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SECTION IX—ANATOMY. Honorary Presidents. Dr. HARRISON ALLEN, Philadelphia, Pa. Dr. FRANK BAKER, Washington, D. C. Dr. Jos. D. BRYANT, New York, N.Y. Dr. CELSO BAMBERáN, Lima, Peru. Dr. P. S. CONNER, Cincinnati, Ohio. Dr. MIGUEL CordERo Y GóMEz, City of Mexico, Mexico. Dr. CORYDON L. Ford, Ann Arbor, Mich. Dr. ENRIQUE HORSTMAN, Puerto Prin- cipe, Cuba. Dr. HUNTER McGUIRE, Richmond, Wa. Dr. L. AUGUSTO ORREGO, Santiago, Chile. Dr. John E. Owens, Chicago, Ill. Dr. L. S. PILCHER, Brooklyn, N. Y. Dr. F. D. WEISSE, New York, N. Y. Dr. BERT. G. WILDER, Ithaca, N. Y. Ececutive President. Dr. JOHN B. Roberts, 1627 Walnut street, Philadelphia, Pa. Secretaries. Dr. D. S. LAMB (English-speaking), 800 Tenth street, N.W., Washington, D.C. Dr. JUSTO (Victoria, 1778), Buenos Aires, Argentine Republic. Dr. MANUEL B. MARIACA, La Paz, Bolivia. Dr. ERNESTO CRISSIUMA, Rio de Janeiro, United States of Brazil. Dr. F. J. SHEPHERD, Montreal, Canada. Dr. FEDERIco HorTSMAN (Prado, 109), Havana, Cuba. Dr. JUAN D. HERRERA (Carrera 11, Nu. 272), Bogota, Republic of Colombia. Dr. JUAN J. ORTEGA, Gautemala City, Gautemala. Dr. A. M. FERNAND EZ (Spanish-speak- ing), 209 West Tenth street, New York, N. Y. Dr. F. L. MINER, Honolulu, Hawaii. Dr. FERNANDO VALQUEZ, Tegucigalpa, Honduras. Dr. MIGUEL ZUNIGA (Botica de Santa Catarina), City of Mexico, Mexico. Dr. E. SOLORZANO, Masaya, Nicaragua. Dr. José M. CARAFſ (Facultad de Medi- cina), Montevideo, Uruguay. Dr. DOMINGO HERNANDEZ BELO, Mérida, Venezuela. ADDRESS BY THE PRESIDENT, JOHN. B. ROBERTS, A. M., M. D. SOME DEFECTS IN ANATOMICAL TEACHING IN THE MEDICAL SCHOOLS OF THE UNITED STATES. - It has been truly said that anatomy and physiology are the foundation upon which the whole structure of medical education is built, and that consequently these sciences must be taught with exhaustive thoroughness and made the permanent intellectual property of the student. - The best medical schools in this country, with their four years' graded course requisite for the medical degree, have now attained an excellence probably not infe- rior to any similar educational institutions in the world. There still exist here, how- ever, numerous useless and low-grade medical schools, destined to be soon destroyed by the rapidly increasing number of State medical examining boards. In some of the former class of schools, and in nearly all of other grades, anatomical teaching 1146 PAN-AMERICAN MEDICAL CONGRESS. 1147 has not reached the standard which the essential character of the subject demands. A consideration of the causes of this defective instruction and a search for efficient remedies seem appropriate. It is my hope that you who are present will discuss the statements of this address freely and fully, so that each of us may thereby find sug- gestions of value in elevating and improving the work done in our own schools and States. It is a notorious fact that few of our students have any knowledge of biology when they begin the study of human anatomy. I know of but three schools in the United States (Johns Hopkins University, University of Michigan, and Hahnemann Medical College of Philadelphia) where a preliminary examination in elementary biology is required. Although an entrance examination in physics is enforced by many medical schools, there are others which admit without any such requirement. In those which submit students to this preliminary test, the examination is prob- ably confined to very elementary questions. Several of our best schools still allow young men to begin the medical curriculum without any previous study of Latin. It is a little embarrassing to know that students entering homeopathic colleges are required by the American Institute of Homeopathy to possess a broader general education than is demanded of our students by the American Medical Association, the Association of American Medical Colleges, or our best medical schools. The preliminary educational requirements of the Hahnemann Medical College of Phila- delphia include botany, chemistry, biology, playsics, and Latin. Certainly not more than one or two schools include all of these topics in the entrance examination. It is not difficult to appreciate the confused ideas of human anatomy obtained by a first-year pupil, who knows little playsics, less biology, and no Latin. What wonder that he ſails to remember the names of the bones and muscles; and is filled with consternation when asked to mention an instance in the human body of a lever of the third class. He has no conception of the meaning of the descriptive Latin names of anatomical structures; wonders what is meant by “lever” and other mechanical terms; and is at a loss to know the significance of the terms “dorsal,” “ventral,” and “thoracic,” and iter a tertio ad quartum ventriculum. Did not I, as a student, sit next to a man who was unable to understand the function of certain laryngeal structures because the professor attributed to them a mysterious use called “phona- tion ?” Yet, under our present system such students listen to lectures on osteology, syndesmology, and Inyology and are expected to learn practical anatomy by dis- secting the human body. To call such indecent butchery dissection is a farcical misnomer, as every demonstrator of anatomy knows. It would be much better to let these ill-trained hands learn the difference between muscle and fascia, nerve and vessel—which is about all such bungling teaches them—upon the dead bodies of the lower animals, and postpone dissection of human cadavers until the second or third year of the course. Ebers has told in fiction of the Egyptian physician who, in the fourteenth century before Christ, ran the risk of condemnation by his heathen gods in order to obtain a human heart for studious dissection. You may remember his chagrin at finding his dearly bought prize so like that of the brutes he had often slaughtered in his quest for knowledge. Let the student of to-day begin his anatomical studies on the body of a dead cat and he will learn much that will enable him to prosecute inves- tigations in human anatomy with the ease of one to whom its fundamental principles are already known. One of the most detrimental results of the acceptance of medical students without preliminary education is that they have had no educational training in using their eyes and hands. An hour's stay in any dissecting room will prove this point. Here is a man holding his forceps as if they were fire tongs, there one making a fruitless attempt to put an edge on his scalpel. Few students can describe what they see, and still fewer can make the crudest diagram of their findings. In scientifically conducted anatomical laboratories pupils should be required to describe orally or in writing what they uncover and 1148 PAN-AMERICAN MEDICAL CONGRESS. should make drawings of the more important features. This method is adopted in nonmedical schools and in the study of histology and pathology in some medical institutions. It is undoubtedly the true method of educating the mind, which is not a receptacle to be simply filled with statements thrown into it from the lips of teachers. That which enters by the ears may lead to culture; but Nasmyth, the Scotch engineer, spoke truly when he wrote “the eyes and the fingers—the bare fingers-—are the two principal inlets to sound practical instruction.” Who doubts that the anatomical discoveries of Ruysch in the early part of eighteenth century were due to his possessing “the hands of a fairy and the eye of a lynx 27” A recent writer on education avers that only in Germany and such countries as neglect to educate the young by means of manual training do we find men of learning who can scarcely sharpen a pencil without cutting their fingers. My experience in post- graduate teaching convinces me that for this reason good operative surgery is impossible for some very intelligent physicians. Manual training is valuable moreover, because as Felix Adler has said, hand cul- ture brings brain culture. We need not only the worth and beanty of the object made, but also the psychological result brought by the effort for the utilitarian end. Physicians know that Seguin actually created intelligence in idiotic brains by manual training, and that mental discipline must not be too much sub- ordinated to mechanical accuracy. The medical growth of not a few capable minds has been dwarfed by modern instruments of clinical precision. The time has cer- tainly come when the medical schools of the United States should insist upon a preliminary examination in elementary biology. As soon as this requirement can be extended to include a certain amount of laboratory work in biology, students will have sufficient deftness and manual dexterity, added to their preliminary knowl- edge of natural history, to fit them for intelligently studying descriptive and prac- tical human anatomy. As you probably know, the British five years' medical course is reduced to four years in a medical school, if the registered student has previously graduated in arts or sciences at a recognized university requiring a year in physics, chemistry, and biology. If no such general education has been obtained these sub- jects are studied during the early part of the professional curriculum, which is then of necessity five years in length. In France the preliminary education of one Who aspires to become “Docteur en Medicine” must show evidence of having had instruc- tion in natural history as well as in all topics of general education. Germany and Italy also require a preliminary knowledge of natural history, as probably do all the European nations except Belgium. In Brazil, and I think in the other Latin-Amer- ican countries, a biological requirement is a necessary part of the preliminary education of those who purpose beginning medical studies. A young man desirous of entering a medical school had much better wait a year, and devote that time to biology, chemistry, physics, and Latin than to attempt to begin professional study without an elementary acquaintance with these subjects. The University Exten- sion courses will, in many sections of the country, give him the needed opportunity. If no such courses are accessible, a few books, even without a teacher, Will answer the purpose. If it be true that much unsuccessful anatomical teaching is due to the poor qual- ity of the recipients, it is none the less demonstrable that a more extended influence for evil is exerted by the inferior mental qualifications of teachers and the unscien- tific methods of teaching permitted in some schools. This is, to a certain extent, the result of a custom that permits a professor, once appointed, to hold his position without forcible criticism until he dies or resigns, and prevents the faculty as a body influencing or regulating the manner or mode of instruction. The occupant of a professorial chair is practically an autocrat by courtesy. Puschmann says that in the eighteenth century anatomical demonstrations on dissected bodies were frequent in many European universities, but that “in other places the neglect of anatomical demonstration was caused not so much by a PAN-AMERICAN MEDICAL CONGRESS. 1149 scarcity of bodies as by the idleness and ignorance of the professors.” Such a state- ment, it is to be feared, is not altogether inapplicable to the anatomical instruction now given in some quarters of the United States. Some men of great learning can not teach. The faculty of imparting knowledge is distinct from the faculty of acquiring knowledge. To teach is not simply to tell, but is to make the fact stated so interesting and so clear that it assumes a living importance and is eagerly sought and intelligently, retained by the hearer as a part of himself. A teacher must draw bold, clear outlines, omitting details, and repeating essentials until his pupils have a mental framework, upon which they themselves may erect more elaborate struc- tures at a future time. - He who has not the power to select the essentials and lead the scholar to reason and observe is destitute of the teaching instinct. Then his lectures become mere recitations as wearisome to himself as to his involuntary hearers. The true teacher furnishes his pupil with compass and chart; no more. The latter must select lis route and reach his harbor by the exercise of those intellectual powers which have been given him. It is experience and not memory that has been fitly called the mother of ideas. Few teachers of to-day read their lectures on anatomy; but in some cases the lecture is still as lifeless as if read from manuscript or text-book, and destitute of either demonstration or true teaching. Didactic teaching can not be entirely relinquished, but it has little place in anatomy. Demonstration by specimen, dis- sected cadaver, blackboard diagram, and living model must be the chief reliance of the professor of anatomy who desires to hold the attention of his class and make anatomy what it is, one of the most interesting branches in the medical curriculum. Not many students will be absent from the lecture hour devoted to anatomy if they know that the statements read in their text-books are to be verified by electrical stimulation of the muscles on the nude model; that they are to see with their eyes and feel with their hands the difference between artery, vein, and nerve; that the teacher will create in colored crayon on the blackboard the diagram illustrating the relations of bone, muscle, and viscus; that the dissected cadaver will be studied in the standing posture; that the muscles of expression will be illustrated by photo- graphs and etchings of public characters; that surface anatomy will become inter- esting because studied on reproductions of the famous works of aneient Greek art. Muscular actions can only be taught effectively by voluntary use of the muscles of nude models, or by their involuntary contraction induced by the electrical cur- rent. Bones and other specimens in the hands of the instructors are of little value to the student seated 20 feet away. This distance effectually prohibits the latter from seeing the fissures, grooves, and foramina so learnedly mentioned by the teacher, who is perhaps simply reading for his own enlightenment the lettering printed on the bone. Even gigantic models in the hands of the teacher are less advantageous than duplicate specimens in the hands of the students during the time of instruc- tion. Some teachers fail to appreciate that an elaborate picture, though valuable for reference by one who has known the anatomical region, is of little service to a student. The crudest diagram, made before the latter's eyes, conveys the idea and fixes it in his brain. A piece of chalk and a blackboard are imperatively demanded whenever and wherever anatomy is to be taught. Yet I recall the dissecting room of a well-known medical school which for years had no blackboard, no chalk, and no skeleton within its walls. Occupants of chairs of anatomy not infrequently look upon their positions as tem- porary, and long for the occasion when they may be transferred to a department in which they feel more interest. Who does not know professors of anatomy that promptly became professors of surgery or obstetrics when the opportunity arose? One can as little expect such temporary anatomical chairs to be filled with enthu- siastic and successful teachers, as to find proper teaching of applied medical and surgical anatomy at the hands of physicians whose daily work is literature or life © 3.º : 1150 PAN-AMERICAN MEDICAL CONGRESS, insurance. Again, it is not reasonable to expect those whose early education has been defective to be able to teach the mutual relations of anatomy to biology, mechanics, and psychology. The student needs a wide preliminary education in general knowledge; but the teacher of anatomy is helpless without it. No criticism is too severe for the system that places first and second course medical students in one class room to hear the same didactic lectures on anatomy. Such a parody of instruction is probably unknown except in medical schools. To compel half of the class to hear what they can not possibly understand, to force the other half to listen to much that they have already learned, is recognized as idiocy by every one, except the professional phonograph that each year repeats at a given hour the words which successive classes have received as instruction. Teaching that is not graded so as to lead step by step to higher knowledge is unworthy the name. It is impossible to compute the lost hours, undeveloped intellects, and disasters in medical practice due to this almost distinctively American folly. This undesirable method of teaching has been retained in the department of anatomy longer than in some other departn:ents, because the important new facts to be taught in anatomy have been less numerous and conspicuous; therefore the whole subject can be pretty com- pletely discussed in one session of lectures. No method of instruction fulfills its mission if it does not develop the habit of inde- pendent investigation and work. Pupils need to be taught the manner of institut- ing and following out original inquiries and the use of the literature of a subject. Few colleges attempt to thus arouse the powers of observation and to sharpen the senses; for the prizes offered in some schools for a record of anomalies found in the dissecting room scarcely deserve consideration in this connection. Opportunities for original research in human anatomy are now given, and such work is encouraged at the Harvard University Medical School, The College of Physicians and Surgeons of New York, and in the medical department of Clark University, at Worcester, Mass. The last institution, however, confers no degrees in medicine and does not partake of the character of a school for undergraduates. Didactic instruction at the bands of teachers who never contribute a single new fact or thought to anatomical or medical literature is not calculated to encourage a spirit of scientific inquiry in students. The demonstrated usefulness to the scientific world of a teacher's original labor is a powerful stimulant to investigation and Scientific rivalry among his pupils. The need of such opportunity and example is much felt in our schools. In certain things we need to return to methods employed in the middle ages, but later overlooked or forgotten. In the beginning of the fifteenth century naked men were used to demonstrate (natomical facts, and it is possible that outline diagrams of the deeper structure were made on the bare skin. Experience with students has abundantly shown me that such “anatomical clinics’ meet with great favor. To group in one lecture several nutle models representing the effects of disease on anatomical landmarks is most valuable and essential in teaching and sustaining interest in clinical anatomy. “Clinical conferences,” in which before his fellows the advanced student points out and demonstrates anatomical relations upon the liv- ing subject, develop a habit of thorough investigation of medical and surgical cases. Its subsequent value in diagnosis is easily appreciated. This form of anatomical teaching is manifestly impossible to an instructor who has no practical knowledge of disease conditions. The necessity for comparative anatomy, morphology, embryology, and anthropology in a perfectly arranged ana- tomical curriculum may require a portion of the instruction to be given by a biol- ogist, pure and simple; as long, however, as a medical school is to train medical practitioners the demand for a physician or surgeon to teach medical, surgical, and artistic anatomy will be imperative. The school that provides an enthusiastic biol- ogist for the one purpose and a practicing doctor for the other will best fill the hours devoted to anatomy in the college course. * The lengthening of the medical curriculum in all schools to compel attendance on four college courses would give titue for laboratory work in embryology and com- ( > Q is tº s: & Q & Q , e. © tº º º' e * * * * * * e e e © º s º © e e º * PAN-AMERICAN MEDICAL CONGRESS. 1151 parative anatomy. Graduation should then be deferred until the age of 22 years, as is now done in one school (Woman's Medical College of Pennsylvania). The museums found in medical colleges lose much of their teaching value because the students have limited access to the specimens. Bones and dissected prepara- tions, both wet and dry, of normal anatomy should be put in the student's hands for comparison with his own dissections and the text-book illustrations. In most cases the teacher alone handles the museum specimens. Wet preparations demon- strating normal regional anatomy are almost unknown in our college collections. The work done by students in the anatomical rooms would be of a much higher grade if each member of the class was required to draw, even in crude outlines, the structures uncovered by his dissections, and under the guidance of an instructor to demonstrate his findings to his fellows. The necessity of preserving cadavers in this country by vascular injection with zinc chloride and similar decolorizing agents militates to a certain degree against fine work in our dissecting rooms. The adop- tion of the principle of cold storage by some schools (Bellevue Hospital Medical College, Chicago Medical College, medical department of Western Reserve Univer- sity) shows a way out of the dilemma. Examinations in anatomy, which might be public, should be conducted at various periods of the course. Those in the early part ought to be restricted to osteology and similar elementary topics; but the later, and more difficult examinations in regional, medical, surgical, and artistic anatomy should be so conducted as to require the use of the earlier knowledge, and include demonstrations of surface anatomy and of dissections. A substitution of English terms for the Latin, nomenclature, still largely retained in anatomy, would aid the average medical pupil to understand anatomical mechanics and remember the facts which he has presented to him. Much was gained in European schools when the mediaeval practice of teaching medicine in debased Latin was relinquished. The professor who had to use the vernacular was compelled to be accurate in statement and clear in expression, and could no longer hide his ignorance in high-sounding Latin sentences imperfectly understood by his class. The true solution of the educational problem in medicine is the discontinuance of the isolation existing between medical schools and schools whose object is gen- eral education and culture. Every medical School should be an integral part of a college or university, and should not be managed by men separated from the whole- some educational atmosphere which surrounds institutions devoted to learning in its broadest sense. The perpetuation and organization of isolated medical schools has been the cause of manifold defects in medical teaching, and has ended in making medical pedagogics an undeveloped science. The educational and educative friend- ships, even the hostilities, engendered by a combination of medical and academical schools would bring about better preliminary qualifications in medical students and more advanced methods of teaching in professors. It is the school and the man in the corner who never comes in contact with his superiors, that fails to improve his methods of work. The valuable “courses preparatory to medicine” now found in several universities, would become more numerous; and more youths, looking for- ward to a medical career, would begin their studies in such courses, if the univer- sity and the medical college were everywhere combined. Thus the study of medicine would be a gradual development of the mind and not a mere attempt to crowd tech- nical facts in the memory; a process in violation of the first principles of educa- tion, and one which makes many medical journeymen, but few medical masters. Universities, academies, and all literary schools would be benefited by the associa- tion with medical colleges, as it would lead to even greater modification of the former rigid classical course by the development of the departments of natural science and languages. This change would meet with the approval of many thinkers, among others the Emperor of Germany, who, you remember, has in recent years shown the value of youthful energy by insisting upon the necessity of modifying the strict and unyielding classical curriculum so long enforced by the German universities. 1152 PAN-AMERICAN MEDICAL CONGRESS. PAPERS READ BEFORE THE SECTION. THE DISSECTING ROOM. By E. W. HOLMES, M. D., of Philadelphia, Pa. I had anticipated the pleasure of reviewing the various problems in the practical management of the anatomical room, in order to derive advantage from the experi- enced discussion and criticism of those present, but the exigencies of time and space enjoin the omission of many. I would not have ventured upon the selection of this topic in this presence were it not for the evident neglect of this important branch of medical study of late years. That anatomical study was the basis of all medical knowledge, that a dis- secting room, a supply of bodies, and a corps of teachers were absolutely necessary, have always been axioms. But more than that, what has been done in the majority of the schools. Look at the immense improvements in other branches. Twenty- five years ago well-equipped physiological and chemical and physical laboratories were uncommon; pathological museums were almost unknown, except in name, and practical hygiene and bacteriology were not in existence. To-day the opportunities for research in any one of these would busy a lifetime, but in anatomy we stand only on the basis of the needs of a quarter of a century ago. Formerly, anatomy claimed a good one-seventh of the required studies; to-day, it but weakly elbows a space with twenty ologies and specialties which have been elevated by their more enthusiastic advocates. * We often estimate the speed of our train by the rapidity with which we rush by Stationary objects; and conversely, as practical anatomists, we can see how we have stood still by the rapid passing of the collateral branches which have asserted their importance and taken to themselves the time and attention which our branch needs. One of the main reasons has been the teaching methods in vogue---the more instruc- tion by lecturing, the fewer instructors required—which has practically resulted in the added emphasis of the lecture system and the minimizing of the personal supervision in dissection. The method of bedside instruction in medicine and surgery does not obtain, as it should, in the dissecting room of to-day. This is peculiarly unfortunate. Lecturing methods are especially ill fitted for the impress. ing of our facts. Really, the exigencies of practice of medicine and surgery demand the application of these facts through the eye and hand and not by the ear, and yet the best lecturer can not exhibit his dissection to more than 50 students seated around him, and when you remember that in the larger schools often there are 700, you appre- ciate how really ineffective is the method. Not that I deprecate in the least the value of the experience of the accomplished anatomist who directs in his lecture the novice in his studies; but a lecture course can not teach, it can only point out the way, while the real learning must be be done by the student himself in his room and at the cadaver. The emphasis, however, is ever laid upon the attendance upon the hours of the lecture, and the compulsion is upon the examination upon those lectures. There is hardly a medical school that absolutely insists upon the student being present at fixed hours in the dissecting room. Dissecting, of course, is obligatory, and it sets apart certain periods for dissecting when the student can come if he wishes to, like the ancient almanacs that stretch across the whole month's page, “Look out for rain about this bime.” Students are divided into small sections for bedside instruc- tion in clinical medicine and surgery, but “nary a bit” for dissecting work. Who ever heard of modernized teaching facilities for the dissecting room? There is nothing beyond the corpse, the cadaver, and the corps of teachers, and a skeleton PAN-AMERICAN MEDICAL CONGRESS. 1153 or two, and the few nude pictures of three decades back. The museum is for the illustration of the lectures, and is separated far and wide from the anatomical room. Then the anatomical room itself—it is a dirty place, you know. If there is any extra paint or adornment, it does not go there. It is the most unattractive room in the school, and the most inaccessible. I need not apologize for wishing that something could be done to vivify the interest in our noble science. There is no branch of so much practical usefulness upon which there is such probable ignorance in the profession as this. Further, when you think that chemistry, p hysiology, etc., may be conducted and studied at a dis- tance, but human anatomy only in the medical school, the need of stimulating the student to use all his efforts to avail himself of oppo Itunities, which assuredly for the majority will never come again, is most imperative. The remedy is not far to seek. The same methods so successful elsewhere have not been, but should be, applied to the study of anatomy. * The classes should be divided into small sections for the “bedside study” of the cadaver. Skilled instructors who make this a specialty should be continually at the elbow to encourage, direct, and drill. A demonstrator of anatomy should not be a practitioner, but a specialist Spending his whole time in the rooms and satu- rated with the anatomical atmosphere. No one can fulfill the office of a teacher who is not filled full of his subject. The hours of the sections for histology or hygiene are fixed and certain; and so should it be here, and not left to an elastic sweet will, which too often does not will to go at all. The anatomical room should properly be in a building by itself, of but one story, easy of access, so that it may be the haunt of the pupil when not otherwise engaged, or when an empty one-fourth hour should tempt to the speedy elucidation of some single point. There should be ample facilities for instruction—strike while the iron is hot, is the right principle. I will guarantee that a specimen, well worked out, placed in the hands of a student while engaged upon a given part, is ten times the worth to him that it is when held up at the distance of 20 feet in the midst of a formal lecture, or when kept high upon the sacred shelf of the medical museum. The museum in a medical school is usually of comparatively little use. Each dissecting room should have its own collection of moist and dry specimens in jars or in cases of ready access when the student may be most interested, and therefore most needs it. This dissection is a two-headed Janus (for we must dissect in order to know), yet in order to dissect intelligently we must have some foreknowledge, and this paradox is best solved by the study of the moist and dry preparations which the student should be encouraged to examine, both before and after, as well as during the procedure of dissection. Then, the instruction should be direct and personal. It is here, as in everyday life—the greatest philanthropist is not he who helps many wholesale or insists upon the unfortunate doing his way, but rather the one who kindly helps when Help is needed, and without protrusion of self gently lifts the fellow out of the rut of wrongdoing. “A friend in need is a friend indeed,” implies that the proper aid is given just at the time required, not before. Demonstrations therefore should be personal and upon the cadaver, not a mere recital of facts. Class demonstrations are useful particularly for a rapid résumé to the more advanced student, but the speechmaking should be subsidiary to the demonstration of structure. An ideal method perhaps would be to encourage each student to carefully prepare and pre- serve his own dissections, as thereby would be acquired a stimulus to more careful work, and then at the time of demonstration each would have in his hands a dissec- tion upon which to follow the explanation of the teacher. I have spoken of the emphasis laid upon the examination after the lecture course. This is only a means to an end, but to the majority it is the ultima Thule. It would be far better to exact an examination upon each dissection and at the end of the course a finality upon the cadaver. S. Ex. 36 73 1154 PAN-AMERICAN MEDICAL CONGRESS. I have already disclaimed any intention of detracting one iota from the value of lectures, but really how opportune if the phonograph could be utilized for this pur- pose. Let the most able and scientific of this society write out a series of lectures which could be spoken into the instrument by the most eloquent member. Then a tyro could turn the crank and deliver to a delighted audience the most perfect of courses and these could be multiplied indefinitely so that each medical school could be supplied on demand, while thereby could be secured that uniformity of nomen- clature which has harassed the minds and hearts of our members for a considerable SéaSOIl. * * There is one other point I wish to touch upon. (1) The absence of systematic records of anomalies and pathological lesions which would be of extreme value if properly noted, and the waste of magnificent material yearly in all of the schools which could readily be utilized for scientific purposes. Think you a dissecting room is only to study anatomy & There is a wealth of pathology, a richness of surgical knowledge, a treasure of medical story, a mine of anomalous relations, all gone, burned, or buried. Like the early miner of the West, in our haste and with our careless or crude methods, we overlook the very gold we fain would grasp, and some more careful worker will enrich himself and his race from the waste which we throw away. I have endeavored to point out some of the more glaring defects in the anatomical room which stand in the way of its improvement. (1) It is subordinated to the lecture method which, rightly, should be subordinate to it. (2) It is too often repulsive and inaccessible. (3) It is not managed with precision that find in other departments. (4) The teaching facilities are rarely what they should be, and should be supple- mented by an extensive museum, ready of access under proper regulations to the student, who should be allowed to handle the specimens himself. (5) The teaching should be personal and demonstrative rather than didactic. (6) The test should be one of practical knowledge of the cadaver, rather than of merely theoretical data. (7) A proper record of all anomalies and pathological lesions found should be kept, and the invaluable specimens added to the teaching facilities of the various departments of the school. THE HUMAN HAND. By GEORGE WILLIAM WEAR, M. D., of Washington, D.C. The human body is one of the most worthy objects of man's study. It is the noblest as well as the crowning work of creation. In it material organization is carried to the greatest perfection. There is no part of the human body which is more significant in its actions, which is more characteristic in its formation than the hand. One of the first points which obtrude themselves upon the student of anatomy is the absolute perfection of the human hand as regards its construction and the uses to which it is adapted. In no other combination of bones, muscles, and nerves, and in no other animal do we find a perfection which results in such superiority with regard to strength, variety, extent, and rapidity of motion; and this perfection undoubtedly resulting from the intimate relations which exist between the hand and the intellect, we are irresistibly to ask with Sir Charles Bell: “Is it nothing to have our minds awakened to the perception of the numerous proofs of design which present themselves in the study of the hand, to be brought to the conviction that everything in its structure is orderly and systematic, and that the most perfect mechanism, the most minute and curious apparatus, and sensibilities the most delicate and appropriate, are all combined in operation that we may move the hand?” PAN-AMERICAN MEDICAL CONGRESS. 