THE NASAL TREATMENT OF ASTHMA.

1151 and native soldiers in India will issued.

presumably

several other details in Dr. Coupland’s paper that make i valuable contribution to the statistics of cancer. I am. Sirs, yours faithfully, T. W. NUNN. Stratford-plaoe, W., Oct. 22nd, 1902.

have to be

a

IMPERIAL YEOMANRY HOSPITALS. Members of the staffs of the Imperial Yeomanry Hospitals who served in South Africa between Jan. lst, 1901, and May 31st, 1902, are requested by the Imperial Yeomanry Hospitals Fund Committee to send their present addresses and the dates of the commencement and termination of their services in these hospitals to Mr. Oliver Williams, The par116, Victoria-street, Westminster, London, S. W. ticulars given are to be compared with the entries on the medal rolls now being prepared by the commanding officers of the hospitals in connexion with the issue of the King’s medal and clasps under the special Army Order of

Sept. 29th,

_..,.,.

THE NASAL TREATMENT OF ASTHMA.

1902.

ROYAL ARMY MEDICAL CORPS

(VOLUNTEERS), parade of the London Companies of the Royal Army Medical Corps (Volunteers) will take place at the church of St. Bartholomew the Great, Smithfield, E.C., on Sunday, Oct. 26th, at 3 P. M. After the service, which will be conducted by the Rev. Sir Borrodaile Savory, M.A., rector of the parish and acting chaplain to the London companies of the Royal Army Medical Corps (Volunteers), a tablet in A church

memory of those men of the corps who have died while on service in South Africa will be unveiled by Surgeon-General W. Taylor, K.C.B., K.H.P., Director-General of the Army Medical Service.

THE MEDICAL ARRANGEMENTS FOR THE ROYAL PROCESSION THROUGH LONDON. At the Cattle Market, Islington, at the Surrey Sessions House, and at Olympia there will be stationed field hospitals, each of 25 beds, while at the Tower of London there will be a detention hospital of 10 beds which will also be used as a temporary field hospital. Along the line of route there will be 16 ambulance stations and 109 stretcher squads will be Colonel W. L. Gubbins has formed at various points. general charge of the medical service. THE MEDICAL STAFF COLLEGE. On the conclusion of the first session of the Medical Staff College in London, the lieutenants-on-probation for the Indian Medical Service will proceed to Netley for duty, where they will receive instruction in military medicine and surgery and in squad and company drill. They will also take part in the ward duties of the Royal Victoria Hospital and there receive clinical instruction. They are to arrive at Netley on Nov. 3rd. The course at Netley will occupy two months.

Correspondence. "Audi alteram

partem."

OVARIAN TUMOUR SECONDARY CANCER OF THE BREAST.

m

TO

To the Editors of THE LANCET.

SIRS,-In the discussion at the Medical Society of London on Oct. 13th, on Mr. J. Bland-Sutton’s case of ovarian tumour secondary to cancer of the breast, reported in THE LANCET of Oct. 18th, p. 1052, there appeared to be a considerable difference ’ of opinion as to "the relative frequency with which cancer attacked both breasts concurrently or after an interval of months or years." As bearing on the point at issue I would mention that in the twenty-seventh volume of the Transactions of the Pathological Society of London Dr. Sidney Coupland gives an analysis of 89 cases of mammary cancer examined after death showing the relative frequency of the seats of secondary growths, compiled from the reports of the surgical registrars of the Middlesex Hospital, 1867 to 1875. Dr. Coupland shows that cancer was found in both breasts in 17 cases (a percentage of 19 ’1) and in the ovary in five cases. This analysis is appended to a report of a case of cancer of both breasts and ovaries under the care of the late Mr. Hulke. The case and the comments by Dr. Coupland areI most interesting reading to students of cancer. There are

