occupied two-thirds of the bulk of the tumor, the other third being formed by a yellowish tissue of firm consistence, and by a shell of bone of oval shape 2x3 cent., containing a soft milky material. No direct connection was found between the body and the vena cava." I at first thought that the tumor was sarcomatous, but I cannot really say what it is. It seems to be connected with the capsule of the liver, but by pulling on it, you can disconnect it entirely. DR. T. F. RUMBOLD here finished his paper on "Nomenclature." DR. ROBERT BARCLAY.-I think the society ought to feel grateful to the Doctor for having drawn its attention to such an important subject as this. In this climate and especially in this city, it is a common trouble. When it comes to sequestration of this peculiar condition, the trouble is so common it may make it worth while to give it a separate name. It is, however, a form of atrophic rhinitis or form of ozena. When I say that, I mean to make a distinction between atrophic rhinitis and ozena. The latter is of scrofulous or syphilitic or constitutional origin; there is always that intense fetor present. As a rule there is disease of the nasal bones as well as ulceration and putrefaction of the pituitary membrane of the nasal tract. Atrophic catarrh is a part of a general process, according to the best authorities. Concerning the pathology of this trouble there is, at first, an acute rhinitis or coryza; repeated attacks of this produce chronic catarrhal rhinitis. If it is continued, there is a change in the structure of the membrane. It is an established fact that wherever there is chronic catarrhal inflammation of the mucous membrane, changes take place most rapidly and most extensively in the deeper layers; this is especially the case in the nose. Changes taking place thus, at first functional and then organic, produce hypertrophy. The fibrous elements becoming organized, interfere with the glandulæ and cells, and constrict them; this prevents the free secretion that was seen before the membrane is drawn down tense against the turbinated bones, and the secretion is checked on nearly the entire membrane. A certain number of the glands escape, and in a few places this secretion goes on and forms crusts. I believe it was said that there are no crusts in rhinitis atrophica; however, there are crusts formed in this disease. If this process goes on long enough, and the patients are careless in regard to cleanliness, this is apt to assume the fetid form of atrophic catarrh, not ozena. The entire process can be divided into these forms. I have heard it stated by a gentleman of this city that he has seen atrophic catarrh in one nostril and hypertrophic in the other. That merely means that the process is older in one than in the other; or that the process developed more rapidly in one than in the other, perhaps owing to a deflected septum. In regard to placing cotton on the crusts, the secretion the doctor tells us does not come from the membrane etc. he is right about that. I would like to read the Society some notes which I hope may be interesting to it. In regard to ozena, it is a different process, of a different character from atrophic catarrh; the fetor is different. Dunglison's Medical Dictionary.-Revised Edition.-1874. p. 744: An affection Ozena.-Coryza atonica, etc. of the pituitary membrane which gives occasion to a disagreeable odor similar to that of a crushed bed bug, etc. It is sometimes owing to caries of the bones; but is perhaps most frequently dependent upon syphilitic ulceration of the pituitary membrane with or without caries of the bones of the nose. DR. G. M. Lefferts.-Lectures on diseases of the Nose and Throat.-College of Physicians and Surgeons, New York. RHINITIS (Nasal Catarrh) Acute Rhinitis (Coryza). II CHRONIC. I Chronic Rhinitis, (Simple Nasal Catarrh) RHINITIS. "Nasal Catarrh" is a too generic term; always specify the diseased condition if possible. First we have increased secretion after a short stage of dryness:-"Cold in the head.Acute Rhinitis:-Coryza. Four forms of Chronic Rhinitis. These cases meet the physician oftener. They come with chronic rhinitis, the simple nasal catarrh--or later with hypertrophic nasal catarrh-after the preceding condition has continued for a long time-there is infiltration of the mucous membrane and cavernous tissue,-causes hypertrophy, and the nasal passage is diminished in calibre and breathing through it becomes difficult, sometimes impossible; if this process goes on, we get atrophic or dry nasal catarrh or fetid catarrh-the plastic fibrin contracts and compresses the follicles and glandulæ and destroys them, now the secretion is diminished in amount or entirely absent, whereas it was profuse before. Some few glands may remain active, but the membrane is abnormally dry and thick. We can now look through the nares and into the su Ozena.