observers have seen a similar association, but the exact relationship of these two affections to each other is doubtful (see page 270). 2. The pathological evidence is even more conclusive. Thus Harke in thirty post-mortem examinations of children dying of diphtheria, whoopingcough, scarlet fever, measles and chickenpox, in every case found suppuration in one or more of the nasal accessory cavities, most frequently in the maxillary antrum. In thirty-seven cases of typhoid fever, pneumonia, influenza, erysipelas, and meningitis in adults, he found suppuration in some of the sinuses in thirty-one. Weichselbaum found pus in the accessory cavities-most often in the frontal sinus and maxillary antrum-in all of sixteen cases of influenza. Similar evidence is provided by the reports of others, among whom may be mentioned Lichtwitz, Frankel and Siebenmann. More recently Kirkland of Sydney has reported the results of an investigation into the condition of the sinuses in one hundred consecutive post-mortem examinations. In twenty-two cases of pneumonia, many of which were probably complicated by influenza, suppuration was found in one or more sinuses in eleven, that is. in 50 per cent. Of the whole series, sinus suppuration was found in 35 per cent. and other similar statistics can be quoted. Thus Harke found sinus suppuration present in 134 out of 400 post-mortem examinations, that is in 33.5 per cent.; Minder in 14 out of 50 examinations, that is in 28 per cent.; Lapalle in 55 out of 169, that is in 32.5 per cent.; Fränkel in 63 out of 146, that is in over 40 per cent.; and Gradenigo in 26 out of 100. These figures raise a point of some importance which merits brief discussion. The frequency of sinus affections as shown by post-mortem examinations is greatly in excess of that found by clinical experience. Thus Chiari and Lichtwitz found sinus suppuration in 2 per cent. of the patients attending their clinics, which is probably a fairly average proportion. The great difference between these numbers is usually explained by stating that acute sinus suppuration is often overlooked during the progress of another disease, and that chronic suppuration may give rise to no marked symptoms beyond nasal catarrh, or at any rate may remain unrecognised during life. This explanation, although accepted without question by many wellknown rhinologists, e.g. Lichtwitz, appears to me quite insufficient. I should prefer to account for the great difference which exists between pathological and clinical experiences by the following considerations: (a) The observations were all on cases of fatal disease; that is, of severe infection associated with grave constitutional disturbances. It is therefore only to be expected that serious complications would be more frequent than in the non-fatal, or milder, cases of the same affection. (b) The pus or muco-purulent secretion found in the cavities may have been present only shortly before death. The action of the ciliated epithelium lining the accessory sinuses must be taken into account. Ciliary movement is a force of very great importance. A large sinus such as the antrum, the lining membrane of which contains glands, must normally secrete a considerable amount of fluid, and this will be greatly increased in catarrh. The secretion is removed through the small opening at the top of the cavity, and its removal therefore depends entirely upon the ciliary movements. While the cilia are active all secretion is removed, but just before death, perhaps some hours before, the action of the ciliated epithelium becomes enfeebled or possibly ceases, and thus it is to be expected that the cavities would in many cases contain secretion after death, especially if there has been any catarrh. The presence of fluid may mean only a little catarrh which would have entirely passed off if the patient had recovered, or it may mean loss of ciliary action only. It is not proved therefore that a little discharge found in a sinus post-mortem is conclusive evidence of sinus suppuration. Definite pathological changes in the sinus walls are the only true criterion. If this caution were adopted in future, more reliable statistics would be obtained and the frequency of sinus suppurations, as based upon postmortem reports, would probably be greatly reduced. The presence of simple serous or mucoid fluid is without any significance. The above explanation has been accepted by Semon, who states that he had never doubted that the frequency with which pus had been found by reliable observers in these cavities post-mortem was only explicable by the assumption that the matter had found its way in after death, or more probably during the agony. (c) Many acute sinus inflammations recover spontaneously; this is a well-known clinical experience, numerous instances of which are on record. During the height of the primary affection a collection of matter in one of the accessory cavities is very likely to be overlooked, and when the patient becomes convalescent the sinus affection passes off. These considerations indicate that evidence derived from post-mortem examination alone must not be accepted as absolute, although it is very valuable when confirmed by clinical observations. Some of the conditions which, upon this evidence alone, are given as causes of sinus suppuration must be regarded with doubt. Thus, E. Fränkel found suppuration in the accessory cavities in five out of eleven post-mortems on patients dying of peritonitis, in two of which the bacillus coli was found in the pus. Glanders, parotitis and other diseases have been mentioned as possible causes on post-mortem evidence alone. 