i

To the Editors of THE LANCET. SIRS,-The paper read at the Clinical Society of London on Oct. 10th by Dr. Alexander Francis of Brisbane on the above subject gave rise to so much discussion that many were unable to speak. Perhaps you will give space for a summary of my experience so far as it can be condensed into a letter. The fact that Dr. Francis stumbled upon his method-it was, he told us (in the first case), quite an accidental application of the cautery-would lead those unacquainted with the results of intra-nasal treatment of asthma and allied conditions to look with doubt upon his results, more especially as he was unable to specify any one area on the septum more likely to give relief than another. I gathered in conversation after the meeting that the sensitive area varied in each, case and he found that many applications of the cautery might be required before the sensitive spot was found, while in others a single application had removed an asthma of several years’ duration. That, Have others any as I understand, is Dr. Francis’s position. ground for believing that the course of our inquiries lead up to the position accidentally secured by Dr. Francis’?? Let me briefly summarise my experience on the subject. 1. The most striking results are obtained in paroxysmal sneezing-patients, men and women, who suffer from profuse coryza and sneezing in the morning so that dressing is a difficulty. The attacks occur also in the night after the first sleep and in this regard closely resemble asthma. In several cases (when the attacks occur frequently in the day) patients have been threatened with loss of employment owing to the inconvenience and the exhaustion produced. In these cases a sensitive spongy area on the septum, which is the same for nearly all, will be found opposite the lower edge of the middle turbinal. The cauterisation of this acts rapidly, relief is magical, and one application on each side has removed a 10 years’ trouble, with resulting improvements in general health. These, as Dr. Francis pointed out, are common cases. For my own part, I am in this, as in many other points, indebted to Dr. Greville MacDonald for my initial knowledge. Success in these cases is most marked when there is no exciting cause. When attacks are due to the odour of animals-e.g., horses, especially on a dry day,to dust, or to particular flowers, success has not been so marked. In this group, however, all inquiries lead to the conclusion that the spot referred to above is not the sensitive area in all cases, for in a few no relief follows, while attention to other parts-for example, in one inveterate case the middle turbinal-affords relief. 2. No one can notice carefully the history of cases of asthma without observing that some abnormal nasal condition frequently exists or has existed. In young people especially nasal obstruction-from adenoids rarely, from hypertrophy of the inferior turbinal not unfrequently-is found ; in others there is a history of paroxysmal sneezing. This latter symptom one might expect, for in its periodicity, in its variation from no assignable cause, and in the wheezy breathing it is so closely allied to asthma. 3. In children with asthmatic attacksbeginning, it would not be difficult to collect evidence to show that after attention to adenoids, and especially hypertrophied inferior turbinals, the tendency has disappeared. Leading up to the intra-nasal treatment in this connexion it must be pointed out that odd results happen, as we know, in all spasmodic complaints. In a solitary instance removal of adenoids has effected-and unexpectedly-permanent relief, or the removal of a single polypus has removed a long-standing asthma. While these sporadic examples must, as in all inquiries, have their place and value as leading to further advance, the notable fact that removal of the grosser lesions, does not remove the spasm in asthma, only leads us to the conclusion, that in removal of these growths, when relief has been afforded, some specially sensitive area has been injured and destroyed. Instead of checking inquiry these isolated examples seem to point out to a further search in the direction indicated by Dr. Francis. 4. With regard to the association of polypi, it is well known that as a rule there is no true asthma. There are in a

1152

good

T

many,

however, wheezing, breathless attacks, disturbedd which is followed

f change to

with

success

and

requires

no

fundamental

effect it, nor does it present any apparent abstrusenights, and many of the symptoms of asthma. Some of ness to the average mind. It consists in arbitrarily regardthese symptoms are due to mechanical obstruction and ex:s ing one grain as equivalent to 5 centigrammes, 15 grains as cessive secretion only, but others can only be explained as reflex phenomena. Again, in a few notable examples thee one gramme, one drachm as 4 grammes, and one ounce as d 30 grammes. This usefully serves all practical purposes for removal of polypi has relieved asthma with a rapidity and completeness, not to be surpassed by the results obtained byy ordinary occasions, and as the error introduced is distinctly Dr. Francis, or in those obtained in cases of paroxysmal on the side of safety it may. therefore be justly ignored. sneezing. One recent instance was of fifteen years’ standing,Where exact accuracy is essential, as, for instance, in typical in every way as to nocturnal habit, thoracic spasm,forming standard solutions, the more correct quantity of Removal of polypi from the right nostril, together withb. 0’065 of a gramme as representing one grain does not &c. a polypoid middle turbinal, was immediately followed by Further, as y present any serious difficulty in calculation. the disappearance of all symptoms and restoration of sleepp the word gramme, or even its contraction, "gm.," is very and health-this in a very active busy life which even asthmaa seldom used in actual practice there is little likelihood of did not invalid. In a man aged 62 years (asthma havingconfusion arising from its possible resemblance, when commenced at 45 years) the same conditions were found,, hurriedly written, to "gr.,"as representing the word grain. but treatment has not yet been commenced. The abovee Perhaps it is almost needless to say that the more usual way remarkable success may be explained as suggested in para- of writing the quantities is to employ the figures only, marking their relative positions by the use of the cypher" 0," graph 3. 5. Once more, in examining cases of paroxysmal sneezingand employing the comma to represent the decimal point. when the cautery has failed one has noticed a pale gela- One gramme would therefore be written as 1, 0 and 5 decitinous middle turbinal. The mucous membrane is pale and grammes, ora gramme, as 0, 50, and lastly, 5 centigrammes abundant, so that it can be moved by a probe and is nott would be expressed as 0, 05. As all the quantities, both dry shrunk away with cocaine. This condition has been reco-- and fluid, are generally weighed-the latter in the dispensing gnised for years as the cause of recurrence of polypi andi bottle placed on the pan of the balances-only the one its removal to be necessary. Now in some cases of paroxys-- system, that of gramme and subdivisions, is commonly mal sneezing and in some cases of asthma this condition hass employed. It would be an advantageous step in the right direction and been found. In one sneezing case polypi were found crowded1 in the middle meatus when the anterior end of the middleone of prime importance if at all teaching centres for medical turbinal was removed. My observations are not sufficientlyr training, and in the further editions of the various books on the Pharmacopoeia, a point could be made of giving the numerous in asthma to justify any conclusions on this point, but as this gelatinous condition has been found I believe at formulas and doses in the nomenclature of both systems. If the mere fact of the greater simplicity and uniformity of the new step has been gained in recognising the necessity ofE removing this gelatinous middle turbinal where no polypii metric svstem were more fully known it would of itself exist. Let it be noticed that there is no pus and that noaccomplish a great deal in more speedily bringing about its ,

