and having poor assimilation, many times should be treated surgically instead of medicinally. I have had twenty-three surgical patients ranging from two and a half to thirteen years in age. Twenty of these had perforated appendices, gangrenous or ulcerated, and abcessed, with a mortality of six. CASE D. C. Age twelve, had ordinary diseases of childhood; taken suddenly ill February 22, 1911; attending physician, Dr. Lyon, summoned and found child suffering with persistent nausea and vomiting; general pains through abdomen; temperature 102°f; pulse 120; bowels moving frequently; character of the stool thin and offensive; under treatment of intestinal antiseptics and anodynes, his condition seemed to improve, and the next morning his temperature was 100°f, pulse 110; no nausea and no pain. By evening he was complaining of severe pains in left hypochondriac region, with occasional vomiting, no tenderness over McBurney's point, but extreme rigidity of the muscles, and a rectal examination revealed a painful spot on pressure in right pelvis. An ice bag was put over the seat of the appendix, which promptly relieved the pain in the left side. The next morning his abdomen was much distended, temperature 103°f, pulse 140; marked evidence of shock, operation advised. On operating the appendix was found to be suppurating, gangrenous and adherent in a mass of omentum; appendix and gangrenous omentum were removed and abdomen drained; recovery uneventful. CASE C. Boy four and a half years old; at twenty months of age had critical attack of cholera infantum, followed subsequently by obstinate constipation. February 12 family physician was summoned, found the child suffering, which was at once diagnosed as appendicitis; operation suggested, and was not permitted until February 23, 1911. Upon incising found an appendiceal abcess; appendix removed and thorough drainage established; child's condition fairly good for seventy-two hours, temperature fluctuating from 99°f to 100°f with pulse varying from 100 to 120; occasional emesis and eructations; child's condition continued to grow from bad to worse; unable to move. the bowels by laxatives, and enemas; abdomen greatly distended, showing all signs and symptoms of obstruction; child's condition at no time justified the opening of the abdomen. The child died the ninth day. Post mortem fiindings: about three feet from the distal end of the ileum found a collapsed bowel, with denuded mucuous surface, its walls adherent; the length of the collapsed bowel being twenty-eight inches. CASE A. Girl nine years old, since six years of age has had attacks of indigestion and diarrhoea; in September, 1910, first attack of pronounced appendicitis; lasted six weeks; temperature ranging from 100°f to 103°f with flatulence, marked distension and profuse emesis. Six weeks after recovery from first attack was sick four days with same symptoms and had similar attack two months later. March 5, 1911, was taken suddenly ill with gastro-intestinal disturbances. Operated on March 9, found the appendix perforated, abscessed; appendix removed; thorough drainage established; recovered. CASE M. S. Age ten, always been healthy and rugged. Began about October 10, 1911, with diarrhoea and occasional griping, which continued until the night of October 19, when the pain became so severe that he could not lie down and sat in a chair all night; he had gone to school regularly up to this time. October 20, the pain was not so severe through the day but was worse in the night than it had been on the 19th. Dr. Lyon called October 21 and found the child with a temperature of 101°f, pulse 130; abdominal muscles rigid, pain paroxysmal; between pains felt easy; he was dressed and up and around, soreness not pronounced but general on palpitation over abdomen. Digital rectal examination revealed an extremely sensitive mass in the right pelvis, patient screaming when only a little pressure was made on it; operation advised. On operating we found a localized peritonitis and an adherent mass in the right pelvis which proved to be gangrenous appendix, bowel and omentum, necessitating a resection of five inches of the bowel and mesentery was gangrenous; bowels were united with pendix had "sluffed" off, and the bowel had a gangrenous perforation an inch in diameter, and about three inches of the bowel and mesentery was gangrenous; bowels were united with Murphy button and abdomen drained. On the evening of October 25, 1911, child's temperature normal, pulse 80, condition good. "The doctors talk Latin, 'tis said, When they meet in the sickroom, oh why? Suits the man who is going to die." Acute Inflammation of the Nasal Accessory Sinuses. *By W. D. SHIELDS, M. D., Holdrege, Neb. Anatomy. The nasal passages are subdivided by the three turbinated bodies into four parts or meatuses, running from the front backward and slightly downward. The inferior meatus is between the floor of the nose and the lowest tubinal, and receives the opening of the nasal duct. The middle meatus lies between the inferior and middle turbinals, and the third meatus between the middle and superior turbinals, while the fourth meatus lies above the third or superior turbinal body and below the cribriform plate of the ethmoid bone. The middle turbinal hides from view several important structures on the outer wall of the nose. In the first place the uncinate process is a ridge of bone running downward and backwards nearly to the posterior end of the middle meatus. Above the uncinate process is the bulla ethmoidalis, a projection caused by one or more of the middle ethmoid cells, and between the uncinate process and the bulla ethmoidalis is the hiatus. semilunaris into which many of the accessory cavities open. The accessory sinuses form almost a continuous chain along the outer side of each nasal fossa, and from a clinical point of view may be divided into two groups according as their openings are above or below the middle turbinal. In the first group are the frontal, the