idiosyncrasies which either may present. But in the intrinsic conditions as certain forms of alcoholism, neuroses, epilepsy, hereditary insanity, etc., we may be compelled to diagnosticate the patient as well as the disease if we would learn more of the probable causes and nature of the lat ter. Now and then, we still meet the man who plays safe. Instead of attempting to diagnosticate accurately, like a pendulum he has swung to the opposite extreme (can it be that he fears pathology?) giving chief attention to the general condition of the patient and attributing to the actual name of the disease, a minor significance. Such a man may be less dangerous than the man who is confident that he can classify accurately every sick man, but he will fail to give mercury or salvarsan in many cases of syphilis, antitoxin to many cases of diphtheria, salicylates to many cases of endocarditis and proper bacterins to many cases of infection. He will treat numerous cases of appendicitis for hyperpyrexia and numerous cases of carcinoma ventriculi or abscess of the gall bladder for dyspepsia. In which and in many other instances, he will prove even more dangerous than the rankest extremist of the opposite type. We should, therefore, it seems to me, make our diagnoses as accurate as possible. Now and then this knowledge may seem superfluous, but really it is not. "Why," ventures the critic, "diagnosticate accurately typhoid when even though successful, we have no specific treatment to offer?" "For the reason," I would answer, "that by so doing we rule out probability of appendicitis, pyelitis and many other conditions of similar symptomatology and which require radical treatment of a different nature. The next case will prove to be one of these." And after all, here is the truth. By perfecting our diagnostic methods, now and then we detect one of these cases and classify it properly when visible phenomena are vague-before it is too late. This, I believe, is sufficient recompense for both examinations. Although desiring to subtract nothing, absolutely nothing from other methods, I have come to place much confidence in certain chemical, microscopic and bacteriological procedures when attempting to make a diagnosis. And I might hasten to say that I speak not as a college clinician or as an ultrascientific faddist but as an active practitioner of medicine. The practitioner, especially he upon whose diploma the ink dried many years ago, has been dazzled by the numerous and innumerable laboratory examinations which have been flaunted in his face during the past twenty-five years. It is safe to say that of these fully three-fourths have proven of little value to the diagnostician; and that many of them are still treasured by the books intended for the practitioner, is a matter quite beyond my understanding. Surely it is not the intention to confuse these men who need this information most. But upon the other hand, the practitioner may perform with ease and accuracy most of the valuable tests, if he but obtains the proper guides and apparatus for the work. While such cannot well be included in a communication of this scope, I have been intensely interested in this very subject for several years and will count it no inconvenience to give any reader the best references at hand if he will be so kind as to enclose postage for a reply. With but little expense and less study, any practitioner may easily place himself in a position to diagnosticate quite as accurately as the man in the most elaborately equipped metropolitan hospital. As I have said, over ninety percent of us are family physicians. There is still need for the accurate diagnosis where this is possible. He who does the best he can (surely he must spare no effort to do this) need not worry: angels can do no more. 109 E. Court St. PERSONAL EXPERIENCES WITH THE SUBMUCOUS RESECTION OF THE NASAL SEPTUM.1 BY WM. FERGUSON, M. D., Laryngologist, House of Refuge; Assistant Surgeon, New York Throat, Nose and Lung Hospital. New York City. If we review the history of any enterprise we will notice various milestones marking achievements on the road to progress and success. In the history of rhinology and laryngology, to my mind, no milestone stands out so distinctly typifying progress and achievement as the adoption of the submucous resection. Previous to the introduction of this operation the specialist strove to relieve the catarrhal conditions present in the nasal cavities by such means as the Asch operation and the use of the snare, saw or cautery. In fact, he was simply a patcher and trimmer, but with the introduction of this comparatively new operation he at once leaped into the position of the conservative surgeon, as he not only re Read befo e Clinical Society of the New York Throat, Nose and Lung Hospital, Nov. 6, 1911. , 1913 , Vol. VIII lieves the congested turbinates, inproves ventilation and drainage but saves and improves the functional nasal mucous membrane. Some surgeons are likely to become too enthusiastic over this operation. Patients have informed me that the operation has been suggested to them, who on examination exhibited slight deviations of the septum but not sufficient to interfere with drainage or ventilation and in whom the function of the swell bodies was normal; this would be meddlesome surgery. Not every deflection needs operative procedure but where