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AN UNUSUAL CASE OF NASAL POLYPUS.
9 soon rises in the inner tube, and its quantity may be read from the scale. The stopper of the inner tube being removed for a moment, the tube refills itself with water, and can be used for a second trial at once. A battery having an electro-motive force of about six volts should, when connected with this voltmeter, cause mixed gas to the extent of about six of the small divisions to collect in the upper portion of the inner tube when the circuit has been closed for two minutes. The method is rough and ready, but non-technical people make sad mistakes with a proper voltmeter, and at any rate one can obtain sufficiently accurate information as to the working condition of the battery by the voltmeter. I am having some constructed specially for this purpose under my supervision, in which a larger quantity of gas is formed, by altering certain structural and other conditions. With such a method and such simple apparatus, I think it will be found that electricity may claim for itself a position amongst the therapeutical agents regularly employed in Graves’ disease. It is self-applicable, and the very slight extra trouble entailed is more than compensated for by the results obtained and trifling expense of the apparatus as compared with that of drugs, when treatment has to be extended over a lengthened period. (The patient’s battery as described iR supplied complete with electrodes and conducting wires for £1with liquid cells, £11s. with dry cells. The chemical energy of these cells is sufficient for over a year, when only 3 milliampères are used for eighteen minutes daily.) (To be coneluded.)
decomposition
injection of ether, hot cloths to the head, and the administration of an enema of brandy-and-water. Fishing gut sutures were employed to unite the parts. The patient made a speedy and good recovery, the incision rapidly united, and she sat up on the seventh day. Remarks.—The clinical signs which denote malignancy in a nasal polypus are a tendency to bleed freely, rapid growth, and advanced age of the patient. The present case illustrates this. It is principally interesting, however, as showing how exceedingly insidious and deceptive may be the origin and progress of antral tumour. None of the ordinary signs of antral distension were present, yet the whole cavity was filled by a growth which had obviously gained ingress to the nose by the orifice of the antrum. In the nose the tumour assumed a polypoid shape, in space, rather than expanding its bony surroundings. The haemorrhage experienced was very serious. Without skilled assistance and prompt resuscitating measures, I doubt if the patient would have survived. This suggests the advisability of placing a temporary ligature on the carotid in cases of vascular tumour of the jaws, especially when the patieno is exhausted by previous bleedings. In conclusion, the case affords a striking lesson of the caution with which we should regard cases of polypus of the nose in adults, which are of rapid growth. They are likely to be malignant, and have far deeper connexions and attachments than it is possible to ascertain by inspection. Partial operations by the snare or forceps are useless, and the free removal of the affected bone as early as possible affords the only chance of lengthy immunity from recurrence. Stratford-place, W. cutaneous
growing freely
AN UNUSUAL CASE OF NASAL POLYPUS. EXTENSIVE HYDATID DISEASE OF THE BY A. MARMADUKE SHEILD, M.B., F.R.C.S., ABDOMEN; RECOVERY. SENIOR ASSISTANT SURGEON AND AURAL SURGEON TO BY HENRY HANDFORD, M.D., M.R.C.P., CHARING-CROSS HOSPITAL. PHYSICIAN TO THE GENERAL
subject of this condensed report was the wife of a publican, a patient of Dr. South of Peckham, with whom I saw her on May 5th. She was advanced in life, and had enjoyed good health until about five months previously, when she noticed obstruction of the left nostril, which gradually increased. Aching pain in the left eye and lacrymal obstruction had supervened. On examination, the left nasal passage was filled by a large polypus, having the usual gelatinous consistence and appearance of the common myxomatous nasal polyp. The tumour was There was no expansion mobile and pedunculated. of the nose, and the naso-pharynx was free. While examining the connexions and mobility of the tumour wich a probe it bled freely. This symptom, rare in simple gelatinous polypus, led to the suspicion that the case might prove to be malignant. The parts being cocainised, the tumour was removed with the cold wire snare. The resulting haemorrhage was pulsating in character, and very profuse. Ultimately the nose was plugged with lint and tannin, and no bad effects followed.-May 19bh: Dr. South assisting, some more gro wth was removed by the snare. This was soft, granulomatous, and malignant. The nasal passage was " clear " after this operation, but the bleeding was again profuse.-June 2od: There is extensive return of the growth, but it seems mobile, and believing it originated in the turbinate bone I advised opening the nose laterally, free removal of the turbinate bone, and the application of Paquelin’s cautery.-16th (operation): Dr. F. Hewitt administered anaesthetics. Assisted by Mr. Waterhouse, I opened the nose laterally. On introducing the finger, it was at once obvious that very serious disease was present. Firm lobules of growth could be felt, which obviously had their origin from the antrum. It was therefore decided to removethe entire jaw, and this was at once done in the ordinary The bone was friable, and "broke downunder manner. the lion forceps. The whole antrum was filled by a malignant growth, which extended above to the region of the cribriform plate, and behind to the pterygoid region. Yet the tumour was fairly circumscribed, and at the conclusion of the operation it seemed completely removed. Although the operation was executed as rapidly as possible, the bleeding was exceedingly profuse, and at its close the patient was pulseless and appeared moribund. Her condition was for ten minutes ptecarious in the extreme. This was met by the sub-
HOSPITAL, NOTTINGHAM.
