A Further Contribution to the 
Study of Suppurative Disease 
of the Accessory Sinuses, 
WITH REPORT OF CASES. 
BY 
J. H. BEY AN, M. D., 
WASHINGTON, D. C. 
BBPBINTBD FBOM THB 
Jfcto 3-orft IHetifcal Soutnal 
for October 12, 1895. Reprinted from the New YorTc Medical Journal 
for October 12, 1895. 
A FURTHER CONTRIBUTION TO 
THE STUDY OF SUPPURATIVE DISEASE 
OF THE ACCESSORY SINUSES, 
WITH REPORT OF CASES* 
J. H. BRYAN, M. D,, 
WASHINGTON, D. 0. 
While a great deal has been written on the subject of 
suppurative inflammation of the accessory sinuses of the 
nose within the past few years, it is a subject that can 
hardly be said to be exhausted. It is one of great impor- 
tance, and is equally interesting to the ophthalmologist as 
to the rhinologist, and I trust not without interest to the 
general practitioner. I hope to demonstrate in this com- 
munication not only the serious nature of these affections, 
but also to point out the frequency with which they are 
overlooked; for, in spite of the advances that have been 
made in the study of diseases of the nose and its neighbor- 
ing sinuses within recent years, we still find abscesses that 
have existed in these cavities for a long period and have 
been treated for neuralgia. 
* Read before the American Laryngological Association at its seven 
teenth annual congress. 
Copyright, 1895, by D. Appleton and Company. 2 
SUPPURATIVE DISEASE OF 
I have selected a few typical cases from my case book 
which show the various phases of abscesses affecting these 
sinuses. 
Case I. Abscess of the Right Maxillary Sinus resulting from 
Dental Caries.—This patient, a man, thirty-nine years of age, 
stated when he consulted me that he had suffered from nasal 
catarrh for a number of years, the secretions being greater 
from the right than from the left nostril. He complained of 
frequent attacks of neuralgia, the pain being referred to the 
supraorbital and infraorbital regions rather than to the side 
of the face. His general health during the past year has been 
greatly impaired, having lost in weight, and complained of 
morning nausea, loss of appetite, foul breath, and difficulty in 
concentrating his attention on his work—that of a book- 
keeper in a banking house. 
When first seen by me he was emaciated, tongue furred, 
and complexion yellow. There was no swelling of the face, 
but there was some tenderness on pressure over the right 
canine fossa. He attributed his condition to nervous dys- 
pepsia, and was under treatment for that affection when he 
came under my observation. A rhinoscopic examination 
showed a slight hypertrophy of the inferior turbinated 
bodies, but no secretion was observed in either nasal cham- 
ber. On blowing the nose, however, there was a slight dis- 
charge of foul-smelling pus from the right nostril. The upper 
first and second molar teeth of the right side were carious. 
He was referred to his dentist for their removal, and when 
he returned he brought with him the first molar, with a por- 
tion of a needle projecting about an eighth of an inch beyond 
the apex of one of its roots which had penetrated the floor 
of the antrum. He then recalled that about eight years 
previously he had picked the tooth with a needle which had 
broken off in the cavity. As it gave him no further trouble 
the incident was forgotten. 
The treatment consisted in washing out the sinus with 
hydrogen dioxide and a saturated solution of boric acid 
through the opening left by the extraction of the first molar. THE ACCESSORY SINUSES. 
3 
In the course of three weeks pus had ceased to form and the 
alveolar opening was allowed to close. 
The interesting feature of this case is the marked de- 
pression of the general health which was due to the swal- 
lowing and possibly slow absorption of the purulent secre- 
tions which had been going on for some time. Almost 
immediately after the removal of this source of irritation 
the dyspeptic and other nervous symptoms disappeared, 
and he soon regained his normal health. 
Case 11. Suppurating Ethmoiditis terminating in Caries of 
the Anterior Ethmoid Cells.—Mr. C., sixty-eight years of age, 
consulted me December 4, 1894, stating that for ten years he 
had suffered with neuralgia, the pain starting at the inner 
angle of the left orbit, radiating over the corresponding side 
of the face and head, and was increased in intensity by an 
acute head cold. For a number of years he had a slight yel- 
low secretion coming from the left nostril, but was not aware 
that it was accompanied by a bad odor. There was no swell- 
ing at the inner angle of the orbit and no disturbance of the 
vision. 