we find spurs on one or both sides of the vomer, with deviation of the septal cartilage and the perpendicular plate of the ethmoid, resulting in bad ventilation, accumulation of secretions, post nasal catarrh and negative pressure in the sinuses. Here the operation is imperative. In fact, wherever we find such spurs and deflections present and associated with a history of recurrent attacks of acute rhinitis, the presence of chronic hypertrophic or hyperplastic rhinitis, acute or chronic sinusitis, polypoid degeneration of the nasal mucosa, chronic catarrhal otitis media, chronic hypertrophic pharyngitis and laryngitis, the operation is indicated. One other indication for this operation, and to my mind, an important one which I believe will be recognized in time, and that is certain cases of simple atrophic rhinitis. I would like to say a few words regarding this last condition in reference to operation. From my experience in nose and throat work, I believe such patients derive much benefit from the operation in spite of the stand taken by many rhinologists of the present day who look upon it as an incurable condition and claim by improving the air space we only increase the drying and crust forming tendency of the disease. With these gentlemen I beg to differ. Whatever is the cause of the condition, and so far no one has advanced a well established theory (nor will I attempt to, I simply deal with results obtained) some claim the process begins in the sinuses, others that it is a sclerotic atrophy of the mucosa, while others claim that such unfortunates are born with pavement instead of columnar ciliated epithelium. ever the cause, the results you have all seen in varying stages of the disease. What Now by performing a submucous resection on these cases we improve the drainage of the sinuses, relieve post nasal catarrh and virtually establish a new circulation. As a result in both hospital and private practice I have obtained most remarkable improvement, cessation of pus and odor, disappearance of crusts, return to normal appearances of the nasal mucosa, with relief from the distressing throat symptoms and from an examination of these cases, three months after operation you would hardly credit that these healthy looking mucous surfaces had at one time been the seat of atrophic rhinitis. Some surgeons might ask, "do you advise operation in all atrophic cases? And if not, why not?" Well, if we are conservative surgeons we would not operate on inoperable cancer, either to exhibit our skill or for pecuniary benefit, so in atrophic rhinitis in the early or mid course of the disease with spurs and deflections present I would do the submucous resection but where the atrophic process had done its worst, or nearly so, I certainly would decline. To operate on these atrophic cases is no sinecure, as the tissues are like wet tissue paper and tear easily but with a steady hand and patience you will succeed and in a large percentage of selected cases the operation holds promise of much relief, if not cure, to these unfortunates. As to the technic of the operation, much has been written and many instruments devised and they still grow in numbers and variety of shape, bidding fair to outnumber the inventions for the removal of tonsils and adenoids. The more simple the equipment the better the work. A short bladed scapel, a sharp and dull elevator, Mosher extension speculum, McCoy or Jansen-Middleton forceps, a chisel and pair of Knight's forceps should suffice, with a good light, for no step should be made unless your field of operation is clear and under a good light. One great stumbling block in the operation is the getting safely through the cartilage. I first used the curette, but I found it required considerable pressure, they dull very easily, and again in traumatic cases, instead of one layer of cartilage I met two, which was at first very confusing and when I inserted my elevator in the irregular deep scoop made by the curette unless great care was taken you could easily perforate as the edges of the cartilage are not sloping but concave. At present, I use the same scalpel as used in my primary incision and if the cartilage be much deflected, irregular or evidence of trauma, to be perfectly safe I insert the tip of my left little finger into the opposite nostril and can follow the point of my knife from top to bottom without danger, leaving a clean sloping incision through which one can easily insert the elevator under the perichondrium of the opposite side. Another difficulty met in the operation is elevating along spurs. I always make my primary incision on the left side, no matter what the deformity, for to work successfully with a right side incision one must be ambidextrous or you will certainly do much tearing and injury to the mucosa. With spurs I work down to the spur and well back, then carry my primary incision outward across the floor of the nose and elevate up to the spur, then with my elevator I go above the spur well back over the perpendicular plate of the ethmoid and by hugging the spur gradually insinuate my elevator downwards and forwards. In cases with double spurs the same method is carried out on the opposite side. All spurs should. thoroughly cleaned out or you fail in results. One very important spot which is sometimes overlooked is where the septal deflection presses against the middle