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"The association of suppuration in the frontal sinus with ethmoidal and antral disease may well repay discussion," says Greville MacDonald.

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Let us now return to our case. before shown, there were most insufficient grounds for the diagnosis of the frontal sinus empyema, much less to undertake so serious an operation as the external treatment demands. In point of fact I made but a tentative diagnosis and was led to the classical operation merely by the desire to follow the maxim, "When one finds pus, give it free exit and don't stop until you do, and remove the cause. I made the usual incision below the supra-orbital ridge, joining it with a perpendicular incision on that position of the face forming the internal wall of the orbit; turning aside this triangular flap, I raised the periosteum with the elevator and after controlling the hemorrhage, which was inconsiderable, I now followed my fistula into the frontal sinus,

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larging it so as to introduce a sterilized silver Eustachian catheter. Immediately there was a gush of pus. I then enlarged the opening still more, but could find neither granulations nor necrosed bone in the frontal. But turning the probe toward the ethmoid, I got dead bone and with chisel and raw-hide mallet enlarged the whole cavity so as to introduce my little finger. Feeling dead bone towards the ethmoid, I gouged and curetted as much as I considered safe, and after cleaning with sterilized water and packing with iodoform gauze, I closed up the wound, leaving space at the base in the neighborhood of an old fistulous opening, for the exit of pus. The wound did well, primary union resulting in all except that portion of the wound designed for drainage. The fourth day after operation a great deal of edema set in over the root of the nose and over both eyebrows, but subsided in a few days. Granulation tissue formed very exuberantly, so much so that I was forced to curette much of it away. The wound is washed out daily and packed with iodoform gauze.

As there seems still to be much necrosis of the ethmoid, I shall do what

ought to have been done at the time of the operation, and as I supposed, I did do, i. e., open directly into the nose and drain also through the cavity. I have had several other cases of chronic empyema of the frontal sinus, none of which had either ophthalmos nor other disturbances of vision, neither did they suffer much from supra-orbital neuralgia. Since writing the above, I have drained the sinus directly into the nose by forcing a large trochar from the external wound through the anterior ethmoidal cell by way of the infundibulum of the nasal cavity of that side. Through this wound I have introduced a drainage tube through which the wound is daily washed with antiseptic fluids. The object is to keep open this fistulous track so long as there is any pus to be seen or dead bone to be felt.

A sense of fulness and discomfort associated with one-sided discharge of illsmelling, thick muco-purulent matter, or "catarrh" as my patients called it, and came to be treated for, were the main symptoms of these cases. Some of them had also several small polypi, and the others more or less hypertrophy of the middle and inferior turbinates which were first radically treated. The diagnosis was readily established by carrying the same along the infundibulum to the opening of the frontal sinus, which was followed by a free discharge of pus over the anterior end of the middle turbinated bones. Now these cases were all treated by the intranasal method. That is, by removing all impediments to free drainage, carrying hydrogen dioxide (or other antiseptic clearing solutions) into the sinus through the middle meatus. When H, O2 is used, it is followed by a thick frothy pus and finally after no more frothy pus follows the application, a sterilized Eustachian catheter is carried up and by the air-bag the cavity is cleared. This usually suffices, and in a few weeks, sometimes only one week, the empyema is cured.

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ease very frequently come together. 3. That we must not rely implicitly upon the classical signs and symptoms as shown by my meager experience. 4. To ask what relation the occipital neuralgia has to the malady. 5. That the question is not which is the better method, the intranasal or external, but either, according to the case at issue. When practical, every case should be treated through the nose, but when it is found not to furnish a reasonable hope of cure we should not hesitate to resort to external surgery, as the operation

under proper precaution is not so very formidable. When so operated on (externally) one should never leave the case until they establish free discharge into the nose. As Dundas Grant has lately shown, this can be easily accomplished by passing a pewter wire from the wound into the nose and slipping over it thin rubber tubing, which will perfectly drain the cavity. Finally, from what I saw and what I can learn from the results of others, no importance can be attached to the electric trans-illumination.

SPECIFICS.

By Edward Anderson, M. D.,

Rockville, Md.

