encouragement in a large series of cases, although in certain of these cases the Wassermann reaction became negative, and a safe and correct dosage was determined, i. e., 0.3 gramme. Shortly thereafter, Wechselmann employed salvarsan extensively at the Rudolf Virchow Hospital in Berlin, and published the results of treatment in 1400 patients comprising all forms and stages of syphilis, a large number of which had no treatment with mercury.

There are certain untoward effects or reactions that may follow these injections, but the general opinion in the profession seems to be, that seldom as they occur they are even less common with neosalvarsan than with salvarsan. They include flushing of the face, headache, dilatation of the pupils, dyspnea, rapid pulse and, at times, cyanosis and some edema of the face. One hour or longer after injection, such symptoms as high temperature, rigors, vomiting and urticaria have been noted. French writers lay stress on a condition, not common in this country, which is characterized, days after injection, by a symptomatology quite analogous to hemorrhagic encephalitis, and which, as pointed out by Ehrlich, would seem to be the expression of the toxicity of the oxidation products of salvarsan. Other reactions may manifest themselves in suppression of the urine, erythema and jaundice.

With these possible complications in mind, the writer cannot help but arrive at the conclusion that while they may occur in the very best of hands, he, nevertheless, inclines to the belief that many of these ill-effects are due to faults in technic, imperfect asepsis and want of precaution on the part of both operator and patient, for with a large experience both in civil and military practice, the writer has found that skill and understanding on the part of the physician and precaution on the part of the patient are the best possible safeguards against many of these so-called reactions.

Careful Technic

In brief, the operator needs be most mindful of his technic, his asepsis, of the purity and the freshness of the water used in making up the solutions, and of the rate of flow of the injecting fluid. There are a number of other influencing factors, but we emphasize that at times, there are differences, however slight, in different samples of the same preparation; as salvarsan and its modifications, as well as closely allied products, are not stable chemical compounds, and certain toxic properties are alleged to have arisen in the course of manufacture.

Again, many persons have an idiosyncrasy to arsenie and to compounds containing it; and, lastly, the great mass of endotoxins that are liberated with the destruction of many spirochaetes may engender these reactions. The latter theory was first announced by Ehrlich.

As late as 1913 the modus operandi of drugs

of this class was more or less in an experimental stage and the causation of reactions not well understood. In 1920, a committee of German specialists reported that in 225,780 injections of old salvarsan, sodium salvarsan and neosalvarsan, they found only twelve deaths attributable to the drug, or one death in 18,815 cases. They also found that the dose played an important part in the mortality, especially with neosalvarsan; the mortality with this drug was only one in 162,800, with doses not exceeding 0.6 gramme, but if this was exceeded it rose to 1 in 3,000. The only absolute contra-indications to the employment of the drug are in grave visceral disease, hemophilia, and it is asserted in Addison's disease. Albuminuria is not a contra-indication, as was formerly taught.

The Wasserman Test

The effect of salvarsan upon the Wassermann reaction appears to be neither constant nor permanent. Indeed, it seems to be the result of common experience that drugs of this class are less capable of transforming a positive into a negative reaction than when combined with energetic mercurial treatment, such as inunction. It would be impossible in our brief space to attempt to give all the effects of treatment upon the Wassermann reaction, but it can be incontrovertibly stated that the Wassermann test by itself is no criterion of a cure of syphilis, but is only of value when compared with the results of clinical experience.

Hunt points out that a latent syphilis should always be thought of as a possibility, especially when myocardial involvement is associated with nervous lesions due to this cause, with high arterial tension or definite thickening of the arteries. He maintains that a negative Wassermann is no proof that clinical observations are faulty. He advances the thoughts that negative Wassermann reactions are not infrequently evidenced in late syphilis, and that an error in technic may have been committed in making the test. Hunt also insists that, although the cerebrospinal fluid may give a negative reaction, the thought of latent syphilis should never be abandoned until the collodial gold test or the lutein test has been resorted to, and, if necessary, the administration of a provocative test of salvarsan, for such a test will make the blood positive when before it was negative.