Rhinoscopic examination showed the left middle turbi- 
nated body slightly enlarged, and a thin, purulent secretion 
was observed coming both from above and beneath it in the 
middle meatus. The mucous membrane was so much swollen 
as to block up the upper part of the nasal chamber and pre- 
vent a thorough inspection of this cavity. On the introduc- 
tion of the probe into the middle meatus, caries of the an- 
terior ethmoid cells was readily detected. 
The ethmoid cells were opened by means of a sharp cu- 
rette introduced into the middle meatus and all diseased 
hone removed under cocaine anaesthesia. It required a num- 
ber of operations to accomplish this, and great caution had 
to be exercised in order not to injure the orbit, as the nose 
in this part was exceedingly narrow. At the last examina- 
tion there was no pus present and apparently all diseased SUPPURATIVE DISEASE OF 
bone had been removed. The patient was entirely relieved 
of the pain referred to in the orbital region. 
Case 111. Abscess of the Left Frontal Sinus resulting from 
Nasal Polypi and Hypertrophic Rhinitis.—The case was that 
of a man fifty years of age, who stated that he had been 
afflicted with nasal catarrh for a number of years, the secre- 
tions coming principally from the left side. He has had in- 
tense headaches, the pain being referred to the left forehead. 
For the past year he had not been able to breathe freely 
through the left nostril, and he believes his general health 
has been greatly impaired by his nasal trouble. 
When he consulted me on April 1, 1895, he had just recov- 
ered from a severe attack of influenza, which had greatly in- 
creased his painful symptoms. The headaches were intense 
and were accompanied by marked mental depression, and 
greatly increased by any mental effort. The secretions were 
profuse and muco-purulent in character. 
On examination the supraorbital ridges were observed to 
be very prominent, and the integument overlying the left 
frontal sinus was somewhat swollen and red, the blush ex- 
tending down on the corresponding upper eyelid. There was 
pain on pressure both above and below the supraorbital ridge, 
and slight pitting of the skin on pressure over the sinus. 
Ehinoscopic examination showed slight hypertrophy of the 
right inferior turbinated body, with little or no secretion in 
this nostril. The left nasal chamber was found blocked up 
with numerous polypi springing from the middle turbinated 
body, and there was a marked hypertrophy of the inferior 
turbinate, which had become adherent to a small bony spine 
springing from the sseptum. The secretions could be blown 
from the nose, but a large quantity was observed passing out 
through the post-nasal space. 
The treatment consisted in simply removing the polypi 
and the bony spine and reducing the hypertrophy of the in- 
ferior turbinate. This was sufficient to establish free drain- 
age between the frontal sinus and the nose, which were found 
to communicate by an unusually large fronto-nasal duct. The 
secretions passed into the nose after all obstruction had been THE ACCESSORY SINUSES. 
5 
removed. With the rapid subsidence of the inflammation the 
patient has been relieved of all his distressing symptoms. 
There is still a slight secretion of mucus coming from the 
sinus, blit this is also rapidly diminishing in quantity. This 
case is still under observation. 
Case IY.—Abscess of the Frontal, Ethmoidal, and Maxillary 
Sinuses, with Caries of the Fronto-ethmoidal Cells.—Mrs. —, 
aged forty-eight years, a native of Santa Oruz, West Indies, 
consulted me May 10, 1894, giving the following history: For 
the past twenty years she has been subject to frequent catar- 
rhal inflammation of the upper respiratory tract. She has 
given birth to ten living children, eight of whom are alive 
and healthy, and she has had fourteen miscarriages. 
She did not consider her condition a serious one until 
about seven month ago, when she noticed for the first time a 
thick, yellowish discharge from the left nostril. This secre- 
tion increased in quantity and was accompanied by a bad 
odor. She has had constant nausea and a bad taste in the 
mouth for several months. There has been no pain in the 
teeth, which are absolutely sound. She has noticed, how- 
ever, that the upper teeth of the left side project farther than 
those of the corresponding side, which is especially notice- 
able on closing the Jaws. Her condition has been growing 
steadily worse, and about three months before coming to 
Washington the occasional headaches gave way to constant 
painful sensations over the whole of the left side of the face, 
but especially severe over the supraorbital ridge. At times 
the pain was almost unbearable. Examination showed a con- 
gestion of the whole of the left side of the face Avith a slight 
swelling of the corresponding supraorbital and infraorbital re- 
gions, and a superficial injection of the conjunctiva of the left 
eye. Severe pain on pressure over the supraorbital ridge and 
canine fossa. There was some pitting on gentle pressure over 
the affected sinus. The teeth were unusually large and sound, 
with some recession of the gums, leaving a well-defined sep- 
aration betAveen the gums and the enamel. Rhinoscopic exam- 
ination revealed a slight turgescence of the inferior turbinated 
body of the right side. On the left side both inferior and 6 
SUPPURATIVE DISEASE OF 
middle turbinated bodies were deeply congested and swollen, 
and the nose was filled with pus, which passed freely both 
from the front and into the post-nasal space when in the re- 
clining posture. 
