TEXT-BOOK OF MEDICINE

by the patient. An X ray examination showed the left frontal sinus to be hazy, and no sequestrum was seen. On October 13, 1936, the patient again attended the outpatient clinic, complaining that the discharge of pus from the sinus had become worse and caused discomfort, and he was afraid that it was affecting his left eye. He had no other complaint, only very slight headaches occasionally, when that was suggested to him. He had no nasal or postnasal discharge. On examination pus was pouring in large quantities from the sinus situated above the inner canthus; the amount could be increased by pressure, and the pus poured directly onto his left eye. Here there was an ectropion of the lower lid and considerable conjunctivitis. There was neither tenderness over the left frontal sinus nor (Edema, and nothing abnormal was detected in the nose, naso-pharynx or pharynx. The patient's temperature was 37·6° C. (99,8° F.) and the pulse rate was 108. He was admitted to hospital and an operation was performed by Dr. Foster on October 16, 1936, under general aneesthesta, An incision 1·5 centimetres above the left supraorbital margin was made across the forehead, the skin was retracted, the periosteum was divided, elevated and retracted, and the anterior table of the left frontal sinus was removed. Thick purulent discharge was now seen forcibly pulsating through this opening with a pump-like action. The removal of the anterior table was continued across to the right frontal sinus, as the interfrontal septum had disappeared. When all the pus had been removed by suction it was seen that a large area of pulsating dura mater (about four square centimetres) had been exposed, the posterior table of the left frontal sinus having almost completely undergone necrosis. 'l'he exposed dura mater was covered by red granulation tissue and was bound down to the edge of the bone by fibrous tissue. The left orbital plate was extensively necrosed and partially removed, and what mucous membrane of the cavity was left was removed to prevent refilling with secretion. It was found that the naso-trontal duct was already completely obliterated by fibrous tissue. Several small sequestra were removed from the region of the fistula. The cavity was syringed with saline solution and flavine and was completely closed, except for one small gauze drain inserted at the outer extremity of the wound. Healing occurred by first intention and the patient made an uneventful and rapid recovery. The patient was discharged from the hospital in two weeks. Considerable deformity of the forehead resulted from the operation; but nothing was done about it on account of the age of the patient. A similar deformity in a young woman in her twenties following an obliterating frontal sinus operation was successfully treated in our clinic by filling the depression with a cartilage graft from the sixth and seventh costal cartilages. This was done about six months after the frontal sinus operation. This case is interesting on account of the duration of the large extradural abscess-probably between one and two years-the almost complete absence of symptoms while such extensive suppuration and bone destruction could proceed, and the rapid recovery after operation. •