551THE BRITISH MEDICAL ASSOCIATION.

pointed out the probable mode of its formation and the factthat the condition was normal and usual in some animals.

Vartations in the For7n of the Stoi)iae7t in 3fan.Dr. WATERSTON also exhibited a series of stomachs showing

varying forms but giving no indications of pathological con-ditions. He believed that they were all normal, that theywere fixed phases of the changes in form of the stomach, andthat they showed definite indications of the division of thestomach into storage and digestive sections.

Professor ELLIOT SMITH, Professor FRASER, ProfessorSYMINGTON, and Professor ANDERSON took part in the dis-cussion which followed.

Changes in the SIzit6’1 in Acromegaly.Dr. GEDDES described the changes found in the skull of

an acromegalic patient who had been under observation fora number of years. His investigations led him to the con-clusion that acromegaly was a symptom, not a disease, andthat the processes of acromegaly affected the ontogeneticallyand phylogenetically younger parts of the body.

Professor PATTEN, Dr. WATERSTON, and the PRESIDENT ofthe section took part in the discussion.

Jfeso -ph ot oqrav 7ty.Professor PATTEN described a new method of photo-

graphing embryos by means of a lens of special constructionattached to a camera. He called the method meso-

photography, as it was neither "micro-" nor "macro-,"but reproduced objects at about their natural size. He hadbeen led to adopt it by the distortion and loss of trans-

parency produced in embryo by the old fixing methods. Bythis new method living embryos could be photographed.Professor Patten showed upon the screen some excellent

pictures which he had obtained in this manner.The Post-nasal Deccelopment and Growth of the Accessory

Sinuses of the Nose.Professor SYMINGTON and Dr. P. T. CRYMBLE showed a

series of lantern slides of Dissections of the Air Sinuses con-nected with the Nasal Cavities, by means of which they wereable to demonstrate the various stages of growth of thesinuses and their relationships to adjacent parts.

Development of the Teeth in Man.Professor SYMINGTON exhibited in his own and Dr. J. C.

RANKIN’S names a series of x ray photographs of Teeth inVarious Stages of Development, and he discussed the advan-tages of the process over other methods for certain purposes.-There was no discussion.

A series of interesting exhibits was set out in theanatomical laboratory adjoining the theatre in which thesection held its meeting. It may be said that the I labora-

tory " itself afforded an excellent object lesson to the manyvisitors who had in their student days worked in dissecting-rooms of an older order. The large plate-glass windowspractically forming one wall of the room, with the micro-scope bench beneath them, the parquet floor, metal tables,and well-stocked wall-cases containing models and speci-mens, make a really attractive laboratory in which theSheffield student can perform his dissections. Upon thetables the following exhibits were shown :-By Dr. C.BRADLEY: Models of an Embryo, six millimetres long, ofthe Flying Squirrel. By Professor SYMINGTON: Skiagramsof Developing Teeth, including Skiagrams of Foetuses and ofChildren from Birth to Puberty. By Dr. H. M. JOHNSTON :Specimens illustrating - the Movements of Inversion andEversion of the Foot. By Dr. R. J. GLADSTONE: (1) ASpecimen of .Cervical Ribs, and (2) two cases of Diaphrag-matic Hernias. By Professor PATTEN : (1) Arrest of Develop-ment of the Diaphragm (Human Foetus) ; (2) Absence of the ,eUpper Cornu (Unilateral) of the Thyroid Cartilage; and(3) an Anthropoid Feature in the Hallux of a Human Foetus.Dr. J. S. FRASER (Edinburgh) showed a complete series ofMicroscopical Preparations to demonstrate the developmentof Mucous Polypus of the Nose from its earliest stages. !

DENTAL SURGERY.

WEDNESDAY, JULY 29TH.This section, which was well attended, met under the

presidency of Mr. F. HARRISON (Sheffield).The PRESIDENT, after a few words of welcome and of

acknowledgment,-said that the existence of a section dealing

with dental surgery, although not altogether desired by some,was a matter of general rejoicing to all interested in the

progress of that science and art. He proceeded to speak ofthe investigation of the physical condition of schoolchildren, which he welcomed, for the examination was tobe made by medical men who, together with other diseases,would report upon the condition of the teeth, and muchgood would arise by bringing home to medical men, educa-tion committees, and the public the horrible condition of theteeth of the rising generation. Dental disease was the most