Upon the use of the electric light the left frontal and 
maxillary sinuses were observed to be opaque, while the cor- 
responding cavities of the opposite side were translucent. The 
examination of the eye made by Dr. W. H. Wilmer revealed a 
narrowing of the visual field for red and green colors, while 
the field for white remained normal. 
The diagnosis of abscess of the maxillary and frontal 
sinuses having been made, on June Ist, after the extraction 
of the first molar tooth, I trephined through the alveolar pro- 
cess at this point; pus followed the withdrawal of the instru- 
ment, and about a teaspoonful of yellow gelatinous mucus, 
which is characteristic of inflammations of this cavity, was 
washed out with a warm saturated solution of boric acid. 
The sinus was washed out daily with hydrogen dioxide and a 
boric-acid solution. In the course of two weeks the secretion 
of pus within this cavity had apparently ceased, but large 
quantities of pus were still observed in the middle meatus, 
and the severe headaches continued. 
With the subsidence of the inflammation within the max- 
illary sinus and upon the use of detergent and antiseptic lo- 
tions within the nose, the swelling of the turbinated bodies 
subsided to such an extent that ethmoid disease was excluded 
from the case. No diseased bone could be detected with the 
probe, and all attempts at sounding the fronto-nasal duct 
were futile. 
June 18th.—The patient was sent to the Garfield Hospital 
and the frontal sinus opened in the following manner : After 
observing the customary aseptic precautions, the integument 
covering the supraorbital ridge was drawn up so that the 
line of incision would be just under the ridge when it 
returned to its natural position. The incision was then 
made through the skin down to the bone, beginning just 
within the supraorbital notch and terminating on the nose. 
After elevating the periosteum, an opening into the sinus THE ACCESSORY SINUSES. 
7 
about one centimetre and a half in diameter was made with a 
chisel at a point about midway between the supraorbital 
notch and the nasal boss. Something less than a teaspoonful 
of dark green and foetid pus was washed out of the cavity. 
As the solutions seemed to pass freely from the sinus into the 
nose, it was not thought necessary to pass a drainage-tube 
from this cavity into the nose. The sinus was thoroughly 
explored with a probe, but no exposed bone could be detected, 
and the frontal sseptum was found intact. A drainage-tube 
was inserted into the outer opening and the wound closed. 
The cavity was washed out daily with hydrogen dioxide and 
a saturated solution of boric acid for a month. When the 
secretion of pus had apparently ceased, the drainage-tube was 
withdrawn and the opening allowed to close. I was about to 
discharge the patient cured, when she returned to the office 
one morning with pus discharging into the nose and through 
the fistulous opening in the forehead, with all of the former 
painful symptoms returned. She was sent back to the hospi- 
tal on July 29th and the sinus reopened. Granulations were 
found around the margins of the opening in the bone and 
also at the inner and most dependent part of the sinus. 
These were scraped away with a sharp curette and the open- 
ing enlarged with the chisel. The cavity was again thoroughly 
explored with the probe for diseased bone or any other cause 
of the recurrence of the inflammation, but nothing could be 
detected. As the solutions passed freely through the fronto- 
nasal duct I did not even now feel justified in passing a 
drainage-tube from the sinus into the nose. The sinus was 
washed out with a solution of bichloride of mercury (1 to 
6,000) and packed with iodoform gauze. This form of treat- 
ment was continued for two weeks, when, owing to a tend- 
ency of the external wound to close, the gauze dressing had 
to be discontinued and simple irrigations of the cavity with 
antiseptic solutions resorted to. Such antiseptics as the bi- 
chloride of mercury, tricresol, iodoform, and pyoctanin had no 
effect whatever on the secretions of pus, which continued to 
form in increasing quantities. In the mean time, pus was dis- 
covered again in the antrum, and during the irrigation of this 8 
SUPPURATIVE DISEASE OF 
cavity one morning I noticed that solutions injected into it 
found their way out through the frontal sinus opening, show- 
ing there was a direct passage between the two sinuses, thus 
accounting for the accumulation of pus in the antrum, 
amounting sometimes to as much as an ounce. As the stronger 
antiseptics seemed to irritate the mucous membrane of the 
sinus and the nose, I returned to the use of hydrogen dioxide 
and boric acid. The wound had now closed to such an ex- 
tent that a small silver drainage-tube was passed into the 
sinus through which the pus found a ready exit. 
