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NASAL OBSTRUCTION AS A CAUSE OF DEAFNESS.
835 These suggestions and criticisms would be logical and just if I had suggested the routine prevention of fibrin formation in peritonitis. In my paper I indicated a method, proved experimentally, for preventing the encapsulation of drains inserted in the normal peritoneum, and in the presence of a socalled chemical peritonitis, produced by tincture of iodine. I stated the opinion that the method had possibilities in the treatment of bacterial peritonitis. At the present time I am carrying on the second phase of this work, dealing with the bacterial peritonitis. It is not my intention to prevent fibrin formation and thereby increase the area of peritoneum involved in the infective process. I believe that it would vastly increase the mortality from peritonitis were we routinely to prevent or interfere with fibrin formation. But in the virulent forms of peritonitis evidence of fibrin is frequently absent. We have found, experimentally, that in the most virulent form of the disease the fluidity of the exudate is greatly increased, and there is not the slightest trace of fibrin, as shown by a total absence of agglutination. Under such conditions I believe that the use of hypertonic dextrose solution will not interfere with the most important of the normal defence mechanisms of the peritoneum. The flow from the drainage-tube, instead of being a pure serous fluid, would contain a large percentage of toxic exudate. The drainage of this toxic exudate, instead of permittingits absorption, is as much to be desired as in the case of thoracic empyema. That the increased lymph flow provides a suitable medium for the growth of streptococci, is in this instance correct. But this increased lymph flow contains a considerable amount of dextrose. It has been shown by Kendall and others that the streptococcus, as well as other types of virulent pathogenic bacteria, in the presence of a medium containing dextrose, becomes converted into harmless
5 and 6 in., and the greater part consist of respiratorv membrane. If the area which this represents be contrasted with the scar resulting from the use of the cautery, I submit that the effect of the latter is negligible. This reasoning would be fallacious if the second criticism were valid that the surface was injured over an extensive indefinite area round the site of cauterisation. Anyone can satisfy himself that this is not so by repeating an experiment which I made to verify this point. I split the end of a small wooden match and I wound the frailest fragment of cotton-wool round one of the limbs. I then dipped it in water and laid it horizontally on the side of my first finger with the naked limb uppermost. I found that I could cauterise the naked limb through without causing discomfort. A friend measured the distance of the cautery point from my finger at the conclusion of the experiment and as far as we could judge it was the 1/12 in. The experiment revealed the advisability of using a cautery at the lowest practicable temperature. The object of the wet cotton-wool was to prevent the wood conveying heat to the finger, and to ascertain if moisture in the nose was a contra-indication to the use of the cautery. The necessity of cilia for the maintenance of drainage depends on the angle which the surface to be drained makes with the horizontal, and whether drainage is assisted or opposed by gravity. On the upper and lower surfaces of the turbinals and on the floor of the fossæ it is necessary ; but on the smooth vertical surface of the turbinal its function must be limited to filtration. In private practice the ill-effects of treatment come under observation, and shortly before the war, in verifying a cocaine account, it transpired that I had anaesthetised 1700 cases in six months. I feel, therefore, justified in asserting that ill-effects resulting from the scientific use of the cautery are exceedingly rare. The desiderata are delicacy, and that neither manipulation nor gas-producing organisms. T am. Sir. vours faithfullv. examination should be made unless both hands and J. R. BUCHBINDER. instruments are effectively sterilised. This applies to the application of the cautery, but particularly to the preparation of the nose, which involves touching NASAL OBSTRUCTION AS A CAUSE OF cotton-wool, and foot-controlled basins, which I had in both consulting-rooms, are highly desirable. DEAFNESS. I have stood behind men drying the mucous membrane To the Editor of THE LANCET. and would have regarded it as a miracle if it escaped The conjunctiva, if anaesthetised, would SIR,—I think Mr. Macleod Yearsley must have injury. not have been similarly treated, and yet it is hardly misunderstood me. I wrote nothing in deprecation of resection. In fact, the second case to which I more sensitive. referred in my letter was treated by the removal of H. MACNAUGHTON-JONES. a septal spur by an antiquated method which, although a it gave excellent results, was not comparable to submucous resection. My experience has convinced me that resection and the cautery may be suppleTONSILLECTOMY AND RHEUMATISM. mentary or alternative methods, or that either alone indicated. the I be war To the Editor of THE LANCET. was may clearly During appointed surgeon to a hospital reserved for officers SIR,—Dr. Ogilvie and I were fully alive to the of the Air Force. One of the primary objects of the criticism to which we were exposed by the small hospital was the treatment of nasal conditions ; and number of our cases; not that our figures were liable one of the first cases I treated was an officer who had to error, but that our conclusions from so small a had his tonsils and septum removed privately before series of cases might prove unconvincing. The admission. He was sent into hospital because in assessing the value of conclusions drawn difficulty pronounced nasal obstruction was still evident. from a small number of cases lies rather in the " Both operations had been skilfully performed. The uncertainty that the cases were a " fair sample result of a few cauterisations was to convert an than in the figures themselves ; and Dr. Stallybrass. apparent failure into a complete success. The whose interesting criticism of our figures appeared that case has times itself. of repeated history many in your issue of April 14th, will doubtless admit that In reply to the criticism that the use of the cautery calculations of probable error are themselves fallacious necessarily leads to the injurious destruction of the when applied to small numbers. In the death-rates shown in Table II. of our paper secreting surface, I will describe the method I employ. My object is, of course, to produce not a (of 35 tonsillectomy cases 3 died (8’7 per cent.)i and passage but a scar which on shrinking will drag of 45 non-tonsillectomy cases 6 died (13-3 per cent.)). the surface down to the bone. I use a fairly sub- Dr. Stallybrass calculates a probable error of stantial platinum wire (about 1 mm. in diameter) 4-8 per cent. in a difference of 4-6 per cent. as a cautery point. Owing to the movements of I suggest that in these figures there is no possible the hand this creates a wound about 2 mm., or error, and that calculations of probable error are possibly 1/10 in. in width. If a vertical section were valueless. By his paraphrase of our Table IV. made through the middle of one of the nasal fossae, Dr. Stallybrass appears to have fallen into an error and a narrow strip of mucous membrane were removed which invalidates his final criticism of our figures. at the site of section, it would measure between Table IV. was as follows.
