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bone has not reformed, and the cicatricial tissue shows a depression noticeable upon the cheek. Severing the attachment of muscles mentioned may also have contributed to the objectionable result—a result, as I have said, which will not follow the loss of a tooth, even if it must be sacrificed in the operation.

Discussion. Dr. M. L. Rhein, New York: I believe it is impossible to handle this subject as suggested by the essayist, and the pathological conditions present in the maxillary sinus are so different in their etiological factors and in the shapes that present themselves to us that it is impossible to outline a uniform course of treatment. The varying conditions must govern the method. The case which Dr. Patterson has cited is an argument against the form of treatment which he suggests. The fact that the surgeon who operated on the external plate of the antrum failed to find the quill that was lodged therein, and was unable to remove the pathological conditions present, is no argument against the fact that the operation was the proper one at that time, but merely shows that a poor operation was performed by an incompetent operator. I cannot see how Dr. Patterson could have removed the quill, and pursued the course of treatment by means of which he cured the case, unless that portion of the external plate had been previously removed and he were able to utilize the space in removing these pathological conditions. I do not believe a radical operation for a serious condition in the maxillary sinus can be performed through the limited space afforded by the socket of a tooth. The pathological conditions found in the antrum may be divided into two general classes-acute and occurring for the first time, or chronic. In an acute condition, with the infection recent, radical operative intervention is frequently uncalled for and unnecessary, for in a large number of these cases treatment can be made through the nasal canal or irrigation through the socket of a tooth where the opening into the antrum is sufficient, and a cure be effected in that way. However, where there is a tumor, or polypoid growth, or some condition necessitating thorough curetment of the entire antrum, it seems to me impossible to effect a cure unless the whole of the antral cavity is laid bare.

Dr. W. H. G. Logan, Chicago: This paper is in direct opposition to the method set forth by me at the last annual meeting. My belief held at that time has not been changed by observation, so I must dis

agree with the essayist. The first objection made to the buccal opening is that the perfect drainage sought is not obtained. If the buccal opening is made we are in position to explore the antrum and ascertain if the penetration is made into the sinus, a condition that sometimes cannot be determined through an opening from the alveolar process. This is proven, not by my statements, but by the casts and charts shown by Dr. Cryer in years past. The next step is to carry the opening to the lowest point of the antrum, and thorough drainage is then obtained.

To take up the second criticism, that an objectionable cicatrix of soft tissue frequently results over the buccal opening, I would say that the size of the ordinary buccal opening in the soft tissue is not greater than the aperture produced through the mucous membrane and tissue by the removal of a first molar. Furthermore, both openings close by the same process-of granulation, and the tissues are practically the same, mucous, because we have not gone into the fibrous mass of the muscles.

The third objection is that the origin of the masseter muscle and the attachment of the buccinator are sometimes seriously impaired. Eckley says "The masseter muscle. Divisions: Superficial and deep layers. Origin: Superficial layer; lower border malar bone and anterior two-thirds of lower border of zygomatic arch." In other words, we reach the superficial but not the deep fibers. "The buccinator arises from (1) the pterygomaxillary ligament; (2) from the alveolus of the upper jaw; (3) from the alveolus of the lower jaw." We have made our opening above the alveolar process -draw your own conclusions.

In reply to the fourth objection I would say, carry the opening forward or backward and obviate the possibility of exposing the molar roots.

I entirely agree that the majority of cases which present themselves for treatment are of long standing, and that from the constant discharge from this sinus into the nasal fossa result the polypoid growths so often present. The nasal fossa has free exits for its secretions, and if a discharge of pus into it results in the proliferation of that tissue, should we not expect to find the polypoid growths from the mucous tissue lining the antrum growing more profusely, since the pus is more constantly present and the irritation is more

persistent. Clinical observation proves that when the mucous membrane of this sinus has been subjected to the irritation of suppurative and necrotic bacteria for a number of weeks, mucous tissue development in the form of polypi is a natural result. Irrigation of the antrum will reduce the size of these growths but not remove them, and so long as they remain the sinus cannot return to a normal condition. Permanent cure depends largely upon the removal of all carious bone and polypoid growths by curetment, and without it treatment cannot be thoroughly carried on. Furthermore, to know that cavity thoroughly an ocular examination should be made. through the buccal opening. Finally, if sarcoma involves the maxillary bone or antrum, remove the floor and facial portion of the sinus and almost all the maxillary bone, or you will not permanently aid your patient.

