atrophic condition of the turbinals, which gave rise to a certain dryness, her nose gave her no trouble for about four years. At this time I found quite a mass springing from the middle turbinated bone on the right side. This was removed and treated as before.

Nasal tuberculosis. Winkel. Obj. 4, Oc. 1. (Wade Thrasher.)

Last October I examined her and found her nose perfectly free from tubercular granulations and her general health excellent.

HISTORY.

In looking over the literature I have collated a list of 112 articles dealing with the subject of nasal tuberculosis; 102 are foreign, while 10 are written by Americans. I believe this includes nearly everything of an original character on the subject.

There have been about 125 cases of nasal tuberculosis reported. There seems to be some discrepancy in the statistical tabulation of these cases. Melzi' gives a list of 90 cases, 19 of which are primary and 71 secondary. Steward,2 in his classification of 100 cases, which includes Herzog's list of cases, reports 58 primary, 37 secondary, and 5 doubtful.

I think it quite possible that several of the cases in this table reported as primary are really secondary in origin, for I believe we are justified in classing cases showing suppurating tubercular cervical adenitis or dullness over the apex as secondary in character.

The reports of the primary cases show that about 30 per cent. were ulcerative, and about 70 per cent. were neoplastic in form, while in the secondary variety the ulcerative condition seems to be the more common.

Two cases have been reported, one by Koschier and another by Wroblewski, of a form of tubercular periostitis with caries, and a perichondritis where the tubercular process, instead of starting superficially, seemed to attack the bone and cartilage of the septum first, and then invade and break down the

would be influenced by the general condition of the patient, seems to be responsible for the character of the lesion found in any given case.

The broken-down ulcerated type in secondary cases is probably due to the malig

Nasal tuberculosis. Winkel. Obj. 1-7, Oc. 1. (Wade Thrasher.)

nancy of the infection, for in these cases the sputum is teeming with bacilli and the resistance of the membrane is lowered by the general systemic infection of tubercular degeneration elsewhere.

Histologically, a tubercular ulcer of the nose presents the same characteristics as a tubercular ulcer in any other locality. The tubercular infiltration breaks down and ulceration takes place. The secretion from this ulcer soon forms itself into a crust, which rapidly becomes detached, and then forms again. Small greyish-white nodules, tubercular in character, appear on the edge and at the base of the ulcer thus formed, some of which remain intact, while others disintegrate and excavate, forming little cavities the size and depth of which seem to depend on the length and virulency of the infection. edge of the ulcer is more or less indurated and covered with pavement epithelium.

Microscopically, the tissue consists of small round cells, among which, according to Melzi, are other cells with branching processes. In this mass are found, variously disposed, giant cells, i. e., tubercles.

The typical giant cell is quite large and has extending from its periphery numerous processes which anastomose with each other and form a net-work, in the meshes of which lie the epithelioid cells. The latter are large,

flattened, have a single large nucleus, and are arranged in concentric rings around the giant cells. Frequently several giant cells, with their accompanying epithelioid cells, lie in such close proximity that they coalesce and lose, to a certain extent, their original shape.

The bacilli are usually found in the giant cells, but the task of staining them is extremely difficult. Nothing is easier than the staining of tubercle bacilli in the sputum, but efforts to stain them in the tissue usually result in disappointment. Dr. Rowe's explanation for this difficulty is as follows: "The carbol-fuchsin stain is essentially a spore stain, and it is quite possible that most of the bacilli in sputum are in the spore condition, while those found in the tissue are not."

The presence of areas of caseous degeneration is important from a diagnostic standpoint, especially when the bacilli fail to take the stain. The caseous degeneration of the tubercle, which in superficial lesions results in breaking down and ulceration, begins as a fatty degeration in the centre of the giant cell. As the tubercle is non-vascular, this point is farthest from the blood supply.

As giant cells are found in syphilitic and granulation tissue, the typical areas of caseation found in tubercles are of great diagnostic value.

The favorite site for tubercular ulceration is on the septum, especially the cartilaginous portion. The floor would come next in point of frequency, and then the lower and middle turbinals.

If the lesion is on the septum and the process of ulceration allowed to continue, a perichondritis or a periostitis, followed by necrosis, resulting in a perforation of the septum, frequently results.

