space permits and is pointed upward. If it enters the nasal wall too far in front, it may penetrate through the anterior maxillary wall, and the subsequent injection may cause swelling and possibly infection of the cheek. When the socket of the second bicuspid or first or second molar tooth is available, the antrum can easily be reached by means of a small drill. An effort should first be made to blow out the secretion by means of an air-bulb, since a serous fluid would escape detection when mixed with water. Subsequently a stream of tepid sterile salt solution may be forced through the needle, and the escaping fluid caught as it flows from the nose.

50. Treatment. It is doubtful whether a chronic maxillary empyema ever heals without evacuation even under favorable circumstances. The treatment, therefore, consists in the evacuation of the fluid. This may be attempted by irrigation through the natural or accessory orifice by means of a slender silver or rubber cannula bent near its tip. This procedure, only occasionally possible, is unreliable as to permanent effect. It is facilitated by the removal of the front end of the middle turbinal in case this operation is indicated by reason of hypertrophies in the middle meatus. If any of the upper teeth back of the incisors are diseased at their roots, tender to pressure or to heat or cold, their extraction is indispensable.

The easiest operation for draining the antrum is through the socket of an extracted tooth, preferably the first molar, or, if need be, the second molar or second bicuspid. It is rarely desirable to sacrifice a healthy tooth. A narrow orifice can be drilled on the internal side, between the two molars or first molar and bicuspid, but this opening has its drawbacks and is usually too small. The drilling can best be done with a drill attached to a dental motor. A conic hand drill can be used (Fig. 47) instead, but is more awkward where the alveolar process is thick. The hole should be at least 5 mm. wide. Cocain or nirvanin injected under the gums secures painlessness. The thickness of bone varies from

perhaps 2 to 8 or 10 mm. When the facial wall of the sinus is deeply sunken in, there is a small possibility of drilling from the alveolar socket through the canine fossa into the cheek. Perforating into the nose can happen only when the instrument is held too slanting and when the nasal meatus is excessively wide at the expense of the sinus. After irrigation the hole may be plugged with iodoform gauze for a day or two. Later a rubber plug or cannula should be fitted by a dentist. This must be guarded from slipping in by a thickened inferior edge, and will readily stay in place if slightly club-shaped at its upper end. If the plug is hollow, irrigation can be practised through it without the necessity of removing it every time. Food does not enter through a small opening. Without plug the fistula would close rapidly by

FIG. 47. Hand drill for the maxillary antrum.

granulations. The patient learns easily to irrigate through the opening, using warm sterile salt or boric acid solution in a rubber bulb syringe with pointed nozzle. There is no natural drainage through the opening, as the fluid is too viscid, and the opening is not necessarily at the lowest point of the sinus.

The puncture through the alveolar process, known as Cowper's operation, gives immediate relief from all symptoms, but cures only a fair minority of cases, especially those of dental origin. If the secretion does not diminish steadily in the course of weeks, and has not ceased entirely after the lapse of from three to four months, no further improvement can be expected, except from a more radical operation. Comfort, however, can be secured as long as the opening is patent and irri

gation is practised. When no more secretion is found, the opening should be maintained about two weeks for a further test before the plug or çannula is withdrawn permanently. If a scanty secretion still persists, it will become noticeable again during a week or two of intermission. Upon withdrawing the rubber plug the opening shrinks within about one week to a fine fistula, which then closes more slowly. If a foreign body gets into the sinus through the opening, the suppuration continues until it is removed.

51. Drainage into the inferior meatus of the nose is preferred by some operators to Cowper's operation. In several recent reports by German and American observers this operation has been highly praised, although most rhinologists have formerly found it objectionable. A stout curved trocar (Fig. 48) is thrust through the thick

FIG. 48.-Curved trocar for perforating the maxillary sinus through the nose.

nasal wall of the sinus underneath the inferior turbinal, and nearly 3 cm. behind its front end, the instrument pointing slightly upward. In spite of cocain this is apt to be painful. The opening has not so much tendency to shrink as the puncture through the alveolar socket. On the other hand, it is practically impossible to fit a cannula into it. It is more difficult for the patient and often more painful to learn to wash out the sinus through this opening. But it has been claimed recently that many cases heal even without irrigation, except during the first few days, if the opening is only kept patent. Insufflations of boric acid or iodoform have been practised with good results.

52. The obstacle to a permanent cure of maxillary empyema may be the existence of polypi or granulations in the sinus, or, less commonly, caries of its walls. Cases

not cured by irrigation through a small orifice require removal of the anterior wall. This procedure, known as Küster's operation, can be tolerated under cocain or nirvanin injection, but may require narcosis in the case of a timid person. A horizontal incision is made down to the bone below the canine fossa from the canine tooth to the second molar. At its front and rear ends the incision is curved upward in order to form a flap. The periosteum is detached upward, and the thin anterior wall of the sinus perforated either with a large trephine run by a motor or with a chisel. The opening is enlarged with bone nippers until a fair view can be had of the interior of the sinus. If the probe or inspection reveals no extensive changes in the interior, the operation may be considered finished. The view at the time is, however, often hindered by bleeding. A tampon of iodoform gauze is then inserted for a couple of days. After that time the interior can be inspected, and polypi and patches of granulations can be removed under cocain anesthesia. A rubber obturator plate is then to be fitted by a dentist. The patient irrigates several times daily, and the cavity is inspected from time to time in order to treat surgically any hypertrophy of the mucous membrane or patches of granulation. The healing always requires a number of months. A large opening will persist without harm for a long period or indefinitely.

When inspection shows extensive changes in the cavity at the time of the operation, or when such changes can be assumed on account of rebelliousness to previous treatment through a former opening, a more radical operation is to be performed. The entire anterior bony wall is then to be resected, and, after thorough curetting of the interior, the anterior flap of periosteum and mucous membrane is pushed into the cavity after loosening it by two lateral vertical incisions. It is then made to cover the denuded walls by tamponing. In extreme instances Boenninghaus has added to this operation the removal of the nasal wall of the sinus by careful chiseling from the

side of the antrum. He thereupon pushes the mucous membrane into the sinus from the nose, and thus practically covers what is left of the sinus walls with healthy. mucous lining from the nose and from the gum. As cicatrization proceeds very slowly over the denuded sinus walls, the transplantation of Thiersch grafts has been practised to advantage. The healing requires many months, but ultimately an entire cessation of secretion can be obtained.

A similar but less radical operation has been practised by Caldwell and is warmly indorsed by Luc. The anterior bony wall is lifted up in the form of a flap with base up by chiseling and finally breaking the bone. The cavity is inspected and treated, and a counteropening is made into the nose. The diseased lining of the sinus is thoroughly destroyed by swabbing with a saturated chlorid of zinc solution. After a gauze drain has been placed through the nasal opening, the anterior flap is replaced and sutured.

CYSTS IN THE MAXILLARY SINUS.

53. Autopsies and surgical explorations have shown the frequent occurrence of cysts in the maxillary sinus, sometimes with very little concomitant disease of the mucous membrane. They are either retention cysts, originating from the mucous glands, or edematous accumulations in the interior of polypoid hypertrophies. The contents are usually a clear, yellowish, viscid fluid which coagulates spontaneously. Glandular cysts may also have purulent contents due to secondary infection. The symptoms due to cysts are vague. Probably no annoyance is caused in many instances. In others they may induce nasal irritability. Local discomfort, headaches, and illdefined neuralgic pains are sometimes produced by them, and are relieved by treatment. If not accompanied by empyema or not purulent in themselves, these cysts cannot be recognized with certainty. Translumination usually shows a suspicious reduction of translucency, but