Tabetic Cases

Intraspinous therapy in urology and syphilis is still in the stage of experimentation and the results attained offer a wide field for discussion and speculation. Howard, quoting Swift, emphasizes fact that the relatively impervious state of the arachnoid and the pia may at times explain why in some instances the therapeutic agent does not reach the cerebro-spinal fluid by way of the blood stream and *New York Medical Record. March 29, 1919. **Northwest Medicine, February, 1919.

why effect is so often perceived by placing the agent directly into the cerebro-spinal fluid. When syphilization of the meninges occurs, then a perivasculitis occurs, and one is prone to find that irritation of the sensory nerve roots causes pain and parasthesia, and depending upon the nerves involved may simulate prostatitis, cystitis, renal colic, etc. It is, therefore, of paramount importance to determine the presence or absence of tabes, and he frequently finds this to be the cause of the urinary disturbance complained of. In the same paper is a quotation from Coulk, showing that a syphilitic perivasculitis is responsible for urinary disorders when he says that in an analysis of 117 cases "almost 50 per cent. of the patients suffering from diseases of the central nervous system may have as their initial symptom a disturbance of the bladder function, such as frequency, dribbling and the like."

Intraspinous therapy for syphilis of the cerebrospinal system is the replacement of a certain amount of fluid by an equal amount of a suitable menstruum containing the specific drug. The most suitable menstruum is the patient's own blood serum, and Swift employs arsenobenzol and mercury. Both can be added directly or indirectly, or both ways at the same time; indirectly in the case of arsenobenzol, by it being recovered in the serum of a patient previously injected intravenously; and in the case of mercury in the serum, by it being administered by inunction. However, the indirect administration of mercury into the cerebro-spinal fluid has been practically abandoned because of the infinitesimal amounts secured; but the indirect administration of arsenobenzol into the cerebro-spinal fluid is very popular and effective and is known as the Swift-Ellis method. The direct method of administering arsenobenzol, he asserts, with serum as a vehicle, is not so popular as that of mercury in the form of bichloride.

In further observations on intraspinal treatment, Thomas states: "It is not claimed that such therapy, either intravenously or intraspinally, can restore degenerated spinal cords or rescue victims from impending institutional care. And although patients, even tabetics, respond to general or intravenous treatment, the accessory employment of intraspinal treatment accelerates the restoration of the spinal fluid to normal, arrests degeneration and insures greater likelihood of permanent therapeutic results." He also underscores the circumstance that intraspinous treatment should only supplement the intravenous method when actually and positively necessary and never as a routine or as a mere addition for complete treatment. Cases of endarteritis with vascular or circulatory disturbances, and those with exudative gummatous meningitis and certain cases of tabes require the intravenous administration only.

No hope is to be held out to those suffering with tract or cortical degeneration. Mercury and the iodids are indispensable adjuncts and should never be discarded in the treatment of cerebro-spinal syphilis. Cure?

Regarding the criteria as to cure in syphilis, this opens up a lot of bitter controversy. One statement offers no room for argument, and it is this: that injection treatment with the newer drugs cannot be accurately gauged, as compared with the ultimate results of mercurial treatment. LeComte forcibly illustrates this point, in that sufficient time has not elapsed to learn of the true value of salvarsan and its allied products. Under the older method probably fifteen or more years would elapse before paresis or other late manifestation developed, the intervening years having been spent in apparent good health. If, he insists, in 1925 or 1930, it can be shown that the late lesions have developed considerably later than under mercurial medication, giving the patient a longer period of healthy life, or that, if they do occur, they are less severe and more amenable to treatment, we may consider the drug an advance; while if none of these are proved, it must be considered only as an agent for the rapid control of symptoms. He furthermore avers that mercury has not been superseded by the more recent drugs, and should be used in every case, both early and late, and after the more powerful spirochæticide has controlled the acute features of the infection.

Although the writer clings to the belief that in this disease, as in so many other instances in modern medicine, the best possible results are to be attained by retaining all that is good in the old and welcoming the signal advances in the great march of progress, he feels it incumbent to mention the opinion of many Canadian specialists", in this field whose opinions are so well represented by the following telling sentences: "Today the former treatment has given way to intravenous injections of one of the arsenical compounds, supplemented by the former treatment, or at least by hypodermic injections of some mercurial compound. Can the results achieved by this form of treatment be termed successful? Are we any better off than with the old treatment? And which is the remedy, the arsenical compound or the mercury?" And again: "And considering the class of cases that we dealt with at our clinic (Toronto General Hospital), the results are not at all discouraging." This latter statement is of extremely doubtful meaning and value.

