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foramen and supraorbital fissure are sensitive against pressure, redness of the conjunctivæ half closing of the eye are not very frequent. I repeat, the pains are of a neuralgic character, that is, they return often at the same hour, or the branches of the trigeminus nerve show a general sensitiveness and the pains become stronger at certain hours. Fever is not frequent, but slight increases of the temperature can often be observed. On the whole, these are the usual signs in adults, but we find them quite different with children, of course, to state it at once, the symptoms, which we may call the anatomical are always the same.

The suppuration in any of the cavities will always show up in the nose in the same place. Also, we always find pus in the middle meatus between the lower and the middle turbinated bone in case of an affection of the frontal sinus or Highmore cavity. But the exterior appearances are quite different. The empyema manifests itself under the signs of a serious general illness, high fever as much as 40° C. and more, sometimes somnolence and dulness of the intellect. The most pregnant symptoms are the pains which appear spontaneously and mostly with enormous intensity, very much stronger than ever in adults. The branches of the trigeminus are extremely sensitive against pressure. Examining the patient you cannot but notice immediately the severe edema which corresponds to the part of the affected cavity. In case of the inflammation of the Highmore cavity severe edema of the cheek, swelling of the eyelids strong injection and swelling of the conjunctivæ which can reach the state of chemosis. In case of the affection of the frontal sinus you will find the edema above the eyebrows on the forehead as far as the middle line and beyond same, and even so far as the other side. The conjunctiva is affected in the same way as in case of an inflammation of the Highmore cavity. On examination of the nose there is to be noticed a large quantity of mucopurulent secretion in the middle meatus, exactly as we used to find it with adults. The most important differences, however, appear in its course. Same becomes relatively as mild as the beginning was strong and sudden. In no case have I seen the disease changed into a chronic one and in all cases I found the conservative treatment quite sufficient. In cases of adults it will rarely be possible to heal the suppuration, for example of the Highmore cavity, without any washing out of the cavity. I never found this necessary with children, nevertheless the treatment can do a great deal and I found the following way the best: it is most necessary to procure free egress for the pus; as a swelling of the mucous membrane of the middle turbinated bone occurs always in this dis

ease, it must be our task to reduce this swelling as much as possible.

This result is easiest obtained by use of cocaine and, for the past two years, adrenalin. I use a 20 per cent solution of cocaine in the usual solution of adrenalin, 1-10, and introduce a probe with cotton wetted therewith into the middle meatus outward of the middle turbinated bone. Within a few minutes the mucous membrane contracts, becomes anemic and often perfectly white, and we may observe a nearly immediate effect,—the diminution of pain,—for the pus can now leave freely. A good result is additionally obtained by giving aspirin in large doses, according to the age of the children, using further a great deal of fluids, especially hot tea, and regulating the diet. The external application of mesotan with oil, equal parts, on the diseased and painful place will be found quieting, combined with the application of ice; but sometimes the little patient cannot stand the cool, and tolerates fomentations better. The fever and pains, as a rule, last but four or five days and mostly disappear, whereas the suppuration usually lasts a fortnight or three weeks. The treatment remains the same as long as we find any pus; the nose might be cautiously washed out to make it permeable, only great care must be taken that the fluid does not penetrate in the Eustachian tube, as this would cause immediately a severe inflammation of the middle ear in consequence of the septic pus. When not absolutely necessary, it is much better to omit the washing out. The following cases are instructive:

CASE I.-A child, 4 years old, comes with its mother to the hospital; the child has high fever, terrible pains, cries all night. Since yesterday there is a swelling on the cheek. The eye is swollen and very red. There are great pains when you touch the swollen part. The examination of the nose shows up yellow pus in the middle meatus.

Diagnosis : acute empyema of the left Highmorean cavity. Therapy as described above. The pains last for three days with great intensity so I thought, to relieve the child, it would be necessary to perform a puncture of the Highmore cavity, but during the night the pains were gone. The skin on the swollen part came off and after a fortnight the process was ended.

CASE II.-A child of 12 years called for consultation. I found high fever, terrible pains, severe edema above the eye, chemosis of the conjunctivæ, sensitiveness against pressure on the supraorbital nerve. The physician thought there might be a retrobulbar phlegmon, but the oculist had found that the eye itself was normal. The examination of the nose showed pus in the middle meatus.

Diagnosis: frontal sinus empyema. The treatment was the same as in the first case.

CASE III.—Child, 10 years old, case as the second; especially remarkable by the pains and high fever ; dulness of the intellect. Diagnosis: frontal empyema ; fever and pains last, but after seven days the process was the same as in the other cases.

CASE IT.-Boy, 12 years old, called upon me in the hospital with the diagnosis empyema of the Highmore cavity. The diagnosis was made by another specialist and it was intended to open at once the Highmore cavity from front without trying any local treatment. I started with the same treatment as experienced in the other cases and the farther progress was that the case, which came eight days after beginning of the disease under my observation was slower than I used to see ; it took about a week before the acute signs were gone; during the examination the exudate changed from a purulent to a mucopurulent, and lastly into mucus. It took more than five weeks to finish the whole process.

I will not trouble you longer with the description of other cases, as they have nearly the same histories, there being slight differences only in regard to the pains, the fever and the time for cure.


From the Surgical Clinic at the Buffalo General Hospital.


ARLY in December, 1904, a little girl, 18 months of age, was

brought to the surgical clinic of the general hospital by frightened parents, who stated that she had swallowed, or, at least, had passed down her throat beyond reach, a toy stick pin, "shaped somewhat like the picture of a doll,” with a long pin in the white metal part which represented the body of the doll itself. She had sustained this accident some two hours before she reached the clinic, at which time she was suffering very slight embarrassment of respiration with inability to swallow, but did not complain very much, except when this effort was made.

In a general way it was learned that the pin was an inch and a half or so in length, of irregular shape and made of flexible white metal. A radiograph, at once made by Dr. Plummer, gave the accompanying picture, showing apparently that the pin was impacted in the throat and esophagus, with the head downward.


Fig. I.—Radiograph, showing location of pin in the child's throat, and its relative size.

The sharp pin part seemed to be shown in the picture projecting upward in such a way as to complicate the effort to disengage in removing it.

The child was thoroughly scrubbed and prepared for external operation, if need be ; then chloroformed and placed upon the table with a sand bag under her neck, the head being thrown backward. Under the relaxation of complete anesthesia, the mouth was widely opened with an O'Dwyer mouth gag, and Dr. Park was then able to feel the upper end of the metal object just below the level of the tip of the epiglottis.

He selected forceps with blades bent at right angles to the handle portion, and passing this down behind the tongue and epiglottis, was able, after some effort, to disengage and finally withdraw the object almost entire. In the first efforts that were

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Fig. II. — The pin as it was removed from the child's throat,

exact size. The sharp pin part is shown by black line.

made, one, or perhaps two, of the projecting portions of the body of the pin were broken loose, and one of them was withdrawn. This will account for the irregularity of the figure shown in the photograph.

Very little blood was lost during the brief operation. The exigency of the case calling for both the surgeon's finger and forceps in the throat, there was caused considerable embarrassment of respiration, and at one time the child became quite cyanosed.

Dr. Park called attention to the fact that one of the immediate dangers in such cases was edema of the glottis, and he directed that ice be applied to the neck externally, and at the same time authorised the house surgeon to do intubation or tracheotomy at any moment, should urgent or distressing symptoms require it. The subsequent course of the case was so uneventful, that nothing

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