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Buffalo Medical Journal



PKKSENTKD BY
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BUFFALO

MEDICAL JOURNAL



EstabUshed 184S by AUSTIN FLINT M. P.



EDITOR:

A. L. BENEDICT, M.D.. Bufifalo



ASSOCIATE EDITOHS:

GROVER W. WENDE. M.D., Bufifalo
CHARLES W. HENNINGTON, M.D., Rochester

Syracuse

FAYETTE H. PECK, M.D.. Utica
MARTIN B. TINKER. M.D., Ithaca



VOL. LXVII.

Auguat, 1911 to July, 1912

BUFFALO, N. Y.
1912

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BUFFALO MEDICAL JOURNAL

Vol. Lxvii. AUGUST, 1911. No. i

ORIGINAL COMMUNICATIONS



Latent Sinusitus

By GBORGB P. COTT. M.D.
Buffalo. N. Y.

THE four sinuses of the skull, frontal sinus, ethmoid cells,
sphenoid sinus and antrum of Highmore, have been made
the subject of many papers. The antrum of Highmore, however,
held the field against all comers and was referred to the dentist
mostly, as properly belonging to his field for treatment; and
perhaps justly so, since so often the antrum became infected
through the root of a tooth. About twenty years ago, how-
ever, during the epidemic of American grippe so aptly de-
scribed by Carl Seiler in Burnett's Otology, conditions
changed. The other sinuses became more involved and were
left crippled to give further trouble years later. The immedi-
ate effect of the epidemic was to leave the cell cavities denuded
and the nerves exposed lying upon the bone unprotected
by their periosteal covering which left them in a condition
readily to be acted upon by some peculiar irritant in the air.
The apparent causative factor is a mixed infection not due to
the influenza or grippe germ. In our city, as observed by
me since the first epidemic, the antrum of Highmore became the
offending organ a number of years after the epidemic. Pus was
invariably found upon opening that cavity, always denuded of
its membrane, and at times foul granulations and quantities of
polypoid degenerations were removed, with uniformly good
results. After the ani^ui. disease had run its course the eth-
moid cells became troublesome and for several years they re-
ceived apparently exclusive attention. Then that subsided and
the frontal sinus came into play. The sphenoid then showed
considerable unrest and was heard from next with all its dire
consequences. During 1^10 the maxillary sinus again became
very prominent in surgery. In other parts of the country the
rotation was not so exact as I have noticed it, the different sin-
uses receiving attention from time to time and had to be radical-
ly treated.

Disease of the sini ^s is far more common in the adult than
in children because , fi.st the sinuses are not so fully developed



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2 cott: latent sinusitus.

in the young, and secondly they seem to be more or less
immune as compared to the adult ; per contra, the child suffers
much more frequently from involvement of the middle ear from
disease of the throat thru the Eustachian tube than does the adult.
The sinuses are located as follows: Frontal sinus in the
frontal bone, its inner wall forming part of the outer wall of the
cranial cavity. It communicates with the brain by blood vessels
perforating the inner plate.




right optic nerve more exposed than left

The ethmoid cells are located immediately under the frontal
lobes in the median line, the separating cortex being very thin
and perforated by numerous foramina for the olfactory nerve.
The anterior and posterior ethmoid arteries and nerves also pene-
trate the bone.

The sphenoid sinuses are located in the body of the sphenoid
bone separated from each other by a thin bony septum. They
are very irregular in shape; the one often differs from its fellow
of the opposite side. All these sinuses occur in pairs. The
optic nerve runs close by the sphenoid sinus and sometimes
encroaches upon its cavity, as will be noticed from the plates.

The antrum of Highmore lies in the superior maxillary bone
and its outer wall forms the prominence of the cheek; its inner



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COTT : LATENT SINUSITUS. 3

wall — thin plates of bone — forms part of the outer wall of the
nasal cavity and its roof is composed of the orbital plate. The
second branch of the fifth nerve runs along in a groove under
the orbit and occasionally penetrates its plate.

These different sinuses are covered with periosteum and
mucous mwnbrane. They all open into the nose, as follows : the
frontal sinus through the infundibulum opens into the middle
meatus ; the anterior ethmoid cells and the the antrum of High-
more likewise into the middle meatus.



OPTIC NERVE




/Jy, /^t^-^^^



OPTIC NERVE AT MARGIN OF POSTERIOR ETHMOID CELL

The posterior ethmoid cells open into the superior meatus
with the sphenoid sinus. Thus it will be seen that infection can
readily enter any or all of these air spaces thru their natural
openings.