The neoplastic form consists of tumors ranging in size from that of a millet-seed to a hazel-nut, or larger. The septum is the favorite site of attachment for this form, too, but the turbinals are more frequently involved in the hyperplastic than in the ulcerative form. These tumors do not show a tendency to ulcerate, but remain intact for a long time. The surface is sometimes smooth, but more frequently cauliflower in appearance, and in color ranges from a pale red to a pale grey. They are soft in consistency and bleed readily when touched.

ETIOLOGY.

Certain phases of the etiology of nasal tuberculosis are more or less obscure.

It is quite easy to understand why and how the larynx, or even pharynx, is so often involved as a secondary infection in pulmo

nary tuberculosis, but it is equally hard to see just why the nasal mucous membrane should be so immune to the action of Koch's bacilli.

The lodgment of a bacillus on an abrasion or on an area of inflammatory excoriation of a person whose resistance is at low ebb is probably the most simple explanation of a primary infection.

The secondary form may be the result of an infection through the blood or lymphatics, or directly infected by means of septum or bacilli-laden secretions from below.

A tubercular diathesis might also be mentioned as an etiological factor.

SYMPTOMS.

The symptoms depend upon the type of the affection.

In the ulcerative form, the muco-purulent discharge, which is frequently mixed with blood, and the frequent expulsion of crusts, may be the only symptoms noticeable to the patient. There is usually very little if any pain. In the other type, the tubercular granulation may be sufficient to cause complete stenosis. The secretions are increased and are of a muco-purulent character.

Of course, complete occlusion of both nares would result in mouth-breathing, which in itself is productive of several disagreeable symptoms. Headache and neuralgic pain in the head may be the result of stoppage of the nares or the pressure of the tumors.

Febrile disturbance is not noticed in the primary type, but in the secondary form we have the characteristic temperature found in pulmonary tuberculosis.

TREATMENT.

The treatment is surgical in character. The ulcers should be curetted and then cauterized thoroughly. Carbolic acid, lactic acid, trichloracetic or the electro-cautery may be used, after which the parts should be frequently sprayed with an alkaline solution followed by an antiseptic oil or powder.

If tumors are present, they should be removed until healthy tissue is found, and the base cauterized as in the ulcerous form.

In connection with the local treatment, the patient should receive the benefit of large doses of fresh air, sunshine, and perhaps some reconstructive medication.

The prognosis in primary nasal tuberculosis is good, although there is a tendency for the growths to recur to some extent. This depends upon the completeness of removal, thoroughness of cauterizing, and the resistance of the patient. The ultimate result in

the secondary case, of course, depends upon the extent, stage and virulency of seat of the primary infection.

BIBLIOGRAPHY.

1 Melzi: Arch. Internat. de Laryngol., Paris, 1904, xviii, 109-123.

2 Steward: Grey's Hospital Rep., 1897, London, 1900, liv, 149-181.

3 Herzog: American Journal Med. Sciences, Phila., 1893, cvi, 677-700.

4 Koschier: Wein. Klin. Woch., 1895, 633, 656, 685, 707, 721, 740.

5 Wroblewski: Gaz. Llk. Warszawa, 1893, 2S, xiii, 494-498.

6 Morgagni: De Ledibus et Causis Morborum, 1765.

7 Willigk: Prager Viertel-Jahrschrift, xxxviii, p.4. 8 Laveran: Union Medicale, Nos. 35, 36.

9 Mertens - Weber: Tuberculose der Nasenschleimhaut, Wurzburg, 1889.

10 Farlow: Trans. Amer. Laryngol. Asso., 1893, 3 S., xli, 67-72.

11 Reynolds: Brooklyn Medical Journal, 1901, xv, 599-605.

12 Shurly: Trans. Amer. Laryngol. Asso., 1891, 4, iv, 149-181.

13 Boylan: LANCET-CLINIC, 1888, xx, 4-7. 14 Lincoln: Trans. Amer. Laryngol. Rhin. and Otol. Assn., 1901, N. Y., 1902, vii, 27-32.

