m I 1 ■ l • THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY CONCERNING SOME HEADACHES AND EYE DISORDERS OF NASAL ORIGIN CONCERNING SOME HEADACHES AND EYE DISORDERS OF NASAL ORIGIN BY GREENFIELD SLUDER, M.D. CLINICAL PROFESSOR AND DIRECTOR OF THE DEPARTMENT OF LARYNGOLOGY AND RHINOLOGY, WASHINGTON UNIVERSITY MEDICAL SCHOOL, ST. LOUIS. WITH 115 ILLUSTRATIONS ST. LOUIS C. V. MOSBY COMPANY 1918 Copyright, 1918, By C. V. Mosby Company Press of C. V. Mosby Company St. Louis Biomedieal Library WY TO THE MEMORY OF JOHN BATES JOHNSON, M.D. (HARVARD) PROFESSOR OF MEDICINE IN THE ST. LOUIS MEDICAL COLLEGE (LATER THE MEDICAL DEPARTMENT OF THE WASHINGTON UNIVERSITY) FROM 1853 TO 1903. WHOSE FRIENDSHIP HAS BEEN INSPIRATION AND STRENGTH THROUGHOUT MY LIFE PREFACE My interest in the subject matter of these pages com- menced in 1894 when my friend Dr. Arthur E. Ewing began what was to be a convincing argument, that the i ' asthenopics ' ' delineated in Chapter I were really not eye cases but "nose cases of some kind not yet understood.' 1 It is therefore easy to understand a deep sense of gratitude and obligation on my part for not only the novel idea but the material for the study and determination of the underlying facts. It resulted in my be- coming a rhinologist and abandoning internal medicine for which I had made elaborate (ten years) preparation. Very early were added the influence of my friends Dr. M. H. Post and Dr. John Green to the argument of Dr. A. E. Ewing, all renowned ophthalmologists. From then until now my interest in the nasal factors of headaches and eye lesions has been deep and constant. During these years much has been written on this dual subject, a complete bibliography of which would serve little or no purpose for the present text, aside from the labor of supplying it. The suppurative nasal diseases have been learnedly pre- sented by Dr. Ludwig Gruenwald in Die Lehre der Naseneiter- angen 1892, and later elaborated and much valuable informa- tion added thereto by Dr. Marcus Iiajek in Die entzundliche Erhranhungen der Nebenhoelen der Nase, 1899. To Doctor Hajek as my teacher — 1896 to 1898 — I owe a great debt of grat- itude. I soon learned however that the cessation of the nasal suppuration was not always the cure of the case by any means. In the effort to solve the questions for such patients the tis- sues removed from their noses were submitted in vain to many pathologists, some of them being the most renowned of their day. They remained a closed secret until 1909 when I pre- sented the specimens to Dr. Jonathan Wright. He at once read the story from the tissues presented by virtue of his learning as a rhinologist combined with that of the pathologist (a rare combination). It will therefore be easy to understand my deep 9 10 PREFACE obligation and gratitude to Doctor Wright for this inestimable service, in which I feel that both rhinologists and ophthalmol- ogists should unite. He has been good enough to furnish me with a summary of the general remarks he has had to make in our discussions of the subject now extending over a period of a number of years and has illustrated the points he has wished to emphasize by a number of drawings. This material I have employed as an introduction to the pathological aspects of the subject. Some macroscopic anatomical observations will also be found here. In large part I am indebted to my friend Dr. Eob- ert J. Terry, Professor of Anatomy, Washington Medical School, St. Louis, Mo., for much of the material upon which these observations were made. They date from 1898 when I began observations on the sections of decalcified skulls. From then until now I have recorded no anatomical conclusions with- out consultation with Doctor Terry. It is with great pleasure that I acknowledge this debt, no mention of which heretofore has had his permission. During the winters of 1896 and 1897 it was my privilege to be a student in the Physiological Laboratory of the University of Vienna under the guidance of Professor Sigmund Exner. There I was given chance for much elementary study of the nose and throat and witnessed much research upon the larynx. I was also guided in some research efforts. I feel that that opportunity was a most fortunate one. It had much to do with establishing my point of view which in large part has finally crystallized out in the observations here recorded. From then until now I have ever borne Professor Exner a deep feeling of gratitude and affection for his kindness, generosity, patience and wise guidance. Greenfield Sltjder. St. Louis, Mo., U. S. A. June 1, 1918. CONTENTS PAGE Introduction to the Pathological Anatomy, by Dr. Jonathan Wright . 17 The Nose. — A General Consideration 25 Headaches in General 27 Headaches of Nasal Origin 29 Megrim 29 Chapter I. — Vacuum Frontal Headaches with Eye Symptoms Only . . 30 Clinical Picture 32 Ewing's Sign 32 Gross Etiology 34 Anatomy of the Middle Meatus 35 Pathology and Method of Closure 47 Differential Diagnosis 53 Headaches from all Causes and their Differentiation 54 Prognosis 54 Treatment 54 Vacuum Ethmoidal Headaches, with Eye Symptoms Only 56 Vacuum Maxillary Antrum Headaches 56 Chapter II. — The Syndrome of Nasal (Sphenopalatine — Meckel's) Gan- glion Neurosis 57 Anatomy of the Nasal Ganglion 57 Topographical Anatomic Relations 61 To the Nose and Paranasal Cells 61 In the Sphenomaxillary Fossa 64 To the Walls of the Cells 65 To the Lateral Wall of the Nose 6^ Clinical Relations 66 The Neuralgic Syndrome with the Usual Forerunner 69 The Sympathetic Syndrome 70 Diagnosis 78 Differential Diagnosis 79 Prognosis 79 Treatment 82 Anatomic Considerations 82 Instrumentarium 89 Technique ^0 Chapter III. — Hyperplastic Sphenoiditis and Its Clinical Relations in the Environing Nerves; Namely, the Optic, Oculomotor Troclear, Trigeminus, Abducens and Vidian (N. Canalis Pterygoideus) Nerves and the Nasal Ganglion .... 96 11 12 CONTENTS Anatomical Relations 97 Clinical Relations Ill Differentiation of Nasal Ganglion Neurosis from the Syndrome of Hyperplastic Sphenoiditis 112 Dr. Jonathan Wright's Observations 117 Dr. Ladilaus Onodi's Observations 124 Explanation of the Headaches and Eye Disorders. Clinical Difference Between the Nerves in the Canals and the Sphenoidal Tissue 127 The Lesion in Children 128 Postoperative Results and the External Skull 129 Dr. Jonathan Wright 's Conclusions 129 Diagnosis 131 Source of Light 131 The Normal Post-ethmoidal-sphenoidal District 133 Distribution of the Morbid Process 134 Hyperplastic Post-ethmoiditis 135 Polyp Formation 136 The Wiping Action of the Soft Palate 137 Oblique Illumination of the Epithelium 138 Transference of Pus 140 Significance of Unilateral Lesion '.'" . 140 The Subdivided Sphenoid Body and Its Diagnosis 142 The Inequality in the Two Sphenoid Cells and Its Clinical Importance 145 Diagnosis in Children 145 Prognosis 149 Treatment 152 Surgery of the Paranasal Cells 154 Nerve-trunk Anaesthesia 160 The Operative Procedure 162 Maxillary Sinus Surgery 185 Case Histories 192: ILLUSTRATIONS FIG. PAGE 1. Osteoblasts 18 2. Hyperplasia of bone of sphenoethmoidal wall 19 3. Papillary hypertrophy of mucous membrane of sphenoidal sinus — rarefying osteitis 20 4. Rarefying osteitis 21 5 Chronic hypertrophy of middle turbinate body 22 6. Chronic hypertrophy of middle turbinate body 23 7. Showing where needle has been passed through the floor of the frontal sinus 30 8. Showing a dissection of the right orbit from above 31 9. Showing a needle passed from frontal sinus 33 10. Showing hiatus semilunaris infundibulum and frontal sinus in direct and uncomplicated connection 36 11. Showing ethmoid cell entering infundibulum from above and behind ... 36 12. Showing ethmoid cells entering infundibulum and hiatus semilunaris from above and below in front 36 13. Showing ethmoid cells entering infundibulum and hiatus semilunaris from above in front and behind and below 36 14. Showing hiatus semilunaris ending in blind pocket above infundibulum limited above by roof of nose 37 15. Bristle passed from frontal sinus into hiatus semilunaris 37 16. Showing ethmoid cells opening into hiatus semilunaris 37 17. Showing hiatus semilunaris ending in blind pocket above 37 18. Roentgenograms showing hiatus semilunaris situated unusually far back . . 38 19. Amputation of middle turbinate with the line of origin from the lateral wall. Cavernous tissue on the internal aspect of frontal pouch ... 39 20. View of lateral wall showing what appears to be normal conditions ... 40 21. View of lateral wall showing total absence of cavernous tissue. Otherwise apparently normal 41 22. Showing middle turbinate detached in its anterior two-thirds and turned up at bulla ethmoidalis 42 23. Bulla ethmoidalis in contact with processus uncinatus 42 24. Septum showing well-marked tubercle and deeply marked imprint of entire middle turbinate 43 25. Sagittal section showing relations of middle turbinate to the tubercle of the septum 44 26. Showing middle turbinate placed with free space between septum and lateral wall 45 27. Showing septum well marked almost like spur at the site of its tubercle . 46 28. Showing posterior spur and well-marked ridge with large tubercle .... 47 29. Cross section in posterior part of nose showing spurs above and below middle turbinate 48 30. Wood's metal casts of a narrow middle meatus 51 31. Wood's metal casts of a wide middle meatus 51 13 14 ILLUSTRATIONS FIG. PAGE 32. Wood's metal cast of a wide middle meatus with very wide frontal and ethmoidal pouches 52 33. Wood's metal cast of a wide middle meatus with very wide frontal and ethmoidal pouches 52 34. Showing nasal ganglion, Vidian nerve, and nasal palatal branches ... 59 35. Showing sphenopalatine foramen bounded above by sphenoidal sinus and in front by ethmoidal cells 62 36. Sagittal section 7 mm. lateral to the sphenopalatine foramen 63 37. Showing left sphenoidal sinus prolonged downward to form the anterior wall of the sphenomaxillary fossa 64 38. Showing anatomy of the nasal ganglion 65 39. Showing anterior face of right pterygoid process 66 40. Sagittal section 3 mm. lateral to the sphenopalatine foramen 67 41. Showing middle turbinate and sphenopalatine foramen 68 42. Showing pterygoid process projecting forward beyond the posterior limit of sphenopalatine foramen 83 43. Showing usual sphenopalatine foramen 84 44. Showing correct placing of needle . 85 45. Showing both straight and curved needles correctly placed 86 46. Showing nasal ganglion needle having passed across the sphenomaxillary fossa and then through the thin wall of a low set sphenoidal sinus . 87 47. Showing needle transfixing the middle turbinate 88 48. Showing needle having passed across the sphenomaxillary fossa .... 91 49. Straight needle 92 50. Left sagittal section 5 mm. lateral to sphenopalatine foramen showing post- ethmoidal cell above and beyond optic nerve 96 51. Showing prolongation of sphenoidal sinus around optic canal .... 97 52. Anterior and middle fossa? of skull seen from above 98 53. Showing an older representation of the sphenoidal sinus and the cavernous sinus 99 54. Cross transverse section of the cavernous sinus 99 55. The usual cavernous sinus with large cross section and great length ... 99 56. Cavernous sinus district 99 57. Cavernous sinus district showing foramen, cavernous sinus, and crista galli 100 58. Left middle fossa of skull showing foramen ovale separated from sphenoidal sinus by thin bone 100 59. Showing foramen rotundum, bone separating sphenoid cell from foramen rotundum 100 60. Top view of left sphenoidal district dissected 101 61. Shows a sagittal section of left side through the ophthalmic nerve .... 102 62. Sphenoidal cell showing columnar marking of the internal carotid artery . 103 63. Showing Vidian exposed in sphenoid sinus 104 64. Left Vidian canal deficient at point of indicator 105 65. Eight sphenoid cell 105 66. Showing paper-thin separation of maxillary nerve in foramen rotundum from sphenoid sinus 106 67. Cross section just anterior to anterior clinoid process 106 68. Cross section 106 ILLUSTRATIONS 15 FIG. PAGE 69. Cross section of sphenoid body through anterior clinoid process posterior to optic canals 107 70. Lateral part of sagittal section through line 10 of Fig. 69 107 71. Sagittal section between the foramen rotundum and Vidian canal right side 108 72. Sagittal section of specimen shown in Fig. 73 109 73. Showing the nasal (internal) surface of specimen 110 74. Sagittal section between foramen rotundum and Vidian canal, viewed from without . Ill 75. Showing a cell which appeared to be the sphenoidal cell 140 76. Same as Fig. 75 showing probe in lower cell. Upper cell. Sella turcica . 141 77. Showing an upper and lower subdivision of the sphenoid body .... 142 78. Showing an anterior and posterior subdivision of the sphenoid body . . 143 79. Showing subdivided sphenoid body 144 80. Showing probe in large undivided sphenoid body 145 81. Shows probe introduced into a very large sphenoidal cell downward to the bifurcation of the plates 146 82. Same as Fig. 81 taken from in front 147 83. Eight sphenoidal sinus extending into left side to border left optic canal 148 84. Two views of palate hook 148 85. Sluder's upper cell operation. Two views of the angle knife 165 86. Sluder's upper cell operation. Shows the angle knife introduced between the septum and middle turbinate 167 87. Sluder's upper cell operation. Same as Fig. 86, the knife has been passed a second time along the cribriform plate 168 88. Sluder's upper cell operation. Knife introduced sagitally under the middle turbinate 169 89. Sluder's upper cell operation. Shows the snare loop placed around part detached 170 90. Sluder's upper cell operation. Showing the line of amputation of the pendulous middle turbinate 171 91. Sluder's upper cell operation. Shows knife passed backward along cribri- form plate 172 92. Sluder's upper cell operation. Shows knife to have been reintroduced through uppermost part of sphenoidal cut 173 .93. Sluder's upper cell operation. Shows the Knight forceps introduced into the anterior face of the sphenoid body 174 94. Sluder's upper cell operation. Shows the Knight forceps in position to bite out the post-ethmoidal wall which has been cut loose 175 95. Sluder's upper cell operation. Shows post-ethmoidal wall in grasp of forceps 176 96. Sluder's upper cell operation. Shows a three-quarter view of specimen with operation completed 177 97. Sluder's upper cell operation. A three-quarter view of a post-ethmoidal forceps made right and left 178 98. Sluder's upper cell operation. Sphenoid and turbinate knives .... 178 99. Sluder's upper cell operation. Shows the knife in position for cutting away the uncinate process preparatory to Ingals' removal of the fron- tal sinus floor 179 16 ILLUSTRATIONS FIG. PAGE 100. Binder's upper eel] operation. Shows knife approaching a post-ethmoidal eel] which lies ■ • ABC Fig. 1. — Composite drawing from Wright and Smith. A. Osteoblasts depositing bone salts. B. Transition stage. C. Osteoclast absorbing bone salts. of the nose and it is also responsible for the maps, so to speak, of the turbinated bones, as they appear in transverse section. In Fig. 1 it will be observed that A represents an edge of bone lined with ovoid cells, or osteoblasts, which are deposit- ing lime salts in the formation of the bone structure. Much of the finer structure of all these sections has been destroyed by a decalcifying process. In the drawing B a locality has been chosen where the ovoid cells, or osteoblasts, are being grouped together; but they have not as yet lost the outlines of their limiting individual cell membranes. They are grouped together so that their peripheries, or external cell membranes, are touch- ing one another. Subsequently, over the area of the surfaces which touch one another, these limiting membranes disappear, the cell bodies are thrown into one; and out of several mono- *Wright, Jonathan, M.D., and Smith, Harmon, M.D. : A Text-book of the Diseases of the Nose and Throat, New York, Lea & Febiger, 1914. INTRODUCTION 19 nuclear osteoblasts, we have one large multimiclear giant cell, or osteoclast, shown in the drawing C. With this change in cell form, brought about by a coali- tion, there results a change in the metabolism. The process is reversed. Bone salts are absorbed in place of being precipi- tated. What chemical change in the cells induces this reversal, it may be less difficult to imagine than the biological change which initiates it and of which the chemical change is only a / ' Fig. 2.— Hyperplasia of bone of sphenoethmoidal wall. (X 200, camera lucida.) part. It is fair to assume that it is the physiological bone proc- ess by which nature shapes the framework of the body; but evidently there are other ways of giant cell formation, one of which is shown in Fig. 4. In the material Doctor Sluder has left with me, I select that from the case of E. II. G., which consists of pieces of the post- ethmoidal wall, to show in Fig. 2, a hyperplastic bone process. 20 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN While oilier localities in the same material show other con- ditions, it is strikingly evident we have here a thickening of the bone. The osteoblasts, not shown, of course, in the low- power magnification, beneath a thickened epithelium, have built up a solid wall of bone. If Ave turn now to the tissue from the sphenoidal wall of Ed. D., we find that a rarefying osteitis represented in Fig. 3, has been at work, perhaps in bony tissue which had been formed in the condition we have studied in Fig. 2. It is possible that the duration of the sinus diseases may have been longer in the Ed. D. case (Fig. 3) than in the E. II. G. X io- CAM. LUC. PAPILLARY HYPERTROPHY OF MUCOUS ME MBRANE. or 5PHE1N0ID SINUS Fig. 3. — (X 10, camera lucida.) RAREFYING OSTEITIS) case (Fig. 2), but that is not necessarily so. We perceive, how- ever, in Fig. 3, the papillary hypertrophy of the mucous mem- brane lining the cavity, which is so common in these old cases, usually suppurative, of sinus disease. The drawings (Figs. 2 and 3) have been made with camera lucida, from appearances under very low magnifications. I select from the case of Mrs. L. E., a field (Fig. 4), made under high magnification, admirably adapted to act as a com- panion piece to the partially schematic drawings in Fig. 1. A INTRODUCTION 21 careful study of it will reveal a number of osteoclasts, or giant cells, varying from indeterminate binuclear affairs up to the large miiltinuclear cell seen in close juxtaposition to the edge of the bone. This cluster of osteoclasts seems to have indented the surface of the bone by virtue of their bone-absorbing func- tions. In the normal process of cavity formation, the sinuses grow in capacity by virtue of this activity of the osteoclasts. C v. > r v< Fig. 4. — Rarefying osteitis. (Vil' 0. imm.) Showing action of osteoclasts. In almost the same locality of a single specimen of the patho- logical process, we may have both this absorption, or osteoclastic activity, and the bone-forming, or osteoblastic activity going on. Where the bone formation along one surface goes on at the same time that bone absorption goes on along the other surface of the anterior part of the middle turbinate bone, we occasionally get the formation of a bony cyst. I have remarked that the method of osteoclast, or giant cell formation, as exhibited in Pig. 1, is not always the apparent method of genesis. Occasionally 22 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN the evidence suggests, as it does here in Fig. 4, that the giant cell grows, not by apposition of separate cell bodies, but by the multiplication or proliferation of nuclei, beginning in a single cell. It now remains for me to show in Figs. 5 and 6, drawn from the specimen of the middle turbinate bone of Miss F. P., how this bone process starts as a sequence of an ordinary hyper- plasia of the mucous membrane of a turbinate body. In Fig. 6, you will see this typical hypertrophy represented under the Fig. S. — Chronic hypertrophy of middle turbinate body. (X 10, camera lucida). A. B. Showing osteophytic growth. C. Fibrous hyperplasia at points from which Fig. 6 was made with high power. high power at a point (C) selected from the structure shown under low power in Fig. 5. There is only one thing ex- ceptional in the picture presented by the latter. You will see at A and B an osteophytic process starting at the edges of the middle turbinate bone, with suggestions of the existence al- ready in the newly formed low-grade bone of a rarefying proc- ess. Now this new activity is representative of how a tissue change, which we know begins in the soft parts, inaugurates a INTRODUCTION 23 tissue change in bone, which when arising in a locality chan- nelled by sensitive nerves or nerves of special sense, leads to distressing symptoms and grave consequences ; but on a middle turbinate bone hanging free in a nasal cavity, nothing of vital importance usually results. In Dr. Sluder 's cases, then, it is not the specificity of patho- logical activity which engages our clinical attention, but the specificity of locality. i AmMi wMM <> • • - « * • • • •»* i \ v " -\ „- • - .* *?••' "■»--. >v^ H^B '"---. Fig. 6. — Chronic hypertrophy of middle turbinate body. (X 500.) Taken from a section shown in Fig. 5 at C. It would probably be difficult to find an adult individual in temperate or cold climates who does not present an example of this bone change within his nasal chambers, which we have a right to call pathological. It is only exceptionally that the symptoms to which it gives rise are sufficient to cause him to seek relief. When, however, it causes bonj^ occlusion of a nasal fossa by means of a spur or deviation, when it stops up 24 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN the ostium of an accessory nasal sinus and prevents proper drainage, when it impinges on a branch of a sensitive nerve or involves its peripheral distribution, marked symptoms and a long train of the consequences may ensue, which Dr. Shider describes. When in the walls of the sphenoidal or ethmoidal sinus there is involvement of the optic nerve, in so far as it depends on bony pressure, blindness, partial or complete, is pretty sure to occur. When, however, the alarming symptoms of optic in- volvement are recent and slight, the trouble may not be due to a bony pressure, but to a pressure of soft parts, or to an ex- tension of their inflammation or of their vascular congestion. These latter conditions may be relieved by giving free drainage and ventilation to an occluded sinus ; but in an inaccessible region, if there is pressure of a bony surface, such as the swell- ing, in Fig. 2, upon a sensitive or an optic nerve, it is difficult to see how the symptoms are to be relieved. Fortunately, there is good reason to believe that in the nature of things, the en- croachment of the field of engorgement and soft hyperplasia upon the nerve structures gives a timely warning so that sur- gical interference is possible before an irreparable condition results. It is perhaps well to remark that we have sought some ob- jective evidence of inflammation spreading along the sheath of the optic nerves from the foci of inflammation in the sinuses. Though there is clinical reason to suppose this sometimes oc- curs, we have not as yet secured objective proof of it in the material at our disposal. THE NOSE A General Consideration The nose seems to me an anatomical and clinical region that lias special features to be considered (that are self-evident as soon as thought is directed to them) which, so far as I know, have not been emphasized even in this day of highly specialized specialties. First, the nose, as the most protruding feature of the face, is exposed to injury far more than the rest of the face, as has often been remarked. Falls and blows readily injure the nose, that do not harm the eyes or teeth; and probably during birth the nose is often injured despite its then elastic, pliable con- sistency. This seems the only etiology for the dislocation of the anterior part of the septum from the V of the wings of the premaxillary bones, giving rise to a deflected septum in pa- tients who have never had an injury. Mosher 59 has given us this anatomy comprehensively. A slightly deflected septum may seem clinically negligible, but later in life give rise to the low grade vacuum headache with asthenopia. Second, in the human being the nose has two paranasal cells that have no gravity drain, to wit, the maxillary antrum and the sphenoidal cell, which is a great disadvantage. To these may be added possibly some of the ethmoid cells. In- fection in these cells, which leads to suppuration, is therefore less apt to subside spontaneously than in the frontal sinus when the outlet (or inlet) to it is normal; but here the normal is so easily disturbed as also to be striking. In the animal that spends much of its life with its nose pointing more or less to the earth these sinuses have a gravity drain. Third, the upper air passage from birth to death is sub- jected to recurrent severe inflammatory attacks (coryza) which usually have no analogue or homologue in any other part of the body. These attacks bring about changes in other parts of the upper air passage as well as in the nose In the nose the per- iosteum is in peculiarly close relation to the membrane which is so frequently subjected to this inflammatory attack. In most other parts of the body the periosteum is separated front 25 26 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN" its coverings by loose connective tissue which permits of much inflammation of the coverings without involvement of it. Fourth, most of the cranial nerves leave the skull through close fitting bony foramina, except those which pass through the sphenoidal fissure (the oculomotor, trochlear, abducent, and oph- thalmic). The optic, maxillary and Vidian pass through for- amina or canals in the sphenoid in a part of the nose which is subject to the pernicious influences that beset the other parts of the nose. These nerves represent the special sense of sight, as well as the motor, sensory and sympathetic systems. The frequency of lesions of the optic, maxillary and Vidian is at once striking when compared to the infrequency of the other cranial nerves. The oculomotor, trochlear, abducent, and oph- thalmic in the sphenoidal fissure are also associated with a part of the sphenoid which is often a part of the nose, but less in- timately as a rule, for two reasons — first, because the sphenoid sinus is only sometimes prolonged into the great wing (not as a rule — if there be any rule for the anatomy of the nose) and secondly, they are not confined here in tight fitting bony fora- mina — they have loose connective tissue around them. The sphenoid sinus sometimes extends to the foramen ovale and to the semilunar ganglion also, as well as into the great wing, but only seldom. The nerves in the sphenoidal fissure even though they be surrounded by loose connective tissue, are more often involved (from the nose) than are the cranial nerves which are totally removed from the nasal anatomy. Further- more, these nerve complications are greatly increased by the presence of the nasal (sphenopalatine — Meckel's) ganglion, ly- ing almost submucous to the nose. It is, moreover, situated in a fossa (sphenomaxillary) which is in many respects tanta- mount to a paranasal cell. In no other part of the body is a sympathetic ganglion or sensory ganglion so exposed to sur- face influences. These facts bring these associated nerves with all the various questions arising with them, to wit, headaches and eye disorders, with all that these maladies may mean in the life of the patient, into the concern of the rhinologist. They are also, of course, matters of concern for the cranial surgeon Here the two fields overlap intimately. Each, therefore, needs the cooperation of the other to avoid errors in diagnosis. These THE NOSE 27 facts also make the field of the rliinologist overlap that of the ophthalmologist, and here also each needs the cooperation of the other to avoid error. And the same reasons make the field of the rliinologist overlap that of the internist; nasal head- aches must be differentiated from those of the various systemic disorders. The neck and shoulder pains of some nasal diseases -call into question the orthopedic problems of these parts; and the dizziness of some nose disturbances requires all the cunning of the internist, neurologist, aurist, and rliinologist for their differentiation. I have tried to determine whether the hypo- physis is not sometimes disturbed by inflammation, but so far I have not been able to draw conclusions. Citelli lla has de- scribed what he believes are such disturbances. The paranasal cells are often the source of infections (focal infections) which supply organisms that are active in other parts of the body. It is unfortunate for rhinology that the nose in animals is not better adapted to experimentation. Headache, whether it be seldom, or frequently recurrent, and bear the names "Megrim," "Bilious-headache," "Blind" or "Sick-headache" or "Hemicrania," like all other pain, accord- ing to present thought, must be a SAmrptom of a lesion of some kind, whether a pathological-histological change, or a toxemia, be (at present) recognized as its cause. Just so it would seem that weak eyes (asthenopia) must be a symptom of a lesion, whether its nature be known now or not, and optic neuritis and atrophy and retinitis and choroiditis must have causes under- lying them. In these fields, as in the domain of "hysteria" and "neurasthenia" and "syphilis," the number of cases left in the categories of "migraine" and "asthenopia" and 'idiopathic optic neuritis" and "idopathic atrophy" becomes smaller with each advance in our understanding of deeper lying facts. Recurrent headache when at all severe (or even when slight) in the course of time becomes a matter of serious moment for the individual ; and with the higher grades, is the cause of so much disaster both in his affairs and to the general welfare of the family, that from the earliest times to the present hour it has had the serious efforts of some of the best minds bestowed upon the solution of its causes and treatment. To this end, many 28 HEADACHES AND EYE DISORDERS OE NASAL ORIGIN famous monographs have been written ; and special chapters in all kinds of treatises and textbooks, with countless journal articles have been directed to the better understanding and treatment of this symptom. Headache of any grade is a symptom in many diseases that are at once, or easily, recognizable ; and in the course of which, it needs no more than the merest passing mention. These are self-limiting by either recovery or death in a period of time that represents proportionately a short span in the life of the individual. But headache is also a symptom of another disease or class of morbid conditions which present no signs; of which it may be the only symptom; and which arc not self-limiting by recovery or death but persist throughout the life of the in- dividual from childhood to age, and yet permit him to live the "allotted time of man. ' : It is this class of headaches that in earlier times were considered diseases per se. Hippocrates did not differentiate the headaches. The first to do this was Aretaeus of Cappadocia in the second century A.B. Galen in that century, aside from their description, advanced a theory for their explanation, based on the Humoral-pathology of Hip- pocrates. This remained practically unchanged until the Re- naissance, since which time many theories* have been advanced.'!" It has been my opinion for fifteen years or more that many, if not all of the diseases that produce this symptom and at the same time let the patient live his life to fullness of years and in health otherwise, are some kind of a disorder that involves the nerves independent of the brain centres, that its mechanism is a local one. I have recently found that this theory is far from original with me, that it was advanced by Laborrocpie 38 in 1837 and Symonds 91 in 1858. My ideas differ from theirs, however, in some essentials, as will appear. Contributory to this class, is the large sub-class of ocular headaches which may endure as long as the ocular defect re- mains unrectified; and the large sub-class of nasal headaches which may recur indefinitely, made by suppurations of the vari- *Dubois Raymond. Mollendorf, Laborroque, Piorry, etc. Quoted by E. Liveing: On Megrim, Sick Headache, etc., London, 1873. fExtensive historical references are to be found in many of the monographs on Head- ache or Megrim, notably K. Liveing, L. Thomas, Harry Campbell, E. Flatau, J. P. Moebius. THE ]S T OSE 29 ous paranasal cells. Both of these classes have been described by many of the master minds of our times and much wondrous, admirable surgical teclmic has been evolved for their relief.* The study of the severe headaches by the authors of the many superlative monographs has included the local causes of eye, ear and nose ever since the understanding of these organs began to be comprehensive. The eye through Helmholtz's dis- covery of the ophthalmoscope was the first to be better under- stood. The ear also was the object of special study and under- standing; and special study of the anatomy of the nose and the discovery of cocaine have done much to rank rhinology with ophthalmology; and latterly the ear is much better understood. Through the development of these specialties the classes of asthenopia and idiopathic optic neuritis and idiopathic head- aches have been much narrowed. It is my desire here to assemble the descriptions of some nasal lesions which give rise to these conditions without the gross symptoms or signs that betray the nasal origin of the primary lesion. The well-known, almost self-evident paranasal sinus suppurations, as well as the many systemic and central nerve causes for headaches ; and the various eye disorders will uot be considered here more than to be incidentally mentioned when a purpose is to be subserved. Perusal of the literature on the subject of headaches re- veals that the terms Megrim (Migrant, Migraene), Sick Head- ache, Bilious Headache, Blind Headache, Hemicrania, as used by Liveing, are accepted as synonymous by most writers on the subject. t Liveing cites cases to show that they are complete or incomplete pictures of the same disorder. It seems to me that my cases will also bear out this argument. It is the purpose of this essay to describe three varieties of uasal disease or clinical pictures which have as symptoms, head- ache and more or less eye disorder; to wit, (1) Closure of the Frontal Sinus without Suppuration, (2) The Syndrome of Na- sal Ganglion Neurosis, (3) The Picture of Hyperplastic Sphe- noiditis. *In the list of these procedures stand conspicuous the Tngals, 32 the Watson-Williams,* 4 the Halle, 28 intranasal frontal, the Hajek? 6 ethmoidal-sphenoidal, the Mosher 58 frontal-ethmoidal- sphenoidal 1he Mikulicz 53 and the Denker 14 maxillary; and the Killian 36 external frontal and the •Caldwell'-Luc 45 external maxillary operations. tE. Liveing, 42 Purves Stewart,"' Harry Campbell. 8 J. P. Moebius, 8 ' Flatau, 19 Gowers CHAPTER I VACUUM FRONTAL HEADACHES "WITH EYE SYMPTOMS ONLY A low grade unending headache is established by closure of the frontal sinus, without nasal symptoms or signs, i. e., ob- struction or secretion, and is made worse by use of the eyes- These patients have ocular symptoms only. The air is partly Fig. 7. — Showing where needle has been passed through the floor of the frontal sinus at the- point of attachment of the pulley of the superior oblique. absorbed in the sinus and the negative pressure makes the- walls sensitive.* The floor of the sinus is its thinnest wall and has attached to it the pulley of the superior oblique. (Figs. 7 and 8.) The sensitive floor is pulled on by use of the eyes. I once (1900 GT ) thought that the closure of the sinus was an ac- cident of the anatomy. I now believe that this is rare although. *I have recently found that this idea was advanced prior to 1900 by P. McBride 48 in 1891_ 30 VACUUM FRONTAL HEADACHES 31 possible. The mechanism by which closure is produced is a combination of unfavorable anatomical settings such as narrow noses present, plus hyperplastic changes in the soft parts and the bone. (Compare Doctor Wright's introduction.) This class of cases never has pus in the nose; never has the severe pain produced by suppurating sinuses ; and never is complicated by blindness or changes within the globe. The eye disturbance is of the nature of ""asthenopia." They are almost always closed frontal sinuses which are otherwise normal. Oc- casionally it is the anterior ethmoidal labyrinth that has become closed. I have not been able to determine that contacts of one Fig. 8. — Showing a dissection of the right orbit from above. I. Frontal sinus. 2. Su- perior oblique muscle. 3. Pin passed from orbit into frontal sinus at point of attachment of pulley of superior oblique. 4. Ethmoidal cells. part of the lateral wall with the septum are ever responsible for similar symptoms. (This opinion is contrary to the statements of some writers.) It is my wish in this chapter to classify from a rhinologic standpoint, the origin of this class of cases, which was first de- scribed in two papers presented by Dr. A. E. Ewing and by me before the American Ophthalmological Society, May 2, 1900. 67 Ewing was the first to recognize these cases and to describe the symptoms, which briefly are: "Inability to use the eyes for near work because of the headache which is produced thereby, 32 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN and which is not relieved by glasses or eye treatment. ' ; It is accompanied by a tender point in the upper inner angle of the orbit (Ewing's Sign). This class of cases is as a rule not accompanied by nose symptoms, unless they be produced by some lesion other than the one closing the sinus. Occasionally there is some obstruc- tion to breathing, because of the narrow nose. CLINICAL PICTURE The headache is frontal, usually; very rarely it is referred to the external angular process of the frontal bone. It is fre- quently present on rising, but grows worse on using the eyes; or is brought on by use of the eyes. The pain never reaches the intense degree of that produced by a confined empyema, but is quite sufficient to prevent the use of the eyes. Occasionally a patient relates that "blowing his nose is sometimes accom- panied by a squeaking sound and sensation of air running up into his brain," which is followed very soon by temporary re- lief of the discomfort. EWING'S SIGN The nasal trouble in these cases is revealed by tenderness of the upper inner angle of the orbit at the point of attachment of the pulley of the superior oblique, and internal and posterior to it. (Fig. 9.) Tins is the portion of the orbit which is made by the frontal sinus, the wall of which at this site is thinnest. Kuhnt' 7 observed that in empyema of the frontal sinus this was an exceedingly sensitive area, and suggested that this tender- ness was in the supratrochlear nerves which were inflamed be- cause of their juxtaposition. As a fact, it is in the bone at a point where the nerves are absent. 68 It should be remembered that Ewing 15 put forth this sign as a diagnostic help for cases which had up to that time been declared not frontal sinus cases, not nasal cases at all, because there Avere no nose symptoms, nor any pus, nor secretion from the sinus, nor any of the grosser commonplace anatomic changes. This sign is some- times the only indication of the nasal trouble, the rhinologist's findings being negative. VACUUM FRONTAL HEADACHES 33 The frontal sinus is most frequently the one involved be- cause of the peculiar anatomy of its outlet (or inlet). Rarely is the anterior labyrinth of the ethmoid the one involved, and then the symptoms are different; and the tenderness is at the site of the lacrimal bone. Patients affected this way have the feeling of sand in the eyes, and refer the pain to " behind the eyes." The posterior labyrinth of the ethmoid and the sphenoid, in my opinion, never give rise to these symptoms. They may give rise to occipital or parietal or frontal headache, or head- ache brought on by use of eyes because some of the ocular mus- Fig. 9. — Showing a needle passed from frontal sinus at a point back of the attachment of the pulley of the superior oblique. This is the author's favorite point for eliciting "Ewing's sign." Dr. Ewmg prefers the point of attachment of the pulley. cles arise in the apex of the orbit from parts made by the walls of these sinuses; or to blindness by reason of their nearness to the optic nerve; but never to this enduring low grade frontal pain with inability to use the eyes, accompanied by Eiving's sign. Eighteen years' observation of this class of cases leads me to believe Ewing's sign to be trustworthy and almost con- stant. The rare exception is in the case of the sinus having very thick walls, when the bones of the individual will in gen- 34 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN eral be" found to be very heavy and thick. Under these condi- tions I have found it absent even in acute empyema of the sinus accompanied by great pain. GROSS ETIOLOGY In 1900 I G7 stated that I believed the tenderness of the wall of the sinus arises secondarily to closure of its outlet, and that a similar condition obtains here to that produced in the middle ear by an acute closure of the Eustachian tube. Many years ago this was recognized as a condition in which the oxygen of the enclosed air was absorbed and a negative pressure, a par- tial vacuum, established within the cavity. Brawley 5 concurs in this opinion of the mechanism of the frontal pain. I still believe this is the correct explanation, and that secondarily to the closure of the sinus, arises a congestion of the lining mem- brane in which the bone takes part to a degree which, however slight, is sufficient to render the thin wall of the sinus sensitive to external pressure — even to very slight pressure. The pul- ley of the superior oblique is attached to this thin Avail. The function of this muscle being to turn the eye downward and inward, it is called into use for most of the acts of accommoda- tion. So for close work there continues, more or less, a tug- ging at this tender point. This intensifies the dull ache made by the simple closure of the sinus. In cases of slight severity the patient is not especially uncomfortable until he begins using his eyes for close work. The frontal srms is the one by far most frequently the cause of this heada according to my experience it being the origin of about 99 r $ t>"\se cases. The attempt to classify the origins » esolves itself, therefore, into a reference to the irouu s to that extent. For the present I shall neglect the other sinuses. In 1900 I made no effort to do more than mention the ways in which the outlet might become closed. I did not report cases. I felt that my number of cases was too small. My material now comprises 580 cases. These were nonsuppurative at the time they came under observation; and never at any time showed pus in the nose, nor did transillumination or x-ray examination show any clouding. VACUUM FRONTAL HEADACHES 35 ANATOMY OF THE MIDDLE MEATUS Familiarity with the anatomical detail of the middle meatus is necessary for a comprehensive understanding of this class of cases. The Correlated Anatomy of the Middle Meatus of the Nose These cases usually have narrow nasal fossae. Closure of the frontal sinus outlet or inlet may be brought about rather easily by a number of causes, because of its pecu- liar settings. It lias always seemed to me that a comprehen- sive understanding of the middle meatus (which is the begin- ning of the inlet) would have to come through a correlative study of the district. In this way only, can an understanding of the workings of this region be had. These anatomical ob- servations relate to the anterior ethmoid cells also. The extant anatomical descriptions of the parts of the middle meatus and its paranasal cells and their means of com- munication with it, as well as the terms employed, are so various that an effort to synonymize them would be difficult if indeed possible. This arises probably from the fact that the various observers have each seen the parts variously, together with the difficulty anatomists have (apparently) had in understand- ing eacli others' description. Heymann and Bitter 30 in a mas- terful presentation of the entire set of questions, with the confusions, besetting this district have systematized them for a comprehensive understanding and catalogued their varia- tions. The term Infundibulum was r luced by Boyer 4 in 1803 to designate the flattened- f ped uppermost part of the middle meatus lot ■ ntal sinus, which in its simplest arrangement p tl .^t_j between the uncinate process in front and ethmoidal bulla behind, i. e., smoothly, di- rectly upward from the hiatus semilunaris, uncomplicated by pocketings, cells, or diverticula in any direction. (Boyer in- terpreted the infundibulum as an ethmoid cell.) This then means that as long as the neck of funnel runs in parallel lines it is the hiatus semilunaris and as soon as its lines diverge it becomes the infundibulum. This is the construction and ac- ceptation that the B. N. A. puts upon this district. These were 36 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN also the ideas of Zuckerkandl, 96 Logan Turner, 92 Mihalcovics, 52 This complete flattened-funnel (cone and neck) is smooth lined. But this smooth-lined funnel is varied in many ways by pocket- ings or cells developing anteriorly, laterally, superiorly and posteriorly from both infundibulum and hiatus ; and by the hiatus becoming disjointed as it were from the infundibulum. These variations were also observed by Boyer. Heymann and Bitter have apparently taken the view that the simple smooth- Fig. 10. — Showing hiatus semilunaris, in fundibulum and frontal sinus in direct and uncomplicated connection. 7. Frontal sinus. 2. Infundibulum. .}. Line of attachment of middle turbinate. 4. Hiatus semilunaris. 5. Normal outlet of anterior ethmoid cells. Fig. 12. — Showing ethmoid cells entering in- fundibulum and hiatus semilunaris from above and below in front. /. Ethmoid cells. Fig. 11. — Showing ethmoid cell entering in- fundibulum from above and behind. /. Eth- moid cell. Fig. 13. — Showing ethmoid cells entering in- fundibulum and hiatus semilunaris from above in front and behind and below. 1-2-3. In- fundibulum and hiatus cells. lined funnel does not exist and have started with the next sim- ple arrangement, that of the cone and neck (infundibulum and hiatus) being slightly disjointed. They have then shown all the variations in logical sequence, so clear is their systematiz- ing of the district. Figs. 10 to 17 show diagrammatically the commonplace variations in the scheme of these parts. Fig. 18 shows a specimen in which there is no expanse of the breadth of the hiatus semilunaris at any point. It communicates with VACUUM FRONTAL HEADACHES 37 frontal sinus by a pipe-like channel which has become more nearly horizontal, but not any wider. A large ethmoid cell enters this channel from below and in front. As a rule anatomists have described the way the frontal sinus communicates with the middle meatus. For my purpose it is advantageous to emphasize the way the middle meatus communicates with the frontal sinus. The means of communication of the middle meatus with Fig. 14. — Showing hiatus semilunaris end- ing in blind pocket above, infundibulum limited above by roof of nose. Frontal sinus enter- ing infundibulum from above and laterally. /. Frontal sinus. 2. Outlet of frontal sinus. ;. Infundibulum. Fig. 16. — Showing (/ and i) ethmoid cells opening into lr'atus semilunaris which ends above in a blind pocket. The frontal sinus enters the nose at a point above and behind the hiatus semilunaris as shown by bristle in position. Fig. 15. — /. Frontal sinus. ?. Bristle passed from frontal sinus into hiatus semilunaris. (Note that it takes a much more horizontal direction than usual.) ;. A large hiatus cell of the ethmoid. Fig. 17. — Showing hiatus semilunaris end- ing in blind pocket above. ;. Hiatus semi- lunaris. ~'-.-i--/. Ethmoid cells entering infundi bulum from above, in front and behind, and from above and laterally in common with lower ethmoid cell -/. the frontal sinus are primarily from the "vault"' of the mid- dle meatus through or by way of its "frontal pouch." What- ever may be the further (upper) subdivision of the passway, i. e., hiatus semilunaris, infundibulum, nasofrontal duct, the start from below is, under the middle turbinate into the "vault' which is pouched upward at a point in the anterior third. "Vault" is a term that I employ to designate the entire uppermost extent of the middle meatus. At the junction of the anterior with the middle third of this space it extends upward, 38 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN pocket-like, to eventually communicate with the frontal sinus. This particular district it seems to me may be advantageously termed the frontal pouch of the vault of the middle meatus. This pouch has been observed and named by Killian 34 ' ' recessus frontalis," and by Mihalkovics 52 "recessus meatus medii" (Tasche des mittleren Nasenganges). Its association with the remaining vault has not been described. At about the middle of the vault, behind and above the bulla, is a similar smaller pouch which communicates with the anterior ethmoidal outlet or inlet, which may be termed the ethmoidal pouch of the vault Fig. 18. — The hiatus semilunaris in this specimen does not expand as it passes upward. It is situated unusually far back and communicates with the frontal sinus by a channel more horizontal than usual. of the middle meatus. The frontal pouch is usually not only larger but extends higher than the ethmoidal pouch. For the maintenance of these pouches and their communication with the middle meatus, it is necessary that the middle turbinate occupy a position somewhat raised from the lateral wall. Any- thing which presses the turbinate outward closes these pouches ; or they may be closed by swelling of the membrane in the vault even though the turbinate be in normal position and otherwise normal; for these spaces at most are small. Examination of VACUUM FRONTAL HEADACHES 39 the distribution of the cavernous tissue of the anterior half of the middle turbinate shows that it often extends upward on the lateral surface of the turbinate into the frontal pouch of the vault (Fig. 19). Fig. 20 shows what appears to be normal con- ditions. The rule, however, is that it should not extend so far Fig. 19. — Three-quarter view of lateral wall from below upward and outward. Shows 1-2 line of amputation of middle turbinate, with the line of origin from the lateral wall. 3. Cavernous tissue on the internal aspect of frontal pouch. up. Fig 21 shows a striking absence of cavernous tissue in this district of an otherwise normal nose. The lateral wall of the pouch is marked below by the begin- ning of the hiatus semilunaris bounded by the uncinate process in front and the bulla ethmoidals behind. It may have lateral and 40 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN antero-posterior measurements of as much as 3 nun. each. The uncinate and bulla may be on the same plane which, however, is V Fig. 20. — Three-quarter view of a normal left lateral wall from below upward and outward. /. Orbit. 2. Middle turbinate. 3. Sphenoid sinus. 4. Eustachian tube orifice. 5. Soft palate. Compare Fig. 19. not the rule. The bulla is usually well internal to the plane of the uncinate and often fitted accurately into a corresponding- cup on the lateral aspect of the middle turbinate. (Fig. 22.) VACUUM FRONTAL HEADACHES 41 The bulla may have come forward to meet the lower part of the uncinate and obliterate the lowest part of the hiatus or it may extend this contact higher up (Pig- 23). Under these condi- tions the inlet of the frontal sinus is closed in the middle meatus unless the pouch in its internal limitation be of sufficient am- plitude to permit it to extend both above and internal to the India. Under such conditions (closure of hiatus) should the cavernous tissue extend into the pouch it will, upon slight siuell- Fig. 21. — Three-quarter view of lateral wall seen from below upward and outward. 1-2. Free margin of middle turbinate showing total absence of cavernous tissue. This specimen is otherwise apparently normal.' 5. Uncinate process. ing, close it as a cork stops a bottle (see Fig. 19). The main mass of the cavernous tissue of the middle turbinate is devel- oped on its lower half. Frequently, the bulla behind and the lower limit of the uncinate in front occupy a position just above this line and project inward beyond the plane of the lower part of the lateral wall of the middle meatus with a shelf-like resem- blance under which rests the external half of the mass of the cavernous tissue. These conditions arc nearly always found 42 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN when the markings on the lateral wall are, in general, empha- sized (Fig. 23). The nose that shows such markings is apt to have the tubercle of the septum also well marked (Fig. 24), and to be of scant space because of the full development of all Fig. 22. Fig. 22. — Lateral view showing middle turbinate detached in its anterior two-thirds and turned up at /. Bulla ethmoidalis. 2. Cup on lateral surface of turbinate into which bulla was accurately fitted as shown in three-quarter view in Fig. IS. Fig. 23. — Three-quarter view from below upward and outward. This anterior middle meatus was closed. Showing bulla ethmoidalis 1 in contact with processus uncinat'us. 2. This contact extends far above line of attachment of middle turbinate to lateral wall 3. 4. Cup on lateral wall into which middle turbinate was fitted. the tissues within the (usually) narrow nasal fossa. The great- est development of cavernous tissue on the middle turbinate is over its anterior third. Just below, in front and internal to VACUUM FRONTAL HEADACHES 43 this mass of cavernous tissue is developed the tubercle of the septum. In many specimens the relations of the middle tur- binate are so intimate (close) that the outline of its anterior third or half is clearly graven not only upon the tubercle below and in front (Fig. 25) but equally upon the lateral wall (Fig. 23). The depression on the lateral wall combined with that on Fig. 24. — Septum of specimen shown in Fig. 23. Showing well-marked tubercle /and deeply marked imprint of entire middle turbinate 2. This septum was not deflected to either side. the tubercle then forms more or less completely a rigid case in which the turbinate is enclosed. In normal noses these mark- ings are poorly defined or absent; and the turbinate lias room to hang free in its confines — that is, there is room between it and the septum and between it and the lateral wall (Fig 2(5). 44 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN These spaces may be slightly narrowed. Then there will be only moderate marking- of the turbinate on both walls. Should these spaces be wide, that is, wide enough to allow normal ex- cursions of the cavernous tissue without its being clamped, neither the lateral wall nor the septum will be marked (Fig. Fig. 25. — Sagittal section through the capsule of the ethmoid left side showing relations. of middle turbinate (attached) to the tubercle of the septum /. 2. Middle turbinate sharply graven into the septum in its entire length. The tubercle of this septum is very well marked but not deflected. 