Other high localities are Leadville, Colorado, with an altitude of 10,185 feet. If it were not for the fact of the presence of gold and silver mines, people would never have thought of establishing a dwelling place at such a great height.

The Hospice of St. Bernard in Switzerland, Europe's highest inhabited point is but eight thousand two hundred feet Quito, the capital of Ecuador, situated near the Volcano Pichincha, is 8934 feet above the sea-level. The Oroya Railroad, in Peru, South America, climbs an altitude of 15,500 feet in order to cross the range of Andes mountains. A tunnel, the highest in the world, five miles long, is now being pierced through the Andes mountains, from Arica, Chili, to La Paz, Bolivia, at a height of 12,000 feet above the sea-level, seven hundred men being employed day and night on the work. The world's highest funicular railway, when completed, will reach the summit of Mont Blanc, 15,782 feet above the level of the sea.

The yearly average pressure, which the atmosphere exerts upon the surface of the sea (Atlantic Ocean under the 45th degree of northern latitude) is equal to the pressure of a column of mercury at the height of 760 millimeters, or 1,033 kilogrammes per cubic centimeter. The atmospheric pressure and density of the air are decreased with the elevation over the surface of the sea. At Potosi, at a height of 4296 meters, the atmospheric pressure is only the 0.60 fold of that which exists at the seashore. Calculations have shown that at an elevation of 20 kilometers the atmospheric pressure measures still 42 millimeters, at 50 kilometers only but 0.3 millimeters, and at 100 kilometers scarcely but 0.02 millimeters. (Translated from the German by the writer.)

The Duke of the Abbruzzi, who has established a record in mountain climbing, recently (Aug. 10, 1909) ascended Mount Godwin-Austen, belonging to the Himalayan range of mountains, to the height of 24,600 feet, but was unable to proceed higher. Mount Godwin-Austen is 28,500

$Lehrbuch der Anorfanischen Chemie von Prof. Dr. H. Erdmann, 1906, p. 237.

feet high, and the Duke of the Abbruzzi was within 3,650 feet of its summit.

Sir Martin Conway, speaking of the high Bolivian plateau, says that it reminds him in many respects of Thibet. At 12,500 feet above sea-level the climate must always be severe. The natives' habit of wrapping up their heads in shawls or ponchos is easily accounted for. Pneumonia is the commonest and most fatal disease in the high parts of Bolivia. Few people live to any great age there. Even in the town of La Paz, which lies in a hollow and is well protected from most winds, old people are rare, and a man seventy years old is pointed to as a phenomenon. He graphically describes the redoubtable sorocche, or mountain sickness, with which he was affected at a hotel in the Plaza where he was staying, at an elevation of 11,945 feet.

He says that it takes time to habituate one's self to living day in and day out far above one's usual altitude. Many persons can never become habituated to the altitude, and are more or less ill during the course of their stay. This is particularly the case with children and persons of advanced age.

It may be said that horses are more sensitive than men to differences in atmospheric pressure, and doubtless a man can climb many thousand feet higher than he can take a horse. I have not myself seen a horse or mule capable of carrying a man over easy ground at a higher altitude than about 16,500 feet, where they almost uniformly break down, though I have been. told that in Sikkim horses carry travellers to an altitude of 18,000 feet. From sealevel upward, as the air becomes rarer and the supply of oxygen less, the strength of man diminishes. Though this diminution. may not be perceived, except as the result of minute and careful experiments, and the man himself may be unconscious of it, it is none the less true."

SOME OBSERVATIONS CONCERN

ING NASAL SINUSITIS.*

BY LEWIS S. SOMERS, M.D.,

Philadelphia, Pa.

As the result of more thorough investigation of nasal diseases, and particularly of those associated with a purulent discharge, it has become quite clear that involvement of the sinuses, and especially of the ethmoid labyrinth, is a frequent cause of nasal catarrh, of headache and of neuralgia. It is with these three factors that I wish to direct attention here, as in many patients with sinusitis, whether of the antrum, ethmoid, frontal or sphenoidal sinuses, these symptoms are frequently present. As the nasal chambers are the common outlet of all the sinuses and the mucous membrane is continued into them, it is apparent that these symptoms must assume a prominent place in inflammatory affections here, and this intimate relationship becomes evident, when it is realized that the nasal mucosa forms the mucoperiostium of the sinus walls, so that the continuity of tissue plays an important part in the symptomatology.