"Festina lente" should be our motto unless we wish to lose the respect and confidence of our lay brethren. In olden times the physician was more cautious than he is at the present day and specifics had to be tried before they were proclaimed such. On looking over my grandfather's account books, those of the late Dr. James Anderson, of this place, I find that although Jenner declared in 1796 that vaccination rendered mankind proof against smallpox, he did not begin to vaccinate but continued to inoculate up to 1814. This tardiness on his part was no proof that he was not progressive, for he was one of the incorporators of the Medical and Chirurgical Faculty of Maryland and he did not hesitate to puncture the liver, drain an abscess located therein, and thereby save the life of his patient and that too when the symptoms were very obscure.

Some years ago, Chian turpentine was pronounced a specific in the treatment of cancer and put to the test throughout the civilized world has proved a signal failure. Not long after the turpentine experience comes the announcement that sulphuretted hydrogen forced into the bowel would arrest tubercular consumption and that too proved a failure. While attending a meeting of the American Medical Association, some years

since, I heard tuberculin as highly extolled in the treatment of tuberculosis as antitoxine was in the management of diphtheria at the late meeting of that body in Baltimore. Unless antitoxine proves a safe and reliable remedy, which I fear it will not, the regular profession will receive a blow from which it will be hard to recover.

If we do not wish to gain the unenviable reputation of pretenders there should be some concert of action among us in regard to such agents as antitoxine. They should be thoroughly tested before being endorsed by the medical profession. What the fatality from diphtheria is will be hard to determine but my mortality record shows a death rate of about twenty-five per cent. Taking into account those cases that I know to have been diphtheritic and were not treated at all, would bring the mortality down to fifteen per cent. It has not been an uncommon experience with me to be called to a case of laryngeal diphtheria and find that all the other members of the family had had the disease and recovered without any treatment whatever.

Dr. Jacobi has said, and with truth, that there are more cases of diphtheria on the street than in bed. The younger the child the more apt is this disease to assume the laryngeal form. I have

never lost a diphtheria patient except where the larynx was invaded when first seen and never saved but one where such was the case.

Two years ago two boys eight and ten years of age were attacked by diphtheria. They were treated by a competent physician, and both died. I was called in consultation to the last one of these cases and whilst there was asked upstairs to see a family, a mother and six children, down with the same disease. I gave general directions as to their treatment but saw them no more. They every one recovered though no physician was in attendance. Had antitoxine been employed their recovery would no doubt have been attributed to that agent. I think physicians have made a

TRANSIENT CLUBBING OF FINGERS DURING EMPYEMA. Schon (British Medical Journal) reports the following case : A girl, aged 10, presented symptoms of a localized pneumonia in the upper part of the lower lobe of the left lung, which later spread over the whole lung. As the disease did not progress in the orthodox manner and the temperature kept high an empyema was suspected. On the seventeenth day of illness there were physical signs of fluid, and pus was withdrawn by the aspirator. The following day the usual operation was performed, and the same evening the temperature was normal, and remained so throughout the illness. Some time after the operation the deformity of the fingers was noticed. This became very marked; the terminal phalanges were enlarged both from side to side and in the dorso-volar direction; the nails were abnormally convex, but their color natural. The deformity quickly disappeared, and by the time the sinus had closed the patient's fingers were quite normal again. The author regrets his neglect to make a bacteriological examination of the pus evacuated from the pleura, as he thinks this affection must in some way be connected with pyogenic bacteria or their products. It has been noticed in connection with other suppurating processes, as, for instance, by Marfan in a case of pyelonephritis. The author has found only four similar

great mistake in substituting hydrogen peroxide for the persulphate of iron, carbolic acid and glycerine as a local application in the treatment of diphtheria. The former merely removes the pus, whilst the latter in my hands has always arrested the spread of the membrane.

I hope that antitoxine may prove to be all that is claimed for it, for the medical profession has not the influence that it once had either individually or collectively. The Medical and Chirurgical Faculty of Maryland, in by-gone days, had the right to say who should and who should not practice medicine in this State and the physician held a place in the esteem of the people not even second to that of the parson.

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HOUSEHOLDERS AND SANITATION.— A question of equal interest to owners of house property and to their tenants was decided in court last week. The plaintiff, says the Lancet, who, acting upon the assurance of an agent, had taken a furnished residence at Sandgate, attributed a sore throat and other illness afterwards occurring in his family to damp and effluvia due to insanitary conditions. Evidence was adduced for and against this theory, and a verdict was finally given in favor of the defendant. The case, into the merits of which we do not enter, is, as we have said, doubly instructive. It ought to emphasize a necessity always incumbent upon tenants on making a change of residencenamely, that of providing for thorough inspection of all sanitary arrangements in a new abode. Such forethought, unfortunately, is not too common, and this is the more to be regretted since the services of a qualified inspector can be readily obtained and at small cost, while the consequences of an oversight in regard to this matter may be serious in the highest degree. House-owners on their part will find that it is true wisdom and true economy in the end to test their property periodically, with a view to its timely repair.