-a term misused to mean Fetid Catarrh-but is properly used to signify absolute necrosis of the nasal bones in scrofula or syphilis and ulceration of the nasal mucous membrane-this stinks and discharges nasty matter. Use the prefix syphilitic or scrofulous. This is not catarrh. Syphilis is more common in the nares than scrofula. Remember that ozena is never catarrh. DR. G. M. LEFFERTS.-The diagnosis and Treatment of Chronic Nasal Catarrh, second edition, 1886, page 18: "The one symptom that patients most fear, and justly so, I have alluded to the foul smell from the nose; but it is in reality a rare one; it only occurs in the fetid or atrophic form of nasal catarrh, which is by no means so common as the other varieties, and in ozena, but this has nothing to do with nasal catarrh. Do not forget this. It only occurs in patients who are victims of syphilis or struma-patients who have syphilitic necrosis of the nasal bones, with a stinking, purulent discharge, a discharge due to the presence of dead bone. The same thing sometimes happens in scrofulous subjects. Under these circumstances, then, you may have the fetid stinking disease, ozena, but only under these circumstances. Do not call cases of nasal catarrh, even the fetid form, ozena; they have, pathologically, nothing in common." Dr. Francis DELAFIELD.-Lectures on the Practice of Medicine, Reported by M. Josiah Roberts, M. D., New York, 1881, page 9-10: "The changes which take place in acute catarrhal inflammation (Dr. D. is speaking of acute catarrhal inflammation of mucous membrane) are always much more evident during the life of the patient than after death, and you will observe that these changes are not, properly speaking, structural changes. * * * Hence we may examine the part after death, and find no changes indicating that inflammation existed during the life of the patient. * * * It is important for you to remember this fact, that acute catarrhal inflammation cannot be affirmed or denied from evidence obtained at an autopsy." com I think in arranging these terms, it is absolutely necessary that a term that is a pound word should be made entirely of Greek or of Latin. On pathological grounds, I ob ject to the words, "ethmoiditis" and "sphenoiditis,,' because, as he says, they are not strictly inflammation of the ethemoid or sphenoid bones. Better term them ettomoiditis (?), etc., and then we have to put on the words "anterior," or "posterior." DR. M. D. JONES.-I have lately seen three or four cases of inflammation of the middle ear where there was suppuration, where there was atrophic rhinitis, and they are as obstinate as if they were attic troubles,having been under treatment for some time, care being devoted to the nose and throat, but they are still as they were. I would like to know what the gentlemen would do under such circum. stances. I would rather have a case where there was hypertrophy of the membrane than atrophy. In the former we generally have chronic catarrh of the middle ear, and I think in atrophic rhinitis we are not so apt to have that condition, but we are apt to have acute inflammation which rapidly runs on to suppuration. DR. A. D. WILLIAMS.-I think Dr. Rumbold confounds us very much in his subdivisions. While his nomenclature is proper, to divide it in so many names is confusing. The treatment is the same all through, and so is the prognosis. So far as suppuration in the drum cavities is concerned, I have only met with one or two cases that would not get well, and in these cases I am under the impression that the bone somewhere was involved, which was the reason. I have lately seen a couple of cases of what is known as complete atrophy of the turbinated bones. They were practically gone, mere rudiments of them were left, and the space in the nasal cavity was so great that the opposite mucous membranes would not keep each other moist, and so were perfectly dry, and covered with stiff nasty crusts. In both cases the drums were involved, and the prognosis was absolutely hopeless. There is no possibility of bringing the surfaces together, consequently no possibility of remedying this condition. Fortunately these things are not very common. DR. POLLAK.-You speak of the turbinated bones; you have reference to the bones themselves or the membranous part? DR. WILLIAMS.-To the bones. DR. RUMBOLD.