5 and 6 in., and the greater part consist of respiratorv membrane. If the area which this represents be contrasted with the scar resulting from the use of the cautery, I submit that the effect of the latter is negligible. This reasoning would be fallacious if the second criticism were valid that the surface was injured over an extensive indefinite area round the site of cauterisation. Anyone can satisfy himself that this is not so by repeating an experiment which I made to verify this point. I split the end of a small wooden match and I wound the frailest fragment of cotton-wool round one of the limbs. I then dipped it in water and laid it horizontally on the side of my first finger with the naked limb uppermost. I found that I could cauterise the naked limb through without causing discomfort. A friend measured the distance of the cautery point from my finger at the conclusion of the experiment and as far as we could judge it was the 1/12 in. The experiment revealed the advisability of using a cautery at the lowest practicable temperature. The object of the wet cotton-wool was to prevent the wood conveying heat to the finger, and to ascertain if moisture in the nose was a contra-indication to the use of the cautery. The necessity of cilia for the maintenance of drainage depends on the angle which the surface to be drained makes with the horizontal, and whether drainage is assisted or opposed by gravity. On the upper and lower surfaces of the turbinals and on the floor of the fossæ it is necessary ; but on the smooth vertical surface of the turbinal its function must be limited to filtration. In private practice the ill-effects of treatment come under observation, and shortly before the war, in verifying a cocaine account, it transpired that I had anaesthetised 1700 cases in six months. I feel, therefore, justified in asserting that ill-effects resulting from the scientific use of the cautery are exceedingly rare. The desiderata are delicacy, and that neither manipulation nor gas-producing organisms. T am. Sir. vours faithfullv. examination should be made unless both hands and J. R. BUCHBINDER. instruments are effectively sterilised. This applies to the application of the cautery, but particularly to the preparation of the nose, which involves touching NASAL OBSTRUCTION AS A CAUSE OF cotton-wool, and foot-controlled basins, which I had in both consulting-rooms, are highly desirable. DEAFNESS. I have stood behind men drying the mucous membrane To the Editor of THE LANCET. and would have regarded it as a miracle if it escaped The conjunctiva, if anaesthetised, would SIR,—I think Mr. Macleod Yearsley must have injury. not have been similarly treated, and yet it is hardly misunderstood me. I wrote nothing in deprecation of resection. In fact, the second case to which I more sensitive. referred in my letter was treated by the removal of H. MACNAUGHTON-JONES. a septal spur by an antiquated method which, although a it gave excellent results, was not comparable to submucous resection. My experience has convinced me that resection and the cautery may be suppleTONSILLECTOMY AND RHEUMATISM. mentary or alternative methods, or that either alone indicated. the I be war To the Editor of THE LANCET. was may clearly During appointed surgeon to a hospital reserved for officers SIR,—Dr. Ogilvie and I were fully alive to the of the Air Force. One of the primary objects of the criticism to which we were exposed by the small hospital was the treatment of nasal conditions ; and number of our cases; not that our figures were liable one of the first cases I treated was an officer who had to error, but that our conclusions from so small a had his tonsils and septum removed privately before series of cases might prove unconvincing. The admission. He was sent into hospital because in assessing the value of conclusions drawn difficulty pronounced nasal obstruction was still evident. from a small number of cases lies rather in the " Both operations had been skilfully performed. The uncertainty that the cases were a " fair sample result of a few cauterisations was to convert an than in the figures themselves ; and Dr. Stallybrass. apparent failure into a complete success. The whose interesting criticism of our figures appeared that case has times itself. of repeated history many in your issue of April 14th, will doubtless admit that In reply to the criticism that the use of the cautery calculations of probable error are themselves fallacious necessarily leads to the injurious destruction of the when applied to small numbers. In the death-rates shown in Table II. of our paper secreting surface, I will describe the method I employ. My object is, of course, to produce not a (of 35 tonsillectomy cases 3 died (8’7 per cent.)i and passage but a scar which on shrinking will drag of 45 non-tonsillectomy cases 6 died (13-3 per cent.)). the surface down to the bone. I use a fairly sub- Dr. Stallybrass calculates a probable error of stantial platinum wire (about 1 mm. in diameter) 4-8 per cent. in a difference of 4-6 per cent. as a cautery point. Owing to the movements of I suggest that in these figures there is no possible the hand this creates a wound about 2 mm., or error, and that calculations of probable error are possibly 1/10 in. in width. If a vertical section were valueless. By his paraphrase of our Table IV. made through the middle of one of the nasal fossae, Dr. Stallybrass appears to have fallen into an error and a narrow strip of mucous membrane were removed which invalidates his final criticism of our figures. at the site of section, it would measure between Table IV. was as follows.