THE
history of cases of hydatid disease of the abdomen so widespread as in the present instance, however treated, is usually one of gradually failing health, exhaustion, and death. A successful result is therefore worthy of record. It is also of interest to contrast in the same patient the In treatment by free incision with that by puncture. addition to the cysts removed by laparotomy, and those discharged through the wound that remained, four cysts in various parts of the abdomen were treated by aspiration and none of them refilled, and the liver was aspirated eight times in two years and a half. It is now three years since the last aspiration. Hydatid disease is not very uncommon in this neighbourhood, and during the last ten years I have seen in my own practice and that of my colleagues a very considerable number of cases affecting the liver, peritoneum, kidney, retro-peritoneal tissue, abdominal parietes, and even a metacarpal bone ; and there is a specimen in our museum of a hydatid removed from the breast. On the whole I am strongly in favour, at any rate in the first instance, of aspiration rather than free incision in most cases. Very many are cured by a single tapping, notwithstanding the retention of the cyst wall. I have seen no advantage in taking only a small quantity of fluid, but prefer to withdraw as much as will readily now. L. B-, aged twenty-one, a lace-dresser, was admitted on July 21st, 1885, complaining of pain in the abdomen, headache, and loss of appetite. She used to be very stout, but has been losing flesh for the past six months, and now is rather thin. She first noticed a lump in the abdomen, just below the umbilicus, a year ago. For the past ten days the epigastric region has become distended and painful, and she has suffered from headache and loss of appetite. On admission the temperature was 102°F., the pyrexia being probably due to an attack of localised peritonitis, which soon subsided. The abdomen was tense and greatly THE
distended.
marked want of symmetry, rather more prominent than the left. The distribution of the dulness was very irregular. On palpation, rounded masses, varying in size from a walnut to a large orange, could be felt; but on account of the great tension I could not satisfy myself that any of them moved independently of the rest. The most prominent
though
the
There
was
right flank
no
was
43 A2
decomposition
injection of ether, hot cloths to the head, and the administration of an enema of brandy-and-water. Fishing gut sutures were employed to unite the parts. The patient made a speedy and good recovery, the incision rapidly united, and she sat up on the seventh day. Remarks.—The clinical signs which denote malignancy in a nasal polypus are a tendency to bleed freely, rapid growth, and advanced age of the patient. The present case illustrates this. It is principally interesting, however, as showing how exceedingly insidious and deceptive may be the origin and progress of antral tumour. None of the ordinary signs of antral distension were present, yet the whole cavity was filled by a growth which had obviously gained ingress to the nose by the orifice of the antrum. In the nose the tumour assumed a polypoid shape, in space, rather than expanding its bony surroundings. The haemorrhage experienced was very serious. Without skilled assistance and prompt resuscitating measures, I doubt if the patient would have survived. This suggests the advisability of placing a temporary ligature on the carotid in cases of vascular tumour of the jaws, especially when the patieno is exhausted by previous bleedings. In conclusion, the case affords a striking lesson of the caution with which we should regard cases of polypus of the nose in adults, which are of rapid growth. They are likely to be malignant, and have far deeper connexions and attachments than it is possible to ascertain by inspection. Partial operations by the snare or forceps are useless, and the free removal of the affected bone as early as possible affords the only chance of lengthy immunity from recurrence. Stratford-place, W. cutaneous
growing freely
AN UNUSUAL CASE OF NASAL POLYPUS. EXTENSIVE HYDATID DISEASE OF THE BY A. MARMADUKE SHEILD, M.B., F.R.C.S., ABDOMEN; RECOVERY. SENIOR ASSISTANT SURGEON AND AURAL SURGEON TO BY HENRY HANDFORD, M.D., M.R.C.P., CHARING-CROSS HOSPITAL. PHYSICIAN TO THE GENERAL