Dual Infection

It is impossible in the succinct space allotted to a medical contribution even to hint at many important and practical thoughts that present themselves to the clinician or inquiring physician. One thought,

first molar teeth which often jut into the cavity, being covered only by the mucous membrane lining it. Extraction of these teeth sometimes open up avenues of infection from the mouth. Errors in nasal and dental surgery not infrequently leave an infection of the sinus. Packing the nose after nasal operations, or as a means of controlling hemorrhage, render liable to infection not only the antrum of Highmore, but the other sinuses as well. Some time ago I removed from an infected antrum a dental bur which had been lost in the sinus during the excavation of a first molar tooth at some previous time.

Symptomatology

The symptoms of maxillary sinusitis are, first, pain. This may be periodical or constant, but is usually worse during the night or early morning hours. As has already been noted, the pain may be in the gums, teeth, walls of the antrum, temples, eye, or it may be far removed from the point of infection, as, for instance, the occiput, a not unusual location. The pain is nearly always increased by stooping. This position also causes more or less vertigo. Because of the general distribution of the pain, and because disease of the other sinuses may occasion pain in the same regions, no particular stress can be put upon this feature of the disease as a factor in determining the nature of the condition. The tenderness produced by pressure is of some service to us in diagnosis. There is usually soreness to the touch in the gums over the cheek bone and the lower floor of the orbit. The skin over the sinus is sometimes drawn taut and may be glistening and reddened. Where a pronounced empyema of the antrum exists the thin walls may bulge, causing a crowding upward into the orbit and a consequent protrusion of the eyeball. A bulging of the inner wall of the antrum may occur which, though seldom seen, as surely indicates antral empyema as does a protrusion of the posterior wall of the auditory canal mean pent up pus or cholesteatoma in the mastoid. The teeth are tender and more or less discomfort is experienced during the act of chewing. I operated a case at one time who had a pronounced empyema of the sinus, the principal symptom of which, besides pain in the temporal region, was a soreness of the gums and an inability to masticate.

The temperature is usually elevated, though it seldom runs over 101 or 102. Sometimes there is no rise whatever in the temperature. If the drainage is not entirely cut off there will be seen pus in the middle meatus between the superior and inferior turbinals. This oozes constantly when the patient is erect or lies on the side opposite to the one affected. When lying on the back or on the affected side no discharge will be seen. This accounts for the freeness of the discharge in the mornings, the patient, as a matter of course, maintaining during a part of the

night, positions of the head which hold the normal opening above the level of the pus. While the patient is in the erect position the pus flows over the top of the inferior turbinal. If it is wiped away with cotton on a probe, it quickly reappears. This symptom should always be looked for and when found, providing the pus oozes up from under the middle turbinal, is pathognomonic of empyema of the antrum. Diagnostic Aids

Transillumination is a valuable aid in diagnosis. When performed in an absolutely dark room with a suitable electric bulb placed as high up and as far back in the mouth as possible, an empyema of the sinus may be outlined by the darkened area over the fluid which is in pronounced contrast to the same surface of the opposite side. A high leucocyte count is usually to be had. The X-ray is another valuable aid in diagnosis. A skiagraph made for me in a case of suspected maxillary sinusitis showed a heavy shadow over the right antrum and verified a diagnosis based upon a very incomplete and obscure chain of symptoms. An operation was done and the antrum was found to contain fibrous polypi, which were removed, followed by prompt recovery. I am doubtful if I should have operated this case had it not been for the verification of my diagnosis by the X-ray picture. It is well to remember, however, that the X-ray is not a diagnostic certainty in every case. Treatment

The treatment is mechanical, and may be divided into two classes, palliative and radical. The palliative treatment consists of daily douching the antrum through its normal opening. This, though not often fruitful of good results, may be resorted to before a radical operation is attempted. The old method of removing a first or second molar tooth and irrigating the cavity through the opening left by it is now condemned because of the uncertain results to say nothing of the impropriety of destroying a good tooth. The Intra-Nasal Operation

The intra-nasal operation gives very good results in cases of moderate severity where there is no evidence of bony necrosis. This consists of opening the nasal plate of the antrum and inserting a drain through which the cavity is to be washed daily. The front end of the inferior turbinal is to be removed preparatory to opening the antrum. With the room offered by this procedure it is an easy matter to curette through the antral wall and enlarge the opening by means of the Rongeur forceps. This operation may be accomplished under cocaine anæsthesia in all but the most sensitive patients.