3. A certain amount of bacteriological evidence has also been produced. Lindenthal showed that the bacillus of influenza was present in the pus of a sinus affection due to influenza. E. Frankel and Howard confirm this result in two other cases. The diphtheria bacillus has been found by Weichselbaum, Fränkel and Dmochowsky, but it is not invariably present in the cases due to diphtheria, as shown by Zuckerkandl. Killian states it is present in fifty per cent. of the cases. The diplococcus of observers have seen a similar association, but the exact relationship of these two affections to each other is doubtful (see page 270). 2. The pathological evidence is even more conclusive. Thus Harke in thirty post-mortem examinations of children dying of diphtheria, whoopingcough, scarlet fever, measles and chickenpox, in every case found suppuration in one or more of the nasal accessory cavities, most frequently in the maxillary antrum. In thirty-seven cases of typhoid fever, pneumonia, influenza, erysipelas, and meningitis in adults, he found suppuration in some of the sinuses in thirty-one. Weichselbaum found pus in the accessory cavities-most often in the frontal sinus and maxillary antrum-in all of sixteen cases of influenza. Similar evidence is provided by the reports of others, among whom may be mentioned Lichtwitz, Fränkel and Siebenmann. More recently Kirkland of Sydney has reported the results of an investigation into the condition of the sinuses in one hundred consecutive post-mortem examinations. In twenty-two cases of pneumonia, many of which were probably complicated by influenza, suppuration was found in one or more sinuses in eleven, that is. in 50 per cent. Of the whole series, sinus suppuration was found in 35 per cent. and other similar statistics can be quoted. Thus Harke found sinus suppuration present in 134 out of 400 post-mortem examinations, that is in 33.5 per cent.; Minder in 14 out of 50 examinations, that is in 28 per cent.; Lapalle in 55 out of 169, that is in 32.5 per cent.; Fränkel in 63 out of 146, that is in over 40 per cent.; and Gradenigo in 26 out of 100. These figures raise a point of some importance which merits brief discussion. The frequency of sinus affections as shown by post-mortem examinations is greatly in excess of that found by clinical experience. Thus Chiari and Lichtwitz found sinus suppuration in 2 per cent. of the patients attending their clinics, which is probably a fairly average proportion. The great difference between these numbers is usually explained by stating that acute sinus suppuration is often overlooked during the progress of another disease, and that chronic suppuration may give rise to no marked symptoms beyond nasal catarrh, or at any rate may remain unrecognised during life. This explanation, although accepted without question by many wellknown rhinologists, e.g. Lichtwitz, appears to me quite insufficient. I should prefer to account for the great difference which exists between pathological and clinical experiences by the following considerations: (a) The observations were all on cases of fatal disease; that is, of severe infection associated with grave constitutional disturbances. It is therefore only to be expected that serious complications would be more frequent than in the non-fatal, or milder, cases of the same affection. (b) The pus or muco-purulent secretion found in the cavities may have been present only shortly before death. The action of the ciliated epithelium lining the accessory sinuses must be taken into account. Cili ment is a force of very great importance. A large sinus such as the antrum, the lining membrane of which contains glands, must normally secrete a considerable amount of fluid, and this will be greatly increased in catarrh. The secretion is removed through the small opening at the top of the cavity, and its removal therefore depends entirely upon the ciliary movements. While the cilia are active all secretion is removed, but just before death, perhaps some hours before, the action of the ciliated epithelium becomes enfeebled or possibly ceases, and thus it is to be expected that the cavities would in many cases contain secretion after death, especially if there has been any catarrh. The presence of fluid may mean only a little catarrh which would have entirely passed off if the patient had recovered, or it may mean loss of ciliary action only. It is not proved therefore that a little discharge found in a sinus post-mortem is conclusive evidence of sinus suppuration. Definite pathological changes in the sinus walls are the only true criterion. If