widespread of all disease, not only here but in other countries,and for this if for no other reason demanded investigation.Bad teeth operated on nutrition by impaired mastication,promotion of septic absorption, and actual infection by manymicro-organisms. Fortunately, medical men now recognisedthe wide influence of dental disease. It would be scarcelymaking an untrue statement to say that the etiology of thecommonest of all diseases, dental caries, was practicallyunknown, and it was a vast field open for investigation, butthe investigation must be undertaken not by dental surgeonsand medical practitioners engaged in the routine of every-day work but by skilled investigators with the advantage ofproper conditions for their work. The fact that at the

present time 80 per cent. of children under 12 years of

age were affected by dental disease was an object-lesson forthe medical man, the mother, and the teacher.

Mr. HERBERT TILLEY (London) then opened a discussionuponAntral Disease in its Relation to General and Special Sroryery.In the course of his remarks he said : The diseases of the

maxillary antrum appeal both to the general as well as thespecial surgeon, and the latter comprise the rhinologist orsurgeon with special knowledge of nasal diseases and thedental surgeon whose studies have been focussed on patho-logir,al conditions of the teeth. Speaking generally, it maybe said that the general surgeon will be more familiar withthose diseases which cause obvious external swelling or

deformity of the upper jaw or of the adjacent soft parts, andso he will be consulted for large alveolar abscesses, dentalcysts, and malignant disease of the antrum, and necrosis ofthe upper jaw. Since these affections are also frequentlyseen by the rhinologist and dental surgeon we may as welldiscuss them at once.

Alveolar abscess.-When this occurs in the upper jaw atthe root of one of the incisor teeth, the swelling may appearin the floor of the nose, just within or beyond the vestibule,and cause nasal obstruction of a marked degree. When thecanine tooth is affected the tumefaction may appear externallyat the side of the nose below the nasal bone, and may seemat first sight to have little to do with a diseased tooth. Ifsuch abscesses become chronic numerous cholesterin crystalsare often found in their contents.

Dental eysts.-These by their expansion often cause con-siderable external deformity, and may so encroach upon theantral cavity that the sinus is almost obliterated.

Treatment.-The most effectual, speedy, and certain treat-ment is to reflect the mucous membrane from the buccal

aspect of the cyst wall, freely open the cyst, remove all itsthin, bony wall, especially that portion which projects into,and often almost entirely obliterates, the true antral cavity,then remove the inner antral wall together with the anteriorhalf of the inferior turbinal, so that a large permanentopening into the nasal cavity is provided. Finally, thebucco-antral incision is sutured with a couple of horse-hairstitches and immediate union of the wound will take place.Practically there is no after-treatment beyond the 7Lise of awarm alkaline nasal douche for two or three weeks.

, Malignant disease of the antrum. -Sarcoma and epitheliomaare the commonest forms of malignant disease which affectthe antrum.

Symptoms.-Pain of an intense and boring character isoften an early symptom in epithelioma. With increase ofthe growth there may be distension of the anterior antralwall, producing swelling of the cheek, depression of the hardpalate, nasal obstruction, and bleeding from the nose.

Epiphora is a not uncommon symptom and is due to the-- invasion of the tear duct by the growth. Transilluminationreveals marked opacity of the antrum, and exploration of theantrum through the inferior meatus shows no sign of pus butis often followed by the flow of a few drops of blood throughthe cannula. The only efficient treatment is a free excisionof the, upper jaw and the operation should be performed

n4

552 THE BRITISH MEDICAL ASSOCIATION.- .-

directly the diagnosis has been made. Care must be takennot to mistake a large cyst for malignant disease of the

antrum, and the following points will enable a diagnosis tobe made :-

Cyst. Malignant Disease.Pain slight or absent. Severe pain of a neuralgic

character.

Transillumination more or less Quite opaque.clear.

Fluid contents on exploration. No discharge, or only a few dropsof blood.

