Society, I regard the affection commonly known as "hay fever" simply as a grouping together of certain prominent and frequent symptoms of a particular form of nasal inflammation for which I have proposed the name rhinitis sympathetica, and which is characterized by a peculiar excitability of the nasal cavernous tissue possibly linked to an exalted state of the nerve centres. In order, however, to the intelligent appreciation of the treatment of the disease, I must invite your attention to certain principles which in my judgment underlie the etiology and mechanism of the paroxysms.

It should be borne in mind, in the first place, that the excitability of the turbinated nasal tissue is a secondary phenomenon, dependent as a rule, upon a direct impression made upon the sensitive nerves of the mucous membrane and upon the terminal filaments of the olfactory ; or, an indirect influence conveyed or reflected through the vasomotor centres from a distant organ, or finally, from some excitation starting in the centres themselves. This stimulation of the nerve centres, from whatever cause originating, is reflected outward probably through the sympathetic filaments which reach the turbinated structures with the spheno-palatine nerves.

Now as these nerves are distributed over the posterior and inferior portions of the nasal fossæ, (sensitive reflex area) the turgescence of the erectile substance is more noticeable over that particular area; and it will be found that this surface represents the most sensitive spot to reflex-producing expression-at least, this is my experience. If then we destroy the terminal filaments of the sensitive nerves, it follows that one avenue at least is closed against the irritative action on the nerve centres of substances derived from the external world. My practice, therefore, is to simply sear the most sensitive portions of the membrane with the flat cautery knife, taking care to include only that portion in the operation, which has been found most sensitive to irritation. I have found this procedure alone sufficient to arrest the paroxysms and give prolonged immunity from them.

This destruction of the sensitive nerve ending accomplishes then one result, and one only-it closes one door against ab extra irritation of the nerve centres. In order to exclude completely the influence of the latter, it is necessary in addition to remove all sources of local irritation, from whatever cause arising. If this be radically done, it will put a stop to the production of paroxysms from external influences acting directly on the nasal mucous membrane-that is all. When paroxysms are induced by agencies operating within the organism or

from reflected irritation of other parts of the body, the destruction of the sensitive nerve endings in the nasal mucous membrane will obviously be insufficient to secure immunity from further attacks. The indication here is to search carefully for any such source, or cause of irritation and to direct treatment accordingly. I shall not attempt to lay down any rules for treatment in this regard. The chief indication, as I have insisted over and over again, is to diminish or abolish the reflex excitability of the erectile tissue-mark it, not to produce artificial contraction of its muscular elements-this can only be productive of temporary and not permanent good-not to repeatedly and violently bring into play the contractile power of the tissue or keep its muscular structure in a state of tetanic spasm. This can only result in a weakening of these structures and may lay the foundation for permanent dilatation of the erectile cells-butto so alter the nutrition of the nerve centres that they may not respond so easily to the impression which occasions the reflex. This is best accomplished by tonics addressed to the nervous system and by such remedies as experience shows are capable of controlling the reflex excitability of the centres.

Failing in the above methods, the destruction of the cavernous tissue with the galvano-cautery should be undertaken as a last resort. To the accomplishment of this end, the surgeon should proceed with caution, taking care to destroy as little tissue as is compatible with the radical removal of the disease. I generally make a more or less stellate incision, the advantage of which resides in the resulting cicatrix, and the greater patency of the nostril secured therefrom.

In the large majority of cases extensive destruction of the cavernous tissue is neither necessary nor advisable. The amount to be sacrificed must be determined by the exigencies of the particular case. *

In answer to the question, as to whether the operation should be performed during the so called season, or whether it were better to wait for the interregnum of immunity from the attacks, I would reply

*In regard to the operative measures to be used in a given case of hypertrophic inflammation of the nasal passages the following are my rules of practice:

1st.-Posterior hypertrophic enlargements of the turbinated bodies are most satisfactorily removed, if practicable, with the cord wire snare.

2nd. For destruction of anterior hypertrophic swelling both of the turbinated bodies and septum, and in the rare cases when operation is necessary on the enlarged erectile bodies of the posterior portion of the septum the galvano-cautery is the most available and satisfactory agent

3rd.-Extensive destruction of cavernous tissue is most satisfactorily accomplished by means of the galvano-cautery or electrolytic process.

that there is nothing to be gained by delaying radical treatment and it is therefore my custom to operate in the interval between the paroxysms. By this means I have succeeded in preventing their return, even when the individual has been exposed to the exciting causes of the attack.