26). In some narrow noses the imprint of the turbinate on both, walls is perfect throughout its length (Figs. 23 and 25). A tilting of the septum to one side, even though slight, is very apt by the help of the tubercle to close the lower slit open- ing of these case-like confines. A clamping of the turbinate below by a septal spur (Figs. 27, 28 and 29) or ridge is equally VACUUM FRONTAL HEADACHES 45 or even more efficacious. Swelling of the cavernous tissue then can take only an upward direction into the olfactory fissure and the vault of the middle meatus. In that way the lowest part or beginning of the frontal inlet may be closed. The uncinate and the bulla with the hiatus between them are present on the lateral wall at this (lower) level and extend thence upward and forward. Normally the Fig. 26. — Showing middle turbinate / placed with free s;:ace between septum and lateral wall. hiatus should remain open from below upward into the infun- dibulum. The bulla, however, is often developed from behind and below in a forward and upward, or upward and forward direction to meet the uncinate process, and for a longer or shorter distance, obliterates the hiatus (Fig. 23). This is usu- ally on the line of origin of the pendulous or free middle tur- binate from the lateral wall, which line may be accurately 46 HEADACHES AISTD EYE DISORDERS OF jS t ASAL ORIGIN located at the anterior limit of the origin of the turbinate. The frontal pouch is not necessarily closed, however, by the oblit- eration of the hiatus, as it should still have an opening internal to the plane of this closure and may have its uppermost dimen- sions undisturbed by it. But should the bulla develop further in the directions of upward and forward, it will be found to develop also inward and backward to fit tight under the tur- binate, and so close the frontal and ethmoidal pouches from all Fig. 27. — Showing septum tubercle well marked almost like spur at the site of its tubercle. R I shows a mechanical drawing of same seen from in K u front. directions and completely (Figs. 22 and 23). This may often be discovered by the use of Killian's long speculum inserted be- tween the middle turbinate and the lateral Avail (Killian's rhi- noscopic media). Above the limit of the frontal pouch is the infundibulum, which is usually more capacious and is not so readily closed in the manner just described. The opening of the infundibulum into the frontal sinus, however, may be small and tortuous as pictured (Fig. 18). VACUUM FRONTAL HEADACHES 47 Pathology and Method of Closure. — The method of closure (or accidents of the anatomy) of these vacuum nasal headaches may be divided into six classes. The histological changes re- corded in these classifications are the observations of Dr. Jona- than Wright from 207 specimens. Class I. — From the above correlation of the parts of the middle meatus it may readily be seen that enlargement of the Fig. 28. — Showing posterior spur I and well-marked ridge 3-4 with large tubercle. 2. This septum would clamp the middle turbinate in front, below and behind. septum tubercle or the tilting of it out of the middle line in a normal or particularly in a narroiv- nose will so narrow the confines of the middle turbinate as to cause the cavernous swell- ing to take the direction of the vault and its pouches, and in this way close the inlet of the frontal sinus at its beginning. In a study of 451 vacuum frontal ca ses, 75 38% proved to have 48 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN been established in this way, i. e., to have this mechanism as an etiology. The turbinate is histologically normal. The eti- ology of the deflected septum then comes into causal relation (see Mosher 59 and Lack 30 ). Class II. — Noses with clinical appearances normal. By this I mean that the middle turbinate is not hypertrophied ; that the tuberc]e of the septum is normal; that the vault of the middle meatus is open. In this class of cases there is no history of empyema or of coryza as starting the trouble. These were S^Atxvt^. Tig. 29. — Cross section in posterior part of nose showing spnrs 2-4 above and below middle turbinate 3. J. Upper turbinate. the most mysterious until they were operated upon; that is, the middle turbinate removed. Then it was found that the hiatus semilunaris was narrowed or occluded, by bony narrow- ing, the uncinate process and bulla being in contact. It was this class of cases that I emphasized in the title of my paper in 1900. 67 At that time I thought them to be more frequent than subsequent experience has proved them. (The tubercle class I find is larger.) Twenty-four per cent of the cases were of this •origin. The turbinates showed thickened periosteum with great VACUUM FROXTAL HEADACHES 49 bone activity, active osteoblasts and few osteoclasts with large bone areas. Class III. — Edema of the vault of middle meatus. The vault of the middle meatus may be closed by swelling of its soft tissues (edema) without special hypertrophy of the soft tissues of the middle turbinate proper, that is, of the cavernous portion of the middle turbinate. Under the influence of an acute coryza these noses often develop polyps. As the coryza subsides the polyps subside, but the edema remains. Fifteen per cent of the cases were of this origin. The turbinates showed some connective tissue in the stroma of the mucosa without any great activity in the bone, nor was the amount of bone in- creased. Some now bone formation showed at some places. In these patients, in whom the middle turbinate has been removed, I have many times seen, during a coryza. the hiatus semilunaris fill out with an edema and develop broad-base polyps in the hiatus and over the bulla, accompanied (without pus) by all the symptoms and signs of the original case. These would subside in a little longer time than is required for a coryza in a normal nose and would not appear again until the next coryza. As time goes on, however, the condition gets more marked until the polyps are permanent. Class IV. — Middle turbinate hypertrophy. The vault of the middle meatus may be closed by hypertrophy of the mid- dle turbinate, uncomplicated by suppuration or polyps. Eleven per cent of the cases were of this origin. Turbinates from this class showed the same changes as Classes II, III and VI, but more marked. Class V. — Anatomical insufficiency of vault. The vault of the middle meatus may be obliterated by the middle turbin- ate being simply lapped down against the external wall, in a nose that is otherwise normal. Seven per cent of the cases were of this origin. This seems an anatomical peculiarity; al- though the more I observe the nose, the more it seems to me that it is the result of a correlated influence in the past that has left no trace in its wake. Turbinates of this class were normal. Class VI. — Empyemas or coryzas without suppuration which have got well, but have left a degree of swelling in the 50 HEADACHES AND EYE DISOKDEKS OF NASAL ORIGIN vault of the middle meatus sufficient to keep the frontal sinus closed and so keep up enough pain to render the eyes unfit for ordinary work. Three per cent of the cases were of this origin. (These cases might be said to belong to Class III. They are, however, in a different stage of development.) In addition to these chronic cases, one occasionally sees others that are excited by an acute coryza (without sinus sup- puration) by reason of the swelling of the membrane in gen- eral, and subside with the coryza, spontaneously. I have con- strued these cases as having a small inlet to the frontal sinus. Swelling of the membrane in the vault from the coryza is suf- ficient to close the inlet, but as soon as the coryza subsides, the swelling also subsides ; and the sinus opens ; and the symp- toms subside. Rhinologists at the present time usually demand the pres- ence of pus coining from the paranasal cells as essential for the clinical diagnosis of the painful diseases of these cells, and many superlative treatises upon these forms of their diseases have appeared in the recent past at the hands of the modern masters. Clinical recognition of changes in the ethmoid bone consequent to or upon inflammation of the mucous membrane was begun with the observations of Edw. \Voakes o:5 in 1885 and have finally been concluded in the chapter of Hyperplastic Eth- moiditis by E. Zuckerkandl, 97 L. Gruenwald, 23 M. Hajek, 25 H. Cordes, 12 W. Uffenorde, 93 and Cholewa. 11 These observations relate to the anterior ethmoid only. Doctor Wright's obser- vations summarized in the introduction form an additional and conclusive chapter on this subject. Woakes was a shrewd enough observer clinically to recog- nize that polyps were secondary to other changes in the nose. This was a great advance. His method of investigation, how- ever, was unfortunate, seemingly. He used and recommended a small pointed probe, a " canniliculus probe," stating that the bulb-tipped probes did not answer the purpose. (It would seem that for the purpose of palpation the bulbous-tipped probe would give much more trustworthy results.) And he adhered to an unfortunate name, "necrosing ethmoiditis," even after Dr. Sidney Martin 50 who made the microscopical pathological examinations for him had disclaimed that ''necrosis" could be VACUUM FRONTAL HEADACHES 51 recognized. A perusal of his (Woakes) text, in the light of the present, gives the impression that he observed several classes of cases with the common factor, rarefying osteitis (which may have given the impression of necrosis on palpation). Undoubt- edly he observed hyperplastic ethmoiditis without pus and with pus. Hajek 25 gave the first full account of the microscopic changes in the process underlying polyp formations and proved Fig. 30. — Wood's metal casts of a narrow middle meatus. /. Projection leading into a narrow, small frontal pouch, representing a small infundibulum. .'. Small projection representing a small ethmoidal pouch, j. Mass of metal which had flown: into maxillary sinus (through a large opening). 4. A small groove made by a poorly marked uncinate process. In this specimen the middle turbinate laid close to the lateral wall. A shows front view of cast; B shows in- ternal surface; C shows external surface. Fig. 31. — Wood's metal casts of a wide middle meatus. /. Projection representing frontal pouch. 2. Small projection representing ethmoidal pouch. 5. Projection marking the entrance into maxillary sinus. 4. Groove made by uncinate process, i. Ridge made by hiatus semilunaris. 6. Groove made by ridge on external surface of turbinate. 7. Excess of metal. A, front view; B, internal surface; C, external surface. Observe that although this meatus was wide in its lower part, the entire vault was quite nrrrow. The frontal and ethmoidal pouches are rapidly obliterated from below upward. it to be "hyperplastic ethmoiditis.' 1 Cordes 12 and LTffenorde 93 corroborated his findings, the latter giving a detailed descrip- tion in his monograph of the clinical as well as the pathological aspects of the problem. Cholewa" contested llajek's findings. 52 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN At the time of the controversy over Woakes' statements a most interesting discussion on the ''Etiology of Mucous Polypi of the Nose" was held in the Section of Laryngology and Rhi- nology of the British Medical Assn., 1895. (British Med. Jour., Aug. 24, 1895.) Many of the most prominent rhinologists of the day took part in it ; to wit, Gruye, Luc, Zuckerkandl, McBride. Hodgkinson, Spicer, Hill, Bcsworth, Schmidt, Daly, Mackenzie, Newman, Lake, AYilliams and de Roaldes. Many ideas were 1- Fig. 32. — Wood's metal casa of a wide middle meatus with wide frontal and ethmoidal pouches readily permitting the flow of metal into frontal and ethmoidal sinuses. A, front view; B, internal view; C. external view. /. Frontal pouch. 2. Ethmoidal pouch. 3. Cast of opening into maxillary sinus. Fig. 33. — Wood's metal cast of very wide middle meatus with, very wide frontal and ethmoidal pouches readily permitting flow of metal into frontal ethmoidal cells. /. Cast of part of-very large frontal sinus. 2. Cast of an ethmoidal cell. _■;. Very large hiatus semilunaris and infundibulum. expressed more or less approaching the present day views. Conspicuous are those of Zuckerkandl and P. AVatson-Williams. The former stated that instead of a necrosing process at the base of the polyp he found an hypertrophic process in the bone as well as in the soft parts but no necrosis. Dr. Williams stated that he has observed "formative and rarefying osteitis in the base of polyps. ,: These are Hajek's findings which are given VACUUM FRONTAL HEADACHES 53 in full detail. Hajek stated Martin \s findings in their essentials correspond with his. The anatomy of the nose was first described in detail by Zuckerkandl, otherwise anatomists have given only descriptions of the more self-evident. Since the time of Zuckerkandl rhi- nologists have added much detailed observation. The methods of closure of the frontal sinus from the above description may appear to be accidents of the anatomy, and such was my idea for a number of years. Continued observa- tion of these cases, however, has led me to believe that ana- tomical accidents may be unfavorable to the communication of the sinus with the nose and that these are more marked in a narrow nose than a wide one, as shown by the casts of such noses (Figs. 30 and 33), but that the real, underlying trouble is usually not a pure anatomical accident. It is usually thicken- ing process in the membrane and bone summed up under the caption "hyperplastic process" and further designated by the locality in which it is found. The present descriptions of this lesion limit it to the anterior ethmoid "hyperplastic ethmoid- itis," but according to my observation it may begin and remain in other parts also, with more or less pernicious effects, accord- ing to the parts involved. DIFFERENTIAL DIAGNOSIS The supraorbital nerve emerges from the orbit at the junc- tion of the inner and the middle thirds of the supraorbital ridge. At this point it passes through the supraorbital notch, and is distinctly accessible to finger pressure. Under normal condi- tions the site of this nerve is the most sensitive part of this area. The pressure tolerated by it normally is little. In neu- ralgia of the supraorbital it becomes very much less. The pressure tolerated by that portion of the orbit which lies inter- nal and posterior to the supraorbital notch, which is made by tne thinnest wall of the frontal sinus, is normally much greater than the nerve will tolerate. When the nerve is normal and the frontal sinus closed, the orbit interiorly and posteriorly to the supraorbital notch becomes as sensitive or more sensitive than the nerve itself. The supratrochlear as well as the supra- 54 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN orbital nerves are external to Swing's tender spot. The supra- orbital is more accessible for tests. Headaches from all Causes and Their Separation from That Produced by Closure of the Frontal Sinus Without Suppuration Closure of the frontal sinus gives Swing's sign (see above). This is not found in headaches produced by ethmoidal or sphenoidal sinuses, ocular, digestive, gynecologic, renal, gouty, neurotic, or any other cause except empyema of the frontal sinus. PROGNOSIS The prognosis for the individual case is difficult. The sim- plest treatment is sometimes rewarded by a strikingly satis- factory result. On the other hand, cases that would apparently furnish a satisfactory result are sometimes found to be most stubborn. For these cases everything fails save the removal of the middle turbinate. This alone frees the inlet to the frontal sinus. The prognosis for the operated case will be found to vary according to the microscopic changes in the turbinate which has been removed. If it shows marked periosteal thickening and bone activity, it will be found that in two, three or five years the inlet will have so far narrowed, by the encroachment of the bulla upon the uncinate process of the ethmoid, that the patient will again have pain and a tender Ewing's point dur- ing and for a time following a coryza ; and it may later come to pass that Ewing's point remains tender until the inlet has again been enlarged. On the other hand, cases that show no bone or periosteal activity remain apparently permanently cured. These patients usually show age by change in the skin rather than change of features. Their skin will look old, but their features in fifteen years' time show almost no change. TREATMENT It suggests itself, in logical sequence, that anything that may diminish swelling of the soft tissues, which close the in- VACUUM FRONTAL HEADACHES 55 let to the sinus, will be of service, and to this end I have employed the various astringents in commonplace usage, with satisfactory results for a very great number of cases, the appli- cations being made in and about the middle meatus. My method of procedure is to try these applications in all cases. After a trial of two weeks, if there has not been any response to treat- ment, more radical measures may be resorted to. It is sometimes astonishing to see what may be accom- plished by the simple application of astringents. In this con- nection I should like to narrate the history of a patient. She had suffered for five years from headaches and eye disturb- ances. She came under my charge in 1902. Pier case belonged in Class III. Following the routine, I made an application of 2 per cent silver nitrate to those parts, about twelve times, extending over a period of three weeks, when the headache stopped, and lias not returned. I state this positively, because my association with the patient socially gives me full oppor- tunity to know. It is well known that the obstruction to the outflow of pus from the frontal sinus is usually the middle turbinate ; and so it is likewise the middle turbinate that is usually the obstruc- tion to the ingress of air to the frontal sinus. The more radical treatment is then the opening of the inlet of the frontal sinus, which is usually accomplished by the removal of the middle turbinate. My method is to free the inlet to the anterior labyrinth of the ethmoid at the same time, removing the anterior two-thirds or three-fourths of the middle turbinate. It is my especial effort to put my incision as high upon the capsule of the ethmoid (the external wall) as possible, about 2 mm. from the cribriform plate. In my experience this has been accomplished most readily by the method I described in the Journal of the American Medical Association, June 29, 1907, and again in more detail and elaboration, before the American Lai yngological Association, 1916. I prefer to give this technique in detail in connection with the ethmoidal sphe- noidal technique in Chapter III, page 164. By this method the turbinate may be cut out up into the infundibulum. This seems to me also to be necessary, as it is at this place that the obstruction very frequently exists. In the great majority of 56 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN cases this suffices to open the sinus and thereby effect a cure; the headache stops ; and the eyes go into unlimited service. Three times I have found the uncinate process and the bulla of the ethmoid in a firm contact, reaching so high up that I was obliged to remove the uncinate process up to the level of the cribriform plate, and once some little above it. Fifteen times I found the hiatus semilunaris filled out by a fibrous hypertrophy of the membrane covering the bulla; in these cases I succeeded in getting the result by a superficial galvanocautery destruction, the line of which ran parallel to, and just posterior to the uncinate process. The contraction of the scar resulting from this wound tends to pull the tissues out of the hiatus semilunaris. VACUUM ETHMOIDAL HEADACHES WITH EYE SYMPTOMS ONLY Headache may arise from closure of the anterior labyrinth of the ethmoid, and is in every way similar in its mode of estab- lishment to the frontal sinus headache just described. This will appear from a perusal of the anatomy just described. It does not, however, occur anything like so often. The few cases that I have recognized have had the external tender point at the site of the lacrimal bone instead of at Ewing's point and refer the pain to behind or between the eyes. Use of the eyes is not so much a factor in making the headache in these cases as in the frontal sinus cases. Considering the anatomy in the light of the description just given it is somewhat surprising that they do not arise oftener, especially from the cells which so often open into the infundibulum and hiatus semilunaris. The pathology, diagnosis, prognosis, and treatment in these cases are otherwise the same as for the frontal sinus cases. The outlet of the maxillary antrum in the hiatus semi- lunaris is so placed as to render it possible of closure under the same influences that close the frontal and anterior ethmoidal cells. I have not, however, ever seen a case that seemed to me to be such. I have construed this as explicable by virtue of the fact that the walls of the antrum are thick and do not be- come sensitive under these conditions. Nevertheless, I can con- ceive of such a case, and, moreover, R. C. Lynch 47 has reported a number of them. CHAPTER II THE SYNDROME OF NASAL* (SPHENOPALATINE- MECKEL'S) GANGLION NEUROSIS In 1908 I 70 called attention to a sot of neuralgic phenomena that in my opinion were produced by lesions affecting the nasal ganglion. Since then in several articles I have recorded motor, sensor}', gustatory, 71 - 72, 73 ocular, respiratory and sympathetic 84 (vasomotor and secretory), phenomena attributable to the same causes. It is my desire in this essay to present fully the various manifestations of nasal ganglion neurosis as far as I know them at present, and to call attention to the anatomy of the district in which the ganglion is found. So far as I can determine, the histology of ganglion in man has not been observed. ANATOMY** The Nasal Ganglion. — The sphenopalatine ganglion (g. sphenopalatinum), also known as Meckel's, the sphenomaxil- lary or the nasal ganglion, is a small triangular reddish-gray body, with the apex backward, situated in the upper portion of the sphenomaxillary fossa. It is Hat on its mesial surface, and convex on its lateral, and measures about 5 mm. in length. It lies in close proximity to the sphenopalatine foramen and .just beneath the maxillary branch of the trigeminal nerve. The ganglion is regarded as belonging to the scries of sympathetic nodes and consists of an interlacement of nerve-fibres in which are embedded numerous stellate sympathetic neurones. Roots. — The sensory root consists of two, sometimes three,. short stout filaments, the sphenopalatine nerves dm. spheno- palatine, which pass directly downward from the lower mar- gin of the maxillary nerve to the upper border of the ganglion. *The term "Nasal Ganglion" is used by authoritative anatomists at the present day, although the "Nomina Anatomica" accepted by the Anatomical Society at Hasel in 1895 (B. N. A.) included that of Sphenopalatine Ganglion only. I prefer the term "Nasal Gan- glion" because it directs the clinician more readily. **This description is taken from Piersol 63 and Quain. 84 57 58 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN While some few of the fibres of this root are axones of the sympathetic ganglion-cells, the great majority are dendrites of the cells of the Gasserian ganglion which pass to a limited ex- tent through, but mostly around the sphenopalatine ganglion independently of its cellular elements. They are continued entirely into the various trunks that are usually described as branches of distribution of the ganglion. The motor root is the great superficial petrosal nerve (n. petrosns sivperncialis major) which in all probability carries sensory as well as motor fibres. It arises from the facial nerve in the facial canal, passes through the hiatus Fallopii and a groove in the petrous portion of the temporal bone and then under the Gasserian ganglion to reach the cartilage occupying the middle lacerated foramen. Here the great superficial petrosal nerve is joined by the sympathetic root, the great deep petrosal (n. petrosus profundus), which is a branch from the carotid plexus. The two great petrosal nerves fuse over the cartilage at the middle lacerated foramen to form the Vidian nerve (n. canalis pterygoidei [Vidii] ) which traverses the canal of the same name and enters the sphenomaxillary fossa to join the nasal ganglion. In its course through the canal the Vidian nerve gives off a few small nasal branches, which, composed of trigeminal and sympathetic fibres, supply the pharyngeal os- tium of the Eustachian tube and the posterior part of the roof of the nose and the nasal septum. While in the canal, the Vid- ian nerve receives a filament from the otic ganglion. Branches. — The branches of distribution of the nasal gan- glion are conveniently grouped into four sets: (1) the ascending, (2) the descending, (3) the internal and (4) the posterior. (Fig. 34.) 1. The ascending or orbital branches (nn. orbitalis) are two or three small filaments, which pass into the orbit through the sphenomaxillary fissure and, after traversing the posterior ethmoidal canal or a small special aperture, are distributed to the sphenoidal and posterior ethmoidal air-cells and the peri- osteum of the orbit. 2. The descending branches (nn. palatini) are three: (a) the large posterior palatine, (b) the posterior palatine, and (c) the accessory posterior palatine nerves. SYNDROME OF NASAL- GANGLION NEUROSIS 59 a. Tlie large posterior palatine nerve (n. palatinus poste- rior) leaves the sphenomaxillary fossa by means of the large posterior palatine canal, through which it descends to the infe- rior surface of the hard palate. While in the canal, it gives off one or two posterior inferior nasal branches (nn. nasales pos- teriores inferiores), which escaping through small apertures in the perpendicular plate of the palate bone, enter the nasal fossa and supply the mucous membrane of all but the anterior portion of the inferior turbinate bone and the adjoining por- tions of the middle and inferior meatuses. Emerging from its canal the main nerve passes forward in a groove on the inferior Fig. 34. — I. Nasal ganglion. 2. Vidian nerve. Nasal and palatal branches. (After Quain.) aspect of the hard palate and inosculates with the terminal filaments of the nasopalatine nerve. It supplies the hard pal- ate and its mucous membrane, as well as the inner side of the gum. b. The small posterior palatine nerve (n. palatinus pos- terior) descends in the small posterior palatine canal. It sup- plies sensory filaments to the mucous membrane of the soft palate and the tonsil and motor ones to the levator palati and azygos uvulae muscles. c. The accessory posterior palatine nerves (nn. palatinus medius), are one or more small filaments which pass through the accessory posterior palatine canals and supply the mucous membrane of the soft palate and tonsil. 3. The internal branches (nn. nasales posteriores superi- 60 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN ores) pass from the sphenomaxillary into the nasal fossa through the sphenopalatine foramen. They are: (a) the pos- terior superior nasal and (b) nasopalatine nerve. a. The posterior superior nasal nerve (r.n. laterales), sup- plies the mucous membrane of the posterior superior portion of the outer wall of the nasal fossa. \). The nasopalatine nerve (n. nasopalatinus), crosses the roof of the nasal chamber and passes downward and forward in a groove in the vomer and septal cartilage to reach the an- terior palatine canal. It then passes through the foramen of Scarpa, the left nerve through the anterior and the right one through the posterior canal, the two nerves forming in this situation a line plexus. Having reached the inferior surface of the hard palate, the nasopalatine inosculates with the large pos- terior palatine nerve. It supplies the roof and septum of the nose and that portion of the hard palate which lies posterior to the incisor teeth. (Fig. 34-). 4. The posterior branch, also known as the pharyngeal or pterygopalatine, leaves the sphenomaxillary fossa through the pterygopalatine canal and supplies the mucous membrane of the nasopharynx in the region of the fossa of Rosenmiiller. Variations. — Branches of the ganglion have been described as passing to the abducent nerve, to the ciliary ganglion and to the optic nerve or its sheath. The accessory posterior palatine nerve is sometimes absent. Quite frequently the left naso- palatine nerve passes through the posterior foramen of Scarpa and the right nerve through the anterior. In addition to sup- plying (according to many anatomists) motor fibres to levator palati and azygos uvulae muscles, some of the facial fibres are especially destined for glandular structures. Such fibres are probably interrupted around the stellate cells of the nasal ganglion, the axones of which then complete the paths for the secretory impulses. The sensory constituents of the great superficial petrosal nerve are, perhaps, of two kinds; (a) fibres from the cells of the geniculate ganglion of the facial to the palatine taste buds, and (b) recurrent trigeminal fibres, that, by way of the maxillary, sphenopalatine and great super- ficial petrosal nerves, are distributed with the peripheral branches of the Vidian or of the facial nerve. SYXDROME OF XASAL GAXGLIOX NEUROSIS 61 The great deep petrosal nerve represents the association cord between the superior cervical sympathetic and the nasal ganglion. Many of its fibres end in arborizations around the stellate nasal ganglion cells, from which, in turn, axones pass to blood-vessels and glands by way of the ganglionic branches of distribution. The environment of the ganglion is of the greatest impor- tance for the clinician. No mention of it has been made more than kk it lies deep in the sphenomaxillary fossa" or "close to the sphenopalatine foramen.'' Anatomical Relations. — The treatises on anatomy describe the nasal (sphenopalatine-Meckel's) ganglion "as lying in the sphenomaxillary fossa close to the sphenopalatine foramen.' 1 (Qua in, Pier sol, and others.) The sphenomaxillary fossa is described as "formed above by the under surface of the body of the sphenoid and the orbital process of the palate bone; in front, by the superior maxillary bone; behind, by the anterior surface of the base of the pterygoid process and lower part of the anterior surface of the great wing of the sphenoid; inter- nally, by the vertical plate of the palate."* Neither this description nor any found in other textbooks on anatomy suggests any close relation of the nasal ganglion to the nose or the paranasal cells (sinuses) ; nor do the special treatises upon the nose make mention of such relation. As a fact, however, the nasal ganglion lies very close to the lateral bony wall of the nose, in which the sphenopalatine foramen occurs as a small deficiency at its upper posterior part. By actual measurement the nasal ganglion frequently lies as close as one or two millimetres from the nasal mucous membrane; it may lie as deep as seven or even nine millimetres. Krause, 36 whose text was found after the preceding observations were made, states that it is sometimes two ganglia, one suspended on each sphenopalatine nerve. He also states that it sometimes projects through the sphenopalatine foramen to lie submucous to the nose. The current descriptions of the sphenomaxillary fossa give the impression of its being surrounded by solid bones. This also is misleading. More comprehensively, the description 'This description is tak?n from Cray's Anatomy, 1896. 62 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN "formed above by the under surface of the body of the sphenoid and the orbital process of the palate bone" means that it is bounded above by the Avails of the sphenoidal sinus, including the sphenoidal process of the palate bone closing it, and that --- 1 Fig. 35. — Showing sphenopalatine foramen / hounded above by sphenoidal sinus .?. and In front by ethmoidal cells 2 and 4. The sphenopalatine foramen is in the inner limit of the sphenomaxillary fossa. the separating wall is a thin one. The description "in front, by the superior maxillary bone,'' means that it is bounded in front by the wall of the maxillary sinus and that this wall too is of thin bone. The description "behind, by the anterior sur- face of the great wing of the sphenoid" means that this wall also is, in some cases, only a thin plate separating the fossa SYNDROME OF NASAL GANGLION NEUROSIS 63 from a downward prolongation of the sphenoidal slims into the pterygoid process and into the great wing; a condition which is not uncommon, although in the majority of cases the pterygoid process is of solid hone. The outer aspect of the sphenomaxillary fossa is then the only one that is not in intimate association with the cavity of the nose or the paranasal cells. It seems essential that in a comprehensive description of Sinus frontal CclluJit tthmoidales Gwitenores Cellulae ethmoidales (posteriores) A m Nervus opticus / \ Jm Ganglion ^^g~ '. A bpbenopaloJjinunv^^HlH^^V ^^Vl Sinus sphenoidal Processus pterygoideu. Sinus m2L.xil!aris>^l -S&ccus ls.crltn;vlis mm m&xilUre. jpfjgn l|H% Fig. 36. — Sagittal section 7 mm. lateral to the sphenopalatine foramen. (Specimen decalcified in hydrochloric acid.) these parts special emphasis should be laid upon their intimate relations to the nose and paranasal cells. The variations of the paranasal cells ought also to be studied in detail: The sphenoidal sinus may form the entire upper boundary of the sphenomaxillary fossa. (Fig. 35.) The sphenoidal sinus may also form the posterior boundary of the sphenomaxillary fossa as a result of its being prolonged down- 64 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN ward into the pterygoid process and great wing (Fig. 36). A post-ethmoidal cell may bound the anterior half of the upper part of fossa (Fig. 35). The sphenoidal sinus may be extended downward and forward to form the upper half of the anterior "boundary of the fossa (Fig, 37). The wall of the nose may curve so sharply outward as to form a part of the anterior boundary of the fossa. The nasal ganglion lies high up in the sphenomaxillary fossa. It is apparently prolonged backward into the Vidian (pterygoid) nerve. (Quain, Anatomy, 1897.) (Fig. 38.) There Fig. 37. — Showing left sphenoidal; sinus /, prolonged downward in front to form the anterior wall of the sphenomaxillary fossa 3. 2. Right sphenoidal sinus. is usually a marking upon the bone corresponding to this ; a well- modeled funneling at the anterior end of the canal (Fig. 39). Relations of the Nasal Ganglion in the Sphenomaxillary Fossa. — The ganglion lies close to the top of the sphenomaxil- lary fossa. (All textbooks are agreed upon this point.) In SYNDROME OF NASAL GANGLION NEUROSIS 65 front the ganglion is in relation with the arteria palatina de- scendens and arteria sphenopalatina and with the correspond- ing veins. These vessels, with some surrounding connective tissue, form a separation of 3 or 4 mm. from the wall of the maxillary sinus, — the anterior boundary of the fossa. The Relations of the Nasal Ganglion to the Walls of the Paranasal Cells. — When the upper boundary of the fossa is SincLs frontalis ellulae ethmoid&ks (antenores) ellulae ethrnoidales (posteriores^ ervus opticus linus sphenoidale k A pa.la.ti risv \/ descenderls . ToltUmm duru hcno Sflion sph aJ6.tin.urn pteryQoid eusfvTdu]. m&>illa.ri!i ma-rih __cessu$ pterygoideus fTuta. Nfiuidjttva [LuAtiachit] ovum Ti»o.sJ , onchcx TiExso-lta inferior , Fig. 38. made wholly by the sphenoidal sinus, the ganglion lies in close relation to the sphenoidal sinus. When the upper boundary of the fossa is made by the sphenoidal sinus in its posterior half and by a post-ethmoidal cell in its anterior half, the ganglion lies in close relation to both. Wlien the sphenoidal sinus is prolonged downward and forward the ganglion will lie in close 66 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN relation to it in front. When the sphenoidal sinus is prolonged downward into the pterygoid process, the ganglion will then lie posteriorly in close relation to the sphenoidal sinus. Fig. 37 shows a specimen in which the ganglion is in close relation to the sphenoidal sinus anteriorly, superiorly, and posteriorly. Anteriorly the fcssa is formed by the Avail of the maxillary sinus. But the ganglion can never lie in close relationship to this wall because of the pad formed by the arteria palatina descendens and the arteria sphenopalatine with their accom- panying veins and surrounding connective tissue (Fig. 40). The Relation of the Nasal Ganglion to the Lateral Wall of the Nose. — The sphenopalatine foramen is accurately placed at a point just posterior to and immediately above the posterior Fig. 39. — Showing anterior face of right pterygoid process. I. Foramen rotundum. 2. An- terior outlet of Vidian canal. tip of the middle turbinate. The ganglion usually lies close to the plane of this foramen. (Fig. 41.) The ganglion does not, however, always show the same relation to the foramen. I have found it as close as one or two millimetres from the general membrane of the nose, and as far as nine millimetres. I have found the variation in the position of the ganglion, whether higher or lower, to be very slight. The sphenomaxillary fossa considered from this point of view is seen to resemble — is tantamount to — a paranasal cell. It is, however, not closed externally by nasal tissues and is filled by the before-mentioned structures with their accompany- ing connective tissue instead of air. Below it is closed by the apposition of its anterior and posterior walls. Clinical Relations. — With such intimate anatomical asso- ciation, clinical manifestations from the extension of inflamma- SYNDROME OF NASAL GANGLION NEUROSIS 67 tion in the nasal fossa or its products would seem of almost necessary occurrence. The nasal ganglion is, in fact, in quite as close relation to the nose and the paranasal cells as is the optic nerve. It has long been recognized that inflammatory processes in the sphenoidal and post-ethmoidal sinuses extend to the optic nerve, and this fact has been demonstrated post- mortem by Birsch, llirschfeld,* and Uffenorde,t and possibly others. I also have seen lesions on the optic canal in life by means of Holmes ' 30a nasopharyngoscope (page 118), illustrating Siccus lacrimals Sinus maxillaris. Palatum, durur- Sinus frontalis . ^ellulac ethmoidals (ajiteri ores') Cellulae cthmmdales (posteriores) Nervus opticus. Sinus sphenoidalis palalina descenders . --Gaorujlion sphenopalalinurn ^A. sphenopalaTina • i jCanalis pterygoideus IVidnJ . ossa ptcryg;opala.Tina. . — - — R-occssu s pTerygoideus - ---"^^-JRirics lateralis cavi nasi . i — Tubtx auditive [Existachn I Fig. 40. — Sagittal section 3 mm. lateral to the sphenopalatine foramen. (Specimen decalcified in hydrochloric acid.) Showing a dissection of the sphenopalatine fossa. this fact in a most striking manner both at the time of opening the sphenoid and as subsequent phenomena in the course of the case. It is therefore altogether reasonable to assume that these processes also pass over to the nasal ganglion, although the clinical picture is very much less evident than the blindness produced by involvement of the optic nerve. According to my observation, characteristic disturbances *Graefe's Archiv, 1907. tZeitschrift f. Laryng., vol. iii. 68 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN have followed post-ethmoidal and sphenoidal suppurative in- flammations which cannot be explained otherwise than hy as- suming- that the nasal ganglion has become involved by exten- sion ; some of these disturbances have been transitory, and some have persisted for many years. In other cases the convic- tion has been equally positive that the extension has been from the nose proper. Thus far, I have not seen anything that I Fig. 41. — Showing / middle turbinate. 2. Sphenopalatine foramen directly posterior to and slightly above posterior tip of middle turbinate. could interpret as an extension from the maxillary sinus. From the anatomical relations of the nasal ganglion to the anterior boundary of the sphenomaxillary fossa, i. e., to the posterior wall of the maxillary sinus, I do not believe that it is at all likely to be involved by extension of an inflammatory process from that sinus, inasmuch as the arteria palatum descendens and the arteria sphenopalatina, together with their accompany- SYNDROME OF NASAL GANGLION NEUROSIS 69 ing veins and the surrounding connective tissue, lie between the ganglion behind, and the wall of the maxillary sinus in front. This relation appears to be constant; and, I believe, explains why clinical manifestations referable to the ganglion do not ordinarily follow inflammatory processes in the maxillary sinus. Furthermore, pus in the maxillary sinus Avill remain much below this level, which may possibly be another factor in the explanation. During 1907 I saw a number of cases of acute suppurative inflammation, of grippe origin, in the sphenoidal and post- ethmoidal cells, which got well of the suppuration in from three to four weeks, but in which pain still remained which seemed neuralgic in nature. (Sometimes the neuralgic manifestations arose a few days after the inflammatory onset.) The peculiar dull pain of the suppurating sphenoid referred to the occiput, or the post-ethmoidal cells referred to the parietal eminence, usually preceded these neuralgic phenomena. In 1914 I s4 rec- ognized a symptom-complex referable to the sympathetic auto- nomic elements of the ganglion. In a preliminary report, 70 based on ten cases, I described certain of these manifestations; now, after an observation of several hundred cases, it is pos- sible to draw a more complete clinical picture. The Neuralgic Syndrome with the Usual Forerunner A patient presenting all the features will tell of a coryza of lesser or greater severity — sometimes astonishingly slight and often forgotten, or, it may have produced a post-ethmoidal-sphe- noidal empyema of greatest intensity. A short time later, pain began at the root of the nose, in and about the eye, the upper jaw and teeth, sometimes also the lower jaw and teeth, and ex- tending backward to the temple and about the zygoma to the ear, making earache; emphasized at the mastoid, but always severest at a point 5 cm. back of that ; thence reaching backward by way of the occiput and neck, it may extend to the shoulder blade and shoulder (less often to the axilla and breast), and in severe attacks to the arm, forearm, hand, and even the finger tips. This is the most frequent picture, but at times there may be also a sense of "stiff" or "aching" throat; or of pain (oftener itching) in the hard palate; or pain inside the nasal 70 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN fossae; or a feeling that the teeth are "too long"; or a per- verse (metallic) sense of taste (parageusia) (rare) or seotoma scintillans (rare) or salivation (rare). Itching of the shoulders has also been observed. The sense of taste is slightly less acnte over the anterior two-thirds of the tongue on the affected side. Rarely, in the beginning or at the height of the attack it is slightly more acute. The arch of the soft x>alate is higher on the affected side; the uvula and dimple which forms above it on gagging are deflected to the well side. A slight blunting of sensation is found in the nose and throat as far down as the tonsil on the affected side. There may be a sense of stuffy ears, which are . easily inflated with but short relief. I have construed these as tubes which are not opened normally by the levator palati; and that this happens because the motor function from the ganglion is lessened at the time of the attack of pain. As the pain subsides this symptom disappears. Itch- ing of the upper extremity has been observed. Mild cases are described as a sense of tension in the face and stiffness or " rheumatism' 1 in the shoulders and neck. The ganglion is accessible for cocainization which relieves the pain. The Sympathetic Syndrome. — The above described picture is sometimes supplemented by a sympathetic syndrome very wide in its distribution and wondrously complex, a prominent part being vasomotor and secretory phenomena. And some- times it happens that these are the only symptoms of disturb- ance in the nasal ganglion. I think, however, that the sympa- thetic syndrome occurs less often than the painful syndrome. But a sharp division is impossible because the sympathetic plays a prominent part in the pain complexes also. The same etiology is found. Inflammation of more or less severity in the district, usu- ally has preceded the vasomotor-secretory phenomena. They may be aroused by a slight coryza that has had little time for development, and appear with explosive effect, out of propor- tion to the pathological lesion. The patient in health is- for the first time, regardless of the season of the year, seized with se- vere and protracted sneezing accompanied by much nasal con- gestion and thin hot secretion, so profuse at times as to have him resort to a towel for use as a handkerchief. With the SYNDROME OF NASAL GANGLION NEUROSIS 71 great congestion of the nasal fossae is found great sensitiveness of the internal nose, with great redness (congestion) and swell- ing of the external nose, and soon thereafter, may appear more or less roughing of the skin from the secretion and the wiping it necessitates. In addition to these symptoms, the eyes are greatly reddened (congestion of the conjunctiva) and bathed in tears of a profusion corresponding to the nasal secretion, accompanied by dilatation of the pupil and the appearance of staring. The lids are wide open, giving the appearance of prominent eyes. (One case had a slight exophthalmos.) They are involved almost if not quite simultaneously with the nose. A sense of itching or burning, or a feeling of wind bloAVing into them accompanies the lacrimation, together with a feeling of discomfort of a peculiar kind which seems independent of the secretion and congestion ; and there may be the greatest photo- phobia or sense of intense light when no light at all is present. Work requiring near vision is usually very difficult or not pos- sible under these conditions. Sometimes these symptoms are accompanied by dyspnea with dry rales (asthma). This description in the main is at once recognized by rhi- nologists as "the terrible or terrific cold" which lias been de- scribed with great emphasis by patients from time to time. For a number of years I have thought that these were symp- toms on the part of the sympathetic which supplies the nasal ganglion, and felt that cocaine could be used to control them. Various other thoughts prevented me from drawing conclusions from cases of longer standing (vasomotor rhinitis, hay fever, paroxysmal sneezing, rhinitis nervosa). During the recent past, however, I have had these cases so acute and so severe that they seemed perfect for the experiment. The nasal gan- glion was cocainized usually from its internal aspect, that is, the sphenopalatine foramen — the side from which the Vidian enters. One-half of one drop saturated watery solution (90%) was applied, sometimes once only, and sometimes repeated. The effect was to quickly stop the secretion in the nose and eyes and bring them back to normal appearance. The swollen, red nose (rosacea) and the puffed, red, disabled, staring, tearing eyes became normal, and likewise the nasal fossae; and the photophobia ceased; and the pupils contracted. 72 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN Further experience revealed that these cases in their be- havior to cocaine were not unlike the painful ones arising from the ganglion. Cocainization (once) was curative for those that were provoked by a slight inflammatory condition. Those aris- ing in the wake of more pronounced change — post-ethmoidal- sphenoidal inflammations — but of short duration, often yielded to a few applications repeated from day to day. Two per cent silver nitrate and 1 per cent formalin are helpful in older cases. Severe, long-standing cases were sometimes not helped by any- thing short of injection and then very little or not at all by one injection. They required reinjection. A considerable per- centage of the ordinary coryzas is of this type. Deep infection of the membrane which leads to suppuration of the sinuses is of course not to be classed with these cases. When the sympa- thetic attributes (vasomotor, secretory, etc.), are once added to the picture they are very apt to recur more or less marked in subsequent coryzas. When the case lasts a little longer, the paroxysms begin to appear irregularly and often settle down into the morning sneezing of "rhinitis nervosa. r The clinical course of a given case may be of the sympathetic type pure, but upon questioning closely, it is very often found that a low grade ganglion neu- ralgic complement exists which the patient often refuses to have connected with his nasal disturbances. He maintains that his head, neck, shoulder, etc., pains, are " rheumatism, ' ; or "stiff muscles" or "neuritis" or some one of a dozen explana- tions which are absolutely satisfactory to him and about which he does not want to have his mind changed. Following these cases further, it appears that the syndrome becomes subdivided and betrays itself as single symptoms ; e. g., eyeache, earache, toothache, neckache, etc. So it happens that the sympathetic symptom-complex may present the single symptom — sneezing — or thin secretion, or the eye disturbances which simulate a low grade conjunctivitis with asthenopia; and a few times I have seen a red external nose (rosacea) of this origin. It is not possible at present to explain the various nerve manifestations produced by inflammation in these parts ; i. e., why one case suffers from the neuralgic part of the syndrome only and why another under the same macroscopic appearances SYNDROME OF NASAL GANGLION NEUROSIS 73 suffers only the sympathetic syndrome. I believe that others suffer only the motor or gustatory disturbances, but I am not sufficiently assured of this to make a positive statement to that effect. The more unusual phenomena are even more strikingly out the line of inductive philosophy; i.e., that injection of the nasal ganglion should cure a most pronounced red and enlarged external nose, a most pronounced writer's cramp, a most pro- nounced blepharospasm, a most obstinate, recurrent superficial corneal ulceration; and equally striking has been the almost kaleidoscopic change — betterment of some of the severest dis- orders of the uveal tract immediately following full anaesthesia of the nasal ganglion. That the severest pain of photophobia, glaucoma, iritis, corneal ulcers, phlyctenular keratitis, inter- stitial keratitis — may be stopped by anaesthesia of the nasal ganglion, frequently with immediate betterment, is to me also at once striking and strange. According to present thought, the only explanation for this is that it is the sympathetic by way of the nasal ganglion that conveys the pain sense to the occiput and neck, from these lesions, and that it is a nerve blocking at this point. To stop pain, influences the lesion for better. The fact that the pain of glaucoma could be stopped by anaesthetizing the nasal ganglion was discovered by A. E. Ewing. 17 H. Ed. Miller 54 and W. H. Luedde 46 proved that in- jection of the ganglion lowered the intra-ocular tension of glau- coma, and that the effect was transitory. I have verified this. The course of glaucoma may or may not be influenced by treat- ment of the nasal ganglion. Xo clear statement can be made on this point at present. It is generally admitted that the functions of the sympa- thetic nervous system among others, are vasomotor and secre- tory. Sensory attributes have also been proved for it. Ana- tomically the fibres of the cervical sympathetic from the nasal ganglion pass downward by way of the Vidian and carotid plexus to the cervical sympathetic and give branches to the cervical nerves and proceed finally to the lower cervical gang- lion which is in intimate connection and often fused, with the first thoracic. These ganglia are anatomically in association with, or allied to, the nerves which in addition to supplying the neck, also make up the brachial plexus, and supply the upper 74 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN extremity. Accelerator fibres for the heart and vasomotor fibres for the lung also pass through these ganglia. The anatomical and physiological problems of the auto- nomic nerves (sympathetic) are very complex, and a clinician may well hesitate approaching them; but it would seem that the knowledge of the present on this subject permits the thought that it is a lesion of the sympathetic elements of the nasal gan- g-lion that explains not only these vasomotor secretory phenom- ena, but also the pain referred into the neck, shoulders, arm, etc., the Vidian neuralgia; and that these referred pains prob- ably come to pass by virtue of the sympathetic fibres which ar- horize about cells (Thane, Van Gehuchten, Dogiel, Retziens) in the spinal ganglia of the nerves which make, eventually, the supply of the neck and upper extremity. Also, the thought arises that it is the anatomical connection of accelerator fibres for the heart and vasomotor fibres for the lungs with the gan- glia through which the cervical sympathetic passes (lower cer- vical and first thoracic) that explains some of the cases of asthma of nasal origin ; and that the path of the impulses is from the nasal ganglion through Vidian, upper, middle and lower cervical and first thoracic ganglia, through the last two of which pass the heart and lung fibres. Much more physiologic fact is needed before such conclu- sions can be asserted. I have been unable to find any statement of what influence is exerted over nerve fibres in their passage through a ganglion with whose cells they have no other relation. Moreover, the question may arise whether such a state of things exists phys- iologically or anatomically ; i. e., whether there is not always ■some connection when the fibres pass through a ganglion. Some influence must be assumed to exist for the above hypothesis. It would also appear to a clinician to exist. If the cells of the nasal ganglion are as resistant as those of the semilunar ganglion, it explains how they may for some time resist in an inflamed environment ; but when once attacked they may in the same manner resist treatment. So it might be explained that intractable Vidian neuralgia is not unrelated to the intractable vasomotor-secretory phenomena, inasmuch as SYNDROME OF NASAL GANGLION NEUROSIS 75 they are often associated and are alike resistant to treatment. In this connection it should be recalled that the vasomotor- secretory phenomena of the nose may be excited (1) from the nerve-endings; (2) the neuralgia and sympathetic symptoms from the nasal ganglion, or (3) the Vidian nerve trunk within the floor of the sphenoidal sinus. In the first instance the trunk injection of Otto J. Stein 88 succeeds ; in the second instance the ganglion injection may succeed, or need repeating; in the third instance the disorder must be attacked from within the sinus, when it may succeed in even the worst cases. Buch 6 made the observation that the sympathetic in health was not specially sensitive, but that it becomes very sensitive if the animal be worried or the nerve become congested. These facts readily explain how these cases may relapse from fatigue, anxiety, apprehension, fright, anger, or slight systemic toxe- mias, inasmuch as the environment of the ganglion and nerve tissues may remain slightly inflamed for almost any length of time, and pass under the generic term "catarrh." I have stated that I thought that the control of glaucoma pain from the nasal ganglion was a nerve blocking, and I believe that this is true with the control of the other eye pains men- tioned above. The thought now arises that it is the sympathetic which runs through the nasal ganglion to the Vidian, etc., that transmits the pain posteriorly in many of the painful eye troubles. Therapeutically, it has seemed advantageous to stop the pain and photophobia of some of the eye diseases at the nasal ganglion, not for the comfort of the patient only, but also be- cause some cases have been turned thereby in their course for immediate improvement of what had been a more or less stub- born condition (iritis, glaucoma, corneal ulcer, interstitial keratitis, conjunctivitis), which may argue possibly a trophic influence. Cauterization of the membrane over the nasal ganglion (acetic acid) has in some instances prolonged the helpful influ- ence; and some were injected with phenol alcohol. In one patient suffering severe photophobia with severe 76 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN pain in the lower half of the head and neck from a traumatic ulcer of the cornea, full cocainization of the ganglion stopped the photophobia and lower-half headache completely, and left only the sense of irritation produced by the cinder upon its ar- rival on the cornea, which was slight. The sense of first irri- tation remained, carried by the ophthalmic nerve, and the "deep and heavy pain" passed through the nasal ganglion and was stopped at that point. Close scrutiny is required to separate some of the eye dis- turbances which are referred from the ganglion, from some eye diseases proper. In several pronounced cases of asthma which remained after the hay fever season, cocainization of the ganglion stopped the dyspnea; and it did not return. In four other cases secondary to post-ethmoidal sphe- noidal inflammation in mid-winter, of greater or lesser sever- ity, cocainization of the ganglion of one side either stopped or greatly lessened the sibilant rales in the lung of that side, and relieved the sense of oppression on that side; and in one case of right-sided sphenoidal empyema, the rales and sense of oppression were on that side only, and were stopped by co- cainization of the ganglion. I believe now that it is irritation of the sympathetic fibres at the nasal ganglion that explains the dilatation of one pupil at the time of coryza, rather than blunting of the third nerve function, as I previously thought. The argument outlined above seems to me applicable in the explanation of pain of cardiac origin (angina pectoris) be- ing referred into the arm; i.e., originating in the heart, the impulse passes by the sympathetic upward to the lower cer- vical and first thoracic ganglia, and then to the spinal ganglia of some of the nerves of the brachial plexus. Cocainization of the nasal ganglion in four cases of au- tumnal hay fever stopped the lacrimation and burning or itching eyes. The effect was permanent in one case, and lasted one to seven days in the others. (In these observations I had the assistance of H. E. Miller and C. A. Gundelach.) Rhinorrhea and sneezing with frequent coryzas, with asthma and fever, but with little or no headache are seen in SYNDROME OF NASAL GANGLION NEUROSIS ~( children, as concomitant of post-ethmoidal-sphenoidal inflam- mations and, I believe, are another phase of the picture de- scribed above. It seems to me that, clinically, there are several types of coryza, and among these T am disposed to class rose colds, hay fever and horse, etc., fevers produced, probably, by as many varieties of causative agents; and that their actions are se- lective, one or more being peculiar in that they attack the sym- pathetic nerve elements in the nose and, furthermore, the vas- omotor secretory elements often totally independent of the pain-producing elements of the sympathetic. We have frequently seen the coryza manifest by dryness without nasal obstruction, which suggests paralysis of secre- tion. Bacterial cultures made by clinicians, from the nose, at the present time, fail to differentiate these cases. These differences may be explicable along the lines of sensitization (as these ideas now stand) : i. e., that everyone is probably sensitized to or for some extraneous agent which is then for linn pernicious. As is well known, some individuals are sensitized to or for egg albumen, others for strawberry, others for apple, etc. ; others for horse serum, others for the pollen of some grasses, others for golden-rod and ragweed. The last three classes are those who develop horse asthma and spring and fall hay fever. J. L. Goodale's text 21 in 1914 records his observations (with case reports), which seem to me to promise a better under- standing of the above-enumerated problems. W. H. Haskin 29 read a text to the American Laryngological, Rhinological and Otological Society, 1913, and showed a most exquisite dissection, in which attention was called (with dem- onstration) to the widespread anatomical connections of, and the recognized physiological phenomena connected with the sympathetic. H. H. Martin 49 has had success in the treatment of these neuralgic cases by injection of the ganglion. I suggest for those interested in these phenomena a peru- sal of Langley's test* on the sympathetic nervous system in Schaefer's Text Book of Physiology. 