Necrosis of the upper jaw involving the antrum.-This is

’usually the result of tertiary syphilis. There may be slightswelling or oedema of the cheek, with obliteration of the’folds between the ala nasi and the cheek. The diagnosiswill depend on the above signs, together with a history of- syphilis and the presence of luetic lesions in other parts ofthe body.We may now pass to the acute and chronic inflammatory

!lesions of the antrum, which are of special interest to therhinologist and dental surgeon. Before discussing thecausative factors of antral inflammation let me point out one- or two anatomical features of the antrum which- may be ofsurgical importance. 1. The antral cavities often vary much’in size in the same individual. 2. When there is a tendencyfor the palate to be high and the face is of the narrow type’then the alveolar process will be thick and the antrumrelatively small. 3. The inner antral wall is of interest inconnexion with the more radical operative measures and is’divided into two parts by the line of attachment of theinferior turbinal ; the anterior and lower triangle is bony and- corresponds to the inferior meatus ; the upper and posterioris mainly membranous and forms a portion of the middlemeatus, and in it is situated the natural ostium of the antrum.4. The actual cavity of the antrum is often very irregularand may be more or less divided up by bony septa.5. Finally, certain of the lower anterior ethmoidal cells may.- extend externally into the inner, posterior, and superiorregions of the roof of the antrum.

Etiology of antral suppuration.-It is now a well-established fact that infection of the antrum may arise byway of the nasal cavities or through disease of certainteeth. Acute antral suppuration by the intra-nasal route ismost commonly due to infection by the pathogenic organisms’of certain of the acute specific diseases. Of these influenzahas been the most active, although the worst cases of’bilateral suppuration of all the nasal accessory sinuseswhich I have seen followed enteric fever, and one of themost interesting was met with in a lad of nine years of age,where acute frontal sinus suppuration necessitating external- operation complicated scarlet fever. A second common"cause of antral suppuration is infection from a diseasedtooth, an apical abscess, or suppurative periodontitis.,Chronic suppuration within the antrum is usually the

sequela of an acute attack of inflammation which has failedto undergo resolution. Such failure may be due to the’virulence of the initial inflammation, to defective drainagecaused by pathological intra-nasal conditions, or to the con-tinuance of the initial cause of the inflammation-e.g., anapical dental abscess which continues to supply infectivematerial to the inside of the antrum. And finally, a de-bilitated state of the patient’s general health will be a strongpredisposing factor in the formation and continuance ofchronic suppuration in one or more of the sinuses.

Acute antral suppurration.-When the inflammation is theresult of dental infection the earlier symptoms are usuallylocated around the tooth. The prognosis will be particularlygood -if the offending tooth be removed early and suitable- treatment be instituted. As to treatment, when antral suppura-tion is obviously of dental origin the offending tooth should beremoved and free communication with the antrum made

through the alveolus by means of a suitable perforator. The- sinus should be gently irrigated with a warm sterile, normalsaline solution, boric lotion, or weak Condy’s fluid. Thealveolar opening should be kept open by a suitable plug and irrigation practised twice or thrice daily at first and at in-

creasing intervals as the amount of pus observed in the re- ’

turning fluid becomes less. ’When after an interval of from fiveto seven days no pus is seen in the basin after irrigation the plug may be finally removed over night and by the morning lthe alveolar perforation will be nearly closed. When antral :suppuration is of nasal origin the prognosis is less favourable ,4

and the treatment may be less simple for reasons which willbe discussed immediately. In these circumstances we mustendeavour (1) to treat the primary constitutional disease byrest in bed and such medication as the nature of thegeneral infection may indicate ; (2) to allay the localdiscomfort caused by the complicating acute sinusitis ;(3) but locally our chief efforts must be directed to pro-moting the free and spontaneous discharge of pus from theantrum by way of the natural ostium, and these ends may beattained (a) by directing the patient to lie in bed with thediseased antrum uppermost ; (b) the application of cocaineand adrenalin solutions to the regions around the middlemeatus-this may be done every four or six hours;(c) scarification of these regions is recommended by Lackand my experience confirms the effic’1cy of the method;and (d) in the intervals of such treatment inhalation .ofmentholised steam will have a similar effect in inducingcontraction of the swollen intranasal mucosa. It will thusbe seen that the clinical course, prognosis, and treatment ofacute suppuration of dental origin are more favourable thanwhen the sinus is infected by way of the nose.

Chronic antral suppuration.-I have already said thatchronic antral suppuration is the sequel of an acute dental orintranasal infection which for some reason or reasons hasnot undergone resolution. Whatever be the original cause ofthe trouble the patient will usually complain of one or moreof the following symptoms : (a) an unpleasant odour inthe nose which is often most marked on lowering the head;(b) headache, often over the corresponding eye, and the

aching may have a marked periodicity--e.g., it is peculiarlyapt to occur in the morning and pass off about mid-day, andthis periodicity has often led to its being mistaken for amalarial symptom, especially when the patient had residedin regions where that disease is endemic ; and (c) more orless nasal obstruction. Cough, liability to colds in the head,anæmia, indigestion, anorexia, and general debility are oftencomplained of. With regard to diagnosis, in a suspectedcase of chronic antral suppuration our first duty will be toexamine the teeth on the same side and also the corre.sponding nasal cavity. Transillumination is a very valuable

diagnostic help if used with discretion and if taken in con-junction with the other symptoms exhibited by the case.