These spaces are natural cavities in the bones of the skull
and are developed as follows : The frontal sinus is absent at birth,
develops about the 7th year of life and gradually increases un-
til the age of 20. They are often unequal in size and vary in
extent in different individuals. Some are very small on one or
both sides and sometimes extend away up into the frontal bone.
The cavities may contain trabeculae of irregular siz.e.



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4 cott: latent sinusitus.

The sinuses are separated by a septum which may contain
an opening. Occasionally they communicate with a cell in the
Cnsta Galli. In a few cases it has been noticed that the sinuses
are not developed at all.

The ethmoid cells are not developed until the fourth year,
exceptmg perhaps the rudimentary bulla and another small
space. The outer surface of the lateral mass of the ethmoid is
formed by a thin plate of bone called the os planum or lamina
papyracia and forms the inner wall of the orbit. In some cases
this plate of bone never develops and the sinuses are separated
from the orbit by membrane only.

OPT^IC NeF?V£



Of^ric NE




^ >©»-w-^^




BOTH



NERVES OUT OF DANGER
ZONE



ONE NERVE IN DANGER OF INFEC-
TION



The Sphenoid sinuses do not exist in early childhood but
develop after the seventh year, or from that to the twentieth.
Occasionally one sinus or both may be absent. In his investi-
gation Onodi has found thirty-eight varieties of sphenoid cells,
that is in shape, size, location and difference between the two
cavities. One may be very much larger than the other. They
increase in size as age advances. They have been found to ex-
tend in the pterygoid process and base of the greater wing of
the sphenoid bone or extend into the basilar process of the occi-
pital bone nearly to the formen magnum (Gray).

The antrum of Highmore is rudimentary at birth and gradu-
ally increases to its full size at puberty.

I have gone into some detail regarding the anatomy of these
sinuses because operations are so frequently performed upon
them by surgeons and near-surgeons. If the peculiar and varied
shapes and sizes of the different cavities are not borne in mind
some avoidable accidents with most serious consequences are
apt to follow.



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cott: latent sinusitus. 5

To come back now to the diseases which commonly affect the
sinuses. The antrum of Highmore was mostly infected from
carious roots of teeth, occasionally by zymotic disease so com-
monly affecting the throat and nose; but since the advent of
grippe or influenza all other causes have been put into the
«ihade and the millions of sinus cases now extant are by a large
majority due to its destructive influence. Those of us who
practised during the epidemic twenty years ago know how seri-
ous were the cases we encountered daily ; pain in back and limbs,
nasal rhinorrhoea, after some days formation of pus in profuse
quantities in the nose, intense headache to the verge of delirium.




OPTIC CANAL RUNS THROUGH
SINUS




^PHENOIO SINUS

OPTIC NCRVC

CAROTIO ARTCRV



^ An-^



CLOSE RELATION OF SPHENOID
SINUS AND OPTIC NERVE



Since we know more of the effects produced by this virulent
poison we can readily explain the source of pain. The dura
mater is supplied with nerve filaments from the sympathetic,
the 4th, oth and 12th nerves while the pia mater is supplied by
filaments of the 3rd, 5, 6, 7, 9, 10 and 11th cranial nerves, some
of these as you will observe are motor nerves, but each one receives
sensory filaments from the tri-geminus, glosso-pharyngeal
or pneumo-gastric. The effect of pain is not due to brain in-
volvement but to neuritis which may extend throughout the sen-
sory nerve influence, though brain abscess or meningitis has
occurred principally when pus was found in the sinuses. In
the present state of sinus disease however, we do not always
find pus, the sinuses usually being dry, but the nerves exposed
and through some peculiar external irritation the mucus mem-



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6 cott: latent sinusitus.

brane of the nose becomes swollen, drainage becomes defective,
or, where this is not the case, the peculiar irritation acts upon
the exposed nerves without the nasal mucous membrane having
become involved primarily jmd causes neuritis with all its pain-
ful and destructive influences.

In the first epidemic, pneumonia was a great source of reve-
nue to the undertaker. Most all patients who had a severe at-
tack of grippe at that time or since and escaped pneumonia iaind
apparently recovered have had some defect which lowered their
resisting power. One of these is denudation of the sinuses and
exposure of the nerves either one or more, and these lie quiescent
until some sort of semi- or quassi-epidemic calls upon this sen-
sory nerve supply to help along the inglorious work of pain.
One of the principal symptoms is pain and this is of so intense a
nature that the patients have actually been adjudged insane by
relatives and advised to have them removed to the custody of
keepers. In others there was intense pressure immediately above
the eyes, sufficient to keep them from their usual occupation ; still
others had severe pain on top of the head and others at the base
and cerebellum ; in some supra-orbital ; in others infra-orbital pain
of intense character, which nothing relieved. I know of two
cases of pain in the second division of the 5th in which finally the
nerve had to be drawn out and then the patients did not recover
for months afterward. Of the ntimerous patients suffering now,
and during the past year, I have met but three who actually had
pus in the sinuses. One of these had pus in all the sinuses which
were not influenced by any drainage or washings out, and has
since died 6f tuberculosis, the other two were antrum disease.
One complained of foetid discharge, the other of discharge and
pain of the second division of the fifth and supra-orbital region.
In both the antrum contained foul smelling granulations.

