LARYNGOLOGY AND RHINOLOGY.

533 no cases in which there were physical signs of the polypi grew; (3) the polypi originating also from the infantilism but where ovulation and menstruation were interior of the ethmoidal cells ; and (4) the primary cause delayed. These errors were of considerable practical of the polypi in many cases was a neglected latent empyema. importance, and two instances might be cited. The first The treatment always depended upon the particular conexample was seen in hypertrophy of the cervix. In the child dition present. It might include (1) resection of the greater the cervix formed two-thirds of the uterus, but at puberty part of the middle turbinated body; (2) removal of the corpus uteri enlarged out of proportion to the cervix. the bony base of the polypus ; or (3) opening of the Occasionally the cervix might hypertrophy at puberty to ethmoidal cells and removal of their lining membrane. such an extent that it protruded at the vulva. Clinically Cutting instruments only were to be used, chemical and the case was usually first brought under notice as an electric cauterisation being contra-indicated. The treatment example of "prolapse." Both fornices were, however, always required several sittings. A good view of the operapresent. If the cervix was amputated and the perineum tive field was indispensable. An interval was necessary repaired the condition was cured ; otherwise it gave rise to between the individual operative proceedings. All polypus dyspareunia, and if labour occurred the condition was cases could be cured in time if no cause prohibited operative exaggerated by laceration, subinvolution, and oedema. treatment. Lack’s method-the removal of all polypi at one There was no necessity to distinguish between hypertrophy time under chloroform-might sometimes be considered, but of the vaginal and supra-vaginal portions or between hyper- was not generally employed. Operative treatment under trophy in virgins and parous women. These terms might be general narcosis was difficult owing to the view of the replaced by the simple one of hypertrophy of the cervix at operative field being less than under cocaine anaesthesia ; puberty. A second example of a developmental error was also because of the necessity for completing the operation at seen in the menorrhagia of young girls at and about one sitting it was performed in the absence of a knowledge puberty. Normally a great increase in the amount of of precise conditions, a dangerous procedure ; moreover, all muscle occurred at this period. If this was not sufficient diseased parts could not be removed at one sitting. then menorrhagia followed, since the loss of blood was directly (b) When the principal feature was suppuration and the controlled by uterine contraction. The endometrium in these discharge free the treatment always depended upon the cases was usually hypertrophied. - Ergot and hydrastis were diagnosis after excluding other empyemata and the freedom useless in treatment because the muscle was deficient. of the openings of the ethmoidal cells. The removal Time alone would cure the condition, but relief might be of all the polypi and hypertrophied parts of the ethmoid obtained by rest in bed and curettage, which might have to was generally preceded by the resection of the middle turbinated body. The suppurating cells were precisely be performed more than once. Dr. PURSLOW could not agree with Dr. Fothergill’s determined with the probe, and opened up with the details of the remarks concerning hypertrophic cervix in virgins. He had hook and curette, the operation seen many cases, and the majority, he felt sure. were the depending on individual conditions. Special care was result of hard work and were but one variety of uterine required in the region of the infundibular cells, from the prolapse. In hminorrhage in young girls he had curetted proximity of the orbit and the lamina cribrosa. When the infundibular cells were situated high up an external operawith good results. In opening the posterior ethmoidal Dr. CHIPMAN thought, as regarded the two groups of tion was indicated. developmental errors, that the one consisted rather of abnor- cells one might begin at the anterior cells and gradually malities in the proper" assembling"of the parts, whereas proceed backwards, or begin at once with the posterior the other was rather an alteration in " growth." His own labyrinth. The latter was attacked above in the level of the practice in the case of menorrhagia at puberty was to send middle turbinated body. A high septal deviation, it the patient to a higher altitude. He never curetted unless present, must be previously corrected. As much as possible the case was desperate. might be done at each sitting, but only so long as a good The PRESIDENT agreed with Dr. Chipman’s views. He also view was obtainable. An interval between sittings was thought that hypertrophy of the cervix was certainly indispensable to allow the reaction to subside. Packing of the nose after the operation should be avoided. Healing aggravated by hard work. Dr. STOOKS asked how long it was necessary to go on was always by superficial cicatrisation, never by the filling curetting. Cases drifted off and it was impossible to tell up of the ethmoidal cells. The external method was when they were really cured. Although in Liverpool they indicated (1) in cases with high infundibular cells inaccessible lived in what might well be called a " calcium atmosphere," from the nasal cavity, (2) in very narrow nostrils with he had never found this condition improved by the adminis- threatening symptoms, and (3) in cases complicated by tration of such salts. In cases in which a perforation had severe frontal sinusitis. Dr. HEDLEY asked if hypertrophy of the supra-vaginal occurred the choice of operations depended on the nature of cervix was common as a developmental error. He had always the case. Slight relapses were frequent even after radical taught that it was dragged out by prolapse of the vaginal’ operation. When the principal feature was suppuration and the ethmoidal cells were closed. the treatment generally coiiwalls, the uterine body being fixed. Dr. FoTHERGILL replied. sisted of opening a prominent portion of the dilated ethmoidal ERRATUM.—In THE LANCET of August 17th, p. 459, Pro- cells to obtain free discharge. That necessitated the removal of fessor J. B. Hellier was reported to have expressed the a large part of the bony wall. The details of treatment by the findings after investigation with the opinion that in 99 cases out of 100 albuminuria in pregnancy were decided can be cured by milk diet. Professor Hellier writes to point probe. No important differences existed between the treatont that it was not he who said this, and that he regards it ment of diseased single cells and that of the greater part of An external operation was necessary only as rather an exaggeration of the truth. We regret our the labyrinth. if the disease was complicated by perforation. II. In reporter’s mistake. ethmoiditis associated with ozæna operative treatment was contra-indicated if the discharge was free. Curettage was LARYNGOLOGY AND RHINOLOGY. resorted to only in cases of very definite disease of single cells. Threatening complications were treated by external FRIDAY, JULY 26TH. operations. III. The treatment of secondary suppurative President, Dr. J. MIDDLEMASS HUNT (Liverpool). disease of the ethmoidal cells-e.g., tuberculosis, syphilis. Professor M. HAJEK (Vienna) opened the discussion on malignant growths-depended upon the nature of primary The Treatment of Chronic Suppurative Disease of the disease. Ethmoidal Sinitses. JJr. JH.. LAMBERT LACK (London), in his introductory He divided the subject as follows : I. Chronic suppuration paper, said that operative treatment was invariably indicombined with hyperplasia. (a) When the principal feature cated, although there were non-operative adjuncts to the was polypus formation the treatment consisted in the retreatment. The symptoms were more serious than those moval of the polypi and the prevention of relapses. The occasioned by the same disease in the other sinuses. He best method was under local cocaine anaesthesia ; the removal regarded piecemeal operations under cocaine as dangerous. with the snare and by avulsion if possible, and the removal He advised packing of the nose with a solution of cocaine of the base with curettes or forceps. The causes of relapses and adrenalin half an hour before operation with the ethmoidal curette. The antrum thereby could be more were : (1) The overlooking of polypi originating in the depths from which of the meatus ; (2) disease of the bony parts readily examined and if found diseased could be treated