15 Knight: Laryngoscope, St. Louis, 1904, xiv, 417-422.

16 Ballenger: Amer. Laryngol., Rhin. and Otol. Assn., St. Louis, 1901, x, 6-8.

17 Fitzpatrick: LANCET-CLINIC, 1891, N. S., xxvi, 46S-470.

18 Potter: Buffalo Med. and Surg. Jour., 1887-8, xxvii, 295-302.

marked that she thought the winter the best time to invest, as the mercury was lower then.

Speaking of hot times reminds me of an incident that occurred in Xenia a few months ago. A colored minister of that city went to New York, and while there visited one of the large churches where there was a boys' choir. The minister was very much impressed by the way the boys dressed, as they were in robes, the leader carrying and swinging the censer as they marched by the altar chanting the hymns. Upon his return home he got together a number of boys, fitted them with robes and drilled them in the hymns. One Sunday morning he introduced this innovation into the service, much to the surprise of the congregation. All went well until, as the boys marched past the pulpit, the minister noticed that the leader was without the censer. Not wishing to interrupt the service, he took up the same tune the boys were using and chanted his question:

"What has you did wid the incense pot?" Instantly the leader chanted back: "I sot it in de aisle it was too dd hot-hallehalle loo-yer!"

The committee has given me rather a large order to-day to speak for the Montgomery County Society, a society that has given to the profession such men as John Davis, O'Neal, McDermott, and last, but not least of that phalanx of medical giants, who as pioneers in the profession have blazed the way for future progress in medicine and surgery, Dr. J. C. Reeve, who, we are glad to say, still lives to grace the profession that he has loved and honored so long.

I bring the greetings of the Montgomery County Society to you who are assembled here to-day as the representatives of the medical profession of these fertile Miami valleys, which, if they were not the site of the original Garden of Eden, only escaped that honor by the mere incident that Adam did not see them first.

We have in Montgomery County about five hundred physicians of all schools, not counting the Eddyites, Dowieites and the non-resident practitioners, such as Munyon, Hartman and Lydia Pinkham.

Our society is the only thoroughly democratic organization with a purely representative form of government that has a King at its head.

The society is a most cosmopolitan one; in it are represented all colors, races, creeds and countries, typical of that broad humanitarianism which is so characteristic of the medical profession. While most of our members are white, we have Gray, Greene and

Brown, some chocolate and a few with a yellow streak.

We have the German to look after the germ diseases, the Frenchman to treat those arising from Paris-ites and the Irishman to handle those due to "Mike Robes."

There are specialists for all parts of the body. One man in Dayton advertises that he is a specialist in "Diseases of Men, Women and Children." (He does not treat horses or elephants.) But he would not do for our society, where specializing is so popular. The human body is divided up among these men, and the general practitioner takes what is left-or rather is the commanding factor that welds the skill of the others into

success.

One man deals in "internal medicine never rubs anything on the outside. One takes the outside, preferring to deal with the visible and known, leaving the sparker cylinders, etc., to other hands.

You

The oculists are popular fellows. should see the farmers bringing in their seed potatoes in the spring to have their eyes examined before planting. It is quite a spectacle. One of them removed the crystalline lens from a patient's eye not long ago, and by way of experiment substituted the lens from the eye of a cat. The wound healed very promptly and the operation was a success, but will never become popular, as it is said that the man's wife has great difficulty in keeping him away from rat holes.

The English go to them to have their eyes operated upon so that they may be able to see the points to American jokes. It is safe to say that they have their eyes opened at least.

The children's specialists are fitted with powerful lenses so that they may see their incomes. Nor is their work on the throat any less wonderful. It is said that by a delicate operation on the throat of a nature fakir they can render him capable of telling the truth.

The stomach men are not less popular. Their favorite treatment is:

1. An N. C. R. breakfast, which consists of a horseback-ride at day break, followed by a rub down and a capsule of white sand.

2. A Battle Creek dinner of a bale of hay, sample size, and shavings of second year's growth of maple (sterilized).

3. A supper of bread and milk, shifting the milk supply from a white cow to a red cow and then red and white, etc., so that the patient will not tire of the diet.