Exploration test.-This is a final and certain test whenother means fail, as they frequently do. A fine trocar andcannula are passed through the inner wall of the antrumunderneath the inferior turbinal and some warm normal saltsolution is then injected into the antrum and returns fromthe nose ; the presence of pus in the returning fluid can thusbe determined with absolute certainty. I have frequentlyfound that perforation and irrigation of the antrum have beenimmediately followed by pain in a certain diseased tooth. Asto prognosis, as in the acute inflammation, chronic suppura-tion of dental origin is of better prognosis than when due tointranasal infection. In discussing the treatment of a

chronic antral empyema we must remember that we

are dealing with an abscess of a bony cavity the wallsof which cannot contract, and that if we are to checkthe suppuration and promote the return of the mucousmembrane to a natural condition we must provide for free,unhindered, spontaneous drainage. These ends may besecured by drainage through the alveolus from the caninefossa or by an opening from the antrum into the nose. The

principles which should guide us in the selection of themethod of operation is the main object of my theme to-day,and it is upon the method of treatment that discussion will

probably centre, and differences in opinion based uponexperience will be as numerous as they are valuable.Alveolar drainage.-If the clinical history sèems to show

that the antral suppuration was of dental origin, and exa-mination has proved that the second bicuspid or the first orsecond molar teeth were diseased, then it may reasonably beargued that such a tooth or teeth should be removed, a freecommunication made with the antrum, a plug or tubeinserted, and frequent irrigation practised until the dis-charge lessens or completely ceases. In my own practice, aswell as in those of my colleagues and of dental surgeons, Ihave seen a large number of failures with alveolar drainage.The causes of some of these have been very obvious-e.g. :(1) drainage-tubes which projected half an inch above thelevel of the antral floor and therefore did not drain until theantrum was already half filled with pus ; (2) drainage-tubesof narrow calibre which do not drain at all, (3) tubes which

553THE BRITISH MEDICAL ASSOCIATION.

are too short; and (4) tubes which have a free opening intothe mouth. We may say, then, of alveolar drainage that itwill probably be successful in all acute cases of dental

origin and in a moderate proportion of chronic cases due tothe same etiological factor. A plug is probably more satis-factory than a tube, because unless the calibre of the latteris comparatively large drainage does not take place andthe antral cavity may be contaminated by infection from themouth.Drainage through the canine fossa.-By this method a large

opening is made in the canine fossa, the soft parts and

periosteum having been first reflected from the bone.

Through the opening the mucous membrane may be curettedand the bucco-antral opening is kept open by rubber plugs,wicks of gauze, &c. One only mentions this operation tocondemn it, and anyone who has ever employed it will havevivid recollections of the difficulties involved in keeping theopening patent, of the pain, of the difficulties of irrigation,and, above all, of the failure to cure.Intranasal drainage.-The advantages of treating a chronic

antral suppuration by this route are numerous, and extendedexperience has proved beyond cavil or dispute that thismethod is the best for all cases where the primary infectionhas been by way of the nose, and for those instances ofchronic empyemata of undoubted dental origin which havefailed to get well when drained by the alveolar route, or

where there are reasons for not adopting that method.[Mr. Tilley passed on to consider the Caldwell-Luc and the

"simple route" methods of intranasal drainage, and pro-ceeded :]To sum up, I may state : 1. The alveolar route is espe-