1155 As Galen remarks: “Let us then scrutinize this member of the body and inquire, not simply whether it be in itself useful for all the purposes of life, and adapted to an animal imbued with the highest intelligence, but whether its entire structure be not such that it could not be improved by any conceivable alteration.” The wants of man are greater and more varied than those of any other animal; therefore, he has had given to him what he alone of animals possesses, and what to him alone is necessary, viz, the hand. The genus homo, or man, takes rank in the classification of mammals as a distinct order, Bimana, in consequence of man being the only ani- mal possessing two hands. At first sight, it might be considered that four-handed animals, the monkeys, apes, and their allies which are placed by zoölogists in the order Quadrumana, were superior to those which possess only two hands, but this is far from being the case. None of these four hands are adapted to the variety of actions which the human hand is capable of performing, and they are all to some degree, required for support and locomotion; so that while in the higher forms of the quadrumana the extremities present an approximation in structure to those of man, in the lower they gradually tend to resemble the ordinary quadrupedal type. “That,” says Cuvier, “which constitutes the hand, properly so called, is the faculty of opposing the thumb to the other fingers, so as to seize upon the most minute objects, a faculty which is carried to its highest degree of perfection in man, in whom the whole anterior extremity is free and can be employed in prehension.” The peculiar prehensile power of the human hand is chiefly dependent upon the length, power, and mobility of the thumb, which can be brought into exact opposi- tion to the extremities of all the fingers whether separately or grouped together. Some animals are bold and fierce, others are timid and gentle, some are gregarious and coöperate for their mutual sustenance and defense; others are solitary and avoid the society of their fellows; but all have a form or body accommodated to their natural dispositions and habits. Thus, the lion has powerful fangs and claws; the hare has swiftness of foot, but is otherwise defenseless. And the fitness of this arrangement is obvious; for those weapons which the lion is furnished with are as appropriate to his nature as they would be inappropriate to the timid hare, whose safety, depending entirely on flight, requires that swiftness of foot for which she is so remarkable. But to man, the only animal that partakes of divine intelligence, the Creator has given, in lieu of every other natural weapon or organ of defense, that instrument, the hand, an instrument applicable to every art and occasion as well of peace as of war. Man, therefore, wants not a hoof or a horn or any other natural weapon, inasmuch as he is able with his hand to grasp a much more effect- ive weapon, the Sword or the spear; for a Sword or a javelin are better arms than the nails, and cut and pierce more readily. Besides which, natural weapons can be employed only in close conflict, while some of the weapons employed by man, such as javelins or arrows, are even more effective at a distance. He is enabled more easily by this instrument to clothe himself with armor of various kinds or to intrench himself within camps or fenced cities, whereas were his hands encumbered with any natural armor, he would be unable to employ them for the fabrication of those instruments and means which give him such a decided advantage over all the other animals of creation. - With the hand we weave the garments which protect us from heat and cold in summer and winter, and construct the nets and snares with which we subjugate the brute creation. With the hand we fashion all the implements of art and Science, and, lastly, by means of the hand man bequeaths to posterity in writing the intel- lectual treasures of his own divine imagination; and hence we who are living at this day are enabled to hold converse with Plato and Aristotle and all the veneralle sages of antiquity. Thus the hand keeps constantly before us the proofs of the spe- cial adaptions of the various parts of the body to the uses to which the parts are to be put. “In man,” says Prof. Owen, “while one pair of limbs is expressly organ- ized for locomotion and standing in the erect position, the other pair is left free to 1156 PAN-AMERICAN MEDICAL CONGRESS. execute the manifold behests of his rational and inventive will, and exquisitely organ- ized for delicate touch and prehension, emphatically called manipulation.” The hand is essentially the organ of the mind, the medium of its expression, and the instrument whereby its promptings are carried into execution. “We first see the hand,” says Sir Charles Bell, “ministering to man's necessities and sustaining the life of the individual; in a second stage of his progress we see it adapted to the wants of society, when man becomes a laborer and an artificer; in a state still more advanced, science is brought in aid of mechanical ingenuity, and the elements which seem adverse to the progress of society become the means conducing to it.” The seas, which at first set limits to nations and grouped mankind into families, are now the means by which they are associated. Before entering further into the description of the hand, it is mecessary to say a few words on the upper extremity generally, of which the hand may be regarded as the essential part. The general plan of the osseous framework of the upper and lower limbs is very similar. The humerus, or arm bone, corresponds to the femur, or thigh bone; the lower end of the humerus is connected with the two bones of the fore- arm, the radius and the ulna, which correspond with the two bones of the leg, the tibia and fibula. Then come the carpal bones, the metacarpal bones, and the pha- langes, just as we have tarsal bones, metatarsal bones, and phalanges in the foot. It is not necessary to enter into any anatomical details regarding the individual carpal bones. Collectively they are so arranged that the carpus presents a dorsal convex surface, upon which the tendons of the extensor muscles of the fingers play, and a palmar concave surface, on which the tendons of the flexor muscles lie. The several bones are joined to one another, each bone being united to three or more others by a large extent of surface, and are girded together by strong ligamentous bands. The wrist is thus as strong as if had been constructed of one solid piece of bone, while the slight gliding movements which occur between the Several bones give it an elasticity which serves to break the shocks that result from falls upon the hand. The uppermost surface of the first row of carpal bones is convex, and this convex surface is received into a wide cup, or socket, formed by the lower articular surface of the radius and by a ligament passing from that bone to the ulna. The metacarpal bones and the phalanges require no special description. Like the great toe, the thumb has only two phalanges, while each of the other digits has three. The scapula, or shoulder blade, with which the principal arm bone articulates, is itself movable to a considerable extent on the surface of the ribs, on which it rests. Again, the socket in which the nearly spherical head of the humerus, or arm bone, lies is very shallow, not unlike the cup in the well-known toy cup and ball, and the arrangements of the shoulder joint generally are such as to permit so great a variety and so extensive a range of movements that we are able to apply the hand to every part of the body. This freedom of motion is due in a great degree to the clavicles, or collar bones, which, by steadying the shoulder blades and keeping the shoulders apart, afford a fixed point for the various muscles which we employ in raising the arms, in folding them over the chest in the act of hugging, or in the attitude of prayer. The movement of the next junction of bones, the elbow joint, are very differ- ent from that at the shoulder. The latter is termed, from its construction, a ball-and- socket joint, and admits of motion in all directions, within definite limits, while the former is a hinge joint, and merely admits of bending and straightening, or, in other words, of motion in one plane. A full consideration of the muscles of the hand would take too much time. We may demonstrate upward of fifty muscles of the arm and hand, all of which must consent to the simplest action. Nothing appears to us more simple than raising the arm or pointing with the finger; yet, in that simple act, not only are innumerable muscles put into activity, and as many thrown out of action, but both the relaxing and the contracting muscles are controlled or adjusted with the utmost precision, though in opposite states, and under one act of volition. To the anatomical stu- dent, the mode of demonstrating the muscles of the human hand and arm becomes PAN-AMERICAN MEDICAL CONGRESS. 1157 the test of his master's perfection as a teacher. When they are taken successively, just as they present themselves in the arm, nothing can be more uninteresting, tedious, and difficult to attend to than such a demonstration; but when they are taught with lucid arrangement, according to the motions performed by the distinct groups of muscles, it is positively agreeable to find how much interest may be given to the subject. Just here we will consider a class of movements of the forearm and hand, to which there is nothing analogous (at least to any material extent) in the leg. The move- ments in question are called pronation and supination. In pronation (derived from pronus, with the face downward) we turn the palm of the hand downward, as in picking up any substance from the table; in supination (derived from supinus, with the face upward) we turn the palm upward, as for the purpose of receiving any- thing that may be placed in it. These movements of pronation and supination are so important to the usefulness of the hand that it is necessary to notice the three muscles by which they are chiefly produced. One of the three muscles passes from a projecting process on the inner side of the humerus, at its lower end, to the outer edge of the middle of the radius. Its contraction causes the radius to roll over, or in front of, the ulna; it thus pronates the hand, and is called a pronator muscle (pro- nator radii teres). Another muscle passes from a projecting process on the outer side of the humerus to the inner edge of the radius near its upper part. It runs, there- fore, in an opposite direction to the former muscle, and produces an opposite effect, rolling the radius and the hand back into the position of supination; hence, it is called a supinator muscle. The third is a very powerful muscle, termed the biceps, which not only bends the clbow, but from the mode in which its tendon is inserted into the inner side of the radius, also rotates the radius so as to supinate the hand, and it gives great power to that movement. Mechanicians have observed that they have more power to supinate the hand than to pronate it. Supination can only be performed to its full extent by man, and even in man it is not the natural or habitual position; monkeys can partially effect the movement, and in most of the lower ami- mals the part corresponding anatomically to the hand is constantly in a state of pronation. The movements of which the hand itself, without reference to the arm, is capable, are very numerous, and in this respect differ considerably from the corresponding movements of the foot. Thus the fingers can be bent down upon the palms or they can be extended beyond the straight line; they can be separated from one another to a considerable extent, and they can be closed with considerable force. The wrist and hands are bent forward, or flexed, upon the forearm by three muscles which pass downward from the inner condyle of the humerus, and are termed the radial flexor, the ulna flexor, and the long palmar muscles. The first two of these muscles are inserted into the wrist bones on the radial and ulna sides, respectively, while the third expands into a fanlike fascia, or membrane, in the palm of the hand, and thus serves both to support the skin of the palm and to protect the nerves and vessels which lie below it. Beneath the palmar fascia lie two sets of flexor muscles of the fingers, and they present so beautiful a mechanical arrangement as to merit special notice. The superficial or perforated flexor muscle passes down the front of the forearm and divides into four tendons, which becomes apparent after removing the palmar fascia, and are inserted into the second phalanges of the fingers, each tendon splitting at its termination, to give passage to the similar tendons of the deep or perforating flexor muscle, which passes from the upper part of the ulna to be inserted into the last phalanx of each finger. These flexor muscles are antagonized by the common extensor muscle of the fingers, which, like the flexors, divides into four tendons, one for each finger. Besides these, there is a special extensor of the index finger, a series of muscles forming the ball of the thumb, which move that organ in almost every direction, and various small slips giving lateral and other movements to the fingers. 1158 PAN-AMERICAN MEDICAL CONGRESS. The hand contains two principal arteries, the radial and the ulnar. The ulnar proceeds in a curve from the wrist to the first finger where it joins a branch of the radial, forming what is known as the superficial palmar arch. Four digital arteries go from its convexity, which subdivide into collateral branches about two lines below the metacarpo-phalangeal articulations. These supply the palmar and lateral sur- faces of the fingers, excepting the thumb and the outer side of the index, the branches coalescing at the tips of the fingers, whence branches arise to supply the pulp of the fingers with blood. The radial goes from the end of the forearm (radius) round the wrist, between the thumb and index finger, and back into the palm, where, joining the ulnar, it forms what is known as the deep palmar arch. Before, however, it does this, it gives off two arteries, one of which (the superficialis volae) supplies the palm, whilst the other divides into two branches (the arteria dorsales pollicis) which run along either side of the thumb, one of which branches sends off an artery to the index finger. When the radial dips into the palm it gives off branches to the thumb and forefinger or index, and to the deep palm (where it joins the ulnar). The veins, which are generally very deep, accompany the arteries. The most important subject for our consideration is that of the nervous system of the hand, of that complicated plexus of nerves which gives to the hand its direct and constantly apparent connection with the brain. Without the hand, princi- pal seat as it is of the sense of touch, the other senses would be comparatively useless. The sense of touch is the only sense which is reciprocal. That is, though the senses of sight, hearing, taste, and smell, can only receive impressions without giving them, that of touch, both receives and gives; and it is this sense of touch, dependent as it is upon the nervous system, which is the most important of all, and which is found in its highest state of development where that nervous system is the most complete, namely, in the hand. .* An accumulation of fat and fibrous tissue under the skin forms the “pulps” at the ends of the fingers. The slightly conical form and exquisite softness of the pulps adapts them well for the examination of the surfaces of bodies; and the sense of touch is more acute in them than in other parts of the hand. In connection with them it is interesting to observe that the last bone of each finger and of the thumb swells out at the end into a modulated lump, which serves the purpose both of supporting the pulp and of giving breadth to the nail. The cuticle is the medium through which the external impression is conveyed to the nerves of touch. The extremities of the fingers exhibit all the provisions for the exercise of this sense. The nails give sup- port to the fingers; they are made broad and shieldlike, in order to sustain the elastic cushion which forms their extremity. This cushion on the end of the finger is a very important part of the exterior apparatus, its fullness and elasticity adapt- ing it admirably for touch. Fine as the sense of touch usually is in the hand, it becomes far more so when an unusual demand is made upon it in consequence of a deficiency or absence of other senses. The rapidity with which blind persons can read with their fingers is truly astonishing. Some are said to distinguish colors by the feel. It should rather be said that they are capable of recognizing the nice differences in certain substances by which colors are caused; for one can scarcely conceive it possible to distinguish by feeling the colors in a ray of light separated by a prism. It was said of a lady who had been not only blind but deaf and dumb from infancy: “The sense of touch was, theref, re, almost her only avenue for impressions from without, and it was surprising how much information was conveyed through it, and how quickly ſt enabled her to hold converse with her relatives, by the language of the fingers, almost as freely and as briskly as others did with the tongue. A few touches were sufficient to transmit a series of thoughts. After one shake of the Iland of a stranger she would immediately recognize him on meeting him again.” Persons who have had much experience in the instruction of the deaf and dumb find that the hand, by means of writing and “dactylology,” or the language of finger signs, is abundantly sufficient for all the intercourse to which a deaf-mute is equal; PAN-AMERICAN MEDICAL CONGRESS. 1159 and they are, therefore, disposed to discourage the teaching of articulation. The capacity, therefore, which the hand enjoys of ascertaining the distance, the size, the weight, the form, the hardness or softness, the roughness or smoothness of objects, results from its having a compound function, from the sensibility of the proper organ of touch, being combined with the consciousness of the motion of the arm, hand, and fingers. But it is the motion of the fingers that is especially necessary to the sense of touch. These bend or extend, or expand or move in every direction, like palpa, with the advantage of embracing the object, feeling it on all its surfaces, estimating its solidity or its resistance when grasped, moving round it, and gliding over its surfaces, so as to feel every asperity and be sensible of every slight vibration. Why is man usually right-handed? Many attempts have been made to answer this question. Is the superiority of the right hand real and natural, that is, con- genital, or is it merely acquired? All men are not right-handed; some are left- handed; and some are ambidextrous. In the tribe of Benjamin “there were seven hundred chosen men left-handed; every one could sling stones at an hair breadth and not miss.” (Judges xx, 16.) When David was at Ziklag there came to him a company of men who “were armed with bows and could use both the right hand and the left in hurling stones and shooting arrows out of a bow.” (1 Chronicles, xii, 2.) There is an universal consent among all nations to give the preference to the right hand over the left. This can not be a conventional agreement; it must have a natural source. For the convenience of life, and to make us prompt and dex- terous, it is pretty evident that there ought to be no hesitation which hand should be used, or which foot should be put forward; nor is there, in fact, any such inde- cision. Is this readiness taught, or is it given to us by nature? It is suggested that if the right side were orginally the most powerful in man, we might expect to find it the same in other animals. It is affirmed that squirrels, monkeys, and par- rots feed themselves with the left leg rather than with the right. But the parrot may be said to use the strongest foot where most strength is required; that is in grasping the perch and standing, not in feeding itself. It must be observed at the same time that there is a distinction in the whole right side of the body as well as in the arms, and that the left side is not only the weaker in regard to muscular strength but also in its vital or constitutional properties. The development of the organs of action and motion is greatest upon the right side, as may at any time be ascertained by measurement or the testimony of the tailor or shoemaker. Certainly this superiority may be said to result from the more fre- quent exertion of this side; but the peculiarity extends to the constitution also; and disease attacks the left extremities more frequently than the right. In walking behind a person it is seldom that we see an equalized motion of the body; and if we look to the left foot, we shall find that the tread is not so firm upon it, that the toe is not so much turned out, and that a greater push is made with the right foot. The horseman puts the left foot in the stirrup and springs from the right. We think we may conclude that the adaptation of the form of everything in the conveniences of life to the right hand, as for example, the direction of the worm of the screw, or of the cutting end of the auger, or the shape of other tools or instruments, is not arbi- trary, but is related to a natural endowment of the body. On the whole, the pref- erence of the right hand is not the effect of habit, but is a natural provision, and is bestowed for a very obvious purpose; the preference is given to the right foot as well as to the right hand. DISCUSSION. Dr. Lamb said that the general opinion seems to be that the left side of the brain appears to be better supplied with blood as a consequence of the arrangement of the branching of the arch of the aorta. As a consequence of this greater development of the left side of the brain, we have the greater development and use of the right upper extremity. It may be well to notice in this connection the fact that in very 1160 PAN-AMERICAN MEDICAL CONGRESS. many cases there are eight costal cartilages connecting with the sternum on the right side, giving, therefore, a greater support to the right upper extremity. Dr. Lamb has recently made a post-mortem examination of a woman who was left handed, and there were eight cartilages on that side connected with the sternum. Dr. Reyburn stated that in all probability the larger supply of blood given to the right upper extremity will account for its greater development. The great difficulty in this matter is the want of text-books on anatomy written from the standpoint of studying human anatomy as the development from the human brain; but it will be done soon by someone, and the book will render his name immortal. Dr. Baker remarked that the dextral preference had been variously explained as due to the position of the foetus in utero, the position of the vessels on the arch of the aorta allowing a greater supply of blood to one side of the brain than to the other, etc. The most plausible theory that has been urged seems to be that it is derived from the necessity which primitive man found to protect his left side. The left arm becomes the shield or defensive arm, the right the spear or offensive arm. This necessity, continued through countless generations, has caused the differen- tiation. . Dr. L. S. Pilcher, Brooklyn, N. Y., said: The Chair remarked that he had hoped to hear some reference on the part of the eminent members of the section upon the relations of the development of the cerebral centers which govern the actions of the hand to the question of dextral preference. It seemed to him that in the laws of cerebral development was to be found the explanation of this phenomenon. He did not think there was any substantial difference in the nutrition of the two sides of the brain, due to the slight differences which measurements had shown to exist in the respective capacities of the blood vessels on the two sides of the neck that transmitted blood to the cerebrum; the freedom of anastomosis that existed within the cranial box favored the uniform dif- fusion of the blood that was brought to the brain. Nevertheless, he believed that an earlier or more complete development of the centers in the left brain occasioned the more perfect and constant use of the right upper extremity in the various affairs of life. The reflex effect of such preponderating muscular work upon the further development of the nerve-centers that controlled them was a well recognized fact, and from this had been drawn the practical recommendation to begin, at an early date, to exercise the left as well as the right upper extremity, so that the possibili- ties of disaster in later life from possible degenerations of the developed side might be guarded against by the more equal development of both sides. He invited dis- cussion on this phase of the subject. - LAWS OF THE GROWTH OF THE CELL APPLIED TO HUMAN ANATOMY. By ROBERT REYBURN, A. M., M. D. Professor Physiology and Clinical Surgery Medical Department, Howard University, Washington, D. C. The humam ovum or egg, from which all the tissues and organs of the human body are built up, is in the earliest stages of its embryonic life nothing more or less than a simple cell or mass of protoplasm. These cells or masses of protoplasm are practi. cally identical in all animals and consists, after impregnation, of a fecundating liv- ing germ, which has surrounding it a limited supply of food yolk or nourishment, which serves to nourish the embryo until other structures are developed, which carry on the process of nutrition during the entire period of foetal existence. As the human ovum is directly transformed during its process of development into the human body, it is obvious that the laws governing the growth of the ovum must furnish the key to the growth of the human body in its adult or completed form. What, then, are these laws, or rather the causes or conditions, which modify the growth of the cells composing the body? The first of these conditions is that cells, PAN-AMERICAN MEDICAL CONGRESS. 1161 when young and growing, increase in size by layers of nutriment deposited upon the outer surfaces of the cells, accompanied by a nearly equivalent amount of the waste products of the cell, which is absorbed from its inner surface. So long as the amount of nutritive material deposited upon its outer surface is greater than the waste from the inner surface, the cell continues to grow and increase in size until the time of maturity is reached. At this point the forces of waste and destructive assimilation are just balanced by the powers of the organism to absorb and assimilate nutriment. After this period is reached the individual cells (and in consequence the body as a whole) gradually cease to absorb and assimilate as much of nutritive material as is required to supply the waste, and hence the result of inevitable death, which is the pitiless law that rules the organic world. How, then, does the human body as a whole grow from infancy to maturity? Precisely in the same way as the individual cells of the body do. Take, for instance, the development of the aorta, the great arterial trunk of the body. In the new-born child the aorta is a tube the lumen of which will measure perhaps three-eighths of an inch across; when this same child has reached adult manhood, his aorta will have become a great tube an inch or more in diameter. This increase in size, it is very evident, must have been produced in the way above described. As years pass on numberless layers of microscopic tenuity have been piled up upon its outer surface, thus increasing the thickness of its walls. Along and simultaneously with this process goes on the absorption from the inner walls of the waste tissue, thus increasing its dimensions both externally and inter- nally. This same law of growth is applicable to the development of the intestinal canal with the stomach and accessory organs of digestion, to the growth of the Haver- sian canals and medullary cavities of bone, to the growth of the shafts of the long bones of the extremities of the body, and, indeed, to the growth of the limbs in their entirety. Not only is this law of growth true of every organ and structure found in the body, but it is just as true when applied to the growth of the human body as a whole. - The second of the causes which modify the shape of the living cells of the body is their tendency to grow towards the source of nutriment. Living cells when free or floating in the liquids of the body are always more or less circular in shape. As found in other parts of the body, they are very variable in size and form. Take, for instance, the cells in the lacunae or the bone cells; these were originally circular or ovoidal cells. As the process of transformation of cartilage into bone, for instance, goes on, these cells gradually become incased by layers of earthy matter surrounding them, which would prevent the absorption of the pabulum necessary for their nourish- ment. In order to overcome this difficulty the cells in their process of growth absorb certain portions of the walls inclosing them, and thus the myriads of canaliculi, or fine tubes, which connect the bone cells with each other, and the Haversian canals are formed. The canaliculi are of course entirely too small to admit the entrance of the red or white corpuscles of the blood, or even the blood plaques of Bizzozero, and their nourishment is maintained by the liquid plasma of the blood. Many illustra- tions of this second cause are to be found in the body. It is only necessary here to mention the rapid repair of fractures of the long bones, when the fracture occurs just below the point where the nutrient artery enters the bone, as compared with the slowness of repair when it occurs just above (thus partially cutting off the cir- culation of blood in the part). In fact, it is universally admitted that the growth and development of every organ and tissue in the body is directly proportioned to the amount of its blood supply. The third cause modifying the form of the cells of the boily is that each cell and the body as a whole tend to reproduce, under favorable conditions, the same type of the parent cell from which it sprang. Bone tends to reproduce bone. Muscle repro- duces muscle, and so, in like manner, do all the tissues and organs of the body. In pathologic growths we do find alien and foreign tissues in the diseased por- tions of the body. Bone, for instance, is often found in epidermoid cysts, and in parts of the body which in health are composed of cartilage and muscle. 1162 PAN-AMERICAN MEDICAL CONGRESS. One important fact, however, is to be noted in studying the constituents of patho- logic growths, and that is that all pathologic growths are histologically true to the class of tissues generated by the layer of the embryo from which they were origi- nally formed. As is well known the human embryo primarily divides into two layers, the ectoderm or epiblast and the endoderm or hypoblast. A third layer is afterwards developed between these which is called the mesoderm or mesoblast. Tissues, therefore, which originally sprang from the first two primary layers of the embryo, do not tend to reproduce the tissues which are formed from the mesoderm or middle layer of the embryo. The exceptions to this rule are rare. - The fourth cause or condition, modifying the shape and growth of cells, is the pressure of other cells upon them during the early period of their growth. The multiform shapes of the cells found in cancerous tumors are evidently due to this cause, as well as the flattened shape of the cells found in the epidermis, hair, and many other parts of the body. After maturity, the retrograde change or metamorphosis at once begins in the cells, and as a necessary consequence in the body as a whole. The powers of assimi- lation of nutriment gradually become insufficient to supply the waste, and hence the body as a whole tends to emaciate. Not only is this the case, but the power of the individual cells to separate the waste materials which are the results of their nutri- tion, become impaired. These waste materials of the cells as a consequence accumu- late and cause thickening of the cell walls of all parts of the body. One of the most striking of the results of this process is seen in the hardening and calcification of the arteries of the body, which is so commonly found in persons of advanced age. The tissues themselves tend to degenerate in old persons. Muscle becomes degraded into fat, and the same degenerative process invades the connective and other tissues of the body. A familiar example of this is to be found in the arcus senilis, which is a sure sign of the degeneration of the tissues. - It may seem, perhaps, necessary to apologize to an audience like this for such an elementary sketch of the growth and development of the human body. My object in doing so has been to call attention to what I believe to be our unscientific method of teaching human anatomy, as it is usually taught in our medical schools and colleges. The most usual or ordinary method of teaching human anatomy is to begin by studying the bony framework of the adult human body. This has always seemed to add unnecessary complexity to the study, and prevents the student from grasping the real simplicity of the idea of the structure of the human body when studied from the point of view of its being simply a development from the human ovum or cell. The study of the various organs of the body also is much better com- menced by examining them, with the aid of the microscope, as the same organs are found in the lower order of animals. The kidney, for instance, in man is quite a com- plicated organ, many of the parts of which it is difficult for the student to under- stand. In the common newt it is composed simply of a layer of tubes which can be studied and comprehended by the student with comparative ease. What is our plan in pursuing other studies? If we, for instance, take up the study of chemistry, we never begin by studying the complex compounds first; on the contrary, we first study the elements out of which the complex bodies are formed, and thus proceed from simplicity to couplexity. The same method is adopted if we take up the studies of botany, geology, mineralogy, or, in fact, any of the branches of natural science. Why, then, do we adopt a different method in the study of human anatomy from the one we adopt in studying all the other branches of science? My idea of the true way to study human anatomy, then, would be to begin by studying the human ovum or cell, then the fluids, such as the blood and lymph in which the cells are found free and floating. After this study the changes produced in the ovum by impregnation, the segmentation of the ovum, with the development of the blastodermic membrane of the embryo and its further division into the external and internal layers. Study, then, the tissues and organs formed from these layers in the order of their develop- ment. Then take up the study of the middle or third layer of the embryo, with the PAN-AMERICAN MEDICAL CONGRESS. 