Then comes the surgeon, with a scalpel in one hand and a diagnosis in the other. He delights to cut our acquaintance, and has an

especial affinity for the appendix. One of them operated on Casey not long ago and Casey's friend McGrill told Finnigan about it in this way:

McGrill: "You should call in Dr. Riley when you air sick; he's the foine doctor. He operated on me frind Casey. Casey had the stomach ake and he sent for the doctor, and the doctor came and looked at him and plumped a thermometer in his mouth and thumped him in the stomach and said, ‘Ye have appendicutus; I'll have to operate ye'; and Casey says, 'Devil a bit will ye operate me!' And the doctor says, "Then ye'll be a dead mon by three o'clock.' So Casey let him operate.

Finnigan: 'And did he save his life?" McGrill: "Yis, he saved his life-one hour; he didn't die till four."

It has been suggested that the Legislature pass a law making the game laws apply to the appendix, so that there may be a closed season and the number of appendices which one man may take in a season shall be limited. In this way it is hoped to prevent the extermination of the appendix before its real function has been discovered. The only way to save your appendix now is to put it in your wife's name. Then they cannot take it from

you.

The ensiform cartilage is now the only portion left unclaimed. The hopeless patient who cannot find a disease which some specialist will treat must be content with the general practitioner, or he may fall back on Christian Science and skim-milk.

Yet the specialists are not altogether selfish. They have left the head to the barber and the soul to the minister, and it will be a close shave if these two make both ends meet.

It is only natural that with so many fine divisions of labor confusing incidents should sometimes arise. Not long ago I was called to task by an oculist for lancing a baby's gums. He said those were the baby's eye teeth, so the case should have been sent to him.

Our society is well equipped both for business and pleasure. At our evening meetings we always have Light. If we wish to have a picnic we have a Dale and a Dels Camp, as well as a House in case of bad weather. For lunch we have Bunn, with enough Dunham to make plenty of sandwiches. At least we can always have a Crum. If we wish chicken we have a Hatcher as well as a Henry, and a Breese to keep all cool. For music we have a Fife and a Mel-drum Floyd.

We are glad to be out here for a brief time to-day to meet thus in fellowship. Much as

has been accomplished in the past, I feel that a profession thus united promises still greater things for the future. We shall take with us from this place something more than indigestion, mosquito bites and chiggers, but a fraternal spirit that shall mean much in the days and the years that are to come.

Correspondence.

ORANGE-PEEL POISONING-DEATH.

CINCINNATI. July 24, 1907.

EDITOR LANCET-CLINIC:

About May 1, 1907, I operated upon a man, twenty years old, for chronic appendicitis. His recovery was exceedingly rapid without complications.

On the sixth day after operation he ate two bananas, one large orange, including its skin, one doughnut, one glass of beer and one glass of water, all within a few minutes. He began to vomit severely within an hour, followed by the classic symptoms of orangepeel poisoning. He admitted the facts, stating that he had taken the food from his little nephew without his (nephew's) knowledge. Dissolution occurred six days after the reception of the food into the stomach, or twelve days after the operation. Dr. Stephenson, of Manchester, O., who referred the patient, relates the death of a boy from eating an orange-peel on his brother's farm. ejection of the orange-peel from the stomach was followed by incessant vomiting till death.

The

Action of Orange-Peel.-"Aromatic smell and pungent and bitter taste. Stimulates the digestive organs, to which it gives the sense of warmth. The oil has active properties, in that the hands of those employed in the industry become inflamed with an erythematous, a papular or vesicular eruption; they suffer from headache, dizziness, tinnitus aurium, deafness, neuralgia, oppression in breathing, constriction of the throat, nausea, pyrosis, eructations and thirst, also dreams, twitchings and cramps of muscles and sometimes convulsions."-M. IMBERT-GOURBEYRE, Constantts Jahres-Bericht fuer 1853, p. 158; from Gaz. Med. de Paris. B. MERRELL Ricketts.

Diagnostic Flashes on Tuberculosis.

The first hemorrhage in a case of phthisis does not come from healthy lung tissue contiguous to the diseased area, but from diseased lobules.

As the lung consolidates, the respiratory sounds acquire a bronchial quality, and the heart sounds become more intense over the affected part.

Alcohol, by its power of degenerating the nerve fibres of the pneumogastric, may impair the action of the lungs so materially as to make the individual an easy prey to phthisis pulmonalis. Everybody ought to be cognizant of this, and yet—