78 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN DIAGNOSIS The diagnosis of nasal ganglion neuralgia has called into consideration phenomena that heretofore have been inexpli- cable, an understanding of which T think I now have. The above-mentioned syndrome may be produced by lesions of the nerve-trunks which supply the ganglion, namely, the max- illary and the Vidian nerves. It is supplied with sensory fibres by the maxillary. The Vidian is composed of the great su- perficial and the great deep petrosals. The great superficial petrosal comes from the geniculate ganglion, bearing motor fibres from the seventh and taste fibres which have arisen in the anterior two-thirds of the tongue and are to reach the brain by the fifth nerve; the great deep petrosal is a sympathetic nerve, branch of the carotid plexus. Both the maxillary and the Vidian trunks (Figs. 63 and 66) frequently lie in very close association with the sphenoid sinus. They may be separated from the cavity in the body of the sphenoid by only an eggshell thickness of bone ; and this may be a fact as early as the third year of life for the second division of the fifth, and the seventh year for the Vidian. Each year of life presents the same pos- sibilities, from childhood to maturity. I learned this from a recent inspection of the matchless material, property of Warren B. Davis, 13 Keen Research Fellow of the Jefferson Medical Col- lege, Philadelphia, and published 812 it with his consent. This material consists of 145 sections of the Caucasian head from two months fetal life to maturity (twenty-five years) uninter- rupted, several specimens for each year (except the eleventh — only one) showing the changes of each year. Therefore, when inflammation exists in the cavity which occupies the body of the sphenoid (the sphenoidal sinus or a post-ethmoidal cell) it may readily involve the associated nerve-trunks, either by its extension, or by its toxin passing through the thin sep- arating bony wall. In 1912 I TS found in some patients that cocaine readily passed through this Avail and paralyzed one or sometimes all the branches of the fifth nerve. A lesion in- volving the nerve-trunks central to the point of union of these trunks can reproduce or simulate the syndrome arising from a lesion of such a point of union. There exist, however, at SYNDROME OF NASAL GANGLION NEUROSIS 79 this point of union, ganglion cells. It is not a mere coalition of fibres. What part clinically, these multipolar cells may play, is as yet unknown ; but the clinical fact remains that cer- tain sphenoidal inflammatory cases simulate completely the typical neuralgic and sympathetic phenomena arising in the nasal ganglion. The differential diagnosis may he made by the following facts : 1. Cocainization of the nasal ganglion stops the pain of a lesion in the ganglion proper. 2. Cocainization of the nasal ganglion does not in any de- gree stop the pain created by the more central lesion of the nerve-trunks, maxillary and Vidian, secondary to sphenoidal inflammation. These points had, as a rule, better be proved on several occasions before injection is done. / believe these points have been overlooked or neglected by some surgeons who have complained that their results were not as good as mine. 3. On the other hand, intrasphenoidal application of pain-reducing remedies, such as cocaine, will under these con- ditions stop the pain — that is, a local anaesthetic applied cen- tral to the ganglion is effective. In addition to these x )om fs of difference, there is often a congestion and thickening (hyperplastic post-ethmoiditis) at the site of the sphenopalatine foramen when the nasal gan- glion is the starting point for the neuralgia. This is more par- ticularly true for the cases of inflammatory origin, which are the usual cases. PROGNOSIS The prognosis of nasal ganglion neuralgia is beset by several perplexities on which I have speculated. Frequently in severe cases that had been relieved by injection of alcohol, the benefit proved so transitory as to arouse the inquiry: Was it worth while? In contrast with these, however, are others of high grade which were easily cured by simple applications of cocaine, formaldehyde, or silver to the inflamed sphenopal- atine foramen district. Possibly all such variations could be satisfactorily explained were post-mortem material as fre- quently available in these cases as is the diseased lung or liver ■ 80 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN or heart. Possibly an exact knowledge of the anatomy of the ganglion in man (which is not known) would be helpful also. I feel, however, that I have a better understanding of some of these points now, from further clinical experience and a knowl- edge of work on collateral lines by May, 51 of London, although animal experiment, or post-mortem observation of my own is still wanting. The best treatises on anatomy give only a few words of description to its histology. The gray matter of the ganglion does not involve all of the sphenopalatine branches of the maxillary nerve, but is placed at the back part at the point of juncture of the Vidian nerve, so that many if not all of the fibres of the sphenopalatine nerves proceeding to the nose and palate pass to their destination without being incorporated with the ganglion mass. The fact that herpes has never been seen as a part of this syndrome would seem to bear out this point, for herpes is never produced by lesions of the sensory nerve trunks ; but only Tby lesions of the sensory cells. The ganglion colls, therefore, would seem to be a part of its sympathetic attributes, which are constituted by the Vidian nerve. It seems true from clin- ical experience, however, that the Vidian nerve carries fibres which transmit the sense of pain also. Certain noses have been propitious for cocainization of the tissues internal to the as- sumed position of the ganglion with the effect of stopping en- tirely the pain of posterior distribution; and then, when the applicator was placed external to the assumed position of the ganglion the pain of anterior distribution stopped. When placed in the center, it would stop both anterior and posterior pains. In other Avords, it would seem that the trunks of the nerves supplying the ganglion in these cases could be cocainized separately. This has seemed true also for injection and elec- trical (faradic) stimulation. Alcohol injected on the Vidian side of the ganglion lias produced great pain of posterior dis- tribution ; injected on the side of the second division of the fifth it made the anterior pain. The needle in these positions was attached to the faradic current, the other pole in the hand, with the same results. The recent work of Dr. Otto May, 51 seems to me to explain some of the transitory results of injection. He proved ex- SYNDROME OF NASAL GANGLION NEUROSIS 81 perimentally that the cells of the Gasserian ganglion in the goat, cat and dog are not at all readily destroyed by alcohol; that they are quite resistant to its action even though the gan- glion were surgically exposed and the injection put directly into its substance. He also proved that the nerve-fibres arc much more vulnerable to alcohol than the cells; but that the injec- tion must be made exactly into the nerve-trunk. When the al- cohol was put merely around the nerve, its effect, although marked, was transitory — the nerve quickly recovered its func- tion. Lannois and Berial 41 have proved the anatomical effect of the clinical injection of alcohol into the nerve-trunks is very slight. So it would seem that inasmuch as the ganglion is small (5 mm.) and difficult of access, we may assume that the trans- itory results have followed the instillation of alcohol into its environment rather than into its substance; and that the highly satisfactory results have followed the exact instillation of the alcohol into its midst, or into the trunks supplying it; and that the results may not be permanent even under these cir- cumstances, because these tissues are so difficult of destruction. (Whatever made the pain in the original cell, one may sup- pose, may make it in the regenerated cell.) The clinical value of the injection, however, must be admitted. And, on the other hand, the severe cases from which the patients have recovered so satisfactorily from surface applications to the membrane covering the sphenopalatine foramen, and its immediate sur- rounding (whereby an inflammation was allayed), we may as- sume to have been produced by irritants to the cells and fibres without their actual structural involvement, their power of re- sistance being great, as shown by Dr. May. In this I am as- suming these cells and fibres to be alike with those observed by Dr. May. These assumptions may likewise explain why the complete clinical picture has so seldom been observed in a sin- gle case. The complete picture would require the complete in- volvement of all the cells and fibres of the ganglion alike, which in accordance with the above assumption would not be apt to happen. The nasal ganglion neuralgia that recurs at long intervals secondary to a suppurative post-ethmoiditis I believe is ex- 82 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN plained by the fact that a pad of about 0.5 cm. lies between the post-ethmoidal or upper anterior wall of the sphenomaxillary fossa and the nasal ganglion. The establishment of the pain at long intervals (3 to 12 months) has been, almost uniformly, by a coryza recognizable in this district. I translate this as a condition which gives freedom from pain in times when there is no acute inflammation, by virtue of the thick pad which separates the ganglion from the inflamed cells. At the time of an acute inflammation in the cells enough toxins are made to spread through the pad and affect the ganglion. I have seen this form a number of times make the picture of a complete ophthalmic migraine, recurrent at 3 to 18 months' intervals. A nasal ganglion neuralgia that arises secondary to a hyperplastic post-ethmoidal sphenoiditis, without pus, is very much more apt to recur at much shorter intervals if indeed it be not more or less present constantly. There is no separat- ing pad between the anterior face of the sphenoid and the gan- glion. Only a small amount of connective tissue is present here. The inflammatory process or its toxins have only a small sepa- ration to traverse to reach the ganglion. TREATMENT In the treatment of these cases various remedies and sev- eral surgical means have been employed. Applications were made to the region of the sphenopalatine foramen of 2 per cent solution of silver nitrate, 0.4 per cent solution gaseous for- maldehyde, 0.5 per cent phenol with 0.1 per cent iodine as a wash. In the more severe and stubborn cases injections of phenol alcohol were used and in the worst, the patients were operated on (intranasally) with the intention of removing the ganglion. But treatment has heretofore had only passing men- tion. I feel that it should be taken up here in detail. Anatomic Considerations The treatment of these neuralgias has always been beset by difficulties which are occasioned by the anatomy of these parts. The simple painting of the region of the sphenopalatine foramen will often be found difficult because of an irregularity on the septum, or the configuration of the lower turbinate, or SYNDROME OF NASAL GANGLION NEUROSIS 83 both. Certainly, in a nose which presents a straight septum, a wide caliber nasal fossa, and a straight lower turbinate there can be no difficulty in reaching accurately the region of the sphenopalatine foramen. In such a nose, a needle bent at a right angle 0.5 or 0.66 cm. from its end could be introduced along the septum, to a point 0.33 cm. posterior to and slightly Fig. 42. — Showing pterygoid process i projecting forward beyond the posterior limit of spheno- palatine foramen. above the posterior tip of the middle turbinate ; and could then be turned to point outward which would bring its point to the membrane covering the sphenopalatine foramen. This could readily be punctured, thereby bringing the needle's point di- rectly into the sphenomaxillary fossa at the site of the nasal ganglion. 84 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN This would seemingly be the simplest and best method of injecting- medicaments into the ganglion. But even were this always a possible technique, it would still fail at times because the sphenopalatine foramen is sometimes placed posterior to the anterior surface of the pterygoid process (Fig. 42) opening as it were into the Vidian canal rather than the sphenomaxillary fossa. (Compare Fig. 43.) Such a pterygoid process is V- Fig. 43. — Showing usual sphenopalatine foramen. The pterygoid process is behind it. shaped, apex forward. Injection under these conditions would be into the Vidian nerve and not into the ganglion. It is for these reasons that I should like to call attention to the method of injection by means of the straight needle, which may be done in practically all noses, however irregular or narrow, and, under control, is almost infallible in its accuracy. The con- trol consists in measurement of how far back of the posterior tip of the middle turbinate the ganglion lies, irrelevant to the SYNDROME OF NASAL GANGLION NEUROSIS 85 pterygoid process. The sphenomaxillary fossa is constantly reached about at its center, 0.33 cm. back of the posterior tip of middle turbinate; and it is this fact that I utilize in the therapeutic injection. Should the surgeon rely on the but- tress of a solid pterygoid process to stop his needle when it is being pushed backward, as might seem perfectly feasible under the rule of the anatomy of the pterygoid process, he will find himself disappointed frequently because the pterygoid proc- ess is hollowed out by a prolongation of the sphenoidal sinus downward into it as far as the bifurcation of the plates. The Fig. 44. — Showing correct placing of the needle. (After Loeb.) needle then crosses the sphenomaxillary fossa and penetrates a thin film of bone to enter the sphenoidal sinns to meet with firm resistance only in the posterior Avail of the sinns, or pos- sibly not even there. It might readily enter the cranial cav- ity. The injection will then be into the sphenoidal sinus or cranial cavity. Then too, the sphenoidal sinus is sometimes set so far down in the body of the sphenoid that its lower aspect lies below the line of the needle thrust. (Fig. 4(5.) liider these settings the needle enters the main cavity of the sphenoid as soon as it crosses the sphenomaxillary fossa. The relation of the sphenopalatine foramen to the pos- 86 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN terior tip of the middle turbinate is one of the most constant in the nose. Even though the anterior aspect of the pterygoid process be V-shaped and be relatively forward of the opening sphenopalatine foramen it disturbs this relation little or none. The posterior tip of the middle turbinate always marks the anterior limit of the sphenopalatine foramen. The spheno- maxillary fossa must, of course, needs lie lateral to the plane of the sphenopalatine foramen. These relations being borne in mind, it must appear that a straight needle introduced into Fig. 45. — Showing both straight and curved needles (/-.?) correctly placed. 3. A satisfactory Record syringe. the nose from the nostril to pass under the posterior tip of the middle turbinate at its origin from the lateral wall, in a direction backward and upward and slightly outward, must pass out of the nasal fossa into the sphenomaxillary fossa and enter the nasal ganglion or its immediate vicinity. The dis- tance from the point of entrance of the needle so placed and ganglion tissue is almost invariably 0.66 cm. The lateral wall of the nose plays an important part in this technique and its variations should be borne in mind, to wit: SYNDROME OF NASAL GANGLION NEUROSIS 87 1. In the middle meatus the lateral wall sometimes extends abruptly outward and slightly forward, from the posterior tip of the middle turbinate, even to such a degree that it forms the anterior limit of the sphenomaxillary fossa, excluding the pos- terior wall of the maxillary antrum from participation in these boundaries. When this is true, a very careful estimate must be made of the origin of the middle turbinate at its posterior Fig. 46. — Showing nasal ganglion needle having passed across the sphenomaxillary fossa and then through the thin wall of a low set sphenoidal sinus. (In this picture the needle is shown at a point slightly forward of the correct point for the injection of the gangljon in order to exaggerate the error.) tip, because such a pouching outward (concavity) of the lateral wall permits the tip of the needle to be placed as far outward (lateral) as the line of the foramen rotundum. Pushed back- ward under these circumstances, the needle would reach a point lateral to the ganglion. Such a wall is, however, not dif- ficult to estimate and is readily punctured, usually because the needle approaches it at almost a right angle. 2. The lateral wall in the middle meatus is sometimes straight and smooth and of very hard bone. The point of the 88 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN needle placed under the tip of the turbinate attached to such a wall may often be pushed backward without penetrating the wall. The tip of the turbinate will be punctured and the point of the needle pass submucous backward and upward to slip into the opening of the sphenopalatine foramen and if carried farther backward will enter the Vidian canal, Avhich is on a line internal to the ganglion. This wall indeed may be so straight, hard and smooth as to defy all attempts to pierce it Fig. 47. — Showing needle transfixing the middle turbinate. It has been placed too far forward. The needle 2 shows the correct placing. with a straight needle introduced from the nostril. It must then be cut away with a burr, thereby making a permanent and easy access to the ganglion; or the curved needle passed around the posterior tip of the middle turbinate through the spheno- palatine foramen may be better in these cases. The practice of cutting away the wall with a burr is not to be recommended as a routine measure because the sphenopalatine or descend- ing palatine or even the internal maxillary artery may be in- jured with considerable hemorrhage which may be difficult to SYNDROME OF NASAL GANGLION NEUROSIS 89 control. These arteries are rarely injured by the use of the needle alone. 3. Very rarely is the lateral wall convex. 4. The lateral "wall in the upper meatus of the nose is usually on a plane internal to that of the middle meatus; hut not always. It sometimes dips sharply outward, leaving the middle turbinate a very prominently marked thin film of the bone ; posteriorly, however, it proceeds inward finally to come to be on the same plane as the middle meatus, one meatus above and the other below the crista ethmoidalis as it ends on the an- terior semi-circle of the sphenopalatine foramen. (Compare with Fig-. 47.) This foramen is constantly immediately posterior to, with its center slightly above, the posterior limit of the origin of the middle turbinate from the crista ethmoidalis (Figs. 41 and 43). The crista ethmoidalis of the perpendicular plate of the palate bone almost always extends slightly into the sphenopalatine foramen, subdividing its anterior semi-circle into an upper two- thirds or three-fourths and a lower third or fourth. There is usually a like marking on the posterior semi-circle. In forty- seven heads this rule was broken once when the entire spheno- palatine foramen was placed 2 mm. above the crista. The di- ameter of the sphenopalatine foramen varies; but this seems to make little or no difference in this technique. Instrumentarium For the injection of the nasal ganglion I use a simple straight steel needle 1 mm. in diameter. This is of consider- able strength; and fastened in a heavy crossbar enables the surgeon to secure it in a strong grasp and put great pressure on it. My associates, Drs. A. C. Gundelach, II. F. Miller, and \V . E. Saner, have suggested (and employed) a needle with a trocar and flange or ring from 0.5 to 0.66 cm. from its point to prevent too deep placement or insertion. Familiarity with this technique I believe will render the flange unnecessary. I al- ways have at hand a curved tip needle also, because sometimes the lateral wall of the nose is so hard that it cannot be punc- tured by the straight needle. The curved tip enables one to curl around the tip of the turbinate and enter the fossa through DO HEADACHES AND EYE DISORDERS OF NASAL ORIGIN the sphenopalatine foramen. It seems to me a less satisfac- tory means of approaching- the ganglion than the straight needle. Technique The ganglion is cocainized by an applicator carrying one -drop saturated (90%) watery solution cocaine hydrochlorate placed under the tip of the middle turbinate for five minutes. It is then moved to lie over the sphenopalatine foramen just posterior to the posterior tip of the middle turbinate and al- lowed to remain there five minutes. The combined application under and posterior to the tip of the middle turbinate is ten minutes, one applicator carrying the one drop being moved from one place to the other. Injection under insufficient an- aesthesia is very painful. From the preceding description it is evident that a straight needle introduced through the nostril in a direction backward, upward and slightly outward, approaching the lateral wall of the nose at a point in the middle meatus marked by the origin of the posterior tip of the bony middle turbinate, arrives al- most at once on the anterior wall of the sphenomaxillary fossa. Should its point now be pushed backward 0.66 cm. it will usually enter the sphenopalatine ganglion or its immediate vi- cinity (Fig. 44). Experiment on the cadaver has proved, how- ever, that it is better to enter the point of the needle 2 mm. an- terior to the posterior tip of the middle turbinate. Pushed back- ward from this point it proceeds in a direction slightly more up- ward and more outward than it would from the point farther back, and thereby it strikes more accurately the region of the ganglion. It may appear that the correct placing and insertion of the needle is a bit of technique of easy and certain execution. It has not, however, proved so in my hands. A number of speci- mens operated on show the possible failures: (1) The Vidian canal may be injected because the lateral wall of the nose is very hard and smooth. The tip of the needle will not pene- trate it, but slides over it to the outlet of the Vidian canal. When it is pushed backward it passes under the tip of the mid- dle turbinate and crosses the sphenopalatine foramen to enter SYNDROME OF NASAL GANGLION NEUROSIS 91 the anterior outlet of the Vidian canal. A perfect application to the Vidian nerve may then be made. (2) The middle meatus wall may clip abruptly outward from the sphenopalatine fora- men before it begins to extend forward; and the upper meatus wall may be of similar curvature. In such a nose, the needle may of course be placed correctly and arrive at the proper point in the sphenopalatine ganglion. If, however, it be placed a little too far behind and below, it will, when pushed backward, pass under the tip of the turbinate and cross the sphenopala- Fig. 48. — Showing needle (point) having passed across the sphenomaxillary fossa 4 to be free in a prolongation of the sphenoid sinus 2 prolonged downward into the pterygoid process. /. The general cavity of the sphenoid. 3. The nasal ganglion. 5. The needle. This drawing is from a sagittal section just lateral to the Vidian canal seen from without. tine foramen, as stated above, to enter the Vidian canal. And should it be placed slightly too far forward it will readily trans- fix the thin film of bone representing the middle turbinate. Its point, when pushed 0.66 cm. backward, will lie free in the upper meatus (Fig. 47). Injection in the first instance will be into the Vidian nerve and in the second instance into the free upper meatus. In the latter circumstance, the injected solution will flow immediately backward and downward into the pharynx, assuming the operation to be performed in the erect posture. 92 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN (3) A needle carried too far back may cross the sphenomax- illary fossa to enter the cavity of the sphenoid, which may be set rather low in the body of the sphenoid (Fig. 46). (4) A needle pushed too far back may cross the sphenomaxillary fossa to enter a prolongation of the sphenoidal sinus down- ward into the pterygoid process (Fig. 48). The lower turbinate frequently interferes with an easy and accurate placing of the needle point. This happens read- ily when the turbinate is placed somewhat higher rather than lower on the lateral Avail. Under such conditions, the tip of the nose must be raised well up before a straight line may pass over the upper convexity of the body of the lower turbinate to reach the desired point under the posterior tip of the middle turbinate; and sometimes even then, considerable downward pressure will have to be exerted on the lower turbinate by the Fig. 49. needle as it passes backward, in order to permit it to reach its destination. Irregularities on the septum may interfere with the pass- ing of the needle backward. They are apt, however, to be in- dividual for that particular nose. The tubercle of the septum lies above the line sought by the needle. I prefer the simple straight needle (Fig. 49) to be inserted under slight or great pressure, as the case may be. Under slight pressure it is very easy to measure 0.6(5 cm. distance inser- tion; but when it requires great pressure, it is by no means easy to estimate this distance. For this reason I prefer to withdraw the needle when I think I have gone the right depth. While the needle is out of the nose, I determine that it has not been plugged with bone — that it is open— and reinsert it into the opening from which it has been withdrawn. On reinsertion the correct distance may be measured exactly, because it requires SYNDROME OF NASAL GANGLION NEUROSIS 93 no strength or pressure to replace it. One-half e.c. 5 per cent phenol in 95 per cent alcohol is then injected. It is my practice to rest the hypothenar eminence of my hand on the patient's chin, placing the other arm around the patient's head as soon as the point is in position. In this way strong and controlled pressure may be put on the needle. It is desirable that it should not jump across the sphenomaxillary fossa, but proceed backward cautiously. Should the wall be hard and straight and not possible of penetration by pressure thus applied, the needle may be taken firmly by the crossbar mentioned above, and thereby rotated to and fro through a semi-circle from side to side, using it as a hand drill to pene- trate the bone. The lateral wall may possibly be too hard to be penetrated this way. Should the bone be too hard to pene- trate by a straight needle, a curved-tip needle may be employed curling from beloAv upward and outward just back of the pos- terior tip of the middle turbinate. (Fig. 45.) It is usually not difficult to pass through the sphenopalatine foramen in this way. E. M. Holmes 31 uses his nasopharyngoscope to direct the placing •of the curved needle. A machine drill or burr may be employe* 1 (see above) to remove the lateral wall for access to the ganglion. It is not, however, to be recommended as it may injure the large arteries found here. I have already spoken of applications of silver nitrate so- lution and formaldehyde made to the membrane covering the sphenopalatine foramen (which is usually inflamed). Often this suffices to stop the pain. When it does not, I recommend that the ganglion be injected with a 5 per cent phenol solution in 95 per cent alcohol. Formerly, I injected approximately two or three drops of this solution, and very often it sufficed; but the number of failures seemed to me unnecessarily large. For this reason, I have gradually increased the amount of the injection to 0.5 c.c. This larger amount is more successful, possibly for the reason that the ganglion is small and probably frequently missed, to be influenced by the solution placed in its neighborhood. Alcohol alone, as advocated by Schlosser 66 in 1893, used in these parts is intensely painful. For this reason I have added 5 per cent phenol 74 to it, which renders it painless in small injections — three or four drops. In 0.5 c.c. amounts 94 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN it is usually followed by a slight sense of pain, which, the pa- tient recognizes as different from his neuralgia, and which lasts from two hours to three days. I have used 5 per cent phenol in water with possibly less satisfactory results than the alcohol combination. No untoward consequences have followed this procedure, except on one occasion 80 when the tissues of the sphenomaxillary fossa were evidently very loose. The alcohol passed outward and upward to reach the abducens in the sphe- noidal fissure, paralyzing it. It recovered completely in three months. This treatment has been highly satisfactory in the great majority of cases. The injection, however, in old and severe cases must be repeated, possibly as often as ten times, usually, however, not more than three. Rarely there recurs, in severe cases, a considerable degree of pain, after from four to six weeks of comfort. In these cases, a rather strange phe- nomenon appears ; namely, that cocaine applied to the region of the ganglion is at once painful, and the deeper the cocainiza- tion the more so it becomes. And, on the other hand, irritants such as stronger solutions of silver nitrate are soothing. I have seen five cases of this type. This phase was transitory. In old severe cases, I believe the difficulty of obtaining lasting relief is explained by the fact that the ganglion is surrounded by the changes of a hyperplastic post-ethmoidal sphenoiditis. In this condition it is not uncommon to find on opening the cells, that they contain polyps where no evidence of their pres- ence existed in the nose. Inasmuch as the sphenomaxillary fossa is so like a paranasal cell (page 61), it is most plausible to assume that changes occur in it as a result of the hyper- plastic changes that surround it on all sides, save the external aspect. A ganglion imbedded in this tissue of low grade chronic inflammation, it would seem, must be irritated by it. Injection of this fossa with phenol-alcohol often has the effect of reduc- ing the hyperplastic changes. Each injection should be followed by some lessening of the patient's suffering. It may be repeated as often as needs be, allowing an increasing span of time between each, i. e., the second two or three weeks after the first, the third from four to six weeks after the second, increasing the span then to six weeks each time. I suggest this, because the reaction following SYNDROME OF NASAL GANGLION NEUROSIS 95 the instillation of the phenol-alcohol becomes more severe the oftener it is done. Severe cases of this class are not only a terrible affliction for the patient, but they also put the surf/con to his wit's end for judgment, perseverance and skill. These facts cannot be too greatly emphasised. Particularly difficult of judgment are cases where anaesthesia of the ganglion stops the pain, but in which there is in addition, a considerable hyper- plastic sphenoiditis, in frail, nervous patients. The surgeon hesitates to perform the radical sphenoid operation because of the low resistance of the patient. Patient efforts by injection usually succeed. The shock of the injection is very much less than the sphenoid operation, but these cases usually require more perseverance because the sphenoiditis may reestablish the pain by virtue of the maxillary and Vidian nerves passing- through the bone before reaching the ganglion. This class of cases will be considered again with more detail in the chapter on Hyperplastic Sphenoiditis. CHAPTER III HYPERPLASTIC SPIIENOIDITIS AND ITS CLINICAL RELATIONS TO THE ENVIRONING NERVES, TO WIT: N. OPTICUS, N. OCULOMOTOEIUS, N. TROCHLEARS, N. TRIGEMINUS, N. ABDU- CENS AND N. CANALIS PTERYGOIDEI (VIDII), AND NASAL GANGLION* Although hyperplastic changes within the nasal fossae have been described by many writers and although special at- tention has been given to the study and description of this mor- elluU ethmoidals [posteriori fronla.1 CclluU ethmoid*.! (.interior) Orbit ■S&ccus I2s.cn mMis. A. oph.tha.lr Vontali dtaris) FVotebSus Fr;ont (Ossi^ macK Ductus na.£.olicrim&li Fknes ldle.raj.is c&vi n&s N. oculomoto ri us ptery^oideus poJ&Xma. descendeas ubi a.uditiva [Lustachn] Hamulus ptervQ£idcus Fklalinum dururnJ Sinus rn.2011lla.r1s Tig. 50. — Left sagittal section 5 mm. lateral to sphenopalatine foramen showing post-ethmoidal cell /, above and beyond^ optic nerve. Viewed from without inward. bid process in the ethmoidal district, no mention or study of this process in the sphenoidal district existed until 1915 Avhen I presented it to the American Laryngological Association. 83 To me it seems a matter of the greatest importance and far- *The first allusion to this subject by me was in an article read before the American Laryngological Association, 1912. 7S 96 HYPERPLASTIC SPHEXOIDITIS 97 reaching possibilities because of the intimate association of the many nerve-trunks in the region of the body of the sphenoid. In 1912 I 7S presented the anatomy of this district in a way differing from the extant descriptions in all particulars. These observations were confirmed by Dr. Ladislaus Onodi 01 work- "t Fig. 51. — Showing prolongation of sphenoidal sinus around optic canal. The ligatures are passed under the optic canal and anterior clinoid process. ing by a different method. We worked independently and un- known to each other. (Tie did not, however, observe the Vidian nerve at that time.) Familiarity with this anatomical detail is necessary for the purposes of this essay. Anatomical Relations. — The body of the sphenoid bone is 98 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN usually hollowed out by the sphenoidal sinus. This cell may, however (rarely), be rudimentary and occupy a very small space in the lower anterior part of the body, which is otherwise hollowed out by a post-ethmoidal cell, or the body may be more or less evenly divided by these cells. It is of the cell which hollows the body of the sphenoid that I write, regardless of whether it be the sphenoidal sinus proper or a post-ethmoidal cell or both. The body of the sphenoid is covered above and laterally Fig. 52. — Anterior and middle fossae of skull seen from above. /. Lesser wing of the sphenoid cut open just lateral to the anterior clinoid process to show bristle .' passed from the sphenoidal sinus under the optic canal -t. 4. Bristle from a post-ethmoidal cell. The extent and association of this cell with the optic canal is shown by the removal of the cranial plate exposing the optic canal j? for 1. cm.. 5. Floor of very large frontal sinus the cranial plate of which is removed. 6. Ethmoidal cells. by the dura mater, with the cavernous sinus between its exter- nal and internal surfaces (in it), occupying a position for the most part above and lateral to the body. The optic canal is sit- uated at the upper outer anterior part of the body of the sphe- noid. Its inner part is always in association with either the HYPERPLASTIC SPHEISTOIDITIS 99 Fig. S3. — Showing an older representation of the sphenoidal sinus and the cavernous sinus. /. N. oculomotorius. 2. N. trochlearis. 3. N. abducens. 5. N. maxillaris. 6. Stvloid proc- ess of temporal bone. (After Merkel.) Fig. 54. — Cross transverse section of the cav- ernous sinus. 1. Hypophysis. 2. Internal caro- tid artery. 3. N. abducens. 4. Sphenoidal cell. 5. X. oculomotorius. 6. N. trochlearis. 7. N. ophthalmicus. S. N. maxillaris. (After Ouain.) Fig. 55. — The usual cavernous sinus with large cross section and great length. Shows wide separation of all cranial nerves from body of sphenoid. /. X. opticus. 2. X. trochlearis. 3. X. oculomotorius. 4. X. ophthalmicus. 5. X T . abducens. 6. Cavernous sinus. 7. Vidian canal. Fig. 56. — Cavernous sinus district. (After Rouber and Kopsch.) sphenoidal sinns or a post-etlimoidal cell. And not infrequently these cells send a prolongation outward to extend more or less around the canal from above or below (Figs. 50, 51 and 52). 100 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN The optic nerve is in no way associated with the cavernous sinus. All the other nerves in this district, i. e., third, fourth, first and second divisions of fifth and sixth are in association with Fig. 57. — Cavernous sinus district. I. Foramen magnum. .'. Cavernous sinus. 3. Crista galli. (After Piersol.) 1 1 V 1 J, J It 1 1 2, Fig. 58. — Left middle fossa of skull, viewed from above and to the left showing foramen ovale separated from sphenoidal sinus 2 by thin bone 3. (The third division of the fifth passes through the foramen ovale.) 4. Foramen ro- tundum. Fig. 59. — Same specimen as Fig. 42 viewed from above and to the right. /. Foramen ro- tundum. 2. Bone separating sphenoid cell 4, from foramen rotundum. 5. Vidian canal dehiscent at point of indicator. it. "Within the cavernous sinus are found the internal carotid artery and the third, fourth, and sixth cranial nerves, with the first division of the fifth lying in the lower part of its lateral HYPERPLASTIC SPHEX01DIT1S 101 wall. The impression given in the treatises on anatomy is, usually, that those nerves are rather widely separated from the sphenoid sinus, as shown in Figs. 53, 54, 55, 56, and 57. The second and third divisions of the fifth and the Vidian are usually represented as well removed from the cell; that is, separated by a considerable thickness of bone (Fig. 53). The fact is, the sixth and third division of the fifth are the only ones that are b-^. Fig. 60. — Top view of left sphenoidal district dissected. I. Petrous part of temporal bone. 2. Semilunar (Gasserian) ganglion. 5. Foramen spinosum. 4. Foramen ovale with man- dibular nerve in it. Inside the sphenoid cell the foramen ovale containing the mandibular nerve is marked as a canal 5 mm. long, separated in a semicircular exposure from the sphenoid cell by bone 1 mm. thick. 5. Abducent nerve. 6. Oculomotor nerve. 7. Maxillary nerve entering foramen rotundum. S. Trochlear nerve. 0. Ophthalmic nerve. 10. Inner limit of sphenoidal fissure. //. Opening dissected into/ sphenoidal sinus. /-'. Optic nerve. 13. Ophthalmic artery. 14. Abducent nerve. 75. Internal carotid artery. 16. Posterior clinoid process. 17. Clivus of Blumenbach. 18. Abducent nerve. Dotted line shows outline of sphenoidal sinus. It is separated from the overlying structures by a wall of bone, eggshell thin, including those in the sphenoidal fissure. The inner two-thirds of the semilunar ganglion for almost one-half its length are also included in) this close association. not at times in close association with this cell; that is, sepa- rated from it by a very thin layer of bone; and even the third division of the fifth is sometimes also in rather close associa- tion with it (Figs. 58, 59, and 60). The sixth, so far as I have 102 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN found, in the cavernous sinus is uniformly placed on the lat- eral aspect of the carotid and always removed from this bony wall. Thus far I have been speaking of a sphenoid sinus which is limited to the body of the sphenoid. Should it be extended into the greater wings, the sixth nerve may come into close association with it in the sphenoidal fissure below (Fig. '60). Should the sphenoid sinus be prolonged backward to the clivus of Blumenbach (Fig. 60), the sixth will be in very close asso- n J 4 3' 2-- Fig. 61. — Shows a sagittal section of left side through the ophthalmic nerve. /. Eu- stachian tube with bristle in its lumen. 2. Tensor palati muscle. 3. Part of internal! carotid artery. 4. Semilunar ganglion in Meckel's cave. 5. Pin passed through wall of sphenoid. 6. Sphenoidal sinus. 7. Ophthalmic nerve. 5. Lesser wing of sphenoid. 0. Optic nerve.. 10. Post-ethmoidal cell. //. Pterygomaxillary fossa. /.». Opening dissected into maxillary antrum. 13. Wall of nose. 14. Internal pterygoid muscle. ciation with it as, it passes under the dura mater. This was first pointed out by Ladislaus Onodi." 1 The fact which determines the relations of these nerve- trunks to the sphenoid sinus is the size of the cavernous sinus rather more than the size of the sphenoid sinus. If the cavern- ous sinus be large in length and cross section, these nerve- trunks will be far removed from contact with the body of the sphenoid and the sinus within it. On the other hand, if the cavernous sinus be small in length or cross section, these nerve- trunks may be closely associated with a sphenoid sinus limited to the body of the sphenoid bone. Nerves in the canals, to wit, the optic, maxillary and Vidian, are not under this control. HYPERPLASTIC SPHENOIDITIS 103 Of course, a small sphenoid sinus in the center of the body of the sphenoid bone will be widely removed from contact with these nerve-trunks, regardless of whether the cavernous sinus be large or small (Fig. 53). A sphenoid sinus of large extent, prolonged backward and outward, may readily closely approach the third division of the fifth in the foramen ovale (Fig. 58). and Dr. H. P. Mosher has loaned me two specimens in which the sinus extended to a close association with the semilunar Fig. 62. — /. Sphenoidal cell. -'. Columnar marking of the internal carotid artery. _ Note that the sphenoid cell extends far lateral, to this. At the place / it extends to the region of the Gasserian ganglion. ganglion. I too have found such specimens and here report two of them in detail. 8 "' (Figs. 60, 61, and 62.) The semilunar ganglion is at present thought of as so far removed from the sphenoidal sinus that they have not been associated in the minds of the anatomists or clinicians. The internal carotid artery usually rises on the lateral aspect of the body of the sphenoid and the semilunar ganglion is usually lateral and posterior to the ascending artery. This, however, is not always true. The position of the artery seems to have a large part in determining these relations. 104 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN I present drawings of two specimens showing- an intimate association of the sphenoid sinus to the semilunar ganglion, or parts of it. Fig. 60 shows dissection of the caverous sinus, semilunar ganglion and sphenoidal fissure viewed from above. The sphenoid sinus lying beneath these structures is shown in dotted line. The thickness of bone separating the cavity of the sphenoid from these structures is eggshell thin. The inter- nal two-thirds of the ganglion are exposed to the uppermost part of the sphenoid cell and the external third is exposed at a little greater depth as the nerve tissues approach the foramen ovale. The mandibular nerve in the foramen ovale is exposed Fig. 63.- — Showing Vidian exposed in R sphenoid sinus. Cross section through the pterygoid processes. i". Left sphenoid cell. 2. Vidian canal. 3. Pterygoid process. 4. Right sphenoid cell. 6. A groove marking the Vidian canal. Its upper part is missing. for 10 mm. to an eggshell bone separation from the sphenoid cell. In the sphenoidal fissure the oculomotor, abdncens and ophthalmic are exposed to an eggshell separation from the sphe- noid cell. The trochlearis alone is not in this contact because it lies on top of the oculomotor. Fig. 61 shows a sagittal section through the oculomotor nerve within the cavernous sinus. The specimen is viewed from within outward. In this specimen the ganglion is exposed on its anterior limit for 10 mm. to an eggshell thin bone separa- I [ YPERPLASTIC SPHENOIDITIS 105 tion from the sphenoid sinus at the origins of the ophthalmic and maxillary divisions. The sphenoid cell measured 1.50 cm. sagittal, 4.50 cm. vertical, 5.50 cm. transversely. In 1912 I 78 proved the permeability of the sphenoid sinus wall to small amounts of cocaine. Following this observation,. Fig. 64. — I. Left Vidian canal deficient at point of indicator. 2. Basilar process of occiput. 3. Septum sphenoidale. with its lesson, into these anatomical associations seems to me to offer an explanation of the herpes which develops in the wake of sphenoidal infections or which arises in some patients from ordinary coryzas (irritation of the sensory ganglion cells Fig. 65. — /. Right sphenoid cell. 2. 1st division of fifth nerve. 3. 2nd division of fifth nerve. being necessary for 'the development of herpes), and to explain why semilunar ganglion neuralgias and tic-douloureux of sphenoidal origin sometimes recover as a more or less acute or subacute lesion and at other times require a ganglion re- moval or a posterior root section; i. e., sometimes the sphenoid lesion can be controlled and at other times it cannot. 106 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN A sinus extending downward soon approaches the Vidian nerve. In fact, the upper side of the bony case of the Vidian canal is often partly deficient under these circumstances (Fig. 63). The excavation may also extend below the level of the canal and leave it stalking through the sphenoid sinus like an ancient aqueduct, over the plain, connected with the bone be- low by a paper-like support (Fig. 64). Or it may be protected on one side of, and exposed on the floor of the sinus of the other Fig. 66. — Showing paper-thin separation of maxillary nerve in foramen rotundum from sphenoid sinus, i. Sphenoid sinus. 2. Foramen' rotundum. Z-k."' Fig. 67. — Cross section just anterior to an- terior clinoid process. /. Lesser wing of sphe- noid. 2. N. trochlearis. .?. N. oculomotorius. 4. N. opticus. 5. Anterior beginning of cavern- ous sinus. Fig. 68. — Cross section. /. Anterior clinoid process right. 2. N. oculomotorius. j. N. trochlearis. 4. N. ophthalmicus. 5. N. maxil- laris. 6. Anterior beginning of cavernous sinus. side of the skull (Fig. 63). The sphenoid sinus extended lat- erally soon reaches the foramen rotundum and may then envi- ron one-half of its circumference, bringing the second division of the fifth at this point, and for some distance posterior to it, into very close association with it (Figs. 65 and 66). The third and fourth nerves are in close association with the ante- HYPERPLASTIC SPHENOIDITIS 107 ©; @i © Fig. 69. — Cross section of sphenoid body through anterior clinoid processes posterior ten optic canals, seen from in front. /. Remnant of pharyngeal tonsil. 2. Anterior outlet of Vidian canal with Vidian nerve. 3. Anterior clinoid process. 4. Internal carotid artery in the cavernous sinus making its upturn. 5. Right sphenoidal sinus. 6. Left sphenoidal sinus. 7. Foramen rotundum with maxillary nerve. 8. Dotted line showing the prolongation of sphenoid sinus outward at a place posterior to line of transverse cut showing how it approaches the foramen rotundum. 9. Sphenoid-vomer junction. 10. Line of sagittal cut, the outer portion of which is shown in Fig. 70. Fig. 70. — Lateral part of sagittal section through line 10 of Fig. 69. 1. External pterygoid muscle. 2. Internal carotid artery. 3. Oculomotor nerve. 4. Ophthalmic nerve. 5. Cavernous sinus. 6. Lateral limit of sphenoidal sinus. 7. Bony wall of sphenoidal sinus. S. Tensor palati muscle. 9. Eustachian tube with bristle in its lumen. 10. Tensor palati. n. Internal pterygoid muscle. 12. Levator palati muscle. 108 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN rior clinoid process or lesser wing of the sphenoid, which are not infrequently hollowed out by a prolongation of the sphe- noid sinus or (from in front) by an extension from a post- ethmoidal cell, thereby bringing these nerves also into close Fig. 71. — Sagittal section between the foramen rotundum and Vidian canal right side, viewed from without inward. /. Hamular process. .?. Tensor palati muscle. 3. Levator palati. 4. Eustachian tube with bristle in its lumen. 5. Sphenoidal sinus prolonged downward into pterygoid process to bifurcation of the plates. 6. Clivus of Blumenbacb. 7. Groove for carotid artery. S. Nasal (internal) part of sphenoidal sinus. 0. Vidian canal crossing the sinus. 10. Internal carotid. 11. Optic nerve. 12. Lesser wing of sphenoid. 13. Post-ethmoidal cell. 14. Superior rectus. 15 Orbital fat. 16. Frontal sinus. 17. Bristle passed from maxillary antrum through its outlet into middle meatus of nose. 18. Hard palate. 19. Maxillary antrum (nasal wall seen from without). 20. Nasal ganglion. si. Internal pterygoid muscle. 22. Soft palate. The optic canal in this specimen is surrounded two-thirds of its circumference by sphenoidal sinus for 10 mm. of its length. Observe close association of Eustachian tube to sphenoidal sinus. association with these cells (Fig. 67). The first division of the fifth comes into close association with the sphenoid sinus ante- riorly, if the cavernous sinus be small in either direction (Figs. 65 and 68). HYPERPLASTIC SPHEX0IDIT1S 109 The relations of the Eustachian tube to the sphenoidal sinus were described by me in 1916. 86 In the usual skull the tube at all points is far (1.50 cm.) removed from the sphenoidal sinus. Fig. 69 shows a transverse section through a sphenoid which seems to me to represent average large sphenoid cells. The right measures 2.25 cm. transversely, 2 cm. vertically, and 2 cm. sagittal. The left measures 2 cm. transversely, 1 cm. ver- tically, and 2 cm. sagittal. Fig. 70 shows a sagittal section of same specimen just internal to the foramen rotundum. The Eustachian tube (with bristle in its lumen) is seen to be 1.5 cm. i 1 J ~''V»»~ at> t^. Fig. 72. — Sagittal section of specimen shown in Fig. 73 through the maxillary nerve. /. Pterygomaxillary fossae. 2. Sphenoidal sinus prolonged into pterygoid process to the bifur- cation of the plates. 3. Maxillary nerve. 4. Eustachian tube with bristle in its lumen. 5. Pterygoid process. The dotted line of Fig. S is shown as superimposed. Observe the very close association of Eustachian tube 4 with bristle in its lumen with the sphenoidal sinus 2. removed from the nearest approach of the sphenoid cell. Such relations preclude that a prejudicial effect be exercised on the tube by an inflammatory process in the sphenoid. When the sphenoid cell is prolonged downward into the pterygoid process it approaches the Eustachian tube more or less, and it may come to such close association as to be sepa- rated by an eggshell thickness of bone (Figs. 71, 72, and 73). This conies through two factors, first the thickness of the bone 110 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN of the pterygoid process is absent, and secondly the origin of the tensor palati is not from the uppermost limit of the plate. Should the tensor palati arise high on the plate the thickness of the muscle will enter in between the tube and the bone of the sinus wall (Fig. 74). Should, however, the tensor extend a lesser distance upward on the plate the tube comes into closer relation and in some specimens is in contact with the eggshell- thick wall of the sinus (see Figs. 71, 72, and 73). Piersol (Human Anatomy, 1907, p. 1503) states that the Fig. 73. — Showing the nasal (internal) surface of specimen shown in Fig. 72. I. Post- ethmoidal cells. J. Anterior limit of sphenoidal sinus. .?. Sphenoid sinus. 4. Upper limit of sphenoidal sinus. 5. Looking into lateral part of sinus. 6. Posterior limit of sphenoidal sinus. 7. Eustachian tube mouth. 8. Soft palate. 9. Lower limit of sphenoidal sinus. 10. Vidian canal. ;/. Hard palate. 13. Lower turbinate. The dotted line of Fig. 72 is shown in the depths. glands of the membrane lining the tube pierce the depths to perforate the clefts in the cartilage extending into the environ- ing connective tissue. In 1912 I proved 78 the permeability of the thin sphenoidal wall by an intrasphenoidal application of cocaine, paralyzing the entire fifth nerve. Such permeability it seems to me would allow an irritation in the tubes in such a case as Figs. 71, 72, and 73 as long as the sphenoidal inflammation continued. I HYPERPLASTIC SPHENOIDITIS 111 believe this is the explanation of some surprisingly fine re- sults for abandoned cases of low grade deafness following post- ethmoidal sphenoidal surgery. I have previously thought these cases to have been crippled Vidian nerves from sphenoid sinus inflammation — the great superficial petrosal nerve from the geniculate ganglion of the seventh (part of the Vidian) being the motor supply to the tensor and levator palati — they being thereby unable to perform their full functions so that these muscles did not open the tube properly. Fig. 74. — Sagittal section between foramen rotundum and Vidian canal, viewed from without. /. Hamular process. 