October 21st.—On irrigating the frontal sinus the solutions 
were observed for the first time to pass through both nos- 
trils, showing that the saeptum had become perforated. 
Owing to the possibility of there being a specific element in 
the case, the patient was given five drops of a saturated solu- 
tion of the iodide of potassium three times a day, which was 
later increased to thirty drops three times a day without any 
benefit being observed. 
November 16th.—The disease has evidently been a progress- 
ive one, for upon passing the probe into the middle meatus 
diseased bone was detected for the first time about the ante- 
rior ethmoid cells. The anterior half of the middle turbinated 
body was now removed with the electric burr in order to 
facilitate freer drainage and to render more accessible the 
anterior ethmoid cells, which were broken down and scraped 
away with a sharp curette. This, of course, was not done at 
one operation, but only after a number of sittings, and work- 
ing from before backward until all carious hone was removed. 
From this time on the patient made progress toward recovery. 
The drainage-tube in the frontal sinus opening was removed 
February Ist, when it was evident that all secretion of pus 
had ceased. As soon as the metallic drainage-tube was re- 
moved the opening closed and the resulting scar was scarcely 
perceptible. As a precautionary measure a gold drainage- 
tube was introduced into the opening in the alveolar process, 
which she continues to wear in order to admit of free drain- 
age of that cavity in case the secretions should be started 
again as the result of a cold. She was discharged cured THE ACCESSORY SINUSES. 
9 
March Ist, having been under observation for ten months. I 
have recently seen this patient, about two months and a half 
after she was discharged, and I am glad to report the sinuses 
were free from secretion, and the patient is comfortable and 
enjoying good health again. 
Owing to the position of the accessory cavities, they 
are especially prone to inflammation, which may extend 
into them either from the nose or from the teeth when dis- 
eased, as in the case of the maxillary sinus. During the 
several epidemics of influenza that have prevailed here, I 
have met with a large number of cases in which the in- 
flammation had extended into one or more of these sinuses 
and complicated the simple nasal affection to a very painful 
and serious degree. Aside from the true influenza, the in- 
flammation of a simple rhinitis frequently extends into one 
or more of these cavities, and unless recognized and treated 
early is most likely to result in an abscess. It is very im- 
portant that these cases should he recognized and treated 
early, for upon their early recognition depends their final 
issue, which in many cases has resulted in the death of the 
patient. 
In previous communications on this subject I have de- 
voted some attention to the suppurative inflammation of 
the maxillary sinus. In this paper I will limit my remarks 
as much as possible to the suppurative inflammation of the 
frontal and ethmoidal sinuses. 
Aside from acute inflammations extending into these 
cavities, their secretions being retained and finally resulting- 
in suppuration of their lining membrane, there are other 
and more frequent causes—viz., chronic catarrhal rhinitis, 
hypertrophic rhinitis, polypi, foreign bodies blocking up 
the middle meatus so that the secretions are retained with- 
in the sinuses, and finally giving way to the formation 
of pus. 10 
SUPPURATIVE DISEASE OF 
In well-marked cases the diagnosis of abscess of the 
ethmoid ceils is not a difficult matter ; but in many instances 
the symptoms are obscure, and there is frequently an im- 
plication of One or more of the neighboring cavities, so that 
it is almost impossible at times to tell which is the source 
of the pus. Then we can arrive at a diagnosis only by ex- 
clusion. 