-Dr. Williams did not un derstand me, or he would not have stated that there was no object to be gained by the nomenclature proposed. I said that I made no difference in the treatment, but others would have to, and the very reason of my giving these names was to point to the places of disHe says, call it all rhinitis; this means inflammation of the passages alone. The tur ease. binated process has been treated as the location of the disease. I have pointed out the location of the disease, and that is not the turbinated bones. I said atrophic catarrh does not secrete pus; atrophic mucous membrane does not secrete mucus. There is nothing to form crusts, which is proved by the cotton I spoke of. This process (illustrated) is not the location of the disease. That is the object; it is to prevent confusion. The disease is not there (illustrated). If you make the treatment all the time there it does make a difference. It does not make a difference with me because I don't treat the disease in that way, with the galvano-cautéry. ĎR. BARCLAY.-For information I would like to know who does that. DR. RUMBOLD.-Dr. Harrison in one of the late books treats it by galvano cautery. Michel cures it that way. It is not at all uncommon; in fact the galvano-cautery is considered the thing to cure atrophic catarrh. If we have ozena with hypertrophy, that proves we have a disease of the anterior or posterior ethmoid cells, that is, hypertrophy. Then if it secretes not enough mucus to prevent the drying of this mucus, there we have crusts. You can have disease of the mucous membranes with hypertrophy, but you don't see the crusts, and where the persons see the crusts, they treat it as atrophic catarrh. This is common; wherever the crust is lodged, they say that that is the place of the disease. Speaking about the nasal cavities being so far apart that they do not keep each other moist, that is true to a certain extent. But it is not because they are far apart; it is because the mucous membrane is atrophic. If you get mucous membrane so much atrophied that it will not moisten, that inflammation extends into these cavities which are not mentioned, and the secretion from them flows down on this enlarged nasal passage, and in that way produces fetid catarrh. DR. POLLAK.-When you speak of atrophy of the turbinated bones, do you have refer ence to the bone? DR. RUMBOLD.-If the bone is diseased I say "inferior turbinated bone of the ethmoid" is diseased. Therefore when I say the turbinated process I mean the mucous membrane. DR. W. A. MCCANDLESS.-I have here a specimen taken from a patient who died from hepatic hemorrhage. He presented himself to me on the 24th of May, pale and anemic. Said that on that morning while walking along the street he felt a severe pain on the right side and was compelled to go into an office. The pain passed away, and later in the day he called at my office. I prescribed for him, and the next day he came back saying he felt no better. I then discovered that there was swelling of the abdomen. I examined his heart and urine and found noth. ing diseased in them. The next day he complained more of this distention, and I saw that the abdomen was filled with foreign fluid. This so rapidly increased that I called in others but we were unable to make a diagnosis. He weighed twice as much on that day as he usually did. The fifth day it interfered so much with respiration that he said something must be done. I introduced a trocar and drew off seven quarts of blood. The cavity rapidly filled again, he was tapped again on the 30th and then on June 8th I attempted to draw some blood but failed. The whole abdominal cavity then felt as a gelatinoid tumor does; it did not fluctuate like ascites. He died on the 14th. We found the cavity filled with clots of blood, and on the liver I found on its upper surface an excavated space that looked very much like an ulcer. There was a large clot which covered the place where as you can see, the blood vessel had ruptured, and the blood had been extravasated underneath the peritoneum, where it is reflected on the liver, and then bursting through into the peritoneal cavity, and the patient died from hemorrhage from this point. Two years previous to this time the patient had a specific trouble, and he said although he had been treated successfully and had taken medicine for more than a year, yet he had never felt as well afterwards as before the contraction of the disease. DR. F. J. LUTZ.-What was the condition of the blood that was with drawn on the first examination? DR. MCCANDLESS.-It looked like pure venous blood, undecomposed. The peritoneum was not inflamed. DR. LUTZ.-I would like to ask why, after the first tapping, and it was found to be a sanguineous effusion a second tapping was resorted to? Would it not have been saving the patient's resources not to have done so? DR. MCCANDLESS.