These patients also suffer mentally not to a point of insanity
but sufficiently to keep them from attending to business or work^
At times during the wet, damp or dusty season they complain
of mouth breathing, or of easily catching cold, winding up with
purulent discharge. These so-called colds are not easily amen-
able to treatment but seem to extend over several weeks or
months before they can be made to yield. In addition to the
swelling of the mucous membrane of the nasal cavities we find
the throat affected ; this however is usually cursorily only, but
the trachea suffers most, and occasionally the bronchi. Re-
cently some feebly resistant patients were furthermore afflicted
by developing pleuropneumonia with an accumulation of fluid in
the pleural cavity which when withdrawn consisted of blood in-
stead of serum or pus (Buswell). What other phase this terri-



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COTT : LATENT SINUSITUS. 7

ble scourge will next exhibit we must anxiously await. I cer-
tainly believe that in the last twenty years more people died of
grippe, or its consequences than many destructive diseases put
together, the certificate of death giving the cause as some partic-
ular ailment, but fundamentally due to latent grippe.

The principal objective symptom affecting the trachea is in-
tense congestion down to and beyond the bifurcation. The mu-
cous membrane of the pharynx and larynx is generally involved.
The subjective symptom is cough, which may occur every few
minutes and often spasmodically during the night keeping the
patient from sleep. This cough consists more of a bark than
anything else, causing pain in the lower chest due mostly to
muscular strain and to sensitive nerve areas at the bifurcation,
spasm of the glottis, headache and fatigue due to want of rest.
Exceptionally is anything raised by the tremendous exertions.
This tracheitis often lasts a month or two but finally improves
with or without treatment.

The pain can often be traced to branches of the fifth nerve
although the glosso-pharyngeal and pneumogastric play an im-
portant part in its production. It differs from neuralgia by first
being traced to a specific cause and not of that peculiar period-
ically intense nature affecting a certain nerve but of a constant
depressing or pressure-like pain, unless a separate branch is
affected when the pain will be so intense that death seems pref-
erable to these patients than to bear it. The pain may show itself
in other parts of the nerve not periodically as we commonly find in
neuralgia but lasting indefinitely, of varying intensity not at all
uniform in character, but in its different varieties lasting over a
long period, recurring milder and milder, say for several years.
A very important difference between neuralgia and neuritis in-
volving the cranial nerves is the effect of treatment. Neural-
gia is obstreperous and obstinate, while neuritis yields quite read-
ily, in many cases immediately and permanently while in others
cessation of pain is apparently a remote effect of treatment while
in a third class all symptoms vanish to re-appear, mildly or
severely for a few weeks then stay away; a few remain severe
whenever an attack occurs.

Thus, has been this peculiar cycle of the latent effects of
grippe. The antrum of Highmore suffered mostly for several
years and was usually only relieved by operation. Following up-
on this we had a period of ethmoid disease also relieved by opera-
tion; then the frontal sinus caused more trouble, and the others
seem to have been forgotten, excepting the sphenoid, which
lately sprang into prominence and now again the antrum of
Highmore. I do not mean that these different sinuses are not
in a receptive state but irritation seems by predilection to call



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8 cott: latent si nusitus.

forth symptoms referable to a particular sinus only, or the
nerves connected with that sinus.

For purposes of diflferentiation let us divide the sinus affec-
tions into suppurative, hyperplastic and dry stages, the latter be-
ing the latent stage or that one following suppuration. The
suppurative and h)rperplastic stages may and do occur independ-
ently while the dry stage always follows suppuration.

The latent stage seems harmless unless called into activity
by some irritant. Such patients are susceptible to rapid changes
of temperature, to dust and to hig^h humidity. They complain
of colds which do not seem to get well. The secretion when
present in such cases is viscid and commonly clings to the pharjm-
geal wall and occasionally the effort to remove it causes vomiting ;
when abundant it escapes down the oesophagus at night causing
indigestion and diarrhea and consequent emaciation in instances
to a point of starvation. In another class of cases in this stage
the mucous membrane and periosteum have been destroyed and
the nerves exposed. Now when drainage has been obstructed,
either pneumatic or exudative, there is always a chance for
trouble. This may come during subacute attacks or periodical
colds or without any apparent cause. The commonest remote
effect is neuritis involving principally the fifth nerve. Now if we
lollow up the distribution of this sensory nerve we readily find
an answer for the causation of the severe pain. I do not lay
much stress upon the so-called localized meningitis in those
cases of long standing but consider them nearly always as neuri-
tis. Compare their actions with nerves inflamed anywhere else
in the body; the result is practically the same. Very many pa-
tients recover and a few withstand their sufferings for years.