2. Internal pterygoid muscle. 3. Lower meatus. 4. Middle meatus. 5. Nasal ganglion. 6. Upper meatus. 7. Optic nerve. 8. Sphenoidal sinus. 0. Vidian canal. 10. Abducent nerve. 11. Internal carotid artery. 12. Internal carotid, ij. Tensor pa- lati muscle. 14. Eustachian tube with bristle in its lumen. 15. Palatopharyngeus muscle. 16. Levator palati. ■ 17. Soft palate. Observe 12 mm. separation of Eustachian tube 14 from sphenoidal sinus 8 despite the prolongation of the latter into the pterygoid process to the bifurcation of the plates. In this case the tensor palati rises high and separates them. I believe both explanations are correct in two types of cases respectively. Clinical Relations. — Clinically the inflammatory diseases of the paranasal cells vary greatly. Each has, however, some semblance of constancy in its behavior, at least as far as symp- toms with signs go, with the exception of the sphenoid. As is known to us, it is no uncommon thing to see a sphenoidal 112 HEADACHES AXD EYE DISORDERS OF NASAL ORIGIN empyema give rise not only to its own characteristic symptoms, hut to simulate the pains produced by all. the other sinuses. Pain of a frontal sinus inflammation may he simulated by a sphenoidal inflammation — the differential diagnosis being made by the absence of pus from the frontal, with no tenderness of its floor — " Swing's sign" — as well as a negative finding on the x-ray picture. The pain of a maxillary antrum inflammation may be differentiated by a negative antrum puncture as well as a negative x-ray picture. Absence of pus in or from the ethmoid would exclude the ethmoidal cells. These symptoms, when pro- duced by the sphenoid, are, however, more apt to be nocturnal than diurnal. It seems to me there are two pictures produced by inflam- matory disease of the sphenoid sinus. The primary simple one is that produced by the pressure from an obstructed outflow of pus. I have construed this as the explanation of the somewhat "dull,' :i "heavy" pain in the back of the head described by these patients. The more complex one, simulating the pains which are ordinarily produced by the other sinus, can only be explained by assuming that the associated nerve-trunks have become involved either by the inflammatory process or by its toxins. This assumption applied to the third nerve may ex- plain also the dilated pupil seen in some of these cases, when the ophthalmologist or neurologist can assign no reason for it; and the asthenopia that is sometimes met with when no reason may be found in the eye or nose, otherwise. Some of these cases show a paresis of the superior oblique. From the above described anatomy, in which the sphenoid sinus is separated from the nerve-trunks by thin divisions of hone, such an extension of inflammation might easily occur. In an effort to prove the accessibility of these nerve-trunks I Iiave often painted the cavity of the sphenoid in a stripe from above downward and outward with a very small applicator hearing about one-half to one drop saturated water solution of cocaine (90%) and paralyzed one or all three divisions of the fifth for tactile sensation and pain, accompanied by a marked sense of stiffness of the lower jaw on that side. A needle could be passed through the skin supplied by these nerves and fail to evoke sensation. In these cases the separating wall must HYPERPLASTIC SPHENOIDITIS 113 have been a very thin one, thereby permitting the cocaine to pass quickly and easily through to the nerve-trunks. I have also, for therapeutic purposes, filled the sphenoid with oil so- lutions — 1 per cent phenol, 2 per cent menthol, 5 per cent and 10 per cent oil of wintergreen and 1 per cent cocaine alkaloid — and found that they all produce a well-defined analgesia of the second and sometimes the first and the third divisions of the fifth, accompanied by very little or no tactile anaesthesia. It therefore seems to me reasonable to assume, when the diagnosis is sphenoid empyema and the symptom is pain in the brow, that it is inflammation or irritation of the first division of the fifth by the process within the sinus which makes the symptom. When the symptom is pain in the upper jaw and teeth, or tem- ple, it seems reasonable to assume the second division of the fifth has become involved. When the symptom is pain in the lower jaw and teeth, accompanied by a sense of stiffness in the jaw on that side, it may be assumed that the third division has become involved and that probably in the foramen ovale. The behavior of certain sphenoid empyemata has inter- ested me much for several years. These are cases hi which the pains and aches have continued unchanged, despite wide open- ing of the cavities and cessation of all pus or signs of local dis- ease. It is my habit to perform a radical post-ethmoidal sphe- noidal operation (see page 164). It seems to me the most comprehensive treatment. Some of these cases, however, al- though recovering from the suppurative inflammation, and later from all signs and symptoms, have frequently subse- quently developed headache and behaved as cases of migraine. Dr. M. A. Bliss has seen a number of these cases in consulta- tion, and has sent some of them to me and has agreed in the diagnosis of migraine. I have felt that in this class of cases which have simulated and borne the name of migraine, the origin of the pain was a local one. These are of similar symp- tom-complex to those of toxic origin. The distribution of the pain has been that suggesting as its origin the first division of the fifth, as well as the second division, sometimes, or the third division, and combined at times with the posterior pain, which I have attributed to the irritation of the Vidian. In a recent paper 70 I mentioned that in the injection of the nasal ganglion 114 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN with alcohol, when the needle was placed too far internal, the pain produced by the alcohol was projected backward and into the shoulder, etc., and when placed too far external the pain was referred to the upper jaw; that is, when the side of the gan- glion upon which the Vidian enters was injected, the pain was referred posteriorly, whereas with the side upon which the sec- ond division entered, the pain was referred to the upper jaw. When the alcohol was placed in the ganglion direct, the pain was referred in both directions. (The relative position of the Vidian and second division of the fifth is shown in Fig. 39, which portrays the foramina through which they pass at these points. Faradic stimulation of the Vidian produces pain in the ear, mastoid, neck, shoulder, etc. (See Chapter II.) These cases of recent origin (three to six months approxi- mately) when well of the suppuration, Avere usually well of all symptoms and remained so until a coryza infected the general nasal cavity, when they again developed their pains, often with- out suppuration of the sphenoidal and post-ethmoidal cells. The membrane of the sphenoidal sinus, however, usually showed under these circumstances a red swollen, or edematous condition (even polypoid) analogous to that shown by the ante- rior ethmoidal region in hyperplastic ethmoiditis under sim- ilar inflammatory influences; that is, clinically it is hyper- plastic sphenoiditis. In the recovery the swelling and edema would subside, but more or less of the pain would continue, and at a time later begin a cyclical reappearance, with no visible disturbance in the sphenoid sinus, even when its anterior wall had a permanent opening in it large enough to permit a good view of its interior. I did not, however, at this time employ Holmes' nasopharyngoscope. Use of this instrument later showed that patches of inflammation within the sinus are usu- ally discoverable on the floor or lower lateral part of its walls. The Vidian canal with the Vidian nerve is on the floor, and the foramen rotundnm, containing the maxillary nerve is at the lower lateral anterior part of the body of the sphenoid. I have observed a similar behavior of the nasal ganglion ; i. e., intermittent reappearance of the neuralgia usually with an in- flamed spot at the sphenopalatine foramen. I have also ob- served in these sphenoidal cases a picture identical with the HYPERPLASTIC SPHENOIDITIS 115 neuralgia which starts in the nasal ganglion. This is not sur- prising, on the contrary, would be expected after one has proved the accessibility of these nerve-trunks. The entire nerve supply of that ganglion, to wit, the second division of the fifth and the Vidian nerve, being so closely associated with the sphenoid sinus, the picture of the ganglion neuralgia is readily repro- duced under inflammatory conditions within the sinus. The differential diagnosis is made by the facts that cocainization of the ganglion stops the pain when it is made in the ganglion, but fails to stop it when it is made in the sphenoid, because the ganglion is peripheral to that point of origin ; and that co- caine solution applied within the sphenoid sinus does stop the pain. In the case of ganglion neuralgia, the membrane cover- ing the sphenopalatine foramen is usually but not always, con- gested and thickened. This appearance may be absent in the case where the pain is started in the nerve-trunks from within the sinus. I have seen this class of sphenoidal cases behave as vaso- motor rhinitis or rhinorrhea or "hay fever," as the patients call that form of paroxysmal sneezing, accompanied by profuse watery discharge and by asthma. In these cases all therapeu- tic measures applied peripherally (intranasal) were of no avail. They yielded to intra sphenoidal applications. In the observation of these cases I am led to the belief that a large number of the frequently recurring headaches, of what- ever length of time standing, that usually bear the name "mi- graine," that are met with in the general practice of medicine, that have defied diagnosis and treatment, are sphenoidal in- flammations existent, or were started as such. They may have lost all the evidences of local disease, which some months or years before were easily recognizable. I believe that the sen- sory and sympathetic nerve-trunks have become diseased from juxtaposition, just as the optic is known to do. Disease of the nerve-trunks under these circumstances is in no wise dif- ferent in its clinical behavior from that which is started fur- ther toward the periphery, as for instance, from an antrum of Highmore suppuration or a diseased tooth, which after the cure of the local disorder continues painful at intervals or becomes a tic-douloureux. The second division of the fifth in the fora- 116 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN men rotundum is in as close association with the sphenoid sinus as is the optic nerve in the optic canal, and under iden- tical setting, namely, surrounded completely by a firm, bony ring. This is true of the third division of the fifth also ; but it is not, as a rule, so closely associated with the sphenoid sinus. Optic nerve disease, secondary to the sinus disease, is too well known and proved to require argument here. I see no reason why we may not assume as much for the other nerve-trunks, in close association with these sinuses, with the difference be- tween the types of nerves. This sphenoidal area being central to the place of injection of alcohol into the branches of the fifth nerve, from under the zygoma, may explain some of the cases that have not been relieved by that treatment. Also, for the same reason can we understand that when the semilunar ganglion has become involved and gives rise to the pain, intra- sphenoidal applications will fail to relieve. The involvement of the nerve-trunks in the sphenoidal dis- trict producing the sneezing explains why the injection of the branches in the neighborhood of the sphenopalatine foramen (Stein 8S ), combined with the same treatment of the anterior nerves, iias failed to influence the sneezing in some cases, the sphenoidal area being central to the other nerves. It appears that whatever may be the lesion of the nerves, it is rather easily remediable in its earlier stages by intra- sphenoidal medication. The worst cases by sedulous treatment may be greatly improved if not cured. I have not thus far been able to secure any post-mortem material bearing on the above question. This happens because we as rhinologists are apt to see the patient only while he is in good general health. Later in life when his general health fails he seeks the help of the internist and dies in his charge unknown to us. We learn of his death only some time later. In the public hospitals the chief obstacle to securing this mate- rial is the antagonism of the undertakers to any form of au- topsy. They seem, somehow, to be able to accomplish this. That the cavernous sinuses may become infected and thrombotic, secondary to sphenoidal infection, is well known. In these considerations the cavernous sinus, however, plays only an anatomical part. HYPERPLASTIC SPHENOIDITIS 117 I have stated in the records of some of these cases that they behave as a hyperplastic ethmoiditis, and that some did not. So far as I have been able to learn, there is no post- mortem histologic proof of a hyperplastic process in the sphe- noid such as has been proved in the ethmoid. Hyperplastic disease in the nose involves not only the bone but the soft parts covering it, in the nose and in the paranasal cells, as shown often at the time of operation by polyps within the cells. Whether such changes ever occur on the orbital side of the ethmoid or maxillary antrum or the dural side of the sinuses, is a question I have not as yet been able to solve. A case reported by W. B. Chamberlain 1 " indicates that polyps may form in the cranium. The conclusions here recorded are the results of examina- tions of bone removed from 185 such cases in my own practice; and I have been assisted by Dr. Jonathan Wright's examina- tions and conclusions regarding the microscopic changes in them. The clinical diagnosis of hyperplastic sphenoiditis is con- firmed by Dr. Wright from the examination of the anterior and inferior sphenoidal walls removed from these cases. Further- more, Dr. Wright's conclusions passed upon the bone sections from these cases, whose histories were unknown to him, cor- responded so closely with their history before and after oper- ation as to be very striking. The list comprises those oper- ated for suppuration of longer or shorter standing without other symptoms, which 1 feel should be classed as the simplest cases; and others operated for pus with more or less headache and of longer (six months) or shorter (two months) standing which were mild cases; and others for acute exacerbation with suppuration and others for acute ocular involvement and some totally blind with little or no disc changes; some with transi- tory amblyopia; some with choroiditis simple, and others of this class with ocular palsies also, third, fourth, and sixth nerves, which are of the type of ophthalmoplegic "megrim"; others of many months or years standing without pus, with slight disc swelling slowly increasing with a narrowing visual field; some with choroidal hemorrhages and total clouding of the uveal media; some serous iritis and cyclitis and anterior 118 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN chamber hemorrhages, others without, pus but with sensory (fifth) trunk involvements (hypaesthesia) and recurrent head- ache of the type (severe) vulgar migraine, without and with pallor (sympathetic migraine), and one recurrent headache with loss of consciousness, of ten years' standing of the type of epileptic migraine; and sixteen with ophthalmic migraine, complete pictures of all grades, four with great headache and hallucinations, the type of psychical migraine, and eight major epilepsies (one cured 18 years). Most were uncomplicated by systemic conditions. Some, however, occurred in the course of nephritis and a number in arteriosclerosis and heightened blood-pressure, and some with arthritis deformans; some with severe digestive disorders and some in syphilitics. All sys- temic conditions seemed to have so little influence on the local conditions as to be unrecognizable. The length of time over which these cases have been observed varies from nineteen years to twenty-three months. Intrasphenoidal observation with Holmes' nasopharyngo- scope 24 after the anterior wall was removed has shown thick- ening of the membrane, and sometimes a marked sclerotic state, and often localized inflammation, and sometimes polyps or cysts within the sinus, and sometimes vessels entering and leaving the sinuses through that part of the wall which makes up the optic canal. Furthermore, the configuration of the sinus can often be made out accurately, especially the most important parts. These are more or less at a right angle to the shaft of the instrument, which is the direction in which the prism looks ; e. g., the regions of the optic canal, foramen rotundum and Vidian canal. As the instrument is now constructed it has the defect that it cannot look forward or backward more than its 60° visual angle (30° to each side of the perpendicular) and requires a cell 12 mm. front to back, to contain its light and prism, as Dr. Gundelach has stated. It has, however, been of much help in the understanding of these cases as well as determining the comprehensiveness of my post-ethmoidal- sphenoidal operation. By these means I have been able to con- firm the diagnosis of hyperplastic sphenoiditis by intra-sphe- noidal observation and to learn that the process is not always universal, and that the exacerbations which may take place in HYPERPLASTIC SPHENOIDITIS 119 this district from coryzas may be localized; and that accord- ing to their position they may be more or less pernicious or disastrous; e. g., when localized about the optic canal they may impair vision without other symptoms; or when localized on the lower latter aspect of the sinns they may cause maxillary neuralgia: or on the floor they may give rise to Vidian neu- ralgia of any grade. I use the term "Vidian neuralgia" to express pain in the ear, mastoid, occiput, neck, shoulder blade, shoulder, arm, forearm and hand because "I found on experi- ments upon the nasal ganglion that it could be produced by the faradic current attached to the needle when in situ for injec- tion of the ganglion and that it could be produced separately from the anterior or maxillary part of the symptom-complex (pain in the teeth, eye and temple), by inserting the needle into the Vidian on the internal side of the ganglion. The de- pressing peculiarity of this pain has been emphasized by M. A. Bliss. 3 Marked anaphrodisia power has been ascribed to it by some patients. In considering hyperplastic sphenoiditis as a pathological process with the part it plays clinically, I feel that, primarily, attention should be called to the anatomy of these parts, as recorded above. The relations of the optic canal with the con- tained optic nerve, to that cell are at once important and strik- ing and have been remarked upon by many observers, notably Emil Berger ; 2 and latterly emphasized by A. Onodi, 00 and again by H. W. Loeb, 43 who has furnished us with the best pictures I have seen of that district and its variations. Attention to the anatomical relations of the sphenoid cell to the foramen rotundum containing the maxillary nerve, and the foramen ovale containing the mandibular nerve, and Vid- ian canal containing the Vidian nerve, as well as the clinical importance of these relations was directed for the first time in my above cited text. 78 Those anatomical observations were confirmed by Ladislaus Onodi, working by a different method. Our results were published May 11, 1912, 7S and July 10, 1912, 61 respectively, except for the Vidian nerve, which he did not at that time consider as I remarked above. Later he confirmed the Vidian relations. Dr. Onodi in this latter text''- refers to inv observations numbered in these references 78 and 81A. He 120 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN lias, however, made mistakes possibly explicable by differences of language, which require correction: i. e., text No. '78 was not a "lecture'' but presented as an official communication to the American Laryngological Association at its Thirty-fourth An- nual Meeting, held in Atlantic City, N. J., May 9 to 11, 1912. The presentation was accompanied by the drawings which were published with the text as well as the specimens from which the drawings were made, no mention of which has hitherto seemed to serve a purpose. In his citation of the second text (No. 81 A) he has made a mistake as to whose researches are recorded in that text. The determination of the age at which the sphenoidal sinus reaches close relations to the foramen rotundum with the maxillary nerve and Vidian canal with the Vidian nerve was made by me and not by Dr. Davis. Through personal favor Warren B. Davis allowed me to examine his matchless collection of Caucasian specimens with the understanding that I might enjoy the privilege of recording my observations, giv- ing him credit for the material. At that time Dr. Davis, was not interested in the foramina and canals or nerve-trunk re- lations to the body of the sphenoid. His desire was to con- tribute to anatomy a full and accurate knowledge of the "De- velopment and Anatomy of the Nasal Accessory Sinuses in Man' : (to quote the title of his monograph, 1914), and he did this with a completeness and an accuracy that surpassed all description or portrayal extant. And so it was that he had definitely determined the beginning and the manner of the de- velopment of the sphenoidal sinus, but he was not concerned with its approach to the foramen rotundum or the Vidian canal, nor did he realize any clinical significance or importance in those relations. I attempted to make this clear in my text. In addition to differences in the languages (which make mistakes very easy) these points might have been brought forth with greater emphasis, which did not, however, seem to me, at the time to be necessary. The statement is made in Dr. Onodi's text that his ob- servations were first published in "Orvosi Hetilap," March 24 r 1912. Perusal of that journal shows his text to have been pub- lished November 3, 1912. Dr. Onodi and I made some similar observations. Mine HYPERPLASTIC SPHENOIDITIS 121 were made as a necessary chapter — the applied anatomy — in a very difficult and complex clinical problem. The question of the adjacent foramina and canals was at that time a matter of importance and record for me and has grown constantly more important. I do not, however, regard the nerve contacts with decreasing- importance. Dr. Onodi's method was to fol- low the nerve-trunks in their courses and when found in con- tact with the bone to measure the lengths of such contacts and note the thickness of the bone separating the trunks from the sphenoid sinus, and I believe this to be very valuable contri- bution to our knowledge of this district. He did not consider the foramina or canals or the part played by the cavernous sinus in determining the contacts. I, too, had tried that method, but in my hands it was less satisfactory than the method by serial cross section of this district, using material carefully hardened in formaldehyde and decalcified in dilute HC1. Such material may be sectioned with a good knife, as thin as 1.5 nun., or even 1 mm. when desired. These sections when ex- amined with magnifying glasses were most satisfactory. The macerated bones, too, in some instances were advantageous. The cross sections have the advantage that they determine all contacts most accurately as well as the relations of the fora- mina and canals and the thickness of the separating bone. They also give an estimate of the amount of fat or connective tissue surrounding the nerves in the foramina and canals. In my text/ 8 hyperplastic sphenoiditis was referred to as being in my opinion the lesion underlying many of the recur- rent headaches, in healthy people, which at present bear the name "migraine." I spoke of this class of cases again at the meeting of the American Laryngological Association in 1913 and again at its 1914 meeting, explaining some of its features. Its (hyperplastic sphenoiditis) very great importance in the life of the patient and its far-reaching pernicious possibili- ties were not, however, so clearly impressed upon me then (1912) as now. At that time I thought that many of the cases,, if not all, were explained by the inflammatory process either extending through or transmitting its toxins through the thin bone walls to the adjacent nerve-trunks because I had proved that cocaine readily passed through from the sphenoid sinus to 122 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN the nerve-trunks. But within the past few years, as a result of a much wider clinical experience, I have come to feel that there are probably several factors contributing to the clinical pic- ture, those being two of them, and that a third and probably much more serious one is the bone change in the hyperplastic process with or without periostitis. The bone change, how- ever, required the proof which Dr. Wright has supplied. It would seem that such material ought to be obtainable post- mortem, but so far that has not been my experience. My ideas therefore have of necessity been formed by the association of some facts with an inductive philosophy. In this connection it might be argued that the condition of the anterior wall of the sphenoid cell (which must include its post-ethmoidal face) is not a criterion for the remaining part of the body, and that conclusions drawn from that material dare not be generalized for that district. Holmes' nasopharyngoscope is an aid which permits of much conclusive observation. By it we find that the hyperplastic process is not always uniformly distributed within the cell. It may be distributed irregularly but is usually more marked in the lower half of the cell. Hyperplastic anterior ethmoiditis may sometimes precede a like change in the post-ethmoidal-sphenoidal district; and it was from such cases that I began to form the ideas embodied in this text. I have observed some of them for nineteen years. The first clinical effect in such a case is the closure of the frontal sinus, the outlet of which, aside from being in the dis- trict Avhere the process so readily begins because of the direct blast of inspired air with its dust and bacteria, lends itself easily to clinical manifestations because of its being narrow usually at some point if not in much of its length ; and therefore easily closed. Also the fact pointed out by Uffenorde 93 that the submucous connective tissue on the lateral aspect of the middle turbinate and ethmoidal wall is loose, readily contrib- utes to the clinical picture. These facts give rise to the (non- suppurative) cases which Ewing and I described in 1900. 07 A part of the air within the cell is then absorbed, resulting in a negative pressure and headache accompanied by Swing's sign (a tender point at the upper inner front of the orbit) and asthenopia. The closure may also be brought about by other HYPERPLASTIC SPHEXOIDITIS 123 causes, irrelevant to the argument here, a detailed enumeration of which with differential diagnosis may be found in Chapter I. The pathological state bearing upon the questions here in hand, is that where the tissues of the middle meatus become hyperplastic. In these cases the membrane readily becomes edematous, and coryzas make polyps, which in the early his- tory of the case disappear with the subsidence of the acute con- ditions ; later as the bone becomes more hyperplastic the polyps remain permanent. It has been my habit to remove the middle turbinate in such cases by an incision placed about 2 mm. below the cribriform plate. This gives, in usual skulls, a funnel-shaped outlet to the frontal sinus, apex down, made by the uncinate process in front and the ethmoid bulla behind and below, the lower part being the hiatus semilunaris, measuring normally 1 to 2 mm., expanding to 5 mm. above, anteroposterior^, and 2 to 4 mm., laterally. These anatomical details are elaborated in Chapter I. The immediate result of such surgery is a wide opening of the frontal sinus into the nose and a cessation of all symptoms for five to ten years (approximately). The pa- tient then returns for treatment at the time of a coryza, be- cause of slight headache and asthenopia, which he is anxious about from previous experience. The rhinologist finds the out- let or inlet of the frontal closed, but as the swollen membrane shrinks he finds that the symptoms subside and that the outlet or inlet is then open, but smaller than it was. As the years pass he finds that the uncinate thickens a little, but that the bulla enlarges more and the outlet or inlet of the frontal be- comes smaller and finally closes again and the orginal head- ache, etc., syndrome is re-established without pus. The tis- sues from such cases were examined by Dr. Wright and found to show the changes of hyperplastic ethmoiditis. The picture in the nose shows the macroscopic changes to correspond and to be extending backward; and later (without pus) the pain of maxillary and Vidian nerve involvement; that is, pain around the eye and in the upper jaw and temple; with pain in the occiput and neck, etc., is added as the process in the bone ex- tends backward; and polyps begin to form above the middle turbinate line at the time of a coryza. At first they disappear with recovery from the coryza; later they become permanent. 124 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN In the progress (development) of the bone disorder backivard, the maxillary and Vidian headaches appear only at the time of coryza. Later, however, they recur at longer or shorter intervals in more or less severity without visible local changes and continue to do so indefinitely with the neurologist's diag- nosis " migraine.' : (I have seen such headaches of forty years' standing very greatly relieved by the sphenoidal operation. They cannot be cured by operation if the pathologic mechanism be correct in its idea.) The same clinical picture is produced by irritation of the nasal ganglion, but this may be differen- tiated by the fact that the nasal ganglion pain can be stopped by cocainization of the ganglion, whereas the pain made by the sphenoid in the nerve-trunks, central to this, cannot be stopped that way. (See Chapter II.) Optic nerve disorders arise often, secondary to hyperplas- tic bone change of the spheno-post-ethmoidal district. A large percentage are preceded by those headaches — often for many years. In some cases there is a slow encroachment upon the optic nerve, as shown by slight swelling of the margin of the disc, which increases slowly with gradually failing vision. This may be a process of years. Adamkowitz 1 found that slow com- pression of nerves destroys function slowly. In other cases the eye becomes quickly blind with or without changes in the disc. Some cases have a transitory amblyopia. Some show muscle imbalance, probably because of discomfort arising from the attachment to inflamed bone at the apex of the orbit. Some show hyperaesthesia and hypalgesia over the maxillary dis- tribution. The explanation of the headaches and optic disorders in such cases, I believe, is hyperplastic bone process and that its mode of operation is to narrow the bone canals through which the respective nerves pass ; i. e., the optic canal with the optic nerve, the foramen rotundum transmitting the maxillary, the Vidian canal with the Vidian nerve. The foramen ovale with the mandibular nerve only rarely conies into these considera- tions because it is usually far enough removed from the sphe- noid cell to be exempt as a clinical factor. (It does, however, sometimes become a part of these pictures.) This seems to me a reasonable deduction from Dr. Wright's findings in the HYPERPLASTIC SPHEXOIDITIS 125 wall of the sphenoid in conjunction with intra sphenoidal (pha- ryngoscope) observation, together with the easily seen behavior of the process on the lateral wall anteriorly, where the fron- tal outlet may be seen narrowing from year to year. It may here be urged that the intranasal observation was made in a part exposed to the atmospheric air and that the foramina and canals mentioned are not so exposed ; and that the frontal out- let being empty offers ho resistance to encroachment Avhereas the foramina and canals are snugly filled and would offer some, if not considerable resistance; and that the osteoblasts -are active only on convexities. I have, however, seen the unci- nate process become markedly thickened and enlarged in its concavity in the progress of hyperplastic anterior ethmoiditis (also observed by Uffenorde 93 ). And it may be urged that the lesion in the foramina and canals is probably a periostitis, which is, judging from the removed bone, probably true in -some cases, but not all, by any means; whereas the hyperplas- tic bone change was constant for this class of cases and ex- tended through the depths of the tissues. In other words, it was uot limited to the part exposed to the air and was irregularly accompanied by periostitis. Dr. Wright and I believe that the process begins as a surface tissue change, and proceeds to the periosteal layers and bone. But the sections show that the sur- face and periosteum may recover and the deeper changes go on. The canals in the skulls of present-day children have often •seemed to me larger than those of the present-day adult. This, however, is a difficult point to determine and mav very readily lie only apparent and not real. In truth it would seem that in the National Museum, Washington, the privileges of which were kindly permitted by Dr. Ales Iirdlicka, the di- rector, in specimens of the skulls of aboriginal American In- dians this is probably not the fact. Professor Arthur Kieth 's observations 33 argue against anatomical change being possible in a few thousand years. Larger canals would explain why these headaches and optic nerve troubles do not begin more oft en in childhood. I have, however, seen the headaches at the age of three and seven years and the eye trouble at six years. It is easily conceivable that a small spare around each nerve is left more or less filled with fat or loose connective tissue 126 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN This tissue would be easily compressible in the foramina and canals and might allow for or accommodate a congestion rising from whatever of many causes ; e. g., a digestive or other sys- temic toxemia or the mechanical gravity congestion produced by making the head the lowermost instead of the uppermost part of the body (in other words, when the head is turned downward in any considerable degree). If the narrowing of the canal or foramen is merely enough to take up this small space, it will, it seems to me, place that nerve in a vulnerable position, which explains some of the phenomena of these cases, namely, pain established instantly by bending the head down or by coughing or sneezing in which the peripheral blood-pres- sure is suddenly raised, and sudden transitory amblyopia. Fur- ther encroachment on their calibre would explain the slow pro- gressive optic nerve cases and the more protracted severe head- aches. If now it be conceded that hyperplastic bone process can and does narrow the bony foramina and canals adjacent to the sphenoid sinus, and that the narrowing is the cause of the pain in all the contained nerves except the optic; and that the optic also suffers according to the degree and rapidity of the patho- logical process— we have also the explanation of why maxillary and Vidian pains are so very much the more frequent symp- toms, because the lower part of the sphenoid sinus where the canals run which transmit those nerves is most often affected, and the factor of secretions and their toxicity plays here in addition to what may be the process in the bone. They re- main in the lower part. Next in order of frequency is affec- tion of the optic nerve. That this, however, is less frequent than the maxillary and Vidian lesions is probably likewise a matter of drainage, it being higher and forward in the sinus. The wall of the optic canal cannot as a rule be submerged in secretion in any position in which the head may be placed unless the ostium sphenoidale be closed. In the erect posture the sinus will overflow ere this is reached. The only positions of the usual skull making the optic canal dependent is face downward, and that again would fail beeause the ostium would be placed below and drain the cavity, or possibly lying on that side of the head ; i. e., left side for left optic canal, with con- HYPERPLASTIC SPHENOIDITIS 121 siderable secretion contained in the sinus. Loeb 43 has shown that the ostium is usually midway between the roof and floor of the sinus. The optic canal would seem to be almost of necessity a later involvement, by bone extension; or localized inflamma- tory areas from a coryza. In contradistinction to the clinical lesions of these nerves in bony confines, are such lesions of the nerves in the soft (loose) confines of the sphenoidal fissure; to wit, the oculo- motor, trochlear, ophthalmic, and abducent, although these nerves are in contact with the bone for a longer or shorter distance as they pass through the sphenoidal fissure into the orbit or the clivus of Blumenbach. The bone here may be hol- lowed (often) by the sphenoid sinus extending into the great wing or even by the frontal extending backward into the les- ser wing (rare) or by sphenoidal or ethmoidal cells projected into that district. In my experience a supraorbital nerve pain of sphenoidal origin is rare. Ophthalmic nerve contact with a thin walled sinus, however, is also rare. Pain in the brow is frequent and may arise from a number of causes ; e. g., fron- tal sinus vacuum or empyema, or maxillary irritation in the sphenoid, and these must be very carefully differentiated. Supraorbital neuralgia, however, of systemic toxic origin is very frequent. A lesion of the trochlear is also very rare, according to my experience and that of my ophthalmological as- sociates. Sphenoidal lesions of the oculomotor and abducens are seen oftener because of their arrangement in the sphe- noidal fissure (the sixth is exposed on the clivus of Blumen- bach and the sixth and third come into relation with the wall of the sinus as soon as it is prolonged into the great wing, the fourth is more protected). These lesions are seen, however, much less often than those of the optic and infinitely less often than the maxillary and Vidian lesions. It is a fact that the nerves in soft confines are not as often exposed to the sphenoid sinus as those in the bone confines. But this, to my mind, ex- plains only a small part of the great statistical differences, i. e., the very frequent involvement of those in the bone con- fines and the very infrequent involvement of those in the soft confines. And in this connection I emphasize again that nar- 128 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN rowing of their confines is the probable prominent part of the lesion. Were the simple inflammatory process in the membra- nous lining- of the sinus responsible for the clinical pictures by transmission of its toxins through the bone, or were a peri- ostitis of the foramina and the sphenoidal fissure, or were the lesion a neuritis from continuity, to blame, then in all reason- able probability would the oculomotor, trochlear, ophthalmic and abducent take part in these pictures more often. I believe this because of my cocaine experiments (see page 112). In some skulls the entire trigeminus may be paralyzed by painting the sphenoid sinus with cocaine solution, with great confusion in the eye which the patient cannot describe. The sphenoidal sinus enlarges until it comes in close relation with the foramen rotundum often as early as the third year of life and by the seventh year often reaches to the Vidian canal. This seems to me to be the anatomical explanation of these cases in childhood. They are, however, rarer in childhood, as may be expected if we accept the theory of narrowing of the canals. Dr. Wright believes tha.t some of the pain in these cases must be made by a periostitis in the nasal fossae just as such a lesion on the shaft of the tibia causes pain. Post-ethmoidal-sphenoidal inflammation in the young often takes on the hyperplastic bone process evidenced by thickening, polyps and general edema. In children it is often the cause of frequent coryza with paroxysmal sneezing, asthma, bronchitis and fever. I believe these symptoms, not fever, are brought about as a sympathetic nerve manifestation from the nasal gan- glion. Pediatricians often report this syndrome as the result of other causes without the nose having been excluded as a possible factor. An index to the hyperplastic process seems to exist. The degree of hyperplasia of the plica septi seems to indicate a cor- responding degree in the sphenoid, explicable probably by vir- tue of the fact that secretion from the sphenoid descends over the plica (usually) whereas that from the post-ethmoid passes over the end of the turbinate. The secretion is often serous. I believe, however, it is distinctly irritant. This would seem so from its effect on the skin of the tip of the nose and the lip. HYPERPLASTIC SPHENOIDITIS 129 The middle turbinate in general is not, however, an index of the changes in the post-ethmoidal-spJienoidal sinuses. Hyperplastic sphenoiditis, in my opinion, is the explana- tion of why the treatment of nasal ganglion neuralgia is so often disappointing. The diagnosis may seem clear inasmuch as the pain complex may he controllable from the nasal gan- glion by cocaine, but injection of the ganglion is followed by only short time relief because the irritation continues. The injection of the ganglion helps, but the satisfactory relief of the case is accomplished only after the hyperplastic bone proc- ess has been controlled. This happens sometimes as a result of the injection but at other times reinjection and in many, a post-ethmoidal-sphenoidal operation with after treatment are required. Until this is accomplished, the hyperplastic bone process may keep up the ganglion irritation indefinitely. The best post-operative anatomical results — I mean by this, that the result has remained better, for a longer time, i. e., remained less altered by a continuance of the hyperplastic process, according to my observation — have been in patients whose general bony skulls have changed least from year to year. These patients show age by change in the skin rather than of feature. In all these cases a slight acute process added to the ex- istent hyperplastic process livings on disaster out of propor- tion to the acute process., I record the observations of Dr. Wright made upon the conclusion of the examination of the series of specimens: "As a result of the observations made upon Doctor Slu- der's specimens and as the result of the conference with him in which he has detailed the history of each case in connection with the pathological findings, one may say in a general way that the coincidence of inflammations of the middle turbinate with inflammations of the sphenoidal sinus, is by no means uni- versal, that is, in some of the cases marked involvement of the mucous membrane and of the bony structures in and around the sphenoidal sinus was observed while the middle turbinate was in a fairly normal condition, and the same is true in a re- verse sense. I have been especially struck in examining the cases to i i' 130 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN observe that the vast majority of specimens submitted to me were from female patients. Doctor Sluder perhaps can go more carefully into the relative proportion of these, but so far as the slides which he has submitted to me go, it is quite evident that perhaps three-quarters of them are from females. "As to the histological findings, again it may be said that evidently the inflammation of the upper sinuses of the nose is a very frequent occurrence with many of the symptoms of pain in and about the nose or even of diffuse headaches appar- ently due to a periostitis with a local cause. Apparently, pro- found changes may occur in these cases in the mucous mem- brane and in the bone without serious involvement of the im- portant structures with which Doctor Sluder has so long been busy, but when inflammatory exudates occur in such a way that the Vidian nerve and the second division of the fifth are affected by the pressure of inflammatory exudates, we get periphery manifestations of pain in the lower part of the head and the cervical region running down to the shoulder which is very distressing and obstinate and may last for years. Appar- ently, the same principle may be applied to the optic nerve. "The patient may have had inflammatory conditions of his sphenoidal sinus for many years before serious involvement of the optic nerve occurs. When it does, the evidence goes to show that the inflammatory process has extended to the neigh- borhood of the course of the optic nerve from the upper and outer wall of the sphenoidal sinus inducing marked functional disturbance in the eye or even complete destruction of the func- tion of the optic nerve." Dr. Wright's observation that most of the patients were females is true for the series presented. In practice, however, I think the preponderance of females over males is much smaller, if they be not almost equally divided. In an epidemic of post-nasal infections such as has existed in St. Louis for three years (1912-1914 inclusive), and I understand has ex- isted in other parts of the United States also, the sexes seemed to me to be equally attacked. The females seem to become chronic sufferers somewhat oftener than the males, possibly because their bones are often lighter, which means that the above considered nerve-trunks have less protection. HYPERPLASTIC SPHENOIDITIS 131 DIAGNOSIS The clinical diagnosis of hyperplastic post-ethmoidal sphe- noiditis follows the same general rules that govern the anterior ethmoidal region. The former is, however, very much more in- accessible and must be illuminated through a much longer and narrower channel when examined from the throat. Examina- tion from the front of the nose is so seldom satisfactory that it cannot be relied upon. If a cadaver be examined and meas- ured if will be found that from the post-nasal glass as it rests in the throat to the upper meatus and the sphenoethmoidal recess is, in a full sized head, a distance of from 6 to 8 cm. This illumination must be supplied by reflection from a glass often as small as 1 cm. in diameter and be projected into the narrow olfactory fissure. It therefore requires a powerful source of light to be sufficiently illuminating when reduced to this small pencil at that distance. These points may appear trite but from great experience with the patient I feel that they cannot be too much emphasized, and from a wide experience with rhinologists of all degrees of professional acumen, I feel that the intensity and quality of the light employed for these pur- poses are very often unsatisfactory for the necessities beset- ting this district. The one, oldest light, all powerful, uniform, white and available for everyone is the direct sun. "When focused, how- ever, by the concave head mirror it is too hot to be borne by the patient. It must therefore be used with the head mirror more or less out of focus. Moreover the direct sun on a clear day focused by a 10 cm. head mirror is so very intense that it is apt to obliterate much if not all of the detail of the picture and so defeat its own special ends. Furthermore the brighter the light, the more evident become all flaws in the post-nasal glass however minute (such as scratches made by wiping), which make more or less added difficulties. Using the head mirror out of focus therefore serves three important purposes. The same objects are attained by using the sun shining through thin fleecy clouds or something giving this effect. Among the electric lights must be mentioned an arc light made and sold by Ernst Leitz of Wetzler, Germany, under the name of "Lil- 132 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN" liput Arc Lamp" which is as satisfactory as the direct sun, with the advantage of being- available at any hour. The car- bons meet at a right angle and give a very brilliant white light which is condensed into a pencil by a convex lens. When this pencil is reflected by a concave head mirror and focused it is practically indistinguishable from the sun but not quite so brilliant or so hot, both of which points are advantageous. It is a different light from that of the arc lamp in common use as street illumination. In burning, a little white smoke is given off which condenses to a white powder suggesting zinc oxide, suggesting that the carbons had been impregnated with a zinc salt which may be the way in which the "white" light is made. Leitz declines to tell the process of manufacture. No incan- descent bulb light that I know of is anything like so satisfac- tory as the sun or the "Lilliput Arc" for brilliancy or color. The gas lights have more serious faults, namely, less brilliancy and more colors. The light should be white and bright. A yellow or red color to the light interferes with the correct es- timate of the color of the membrane and sometimes the thick- ness of the epithelium in the parts examined and a green or yellow color makes the recognition of small amounts of thin greenish or yellowish secretion very difficult or impossible. The Argand gas lamp is quite red and yellow and the incan- descent gas mantle (Welshach or Auer's) is green and yellow and of far too little brilliancy. So it is (to my mind) the source of light in routine use by rhinologists at present is usu- ally unsatisfactory for post-nasal observation although I rec- ognize that for anterior rhinoscopy they answer their purposes. The advantages of a brilliant white light have been recognized by laryngolo gists for many years. Morell McKenzie in The Laryngoscope, third edition, described the oxyhydrogen cal- cium light and I saw it in use in the London clinics a number of years ago. The calcium light is perfect but more trouble- some than the electric arc. The importance and advantages of bright white light for the spheno-ethmoidal district have not heretofore been emphasized. One other source of light and means of observation should be mentioned, namely, Holmes' nasopharyngoscope. Sometimes it is of the utmost help by virtue of its right angle vision and should always be at hand, HYPERPLASTIC SPHEXOIDITIS 133 but its short focus and incandescent lamp make the interpreta- tion of its picture more difficult than that of direct vision with strong white light. Another item that may seem supererogatory is a descrip- tion of the normal post-ethmoidal-sphenoidal district. No clear description, however, such as will answer my purposes, exists so far as I know. The posterior end of the middle turbinate should be con- sidered the lower boundary of this region. The posterior mar- gin of the vomer bears the plica septi. In the effort to describe the normal of this region, emphasis should be laid on the color, thickness and translucency of the membrane of the olfactory fissure and the size and character of the posterior tip of the middle turbinate and the plica septi. The color of the normal membrane is pink and it fits close to the bone. It gives the impression of thin pink silk velvet. The epithelium is smooth and transparent and the effect is given that the membrane is translucent. It appears moist but not wet. If it is wet it will glisten. (The degree of moisture here is, to my mind, an important item.) No vessels are rec- ognizable clinically. The middle turbinate tip is smooth and pink but gives the impression that the membrane is less closely applied to the underlying bone. The plica septi is only slightly developed and is of pearl pink appearance, that is to say, it is slightly less translucent than the surrounding membrane. Such a picture is not seen in the routine of a rhinologist's practice as a rule. Patients who consult him have had some disturb- ance in this district in the great majority of instances. He can, however, familiarize himself with it by observation on chil- dren suitable for the purpose or on adults who have been free of nasal disorders and who are not " subject to headache and stiff neck." I emphasize this point because such patients are frequently unconscious of an existing nasal lesion as their causes. Another district which furnishes a membrane similar or identical is the septum in the lower anterior half but well back of the vestibule. The membrane here is not apt to show hyperplastic changes until the remaining nose is markedly in- volved by that process. An acute inflammation in this district causes the membrane 134 HEADACHES AND EYE DISORDERS OE NASAL ORIGIN to swell and become darker red and more moist — wet. (Some- times it is found that the appearance of acute inflammation is not an acute state, hut is present as a chronic state and some- times it is present throughout the nose.) Pus may or may not accompany it. It does not cause the vessels to show or the epithelium to become opaque or rough. When, however, it is oft repeated, some swelling remains permanent and some small vessels become visible and a quality of opacity is added which is from thickening and clouding of the epithelium. Moisture or pus may or may not always be present. The surface ap- pears more or less roughened. Swelling of an edematous na- ture may be present but it is much less likely than in the middle meatus in front, under similar conditions. Another change in the membrane of this district which should be carefully observed is a velvet-like thickening with- out much if any change in color or moisture and without the appearance of macroscopic blood vessels. Slight roughening of the surface may be discernible without opacity. It reminds one of the "lymphoid enlargement' 1 of the tonsil in contra- distinction to the "inflammatory enlargement." All changes in these parts should be carefully noted be- cause a very slight surface change is often accompanied by much more advanced and serious change in the deeper parts as is often shown by the finding of polyps within the cells at the time of operation, no evidence of which was previously recog- nizable. And furthermore, patches of inflammation may often be found with the pharyngoscope within the cells which are very pernicious and disastrous according to their location ; e. g., upon the optic canal. These patches are often much more marked than the changes in the parts exposed for observation prior to the opening of the cells. For these reasons I feel that the normal should be clearly fixed in the rhino! ogist's mind and all changes departing from it, however slight, should be most carefully considered. There is a tendency at present among rhinologists to advocate a post- ethmoidal-sphenoidal operation in cases of optic neuritis even though- the sphenoid is normal. I believe close attention to these points will show that very few if any of these cases are normal. Furthermore I do not believe that the post-ethmoidal- HYPERPLASTIC SPHENOIDITIS 135 sphenoidal operation is free of danger in the hands of any rhinologist. The most experienced rhinologist may get lost in this region at times. I have seen the eye which it was intended to save, lost for the vision it had at the time of operation, and Harmon Smith S7a also has reported such disaster. In private conversation with rhinologists I have learned of death follow- ing a number of these operations. Simple opening of the sphe- noid from its natural opening downwards is as nearly free of danger as surgery may well he, but that is utterly insufficient in many cases, as will be at once seen from an inspection of almost airy set of a dozen specimens. Sometimes the sphe- noid sinus makes the inner part of the optic canal and some- times the post-ethmoidal makes it; and there is no way to tell in the patient at the time of operation which it is. Therefore the sure practice is to do the combined operation. The distribution of the hyperplastic process here is of great interest, and various. Sometimes it is an extension back- ward of an easily recognizable hyperplastic anterior ethmoid- itis* 93 manifest by enlargement of the soft parts and bone of the middle turbinate with edema and polyps in the middle meatus or sometimes extension backward of a general hyperplastic rhinitis. But these are to my mind by no means necessary forerunners. Frequently I have seen hyperplastic post-eth- moidal sphenoiditis develop in adults who had been my patients from early childhood and who to my personal knowledge had never had a clinically recognizable affection of any of their paranasal cells, and did not have a general hyperplastic rhi- nitis. In these patients it began as the primary, and was the only sinus involvement. It was the result of repeated infec- tion of this district alone. It furthermore is capable of other niceties of distribution. Later it develops more markedly as a post-ethmoiditis or a sphenoiditis. It seems to me from close observation that a post-ethmoiditis in time brings about a hyperplasia of the posterior tip of the middle turbinate, and that a sphenoiditis likewise produces a hyperplasia of the plica septi. Explanation of these phenomena seems to me to lie in the fact that the thin serous secretion which usually accom- panies this process is discharged from the post-ethmoidal out- *Uffenorde has given a careful description of this anterior picture clinically and anatom- ically to which the reader is earnestly referred. 