Among the earlier symptoms of abscess of the ethmoid 
cells may be mentioned pain, neuralgic in character, refer- 
ring to the bridge of the nose, increasing in intensity with 
the progress of the disease, and extending outwardly along 
the infraorbital ridge, and occasionally along the supra- 
orbital ridge, as was observed in Case 11. With a disten- 
tion of the cells there is a sense of pain and pressure felt in 
the orbit, exophthalmia, a narrowing of the field of vision, 
and if there is softening of the bone at tbe inner angle of 
the orbit crepitation may be present. On rhinoscopxc ex- 
amination, if the abscess is of the open variety, pus will 
always be found in the middle meatus, and if the posterior 
cells are involved it will occasionally be found passing into 
the post-nasal space. The middle turbinated body may or 
may not be enlarged; this depends on whether it commu- 
nicates directly with the ethmoid cells. 
In Case II this body was only moderately enlarged, 
while in Case IV it was about normal in size. The probe 
will in the majority of instances reveal carious bone when 
passed into the middle meatus and upward beneath the 
middle turbinated body. 
While occasionally an abscess may exist in the frontal 
sinus without giving rise to any symptoms except a slight 
discharge of pus from the nose, as in the case reported by 
Luc (1), in the majority of cases the symptoms are very pro- 
nounced, and vary in intensity according to whether the 
fronto-nasal duct is open or closed. Pain in the frontal re- THE ACCESSORY SINUSES. 
11 
gion, at first dull and then becoming lancinating in character 
as the secretions distend the cavities, is the most common 
symptom ; there is pain on pressure over and under the 
supraorbital ridge; there may also be some redness and 
swelling of the skin over the affected sinus, which some- 
times extend down and involve the corresponding upper 
eyelid. If the fronto-nasal duct is open, there will be a 
discharge of pus from that side of the nose, and upon 
rhinoscopic examination pus will be found in the middle 
meatus, just under the anterior extremity of the middle 
turbinated body. This is the variety of the disease that 
the laryngologist most frequently meets with. If, however, 
the duct should be closed, then there is a dilatation of the 
sinus, with a tendency to bulge at its thinnest part at the 
inner angle of the orbit on a level with the root of the nose, 
and it occasions a displacement of the eye forward, down- 
ward, and outward. If there is no relief, the pus finds its 
way through this swelling into the orbit in the form of an 
orbital abscess, or ruptures posteriorly into the cranial cav- 
ity. Besides the possibility of an orbital abscess forming, 
among the other eye complications may be mentioned 
changes in the corresponding papilla, generally a hyperaemia 
associated with dilated and tortuous veins and a narrowing 
of the field of vision. 
Occasionally abscess of the frontal sinus is complicated 
with an abscess in the ethmoidal and maxillary sinuses, as 
was shown in Case IV. In this case the inflammation 
affected the deeper cells, or the fronto-ethmoidal cells, 
which are well illustrated in Fig. 1. 
These cells are in close proximity to the frontal sinus, 
and in all cases of obstinate or prolonged suppuration in 
this cavity they are involved in the suppurative process. 
In Case IV they were undoubtedly involved, which fact 
would account for the recurrence of the inflammation in 12 
SUPPURATIVE DISEASE OF 
the frontal sinus after it had apparently ceased secreting 
pus. It was not until the disease advanced and the super- 
ficial cells became involved that ethmoid disease could be 
fully established. 
Another interesting feature of this case is that after 
the inflammation of the maxillary sinus had been relieved, 
pus was found in this cavity coming from the frontal sinus, 
as is plainly evident from the fact that solutions injected 
Fig. 1.—a, frontal sinus ; b, fronto-ethmoid cells. 
into the antrum found their way out through the opening 
in the supraorbital ridge. This unusual condition can be 
explained in two ways: either there was a natural commu- 
nication between the frontal and maxillary sinuses—an 
anomalous condition that I have previously called attention 
to, and which is shown in Fig. 2—or it was pathological, 
resulting from caries of the anterior ethmoid cells. The 
latter I believe to have been the case. This anomaly has 
been noticed also by others. The late Professor Leidy said 
that he had met with it two or three times, and Mac Do- 
nald (2) states that Dr. Curnow, professor of anatomy in 
Kings College, has also met with the same condition. THE ACCESSORY SINUSES. 
13 
Fig. 2 shows the inner wall of the maxillary sinus, in 
which only two of the three openings into the middle mea- 
tus are visible. 
Fig. 2.—a, b, openings into the middle meatus ; c, c, a probe passed from th 
frontal sinus into the antrum; d, sphenoidal sinus. 