Dr. R. H. Hofheinz, Rochester: One statement of Dr. Patterson's largely justifies his opinion. If I am not mistaken he said that most antral trouble was due to the teeth, and I believe that where they have caused the disturbance it is almost invariably necessary to remove the offending members, because the trouble has been of sufficiently long standing that the necrosed roots penetrate the antrum, necessitating extraction. Probably this is the main reason why Dr. Patterson advocates extraction as the best method of curing these troubles. On the other hand, during the last few years we have all observed many cases of irritation of the antrum and other sinuses as the result of the grip. Frequently antral trouble continues after the grip germs have disappeared, owing to their ptomaines remaining. Under such circumstances, where dental trouble has probably had nothing to do with the production of the irritation, would not Dr. Patterson prefer to make his buccal opening rather than to extract a tooth-at least until he has definitely decided that he is unable to effect a cure without extraction?

Dr. Thos. L. Gilmer, Chicago: The character of the operation depends entirely upon the condition present. If we have an empyema of the maxillary sinus that is caused by the septic roots of a tooth, perhaps extraction of the tooth is all that is necessary. If we have a simple engorgement which has come as a sequella to the grip, or has perhaps been transmitted through continuity of tissue from an inflamed lining of the nose to the sinus, an opening large enough to

give drainage may be all that is necessary. But if we have a prolonged empyema, which is dependent upon a general diseased condition of almost the entire lining of the wall of the sinus, extraction of a tooth or a small opening through the socket is not sufficient. If there is trouble present that cannot be cured by ordinary irrigation and slight drainage, we should have an opening sufficiently large to admit the small finger, so as to obtain the benefit of the tactile sense, and large enough that we may introduce a small electric lamp to illuminate the cavity and show its condition as treatment progresses. These aids cannot be employed in conjunction with Dr. Patterson's method, and it is impossible to curet the entire antrum with the smaller opening. It is often necessary to renove the entire lining of the walls of the antrum to effect a cure. To enter the cavity by an opening through the alveolar process, if it is made large enough for curetment, entails cutting an immense amount of the process, and is much more destructive of bone than is necessary or is occasioned if the opening be made in another way. If the patient is somewhat along in life the buccal wall of the antrum is quite thin, but at any age it is easily penetrated from this direction and in the most dependent portion of the sinus.

Another objection I would urge against the opening suggested by the essayist is the liability of food being forced into the cavity in mastication. If the opening be made on the buccal side the cheek folds over it and makes a cover which in a measure prevents the entrance of food. As to the disfigurement, I have performed the radical operation-making a large opening through the buccal wall of the cavity-very often, and have never seen a case where deformity resulted. I am therefore led to suppose that the case reported by Dr. Patterson is exceptional. Possibly the surgeon made the opening from the exterior of the face, and if so we should expect a deformity.

I do not make the opening in such a way as to interfere with the buccinator muscle. I make a horizontal incision at the duplicature of the mucous membrane and the gum, then, using a periosteotome, the soft tissues are dissected from the bone and held up out of the way in such manner that the muscle is not materially injured and certainly is not destroyed. I begin the opening with a large drill very near the alveolar process, cutting upwards, and then enlarge

with cross-cut burs, mesially, distally and upwards, sufficiently to get at the cavity in such manner that I can see into it or feel it, and thus know its condition.

Dr. T. W. Brophy, Chicago: I would not remove a tooth to secure drainage unless it were absolutely necessary to do so, as that tooth may give good service many years after complicated disease of the antrum has been cured. In recent acute cases of abscess of the antrum I have frequently perforated the wall with a very fine spearshaped drill, carrying it through the nasal passage, and in a week the trouble would be ended. However, I would not advocate that generally, any more than I would always recommend removal of a tooth or an external opening through the buccal wall. The conditions present in each case must guide us. The X-ray does not help us in determining whether there are polypoids, carcinoma or anything of that nature in the antrum, so in severe cases we not only obtain the proper drainage but can also make an ocular and tactile examination through the buccal opening. We may have other complications that have not been mentioned, as the frontal sinus, infundibulum, ethmoidal cells, etc., may be involved, and we cannot hope to cure the majority of these cases through a tooth-socket. Some patients have been cured through tooth-sockets, and many others have suffered with antral disease for years, carrying a drainage tube and having the cavity irrigated several times a week, but all to no purpose.

Dr. J. Y. Crawford, Nashville: Take a case where a tooth pulp has been devitalized and an abscess forms and discharges into the antrum. There is merely a discharge of pus and a slight disturbance of the mucous membrane-a simple empyema, without foreign growths or any other complications. The infection will subside the moment the cause is withdrawn. In such a case I feel sure Dr. Patterson would recommend the buccal opening. I am satisfied that many antrums have been opened, explored, cureted and treated, that never got well and never will get well, where a cure might easily have been effected if such radical measures had not been adopted. Where the mucous membrane is very sensitive the daily syringing frequently tears down all that nature has accomplished. The antrum is more often over than under-treated.

Dr. G. V. I. Brown, Milwaukee: In justice to Dr. Logan I

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