all inflammatory disturbances have subsided, to curette the ethmoidal region thoroughly under general anaesthesia. The anterior ethmoidal cells, including the bulla ethmoidalis, must be broken down and the uncinate process removed. In this way the lower end of the infundibulum is thoroughly opened up. It might seem at first sight that this treatment was unnecessarily severe, but it must be borne in mind that the diagnosis still remains in doubt, and that even if frontal sinus suppuration alone be present, the removal of the anterior ethmoidal cells is necessary for its cure. Another interval of three or four weeks must be allowed for the healing of the wound in the upper part of the nose, and for the disappearance of the inflammatory oedema. During this time the nose should be cleansed regularly twice or three times daily by irrigation with alkaline or mild antiseptic solutions.

Results. The operation allows free drainage from the frontal sinus, and may suffice to effect a cure, especially in recent cases. I have had several cases in which acute symptoms have been immediately relieved, and a few in which all discharge has ceased. It even seems probable that a cure of chronic frontal sinus suppuration is occasionally effected. Thus Hajek reports that by this means alone in 25 cases of recent disease, all were relieved, and many cured; in 27 chronic cases, 9 were cured, and all relieved. Although, as above said, these and similar statistics are invalidated by the fact that the diagnosis is uncertain, the treatment is thoroughly justified as in nearly every case of frontal sinus suppuration the fronto-ethmoidal cells will be found involved. Unless urgent symptoms are present, intranasal treatment therefore should always be adopted in the first instance, as it may save an external operation. Should it fail, and should a considerable quantity of pus still continue to come down from the anterior part of the middle meatus, the question of further treatment must be considered.

Intranasal Irrigation. The next step in intranasal treatment consists in washing out the frontal sinus through a cannula passed up the infundibulum. A study of the anatomical relations of the parts showed that there was great difficulty in passing a probe into the normal frontal sinus, that the manoeuvre was only possible in about 25 per cent. of skulls, that there were no means of knowing when it would be possible, and no certainty in any given case, that the probe had entered the sinus, however far it had passed up into the nose (see p. 18). But when the fronto-ethmoidal cells are broken down, and the approach to the infundibular region thoroughly cleared as above described, the passage of a suitably curved instrument is much facilitated, and with care will probably succeed in about 50 per cent. of patients. The want of an absolute criterion that the probe had really entered the frontal sinus, rather than slight differences in the methods practised, probably accounted for the great divergence of opinion amongst the older rhinologists. Lothrop, in an exhaustive article. already quoted, showed that probing was only possible in about one in four normal sinuses, and that it was always a matter of great difficulty and uncertainty. Until the sinus had been opened externally, it was impossible

to be certain that the probe had really entered the cavity. Owing to the anatomical irregularities, no certain rules or guides could be laid down. In disease, however, these conditions are altered, the infundibular passage is frequently dilated as the result of rarefying osteitis and destruction of the ethmoidal cells, and the passage of a probe is frequently easy. Further, the spot from which the pus exudes into the nose forms a certain guide as to the direction in which the probe should be passed. Of late years the X-rays have provided a reliable means of ascertaining the position of the probe. In photographs taken by this means the position and extent of the frontal sinus can be accurately observed, and I have frequently passed a probe into the sinus, and by means of a photograph or of the fluorescent screen, have been able to determine with absolute certainty, that it had entered the frontal sinus (see Fig. 114). Later observations show beyond all doubt, that in disease the probing of the frontal sinus is relatively easy and can be carried out in the large majority of cases, as the older clinical observers had indeed maintained.

Method. An easily bent probe should be first used, and insinuated gently in various directions until it is found to enter the sinus. The most suitable curve to give the probe, the direction in which it passes most easily, and any obstructions met with in its passage, should be noted. A flexible cannula, about the calibre of a Eustachian catheter, should be bent to the same shape as the probe and retained entirely for the patient's Hartmann recommends that the probe be bent at an angle of 135° an inch and a half from its tip, but the most suitable curve is best ascertained by careful experiment on each patient.

use.

The cannula being inserted, the sinus is washed out with a mild antiseptic, such as boracic acid solution. Other antiseptic fluids may be used, and formalin has been strongly recommended; but in the first instance unirritating lotions are the best. If simple boracic fails I prefer hydrogen peroxide used in the way above described (see page 315). Having cleansed the sinus and sucked out any remaining fluid, Symonds has suggested laying the patient on a table with his head hanging well down over the end, and then filling up the frontal sinus through the cannula with iodoform emulsion. Hajek recommends that the sinus be occasionally irrigated with a 2-5 per cent. solution of copper sulphate (see page 315).

The objections to the employment of this method are that the treatment must be carried out daily by the surgeon himself; that it generally fails to produce other than temporary benefit; that in some cases delay in performing a radical operation is dangerous, namely, when there is caries of the posterior wall of the sinus; and finally, that the method is dangerous in itself. There is, however, probably little risk when there is free communication between the sinus and the nose, and fortunately these are just the cases in which irrigation is most easy. With great care and the avoidance of all force the danger of perforating the floor of the skull is slight, but although it can hardly be demonstrated, there may be a risk of infecting a healthy

Y

sinus by passing a cannula through a suppurating region to reach it, for, as already emphasised, the diagnosis is uncertain. Where there is difficulty in entering the sinus it is wisest to desist: it is never right to employ force.