The Modified Caldwell-Luc Operation In severe cases of necrosis a modified Caldwell-Luc operation may be chosen. Under general anesthesia the lip should be retracted and an incision one and one-half inches long should be made over the roots of the molar teeth extending through the periosteum

down to the bone. The periosteum is now elevated and with a mastoid curette or a chisel an opening is made through the antral wall and is enlarged sufficiently to admit the index finger. The cavity is now explored. Polipi, if present, should be removed, and their pedicles thoroughly curetted away. Areas of necrotic tissue should be sought for, and, when found, completely obliterated. An opening is now made through the inner wall into the nose, the inferior

BY A. L. BLESH, M.D., F.A.C.S., Chief of Staff and Surgeon in Chief, Wesley Hospital, 308 Patterson Bldg., Oklahoma City, Okla.

T

The Talk of the Hour

Radium is the talk of the hour. The hope of multitudes of sufferers, pierced by the deadly tentacles of the cancerous octopus, is focused upon this agency. Will these expectations be realized? Will the problem of the day be solved? What are really the possibilities, probabilities and potentialities of this therapeutic star? Dr. Blesh is neither dreamer nor condemner. He has studied radium in the practical domains of the hospital clinic and surgical laboratory and narrates his findings in this excellent paper.EDITORS.

HIS PAPER will not deal with the history of radium, nor with the rapidly growing literature of the subject, but will be an exposition of our work with it, in the hands of the Oklahoma City Clinic, at Wesley Hospital.

Out of our work, here, has come certain positive findings upon which we believe it profitable to dwell. One of the greatest of American humorists once remarked, that "it is better to not know so much, than to know so much that is not true." One of the greatest faults of our profession has been to rush into print with half-baked theories which, when uttered with due pompousness by some "big gun," was followed literally by too many of the "rank and file" to the discredit of the profession. What we say here in this short paper has been learned by the actual use of the radium in concrete cases.

To the surgeon the use of radium may be indicated broadly in two classes of cases: 1. Malignant conditions.

2. Non-malignant conditions.

Of the former, we have used it as the primary treatment only in inoperable cases. Where opera

tion is feasible we have used it consistently as a preliminary and post-operative measure.

In non-malignant conditions it has also been used sometimes as a preliminary treatment, as, for example, in myoma uteri, with prolonged and exhausting metorrhagia. Here it is used to change a bad surgical risk into a good one in a disease essentially surgical.

Malignant Conditions: In the present state of our knowledge of radium, in the treatment of malignant neoplasms, it must be rated as an adjuvant to radical surgery on the one hand, or palliative surgery on the other. Unquestionably the radium rays will penetrate further than the scalpel can go in even the most skillful hands. Also since the fixing infiltration, which always accompanies and is a part of the process of malignancy, adds to the dangers and difficulties of radical surgical removal, irradiation will often loosen to a degree this fixation and render inoperable conditions operable. These anchoring in- · filtrations are not always composed only of malignant cells. Often they are inflammatory and due to secondary infections. In fact, there is little difference in the process of infiltration, whether malignant or inflammatory. Indeed the routes and process even of metastasis are the same in both cases.

We have observed in many cases of seemingly advanced malignancy which were inoperable, because of extensive fixation, become relatively mobile after one or two irradiations.

Advanced Cases of Malignancy

Advanced cases of malignancy with extensive destruction of tissue can rarely be dealt with satisfactorily surgically. Primary surgical mortality is appalling and ultimate results as to cure are practically nil. These have been the hopeless cases which haunt first one and then another doctor's office. It makes little difference as to the location of the neoplasm, whether in breast, uterus or stomach, or on the face. These advanced inoperable cases, together with those which by location are surgically inaccessible, and those the removal of which, by operation,