complished preferably under cocaine-adrenaline application, the former in a ten per cent., the latter in a one to 5000 proportion. If injected, then the cocaine or eucain in a one to two per cent., and the adrenaline in 1-5000 or 1-10000 make very satisfactory proportions, as the hemorrhage following the reaction seems lessened, and the constitutional effects in those predisposed are lighter. The larger doses of earlier days do not seem necessary, except in occasional cases. The reaction following these operations may be severe in some persons, depending on the individual, so you will do well not to set the day for returning to the usual occupation too definitely. This reaction is manifested in fever, headaches, pains in and about the throat and neck, with soreness and stiffness of the muscles, enlarged glands and a general state of misery. The swelling of the tissues surrounding the wound may be excessive for several days, producing complete obstruction, thick grumous discharge, difficult to dislodge. Local cleansing and patience will in a few days produce their own reward, and slowly the parts take on recovered tone and the blessings of the patient are yours. To those who never knew what good breathing was the opening up of this new air space is a revelation, which must be experienced to be appreciated. These conditions are of slow growth, dating back to adenoids' days. We will find them in children especially if good results fail to follow the removal of adenoids. At any rate the nasal space should be carefully examined before such operations, so that you may forestall the disappointment of the parents, and prepare them for the possibility of a second operation. In young children it is not always easy to discover any posterior enlargements either with the speculum or with the sense of touch. It is not unusual to find them in children of ten years upward associated with the tonsils and adenoids, or coming with the complaint of discharge from the nose, obstructed breathing, and with the history of having the tonsils and adenoids removed at a more or less indefinite period in the past.

Whether we desire to treat the conditions or not, every one ought to be able to use the mirror sufficient to determine in a general way, whether we have enlarged turbinates, deviated or thickened septums, or polypoid degenerations. This is not difficult. Many cases, however, of obstructed breathing are not easy to determine, explain or treat successfully. During the day comfortable nasal breathing, but on falling asleep trouble comes on, and we have the snoring sleep, and the dry throat in the morning tells the patient of the mouth breathing. In this class of cases you will discover very little except by inference and that unsatisfactory. It is true there is a narrowing of the nasal tract and perhaps several places which look as if very little increase of the tissues would produce contact, but you do not see the contact. Could you examine these patients during sleep, you would probably find your contact points without difficulty, for then some weakened area in the circulation shows itself in dilatation and stasis. The

only treatment possible is one continued over a long interval, consisting largely of stringents or measures which will contract or tone the walls of the blood vessels and stimulate the venous flow.

Persistent, often localized, muco-purulent or purulent discharges should awaken your suspicion of sinus trouble, which may be confined to a single sinus or may involve several. They should be, as far as possible, carefully differentiated from each other, and from other causes of exudation. These may be stated in general terms as follows: a one-sided or bilateral headache, confined to region of frontal sinus, not apparently involving supraorbital nerve, aggravated on stooping, with tenderness on pressure in frontal orbital angle, and with a discharge of pus coming down between the middle turbinated and outer wall, and which can often be shut off by careful packing, points to frontal sinus involvement. In ethmoiditis we have the pain located over the bridge of the nose, with ill-defined frontal headache, extending along inner wall of the orbit; some photophobia, with a discharge covering a larger surface of the middle or superior meatus. In sphenoidal troubles we have a deep-seated, intense pain from occiput to base of brain, pain behind the eyes and photophobia; dizziness at times, the latter rarely occurring with frontal or ethmoid conditions.

In antral disease we have pain, often swelling, in the upper maxilla, associated more or less frequently with pains in and about the teeth and infraorbital nerve; the discharge is apt to be profuse and accelerated by forced bending forward of the head, with a disagreeable odor coming from one nostril. If the sinus can be washed out the diagnosis is assured. It must be understood that these brief diagnostic points are very general, and that it is not infrequent to see cases where two or more sinuses are involved at the same time or successively, and the conditions by that much complicated in diagnosis and treatment.