1163 tissues and organs formed from it. The study of human anatomy carried out in this way gives to it a simplicity and beauty that renders it worthy to be classed among the exact sciences. - It may be here remarked that this method of teaching anatomy is not a new or untried one. Prof. Piersol, of the University of Pennsylvania, I am informed, teaches human anatomy in a manner essentially the same to the one above described, and the Writer, a number of years ago, when professor of anatomy in Georgetown Uni- versity, adopted with success the same plan. DISCUSSION. Dr. John B. Roberts said: - The teaching of anatomy is, as the author has said, usually taught in an unscien- tific manner, because the complex human body is studied by students who know nothing of biology. The true method is to begin the study with simple forms, ver- tebrate and invertebrate. Dr. West said: - In reply to Dr. Robert Reyburn's most able paper on laws of the growth of the cell applied to human anatomy, in which he suggests that the proper mode of teach- ing anatomy is to begin with the cell structure (histology or general anatomy), I agree with him perfectly, but the question comes up, under whose chair does this important branch of anatomy come. I claim that it does not come under the chair of anatomy, whose duty it is to teach descriptive and special anatomy, but it prop- erly comes under the chair of physiology or that of normal histology, which chair every medical college should have, armed and equipped with a microscope as well as everything else pertaining to the proper teaching of that chair, which I consider as important as any other chair in a well-equipped medical college. The professor of anatomy proper, that is of descriptive and general anatomy, has just as much as he can attend to and more besides, to do justice to his subject in the short space of time (two years) given him. He would be getting into deep water to begin with such a task, covering so vast a field as it does. ON THE RECENT OCCURRENCE OF LINGUATULA RHINARIA, RAILLIET, 1886, AND TAENIA ECHINOCOCCUS, W. SIEBOLD, 1853, IN THE UNITED STATES OF NORTH AMERICA. By CHARLES W. STILES, PH. D. Medical Zoologist, Bureau of Animal Industry, U. S. Department of Agriculture, Washington, D. O. I wish briefly to call attention to two parasites, comparatively rare in this coun- try, found both in man and domesticated animals. The first one, Lingwatula rhinaria (L. Serrata, Pentastoma taºnioides), is by no means uncommon in Europe and has been reported several times in South America. Until recently, however, it has not been noticed in the United States. F. L. Kilborne, B. W. S., of the Bureau of Animal Industry, found eight specimens in a rabbit at Wash- ington, D. C., several years ago (Curtice, Journal of Comparative Medicine and Veterinary Archives, 1892, p. 231), and Dr. Cooper Curtice found one specimen in another rabbit in this city (Curtice, l.c.). These two finds are, so far as I have been able to learn, the only cases on record of this parasite in North America. Quite recently (July 3, 1893) my colleague, E. A. Schroeder, M. D. V., in making post-mortems on cattle at the Soldiers' Home, in the District of Columbia, observed a peculiar appearance of the mesenteric glands and, upon cutting them open, he dis- covered an organism which he suspected belonged to the species now under consid- eration. The parasites (forty in all) were present in three different steers. Dr. Schroeder kindly turned the material over to me for final diagnosis and I instantly confirmed his specific determination. - 1164. PAN-AMERICAN MEDICAL CONGRESS. As the rabbits and cattlementioned above were all raised in this region, the finding of these parasites proves conclusively that the infection took place in this vicinity, or in other words, that the adult from this parasite is present in dogs in the district. This is a point of considerable interest to physicians, since man is subject to infec- tion by this parasite. It is not my intention to give an exhaustive account of this subject, as the species in question has already been worked up by my European colleagues, and as I have already published on this same matter myself. As this arachnoid is, however, com- paratively unknown in North America, it will perhaps be in place for me to give a very brief summary of the biology of the subject. The specimens which I now exhibit to you measure 4 to 6 mm. in length. These represent the larval stage generally known as Linguatula serrata or L. denticulata, which is found in the liver and other viscera of herbivorous animals. It has also been found in the domestic cat. If these parasites gain access to the nasal cavities of dogs, they develop into the adult stage known as Pentastoma taºnioides, which grows to the length of 18 to 26 mm. (male) or 70 to 130 mm. (female). The animals copulate, and the female produces an immense number of eggs, which escape with the nasal mucus of the host. Each egg contains a minute 4-legged embryo, which in turn develops into the larval stage upon being swallowed by a herbivorous animal. The species can be recognized by the following external characters: The animals are more or less flat dorso-ventrally; they possess about thirty transverse rings; on the ventral surface of the anterior portion in the median line is situated the mouth, and on each side of the latter are to be found two hooks; the vulva is posterior, while the male opening is just caudad of the mouth. The life history as given above is the usual and most simple cycle, but is subject to several exceptions. As I have treated these exceptions in detail elsewhere (Sur la Biologie des Linguatules, Compt. rend. de la Soc. d. Biologie, Paris, 1891, p. 348), I will note here only one or two cases which seem to me the more important from the standpoint of the practitioner. - - In cases where men have harbored this species, it seems incontestable that the infection has generally taken place in one of the following ways: (1) By obtaining the embryos directly from dogs infested with the adult form; (2) by swallowing embryos with the drinking water; (3) or by eating vegetable food which has been soiled by the nasal discharge of dogs. All authors seem to agree upon these three modes of infection. Personally'I have suggested a fourth (loc. cit.) mode of infection, based partly upon theoretical grounds, partly upon observations and experiments with an allied species (Poro- cephalus crotali; Pentastoma proboscidium). If larval forms of this latter species are fed to snakes, some of the specimens reach the lungs, while others simply bore through the intestinal walls and become encysted in the body cavity. Theoretically the same must apply to Linguatula rhinaria, that is, if a mall should eat a piece of liver or other organ containing living specimens of this species, it is perfectly pos- sible that some of the parasites would bore their way to the abdominal cavity and be found later in that place. Carrying the matter further, I prophesied two years ago (loc. cit.) that Procephalus crotali would one of these days be found as a parasite in the opossum (Didelphys virginiana), and as a chance parasite in the American negro, the latter receiving his infection from eating the opossum. The first part of my prophesy has already been fulfilled, for my assistant, Dr. Hassall, and I have recently found this parasite in several opossums, and Leidy some years ago made a similar find, which was not known to me at the time I wrote the article referred to. I can hardly leave this subject without referring to Babes' theory in regard to the wanderings of Linguatula rhinaria in cattle. He believes that the parasites bore from the abdominal cavity into the lumen of the intestines, are expelled with the faeces, and are afterwards taken up from the ground by dogs. As I have stated elsewhere, this seems perfectly possible, but certainly-can not be looked upon as the PAN-AMERICAN MEDICAL CONGRESS. 1165 general mode of infection, for I have convinced myself by repeated experiments that the larval tongue-worms may develop in the intestinal wall. Now, when they burst their cysts, they will unquestionably fall into the abdominal cavity, or into the intestine, according to the direction of least resistance. The second parasite to which I wish to call your attention, is Taenia echinococcus. It is well known to you that the larval stage (Echinococcus polymorphus) of this par- asite is more or less common in certain countries, and that a number of cases have been reported in man in this country. Most of the cases found in man in this coun- try have, however, been in foreigners. We have also four cases on record of its occur- rence in American hogs (Welch 3, Moore 1), and one case in cattle (Stiles). These cases in domesticated animals, as well as the cases in Americans who have never left the country, demonstrate that the adult tapeworm is present (though rare) in Amer- ican dogs; in fact F. L. Kilborne has found it in one dog in this city (Curtice, l.c. p. 231). * Quite recently reports have come to me that the echinococcus hydatid is very prevalent among Texas cattle, and surprise has been expressed that it has not been found more frequently in man in that State. It is in order to explain this apparent inconsistency that I mention this parasite at present. Within the past two months I have had no less than 30 cases of this “Texas echinococcus” referred to me, and I have personally examined no less than 5,000 Texas cattle for this species, and after a most thorough study of the various speci- mens diagnosed as echinococcus hydatids I can state positively that not a single one of the cases I have examined represents an echinococcus. The pathologic specimens have, indeed, a superficial resemblance to the parasite in question, but when opened are found to be abscesses. At the request of Dr. V. A. Moore, I made bacteriologic cultures from the abscesses, and we may expect from him a report on the exact nature of the trouble. In the meantime we can rest assured that the reported prevalence of echinococcus hydatids in Texas cattle is greatly exaggerated and that we have no reason to fear that this parasite will become prevalent among the inhabitants of that State. By this, of course, I by no means state that there are absolutely no cases of this parasite in that region. I only say that none of the cases referred to me under the diagnosis given represented hydatids. A NOTE ON THE OCCURRENCE OF THE SCAPULO-CLAVICULAR MUSCLE. By ROBERT ORTON MOODY, B. S., of New Haven, Conn. Last January at Yale Medical College, while dissecting the left shoulder of a male subject, I found this anomalous muscle, the scapulo-clavicular. A careful study of the literature on the subject of muscular anomalies revealed the fact that the recognized occurrence of this muscle is very rare. I could discover no record which showed that the muscle had ever been found in this country. Dr. L. Testut, in his excellent work entitled Les Anomalies Musculaires Chez L’Homme, describes its occurrence in two subjects. He says it also has been described by Wood and Gruber, and that its occurrence has been noted by Luschka, MacWhinnie, and Hallet. So careful an observer as Macallister declares that he has never found it. The scapulo-clavicular muscle is an incomplete form of the sterno scapular mus- cle, which, anomalous in man, is constant in many species of vertebrates, reaching its highest development in the Pachyderms and Ruminants, notably the hippopot- amus, the elephant, the pig, the donkey, and the horse. If the clavicular attachment of the scapulo-clavicular muscle were prolonged a few centimeters mesiad (toward the median line), it would become a sternal or costal insertion, and the muscle would then be a complete form of the sterno-scapu- lar muscie. 1166 PAN-AMERICAN MEDICAL CONGRESS. Muscles homologous to the scapulo-clavicular muscle in man are found in a large number of mammals. Wood has found this muscle well marked in the rabbit and the Guinea pig. Cuvier and Lorillard have figured it in their atlas under the name of “scapulo-clavien.” * The muscle which I found was 7 centimeters in length. Its diameter in its fleshy portion was about the same as the diameter of the fleshy portion of the posterior belly of the omo-hyoid muscle in that subject. It took its origin from the superior border of the scapula by a tendinous margin, in common with the attachment of the internal portion of the posterior belly of the omo-hyoid, and by a slender tendon, which was continuous with this tendinous margin, and which extended mesiad to within 1 centimeter of the superior angle of the scapula. In its scapular two-thirds it was internal to and parallel with the posterior belly of the omo-hyoid. At the junction of the scapular two-thirds with the clavicular third, it passed beneath the omo-hyoid muscle and continued parallel with the posterior surface of the clavicle to be inserted by a well-marked tendon into the clavicle at the junction of the pos- terior border with the rhomboid impression. It is in relation dorsad, or internally with the suprascapular artery and nerve, the serratus magnus muscle, the axillary artery and vein, and the brachial plexus; superficially with the omo-hyoid muscle and the clavicle. THE WERMIFORM APPENDIX. By R. H. PLUMMER, A. M., M. D., M. R. C. S., of England. Professor of Anatomy, Cooper Medical College; Chief of the Surgical Olinic and of the Genito-Urimary linic, Cooper Medical College, San Francisco, Cal. The field for anatomical literature is so limited by the fixed laws of nature, and so well have these been conned, that ground for new material is found only in deviations from the usual type, which curtails the work in this department. Not many years since health statistics teemed with reported cases of so-called ‘‘idiopathic peritonitis,” but the cause became more apparent as post-mortem exami- nations revealed, in many cases, suppuration, perforation, or gangrene in the vermi- —” form appendix, sometimes with a stercolith (coprolith) or some foreign substance, as the seed or stone of fruit, lodged therein. This knowledge has invested the appendix with new interest to the surgeon, the chief points of which are, first, its form and attachments; second, its situation and relations, having reference to oper- ative measures. It is usually described as a “blind, worm-like tube” arising from the inner and posterior part of the caecum, near the ileo-caecal valve, passing thence upward and inward behind the caecum. Extended observations, however, have demonstrated that its form and attachments vary not a little. It may arise from the posterior, the internal, or the anterior surface, or from the apex of the caecum, the longitudinal muscular bands which characterize the large intestine being continued upon it. In some of the latter cases it appears as a funnel-form prolongation of the caºcum downward and inward somewhat as represented in the above sketch. VERMIFORM APPENDIX. VERMIFORM APPENDIX. VERMIFORM APPENDIX. PAN-AMERICAN MEDICAL CONGRESS. 1167 But the variation in form and attachments to which I desire to direct special attention, since I have not seen it described elsewhere, is one recently discovered in the anatomical room by one of my prosectors, Mr. Lawrence Boido. It was found to have its origin from the inner margin of the apex of the caecum, passing thence downward and inward, crossing the brim of the pelvis, dipping somewhat into its cavity, thence ascending until it reached the ileum, about four inches distant from the cascum, where it opened into its posterior-inferior border. It is nearly seven inches in length and about the size of a goose quill, except the last two inches, where it is dilated to about twice that size. The orifice of entrance into the ileum is somewhat constricted, but freely admits an ordinary probe. The following sketch represents the caecum open from the front, exhibiting the slit-like orifice of the ileum, just below which, in the apex, is the smaller opening of the appendix, showing, also, its course and attachment to the ileum. The subject from which this specimen was taken was a German, male, laborer, sixty-two years of age, and died of pulmonary tuberculosis. So far as known he presented no history of abdominal trouble, nor was there any evidence, on post-mor- tem examination, of previous inflammation which might have resulted in adhesion and perforation into the ileum. The chief interest attached to its variation in position has reference to the facility and safety of operative procedures. In 30 per cent of the large number of cases exam- ined the caecum has been found resting upon the psoas near its outer border on a line and midway between the umbilicus and the anterior-superior spine of the ilium. In the remaining cases it occupied various positions, viz: External to the psoas, resting upon the iliacus, lower or higher than the point above designated, or toward the pelvic cavity, reaching sometimes to, or even beyond, the median line. The variation may depend upon the mode of development, or it may depend upon the length of the meso-calcum, when that exists; and it is not always possible to accurately determine the position before operating. In one hundred cases examined only 26 per cent are found to have a mesentery, the peritoneum merely covering its Stump Trimmed Tlapsin- slit. flaps. vaginated down. and sul- tured. anterior surface in the other cases. When the cacum occupies the iliac fossa the appendix may be reached with greatest facility and safety through the ordinary semilunar incision for ligation of the external iliac artery. Frequently it will be found unnecessary to open the peritoneal cavity, thus lessening the danger by reason of the bowel being uncovered on its postero-external surface. If, however, during the operation the case be found to be one where the caecum lies higher in the cavity, or where there is a mesentery which permits more or less movement toward the median line, it may still be readily reached by extending the incision upward and 1168 PAN-AMERICAN MEDICAL CONGRESS. inward toward the umbilicus. In removal of the appendix the closure of the lumen may be effectually accomplished by slitting down the sides of the stump and trim- ming the angular corners of the flaps, which may then be inverted or invaginated, thus bringing the serous surfaces together, where they may be sutured in position. DISCUSSION. Dr. Lamb said that in his post-mortem experience the caecum was generally covered with peritoneum, except, perhaps, a portion of the posterior surface. The vermiform appendix has also been generally covered with peritoneum, of very varied length, anywhere from 2 to 8 inches, and many times twisted and angled, sometimes with adhesions. In the case of Dr. Stiles, Dr. Lamb thought that probably there had been an accumulation in the terminal portion of the sharply-bent appendix, and set up inflammation. Dr. Lamb remembered having seen but one case in which the appendix was absent. It was astonishing to notice how small an amount of disease of the appendix was apparently sufficient to cause death. THE RELATIONS OF THE HEART AND LUNGS TO THE ANTERIOR CHEST WALL AS DETERMINED BY COMPOSITE PHOTOGRAPHY. By IRVING S. HAYNES, PH. B., M.D., Demonstrator of Anatomy in the Medical Department of the University of the City of New York, Member of the Society of the Alwºmmi of Bellevue Hospital, of the New York County Medical Society, of the Association of American Amatomists, etc. The study of the relations of the heart and lungs to the anterior chest wall is of the utmost interest to us, not only as anatomists searching after the exact rela- tions of the various parts of the human body, but also as surgeons and physicians engaged in the treatment of these organs in their various morbid states; for how can a departure from the normal relations of the body be detected unless we are familiar with those relations? It is practically impossible to determine the surface relations of the heart and lungs in the living except in the most general way, and we are forced to study out the problem upon the cadaver. After we have obtained our post-mortem measurements we can not apply them indiscriminately to the living individual. Due allowances must be made for the constantly changing positions of the heart and lungs with every pulsation of the former and respiration of the latter, for the changes caused by the different positions assumed by the individual or produced by the states (physiologic or pathologic) of the neighboring viscera (stolnach, liver). The vary- ing thickness of the superficial tissues and the sexual peculiarities of the chest and mammary configuration must also be taken into account. Notwithstanding all these difficulties with which we must contend, our post- mortem results do admit of the most practical application, and, when the necessary corrections of age, sex, posture, etc., are made, become of such reliability as to deserve our confidence. Of the methods heretofore employed for determining the surface positions of the heart and lungs, I will speak briefly of two, namely, transfixion and frozen sections. Transfixion by long pins is a method subject to many sources of error, and 1n the end becomes a good deal like guesswork; for, unless the differences between the positions of the pins and the actual position of the viscera under consideration are correctly taken and referred to corresponding points upon the chest, the results from this method will be too uncertain to be depended upon. Frozen sections, care- fully made as directed by Prof. Thomas Dwight, will give correct results, but the method is very laborious, takes a great deal of time, can be used only at a certain Season of the year, and then only in favorably situated places. PAN-AMERICAN MEDICAL CONGRESS. 1169 In the face of these difficulties, and with the confusion of mind following a hasty comparison of the measurements given in some of the standard text-books, I cast about for some way of determining these relations for myself, rapidly, accurately, easily. and without reference to place or season, and thought of my camera as a faithful agent to fulfill these diverse requirements. Composite photography has been applied to the solution of other problems, but I think I am the first to apply it to the determining of the external relations of the heart and lungs. I began my experiments in May, 1893, and would say in this con- nection that I have applied the same method to solving the abdominal relations with most satisfactory results, which I hope to be able to present to the society at some future occasion. Before entering upon a description of composite chest photography, I wish to digress for a moment to offer a few comments upon the text-book literature of the subject and to make a plea for greater exactness in such works. I do not contend that the statements of the various authors must agree with one another—that is impossible from the very nature of the subject—but I wish to object to the sweeping general statement that on close study furnishes us with so very little reliable information. As an example of this style, I quote the following verbatim from a text-book of anatomy: “The heart lies upon the tendinous center of the diaphragm, its base pointing upward and backward, and its apex pointing at the junction of the fifth rib and cartilage.” And this is all there is in the entire volume respecting the location of such an important organ as the heart. Again, I wish to call attention to rules apparently so exact, but really hiding many perplexities, and for the first illustration I shall quote, with all respect, from that storehouse of anatomical information, Quain's Anatomy, Vol. II, ninth American edition, page 493, the following: Speaking of the left border of the heart, and where to draw its outline upon the chest, he says it is indicated by a “line from the third cartilage,” etc. Now, the third cartilage is anywhere from 13 to 2% inches long, about three-fourths of an inch wide. How can such an area be the starting point of a line? One more: Quain and Gray both give the base of the heart as a “line drawn across the sternum on a level with the second costal cartilages.” Might we not with propriety ask, Is the upper border or the center or the lower border of these cartilages meant? - - Many errors in our text-books are excusable, but I offer that in text-books primarily intended for students, and designed to be as concise and accurate in statement as is consistent with brevity, serious omissions should not be covered by a few generalities, nor should “points” mean any dimension of length up to an inch or any dimension of surface from its proper definition up to an area of 1 or 2 square inches. Again, we meet with difficulties in the application of these statements, however accurate, to the individual. For while in a thin person it is easy enough to recognize cartilages and ribs, when these landmarks are covered with even a moderate layer of fat their recognition becomes uncertain, to say nothing of locating the costo-chondral and chondro-sternal articulations. If I might offer a plan to assist in fixing the rela- tions of the theracic viscera to the exterior of the chest in connection with the usual landmarks of sternum, ribs, cartilages, and their articulations, I would sug- gest that we start from the supra-sternal notch and mark the distance to below the ensiform along the median line in inches or cell timeters, and the distance of points transversely to the right or left of this line to be given with the distance on the mid-sternal line (from the supra-sternal notch) from which the lateral lines are drawn. w For example, the apex point in Subject I is 2+ inches transversely to the left of the mid-sternal line (which will be referred to by the letters M. S. L.) at its 7-inch point, i.e., at the point 7 inches from the supra-sternal notch. No matter how thick the layer of adipose tissue is over the chest, and how obscure the cartilages and ribs in consequence become, the supra-sternal notch can always be accurately S. Ex. 36—74 1170 PAN-AMERICAN MEDICAL CONGRESS. determined by the same manoeuvre—only reversed—by which the anterior superior iliac spine is fixed; namely, by carrying the thumb from above downward into the notch until it comes in firm contact with the upper margin of the sternum, and from this point make the downward measurement. The measurements to right or left must always be made at right angles to the mid-sternal line. Source of error.—Of course, all chest walls and their contained viscera do not have the same dimensions, and it would be obviously incorrect to apply the results obtained from a large subject directly to a small one. Yet, after the measurements for the average male and female adult are obtained, these can be applied to the determining of similar points in the average person, and the extremes of our scale in the one case to the extremes in the other. Perhaps we can subsequently determine a certain ratio between the chest measurements and its circumference or some other representative measurement that will help us to overcome the above source of error, but my experi- ments have not yet been sufficiently numerous to justify the formnlation of any reli- able suggestion in this connection. Directions for taking the composite chest photographs. Place the subject perfectly horizontal and inject carefully through the carotid (right or left) a thin plaster mixture (colored if desired) to moderate fullness. Some subjects should be used without the injection, but the injection when moder- ately given, and after it has firmly set, serves to maintain the heart in a fixed posi- tion, and is consequently an advantage. Moreover, by distending the heart moderately, as is usually the case, its natural position in diastole will be closely approximated (Subject I) and in those instances where the injection does not fill the ventricles and they happen to remain firmly contracted, you will secure the leart in a state closely allied to its condition during systole (Subject II). Locate the posi- tion of the nipples with reference to the ribs and mid-sternal line as previously described, then carefully incise them through their center to the deep parts and mark such places with an aniline pencil so they may be found later on. Remove all superficial tissue and muscles (pectorals and abdominal) over an area sufficiently large to expose the entire chest from above the clavicles to below the lower ribs and from side to side as far as the anterior axillary lines. Expose the trachea, cut it in two below the thyroid cartilage, insert a rubber tube into it, and connect with the bellows or pump. Thoroughly clean the ribs, cartilages, sternum, external inter- costal muscles, clavicles, and the origin of the sterno-cleido mastoids. Now place a narrow tape measure or a strip of white paper, upon which the inches have been marked, from the upper margin of the sternum (suprasternal notch) along the middle line to below the ensiform appendix. Upon each cartilage and rib indicate the dis- tance in inches, measured transversely from the mid-sternal line, by narrow strips of white paper as long as the cartilage or rib is wide and placed vertically upon the same to the number of 4 or 5 on either side of the middle line. These strips of paper will help very much in determining the position and direction of the various ribs and cartilages. Set up the camera vertically over the subject, focus on the nipple points (indicated by small circles of white paper), and fix the focus with the set screw. You will need two double plate holders A and B, and very slow plates, num- bering the slides A 1 and 2, B 1 and 2. Take the chest in expiration on plates A 1 and 2. (Expiration, first exposure.) The time of this exposure must bear the ratio to the full exposure of about 1 to 3. Inflate the lungs to moderate distention, counting the number of bellows’ or pump fulls, and expose plates B 1 and 2. (Inspiration, first exposure.) Let the air escape from the lungs. Remove the sternum from the lower level of the first cartilage to the upper border of the seventh, the included cartilages and ribs for a distance of 4 or 5 inches from the median line. Do not open the pleura. Now inflate the lungs with the same number of bellows’ or pulmp fulls as before, - SUBJECT . º/ º | W. | | |||||||| º!'s º - W º º - N | . - | - wº \\ | º | º | \\ *AM |- - n l | º º - | º º - - º º N º º No. 1.-CoMPOSITE PHOTOGRAPH of cHEST AND HEART; HEART EXPANDED. Pericardium removed. SuBJECT . No. 3.-CoMPOSITE PHoTogº APH of CHEST AND LUNGS IN INSPIRATION. Pleurae unopened. PAN-AMERICAN MEDICAL CONGRESS. 1171 Earpose B 1 (inspiration, second exposure; pleura not opened).-Open the pleural sacs and remove the anterior portions. - Expose B 2 (inspiration, second exposure; pleura removed).—Allow the air to escape from the lungs. Expose A 1 (expiration, second exposure; pericardium intact).-Remove the pre- senting portion of the pericardium from heart and great vessels. Expose A 3 (expiration, second exposure; pericardium removed). These photographs will give you the position of the lungs, with and without their pleurae, and of the heart, with and without its pericardium, upon the chest Wall from which the necessary measurements can be accurately determined. & By the preceding method the following relations were obtained:" Subject I.--Adult male negro, apparently about 35 years of age; cause of death unknown. Subject had been injected with chloride of zinc and starch color mix- ture of iginally for another purpose, but was used for this experiment. (A) Nipples: Located over the lower half of the fourth rib, 3% inches transversely from the mid-sternal line (and at a point on that line 5 inches from the Suprasternal notch) both alike. (B) Heart: This organ had been distended by the injection, and approximately represented the heart in diastole. Its relations were as follows: (1) Base: This is taken as the upper limit of the heart. It is indicated by a line drawn across the sternum from just below the middle of the second intercostal space on the right side, 14 inches from the mid-sternal line (at its 3 I. P.) to the left to cross the median line (at the 2# I. P.) and end at the upper portion of the second left space, 1% inches from the mid-sternal line (opposite its 2; I. P.). - (2) Apex: Behind the center of the fifth interspace 2+ inches to the left of the median line (at its 7 I. P.). (3) Left border: From the left extremity of the base line downward and slightly outward to cross the third costal cartilage 2 inches from the M. S. L. (at its 3; I. P.). It continues downward and outward until the fourth interspace is reached, then turns inward as it passes to the apex point. This line crosses the fourth left costo- chondral articulation, which is 2% inches from the M. S. L. (opposite its 5 I. P.), the fourth interspace at the center of which it is 2% inches from the M. S. L. (at its 6 I. P.); from here it curves downward and inward, crosses the fifth cartilage 2#inches from M. S. L. (opposite the 6; I. P.), and ends at the apex (86e 2). - (4) Right border: Begins at the right end of the base line passes outward and downward across the third right costal cartilage 1% inclues from the M. S. L., (at 3} I. P.) over the third interspace and fourth costal cartilage 1% inches from the M. S. L. (the former opposite the 4; and the latter the 5 inch points, respectively). It now curves downward and inward, and terminates over the center of the fifth costal car- tilage 13 inches from the median line (at 6 I. P.). (5) Lower border: This joins the lower ends of the right and left borders. In doing so it describes a wavy course, with a concavity at each end looking upward, and one in the center, as it crosses the middle line, looking downward. It crosses the sixth and seventh right costal cartilages transversely to their long axes, the median line at its 6%. I. P., over the middle of the ensiform, and the seventh left costal cartilage very obliquely to reach its lowest point at the lower margin of the sixth costal cartilage, 1+ inches to the left of the M. S. L. (at 7# I. P), then turns abruptly upward to join the lower extremity of the left border at the apex. (C) Auricles. - (1) Right: Its upper and outer (right) borders are formed by the portions of the base and right border lines of the heart cut off by a line which forms the inner (left) border of the auricle, and which starts from the base line one-fourth of an inch to the Tight of the median line and passes directly downward until opposite the lower border of the third right costal cartilage (at the 33 I. P. on the M. S. L.); from this point it curves slightly downward, passing outward about parallel with the lower margin of the third costal cartilage, until 1 inch from the M. S. L. (opposite the 4 I. P.), when it turns more abruptly downward and intersects the right border of the heart at the upper margin of the fourth costal cartilage. (2) Left: This shows us only a very small half-moon shaped space bounded above and on the outside by small adjacent portions of the base and left border of the * When a border of the heart or lungs is said to cross a cartilage or intercostal space at a certain distance from the median line the measurement is always made from the center of the cartilage or space unless otherwise stated. The mid-sternal line will be referred to by its initials M. S. J., and tſie numeral following it in parenthesis, as ‘‘ at 6 L. P.” means at the 6-inch point on the mid-sternal line, measured from the suprasternal notch as already described. - 1172 PAN-AMERICAN MEDICAL CONGRESS, heart. Its inner margin is indicated by a line drawn from a point on the base line 1 inch from the left of the M. S. L. and curving downward to intersect the left border, where it crosses the center of the third cartilage. (D) Auriculo-ventricular groove: The two extremities of the line indicating this groove correspond to the lower halves of the inner borders of the auricles. The central portion to a line connecting the middle points of these borders and curving slightly upward as it crosses the sternum. This middle portion indicated the line of junction of pulmonary artery and right ventricle. (E) Coronary arteries. (1) Right: Runs from the middle point of the inner boundary of the right auricle 1 inch from the median line downward in a nearly straight course to the lower border of the heart three-fourths of an inch from the M. S. L. (2) Left: This begins similarly at the midpoint of the inner margin of the left auricle and descends almost vertically and about 14 inclies from the mid-sternal line to the lower border of the heart. (F) Long axis of the heart: Reaches from the right end of the base line to the apex. It crosses the mid-sternal line (at its 44 I. P.) opposite the centers, of the sternal ends of the fourth cartilages. (G) Area of cardiac dullness during inspiration: It is a quadrilateral space, bounded on the right by the median line; below by the lower border of the heart; above by a line drawn from a point on the mid-sternal line (44 I. P.) opposite the centers of the sternal ends of the fourth cartilages along the upper margin of the fifth left cartilage 14 inches from the M. S. L. (opposite its 5% I. P.); and on the left by a line from the last point downward and inward to cross the lower border of the heart three-fourths of an inch to the left of the median line. Roughly stated this area is an inch and a quarter wide to the left of the median line, limited above by i. upper margin of the fifth left cartilage, and below by the lower border of the eart. (H) Aorta: Its axis corresponds to the median line as far as it is shown in the photograph. Its right border being one-halfinch to the right and its left the same dis- tance to the left of the median line, the former reaching from the base (one-half inch to the right of the M. S. L.), and the latter appearing above the pulmonary artery and both disappearing under the upper sternal fragment. (I) Pulmonary artery: This occupies the intervening space between the auricles and is limited below by the line for the auriculo-ventricular groove. It is about 1+ inches wide at its base and extends above the base line about one-half inch where it disappears under the aorta. It conceals the origin of the left portion of the aorta. (J) Superior vena cava: This shows as nearly vertical and three-fourths of an inch wide along the right side of the aorta. Its right border begins from the point of intersection of the right heart border and the upper margin of the third costal cartilage, and passes directly upward to disappear under the upper sternal fragment. Its left border is indicated by the same line as the right margin of the aorta. (K) Lungs: In inspiration (moderately inflated) and contained within the unopened pleurae. Their anterior edges alone traced. - (1) Right: The anterior border of the right lung is nearly vertical for a considera- ble part of its extent. It appears (in the photograph) issuing from beneath the upper fragment of the sternum opposite the 14 I. P. of the M. S. L., and distant from it one-llalf inch to the right. It passes downward and inward to cross the mid-sternal line at its 1% I. P. (opposite the first interspace) and reaches one-fourth incl beyond the center line toward the left. From here it descends vertically parallel with and one-fourth inch from the middle line until on a level with the center of the sternal ends of the fifth cartilages (opposite the 5 I. P. on the M. S. L.), where it turns to the right, crosses the median line, and passes downward and outward, following the direction of the upper margin of the sixth cartilage. - (2) Left: Its outline is more irregular than the right, as it has a large notch for the accommodation of the heart. Like the right, it comes out from the upper por- tion of the sternum the same distance to the left of the middle line at the same point (13 I. P.), passes downward toward the right and meets the right lung on a level with the upper border of the second costal cartilages (opposite the 2 I. P. on the M. S. L.). From here the inner borders of the two lungs (separated only by the pleurae) remain in close contact until opposite the middle point between the fourth cartilages (44 I. P. on M. S. L.), when the left lung abruptly leaves the other and passes outward and downward parallel with the upper border. of the fifth costal cartilage until 13 inches from the M. S. L. (opposite its 5% I. P.); it now passes down- ward and slightly inward until the sixth cartilage is reached, which it follows out- Ward to the left along its upper margin. (3) This notch in the left lung exposes the lower portion of the heart and forms the upper and outer boundary of the area of the leart exposed in inspiration. Tºe in her border of this space agrees with the median line and its lower with the lower margin of the heart. SUBJECT ||. ſ º Nº. º º No. 2.