-For the same reason as at first-that it interfered so mnch with the breathing and also pressed so much on the stomach. --The various faculties of Paris contain 11,000 students, 3696 of which are medical, among the latter being many females from America who seek the advantages, denied them in their own country, on the other side. CHICAGO MEDICAL SOCIETY. their falling into the larynx. With reasonable care I have found it impossible to cavity with this instrument. The operation wound any part of the naso-pharyngeal can be quickly finished and with a little tolerance on the part of the patient it can be completed in one sitting. Discussion of Dr. Webster's paper. See page Stated meeting, July 18, 1887, the President, W. T. Belfield, M.D., in the chair, DEMONSTRATION OF A NEW INSTRUMENT FOR THE REMOVED OF THE PHARYNGEAL TONSIL. DR. HENRY GRADLE.-Some months ago I spoke to the society at length about the importance of hypertrophy of the pharyngeal DR. W. FRANKLIN COLEMAN.-As the tonsil. I then dwelt on the danger both to writer has said in introducing his paper, it the ear aud to the upper air passages pro- certainly seems to me a truth that all aurists duced by this trouble. By following some have, until recently, at least, paid insufficient of my cases for a longer period of time it attention to nasal diseases, and unfortunately has seemed likely to me that in some excep- those whose speciality it is to attend to nasal tional instances even more serious distur- and throat troubles have not been sufficiently bance to health results from enlargement of acquainted with aural affections, and therefore the pharyngeal tonsil. I know now of at the ear patient has not had the benefit of the least five children operated by me during the treatment he should have had. For myself, I last year and a half, all of whom had been am more and more paying attention to the puny up to the time of operation without be- treatment of nasal affections in aural dising exactly sickly. Since the operation eases. I think every institntion in which authese children have gained in flesh, vigorral diseases are treated should have a departand appetite in such a manner that I am inclined to make the former pharyngeal disease responsible for their feeble health. I have pointed out to the society at a previous meeting that the operation of removing the hypertrophied pharyngeal tonsil while neither dangerous, nor difficult, nor very painful, was anything but elegant. For with the various forms of curettes which I had hitherto used the vegetations were apt to slip from the grasp of the instrument thereby necessitating a number of attempts and sometimes a number of sittings before the pharyngeal cavity was cleared. I have since obtained more experience in galvano-caustic treatment of the enlargement, and would rank this method far inferior to that by cutting instruments, on account of the greater soreness left by the galvano caustic operation, as well as the possibility of producing suppuration of the middle ear. The instrument I show you to-night I have found to be the most satisfactory of any method yet employed. It consists of a stout pair of scissor blades, with prolonged handles bent out of the way, while the cutting ends of the blades turn up so as to be placed behind and above the soft palate. These ends are fenestrated triangles with the base up, 13 millimetres wide and 20 millimètres high. They apply themselves to the lateral walls of the pharynx when opened, while the cutting blades at their upper border snip off all prominences from the roof of the pharynx as they come together. The couple of springs on the outside of the fenestrated ends serve as guards to catch any detached pieces and prevent ment for the laryngologist. As far as hypertrophy of the turbinated bodies is concerned I think the galvano cautery has been a good deal overused, and as corroborative of that it is now being less used by those who were enthusiastic about it at first. Dr. Tiem, in Hirschberg's Centralblatt, says he has given it up almost entirely. He recently reported three cases in which it produced impaired vision, congestion of the optic disk with pul sation of the retinal veins, which are said to be secondary effects; the primary cause is congestion of the ciliary body which increases intra-ocular tension to which the pulsation of the retinal veins and hyperemia of the disk is due. Of course there is a primary objection to the galvano cautery, that it destroys too much of the membrane when employed indiscriminately. Dr. Bettman recently made a good suggestion; instead of applying the cautery to the surface of the mucous membrane he punctures it and destroys the submucosa. There are some causes of diseases in the middle ear other than those mentioned in the paper. It is pretty well recognized that middle ear dis eases extend from the nose. In a paper read by Dr. Gradle a short time ago he maintained that they were produced by