These sinuses are often congested or inflamed without going on to suppuration. Especially does this seem to be true of the frontal. The pain is of a severe, boring, hammering, throbbing character, almost unbearable, aggravated on stooping or walking, with little or no catarrhal discharge. Here the warm douche with aconite, belladonna, or rhus, and the high frequency current through the condenser vacuum, bipolar, gives very satisfactory results.

It was, and is still to a degree, the idea that it is easy to cut off tonsils and scrape out adenoids, and in many cases this is true. We are finding, however, that a very respectable minority of cases come back to plague us. We have the history of recurring sore throats, either follicular or suppurative tonsillitis, or a low grade. of subacute pharyngeal catarrhal conditions. Or there may be a return of headcolds, snuffles, obstructed breathing, cough aggravated at night, etc. Adults will come with symptoms and complaints of chronic pharyngeal catarrh, and we find more or less. venous engorgement of the tissues, mucous exudate, soreness and

inclination to frequent swallowing, aggravated at night. In a majority of these cases we find a hypertrophy or thickening of tonsillar tissue, which may show above the pillars. We are more apt, however, to find the tonsils flush with the edges, or even lying within, especially if there is a history of previous operation. There may be only a small surface exposed, and casual observation would scarcely lead to the idea that the tonsils were factors in the cause, yet on lifting up these tissues with a vulsellum we will be surprised at the amount which comes into view. This has been referred to as the "sunken" tonsil. It may extend well up into the supratonsillar fossa and downwards towards the lingual epiglottic space, and very often there will be a cheesy exudate released from the confined chryptic openings, which has been long concealed. In this offensive mass we find many a lurking cause of the persistent irritating sore throats, offensive breaths, and even general malaise. These sunken or basal tonsils we find in the young and adult, following or without previous operation. So we are learning that the mere cutting off of the tonsil is not enough, the tonsillar tissue must be well within the guillotine or snare, and to accomplish this the most successfully the tonsil should be pedunculated rather than basal. The proper way to dispose of these sunken tonsils is by enucleation, in as thorough a manner as we remove cervical glands. Sometimes they can be removed by the finger alone, but usually knife, scissors and snare are required. The adherent edges of the palatal arches are separated with the right angle knife, the tonsil lifted with tenaculum and further dissection carried on with the finger, curved blunt pointed scissors, sharp periosteotome, or similar instrument, until the tissue is free or carried well down, when the snare may be used to complete the operation.

You will also find in some of these cases a deviation of the septum to a greater or less degree, which will also be a factor in the obstructed breathing. Here I believe the dentist to be of more value than the rhinologist, when the patients are young. You will find associated, in the majority of these cases, the decayed teeth, irregular alignment and high arch, all strictly along the work of orthodontia. The profession and the laity are realizing as never before the importance of the teeth in the developmental age, as witnessed by the articles not only in the medical journals but in the lay press. No one who has worked along special lines but will add abundant testimony to this subject. We hope it will not be long before our own Hospital and Out-Door Department will have an abundant equipment for this work, for we think we could guarantee to furnish patients every week.

A source of irritating cough may be found in enlarged lymphatic tissue situated on the latero-posterior walls of the pharynx. On examining the throat you will see these reddened enlarged. masses running up and down the back of the pharynx, oftentimes so irritable that the touch of the probe will produce a paroxysm of

cough. Local treatment with iodine tincture, iodine, tannin, or, if more persistent, two or more transverse cuts with the cautery knife seems the most efficient treatment. We are speaking here of cases we meet in which after careful elimination of cause and effect our attention centers on this condition. Another cause, particularly aggravated after lying down, may depend upon an elongated uvula, it depending on local and constitutional causes, affecting mucous tissues. A moist cough may be indicative of the presence of adhesive, stringy, postnasal discharges, while a dry cough represents some reflex influence, which may be traced to decayed teeth or even impacted cerumen. The cough arising from mouth breathing is easily appreciated from descriptions already given. The enlarged lingual tonsillar tissue is very often the cause of a severe, sometimes strangling, spasmodic cough.