Neuralgia is common to sinusitis, and the presence of facial neuralgia should always direct attention to the sinuses, and especially the frontal sinus and the maxillary antrum, while headache as differentiated from neuralgia is more apt to accompany inflammation of the ethmoid, or sphenoid cells. In both acute and chronic sinusitis the pain is sometimes localized over the sinus region, but one cannot always use this as a diagnostic point, as in a number of patients it is referred to other portions of the head than the area directly involved. Both headache and neuralgia may occur interchangeably, at one time the patient complaining of neuralgic pain, while again it will remain quiescent and headache alone will be present. In all intractable headaches, therefore, even in the absence of nasal symptoms, the sinuses should be carefully studied as possible factors in their production; and while other causes will

*Read at Germantown Branch, Philadelphia County Medical Society, April 1, 1909.

often be found, yet sinusitis will be present with sufficient frequency to justify its inclusion as a cause of such a symptom.

The pain of sinusitis presents nothing in itself that is characteristic or peculiar to the condition, and it is also the most variable symptom, being influenced by many extraneous causes and not infrequently it will be observed that in two cases apparently identical as far as the pathological conditions are concerned one will complain of pain, while the other will be entirely free, or consider it only of the most trivial nature. In acute cases, irrespective of the sinus involved, pain of some degree is practically always present, its severity depending upon the extent of the inflammation, the amount of secretion retained in the sinus and the degree to which drainage is obstructed. Neuralgic pain being especially marked in the sinusitis of acute coryza and grippe, it will be found that the site of such pain bears a somewhat close relation to the particular sinus affected. There are many exceptions to this, however, but as a supplemental aid in correctly interpreting symptoms, the location of the neuralgia is undoubtedly of value, while its relation in regard to cause and effect cannot alone be disclosed without more certain corroborative evidence. Taken as a whole, however, it will be found that in all forms of sinusitis, accompanied with neuralgia, its location over the supraorbital region is the most frequent type, and this is apt to lead one into error if too much credence be placed upon this factor of pain location.

Undoubtedly in a number of cases in which the only symptom attracting the patient's attention is neuralgia, or severe headache, the sinusitis is overlooked and the patient treated for various disorders; or the severe pain itself is considered as the actual disease, instead of being recognized as a symptom. Such errors are most frequent in chronic cases and occur to a less extent in acute sinusitis, as in the latter other more characteristic symptoms are sufficiently prominent to direct attention to the cause of the pain at a comparatively early date. Headache or neuralgia, and espe

cially the latter, should be given considerable credence as a presumptive sign of sinus empyema, but at the same time it is a most deceptive sign and also an irregular one, so that at the best one will find many exceptions to it. For instance, it is well known that sinusitis may be present with severe neuralgia, and yet it does not necessarily follow that one is dependent upon the other, for no relation may exist between the two, the former disappearing under appropriate treatment, yet the neuralgia remaining uninfluenced until it is found that it is the result of entirely different causes, the two conditions being but a mere coincidence.

As far as headache is concerned in contradistinction to neuralgia, one may find in the same patient with sinusitis either a continuous or intermittent headache of a severe type and yet there will be no relation at all between the two as mentioned in relation with neuralgia, the cause of the headache being an abnormal condition of the eyes, or as a result of deviation from the normal at some distant point of the body. In those cases of neuralgia or headache however, which are indubitably dependent upon a nasal origin, it will be found that sinusitis is the cause of such a symptom much more frequently than any other intranasal condition, and in many instances the history of the patient as to the presence of headache or neuralgia which is relieved by the discharge of pus or mucus from the nose, is strong presumptive evidence that at least one of the accessory sinuses is the seat of inflammatory changes. At the same time before any direct relationship between such pains and sinusitis can be definitely proven, other local or general factors must be eiiminated as possible causes of the symptoms of which the patient complains.

