a tendency to drain these cavities and ventilate them. It is for this reason that many patients with a perfectly unobstructed inferior meatus which is so patulous that it is apparently more than sufficient for any respiratory function, still complain of nasal obstruction.

In these cases the obstruction of the middle and superior meatus forces the air in an unnatural direction along the inferior meatus and a sense of fulness and obstruction is felt at the bridge of the nose. The anterior third of the middle turbinate occupies an area into which empty the frontal and maxillary senuses and also the anterior ethmoidal cells. The middle turbinate itself not infrequently contains a pneumatic cell at this point and a cystic condition of this cell may enlarge the middle turbinate to an enormous extent. Successive inflammations from colds and chronic catarrh cause such a charge in the formation of the anterior end of the middle turbinate that it may completely and permanently block the nose in this region.

The effect of such blocking on the adjacent cavities is to cause a stagnation of the secretions and a low grade inflammation. This produces mental dullness and headache. These symptoms are further increased if a negative pressure or partial vacuum obtains in these cavities similar in nature and cause to that obtaining in the middle ear when the eustachian tube is obstructed.

When an acute infection is imposed on this condition and the cavities become filled with pus or mucopus, there is a positive pressure produced.

In considering the symptoms of this condition I will embrace under the classification of the upper nasal passage the frontal, maxillary and ethnoidal cavities, as a severe infection in this region is usually general among these cavities and does not confine itself to any one particular cavity. An exception must be made of a maxillary sinus infected from a tooth. In the quiescent form of ethmoiditis the main symptom is headache. This may be of daily occurrence but more frequently comes on at irregular periods. The diagnosis of the cause of this headache is frequently rendered difficult by concomitant conditions which act as exciting factors in producing it. These may be mental or bodily fatigue, constipation, intestinal auto intoxication, or the headache may come on with no remote exciting cause discoverable but with no local pain in the nasal region to direct attention to it. The headache is generally frontal or behind the eye. Occipital headaches are not infrequent, especially when the posterior ethmoidal cells and the sphenoidal

sinus are at fault. In some cases refractive or muscular errors of the eyes complicate the situation. The correction of these errors in the ocular function is necessary but if the ethmoid disease is present the surgeon will have to give it attention before the patient will obtain relief. It is such cases that often seek relief fruitlessly by innumerable changes in their lenses. .

When there is some elevation of the temperature combined with intestinal disturbance the picture may simulate typhoid.

Ethmoiditis in its quiescent or in its acute form is not infrequently found in children. A succession of colds in the head without complete resolution produce an ethmoiditis. These cases are usually accompanied by adenoids and on removal of these growths the expected relief in respiration is not experienced owing to the blocking of the middle meatus. The failure to secure free nasal breathing is often then wrongfully attributed to an incomplete operation, or to a return of the adenoids and with this idea repeated scrapings of the naso pharynx are performed all without relief to the nasal obstruction. These children will be found to be trying to carry on nasal respiration entirely through the contracted passages along the inferior turbinate, the middle turbinate perhaps completely blocking the upper half of the nasal chamber. In these small children, ranging from five to twelve years of age, an operation under local anesthesia is impossible and the anterior ends of the middle turbinate must be removed under general anesthesia. The fullness of the bridge of the nose seen in the adenoid face is frequently caused by the pressure on the nasal bones by the stoppage of the middle and superior meatus.

The tympanic cavity is often spoken of and considered as one of the accessory cavities of the nose, and many chronic middle ear catarrhs with their resulting deafness are primarily due to the defective condition of the ethmoid. The orifice of the eustachian tube is bathed and clogged by the secretions of the diseased posterior ethmoidal cells and the air passing into the naso pharynx is insufficiently warmed and moistened.

In considering the bacteriology of the nasal passages I shall refer very extensively to the work done recently by A. Logan Turner of Edinburgh. He and Lewis found from twenty-six specimens of the secretions of healthy noses only three were sterile. Allan from the examination of twenty normal noses found none sterile. The staphylococcus, streptococcus and penumococcus were the bacteria most frequently found. C. E. West concludes that the bacterial flora of the healthy nose differs very little in variety from that found in chronic catarrh.

Owing to the difficulty in obtaining uncontaminated swabs from the accessory cavities the cultures had to be made from the cadaver as soon after death as possible. From Törne's work the evidence seems to show that the healthy accessory cavities are in life free from bacteria.

In acute and chronic fronto-ethmoidal sinus suppuration, Turner found in twenty-two cases which were operated upon, pneumococcus 36%, streptococcus 40%, staphylococcus 45%, with a bacillus closely resembling the influenza bacillus in one case. In forty-three cases of maxillary sinus he found pneumococcus 30%, the streptococcus in 76% and the staphylococcus in 79%, the B. influenzae in one, the T. B. in one, and the micrococcus catarrhalis in two. In the healthy nasal cavities the bacteria are few in number, of low vigor and little virulence, while in the acute inflammatory conditions they are numerous, vigorous and often very virulent.