-CoMPOSITE PHOTOGRAPH of CHEST AND HEART: HEART contRAcTED. Pericardium removed. º º º Nº. º ºvºw --~~~ N | - *III/III º º |||||W | º - lininiiliºn in º | § i. T N R |||ſ|||||||||||||||| º | T | | * |Tººn W. º |||||| - - W. º | |||}|| | º ºº s s º | º a - lº. W. - Wºº. º º ſº | | | / - º // - . |/|| º º "|| | | - - | / | º º | ||||W º º s º | º | | º - º/ º - º/ - ſ W º º * \º º W!" | º º . º/ 2% º º . º º ||||W º | º º º - º º º º º | Z º fºº º º ſºlº º - | - º Wºº- º sº ºn. § 7 | - | º | | º | - | | - º º W - º - - º - - | | º | Mº-Tº - TI º º | ºnlinn. ". |- | º - º º w … ºwn. | - |\º º | - º º "I'll - - º!"Wºº |Mººººº. | º!" |- º | - | - PAN-AMERICAN MEDICAL CONGRESS. 1173 Subject II.--Adult male; white; about 45 years of age; cause of death unknown. Subject had been injected with zinc chloride and plaster color mixture. (A) Nipples: These are situated 34 inches from the median line on the extreme lower margin of the fourth rib. As the left ribs slope down slightly farther than the right, it follows that when referred to the median line the left nipple is one- fourth inch lower than the right (or the left is opposite the 54 I. P. and the right opposite the 5 I. P. on the M. S. L.). (B) Heart: The auricles and aorta were injected, but the ventricles were not and were in a state of firm contraction, and so represent fairly accurately the position of the heart in systole. (1) Base: This is indicated by a line from just above the upper margin of the third right costal cartilage, 15 inches from the M. S. L. (at its 34 I. P.), drawn across the sternum to end three-fourths of an inch to the left of the median line opposite the center of the second interspace (at the 3+ I. P. on M. S. L.). (2) Apex: Over the center of the seventh left costal cartilage, three-fourths of an inch from the median line (opposite its 7%. I. P.). - (3) Left border: From the left extremity of the base line nearly vertically down- ward to the apex point; it crosses the cartilages of the third, fourth, fifth, and sixth ribs at a distance of seven-eighths of an inch from the M. S. L. (opposite the follow- ing points on this line: Third, 3; I. P.; fourth, 5 I. P.; fifth, 6 I. P.; sixth, 7 I. P.). (4) Right border: From the right extremity of the base line downward and slightly outward to the middle of the fourth costal cartilage, 1% inches to the right of the M. S. L. (at its 5 I. P.). In crossing the third cartilage, it is 13 inches from the same line (at its 3; I. P.). The line now passes downward and inward to the center of the fifth cartilage, 1 inch from the M. S. L. (opposite the 6 I. P.). - (5) Lower border: Really continues the direction of the right border from the last point above, downward and inward in a nearly straight direction to cross the median line at its 7%. I. P. over the xipho-sternal articulation. To the left of the median line it descends a slight distance as it passes outward until about three- fourths of an inch from the same, when it turns upward to the apex and joins the lower extremity of the left border. This line is slightly concave downward and toward the right as it crosses the sixth and seventh right cartilages. (C) Auricles. (1) Right: Presents a pear-shaped outline in the photograph, its upper and outer margins being formed by the adjoining parts of the base and right border of the heart. Its inner boundary is indicated by a line from the base one-half inch to the right of the median line, passes vertically downward for three-fourths of an inch, then downward and outward to intersect the right border where it crosses the upper margin of the fourth costal cartilage. (2) Left: Shows as the merest oval space in the angle of the base line and left border, and limited on the inside by a line drawn downward and outward from a point on the base one-half inch to the left of the median line to the left border at the lower margin of the third costal cartilage. - (D) Auriculo-ventricular groove: This is indicated at either extremity by the lower portions of the inner auricular margins, and its central portion by joining these two extremities by a line slightly convex upward as it crosses the M. S. L. (at its 4 I. P.) opposite the lower margins of the third costal cartilages. (E) Coronary arteries. (1) Right: This comes out from under the lower and middle thirds of the inner border of the right auricle nearly 1 inch to the right of the median line, and with many turns and twists, due to the contracted state of the heart, passes downward nearly vertically to the lower border of the heart. (2) Left: This shows on the extreme left of the heart, issuing from the lower por- tion of the inner margin of the left auricle and descending directly to the apex, varying in its distance from the left of the median line from three-fourths of an inch in the upper third to one-half of an inch in the lower third of its course. (F) Long axes of the heart: From a point on the base 1+ inches to the right of the median line to the apex. This crosses the middle of the sternum (opposite the 6 I. P.) on a level with the lower border of the fifth cartilages. (G) Area of heart exposed in inspiration: Owing to the contracted state of the heart its entire lower portion to the left of the mid-sternal line and below the lower border of the fourth left cartilage is uncovered. (H) Aorta: Right border. This is shown by a line from the right extremity of the base drawn vertically upward across the second costal cartilage 1% inches from the M. S. L. (at its 2% I. P.) then curved upward and toward the left to pass under the upper sternal fragment 13 inches from the M. S. L. (at the 2 I. P.). The left border is covered at its beginning by the pulmonary artery and only shows as a short curved line reaching from the level of the lower margin of the second right costal cartilage one-fourth inch from the median line (at 3 I. P.) toward the left to cross :* ; L. on a level with the upper margin of the second costal cartilages (at the 2} I. P. 1174. PAN-AMERICAN MEDICAL CONGRESS. (I) Pulmonary artery: Occupies the interauricular space; with this width it passes upward, curving toward the left, and disappears on a level with the upper border of the second cartilages. (J) Superior vena cava: Does not appear in the photograph. (K) Lungs: In inspiration (moderately inflated) inclosed within the unopened. pleural sacs. * - (1) Right: Appears from under the upper fragment of the sternum 1 inch to the right of the M. S. L. (at its 1% I. P.), passes downward and inward, crosses the middle line (at its 2}. I. P.) opposite the upper border of the second cartilages, con- tinues its course to about one-fourth inch to the left of the median line, and then descends nearly parallel with the same, and at an average distance from it of one- fourth inch until opposite the upper margin of the sixth costal cartilages (at the 6# I. P. on the M. S. L.) it bends to the right, crosses the mid-sternal line (at its 6% I. P.), and runs outward and downward parallel with the upper margin of the seventh costal cartilage. (2) Left: This issues 1 inch to the left of the median line opposite the same point (1} inch) as the right, inclines downward and inward until at the lower margin of the second costal cartilage (left) it takes a course parallel with and nearly half an inch from the (left of the) median line until just below the lower border of the fourth left cartilage (at the 5% I. P. in M. S. L.), where it turns transversely out- ward for one-half inch, then downward and outward to the fifth intercostal space an inch from the M. S. L. (at its 6% I. P.). It now bends inward to meet the upper margin of the seventh costal cartilage, then turns outward along the upper margin of the same. The two lungs come in contact for only one-fourth of an inch opposite the lower margin of the third cartilage. (3) The amount of heart uncovered by the left lung is in this case an area at the left of the median line an inch wide and nearly 2 inches long, reaching from the lower border of the fourth to that of the sixth left cartilage. Subject III.--Adult female; white; about 25 years old; well formed and quite mus- cular; probable cause of death pneumonia (double). Subject was not injected. A different plan was followed in this instance from that in the two preceding cases. The subject was firmly strapped to a tilting table and suspended by the neck in a nearly vertical position. The camera was adjusted, focused, and set. Then neg- atives of the chest (before and after dissection), of the heart (with and without the pericardium), and of the lungs were made without disturbing the subject or camera, and these negatives fit upon each other perfectly, so that after prints were made the measurements were obtained by placing the photograph of the heart or lungs over that of the exterior of the thorax and tracing upon the latter the out- lines of the former by pricking through the two with a pin. This method gives good results provided no change of focus or of the position of subject or camera is made. As the images of the deeper structures are not obscured by those of the more superſicial ones, perfect outlines of the heart, with its vessels, and of the lungs can be obtained by tracing them as above shown. (A) Nipples: The breasts were small (for a female of this size) and firm. . (1) Right: In the center of the fourth interspace 4 inches from the M. S. L. (oppo- site its 5: I. P.). (2) Left: Over the lower margin of the fourth rib, 4 inches from the mid-sternal line (at same point as above). - The ribs on the left side curve downward slightly more than on the right, and this accounts for the different relations of the two nipples with reference to the thoracic wall. Referred to the median line they are exactly on the same level. wº Heart: This organ, with its vessels, was only moderately distended with OOCl. (1) Base: Begins in the center of the third interspace, 1% inches to the right of M. S. L. (at its 4 I. P.), curves slightly upward as it passes to the left to cross the median line (at its 3} I. P.), on a level with the lower border of the third costal cartilages, and ends 13 inches to the left of the M. S. L. (at its 34 I.P.) at the upper margin of the third costal cartilage. (2) Apex: The apex point is over the interchondral articulation of the cartilages of the fifth and sixth left ribs 1} inches from the M. S. L. (at its 74 I. P.). - (3) Left border: Begins at the left extremity of the base line, passes downward, inclining slightly outward until the middle of the fourth interspace is reached, 2 inches from the M. S. L. (at its 64 I. P.). From here it turns downward and toward the right to end at the apex point. The left border crosses the third costal cartilage 1% inches from the M. S. L. (at 3:# I. P.), the fourth cartilage 2 inches from the same (at the 54-inch point), and the fifth cartilage 1% inches (at the 64 I. P.). (4) Right border: Extends from the right extremity of the base line vertically downward to the center of the sixth costal cartilage 1 inch from the M. S. L. (at its 6+ I. P.). This border crosses the fourth and fifth cartilages at the same distance from the median line (the former opposite the 4; and the latter the 5 # I. P.). PAN-AMERICAN MEDICAL CONGRESS. 1175 (5) Lower border: Is indicated by a line from the lower end of the right border drawn downward and toward the left to cross the seventh right cartilage trans- versely to its long axis, the mid-sternal line (at its 7+ I. P.), over the middle of the ensiform, continues still downward and toward the left to the center of the sixth left costal cartilage 1 inch from the M. S. L (at its 7# I. P. ), then curves upward to end at the apex point and connect with the lower end of the left border. This line is slightly concaved upward and to the left as it crosses the median line. (C) Auricles. (1) Right: The inner border is indicated by a line which starts from the base one- fourth of an inch to the left of the M. S. L., passes vertically downward until oppo- site the middle of the sternal ends of the fourth cartilages (at 44 I. P. of the M. S. L.), where it turns toward the right across the median line (at its 43 I. P.), then with a slight convexity toward the right shoulder passes to meet the right border of the heart as it crosses the lower margin of the fifth costal cartilage. The auricle is bounded on its upper and outer sides by the adjoining portions of the base and right border of the heart. In this case the auricle reaches to the left one-fourth of an inch beyond the median line. (2). Left: This is a very small space cut off at the angle of junction of the base and left border by a line beginning seven-eighths of an inch to the left of the M. S. L. on the base line and passing downward and outward to meet the left border at the lower margin of the third costal cartilage. (D) Auriculo-ventricular groove: Corresponds to a line joining the middle points of the inner auricular boundaries plus the lower halves of these borders. (E) Coronary arteries. (4) Right: Issues from the inner border of the right auricle one-half inch to the right of the M. S. L. and passes downward and inward to the lower margin of the heart at the median line. - - (2) Left: This issues from the inner border of the left auricle, 14 inches from the mid-sternal line, and passes vertically downward until near the apex, when it turns inward to reach the lower border one-half inch to the left of the median line. (F) Long axis of the heart: From the base line three-fourths of an inch to the right of the M. S. L. to the apex point. It crosses the median line (at its 4%. I. P.) oppo- site the npper border of the fifth cartilages. (G) Area of heart exposed in inspiration was not determined, owing to the condi- tion of the lungs in expiration—the lungs collapsed. The entire lower two-thirds of the heart to the left of the median line and below the level of the upper margin of the fourth costal cartilage is exposed. (H) Aorta: In width as shown in the photograph about 1 inch. Its right border starts from the base 1 inch to the right of the M. S. L. and passes upward across the third cartilage seven-eighths of an inch from the median line (at the 33 I. P.) across the second cartilage five-eighths of an inch from the central line (at the 2 I. P.), and is host curving toward the left under the upper sternal fragment. Its left border shows only for a short distance curving over the pulmonary artery from right to left about 1 inch from and parallel with the right border. (I) Pulmonary artery: Includes the space left between the auricles and also comes from behind the entire inner half of the left auricle. It reaches as high as the lower margin of the second costal cartilage (opposite the 24 I. P. on the M. S. L.). (J) Superior vena cava: Shows in a collapsed state to the right of the aorta. Its right border reaches from the extreme right end of the base vertically upward to disappear under the upper sternal fragment and cartilage of the first rib. Its left margin is the same as the right for the aorta (in the photograph). (K) Lungs: These could not be inflated satisfactorily (death due to a double pneu- monia), so no attempt at securing photographs of them in inspiration was made. The following measurements give the outlines of the anterior margins of the lungs in their partially collapsed state, pleurae removed: (1) Right: The anterior border appears above in the median line (at the 14 I. P.), passes downward and to the left of M. S. L. until opposite the center of the sec- ond interspace (at the 24 I. P. on the M. S. L. and one-fourth of an inch to its left), runs parallel with the median line until (opposite its 3% I. P.) on a level with the center of the third space, when it curves downward and toward the right and is lost running parallel with the upper margin of the sixth costal cartilage. (2) Left: Issues from the upper sternal fragment three-eighths of an inch to the left of the M. S. L. (at the same 14 I. P. as above), descends, almost touching the right lung, until opposite (the 34 I. P. on the M. S. L.) the lower border of the third cartilage it turns outward toward the left along the upper margin of the fourth costal cartilage until it reaches the left border of the heart, which it follows until near the apex, then turns to the left, following the curve of the sixth costal cartilage (upper margin). - (3) Area of heart exposed in expiration (8ee § G preceding). 1176 PAN-AMERICAN MEDICAL CONGRESS. Comparative measurements. (1) Base of heart: . “Level of second costal cartilages.” Quain, Gray. . “Below level of second costal cartilages.” McLachlan, Allen, Sibson. . “Second right interspace to left first interspace.” Wilson. . Just below middle of right to above middle of left second interspaces. Haynes, Subject I. . “Upper border of third costal cartilages.” Holden, Treves. . “Junction of third cartilage with right border of sternum.” McClellan. . “Upper margin of third right cartilage to center of second left space.” blaynes, Subject II. h. “From center of third right space to upper margin third left cartilage.” Haynes, Subject III (suspended vertically). Length of base: . Not given. Quain, Gray, McClellan. . “One-half inch to right and 1 inch to left of sternum.” Holden. . “One-half inch to right and 13 inches to left of sternum.” McLachlan. . “One inch to right and 24 inches to left of sternum.” Wilson. . Haynes— Subject I, 14 inches to right and 13 inches to left of median line =2# inches. Subject II, 13 inches and # inch, respectively, = 2; inches. Subject III, 14 inches and 13 inches, respectively, = 2% inches. Apex point: a. “In fifth left interspace 3% inches from median line.” Quain, Gray, McLach- lan, McClellan. b. With reference to left nipple, “1} inches below and three-fourths inch to inside,” Quain, Gray; “2 inches below and 1 inch to inside, Holden;” “2 inches below and one-half inch to inside,” Wilson. c. “Fifth left interspace at costo-chondral articulation,” Treves. d. Haynes: Subject I. Fifth left space 2+ inches from M. S. L. (at its 7 I. P.). Subject II. Behind center seventh left cartilage three-fourths inch from M. S. L. (at its 7 I. P.). Heart in I distended, in II contracted. Subject III. Behind interchondral articulation between fifth and sixth cartilages 1% inches from M. S. L. (at its 7; I. P.). Subject suspended, heart mod- erately distended with blood. (4) Right border: The farthest point reached from the mid-sternal line. Quain says 1% inches. None of the other writers I consulted mentioned it. Haynes—Subject I, 1% inches over fourth cartilage; subject II, 1% inches over fourth cartilage; subject III, 1 inch over fourth cartilage. (5) Left border: Farthest point reached from the mid-sternal line. None of the above writers referred to it. - Haynes— Subject I. Heart distended “in diastole,” 2; inches over the center of the fourth interspace. Subject II. Heart contracted “in systole,” seven-eighths inch over center of fifth cartilage. - Subject III. Midway between “systole” and “diastole,” 2 inches over fourth interspace. (6) Lower border: The point at which it crosses the sternum. a. “Bottom of sternum,” Holden. b. “Xipho-sternal articulation,” McLachlan. c. “Upper third of ensiform,” Quain. d. Haynes— Subject I. Middle of ensiform. Subject II. Xipho-sternal articulation. Subject III. Middle of ensiform. (7) Area of cardiac dullness in inspiration. a. Quain: “Two lines from point of apex beat to the middle line of the sternum; *: horizontal, the other obliquely upward to between the fourth carti- 1ages. b. Gray quotes from Holden. - c. Holden quotes from Latham : “Make a circle 2 inches in diameter round a point midway between the nipple and end of the sternum.” d. Treves quotes from Latham. e. McClellan: “Line from middle of the sternum opposite fourth left costal car- tilage to the point of junction of the left fifth rib and its cartilage, and from this point horizontally back to sternum.” : ſ (2 ) : (3 ) PAN-AMERICAN MEDICAL CONGRESS. 1177 (7) Area of cardiac dullness in inspiration—Continued. f. Haynes— Subject I. A quadrilateral space bounded on right by median line, below by lower border of heart; above by a line from middle of fourth cartilages along upper margin of fifth left cartilage to 14 inches from median line; on left by a line from last point downward to intersect the lower border of the heart three-fourths of an inch from the left of the median line. Subject II. Heart contracted. All of the heart to the left of the median line and below the lower margin of the fourth left cartilage. Subject III. Lungs (in expiration) collapsed. Entire lower two-thirds of heart to left of median line and below the upper margin of the fourth left cartilage. (8) Auricles: a. Quain: “The right auricle lies behind the sternal ends of the third, fourth, and fifth cartilages, and the intervening portions of the intercostal spaces, and is also partially covered by the right edge of the sternum. The point of its auricular appendage is exactly behind the middle line on a level with the upper border of the third costal cartilage. The left auricle extends vertically from the level of the lower border of the second left cartilage to the upper border of the fourth (sternal end). The apex of its appendage is in the lower part of the second intercostal space, or behind the third cos- tal cartilage, about 14 inches from the left of the sternum.” b. Haynes— Subject I. Right: The outline in the photograph is markedly “ear-shaped.” It is bellind the first inch of the third right costal cartilage with the adjacent border of the sternum and the third space. Left: Oval outline one-half inch by 1 inch placed over a portion of the second space and third cartilage. The center of the area being 14 inches from the left of the median line and its long axis extending from above downward and toward the left. Subject II. Right: Pear-shaped outline, base uppermost covers first inch from sternum of third right cartilage and space. Left: Behind the chondro-sternal articulation of the third left cartilage; oval shaped; long axis as in No. I. Subject III. Right: Distinctly auricular shaped. Includes fourth and fifth right cartilages for 1 inch from sternum and the included space, with the right half of sternum opposite the fourth chondro-sternal articulation. Left: Behind the third left cartilage, its center 14 inches from the median line, its long axis inclined as in No. I, and the shape the same. (9). Auriculo-ventricular groove— e - a. Quain: “The auriculo-ventricular sulcus corresponds with a line drawn obliquely upward from near the sternal end of the sixth costal cartilage on the right side to the third cartilage on the left.” b. Haynes— Subject I. (Approximately stated.) A curved line, with the convexity upward from the upper margin of the fourth right cartilage, 1% inches from the median line to the middle of the third left cartilage, 1% inclies from the middle line. This line crosses the center of the sternum on a level with the lower border of the third cartilages. Subject II. This line takes the same course as in No. I, except it ends at the lower margin of the third left cartilage, seven-eighths of an inch from the median line. Subject III. (Suspended.) A line convex upward from the upper margin of the sixth right costal cartilage, 1 inch from the median line to the lower border of the third left cartilage, 13 inches from the central line. The º is crossed on a level with the lower border of the fourth car- tilages. - (10) Aorta (first portion): a. Commences “behind the sternum, on a level with the lower border of the third costal cartilage on the left side, and rises as high as the upper border of the second costal cartilage of the right side. Its length is about 2 or 24 inclues.” Quain. b. **Commences on a level with the lower border of the third costal cartilage behind the center of the sternum; passes obliquely upward to the right' side as high as the upper border of the second right costal cartilage. It is about 2 inches long.” Gray. c. “Its origin is on the left side of the middle of the sternum, about on a level with the lower border of the third costal cartilage, ascends with a slight curve, the convexity looking forward and to the right side as far as the upper border of the second costal cartilage of the right side. It is about 2 inches in length.” Holden. 11.78 JPAN-AMERICAN MEDICAI, CONGRESS. (10) Aorta (first portion)—Continued. d. “The aortic opening is behind the left border of the sternum close to the lower edge of the third cartilage. The trunk ascends behind the second cartilage of the right side.” Treves. e. Haynes— Subject I. Its axis corresponds to the median line. It is about an inch wide and reaches from the upper border of the third cartilages to the middle of the cartilage of the first rib. . It is about 2 inches long. Subject II. The aorta reaches from the upper border of the third right car- tilage to the upper margin of the first cartilage. It is entirely to the right of the median line for the first two-thirds of its course and only curves toward the left after reaching the upper margin of the second cartilage. Same length as in Subject I. Subject III. (Suspended, not injected.) Reaches from the upper level of the fourth cartilages at their sternal junction, entirely to the right of the median line upward to the lower level of the first cartilage, where its center is behind the mid-sternal line. - (11) Pulmonary artery: a. Quain: “The pulmonary orifice is placed opposite the upper margin of the third left costal cartilage, close to the sternum. The artery proceeds upward to its bifurcation behind the second costal cartilage. It is nearly 2 inches long.” - - b. Treves: Essentially same as Quain. c. Gray, Holden: Do not give its surface relations. d. Haynes— Subject I. Begins on a level with the lower border of the third cartilages; its center being half an inch to the left of the middle line. It proceeds upward and toward the left and terminates just above the lower margin of the second left cartilage; here its center is about three-fourths of an inch to the left of the median line. The artery is a little over an inch wide and 1% inches long. - Subject II. Begins on a level with the lower margin of the third cartilages; its center behind the median line proceeds upward, inclining a little to the left, and ends on a level with the upper border of the second carti- lages, its center being one-fourth of an inch to the left of the median line. It is about 1 inch wide and 1% inches long. - Subject III. Begins on a level with the lower margin of the third left carti- lage entirely to the left of the middle line, being about 14 inches wide, passes upward until opposite the middle of the second left cartilage, where the center of the vessel is three-fourths of an inch from the left of the median line. It is a little over an inch wide at its beginning and about 1% inches long. (12) Coronary arteries. Haynes: Subject I. (Heart distended.) They run nearly vertical and parallel with the median line, the right 1 inch and the left 13 inches from the same; the former from the lower border of the third right cartilage, and the latter from the middle of the third left cartilage, and each extends to the lower level of the sixth cartilage. - Subject II. (Heart contracted.) Right artery is at an average distance of seven- eighths of an inch from M. S. L., parallel with same (nearly), and extends from upper border of fourth to upper border of sixth cartilage. Left is parallel with central line and three-fourths of an inch from it, and reaches from lower level of third cartilage to apex. Subject III. (Heart moderately distended.) Right: From upper border of fifth cartilage close to sternum to middle of ensiform. Ileft: From lower. margin of third cartilage 1 inch to left and parallel with median line toward apex. (13) Anterior margin of the lungs and the extent of their contact during inspira- tion. a. Quain: “Meet at junction of manubrium and body of sternum, descend together, right sometimes projecting a little to left of middle line, as far as the fourth costal cartilage; right lung continues straight course to sixth costo-chondral articulation; left slopes outward behind fifth costal carti- e lage, indicated by a line from fourth left chondro-sternal articulation to apex point.” b. Gray. Holden : “Anterior border of right lung corresponds to median line from junction of first and second pieces of sternum as low as sixth costal cartilage; anterior border of left lung lies in the middle line only as far as the fourth costal cartilage.” PAN-AMERICAN MEDICAL CONGRESS. 1179 (13) Anterior margin of the lungs and the extent of their contact during inspira- tion—Continued. c. Treves: “Meet in middle line at junction of manubrium and gladiolus; right continues vertically downward bellind middle line to sixth chondro- sternal articulation; left keeps close to right to fourth chondro-sternal articulation, when it turns off, following a line from fourth cartilage to apex of heart.” d. Haynes— - Subject I. Converge from apices and meet at level of upper border of second cartilages one-fourth inch to left of median line and run parallel with same to level of the upper border of fourth cartilages. The right lung continues at the left of the middle line until at the upper margin of the sixth chondro-sternal articulation, when it crosses to the right. The left turns outward along the upper margin of the fifth cartilage. Length of contact, nearly 3 inches. Subject II. Anterior of right lung crosses to the left of the middle line on a level with the upper border of second cartilages and continues straight down to lower level of sixth costal cartilages at sternum. The left nearly meets the right at lower level of second left costal cartilage, continues nearly in contact (and opposite third space in actual contact) to level of upper border of fifth left cartilage at sternum, along which it passes outward and toward the left. (14) Points on the mid-sternal line opposite the centers of the sternal ends of the costal cartilages: - & Subject I. | Subject II. Subject III. Number of cartilage. (Male.) (Male.) (Female.) Inches. Inches. Inches. First------------------ 1% 13. 1. Second ---------------- 2} 2g 2 Third ... --------------- 3# 3# 3% Fourth ---------------- 4}. 5 4% Fifth------------------ 5% 53 5 Sixth . . . . . ------------ 6 6# 5% Seventh . . . . ----------- 6# 7 6; I)ISTANCES BETWEEN TIIE CARTIL AGES. Between first and sec- ond ----------------- § # 1 Between second and third ---------------. 1; 1} 1% Between third and fourth--------------- l 1% 1 Between fourth and fth----------------. # # # Between fifth and sixth ---------------- # # # Between sixth and seventh ------------- # # # (15) Relative position of nipples. All the authorities agree in placing them in the fourth interspace, three-fourths of an inch external to the junction of the ribs and cartilages, or rather more than 4 inches from the median line. In the two male subjects (I and II), the nipples were over the lower half of the fourth ribs, 3% inches from the median line. In the female (Subject III), they were 4 inches from the median line, the right in the center of the fourth interspace and the left over the lower margin of the fourth rib. In the males the measurements were made upon the thorax after removal of the superficial tissues; in the female upon the exterior of the chest before such dissection. From a comparison of the preceding quotations and the original measurements we see that at many critical points there is a wide difference between the accepted relations given in the text-books and those revealed by composite photography. As regards the lungs, these differences are so small as to be of little importance, but in reference to the heart are so pronounced as to make us wonder if the cur- rently stated relations of heart and chest do not need revision. For example, is it not possible, nay, more than probable, that the authorities, in placing the apex beat 1180 PAN-AMERICAN MEDICAL CONGRESS. 34 inches to the left of the median line, have not gone at least an inch over the mark? For the apex point in Subject I, where the heart is fully distended, is only 24 inches from the median line. Neither can it be said in explanation of this difference that the heart has been moved bodily toward the right. It has not we can see, for its right border only reaches 1% inches from the middle line. Nor can it be claimed that the heart has been foreshortened by the camera at the expense of the chest, for the heart in the photograph is nearly 5 inches wide. Besides, this error of foreshortening is prevented by measuring the distances upon the bony framework of the chest itself before taking the photographs, and any foreshortening of the heart is compensated for by the same occurrence in the image of the chest, and the results are unimpaired. More- over, the heart has not received complete treatment by the authorities quoted, in that its auricles, borders, and its great vessels have not been traced in sufficient detail upon the bony framework of the chest. This is due no doubt to the uncertainties of the methods used for ascertaining these relations. In these composite photographs the relations lost by the former method are brought out with remarkable clearness and can be readily traced, and their details have been given in the preceding pages, too full to produce attractive reading, but not, I hope, for accurate reference. In concluding this paper I offer the following summary of the external relations of the viscera in question. These results comprehend the conclusions derived from the statements of the authors consulted and from my own observations. CONCLUSIONS. (1) Base of heart: A line crossing the sternum obliquely from the upper margin of the third right to the lower border of the second left costal cartilage, 13 inches from the median line on each side. (2) Apex: In the fifth space, near the upper margin of the sixth costal cartilage, 2% inches to the left of the median line. (3) Right border: From the right end of base curved slightly outward to reach a point 1% inches from right of middle line over the fourth cartilage and end at the center of the fifth cartilage, 1 inch from the mid-sternal line. (4) Left border: From the left end of base, with a convexity outward, to the apex. It reaches its greatest distance of 3 inches from the sternal center over the fourth space. (5) Lower border: A line curved downward at its beginning (at lower extremity of right border) and ending (at the apex), and slightly convex upward in its center as it crosses the middle of the ensiform. - (6) Heart dullness: A quadrilateral area to left of median line and below the upper border of the fifth cartilage, nearly 2 inches in vertical and 1% in extreme lateral measurements. (7) Auricles: Right “ear-shaped” (facing to left), covering the first inch of the third right space and cartilage with the portion of the sternum adjacent to the lat- ter. Its long axis measures about 2 inches and is inclined from above downward and outward. Left, is a small oval space # by 1 inch (its center 14 inches to left of median line) behind the second left space and third cartilage. Its long axis directed from above downward and outward. (8) Auriculo-ventricular groove: Is indicated by a line from the right to the left heart borders, beginning on a level with the upper margin of the fourth right, and ending on a level with the lower edge of the third left cartilage. This line is con- vex upward and crosses the middle of the sternum on a level with the lower border of the third cartilage. (9) Aorta: A little more than an inch wide and 2 inches long. Extends from the upper border of the third to behind the middle of the first cartilages. At its begin- ning and ending its center is behind the median line, but in the middle of its course the artery is convex toward the right. PAN-AMERICAN MEDICAL CONGRESS. 1181 (10) Pulmonary artery: About 14 inches wide and 1% inches long (in the photo- graph). Begins on a level with the lower border of the third and ends behind the middle of the second left cartilages. Below, its center is one-half inch and above, three-fourths of an inch to the left of the median line. (11) Coronary arteries: Both are nearly vertical (incline slightly toward the median line at their lower ends). Right, 1 inch from mid-sternal line. Extends from the upper border of fourth to lower of sixth cartilages. Left, 1% inches from middle line in expansion and three-fourths inch in contraction. Extends from middle of third to lower border of sixth cartilages. (12) The anterior margins of the lungs in inspiration: Right, lies to left of median line, one-fourth inch from and parallel with it from the upper margin of second to that of sixth cartilages (sternal ends). The left is in contact with the right from the upper border of the second to the midpoint between the fourth cartilages, where it turns downward and outward along the upper margin of the fifth left cartilage. Length of contact, 2% inches. (13) The centers of the sternal ends of the costal cartilages are opposite the fol- lowing distances on the mid-sternal line measured from the supra-sternal notch. (a) Male (average of 2). (b) Female. Distan e & 4 $º gº C0S Cartilages. ºnces from each from each other. No. 1.