"

,-

,

granulations are visible. In

and I feel that its acceptance may well-directed but influential and organised effort to render it a completed fact. I am, Sirs, yours faithfully, KENNETH SCOTT. Manchester-square, W., Oct 21st, 1902. own

general adoption,

conclusion, it may be said that the remarkable relief, perhaps only require

afforded in cases of paroxysmal sneezing justifies the employment of the cautery in asthma ; that relief in all cases is; afforded by removing the gross lesions and in some the attacks disappear; that in children the removal of all nasal irritation, especially noting the condition of both middle and inferior turbinals, may be followed by great amelioration and even arrest the progress of asthma ; that when a history of paroxysmal sneezing exists there is a good prospect of success ; that the unexpected relief afforded in isolated cases by removal of polypi or a gelatinous middle turbinal or in the application of the cautery, indicates that the sensitive area from which a reflex may start is not the same for all ; and that all observation lends support to Dr. Francis’s empirical position, so that one cannot but consider it a duty to advise and to employ the cautery-lightly and painlesslyeven where no morbid condition is seen. I am, Sirs, yours faithfully, CHARTERS J. SYMONDS. Portland-place, W., Oct. 20th, 1902. .

some

To the Editors of THE LANCET. not see the letter of Sir William Gowers in THE LANCET of Oct. 4th, headed The Metric System in Pharmacy," until last week. I should like to say that the letter seems to me to deal in a practical way with a practical difficulty. I would point out in passing that I do not think there is any difficulty on the part of pharmacists in dispensing prescriptions written in the metric system. One of the great hindrances to its adoption has been the trouble of making calculations for the conversion of the one system into the other, perhaps repeatedly so in a busy dispensing day. The alternative suggested certainly would tend to remove this, as not only would the calculations be easily made I am,not but without much effort be remembered. " would always be clearly sure that the contraction" gm. distinct from "gr.," but the three additional helps to a THE METRIC SYSTEM IN PHARMACY. solution should practically prevent any possibility of error. To the Editors of THE LANCET. From the point of view of practical pharmacy, some such further SIRS,-In support of the plea made by Sir William practicable plan, without entering into the question of Gowers for the more general acceptance and use in practice whether one combination of figures was the exact equivalent of the metrical system for pharmacy, there should be no of the other, is in my opinion the surest means of getting the difficulty on the part of the pharmacists, and hitherto I have system carried into practice, the result then being, as sugfound none, as the only trouble entailed on them is that of gested in the letter, the "survival of the fittest." Might I obtaining, if not already possessing, a set of metric weights point out that in the presentation of a badly or hurriedly and measures, which is but a slight expense. It may be, how- written 0 in the metric system there is a danger of its being I am. Sirs. vours faithfullv, ever, that, the process of transition from our present system read for 6. to this one forms the principal deterrent to its adoption, but FRANK A. ROGERS. Oxford-street, W., Oct. this only appears difficult to those who are unfamiliar with it. Whilst according all deference to the suggestion put forward ERRATUM.-The last paragraph of Dr. W. R. Huggard’s by Sir William Gowers to facilitate the process by increasing, letter on "The Metric System in Pharmacy," published in in a small and merely nominal degree almost, the value of THE LANCET of Oct. 18th, p. 1078, ought to have appeared our present unit, the grain, and whilst duly acknowledging as follows : "In tabular form the points to be remembered the undoubted efficacy of such a change, I fear that it might are that practically," and the last threeditto marks" in fail through the introduction of the additional arithmetical the table of equivalents should be omitted. factor involved, combined with the effect of a proposal which to some might seem too radical for it to receive the support ISOLATION HOSPITALS. necessary for its adoption, and thus such a measure, if its introduction were seriously attempted, might have the result To the Editors of THE LANCET. of defeating its own ends. From considerable knowledge of the use of the metric SIRS,-Isolation hospitals seem to be in bad odour just system amongst the members of our profession practising out now ; but it will be a sorry day for this country when they of England, I should like to mention a method of transition cried down. They could be, and should be, above

SIRS,-I did

15th, 1902.

are