The prognosis in a given case presenting the peculiar association of symptoms of sympathetic rhinitis (coryza vasomotoria periodica) commonly known as "Hay Fever" will depend not only upon the special predisposing and exciting causes of the disease and the facility of their removal, but also upon the amount of structural injury done to the respiratory organs, to the central nervous system and to other portions of the body subjected to the reflex disturbance to which the frequency of the paroxysms has led. Thus, in long standing cases, chronic changes may be induced in these structures which may militate against the thorough eradication of the affection.

Each case has its peculiarities, its difficulties. In general, the prognosis can be said to be good. If the above principles of treatment be faithfully carried out, relief can always be secured, and in a fair proportion of cases, a permanent cure may be effected.

DISCUSSION OF DR. MACKENZIE'S PAPER ON HAY FEVER.

DR. J. F. PERKINS endorsed Dr. Mackenzie's position that no definite line of treatment could be laid down suitable to every case, where there should be operative procedures, or whether the conservative line of treatment should be adopted. For his own part he generally followed the latter course.

A REPORT OF FIVE CASES OF OVARIOTOMY FROM THE RECORDS OF THE HOSPITAL FOR

THE WOMEN OF MARYLAND.

BY C. O'DONOVAN, JR., M.D.
Assistant Surgeon to the Hospital.

Though the diagnosis of ovarian cystoma is every day becoming easier; though the operation for its removal is every day reaching nearer and nearer perfection in the ideal operation as well as in the manner of dealing with the numerous difficulties that are liable to mislead the most skillful and careful diagnostician; though the standing of the operation is so fully assured that gynecologists no longer seek to eliminate unfavorable cases through fear of bringing discredit on the operation as well as on themselves; yet in Baltimore the number of operations have been somewhat limited, and it gives me great pleasure to be able to describe before this Society the methods pursued in the cases that have occurred in the service of Prof. Wm. T. Howard at the Hospital for the Women of Maryland, with a detailed history of each case.

It will be seen that two of these cases were women much advanced in life, one being 56, the other 61; a fact well worthy of mention when we remember that Thomas, in speaking of Ovarian Cysts, says: "They are rare under twenty and over fifty." (Diseases of Women, 5th Ed. p. 692.) Yet in our oldest cases the tumor de. veloped rapidly sixteen years after the cessation of menstruation, and twenty-three years after the last pregnancy. I have never seen the statistics upon which Dr. Thomas bases his statement of the rarity of ovarian cysts in women over fifty, but from a table on pp. 319, 320, and 321 of Wood's reprint of Mr. Lawson Tait's book, Diseases of the Ovaries, it appears that such an occurrence is far from rare in his experience. The whole number of operations reported covers IOI Consecutive cases with three deaths, and of this

number four were under twenty, nineteen were between, fifty and sixty, and eight were over sixty, the oldest being sixty-seveninte

The other case was equally interesting, occurring at the age of fifty-six, in an unmarried woman, who had never been pregnant, and in whom menstruation had ceased since ten years. She was in wretched condition apart from the evil influence of the tumor, poorly nourished, with angular curvature of the spine, the result of disease in childhood. This case seems to contradict Thomas' teaching concerning the origin of ovarian tumors. "Certainly nothing can be assured beyond this, that it is probable that those influences which keep up and intensify ovarian congestion, and interfere with the rupture of the follicks of De Graaf, tend to produce cystic and follicular degeneration." (Diseases of Women 5th Ed. p. 692.) Certainly a woman may be said, after her fifty fifth year, to have at last escaped the dominion of those congestive influences.

With regard to the effect of "depreciation from poor living," enumerated by Thomas as one of the predisposing causes, I may mention that all of our cases had experienced more or less of "hard labor, poor diet and depressing surroundings," though I can attach no importance to this as affecting relative frequency, the cases ad'mitted to the hospital being only from the poorer class.

The fourth case in our series is perhaps the one deserving of most mention, from the rarity of the disease, the age of the patient and the rapid recovery made after a very trying operation, so trying that no one present imagined her chance for life as more than a bare possibility. The incision was a long one, the tumors removed were large, and very difficult was it to lift them from their position in the abdominal cavity where they were tied by adhesions. The operation had been prolonged, the condition of the patient towards the conclusion of the operation had been so bad that several hypodermics of whiskey were considered necessary to stimulate the failing action of the heart; yet, in the face of all this, she reacted well after the withdrawal of the anesthetic and recovered with no check whatever. Of the tumors removed I have a detailed account from Dr. W. T. Councilman, the pathologist to the hospital, which I shall read with the history of the case.

Case No. V. of this series was by far the most difficult of them all, both in the differential diagnosis as well as in the operative procedure. In point of fact the diagnosis was not made before the incision, nor was it possible to say, after the cyst that was found hạd