Vol. 60, 1909 - University of North Carolina at Chapel Hill

190 THE CHARLOTTE MEDICAL JOURNAL. I
have to consider whether the onset of orbit- minal muscles covering an active gastric or ;<
al complications should be made an indica- duodenal ulcer will be found to be rigid,
tion for opening the affected frontal and and this rigidity is quite localized. The
ethmoidal sinuses by an external operation, hardness of the upper part of the right rec-'
Notwithstanding the fact that a number of tus overlying an active pyloric or duodenal
cases have been recorded-iu which inflam- ulcer is therefore an important sign. A
matory cedema of the eyelids complicating tumor. A tender nodule or an indefinite
an acute inflammation of these sinuses have induration, especially in the neighborhood
been completely cured by endonasal treat- of the pylorus, with a history of long standment,
he is of the opinion that the external ing stomach trouble, are characteristic of
operation is the wiser procedure. It is often chronic ulcer, and furnish its most importimpossible
to say whether the orbital swell- ant sign. A considerable tumor may be
ing is merely due to cEdema, or whether caused by inflammatory exudation and in-
pus has already formed within the cavity duration round a chronic ulcer, but this is '
of the orbit. Early evacuation of an ab- rare. A definite movable tumor suggests a'
scess in this situation is essential, not only cancerous rather than a chronic ulcer. The ]
for the preservation of the function of the symptoms which distinguish a chronic gas- '
eye, but in order to prevent the risk of trie from a chronic duodenal ulcer related •
secondary intracranial complications. In chiefly; 1. To pain. To the time at which !
cases of chronic sinus suppuration, in which pain occurs after taking food, that is, soon ;
an abscess forms in the orbit, there is in all in gastric, later in duodenal ulcer. The in- ,
probability, caries and destruction of a part iluence of food upon the pain; solid food j
of the bony wall of the sinus contiguous increasing gastric, but relieving duodenal j
with the orbit; consecjuently an external pain. The effect of rest in bed on the pain; j
operation is the only possible procedure, rest relieving gastric, but producirg no good I
The incision should be made immediately effect on duodenal pain. 2. To the charbelow
the eyebrow, and great care should acter of the vomiting. Its close relation-
be taken to detach the periosteum from the ship to food and pain; its involuntary char-
inner and upper wall of the orbit without acter in gastric, and its voluntary appear- !
injuring it, and exposing the orbital fat. ance in cases of duodenal ulcer. 3. To the ;j
As a rule, the pus is found between the form of hsematemesis. Recurrent, and in i
periosteum and the bone. The ethmoidal relatively small quantities in gastric, over-
cells can then be freely opened by the re- whelming and followed by meleena in duod- .
moval of the lamina papyracea, and the enal cases. The diagnosis of stricture in I
frontal sinus can be explored by removal the neighborhood of the pylorus is so easy j
of the inner portion of the roof of the orbit that no excuse can be offered for mistakes. ,<
which forms the floor of the sinus. The With the history of a chronic gastric or i
sinuses may then be dealt with according duodenal ulcer some years back, and peri- i
to the condition and size of the cavity. In ods of remission of the symptoms, each re- :
the ethmoidal cells it will probably sufBce mission being followed by a less perfect re- 1
to establish a large communication with the covery until the evidences of stomach dila- '^
nasal cavity, while the orbital wound is tation are complete—with such history the M
lightly packed, the skin incision being left diagnosis of cicatricial stricture as a conse- i
unsutured for a few days. The nasal drain- quence of the ulcer is unmistakable. This ]
age is assisted by the removal of the middle is fortunate, as these cases demand opera-