The anterior or third opening, which is not shown in 
this view, is normal in position, but it communicates with SUPPURATIVE DISEASE OF 
a deep groove just in advance of the hiatus semilunaris 
which leads into the frontal sinus. By means of this 
groove it is possible to pass a probe from the cavity of the 
antrum directly into the frontal sinus, although, in so 
doing, it is made to enter the middle meatus first. The 
natural channel for pus or fluid coming from the frontal 
sinus would be into the antrum, in preference to the mid- 
dle meatus. How often this anomalous condition occurs 
we do not know, but in all these cases of antral trouble 
which have apparently responded to treatment, but in 
which pus continues to accumulate, it is well to bear in 
mind the possibility of its coming from one of the sinuses 
situated above through a false or natural passage, as shown 
in the above figure. 
In simple uncomplicated cases of suppurating ethmoid- 
itis, after removing the cap of the middle turbinated body 
either with the snare or the electric burr, I prefer to con- 
tinue the opening of the individual cells with a sharp 
curette, an instrument I consider safer than the electric 
burr, for it must be borne in mind that this is a dangerous 
region, and if there is any undue amount of roughness 
used, or if the instrument should slip, there is the possibil- 
ity of penetrating the orbit or the cranial cavity. 
Fig. 3 shows very well the ethmoid cells with their 
thin bony trabeculae, and also their relation to the frontal 
and sphenoidal sinuses. 
Fig. 4—a cross-section of a skull showing a sectional 
view of the ethmoid cells and their relation to the orbital 
cavities—demonstrates the narrow space between the nasal 
wall of the ethmoidal sinus and the orbit. 
In case the deeper or fronto-ethraoidal cells are in- 
volved, then we should not attempt to relieve them through 
the nose, although it was done successfully in Case IV, 
as the operation is not unattended with danger, but the THE ACCESSORY SINUSES. 
15 
case should be treated, as one of frontal sinus abscess, of 
which this condition is a very frequent complication. The 
same object is to be sought in the treatment of abscesses 
of the frontal sinuses as in the other neighboring cavities 
of the nose—that is, to evacuate the pus and establish free 
drainage. In a few cases this can be accomplished, as in 
Case Til, by removing any hypertrophy, polypi, or any- 
thing within the nose that serves to obstruct the fronto- 
nasal duct, when, if this duct is pervious, free drainage 
Fig. 3.—An anteroposterior section through the ethmoid cells, showing their 
relation to the frontal and sphenoidal sinuses. (Gouguenheim and Glover.) 
can be maintained, and the inflammation of the lining 
membrane, if not having existed too long, may subside 
and the patient eventually fully recover. If, however, the 
duct should be blocked, then an attempt should be made 
to pass a probe into it so that its permeability can be 
re established. Sounding the fronto-nasal duct is by no 
means an easy procedure, and when possible it is more 
applicable in cases of mucocele than in cases of suppura- 16 
SUPPURATIVE DISEASE OF 
tive inflammation, and it prevents the former painful con- 
dition from being converted into the much more serious 
affection of abscess of the frontal sinus. 
Fig. 4.—Cross section of a skull, showing a sectional view of the ethmoid cells 
and their relation to the orbital cavities and the middle turbinated bodies. 
In the majority of cases of abscess of this sinus, if 
of long standing, it will he found necessary to make an 
artificial opening. The incision, after gently drawing the THE ACCESSORY SINUSES. 
17 
skin on the forehead, should he made along the lower 
border of the supraorbital ridge down to the bone, com- 
mencing just within the supraorbital notch and termi- 
nating on the nose ; generally this form of incision will be 
sufficient, but in those cases where there is well-defined necro- 
sis of the outer table of the bone, then the method of Panas 
(3) should be adopted—that is, of making another incision 
perpendicular to that along the supraorbital ridge, and the 
triangular flap thus formed is detached from the hone to- 
gether with the periosteum, and the sinus perforated near 
the inner angle of the orbit. The opening should he suffi- 
ciently large to admit of a thorough exploration of the sinus 
with the finger and probe. Any osteophites or granula- 
tions must be removed with the curette. If the sseptum 
dividing the two cavities is not already broken down, a 
thorough exploration with a probe should he made to as- 
certain whether there is a perforation present through 
which the secretions could pass into the adjoining sinus. 