When there is a purulent sinusitis with slightly impaired drainage and but little or no retention of secretion, pain is often absent, the patient complaining of catarrh as the result of the subsequent rhinitis, such as impaired nasal respiration from the purulent secretion, causing swelling of the

turbinal tissues. Or again in quite a number of cases, there will be all the symptoms of atrophic rhinitis with ozena, crust formation, etc., and the basal cause will be found as an ethmoiditis of long standing. The majority of patients, however, with sinus disease of a subacute form are apt to consider it as a cold in the head that fails to respond to the usual remedies, and from time to time depending upon the severity of the sinus affection, frequent fresh colds are complained of. Such cases are tremely common and should be carefully examined, as much good can be accomplished; but it will be found that in the majority more than one sinus is involved, and not only must the intranasal conditions be rectified as far as possible, but the general health of the patient must be carefully looked after.

In acute empyema of the maxillary antrum, the location of the pain is in many cases quite characteristic and facial neuralgia is exceedingly frequent, but not to the same extent as that resulting from frontal sinusitis. In both acute and chronic maxillary inflammation we may have as a symptom supraorbital, infraorbital or dental neuralgia, and while in many cases the pain extends into the teeth, the affection is for a long time unrecognized and the patient treated for idiopathic neuralgia. While in chronic maxillary sinusitis the pain is often periodic in its intensity, increasing in degree, then slowly diminishing and entirely. disappearing for a short time, the minimum taking place as a rule late in the day, while it frequently returns in the morning. Where drainage is bad and the inflammation severe, the cheek of the affected side is tender, while a characteristic symptom is a feeling as if the teeth were longer than they should be in the upper jaw of the affected side, and, in addition, they may be tender to the slightest tapping. scure cases transillumination may reveal some opaqueness on this side, while a skiagram will often show pus here and is a satisfactory aid in interpreting the symptoms of this affection.

In ob

In the treatment of acute or subacute sinusitis of the antrum of Highmore I have had good results in the majority of cases by the following procedure: The nasal chambers are sprayed with a warm two per cent. sodium bicarbonate, or normal salt solution, then four per cent. cocain is applied on a cotton pledget to the anterior end of the middle and inferior turbinals, where it remains for five minutes, and this is followed by a 1:2000 adrenal solution for the same length of time. This alone is often productive of great relief, but if such is not the case, a pledget of cotton moistened with ten per cent. cocain is placed under the middle turbinal over the hiatus semilunaris and from one to two centimeters back from its anterior end, so that the mucous membrane in the vicinity of the antral opening will be anæsthetized and well contracted. The normal, or one of the accessory openings, is then sought for with a probe and the outlet freed from obstruction as far as possible, which can be accomplished in many cases. When this has been attained and the opening remains patulous, the symptoms will greatly ameliorate, and the patient should wash the nasal chambers two or three times daily with the solutions previously mentioned, followed with a 1:10,000 adrenalin solution. Should such treatment prove ineffectual, surgical measures must be adopted, which time will not permit to be discussed here.

In acute inflammation of any sinus, the tendency is towards resolution in the majority of cases, and if properly cared for but a small number go to serious pus formation or chronic changes. The main requisite, therefore, is the early recognition of the particular sinus affected, with prompt treatment of this sinus and also of the nasal interior. Along these lines two principles underlie the treatment: the cause of the sinusitis should be removed as promptly as possible; and, secondly, the natural openings must be kept in a patulous condition, As the sinus mucosa, as has been seen, is continuous with that of the nasal chambers, the treatment in the early stages is essen

tially that of the acute coryza, which is practically always present. If there is profuse secretion with much swelling of the nasal mucosa, small doses of atropine are of value, such as 1/500 grain every three hours. As a rule, pain is the main symptom for which the patient applies for relief, and when there is much suffering, analgesics such as phenacetine, etc., should be given until local measures can be effectually adopted, opium as a rule being best avoided, although at times it is essential to tide over some particularly painful exacerbation. The most important essential of treatment, however, is the reduction of the swelling of the mucosa and other soft tissues in the neighborhood of the sinus opening, so that drainage may be early established, and for this purpose adrenal and cocain are the remedies par excellence.