------------------------------------------------- 1; ------------ 1 ------------ No. 2.------------------------------------ *---------- 2} $ 2 1. No. 3.------------------------------------------------- 3# 14 3# 14 No. 4-----------------------------------------------. 43 1; 43. 1 No. 5------------------------------------------------- 5} # 5 # No. 6------------------------------------------------. 6# # 5% # No. 7------------------------------------------------- 6# * 63 % (14) Nipples: Over the lower margin of the fourth ribs, 4 inches from the middle line. A UTHORS CONSULTED. . Quain, Wols. I and II, ninth American edition. . Gray, Keen's revision of eleventh English edition. . Holden's Medical and Surgical Landmarks, revised by Keen and appended to Gray. . Holſ'en's Manual of Dissection, fifth edition. . Treves Applied Anatomy. . McLachlan's Applied Anatomy, third edition, Vol. II. Wilson's Wade Mecum, 1892. . Allen's Anatomy, Vol. II. . McClellan's Regional Anatomy, Vol’I. . Morton's Human Anatomy. . Cruveilhier, Pattison's Translation. : : ! SECTION X.—PHYSIOLOGY. Bonorary Presidents. Dr. José M. BANDERA, City of Mexico, Mexico. Dr. JAMES BLAKE, San Francisco, Cal. Dr. R. H. CHITTENDEN, New Haven, Conn. Dr. AUSTIN FLINT, New York, N.Y. Dr. C. HEINEMANN, Vera Cruz, Mexico. Dr. Joseph Jon Es, New Orleans, La. Dr. J. B. DE LACERDA, Rio de Janeiro, Brazil. Dr. H. N. MARTIN, Baltimore, Md. Dr. WESLEY MILLS, Montreal, Canada. Dr. S. WEIR MITCHELL, Philadelphia, Pa. Dr. E. T. REICHERT, Philadelphia, Pa. Dr. ANTONIO PáREZ RocA, Lima, Peru. Dr. MAGſN SAGARRA, Santiago de Cuba, Cuba. - Dr. CKRLos SCIIüNLEIN, Santiago, Chile. Eacecutive President. Dr. Isaac OTT, Easton, Pa. Secretaries. Dr. A. P. BRUBAKER (English-speaking), 40 N. 19th St., Philadelphia, Pa. Dr. SENORANS, (Defensa 293) Buenos Ayres, Argentine Republic. Dr. ENRIQUE HERTzog, La Paz, Bolivia. Dr. J. PAULO DE CARVALHO, Rio de Ja- neiro, U. S. of Brazil. Dr. A. B. MACALLUM, Toronto, Canada. Dr. JULIO SAN MARTIN (Dragones 94), Havana, Cuba. Dr. ANTONIO WARGAS VEGA (Calle 10Núm. 305), Bogota, Rep. of Colombia. Dr. CKRLos DURAN, San José, Costa Rica. Dr. WM. A. THOM (Spanish-speaking), 128 Main St., Norfolk, Va. Dr. CARLOS PADILLA, Guatemala City, Guatemala. Dr. F. L. MINER, Honolulu, Hawaii. Dr. ESTEBAN PERRAN, Tegucigalpa, Hon- duras. - Dr. MANUEL TOUSSAINT (San José de Gracia 12) City of Mexico, Mexico. Dr. GUERRA, Rivas, Nicaragua. Dr. JUAN MORELLI (hijo), [Arapey 192] Moñtevideo, Uraguay. Dr. RAMóN PoltrA PICóN, Merida, Vene- Zuela. ADDRESS BY THE PRESIDENT, ISAAC OTT, M. D., OF EASTON, PA. GENTLEMEN: In opening the physological section of the Pan-American Congress, I have the great pleasure to extend to the medical representatives from the Americas, North and South, as well as the United States, a most cordial welcome. I hope that all our friends will do us the great honor of being present at our meetings, and that they will enter into the discussion of papers which will be presented. You are invited to take a deep interest in the proceedings, as many subjects of importance to scientific and practical medicine will be considered. As this is our first meeting as Pan-Americans, let us make it one of fruition and value to humanity. It is my pleasant duty to announce to you that during our sessions we shall be honored with representatives from other countries, and it is very agreeable to first mention the name of Prof. Johannes Gad, most worthy representative of the University of 1182 - PAN-AMERICAN MEDICAL CONGRESS. 11.83 Berlin and the Centralblatt für Physiologie. I have next to announce the name of Prof. A. B. MacAllum, of Toronto University, who represents most excellently Cana- dian physiology. With regard to the subject of to-day, I shall only speak of Amer- ican physiology as far it relates to the United States. I restrict myself to this plan, as I am not sufficiently acquainted with the literature of either North or South America to treat it with any precision. . gº Before taking up the subject of physiology in detail, it might be well to note the state of physiology abroad at the beginning of this century, for the influence of French physiologists was great up to 1870, since which time we have been greatly reacted upon by the physiologists of Germany, and, to a certain extent, by the French. As we all know, the immortal Haller died in 1777. In France, at this period, Lavoi- sier published his experiments upon the respiration of animals, and in 1780, in con- junction with La Place, his great memoir upon animal heat. About the year 1800, the French physiologists were Petit at Namur, Housset, Le-Gallois, and Bichat. In England, in 1811, Charles Bell published his epoch-making memoir on “A New Anat- omy of the Brain,” at the age of 26. In Germany, Fiedemann and Bendach were the chief exponents of physiological progress. But at the end of the first quarter of this century the mighty influence of Magendie was felt by the introduction of the experimental method in physiology. In the study of the playsiological papers of the United States I shall only take notice of articles containing some original observations, and waste no time on theo- retical lucubrations. “Hablem cartas y callen barbas.” Further, I shall not pretend to make this review exhaustive, as neither the time nor the libraries are sufficiently accessible to me, yet I shall try not to miss the main papers. In 1795 Samuel Latham Mitchill, a professor of chemistry in the College of New York, made the observation * that pulsations of the heart can be accelerated or retarded by the varied state of the respiration. In the year 1800 I find a thesis pre- sented to the University of Pennsylvania by Dr. John Baptiste Clement Rousseau, of Hispaniola. It was upon the subject of absorption, and, singularly to state, the first third of this century is mainly devoted by our writers to this subject. I can only account for it by the fact that the great external use of mercurial ointment in prac- tice led our professional brethren to theorize upon its action and finally to experi- inentally determine the truth or falsity of their hypotheses. He held that no absorption could take place from the skin unless the cuticle was destroyed by friction, although the cuticular injury might not be apparent to the eye. He states that it never has been decidedly proved that mercury was received and carried into the system by absorbents, for he found no mercury in the urine, milk, or other fluids of animals to whose surface mercury was freely applied. He is not able to positively say, but he states it seems probable, that mercury is volatilized by friction and is absorbed in fine particles like musk and spirits of turpentine. In his first experiment he swallowed, at 10 A. M., a few drops of spirits of turpentine with sugar, water, and sweet spirits of nitre. He soon found a violet odor in the urine. In his second experiment he exposed some turpentine in an open bowl in a close room at the temperature of 61° F. In half an hour he found his urine with an odor of violets. In his third experiment he breathed through a tube opening outside the room, and closed his nose, then exposed turpentine in the room, but no violet odor was perceived in the renal secretion. In the fourth experiment he immersed his hand and wrist in turpentine and breathed through the tube outside the room with nos- trils closed, but no violet odor was perceived. In fifth experiment, still breathing through a tube outside room, nostrils closed, then smeared body with turpentine by means of a sponge, but no odor to urine. In experiments, 6, 7, and 8, found inhalation of fumes of turpentine from a bottle sufficient in half an hour to be perceived in the urine. His conclusions were: (1) Absorption is performed by the lungs; (2) absorp. tion is performed by the lungs alone; (3) no substance can be introduced by the skin when the cuticle is sound and entire. *On Gaseous Oxide of Azote, New York, 1795, 12 mo., p. 12. 1184 PAN-AMERICAN MEDICAL CONGRESS. In the same year (1800) a thesis of the University of Pennsylvania was published by Dr. James Agnew, of New Jersey, upon the perspiration.” In 1805 Dr. Danger- field repeated Rousseau's experiments. He also put large plasters of mercurial oint- ment to the calves of the legs, bandaged them fast, and covered the whole with a stocking. He wore these eight days, but no ptyalism ensued. He then restricted his diet, bled himself 20 ounces, and then left the plasters on for seven to eight days, but no salivation ensued. In other experiments he applied less mercurial oint- ment, but with friction, and in three days ptyalism ensued. In another experiment he applied mercurial ointment to upper surface of each foot and wore oilcloth stock- ings for ten days, without effect. He concludes that substances are not carried to the circulation from Sound or abraded skin, but he does not conclude that there are no absorbents beneath the skin. . - In 1806 Dr. Reuben D. Mussey, of Massachusetts, published some experiments on cutaneous absorption. f. He states that doubts as to the absorption by the skin were first raised by Mr. Segum, of Paris, and by the experiments of Drs. Rousseau, Dangerfield, and Klapp. Although he aliudes to Dr. Klapp's experiments, I can. not find any publication of the same before 1811. Since colored substances, as mad- der, are absorbed by the intestinal canal unchanged, he started some experiments with it. In his first two experiments he immersed himself in a bath of strong watery infusion of madder. He found his urine tinged red in three to five hours and when treated with Fe SOA gave a purplish brown color. In another experi- ment he was bled three and five hours after the bath, but the blood serum appeared the same. From these experiments he concluded that madder entered the system by cutaneous absorption, and not by the lungs. In 1809 Dr. J. Redman Coxef published a paper supporting the doctrine of cuticu- lar absorption, but he made no experiments. In 1811 Dr. Joseph Klapp & published a paper upon absorption, criticising Dr. Mussey’s experiments. He probably was the first man in the United States to make a vivisection. In a dog the trachea was tied off, when a tube from a bottle of tur. pentine was introduced into the trachea below the ligature. The dog inhaled the turpentine for two hours, when the tube and ligature were removed from the trachea. The urine collected had a strong violet odor. After quoting Dr. Danger- field’s experiments, he arrives at the conclusion that the mercury is volatilized and inhaled by the lungs. To support this view, he had his servant rub mercurial oint- ment on the inside of the doctor's leg an hour at a time, twice daily, for six days. Dr. Klapp breathed pure air from out of doors by means of tube through a window. At the end of six days he had not the slightest salivation, but the servant was badly ptyalized, so that the experiment was arrested, although the servant wore gloves during the frictions. In this paper he alludes to Dr. Darwin's theory of a supposed occasional conveyance of fluids from the stomach to bladder by supposed inverted motion of urinary lymphatics. To disprove this, Drs. Klapp and Rogers performed the following experiment: Opened the abdomen of a dog; both ureters were tied off above the bladder; urine passed out of bladder; his penis ligated. Dog was then given gin, madder, and nitre for an hour or two. At the end of eleven hours the bladder was found empty. Drs. Smith and Rousseau, in 1811, made some experi- ments upon cuticular absorption. They found, as Mussey, that madder is absorbed by the skin and colors the urine. They found the same to be true of rhubarb. They also state that no astringents, narcotics, or coloring substances have the slightest effect if the nostrils are stopped. * Thesis University of Pennsylvania. # Philadelphia Medical and Physical Journal. # Philadelphia Medical Museum, vi, 55. § Philadelphia Medical Museum, vi, 83. |Philadelphia Medical Museum, 1811. PAN-AMERICAN MEDICAL CONGRESS. 1185 From 1811 to 1821 there is no record of any physiological papers. In 1821 Drs. Richard Harlan, J. B. Lawrence, and B. N. Coats,” a committee of the Academy of Medicine of Philadelphia, made a report on the means by which absorption is effected. William and John Hunter thought Hippocrates and Galen in error in stating that absorption took place by the veins. The Hunters proved that it was accomplished by the lymphatics. Magendie, about this period, believed it took place by the veins, which was confirmed by Harlan, Lawrence, and Coats. They showed the error of Hunters' experiments. These gentlemen used forty-three animals. Their conclu- sions were that the coloring matters were not absorbed by the lacteals in the living body. Prussiate of potash enters by the lacteals and thoracic duct. If you mix nux vomica and prussic acid you destroy life by an action upon the nerves. Con- trary to the ass ºrtion of Magendie, ink will not infiltrate the living body. When it was placed in the intestine, peritoneal, and pleural cavities it was not absorbed. The odors of camphor, mint, and asafetida infiltrate through the intestine. The chemical and odorous substances above mentioned are absorbed from the stomach slower than from the intestine, and from the peritoneal cavity even slower and with more difficulty. They showed that absorption does not come from the arteries exclusively. They bled animals to death, tied their aorta, and then injected saline fluid into the peritoneal cavity and found that some disappeared. In 1822 Dr. John Hubbard f made some experiments upon absorption. He tried to prove that absorption took place by the lymphatics, and not through the walls of the veins and arteries. He exposed in a number of animals the arteries and veins, and placed lead plates on cards underneath the vessel so that the wall of the vessel could be bathed by the solutions without the solutions touching the wound. He then applied prussic acid and nux vomica to the walls of the vessels for twenty to thirty minutes, and they had no effect. Later he placed these drugs in the wound and they were promptly absorbed and produced characteristic effects. He also made control experiments to show that the nux vomica and prussic acid were good preparations. In the same year Dr. Robert Melnorf published a paper on the absorption of active medicine into the circulation, and also the effects of nutritive enemata. He first shows the physiological action of gamboge and tartar emetic when injected directly into the jugulars of cats and dogs. He then injected asafetida into the veins, and found its odor in the blood for some time. He injected milk into the jugular vein in three instances without producing death, showing that nutritive fluids can be directly thrown into the circulation with impunity. He fed a dog upon garlic in meat; afterwards he killed the animal and found the whole body saturated with the odor. The blood gave off the odor of garlic after the animal had been fed on it for a few days. He fed a dog on indigo and found the color in the lacteals. He fed a dog on rhubarb, killed him in one hour and a half, and found rhubarb in the bile. He 1njected madder into the blood and found it in the bones. He fed several cats on enemata of milk, mutton, and chicken broth, and found slight alteration in weight. This demonstrated that they could readily take nutriment per anum, and that suffi- cient was absorbed to sustain life. In 1825 Dr. Beaumont began his celebrated researches upon Alexis St. Martin, showing effects of the gastric juice upon the foods. In 1827 Dr. Togno f made a series of experiments upon endosmosis and exosmosis. His experiments were confirmatory of Mr. Dutrochet. The experiments were made with the intestines and crops of fowls, as well as with the skin of a rat. The fluids used were gum-arabic solution, water, weak acid, and alkaline solution. He proved that endosmosis occurs in a certain membrane as long as its composition is normal. When it becomes putrid, exosmosis takes place very rapidly. He showed that endos- mosis and exosmosis can go on at the same time, The denser of two liquids induces * Philadelphia Medical and Physical Sciences, 1821. f Philadelphia Journal of Medical and Physical Science, Vol. IV. # American Medical Journal, 1827. S. EX. 36—75 : © : . 3. : : 1186 - PAN-AMERICAN MEDICAL CONGRESS. the rarer to form a current toward the former. By inverting the experiment he found the same thing would take place the other way through animal membranes. In 1827 Dr. James Moultrie, Jr., * published a paper upon the use of the lymph. He concludes that lymph is not a residuary fluid transmitted from arteries to veins nor decomposed matter of tissue which it is the office of absorbents to remove. The origin, nature, and destination of lymph rentler it probable that it is a special secre- tion. Its office is to vivify the chyle, to augment the animalization of arterial blood, and, lastly, to produce all those effects which constitute the phenomena of reproduc- tion, adhesion, etc. The lymphatics, according to him, are not the absorbents of the body. In 1830 Dr. Edwin D. Faust, f of Columbia, S. C., made a series of experiments and observations on endosmosis and exosmosis of gases and the relation of these phenomena with the functions of respiration. He reviews the work done on the interchange of gases through animal membranes. He makes some experiments with endosmometer, using nitrogen, hydrogen, carbonic acid, and air. When gases are separated by a membrane, both of them pass through partitions, but one or other pre- dominates. He then applies interchange of gases to respiration, showing there is a chemical combination. In 1830 Dr. Samuel Jackson; published a paper upon the pulse and its modification. He shows that the frequency, force, and rhythm of pulse depend upon the heart; the volume of the pulse on the condition of the capillaries. The condition of the arteries modifies the tension of the pulse. In 1830 Dr. J. K. Mitchell & published a paper on the penetrativeness of fluids. After showing low gases penetrate membranes of gum elastic and also animal mem- branes, he made experiments with sulphuretted hydrogen, carbonic acid, nitrogen, and hydrogen. He shows very clearly that they penetrate the membranes of the body. He injects acetate of lead into the peritoneal cavity, and the sulphuretted hydrogen into the rectum. The animal dies and he finds a precipitate over the intestine. He then tries the interchange of different fluids, alcohol, ether, acid, and alkali water, etc., through different animal membranes, gum elastic, bladder, and human skin. He shows very well the penetrativeness of gases in organic tissue. The ratio of penetration for gases depends on them alone, while for liquids it depends on both the liquids and tissues. - In 1831 Dr. William V. Volk, of Providence, R.I., published a paper upon micro- scopical observation on portions of animal tissue, with additional experiments on endosmosis and exosmosis. His results were not in harmony with those of Dr. Togno. He ran his experiments for several days with crop and intestines of a fowl. He found endosmosis in intestines, and exosmosis in crop and cacum. It is probable that the decomposition of his membranes caused his disagreement with the results of Dr. Togno. In 1833 Dr. Maurice Fitz Gibbon I published a paper on the forces by which the blood circulates. He dissected several hearts to determine the arrangement of the muscular fibers. In 1834 Dr. Samuel Jackson, of Philadelphia, published a review of the subject of absorption, with some experiments. The paper is a very lengthy and exhaustive one, and I shall only speak of a few points in it. According to him the skin absorbs, as do the lungs, stomach, cellular, and serous tissues. He speaks of Dr. J. K. Mitchell injecting into the pleural cavity solution sulphate of iron and prussiate of potash into the peritoneal cavity. He saw a blue color in the veins of diaphragm. He also speaks of vascular absorption, the part of absorption in nutrition, and the mechanism of absorption. Dr. Jackson exposed and ligated the external jugular vein in two places, applied prussiate of potash to wall of vein and obtained a blue * American Medical Journal, 1827. § American Medical Journal, Vol. VII. f American Medical Journal, Vol. VII, p. 23. | American Medical Journal. #American Medical Journal, May, 1830. TI American Medical Journal, 1833. *e e? © © :25: ** : **- : : -*. :*: *::... ...; PAN-AMERICAN MEDICAL CONGRESS. 1187 color on treating lining of vein or serum with sulphate of iron. According to him they proved that lymphatics were not exclusively the only means of absorption. He states that dropsy is caused by defective absorption, that it is a vice of nutrition and impoverished state of the blood. In 1836 Dr. J. K. Mitchell” published a paper on penetration of gases. He repeats many experiments in a paper just noticed and shows that the laws of diffusion estab- lished by Mr. Graham, of Glasgow, do not apply to animal membranes of a closer structure than stucco. In 1836 Dr. Robert E. Rogers, f of Philadelphia, published some experiments upon the blood. He found that exhaustion by his air pump had no effect on evolving CO2. A temperature of 212° F. does not displace carbonic acid. Carbonic acid is absorbed by exposing venous blood. The exposure of venous blood to oxygen, nitro- gen, hydrogen, and nitrous oxide does not displace carbonic acid, although some of each gas (except hydrogen) is absorbed. When venous blood is put in a bag with access to an atmosphere of oxygen, hydrogen, etc., then more carbonic acid is given off. In 1838; Dr. John D. Fisher, of Boston, published a paper upon the cerebellum, showing a loss of sexual sense. In 1838 y Dr. John W. Draper published a paper on some mechanical functions, the coãrdination of the diffusion laws, by Professor Graham, and the experiments of Dr. J. K. Mitchell. This paper deals with diffusion of gases, and shows that peculiar mechanical functions depend on the condition of texture. They often, in appear- ance, are the generators of power. Endosmosis is a manifestation of capillary attraction and does not bear any peculiar relation to organization. There is no case on record where endosmosis has effected a real chemical change. In 1839 Dr. J. J. Allison | published experiments proving the existence of a venous pulse, independent of heart and nervous system, with remarks on contractility of veins in general. He made experiments upon animals, and noted that the venae cavae and pulmonary veins pulsate in four classes of vertebrates. Distension by blood is not necessary for their contraction. In 1839 Drs. C.W. Pennock and Moore iſ published a paper upon the heart's action. Their experiments were made upon six- teen calves and sheep, Drs. Hardy, Stillé, George B. Wood, and Mr. Burns being present. The animals were knocked on the head with an axe. Artificial respira- tion being kept up by a bellows, the chest opened longitudinally, the heart observed and its sounds listened to by another member with a stethoscope. They determined that the impulse was synchronous with the ventricular contraction caused by apex striking chest wall. The blood is expelled from the ventricles by approximation of walls and not by contraction of apex toward base. During systole the heart performs spiral movements and becomes elongated. The ventricle con- tracts and the auricle dilates at the same time, occupying one-half the whole cycle of time. Diastole immediately follows systole, equal to one fourth of cycle, the auricle diminishing by emptying blood into Ventricles without muscular contrac- tion. The remaining one-fourth is devoted to rest, near the termination of which the auricle contracts actively. The sounds of the heart are produced by motions of heart on its contents and not by striking against chest wall. Sounds were much louder when stethoscope directly applied to heart than when chest wall or lung is interposed. The sounds are more distinct when muscle is thin and con- tracts quickly. Hence clear flapping sound over right ventricle as compared with left. First sound impulse and ventricular systole are synchronous. Muscular con- traction is the chief factor in its production, for it is heard in extirpated heart with auriculo-ventricular valves held up. Contraction of auricle, flapping of auriculo- ventricular valves, and rushing of blood may contribute to it. The second sound *American Medical Journal, 1836, p. 100. § American Medical Journal, 1838. f American Medical Journal, 1836, p. 277. |American Medical Journal. t American Medical Journal, 1840. T Medical Examiner, 1839. 1188 PAN-AMERICAN MEDICAL CONGRESS. exclusively due to closure of the semilunar valves. The second sound is synchronous with diastole of ventricle. In 1839* Prof. Joseph Henry was the first to graduate electrical currents by sliding the secondary coil in a groove to and from the primary, as is done in Du Bois-Reymond's inductorium. In 1840 the medical faculty f of Lancaster, Pa., made some experiments upon the body of an executed criminal. Drs. John and Washington Atlee were among the observers; also Dr. J. K. Mitchell. They found that when the air taken from the lungs before and after execution was analyzed that the CO2 increased and the oxygen diminished after the execution. In 1842 Dr. C. A. Leef published a monograph on the thymus gland. Under the microscope the gland was seen to contain an enormous number of white blood corpuscles, and he believed its function to be closely con- nected with ha-matosis and chylification. In 1842 Dr. Blanchard Dogati ) reported a case of a girl, ast. 16, having passed puberty, who went into a deep sleep, or “catalepsy,” as he calls it, when acted upon by a magnetizer for fifteen minutes. In 1847 Dr. Samuel Kneeland,) of Boston, published an article upon the use of cold water for the prevention and cure of disease. He speaks of the use of cold baths in fewers and hydrotherapy in general. In 1847 Dr. C. W. PennockW published a paper upon the frequency of the pulse and respiration of the aged. He made his observations in the Philadelphia Hospital. He excluded all cases with cardiac, pulmonary, or other disease. The observations were made four hours after meals, with the patient sitting or standing. He exam- ined 170 men, ages from 50 to 90 years, and 203 women, ages from 50 to 115 years. The average age of the men was 64.09 years. Their average pulse was 71.83; average respiration, 20.51; ratio 1:3.5. The average age of the women was 70.57 years; their average pulse, 78.02; their average respiration 22.06; ratio 1:3.50. He concludes in this very valuable and scientific paper that the frequency of the pulse of the aged is greater than usually admitted. The respiration frequency of old age is equal to that of the adult middle age. In 1849–50 Dr. Bennet Dowler || made some contributions to physiology. He cut the spinal cord of alligators and found movements in the head and in the parts behind the section. The head tried to bite when one came near it, and it winked. He argues that this was not reflex, because there was no contact. According to him the spinal cord movements were from memory and not reflex. Evisceration does not kill the alligator, the heart beating for hours. Ligature of the trachea kills this animal quicker than section of the spinal cord. - In 1848 Dr. Charles Frick, ſſ of Baltimore, published his paper upon the blood, its amount of fibrin in different diseases. In 1848 Dr. George Wymberly Jones, of Georgia, made an experimental inquiry into the correctness of Poisenille's theory of the purgative action of certain salts. He can not see why one should conclude that cathartics purge by means of endos- mosis because the blood serum permeates an animal membrane to mingle with the sulphate of soda. In 1849 Dr. James Blake, of St. Louis, gave a résumé of experiments to determine the quantity of blood by means of sulphate of alumina. In 1849 || Dr. J. Locke, of Cincinnati, gave us the principle of the electro-magnetic time marker. In 1851 Dr. J. C. Walton published his famous researches upon the corpus luteum. In 1852 Dr. Brown-Sequard gave us the great researches which he had worked out during the past eight years. They are too voluminous to abstract. * Electro-Physiology, Morgan's, 1868. f American Medical Journal, 1840. f American Medical Journal, 1842. § American Medical Journal. | New Orleans Medical and Surgical Journal, 1849–50. T. Physiologeische Methodik Gescherdlen. - PAN-AMERICAN MEDICAL CONGRESS, 1189 In 1852 Dr. S. Weir Mitchell published a paper showing that feeding frogs upon sugar produced cataract. In 1854 Dr. J. C. Walton published his paper upon the movement of the glottis in respiration, demonstrating that during normal respiration there is a constant and regular movement of the vocal cords by which the glottis is alternately enlarged and diminished. In 1854 Dr. S. Weir Mitchell published a paper upon the relation of the pulse to the respiration. He finds the pulse rate lessened in inspiration and increased in expiration. - In 1854 Dr. Samuel Jackson gave us a paper upon the digestion of fatty matters by the pancreatic juice, confirming Bernard's work. - In 1855 Dr. William A. Hammond published a paper showing the relation of urea to uric acid. He showed that exercise increases urea and diminishes uric acid, while rest diminishes urea and increases uric acid. In his Physiological Memoirs he makes a number of urological contributions, such as the effect of alcohol and tobacco upon the constitution of the urine. He also has a paper upon the nutritive value of albu- min, starch, and gum. Another paper is upon the effect of the injection of urea and other substances into the blood. He also contributes a paper upon the action of certain vegetable diuretics. In 1855 Dr. Joseph Jones published a paper upon the kidneys and its excretion. He states that the amount of excretion depends upon the amount of the force and rapidity of the circulation; the activity of the skin, action of colon, activity of the respiration, et altera. In 1856 Dr. Joseph Jones gave us a paper upon the digestion of albumin and flesh and the comparative anatomy of the pancreas. He confirms Bernard’s work. In 1856 Dr. Francis Gurney Smith made some experiments upon Alexis St. Martin, showing that acid of the stomach is lactic and that amylaceous materials are converted in the stomach into glucose. Dr. Dalton opposed this statement, assert- ing that the glucose existed in the bread used as food. To this statement Dr. Smith replied by feeding Dr. Brown-Sequard (after washing out his stomach) with arrowroot, which he soon vomited. Glucose was found to be present. No insaliva- tion of the arrowroot was permitted. In 1856 Dr. Joseph Jones, of Georgia, made a series of experiments, under the direc- tion of Prof. Joseph Carson, on the action of saline solutions of different densities upon living animals and also the reciprocal action through dead animal membranes of serum, water, and saline solution. He concluded that the laws which regulate action of saline solution on living animals can not be demonstrated with dead ani- Imal membranes. * In 1856 Dr. Joseph Jones published another paper upon the chemical, physical, and physiological investigation upon the vital phenomena, structure, and offices of the solids and fluids of animals. In 1856 Dr. J. C. Draper published a paper, “Is urea due to muscular motion?” and experimented upon the respiration. - In 1856 Dr. G. P. Camman published a paper upon the capillaries of the lungs. In 1856 Dr. J. C. Dalton published a paper on the decomposition of iodide of starch. - In 1857 Dr. J. C. Dalton published his experiments upon the secretion of bile. He made 67 experiments upon animals, showing the different constitution of the bile in different animals, its reaction with gastric and intestinal juices, and lastly its uncae of disappearance in the alimentary canal. In 1857 Dr. Austin Flint, Jr., published a paper upon the phenomena of the capil- lary circulation. In 1858 Dr. H. F. Campbell, of Georgia, was the first to announce the theory of reflex secretion and the excito-secretory system of nerves. In 1859 Dr. J. C. Dalton published a paper upon the physical and chemical changes in the interior of the body. 1190 PAN-AMERICAN MEDICAL CONGRESS. In 1857 Dr. S. Weir Mitchell published his paper, “Effect of alcohol, glycerin, water gum, ammonia at the vacuum upon the exposed hearts of frogs, snapping tur- tles, and sturgeons.” In 1860 Dr. S. Weir Mitchell published his valuable monograph upon the venom of the rattlesnake.” In 1861 Dr. J. C. Dalton published a paper upon the cerebellum. In 1861 Dr. Austin Flint, Jr., gave us a paper on the points connected with the action of the heart and respiration. His results are as follows: (1) The heart of the dog elongates during systole. (2) The natural stimulus of the heart beat is the blood, and the stimulus can not be supplied by water or any fluid of lesser density. . (3) The excitation causing the reflex act of respiration is received from the general system and not from the lungs or heart. The excitation is due to a want of oxygen in the tissues and not to stimulating properties of venous blood. In 1862 Dr. Austin Flint, Jr., published a paper upon a new excretory function of the liver, showing that cholesterin is removed from the blood and discharged from the body in the form of stercorin. In 1862 Dr. Austin Flint, Jr., published a paper upon the glycogenic function of the liver. In 1863 Dr. Austin Flint, Jr., gave us a paper upon the organic nitrogenized prin- ciples of the body. In 1863 Dr. S. Weir Mitchell gave us a monograph upon the physiology of the respiration in cheloma. In 1863 Drs. Hammond and Mitchell published their experiments upon corroval and NaO. In 1867 Dr. T. R. Noyes published a paper upon the excretion of urea. In 1867 Dr. S. Weir Mitchell gave us a paper upon the retrogressive motion in birds produced by the application of cold to the cervical spine. In 1869 Dr. S. Weir Mitchell published a paper upon the physiology of the cere- bellum. - In 1869 Dr. S. Weir Mitchell published a paper upon the insusceptibility of pigeons to opium. In 1870 Dr. Wm. Lusk published a paper upon the origin of diabetes. In 1870 Dr. H. C. Wood published a paper upon the physiological action of viridia, veratroidia, and veratria of commerce. In 1871. Dr. H. C. Wood published a paper upon the action of atropia on birds. In 1871 Dr. H. C. Wood gave us a paper upon nitrite of amyl, its physiological action. In 1873 Dr. H. C. Wood gave us a paper upon the action of atropine, and during the same year a paper upon the section of the vagi and the effects of enetics and cathartics. In 1874 Dr. Austin Flint, Jr., published a paper upon the mechanism of reflex nervous action in normal respiration. In 1874 Dr. James Putnam published a paper upon the physiology of the cortex cerebri. - - In 1874 a monograph upon cocaine, veratria, and gelsemium by the speaker. In 1874 Drs. H. P. Bowditch and Minot published a paper upon the influence of anaesthetics on the vasomotor centers. In 1876 Dr. H. P. Bowditch published a paper upon ciliary motion, and in the next year a paper upon the growth of children. In 1878 Dr. W. H. Klapp published a paper upon the action of strychnia and Dr. James Munro Murray upon the action of aconitia and napellina. Prof. Robert Meade Smith in the same year published a paper upon the action of sanguinaria. * American Medical Journal. PAN-AMERICAN MEDICAL CONGRESS. 