As to the results of this method of treatment there is great divergence of opinion. I have adopted it in eight chronic cases, washing out the sinus daily for two or three weeks. One was cured, three were considerably

improved, in one of which the discharge almost ceased; in the remaining four there was merely temporary benefit. Lichtwitz treated 17 cases by this method-one was cured and all were relieved; Hartmann thinks irrigation will cure the majority of cases; Charters Symonds reports one success in three cases. Lothrop, MacDonald, Dundas Grant, Sergeant Snow and others speak hopefully of it. Hajek thinks the majority of acute cases can be cured by this means. Personally I should recommend it only under very exceptional circumstances. When the affection is recent, the symptoms

not acute, the method easy, and the patient willing to submit to daily visits, it might be tried for a time. In my one successful case the patient quickly learnt to irrigate the sinus for himself, and in less than a week there was marked decrease in the discharge.

Puncture of the Floor of the Sinus from the nose was first recommended by Dieffenbach, and subsequently adopted by Schäffer, with whose name it is generally associated. Schäffer claimed to have cured 18 out of 25 cases, and Winckler 6 out of 15 by this method. Other observers could reach the sinus in only a small number of cases. The floor of the sinus may be punctured from the middle meatus, as recommended by Killian, or from above the middle turbinate, as Schäffer suggested; the latter is by far the more difficult and dangerous. Schäffer recommends that the cannula should be forcibly pushed into the sinus, the sensation of passing into the cavity being easily recognisable by the crackling of the bone and the sudden yielding of resistance. But as already shown the frontal sinus may be absent, and Mermod, who attempted the operation in such a case, perforated the dura mater and caused fatal meningitis. Two other fatalities are on record, and the method must always be uncertain and dangerous. More recently Gustav Spiess has revived this operation. He recommends cocaine anaesthesia, and operates with an electric drill, guided by the X-rays in a darkened room. The passage of the drill into the sinus is seen upon the fluorescent screen. He reports many successful cases, and Moritz Schmidt speaks highly of the method. Still even this modification seems to me unjustifiable. As will be seen later, certain external operations which provide much freer intranasal drainage almost invariably fail to cure. The opening thus made, even if large at the time, will rapidly contract and become useless for drainage purposes, whilst the danger of the operation must be considerable.

External Operation. When the above means of treatment fail the question arises whether it is better to leave the patient alone or to perform an external operation. Unfortunately experience has shown that these operations are by no means free from danger, and that some methods fail to cure. On the other hand the risk of leaving the disease alone does not appear to be great, provided free drainage be maintained. In many of my cases suppuration has existed for ten, twelve, or even sixteen years without impairing the patient's general health or causing him serious inconvenience. As already seen, changes in the bony walls of the frontal

sinus are seldom found, and cerebral complications are extremely rare. Therefore, when no symptoms are present other than nasal discharge, the facts must be clearly put before the patient, and it must be left to him to decide as to operation. Under these circumstances he may decline it, in which case he should be seen from time to time, so that any polypi may be removed, and free nasal drainage maintained.

On the other hand operation may be required for one or more of the following reasons. Pain, which may be severe. Sometimes it is described as maddening, and though intermittent may last hours or even days at a time, and totally incapacitate the patient. In other cases there is frequent severe headache, rendering the patient unable to work or to attend to household duties. More than half my patients sought relief for this reason. Deficient drainage. The opening into the nose may be small and frequently blocked in these circumstances delay in operating is dangerous. Bulging of the cavity or a discharging external fistula. These conditions imply disease of the bony walls, and naturally demand operation. Symptoms of cerebral trouble are an urgent indication for operation. General ill-health, if apparently due to the disease.

The main objections to an external operation are that the operation itself is dangerous; that in the past a cure has been by no means certain; and that the resulting deformity is often great. As operative methods improve, become less dangerous and more certainly curative, it is to be hoped that it may be possible to advise operation in almost every case in order to stop the nasal discharge and to remove the liability to subsequent complications.

The following are some of the more important methods of operation that have been recommended:

Method of Ogston. Ogston has an undoubted claim to be considered the pioneer in the surgery of the frontal sinus. In 1884 he reported three cases on which he had operated in two the result was successful in one it is not given. He made a vertical median incision running from the root of the nose upwards on to the forehead for about an inch. Having opened the frontal sinus by trephining, he enlarged the ostium and infundibular canal with a gouge, and passed a tube the size of a crow-quill into the nose, leaving its upper end in the sinus. The external wound was closed and the tube retained for a week. Ten years later, in 1894, Luc published cases in which he had adopted this method, and the operation is generally known at the present day as the "Ogston-Luc." Luc used the incision in the supra-orbital ridge and recommended a funnel-shaped tube so that it might be more easily retained in the sinus; still the principle of his operation is essentially the same as that devised by Ogston.

Method of Jansen. Jansen makes an incision parallel to and a little below the supra-orbital margin, turns back the periosteum from the roof of the orbit, and removes the entire inferior wall of the frontal sinus. He then scrapes away the lining mucous membrane and curettes the infundibulum