136 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN let over the posterior tip of the turbinate, whereas the thin secretion from the sphenoid in the sphenoethmoidal recess is usually found over the plica septi while the head is erect. I have proved these facts on the cadaver. This secretion is in all likelihood irritant if the effects of nasal serous discharge on the lip may he taken as a criterion. I should like particularly to call attention to a hyperplas- tic inflammation of the posterior tip of the middle turbinate and the sphenopalatine foramen district, for the reason that this lesion has so often been the accompaniment of chorioiditis with clouding- of the vitreous, iritis and hemorrhage into the vitreous and anterior chamber. I do not recall that this has been associated with optic neuritis. Dr. Wright observed that the vessels in the material removed from these cases showed more involvement than the specimens removed from the headache or the optic cases with less bone involvement. Polyp formation may accompany hyperplastic post-eth- moidal sphenoiditis and show in the olfactory fissure constantly or only at the time of a coryza to disappear with recovery from the coryza. These, however, are the less frequent cases. The probe may recognize the more advanced degrees of thickening. Post-ethmoidal-sphenoidal suppuration is readily recogniz- able if the pus is thick and adherent so that it remains at the point of entrance into the nose; and is at all profuse. As the case begins to recover and the secretion becomes less and thin- ner it is not always so easily recognizable. This is true for several reasons. Firstly, thin secretion easily descends from its point of entrance into the nose and is not readily found at that point, as is thick adhering pus. Secondly, the outlets of the post-ethmoid and sphenoid cells are so frequently not to be seen by any method of inspection that unless the pus is ad- herent enough to accumulate at those points it will not be found. In a narrow nose secretion from the post-ethmoid, in the erect or reclining posture flows over the middle turbinate at a point which makes it very difficult or impossible to recog- nize by any of our present means of investigation. In a wide nose this is easily seen by posterior rhinoscopy, sometimes by Holmes' pharyngoscope. Some of the secretion passes down- OT HYPERPLASTIC SPHENOIDITIS 137 ward and backward over the posterior tip of the turbinate and would be easily recognized if it remained there, but in small and medium sized pharynges the soft palate rises in swallowing, and certainly in gagging (which frequently happens in the ex- amination) to a height that wipes it away from the tip. I have proved this repeatedly. It is necessary therefore to recognize the secretion anterior to the choanal plane. In many instances this is very difficult or impossible; to wit, in such cases as have small choanal outlets which are placed rather high compared to the level at which the post-nasal glass must rest. It will therefore be recognized that my argument is that a post-eth- moidal sphenoiditis may exist and pour in the nose a thin secre- tion which cannot be recognized at the points of entrance into the nose. Secretion from these parts, when from a process of long standing eventually becomes serous, transparent and col- orless. When from a process of more recent origin it is sero- purulent, not unlike thin cow's milk in color and thickness. The picture may be reproduced in great verisimilitude by the instillation of a few drops of thin cow's milk into the olfactory fissure. Such an experiment will also prove the short time such a fluid remains recognizable. In from three to five minutes it will have disappeared: and also, in a small pharynx the wiping effect of the palate may easily be seen. Wry seldom is to be seen a stream of pus coining from the sphenoid and descending from the sphenoethmoidal process over the posterior pharyngeal wall to descend before it. This happens only in large pharynges where the soft palate is too short to reach up to wipe it off. Were it not for the wiping effect of the palate, this would be a frequent picture. As the inflammatory process continues the secretion loses all purulent character, and the hyperplasia begins. Hyper- plastic post-ethmoidal sphenoiditis is usually accompanied by a scant serous secretion but by no means is this always true, just as the same process in the middle meatus is usually accom- panied by a little serous secretion but not always. And some- times the serum may be profuse, but I have uniformly found this to be from the process localized or at least well marked in the membrane over the sphenopalatine foramen; that is, just posterior to the tip of the middle turbinate The nasal gan- 138 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN glion is immediately beneath this membrane. I have construed and described 84 these cases as manifestations on the part of the sjonpathetic autonomic elements of the nasal ganglion, and not the result of a hyperplastic process in the general expanse of the nose. Treatment of the ganglion will stop the profuse serous secretion but will not stop the hyperplastic process. Not infrequently it is found that secretion of any kind is totally absent. The membrane is dry. But with secretion or without, under the microscope the lesion is the same. So it is therefore necessary to recognize the changes in the membrane, irrelevant to secretion. This is done by translating the color, thickness, translucency of the epithelium and membrane, and vascularity, which are the points I emphasized in the descrip- tion of the normal. A typical hyperplastic picture shows some increase in redness with more or less thickening of the mem- brane and epithelium. The epithelium may be thickened and rest on a membrane which is not thicker than normal or the membrane may be thickened and covered by epithelium which is normal. The vascularity is increased, manifested by the presence of macroscopic vessels, especially radiating from the sphenopalatine foramen. In addition to this picture exists one manifest only by great diffuse redness and some swelling. It shows no change in the epithelium and no macroscopic vessels and can be shrunk away by adrenalin.. At present I do not be- lieve this to be a lesion to be classed as in some manner hyper- plastic. I know, however, that it may make the entire clinical picture as portrayed in this chapter and that it may endure anv length of time. There remains one more item which I feel should be em- phasized. In the examination of a case it is of course the rhi- nologist's concern to determine not only the presence of secre- tion but also the character of it. Great emphasis is always laid on the presence of pus. The point I wish to make in this connection is the appearances of the epithelium under different conditions. The epithelium on a normal membrane is transpar- ent whether viewed in the perpendicular to the surface or ob- liquely. When, however, the thickened epithelium is viewed obliquely it is nearly if not quite opaque and on the sharp con- vexities and concavities presented in the olfactory fissure and HYPERPLASTIC SPHEX0ID1TIS 139 spheno-ethnioidal recess gives the impression of a layer of pus or seropurulent secretion. This is emphasized in the depths of the sphenoethmoidal recess around the sphenoidal opening which is often visible in good light, and in the upper meatus around the post-ethmoidal outlet. Their edges appear opaque and the depths indistinctly visible so that the appearance of a spot more or less like pus results. The differential diagnosis may be made usually (and without great difficulty) in a light of increased brightness, for example if the electric arc is in- sufficient the direct sun from a 10 cm. concave glass is ample to settle all question as to what the spot is. Moreover, should it be pus, it is almost invariably greenish yellow or yellowish green whereas the opaque epithelium is white or very slightly bluish white. The spot made by scant pus at the site of the sphenoidal or post-ethmoidal outlet is readily reproduced in the cadaver 82 by the instillation into the cell of a very small amount of bismuth hydroxide in suspension to flow through the outlet into the nasal fossa. The head is then examined by reflected light as in life. Another place where the obliquely illuminated epithelium may give the impression of pus is the upper choanal arc. It is usually marked by a ridge which is the demarcation between the upper limit of the pharynx and the back part of the nose. Here it may appear opaque and give the impression of pus. Just anterior to the ridge is often a sulcus or an ex- panse that reaches as high or higher than the sphenoidal out- let which is then out of the line of vision. Secretion on this surface therefore cannot be seen. Sometimes it may be seen with Holmes' pharyngoscope. As it descends it would of course be recognizable when it reached the ridge and began to descend into the pharynx, if it remained in position. This is the fact in pharynges of considerable size ; i. e., so large that the soft palate is not long enough to rise to that height and so cannot wipe it away. But in smaller pharynges the palate in the act of swallowing wipes it away and particularly is this true in gagging which frequently happens in the examination. 81 Se- cretion on or over the ridge therefore is very often not allowed to accumulate but is constantly wiped away. The rhinologist's judgment here may be furthermore confounded, not only by the obliquely illuminated epithelium which as stated above may 140 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN give the impression of pus, but by the fact that pus from else- where within the reach of the palate may, by the trowel-like action of its upper surface during - the act of swallowing or gag- ging, be transferred from its point of origin ; e. g., the lower meatus of the same or the opposite side to the upper choanal Fig. 75. — Showing a cell 1-2-3 which appeared to be the sphenoidal cell. The probe 5 shows that the veritable sphenoidal cell 6 is behind and below this. 4. The sella turcica. arc and if it be in sufficient amount will be pushed forward beyond the choanal plane. This will then be not only a decep- tion but one produced by pus really. Hyperplastic post-ethmoidal sphenoiditis is rarely unilat- eral. It may be more marked on one side than the other and HYPERPLASTIC SPHEXOIDITIS 141 the configuration of the district may interfere with its recogni- tion, more on one side than the other. These facts should be borne in mind particularly where the diagnosis is a matter of serious import ; e. g., where a serious eye lesion exists, and the appearances permit of the diagnosis only on the opposite side. Under these circumstances I have operated the side having the eye lesion, despite the fact that the appearances did not per- mit of the diagnosis on that side, and found the lesion under the microscope and have been rewarded by the recovery of the Fig. 76. — Same as Fig. 75 showing probe 4 in lower cell. 1-2-3. Upper cell. .^. Sella turcica. eye lesion. The recognition of the hyperplastic process on the opposite side served as a trustworthy guide. Uffenorde 93 ob- served that hyperplastic ethmoiditis (anterior) is rarely uni- lateral. He states that it may develop more on one side because of "unfavorable circumstances," e.g., a deflected septum. But in a post-ethmoidal-sphenoidal picture such an etiological fac- 142 HEADACHES AND EYE DISORDERS OF NASAL ORIGIX tor does not exist. Moreover, I doubt if that be the correct interpretation of the anterior picture. A feature in the diagnosis quite aside from the patholog- ical lesions described, exists in anomalous anatomical arrange- ments of these parts. Failure to bear these possibilities in mind may defeat utterly the best technical efforts of rhinol- ogists. It not at all infrequently happens that the body of the Fig. 77. — Showing an upper and lower subdivision of the sphenoid body. /. A probe in what was the upper cell. 2. The remains of the separating shelf. .?. The lower cell opened down in the pterygoid process as far as the bifurcation; of the plates. 4. The sella turcica. sphenoid is shared by a post-ethmoidal cell as well as the sphe- noidal cell. The extent of this may vary in wide limits. A cell which seems the size of the usual sphenoidal cell may occupy the upper part, and below it the real sphenoidal cell is found. (Figs. 75, 76, and 77.) It is most important that the upper cell HYPERPLASTIC SPHENOIDITIS 143 be opened for ocular lesions and that the lower cell be opened for for the painful lesions. It may be thought that confusion here could be avoided bv attention to their outlets and utilizing them in the operation. I do not believe this to be the case. There may also be another type of subdivision; namely, antero-pos- Fig. 78. — Showing an anterior and posterior subdivision of the sphenoid body. J. The probe. 2-4. Anterior face (this line has been retouched to show better in the reproduction). 3. Anterior face of posterior cell. 5. Sella turcica. terior. (Compare Fig. 78, 79, and 80.) A cell of the full height of the body may not infrequently be found which at the time of operation appears to be the veritable sphenoidal cell. Later it may be found by the picture of the probe in situ that the real sphenoidal cell is back of this. Once I opened three cells in the 144 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN" body of the sphenoid, each in the antero-posterior arrangement and apparently occupying the full height of the body. Figs. 81 and 82 sIioav a large sphenoidal sinus hollowed out with the pterygoid process to the bifurcation of the plates. The diagnosis of these anomalies is made by taking x-ray pictures of a probe placed in the cell whose identit}^ is in ques- tion. Fig. 78 shows a probe in a cell which I believe every rhi- nologist would have asserted to be the sphenoidal cell. The Fig. 79. — Showing subdivided sphenoid body. i. Probe. -'. Anterior face of anterior cell. 3. Anterior face of posterior cell. picture, however, shows the sphenoidal cell below it. Fig. 79 shows a probe in what I believe to have been an equally decep- tive cell. It also shows another cell behind it. I always take these pictures in cases which have not been benefited by opera- tion. The other cells are of course opened as soon as identified. In this way I have relieved some ocular and painful lesions where previous efforts had failed. HYPERPLASTIC SPHEX0IDIT1S 145 Another anomaly to be borne in mind is the fact that the sphenoidal cell of one side may extend into the other side and occupy it almost completely. Such a cell will then border the optic canal of both sides. (Fig. 83.) A. Onodi eo pointed ont this fact. But it also borders the maxillary and Vidian of the opposite side. I do not at present know how this anomaly may be identified. But bearing it in mind I have operated both sides in some desperate cases where the result on the indicated side Fig. 80. — Showing probe in large undivided sphenoid body. was a failure. In this way I have relieved some ocular and painful lesions which were apparently hopeless. The diagnosis of hyperplastic or suppurative post-eth- moidal sphenoiditis in children is difficult, because it is only seldom that the child may be controlled for a satisfactory post- nasal view. Should this be possible, it presents no other diffi- culties. A palate hook sometimes but not always facilitates 146 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN the examination in children. It does not always help because in the small nasopharynx of children, it is possible for the con- strictors to contract and obliterate the cavity regardless of the position of the soft palate which of course may be held forcibly Fig. 81. — Shows probe introduced into a very large sphenoidal cell downward to the bifurcation of the plates. forward. If the child cannot be controlled for a postnasal ex- amination, the diagnosis is usually still possible from the ante- rior nares but is much more difficult. I have found hyperplas- tic postethmoidal sphenoiditis to be a very frequent lesion in HYPERPLASTIC SPHEX0ID1TIS 147 childhood from as early as the fourth year, producing headache and eye lesions. A palate hook in the adult makes practically every naso- pharynx possible of a satisfactory examination. Fig. 84 shows a palate hook* that locks in position automatically and releases instantly when necessary because of cough or vomiting. Fig. 82. — Same as Fig. cSl taken from in front. It is interesting to observe the behavior of a coryza that affects one part of the nose in full violence and leaves the other undisturbed by anything more than a slight congestion or not even that. The explanation for this cannot at present *To be purchased from V Mueller & Co., Chicago, 111. 148 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN 2 ! 3 l 4/ Fig. 83. — Shows the left half of specimen. I. Right sphenoidal sinus extending into left side to border left optic canal ,2. Left sphenoidal sinus 3 also borders left optic canal. A post-ethmoidal cell 4 also borders left optic canal. Fig. 84. — Two views of palate/ hook. The upper surface of the shaft is milled which provides infallible, instantaneous and secure locking when the prongs press the upper lip. The short sleeve B is thereby rotated upon its transverse axis locking it into, the milled surface of the shaft. It is instantly released by pulling forward the tip A. To be had of V. Mueller & Co., Chicago, 111. HYPERPLASTIC SPHEXOIDITIS 149 be given. It may be in some way a bacteriological phenomenon. It is probably a homologue of phenomena elsewhere ; e. g., in the skin. No explanation can be given for why measles make one picture on the skin and secondary syphilis another. I have twice seen the prevailing localizing to lie post-eth- moidal-sphenoidal in full virulence and at the same time al- most uniformly leaving the anterior sinuses undisturbed. The first occasion was in St. Louis, 1905-1908. The second 1912- 191C). In these years anterior sinus infections were quite rare, not only in my own experience, but in that of my colleagues who also commented on the fact. It was also true in the clinic. The ordinary coryza which affected nearly everyone, young or old, was a post-ethmoidal-sphenoidal inflammation with or without pus. In other years anterior sinus infections have been quite commonplace. Bacteriological investigation of these problems lias failed to give any information. The question of the association of ocular tuberculosis with the nose was raised by Dr. W. II. Luedde, 4Ga 1901. He injected tuberculin into some of his cases of ocular tuberculosis and found the reaction in the eye. At the same time I found a slight reaction in what appeared a typical hyperplastic post- ethmoidal sphenoiditis. Dr. \V. M. C. Bryan and I have tried to get a tuberculin reaction in other typical cases without oc- ular lesions, but so far have failed. Bacteriological investigation of hyperplastic post-eth- moidal sphenoiditis has so far been negative. The x-ray in my experience has failed to help in the diagnosis of hyper- plastic post-ethmoidal-sphenoidal diagnosis. It is of para- mount value in determining cell anomalies, showing probes in positions which determine these. PROGNOSIS Prognosis in the sphenoidal region seems to me to present features for consideration not found elsewhere. The matter of drainage here is often impossible because of an irregularly shaped (large) cavity which cannot be drained from any place in the nose or from any one place, wherever situated. Such a cavity may extend into the great and small wings, into the pterygoid process and down the clivus of Blumenbach, and 150 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN liave obstructing partitions in it. In contrast to such possibil- ities it is very rare indeed that a frontal sinus is not drained by a satisfactory inlet to it. This is true for the maxillary antrum and usually for the ethmoidal cells also. The excep- tion in the ethmoid is so rare as to be practically negligible, although it does exist. But were the difficulties in the prognosis here a question of drainage only they would be comparatively simple. Drainage or ventilation of the frontal, ethmoid, and antrum is sufficient to stop pain and to effect the cure in all but very rare exceptions — these being cases of very long stand- ing. For the hyperplastic sphenoid the best drainage does not stop the pain except very rarely. Part of the sphenoidal floor may be removed, which in a cell of simple arrangement gives perfect drainage. But it does not solve the problem. Some of the hyperplastic sphenoids (some of the worst) are dry. The pain in these cases is not made by pressure of confined secre- tion as in an obstructed frontal empyema. It may be made in great severity by a small area of moderate grade inflammation if situated at the proper place; e.g., at the point where the maxillary nerve passes, particularly through the foramen rotundum; namely, the lower lateral anterior part of cell, or, on the floor where the Vidian passes. I have seen this fre- quently by the nasopharyngoscope and I have seen such a lesion diminish the vision greatly when situated on the site of the optic canal, to wit the upper outer anterior aspect of the usual sinus. I have seen these as the primary pictures ; that is, at the time the sphenoid was opened, to disappear by treatment with recovery from the symptoms and reappear later as a local- ized coryza (several times in the same patient) with reestab- lishment of the original symptoms; namely, pain and blindness. The degree of hyperplasia in these cases is often slight or even nil. I have construed them as having very thin walls separat- ing the maxillary, Vidian and optic nerves. Any disturbance in the cell quickly affects these neighboring nerves by the in- flammation or its toxin passing through the bone and membrane to the nerves. This argument is also borne out by therapy. These are the cases most quickly and satisfactorily helped by antiphlogistic and analgesic applications within the cell. In sharp contrast to these cases are others where upon HYPERPLASTIC SPHENOIDITIS 151 opening the cell the membrane is thick, rough and dry with no markings at the sites of the maxillary, Vidian or optic. The hyperplastic bone process is shown by the microscope to be well marked. Therapy in these is disappointing or at least very slowly satisfactory. Months pass with the host efforts of the rhinologist almost in vain. Continued effort however over a period of several years will usually show a slow improvement. At the end of a year and a half to three years the case shows definite betterment. Were the eye disturbance slight it may have recovered. Were it more than slight it will be consider- ably better. Were it headache it may have so far recovered that the patient has much time free of pain. Coryzas of any grade reestablish the headache more or less. I have construed these not as simple inflammation or toxin transmission lesions, but as thickening bone lesions with consequent narrowing of the canals through which the nerves pass. Part of the narrow- ing may be a periostitis in the canal. But with or without peri- ostitis the increase of the bone volume must encroach on the canals. Such a narrowing means pressure on the nerves with pain. Long continued therapeutic effort will finally reduce the volume to some extent. And furthermore in later years the rarefying state ensues and further helps the case. I believe this is what happens when the case begins to improve spontaneously some time after the fiftieth year as has been observed by neu- rologists in cases of megrim. The megrim gets better without operation. Secretion and gravity apparently play a definite part in the first class of cases. The watery secretion gravitates to the lower part of the cell away from the optic canal. This seem to me to explain the greater number of headaches and the smaller number of ocular lesions (as previously stated). The optic canal is almost never separated from the post-ethmoid or sphenoid cells by any considerable thickness of bone, whereas the maxillary and Vidian are, in a percentage of cases. The percentage is not large according to my observation but I can- not now put it in figures. It appears to me to follow in logical sequence that in the first class of cases the prognosis is for speedy relief from the symptoms, and that they must necessarily be reestablished at 152 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN the time of a coryza. The infection "eoryza" in these parts may be of grades so slight that the patient is not cognizant of it and still make the ocular or the painful lesions. The acutely inflamed area may however be seen with the pharyngoscope after the cells are opened. And for the second class of cases the prognosis is also for relief but it must needs be slower and less complete, although in the long run the result is pre- eminently worth the effort it took to get it. These cases have seemed to me to be less disturbed by coryzas. The post-ethmoidal-sphenoidal radical operation properly performed in the first class of cases almost always gives a tech- nical result that remains satisfactory; that is, the openings of the cells remain as the operator makes them. In the second class they almost always get smaller and very frequently close up completely and so must be made gain, often several times. In later life an involution of the hyperplastic changes- rarefying osteitis — takes place, sometimes beginning about the fiftieth year and sometimes later. I have scon this in unoperated cases accompanied by corresponding cessation of symptoms, (in one case an ophthalmic migraine). TREATMENT The relief of low grade hyperplastic post-ethmoidal sphe- noiditis whether for headache or eye lesions, in my experience, has often been accomplished by the sedulous use of a one and one-half or two per cent alkaline saline solution twice or thrice daily snuffed from the palm of the hand, and the face then quickly turned up so as to make that region the lowest part of the nose, to be flooded by gravity. The same result is se- cured by the use of a douche which pours into the nose. That necessitates the face being turned up to begin with. I use an ancient English mixture, sodium chloride, sodium bicarbonate and sugar of milk* equal parts. I prefer to have this made into tablets of known weight, for the convenience of the pa- tient. They are added to water to make the solution one and one-half to two per cent. That solution is definitely heavier than the blood serum and must set up an osmotic current away from the tissues. That strength is at the same time non-irritant. * Sugar of milk seems to make the solution pleasanter in the nose. It is not necessary. HYPEEPLASTIC SPHEN01DITIS 153 It diminishes the volume of the tissues without irritation or re- action such as follows stronger astringents or adrenaline solu- tions. It is of course cleansing also, but other solutions may be so too, and not accomplish the end if they irritate. This is moreover exemplified by the same solution if it is too weak or too strong, either of which irritates. The occasional application of a two per cent silver nitrate solution in small amount is also helpful. A solution of phenol 1. c.c, liq. iodi comp. 4., c.c. water 200 c.c, is also helpful occa- sionally applied in 5 c.c. amounts with a syringe the point of which is placed in the olfactory fissure at about its middle. It is injected witli some force. But more satisfactory in my experience, is the daily use of one-half or one-third per cent solution of phenol in oleum petrolatum in 5 c.c. amounts injected forcibly into the olfactory fissure by a syringe (fine point) placed in the fissure at about its middle. This is painless and provokes no reaction. I have proved on the cadaver that some of the solution thus instilled enters the post-ethmoidal and sphe- noidal cells in skulls where the openings are of the usual size. This oil is furthermore thick enough to remain in its place for sonic time (one-half to two hours), which helps its effect. When the pain is severe a solution of one-half per cent cocaine alkaloid in oleum petrolatum may be thus instilled. Both the phenol and cocaine are analgesic. Many low grade recent cases (with headache or eye lesions) are satisfactorily treated by these means. The question arises here, natural!) 7 , "Why not instill the solution into the sphenoid by cannula V' One reason for not adopting this as a routine plan is that the daily effort for this purpose in the average nose, inflicts a degree of trauma that is followed by too much reaction to secure the desired effect. Another reason is that the opening of the sphenoid is often so placed that it cannot be catheterized while the middle turbinate is in place. When the patient cannot be treated by the rhinologist, I give him the phenol oil mixture to pour into his nose as he does the alkaline saline solution, not believing however that it in this way, enters the sphenoid. The suction treatment recently advocated by Coffin and Harmon Smith for the suppurating sinuses cannot be of help for these cases because they are not suppurating cases. Some 154 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN have a scant thin secretion that could not be sucked out of the lower part of the sphenoid and many are without any secretion. Mention should be made of change of climate or atmos- pheric or hygienic conditions as a possible therapeutic influence. I have so far failed to recognize these as in any way potent factors for or against the development of hyperplastic post- ethmoidal sphenoiditis. Occasionally a patient thinks he is benefited by a "change of some sort." Should these means fail the sinuses should be opened. For this purpose intranasal surgery if properly done seems to me to offer all that is possible. Extra nasal surgery in some old and far advanced degrees of pathological alterations, (sup- puration, granulation and necrosis) of the cavities, may offer possibilities beyond those of intranasal surgery. But in these cases of hyperplastic post-ethmoidal sphenoiditis, such condi- tions, so far as I know, are never found. The most advanced change I have so far found has been broad based edematous, polypoid swelling without pus or recognizable secretion. This has usually subsided after opening the cells. Surgery of the Paranasal Cells The upper paranasal cells may be approached by two in- tranasal routes — an anterior and an internal. The anterior was probably sought in an effort to save the middle turbinate. It was first utilized by Schaeffer 65 who punctured the wall of the nose anterior to the middle turbinate with a small curette. This usually enters a prefrontal cell of the ethmoid. Through this he reached the uncinate process and removed it to gain entrance to the frontal sinus. He then proceeded backward to open the ethmoid cells and further backward to open the sphenoid, operating in a direction from in front upward and backward, in a plane lateral to the middle turbinate which was left in situ. This was done with the desire to save the turbinate for its function. If this were not the idea of Schaeffer it has been that of its subsequent advocates (Uffenorde 93 ). Schaef- fer 's text is not clear as to whether he removed the uncinate process. Uffenorde, however, is very clear. The only condi- tion in which that procedure seems to me advantageous is where there is an unusually wide middle meatus with a cor- HYPERPLASTIC SPHEXOIDITIS 155 respondingly wide nasal fossa. Here it is advantageous to save the middle turbinate to avoid subsequent drying. I am one of those opposed to this procedure for several reasons. First, it is by no means the rule that it is the cells themselves that are diseased; e. g., a normal turbinate may be crowded to the lateral wall by a septum tubercle combined with a slight deflection or swelling; or hypertrophy of the tur- binate may exist blocking some secretion which stops as soon as drainage is given. Second, in an active hyperplastic process that has included the bone in its activities, the curette is fol- lowed by great bone reproduction which defeats the object. Under these conditions it has been much more satisfactory to remove by a clean cut the diseased tissue which can be done by the internal approach. Third, the anterior approach must be more dangerous than the internal approach. The latter re- moves the middle turbinate then permitting a cut of the tis- sues instead of from below and in front upward and back- ward — from above and behind downward and forward. Fourth, the internal approach may be most conservative. The removal of the middle turbinate takes as it were, the flap valve off the normal outlets of the frontal, maxillary antrum and anterior ethmoid. The more these outlets are left undisturbed, that is, the less their epithelial covering is injured, the more satisfac- tory. In cases of advanced disease — suppuration Avith gran- ulation and necrosis — of course all the tissues must be removed. But in simple suppuration simple drainage suffices. For these reasons my choice is the internal approach. This consists pri- marily in the removal of the middle turbinate which lies over (internal to) the openings of the frontal, anterior ethmoid and maxillary cells. The simple removal of the pendulous tur- binate must be considered the simplest and most conservative procedure. The argument is made that it is desirable to con- serve the turbinate. Experience here, however, proves that the removal of the turbinate is not followed by drying or the sen- sation of cold from the inspired air, as might be argued on theoretical ground; nor by any other disturbance within the nose. The next step in the direction of radical procedure is the high (cribriform) cut on the lateral wall which removes the innermost part of the ethmoid capsule as well as the mid- 15(3 HEADACHES AXD EYE DISORDERS OF NASAL ORIGIN die turbinate. This opens the prefrontal cells, the complete infundibuluni and the nasal wall of the remaining ethmoid cells. The complete radical procedure removes the remaining part of the floor of the frontal sinus with the remaining part of the ethmoid capsule leaving the paper plate. Mosher's 58 operation takes the anterior route but utilizes the middle turbinate as landmark or guide, and then removes it. As a finished pro- cedure it is the radical intranasal operation for the upper paranasal cells rendered safer by utilizing the turbinate as a guide. For the maxillary antrum the effort for drainage or ven- tilation is to leave an opening at its lowermost part into the nose. At the present time the older procedures which provided some other opening to permit washing seem to have been uni- versally abandoned for self-evident reasons. Technique for the relief of the antrum may be divided into that which saves the lower turbinate and that which removes it in the effort to provide drainage or ventilation. The conservation of the tur- binate here, is far more important than that of the middle tur- binate for the upper cells and presents no difficulties or ob- jections. In most noses where the middle turbinate has been removed for the relief of the upper cells it is imperative to save the lower turbinate if the nasal functions of moistening, warming and filtering the inspired air are to be preserved. Removal of it leaves a too wide channel permitting a direct blast of the dry cold impure air into the pharynx. The patient then suffers from a dry, more or less crusted, pharynx for life. In addition to the above described procedure is to be recom- mended the removal of the floor of the frontal sinus in cases where it is found after the cribriform turbinectomy, that the inlet to the frontal sinus has been obliterated. This was first conceived and executed by E. Fletcher Ingals, 32 who passed a small probe into the sinus to be used as a guide to limit the posterior cranial cut of a drill used to remove the anterior part of the floor of the sinus, which is here made of heavy bone. After the opening has been made sufficiently large, a gold tube which has been split in several places longitudinally for a distance of two-thirds cm. from its upper end and spread out to resemble a funnel, is placed in the opening. The spreading HYPERPLASTIC SPHENOIDITIS 1 57 of the upper end is controlled at the time of introduction by confining the split parts in a gelatine cap. This facilitates its introduction. Later the cap melts, the end spreads out and is in this way self-retaining. To prevent the tube from slipping up into the sinus it carries a flange on its lower end. The advantage of removing the floor of the frontal sinus lias appealed to other surgeons who have modified the pro- cedure more or less; e.g., Halle, 2S Watson- Williams ; 94 and re- cently Lothrop 44 has proposed to convert the two frontals into one by the removal of the frontal septum, and then to remove the floor of the combined cells with that part of the nasal sep- tum encountered in the downward progress of the procedure. Lothrop 's operation is external. Halle's and Watson- Williams ' arc intranasal. The difficulty met with in these procedures is to maintain an opening with the nose; i. e., to make one that re- mains permanent. Lothrop 's undoubtedly makes the largest opening. Ingals avoids closing by the self-retaining gold tube. In contradistinction to these procedures is that (the author's) which lays open the full extent of the infundibulum but leaves its epithelial (permanent) linings undisturbed. Such an outlet or inlet remains permanent. The only thing which can close it is the advance of the hyperplastic osteitis under the membrane. When no communication between the nose and infundibulum exists the floor must be removed. My experience is that the patient has far less trouble with Ingals' tube in position. Kil- lian's 35 and the other radical external frontal operations are not designed for this class of cases. I have always thought that the surgery of the paranasal, especially the upper cells should be in the charge of the sur- geon who is thoroughly learned in the anatomy of the parts and who possesses the skill to execute that which he should thoroughly understand. Shortcomings in either of these qual- ifications is most unfortunate for the patient for the reasons (1) that surgery imperfectly performed at the initial operation Is difficult or often impossible of satisfactory later correction because of the loss of landmarks and the reproduction of the bone that is so hard that it is at times almost impossible to deal with it satisfactorily. Of course a drill or a burr can cut bone of any degree of hardness, but when these instruments must 158 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN cut upward and backward, the surgeon becomes timid and fails to reach the furthermost points at which the difficulties lie. (2) Surgery improperly performed for the relief of eye lesions, may not only fail to relieve, but may make them rapidly worse. I have seen this happen. Personally I cannot but feel that post- ethmoidal-sphenoidal surgery for the relief of eye lesion is always fraught with great responsibility. For this reason I feel that it should be executed only upon the basis of a definite diagnosis. To be satisfactory it must always be complete be- cause we have no way to tell which of the post-nasal cells is doing the damage. For this reason the simple opening of the sphenoidal sinus from its natural opening cannot be recom- mended if we are to accomplish the greatest good for the great- est number. At the present time this procedure is recommended by an occasional author, because it is so easy and simple. I believe this judgment rests on an insufficient knowledge of the anatomy of this district. And while saying this, I am, more- over, fully conscious that an occasional headache or eye lesion may be and is relieved by this easy and simple procedure. But should it, as it often does, fail, the second operation which must quickly follow must be performed under much less advanta- geous conditions; to wit, reaction, swelling, bleeding and in- creased difficulty in keeping one's bearings. (For the anatomy bearing upon these questions see page 57). Furthermore, the pathological process in the post-ethinoidal and sphenoidal si- nuses so constantly involves both sinuses, that it is a difficult question to decide whether they are ever wholly separately in- volved. It is a question corresponding to whether the frontal sinus is ever involved without that of the anterior ethmoid. For these reasons I feel that the only procedure that embodies good judgment and security for all cases is the complete post- ethmoidal-sphenoidal operation, as described in the succeeding pages. I furthermore believe that the best judgment calls for a complete cribriform cut of the nasal wall of the anterior ethmoid extended to the complete cribriform cut of the tur- binate, thereby not only removing the entire middle turbinate but opening the entire ethmoidal capsule with the infundibulum to its full extent, whether these cells be involved at the time or not. A small stump (one-third cm.) of the posterior tip of HYPERPLASTIC SPHENOIDJTIS 159 the middle turbinate should be left. It is clinically negligible and serves as a landmark, useful should any subsequent pro- cedure be necessary. I believe this to be the best judgment because when the anterior half of the turbinate is saved it later enlarges so as to necessitate further surgical interference Hajek 27 made this observation on the lower turbinate where the posterior half was saved in intranasal antrum operations. When the complete sphenoidal-ethmoidal-frontal operation is properly performed for the usual case, the result remains per- fect for many years if not forever. This may, however, oc- casionally be not true when the hyperplastic process in the bone is of very high grade in younger patients. The bone reproduc- tion then may be so great and rapid as to require secondary operation at a future time. I have never seen any functional disturbances as the result of the complete operation. In the procedure for the relief of the frontal sinus, I re- move the middle turbinate three-fourths back in order to also free the outlets of the anterior ethmoidal cells completely. This leaves a small stump posteriorly which is helpful as a landmark should a subsquent operation be needed. It becomes hyper- plastic or hypertrophic later but remains clinically negligible, because its position does not obstruct any of the outlets. This is not true for the anterior half of the turbinate which obstructs the frontal and ethmoidal outlets when it enlarges. The Author's Technique The author's technique 87 for the upper cells may be com- bined for all or separated into that for the single cells. Its advantage (and original feature) is that it cuts always down- ward and forivard, that is always in the direction of safety. Anaesthesia. — It may be executed under local or general anaesthesia. It has always seemed to me that there is more bleeding, under ether anaesthesia which adds much to the in- convenience and confusion of the surgeon. Under these condi- tions, it is easier for him to lose his bearings which may pre- vent its perfect performance or be disastrous. On the other hand the consciousness of the patient sometimes makes the sat- isfactory control of him difficult or impossible, especially in 160 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN hysterical patients. This difficulty, however, is usually con- trolled by the administration of a small dose of morphine one- half hour before. Its effect is greatly intensified by the addi- tion of a small dose of hyoscine (morphine Yq gr. (0.01 gm.) hyoscine %oo gr. (0.0003 gm.) In this way I have seen the greatest anxiety and apprehension allayed. Cocaine has often been impotent at the time of great fear (in my experience), and perfectly potent and satisfactory in the same patient who had previously had a quieting dose of morphine — hyoscine. For these reasons the psychical state of the patient should be care- fully estimated. Much post-operative nervous depression— "neurasthenia'' may be avoided if anxiety, apprehension and fear can be eliminated at the time of operating. These facts are well known to experienced rhinologists. I believe them, however, to always merit emphasis, and especially so, when the patient to be considered is one who has suffered the harassing headaches of these lesions for months and years. Most of these patients were long ago adjudged "neurotic' 1 and well they might be. I know of few bodily states better calculated to make the ablest bodied "neurotic" than the endless severe suffering that many of these patients have endured, some- times from childhood. The neurotic state is moreover fre- quently interpreted as the cause of the headaches, which seems to me, to add to the mental difficulties of the patient. Not in- frequently they think themselves ''half crazy," (and they seem so). A feature that comes into consideration for all patients, is not only a satisfactory anaesthesia but the amount of cocaine necessary to obtain it. The complete operation for the upper cells extends over so large a part of the lateral Avail, that anaesthesia by surface painting with a solution of sufficient strength is apt to be followed by cocaine absorption to such a degree, as to constitute poisoning. This happens by virtue of the extent of surface painted and the amount of cocaine used. In order to obviate this difficulty, I began in 1913, 76 the use of a nerve trunk anaesthesia, which requires much less cocaine and is applied over a much smaller area. The nerve supply of the nose in great part is from the nasal ganglion and enters through the sphenopalatine foramen. The remaining supply HYPERPLASTIC SPHENOIDITIS 161 is the internal nasal nerve which enters through the longitudinal fissure of the ethmoid (Piersol, Human Anatomy, 1907, page 192, line 6) at the apex of the angle formed by the roof with the anterior limit of the nose. At both of these points the nerves may be blocked by a small amount of strong cocaine solution applied to the membrane. For this purpose I set a small aluminum applicator which carries about one drop of saturated (90 per cent) water solution under the posterior tip of the middle turbinate, and leave it five minutes for effect on the nasal ganglion. It is then changed to rest just back of the tip in an upward and backward direction, to lie approxi- mately over the trunks in the sphenopalatine foramen and al- lowed to remain another live minutes. I do this because the ganglion anaesthesia may not always be complete in five min- utes. The trunk application usually completes it. I have also tried both of these positions singly. I find the combination more satisfactory. At the time the posterior applicator is changed at the end of the first five minutes, I set the anterior applicator for the internal nasal nerve. I use a toothpick-like wooden stick carrying about one-half drop of the same solu- tion, using the anterior limit of the nose as a guide, passing it upward until it reaches the roof, where it automatically lodges in the apex of the angle, allowing it five minutes in position. Anaesthesia thus secured is complete and comprehensive for the distribution of the respective nerves, namely, that half of the nose. I have repeatedly had patients show no trace of cocaine disturbance, and tell me afterward that they felt no pain from the complete upper cell operation. On one occasion I did the, upper and antrum operations at the same time with such anaes- thesia. But usually I have not found the indications combined, necessitating both together. The patient at the time of operation should be instructed that he will have three things to engage his attention. First, pain; second, the noise of the bone cutting; third, the pulling (force) required to put the knife through the tissues (which often is great). He will not confuse the first with the second and third, if his mind be directed properly. No anaesthsia has been so satisfactory as this, (in my ex- perience) and cocaine poisoning has been almost eliminated 162 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN (in my experience) by its use. All cocaine anaesthesia may, however, fail sometimes for two reasons. Acutely inflamed tissue will not become anaesthetic by cocaine, nor can a ter- rified patient be anaesthetized. The former is easier to under- stand. I have repeatedly been assured by the most intelligent but terrified patients whom I have operated on, despite their mental state, with what was a superabundance of cocaine, that the pain was as though no anaesthetic had been used. This has been true for all methods of applying cocaine. This is not so easily understood. Added to these is a small class in whom neither terror nor local inflammation explains the resistance of the tissues to cocaine. It is, however, fortunately a very small class. An application of adrenalin solution is helpful in reducing swelling, giving a wider field of operation, as Avell as control- ling bleeding, and possibly helping the anaesthesia. The Operative Procedure Anatomically the paranasal cells are designated according to which meatus of the nose they enter. This is more or less an anterior and posterior subdivision, and for the purposes of diagnosis this must remain unchanged. For surgical pur- poses, however, it seems to me that they may advantageously be thought of as upper and lower, the latter being the antrum of Highmore, the former being the remaining cells. This sub- division establishes a horizontal dividing line on the lateral wall at about its middle. Successful surgery of the antrum must leave a drain at the level of the nasal floor. The lower- most part of the upper cells is along the line separating them from the antrum ; i. e., the horizontal midline. Successful sur- gery of the upper sinuses, however, is not achieved by a drain along this line, for the reason that there are usually cells which are limited to a part far above the midline. Successful sur- gery of the upper sinuses must lay open for drain the upper cells in their entirety beginning at or very close to the crib- riform plate of the ethmoid — the roof of the nose — opening at the same time the lowermost of these cells, that is, removing the lateral wall with the middle and upper turbinates above the midline. HYPERPLASTIC SPHENOIDITIS 163* This procedure may be conservative or radical. The for- mer consists of the removal of the turbinate and the very super- ficial nasal layer of the capsule of the ethmoid. The radical operation consists of removing the capsule "part and parcel' including the orbital plate when desirable for drainage of the orbit into the nose, at any or all points from its anterior limit to its apex. One comprehensive surgical procedure has been offered for this district. To this therapeutical end particularly was di- rected the intelligence of Dr. H. P. Mosher 58 when he proposed the "Surgery of the Ethmoidal Labyrinth." That procedure must of necessity be a radical one, although he does not recom- mend it for the extreme of radical ; to wit,— opening the orbit. He proposed it for the relief of cases in advanced stages of suppuration and degeneration, not such cases as I have delin- eated. It is admirable for the cases he proposed it for. The- procedure recommended by Dr. Otto Freer, 20 in which he pro- poses to enter the frontal sinus by way of the bulla ethmoidalis, seems to me to be based on a wrong conception of surgery and insufficient knowledge of the anatomy of the parts. It is also fraught with the danger of upward and backward and down- ward and backward cutting without a guide and should be con- demned. It seems to me that the procedure that I now submit has some advantages that are not otherwise offered. It has been satisfactory in my hands for ten years. It may be limited for the frontal sinus, providing a very high cut of the middle tur- binate which I have frequently mentioned in various texts as a "cribriform or infundibulum turbineetomy.' 