subject of this condensed report was the wife of a publican, a patient of Dr. South of Peckham, with whom I saw her on May 5th. She was advanced in life, and had enjoyed good health until about five months previously, when she noticed obstruction of the left nostril, which gradually increased. Aching pain in the left eye and lacrymal obstruction had supervened. On examination, the left nasal passage was filled by a large polypus, having the usual gelatinous consistence and appearance of the common myxomatous nasal polyp. The tumour was There was no expansion mobile and pedunculated. of the nose, and the naso-pharynx was free. While examining the connexions and mobility of the tumour wich a probe it bled freely. This symptom, rare in simple gelatinous polypus, led to the suspicion that the case might prove to be malignant. The parts being cocainised, the tumour was removed with the cold wire snare. The resulting haemorrhage was pulsating in character, and very profuse. Ultimately the nose was plugged with lint and tannin, and no bad effects followed.-May 19bh: Dr. South assisting, some more gro wth was removed by the snare. This was soft, granulomatous, and malignant. The nasal passage was " clear " after this operation, but the bleeding was again profuse.-June 2od: There is extensive return of the growth, but it seems mobile, and believing it originated in the turbinate bone I advised opening the nose laterally, free removal of the turbinate bone, and the application of Paquelin’s cautery.-16th (operation): Dr. F. Hewitt administered anaesthetics. Assisted by Mr. Waterhouse, I opened the nose laterally. On introducing the finger, it was at once obvious that very serious disease was present. Firm lobules of growth could be felt, which obviously had their origin from the antrum. It was therefore decided to removethe entire jaw, and this was at once done in the ordinary The bone was friable, and "broke downunder manner. the lion forceps. The whole antrum was filled by a malignant growth, which extended above to the region of the cribriform plate, and behind to the pterygoid region. Yet the tumour was fairly circumscribed, and at the conclusion of the operation it seemed completely removed. Although the operation was executed as rapidly as possible, the bleeding was exceedingly profuse, and at its close the patient was pulseless and appeared moribund. Her condition was for ten minutes ptecarious in the extreme. This was met by the sub-
HOSPITAL, NOTTINGHAM.
THE
history of cases of hydatid disease of the abdomen so widespread as in the present instance, however treated, is usually one of gradually failing health, exhaustion, and death. A successful result is therefore worthy of record. It is also of interest to contrast in the same patient the In treatment by free incision with that by puncture. addition to the cysts removed by laparotomy, and those discharged through the wound that remained, four cysts in various parts of the abdomen were treated by aspiration and none of them refilled, and the liver was aspirated eight times in two years and a half. It is now three years since the last aspiration. Hydatid disease is not very uncommon in this neighbourhood, and during the last ten years I have seen in my own practice and that of my colleagues a very considerable number of cases affecting the liver, peritoneum, kidney, retro-peritoneal tissue, abdominal parietes, and even a metacarpal bone ; and there is a specimen in our museum of a hydatid removed from the breast. On the whole I am strongly in favour, at any rate in the first instance, of aspiration rather than free incision in most cases. Very many are cured by a single tapping, notwithstanding the retention of the cyst wall. I have seen no advantage in taking only a small quantity of fluid, but prefer to withdraw as much as will readily now. L. B-, aged twenty-one, a lace-dresser, was admitted on July 21st, 1885, complaining of pain in the abdomen, headache, and loss of appetite. She used to be very stout, but has been losing flesh for the past six months, and now is rather thin. She first noticed a lump in the abdomen, just below the umbilicus, a year ago. For the past ten days the epigastric region has become distended and painful, and she has suffered from headache and loss of appetite. On admission the temperature was 102°F., the pyrexia being probably due to an attack of localised peritonitis, which soon subsided. The abdomen was tense and greatly THE
distended.
marked want of symmetry, rather more prominent than the left. The distribution of the dulness was very irregular. On palpation, rounded masses, varying in size from a walnut to a large orange, could be felt; but on account of the great tension I could not satisfy myself that any of them moved independently of the rest. The most prominent
though
the
There
was
right flank
no
was
43 A2