1.191 In 1879 Dr. Austin Flint, Jr., published a paper, Experiments and reflections on animal heat. In 1879 Prof. E. T. Reichert” published a paper on apomorphia. In the same year Drs. Martin and Hartwell published a paper on the respiratory function of the intercostal muscles. - In 1879 Dr. R. H. Chittenden published a paper on the formation of hydroxanthin from albumin. In 1879 a paper by speaker on the spinal cord. In 1879 Drs. Bowditch and Garland published a paper on the effect of respiratory movement on the circulation. In the same year Dr. Sewall published a paper on the effect of two succeeding stimuli on muscular contraction. Dr. C. Sibler also published in this year a paper on heat dyspnoea. As the titles of papers have become too numerous to mention, I shall refer to the number produced each year, as compiled from the Index Medicus. In 1879 there were 36 articles on physiological subjects; 1880, 52; 1881, 21; 1882, 39; 1883, 19; 1884, 26; 1885, 22; 1886, 20; 1887, 44; 1888, 38; 1889, 25; 1890, 17. Having reviewed the past labors of American physiologists, it remains to speak briefly of the present. The present state of physiology in the United States is in a very promising condi- tion. Unlike England, we are not hampered by licenses and restricted in methods in experimentation. The antivivisectionists are, however, still active, especially in the State of Pennsylvania. It seems to me that the unanimous indorsement of vivi- section by the Pan-American Congress would be quite appropriate. The well- furnished laboratories at Boston, Worcester, New Haven, New York, Philadelphia, Baltimore, and Chicago offer great opportunities for anyone endowed with any special love for this work. I say special love, for without it you will not labor long at it, as it is exhausting both financially and physically. As to the future, every- thing is of a rosy hue. With Maecenas giving from five to twenty millions to start universities, it ought not to be difficult to lave fellowships in physiology at our universities, which should be open to competition, and held as long as the party gives evidence of progress. They should be of sufficient value to attract able young men. At least $1,000 should be the amount of salary. With a few fellowships in physiology the laboratories would be in continual activity, and thus physiological enthusiasm would be stirred up among all concerned. The laboratories themselves should be endowed with a perpetual income, that new apparatus may be built or purchased, for no laboratory of physiology will ever be within any possibility of sup- porting itself. Money is especially needed to purchase animals, for simians are expensive, but results obtained from them are greatly to be desired, as they more nearly approach us in general constitution. After all, the physiology of man is what we need in our practice as physicians. THE PHYSIOLOGICAL BASIS OF THERAPEUTIC ACTION; AN EXPERI- MENTAL INQUIRY. By THOMAS J. MAYS, A. M., M. D., of Philadelphia, Pa., Professor of Diseases of the Ohest in the Philadelphia Polyclinic, and Visiting Physician to the Rush Hospital for Consumptives, of Philadelphia. In this paper an effort will be made to explain some of the fundamental principles of medicinal action on a physiological basis. I think from the present standpoint of physical science we have great reason for believing that every phenomenon in nature may be viewed as the effect of force, and that therapeutic action, as a part of the grand chain of natural phenomena, becomes intelligible only when it is * Philadelphia Medical Times. 1.192 FAN-AMERICAN MEDICAL CONGRESS. reduced to the same terms. This is indeed demanded by the modern doctrine of the conservation of force. From this it follows that any system of therapeutics which fails to take into account the relation between drug action and the outer world must necessarily be imperfect and limited in its practical application. The fireman looks upon the coal with which he fires his engine as the ultimate source of heat, while the philosopher regards the same material as a storehouse of force in the accumu- lation of which an equal quantity of force was consumed in the sun thousands of years ago, and that ultimately the force which is concentrated here is but a part of the force which pervades the universe. That which is true here is also true of ther- apeutic action. Heat is applied to the animal organism in various ways. Applied in moderate quantity to a beating frog's heart, as Kronecker has demonstrated, it accelerates the pulsations of this organ, but when applied in greater quantity its pulsations are arrested. When applied in excess, as in the form of steam, or the hot iron, it destroys animal tissue. Now, he who takes a disconnected view of these effects necessarily concludes that heat possesses at least three different properties, (1) that of a stimulant; (2) that of a depressant; and (3) that of an escharotic. But he who believes in the universality of force knows that heat is force, and regards these different phenomena as the varying effects of this force applied in varying quantities. About fifteen years ago I ventured to express the opinion on a purely inductive basis that our therapeutic agents behave like physical forces, inasmuch as in the case of heat they enhance vital action in small and depress it in large quantities. Since then I have investigated this question from an experimental standpoint and believe that I have succeeded in verifying this opinion of the action of a large num- ber of our most important therapeutic agents, at least so far as this stands related to the behavior of the frog's heart. The method which I employed was the fol- lowing: A frog's heart was securely adjusted to a double canula and then attached to a Kronecker. Bonditch heart apparatus. In this position the heart may be filled with any desirable fluid, and the action of this on the heart may be estimated by the elevation or depression of the tracings which it records on the smoked surface of a revolving cylinder. If it is filled with a 2 per cent solution of blood and receives regularly minimum induction shocks it will continue to beat for many hours in succession, and the elevation of its tracings under such conditions is taken as a standard of the heart's best work. This being constant under the action of the blood solution, any deviation from this normal line which may be brought about by the addition of an agent to the blood solution must hence be ascribed to the influ- ence of such agent. Before going any further, I wish it clearly understood that in these experiments we must not view the frog's heart as being simply the representative of the heart's function in general, but as that of an isolated organism through which, on account of its vital simplicity and tenacity, and of its peculiar physiological adaptability, we are able to demonstrate and measure the action of different substances on organized animal life. These experiments, as has already been stated, were undertaken with a view of finding whether a drug, in any quantity, added to the 2 per cent blood solution, has the power of producing a higher tracing than that which can be obtained from the blood solution alone. After many trials it was found that all the drugs which were investigated showed such an action in certain doses, which, on account of their diminutiveness, are named minimum doses. On the other hand, it was found that larger quantities paralyzed the heart's action to such a degree that its pulsations were arrested either in systole or diastole, according to the nature of the drug. The quantity which produced this effect is called the maximum dose. This double action is well exemplified in the following tracings which were obtained from sodium hydrate. The minimum dose of this drug was found to be 1:160,000, i.e., one part of sodium hydrate to one hundred and sixty thousand parts of blood; and the maxi- mum dose, 1:1000, i. e., one part of sodium hydrate to one thousand parts of blood. Atropine. 1:160,000. Ether sulph. Their combined effects. 1 : 1 (). Atropine. Alcohol. Their combined effects. 1:160,000. 1 ::25. AcOnitine. Ether sulph. Their connbined effects. 1:60,000. 1:5. Lycopin. Chloroform. Their combined effects. 1:160,000. 1 : 4)(). Culrare. Their combined effects. 1 : 160,000. 1:26. A conitine. EXAMPLES OF ANTAGON |SM. (Read from left to right.) Lºw"| Curare. Chloroforn). Their combined effects. 1:80,000. 1:500. Aſ||ww. º, Millſ Ether sulph. Chloroform. Their combined effects. 1:400. 1 : 500. Aconitine. Ether sulph. Their combined effects. 1:160,000. 1:5. Aconitine. Chloroform. Their combined effects. 1:160,000. 1:500, Curare. Ether sulph. Their combined effects. 1:8,000. 1 : 10. EXAMPLES OF ANTAGON ISM. (Read from left to right.) Strychnine. Chloroform. Their combined effects. 1:160,000. 1:500 A tropine. ( 'llral’e. Their combined effects. 1:160,000. 1 : 50. Atropine. Strychnine. Their combined effects. 1:160,000. 1:1,000 Strychnine. Atropine. Their combined effects. 1:160,000. 1:2,000. EXAMPLES OF ANTAGON ISM. (Read from left to right.) (C) (b) (c) V. "| Atropine. Chloroform. Their combined effects. 1:160,000. 1:500. ANTAGON }SM BETWEEN ATROPINE AND CHLOROFORM. (Read from left to right.) Blood Sol. 1:160,000. TRACE VI.-Showing the effects of hydrate of soda. EFFECTS OF MINIMUM, INTERMEDIATE, AND MAXIMUM DOSES OF SODIUM HYDRATE. (Read from left to right.) Blood Sol. 1:40,000. 1:1,000. TRACE X. —Showing the effects of hydrate of potash. Blood Sol. 1:2,000. 1:4()(). TRACE XI.-Showing the effects of bicarbonate of potash. Blood Sol. 1:4,000. 1:200. TRACE XII. —Showing the effects of chlorate of potash. EFFECTS OF M |N|M U M AND MAX|MUM DOSES OF POTASS|UM AND SOME OF TS SALTS, (Read from left to right.) Blood Sol. 1:80,000. 1:1,000. TRACE XXIV.-Showing the effects of digitalin. Blood Sol. 1:160,000. 1 ::25(). TRACE XX. —Showing the effects of carbolic acid. Blood Sol. 1: 160,000. 1 : 1,000. TRACF XXI. - Showing the effects of sulphate of atropine. Blood Sol. 1:320,000. 1:1,000. TRACE XXV.—Showing the effects of aconitine. EFFECTS OF MINIMUM AND MAXIMUM DOSES OF DIGITALIN, CARBOLIC ACID, ATROPINE, AND ACON |T|N E. | Head from left to right. ) PAN-AMERICAN MEDICAL CONGRESS. 1193 TRACING OF SODIUM HYDRATE. These tracings show us that the addition of a minimum dose of sodium hydrate to the blood produces higher heart beats than are given by blood alone, and that a maximum dose arrests the leart in systole. This is positive evidence that sodium hydrate when administered in suitable doses is capable of pushing the function of the heart over and above the point which it is capable of exerting in its ordinary state of nutrition; and that on the other hand the same agent when given in large doses has the power of completely inhibiting the heart's action. Now, that which has here been shown to be true of the action of sodium hydrate is also true of the behavior of the following substances which were included in this research, and which are here given in alphabetical order: Acetic acid, aconitine, alcohol, aloin, ammonia, atropine, apomorphine, brucine, ammonia, caffeine, cannabin tannate, carbolic acid, chloric ether, chloroform, chloral hydrate, cocaine, colchicine, conium, curare, delphinine, digitalin, ether, ethyl bromide, gelsemine, guaranine, hydrastine, kairine, lactic acid, lycopin, morphine, corrosive chloride of mercury, piperidine, pilocarpine, potassium and its salts, quassin, quinine, resorcin, sanguinarine, salicin, Saponin, spirit of nitrous ether, Strychnine, sodium and its salts, theine, and veratrine. - In this connection it is worthy of note, as one of the many interesting phenomena which developed during this investigation, that while large doses would invariably arrest the heart's action, yet this arrest was brought about in either one of the two ways. Such agents as the acids, the potassium salts, aconitine, Strychnine, cocaine, curare, chloroform, ether, etc., arrested it in diastole; while the sodium salts, ammonia, digitalin, morphine, quinine, caffeine, theine, etc., arrested it in systole. These experimental results give us the assurance that all these drugs have at least two kinds of effect on animal life—in minimum doses they exalt normal vital action, and in maximum doses they depress or annihilate the same. Further investigation in the same direction brought out the fact, too, that minimum doses are directly antagonistic in their action to maximum doses. For example, a maximum dose of chloroform, which was found to be one part to five hundred parts of blood, almost entirely inhibits the action of the heart, but when a minimum dose of atropine, which was found to be one part to one hundred and sixty thousand parts of blood, is added to this dose and administered at the same time the tracings may be as high, or even higher, under this combined influence than they are under the influence of minimum doses of this agent, or under the blood itself. This is well shown in the following tracing obtained from chloroform and atropine. The first part of the tracing (a) was produced by atropine in a minimum dose, the second part (b) by chloroform in maximum doses, and the third part (c) by combining a minimum dose of atropine and a maximum dose of chloroform. The same is true of chloroform and strychnine, of atropine and Strychnine, and of many other agents as will be seen from the following tracings: These examples not only give us experimental proof of the power of interference of one drug with the action of another, but they demonstrate the fact how a thera- peutic force may be able to overcome and successfully resist the action of disinte- grating forces. If we look beneath the surface of these phenomena we find at work here two forces, which, on being properly adjusted, become antagonistic to each other in their action on organic tissue, the one tending to enhance or to elevate, and the other to depress the function of the latter. These antagonistic effects are displayed as decidedly by drug interference as if they were produced by the two mechanical forces of attraction and repulsion, and they give us an exact and measurable demonstration of the power which drugs exert in supporting and preserving life when attacked by adverse forces. Now, if we admit that disease is but the manifestation of the action of morbid forces—forces which move in a direction inimical to health—and if we agree to substitute these in place of the operation of maximum drug doses, as given in the above illustrations, we have a clear picture before us as to the manner in which drugs combat disease, viz, by interference. Now, in what does this principle 1194 PAN-AMERICAN MEDICAL CONGRESS. of interference consist? What, in other words, is the intimate nature of the combat between drug action and disease? In explaining this we must, of course, take into consideration the fact that in a broad physiological sense all the textures of the animal body are in a state of continual molecular motion, which is maintained prin- cipally by internal chemical changes, and that so long as the molecular motion of each texture harmonizes with that of every other, health is the result; but that as Soon as perturbation arises among any one or a number of these forces disease must follow. It is readily seen, therefore, how molecular motion may be maintained and enhanced in the body by the introduction of substances, like albuminous and carbonaceous foods, which we know undergo chemical change and apply the force thus arising to this purpose; but how forces—forces of a mechanical nature and which are antagonistic to the bodily forces—can enliance molecular activity is less easily seen, for on the surface it appears as though forces of such a character would naturally tend to produce disintegration under all circumstances. But that aggressive or antagonistic forces have the power of augmenting healthy molecular motion, under certain conditions, will appear patent from the following observations: If, for example, gentle friction or massage is applied to the body the molecular activity of the latter is at once aroused to its utmost physiological capacity. We have here the antagonism of two kinds of forces—the force of fric- tion or of massage, and those of the tissues to which these were applied—moving in different directions, but which are governed by the same fundamental physical laws, viz, motion takes place in the line of least resistance, and action and reaction are always equal; or, in other words, one force acting on another always calls forth a corresponding reaction. Then, when two forces of equal strength meet each other from opposite directions rest is produced. This is exemplified in the production of darkness by two waves of light. When, however, two forces of somewhat unequal strength come in conflict with each other, the stronger will cause the weaker to move in a direction parallel to its own and to a point where a mutual balance takes place; and although the latter may tend to rebound and to assume its former posi- tion, yet, through the operation of a series of such impactions, it will be finally forced to seek a new or another state of equilibrium in which it will remain after the attacking force has ceased to act. The modus operandi of this is well illustrated in the following example: When a gentle gale blows over a wheat field the stalks of grain are generally blown into a leaning position which is more or less permanent; but a steady and continuous wind of equal force applied afterwards from an opposite direction will cause the stalks to become straight again—to resume and to remain in a normal equilibrium after the latter force has ceased to operate. This not only illustrates the intimate nature of the beneficial action of massage and of friction, but that of many other agents, of which strychnine, quinine, atropine, and digitalis in suitable doses are good examples, and shows how the effects of these therapeutic measures, although moving antagonistically to the bodily forces, become permanent in their influence. Moreover, if we view our therapeutic agents in the light of forces, we are not only enabled to explain their action in varying doses and the antagonism of these, as has been done, but we can also account for the fact that many, if not most of our medicines, prefer to act on one tissue rather than on another; or, in other words, we can say why cathartics act on the intestinal canal, emetics on the stomach, digitalis, strophanthus, and caffeine on the heart, cantharides and copaiba on the urinary tract, etc. For the law of the “physiological division of labor” means that the integrity of the body is maintained by many diverse forces or functions within itself, each force or function having its own particular duty to perform; and if an antag- onistic force is introduced among so many different forces, widely varying results must be produced—some physiological forces being disturbed, while others are altogether untouched—those showing the greatest opposition or antagonism being most strongly influenced. The phenomena of acoustics give us a fitting illustration PAN-AMERICAN MEDICAL CONGRESS 11.95 here. Two sounds interfere with each other in proportion to the disparity which exists between them—a small difference causing a slight degree of interference, and two diametrically opposite and equal sound waves will annihilate or neutralize each other, and cause perfect silence. Again, if the tone of E flat is produced simul- taneously with the chord C, E, and G, the former will only interfere with the tone E, because it forms a discordant relation with this tone, and an agreeable relation with the other two sounds. The wave E flat therefore antagonizes the wave E only, and leaves the other two waves undisturbed. This principle of action makes it clear, then, why different therapeutic substances should affect different organs; and the same prin- ciple carried further also explains why some agents act only on one part, while others act only on another part of the same tissue or organic apparatus. The nervous system, for example, is composed of the same general anatomical elements through- out and possesses the common function of generating and transmitting impulses; yet morphine, cocaine, Strychnine, curare, pilocarpine, atropine, hyoscine, gelsemine, hydrastine, and ergotine all affect this system in different regions and in different Ways. Now, while it is true that there is a general uniformity of structure and function of the nervous system, it is also true that there exists special structural and func- tional differences in this mechanism which are brought about by special require- ments and conditions. Thus it is the function of motor nerves to transmit motion, but it is also the function of different parts of motor nerves to transmit different degrees and kinds of motion. The impulses which are transmitted by the nerves of general sensation differ from those which travel along the nerves of special sensation. The pneumogastric nerve supplies the lungs, heart, stomach, liver, and intestines, and its variable and extensive distribution is evidence that the impulses which are conveyed by its branches must differ greatly, for the impulses which have the power of maintaining the function of the heart are not adapted to the necessities of the stomach, nor are those which are essential to the support of the function of the liver suited to the wants of the respiratory apparatus, or to those of the intes- times, showing how, on the score of the principle of interference, a therapeutic force may affect a special branch of a nerve and leave all the other branches unaffected. The fundamental principles of drug action, therefore, resolve themselves into (1) stimulant effects of small doses; (2) depressant effects of large doses; and (3) elec- tive, affinity. From this it follows that whatever the elective affinity of a drug may be, the dose which is administered will decide whether it enhances or depresses the function of the organ on which it acts. Hence, when we come to classify the action of drugs, we have stimulants and depressants of every important organ in the body. Thus we have stimulants and depressants of the general nervous system and of special parts of the same, of the heart, lungs, liver, intestines, kidneys, skin, etc.. which demonstrates that the old grouping of the action of drugs into stimulants, tonics, narcotics, expectorants, emetics, cathartics, cholagogues, diuretics; diapho- retics, etc., is the only scientific and natural classification. Time and space forbid me, however, from going into the details of this part of my subject any further, and after having run the risk of wearying you nigh unto intoleration I trust I may indulge in the hope that this feeble effort in placing the study of therapeutics on a firmer and more scientific basis than it has heretofore occupied may give an impulse to future inquiry in this direction. - DISCUSSION. Dr. MaCallum observed that the heart is developmentally the oldest organ in the body, and from the point of view of structure one of the most bighly differentiated. One would expect, therefore, that drugs would affect this organ, to a certain extent, differently from the way they would affect a more simple organ, like a simple 1196 PAN-AMERICAN MEDICAL CONGRESS. cell or a collection of simple cells. To make a fundamental classification of drugs according to their action, an organ such as a simple cell or group of simple cells should form the basis of experiments. Dr. MaCallum has been in the habit of urging the use of ciliated cells for this purpose, and the possibility that they could be studied in this respect by means of Engelmann's Ciliary will, no doubt, when some experienced experimenter should endeavor to carry the use of that instrument beyond that to which Engelmann subjected it, modify it to show finer and more delicate results than the machine gives as it is now constructed. Dr. Ma Callum referred to the excellence of the graphic tracings which Dr. Mays obtained to sup- port the contentions of his paper and expressed the pleasure with which he listened to Dr. Mays's paper. Dr. Mays, of Philadelphia, said he had nothing to add except to warmly thank the members of the section for the kind manner in which they received what he said. He would say, however, that he believed that the experiments of Englemann, at least in part, confirm the result which he had obtained from the heart. SOME OBSERVATIONS ON NORMAL GROWTH AND DEVELOPMENT OF THE HUMAN BODY UNDER SYSTEMATIZED EXERCISE. By HENRY G. BEYER, M. D., Surgeon, U. S. Navy. Some of our best naturalists inform us that the first living things on this globe must have been microscopic, monocellular organisms, inhabiting the surface of the great oceans and leading a free-swimming existence, like the protozoa, their direct descendants, of the present day. Most all of them, furthermore, agree, I think, that there could have been no departure whatever from this monocellularism of existence—no aggregation of cells to build up more complicated organisms could have taken place until some of these protozoa began to assume a sessile form of exist- ence at the bottom of the ocean, whereby nutriment came to them in the current flowing by them, instead of their having to everlastingly hunt for it, and thus expending all their available energy in this direction only. The law of growth and development, in other words, depends on alternate rest and activity, and is one of the oldest and most fundamental in its relation to life in general. Where and how- ever we may study life, whether it is during the embryonic conditions of the higher organisms, or in the adult conditions of both high and low forms of life, we recog- nize everywhere the existence of resting stages alternating with stages of activity. Thus, in the higher animals, we find the corpuscles of blood and lymph ever active and in constant motion microscopically small. According to the laws of growth they must remain so, but at the bottom of this sea of blood and lymph we find a number of sessile organs, aggregations of cells belonging to the same organism, and made possible only under the same law of alternate rest and activity. Further reflection and observation have shown this great and fundamental natural law to be at the bottom not only of the evolution of all living forms at present existing, but we can observe it and study its influence in every individual living being. It is consequently clear, then, that growth and development of the human body must be subject to the same unerring laws, and in order that they shall exert their most favorable influence on the formation of that body, they must be duly observed and properly administered. Exercise, alternating with rest, then, are the two most important factors with which scientific physical training will have to deal for the purpose of producing the highest results. Speaking physiologically, there is no difference between the labor performed by the workman and that per- formed by the gymnast. Both the wood-chopper and the football player do muscular work. But the one has his exercise at his own hours and follows the laws of hygiene, diet, and rest, while the other does not do so, nor can he do so, and we can easily PAN-AMERICAN MEDICAL CONGRESS. 1197 understand why exercise strengthens the one and wears out the other. Neither does it make any difference to the contracting muscle whether it is made to con- tract according to the Swedish system, or the German system, or even the Ameri- can system; as long as it is caused to contract thoroughly and energetically and is allowed to rest after contraction, it will develop and grow in spite of any system. For a number of years past a system of anthropometric measurements has been introduced into some of our best schools and colleges for the avowed purpose of watching, with more accuracy and scientific exactness than heretofore, the pro- cesses of growth and development of the rising generation of Americans as they march through the college gymnasia of these respective institutions. The highest credit and praise are due to the pioneers in this laborious undertaking. The large number of finely equipped gymnasia that have sprung up everywhere like magic must be looked upon as the direct results of their most excellent missionary work in the cause of physical education. But although growth and development are prima- rily physiological subjects, and therefore should greatly interest physiologists, very little interest has, so far at least, come from that direction. Most of the papers that have appeared, ever since the time of the introduction of these measurements, are most decidedly of more anatomical and anthropometrical interest than of physiolog- ical value, and, so far at least, anthropometry has been made an end rather than a means. However, since we have at last succeeded in discovering not only the perfect typical and ideal man, but the woman also, and have had them both safely landed at Chicago, where the two are now supposed to dwell in unison, if not mutual admira- tion of one another, there is some hope that the leaders in physical education may turn their talents to the much neglected physiological side of this question. Indeed, a beginning has already been made and I have in my possession three papers of the utmost physiological importance as regards physical education. The first of these papers is “The Growth of Children, Studied by Galton's Method of Percentile Grades,” by H. P. Bowditch; the second is entitled “The physical basis of pre- cocity and dullness,” by W. T. Porter, and the third is “Observations on the results of the pedagogical gymnastics of the Luig system,” by Claes J. Enebuske. The object I had in view in preparing this paper is partly for the purpose of invit- ing more interest in this subject on the part of physiologists, and partly also to add some observations of my own, made on 50 naval cadets, as ascertained by two succes- sive measurements made at certain intervals, namely: The first measurements were taken in September, 1892, and the second in April, 1893, the time interval between the two measurements being, therefore, about six months. From the whole number of measurements that are usually taken of each individual only a few were selected for consideration here, since to discuss them all would rather detract from the few more important ones selected for our purpose, and would add nothing to the physiological value of the results that may be derived from them all. These items are: (1) The height, (2) the weight, (3) the lung capacity, and (4) the total strength. We will also take into consideration the vital index, the power index, the strength-weight index, and the vital-strength-weight index, which form very important indices, intro- duced by Enebuske, and all deducible from the first four items. As regards the nature of the gymnastic exercises which the cadets took during the interval of these measurements, I could not say that any one particular system of gymnastics was fol- lowed out to the exclusion of every other system. From the point of view of the physiologist there can be but one system, namely, that of common sense and judg- ment, having for its sole purpose the gradual, progressive, harmonious, and sym- metrical development of the individual according to his needs and according to physiological laws, and in this process the instruments used are the subordinate means to the end, no matter to what particular system of gymnastics they may belong. A brief outline, however, of these exercises seems called for. Thus, during the first month calisthenics or free movements were daily employed, and breathing exer- cises were practiced on the different chest weights. During the second month 1198 PAN-AMERICAN MEDICAL CONGRESS. dumb-bells, Indian clubs, and boxing were introduced. During the third month run- ning, jumping, and vaulting were begun. During the fourth month rope climbing, rope jumping, horizontal and parallel bar exercises were done. After that the out- of-door drills began, and the cadets only exercised in the gymnasium in rainy weather, some also doing special exercises prescribed for them in accordance with their special needs and requirements. This is, in brief, the course that was pursued. All had infantry drill, but none had any fencing, which is begun after the first year of their stay at the Academy. The time devoted to gymnastic exercises was one hour per day, except Wednesday, making five hours per week in all, the remainder of the time, of course, being devoted to mental work, with the usual intermissions for recreation common to all schools. The cadets are also taught dancing during the winter, and the weekly Saturday night cadet hops continue throughout the academic year, not all the cadets, however, taking part. It is perhaps but fair to state that the changes that are recorded in the following tables as having taken place in the cadets are not and can not be looked upon as strictly comparative, nor as due to the gymnastic exercises alone, for in order to make them strictly comparative it would require the records of 50 other cadets of the same age and living under the same conditions that had not taken this exercise, and, besides, there were other exercises taken outside the gymnasium and belonging to the Academy curriculum not strictly to be classified as gymnasium exercises. We will begin, then, first with the consid- eration of their height and see what changes we can detect in that, also what pos- sible standard we may derive from a larger number of cadets that had entered pre- viously to 1892. The records of this Department place at my disposal, so far, two bundred and thirty entries of cadets whose height was accurately measured and recorded upon their entry into the Naval Academy. Inasmuch as there exists no standard for admission to the Academy as regards height for a certain age, except that the candidate, regardless of his age, shall not measure less than 5 feet or 1,624 mm., that he shall be sound and not less than 15 years of age, it seemed promising of some interest to find out just how the average height of the entering naval cadet under this plan compared with that of other schools and colleges from which data for comparison are at hand, taking, of course, the age into consideration in making this comparison. The following table shows the distribution of the two hundred and thirty cadets, as regards height, in millimeters. TABLE 1. Number of | Number of Millimeters. observa- || Millimeters. observa- tions. i tions. 1,850------------. 2 1,625------------- 23 l, 825------------- 1 1,600- - - - - - - - - - - - - 8 1,800------------- 15 1, 575------------- 2 1, 775------------- 19 1, 550. -- - - - - - - - - - - 2 1, 750. -----------. 27 1, 525------------- () 1, 725. ------------ 34 1,500. ------------ 0 1,700. ------------ 36 1,475. ------------ 1. 1,675. -----------. 28 1,650------------. 32 Total - - - - - - - 230 The next table shows their heights, arranged in percentile grades varying from 5 to 95 per cent, as they compare with those of the Amherst students aged 17 years, and those of the Boston schoolboys aged 16, 17, and 18 years, respectively. The average age of the two hundred and thirty cadets is 18 years. - PAN-AMERICAN MEDICAL CONGRESS. 11.99 TABLE 2. [Millimeters.] Num- Aver- ber of Av- Percentile grade. age | obser-| 5. 10. 20. 30. 40. 50. 60. 70. so. 90. 95. er- age. Va- age. tions. | | Cadet.----------------- 18 an 5871, 6111,6281, 6501,6561,6781,6811, 7251,7261.7511, 7751, 679 Amherst students - - - - - 17| 2, 2301, 6251, 6471. 674 1,6921,710.1, 7241, 739 1,756.1, 776||1,804:1, 827, 726 Boston schoolboys..... 18 651, 6021,627;1, 6531,666 1,681|1,696 1. 710 1,725 1.7491,7881, 8021,684 Do--------------- 17 128 1,5671, 5911, 6301, 6531,669||1, 686 1,705.l. 729, 1,7461, 7801,8011, 684 Do--------------- 16 * * 5731, wi, 634 1, 6561, º º, wº 7221, tº, 7831, 665 This table would show that the height of the naval cadet is considerably below that of the Amherst student, as well as that of the Boston schoolboy, at the same average age, and at the time of his entrance into the Naval Academy. The figures from the Amherst students were derived in part from Tables 5 and 7 of the Anthro-, pometric tables published by Professor Hitchcock in 1892; the age was taken from Table 5 and the percentile grades from Table 7. The figures of the Boston school- boys were obtained from Prof. H. P. Bowditch's work on “The Growth of Children, Studied by Galton’s Method of Percentile Grades,” published in 1891. This comparison, however, is perhaps not perfectly fair, since the above two stand- ards were compiled from part of our population noted for their height, while the cadets come from all parts of the country; they are, however, the only ones so far published, and consequently there was no choice in the matter of selection. The height of the average Yale student, according to Seaver's tables, at the age of 18 years, is given at 1,664 mm., and in accordance with this the average naval cadet would come out from 14 to 15 mm., or about three-fifths of an inch taller than the Yale student of the same age. Since Yale College is a larger school than Amherst, and since it derives its students from a larger territory than the latter, the average height of the Yale student is lower, probably on this account, and approaches more nearly the national average standard. As compared with the Boston schoolboys the naval cadet of 18 years of age approaches more nearly the 16-year-old boy in height than the 17-year-old one. The 50 percentile grade of the height calculated from the two hundred and thirty cadets, at an average age of 18 years, is 1,678 mm., and the same grade of the Boston schoolboys, at an average age of 16 years, is 1,677 mm., or one millimeter less than that; while the average height of the cadets is 1,679 mm., and that of the schoolboys is 1,665, or 14 mm. less. The 18-year-old Boston schoolboy, measuring 1,695 mm. in height, is therefore 16 mm. in advance of the average height of the naval cadet, and the naval cadet is about 15 mm. taller than the Yale student of the same age. Heights will probably always form one of the most important indices in our cal- culation and judgment of the playsical possibilities of the man. Long bones natur- ally imply the existence of long muscles to move them, and there seems to be more room in a large frame also for the circumferential growth of the muscles than there is about a small, contracted framework. A capacious thorax, furthermore, will con- tain a larger lung, implying a greater lung capacity than a smaller one. In the adjoining two tables of the heights of the fifty cadets, under more special consideration here, it will be noticed that each one of the two tables represents the measurements of twenty-five. Since this division of them is not merely accidental, but purposive, and will appear throughout this paper, it is necessary at the outset to state how and upon what ground this division was made. The principle in accord- ance with which the total number of cadets was divided is the amount of increase in total strength that took place in all between the first and second measurements. Table A contains all those whose increase in total strength was 100 kilos or less, and Table B contains all those whose increase in total strength was above 100 kilos, 1200 PAN-AMERICAN MEDICAL CONGRESS. Table of heights. A. First, Second An- First, Second An- No. Age. measure- measure- nual No. Age. measure- measure- nual ment. ment. gain. ment. ment. gain. Yºrg. Tm,0s 777,770,. 