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extensively throughout the vascular system to the retina, so that hypertrophy of the heart with degeneration of the arterioles may be found associated with healthy kidneys. The point of this is, that the renal affection is not a mere local affair, but rather a part of wide-spread tissue degeneration. These disorders of the retina appear most frequently with the chronic interstitial nephritis, in those cases, in which by abundant excretion and low specific gravity of the urine, the discharge of the albumen is not very considerable, in which oedema is wanting and the process of long standing. A remarkably strong shock of the heart and pressure in the radial arteries were found and these cases mostly lead to the knowledge of the disease by the ophthalmoscope. Doubtless the diseases of retina are the consequence of acute nephritis of scarlatina. Amyloid degeneration has been observed with these retinal disorders, also eclampsia.
The manner in which the relation between the kidneys and the retina is brought about, cannot be explained up to the present time. Traube, as I stated, depends for explanation on the increased status of expansion of the arteries, which frequently occurs, but cases are known, in which a hypertrophy of the heart did not exist.
Birmer wishes, as do Gull and Sution to explain it by the chemical composition of the blood, as it had been discerned in pernicious Anæmia, Hæmatemesis, Leucæmia, but it is to be taken in consideration, that in this retinal-disease the arteries of the retina have been found diseased in consequence of sclerotic infiltration or fatty degeneration of their walls and that these pathological structural changes are a consequence of less resistance.
Generally, the appearance of the retinitis albumnurica is prognostically very unfavorable for the life of the patient.
TWO PRINCIPLES WHICH SHOULD DETERMINE WHEN
WE SHOULD OPERATE IN THE NASAL PASSAGES.
BY DR. A. B. FARNHAM, OF MILWAUKEE.
It is the opinion among many of the medical profession that throat and nose specialists operate unnecessarily frequently. Many recall frenzies which have seized the profession to perform certain operations on different parts of the body and it is only natural that they should suspect the innocent nasist and laryngist of similar madness.
I wish to make clear two principles the application of which will guide us unerringly as to the performance or non-performance of any given operation. The first principle is that all causes of irritation must be removed. The primary application of this principle takes out of the discussion the larger growths and limits it to the smaller hypertrophies of the mucous membranes and to the exostoses and deviations of the septum. These latter play by all means the leading role in mucous hypertrophies and degenerations. From congenital and accidental causes the growths upon, and deviations of, this partition are numerous and of exceeding variety and complexity.
No matter how numerous or how varied, let them alone unless they are causing irritation and even then take away only sufficient to fully relieve the pressure and chafing of the opposing membrane. By one or more observations determine the most offending growth or portion of a growth and first remove that and wait when we can to see the full result of what has been done. Growths of considerable size projecting into the middle meatus or elsewhere where no irritation be caused can be let alone. If the mucous membrane when distended touch a growth you will find sure indications of its having done so by inspection of the membrane in question. Growths or deflections which we would remove or correct in the young we can often let alone in those more advanced because they have done all the injury they can do and no direct gain will come from surgical interference. Humanize the advice. Are the indications for operation sure? Apply the golden rule. The abnormalities of the septum often cause deviations of the turbinated bones and irregularities in the development of the mucous membrane covering them, consequent pressure, irritation and probably hypertrophy.
Note the point of pressure and irritation and remove enough, just enough turbinated bone or hypertrophied tissue to relieve this irritation. Nature may do much for what we leave.
The second principle governing our action is the securing of proper drainage and ventilation. Interference with these functions is caused by anterior or posterior stenosis. In my experience the former is most frequently produced by septum growths or deflections while the latter is more usually caused by growths upon the turbinated bones. Comparatively less frequently is the vomer at fault.
Lack of proper drainage causes retention and consequent alteration in the character of the nasal discharges, with consequent irritation and its train of evils. The backward drainage of the secretions hardly causes the damage that Dr. Jarvis claims for them as they flow back during sleep, and in cur waking hours a portion of the time, from the position in which we hold our heads. Anterior stenosis may cause among its evils a rarification of the air in the naso-pharyngeal space from the great current being taken in through the mouth and consequent suction upon the membrana tympani and partial deafness. The original stenosis is also heightened owing to the weakening or atrophy of the dilators of the nose and consequent falling of the cartilages of the alae nasi against the septum. Whatever be the cause of interference with proper drainage remove it in the careful conservative way hinted at above.
As this involves operation on the septum I should like to put on record the method of moving over this partition which my experience has led me at present to think the most desirable. Do not use punches. The best method in my experience is to weaken the wall with the small burr of the dental engine exactly where one wishes at the point of greatest resistance. In this way there is no wounding of the membrane on one side, a matter of the greatest importance. There is also less hæmorrhage. If an angle be attached the burr can be aided by the nips and rongeur forceps and any desired portion of cartilage or bone removed, all without wounding the periosteum or membrane on the other side. The attractiveness of this method of operating is the absolute exactness. All that is needed is an appreciation of the requirements of the individual case, a good eye, a more or less delicate touch and patience. The work can be finished if need be under ether by the use of Smith's forceps, though my fore-fingers almost always serve me best. The after details consist in cotton plugs and digital pressure and much care and watchfulness.
I have not felt friendly to the punches since an accident led to a small septal perforation which provided a patient with a permanent æolian harp, a matter of wonder to himself and friends, and of chagrin to his surgeon.
Leprosy, lepra, the elephantiasis græcorum of the ancients, the scourge of so many countries and a terror of the dark ages is much more common than generally supposed.
The fact that it was nearly eradicated in Europe, 200 years ago has led the profession and the world generally to believe it was a very rare disease. Its history accessible to all, clearly points to its presence among the ancients, and Moses in the wilderness, enacted sanitary laws for its suppression, as the following quotation from the 3d chapter of Leviticus clearly shows: “And the priest shall look on the plague in the skin of the flesh, and if the plague in sight be deeper than the skin of his flesh it is a plague of Leprosy, and if the priest see that the scab spreadeth in his skin, he shall pronounce him unclean, it is Leprosy, and if there be quick raw flesh in the rising, it is an old Leprosy on the skin of his flesh, for the raw flesh is unclean, it is a Leprosy, and if it be in sight lower than the skin, it is a plague of Leprosy, broken out of the boil, and the Leper in whom the plague is, his clothes shall be rent, and his head bare and he shall put a covering on his upper lip, and shall cry unclean, unclean. All the days wherein the plague shall be in him he shall be defiled, he is unclean, he shall dwell alone, without the camp shall his habitation be.”
This disease beside being mentioned in the Mosaic scriptures is mentioned by nearly all ancient writers of celebrity. Hippocrates, Aristotle, Celsus, Aretius, Archigenes, as well as Pliny, relate their own observations, of which many cases, according to the latter were imported from Egypt and Asia minor, during the reign of the earlier Roman Emperors. Physicians 360 years after Christ, speak of elephantiasis græcorum, as a disease well known and wide-spread.