properly individualized. It may succeed in a few days or may require many weeks. Faulty habits should be corrected, insufficient clothing, exposure to dust and weather, cold feet, constipation, stomach disturbances, or anemia should receive attention (see ¶ 14 to ¶ 17). Local treatment demands removal of the pus, as this fluid is too viscid to drain off without aid, especially when anatomic configuration favors its confinement. The most efficient measure is the douche, which is to be used daily-even several times a day (see T 25). Irrigation through a small cannula (Fig. 32) may prove more satisfactory when hidden recesses are to be reached. A few days'

_75cm-

FIG. 32.-Grünwald's irrigating tubes.

steady use shows either the benefit of irrigation or its inefficiency in a given case. With abundant secretion and fairly wide passages the douche may be intrusted to the patient. In nasal stenosis this would be contraindicated by the risk to the ear, and we must rely upon the use of a spray. Yet a spray from even a good atom

izer is not an efficient substitute for the douche for the purpose of removing pus, especially if this be dammed up. The addition of medicaments to the spray solution exerts but little influence, as its effect is practically mechanical. A 1 per cent. solution of sodium bicarbonate or the pleasant solution of ethereal oils (T25) may be used.

When a circumscribed area of pathologically changed mucous membrane can be detected, it should be treated by direct localized application. Localized surface inflammation yields to a few brushings with silver nitrate solution (5 to 10 per cent.), while a granulation spot will react well to superficial cauterization with trichloracetic acid.

Some cases, however, prove rebellious. In most of these the hindrance to a cure will be found in structural configuration, causing either stenosis or local damming up of pus. Some of these lesions should receive surgical attention at once-for instance, papillomatous tumors, polypi, and flabby hypertrophies of the turbinals; especially, however, any existing hypertrophy of the pharyngeal tonsil. The same statement applies to deformities of the septum of sufficient degree to cause stenosis; but in the case of septum deviations or ridges of minor degree, an individual study and a proper trial of irrigation should precede the decision to resort to operative meas

ures.

Besides the atypical form of purulent rhinitis just described, some more definitely characterized varieties may be recognized.

35. The subacute rhinitis of scrofulous children begins as a mild or subacute nasal suppuration, and persists until mild weather arrives or until it is successfully treated; often, however, it recurs the next season. The subjects are typically scrofulous young children with tubercular glands in the neck. The discharge is relatively thin, mucopurulent, and leads to excoriations and eczema below the nose. There is, as a rule, moderate enlargement of the pharyngeal tonsil; rarely, excessive nasal obstruction. The disease is often associated with phlyctenular keratoconjunctivitis, and frequently causes purulent otitis. A cure is sometimes obtained by better protection and healing of the excoriations under the nose by silver nitrate (10 per cent.) applications, followed by a zinc or ichthyol-lanolin salve or oil of cade. Cod

liver oil is generally of benefit. The same may be said of all hygienic measures directed against scrofula, such as fresh air, baths, and proper feeding. The douche is very useful, unless a hypertrophic pharyngeal tonsil contraindicates its use, in which case a spray must take its place. Any enlargement of the pharyngeal tonsil that causes symptoms of obstruction calls for its removal. This does not, however, necessarily cure the rhinitis, although always of beneficial influence. As the children approach puberty the relapses cease.

36. Another variety has been named "purulent rhinitis of children" (Bosworth). It is a typical, but not very common, affection. Its subjects are not necessarily scrofulous. It begins early in childhood, and if not checked, persists during adolescence. In a few instances the author has known it to cease spontaneously. The discharge is thick, very profuse, not fetid, and but little. influenced by the season. Examination, difficult in children, does not show the origin of this profuse flow of mucopus. It begins before the accessory cavities are well developed. The nasal lining appears pale. The passages are, as a rule, roomy, especially the pharynx. The pharyngeal tonsil is often normal. When enlarged, its removal, even if otherwise indicated, does not diminish the secretion of pus, at least not for many weeks, perhaps ultimately. Like all purulent nasal affections, it menaces the ear, often leading to purulent otitis with tendency to relapses. A view expressed by Bosworth that this form of purulent rhinitis may be the first stage of ozena has not been confirmed by any one, and was disproved in the author's experience by several observations continued through a number of years. The disease can be cured by the persistent use of the douche for many months.

37. Nasal suppuration was not distinguished sharply from the non-suppurative forms of rhinitis in former text-books. It is only within the last ten years that it has been shown by Ziem, and later by others, especially Grünwald, that many cases of so

called purulent rhinitis are really sinus affections. Perhaps the clearest exposition of suppurative affections of the nose and its adjoining cavities can be found in Grünwald's Lehre von den Naseneiterungen, second edition, 1896 (American edition, Treatise on Nasal Suppuration, 1900). The purulent rhinitis of children was described by Bosworth in his Diseases of the Nose and Throat, 1889. The form I have described as subacute rhinitis of scrofulous children has not been differentiated clearly, except by Klemperer in Heymann's Handbuch der Laryngologie, etc. It is, however, a clinical picture quite familiar to ophthalmologists.

CHAPTER VI.

DISEASES OF THE NASAL ACCESSORY CAVITIES.

38. In communication with the nasal passages are the six hollow sinuses or cavities-viz., in the superior maxillary, the frontal and the sphenoid bones, as well as a series of cellular spaces in the ethmoid bone. They are all lined by a thin mucous membrane continuous with that of the nose and inseparable from the periosteal lining. Nothing is known concerning the utility of these spaces, except that they lessen the weight of the head. While only the severest type of disease of the sinuses was formerly recognized as a very rare surgical accident, it has been learned within the past ten years that affections of these spaces are very common. Their remarkable frequency has been shown even more strikingly by autopsies than by clinical experience. Systematic researches have been made on the postmortem table by Harke, E. Fränkel, Dmochowski, Wolff, Pierce, and others. It has thus been shown that one or more of the sinuses are found diseased in nearly one-half of unselected subjects dead from different causes. In diseases of the respiratory passages the ratio is even higher, and in infectious diseases, like diphtheria and scarlet fever, involvement of some of the cavities is almost the invariable rule. The sinus involved most commonly is the maxillary antrum; about one-half as often the sphenoid cavity is found diseased, while the frontal sinus suffers relatively rarely. The ethmoid cells. have not been examined to the same extent, and there is some discrepancy as regards the frequency of their involvement by different authors. They are evidently much less often diseased than the maxillary sinus. Relatively common is multiple disease of several sinuses.

The lesions found vary from a mild superficial to a