cially suitable for acute empyemata of dental origin ; that itwill cure a certain number of chronic cases due to the samecause, and the likelihood of success is greater the earlier theniethod is adopted. The method is not suited for cases ofintranasal origin. A solid plug will be more suitable than ahollow one. 2. Intranasal drainage by one or other route isa more satisfactory method for dealing with chronic antralabscess. (a) Because free drainage into the nose is estab-lished and this is continuous and permanent, and it involves notrouble to the patient beyond irrigation with some mild anti-septic for a few weeks after the operation. Contaminationfrom the mouth is also prevented and the sacrifice of a usefulthough possibly not a sound tooth will not be called for.(b) From the patient’s point of view there are no painfulafter-dressings, and neuralgic pain, so frequent after alveolarpuncture (so that the patient often dreads the use of thesyringe), is almost unknown with the more radical pro-cedures. (e) Convalescence from the more radical Caldwell-Luc operation is rapid : the patient is rarely detained indoorsbeyond five to seven days. The simple intranasal operationis often done in the out-patient department of hospitals andthe patient goes home a few hours later. With regard totreatment based upon the opsonic index or the use of vaccines,I have had only a small experience and not sufficientlysatisfactory to enable me to regard it as a practical mode oftreatment. So far as I can gather, those who have carriedout the opsonic treatment have been hampered by thevariety of organisms present in the individual patient.From experts who have had much experience in this matterit would be interesting to know if the opsonic or sero-

therapeutic treatment had been curative ; the length of timerequired to effect a cure in a chronic case, say, of 12 months’duration; and whether such treatment might be useful in those patients where improvement but not complete cessa- ;tion of the discharge had resulted from the adoption ofthose surgical measures already indicated. It will thus beobvious to you that apart from acute cases of obviouslydental origin where alveolar drainage may be adopted withevery hope of success I am pleading to-day for the morefrequent adoption of the intranasal drainage, a methodwhich has more advantages than, and none of the drawbacksof, the alveolar method, while its employment is in completeaccord with those general principles of surgery which shouldguide us whenever we endeavour to cure chronic suppurationof a bony-walled cavity.

Mr. ARTHUR S. UNDERWOOD (London) continued the dis-cussion. He had recently made sections of a number of skullsat the Royal College of Surgeons of England for the purposeof examining the antra. The antrum in size and develop.ment stood in definite relation to the development of thecheek teeth: in 160 cases the antrum extended backwards

beyond the third molar forwards to the first bicuspid. Whennormal the floor descended between the molar roots and belowthe floor of the nares. The roots of the teeth were in rela-tion to the wall of the cavity rather than the floor.When the third molar erupted it was contained firstlyin the central cavity itself covered by a dome of bone whichas the tooth was erupted disappeared. As the jaw became-edentulous either bilaterally or unilaterally the floor of theantrum rose. In one case illustrated this rise was three-

quarters of an inch above the antral floor of the oppositeside. Antral septa were found in 19 out of 33 cases-

examined ; 14 were on the left side and five on the right. Thesame figures applied generally to the other series of 160 skulls.In eight cases the left antrum was smaller than the right.In these cases of decreased size or abnormal size one or

more teeth were cut off from the rest of the antrum by septa.passing up from the roots. Sometimes the septa weremultiple. Chronic abscesses were also found in someof the cases examined. In one of the slides shown-the right antium was normal, but the left showed alarge chronic abscess around a tooth. The abscess,although perforating the alveolus on the palatal side,had not perforated the antrum ; the whole tractof the sinus was protected on the antral side bya marked thickening of the bone, and to such an extenthad this thickening progressed that the antral cavity was-greatly reduced in size. Other instances of this over-

development of bone were shown on the screen. Trans..illumination of the skulls showed that in some instances theactual skull was too thick to show and corroborated Mr.Tilley’s remarks. In conclusion, Mr. Underwood thought itwould be possible to map out the extent of the antrum in agiven case by a careful examination of the existing teeth,and stated that at Professor Keith’s suggestion he was

continuing his investigations.Mr. KENNETH W. GOADBY (London) spoke of the bacteria

found in cases of chronic antral suppuration and showed atable which he had compiled from a bacteriological investi-gation of 14 cases, 13 of which had been, or were, under-vaccine treatment. In many cases the infection was mixed.The organisms isolated included staphylococcus aureus,albus, and viscosus, streptococcus brevis, bacillus fusiformis.aerogenes, Friedlander’s bacillus, saccharomyces neoformans,and several distinct bacilli which were not identified. Inone case in which diplococci were found the bacillus tuber-culosis was also demonstrated by inoculation into a guinea-pig. The patient was treated by operation and three months.later he developed tuberculous epididymitis. The organismsnoted in the other cases were all identified by cultural’methods and in five cases the staphylococcus aureus isolatedwas tested in rabbits. In each instance 0 ’ 5 cubic centi-metre of an emulsion of a 24 hours’ growth on agar in fivecubic centimetres of broth produced death when injecttOcllintraperitoneally. The saccharomyces isolated was also’tested and in two instances produced death. On the death?of the animal large masses of growth in the lungs and