1 The cut is actu- ally 2 or 2.5 mm. from the cribriform plate and may be ex- tended to the most anterior limit of the infundibulum. Or this very high cut may be carried backward to include the capsule of the ethmoid, under which condition not only is the middle turbinate removed, but the uppermost line of, and usually all the other ethmoidal cells are opened wide into the nasal cavity. And when desirable the entire anterior wall of the body of the sphenoid from its uppermost limits, with all its post-ethmoid al association and much of its floor may be removed. In my judg- ment and experience it is the technique that most often may 164 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN be trusted to open all of the cells, regardless of unusual or anomalous positions. It accomplishes the frontal inlet as Dr. Freer endeavors hut by safe cutting. I know, however, that cells may exist that not only cannot be opened from the nose but cannot be located by any means at present at our command. They can only be recognized in the cadaver and then only by complete dissection. Everyone who has observed a reasonable number of specimens has seen such cells and been struck by the futility that would attend any surgical effort to reach them ; and everyone of reasonably wide experience has met cases where all efforts had failed to find and treat such cells. But there are many other cells that are placed in positions more or less unusual that will be opened by a technique which lias for its primary plan an incision which will shirt the cribriform plate and remove the ethmoidal wall and, the middle turbinate at its most anterior as well as its most upper limits and extend into the sphenoid body at its uppermost part regardless of the natural opening, and then be extended downivard until it has cut through its floor or found it to be impenetrable. I have avoided the designation of sphenoid sinus because such a term does not always comprehend the full body of the sphenoid. It (the body) may be subdivided, and shared by a post-ethmoidal cell. And it is this variation which I believe to be the most per- nicious from the clinical side (for headache and optic nerve le- sions), as well as anatomically far more frequent than is at present recognized clinically. This variation will (it seems to me) be satisfactorily dealt with by this proposed technique practically every time it is met. Also pre-frontal-ethmoidal cells will be opened into the nose as a ride, if not uniformly. Technique. — In 1907 I 69 published an elementary text in which I described a surgical method which was at that time novel. It consisted in approaching the turbinate from above on its inner side. Prior to that all surgical approach was from below laterally upward, removing it by scissors or snare or a combination of these or such working instruments. I at the time described a knife consisting of a handle, a shaft and a cut- ting end turned at a right angle to the shaft and sharpened so as to cut on the inside of the right angle ; i. e., on the pull. It was also sharpened on a face parallel to the shaft which at HYPERPLASTIC SPHEN01DITIS 1(55 the same time gave it far more strength than a hook could have were it sharpened on its concavity. I selected this shape in preference to a hook for those reasons, and the fact that great strength is necessary for the tasks to which this knife is put. The knife, although possessing great strength is so small that Fig. 85. — On the right the angle knife is shown in the sagittal plane ready for inser- tion under the middle turbinate. On the left it is shown in position for the forward and down- ward cut. It has been introduced into the infundibulum and rotated 30 degrees inwards, i. e., toward the septum nasi. The heavy line A-B shows diagrammatically the line of this first cut which may be accomplished in one stroke or two, according to the surgeon's election (I pre- fer two strokes usually.) it may readily enter spaces which larger instruments could not. I believe it to be the smallest nasal instrument possessing great strength. A glance at the lateral Avail shows that the higher and 166 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN" the more forward the infundibulum is opened the wider and freer will be the inlet to the frontal sinus usually. At the same time pre-frontal ethmoidal cells will usually be opened by such an incision. For thesp reasons it has been advanta- geous, in my hands, to introduce the knife sagittal under the anterior third of the middle turbinate as far back as the un- cinate process, as high as the cribriform plate with its cut- ting edges facing forward. It is then rotated somewhat in- ward and drawn forward and downward. Fig 85. Consider- able forward pressure is kept on it while it is being drawn down- ward. In this way the foremost and uppermost nasal wall of the capsule of the ethmoid (with the attachment of the middle tur- binate) is cut open, and the pre-frontal cells of the ethmoid are thereby thrown open, as the nasal wall of these cells is usually constituted by that part of the capsule, with the attachment of the turbinate. This must be considered the conservative technique. By these means, however, are put an inlet or outlet to the usual frontal sinus that comprehends the dimensions of the usual infundibulum ; i. e., 1 cm. anteroposteriorly and 0.50 cm. later- ally. Should this size be reduced to such a degree as to require some procedure more radical, the knife is then engaged in the hiatus semilunaris with its cutting edges forward or down- ward — usually in the uppermost limit. By a downward pull, the uncinate process will be removed, and the knife may finally be engaged in the floor of the anterior part of the frontal sinus. (Fig. 99.) This may be so thick and hard that it is with diffi- culty, or impossibly, handled by this knife. A large enough opening, however, is usually secured to admit a Good rasp or a burr. The burr is then introduced into the sinus and put in motion with a forward and downward pull. In this way I have slightly modified Ingals' 32 ideal frontal sinus technique. This stroke of the right-angle knife, it will be seen, is safe, as it cuts away from danger (brain), or the knife in position, cutting edges facing upward and forward is likewise safe with a down- ward or forward pull, as it also cuts away from danger. It will cut into the buttress of the lower anterior part of the sinus. For the anterior ethmoidal district the knife is reintro- duced along the cribriform plate — its smooth elbow with a gen- tle touch, recognizing the smooth uppermost limit of the nose— HYPERPLASTIC SPHENOIDITIS 167 * ~<5 \ Fig. 86. — Shows the angle knife introduced between the septum and middle turbinate. It has passed 1 cm. back of the first cut along the cribriform plate. The dotted line X shows it to have been rotated outward until its cutting edges point 30 degrees above the horizontal. The tip of the nose has, at the same time, been forcibly elevated. The heavy dotted line A-B shows the line of cut. to a distance 1 cm. In this position its two cutting edges face downward. It is now rotated until its cutting edges point out- ward and slightly upward. The upward turn is added to the outward for the reason that the outward and upward position 168 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN permits of a more nearly horizontal pull. The slight upward turn keeps the line of incision much more nearly the horizontal despite the fact that the pull must needs he downward and for- ward or forward and downward. The safety of this cut is pro- Fig. 87. — Same as Fig. 86, with the difference that the knife has been passed the second time along the cribriform plate to a distance 1 cm. back of the first cut. vided by two factors, i. e., the cells of the ethmoid in their extension into the roof of the orbit rise at once above the crib- riform plate; and the length of the cutting arm of the knife HYPERPLASTIC SPHENOIDITIS 169 which should he 2 mm. is too short to cut through the thickness of the nasal orbital thickness of the ethmoid capsule under any circumstances. This incision is the first of two or three sim- ilar ones. (Figs. 86 and 87.) I prefer to divide it into two Fig. 88. — Shows the knife introduced sagitally under (lateral to) the; middle turbinate for the purpose of cutting into the capsule of the ethmoid. The dotted line I-2-3 shows the successive cuts from above downward. These cuts may be readily made to enter the orbit by inclining the cutting edges 30 degrees outward. In the conservative employment of this technic, this employment of the knife may be omitted. or three because I can keep my bearing upon the cribriform plate more satisfactorily by these shorter cuts than in one longer one. 170 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN Now tlie operative procedure is to be directed by the judg- ment of the surgeon. In my judgment the only turbinectomy should be a cribriform or infundibular turbinectomy; i.e., one that opens the infundibulum to its widest possibilities, for the reason that a lower cut leaves a stump that is physiologically worthless and surgically difficult of later manipulation. This is not in reality a stump although in former years I considered it such. 69 It is that part of the ethmoidal capsule which makes the inner portion of the final entrance of the frontal sinus into the nose — the anterior part being the uncinate process, the pos- terior part being the bulla ethmoidalis, the external and inter- nal parts being ethmoid capsule. The removal of this inner Fig. 89. — Shows the snare loop placed around part detached. part as high as possible usually gives an inlet to the frontal sinus 6 nun. anteroposteriorly by 3 mm. laterally. Some fron- tals enter the nose by a devious channel and cannot be consid- ered as usual (Figs. 14, 15, 16, and 17, page 37). If this upper internal part of the frontal inlet be not removed at the primary operation it seems to me to be unfortunate, as a secondary opera- tion will almost surely wound the epithelial surfaces of the frontal inlet and then be followed by connective tissue develop- ment which will block the inlet. The primary high cut is usually accomplished without. that result, leaving the hiatus semilunaris and infundibulum free of scar tissue. The secondary operation is usually of necessitv done with more trauma to the hiatus HYPERPLASTIC SPHEXOIDITIS 171 regardless of whatever technique is employed. For this reason I emphasize the advisability of doing the foremost cribriform cut primarily if the anterior half of the turbinate is touched at all, regardless of whatever else is to be done surgically. (Com- pare Fig. 90.) The cutting edges of the introduced knife are now turned downward or downward and slightly outward (Fig. 88), and the incision is placed superficial (internally) or may be placed as deep (externally) in the capsule of the ethmoid as the judg- ment of the surgeon directs. For the simplest subacute sup- purative cases, the superficial incision suffices. For most rad- Fig. 90. — Showing the line 1-2-3 of amputation of the pendulous middle turbinate. No ethmoid cells are opened by this procedure nor is the infundibulum opened. ical, e. g., an orbital phlegmon back of the transverse meridian of the eye, the incision goes through the capsule into the orbit in its posterior half. This is readily and quickly done. The detached mass is then by means of the same knife, which may be turned somewhat transverse, pushed downward into the nose where a snare may be put around it and cut it from its attach- ments (Fig. 89). The procedure may be varied by a superficial removal of the turbinate and then the excision of the capsule to any extent desired. In my practice I have had twenty-two orbitals phleg- 172 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN mons, produced by nasal sinus ruptures, twelve of which I opened into the nose in this way back of the transverse merid- ian. In my experience this has far surpassed the results of Fig. 91. — Shows knife / passed backward along cribriform plate penetrating anterior face of sphenoid at its top. The dotted lines 2 and 3 show knife passed back to posterior wall of cell and to have been rotated 20 degrees inward cutting downward to hug the septum nasi. external orbital drainage inasmuch as it drains by the same route that infected the orbit. Should the sphenoidal and post-ethmoidal cells also need HYPERPLASTIC SPHEXOIDITIS 173 the surgeon's care, I then (after the snare amputation of the middle turbinate) pass the angular knife very gently backward along the cribriform plate with its cutting edges downward. In this way its smooth, round elbow glides along the cribriform plate until it meets the anterior face of the body of the sphenoid. This, it will be seen, is the uppermost point of the face and is Fig. 92. — Shows knife to have been reintroduced through uppermost part of sphenoidal cut as shown in Fig. 91 to posterior wall of cell. It is then rotated 30 degrees outward (X) and carefully drawn forward and (necessarily) downward. The introduction of the knife to the posterior wall of the cell at its uppermost part insures the opening of many of the post-ethmoid cells that are developed into the sphenoid body. I believe this to be very important and one of the advantages to be secured by this technic. independent of the natural opening of the sphenoid sinus which is usually well below this point. Gentle pressure is now made on the face of the sphenoid and the knife inclined slightly to- ward the septum. The first stroke perforates the usual sphe- 174 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN noidal face and cuts somewhat downward. The knife, cutting edges downward, is then introduced very gently into the open- ing so made and very gently extended as far back as the cell permits. It is rotated 15 degrees inward, and drawn downward and forward with any degree of force that may be needed. This incision will extend from the junction of the cribriform plate with the body of the sphenoid downward, a varying distance along the septum nasi depending on the thickness and hardness Fig. 93. — Shows the Knight forceps ("made especially for this purpose 3 cm. longer than the original model because this added length is often required) introduced into the opening in the anterior face of the sphenoid body ready to bite out the anterior half of the floor of the body. This is oftentimes easily done, but at other times the floor is too thick to be removed this way. It is removed by a rotatory movement. of the bone. Should this incision not have reached the floor of the sphenoid, another similar one usually does (Fig. 91). Then the knife, edges down, is again passed along the cribriform plate and very carefully introduced back into the uppermost limit of the opening already made. It is then rotated 30 de- grees outward and brought out, forward and downward (Fig. HYPERPLASTIC SPHEXOIDITIS 175 92). This incision includes a considerable part of the wall separating the post-ethmoidal from the sphenoidal cell, and it has the advantage of beginning at the uppermost limit of the sphenoidal face. It has a distinct advantage over all methods which begin their procedure in or from the natural opening of the sphenoid, for the reason that often a post-ethmoidal cell occupies a part of the body of the sphenoid and is placed above the sphenoidal cell. Fig. 100 shows snch a cell which would be opened by this technique and would probably not be opened by any other technique now known. Such cells are exceedingly hard to deal with surgically and sometimes equally hard or Fig. 94. — Shows the Knight forceps in position to bite out the post-ethmoidal wall which has been cut loose, as shown in Fig. 92. impossible to find. Fig. 101 shows such a cell placed all above the line of the cribriform plate. This cell would not be opened by this technique and I do not believe it could be recognized in life by the present means of investigation. Some such cells, however, have a lateral and downward extension which is opened by the second stroke of the knife which is again intro- duced along the cribriform plate and inserted into the cavity in the body of the sphenoid, turned 30 degrees outward and drawn forward and downward. This second cut usually takes the post-ethmoidal nasal wall as well as most of the lateral part of the sphenoidal face and often the mass may be removed in 176 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN one piece. For this purpose I use the Knight forceps (Figs. 94 and 95), made, however, for this particular purpose, being 2.5 cm. longer than the original model. These forceps are then introduced into the cavity of the sphenoid (Fig. 93), and so the floor of the sphenoid is removed in part. Everyone knows, however, that the floor often is so thick and hard that it cannot be removed by forceps. A drill which will do such service may be advantageous. Fig. 97 shows a special post-ethmoidal forceps which is often of service. In the performance of the post-ethmoidal-sphenoidal por- tion of the technique I prefer a knife smaller and slightly dif- Fig. 95. -Shows post-ethmoidal walli in grasp of forceps. It is finally detached by a rotatory movement. ferent from that used in the anterior portion, for the reasons, first, that it is thereby rendered much stronger; it cannot be broken in any of the service it may be put into ; and secondly, a knife 1.5 mm. inside cutting edge cannot inadvertently cut into orbit in this service unless Avielded by some one neglecting the proper performance of the operation and totally ignorant of the anatomy here; and thirdly, I feel that the angle of the sphenoid knife should not have turned the full 90 degrees from the shaft because such a knife could not be engaged in the face of the sphenoid. An angle of 68 degrees off the shaft which will make the cutting edge on the inside of the angle 112 degrees HYPERPLASTIC SPHEXOID1TIS 177 will bite readily into the face; and fourthly, a small knife 2.5 mm. in its entire cross measurement permits a much closer approach to the top of the sphenoid face. One 6 mm. could not get so close by 3.5 mm. In this service a hook sharpened on its concavity would be much less advantageous because, if bent to a right angle, it would not bite into the face and if in 68 de- grees to 112 degrees shape it would not execute the work so well and its point would break easily, when it would take the shape of the knife now proposed without being sharpened. I feel that special emphasis should be laid upon the neces- • A Fig. 96. — Shows a three-quarter view of specimen with operation completed. The an- terior half has been left "conservative," i. e., the wall is intact with all the openings free as far as 1.5 mm. of the cribriform plate. An infundibular cell. A, has been opened as shown first in Fig. 89. The posterior half is "radical," i. e., the anterior wall of the sphenoid cell has been removed witn its entire post-ethmoidal part (lateral part, which is one-half or two-thirds of its extent). The post-ethmoidal cells have of necessity been dealt with radically to accom- plish this, i. e., their entire nasal side has been removed. Bristle B is shown passing from the nose into the frontal sinus. Bristle C is shown passing through the post-ethmoidal-sphenoidal opening. A strip of bone D has been left to indicate the position of the sphenoidal-vomer junction. sity of the surgeon knowing what are the correct models of these knives. For this reason I submit dimensions and draw- ings (Fig. 98/1 and B). Too large a knife has the disadvantage (1) of taking up space unnecessarily, and of (2) biting more bone than it can cut, and (3) of possibly cutting inadvertently into the orbit, and (4) of being much more apt to have its angle cutting portion broken off in the operation. In this con- 178 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN nection it must be emphasized that it is absolutely necessary that the knife be tempered not too hard. Should it be too hard it will always break with the work put on it in this operation. The instrument maker must specially understand this. It is far better to have it too soft. As such its cutting edges may not be as lasting, but it will not break. Summary. — The intranasal surgery of the upper cells may Fig. 97. — A three-quarter view of a post-ethmoidal forceps made right and left.* be performed by this method in any part or the whole as con- servatively or as radically as desired. The ability to place the incision safely 2 mm. below the cribriform plate in any part of or in the whole length of its extent seems to me to be most ad- vantageous, and not a small part of this advantage is the power n ^ e B D Fig. 98. — A. Sphenoid knife.* B. Turbinate knife.* C and D. Turbinate knives* made right and left. Some of my confreres prefer right and left knives. I prefer the straight knife. to extend this incision to the foremost limit of the infundibulum, thereby opening the inlet of the frontal to its widest natural possibilities. It is most desirable to preserve the natural inlet here, and this is done by a cribriform turbinectomy which leaves undisturbed the histologic epithelial covering of the normal inlet ; i. e., the uncinate process, the bulla ethmoidalis, the hiatus semilunaris and infundibulum, regardless of the anatomical •To be had of V. Mueller & Co., Chicago, 111. HYPERPLASTIC SPHENOIDITIS 179 variations of the frontal inlet. Should these parts be wounded, as in a curettement, the resultant sear tissue blocks the inlet. The angle knife removes by cutting any desired tissue with the least possible trauma to the surroundings. In the sphenoidal district it opens the uppermost and lowermost possible parts of the face which has the advantage sometimes of opening also a post-ethmoidal cell which may occupy part of the body of the sphenoid. (Such a cell is often the cause of the entire clin- ical picture.) The angle knife is so small that it takes up the Fig. 99. — Shows the knife in position for cutting away the uncinate process preparatory to Ingals' removal of the frontal sinus floor. Oftentimes the entire frontal floor may be cut away by the knife. minimum room and so leaves the small field open to the best vision possible. Its execution is always in the direction away from the (brain) danger zone. I have so far not seen such sat- isfactory post-ethmoidal surgery by other methods. (This dis- trict seems to me the most dangerous of all, for on the outer upper aspect runs the optic nerve and above is the optic chiasm and cranial cavity.) Satisfactory execution is necessary, par- ticularly for eye lesions. This entire performance may be accomplished within a short time. I have often finished the high frontal ethmoidal 180 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN and sphenoidal combined operation in two minutes (including the post-orbital opening on one occasion). A septum nasi deflected into the affected side may add troubles for the surgeon. I have in such cases where the mid- dle turbinate was not visible from in front in any part used a bi-valve speculum specially constructed for the purpose. Just as Killian elongated the blades of the primary bi-valve for his needs in septum resection, I have elongated them still more Fig. 100. — Shows knife approaching* a post-ethmoidal cell which lies on the top of the sphenoidal sinus and occupies about one-half of the body of the sphenoid. The line A shows position of approach. B shows the position for cutting. From considerable clinical experience I believe this cell would be opened by this technique. and widened them for my needs here (Fig. 103). The speculum should be made of tempered steel blades, knife-like thin, with handles long enough to give leverage to dislocate the entire septum into the opposite nostril. It should have a set screw, for the pressure required is much and the hand gets tired hold- ing it. Its blades should be 9 mm. wide, for narrower ones such as are supplied with Killian 's often do not give sufficient view. HYPERPLASTIC SPHEXOIDITIS 181 pjg io] —A shows the usual sphenoidal sinus and the usual cribriform plate with their usual relations. B shows post-ethmoidal ceil / placed altogether on top of sphenoidal sinus 2. Its lowermost limit is almost on the horizontal of the cribriform plate 3. This cell could not have been opened bv this technic, nor, in my judgment, by any other extent. 182 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN" They should be 88 mm. long, for shorter ones (Killian's) some- times fail to reach the posterior field of operation. Killian's short blades are advantageous for the anterior district. The knives are also made right and left (Fig. 98 C-D). Fig. 102. — Showing the left half of specimen. /, right sphenoidal sinus extending into left side to border left optic canal 2. A! post-ethmoidal cell 4 also borders left optic canal. All three of these cells would probably have been opened by this technic operating on the left side. Some of my associates prefer these. My own preference is for the single, straight, original model. I recommend an extra (2.5 cm.) long shaft for use with the long blade sphenoidal spec- Fig. 103. — Sphenoidal speculum.* It is the primary bivalve nasal speculum made of tem- pered steel blades 88 mm. long 9 mm., wide, knife edge thin near tip. It should have a set screw. It is a simple enlargement of the primary bivalve for this purpose as Killian's enlarge- ment is for the purposes of septum resection. It is 13 mm. longer and 4 mm. wider than the usual model of Killian's. The sphenoidal knife used with this speculum is 25 mm. longer than the regular knife. By means of this speculum the route to the sphenoid may be forcibly widened when it is too narrow. *To be had of V. Mueller & Co., Chicago, 111. HYPERPLASTIC SPHENOIDITIS 183 ulum. A strong, large handle ought always be supplied for the knife. A right-hand surgeon makes his turbinate cuts for the left side, cutting edges in the plane of the handle. For the right side the cutting edges are turned one quarter (90 degrees) into right nostril. This makes them horizontal or transverse when the handle is on the middle line. This technique is especially advantageous in tall noses. Some measure only 5 cm. from roof to floor, others measure Fig. 104. 7.5 cm. Figs. 104 and 105 represent these proportional differ- ences. High operating in the former is much simpler than in the latter. A technique which cuts downward and outward is obviously advantageous. The lower the sphenoidal post-ethmoidal cut goes on the lateral wall, the more likely is brisk bleeding and shock because this incision approaches or reaches the entrance of the vessels and nerves as they come through the sphenopalatine foramen. The bleeding is, however, usually slight at the time of operat- ing, being controlled partly by adrenaline solution and often by the lowered blood pressure of shock which increases as the larger nerve-trunks are cut. A normal blood clot then has time 184 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN to form and close the vessels. It is advantageous to avoid packing the nose here because of great discomfort of a pack put in tight enough to answer, and because of the trauma it inflicts. Apposing surfaces are roughened and later synechias form. In patients with scant general strength, the pack that should usu- ally remain 48 hours exhausts them more than the shock of the operation. This may be prevented largely by carbolizing the Fig. 105. nasal ganglion before the operation, 70 but as a rule of practice I prefer to put the patient (without pack) in a hospital for 24 to 72 hours, and not pack unless brisk bleeding develops. Should it come on it is usually of such volume as to require im- mediate control. If the patient cannot be placed in a satis- factory hospital, I always pack the post-ethmoidal-sphenoidal district. Small doses of heroine prevent sneezing and so elim- inate one factor that brings on bleeding. On the third or fourth day I begin the instillation of phenol oil, and on the seventh HYPERPLASTIC SPHEXOIDITIS 185 or eighth I begin the alkaline saline wash. If this be begun too soon it conduces to bleeding, probably by dissolving the clots in the vessels. Synechias in the posterior district are usually negligible clinically. Should it be desirable to dispose of them, I wait until scarring is complete and divide them with a sharp knife. Usually the scar tension will pull apart the cut surfaces and let epithelium cover them. If they be in a district where a thin celluloid splint can be retained, this may be left in place from four to ten weeks assuring epithelial cov- ering of both cut surfaces. Surgery of the Maxillary Antrum Surgery of the maxillary antrum may be radical or con- servative. The former which opens the antrum in some way that permits the curettement of its lining membrane for the relief of advanced pathological changes consequent to suppura- tion, granulation and necrosis with polyps is never required for the relief of the uncomplicated hyperplastic changes so far as I know. Should the outlet to the antrum become closed as in the cases described by Lynch, 47 the simple opening at another place for ventilation answers the purpose. The well-known Caldwell-Luc and the Denker radical operations therefore need no description here. The procedure which has all the advan- tages and no disadvantages for this purpose is one which I de- scribed in 1909. Furthermore it answers for most of the sup- purative cases. The Author's Antrum Operation The idea of entering the antrum through the nasal wall and later of conserving the lower turbinate in antrum surgery has occurred to various surgeons. So far as I know the first com- pleted procedure of this kind was at my hands in July, 1906. In February, 1907, Hirsch conceived and performed what is practically the same operation. He reported his procedure in the Wiener Medizinische Wochensclirift, July 4, 1908. My re- port was in the Laryngoscope, December, 1909. He confined his operation to the lower meatus. Mine includes the middle meatus also. Aside from this, there are some other small vari- ations in our techniques. Both have as cardinal idea the con- 186 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN servation of the lower turbinate with drainage or ventilation. The operation of opening into the antrum of Highmore through the lower meatus of the nose was first described by Schaeffer 65 in 1885, next by Mikulicz 53 in 1886. It seems to be known usually by the name of the latter. Lack 39 describes and suggests leaving a cannula in position that the patient may wash it through. Rhinologists now seem agreed that the intranasal operation is the choice of the conservative methods, both as affording per- manent drainage and doing away with the necessity of habitu- ally wearing a plug. Should these conservative means prove insufficient, and a radical operation be required later, the open- ing into the lower meatus will not have been in vain. Its great drawback is the removal of a considerable portion of the lower turbinate, which is followed by drying of the corresponding nostril. Furthermore, the stump is very apt later to become hypertrophied, in which case it may have to be removed with the disadvantage of causing increased dryness of the nostril. Hajek 27 emphasizes this tendency to hypertrophy, and offers the explanation, that it is probably a result of congestion fol- lowing lesion of the blood-vessels incidental to the resection. At the meeting of the American Medical Association, Sec- tion of Laryngology, held in Chicago, June 1, 1908, while dis- cussing Canfield's "Submucous Resection of the Lateral Wall of the Nose," 9 I described my own modification of the "Miku- licz" operation. The operation, as I then described it, and as I have performed it for the past ten years, is simple in execu- tion ; and, when properly done, assures a permanent, free open- ing for drainage. It avoids, moreover, the subsequent drying, which is the only drawback to the lower meatus operation. It involves only an insignificant lengthening of the time required in operating. The procedure consists (1) in cutting the lower turbinate from the lateral wall, as far back as its posterior fourth, by means of scissors. The detached part is then pushed well up- wards, while the operator removes the lateral wall of the lower meatus Fig. 106. Fig. 107 shows a separable forceps, helpful in making a quick effective entrance to the antrum from the nose. When the wall of the lower meatus passes outward as HYPERPLASTIC SPHENOIDITIS 187 well as backward it is often difficult to secure a satisfactory beginning for the opening because an ordinary biting forceps fails to effect the first bite — it slips. In order to overcome this difficulty I have made one blade of these forceps lance-like. It is separated from its cup-shaped fellow. It is passed through the anterior limit of the nasal-antral Avail just as a straight Fig. 106. — i. Detached lower turbinate. 2. Opening cut into antrum. needle used in the exploratory puncture of tins cell. While it is in this position its cup-shaped fellow is introduced and locked just as the blades of the obstetrical forceps are introduced separately and locked before they are put to service. A strong bite is then put upon the instrument and by a to-and-fro lateral rocking movement a considerable part of the wall is loosened and 188 HEADACHES AND EYE DISOKDERS OF NASAL OKIGIN removed. The blades should be tempered and the cup sharp as great power is needed in these forceps when the wall is thick. If the cup is not sharp it will slip. Figs. 108 and 109 are self- explanatory. After the first entry has been satisfactorily made it is usually not difficult to reenter it and enlarge it, by these forceps or any other the surgeon may prefer. The detached part of the lower turbinate is next pushed down into the lower meatus, while he removes as much of the wall of the middle meatus as he wishes (Fig. 110). In this manner it is possible Fig. 107.- — The author's intra-nasal antrum forceps.* to remove the entire inner wall of the antrum as far forward as the nasal process of the maxilla. There will still remain the ridge on the nasal process, for the reattachment of the lower turbinate, which is now replaced in its original posi- tion, carefully arjposing the cut surfaces at the anterior end (Fig. 111). Often the parts may be held in position by means of a little cotton or gauze. If this is found to be insufficient, one or two stitches suffice to hold everything perfectly in place. I have never seen the bone fail to unite, or undergo degenera- tion. No subsequent hypertrophy has been observed. Some *To be had of V. Mueller & Co., Chicago, 111. HYPERPLASTIC SPHENOIDITIS 189 Fig. 108. Fig. 109. 190 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN of my cases are of ten years' standing. The replaced turbinate in no wise interferes with the drainage, or with the final good results. It does away absolutely with any subsequent drying. This is an advantage in cases both of medium and wide nos- trils, where some drying is sure to follow any removal of the turbinate. It is especially advantageous also in cases in which the middle turbinate must be or has been removed to drain a Fit;. 110. frontal or ethmoidal empyema. In these cases it conserves the heat and moisture functions of the nose, which would be lost were both turbinates removed. In atrophic rhinitis it is especially indicated. In noses whose calibre is a little too wide or a little too narrow the angle of inclination of the turbinate may be altered HYPERPLASTIC SPHEXOIDITIS 191 in reattaching it, making it less acute for the former and more acute for the latter. This is readily done by tilting the bone upwards by a pack of gauze or cotton put underneath its body after it has been sewn in place, or by pressing the body slightly outwards by a pack between it and the septum. These packs must be continued throughout the healing, the bone afterwards remaining in its new position. Fig. 111. — Showing I lower turbinate replaced to original position. .'. Opening into antrum. It is my habit to remove the entire inner Avail of the antrum — opening it into the middle as well as the lower meatus — replacing the lower turbinate as above described. I believe it is best to remove the wall of the middle as well as of the lower meatus, for the reason that an opening limited to the lower meatus will often close up. CASE HISTORIES Case histories are submitted with some effort to conform to the pathological lesion. It has however seemed to me more interesting to keep in mind the predominating feature. This will explain why the categories overlap in many places, also the seeming neglect to separate nasal ganglion cases from the sphenoidal cases. This may appear more logical when it is recalled that the "lower-half headache' 1 is the most striking manifestation of both lesions as has been made clear in the body of the text. I have deliberately recorded many features which at first thought may appear so rare or infrequent as to deny the justice of their report. When they have been the only cases I have stated tins fact. In recording unusual cases I am justified by the precedent of the most famous neurologists of recent times; to wit, Dr. S. Weir Mitchell, 55 Sir "Win. R. Gowers, 22 and Dr. C. W. Suckling, 90 and others who have re- corded unusual cases, no explanation for which could be given at the time. They justified the record of facts by the hope that the future might discover their causes. Vacuum Frontal Headaches Miss A. B., 28 years old, referred to me by Dr. A. E. Ewing, Oct. 20, 1898, for frontal headache with asthenopia ex- amination showed a large tuberculum septi crowding the mid- dle turbinate of each side tight to the lateral wall. Both tur- binates were removed in November, 1898. Examination by Dr. Wright showed normal turbinates. I append Dr. Ewing 's re- port. This patient shows age by change in the skin with almost no change of feature. She has never had any recurrence (May 1918). "Patient received Oct. 23, 1897. In this case I (Ewing) Avas for a long time deceived, the tenderness not being suffi- ciently marked to be regarded by me as decisive. When the patient first came to me there was marginal blepharitis com- CASE HISTORIES 193 plicated with conjunctivitis, also hypermetropia with astigma- tism. The eyes had been inflamed from time to time for several years, and at times there was a good deal of headache. With correction of the refraction and care of the lids, the inflammation in the main disappeared, and the headaches were greatly les- sened, but there was always inability to use the eyes by arti- ficial light. The relapses of conjunctivitis were also frequent. Afterwards the headaches became more frequent, and were made worse by any use of the eyes in near work. As the sub- ject was a teacher, some use of the eyes was imperative. There was some weakness of the interni which I corrected with prisms, to be worn in near work in addition to the spectacles which cor- rected the refractive error. For a time these served fairly well, with periods every two or three weeks during which the eyes could not be used even with this aid. The headaches gradually became more frequent, and were finally almost constant. "Eventually, when I had almost concluded that my patient was a confirmed neurotic, I detected during a slight exacerbation of the conjunctivitis a positive tenderness in one orbit. A rhi- nological examination by Dr. Sluder revealed closure of the frontal sinus. Under appropriate treatment for this condition the headaches and the conjunctivitis have entirely disappeared, the prisms have been discarded, and the eyes are used freely day and night." L. M., aged 15, consulted me September 22, 1902. For 5 vears he had had a great deal of trouble from headache and his eyes (asthenopia), which interfered with his education. He had been sent to Texas to have the life of the open air upon a ranch, thinking that would stop the headache and relieve his eyes so that they might come into service. All effort to relieve him failed, and he was brought to me for examination. It was found that the middle meatus of each side was closed by the middle turbinates being pushed into the lateral wall by the tubercle of the septum. Ewing's sign was very clearly marked. The case seemed perfectly clear as a closure of the frontal sinus without secretion. January 19, 1903, the right middle turbinate was removed. December 29, 1902, the left turbinate removed. The wound 194 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN healed uneventfully, and the headache stopped, and his eyes went into service, which permitted the complete education of the young man, according to the standards of the family. He went through college and became a celebrated athlete. For some time he has been in business in St. Louis, and from time to time I see him. He remains free of headache. His eyes are as serviceable as anyone's. He shows his age more by the altera- tion in the skin than in change of feature. The bony configura- tion of his skull changes very little. The turbinates were normal (Dr. Wright). This case is a sharp contrast to M. E.'s, where the uncinate process and the bulla became approximated after a short time, necessitating the removal of the floor of the frontal sinus by a burr. Vacuum Frontal Headache with Active Hyperplastic Bone Process M. E., 40 years old, consulted me Dec. 20, 1903, because of symptoms almost the same as L. M. Removal of the middle turbinate gave relief for nine years when the inlet to the frontal was obliterated by enlargement of the bulla to approximate the uncinate process as high up as the cribriform plate. On Oct. 10, 1912, I removed the uncinate and floor of the frontal making a large opening which so far has remained open. Clinically, the case is an active hyperplastic anterior eth- moiditis. She shows age markedly by change of bony feature. It is not possible at present to connect the external face which changes in features as age increases, with the activity of the hyperplastic process within the nose. I have however ob- served it often. Vacuum Frontal Headache with Sphenoidal Involvement Later Mrs. J. B. C, 33 years old, referred by Dr. M. H. Post, October 26, 1910, for frontal sinus vacuum headache of 15 years' standing, with asthenopia, high grade. March 16, 1911, I removed by high (cribriform) cut, the L. middle turbinate. CASE HISTORIES 195 It showed (Dr. Wright's examination) a hyperplastic (bone and soft parts) process. The R. side was less troublesome and not operated. She got well and remained so until sent by Dr. J. A. Flury again to me July 8, 1915, with a well-marked hyper- plastic sphenoiditis, non-suppurative, more marked L, accom- panied by moderate maxillary and Vidian neuralgia with a hazi- ness of the retina and a blurring of the disc of both eyes with vision L. 6/9, R. 6/6 metric. She was given a l 1 /* per cent alkaline saline solution to pour into the nose three times a day and a phenol spray. Improvement began in two weeks. Sep- tember 13, 1915, she reported herself to be "well.' 1 Dr. Flury reported the fundi V. R. and L. normal. I have three similar cases beginning 15, 17, and 20 years ago, respectively, as frontal vacuum headaches. The middle turbinate bones showed hyperplasia of bone and soft parts (Dr. Wright). They remained well after opera- tion until the past 3 years, since which time they have developed a hyperplastic post-ethmo-sphenoiditis, one with polyps above the middle turbinate line. All have lower-half headache in great degree and very often ; but no fundus changes. In one case a major epilepsy ceased after a post-ethmoidal- sphenoidal operation. He has been well now 17 years. The First Nasal Ganglion Case Mr. S., 45 years old, consulted me November 23, 1903. For ten years he had suffered from headache which incapacitated him for business two or three days of almost every week. Noth- ing in his general health or life was at fault. He defined the distribution of pain as beginning at the root of the nose on the right side, taking in the upper jaw, and extending backward to become emphasized at the tip of the mastoid for a distance of 5 cm. posterior to it. The attacks were not always of equal severity. During a milder attack he could continue his business. In severe attacks the pain extended to the neck, shoulder, and shoulder blade of the same side, and was so intense as to com- pel him to go to bed. They were accompanied by vomiting. These severer attacks lasted from twelve to twenty-four hours. Examination of the nose showed a dusky red swollen area in 196 HEADACHES AND EYE DISORDERS OE NASAL ORIGIN the right olfactory fissure about 1.5 cm. in diameter, roughly •circular, beginning on the anterior Avail of the sphenoidal cells and extending forward (the sphenopalatine foramen district). Applications of a 2 per cent silver nitrate solution were made to the affected area two or three days a week for about three months. It finally became normal in appearance. With the improving appearance of this area went hand in hand a lessening of the frequency and severity of the attacks of pain, until they ceased. Since that time he has enjoyed freedom from painful attacks except at the time of coryza. Coryzas of medium severity are accompanied by a moderately severe attack of pain, as described before. He had one, more severe coryza which was accompanied by great pain. After I had learned to associate these neuralgic manifes- tations with the nasal ganglion, and to apply the anaesthetic in its immediate neighborhood (October, 1907), I was always able to stop the pain during coryzas. With this patient anaes- thetizing the ganglion aborts the attack. At the present time (1918) he is well. During the past three years he has had one slight attack from a coryza. Miss S., 27 years old, consulted me June 13, 1906. For many years "off and on," she had suffered from pain in the head, which she described as paroxysmal, beginning at the root of the nose, involving the upper jaw and teeth (occasionally also the lower jaw and teeth), extending backward to the tip of the mastoid, and becoming intensest about 5 cm. posterior to the point. These paroxysms recurred sometimes two or three times a week ; and when at her best, at intervals of two or three months. Examination of the nose was negative in every particular. She made the observation, however, during an attack, that the co- caine which had been sprayed into her nose, a four per cent solution, had relieved her of the pain. In the absence of a definite diagnosis, but continuing the spraying of the nose with cocaine, it was found that each ap- plication appreciably mitigated the pain. Under this treatment, in apparently much improved condition, she passed from ob- servation. About three months later she returned for treat- ment of a severe coryza, which in ten days localized itself in CASE HISTORIES 197 a suppurating' inflammation of the post-ethmoidal and sphe- noidal sinuses of both sides. Almost simultaneously the old pain reappeared, on the left side,- involving the root of the nose, the cheek, the mastoid tip, and a little behind it, the neck, shoul- der-blade, shoulder, and arm — all in great severity. Remembering the position of the nasal ganglion, in close proximity to these sin uses, and the widespread distribution of its branches and connections, I felt that this distribution of pain was possibly due to the inflammation or its products extend- ing to or acting upon the ganglion; and, if this was true, that cocaine applied (soaked) over the sphenopalatine foramen might probably prove effective in at least mitigating the pain. The experiment was tried, and succeeded even beyond ex- pectation. Since then I have applied the cocaine for her at the same site in severe recurrent attacks, probably twenty times; always relieving the pain and usually aborting the attack. I have also done some experimenting in these cases, but particularly in this case. During an attack an application of a single drop of dilute solution 4 per cent cocaine, through the region overlying the ganglion, was followed by only the faintest relief. This dilute solution was then replaced by a drop of a 10 per cent cocaine solution, with more relief. A drop of 20 per cent solution was then applied, with further lessening of the pain. A drop of a saturated solution (about 67 per cent) was then applied, when the relief would usually become complete. Applications to other areas gave negative results. In very severe attacks the pain would stop except at the point 5 cm. posterior to the tip of the mastoid, where, although greatly mitigated, it never quite disappeared ; a very slight pain always remained here. The applications were allowed to remain twenty minutes in position. This patient suffered greatly from repeated attacks until December 1, 1908, when I began injections of alcohol : making the attempt to put the alcohol in direct contact with the gan- glion. A straight needle directed upward and outward under the posterior fourth of the middle turbinate will reach the sphe- nopalatine fossa just where the ganglion lies. The needle must, however, be passed obliquely through the lateral wall of the nose, which in this case was so hard as to make the procedure im- 198 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN possible. I thereupon drilled through the hone, thus removing the obstacle to the passage of the needle into the pterygopalatine fossa and opening an easy route for subsequent injections. The injection of the alcohol aggravated the characteristic pain al- ready described, but the exacerbation was transitory and was followed by relief. After a course of ten injections the relief seemed complete ; but, after somewhat more than three weeks of freedom from pain, the patient contracted another severe coryza, with sup- purative inflammation of the post-ethmoidal and sphenoidal cells of both sides, rekindling the old pain now for the first time also on the right side, although with less severity than on the left side. One application of saturated cocaine solution on the right side, posterior to and slightly above the posterior tip of the middle turbinate stopped the pain and it did not recur. On the left side relief was more tardy. Miss S. had recently had another "explosion,'' which was relieved by one drop of saturated cocaine solution to the gan- glion with the exception of a rather severe pain, which persisted in the shoulder blade of that side. On the next day the cocaine application was repeated, with complete relief of the pain. At present (1918) she is free of pain except at times of a coryza. Then it develops in her teeth and between her shoul- der blades where it feels like a "ball of fire." Complete Case of Nasal Ganglion Neuralgia Mrs. N., sister to Mr. S., whom I had seen many times in acute coryzas, came February, 1909, with what appeared to be a coryza of ordinary severity ; she complained, however, of pain as in a typical case of nasal ganglion neuralgia. One applica- tion of cocaine afforded complete relief, and there was no recurrence of pain. The coryza was otherwise commonplace and uneventful. Since that time I have seen Mrs. N. many times for vari- ous troubles. One, an enlargement of the thyroid, which seemed to be secondary to a lingual tonsillitis. The lingual tonsil has been treated, resulting in a lessening of the volume of the thyroid and the cessation of the nervousness and weakness of the hyperthyroidism which was at the time quite pronounced. She CASE HISTORIES 199 had no more ganglion neuralgia until the winter of 1916 and 1917. Then in the wake of what appeared to be an ordinary coryza she again complained of pain described briefly as a "lower-half headache," severe, accompanied by violent sneez- ing and a sense of very strong mustard in the nose, lacrimation and marked asthenopia. The entire picture was marked; but knowing that she had passed through such an attack of a much milder nature on an occasion before, I felt that she would prob- ably survive this attack without injection of the ganglion, which I therefore postponed. The case ran a series of ups and downs, more or less, last- ing throughout the autumn and winter. It stopped in the mid- dle of spring. Since that time she has been perfectly well, free of all disturbance referable to the nasal ganglion. Locally, her nose showed a perfectly clear post-ethmoidal sphenoiditis of what I suppose might be termed the catarrhal type ; that is, there was no suppuration, no swelling of the mem- brane; the appearance was simply one of redness with serous in- cretion; throughout the attack cocaine to the ganglion stopped the pain and relieved all symptoms for a number of days at a time. In this case of course the position of the nasal ganglion remained unchanged throughout these years. From the time of the first pain manifestation until this now reported, she has passed through many coryzas of ordinary severity, none of which, however, excited pain. Such a case seems to me to argue that the organism that produces the coryza must vary from time to time, and that there is a special organism or, possibly, more than one, that has a predilection for the nerve tissues; and that there are others that pass through their course with just as much appearance of inflammation as the other attacks, but which make no symptoms with the nerve tissues. Simple Ganglion Neuralgia Mr. B., 35 years old, came to me September 24, 1907, with a high grade deflection of the septum, which I resected. The operation was in every way uneventful and satisfactory. May 14, 1908, he returned with an acute suppurative inflammation of the post-ethmoidal and sphenoidal cells of both sides, accom- 200 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN panied by a headache referred to the parietal eminence and occiput of both sides, which lasted seven days. Three days later pain developed, which he described as beginning in the root of the nose, taking in the maxilla, extending backward into the occiput, and downward into the neck and shoulder blade. It improved under applications of 0.4 per cent formaldehyde solution over the sphenopalatine foramen. Patient was com- pletely well June 23, 1908, and remained so with the exception of some occasional disturbances from coryzas. Simple Sphenoiditis-Suppurative Miss DeH., 20 years old, referred by father, Dr. Dell. For three years a profuse suppuration of sphenoid sinuses. Never any headache or other symptoms. Hajek post-ethmoidal-sphe- noidal operation. Dr. Wright reported "Membrane not mark- edly altered. No involvement of periosteum or bone.' : Simple Inflammation Mrs. P., 55 years old. Diagnosis, sphenoidal empyema. Pain in occiput, left, G months. Relieved by operation. Re- ferred by Dr. A. E. Ewing. Dr. Wright's report: Sphenoidal tissue — bone shows some hyperplasia and there are marked in- flammatory products in the soft parts. Middle turbinate shows marked inflammation of mucous membrane in its deeper layers and considerable hyperplasia of the periosteum along the bone areas ; the bone itself is perhaps slightly thickened and the area of its distribution is considerable. In some places the bone seems to be very much thickened and the veins which it con- tains are gorged with blood. Hyperplastic Sphenoiditis Miss M. M., 37 years old, February 26, 1908, consulted me for general headache with great morning sneezing. There was swelling of the cavernous tissues in the nose with profuse gen- eral watery secretion ; but no pus or visible evidence of sphe- noidal inflammation. In the effort to control this syndrome the anterior nasal nerves were injected with alcohol (Stein) and trichloracetic acid applied to the tubercle of the septum CASE HISTORIES 201 (Francis) and middle turbinate, finally the galvanoeantery to lower turbinates and tubercle, November 6, 1908; December 26, 1908. The nose was opened for air, but the sneezing continued. All efforts failed. She had to abandon a busy and very useful life for an indefinite period of rest. Dr. D. B. Delavan, who saw her in consultation, advised rest in the mountains. After six months in the mountains of the South she returned to St. Louis, well, and remained so for one year. At this time, March 17, 1910, she returned for treatment because of a "bad cold and headache," as she expressed it. She showed a bilateral post- ethmoidal-sphenoidal suppuration, for which I eventually op erated, both sides (April 21, October 27, 1910). On January 10, 1911, she returned to me for an acute coryza with general head- ache and almost insufferable sneezing (sneezing to exhaustion) without evidences of post-ethmoidal-sphenoidal suppuration, for which she was again compelled to retire to the mountains. June 12, 1911, she again reported to me well. October 12, 1911, she consulted me because of intractable sneezing and general headache with intense burning, stinging sensation in the nose ensuing upon a coryza. This time I began the intra-sphenoidal applications of 1 per cent cocaine in oil, with 1 per cent phenol in oil, which controlled the sneezing and headache fairly well. A little later I began applications of 2 to 5 per cent sodium salicylate water solutions, which proved much more satisfac- tory — the sneezing and headache stopped in about six days. February 17, 1912, a coryza again made general headache and sneezing. This time, knowing that salicylate of methyl was a more potent remedy than the soda salt, and that it was usually tolerated, I filled the sphenoid with a 5 per cent solution syn- thetic methyl-salicylate solution in oil. To my surprise and disappointment it aggravated the entire syndrome in great se- verity, and in addition produced asthma lasting five days. A little later, after applications of the sodium salt, she became comfortable; and this in a much shorter time than in the pre- ceding attacks. Locally this case behaves like a hyperplastic ethmoiditis. In the inflammatory stage the membrane becomes edematous with polyp formations, which subside Avhen the at- tack is over. Up to the present time she continues to be disturbed greatly 202 HEADACHES AXD EYE DISORDERS OF XASAL ORIGIN by a coryza, a slight coryza producing violent burning, as mus- tard, inside of the nose, with great pain which wakes her out of her sleep at night. When the case is severe, asthma devel- ops, with the headache which accompanies this syndrome with greater or less severity. The case, however, yields through in- stillation of one-third per cent carbolic acid within the sphenoid sinus better than to anything that has been tried. Two per cent menthol instilled into sinus produced violent headache and severe asthma. Most of the time she is comfortable. She is a very busy hard-working woman. In her, a coryza is always ac- companied by polyps within the sphenoid, which subside as soon as the severity of the coryza is passed. Dr. Wright's ex- amination of sphenoid tissue shows marked ostitis and peri- ostitis. Hyperplastic Process Advancing Under Observation S. R., aged 23 years, consulted me in 1898 because of in- tractable low grade frontal headache made worse by use of the eyes. She was referred to me by Dr. John Green. Effort to re- lieve the eye condition was unsuccessful. Nasal examination showed the middle turbinate crowded to the lateral wall by the tubercle of the septum. She had been passed as a neurotic by the neurologists. Veiy little hope was held out for any benefit except possibly by the lapse of time. Removal of the middle turbinate relieved the frontal headache, stopped the general nervous condition and restored her eyes to full usage. She re- mained free of pain for six years, at which time she suffered a frontal sinus infection with pus. She had a low grade headache with this, which lasted two weeks and subsided practically with- out treatment. Twice she has had suppurative infections of the frontal and the anterior ethmoid. The case has been of great interest in observation showing the gradual increase of volume of the bulla of the ethmoid, a thickening of the uncinate proc- ess of the ethmoid and a swelling of the membrane. Now she has a considerably swollen membrane, the inlet to the frontal sinus is considerably narrowed and she suffers more or less dis- comfort with each coryza. Of greater interest, however, is the observation that three years ago began the appearance of swell- ing with polyps above the line of origin for the middle turbinate. CASE HISTORIES 203 Since that time, of greatest interest, is the posterior pain which has developed since the inflammatory trouble has been above the middle turbinate and backward. At present she has a very well- marked hyperplastic post-ethmoidal sphenoiditis which with each coryza makes polyps in considerable number and volume. In the interval between the coryza the polyps disappear, all ex- cept one which is in the anterior ethmoid and which becomes very much smaller. Much of the time she is free of all pain. Any little inflammatory trouble in her nose which might other- wise not be recognized is registered as headache either frontal or occipital. This case is to me very interesting showing the/grad- ual extension of the process from a hyperplastic anterior eth- moidals of low grade to the posterior district where the typical lower-half headache has been repeatedly produced. In this case a cut which removed the middle turbinate was put up or nearly to the cribriform plate, the cut which I have repeatedly spoken of as a cribriform turbinectomy. It still shows an inlet to the fron- tal sinus of % inch. In the beginning the inlet was % inch. Doc- tor Wright's report of the middle turbinate examination was that it showed a moderate grade otitis or periotitis. High Grade Hyperplastic Sphenoiditis — Blindness E. H. G., 30 years old, consulted me September 21, 1916, referred by Dr. J. F. Shoemaker. He had an optic neuritis. His vision had been failing three weeks, the left more than the right. At that time the vision of the right side was 13/100; the left 3/200. Examination showed a very high grade post-eth- moidal sphenoiditis hyperplastic dry. He never had had head- ache. Tentative treatment failed; and on September 22, 1916, the left sphenoid was opened. It was found to be a sub-divided cavity, one cell above the other. The bone was very thick and very hard. The operation made no improvement in the eye condition. A short time later the cavities closed up. They were re-opened, with no benefit for his eye. The right sphenoid was opened October 12, 1916. The material from this case submitted to Dr. Wright for examination engaged his attention specially. He has submitted a full report in the introduction. 