micro-organisms extending from the nose and eustachian tube into the ear, and I understood him to maintain that all middle ear diseases were produced by these organisms except perhaps, atrophic changes in the middle ear. I might agree with him that rhinitis is contagious, but I question very much if contagion is the usual source of middle ear disease. If rhini tis is usually contagious why is it that naso- cautery has been abused in this manner is no pharyngeal disease may be called the Ameri- reason why it should be universally concan disease as compared with Europe? I demned. He spoke of it destroying too suppose contagion is no less strong in Europe much tissue. I stated in my paper, where we than America, and if naso-pharyngeal have this cauliflower appearance, where we catarrh be caused only by contagion why itis have a membrane that is not healthy, the not more prevalent there? I think atmos- only thing to do is to entirely remove the pheric conditions are very prominent factors growth, but in those cases in which we have in producing naso-pharyngeal diseases. a smooth or nearly normal appearance and Other causes of middle ear diseases are bad the trouble is in the submucous tissue I pass air, for instance an impure atmosphere may an instrument through the growth; some of produce an attack of rhinitis; insufficiently these instruments I have fully an inch long, ventilated rooms; dust, tobacco dust; in cigar and they are passed into and if need be enmanufactories the workmen have nasal tirely through the growth, then the current catarrh and middle ear disease as a conse- is turned on, and we destroy no healthy tissue quence; boiler makers have middle ear dis- except the Schneiderian membrane, where the ease; some think it is due to disease of the electrode punctures it, but we do destroy the labyrinth, but I think it is due to middle ear hypertrophied tissue, and those blood vessels affection. Tobacco secondarily affects the that are enlarged, and then we have the cicamiddle ear. This as a cause of ear disease is trix drawing down and anchoring the parts a little out of the line of the paper, but firmly. I have sometimes used cocaine with within the last week I had a case of laby- the very best results as a local anesthetic. rinth disease produced by tobacco. Another When we make this puncture we do not desource of otitis media is bathing and diving, stroy much of the membrane, the opening is and the cause may be through the cold water very small and closes up almost immediately, entering the external meatus, or during the and is not like a large opening where we cau act of swallowing water, which opens the terize a large surface. But if the cautery faucial end of the eustachian tube, enters the will produce these effects what must be the middle ear and produces acute or subacute effect where we use anything like chromic otitis media. Another cause is the nasal acid or nitric acid? What will we get from douche, which creates inflammation of the something which we cannot control at all? middle ear. Patients, knowing the benefits Dr. Coleman has mentioned several other of the nasal douche in nasal disease, will causes of middle ear disease besides those treat themselves, they place a large reservoir enumerated by myself, especially relating to rather high up, place one end of a rubber tube the nasal douche, but that has been so well an in it and the other they put in the nose, conse- swered by Prof. Gradle that I will pass it by. quently the water enters the middle ear and Many of the cases mentioned by Dr. Coleproduces otitis. Another cause of middle man I think will be included among those I ear disease in children who have earache so have stated as due to bad hygienic surroundmuch between the ages of 1 and 6, is the irri-ings. Bad teeth and dentition undoubtedly tation of dentition and bad teeth, and in older persons an earache that is not accompanied by deafness is very commonly due to decayed or painful teeth, and when the teeth are treated the pain in the ear is soon relieved. have a marked effect on these cases. I have DR GEO. W. WEBSTER, in closing the discussion said, In reading my paper I think I said that I simply meant to give some of the causes of disease of the middle ear, and expected to give particular attention to hyper-scopic trophies. In reference to the galvano-cautery, Dr. Coleman spoke of its use, or rather, what I should consider, its over-use. There is a great difference in burning with an electrode with a fine wire and making a deep burn, and using a cautery wire that is much thicker and burning more at one time than I would think of doing at five or six times; that is the abuse of galvano-cautery, not the use of it. But because in a few of these cases the galvano |