The oval may be closed in the same manner as the ellipse while in other instances it is better to close the oval through its narrow portion as a straight line and at its broad extremity to draw forward the base, much as we do in closing the equilateral triangle so that the completed closure is much the same as the triangle.

(To be continued.)

THE EYE, NOSE AND ACCESSORY SINUSES IN LA GRIPPE By Austin J. Mummert, M. D., Los Angeles, California.

Read before the Academy of Medicine, Los Angeles, Cal.

The parts played by the eye, nose and accessory cavities in influenza would, if they were thoroughly and exhaustively covered, require much more space and time than this paper warrants. We will then confine ourselves to the practical, rather than exhaustive, consideration of this important subject.

The bacillus described by Pfeiffer in 1892, seems to be responsible for this disease as it is not found in any other disease, according to some authorities, and is found in influenza constantly.

In la grippe the eye suffers from acute glaucoma, serous iritis and affections of the optic nerve which may result in blindness. Guilford, of Omaha, observed retrobulbar neuritis. Paralysis of the ciliary and extrinsic muscles have followed la grippe, where the disease resembles diphtheria in its effect on deglutition and speech; iritis and dacryocystitis and secondary to meningitis of this disease, plastic uveitis and panophthalmitis, oedema of the lids and lachrymation are noted. Hopkins, of San Francisco, claims cataract formation may also be attributed to influenza.

What is the cause of eye involvement in influenza? The microbe of Pfeiffer, its products or both, along with the general effect la grippe has upon the gen

eral system, allowing nutritative changes to lessen the resistance that ordinary health exerts, is probably as good as explanation as we can give at present. If the eye has been subjected to strain or is subject to inflammatory attacks, or if it has been injured, the chances are greater for it becoming involved in influenza.

One peculiar and interesting case came under my observation recently that will illustrate the versatility of la grippe. It was in a case of a physician's son-a young man who had been suffering from influenza about a week when suddenly his left eye and ear became excessively painful. Upon examination I found the eye normal, also the ear, both as to function and appearance. The fact that function of both organs being normal and that there was no tenderness elicited upon manipulation, points to affection of the sensory part of the trigeminus.

Mucous surfaces in influenza take on an intense inflammation throughout the body. That of the nasal mucosa may lead to involvement of the accessory cavities. As a matter of fact, these cavities are prone to even take on the inflammation of acute coryza; one can recognize this by the amount of discharge. The frontal sinus is rarely af fected to the extent that distress is pronounced, as the cavity has a broad, deep outlet, but when the cavity is closed in, spontaneous recovery isn't likely to take place, as the sinus has a number of deep recesses, which extend below the level of the internal orifice. Usually, not invariably, suppuration of the frontal sinus is complicated by suppuration of other cavities in the ethmoid bone and in the upper maxilla. The hiatus semilunaris drains the anterior labyrinth of cells of the ethmoid and frontal sinus, and opens in the direction of the maxillary orifice, so that the pus in these cases enters the antrum, the antrum forms, as it were, a drip pan. The inflammation of the antrum

membrane is then secondary. Malformation of the septum and turbinates only adds to the danger of these complications, particularly in influenza, however any severe inflammation of the nasal mucosa renders a case with such malformations more liable to sinus troubles.

Swelling of the mucosa of the inferior meatus leads to closure of the opening of the lachrymal canal, causing epiphora and possibly chronic sack trouble, with retention of pus that is injurious to the conjunctiva.

Symptoms. The symptoms of sinus. involvement are varied. Pain and swelling are pretty constant, then follows pus formation. We must distinguish between the discharge of pure mucus, mucopus, an admixture in which pus predominates over the mucus, and pure pus. The term empyema is properly intended to convey the idea of within pus a closed cavity and should be used only this way. Upon inspection we may find the nostrils with or without a discharge visible. In not being able to find it does not prove that it is not present; if it is found upon first inspection, then comes the task of finding its origin. It is well to have patient clean his nose best he can by blowing it; then, with a cotton applicator, finish the cleansing process. Then have the patient hold his head in the position most liely to allow gravity to assist in its discharge. As is well known, the discharge seen to come over the inferior turbinate only drains the anterior division of the sinuses, viz., the frontal sinus, anterior ethmoid cells and the antrum. If there is great swelling, it may become necessary in order to make the diagnosis, to apply cocaine or adrenalin so that the normal openings may be rendered sufficiently open to allow the pus to find its way out and reveal its hiding place. Even to allow of probing and irrigation, an hypertrophied middle turbinate, if it shelves far forward and downward, will hinder inspection, but one experienced in prob

ing these parts can arrive at a definite diagnosis. It will be remembered that a discharge coming over the middle turbinate means that the posterior ethmoid cells are affected, excluding, of course, the fact whether or not the mucous membrane of the nostril is responsible alone for the discharge, which exclusion must be made every time before laying the blame on the sinuses.

The sphenoid sinus allows its discharge to trickle down the septum and if posterior rhinoscopy is employed with accuracy, aid may be obtained by this method. In this diagnosis probing and irrigation of this pair of cavities can be carried out as in the others mentioned. The accessory sinuses are not inaccessable sinuses A thorough knowledge of the anatomy throws a better light on the subject than all of the trans-illumthe market, ination apparatuses on whose merit may or may not be worthy of mention. The chances are usually against trans-illumination on account of the difference of size of the cavities in different heads as well as a difference existing between the two sides of the same head.

Prognosis is favorable in most cases if care be taken in diagnosis and skill exhibited in treatment. I believe if treatment were instituted early enough and intelligently carried out with an absolute submission and cooperation of the patient, very few cases of chronic sinus troubles would ever be seen.

Treatment of the nostrils in all cases of la grippe is important. If commenced early enough it will keep down the number of sinus cases to a minimum. Alkaline wash or spray is indicated, care being taken to instruct the patient exactly how the best results can be obtained by its use. The great danger is in allowing the fluid to be drawn through nostrils and expectorated. In this way the liability to get the fluid, along with the nasal secretion into the ear, through the Eustachian tube so far over-balances the probable good effect