kidneys were found simulating sarcoma to the naked eye.The other organism to which he desired to draw specialattention was the bacillus fusiformis aerobius, apparently anaerobic variety of that first noted by Vincent. Thecharacters of the organism were as follows. It stain ec!by the ordinary aniline dyes but not by Gram’s.method. On agar the growth was scanty and developmenttook place best upon serum agar. It was not motile and did,not form spores and glucose. Lactose, maltose, caffeine,salicin, cane sugar, inulin, and dulcite were not fermented byit. Subcutaneous inoculation into guinea-pigs was followedby a local swelling at the point of inoculation which persisted’for a week or more, gradually resolving ; the swelling ’it’increased was found to contain a pus in which the organismmight be found during the first few days. Mr. Goadby showed!’a lantern-slide to illustrate this organism and continued ::

"Two points I desire to particularly emphasise : (a) thatantral suppuration occurs by infection from the alveoluswithout the intervention of carious or abscessed teeth. Inalveolar pyorrhoea masses of granulation tissue seers on

extracted teeth on section show a process of rarefying-osteitis spreading into the bone, often with small masses ofbone buried in the tissue, while the tissue farthest removedfrom the advancing inflammation shows fibrous sclerof-is.-The second point to which I desire to draw attention is themethod of vaccine treatment. In my series of cases three

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are still under treatment and the tuberculous one was nottreated by tuberculin. Of the remaining 10, all were of morethan a year’s duration, one of 15 years, and one of eightyears, and in all a copious discharge of pus was present.The treatment adopted was the determination of the

infecting organism by bacteriological and opsonic means ;secondly, immunisation by means of vaccines starting withan appropriate stock of vaccine ; and finally, whenever

necessary, with a vaccine prepared from the patient’s ownorganisms. Bacteriological examination was further madefrom time to time and the diminution of an absence of the

organisms immunised against noted and the case treatedaccordingly. The results of the treatment have been most

encouraging ; in all cases a great improvement in the patient’sgeiteral health has occurred and the anaemia and toxæmia,which is present in practically all cases of chronic antralsuppuration, disappeared, the headache being alwaysrelieved. In most cases a diminution in the pus has taken

place, in six cases the discharge has stopped, and in one casethe discharge is now intermittent. There is no disguising thefact that in certain cases antral suppuration persists formany years despite operations, constant use of antisepticlotions, &c. The discharge in some instances tends

gradually to diminish, due no doubt to the gradual im-munisation of the patient to the infecting organisms so thatan attempt to accelerate their process by immunisation is adirectly proper procedure, while the inoculations necessaryare by no means frequent. Free drainage is essential, butfree drainage is not necessarily the removal of the wholeanterior wall of the cavity, while in those not infrequentinstances where the patient shrinks from the complete opera-tion and where also the frontal sinus is involved the methodshould certainly be tried.

Dr. URBAN PRITCHARD (London) agreed that curettingshould be done with the greatest caution. From Mr. Under-wood’s observations and promised researches he anticipatedmuch advantage in the possibilities of determining the extentof given antra.

Mr. W. STUART Low (London) most decidedly disagreedwith the alveolar route of operation. He also considered theremoval of the anterior part of the turbinate as unnecessaryand liable to produce other symptoms. Irrigation throughthe alveolus would always tend to wash the septic contents’of the antrum into the other sinuses.

Dr. J. S. WALLACE (London) thought that antral plugsshould always be solid.

Dr. E. DONELAN (Glasgow) preferred the nasal to any otherroute of operation.

Mr. G. WILLIAM HILL (London) was disappointed with theline the discussion had taken ; he did not himself considerthat the dental cause of antral disease was in any degree ascommon as nasal infection. He was familiar with some

degree of hyperostosis of the alveolar wall due to dento-alveolar abscess but only rarely perforation.Mr. F. J. BENNETT (London) said that advancing skill and

technical knowledge required the dentist to work with thenasal surgeon. John Hunter had pointed out that the antralcavity was developed in relation with, and probably deter-mined by, the roots of the teeth. Was the thinning of thebone shown by Mr. Underwood related at all to the ageand perhaps decomposition of the skull ? ? Antral septa werelargely related to the developing teeth and were the site ofthe posterior wall of the antral cavity at the moment of

developing of a given tooth and persisted owing to deficientabsorption.Dr J. DUNDAS GRANT (London) regretted that it had not

been possible to have a joint meeting of the Sections todiscuss the question. He referred to the drainage tubeswhich were often retained so long that they acted as

foreign bodies and said that the removal of such an

apparatus was often followed by the cessation of a long con-tinued suppuration. If clinical distinction could be madebetween the rhinogenic and odontogenic origin, the treat-ment adopted would follow the pathological distinction. Hewas glad that the internasal operation was more in favour ; hewould, however, never perform this operation in childrenbefore the second teeth were erupted.