turbinate. Unless this is thoroughly cleared out you may find your patient much improved but complaining of headaches due to pressure at this point and may later require the removal of the operculum, which would be unfortunate. Existing adenoids must be taken care of as they sometimes interfere with results desired. Having completed your operation and after inspection found both nasal cavities well balanced and clear of obstructions, you are not at the end of your troubles for dressings can give you trouble, and here we again can only learn from experience, which is generally unpleasant and unprofitable. Some surgeons do not dress the nose, simply bring the surfaces together and leave the result to nature. These will save themselves the possibility of a hematoma but they lay themselves open to the possibility of wound infection. I have never tried this method of after treatment. Some surgeons use Simpson-Berney sponges. This , 1913 , Vol. VIII kind of dressing can make lots of trouble, they are not always sterile and although I have escaped the experience I know of cases developing middle ear inflammation. following their use. Again they are anatomically defective as no provision is made for support in the upper nasal space and I have seen the result sought, defeated by the accumulation of a blood clot between the unsupported mucous surfaces above the level of the Simpson sponge, and this in spite of careful examination of the field of operation for bleeding points before inserting the sponges, this may partially absorb in time but is very disappointing to your patient. I use gauze dressing either bismuth or 5% iodoform 1⁄2 inch, passing the end of my gauze strip up between the septum and middle turbinate. I pack from above downwards on both sides, retaining control of my flap with a pair of small angular forceps Pack lightly otherwise the reactionary swelling of the mucous membrane against a tight pack will be followed by excessive turgescence of the lower turbinates for sometime after dressings are removed. As a final precaution I use a mirror to examine the pharynx and see that my dressing does not endanger the Eustachian tubes. The submucous resection depends not so much on instruments as on a man's ingenuity. No two men will use the same instruments or method in overcoming his difficulties and in some cases one's ingenuity and patience is tested severely. Only by continuous labor and patience can we become adept. What relief we afford our patients: Freedom from recurrent catarrhs of nose and larynx, headaches, stuffiness, constant hacking and restless nights followed by dry tongue and poor appetite P. WM, NATHAN, M. D., To judge from the experience of those who suffer from the severer forms of the so-called orthopedic conditions, there is practically no unanimity of professional opinion, as to the proper methods to be pursued in the treatment of these maladies. That such an opinion should be prevalent amongst the laity is not surprising. They, when threatened with permanent disability, seek much advice, and frequently are not satisfied until they receive promises of cure. They do not know nor are they supposed to know that these promises are often based on cupidity, and alas, only discover the true state of affairs, when they have spent their money or have become disgusted by failure. What is astonishing, however, is the fact that the medical profession generally should, in a measure, share this belief with the laity; the more so, since there is no field in medicine in which the indications for treatment, and the methods for carrying it out are more definite and unequivo cal. Though he cannot often promise cures, and the methods employed by different individuals may vary as to details, the capable and honest orthopedic surgeons far from having indefinite and paradoxical views as to the principles underlying the treatment of the conditions with which they have to deal, are absolutely in accord. It is the fact, that the profession generally takes so little interest in the subject of orthopedic surgery, that its principles are entirely unknown to them; and it is because patients must discover from their own experience, just where they can, besides, find proper treatment, and integrity which causes such widespread doubt as to the efficiency and trustworthyness of the medical man in orthopedic matters. I constantly hear the complaint that the specialist is gradually encroaching upon the field of the general practitioner or the "family physician." If this is true, I fear the "family physician" has only himself to blame. There is no reason why the general practitioner should not have at least an idea of the principles which govern the treatment of diseases, whatever their nature, and thus be enabled to advise his patient and protect him from bunglers and quacks. There are certain principles, governing the treatment of orthopedic cases, which are easily acquired; and the general practitioner who knows them is in a position, not only to retain the general supervision of his cases, but he can, in many instances, save his patient useless expense, and unnecessary suffering, and disappointment. Before calling your attention to a few of these principles, it is necessary to speak briefly, of certain fallacies and bugaboos, carried down by tradition for the last few centuries, which are more or less of a |