While acute infection of the ethmoid is generally limited to the nose with possible involvent of the ear, it extends to other structures. The following is a case in point. Miss Carrie Westergaard was seen in consultation with the physician who saw the case for the first time the day previous. The patient, a young woman of 20, was delirious, temperature 104, head drawn back and slightly to the left side, neck stiff and very painful on motion of the head, the left eye was bulging from the socket and immovable. The mother stated that the girl had had a headache and discharge from the nose three years ago but that the condition apparently entirely cleared up. For the past week the patient had been suffering with severe pain behind the left eye and purulent discharge from the left nostril. Three days ago she became worse and the condition of exophthalmos and delirium commenced at that time. The nose was cocainized and examined and pus was seen draining from under a swollen middle turbinate. Death ensued sixteen hours later.

The acute infections of this region are generally known as grippe, cold in the head and neuralgia. They are generally ushered in suddenly with extremely severe pain, some rise in temperature, deep pain in the eye on the side affected, with some swelling of the lids and photophobia and lacrymation. The mental disturbance may be sufficient to produce delirium. The pain at first constant, usually soon resolves itself into daily or bi-daily exacerbations which return at very regular hours. The discharge of pus is not proportionate to the symptoms but examination of the nose will show a line of pus forcing its way between the middle turbinate and the nasal wall and contraction

of the middle turbinate by cocaine application on a probe, passed between it and the lateral nasal wall, produces instant relief. The pain is sometimes so severe as to take in the whole distribution of the fifth and the whole side of the head is the site of a severe neuralgia. Many of these cases are bedside cases and it is impossible and also unnecessary to diagnose which particular cavity or group of cells is affected, as the same treatment is indicated in all.

The treatment of the acute condition in brief is contraction of the middle turbinate. Cocaine is the only drug that should be used for this purpose. Adrenalin produces such secondary exudation, irritation and swelling that its use is contraindicated. The cocaine is better applied in a 4% solution on a cotton applicator, the applicator being passed between the end of the middle turbanate and the nasal wall. If the patient is so situated that this cannot be done by the surgeon personally a fine spray of 2% cocaine may be given to the patient or nurse with instructions to use very sparingly. It should be impressed on the druggist that these prescriptions should be marked "no repeat" so that there may be no danger of a habit being formed. After the parts are contracted a cleansing alkaline water solution should be used, the best in my opinion being a modified Dobell's solution. This may be followed by an oily spray containing menthol by means of which the contraction of the parts may be maintained for a longer time. Hot moist applications over the whole face seem to reduce the pain and promote drainage. General measures do much to improve the condition of the patient and shorten the attack. Aspirin, the salicylates, phenacetin, quinine and salol may be used as indicated and free catharsis will lessen the local congestion and pain.

I do not find it necessary in these acute cases to attempt any irrigation of the frontal or maxillary sinuses unless there is trouble in the maxillary antrim which can be traced to a carious. tooth. The vacuum treatment by negative air pressure gives a great deal of relief in many of these cases, though I do not consider it has as great value as it has in the subacute or chronic

cases.

The treatment of the chronic cases consists in removing by surgical measures any obstruction to thorough drainage. These obstructions are generally either an enlarged condition of the middle turbinate, polyps or a nasal deflection. After the obstructions are removed an, attempt should be made by washes to cleanse the cavities and it is generally necessary to continue

this cleansing over an extended period of time, aiding the drainage when possible by the use of the vacuum.

In conclusion, in obscure cases with headache or obstruction to the respiration I would urge a very careful examination of this upper nasal cavity with the parts thoroughly contracted by cocaine. 400 Brandeis Theatre Building.

Paranoia and Paranoid Dementia.

*By L. B. PILSBURY, M. D., Lincoln, Neb.

These two forms of mental trouble are not properly in opposition to each other, on the contrary the dividing line is at times perplexingly uncertain. To be sure there are certain criteria of true paranoia, a rare disease by the way, which mark it as an entity when these criteria are plainly in evidence. In part they are of a negative nature, that is to say, certain things must be wanting before we are justified in making a diagnosis of paranoia. Most important of these is mental deterioration. Dementia is incompatible with paranoia in the beginning. One might infer from this that the diagnosis would be easy. In practice it is not so because of the infinite gradations possible in the impairment of judgment, will, memory, etc. Insane persons differ one from another just as do normal individuals. Rarely is the individuality of the patient entirely extinguished even in the most profound grades of dementia. Some trick of expression, some stereotyped or automatic movement, some characteristic reaction will remain in practically every case. In paranoia we have the slightest or perhaps one should say the most narrowly circumscribed impairment of judgment that is to be met with in true insanity. Even here one is likely to underestimate rather than overestimate the real degree of impairment. The patient thinks much and perhaps talks much of some predominant impression, some delusion, which is as a rule eagerly cherished. Rarely is the patient indifferent toward this impression and I question whether he is ever so in true paranoia. Such an attitude in a young individual would suggest the presence of one of the forms of dementia praecox. The very vividness of the predominant impression or impressions may make it difficult for us to ascertain the attitude of the patient toward other matters. When he is reticent concerning even his predominant impressions the difficulty is of course

*Read before the Nebraska State Medical Association, Lincoln, May 7-9, 1912.