Dr. W. S. SYME (Glasgow) asked if teeth were often foundto be present as foreign bodies in the antrum at the time ofoperation.

Mr. TILLEY and Mr. UNDERWOOD replied.

ELECTRICAL MEDICINE.

WEDNESDAY, JULY 29TH.The section was opened at 10 A. M. by the PRESIDENT

(Dr. E. REGINALD MORTON, London) who gave an addressfrom the chair

On the Value of Tele-Rczdiography in Diagnosis,in the course of which he said: ’’ The essential principle onwhich this modification of x ray technique is based is that,other things being the same, the further away the source oflight the sharper, clearer, and less distorted is the shadowcast by an opaque object. Heretofore the distance the x raytube could be removed from the plate has been very limited-more often under 20 inches than over-but with the

improvement in apparatus that has taken place during thepast year or two it is now possible to obtain excellent radio.graphs with the tube at a distance of 2 metres (6 feet8 inches) and these with an average exposure of one secondor slightly less. The apparatus has’ to conform to certain

very definite requirements. In the first place, a practi-cally unlimited supply of continuous current is neces-

sary at a pressure of not less than 100 volts ; as

the primary of the coil has to pass a current offrom 80 to 100 amperes a thoroughly efficient switchof the double-pole type must be used. As no ordinaryinterrupter can pass such massive currents a multi-anode

electrolytic break has been found most suitable. This hasthree or four anodes and each one is first separately adjustedto a certain current-say 25 ampères-the other anodes beingcut out for the time. The three or four anodes are thenjoined in parallel when each passes the current to which ithas been adjusted and, having been tuned to each other, soto speak, act in synchronism. The strain on the x ray tubeis a very severe one and every possible means must be takento make the exposure short. This is very materially broughtabout by the use of an intensifying screen, and if filmsinstead of plates are employed two such screens may beused, one on either side of the film." A number of lanternslides were shown by Dr. Morton which had been preparedfrom some of his negatives. In these it was- easy to see thevalue of having the tube at a considerable distance from theplate and incidentally that of making the exposure as

short as possible. In conclusion, Dr. Morton pointedout as an evidence of the rapidity with which changestake place in a new science like radiography thatwhile at the last annual meeting the orthodiagraph wasdescribed most ably by Dr. H. Walsham and Dr. J. F.Halls Dally, and accepted as the last word in accuratex ray delineation of the heart and great vessels, now but12 months later tele-radiography had quite taken its place aspossessing practically equal accuracy, a freedom from thepersonal equation, less danger to the operator, a great savingin time, and the resulting radiograph of greater value andrichness in detail than could be obtained in any ortho-

diagram.Dr. CHARLES LESTER LEONARD (Philadelphia) then read

a paper on’ 2%6 Value of Instantaneo2cs Exposures in the Diagnosis of

Pulmonary Tuberculosisand incidentally opened a discussion on the value of thex rays as an aid to the diagnosis of pulmonary conditionsgenerally. While not claiming too much for the Roentgenmethod he was careful to point out that by means ofinstantaneous radiography it was possible to bring out

clearly enlarged bronchial glands and areas of infiltrationabout the roots of the lungs which were out of the reach ofthe ordinary method of physical examination. A numberof lantern slides were shown to illustrate the various pointsraised in the course of his paper. Dr. Leonard also gave a

description of his apparatus which made such rapid exposurespossible.-A lively discussion followed.

Dr. G. H. ORTON (London) drew attention to the smallsize of the heart and consequent enfeeblement of the circula-tion frequently observed in patients with a phthisicaltendency. It was also more vertically placed. These pointswere much more easily and accurately ascertained by thex rays than by any other method.

Dr. J. F. HALLS DALLY (London) emphasised the import-ance of studying the diaphragmatic movements, and whileagreeing that tele-radiography was the easiest method he wasof the opinion that the orthodiagraph was more accurate and