A very important effect of latent sinusitis is blindness. The
sphenoid sinus and the optic nerve are very close associates, and
may be in actual contact by dehiscence, or weakening of the optic
canal where it forms a part of the sinus wall and thereby the
nerve easily becomes infected producing optic neuritis and conse-
quently blindness, as I would apply the term deafness, being of
all degrees. We may have only certain areas affected which is
designated as scotoma, or the entire fundus may have become in-
volved. None of the dozen or so cases which I saw lately were
totally blind because the infection is very much milder than that
causing pus formation. This blindness seems to come on quite
suddenly, perhaps over night and gradually seems to grow worse,
usually accompanied by a sense of pressure over the eyes or on
top of the head. In a few patients no subjective symptoms were
present. The symptoms seem so sudden that fortunately the
patient seeks to ascertain the cause of the defect of vision. Nor



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snow: colds — ^their causes and treatment. 9

is the faulty vision very mild; some cannot distinguish objects
across the room while others cannot make them out a foot from
the eyes. Where certain fields of the nerve are aflfected moving
objects can only be seen at a certain angle or in an irregular
circle in extreme divergence or near the median line then again
vanish. Happily the present quassi-epidemic is within our
power and patients can usually be relieved by operation; some
however have been suflfering for several years and were quite or
totally incapacitated from work of any kind. Their trouble was
not diagnosticated for a long time, but after once located and
treated gradually recovered.
1195 Main Street.



0>lcb— Their Causes and Treatment^

By SARGENT P. SNOW,
Syracuse. N. Y.

EVERY Otologist and laryngologist who attempts to handle
a chronic case has before him at once the problem of con-
trolling the many acute colds of inflammations that occur in the
membranes of the nose and throat.

These inflammatory actions are often so slight that the pa-
tient has not noticed them, but we find them so frequently that
they interfere seriously with our eflforts to the extent that often
in ear affections it is unwise to encourage local treatment.

For fifteen years the reader has groped after the cause of
these recurring membrane disturbances thinking at first they
were caused entirely by morbid intra-nasal states, but later de-
cided that there was always an underlying systemic factor to be
held responsible. What exact trouble this was seemed obscure,
and it was only since I began a closer study of Auto-Intoxica-
tion four years ago, that I have felt I had a sufficient grasp of the
situation to say what this systemic factor was.

In opening the subject of head colds I must ask your indul-
gence for not quoting authorities and literature, as I have been
unable to find time to take up the matter from that standpoint.
This attempt then can in no way be called classical, but I ear-
nestly ask that the views set forth shall have a few moments of
your thoughts.

Auto-toxic colds, colds from self-poisoning, or common colds
if you like, in the opinion of the reader is a condition induced
primarily by toxic substances developed within our own body,
a self-poisoning from our own bacteria, or in other words, a
nitrogenous auto-intoxication of microbic origin.

1 Read at the forty-third annual meetlnflf of the Central New York Medical As
•ociation held at Syracuse. October 19 and 20. 1910.



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10 snow: colds — ^their causes and treatment.

Active inflammation and fever usually mark the limit of
toleration by the system for toxic materials. Such an inflam-
mation is an auto-toxic explosion or crisis of elimination; in
other words, a cold is the expression of an auto-intoxication
showing itself in the mucous membranes. Those infective in-
flammations or influenzas produced by bacilli developed outside o^
of the body, as pointed out by Combe some years ago, are more
properly termed Intoxinations, not Intoxications.

It is now a well accepted fact that our intestinal tract is sup-
plied with digestive bacilH that are capable of becoming very
abundant and pernicious if not kept under proper subjection by
active secretions from the intestinal mucosa, Kver and anti-toxic
glands. These three barriers protect the body from the harm-
ful actions of those digestive bacteria while our glands are kept
in healthy activity, but if the healthy activity of the intestinal
mucosa and liver is impaired, then our body is not producing
anti-toxins sufficient to protect us and we become a prey to our
own bacteria. The system then becomes Auto-Toxic.

According to Combe on Auto-Intoxication, (see page 9), Mar-
fan is quoted as follows : — "We may say that the microbes inter-
vene actively in all digestive processes, but that besides their
undeniably useful role, it is also undeniable that their action



Online LibraryAlexander MackenzieBuffalo medical journal → online text (page 1 of 76)