201 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN This is a case which, it seems to me, demonstrates that when the hyperplastic bone process is of high grade, such as this, we fail to get the result for the eye. I have record of many others, where the whole hyper- plastic process in the soft parts and in the bones both are of much lower grade, with perfect result. His was the hardest, thickest bone that I have encountered at the primary operation. I have operated cases that have been operated before, either by myself or by other surgeons, where the bone formation was hard and the case was with difficulty handled. In one such case I found the bone so thick and hard that it could not be penetrated by the little angle knife that it is my habit to use. That was a headache case without eye involvement. The fact of this case being a total failure for the relief of the eye trouble in any degree, seems to me to follow merely the path- ological findings delineated by Dr. Wright. Every possible line of investigation, clinical and labora- tory, for this patient was negative, including a spinal fluid \Yassermann reaction. I have another case, male, 52 years, referred by Dr. V. P. Blair, corresponding with this in all particulars in which there was no eye involvement but great lower-half headache. Open- ing the sphenoid did not help the case. Lower-half Headache and Blepharospasm Mrs. A. B. 1)., a healthy young woman, 25 years of age, complaining of the "lower-half headache" described above, and at the same time complaining of an intractable blepharo- spasm, with great lacrimation. Examination revealed an inflamed district about the sphe- nopalatine foramen. Injection of the district stopped the pain and relieved the blepharospasm and the lacrimation. The case has stood now four years free of pain, lacrima- tion and blepharospasm. L. A. B., 52 years old, consulted me December 7, 1915, at the suggestion of Dr. John Green, Jr., for severe blepharo- spasm and lacrimation which had existed 8 months. He also showed a few slight opacities in the vitreous. Ophthalmological CASE HISTORIES 205 treatment by Dr. Green failed to control the spasm. Nasal ex- amination showed a hyperplastic post-ethmoidal-sphenoiditis, without secretion. Experiments proved that cocainization of the ganglion stopped the blepharospasm. This was repeated many times. Finally, it was decided to inject the ganglia. February 22, 191(3, the right ganglion was injected with cessa- tion of the blepharospasm in both eyes to a large extent. March 6, 1916, the left ganglion was injected with total comfort and relief. This patient did not have headache at any time of his life that he remembered, lie showed a definite hyperplastic eth- moidal sphenoiditis localized about the sphenopalatine foramen. It would have been impossible to have connected his case, that is, of cause to effect, had it not been that I had three times seen marked blepharospasm accompanied by lacrimation and loiver-half headache. The headache was the index to the cases. The ganglion was injected because the headache was controlled from the ganglion. In these cases the blepharospasm and lac- rimation were incidentally relieved with the headache. I there- fore put this case to the test of nasal ganglion cocainization and, to my surprise and delight, found that it controlled the spasm. Although there were no other manifestations of a nasal ganglion neurosis, the anatomical lesion at the proper site ac- companied by the control of cocainization gave me the feeling that the injection of the ganglion would give the result. He has now survived three severe coryzas without return of the spasm. The hyperplastic post-ethmoidal sphenoiditis as the result of the injections has involuted to such a degree as to be scarcely recognizable at present. His vision, which was not quite normal before, has returned to normal, F. B., 38 years old, consulted me Nov. 1, 1917, sent by Doctor F. L. Henderson, who had exhausted all means known to him for the relief of a right-sided blepharospasm of great severity. Examination showed a post-etlimoidal-sphenoidal suppuration, with polyps on the right side. Experiment showed that cocain- ization of the right nasal ganglion opened his right eye and relieved the blepharospasm for a period of three hours. It was therefore decided to inject the nasal ganglion of the 206 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN right side. This was done three times, and was followed by relief of the spasm for three to six hours. The right post-ethmoidal-sphenoidal operation was per- formed Dee. 21, 1917, and also relieved the spasm for a few hours. Treatment of the sphenoid cavity was followed by the cessation of the suppuration, and disappearance of the polyps; but the blepharospasm remained. Intra-sphenoidal cocainiza- tion relieved the spasm for three to six hours. The case was unsatisfactory, at least for the blepharospasm, and I determined to open the sphenoidal cavity of the left side. I decided this because I remembered that nobody could tell the sub-division of the sphenoidal body prior to opening it, and not always then, without x-ray plates with probes in situ. I felt that the irritation might come from the left sphenoidal sinus. Prior to this, the experiment with the left nasal ganglion was performed, and was found to give longer relief from the spasm than had the right nasal ganglion or the right sphenoidal sinus experiment. I then elected to inject the left nasal ganglion. This has been done twice, with transitory relief. April 20, 1918, I opened the left post-ethmoidal-sphenoidal cells. The blepharospasm is unchanged. This case is exceedingly interesting, bringing up the ques- tion of the path of the impulse which may set off the blepharo- spasm. I had assumed that it was sent through the great super- ficial petrosal from somewhere — the seventh nerve, possibly, or the geniculate ganglion; but that it would be of the same side. The fact that the injection of the left ganglion opened the right eye is, to my mind, not to be explained at present. This case is of great interest in connection with the case of L. A. B. and Mrs. A. B. D., where pronounced blepharospasm was relieved, one associated with the lower-half headache, Mr. B. having the spasm alone, without headache, and in both eyes. As I look back over the record of Mr. B. I note with more atten- tion than was given in the beginning, the fact that the injection of the first ganglion opened both eyes, to a very great extent. The case was not completed, however, until the second ganglion was injected. CASE HISTORIES 207 Dilated Pupil Miss J. W., age 44 years, was referred to me Nov. 19, 1917, by Dr. A. E. Ewing, whose patient she had been for various eye troubles off and on for twenty years. Dr. Ewing 's state- ment was that for three months she had noticed an enlarge- ment of the right pupil. She also gave a history of a marked lower-half headache, right, at frequent intervals for fifteen years. The headache, which lias been a great trial to her for the past six years has been accompanied by a sense of "falling back- ward." Dr. Ewing treated her enlarged pupil by the instillation of pilocarpine. The pupil would contract; but did not remain contracted, and because of the unsatisfactory condition he refer- red her to me. Examination of the nose showed a very clearly marked hyperplastic post-ethmoidal sphenoiditis without secretion, of the right side. The left side appeared very much less so, which is contrary to the rule for these cases; the lesion usually being bilateral. Treatment of the sphenoid accomplished nothing. Jan. 24, 1918, 1 did the post-ethmoidal-sphenoidal operation upon the right side. May 10, 1918, she reported saying that she was free of headache. Examination showed that her pupil which had been 6 mm. in diameter had shrunk down to 4 to 4% mm. without pilocarpine. Syphilis was absolutely excluded in this case as well as any intra-cranial lesion. The case is to me unique and interesting because of dilata- tion of the pupil with no other eye disturbance. It is interest- ing to compare it with H. S., page 210, where the paralysis of accommodation was complete but no dilatation of the pupil with it. Unmixed dilatation of the pupil is rare in my experience, this being the only case where the disturbance seemed to arise from the sphenoid. Pupil and Asthma Mr. W. C, 24 years old, very strong, large, normal man. My patient all his life, whenever a rhinologist was needed and intimately known to me in every way, consulted me October 30,. 208 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN" 1914, for a slight "cold in his head," which, as lie said, he would ordinarily have not noticed; but for some special (social) rea- son he was anxious "for tomorrow" to be relieved. I gave him some small doses of calomel and told him to omit any local treatment because the local disturbance was so slight. Two days later he returned stating that his "cold" had taken a most unusual turn — that he had been awakened in the middle of the night with much sneezing and watery, running nose accom- panied by smothering and wheezing. Examination which at first was negative now showed well-marked inflammation of the mem- brane over the sphenopalatine foramina. He had no other symptom of any kind. The dyspnea had diminished much. Co- caine applied to the foramina relieved it altogether. Phenol applied to the district prolonged the relief. The following night he had a slight return of it. The inflammation disappeared from recognition in a few days more, with recovery. Six weeks later he returned, saying that he again had been awakened in the night with smothering, wheezing and running, watery nose. This time he had slight pain in his ears also. This time the attack was slight with slight changes locally, the same as above stated.. Another slight recurrence happened four weeks later. Eight weeks after last note he developed an acute sphenoidal empyema with dyspnea, rales, sneezing, running, watery nose and moderate headache in ears, occiput and neck. This again yielded easily to treatment but did not get entirely well, when after six weeks' duration he developed vertigo and mental con- fusion to a most annoying degree, accompanied by the pecu- liar depressant power of the posterior headache (Vidian neu- ralgia) to a marked degree. (His disposition is normally most cheerful and confident.) (That which I mention as vertigo in these cases is almost never a sense of rotation. It is a sense of the earth shifting from side to side or forward and back or sinking out from under them.) At present (May 15, 1915) he is well again. In one of his years at college in Connecticut he had had some kind of a eoryza, accompanied by more sneezing than he thought usual with his coryzas, but this is the only part of the above experience that was not new to him. CASE HISTORIES 209 Pupil J. H. A., 37 years old, strong, healthy man, had never had a headache in his life that he remembered; consulted me May 27, 1910, because of a severe left-sided headache which had lasted three weeks. He showed a left sphenoidal post-ethmoidal suppuration. His pain was parietal and occipital, for the most part, and irregular in severity, sometimes stopping. "When se- vere it was combined with pain in brow and upper jaw. He was melancholic. Treatment was not satisfactory. (He was com- pelled to be out of the city five days of every week.) On Octo- ber 12, 1910, he took the proposed operation. The reaction was severe. He was free of symptoms in three months. March 4, 1911, he consulted me because of a coryza with pus which re- covered spontaneously. January 6, 1912, he returned because of a coryza with headache which did not recover spontaneously. At that time he did not show pus in the sphenoid. 1 1 e had suf- fered greatly from intermittent general left side headache. Be- lieving that the anaesthetic qualities of carbolic acid could be soaked into the nerve-trunks in juxtaposition to the sphenoid, I filled the cavity with 1 per cent solution in oil, which stopped the pain in six hours. The cavity was filled once a week for three weeks, when he seemed well, and remained so until the next coryza, six weeks later, which was controlled by 1 per cent carbolic acid in oil. The left pupil is larger than the right dur- ing his attacks, and use of his eye is somewhat difficult at those times. He says his pupils were always equal before his head- ache began and are so now in the intervals between coryzas when he is well of headache. This case has so far not behaved as a hyperplastic ethmoiditis. In the inflammatory attack it shows only redness with little swelling, and sometimes pus. Mrs. B. C, aged 33 years, in 1913 consulted me because of obscure headache. She had clearly a vacuum frontal headache, for which the anterior three-quarters of the middle turbinate were removed with full, satisfactory result. She still has at times headache which apparently proceeds from the nasal gan- glion on the right side. It is controlled by cocainization of the ganglion, and shows at that site inflammation over the spheno- palatine foramen. Cocainization of the ganglion in this patient 210 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN is often followed by dilatation of the pupil of that side appar- ently indicating- the reverse action of cocaine, that is, irritation to the sympathetic in contradistinction to the case jnst reported, where it was evident that complete paralysis took place (Mrs. F.). Mrs. C. F., 35 years old, consulted me January 1, 1918, at the suggestion of Dr. Fayette Ewing. She had suffered vio- lently from headache a large part of her life. Dr. Ewing had found some disease of the ethmoid on the left side, and had curetted the capsule of the ethmoid for that reason. She con- tinued to have great headache; and as he was about to depart for service in the National Army, he put her in my charge. In the effort to localize some starting point for the pain, I cocain- ized the ganglion of the right side at a time when the headache was on the right side. The headache Avas stopped; but as an effect of cocainization the right eyelid drooped very percepti- bly, to obscure probably half of the blepharal fissure, and the pupil contracted to be one-half of the size of the fellow of the opposite side. The case presents this interesting* phenomenon: that through the nasal ganglion in this case must pass a large part of the sympathetic supply which goes for the elevation of the eyelid and to the pupil. Paralysis of Accommodation H. S., 35 years old, large, very strong, healthy man, re- ferred by Dr. F. L. Henderson, November 25, 1914, for com- plete paralysis of accommodation L. eye of six months' stand- ing. He had a sphenoiditis of low grade with moderate hyper- plasia and very scant mucopurulent or mucous secretion. Post- ethmoidal-sphenoidal operation November 30, 1914. Accom- modation began to return one month later and in three months had returned complete. The bone has not yet been submitted to Dr. "Wright. Asthma Miss L., aged 60 years, Avas sent to me by Doctor Walter Baumgarten on May 28, 1914, because of an intractable asthma of fifteen years' standing. Examination of the nose shoAved a CASE HISTORIES 211 post-etlimoidal splienoiditis, accompanied by much swelling, and polyps, and very little secretion. Effort was made to control the situation from the nasal ganglion. This failed. October 2, 1915, the sphenoid was opened on the left side, followed by relief of the asthma and general betterment of her physical condition, which, up to that time, was exceedingly bad. The woman is still far from robust; but she is in comfort and fairly good health. The case is interesting as an asthma of long standing, of sphenoidal origin. It is also interesting from a therapeutic standpoint. T have, however, some other cases of more or less this origin and duration, which at present stand as therapeutic failures. They have chest involvement in addition to the sphenoid. Mrs. A. H., 35 years old, consulted me on April 24, 1916, saying that she had lower-half headache, and that she had "hay fever in season ; but it lasted all the year round.' 1 It was worse from August 15, on till frost. Examination showed a well- marked post-ethmoidal sphenoiditis, localized at the site of the ganglion. Cocainization of the ganglion stopped the sneezing, running; and on one occasion a low grade dyspnea, with dry rales, was also controlled by cocainization of the nasal gan- glion. She was subject to frequent (every week) asthmatic at- tacks. They were each time controlled from the ganglion, more or less. This led me to inject the ganglia. At the end of the year now she has been without headache. She says that she has been well, except on one occasion, when she contracted a bad cold in her nose, and she had asthma for one night, without any nausea. She passed through the hay fever season without asthma or headache, except for slight symptoms extending over ten days. January 15, 1918, she consulted me because of a severe coryza, which made a little headache and asthma. This case is interesting because of the long-standing head- ache associated with asthma. It shows also that the symptoms may arise from various irritants; to wit, autumnal hay fever and whatever may make a coryza in the region of the nasal ganglion. Seemingly, the lesion of the nasal ganglion originated 212 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN from a low grade pathological process that Avas controllable by one injection. Ophthalmoplegic Migraine Vertigo G. L. A., 67 years of age, had suffered from dizziness, which he describes as "a shifting of the earth from side to side," for 18 months. He also suffered at intervals with what he describes as a crossing of his eyes, accompanied by a total obscuring of his vision. These attacks last for a few minutes each only. Seldom did he have a slight lower-half headache. His case had been investigated extensively in all departments, and no cause could be assigned for his trouble. Examination of his nose revealed a bright red color throughout, but particularly through the sphenoethmoidal district. Treatment was unsat- isfactory, and finally, on April 5, 1917, the sphenoid was opened. After the operation he was free of dizziness and eye dis- turbances for six months. A coryza re-established symptoms to some extent. His condition in general is improved. This case is of interest because of the color alone being the only indication of sphenoidal trouble. The dizziness is markedly improved; and the attacks of strabismus — "blindness' 1 — have ceased, with one exception, and that at the time of a coryza. This history sounds much like oph- thalmoplegic migraine. I have occasionally seen dizziness in these cases described as a falling sensation. Third and Sixth Paralysis — Ophthalmic Migraine A. A., 22 years old, normal, referred by Dr. A. E. Ewing, October 6, 1914. My diagnosis: Sphenoidal suppuration, R. Dr. Swing's report: The 3 r oung woman, 22 years of age, a week previous to the examination noticed that everything ap- peared double, with considerable headache. At the time of the first examination, October 2, the vision in the right eye varied from 20/38 to 20/24; in the left it was 20/20. In the right eye the vision could be improved to 20/20 by a weak con- cave lens. The muscular disturbance consisted of a slight nys- tagmus when looking strongly upward or downward. On the 6th there was positive restriction in the motion of the right eye outward and a diplopia which was corrected by a prism of 25° CASE HISTORIES 213 base outward over the right eye ; left, 20/24 ; fields normal ; each fundus normal. The nasal examination, made the same day, revealed suppuration from the right sphenoidal sinus. Two days later this sinus was opened. On the 26th the recovery had so far progressed that the diplopia was corrected by a prism of 7° base outward 0. D. ; the vision had risen to 20 20, and was the same with + 0.37 sph. Three weeks later binocular vision had become re-established and the eyes were used freely and comfortably, the vision in each eye being 20/20+ without glasses. This case is of especial interest because of the diplopia that was at first indefinite, the lowering of the vision in the right eye. the accommodative spasm and the nystagmus in extreme up- ward and downward exertion, all of which combined was an evidence of a general slight oculomotor and optic nerve toxemic involvement. Later the abducens became most affected, prob- ably by reason of gravity of the toxic substance and because of proximity to the infected region, the abducens being the low- est of the oculomotor nerves in their passage through the sphe- noidal fissure, and nearest to the post-ethmoidal and sphenoidal sinuses, as well as nearest to the sphenoidal sinus in its course over the clivus and around the posterior clinoid process of the sphenoid after its exit from the dura mater. In addition to the actual lesson taught in this instance, there is another presumable one, which is that many of the hysterical amblyopias, and many of the temporary indefinite muscular anomalies and obscure disturbances of the accommo- dation ordinarily accredited to hysteria, may really be tox- emias due to nasal infection. This case corresponds with the ophthalmoplegic migraines. October 8, 1914, post-ethinoidal-sphenoidal operation. Dr. Wright's report of changes in post-ethmoidal-sphenoidal wall: The mucous membrane of the sphenoidal wall in this ease is the site of some fibrous hyperplasia and of some edema. There are small patches of connective-tissue in which this hyperplasia is quite marked around moderate-sized arterioles. There does not seem much bone change. Turbinate: This consists of edematous connective-tissue beneath the epithelium which is not much altered. The veins and venules are dilated and full of blood and serum, but their 214 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN walls are not markedly thickened. The acini of the glands are somewhat dilated. There is not much production of new con- nective-tissue nor bone lesion. The case is evidently one of sub- acute inflammation. The wound was uneventful in healing. In this case the process had lasted probably only a short time. The status of October 6th was precipitated by an accute or sub-acute inflammation upon the older process. Professional Cramp Mrs. S. S., 40 years of age, had suffered violent "'lower- half headaches '' (nasal ganglion headaches) all of her life, as far as her memory went. For the past ten years she has had added to the picture such pain on writing, as to make this dif- ficult and pass as a writer's cramp of such severity that the only writing she has been able to do, and that with difficulty, has been to sign checks for the household expenses. Examination revealed that the sphenopalatine foramen dis- trict was inflamed for some considerable distance around; that is, she has a post-ethmoidal sphenoiditis hyperplastic; but the pain was controlled from application of cocaine to the ganglion. For this reason I elected to inject the ganglion rather than do the post-ethmoidal-sphenoidal operation. Each ganglion had now been injected three times, with con- siderable relief from the pain; and from the first injection of the right side, the writer's cramp had been absent. She is able to write as much as any other woman. In one severe coryza, the cramp returned for the length of one week, when it passed off spontaneously. A coryza makes headache often severe while it lasts and in the height of the pain, that entire side of the body becomes tender to touch. This case, like some others rej)orted here raises the ques- tion of pain sense transmission and how far can it go; with the suggestion that it is accomplished by the sympathetic. Mrs. S. A., 30 years old, consulted me January, 1913, at the behest of Dr. M. A. Bliss. She had had a cyclical nasal ganglion neuralgia, left, severe for eight years. She was a professional CASE HISTORIES 215 violinist for the concert stage. The pain interfered with her practice until she was compelled to consult physicians. It was declared to be a "professional cramp" by the noted neurologists of Russia, Germany, France, and England. She was advised to stop playing the violin, which was "as dear as life itself' 1 to her. This, together with the depressant nature of the Vidian pain made a state of mind for her exceeding hard to bear. The anterior, maxillary part of the pain was controlled by the first injection of phenol-alcohol. The posterior (Vidian) pain re- quired a second injection. For a year and a half she has been free of pain except at the time of a coryza, which was of short duration. She is able to practice and play in concerts and do an unusual amount of teaching (10 hours a day). I have seen a bilateral nasal ganglion neuralgia pronounced a "piano cramp" for the same reasons that led to the error in this case. J. A., 20 years old, strong, healthy, consulted me April, 1911. He had a well-marked nasal ganglion neuralgia, left, with con- stant pain, sometimes less and sometimes more. He was an en- thusiastic golf player. It was declared to be a "golf arm" by his physicians (internists and surgeons). Three injections of phenol-alcohol were required before relief was complete and per- manent. He has had recurrences from coryzas which have not, however, needed treatment. He has been free of pain for five years. Sympathetic Cases Mrs. M. M. M., 67 years of age, frail, but otherwise in good health, consulted me March 10, 1915. For sixteen years she had had a slight serous secretion, with great redness of the external nose. Examination revealed an inflamed area about the spheno- palatine foramen. Cocainization relieved the serous discharge, and caused the redness and swelling of the external nose to disappear for varying periods of three hours to three days. Injection of the ganglion of each side was followed by a ces- sation of the serous discharge, and a return of the external nose to normal color and proportion. The color was as nearly blood- 21(3 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN red as swollen tissue may ever appear. The degree of swelling was between 15 and 20 per cent, I should say; in other words, there was acne rosacea of 15 years' standing, which, I am sure, in the mind of the dermatologist, might easily have been sup- posed to have been made by the serous discharge. I have a great many other cases, where the serous dis- charge is quite profuse, but in which no rosacea developed. I have also seen many times, with an acute condition in- volving the sphenopalatine district, complete and perfect ex- ternal red and swollen noses, where the serous discharge had not had time to effect any skin irritation. In this case there was, as far as I could make out, no skin irritation. It was a state of red swelling without inflammatory skin involvement. Mr. G. M. L., lawyer, 35 years old, strong and in every way normal man. I should classify this patient as unusually ''nor- mal ;" beside physical well-being he has no idiosyncrasies known. He is not sensitized along any line now known. He does not have hay fever or horse asthma. He consulted me December 15, 1914, for what he said was the "worst cold 1 he had ever had, of three days' standing. He did not have headache, but his mental processes were so slow, together with such a ten- dency to confusion that he was unable to do his work in the courts with justice to himself or client. He complained also of weariness but did not feel sick enough to take to his bed. Ex- amination showed a pronounced post-ethmoidal-sphenoidal sup- puration R. and L. Anterior two-thirds of nose normal. He responded rapidly to acetphenetidin internally and local cleans- ing and draining. In five days he said he felt well enough to go into court again, and he did so, everything being satisfactory. I did not see him again for two weeks, when he again presented himself for examination, saying he felt well. The evidence of the local trouble had nearly disappeared. I asked him to return again for examination in three weeks and to continue the use of his cleansing nasal solution. In two weeks, however, he pre- sented himself, saying that two days before, while seated at his fireside, reading, at 9 p.m., he was suddenly seized with fre- quent sneezing, nasal obstruction, profuse hot, watery secretion and tearing so profuse, as he expressed it, that in about two hours all of the handkerchiefs of the family had been used, as CASE HISTORIES 217 well as all the face towels, and he was driven to use the bath towels, and then used nearly all the supply of them. And, that when he Aras not wiping his nose he was busy wiping his eyes. With these symptoms was a photophobia which rapidly in- creased until he was compelled to go to bed and put out his light, but even then enough light from the gas-lighted street entered his room to "'hurt his eyes," and finally he was com- pelled to wrap them in a vet towel to exclude every trace of light. He remained in bed in this condition two nights and a day. At this time he again presented himself with a rhinorrhea which, although profuse, Avas, as he said, very much better. His eyes were red and itching and streaming tears, his pupils were widely dilated, with still some photophobia, his lids were staring wide open and his eyes seemed to protrude slightly, his external nose was quite red and markedly swollen and slightly chapped from wiping. He said his chest felt "full.' 1 His windpipe and into the bifurcating bronchi was bright blood red. No rales in chest ; temperature normal. He said he thought that if the local nose and eye trouble could be stopped he would feel well. I cocainized the nose anteriorly, without effect, and then cocainized the ganglia by painting the sphenopalatine foramina V 2 drop saturated water solu- tion 90% +. This was repeated three times at (five-minute intervals with marked benefit each time. The nasal obstruction, rhinorrhea, lacrimation, mydriasis, rosacea, and appearance of exophthalmos vanished. He looked normal, and said he felt so. There was a slight return of the symptoms in 24 hours, which again yielded to cocaine, and again in another 24 hours. He then remained free of symptoms until February 10, 1915, when he returned because of another "cold' (coryza), presenting again the above described picture, much milder, however, in every way; but this time accompanied by pain in his ear, mas- toid, occiput, neck, shoulder blade, and shoulder, not very severe. This time he had slight dyspnea and a few dry rales in the first 24 hours. This time he did not show post-ethmoidal-sphenoidal suppuration but only congestion of the olfactory fissure. This case is at once recognized as the one from which the above description was taken. Many times in the course of 20 years have I heard this state described by patients almost al- 218 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN ways emphasized by the statement, "No physician ever thinks I'm truthful when I tell this. They (the coryzas) are awful!' Many times have I tried to have the patient return to me in the midst of the attack. They are not very frequent, however, and the patients usually describe them as occurring at long intervals and often prostrating him, or milder attacks being of short (24 hours) duration he may not recall his promise soon enough. However, since this case impressed itself on me I have learned to recognize the milder types which prove to be rather fre- quent. They may have little or no rosacea, or little or no photo- phobia. The rhinorrhea is more profuse and sometimes the only symptom. H. G. L., 13 years old, small boy, under strength. Consulted me November, 1914. He had a profuse rhinorrhea with great morning sneezing, accompanied by great morning photophobia and moderate exophthalmos. He has a high grade hyperplastic sphenoiditis. Sometimes he has slight asthma. Treatment of his nose has thus far relieved the photophobia and nearly all the sneezing. His eyes are in what seems to be normal position in his sockets. Mrs. E. C, 30 years old, became my patient February 10, 1907, for acute empyema of right frontal sinus, which recovered as an ordinary severe coryza. T.t recurred several times with much pain, and in November, 1908, I removed the middle tur- binate high up, which gave a large outlet to the sinus and cessa- tion of all symptoms. A low grade hyperplastic process in the anterior ethmoid and frontal region existed then, or was started that year, which has extended backward to involve the post- ethmo-sphenoidal region. Great pain of maxillary and Vidian distribution began to develop, occasionally, in 1911 and 1912, and became more frequent and severe. Occasionally a coryza made post-ethmo-sphenoidal suppuration. A Hajek post-ethmo- sphenoidal operation was done on the same (right) side in 1913, followed by irregular intermittent treatment with marked relief from pain. Later, in 1913, she began to complain of con- stant slight watery discharge from left nostril, which was proven to be secretion from membrane in general. The sphenopalatine foramen district, however, began to show changes and treat- CASE HISTORIES 219 ment — silver, acetic acid, cocaine — was directed to it. The se- cretion continued and increased. She had an occasional ganglion neuralgia of the left side. On November 15, 1914, I injected the nasal ganglion, left, with phenol-alcohol, since which she has been free of discharge and has not, so far, had a recurrence of pain. Ophthalmic Migraine S. A., 23 years old, normal but not up to full strength, con- sulted me October 25, 1912. He showed at that time a hyper- plastic post-ethmoiditis most marked over left sphenopalatine foramen. He had had for 10 years a severe cyclical nasal gan- glion neuralgia, left, recurring once in three to six weeks. The attack was always accompanied by scotoma scintillans ambly- opia, lower-half headache, vomiting, aphasia and hemi-paresis of short duration. I injected the left ganglion three times with phenol-alcohol. For two years he has been free of the attacks except that a severe coryza re-establishes the syndrome tempo- rarily. Mrs. M. H., 27 years old, has had for ten years a recurrent life ophthalmic migraine at irregular (months) intervals. Ex- amination shows a post-ethmoiditis left low grade which sup- purates with a coryza. Observation reveals that the attack is uniformly established by a coryza. At other times she is well. Mrs. L. E., 26 years old, referred by M. H. Post, September 24, 1913, with the report that her eyes were normal. She had a complete right-sided ophthalmic megrim, 7 years' duration, scotoma scintillans, violent headache (lower half), nausea and vomiting, hemianopsia amblyopia. The attack came every four days, approximately. My diagnosis: Marked hyperplastic sphenoiditis, R. She grew slowly worse; the attacks became more frequent and more severe. Post-ethmoidal-sphenoidal operation R. January 2, 1914. Dr. Wright's report of the changes in the sphenoidal wall. Here is a very marked involve- ment of the bony structure. The periosteum is greatly inflamed and there is a quite marked hyperplasia of the bone. The soft parts over it are in a state of chronic inflammation. The 2'20 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN middle turbinate shows only a moderate change in the soft parts and the bone is not much involved. The surface epithelium is also not much involved. She became better as soon as the wounds were healed and the reaction totally subsided; and has since then been for the most part well. A coryza re-establishes the syndrome, hui it usually does not need local treatment. In another complete ophthalmic megrim (Mrs. D., 30 years old) the mucous membrane in the sphenoidal sinus at the time of operation showed, with Holmes' .pharyngoscope, a most marked thickening and induration with dryness and pallor. Dr. W right's report of the changes in the sphenoidal wall micro- scopically are : The inflammatory changes here are quite marked. There is a considerable degree of inflammation of the periosteum and some evidence of hyperplasia of the bones while the soft parts over it are markedly involved in the chronic inflammatory process. This was a bilateral case, one side only is so far operated (15 mos.). There has been only moderate betterment clinically. These cases to me show the difference in prognosis between a post-ethmoidal and a sphenoidal lesion. Mrs. L. E. had a mi- graine exploded from the nasal ganglion. In Mrs. D. it began probably in the nerve-trunks. Miss E. S. consulted me Oct. 15, 1916, because of great headache which was more or less constant. She complained also of an admixture of some other kind of headache that came on at intervals of two to three weeks, characterized by scotoma scintillans and vomiting. Examination showed a profuse right-side sphenoid sup- puration which was operated, with relief of the suppuration; also the relief of the headache which had been more or less con- stant. However, the other headache she described has contiued un- changed. Her description is that she feels something which starts in the instep of her right foot, and then extends to the right half of her body, including her head, with violent head- ache and blindness. This case seems to me to be one of rare pure migraine- CASE HISTORIES 221 rare in my experience, where most are independent of the nasal condition. Scotoma Scintillans F. L. H., aged 50 years, consulted me in 1905 because of severe headache that kept him awake, usually sitting up, through six nights out of the week. Examination showed an intensely inflamed post-ethmoidal- sphenoidal district, without hyperplasia or pus. Treatment of his nose helped little or none. He was placed in the charge of all varieties of specialists of the first rank in all parts of the country. All manner of diet was instituted, and every investigation that modern laboratories are capable of making was exhausted. He finally became so bad that he consented to the post-ethmoidal-sphenoidal operation, which was done in 1909 on the right side. It has afforded sufficient relief to permit of his attending to his arduous duties, the headache rarely being so bad that he is helpless from it. Much of the time he is free of pain al- together. A coryza uniformly makes very considerable pain for him. This case, aside from the headache, at the greatest inten- sity becomes blind, develops a scotoma scintillans, which inca- pacitates him totally. This is in great contrast to S. A., reported above, where the type is that of pure ophthalmic migraine, which begins by scotoma scintillans. Optic Neuritis V. 8., age 22, was sent to me by Doctor Adolph Alt in 1914. He had a low grade optic neuritis of recent origin. Examina- tion of the nose showed a hyperplastic sphenoiditis, low grade with an acute process engrafted on it. Forcible injections of carbolized oil to the olfactory fissure began to help at once. In three weeks the optic neuritis had subsided and his eye was normal again and since that time there has not been another attack. The case is interesting to me, showing how sometimes an excellent result is obtained for small effort. 222 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN E. D., strong, healthy man, 24 years old, referred by Dr. John Green, Jr., and Dr. Louis Hempelmann. My diagnosis: Hyperplastic sphenoiditis with subacute suppuration. Dr. Green's report: "Seen first Feb. 20, 1914. Eight vision 6/5; left vision 6/5+. For five years complained of lower-half head- aches and temporary blind spells. "Ophthalmoscope showed: right, mushroom-like swelling of disc with swelling starting abruptly at margin and mounting up. Margins very much veiled, veins a little dilated and tortuous. Apex of disc measured by C D. Refraction about 2 D., so that disc swelling amounted to 4 D. Left same appearances. Disc, measured by 6 D. Retinal level by 2 D. Swelling = 4 D. "Subsequent observation showed slightly greater swelling in right than left disc; no evidence of choroidal change or of peripheral retinitis. Fields shows slight peripheral contraction of right with inversion of red and green fields. On left form field full, blue field contracted, green field larger than red but interlaces in three meridians. Conspicuous clinical feature of the case is the momentary obscuration of vision followed bv rapid restoration. Patient closely followed, vision never got lower than right 6/8 +. Left 6/5. "March 6th: The day following opening of right post- ethmoidal-sphenoidal cells, vision was raised from 6/6 to 6/4 with the right eye. "March 12th: Day following operation on left post-eth- moidal-sphenoidal cells, vision was raised from 6/4 missing 2 letters to 6/4 missing 1 letter. '' April 10th: Distinct recession of papillary swelling; right apex measured by 414 D., and left apex by 5^2 0. From this time neuritis slowly subsided. "November 6, 1914: Both discs were at level of retina and fairly well tinted. "Last observation July 12th, 1915; right and left vision 6/4; fields full. Both discs a little pale but showing no other evidence of antecedent inflammation." Clinical course : Post-ethmoidal-sphenoidal operation, right side, March 5, 1914. Left side, March 11, 1914. Eyes began to improve almost at once (see above, Dr. Green's report). Six CASE HISTORIES 223 days later lower-half headache (maxillary and Vidian neural- gia) began to lessen and later ceased. July 27, 1914, a coryza made head ache and some increased disc swelling and a paresis of the facial nerve of right side. This diagnosis Avas confirmed by Drs. Hempelmann and M. A. Bliss. This condition lasted 7 days. August 15, 1914, began another exacerbation of the local inflammation and was followed by vomiting for 36 hours with some headache. August 27, 1914, appeared a paresis of the left facial nerve with a right-sided exophthalmos (Drs. Green, Hem- pelmann and Bliss). Intrasphenoidal observation with Holmes' pharyngoscope during these periods confirmed the diagnosis of acute exacerbation. By the same means it was known to have been absent before and proved to be absent later (after 14 days) when recovery of eye, facial paresis, and exophthalmos was established. Last observation by me April 10, 1915, confirmed Dr. Green's of November 6, 1914, of recovery. The clinical changes in the sphenoid district had subsided to such a degree as to leave it normal clinically. In the first eighteen months he has had for the first time two epileptic seizures. Dr. Wright has reported this case in full in the introduction. This case is in marked contrast to E. H. G., page 203, the pathological changes in which are also given in detail by Dr. Wright in the introduction. The hyperplastic process in E. H. G. was the most marked of all the cases. Surgically the bone was heavier and harder than any of these cases with one or two exceptions which were equally hard. The result for E. H. G. was a failure as far as his eye went. The process in E. D. showed a rarefying state of the same lesion. The result for E. D. was all that could have been desired. What the significance of the recently developed epilepsy may be cannot at present be stated. L. W., 25 years old, consulted me Jan. 16, 1913, because of great headache, lower half, which had endured for six years. She had been in the charge of various physicians, some of them rhinologists. Some one had opened the capsule of the ethmoid on the left side. Examination revealed a high-grade hyper- plastic post-ethmoiditis ; and it was my judgment to open the 224 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN post-ethmoidal-sphenoidal district. The left pupil was fre- quently larger than the right. The right and left post-ethmoidal- sphenoidal operations were done in October and December of 1913. She was somewhat slow in getting any results from the sur- gery. The bone was intensely hard and with great difficulty cut through by means of the little angle knife described in the foregoing text. I succeeded very satisfactorily, however, in opening the sphenoidal cell proper. Because of the delay in receiving benefit from the surgery, I decided to investigate the sub-division of the sinus and placed a probe in its uppermost limits for an x-ray picture. It showed a small cell above the one opened. I then attempted to open this cell. I succeeded in entering, through very hard bone, a small cell in the upper outer part of the sphenoidal face, the opening remaining. Since that time she has been frequently for long stretches, six to ten weeks, free from pain. The case for the past year has been greatly complicated by a bad dysmenorrhoea. When this patient menstruates, almost every time it is a major illness, and she does not recover in the three weeks' interval from what she loses during the one week in which she menstruates. In this way she has slowly lost ground, and much of the time suffers intense headache, particularly during the men- strual stage. In an effort, to exclude all possible influences that might bear upon this unfortunate case, she was put into the Barnes Hospital, and an entire gynecological and neurological investi- gation carried out by Doctors Schwab, Sachs, and Taussig, and complete x-ray investigation for everything possible, and all the laboratory tests that are at the present time deemed to be serviceable in the elucidation of such a case, were employed. In the course of this investigation, Dr. Meyer Wiener discov- ered that she had a slight neuritis of the right optic nerve. He found the lower inner margin of the right disc slightly blurred ; the veins normal in color, size and contour; arteries slightly more tortuous than usual; refraction in +1 diopter; fields of CASE HISTORIES 225 vision show no abnormality; the blind spots, however, not out- lined. This case to me is intensely interesting, not only showing the influence of menstrual disturbances, which have intensified the headache very much, but, in the course of the routine in- vestigation is discovered an optic neuritis of such low grade that it had not announced itself ophthalmologically. It raises the question in one's mind as to how often these patients suffer more or less eye disturbance. I mean by that optic nerve or choroidal disturbances that are not recognized clinically. They do not attract the patient's attention, and they are therefore not submitted to the ophthalmologist. The attacks of transitory blindness which I have recorded have so often seemed, for the most part, to have been a manifestation — probably a toxemia of the nerve by juxtaposition of the sinuses, which has not regis- tered a visible lesion. Intrasphenoidal Observations of Interest A. B., strong, healthy man, 30 years old, referred by Dr. A. E. Ewing, January 15, 1915, for a severe serous iritis R., with blood vitreous. Vision, 3/120 R. eye, L. normal. Mv diag- nosis : Sphenoid suppuration, U. It appeared subacute with no definite hyperplastic features. No headache. He did not ac- cept the proposed surgical procedure. February 7, 1915, he de- veloped an acute coryza. February 10, 1915, he returned. V. counts fingers at 1 foot, recognizes the movement of hand at 3 feet. The anterior chamber is now full of blood. February 11, 1915, post-ethmoidal-sphenoidal operation. The cavity of the sphenoid was found to be large and lent itself to very satisfac- tory surgical manipulation. The anterior wall was readily cut out with sufficient general shock to lower the blood-pressure so that there was almost no bleeding and withal no syncope. He was then, as it were, a perfect manikin. The Holmes pharyngo- scope was at once introduced into the cavity of the sphenoid which showed on that part making the inner aspect of the optic canal, a patch a little less than 1 cm. in diameter which at this center was a bluish gray and thickened and marked by blood- vessels, centered there from all directions. It was one of those vascular communications described by Shambaugh and others 226 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN between the membrane of the canal. From its center the thick- ening began to recede and the color to approach normal. The remaining membrane showed somewhat of a bluish addition to its color. The cavity held a scant secretion apparently opales- cent. In 8 days the patch and blood-vessels had vanished, and the eye had begun to improve from what was a progressively desperate state according to Dr. Ewing — 5 mos. V. 3/75. Dr. Wright's report of the changes in the sphenoidal wall. Hyperplasia M. M. erectile tissue. Enormously dilated. Sinus gorged with blood. No bone involvement, slight periostitis. Sphenoidal wall. This is an exceptional chronic edematous in- flammation of the mucous membrane, exceptional in this : (1) the great development and dilation of the erectile venous sinuses in this situation. (2) The thickening of the media of the coats of the radicle arterioles. (3) The very moderate amount of bone affection, considering the excessive (for this situation) amount of periosteal thickening, but the bone itself is not materially in- volved. Epilogue : Apparently we have here an inflammatory proc- ess which has extended along the nerve sheath, if we are to pre- serve the character of the inflammation the same in the sinus as in the middle turbinate, before marked change is produced in the underlying bone locally in the nose. Mucous membrane shows extensive degeneration with evidence of primary vascular change. Miss A. K., 40 years old, normal, referred December 13, 1913, by Dr. M. H. Post, Jr., for choroiditis, L. V. 20/94 L. My diagnosis : Post-ethmo-sphenoiditis with edema and pus, L. De- cember 9, 1913, post-ethmoidal-sphenoidal operation. At the time of opening the cells were found by the pharyngoscope to contain polyps. Vision has risen to 20/24. A scotoma remains. She sees a black spot in the upper outer field of that (L) eye. Since the healing was complete and vision largely restored I have seen her in 4 coiwzas. She lost vision in 3 of the attacks and showed by the pharyngoscope a patch of acute inflammation twice in the sphenoid at the site of the optic canal and once in the post-ethinoid with polyps at this site. In one coryza the patch was in the lower and outer area of the sphenoid and ac- CASE HISTORIES 227 eompanied by severe lower-half anterior headache but no loss of . vision. Dr. Wright has not examined the bone from this case. I have a similar case referred by Dr. W. A. Shoemaker with choroiditis, recurrent and great headache relieved by operation with betterment of vision. The bone in this case has not yet been examined by Dr. Wright. In two other cases of diagnosis of non-suppurative hyper- plastic sphenoiditis with headache (lower half), there came at the time of greatest intensity of the pain in one case a loss of consciousness lasting usually from 5 to 10 min., and in the other the sight of innumerable men approaching from the right and countless rats approaching on the floor from the left. In both cases the pain and other features of the case were stopped by the operation to return at the time of a severe coryza and again disappear. Tic Douloureux W. B., 45 years old, consulted me January 20. 