Acute frontal sinusitis is always accompanied with pain, and as a rule it is extremely severe and localized over the frontal region, being quite distinctive of the affection. It may occur late in the morning as a frontal headache, with a feeling of fullness over one or both eyes, and is increased by any movement of the head. Not infrequently there is tenderness to pressure over the sinus and the roof of the orbit at its inner angle, corresponding to the floor of the former. In acute catarrhal sinusitis, the most common type associated with, or following acute coryza, the patient complains of a heavy aching over the sinus, which may become neuralgic in character and is exaggerated by blowing the nose, coughing, sneezing, etc. When the sinus is filled with pus and stenosis of its outlet is practically complete, the pain is throbbing, constant and most severe. Rather characteristic is the disappearance of the neuralgia and tenderness over the exit of the supraorbital nerve, when there is a sudden discharge of mucus or pus from the affected side, in such cases the immediate relief being in marked contrast to the intense pain from which the patient has been suffering.

In addition to the treatment outlined for

acute maxillary sinusitis, which is also applicable here, a 1:5000 adrenalin spray 1:5000 adrenalin spray every two or three hours, directed upwards and forwards around the anterior third of the turbinals, will give great relief, while tepid douches of normal salt solution are also efficient in allaying intranasal inflammation and aiding materially in restoring free drainage. It is not possible to consider chronic frontal sinusitis here, but 1 believe many cases are unrecognized, and as a result a frontal neuralgia may last for years with variable periods of freedom from pain, until proper treatment of the diseased sinus cures an otherwise intractable condition.

ence of necrosed bone in the ethmoid region, as disclosed by probing and the finding of pus in the cellular spaces.

The treatment of acute ethmoiditis may be summed up as the treatment of the basal acute rhinitis plus the reduction of the turbinal swelling, while chronic ethmoiditis almost invariably implies the opening of cells containing pus, or the removal of necrosed bone, although much may be done in a palliative sense by cleansing of the nasal interior with alkaline solutions and the application of alterative, stimulating remedies, as iodine and ichthyol. In no chronic sinus affection is there more apt to be some underlying general dyscrasia as syphilis, for instance, as in ethmoiditis, and in such cases, while local treatment is exceedingly important, constitutional measures are also indicated.

The pain of ethmoiditis, even more so than that of the other sinuses, is rarely characteristic and alone is a symptom of little value, but when present is much more frequently in the form of headache thar. neuralgia. The extent and severity of the headache is mainly dependent on the amonnt of periostial involvement, the degree of retention of secretion and the extent to which the enlarged middle turbinal impinges on adjacent tissues. In acute cases there may be pain in the eyeball, or pain or fullness behind the eyes, in the supraorbital, or in the temporal regions. Again one finds a deep-seated neuralgic pain at the root of the nose, while in those cases where the affection has become chronic, the basal type of headache is a frequent symptom, the patient complaining of a dull headache on a line with the base of the skull, affecting the temporal, mastoid and occipital regions and especially back of the eyes. It is practically always bilateral, and, unlike the neuralgic type, is apt to be continuous. The pain of ethmoiditis is only complained of when some of the cells contain fluid under pressure, while in the open type, when there is no pressure but excessive purulent secretion, it is absent and the patient is frequently treated for postnasal catarrh. And in some instances there is an offensive mucopurulent discharge and the middle turbinal is atrophied, so one has to depend for the recognition of the trouble on the pres

Finally, sphenoidal sinusitis is often difficult to recognize, as the symptoms are not as a rule characteristic, and many cases of chronic empyema here are treated as nasopharyngeal catarrh. As Lermoyez so aptiy states it, sphenoidal sinusitis is not rare, only the diagnosis is rare. Acute inflammation is often overshadowed by the primary affection of which it is a part, as the grippe. acute rhinitis, etc., but when its symptoms are evident, the headache usually consists of a dull, heavy pain above and behind the eyes, and it has seemed to me that at times its location is rather characteristic, as the patient complains of a dull ache in the middle of the head at the site of the sinus; this symptom, however, being more frequently found in chronic empyema than in acute inflammation.

While pain is the most important subjective symptom of pus in this sinus, and especially when it is continuous, deep-seated and severe, yet the diagnosis at times will have to be made by exclusion, well defined cases of sphenoid sinusitis being the exception rather than the rule, as it resembles posterior ethmoiditis. The most prominent symptom of empyema, however, and the most constant, is the presence of pus high up posteriorly near the roof of the nasa chamber in the olfactory fissure, between