suppurative diseases of the body make up a large percentage of the diseases that medical men are called upon to treat, and the methods of procedure to obtain the best results are usually surgical. Probably the larger number of chronic suppurative diseases one finds in practice are confined within the organs that are treated by the oto-laryngologist. These are also of greater prognostic importance, being located within close range of the most vital structures, as the brain, eyes and ears, and therefore possible of causing grave complications. At the same time, the chronic suppurations from the nose, throat or ear are the most neglected and considered of trivial importance by the laity and many general practitioners. A chronic suppurative sinus (fistula) from a tuberculous bone, or any other type of infection of the general skeleton—an abdominal, rectal, chest, etc., fistula, will receive more prompt attention than a chronic purulent discharge from an ear or nose. Even an acne pustule on the face will be regarded of more importance by the laity, simply because of the appearances. Again, symptoms brought about by these chronic suppurations of the nose, throat and ear are not sufficiently recognized and frequently cases are treated for other systemic affections rather than

1Annual Address before Eastern Medical Society, Dec., 1912.

those of the special organs, and when they are treated it is done in a half-hearted and many times unscientific manner that is, it is left to the patient himself.

Chronic suppurations of the nose, throat and ears make up more than fifty per cent. of the cases of the oto-laryngologist in the larger cities, and are in a measure to be ascribed to the lack of preventative means and early interference in their acute forms. The pathological changes that these structures have undergone make it impossible to hope for resolution, and the best that one can expect are cures by the most radical surgical procedures. Anatomical difficulties are encountered, especially in the nasal accessory sinuses, to obtain cures, even when these radical operations are undertaken, as I will show later.

It is my purpose this evening to demonstrate particularly the pathological changes of the tissues of nose, throat and ear, from patients who have been operated upon by me for the cure of chronic suppuration, to draw from them some conclusions on the treatment, and the final results obtained.

The microorganisms that we find in chronic suppurations of the nose, throat and ear are usually the mixture of the pyogenic microorganisms, as the staphylococci and streptococci, in a very attenuated form, and these are usually not the organisms which in the beginning, that is, in the acute stages, were responsible for the trouble. The purulent discharge from these cavities when examined often shows comparatively few pathogenic microorganisms, but a large flora of the non-pathogenic forms, with a great many pus cells and leucocytes. Recently the micrococcus catarrhalis has become recognized as an important factor when present in the dis

act. I wish to say, however, that a single radiogram is of considerable value; in fact, has some advantages as it is not necessary to make as many exposures, consequently there is less chance for the hair to fall out, and it is also less expensive.

The next important point to consider are the complications that so frequently follow neglected cases of chronic suppurative sinus disease, and I believe that the majority are preventable by an early diagnosis and proper interference. In the first place, the partial or total loss of vision. This complication is by far not infrequent and the damage goes on usually slowly and unnoticed by the patient. The manner of its development is a retrobulbar neuritis in most instances. The bony walls of the sinuses, especially the sphenoid and posterior ethmoid and the orbital wall, are destroyed by necrosis and set up a low grade of inflammation back of the eyeball, this affecting the tissues about the optic nerve and the nerve itself. A local toxemic process or an infection by the lymphatic circulation is also claimed to be able to affect the optic nerve.

Local or general meningitis as well as brain abscess of the frontal lobe, and sinus thrombosis of cavernous sinus are frequently enough met with to sound a note of warning against the permission of a chronic suppuration of the nose to continue by simply treating it as a chronic catarrh. The Systemic toxemia, with all its accompanying symptoms of secondary anemia, is a constant complication of chronic suppuration of the nasal accessory sinuses, and the excellent response of a patient as soon as this pent-up pus is relieved is sufficient proof that this train of symptoms or complications is preventable. I have met with all these complications often enough to

warrant me in saying again what I said in the beginning-that chronic suppuration from the nose is a much-neglected subject in the general practice of medicine, and should receive more earnest attention by the general men than it does.