If pus should find its way into the adjoining cavity the 
sreptum must he broken down and the pus evacuated. In 
Case IV, the saeptum as far as could be ascertained, was 
free from caries when the sinus was opened, but during 
the course of the treatment it became ulcerated at the most 
dependent part of the sinus, thus allowing solutions in- 
jected into the left cavity to pass out through the right 
nostril. If the fronto-nasal duct should remain closed, or 
if the fronto-ethmoidal cells are implicated in the suppura- 
tive process, then a communication between the nose and 
this cavity should be established in order to permit of free 
drainage. This is best done by introducing the little fin- 
ger within the nostril corresponding to the affected sinus, 
and then passing a curved trocar through the opening in 
the sinus into the nose, using the little finger as a guide. 
A drainage-tube is now introduced through the nose into 18 
SUPPURATIVE DISEASE OF 
the sinus, and also one in the outer opening, and allowed to 
remain until all suppuration has ceased. The cavity should 
Fig. 5.—A sectional view of a skull, showing the distance from a point just 
within the nostril to the anterior wall of the sphenoidal sinus to he two 
inches and a half, as measured by a band graduated in halfinches. THE ACCESSORY SINUSES. 
19 
be irrigated daily with some mild antiseptic solution, prefera- 
bly a saturated solution of boric acid, and hydrogen dioxide. 
Suppurative disease of the sphenoidal sinus occurs 
much more rarely than it does in any of the other acces- 
sory cavities. While it does occur as an independent af- 
fection, it is more frequently observed as a complication of 
abscess of the ethmoidal sinus, where the thin bony parti- 
tion, as shown in Fig. 3, between the posterior cells and the 
sphenoidal sinus is broken down and their contents dis- 
charged into the latter cavity. 
Fig. 5 is an antero-posterior view of a skull showing 
very well the relation of the sphenoidal sinus to the supe- 
rior and middle turbinated bodies. 
Owing to the frequency of the implication of the fronto- 
ethraoidal cells in frontal sinus abscess, Jansen (4) recom- 
mends the removal of the under wall of the sinus. The 
same object is obtained in passing the trocar from the 
sinus into the nose. These cells are then drained directly 
into the nose. 
The treatment of these cases will occasionally be found 
very tedious and discouraging, but if care has been taken 
to establish free drainage, and the antiseptic applications 
are thoroughly applied, the majority of patients will re- 
cover. 
References. 
1. Arch, internat. de laryngolog. et de rhinolog., vii, 4, July- 
Aug., 1894. 
2. Diseases of the Nose, 2d ed., p. IT6. 
3. Archives of Ophthalmology, vol. xx, p. 658. 
4. Archiv f. Laryngolog., etc., i, 2, 1893. 
818 Seventeenth Street. The New York Medical Journal. 
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FRANK P. FOSTER, M.D. 
THE PHYSICIAN who would keep abreast with the advances in 
medical science must read a live weekly medical journal, in which 
scientific facts are presented in a clear manner; one for which the 
articles are written by men of learning, and by those who are good and 
accurate observers ; a journal that is stripped of every feature irrelevant 
to medical science, and gives evidence of being carefully and conscien- 
tiously edited ; one that bears upon every page the stamp of desire to 
elevate the standard of the profession of medicine. Such a journal 
fulfills its mission—that of educator—to the highest degree, for not 
only does it inform its readers of all that is new in theory and practice, 
but, by means of its correct editing, instructs them in the very important 
yet much-neglected art of expressing their thoughts and ideas in a clear 
and correct manner. Too much stress can not be laid upon this feature, 
so utterly ignored by the “ average ” medical periodical. 
Without making invidious comparisons, it can be truthfully stated 
that no medical journal in this country occupies the place, in these par- 
ticulars, that is held by The New York Medical Journal. No 
other journal is edited with the care that is bestowed on this; none 
contains articles of such high scientific value, coming as they do from 
the pens of the brightest and most learned medical men of America. A 
glance at the list of contributors to any volume, or an examination of 
any issue of the Journal, will attest the truth of these statements. It 
is a journal for the masses of the profession, for the country as well as 
for the city practitioner; it covers the entire range of medicine and 
surgery. A very important feature of the Journal is the number and 
character of its illustrations, which are unequaled by those of any other 
journal in the world. They appear in frequent issues, whenever called 
for by the article which they accompany, and no expense is spared to 
make them of superior excellence. 
Subscription price, $5.00 per annum. Volumes begin in 
January and July. 
PUBLISHED BY 
D. APPLETON & CO., 72 Fifth Avenue, New York.