(3)

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534 fir:,t. The ring knife for curetting the ethmoidal cells it was as well to regard the sphenoidal and frontal sinuses should be introduced with the blunt edge towards ’the as more highly developed cells of the ethmoidal labyrinth. septum and the cutting edge should be turned not upwards He lirged the use of X rays’in the investigation of the extent but towards the orbit. It should be passed without force of the disease and of the presence or absence, as well as the ’directly upwards and backwards, then drawn horizontally size and situation, of the larger cells. He was opposed to forward. After the operation theupper portion of the nose operations which necessitated blindly groping in the dark. became lined with a white starred membrane. A continu- The operative treatment, he considered, should be done under direct ocular inspection. ance of the suppuration after curetting might mean suppuraDr. A. BRONNER (Bradford) objected to general anesthetics tive, disease in the other sinuses, the sphenoidal or the It was necessary to As to the dangers of the operation, his own in operations upon the ethmoid. frontal. statistics showed 1 death in 300 cases. As to the results of remove any intranasal obstruction. He did not regard Dr. the operation at the hands of others he had learnt that 11 Lack’s operation as the operation of the future. Professor HAJEK, in replying, again urged the importance operators had had no deaths and three had had six deaths, .all due to meningitis. The operation was serious, but he of a perfect diagnosis and of everything operative being done thought that the risks were justified. Little danger under the eye. The anatomy varied so much that it was attended the operation if performed skilfully and with impossible to generalise. The middle turbinate body had to aseptic precautions. The patient should be under 40 and be removed in most cases to see what to do. If there were ,Iiot over 50; after the latter age the bones in the no subjective symptoms, and little or no pus, there was no ethmoidal region were more brittle. A rise of tempera- reason for operating. ture after operation was not uncommonly due to packDr. LAMBERT LACK, in his reply, expressed his satisfaction ing the nose ; if hæmorrhage occurred the nose had to be with the debate and his gratification at learning that so packed. The administration of vaccine preparatory to the many had practised his operation. He regarded his operaoperation was considered to obviate fever. Amongst the tion, not as the one of the future, but as the one of to-day. Dr. BALLENGER also replied. complications the orbital bone might be fractured and subsequently evidenced by a black eye. He regarded the operation with the curette as the best method of dealing with cases PATHOLOGY. of uncomplicated ethmoidal suppuration. Dr. W. L. BALLENGER (Chicago), continuing the introFRIDAY, JULY 26TH. duction of the subject, said the disease might be acute or Professor I. WALKER HALL (Bristol). President, chronic, and that obstructive lesions in the nose were assoDr. T. J. HORDER (London) read a paper on ciated with the disease. When chronic, the nasal obstruction The was a factor, and in acute cases the predisposing cause was Investigation of Puncture Fluids as an Aid to Dzaptosis and Treatment. not uncommonly a lowered vitality, which might be induced nasal In obstruction. He described for the comthis he touched first on the technique which, his method bv simple exenteration of the ethmoidal labyrinth. He had found though it appeared, was often barbarous in its application that violent reactions and high temperatures followed from the attempt to use blunt or rusty needles, &c. He partial operations. He exhibited the instruments used for grouped the various punctures into punctures of certain .the removal of the entire ethmoidal mass. Cases in which cavities, of certain solid organs, and of certain adventitious the ethmoidal cells extended over the orbit called for an structures (e.g., abscesses, cysts, &c.). He considered that ,external operation. He never packed the nose, and he had in skilled hands there were no dangers or ill-effects from the had but one death out of a large number of cases. procedure, but he was not prepared to carry out pleural or Dr. H. P. MoSHER (Boston). continuing the discussion, lumbar puncture in the out-patient department or consulting The patient should be