470,771. ºn,771,. Yi's. 'nos.' mºm. ºmºm. Q?????. 1 ---------- 16 0 1,663 1,683 20 15 --------- J6 7 1, 758 1,785 27 2 ---------- I6 8 1,652 1,659 7 16 --------- 20 3 1, 618 1,620 2 3. --------- 17 3 1,710 1,723 13 17 --------- 19 3 1, 748 1,750 2 4 - - - - ------ 18 0 1,730 1,736 t; 18 --------- 18 8 1, 800 1,806 {} 5 ---------- 17 6 1, 719 1,721 2 19 --------- 19 () 1,730 1,740 1() 6 ---------- 18 5 1, 735 1,735 0 20 --------- 19 0 1, 818 1,820 2 7 ---------- 19 6 1, 775 1,779 4. 21 --------- 17 3 1,650 1,658 8 8---------- 19 9 1,682 1,688 . 6 22--------- 17 5 1, 766 1, 766 {} 9---------- 17 0 1, 75.3 1,760 7 23 --------- 17 5 1, 645 1,649 4 10 ---------- 18 2 1, 688 1,700 12 24--------- 18 0 1, 718 1, 733 15 11 ---------- 20 1 1,742 1,742 0 || 25 --- - - - - - - 16 1 1, 780 1,784 4 12 ---------- 15 3 I, 656 1,694 38 1% ---------- 17 1 1, 695 1,700 5 Averages. 18 0 1, 715 1, 723 8 14---------- 18 9 1,638 1, 645 7 |ſs. 1 ---------- 19 11 1, 811 1,811 0 15 --------. 18 5 1,850 1,850 () 2 ---------- 16 0 1,693 1,712 19 16 --------- 18 7 1,670 1,680 1() 3 ---------- 16 6 1, 770 1, 781 11 17 --------- 19 3 1, 720 1, 720 () 4 ---------- 17 9 1,740 1,740 0 18 --------- 19 8 1, 770 1, 770 () 5 ---------- 19 2 1, 708 1, 720 12 19 --------- 19 5 1, 716 1,720 4 6 ---------- 18 2 1,606 1, 610 4 20 --------- 15 5 l, 633 1,670 37 7 ---------- 7 3 1, 669 1,672 3 21 --------- 18 11 1, 704 1,712 8 8.---------. 18 4 1,698 1, 700 2 22 --------- 17 9 1, 700 1, 711 11 9 ---------- 18 0 I, 705 1,712 7 || 23 --------- 16 3 1, 7:30 1,742 12 10 ---------- 19 0 1, 73 1, 733 3 24--------- 16 4 1, 676 1,695 19 Il ---------- 19 () 1,810 1, 810 () 25 --------- 19 7 1, 803 1, 804 1 12 ---------- 17 8 1, 751 1, 754 3 13 ---------. 16 7 1, 754 1, 754 0 Averages. 18 0 1,728 1, 735 7. 3 14---------- 16 3 1,786 1,792 6 On comparing the two tables we will find that their various ages average up albout the same, namely, 18 years. We find, also, that their increase in height is very nearly the same on the average, but the average height of those on Table A is 13 mm. below that of Table B. Now, the question might well be asked, Is it a mere coincidence, or is it of a certain significance that the members of Table B, who were slightly taller in the beginning than the members represented on Table A, had their total strength increased so much more than the members of Table A, all of them living under the same identical conditions? This question will be more fully dis- cussed in connection with the tables of total strength to be presented later on. The average height, then, of the 50 cadets, at the beginning, and as ascertained by the first measurement, is 1,721 mm., and toward the close of the six months, as ascer- tained by the second measurement, it is found to be 1,729 mm., showing an increase in the average height of 8 mm., or about one-third of an inch. At present there exists no standard of comparison of the annual or semiannual growth of boys at all ages. An approximation to such a standard of development in height and weight for the pupils of the Boston public schools has been published in the above-mentioned work of H. P. Bowditch for a period of from 5 to 17 years. But inasmuch as Bowditch has shown that this increase is irregular and grows smaller the nearer the individual approaches to its destined maximum size, in order to fairly compare the growth of our cadets we ought to have a standard giving the increase in height above the age of 18 years, this being the average age with which we started. On looking over the tables of Yale students published by Seaver, I find that the height given for students aged 18 years and 6 months, which period would exactly correspond to the average ages of our cadets at the time of the second measurement, is 1,687 mm, or 23 mm., above the height given on the same tables PAN-AMERICAN MEDICAL CONGRESS. 1201 for 18-year-old ones, and which is 1,664 mm. According to these tables, then, the semi-annual increase in height from 18 to 184 years would be 23 mm., or nearly 1 inch, for Yale students. On examining the table of ages of the students at Amherst College, published by Hitchcock, I find that the height given for students of 18 years and 19 years of age is exactly the same, namely, 1,733 mm., apparently indicating no growth at all during the period between 18 and 19 years. Thus it must be admitted, until we have arrived at an exact standard of growth from year to year for all ages up to the twenty-second year of age, it is impossible to state whether the average increase of 8 mm. ascertained for our cadets is above or below the amount that it should be. One thing, however, seems to be clearly established by our tables of comparison alone, and that is this: The average height of the 50 cadets that entered the Acad- emy in the fall of 1892 being 1,721 mm., it is 42 mm., or 1% of an inch, higher than the average height of the 230 cadets who had entered during the last four years, and which is 1,679 mm., as may be seen on Table No. 2. Annual growth tables, to be of value as standards of comparison, should be pub- lished from all the schools and colleges in all parts of the country, and the stand- ards calculated for each year, or fraction of each year, during the entire period of growth. This, I hope, may soon be done, for there is no lack of material on hand now to work them out. WEIGHTS. In the adjoining two tables of the weights, the same division of the 50 cadets is presented and carried out according to the same principle as was done in the two tables of the heights, namely, 25 on each table, Table A of the weights presenting the records of the same cadets as Table A of the heights, and Table B of the weights presenting the records of the same cadets as Table B of the heights. Table of weights. A. First, Second | First Second No. Age. examina- examina. Gain. No. Age, examina- examina-Gaiu. tion. tion. | tion. tion. | | Yrs. mos. Kilos. Kilos. Rilos. | Yrs. mos. Rilos. Kilos. Kilos. 1 ---------- 16 0 50 El | 1 , || || ---------. 16 7 70 70 0 2 ---------- 16 8 56 57. 4 | 1.4 || 16 - - - - - - - - -. 20 3 § 52 0 3 - - - - - - - - - - 17 3 57. 3 60 2. 7 || 17 - - - - - - - - -. 19 3 59 59 0 4---------- 18 0 57.5 61. 4 || 3.9 || 18 . . . . . . . . . . 18 8 66.8 70.5 3. T 5 ---------- 17 6 59.7 65 5.3 || 19 - - - - - - - - - - 19 0 59.5 61. 5 2 6 ---------- 18 5 65. 5 69. 5 4 20 ---------. 19 0 64. 5 71.3 1.8 7 ---------- 19 6 68.7 71.5 2.8 || 21 - - - - - - - - - - 17 3 48 48 0 8 ---------- 19 9 53.8 57.5 3.7 || 22 . . . . . . . . . . 17 5 70 75 5 9 ---------. 17 () 62 67.5 5. 5 || 23 - - - - - - - - - - 17 5 52 56 4 10 ---------- 18 2 53.5 57.5 4 24 ---------- 18 () 5(), 5 54 3. 5 11 ---------- 20 i 64. 5 69.5 0 25 ---------. 16 1 57 57 O 12 ---------. 15 3 51. 5 58 6.5 13 ---------. 17 1 60 62.9 2.9 Averages. 18 0 59. 1 61. 7 2. 6 14---------. 18 9 58 ol.2 3, 2 I B. 1 ---------. 19 11 69 71.1 2. 1 || 15 . . . . . . . . . . 18 5 72. 5 78 5.5 2---------. 16 () 58 59.7 | 1.7 || 16 - - - - - - - - - - 18 7 57. 5 62. 5 5 3 - - - - - - - - - - 16 6 69.5 74. 2 || 4.7 || 17 . . . . . . . . . . 19 3 59 62. 5 3. 5 4---------- 17 9 62 63. 7 | 1.7 || 18 - - - - - - - - - - 19 8 63. 5 65. 9 2.4 5 ---------. 19 2 64. 7 67.7 3 19 - - - - - - - - - - 19 5 62.5 67 4.5 6.---------. 18 2 51 52.8 | 1.8 || 20 - - - - - - - - - - 15 5 50. 5 53.5 3 7 ---------- 17 3 61. 5 61.9 | . 4 || 21 ..........| 18 iſ 53.5 57. 5 || 4 8.--------- 18 4 55 60. 5 5.5 || 22 - - - - - - - - - - 17 9 60.5 65. 5 5 9 ---------- 18 0 60 60. 5 5.5 || 23 - - - - - - - - - - 16 3 57.7 64. 2 6, 5 10 - - - - - - - - - - 19 0 66.5 72. 3 . 8 || 24 - - - - - - - - - - 16 4 52.5 59 6.5 11 - - - - - - - - - - 19 () 67 75 8 25 . . . . .----- 19 7 71 75.2 4. 2 12 ---------- 17 8 70.6 75.3 4.7 13 ---------- 16 7 53 56 3 Averages. 18 0 60. 9 64, 9 || 3.9 14---------- 16 3 56.9 61. 8 4. 9 S. Ex. 36—76 1202 PAN-AMERICAN MEDICAL CONGRESS. On looking at the averages of these two tables, it will be noticed that Table A gives 1.8 of a kilo less than Table B at the start, and that thus difference between the two tables grows still greater at the second measurement, when it is found to be 3.2 kilos. The average increase of the first 25 cadets is 2.6 kilos, and the average increase of the second 25 is 3.9 kilos, or 1.3 kilos more. Both averages added together give for the entire number of cadets an average of 60 kilos at the time of the first measurements, and 63.3 kilos for the second measurement, amounting to a semi-annual increase in weight of 3.3 kilos. From the observations recorded in the paper by Prof. W. T. Porter, of St. Louis, it would appear that precocious individuals are taller as well as heavier, and furthermore that the difference in weight between dull and precocious boys grows greater as they grow older. Since, then, the first 25 cadets, as we have seen so far, are smaller, lighter, and less strong than the second 25, I have examined their examination marks in order to see how Porter's results are borne out here, although our number is not very large. On adding up all their marks and dividing the sum by 25, those of Table A give 57, and those of Table B give 59 as the average, apparently confirming Porter's observations. On turning to Seaver's tables of Yale students, I find the average weight given for 18 years to be 55.4 kilos, and the weight for students of 18 years and 6 months to be 57.6; while the Amherst tables give 61 kilos for the 18-year-old student. The weights of the cadets, therefore, seem to be higher than those of Yale students, and about the same as those of the students at Amherst. So far, then, we have found not only that the members of Table B were taller, heavier, and stronger at the start than the members of Table A, but also that the increase in these qualities was greater as time went on, and in spite of the conditions being identical. LUNG CAPACITY. On looking at the two adjoining tables of the lung capacity we will find, although the average lung capacity on Table B is greater than that on Table A at the start, the average increase is about 20 cubic centimeters less on Table B than on Table A. The average lung capacity of the 50 cadets at the first measurement is 4,038, and at the second it is 4,192. This would amount to a semi-annual average increase of 154 cubic centimeters. Table of lung capacities. A. First Second - First Second Iné3,8- | Iſleå.S.- e In 88.S- || IIleå.S.- e No. Age. TIEe- Ulre- Gain. Loss.] No. Age. TUUTO- Ut I’6- Gain. Loss. ment. ment. | ment. ment. Yrs. mos C. C. C. C. C. C. C. C. Yrs, mos. C. C. C. C. C. C. C. C. 1---------. 16 0 || 3,605 || 3,768 163 |- - - - - - 15. . . . . . . . . 16 7 || 4, 669 || 4, 915 246 |. -- - - - 2---------- 16 8 || 3,683 3,768 85 - - - - - - 16--------- 20 3 3, 441 || 3, 849 || 408 || - - - - - - 3---------- 17 3 3,522 || 3,605 85 |------ 17. -------- 19 3 || 4,096 || 4,096 |- - - - - - - - - - - - 4---------- 18 0 || 3,441 3,605 || 164 |. - - - - - 18--------. 18 8 || 4,424 || 4, 588 164 - - - - - - 5---------. 17 6 3,932 || 4,096 || 164 |- - - - - - 19--------- 19 0 || 3,768 || 3,932 164 |. . . . . . 6---------. 18 5 4, 669 4, 915 246 (- - - - - - 20--------- 19 () 5,408 5,408 ||--|--|--|- - - - - - 7---------- 19 6 || 5, 244 5, 408 || 164 |- - - - - - 21----- . . . . 17 3 || 3, 605 || 3, 686 81 - - - - - - 8---------. 19 9 || 3,683 || 3,768 85 - - - - - - 22--------- 17 5 || 4,915 4,915 |. -- - - - - - - - - - 9---------. 17 0 || 4,096 || 4, 505 409 |... - - - - 28. -------- 17 5 || 4,424 || 4, 588 | 164 |- - - - - - 10---------- 18 2 || 3,605 || 3,768 163 |... . . . 24--------- 18 0 || 3,683 || 3,768 85 - - - - - - 11---------. 20 1 || 3,768 3,768 - - - - - - - - - - - - 25. -------- 16 1 || 3,683 || 3,932 |... - - - - - - - - - 12---------- 15 -3 || 3,605 || 3,932 327 |- - - - - - 18---------- 17 1 || 3,441 || 4, 0.96 || 655 |- - - - - - Averages 18 0 || 4,007 || 4, 184 177 |... --- 14---------- 18 9 3,768 3, 932 164 - - - - - - PAN-AMERICAN MEDICAL CONGRESS. 1203 Table of lung capacities—Continued. B3. First, Second First Socond In ea S- i. eIII (23 S- * Ur In eth'S - || II) eas- e No. Age. ... "... Gain. Loss. No. Age. . . . Gain. Loss ment. I ment. ment. ment. Yrg. mos C. C. C. C. C. C. C. C. Yrs. mos. c. c C. C. C. C. C. C. 1---------- 19 11 3, 932 4, 260 328 - - - - - - 15.-------- 18 5 5,736 5, 736 ||------|------ 2. --------- 16 () 3, 522 3,768 246 - - - - - - 16. -------. 18 7 3, 605 3, 932 327 l. - - - - - 3---------- 16 6 4, 424 4, 588 164 |- - - - - - 17- - - - - - - - - 19 3 3,932 4, 096 || 164 |. - - - - - 4- - - - - - - - - - 17 9 3,277 3,768 494 | ... --. 18. -------- 19 8 4, 177 4, 260 83 - - - - - - 5---------- 19 2 4,013 4, 090 77 -----. 19. -------- 19 5 4, 505 4, 588 83 - - - - - - 6.--------- 18 2 4,441 3, 605 164 - - - - - - 20. -------- 15 5 3, 277 3, 441 164 - - - - - - 7---------- 17 3 3,932 4,096 164 - - - - - - 21--------- 18 11 3, 932 4, 996 164 - - - - - - 8---------- 18 4 4,096 3,768 |- - - - - - 328 || 22. - - - - - - - - 17 9 || 4, 260 4, ().96 || - - - - - - 164 * * * * * * * * * * 18 0 | 3,441 3.277 |------, 164 || 23. . . . . . . . . 16 3 || 4, 260 4, 260 ------|------ 10---------- 19 () 4,752 4, 752 - - - - - - - - - - - - 24--------- 16 4 3,605 3,768 163 |- - - - - - 11. --------- 19 () 5,324 || 5, 572 248 - - - - - - 25- - - - - - - - - 19 7 4, 341 4, 752 411 |- - - - - - 12---------- 17 8 4,096 4,096 - - - - - - |. - - - - - 3---------- 16 7 4, 260 || 4, 260 - - - - - - - - - - - - Averages 18 0 4,070 4, 201 157 26 14- - - - - - - - - - 16 3 3,605 || 4,096 491 - - - - - - - It remains to be added that the lung capacities were taken by means of a dry spirometer registering cubic inches, which, for the sake of uniformity, were after- wards converted into cubic centimeters. There is, perhaps, no single subject in con- nection with physical training upon which more stress should be laid than the necessity of developing the lung capacity. The capability of drawing a sufficient amount of oxygen into the system to supply at all times and under all conditions and circumstances the necessary quantity for the full performance of the functions of every living cell in that system must ever be looked upon as a condition of the utmost importance. It is one of the principal aims of the physical educator. On the other hand, the reserve materials, not being regularly oxidized, would gradually accumulate, and their presence in excess in the economy lead in the end to the most serious disturbances of health through auto-intoxication. Now, the quantity of air introduced into the system at each inspiration being, naturally, regulated by the capacity of the lungs, it is of great importance that the conditions under which muscular work is capable of increasing that capacity should be thoroughly under- stood. According to Lagrange, too much importance has been attached to the development of those of the muscles that elevate the ribs, and I am sure that the same mistaken idea prevails in this country with regard to the influence on chest capacity to be derived from the use of the popular chest weights. According to the same author, Demény's conclusions to the effect that more air enters the chest in the attitudes in which the scapula are drawn back and fixed by the tonicity and confractions of the rhomboidii, trapezii, and latissimi dorsi muscles, the belly retracted by the aspiration of the viscera into the thorax, than during repose, are entirely wrong. In this condition we find that all the inspiratory mus- cles except the diaphragm are in a state of forced contraction; the diaphragm alone remains in the position of respiration, and yet this is exactly the condition in which we find ourselves in the so-called position of attention so much insisted upon by the instructors of infantry tactics. The truth of this matter is that whatever is gained in lung capacity by the elevation of the ribs is lost by the ascent of the diaphragm, and, therefore, as an exercise for increasing the lung capacity, the manoeuvre is abso- lutely without value. A similar, if not identical, condition of things prevails dur- ing exercises on the various chest weights. If, on the other hand, we will take a very deep inspiration, we find that we are able not only to raise our ribs to the greatest possible limit, but we will also find that the diaphragm, which is the largest and most powerful inspiratory muscle, will share in the movement and will push the abdominal viscera downward, instead of allowing them to be sucked up into the chest, thus materially enlarging the chest capacity. The vertical diameter 1204 PAN-AMERICAN MEDICAL CONGRESS. of the thorax will be increased in this manner, while in the other condition it was diminished by visceral aspiration. In the opinion of Lagrange, with which we are in perfect accord, the most ingenious gymnastic combinations are not as efficient in increasing the intrathoracic space" as are deep inspirations alternating with pro- found expirations made during repose. And it is, therefore, not only of no advantage to increase the thickness of the tho- racic walls and the muscles covering them, but it forms a direct obstacle to the normal and more natural method of enlarging the intrathoracic space from within. It is from within outward that the force capable of expanding the chest must act, and it is to the lungs themselves, and not to the muscles that the chief share in the changes in form and size of the chest belongs. The most powerful inspiratory muscles can not raise the ribs, unless the lungs themselves participate in the move- ment of expansion, as every one can find out on himself, and, on the other hand, the lungs can raise the ribs without the aid of the muscles, for the chests of emphyse- matous people remain vaulted in spite of their efforts to lower the ribs and complete the expiratory movement. In order, then, to enlarge the capacity of the lung, it is clear that we must not attempt to act directly on the muscles that are attached to the chest, but we must prescribe exercises calculated to produce the most extensive respiratory movements, or, in other words, such as produce the greatest respiratory need, and this is a large amount of muscular work done within a short space of time and carefully graded running. The results which we have attained with the 50 cadets so far as their increase in lung capacity is concerned, while not absolutely poor, are far from being satisfac- tory to us, and this point will be again referred to under “Vital index.” In the accompanying Table III and Chart I are exhibited the results of some observations on 18 cadets of an average age of 19 years and 3 months, on whom the above detailed principles were carried out as far as that is possible. The special exercise in these cases consisted principally in free movements without apparatus, and carefully graded, progressive running in the open air on a properly constructed running track. They were, in the first place, taught how to breathe properly, how to carry themselves during running, and a point more espe- cially impressed upon their minds was never to run beyond the time when they became fatigued. No fixed period of time was set, because their endurance could very naturally increase but gradually, and must vary daily owing to outside influ- ences over which we have no control. After a very short time, and while strictly following this injunction of never passing the point of fatigue, they all were soon able to run a mile without fatigue, and some very much exceeded that distance, their general health and strength having at the same time very materially increased and improved. * TABLE III.-Influence of one month’s special exercise on lung capacity of 18 cadets. [Average age, 19 years 3 months; average height, 1,721 mm.; observations in April, 1892.] First ex- First, ox- º First ex- | Second ex- s No. amination. amination. 9°. No. amination. amination. Gains. & - c. c. c. in. c. c. c.im. c. c. c. in. c. c. c. in. | c. c. | c. in. c. c. c.in. 1 ----------- 4, 260 260 4,424 270 163 10 || 11 ---------- 4, 505 || 275 4,915 300 | 407 25 2 ----------- 5,244 320 || 5,408 || 330 | 163 || 10 || 12 - - - - - - - - - - 3, 678 || 230 4, 260 260 || 491 || 30 3----------- 4,915 300 5,078 || 310 | 163 10 || 13 - - - - - - - - - - 3, 849 235 || 4,424 270 573 35 4----------- 3,768 230 3,932 240 | 163 10 || 14---------- 5, 244 320 5, 900 || 360 || 655 40 5 ----------- 4,915 300 5,078 310 | 163 10 || 15 - - - - - - - ---. 4,424 270 5,078 310 || 655 40 6 ----------- 4, 505 || 275 4,752 290 245 15 || 16 . . . . . . . . . . 3, 605 || 220 3,605 || 220 . . . . . . . . . 7 ----------- 5, 244 320 5,489 || 335 | 245 15 || 17 - - - - - - - - - - 5,325 325 || 5, 325 | 325 | . . . . . . . . . . 8----------- 3, 441 210 3,686 225 || 245 15 || 18---------- 4, 915 300 || 4, 915 300 | . . . . . . . . . . 9 ----------- 3,441 210 || 3,768 230 327 | 20 **-* * *-m-, * **E=mº 10----------- 3,768 230 4,096 || 250 || 32 20 Averages...|4, 352 265 || 4, 683 286 331 20 '.\qqoedeo 3ūnų uo ºspolºxò le ſoºds ģO Đouòngu I—’I ,y,…, …» - szóvažººr9/ Z/ 9/ 9/ // €/ 27 // o / 6 & Z9 -9 % ſº '?' / ' // 3 ） |# | s |---- øºgº**** # 3 s S ſº § 9€. PAN-AMERICAN MEDICAL CONGRESS. 1205 The table and chart show that at the end of one month an average increase of 331 cubic centimeters or 20 cubic inches was observed, which amount is twice that observed in the 50 cadets at the end of six months’ gymnastic work. During run- ning most all of the muscles of the human body are actively engaged, some more, some less; a large amount of venous blood is poured into the right side of the heart and through the lungs; an immense thirst for oxygen causes the deepest inspiration which, often repeated as they are, must give rise to an increased lung capacity, pro- viding we do not at the same time take too heavy exercises, engaging the muscles that cover and surround the chest, thus tending to compress it from without. It was said above that besides running a large amount of muscular work, done within a short space of time, was one of the means of increasing the lung capacity. With regard to this point, I thought it interesting to ascertain what influence on the lung capacity of the players was provided by the popular game of football. The foot- ball season at Annapolis begins after October 1, and on October 15 I examined 17 players who were the most likely to continue playing throughout the season with regard to their lung capacities. The same players were examined on November 21, and I must confess my surprise was great when they nearly all came back with the same lung capacities. The only increase in lung capacity that had taken place was noted in two half-backs, just the ones who had to do most of the running. Whether the results of my observations would have been different if I had been able to make my first examination on October 1 instead of the 15th, or not, I am, of course, unable to say; but these observations have gone far to convince me of the fact that if there is any influence in football playing on the lung capacities of the players, that influence must be exerted early in the beginning of the period of training, for after the chest is loaded down with strong, hard muscles, it must become almost impossible for the chest capacity to enlarge to any perceptible extent. Now, while from a physiological point of view it is perfectly possible and intelli- gible by the proper exercise to increase the respiratory efficiency of a certain lim- ited area of lung surface without even increasing the capacity of the lung itself, it might, nevertheless, be deemed good advice to attend to the lung capacity accord- ing to the best principles before attempting to play the game of football in real earnest. At any rate, as long as the exchange of gases in the lung is simply a phys- ical process, depending upon the difference in partial pressure between the CO2 con- tained in the blood on one side of the respiratory mucous membrane and the O of the inhaled air on the other side of this same membrane, the amount of O taken in, and of CO2 given out, must be looked upon as being in direct proportion to the lobal capacity of the lung as ascertained by the spirometer. TOTAL STRENGTH. For the purpose of ascertaining and noting any changes that may have taken place in any individual human being after having had a course of physical training in the gymnasium or elsewhere, it is absolutely necessary that we should have sev- eral very thorough tests and established standards of sufficient scientific accuracy easily applied and uniformly accepted and followed, by means of which progress in certain directions can be definitely ascertained and the results compared. Among those that have so far been recommended the total strength test is a most valuable one. When I first began to work with it I must confess I had little confidence in its value, but further experience with it has caused me to look upon it as a most important and significant index. It was for the purpose of still further testing the value of this index that the 50 cadets in question were divided in accordance with the amount of increase in total strength that had taken place during their six months’ training in the gymnasium. On looking at the table indicating their total strength, I took 100 kilos as the dividing line, placing those whose increase was less than that on one side, and those whose increase exceeded that limit on the other, and found that they were quite equally distributed, namely, 25 on either side; and, 1206 PAN-AMERICAN MEDICAL CONGRESS. So far as we have gone, we have found the average height, weight, and lung capac- ity much in favor of those whose increase in total strength was above 100 kilos, a very significant factor, even if the number of individuals under observation here is not over large. Physiological truths do not require in all cases an over- whelmingly large number of individuals to establish them by, but a smaller number will suffice for them than would suffice for the establishment of the average length of the human femur or the thickness of the thigh. How is this total strength of an individual calculated? The exact amount of work done by our muscles in complicated cases of labor is by no means easily determined and, in fact, has not been determined except in a few special cases. It is well known that during muscular work of any kind, according to the laws of nature, certain substances are used up, the quantity of which must be subject to calculation from the amount of work that was done, for the law of conservation of energy holds true in the organic as well as in the inorganic world. The amount of work done in these cases is generally expressed in kilogrammeters, 1 kilogrammeter indicating the amount of work necessary to lift 1 kilogram to the height of 1 meter, or 1 gram to the height of 1,000 meters, etc. Thus, the amount of work performed in walking is usually calculated, according to Rubner, by the following formula: 0.071 x k. p., in which formula 0.071 is the product of the height of lift and fall in each step, k. the body weight, and p. the number of steps taken. From the amount of work thus attained it is, on the other hand, easily calculated how much of albumin, car- bohydrate, or fat was used up, because the caloric equivalent of work has been found to be 425 kilogrammeters for one calorie, and the number of calories produced by burning certain definite quantities of these substances being also known. But this method, although much more accurate and scientific, merely tells us the amount of energy that is necessary to be expended in certain kinds of special exercise or work, which, furthermore, may be distributed over a longer or shorter space of time. In making serial observations on a large number of individuals we wish more par- ticularly to ascertain what is the total amount of available energy or strength which any of them may bring to bear upon an obstacle to be overcome at any given moment, and to calculate that a more rough and ready method had to be devised and adopted, and this method is the following: According to the Anthropometric Manual of Amherst College, published in 1889, by Drs. E. Hitchcock and H. H. Seelye, the tests to be taken of an individual whose total strength is to be calculated are as follows: ...” - 1. Expiratory strength.-The subject, after loosening the clothing about the chest and filling the lungs, should blow with one blast into the manometer, an instrument made to register the expiratory pressure in kilos and tenths of kilos. Care should be taken that no air escape at the sides of the mouth, and that in expelling the air all the muscles of expiration are brought into play. 2. Strength of back.—The subject standing on the iron foot-rest, with the dynamom- eter so arranged that when grasping the handle with both hands his body will be inclined forward at an angle of 60 degrees, should take a full breath and without bending the knees give one hard lift, mostly with the back. (See Fig. 1.) 3. Strength of legs.-The subject while standing on the foot-rest, with body and head erect, and chest thrown forward, should sink down by bending the knees until the handle grasped Tests against the thighs, then taking a full breath he should lift hard, principally with his legs, using the hands to keep the handle in place over the thighs. (See Fig. 2.) 4. Strength of upper arms; triceps.-The subject while holding the position of rest upon the parallel bars, supporting his weight with arms straight, should let the body down until the chin is level with the bars, and then push it up again until the arms are fully extended. Note the number of times that he can lift himself in this IIlallllóI’. . 1. Fig Fig. 3. . 2. Fig PAN-AMERICAN MEDICAL CONGRESS. 1207 5. Strength of upper arms; biceps.-The subject should grasp a horizontal bar or pair of rings and hang with the feet clear from the floor while the arms are extended. Note the number of times that he can haul the body up until his chin touches the bar or rings. 6. Strength of forearms.—The subject, while holding the dynamometer (Fig. 3) so- that the dial is turned inwards should squeeze the spring as hard as possible, first with the right and then with the left hand. The number of kilos may be read off from the dial and noted. Total strength.-From the above data the total individual strength is calculated as follows: The bodily weight is multiplied by the sum of the dip and pull; this is divided by 10 to prevent too large a number of figures in the calculation. To this is added the strength of back, the strength of legs, the average of the forearm, and the lung strength, and the result is looked upon as the total strength. For example, the weight of the subject being 64, the dip 11 and the pull 12=23; the back strength 150, and the leg strength 180; the forearm strength 45, and the lungs 2.0, the result will be: 64 × 23–– 10 -- 150 + 180+ 45 +2=524. Just why the strength of the muscles of the upper part of the body was not originally included in this test is now difficult to make out. The strength of both the chest muscles and those that extend between the spinous processes and the shoulder plate can easily be ascertained by one and the same instrument. These are actually given in the New Manual for Physical Measurements, by Dr. Luther Gulick, whose excellently illustrated manual should be in the hands of everyone taking such measurements. For the sake of uniformity of records we have, however, adhered to the original formula and our tables have all been calculated in accordance with it, so as to make them comparable with those ascertained by all who are taking such tests elsewhere. This strength test is not devoid of all scientific accuracy, but possesses a certain definite physiological value. If we take, for instance, the gastrocnemius of a frog and pass an induction shock through it, we get a contraction, whether we stimulate directly or indirectly. If we attach certain weights to one end of the muscle and increase them gradually and stimulate, there comes a time when our stimulus is no longer answered by a contraction of the muscle and the weight attached to it will no longer be lifted, although the stimulus passes through the muscle as is indicated by the galvanometer. In this condition, in other words, we have arrived at the weight which exactly counterbalances the absolute power of the muscle under observation. In the above-described strength test we have, undoubtedly, an analogous condition of things. The number of kilos which we can lift with our backs and legs being the exact amount necessary to counterbalance the strength of those muscles that were engaged in pulling, in other words indicating their absolute strength just the same as the absolute power is represented by weight in the experiment with the frog's gastrocnemius. The muscular contraction produced by the stimulus of the will may perhaps not be a maximal contraction and the curve produced in the case may not be anything like the curve produced by a single induction shock, but resemble more nearly a tetanic curve, still the amount of strength that these tests require us to exert at the time represents the greatest possible amount which we are capable of exerting at any one time and which is here expressed in kilos just the same as the absolute power is represented in weight in the experiment with the frog’s gastrocnemius. 1208 PAN-AMERICAN MEDICAL CONGRESS. Total strength table. A. First Second First Second No Age. examina- examina. Gain.' No. Age. examina- |examina | Galil tion. tion. - tion. tion. Yrs. ºnos. Kilos. I(ilos. | Rilos. Yrs. "mos. Rilos. Ičilos. Kilos. ! -- . . . . ---. 16 () 304 343 39 || 15 - - - - - - - - - 16 7 2 629 37 * ---------. 16 8 410 462 52 || 16 - - - - - - - - - 2 3 423 519 96 3---------- 17 3 348 410 62 || 17 - - - - - - - - - 19 3 372 369 97 4---------. 18 () 369 438 69 || 18 - - - - - - - - - 18 8 470 538 68 5 ---------. 17 6 444 522 78 || 19 - - - - - - - - - 19 0 375 408 33 6 ---------. 18 5 447 513 66 iſ 20 - - - - - - - - - 19 0 525 596 71 7 ---------- 19 6 411 452 41 || 21 --------- 17 3 357 440 83 8---------- 19 9 428 517 89 || 22 - - - - - - - - - 17 5 510 557 47 9---------. 17 0 312 394 82 || 23 - - - - - - - - - 17 5 390 452 62 10---------- 18 2 339 381 42 || 24 - - - - - - - - - 18 0 392 419 27 11 ---------- 20 1 435 484 53 || 25 - - - - - - - - - 16 1 289 340 51 12 ---------- 15 3 351 390 35 13 ---------. 17 1 310 400 90 Averages. 18 () 390 467 77 14---------. 18 9 549 611 62 IB3. 1.---------- 19 11 44 604 163 | 15 --------- 18 5 423 539 115 * ---------- 16 () 338 494 106 || 16 . . . . . . . . . 18 7 434 552 118 3---------- 16 6 459 640 181 || 17 - - - - - - - - - 19 3 315 498 18 ; 4---------- 17 9 309 430 | 121 || 18......... 19 8 392 804 412 5---------- 19 2 561 824 263 19 - - - - - - - - - 19 5 312 498 186 6---------- 18 2 322 432 110 || 20 - - - - - - - - - 15 5 326 512 186 7 ---------- 17 3 428 608 || 180 || 21 . . . . . . . . . 18 11 230 463 233 8.---------- 18 4 300 412 112 22 - - - - - - - - - 17 9 410 542 132 9---------- 18 () 270 389 119 || 23 . . . . . . . . . 16 3 356 519 163 10 ---------- 19 () 446 579 133 i 24 . . . . . . . . . 16 4 302 4.25 123 11 ---------- 19 () 56() 672 112 || 25 - - - - - - - - - 19 7 450 575 125 12 ---------- 17 8 443 812 369 - . 13 ---------- 16 7 359 495 136 Averages. 18 0 380 550 170 14---------- 16 5 304 520 216 On examining the two total strength tables we find that they average up as fol- lows: The 50 cadets on their entrance examination developed an average total strength of 385 kilos, and at their second examination, or about six months later, the average total strength was 5084, showing a gain of 1234 kilos, which is the highest average gain ever noted at the Academy between the first and second exami- nations. Furthermore, when we compare their average strength with that of Amherst students of the same age, we find that the cadets on entering were 35 kilos behind the Amherst students, whose average strength at 18 years, and which is our average age, is given by Hitchcock as 420 kilos; but after the second examination and comparing its results with those obtained from the same students, even at 19 years of age, we find that the cadets are 50 kilos ahead of the Amherst students, whose average strength at that age is given as 448 kilos, while that of the cadets is 5084 kilos, which is about 20 per cent above the average total strength obtained from 2,230 of the Amherst students. Looking at Table A, and comparing the average with those of Table B, we find that the average increase of the first 25 is 77 kilos, while that of the second 25 is 170 kilos, although the former were 10 kilos ahead of the later at the first examina- tion. In order to increase one's total strength, however, especially while young and still in the growing period of life, we do not always require very many months to do it 1n. A month or six weeks of well-directed exercise may add on from 25 to 30 per cent of that strength as 1s well shown in Table No. IV and Plate II. -Zoerayes. Ø Q Q .