this caution were adopted in future, more reliable statistics would be obtained and the frequency of sinus suppurations, as based upon postmortem reports, would probably be greatly reduced. The presence of simple serous or mucoid fluid is without any significance. explanation has been accepted by Semon, who states that he had never doubted that the frequency with which pus had been found by reliable observers in these cavities post-mortem was only explicable by the assumption that the matter had found its way in after death, or more probably during the agony. The above (c) Many acute sinus inflammations recover spontaneously; this is a well-known clinical experience, numerous instances of which are on record. During the height of the primary affection a collection of matter in one of the accessory cavities is very likely to be overlooked, and when the patient becomes convalescent the sinus affection passes off. These considerations indicate that evidence derived from post-mortem examination alone must not be accepted as absolute, although it is very valuable when confirmed by clinical observations. Some of the conditions which, upon this evidence alone, are given as causes of sinus suppuration must be regarded with doubt. Thus, E. Fränkel found suppuration in the accessory cavities in five out of eleven post-mortems on patients dying of peritonitis, in two of which the bacillus coli was found in the pus. Glanders, parotitis and other diseases have been mentioned as possible causes on post-mortem evidence alone. 3. A certain amount of bacteriological evidence has also been produced. Lindenthal showed that the bacillus of influenza was present in the pus of a sinus affection due to influenza. E. Frankel and Howard confirm this result in two other cases. The diphtheria bacillus has been found by Weichselbaum, Fränkel and Dmochowsky, but it is not invariably present in the cases due to diphtheria, as shown by Zuckerkandl. Killian states it is present in fifty per cent. of the cases. The diplococcus of pneumonia has been found in disease of the accessory sinuses following pneumonia (Fränkel and Weichselbaum). This diplococcus is frequently found in the sinuses even under normal conditions; and it is not unlikely to be one of the common causes of suppuration. Friedlander's pneumonia bacillus has also been found. The most common organisms found in the pus are the streptococcus, the staphylococcus albus and aureus, the diplococcus lanceolatus, the bacillus pyocyaneus and bacillus coli. In twenty-two cases out of forty Hoffmann's pseudo-diphtheria bacillus was found and Weichselbaum's meningococcus is also frequently present. Stacy, of Sydney, examined bacteriologically twelve cases postmortem in eight the staphylococcus pyogenes was found, in four the streptococcus, and in six a diplococcus resembling the pneumococcus. In ten cases examined by Herzfeld and Hermann the staphylococcus was found in seven and the streptococcus in eight. In twenty-one cases examined by Dmochowsky the streptococcus and staphylococcus were found in three each, the pneumococcus in two and bacillus pyocyaneus foetidus in ten. These organisms are frequently associated with each other and with various saprophytic bacteria such as sarcinae, which render the work of differentiation very difficult. Thus bacteriological observations confirm the clinical and pathological evidence already adduced, that catarrh of the accessory cavities may be due to the acute infectious diseases, and suggest that sometimes the sinus affection may be a primary consequence, and due to the specific microorganism, but that more often it is the result of a mixed infection, for pyogenic organisms are also present. There is no definite evidence at present to show that a particular organism or mixture of organisms is associated with a definite sort or degree of inflammation. Cases showing a close relationship between erysipelas and sinus suppuration have been reported by numerous observers, amongst whom may be mentioned Zuckerkandl, Killian, Ziem, Grünwald, Hajek, Schäffer, and Luc. An organism similar to, if not identical with, the streptococcus of erysipelas has been found in the pus from the nose. It is doubtful whether the sinus suppuration is the result of the erysipelas, or vice versa. Thus Hajek reports two cases, and Luc one, in which the cure of an antral suppuration apparently prevented an annual attack of erysipelas; whilst Grünwald thinks that the erysipelas may be primary. I have twice seen erysipelas follow sinus suppuration, once as a result of perforation of an antrum through the canine fossa. In both my cases the erysipelas was undoubtedly the consequence of the sinus suppuration, the pus of which contained a streptococcus. This is the probable sequence of events in most cases, although it is possible that erysipelas affecting the nose may occasionally originate the sinus suppuration. The relationship between pneumonia and sinus suppuration due to the pneumococcus may be explained in a similar way, namely, that a rhinitis accompanied by catarrh of an accessory sinus is the primary affection, |