fronto-ethmoidal, and anterior ethmoidal cavities and the maxillary antrum; and in the second group are the posterior ethmoidal and the sphenoidal cavities. The relative position of the sinus and its ostium is of great importance clinically on account of draining the cavity. This varies. greatly owing to the position of the head. The ciliated epithelium which lines the cavities aids materially in emptying the sinus if it is not injured by disease. All these cavities are perhaps residual organs, like the appendix, and like all residual organs offer little resistance to inffammatory action. They are all supplied by the trifacial nerve or its branches which is well to remember in tracing reflex symptoms. Inflammation of the antrum is caused by acute rhinitis, the fangs of the first and second molar teeth extending into the cavity or hypertrophy and polypoid degeneration near the natural opening. It also occasionally happens that the antrum Read before the Republican Valley Medical Association. at Alma, Neb., October 26, 1911. is infected from the ethmoid cells, the frontal or sphenoidal sinuses, and by syphiltic necrosis. The symptoms are pain, more or less neuralgic on the affected side with soreness of the teeth involved, bone tenderness over the region and maybe puffiness of lower eye lid, with a feeling of pressure of the orbit and local fever. This inflammation may rapidly terminate by suppuration and the patient notice a discharge from one nostril which smells and has a fetid taste. This discharge is now found to be coming from under the middle turbinate; this is sufficient to establish a diagnosis. This may be corroborated by an electric lamp in the mouth in a darkened room and comparing the two cavities. This seems to be valuable to some authorities and only confirmatory by others as there is nothing reliable to it. The symptoms of frontal sinus inflammation are supraorbital pain on the affected side. The pain is increased by blowing the nose or any stooping, or straining position, with nausea. There is marked tenderness above and under the supraorbital arch. Frequently there is oedema of the skin covering the sinus and the upper eye lid. A diagnosis based on the above indications is conclusive but transillumination and the x-ray are helpful in symmetrical cavities. But we never know when we have similar cavities and same thickness of bone or as occasionally happens one sinus, or one in front of the other. (de Mendosa.) In the acute stage the ethmoid cells and the sphenoidal sinus are known by pain, and in their regions, and between the eyeballs, and occipital headache. The discharge of which trickles into the phargnx. The posterior ethmoidal cells are rarely affected alone. Either the sphenoidal is implicated or some of the anterior ethmoidal cells. In one case however, reported by Watson Williams, in which the posterior ethmoidal cells were affected alone, there was a subjective sense of thickness over the frontal region, deep seated headache, aching at the back of the eye, obscurity of vision, loss of memory, aprosexia and discharge of pus from both anterior and posterior nares. From these discharges draining into larynx and the pharynx we have many resulting complications, even in the acute condition, as pharyngitis, laryngitis, and bronchitis; eustachian catarrh, acute septic tonsilitis, anorexia and general debility. From your knowledge of the orbit and relation to these sinuses it is readily understood that the eye socket is about half way surrounded by these accessory sinuses. And as a result of this relation we have more or less eye symptons. It may be an orbital abscess, orbital celulitis or only a soreness of the muscles in turning the eye. It should be stated that in the great majority of cases of sinusitis it is secondary to an inflammation of one or both nasal fossae, as in measles, la grippe, or other systemic infection. Inflammation of the lining membrance of a sinus is not different from that of a mucous membrane in any other part of the respiratory tract except that it is now in a closed cavity instead of an open cavity and runs a more rapid course through the inflammatory process. The treatment suggests itself; that is elimination and general depletion by a cathartic; a hot foot bath aids in relieving the congestion. Relieve the pain by five to eight grains of aspirin or other analgesic which does not check the secretions. Locally a hot application over the sinus and two to four per cent solution of cocaine on a pleget of cotton, applied to the ostium through the nose. This may be supplemented by adrenalin chloride but its after effect is so great in many cases that I do not use it ordinarily in these cases. A warm alkaline douche is efficient if you do not have cocaine at hand. Thus, we reverse the order, by reducing the patholgic turgescence of the mucous membrane, converting a closed cavity into an open or physiological cavity. It is comparatively easy in most cases to probe the natural opening and know it is open. In fact, many chronic cases can be cured by washing and draining through the naturai opening. I want to insist that by a practical, patient effort in the local treatment with the anatomical picture of the nasal fossae and their connecting sinuses in mind, we could cure more than we are at present in the acute attack. In contradistinction to the radical plan of treatment we may properly term this the conservative method, which is authorized by D. Braden Kyle of Philadelphia. He says "In my clinic at Jefferson Medical College, Hospital, where from 10,000 to 12,000 treatments are made yearly, and also in my private practice, where many of these acute inflammatory involvements of the accessory cavities are observed, this plan has been successfully carried out for a number of years with such satisfactory results that radical interference has been practically eliminated in acute cases. In fact, in the last year, in only two cases, and they were of the chronic variety, was the radical |