1914, because of neuralgia, described as lower-half headache. Examination of the nose revealed an acute post-ethmoidal sphenoiditis, more marked at the site of the sphenopalatine foramen. Cocainization of the ganglion stopped the pain. He was delighted, as it aborted the attack which usually lasted ten days. He had suffered such headache all his life at intervals. It occurred probably at the recurrence of coryzas. He has a low grade hyperplastic post-ethmoidal sphenoiditis. With each of these attacks is developed a severe tic douloureux of the max- illary and Vidian, establishing a lower-lialf tic. Cocainization of the ganglion relieved the tic. It recurred after the cocaine wore away, but usually very little. On another occasion, Dr. B. came to me because of a tic in the mandibular nerve. As far as the ordinary nose is concerned, the mandibular nerve is not related to the sphenoidal sinus, or the nasal gan- glion. Cocainization of the nasal ganglion here did not in any way influence the third division. The experimfiit was tried, and 228 HEADACHES AXD EYE DISORDERS OF NASAL ORIGIN failure was absolute. The next day lie discovered a tooth was responsible for the tic. It is interesting to note that in this case he developed a tic always, whether he developed the constant headache or not. Apparently different lesions of the peripheral distribution of . the trigeminus produced the tic. Miss J. S., 50 years old, was referred to me Jan. 10, 1913, by Dr. T. H. Halstead for a right tic douloureux of the max- illary and mandibular nerves. Peripheral injections had not been satisfactory. She had a right suppurating sphenoid. The post-ethmoidal-sphenoidal operation was done Jan. 15, 1913. The result was relief from the tic until 1917 when it had re- curred and a semilunar ganglionectomy was done. This case seemed to me to originate from the sphenoid. It shows the progress of the "tic" when once well started. G. H., a normal . man, 50 years old, referred to me by Dr. W. E. Fischell, 1901. He had a chronic Eustachian tube obstruc- tion for which I did a posterior cautery operation 863 in 1902 with complete relief. In 1910 he suffered from a severe right post- ethmoidal-sphenoidal suppuration with lower-half great head- ache. It proved to be obstinate and Feb. 26, 1910, the post- ethmoidal-sphenoidal operation (right) was done. It relieved the headache. From time to time he has had coryzas to make slight transitory headache, to cease with recovery from the coryza. May 7, 1918, he again developed a severe coryza accom- panied by an unusual phenomenon; to wit, a violent stabbing pain which pierced his right eye during sleep. It awakened him on two mornings at 3 a. m. and continued through the days in slight degree despite acetphenetidin gr. v and codeine gr. *4 every 3 hours. Examination showed acute inflammation of the right post-ethmoidal-sphenoidal district. Cocainization of the nasal ganglion stopped the eye pain. J. S. consulted me Oct. 20, 1914, because of great pain in the lower half left side of the head, which he had suffered as far back as his memory reached. Examination showed a perfectly well-marked inflammatory CASE HISTORIES 229 patch on the left sphenopalatine foramen. I found that cocaine stopped the pain. It was therefore decided to inject the ganglion, which was done once only. It stopped the pain. It has not returned. I feel special emphasis should be laid upon the character of it. It was more or less a constant pain, hut mixed in Avith it was a perfectly clearly defined tic which came as a stabbing to the lower half of the head, neck and shoulder at intervals not more than a few hours apart. This was particularly marked in the posterior distribution of the pain, the anterior distribution being for the most part free of the tic. To my mind, this case is particularly interesting as an exposition of tic of the Vidian, i. e., relative to the Vidian nerve taking on the sharp recurrent stabbing attacks that character- ize many cases of trigeminal neuralgia. I have, in all, ten eases in which the posterior pain was of this type, where the posterior disturbance was a tic pure and simple, without the general course of more or less constant pain. The case was sent to me by Doctor Sidney I. Schwab. Sphenoiditis and Tic Douloureux Miss J. S. consulted me Feb. 10, 1914, complaining of a severe tic of the second and third divisions of the right side. Examination revealed a high grade suppurative sphenoiditis. The tic had lasted several years and had had peripheral injec- tions with no result. The sphenoid was opened on Feb. 15, 1914, and the case remained free of tic for three years. In a letter recently she announced that the tic returned and all efforts to relieve it failed, till finally a semilunar ganglionectomy was done. The case is of interest to me showing a tic which seemed to be clearly of sphenoidal inflammatory origin. It is also in- teresting to note the duration of the relief that had not been obtained by any other means. It is also interesting to show that such cases once effected may go on until a ganglionectomy is required. Iritis L. R., aged 30 years, sent to me by Doctor A. E. Ewing, Jan. 10, 1918, because of an intractable iritis. Doctor Ewing had given treatment which left much to be desired in the prog- 230 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN ress of. the case for the control of pain. He, therefore, submitted it to me for a nasal examination. A clearly marked post-ethmoiclitis was found upon that side (right). The lesion was soft, velvety, swelling of the pos- terior tip of the middle turbinate, without secretion. Full cocainization of the ganglion relieved all the pain of his eye, and was followed by an immediate turn for improve- ment, which continued from then on. The nasal ganglion was cocainized slightly after that for ten days, when the condition in his eye had improved so much that it seemed unnecessary to pursue the anaesthesia. The case was treated for another ten days by carbolized oil. His eye recovered, and he was dismissed. The lesion within his nose, in the meantime, appeared to sub- side totally. Many times I have seen such cases as this, always of great interest, and impossible of explanation at present. Miss J. B., 24 years old, consulted me June 10, 1914.- She had been my patient five years before for some trifling acute trouble of short duration. Present history: For three years has been subject to attacks of iritis, with photophobia, redness and pain not only in eyes but extending to occiput, which would get nearly well and then continue in low grade for months to be rekindled from causes unknown. The condition is much better than its worst, but far from well. The sphenopalatine foramen membrane of the left side is inflamed and thickened. The iritis is always on left side. Cocaine applied to foramen stopped the discomfort in eye and occiput in five minutes. It did not return. Silver nitrate and acetic acid applications were made to com- plete the treatment. The redness, pain and photophobia of the iritis did not return after the cocaine application. Two weeks later the eye was declared by her ophthalmologist to be well. Photophobia R. A. G., aged 40 years, school teacher, normal man, was sent to me by Doctor A. E. Ewing, because of photophobia that Avas not explained by any ophthalmological condition. Examination revealed a well-marked hyperplastic post-eth- moidal sphenoiditis. CASE HISTORIES 231 Effort to control the photophobia from the nasal ganglion was not successful. The treatment by forcible injection of car- bolized oil into the sphenoidal district was rapidly followed by cessation of the photophobia. The case has stood a year now in comfort. It is of interest as one of the more unusual ocular manifestations, apparently produced by an inflammatory lesion in the post-ethmoidal-sphenoidal district. Paresthesia of Upper Extremity from Injection Miss B. 0., aged 35 years, slender, frail, neurotic girl. Was- sermann negative; no organic lesions discoverable. She was my patient for fifteen years, sometimes for acute sore throat, sometimes for nasal obstruction ; latterly for neuralgia of lower- half of head, of neck and shoulder, and shoulder blade and of arm. Cocainization of the ganglion helped the pain in her head and neck; but made a very unpleasant tingling sensation in her arm. The pathological lesion is a post-ethmoidal sphenoiditis, not specially hyperplastic, but rather high grade, manifested by a great redness, with only a small degree of swelling and little serous secretion. The injection of the ganglion has been followed by a fair degree of relief from pain. The inflammatory post-nasal con- dition is better. The tingling in her arm remains. Effort has been made by Doctor Walter Baumgarten to help the condition by diet free from animal protein. It did not accomplish the result. Internal medicine treat- ment in general did not relieve the nasal condition. The case is of interest because of the tingling sensation in the arm. I have repeatedly heard such paresthesias described as "itching" or "burning." This, however, is the only in- stance when it was produced by the injection. Mrs. N. H., aged 45 years, consulted me April 1, 1900, be- cause of headache and great discomfort in the use of her eyes. The middle meatus of each side was found to be closed. The anterior half of the middle turbinate was for that reason re- 232 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN moved. This gave considerable comfort in the daily use of the eyes; but a recurrent headache of great severity continued at intervals. This arose from hyperplastic post-ethmoiditis. The patient was not seen again for a number of years, when she stated that she thought that she was getting better. Ex- amination last year revealed the fact that the post-ethmoiditis had involuted to such an extent as to appear gone altogether. It appeared normal. She made the statement that she was uoav practically free of the intense headaches that had recurred at intervals of two or three weeks. To my mind, this case is a combination of the vacuum fron- tal headache, which was relieved, and considerable benefit gained, by opening the frontal inlet, and of a post-ethmoiditis hyper- plastic which, as life went on, that is, passed the menopause, slowly involuted. At the present time she is free of such headaches. This patient had been examined by all kinds of intelligent medical men, and all kinds of treatment had been instituted and pursued. The case was classed by neurologists as a vulgar me- grim. To my mind, it was relieved in later life by a rarefying ostitis, in the post-ethmoidal-sphenoidal district. Orbital Hemorrhage H. L., aged 19 years, consulted me Dec. 18, 1914, sent by Doctor M. H. Post, and complaining that he very frequently had a hemorrhage into the eye socket. Examination revealed a bilateral sphenoiditis, which other- wise was without symptoms. Observation of the case revealed that a coryza was usually accompanied by a small hemorrhage into the orbit, first one side, then the other. I know no explanation to offer. I merely record the facts. Tabes Mrs. C, aged 40 years, sent to me by Doctor A. E. Ewing, June 3, 1913, because of failing vision. She had a bilateral sphenoiditis. Investigation at that time showed a well-defined tabes, but CASE HISTORIES 233 it was determined to open the sphenoid cells, despite this fact. No benefit was derived from this operative procedure. I have another case exactly similar in every respect, also referred by Dr. Ewing. A man 70 years of age, who was not operated, because of his advanced years, to whom treatment was given; — forcible filling of the olfactory fissure with carbolized oil. In three months his vision improved markedly despite the fact that he had a well-defined tabes. These cases show the dif- ficulty in separating the causes of eye lesions in the presence of sphenoiditis. Ethmoidal Pain and Peripheral Nerve-trunk Injection S. M. J., aged 25 years, was sent to me by Doctor Vilray Blair on Mar. 1, 1915. She suffered very great headache. Doc- tor Blair in the effort to alleviate the pain had injected with alcohol the second and third divisions of the fifth of that side, but although a perfect peripheral anaesthesia was secured, the pain continued unchanged. Nasal examination showed an eth- moiditis anterior and posterior ; operation for which was suc- cessful, relieving the pain. This case is of interest showing how total anaesthesia of the peripheral nerve distribution may not carry with it relief from the pain produced by suppurative sinuses. Change to Sympathetic Type With Anaphrodisiac Effects S. Y., 50 years old, normal man, had throughout his life what I should term "ordinary" coryzas beginning with sneezing last- ing three or four hours and watery discharge of usually one day, after which, nasal obstruction for two or three days, fol- lowed by thick mucopurulent secretion. Very seldom, a few times in his life, he had slight headache of a day or two dura- tion. In 1912 he developed a type of coryza manifest by watery secretion and sneezing only. The obstruction and suppuration were omitted. During that year he had four such attacks, all much milder than his previous attacks. In 1913 he had added to this a sharp complete nasal ganglion neuralgia which har- assed him more or less for two months and a paroxysmal morn- ing sneezing lasted two months longer. Since 1913 lie has had six such attacks, each with more or less eve discomfort added 234 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN to the profuse watery secretion and great sneezing with pain in and around right eye ; earache and stuffiness, pain in mastoid, occiput, neck, shoulder blade, shoulder, arm and forearm. In this time he has not had the mucopurulent discharge of former times. The sphenopalatine foramen membrane is markedly in- flamed, and once he had a post-ethmoidal-sphenoidal inflam- mation well marked. This case shows Iioav the sympathetic elements once added to the clinical factors have recurred Avith each coryza over a period of six years. He also reports marked anaphrodisiac effects at the time of the attacks. Vertigo Mrs. H. C. M., 35 years old, Joplin, Mo., consulted me De- cember 15, 1917, complaining of great lower-half headaches, right and left, accompanied by dizziness — "the objects went around her" — of such severity that she was able to walk only with difficulty. She had suffered 8 years from these conditions. Examination revealed a well-marked post-ethmoidal sphenoid- itis, with considerable acute element mixed with it. In the ef- fort to localize the point from which the pain proceeded, co- cainization of the ganglion was followed by cessation of the headache, with almost instantaneous relief of the dizziness. After six hours the headache returned to some extent ; but the dizziness was almost absent. Owing to this patient living at a distance, further observa- tion has so far been impossible. This patient had been carefully investigated in every de- partment of a general examination. This case is of interest showing dizziness, of rotatory type stopped by cocainization of the nasal ganglion. Trigeminal Hypalgesia, Paresthesia, Hypesthesia, Pupil Dilated — Sphenoiditis Miss H. M., 35 years old, referred by Dr. F. R. Fry and Dr. A. E. Ewing, March 10, 1914. She had suffered violent headaches as long as she could remember, recurrent at irreg- ular intervals (type of vulgar megrim) but getting worse. CASE HISTORIES 235 My diagnosis: Hyperplastic sphenoiditis (non- suppurative R. & L.). Dr. Fry's report: She has a parasthesia hypesthesia and hypalgesia in distribution of fifth nerves which I feel certain is of organic genesis. The different kinds of impairment are co-extensive at present. The left pupil is a little larger. They react fairly well. Dr. Swing's report of eye conditions March 5, 1914, vision 20/15 11. and L. Slight blurring of disc margins pathological (?). Slight paresis of right side of face. Advised to consult Dr. Fry. Post-ethmoidal-sphenoidal operation of left side June 5, 1914 ; of right side Februray 11, 1915. On June 1, 1915, Dr. Fry reports a return to normal of above stated changes and Dr. Ewing reports disc normal, possibly a slight blurring still of left disc margin. A note dated July 6, 1914, at the time of a corvza shows the left disc to have been swollen, 2 diopters. This lasted three weeks. Dr. "Wright's report: Sphenoidal wall shows a marked chronic inflammation with involvement of periosteum; and bone to a moderate extent. Middle turbinate: There is a chronic fibrous hyperplasia of the soft parts involving the walls of the arterioles. The bone shows no marked changes. June 1, 1915, free of pain, except slight occasional occipital headache. She has at times a low grade tingling sensation of right side of face. Vernal Hay Fever Mrs. J. S., 40 years old, my patient since 1898, for many years has had vernal hay fever of full severity accompanied by red and swollen nose and tearing eyes. Cocainization of the nasal ganglion a few times in the course of the spring months is sufficient to carry her through the attack with only a very slight morning sneezing on irregular days. Her external nose, however, becomes red and swollen at any time of the year from the slightest irritation of the internal nose and remains red without recognizable cause much of the time. Silver nitrate applied to the sphenopalatine membrane two or three times a week out of hay fever season brings the appearance to normal. It then remains so for long periods, to be excited again from within the nose. In the hay fever season she has dyspnea with dry rales equally distributed E. and L. Cocainization of the nasal ganglion of one side will stop the rales on that side. All 236 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN treatment known to me prior to the spring of 1914 was in vain. At that time I began the cocainization of the nasal ganglion and the treatment of the rosacea followed that. Acute Blindness M is. J. D., 38 years of age, referred by Dr. W. E. Shalian, June 21, 1914. Diagnosis: Hyperplastic sphenoiditis with acute suppuration. Dr. Shahan's report: June 12 last was seized with violent headache left side, which lasted five days when it began to subside and the vision of left eye began to fail. Now counts fingers at one foot. Lower and central field absent. Disc appears slightly swollen and slightly hyperemic at upper margin. Right eye normal. June 24, 1914. Post-ethmoidal-sphenoidal operation. Dr. Wright's report: Sphenoidal wall — marked hyperplasia of the bone and the periosteum is markedly infiltrated with products of inflammation in some parts. Some areas of the mucous membrane show marked adenomatous hypertrophy with sub- epithelial edema. The changes in the soft parts are of a chronic nature, probably a very old process in the mucous mem- brane. Middle turbinate — the surface epithelium is papillary and thickened. There is a very great amount of edematous infiltra- tion of the sub-epithelial connective tissue. The lymph chan- nels are enormously dilated in it. The blood-vessels are not markedly involved. The mucous membrane shows evidence of marked chronic inflammation, long continued and still quite ac- tive and there is a great amount of inflammatory change in the bone. Clinical result: In 9 days after operation, vision 3/30: no headache. In 20 days, V. 20/38. In 35 days, 20/19 and normal field; no headache. March 22, 1915, V. 20/19 both eyes. Vulgar Migraine Mrs. M. D. A., 48 years old, consulted me June 11, 1910, because of right side recurrent sphenopalatine ganglion neu- ralgia, or, at least, what seemed to be such. It had lasted twenty-four years. It was stopped by cocainization of the CASE HISTORIES 237 sphenopalatine ganglion and controlled for one year by carboli- zation of the ganglion, at the end of which time she suffered some kind of an explosion which took in her entire head, upper and lower part, on both sides, which confined her to her bed for four weeks despite acetphenetidin, aspirin, codeine and mor- phine. I did not see her during this illness. After this at- tack, however, she came to see me, but showed no local changes. She continued to suffer very greatly, and frequently from what seemed, from its distribution, a trigeminal neuralgia with pain in her occiput and neck almost altogether on the right side. After a careful explanation of her case to her, describing the local conditions and telling of a possible benefit from intra- sphenoidal medication, Dr. Bliss and I advised her to submit to the opening of her sphenoid, despite the fact that no sphe- noidal inflammation betrayed itself. She accepted the pro- posal. Twice prior to the Hajek radical post-ethmoidal-sphe- noidal operation I injected a drop of 5 per cent solution car- bolic acid in 95 per cent ethyl alcohol into the sphenopalatine ganglion, each being allowed to rest five days with the idea of benumbing it and thereby reducing the reactionary shock. The pain of the operation under cocaine and the succeeding depres- sion and pain were, in this case, astoundingly little. Subse- quent filling of the sphenoid sinus with 2 per cent sodium salicylate water solution has been accompanied by a decided betterment, both in severity and frequency of the pain on the right side. Vasomotor Rhinitis and Nasal Ganglion A. L., age 35 years, consulted me on April 19, 1915, com- plaining of intractable sneezing, great watery secretion and total nasal obstruction. She said that she had hay fever all the year round. Examination showed a high grade hyperplastic post- ethmoiditis. The injection of the nasal ganglion, twice on each side has succeeded in checking the secretion and shrinking the swelling which gave rise to the nasal obstruction. At the time of the injection the swelling appeared to be polypoid-edematous swelling of the entire nasal cavity. This case is to me of in- terest particularly showing how sometimes the nerve supply wiil sometimes shrink up the edematous swelling that we oc- 238 HEADACHES AXD EYE DISORDERS OF NASAL ORIGIN casionally see. I have other cases where I tried to give the same treatment and succeeded in some and failed in others, the failure usually being to shrink up the edematous swollen membrane. Transitory Amblyopia Mrs. C. S., aged 25 years, consulted me February 20, 1903, for an acute pan-sinus suppuration with general headache. Prior to this attack she had very rarely in her life been sick in any way. She did not remember to have ever had a bad head- ache, and had always been strong. She has done hard work (shoe machine) since her nineteenth year. Since this attack she has had, up to the present time (nine years), a recurrent headache that seldom skips more than ten days. Much of the time it is frontal, sometimes maxillary, and often intense com- bined with occipital pain. It is worse at night and during men- struation. Meanwhile I have opened the frontal sinuses and antra and ethmoids and sphenoids, and done everything known to possibly help (contacts, etc.). I have from time to time put her in charge of specialists in all the departments of medicine, who have found her normal, save hyperopic astigmatism, for which she wears glasses. November, 1911, I proved that her trigeminus Avas easily accessible (intra-sphenoidal) on both sides. Since then I have filled the sphenoid once in ten days with 1 per cent phenol in oil. She says that this is the first med- ication to help her pain. All characteristics of a nose case disappeared from this patient by the end of the first three months. 1918, during the past year she has developed a transitory amblyopia at the height of the headache which develops from a coryza. Sphenoiditis with Choroiditis — Secondary Closure of Sphenoid With Optic Neuritis Miss M. L., consulted me Sept. 21, 1914, for choroiditis, report of which I herewith attach, by Dr. M. H. Post. Exam- ination showed a post-ethmoidal sphenoiditis of low grade, suppurative (sero-purulent). No mark of hyperplasia. Ten- tative treatment failed to relieve her condition. Bilateral post- CASE HISTORIES 239 ethmoidal-sphenoidal operation was done. R. Sphenoid, Sept. 25, 1914, L. Oct. 12, 1914, with recovery of vision. The patient was brought to me again on December 15, 1917, by Dr. A. E. Ewing, for an optic neuritis of the right eye. There was a swelling of 4 dioptres. Examination showed the sphenoid cavity of the right side totally closed by a membranous formation, which was at once opened; with the result that the improvement of vision was immediate. Ophthalmological notes by Dr. A. E. Ewing. Pain in right eye during the last ten days. 0.1). V. = 20/20. O.S. V. = 20/20. Pain relieved by general treatment. 1914, Sept. O. D. sore for about four weeks. Vision "blurred." O.D. V. = 3/75. O.S. V. = 20/20. O.D. Numerous areas of pigment deposit and white swell- ing with atrophy of choroid in upper nasal portion of the fundus. These are also edematous swellings of the retina. O.S. Condition similar but less marked is mainly in lower nasal portion of the fundus. Treatment, KI, increasing doses. O.D. Three large nearly constant scotomata in field. O.S. Field normal. Sept. 21. Complains of black spot at center of vision O.S. O.D. V. = 20/150. O.S. V. = 20/75. Sept. 27. Operated upon bv Dr. Sluder. Oct. 30. O.D. V. = 20/150. O.S. V. = 20/30. Ophthalmoscope shows very little change. Dec. 7. O.D. V. = 20/96. O.S. V. = 20/20. Each fundus more quiet. 1915, Jan. 18. O.D. V. = 20/38. O.S. V. = 20/20. O.D. Condition of fundus improved, but there are a number of line hemorrhages. O.S. Fundus quiet. March 29. O.D. V. = 20/27. O.S. V. = 20/20. O.D. Fundus very quiet. O.S. Fundus very quiet. 240 HEADACHES AND EYE DISORDEES OF NASAL ORIGIN 1917, Nov. 27. Return of "blurred vision" O.D. for about a week. O.D. V. = 20/192. O.S. V. = 20/15. O.D. Marked neuro- retinitis, disc margins not definable. Swelling of disc measured by 4d. Referred to Dr. Sluder. Dec. 6. O.D. V. = 20/75. Disc less swollen. 1918, Jan. 18. O.D. V. = 20/38. Disc nearly normal. (Not seen since this data.) Many times have I seen sphenoid cases re-develop the eye trouble under acute coryza or closure of the cell; but they have always been the same lesion, that is, sphenoiditis that made a choroiditis on one occasion under the influence of a cor- yza or closure has re-developed a choroiditis again. This is the only case in which a choroiditis of both eyes was the primary lesion, which was followed by an optic neuritis from closure of the sinus two years later. Death from Meningitis Mrs. Buc, 40 years old, consulted the Nose and Throat Clinic, O 'Fallon Dispensary, Washington University Medical Department, for severe headache, worse on left side, extending to neck and shoulders. All examination was negative. After considerable effort I determined a post-ethmoidal-sphenoidal inflammation R. and L., and later, February-July, 1910, opened both sides. The reaction was severe. After some months she was better, and finally became comfortable. A coryza without suppuration later re-established the pain, which on the right side was stopped by intrasphenoidal applications of 10 per cent salicylate of methyl, and much improved on the left side. Ap- plications of cocaine inside the left sinus quickly produced total anaesthesia and analgesia of the areas supplied by all the divi- sions of the fifth nerve, with a marked sense of stiffness of the lower jaw of that side, which I took to be the effect of the co- caine upon the motor function in the third division. Dr. D. E. Jackson, of the Pharmacological Department, Washington Uni- versity, agrees with me in this conclusion. The right side ceased to be painful six months ago (1912), which is shortly after the applications of methyl salicylate were begun. The left contin- ues to be intermittently painful to a considerable degree, but CASE HISTORIES 241 is markedly helped by methyl salicylate, and remains vastly better than before this treatment was begun. She frequently complains of stiffness of the lower jaw on that side. Only once did this case show a tendency toward edema with polyp forma- tion at the time of acute inflammatory attack, and then only slight. Intra-sphenoidal observation in this case at the time (1914) of the severe ear pain has shown greatly reddened Vid- ian and maxillary tract. As the pain subsides, the redness of these districts disappears; or as the redness disappears, the pain subsides. Cocainization within the sphenoid is uniformly satisfactory — it stops the pain. Application of strong cocaine dropped within the sphenoid paralyzes the entire fifth nerve distribution for sensation, with a stiffness of the lower jaw. She continued to improve under treatment, seemingly do- ing well until Dec. 15, 1915, when her husband telephoned that she had had a very violent headache that day ; and that evening- began to vomit without any preceding nausea. I immediately suspected an intra-cranial disturbance, and sent to have the case examined. My assistant reported that the internal medical man had determined that it was gallstone; and that the case seemed to be one of gallstone, and that she seemed very much better. Most unfortunately, an accident in my affairs at that time delayed me four days in my effort to keep in touch with the progress of the case. At the end of this time, I was informed that she had developed a meningitis and had been sent to the infectious hospital. Inquiry was made there concerning the case. It was re- ported that she had died; but that no autopsy had been per- formed. Examination of the spinal fluid had been negative. The case seems unquestionably to be one of extension to the cranial cavity from the sphenoidal sinus. It was most un- fortunate that I could get no autopsy report. In my experience I have had eight cases' to follow more or less their course, that have ended bv some mvsterious menin- geal process. One proved to be a glioma of the middle fossa of the skull. It developed about a year after the sphenoid op- 242 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN eration which liad saved both eyes, and a high-grade optic neu- ritis. Paralysis of the Trochlearis with Dilated Pupil Miss M. R., 21 years old, consulted me March 24, 1912, be- cause of mild posterior headache with dilatation of the pupil on the right side, accompanied by discomfort in use of her eyes, of one week's standing. Ophthalmological examination was negative. An upright rod appeared to her bifurcate below, which, I understand, indicates a paresis of the superior oblique. The anterior Avail of the right half of the sphenoid was red- dened and bathed in serum. The effort was made to till the sinus with iy 2 per cent sodium salicylate water solution. This was repeated three times in nine days, when she was free of all signs and symptoms, and remained so ten days, when she had a "sick headache" (in which I did not see her) and again had a dilated pupil which became normal when the headache stopped. No discernible cause could be assigned for the sick headache. Beginning Optic Atrophy 0. R„ 15 years old, strong, healthy boy, referred by Dr. A. E. Ewing, May, 1911, for beginning optic nerve atrophy, which had lasted one year. My diagnosis: Hyperplastic sphenoiditis, R. and L., not far advanced, non-suppurative. Dr. Ewing 's report, vision R. E. 20 192, L. E. 20/150 with small central scotoma R. Right eye showed narrow pigmented crescent to temporal side of disc and more to temporal side; no headache. He was given a 2^2 per cent alkaline saline solution to pour into nose 3 times a day with a phenol spray. In 5 months he showed V. 20 (30 R. and L., two eyes 20/38. I have had a similar case with Dr. Ewing in a woman 72 years of age. Sphenoidal Headache with Probably a Migraine Added Miss A. M.j 38 years old, consulted me March 20, 1911, be- cause of intermittent headache from which she had suffered years. At this time it had been coming much oftener and has been rapidly growing more severe, then requiring "2\ 2 grains of morphine sulphate subcutaneously administered by her phy- sician to control the pain. She never took morphine herself. CASE HISTORIES 243 The pain was worse in left temple ; but in the height of the at- tack it seemed to extend over the entire head. And very rarely it came on the right side alone or would be much worse on that side. A post-ethmoidal-sphenoidal inflammation was found on the left side, which was operated two months later. The reac- tion was intense. She improved little or none during the next four months under a treatment of simple cleansing of the cav- ities. At this time (October, 1911), intra-sphenoidal applica- tions of 10 per cent methyl salicylate were begun with the idea of soaking the medicament into the environing fifth nerve. Since then the general improvement in her suffering has been very considerable. Much of the time she is free of pain and a large part of the remaining time she suffers only slightly. The recurrence of the intensely severe attacks is less frequent and intense. She recognizes two kinds of pain — one that I can stop by filling the sphenoid sinus with cocaine methyl salicylate or menthol solutions and another distributed over the same area which I have tried in vain to stop by these measures. When this attack begins it progresses despite all efforts to stop it; but it has become less severe and less frequent under this treat- ment, and the last attack, April 1, 1912, was on the right side only. Glaucoma and the Nasal Ganglion Mr. E., age 50 years, consulted me the June of 1913, re- ferred by Doctor Ewing, complaining of great pain in the eye which had been lost by glaucoma. The conjunctiva was greatly swollen red and the eye socket appeared to be fuller than the opposite fellow. Full anaesthesia of the nasal ganglion re- lieved the pain. This was carried out daily for three weeks, at the end of which time the swelling of the conjunctiva and its redness and all of the pain in his eye had subsided. His eye looked at that time like the eye of the opposite side — nor- mal. This case is to me exceedingly interesting shoAving the power exerted over the eye from the nasal ganglion. Whether this be a trophic influence or whether it be the result of the control of pain is to me very difficult to decide. I am undecided as to which it is. It would appear, every now and then, that the influence is a trophic one. The cocainization of the ganglion 244 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN in this case was accomplished first with a drop of 90 per cent solution which was afterwards reduced to a daily application of 20 per cent. It is impossible for me to conceive of this case as being influenced through the lymphatics, that is, the infec- tion; or assuming that the infection is controlled by way of this channel. Many times have I obtained a most beneficial result for the eye condition where the ophthalmologist was having a hard time to control a bad iritis. Full anaesthesia to the nasal ganglion has stopped the pain and the iritis has repeatedly im- proved from that time on. The lesion within the nose in these cases has been almost uniformly a thick velvet-like swelling of the posterior tip of the middle turbinate and just above it, that is, a hyperplastic post-ethmoidal inflammation. The applica- tion of this small amount of cocaine to this district does not seem possible to me to have any controlling power over the in- fection. Nasal Ganglion Injection Failure Mrs. G. was seen by me in the Hopkins Hospital on Oct. 15, 1909, with what seemed to be a high grade nasal ganglion neuralgia. She was presented to me by Doctor Harvey dish- ing. Prior to my examination, however, Doctor Bordely had operated the sphenoidal district. I injected the nasal ganglion or at least attempted to inject it in the acute inflammatory reaction which followed Doctor Bordely 's surgery. The result was a failure. Doctor dishing later removed the semilunar ganglion. In this case the straight needle as I passed it in, went an unusual distance. My feeling about it now is that the sphenoidal face was unusually thin and I crossed the spheno- maxillary fossa to inject into the cavity of the sphenoid. Whether the injection of the sphenomaxillary fossa at that time would have been helpful or not of course I cannot say. It is a failure the anatomical explanation of which is given in the preceding text. Sphenoiditis with Pain in the Shoulder Blades Mr. B. A., age 35 years, consulted me March 7, 1914, com- plaining of very severe pain between his shoulder blades. He was sent to me by Doctor M. A. Bliss who said that he thought CASE HISTORIES 245 that lie suffered from a sphenoidal disturbance. Examination of the nose at that time was negative. Continued effort for a diagnosis was successful for some little time but later a defi- nite sphenoiditis, low grade suppurative was determined and opened. The "ball of fire" as the patient described the pain in this case was fortunately relieved rather quickly; in ten days it subsided, and has not returned. The case is interesting to me showing the intensity of a single symptom in connection with these lesions. The majority of the lesions are accompanied by a number of manifestations. This case complained only of vio- lent burning pain between his shoulder blades. Acute Post- ethmoidal Blindness AY. EL, 20 years old, strong, healthy man, referred by Dr. \Y. H. Luedde, July 22, 1907. My diagnosis: Acute post-eth- moiditis, suppurative with edema. He had presented himself to Dr. Luedde that day, saying that "three days ago the present trouble began with a sharp pain in right eye; 12 hours later a slight swelling appeared around this eye which lasted 12 hours. The pain continued until today. ' : This morning at 7 :30 both eyes became blind. The left eye remained blind about 25 minutes. The right eye can see direction of motions of hand 3 feet, vision of left eye 15-19 by artificial light. Examination showed the right upper meatus of the nose swollen shut and pale (edematous). No pus could be discovered. Effort was made to shrink away the swelling, which was only in small part successful. He was placed in St. Luke's Hospital and the effort repeated at midnight, unsuccessfully. It was repeated at 6 a.m., July 23, 1907, and followed by the discharge of about a teaspoonful of pus into the throat. Three hours later (9 a.m.) lie reported to Dr. Luedde, who found the vision, right eye 15/19, left eye 15/12. The discharge of pus continued inter- mittently, stopping in ten days. It always appeared between the middle and upper turbinates. Never did any appear in the recessus spheno-ethmoidalis. Four days from the beginning of the treatment the right upper meatus swelled shut again for a few hours (about six hours) the pain recurred to a slight de- gree and his vision in the right eye fell temporarily from 15-12 246 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN to 15-24 for this length of time. From the tenth day he remained normal in every way and continues so at present. Conjunctivitis H. H. F., 32 years old, strong, normal man, consulted me March, 1912. He had an intractable low grade conjunctivitis, which was left in the wake of a "bad cold in his head, four years ago.' : Every coryza makes it worse. Cauterization of the sphenopalatine foramen membrane with trichloracetic acid four times at two-week intervals gave prolonged relief. Coryzas rekindle the trouble, but he comes to be comfortable again in a short time. Sympathetic Pain Mrs. A. E. consulted me October 10, 1916, because of head- ache, which in degree I think surpassed probably anything that is the fate of the ordinary rhinologist to meet. It was severe in the extreme. She gave the history of having the pain for many years. She had consulted many physicians because of it. Fi- nally, Dr. Harvey Gushing removed the semilunar ganglion for the relief of this pain. The operation was followed by total loss of sensation for the distribution of the trigeminus ; but the pain persisted with great severity. Examination of the nose showed a violently inflamed sphenoid, which Dr. Thigpin of Alabama recognized. He sent her to me, with the idea that the injection of the nasal ganglion might be helpful. Experi- ment with the ganglion showed absolutely no influence upon the pain. It was therefore decided to open the sphenoid, which was attempted by the angle knife; but the bone was so hard that it could not be cut through. I then drilled by means of a straight hand drill into the sphenoidal sinus, and found upon entrance a small quantity of bloody serous fluid, probably more serum than blood. The headache stopped almost at once and remained so three days, at the end of which time it began to re-appear and developed into its original severity. The opening made by the drill into the sphenoid was not more than 3/16 of an inch in diameter, and it very soon closed up and re-established the headache. I tried to persuade the patient to remain in St. Louis and give me more opportunity CASE HISTORIES 247 to treat the ease, but she was unable to do this. She returned to Alabama. Dr. Thigpin reported that the pain was quite as severe as ever. This case interests me — seems to me to be illustrative of the fact that the sympathetic, when irritated, may produce great pain. Furthermore, that it may produce pain for a wide distribution; for this was not merely a lower-half headache, al- though it was very violent in the lower half, at the same time it involved the entire skull. In this case the semilunar ganglionectomy by Dr. dishing was faultless, according to the observation of Dr. Bliss, upon the peripheral phenomena. In the beginning of my observation of the clinical questions of the nasal ganglion Dr. dishing showed me six cases more or less similar to this one. Supraorbital and Nasal Ganglion Neuralgia Mrs. L., 42 years old, came to me August 3, 1908, complain- ing of pain behind the right eye and in the upper jaw, (all sinuses normal). She described the pain as constant. She stated that she had for thirty years been subject to violent headaches, ending in vomiting. This case was diagnosticated as migraine by Dr. F. R. Fry, who sent her to me. A little later I saw her in one of her "bad spells." The pain was very great. It took in the entire half of the right side of the head and ran down into the neck, shoulder blade, axilla, arm, forearm, and hand. A drop of saturated solution of cocaine was then soaked into the site of the sphenopalatine foramen with marked re- lief except of the pain in the upper half of the head (ophthalmic nerve). A second application was then made with complete re- lief of all the pain except that of the upper half of the head, which remained unchanged. The relief afforded in this attack lasted about an hour, at the end of which time the pain had re- turned just as it had been. I saw her in two more "bad spells," the histories of which were identical with the one given. Each time cocainizing over the ganglion stopped all the pain except that of the upper half of the head, and the relief lasted about an hour. Applications of y 2 per cent formaldehyde were continued over a period of four months; the pain behind the eye and in 248 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN the jaw haying stopped in four weeks, for the most part. It occasionally returned in a lesser degree. The intervals between 1 he "had spells ' ' became longer and their severity lessened. This case shows an involvement of the ophthalmic nerve as well as the nasal ganglion. Transitory Amblyopia Mrs. A. A. B., 30 years old, consulted me October 1, 1917. She had had for six months, great swelling, sneezing, watery discharge, with tearing eyes and intense headache, chiefly pos- terior, accompanied by a transitory heavy gray mist, appearing ing before her eyes, and lasting for periods of twenty minutes to an hour almost every day. Ophthalmoscopic examination by Dr. F. L. Henderson was negative. Examination showed a gray spot in the sphenoethmoidal recess, right and left, at the site of the sphenoidal opening, with a distinctly enlarged and inflamed posterior tip of the middle turbinate on the left side (hyperplastic post-ethmoiditis), with acute process added on. The gray spots were the outlets of the sphenoidal sinus, and probably a trace of secretion which was not perfectly clear. The effort of tentative treatment failed and on the post- ethmoidal-sphenoidal operation was performed on the left side. The nose was very tall and very narrow, and presented a tech- nical difficulty probably as great as such noses ever present. The result was that the headache stopped at once and the 'blind spells" also stopped and have not returned to date. Examination of removed tissue has not yet been made. Clinically, the case appeared to be a low grade hyperplas- tic post-ethmoidal sphenoiditis, with a low grade subacute in- flammation added upon it. The case is interesting, combining headache with a transi- tory appearance of mist or steam which she described as blind- ness. No ophthalmoscopic explanation for this could be found. I have seen this phenomenon often develop after the case was several years old. The secretion and probably the tearing and sneezing were manifestations on the part of the sympathetic fibres of the Vidian nerve. CASE HISTORIES 249 Neck Pain J. W. F., 40 years old, came to me December 15, 1915, com- plaining of a windpipe cough, with a lingual tonsillitis. He also gave the history of very severe stiffness of both shoulders, which he had had for 15 years. He was a strong athlete who delighted in water polo, and always felt that the stiffness of his shoulder was in some wise connected with the exercise of that game. Cocainization of the ganglion stopped the stiffness of his shoulder; and so it was decided to inject the ganglia; both of which have now been injected three times. He is comfort- able at all times, except that of a coryza — then some discomfort in his shoulders redevelops. The coryza for this patient is uniformly a suppurative post-ethmoidal sphenoiditis of high grade. It does not make headache and recovers as an ordinary coryza, and when recov- ered, leaves no mark in its wake. For that reason, I have so far not determined upon any surgery more than the injection of the nasal ganglia. Hyperplastic Sphenoiditis and Pregnancy Mrs. S., aged 28 years, consulted me Jan. 3, 1915, because of lower-half headacre. Examination revealed a low grade hy- perplastic post-ethmoidal sphenoiditis right and left. Inquiry revealed further that she was pregnant three months. The state- ment was made that the headache had begun only with the pregnancy. As an unpregnant woman she did not suffer head- ache. Subsequent pregnancies, two in number, revealed that with each pregnancy the process becomes active, sufficient to make pain and subsides again later when the uterus is empty. The case is of interest in showing the increased activity of the parts during pregnancy. It appears to be a low grade case. She suffers little or none except when aroused under those conditions. Lifetime Headache with Loss of Vision at 54 Years of Age W. K., 56 years old, referred by J. W. Charles, March 9, 1914. My diagnosis : Hyperplastic sphenoiditis with scant se- cretion on right side. States that he has had severe headaches 250 HEADACHES AKD EYE DISORDERS OF NASAL ORIGIN "all of his life" of right side. In one attack which I saw it was of great severity in temple, about eye, and in occiput and neck. This attack was accompanied by the loss of 2 letters on the vision test card, yawning, drowsiness and withal a marked restlessness which compelled him to get out of bed in the middle of the night, also by vertigo, nausea, vomiting, pallor and sweat. The next day, the attack being over, the pain sense was still better E. but not the sense of taste. He had regained the two letters he had lost. A hyperalgesia 11. with more acute sense of taste R. after July 7, 1914. Dr. Charles' report : In 1903 he showed a hyperopia, 2d, R. eye and 2.5 L. eye. Vision 15/7^ R. and L. Bv ophthalmoscope both eyes normal. In 1912 R. eye V. 13/40.' In 1913 V. 13/50. 1914, July 1, V. 23/192 and some clouding of vitreous. Unusually severe headaches ; disc blurred. July 7, 1914. Post-ethmoidal-sphenoidal operation, after which the headaches stopped altogether and his color became normal (his appearance prior to this was evidently that of a low grade sepsis). Vision August 11, 23/38, the last time he ap- peared for examination. By telephone he says he is all right and gained 18 pounds, June 1, 1915. Vasomotor Rhinitis Miss E. C, 28 years old, consulted me June, 1914, because of "hay fever ' : (paroxysmal sneezing with secretion), which had lasted uninterruptedly six years, accompanied by constant discomfort referred to her eyes with slight constant lacrimation and slight Vidian neuralgia (see above) which was intermittent and sometimes severe. She had a low grade (non-suppurative) hyperplastic sphenoiditis, but the entire symptom-complex was controllable from the nasal ganglion which I injected with phenol-alcohol with relief of all symptoms, now for one year. A Failure R. B., strong, healthy man, 21 years old, referred by Dr. H. S. Hughes. My diagnosis: Hyperplastic sphenoiditis, non-suppurative. Dr. Hughes' report: July 20, 1914, patient says his vision was normal, that he never had any eye trouble until one month ago, when he noticed the small prints seemed CASE HISTORIES 251 blurred and that lie could not do his work with facility. No other especial low grade headache. General history, practically negative. Denies luetic history or any other trouble of a general nature. Smokes little, about one package of tobacco a week. Does not drink to excess. External eye, normal. Vision R. E. 6/12; L. E., 2/50 not improved with glasses. Ophthalmoscope, L. E., nerve head seems hazy in outline throughout. Disc mar- gin being completely lost from 5 to 8 o'clock. Temple quad- rant is distinctly pale. At the lower nasal quadrant are sev- eral very minute hemorrhages. The macula? region looks hazy and slightly edematous. The retinal vessels at lower disc mar- gin similar to that found in left, except very much less pro- nounced. Optic nerve pale. August 4, 1914, Dr. Gradwohl reports negative Wassermann but a positive Hecht-Weinberg. Fields for form show concentric contraction varying from 20 to 40 degrees. Diagnosis : Neuro-retinitis ; patient placed upon energetic alterative treatment, supported with strychnia. Vis- ion R. E., 6/40; L. E., Fings. 1M. July 29, 1914, Dr. Sluder opened left sphenoidal sinus. August 4. 1914, vision R. E., 6/50; vision L. E., Fings. 1M. Accurate fields difficult to take. Octo- ber, 1914, R. E. Fings. 2M. This is the last visual record I was able to take of the patient. Subsequent letters from his family's physician at Springfield, Mo., would indicate that his vision for several months following the above date remained about the same. August 7, Dr. A. E. Ewing saw the patient in consultation. Dr. Ewing 's opinion substantiated my own as regards diag- nosis and treatment. He did not think there was any indi- cation for specific treatment but suggested that the nasal treat- ment be continued. Post-etlmioidal-sphenoidal operation, July 29, 1914. Dr. Wright's report of changes in the sphenoidal wall and middle turbinate reveals a moderate degree of hyperplasia of fibrous connective-tissue beneath the epithelium and moderate hyperplasia of the bone. I know of no particular reason for the total failure to im- prove this case. 252 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN Operative Disaster A healthy boy, W. K., 20 years of age, began to lose vision two weeks prior to consultation with me. His ophthal- mologist recognized an optic neuritis of 3 diopters swelling. Nasal examination showed a sub-acute sphenoiditis with very scant secretion. The proposal was made to open the sphenoid at once ; but he declined stating that he did not care to remain in the city. His physician took him away; and the next day operated, removing the middle turbinate and proceeding back- wards in the effort to exenterate the post-ethmoidal-sphenoidal cells. He succeeded in opening the post-ethmoidal district quite well, but he some way failed to open the sphenoid and two weeks later brought the boy back. His vision upon the first visit was 20/30. Upon his return he had only the perception of light. Upon the second visit the sphenoid was opened com- prehensively. Vision slowly returned. In three months it be- came normal. The case is of interest to me showing how the surgery of this district in order to be successful must be right. Miss B. C. consulted: me April 29, 1918, submitted by Doctor Ewing, she being a patient of Doctor Saner, who kindly permitted my examination. She gave a history that she had some headache and eye disturbance a year prior, when one of her acquaintances, she being a trained nurse, proposed to operate upon her nose. She was put under ether and the opera- tion performed. When she came out from the ether she was totally blind in the right eye. Great hemorrhage filled the right eye socket. Doctor Ewing reported that at present the retinal arteries appeared as white silk threads, an appearance which he is somewhat at a loss to explain. To me the case seems to have been one of those great misfortunes in which the optic nerve was cut direct. The posterior third of the middle turbinate re- mained in situ, apparently no sphenoidal post-ethmoidal sur- gery was done. The surgeon seems to have lost his way, prob- ably under ether, combined with blood. I say that it Avas probably a direct cut of the optic nerve because five times in my own experience it has happened that the capsule of the ethmoid or the body of the sphenoid has sustained some small injury which lias resulted in orbital hemorrhage, four of these CASE HISTORIES 253 cases showed a small ecchymosis, one of them, however, was accompanied by great exophthalmos. The condition subsided in three days with no impairment of vision and no fault in any wise found to be with the result. Twenty-two times I have had orbital phlegmons to treat, twelve of which have been back of the transverse meridian with great swelling and high grade exophthalmos. In none of these cases was there any loss of vision. The results gave a perfect eye. Orbital Phlegmon T. C, age 22 years, consulted me Dec. 10, 1899. He gave the history of great pain reaching between his eyes. He was examined 2 weeks before by a rhinologist and the nose declared to be negative. The pain continued, later it ceased suddenly and was at once folloAved by swelling in the eye socket. The swelling continued to increase, his temperature rose to 104° and when I saw him he was a very desperately ill man. Effort was made to drain the eye socket from without but it was not satisfactory. Four days later his condition becoming rapidly worse, (he was apparently moribund) it was determined that the orbit should be drained into the nose. I removed the mid- dle turbinate with the small angle knife, not stopping to take it out, I threw it down into the lower half of the nose and pro- ceeded rapidly through the posterior portion of the ethmoidal capsule, making an opening the size of a man's little finger into the orbit. In twenty-four hours his temperature began to decline and in forty-eight hours the swelling of his orbit also seemed less. The case made a total recovery. At the time of the orbital opening the external erectus was apparently caught in the inflammatory, trouble in such a way that it did not work. Whether that were a catching of the muscle or a disturbance of the muscle function or whether it were a gripping of the abducens I do not know. It took six months to come back into function perfectly. Vision with this patient was never at any time disturbed. Optic Nerve Involvement with Sphenoiditis Mrs. S. X., consulted me April 18, 1907, complaining of lower-half headache of the left side, and nasal obstruction. 254 HEADACHES AXD EYE DISORDERS OF NASAL ORIGIN Nothing was done for her more than tentative treatment which was not satisfactory. She consulted me from time to time as the years passed, always declining operative procedure. During these years she also suffered slow but constant failing of vision in the left eye, until it finally became 23, 96. The right eye was normal. She finally realized something must be done in effort to save the vision of her left eye; and consented to the post-ethmoi- dal -sphenoidal operation. *«./•#■ Date VZZtt&LS* /-k" e*n.O Fig. 112. Very much to my surprise the result in this case has been a recovery of vision as well as the relief of headache. Her vi- sion in the left eye became normal at the end of three months. It is difficult to understand what may be the process in the optic canal that can, as a result of the sphenoiditis, slowly diminish vision to such an extent over a period of nine years and then recover at the end of three months, after the sphenoid is opened, permitting applications of carbolized oil within it. CASE HISTORIES 255 I have frequently seen in this class of cases patients that ap- pear as though there were a regeneration of the optic nerve at times. The question arises whether in this case there could not have been a regeneration of fiber. Dr. Charles, who sent the case to me, has submitted a full report which I herewith attach. This has been one of the most fortunate results of a long experience with such cases. W Date >**■&% // /.:/» %3. 7 "■'*€. ■Jio J 7(1 •/t+f Jiffi-r r = /-^Qo+t. o. Fig. 113. Mrs. 8. X. consulted me Oct. 15, 1907. because her eyes ached and burned constantly, and felt strained in near work. She also saw better upon closing the left eye. Dr. Sluder had treated her "four or five" times and had advised an operation. Fundi and pupils were normal. She was given R.E. +2 Sph. +0.5 cyl. ax. horl. V = 19 12. L.E. +2 Sph. -0.5 cyl. ax. vertl. V = 19/48. These glasses proved satisfactory and I saw the 256 HEADACHES AND EYE DISORDERS OF NASAL ORIGIN patient no more until Feb. 1, 1916, when the left eye had "been failing- since summer.' 1 (Figs. 112 and 113.) Feb. 3, R.E. V = 23/15. L.E. V = 23/60 Vid. field and scotoma. Feb. 9, 1916, with glasses R.E. V = 23/15. L.E. V = 23/96. "Seems to see moving smoke. ' ' April 4, R.E. V = 23/15. L.E. V = 23/60 to 23/38. The scotoma had disappeared under Dr. Sluder's treat- u ii %v ; /■JUL,/ .■*Wi/ / ,o.^/ y so to tio ,y-0 >iii 3j0 SO ■j/o'- m iz jfout^ r ,fl^< ■"!•'■ I 7^^ i ,f--/-j r