the outward origin is the correct view, the cause of ethmoiditis is simply a chronic rhinitis attacking the middle turbinated body; it is a com plication or sequel of chronic rhinitis just as is the tumor-like hypertrophy of the posterior end of the lower turbinate body. Wright believes that pus from the frontal or maxillary sinus flowing over the mucosa of the ethmoid region 3 nay set up suppurative ethmoiditis from without, accompanied by that cedema thus condition which precedes the for mation of mucous polypi. The weight of analogy would seem to require that suppurative processes should begin within the ethmoidal labyrinth; but clinical evidence appears to show that superficial ethmoiditis is much more common than the deeper form, which involves the labyrinth (Wright). A com promise view is furnished by Griinwald, who disputes the claim that intranasal pus (when not due to ulceration) must have been formed in a sinus, by stating that pus is readily formed behind any obstruction in the middle meatus. The most satisfactory view, therefore, is that hypertrophy of the middle turbinated body is not necessarily due to purulent inflammation, but that it favors the for mation of pus by causing stagnation of the secretions. As far as we know, there is no direct proof that the fungoid gran ulations and polypi, the bone-cysts, dry caries, etc., are of pyogenic origin. To sum up, suppurative ethmoiditis is a term which may embrace two different processes. In ordinary hypertrophy of the middle turbinate, polypus formation, etc., pus readily forms as a result of stagnation of secretions from obstruc tion; while exceptionally suppuration arises from within the labyrinth just as it may within the sphenoid or other sinuses. In the first case—so-called superficial ethmoiditis—the exact part played by the pus is obscure. In the second case (deep ethmoiditis) .there is no doubt whatever that the affection is primarily purulent and that the pus is responsible for all the phenomena.
Treatment.—The treatment of eth moidal suppuration will, from what has already been said, naturally necessitate the cure of the chronic rhinitis which may be present. Careful study will show why inflammation of the ethmoidal cells has occurred on one side of the nose rather than the other. Deviations of the septum, spurs on the scptal partition, or a long-continued hypertrophy of the inferior turbinated body, each produc ing general congestion, causes an inter ference with the nasal respiration, cir culation, and drainage. These are all competent to cause inflammation and hypertrophy of the middle turbinated bone, and their evil effects should be corrected by removing them with saw, scissors, galvanocautery, and chromic acid. Cauterizing sensitive areas in pa tients constantly predisposed to acute coryzas is also of use in preventing ex tension of inflammation to deeper parts. Acute suppuration of the ethmoidal cells, unless a chronic empyema of some other sinus is present, may be prevented from becoming chronic unless there is already radical change in the middle tur binated.
Treatment of ethmoiditis includes the removal of mucous polypi and the re duction of the general fungoid granula tions which cover the anterior, internal, and posterior face of the middle tur binated. This tissue is most easily re moved with nasal scissors and with cut ting forceps. The galvanocautery is not a useful instrument in this location. After projecting tissue has been removed by cutting, it can still further be reduced in size by one or two applications of chromic acid. Such preliminary work as this will frequently so improve the condition of the middle turbinated-as to cure the suppurating surface in the eth moidal labyrinth. But there are many cases that will require more radical treat went; that is, removal of the anterior and external portion of the middle tur binated bone with the cold snare or crushing forceps, so that the ethmoidal cells may be reached, more perfect drain age established, and necrosed bone re moved by careful curetting. Once this operation is commenced, great care should be used to secure drainage from above downward in order to prevent sep sis and possible dangerous inflammation of the meninges or of the orbit. It will require the best of judgment to mine when nasal irrigation should give place to the soothing effects of oily sprays or quieting powders. When the antral cavity is filled with pus derived from the ethmoidal cells, that, too, should be drained by an opening through its floor or its internal wall.
Report of 4 cases of emphysema of the upper eyelid from nasal lesions. probably due to perforation of the xvall of the orbit near the middle, whence the air at once enters the space between the orbital periosteum and the first fascia of the eyeball. In ethmoid oper ations the curette is responsible for much of the traumatism occurring to the lamina papyracea. Alligator for ceps or cutting torceps are less apt to perforate, and will equally well drain pus or remove polypi as well as the mucous membrane lining the ethmoid cells.
Removal of any part of the middle turbinate should be avoided, since it forms a very important guide along which an operation may be carried out without risking entrance either in the orbit or brain cavity in operations on the ethmoid. Abscess, destruction of the eye, and possibly meningitis may arise from septic conditions in opera tions carelessly done upon the ethmoil bone. Beaman Douglass (N. Y. Med. Jour., Mar. 23, 1901).
Inflammation of the Sphenoidal Sinus.
This affection, while not uncommonly recognized post-mortem, is indefinite as to symptomatology during life, although now and then individual instances of cor rect diagnosis occur.
Symptoms.—Suppuration of this sinus is often suspected in protracted suppura tion from the nose when other causes can be excluded. Some of the more radical rhinologists have advocated the removal of the turbinated bodies in cases of this sort, so that the region of the sphenoidal and posterior ethmoidal si nuses may be brought within the range of ocular inspection and of free use of the probe and curette.