be too strongly emphasized that the existence of any of these nasal abnormalities in an asthmatic patient does not necessarily imply that they are causal factors. Yet if on the application of cocaine solution. to the nasal mucous membrane the asthmatic attack is aborted or obviously relieved, we are justified in saying to the patient, "It is highly probable that local treatment of the intranasal abnormalities will result in considerable relief and possibly a cure, but whether the relief will be of long-standing or the cure permanent cannot be foretold; it is not even possible to promise that this local treatment will exercise any beneficial effect on the cause of the asthma.”

The Treatment of the various nasal conditions alluded to has already been described elsewhere, but the general treatment of the patient should in all cases receive careful attention. It is curious that it is in cases in which a number of small nasal polypi are found, rather than those where the nose is almost blocked by a large polypus, that asthma occurs. The usual explanation is that large polypi, though causing more complete stenosis, are less mobile, and therefore probably less likely to irritate the neighbouring mucosa. The real explanation probably is that the small polypi are the result of ethmoidal cell suppuration, and that the latter condition is the cause of local irritation and asthma, the polypi in themselves having little to do with the matter. In some of my patients with well-marked and persistent asthma, the affection permanently subsided after removal of ethmoidal and sinus suppuration

In the general treatment of asthma, the importance of tonic measures -exercise, massage, fresh air, cold and needle baths, sea-bathingare often of very great value. For the attacks, iodide of caffeine or sodium, hyoscine, calcium lactate, extracts of grindelia, or Myrtus chekan, or ethereal tincture of lobelia may be given.

EPILEPSY.

Occasionally epilepsy has seemed to be caused by nasal abnormalities, the removal of which has been followed by cessation of the epileptic seizures, and I have had fairly definite proof that epilepsy may be induced by intranasal irritation in a patient who had an ordinary epileptic fit while I was cauterizing the nose for polypi. He never had a fit before, and had no further attack, at any rate during the next eight years.

Other similar cases have been recorded by different observers.

165

SECTION XI.

INFLAMMATORY DISEASES OF THE ACCESSORY SINUSES. GENERAL INTRODUCTION AND ACUTE SINUSITIS.

ETIOLOGY

LEGAL RESPONSIBILITY

GENERAL SYMPTOMS

OBJECTIVE SIGNS

ACUTE SINUS SUPPURATION

GENERAL INTRODUCTION.

DISEASES of the nasal accessory sinuses are of great clinical

importance, for they constitute a large proportion of the nasal affections which come under the notice of medical practitioners. They are sometimes easy, but often very difficult, to diagnose and treat, may cause great inconvenience to the patient, undermine the health, or lead to fatal complications. One assumes a knowledge of their anatomy (see p. 18 et seq.), without which it is difficult, if not impossible, to appreciate the symptoms and signs of inflammatory disease in these sinuses.

Inflammation of the sinuses may be acute or chronic, and the secretions catarrhal or purulent.

A sinusitis may be (1) Latent, (2) Manifest, (3) Open, or (4) Alternating.

If the ostium of the sinus remains more or less open, it is termed an open sinusitis, but if the aperture is occluded we have what is called a closed or " manifest" sinusitis, or a "closed empyema." In other cases while the secretion is able to escape it is unattended with local symptoms; to these the term "latent " is applied.

The division of empyemas of the nasal sinuses into "open" and "closed" is convenient for clinical purposes, and yet often enough a case cannot be placed in either group. For instance, an empyema may alternate between the two conditions, the ostium being more or less closed, with aggravation of the symptoms, till the accumulating secretion forces an exit, with accompanying relief of many of the

symptoms, and from being a closed empyema it becomes an open empyema. Thus the division of empyemas into closed, alternating, and open is more satisfactory for clinical purposes.

Etiology.--The accessory sinuses being lined by mucous membrane in continuity with that of the nose are liable to participate in all acute inflammatory affections of the nasal passages by direct extension, and to be secondarily infected by various chronic diseases, or by the secretion escaping from one sinus finding its way into neighbouring accessory sinuses.

Predisposing Causes.-Probably very few individuals in a civilized community pass through life without more than one attack of acute sinus inflammation in the course of acute nasal catarrh, influenza, etc., yet relatively few suffer from symptoms of definite acute or chronic sinus suppuration, because the secretions usually escape and the mucosa recovers spontaneously. But apart from peculiarly virulent infection which may determine sinus suppuration in some instances, the most frequent determining cause is a more or less obstruction in the neighbourhood of the opening of the sinuses, e.g., by a deflected septum or a large middle turbinal. There is often sufficient space for all purposes so long as the nose is in a state of health, although the swelling of an inflamed mucosa may suffice to cause complete obstruction in the narrowed territory, and consequently prolonged retention of secretions sufficient to result in pathological changes in the mucosa from which spontaneous recovery is no longer possible. In this direction localized obstruction and narrowing in the nasal passage become a source of danger when they may not interfere in any marked degree with normal respiration.