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SUMMARY OF THE EXAMINATION HELD BY THE BOARD OF MEDICAL
EXAMINERS OF MARYLAND, MAY 2, 3, 4, 1895.

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A general average of 75 being required, it will be seen from the above table that of seventyfive applicants, eight were unsuccessful.

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ANATOMY.

1. Describe the frontal bone.

2. How are the vertebrae divided? Name the peculiar vertebrae of each region.

3. Name the branches of the thoracic and of the abdominal aorta.

4. How are the articulations classified? 5. Where are the kidneys situated? Give their relations.

6. Name the various objects seen on the under surface of the cerebrum.

7. Give the names and location of the four sets of valves found in the heart.

8. Give the position of the heart and its valves with relation to the walls of the chest.

PHYSIOLOGY.

1. Describe the gastric juice and tell what it contains.

2. Give a summary of the digestive changes in the small intestine.

3. What are the supposed functions of the ductless glands?

4. What are the functions of the skin?

5. What nerves inhibit the heart's action? 6. What circumstances influence the heart's action in a healthy adult?

7. Give the several supposed origins of the colored blood corpuscles, and also the origin of the colorless corpuscles?

PRACTICE.

1. What is the supposed cause, and what are the types and treatment of intermittent fever?

2. What are the physical signs, the most frequent complications and the treatment of pleuritis ?

3. What are the symptoms, diagnosis, complications and treatment of acute rheumatism?

4. What are the diagnostic characteristics of the sputa of acute bronchitis, acute phthisis and of typical pneumonia?

5. Differentiate apoplexy, epilepsy and acute alcoholism.

6. What are the causes, symptoms, diagnosis and treatment of ascites?

HYGIENE.

I. What precautions should be observed in the management of a case of contagious disease, with reference to the patient and the public?

2. In the hygiene of the infant what are the most important points to be observed during hot weather?

3. What are the differences, if any, between contagious and infectious diseases? Name one or more of each class.

4. Explain the difference between antiseptics and disinfectants, and name one or more of each class.

5. In what manner can it be determined that water is unsafe for drinking purposes? By what methods can such water be purified?

6. While exposed to cholera what importa nt personal precautions should be observed to lessen the risk of the infection?

PATHOLOGY.

I. Describe the morbid changes in the spleen in typhoid fever.

2. What are the principal pathological changes in acute miliary tuberculosis?

3. What are the varieties of cardiac hypertrophy and upon what causes does it depend? 4. Give the pathology of acute myelitis.

5. What post-mortem changes are found in cholera infantum?

6. Give the pathology of locomotor ataxia.

SURGERY.

1. What is the treatment for fractures of the shaft of the humerus?

2. What is an intracapsular fracture of the femur? How diagnosed? Its surgical treatment ?

3. What is a compound fracture?

4. How may a dislocation of the femur upon the os pubis be reduced?

5. What is meant by a subglenoid dislocation of the humerus and how may it be reduced?

6. How may calculus of the bladder be detected?

7. What is a hemorrhoid ? 8. Give three different modes of amputation.

OBSTETRICS.

1. Name and describe the various positions of a vertex presentation.

2. In the progress of all vertex presentations what are the movements of the head?

3. What causes flexion?

4. Diagnose a shoulder presentation.
5. How would you manage it?
6. Describe a brow presentation.

7. Into what is it generally converted spontaneously?

8. How would you manage a case of placenta previa ?

GYNECOLOGY.

1. Name and describe the various displacements of the uterus.

2. What are the physical signs of cervical endometritis?

3. What are the physical signs of uterine cancer?

4. Wherein is the uterine sound a dangerous instrument?

CHEMISTRY.

I. What are the properties of carbon dioxide?

2. How are carbonates formed? What is the composition of sodium carbonate?

3. Name some of the principal compounds in which sulphur occurs in nature. How is it obtained from its ores?

4. What is meant in general by fermentation? Give a well known example.

5. Write the formulas for (a) Magnesium sulphate. (b) Potassium nitrate. (c) Ammonium chloride.

6. How is glycerine obtained? What are its properties?

7. Give a general account of (a) Starch, (b) Cellulose, (c) Carbolic acid.

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