kept in bed for 24 hours said that formerly he had found intranasal operations in the room. and the Even lung punctures he regarded as safe. He had afterwards. preferred sphenoidal region unsatisfactory . external method. Since he had become acquainted with the would submit the fluid so obtained to cytological, chemical, work of Dr. Ballenger he had returned to the intranasal physical, and bacteriological investigation, though one or method. He briefly summarised the results of his anatomical other was usually of special importance according to the case in question. He summed up the value in diagnosis by saying investigations. Dr. P. WATSON-WlLLlAMS (Bristol) considered that an that cytological examination, broadly speaking, diagnosed antero-posterior as well as a posterior obstruction of the nose between tuberculous and pyogenic inflammations. Chemical was a source of great danger even if an ethmoiditis had not examination of fluids from serous sacs determined whether been established. He regarded the disease as an infective they were transudates or exudates. Parasyphilitic disease process of an insidious nature. The object of the operative often gave a cerebro-spinal fluid containing a globulin; treatment should be to establish sufficient drainage, and for urasmia a fluid with urea. Bacteriologically the causal agent ’ that purpose he preferred the forceps before the curette. in meningitis, arthritis, pleural effusion, pneumonia, &c., Dr, WILLIAM HILL (London) dealt with the extent of the was recognised and often allowed of a very early diagnosis ethmoidal region, which lie thought had been exaggerated. before definite clinical signs appeared. The puncture likeMr. R. H. WOODS (Dublin) was opposed to vaccine wise was often of therapeutic value-e.g., drainage of pleural treatment. effusion, meningitic effusion, joints, &c., apart from the fact Mr. HERBERT TILLEY (London) was a supporter of Dr. that the earlier the diagnosis be made the more sure the Lack’s method of operating, as more direct and quicker. results of treatment. The average English patient required the treatment if Dr. PURVES STEWART(London) agreed that pyogenic possible to be carried out at one sitting and under chloroform. infections usually produced a polymorph leucocytosis, He used the ethmoidal forceps. whereas tuberculous infection usually produced a monomorph - Mr. F’. H. WESTMACOTT (Manchester) was against external leucocytosis, but this rule was not absolute, for during conoperations. He preferred general anaesthesia for the primary valescence from a pyogenic infection of the meninges the operation and local anæsthesia for subsequent surgical treat- cerebro-spinal fluid passed through a later stage of He inquired of Professor Hajek his method of monomorph leucocytosis on the way to recovery. Further, ment. correcting a deviated septum when present in cases of sup- during an acute attack of tuberculous meningitis the leucopurative ethmoiditis, whether by a submucous resection or cytosis was not infrequently of a polymorph type. He by fracture of the deviated part. He also inquired why it believed that not the particular organism determined the was that after the removal of nasal obstruction at times the type of the leucocytosis, but the acuteness of the infection-olfactory sense, previously lost, returned while at other times an acute infection producing the polymorph, a subacute or chronic one the monomorph leucocytosis. Moreover, even it did not. Dr. W. JOBSON HORNE (London) said that whilst the title an infection was not essential for the production of leucoof the discussion was useful to themselves in defining its cytosis. He had experimentally injected the spinal theca in cope, nevertheless it might be misleading to others, inas- monkeys with a sterile emulsion of carmine when studying much as it might create the impression that chronic sup- the lymph-paths within the spinal cord. In every case there

plete

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ethmoiditis was an entity. It was quite evident from what had been said that the sphenoidal and frontal sinuses were not uncommonly involved. Moreover, both on anatomical and developmental as well as on clinical grounds,

purative

produced a temporary polymorph leucocytosis, changing a few days to a monomorph leucocytosis, and ultimately clearing up entirely. He had never found a general anaesthetic necessary to perform thecal puncture. ’ was

within