You are often asked, can catarrh be cured? The reply to that is, certainly it can, in many cases, but it takes two winters and a summer. By that we mean that during the first winter, the time the victim usually comes for treatment, you can do little but temporize, while you are contending against the changes incident to the season, or radically removing organically obstructive conditions. During the summer, when the patient is not troubled is the time to treat it for permanent improvement. This can be done along hygienic lines with stringent or stimulating local auxiliary measures. Here also the mild tissue nutrition stimulant of the high frequency current is of benefit. The result of these measures will appear in a better resisting power during the second winter; "colds" when given attention respond quicker, and they occur less frequently or require severe exciting causes to produce them. The patient is still under the observation of the physician, more or less frequently, but at the end of this treatment, he should be in a condition to go it alone for an indefinite, if not continuous, period. It is true, few patients, if any, will go under treatment for so long a period for "only catarrh," nevertheless, catarrh is curable in the broad sense of the word.

We have referred very briefly to internal medication, not because we do not believe firmly in its efficacy, but for fear of exposing our own limitations before this expert body of prescribers, and not to lengthen unduly this paper.

The moral of all this is that obstructive respiration, manifested by mouth breathing, even to a partial degree only, is of prime importance, and it is up to the family attendant to intelligently treat the cause himself, or insist that it shall be treated. And, again, that a purulent discharge from the nose for an indefinite period. may be as serious a matter as a "running ear."

CLINICAL DEPARTMENT.

Conducted by A. H. Ring, M.D.

Case I-Diagnosis: Sacro-iliac strain.

Indicated Treatment: Fixation, or sufficient support of the sacroiliac articulations to avoid all strain or excessive motion.

Treatment: Plaster jacket with patient suspended, which gave great relief until pressure of the jacket caused some atrophy of the soft parts, which allowed it to slip up. A new jacket was applied, this time with the patient on the hammock, and all back and leg symptoms were relieved. A few weeks later a spring steel back brace was made and carefully fitted, when the plaster jacket was discontinued, and the patient has continued to be comfortable, except when under severe strain.

A course of exercises was recommended to strengthen the sacroiliac ligaments and back muscles.

In all severe cases of sacro-iliac strain, fixation apparatus of some kind is indicated for a time. In some, the plaster jacket or a back brace may be used; in others the plaster spica. In less severe cases, a simple elastic or non-elastic girdle or back pad is applied, followed by a course of physical training. In the very mild cases, adhesive strapping can be so applied as to give ample support for the short time required.

Probably nine-tenths of the so-called cases of "sciatica" are traumatic in origin, due to some strain at the sacral or lumbo-sacral articulations, causing irritation of the sacral or lumbar plexus or sciatic nerve. These can usually be relieved by proper support.

Case II: for diagnosis:

(a) (No. 44,867 O. P. D.) Male patient, age 36 years; born in Boston. Family history: parents well, several brothers and a sister died in infancy. Patient was well up to three years ago, except for children's diseases (measles and ptusis). Three years ago had bronchitis. Since then has had a cough and some expectoration, usually in the afternoon. There is pain in the chest on forced expectoration, and some sweating. Cough also in morning on rising, and he has at times noticed blood in sputum.

Temperature

Physical examination: Weight 133 pounds; pulse 90. 98.2. Dullness and subcrepitant rales and slight bronchial respiration at the apex of the left lung. Six months later, after various fluctuations in his condition the report reads: Rales in both apices, broncho-vesicular respiration, dullness in both apices. Weight 138 pounds.

(b) (No. 44,653 O.P.D.) Woman patient, aged 30 years. Born in New York. Family history: father died of rheumatism and mother in childbirth; brother died from a throat operation, and a sister of scarlet fever. Patient had measles and ptusis in childhood. She is married and has three living children. During last pregnancy she took cold and was very weak from it, and has not regained her strength. Is now nursing a seven-weeks' old baby girl. She complains of slight cough, much dyspnoea and some sweating at night. She has little appetite and the bowels are regular.