Direct or Exciting Causes.-To avoid repetition, the various direct causes of inflammatory processes in the different sinuses may be grouped together thus:

1. Simple acute rhinitis may involve the mucosa lining any of the accessory sinuses, and chronic catarrhal or purulent sinusitis may result. The accessory cavities do not invariably participate in inflammatory diseases of the nasal passages, as some are inclined to think. In the course of his anatomical researches on the nose, Harke not infrequently found the mucous membrane of the nasal passages very severely inflamed, while that of the accessory cavities was entirely normal.

2. Acute infectious diseases, especially influenza and septic infections (erysipelas, etc.), less frequently measles, scarlatina, typhoid

fever, small-pox, pneumonia (v. Besser), diphtheria, glanders, gonorrhoea, and acute rheumatism.

3. Chronic infectious diseases, tuberculosis and syphilis, or the presence of a malignant growth.

4. The invasion of a sinus by insects, larvæ, etc., has several times caused a frontal sinusitis. Dochmeins found Ankylostomum duodenale in one patient's frontal sinus. Harke has found particles of tobacco in the antra of snuff-takers.

5. Occlusion of the ostium of one or more accessory cavities. Cases of empyema of the maxillary sinus following plugging of the nasal fossæ for epistaxis are recorded, and this illustrates how mechanical obstructions at or near the opening of a sinus may lead to sinus suppuration, e.g., mucous polypi. We must bear in mind that polypi and polypoid condition of the mucous membrane around the apertures are usually the result rather than the cause of empyema.

The Moral and Legal Responsibility of patients suffering from sinus disease is worthy of fuller consideration than has hitherto been accorded to this aspect of their complaint. E.g., a lady under my care who had frontal sinus suppuration was found to have stolen a valuable ring from a friend's house. Fortunately she was saved from painful exposure, and though she was unaware that the matter had been in the hands of the police, after recovery from a successful operation she told me of what she had done. I have no manner of doubt it was pure loss of memory which led her so nearly into trouble.

All patients who are the subjects of purulent sinusitis are liable to suffer from toxæmic symptoms, toxic products reaching the blood either from direct absorption from the implicated sinuses or from the gastro-intestinal tract, and impairment of memory, mental depression, irritability, etc., are very often marked symptoms. A number of cases of mental derangement have been caused by accessory sinus suppuration, and instances of mental recovery as the direct result of the cure of sinus disease are recorded.

General Symptoms. Before describing in detail the symptoms of suppuration in the several sinuses, it is convenient to review some of the more important general features of these affections, as regards (1) Subjective symptoms, immediate and remote; (2) Objective signs; (3) Complications, although these points are all discussed in greater detail in connection with each particular sinus.

The symptoms of sinus disease are very variable in character and degree. The general health usually suffers appreciably, though in

long-standing cases patients may have become so accustomed to their mental or physical deterioration and consequent inability to work so long or so well as formerly, that they quite fail to recognize their real condition of poor health.

While Localized Tenderness corresponds to the cavity implicated, the headache and neuralgic pain are often referred to other areas in the territory of the fifth nerve; thus in antral suppuration we shall find the pain or headache is frequently confined either to the supra-orbital region or to the occiput.

Localized headache, pain, neuralgia, tenderness may be absent, slight, or severe, but one of the commonest complaints is pain or headache which alternates with a nasal discharge. Usually this alternation is attributed simply to stenosis of the aperture of exit of the implicated cavity, the secreting pus collecting ard causing pain and headache from the increasing pressure, which sooner or later forces an exit through the ostium, with consequent escape of pus in the form of nasal or post-nasal discharge, according to the particular cavity involved, and consequent relief of pain and headache. This undoubtedly is the explanation of the very intense pain, such as is common in acute sinus suppuration and in some chronic cases, but in the latter especially there are three reasons why I believe such an explanation is often insufficient: (1) the aperture tends to become more patent as suppuration continues, (2) the exacerbations often arise while the purulent secretions are continuously escaping, and (3) in females, the exacerbations often definitely correspond to the menstrual period. I believe that the periodic pain and headache are often largely and sometimes even entirely due to inflammation, and that the relief which corresponds in time to increased secretion is really due to the subsidence of the inflammation, exactly as an acute bronchitis is relieved when secretion is promoted. It is a fallacy to assume that the ostia are always narrowed as a result of chronic suppuration, for it is by no means rare to find that a large frontal sinus bougie will readily enter a frontal sinus, and that a sphenoidal sinus ostium is very patent in long-standing suppuration. This point is well exemplified in Plate XXXV, from Zückerkandl's collection, and it is a question of considerable clinical import, for it explains why the mere establishment of free drainage does not always ensure the eventual cure of a chronic suppurating sinus, and in some cases even fails to prevent exacerbations with pain and headache. Under these circumstances we shall find that the