Now, what should be the management of these cases. Local application of medicaments to the nose, in the form of swabs, douches, etc., suction treatment, general hygiene, climatic changes and systemic medication, including the vaccine therapy, are all palliative and delay what becomes ultimately necessary, namely, an operation. I will not go into detail in describing any of the accepted methods of operating, but will simply mention them in the degrees that they are usually applied until a cure is established. In a large percentage of the cases middle turbinectomy will suffice. After waiting some time, if the suppuration still continues, the ethmoidal labyrinth must be opened and curetted, the various ostii to the sphenoid frontal and antrum enlarged. Such procedure will cure an additional percentage of cases, but there still remain quite a number that will continue to suppurate in spite of all these intranasal operations, and more radical measures, namely, extranasal, must be performed. Since Professor Killian first brought out the radical frontal sinus operation many cases of chronic suppuration from this sinus have been cured, but the antrum still continued to suppurate in spite of the most radical measures, as suggested by Professor Denker, simply because it did not permit of complete obliteration of the cavity. The objection to the Killian operation is the marked deformity that remained in very large frontal sinuses, and consequently the method has been modified considerably by various methods to conserve more of the

anterior wall. These modifications have not been very successful, owing to the fact that the cavity was not obliterated and reinfection occurred. To overcome these objections of being able to obliterate both the frontal sinus and antrum, thus stopping the purulent discharge from these cavities and at the same time not have very much deformity, I have been operating by a definite method which is based on the histo-pathological findings of these cavities, as well as the experiments and experiences of a very large material of aids to obliterate bony, non-collapsible cavities. I shall very briefly describe the operation on the antrum and frontal sinus for the radical cure of the chronic suppuration by the obliteration method.

The frontal sinus is opened through the eyebrow in the usual manner, and enough of the anterior bony wall is removed to obtain a good view of the cavity and be able to remove all of the lining membrane and other pathologic tissues. The bony wall The bony wall surfaces are further scraped by the curette to remove any of the possible superficial osteitis existing, and to promote more rapid granulation formation. The cavity is packed loosely with gauze strips, which are impregnated with subiodide of bismuth. The periosteo-skin incision is closed up to the inner angle, where a short piece of stiff rubber tubing, half an inch in diameter, is fixed by two stitches. This tubing reaches just within the cavity, and through it the gauze that is filling the cavity is to come out. It is also repacked through this tubing after two days, and every day after that for a week or two, depending on the amount of granulations that have formed or the size of the sinus.

The next step is to fill the cavity under moderate pressure with a mixture of bis

muth subnitrate, 20 per cent.; vaseline, 70 per cent., and paraffin (120° F. melting point), 10 per cent., which is known as bismuth paste No. 2. This is done by the aid of a glass syringe that has a blunt end that will fit snugly about the tube and subsequently the opening in the skin. After the second injection of the bismuth paste, usually after about three days, the rubber tubing is removed and the lips of the wound are allowed to collapse, or a stitch may be placed and the wound closed. In the case of the antrum, an incision is made on the under surface of the upper lip, beginning in the median line, and extending opposite to the second molar. Dissecting a mucous membrane flap for better suturing purposes, the incision is carried down to the bone over the anterior surface of the superior maxilla. All the structures are retracted upward to expose a greater portion of this anterior surface and an opening large enough to remove the pathological tissue as well as all the mucous membrane lining is made. The same technic of eradication of the mucous membrane, which is really a pyogenic membrane covered with epithelium, as I will show later, is followed, and in addition the osteum maxillary and the accessory opening, if it be present, are cauterized by the actual cautery to destroy the epithelium. Should there be an opening in the inferior meatus, made previously for drainage and washing, then that too should have the epithelium burned off to assist in its closure. The stiff rubber tubing is fastened in the region of the canine fossa, and is allowed to remain in situation much longer than in the frontal sinus, since it requires much longer for the antrum to become obliterated. Great care must be exercised in the removal of the mucous membrane from the thin nasal wall of the an