# J322 .i Jzza H i 6.02. Jo i wai º - J &- — : Joa k- | - | - º | II.-Influence of one month's special exercise on total strength of 18 cadets during spring of 1892. — - i 600 J O i ’ & 3 + 3 6 7 & 9 /ø ſº /2 /3 2. /s /a 27 ~fue-ayes III.-Influence of one month's practice at football on strength of 17 players. PAN-AMERICAN MEDICAL CONGRESS. 1209 TABLE IV.-Influence of one month’s special eacercise on total strength of 18 cadets. [Average age, 19 years 3 months; average height, 1,721 mm.; observation made in April, 1892.] First Second First Second No. exami-|.exami- |Gain. Loss. No. exami- exami- |Gain. Loss. nation. nation. | - nation. nation. i ICilos. Kilos. Kilos. Kilos. Rilos. Kilos. Kilos. Kilos. 1 ------------------- 498 547 49 i------ | 11 ------------------ 724 853 129 |------ 2 ------------------- 376 : 436 60 - - - - - - | 12 ------------------ 419 || 552 | 133 - - - - - - 3 ------------------- 538 604 66 - - - - - - | 13 ------------------ 374 514 140 - - - - - - 4------------------- 674 744 || 70 |- - - - - - | 14 .................. 504 647 || 143 - - - - - - 5 ------------------- 647 717 70 - - - - - - | 15 ------------------ 621 785 164 - - - - - - 6 ------------------- 474 558 84 ||------ il 16------------------ 626 824 198 || - - - - - - 7 ------------------- 431 521 90 - - - - - - 17 ------------------ 498 491 I. - - - - - 7 8 ------------------- 476 568 92 |- - - - - - 18. ----------------- 569 495 |- - - - - - * 74 9 ------------------- 438 536 98 || - - - - - - 10 ------------------- 573 702 | 129 |- - - - - - Averages - - - - - 524 636 || 112 |. -- - - - | * Sickness. Table IV presents the same cadets as regards total strength as Table III and Plate I of the lung capacity, the two observations being made, in other words, on the same cadets at the same time. We see that after such a short time as one month's specially directed exercise, which was very light at that, and beginning with an average of 524 kilos, we had obtained an average increase of 112 kilos=636 kilos. Still more apparent does that become on Table V and Plate III. Here, although the average increase does amount only to 105 kilos, it must be remembered that the initial average strength of the seventeen cadets measured was 644 kilos, and at the end of 5 weeks foot-ball practice it amounted to 747, with a maximum of 974 and a minimum of 612. Assuming, as we must, that there exists a natural individual limit to development in strength, the increase must become slower the nearer we approach that limit, just the same as growth in height becomes slower from year to year as we approach the final limit of our intended height. TABLE V.—Influence of one month’s practice at football on total strength of 17 players. [Average age, 19 years 6 months; average height, 1,765 mm.] First | Second First Second No. examina- examina- | Gain. No. examina- examina- | Gain. tion. tion. tion. tion. Filos. Rilos. Kilos. Rilos. I(ilos. Rilog. 1------------------- 648 689 41 || 11------------------- 500 612 112 2------------------- 7.58 801 43 || 12------------------- 852 974 122 3------------------- 654 703 49 || 13------------------- 500 630 130 4------------------- 621 672 51 || 14---------------- . . 504 635 ) 131 5------------------- 648 700 52 || 15------------------- 664 836 372 6------------------- 716 832 86 || 16------. ------------ 692 88.4 I92 7------------------- 521 608 87 || 17------------------- 626 824 196 8------------------- 692 790 98 9. . . . --------------- 543 649 106 Averages - - - - - - 642 747 105 10------------------- 753 860 107 VITAL CAPACITY. The term “vital capacity” as employed in connection with the usual anthropo- metric records appears to me somewhat misleading, inasmuch as it implies in its mean- ing a certain physiological significance which it does not possess. The name “vital capacity” was originally used by Hutchinson to denote the respiratory capacity of an individual, and which is usually measured by a modified gasometer (spirometer of Hutchinson), into which the subject breathes, making the most prolonged expira- tion possible after the deepest possible inspiration. The quantity of air which is 1210 PAN-AMERICAN MEDICAL CONGRESS. thus expelled from the lungs is indicated by the height to which the air chamber of the spirometer rises, and by means of a scale placed in connection with this the Inumber of cubic centimeters is read off. The vital capacity as recorded on anthropometric charts in use in our gymnasiums is obtained by different methods, namely: tº (1) Seaver (Anthropometry) arrives at it by multiplying the length of trunk, depth of chest, and breadth of chest together; the result is the vital capacity. (2) Gulick (Manual for Physical Measurements) states that the vital capacity refers to the size of the trunk, but “does not represent the cubical size of the body, although it varies in a general way with it.” He calculates it by multiplying the length of the trunk by the average between the depth of the chest and the depth of the abdo- men, this again being multiplied by the average between the width of the chest and the width of the waist. Just what this so-called vital capacity is intended to repre- sent does not appear to be very clearly defined in the descriptions of the methods for obtaining it. If, as Dr. Gulick states, it does not represent the cubical size of the body, what does it represent # It certainly appears to have little, if any, defi- nite physiological significance so far as a man's chances for life are concerned, for these can simply not be measured in this manner, and if not, why should we con- tinue to apply the term “vital capacity” to what is in reality nothing but the capacity of the trunk? In the adjoining two tables of the vital capacities, calculated according to Gulick's method, it will be noticed that the losses on both exceed the gains, and we now must ask ourselves how this result has come about. Let us take the example of a boy 18 years of age just entering college and taking a course in the gymnasium for the first time in his life. He is measured in the usual manner, presents a well-developed chest, padded with a goodly layer of adipose tissue, and a well-rounded abdomen. At the end of the academic year and after working well in the gymnasium he is measured again and it is found that he has grown taller, weighs more, is very con- siderably stronger, and has a greater lung capacity than the year before; but his adipose tissue has almost entirely disappeared and his abdominal walls have become more muscular. Consequently, his abdomen being less rotund; having, furthermore, also increased the strength of his respiratory muscles, he is able to contract his chest better, and the result of both these changes will be that he has lost in vital capacity, much to his chagrin, and it certainly would be most disheartening for him to be told that he had grown taller, heavier, and stronger at the expense of his vital capacity. On the other hand, a man at 40 years of age, the age when in most persons the stomach obtains its final triumph over the chest and permanently establishes its supremacy over the latter, so far as prominence is concerned, will, on being similarly measured, give a greater vital capacity than he did at the age of 25 or 30 years of age, when, perhaps, his physical condition was at its best and his chances for life greatest. I should, accordingly, propose the term “capacity of the trunk” in place of “vital capacity,” as ascertained by the methods above detailed. The average vital capacity of the 50 cadets at the first measurement, as shown by these tables, was 3,152 cubic centimeters, and on the second measurement it was 3,085 cubic centimeters, or 67 cubic centimeters less. Since the anthropometric tables so far published by either Hitch- cock, of Amherst, or Seaver, of Yale, do not include the vital capacity, it is, of course, impossible to make a comparison. PAN-AMERICAN MEDICAL CONGRESS. 1211 Table of vital capacities. A. Capacity. # Capacity. —– No. Age. First Second Gain. Loss. No. Age. First Second Gain. Lost. €Xà Ital- || CX3.I.TI- Öxar Ill - eX3, IIll- nation. nation. nation. nation. Yrs. mos. c. c. C. C. C. C. C. C. Yrs. mos. c. c C. C. C. C. C. C. 1---------- 16 0 | 2, 261 2, 745 || 4.84 |... -- - - 15.-------- 7 3, 828 3, 381 |- - - - - - 4. 47 2---------- 16 8 3, 205 || 2, 999 |- - - - - - 2.06 || 16- . . . . . . . . 20 3 || 2,940 || 2, 727 . . . . . . 2.13 3---------. 17 3 || 3, 307 2,750 |... - - - - 5. 57 || 17- - - - - - - - - 19 3 || 3,009 2,967 - - - - - - 42 4---------- 18 0 || 2, 441 3,016 || 5, 75 - - - - - - 18--------- 18 8 || 3,427 3,856 || 4. 29 |- - - - - - 6.--------- 17 6 3,003 || 2,925 |- - - - - - 78 || 19.- - - - - - - - 19 0 || 2,925 || 3, 513 || 5.88 - - - - - - 6.--------- 18 5 3, 570 3, 620 . 50 |------ 20--------. 19 0 || 3,978 || 3, 853 |... . . . . 1. 25 7---------- 19 6 3, 751 3, 556 |- - - - - - 1.95 || 21- - - - - - - - - 17 3 2, 432 2, 449 17 ------ 8. --------- 19 9 || 2, 770 2, 306 | . . . . . . 4. 64 || 22- - - - - - - -. 17 5 || 3,446 3, 718 2.72 |- - - - - - 9. --------. 17 0 3, 276 3,096 |. - - - - - 1.80 || 23. - - - - - - - - 17 5 || 2, 546 2, 714 | 1.68. - - - - - - 10. --------- 18 2 2,737 2,799 62 - - - - - - 24--------. 18 0 || 2, 964 2, 828 - - - - - - 1. 36 11---------- 20 1 || 3,081 3, 100 19 - - - - - - 25--------- 16 1 || 2, 940 || 2, 589 |... - - - - 3. 51 12. --------- 15 3 || 2, 841 2,496 |. - - - - - 3.45 13. --------- 17 1 || 3, 197 3, 197 |. -----|- - - - - - Averages. 18 0 || 3,051 3,020 1.07 | 1.37 14---------- 18 9 2, 391 || 2, 295 |. - - - - - 96 | B. 1---------- 19 11 || 4, 133 3, 243 ... - - - - 8.90 || 15- - - - - - ... 18 5 4, 132 3, 978 . . . . . . 1.54 2---------- 16 0 || 2, 673 2,916 2.43 |- - - - - - 16--------- 18 7 || 3,762 3,924 | 1.62 |... -- - - 3---------- 16 6 3, 576 3, 531 |. - - - - - 45 || 17- - - - - - - - - 19 3 || 3, 321 3,063 - - - - - - 2. 58 4---------- 17 9 3, 233 || 3,078 |. . . . . . 1.55 || 18-- - - - - - - - 19 8 3,042 3, 132 90 l. - - - - - 5- - - - ------ 19 2 3, 126 3, 407 || 2.81 |- - - - - - 19--------- 19 5 || 3, 367 || 3, 276 - - - - - - 91 6---------- 18 2 || 3, 304 || 2, 590 | - - - - - - 7.14 || 20- - - - - - - - - 15 5 3,044 2, 436 - - - - - - 6. ()8 7---------- 17 3 || 3, 258 || 2,898 |. - - - - - 3. 60 || 21- - - - - - - -. 18 11. 2, 867 2, 541 . . . . . . 3, 26 8---------- 18 4 || 3, 276 3, 180 - - - - - - 96 || 22- - - - - - - - - 17 9 || 3,078 , 495 || 4.17 |- - - - - - 9---------- 18 0 3,092 || 2, 582 |- - - - - - 5. 10 || 23. - - - - - - - - 16 3 2,883 2, 740 - - - - - - 1.43 10---------- 19 0 || 3, 616 || 3, 362 |. . . . . . 2. 54 || 24, - - - - - - -. 16 4 || 2, 451 2, 782 3.31 - - - - - - 11---------- 19 0 || 3, 399 || 3, 752 3. 53 |. - - - - - 25- - - - - - - - - 19 7 || 3, 565 || 3,488 |... -- - - 77 12---------- 17 8 3,056 || 3,469 || 4, 13 |- - - - - - *-º-º-º: 13---------- 16 7 || 3, 226 3, 113 - - - - - - 1. 13 || Averages. 18 0 || 3, 252 || 3, 150 92 | 1.96 14---------. 16 3 || 2,827 | 2,727 |- - - - - - 1. VITAL INDEX. Under the above name, Enebuske has introduced the ratio of lung capacity and weight of Demény. This index appears to me to be of considerable physiolog- ical significance in connection with the subject of physical training and the study of its results. I'rom the physiological, point of view the introduction into scientific physical training of valuable and significant indexes, such as the above, is as much of a necessity and of as great importance now as was the introduction of weights and measures into chemistry a hundred years ago. The original papers of Demény are not accessible to me, but Dr. Enebuske states that Demény has found that in children of the same age the lung capacity is propor- tional to their weight, and that if a curve is constructed of lung capacity and weight in function of age, the two curves are parallel. Demény has furthermore found that the ratio of lung capacity and weight of persons who have undergone a course of systematic physical training is much higher than in persons who have had no such training, from the fact, familiar to us all, that the training on the one hand increases the lung capacity, and on the other diminishes, at least in the beginning, the weight by causing a great quantity of the reserve tissue (fat) to disappear. In the adjoining two tables of vital indices I have applied this index to the 50 cadets under observation. It will be noticed, however, that but 16 out of 50 have gained, 31 have lost, and 3 have remained the same. The average vital index obtained from both tables together at the first examination was 0.0679, at the second examination 0.0667, amounting to an average loss of 0.0012. & 1212 PAN-AMERICAN MEDICAL CONGRESS. It will furthermore be noticed that for the first time, so far as we have gone in our comparative study of these two tables, the first table presents higher aver- ages than the second table. It was found, in other words, that the 25 cadets whose increase in total strength was 100 or more kilos, and who are always repre- sented by Table B, were taller, heavier, stronger, and had a greater average lung capacity than the 25 whose increase in total strength had been found to be less than 100 kilos, and who are always represented by Table A. In the tables of the vital indices we meet with the first exception to this. An average decrease in vital index of 0.0012 may not be very great, but it is certainly appreciable, and must have a cause, for I firmly believe in the validity and significance of this index. On referring back to the tables of the lung capacities and taking Table B, it will be noticed that, besides the average increase being smaller than in Table A, 5 out of the 25 have remained the same and 3 have actually lost in lung capacity. No mat- ter how disheartening it may be to realize such results, the finding them out is as important and salutary as the obtaining of contrary results would be gratifying. Table of vital indices. A. First Second First, §ººd © X:l Ill - || 6 X:Alll- g eXalm- eXàIn (; , ; No. Age. [“. . ." | Gain. Loss. INo. Age. i. i. i. Gain. | Loss. tion. tion. tion. tion. | | Yºrs.nos. Indea. |Indea. Prs, mos. Index. Index. 1---------- 16 0 0, 0721 0. 0740 0.0019 |. - - - - - - 15- - - - - - - - - 16 7 (). ()671 (). 0702 0.0031 | . . . . . . . 2---------- | 6 8 . 0659 | . 0656 |- - - - - - - 0.0003 || 16- . . . . . . . . 20 3 | . 0661 | . 0741 . 0080 |. - - - - - - 3- - - - - - - - - - 17 3 . 0614 | . 0601 - - - - - - - . 0013 || 17 - - - - - - - - - 19 3 | . 0694 | . 0694 |. . . . . . . . . . . . . . 4---------. 18 () { . 0598 | . ()587 i. - - - - - - 0011 || 18- - - - - - - - - 18 8 . 0662 . 0650 - - - - - - - () 0012 5---------- 17 6 | . 0658 . . 0630 - - - - - - . 0028 iſ 19. - . . . . . . . 19 0 | . 0633 . . 0639 . U006 || -- - - - - - 6---------. 18 5 | . ()786 | . 0707 - - - - - - - 0079 || 20. . . . . . . . . 19 0 | . 0.779 . 0758 - - - - - - - . ()021 7---------. 19 6 . 0763 | . ()756 - - - - - - - 0007 || 21. - - - - - - - - 17 3 | . 0749 , 0.769 | .0020 ! ... - - - - - 8---------. 19 9 | . 0684 | . 0655 |. - - - - - - 0029 || 22. . . . . . . . . 17 5 | . 0702 | . 0656 - - - - - - - . ()046 9. --------. 17 0 | . ()660 | . ()667 | . 0007 |. - - - - - - 23. -------. 17 5 . 0851 | . 0.819 - - - - - - - , ()032 10---------- 18 2 | . 0674 | . 0655 |. - - - - - - 0.019 || 24. - - - - - - -. 18 0 | . 0729 | . 0698 - - - - - . . , 0.031 11---------- 20 1 | . 0542 | . 0542 |... - - - - - - - - - - - 25- - - - - - - - - 16 1 |.0646 |. 0689 .0043 |....... 12---------- 15 3 | . ()700 | . 0676 - - - - - - - . 0.024 13---------- 17 1 | . 0573 . . 0651 . 0078 - - - - - - - Averages|- - - - - - - -. . 0692 | . 0688 . 0011 | . 0015 14---------- 18 9 . 0650 0643 |... . . . . 0007 |B3. 1. --------- 19 11 0. 0570 |0. 0600 |0.0030 * * * * * * * 15- - - - - - - - - 18 5 0.0791 0. 0735 s = * * * * * 0, 0056 2. --------- 16 0 | . 0594 | . 0603 | . ()009 * * * * * * * | 16. -------- 18 7 | . 0626 . ()629 0.0003 - - - - - - - 3. --------- 16 6 | . 0636 | . 0618 ... - - - 0.0018 || 17. - - - - - - - - 19 3 | . 0666 . 0655 ! - - - - - - . 0011 4. --------- 17 9 | . ()528 . U591 . 0063 |. - - - - - - 18--------- 19 8 | . 0646 | . 0646 - - - - - - - - - - - - - - 5---------- 19 2 | . 0609 | . 0605 | . . . . . . . 0004 || 19. . . . . . . . . 19 5 | . 0709 | . 0684 - - - - - - - .0025 6---------- 18 2 | . 0675 | . 0683 . 0008 |... ---. 20--------- 15 5 . 0649 | . 0624 | . . . . . . . .0025 7. --------- 17 3 | . 0639 . ()662 | . 0023 - - - - - - - 21--------. 18 11 . 0735 | . 0712 i. - - - - - - | 0023 8. --------- 18 4 | . 0745 . 0623 - - - - - - . 0122 il 22. - - - - - - -. 17 9 | . ()704 | . ()625 | . . . . . . . , 0079 9. --------- 18 0 | . 0573 . . 0542 | - - - - - - - . 0031 || 23. - - - - - - - - 16 3 | . 0.777 | . 0663 || - - - - - - - . 0114 10. --------- 19 () . 0715 . 0657 || - - - - - - - .0058 || 24. . . . . . . . . 16 4 | . 0686 | . 0638 |- - - - - - - , 004.8 11. --------- 19 0 | . 0.784 | . 0743 - - - - - - - .0041 || 25- - - - - - - - - 19 7 | . 0601 | . 0632 | . 0.031 . . . . . . . 12. --------- 17 8 | . ()580 | . 0544 | . . . . . . . 0.036 i 13. --------- 16 7 | . 0800 | . 0761 | . . . . . . . . 0.039 Averages 18 0 | . 0667 .0646 . 0008 .0030 14---------- 16 3 | . 0634 | . 0663 . 0029 |- - - - - - - | I have for some little time past been dissatisfied with the progress that the cadets have made in breathing capacity consequently this last year, in superintending the exercises, special stress was laid on the importance of breathing exercises on chest weights and special attention was paid to carefully graded running, and I am as firmly convinced that the instruction and drill which the cadets have received in the gymnasium was as well calculated to develop their lung capacities as any that could be devised as I am that the vital index is true and not misleading. What, then, is the cause of the decrease in vital index? I believe it due to the snug-fitting PAN-AMERICAN MEDICAL CONGRESS. 1213 uniforms in which cadets of this school are done up and which they are obliged to wear the greater part of the day. Although this seems to me quite a reasonable explanation, this fact can only be established by the study of and comparison with the statistics of other military schools. When, however, we compare our average of vital index of the 50 cadets, obtained at the second examination, and which is 0.0667, and find that it is above the average of the 50 per cent Yale student and only below the average vitality of 113 Swedish navy recruits (aged 19), we have, as yet, no great cause for being alarmed, but are, on the contrary, very much encouraged. It is furthermore obvious that any increase in weight, from no mat- ter what cause, may in a few instances cause considerable lowering of the Vi. This would make it appear certain that a high Wi. would be in most cases a sure indica- tion of perfect training, whether it is noticed in children, women, or men. In a large number of scholars doing a certain amount of exercise, especially after the first few months, I have frequently noticed quite considerable increase in weight as a direct result of the exercise, and, as will be noticed on referring to the tables of weights, this average increase in the cases of the 50 cadets is over 3 kilos. Even admitting that a man in perfect training must have a high Vi., the object is not invariably attained in all cases, and more often requires special attention and training. Our average is higher than that given by Demény of methodically trained French- men aged 22, and which is 0.0615. As regards the meaning of this index, Dr. Enebuske says: If we were compelled to translate this index into popular language, we could not come nearer the truth than to say that it means power of resistance during the emergencies of disease," and that it expresses an essential and fundamental condi- tion for endurance under effort. It does not represent the moral or nerve-dynamic elements of endurance, but it represents a chemico-dynamic component of endurance. Demény (quoted by Enebuske) makes this statement: By taking young gymnasts and arranging them according to the decreasing value of their rates of lung capacity and weight, we have been able to ascertain that thereby we have made a classification that corresponds sensibly to their degree of resistance. - In practicing gymnastics Enebuske has observed a marked correspondence between the vital index and ability in such exercises in which the weight of the body is carried by the arms or thrown from the ground by forcible contractions of the muscles of the legs, as jumping and vaulting. Taking perpendicular rope climb- ing as an example, he found that 6 out of the 26 students examined by him could not climb the rope and that their Wi. was below 0.0478; the remaining 20, whose Wi. was above 0.0478, could all climb except one. Owing to the fact that the publication of Dr. Enebuske's paper was much delayed, I regret that I was unable this year to test his conclusions in this direction, but this much is certain, namely, that for endurance there is nothing more essential from a physiological point of view than a large lung capacity. THE POWER INDEX. This index is the Wi. multiplied by the total strength of the individual. The aver- age power index of the 50 cadets at the first examination was 26.23, and at the second examination it had 1ncreased to 33.38, making a difference of 7.15 between * As to whether we are entitled to this assertion or not, experience in other directions than that of mere gymnastics must prove how this could be brought into harmony with our present understand- ing of infectious diseases. Comparisons must be made at the bedside. I know of at least one in- stance which would not bear out this assertion. A gentleman prominent in football, in excellent condition, whom I measured only three weeks before his death, and whose vital index was 0.0782, died of typhoid fever in the surprisingly short time of a week. 1214 PAN-AMERICAN MEDICAL CONGRESS. the two examinations. Looking over the Amherst table of the 50 per cent student and calculating from the data given there the power index we get a power index of 28.5843 for the average Amherst student. (See the adjoining two tables of the power indices.) TABLE A. Power index. Power index. PO – T. S. W. Po-T. S. W. No. Age. No. Age. First Second º First Second examina- |examina- Gain. examina- examina-| Gain. tion. tion. tion. tion. Yº's. mos Yrg. mos 1 ---------- 16 0 2.1. 88 26.75 i 4.87 || 15 ......... 16 7 39.66 44. 03 '4. 37 2 ---------. 1(; 8 24. 56 30.03 5.47 || 16 - - - - - - - - - 20 3 27.91 38. 40 10.49 3 ---------- 17 3 21, 22 24.66 3.44 || 17 - - - - - - - - - 19 3 17. 95 24.35 6. 40 4---------. 18 0 21.77 25. 84 4.07 || 18. --...--... 18 8 31. 02 34.97 3.95 5 ---------. 17 6 28. 41 32.88 4.47 || 19 - - - - - - - - - 19 () 23. 62 26, 11 2.49 6---------. 18 5 31.73 36.42 4.69 || 20. -- - - - - - - 19 () 40. 95 44. 70 3, 75 7 ---------. 19 6 31. 64 38.77 7. 13 || 21 - - - - - - - -. 17 3 26.77 33.88 7. 11 8---------. 19 9 29. 53 33. 60 4.07 || 22 - - - - - - - - - 17 5 35. TO 36. 20 . 50 9---------- 17 0 20.59 26. 22 5.63 || 23 - - - - - - - - - 17 5 33. 15 37. 06 3.91 10---------. 18 2 22. 71 24.76 2.05 || 24 - - - - - - - -. 18 0 28. 61 29. 33 . 72 11 ---------- 20 1 23. 27 26, 13 2.86 || 25 - - - - - - - - - 16 1 18, 49 23. 12 4, 63 12 ---------- 15 3 24.85 26. 52 1. 67 - 13 ---------- 17 1 17.67 26 8.33 Averages. 18 0 27. 17 31.62 4. 44 14---------- 18 9 35. 68 39.71 4. 03 TABLE B. 1 ---------- 19 11. 25. 13 36.24 11.11 || 15 - - - - - - - - - 18 5 33. 45 39. 61 •6. 16 2 ---------- 16 0 20. 07 26.18 6. 11 || 16 - - - - - - - - - 18 7 27, 16 34. 70 7. 54 3 ---------- 16 6 29. 19 39, 55 | 10.36 || 17 . . . . . . . . . 19 3 20. 97 32. 61 11. 64 4---------- 17 9 16. 31 25. 41 9. 10 || 18 - - - - - - - - - 19 8 25.31 51.93 26. 62 5 ---------. 19 2 34. 10 49.85 | 15.75 || 19 - - - - - - - - - 19 5 22. 11 34. ()6 11.95 6---------- 18 2 21. 73 29, 49 7. 76 || 20 - - - - - - - - - 15 5 21. 15 31. 94 10. 79 7 ---------- 17 3 27. 34 40. 24 | 12.90 || 21 - - - - - - - - - 18 11 16.90 32.96 16. 06 8.---------- 18 4 22.35 25. 66 3.31 || 22. - - - - - - - - 17 9 28. 86 33.87 5, 01 9 ---------- 18 0 15.47 21. 07 5. 60 il 23 - - - - - - - - - 16 3 27. 66 34. 40 7. T4 10 ---------- 19 0 31.88 38. 03 6.15 || 24 - - - - - - - - - 16 4 20. 71 27. 11 6. 40 11 ---------- 19 () 43.90 49. 92 6.02 || 25 - - - - - - - - - 19 7 27. 04 36. 34 9. 30 12 ---------- 17 8 25. 69 44. 17 | 18.48 13 ---------- 16 7 28. 72 37.66 8.94 || Averages. 18 0 25.30 35. 14 9, 84 14---------- 16 3 19. 27 34.47 | 15. 20 STRENGTH-WEIGHT INDEX AND WITAL-STRENGTH-WEIGHT INDEX. For the sake of future reference and comparison I append also the tables of these two indices. vital-strength-weight index by that of Wi. W. The strength-weight index is expressed by the formula T.S. 2 and the The results are recorded in the tables. PAN-AMERICAN MEDICAL CONGRESS. 1215 Strength-weight indices and vital-strength-weight indices. A. First observation. seconºerve First observation. second ºerve. INo. - T. S Ts No. T T. S T.S. . T. S. tº º-ºº º * - - * *...* * . S. : T. S. T. S. * ... lºs º kº gº --------> e --------- Wi. --- s —- -- -- - e --- (**)|(vi §)(*)( **) (**)(vi º)(**)|(vi ¥) 1 --------- 6.1 0. 4392 6. 6 0. 5148 || 15 . . . . . . . . 8.5 0. 5695 9 0. 6300 2 --------- 7.3 . 4745 8 . 5200 || 16. -- - - - - - 8. 1 . 5346 10 . 7400 3 - - - - - - - - - 6.1 . 3721 6.8 .4080 || 17 . . . . . . . . 4. 6 3086 6. 2 . 4092 4--------- 6.3 . 3717 7. 1 . 4189 || 18 . . . . . . . . 7 . 4620 7.7 . 500.5 5 --------- 7.4 . 4736 8 . 5040 || 19 - - - - - - - - 6. 2 3906 6. T . 4288 6 --------- 6.8 . 4828 7. 4 . 5254 || 20 - - - - - - - - 7.5 4850 8.4 . 6100 7 --------- 5.9 . 4543 6. 3 . 4725 || 21 - - - - - - - - 7. 4 5550 9. 1 . 7007 8 - - - - - - - - - 7. 9 . 5451 9 . 5850 || 22 . . . . . . . . 7.3 | . 51] () 7.4 . 4810 9 - - - - - - - - - 5 . 3300 5. 8 . 3828 || 23 ...... - . 7.5. . 6175 8 . 6560 10 - - - - - - - - - 6. 3 . 4221 6. 6 .4290 || 24 - - - - - - - - 7.8 5694 7.8 . 5460 11 --------- 6. 2 3348 7 .3780 || 25 ........ 5 . 3200 6 . 4080 12 --------- 6. T 4690 6.7 . 4556 - 13 --------- 5 2750 6.3 . 4095 Averages 6. 5 4355 7. 5 . 5052 14--------- 9.4 6110 10 . 6500 • IB, 1 --------- 6.4 0.3648 8.5 0. 5100 || 15 ........ 5. 8 0. 4587 6.9 0. 5071 2 --------- 5. 8 3445 8.2 . 4944 || 16 - - - - - - - - 7.6 . 4757 8.8 . 5535 3 --------- 6. 6 . 4197 8.8 . 5438 || 17 . . . . . . . . 5.3 . 3529 8 . 5240 4--------- 5 . 2640 7 .4137 || 18 - - - - - - - - 6.2 . 4005 12. 2 . 7881 5 --------- 8.7 . 5298 12.2 . 7381 || 19 - - - - - - - - 5 . 3545 7.4 - 516.1 6 --------- 6. 3 .4252 8, 2 - 5600 || 20 - - - - - - - - 6.4 . 4153 9. 5 . 5920 7 --------- 6.9 . 4409 9.8 . 6487 || 21 - - - - - - - - 4.3 . 3160 8 . 5696 8 --------- 5.4 . 4023 6.8 . 4236 || 22 - - - - - - - - 6.8 . 4787 8.9 - 5562 9 --------- 4. 5 . 2578 6. 5 3523 || 23 .... - - - - 6. 2 . 4817 8. 1 - 5354 10 --------- 6.7 - 4790 8 5256 || 24 . . . . . . . . 5. 7 . 3910 7.2 . 4593 11 --------- 8. 3 . 6307 9 6687 || 25 . . . . . . . . 6. 3 . 3786 7. 6 4803 12 --------- 6.3 . 3654 10.8 . 5875 13 --------- 6.8 . 5440 8.8 6696 Averages 5.4 . 3601 8.5 5491 14 - - - - - - - - - 5.1 . 3233 8.4 . 5569 EHEART RATE, The association gymnasium record blanks direct that the heart rate should be ascertained before and immediately after the strength tests. Experience has shown that a weak heart beats fast very readily, even on slight exertion, while a strong one does not do so. The principle is perhaps best illustrated by the following table, which belongs to an officer 28 years of age, and who for about a year devoted himself most conscientiously to systematic training: Number of examination. July 4. Oct. 7. Dec. 16. Jan. 4. | May 3. Pulse (1). ------------------------------------------ 100 92 88 88 7 ip------------------------------------------------ 1 3 6 13 14 Pull ----------------------------------------------- 5 11 12 13 12 Back ---------------------------------------------- 155 150 170 200 180 Legs----------------------------------------------- 280 310 320 270 325 Forearm------------------------------------------- 35 45 42 46 40 Strength of lung ---------------------------------- 25 25 25 20 20 Weight-------------------------------------------- 66.5 61.5 62.5 64 64. 5 Pulse (2) -----------------------------------------. 160 134 120 j04 110 Total strength -----------------------------. 511 593 647 686 714 In this diagram we notice a steady decrease in the number of heart beats, not only as regards the initial pulse rate (pulse 1), but also in the rate recorded after the This is as it should be. strength test had been taken. 1216 PAN-AMERICAN MEDICAL CONGRESS. There is, then, no doubt that a strong and vigorous heart is one of the results of sys- tematized exercise, but this result is only attained not only by the greatest possible care and attention to details on the part of the director of such exercise, but it also requires the most conscientious coöperation on the part of the person taking the exercise. In my experience results like these are exceptional as occurring in pupils that are exercised in classes, and without their receiving individual and quite special care and attention. The more we study the subject of physical training the more also the individual differences and personal peculiarities of mankind become appar- ent. There are a number of qualities, no less real than those that we can weigh and measure, that are both imponderable as well as immeasurable. In the 50 cadets under observation the greatest differences with regard to the pulse rate have been observed. Some present a greater initial pulse rate at their second examination than they did at their first examination, and in some even the pulse rate after taking the strength tests was higher at the second examination than it was at the first examination; in some no change has taken place, and in still others marked improvement has been recorded. By practicing certain forms of exercises we no doubt become able to dominate over certain actions not ordinarily under the control of the will. We learn to regulate the working of our lungs, thus also influencing the heart rate; but it is almost impos- sible for any one, no matter how well trained he may be, to do his best at these strength tests without at the same time increasing his heart Tate to some extent. Indeed, one of the first effects of exercise of any kind is to increase the frequency of the heart beat, as we all know, and consequently to quicken the blood current. No one has ever seen a person doing the “dip ’’ or the “pull” without noticing the pale skin over the working muscles become intensely red and congested looking, owing to the increased amount of blood that is flowing not only to the working muscles, but also to the periphery generally. On making so great an effort in so short a time as these strength tests require, one being taken right after the other, without rest during the intervals, and owing to the large amount of blood which is sent to the periphery in consequence it is, perhaps, quite natural to find the arterial pressure fall and the pulse rate quicken. I have myself not been able, owing to an absence of the proper instruments, to make accurate and conclusive experiments in regard to blood pressure, but the accompanying sphygmograms would go far to render the exist- ence of a lowering of blood pressure after this strength test probable in a majority of cases. Nothing, however, short of accurate pressure tests will decide this most inter- esting point. Oertel (Handbuch I, Therapic I, Kreislaufs stêrungen), 1891, in a very painstaking series of experiments, has conclusively shown that the blood pressure rises somewhat on prolonged walking and mountain climbing, also that there is an increased pulse-rate. Both these changes in the circulation produced by this form of exercise persist for some time, even after the feeling of fatigue has quite passed away, which latter point has also been observed by Lagrange (loc. cit.). Our results, how- ever, are not comparable to those of Oertel. The curves which we present were taken immediately after a severe effort was made, and before anything like a thorough equalization of venous and arterial circulation could have taken place. The fall in arterial pressure in a sudden effort may be due to the fact that more blood is sud- denly thrown into the veins than is returned into the left side of the heart, and also to the incomplete oxygenation of the blood, which must have a depressing effect on the heart itself. Oertel’s blood-pressure tests were made hours after the start, con- Sequently long after the balance between venous and arterial circulation had been restored, and the exercise taking place in the open air, the blood after a long walk or climb was in a much improved condition, in so far as oxygenation is concerned, and hence the rise in blood pressure. The accompanying diagram (IV) and Table VI, however, show that well-regulated exercise strengthens the heart so that it may resist, as it were, the sudden invasion of effort to a certain extent. 7 2. ) Tzard, before exercise, April 11, 1893. ( S/SS/SS/s/s/s/s/s/s/s/s/s/s/\!/ >/> Taussig, after exercise, March 30, −. (120.) Hall, before exercise, April 14, 1893, (78.) Hall, after exercise, April 14, 1893. (108.) McConnell, before exercise, March 27, −. (80.) McConnell, after exercise, March 27, −. (160.) Marshall, before exercise, April 11, 1893. (84.) Marshall, after exercise, April 11, 1893. (116.) Olsen, before exercise, March 28. —. (80.) '94 e.I-q,l'eauĮ UO espolºxº Ieſoºds s.ųQUIOUI QUIO JO 90uºnįgūI—'AI Ø9 |---- yº —º – ſº Z75 H– º Ø962/ – º Ø77 — ſº TZ7Z7 — ſº TZgºzi |-~º TZZZZZ – ſº ' º '97 || ' º^ £7 | 4^ 37 || ?/^ 'g' | 'zº ºgrZ^ ^Z25 /y/gº/2///69/ PAN-AMERICAN MEDICAL CONGRESS. 1217 * TABLE VI. Increase in heart rate— - Increase in heart rate— No. Before tak- After one No. Before tak- After one ing exer- month's ing exer- month's cise. exercise. cise. exercise. 1 ----------------------- 70 80 62 72 || 8---------------------. 100 | 124 72 80 2------------------- --- 78 92 66 88 9---------------------- 92 | 124 84 |- 92 3----------------------- 90 110 88 108 || 10 - - - - - - - - - - - - - - - - - - - - - - 92 130 72 100 4----------------------- 80 110 76 92 || 11 ---------------------- 100 140 92 120 5. --------- = ºs s = * as * * * * * * * 96 112 72 72 || 12 ---------------------- 100 140 84 104 6----------------------- 92 || 120 72 96 || 13 ---------------------- 92 || 140 80 92 7. ---------------------- 92 | 120 80 96 || 14---------------------- 92 || 140 80 100 Averages --------- 90 | 120 | 84 || 101 Averages . . . . -- - - - 90 | 120 | 84 || 101 S——-——’ ^–-y-' º X-—º-—” \——y-—’ Average rate of - Average rate of increase - - - - - - - - - 30 17 increase. --- - - - - 30 17 THE GLOBULICIDAL ACTION OF BLOOD SERUM. By WILLIAM S. CARTER, M. D., Assistant Demonstrator of Pathological Histology, University of Pennsylvania. It is well known that if we inject into the veins of some animals the blood serum of certain other species of animals there results a ha-moglobinuria and albumin- uria. The destruction of red corpuscles has also been observed under the microscope by mixing the blood serum with a drop of blood from another species. This was investigated twenty years ago by Landois “ in relation to transfusion. More recently it has been found that blood plasma instead of being simply an inert solution of globulins, albumins, extractives, and inorganic salts, whose chief func- tions it was to serve as a means of conveying the blood corpuscles to different parts of the body, is really a powerfully active fluid and performs a number of wonder- ful phenomena. It has been shown that in infectious diseases in which the bacteria are not found in the blood there are in solution in the serum certain products of bacterial metabolism. What seems more important, it has been pointed out by Mettalf and by Buchnerf and many others that the blood serum of animals refractive to certain diseases is highly destructive to the bacteria causing those diseases. This peculiar function has been called the germicidal or bactericidal action of blood serum and Buchner has shown that it is probably due to a globulin. These observa- tions are very important and indicate that Metchnikoff's well-known theory of phagocytosis is not the only factor in the destruction of bacteria by the blood. The fact has further been established that animals naturally susceptible to certain diseases can be immunized to those diseases by the injection of the blood serum of animals either naturally immune or rendered immune artificially. Furthermore, even after infection has taken place the injection of blood serum of immune animals will promptly neutralize the poison and terminate the disease. This very important practical use of blood serum is certainly the most promising thing of modern medi- cine and the burning question of the day, for now we are able to cure infectious diseases, and apparently in the way nature cures them. Thanks to Belering, Kilasato, Cantani and Tizoni, and the Klemperers, we are now able to meet tetanus, pneu- monia, and diphtheria and not feel that we can not modify the course of the disease. * Centralblatt für die Med. Wissenschaft. n 1873, pp. 883, 897. f Inaug. Diss., Göttingen, 1890. : Centralbl. f. Bakt., Bd. V. S. 817, & Bd. VI, S. 1. S. Ex. 36 77 1218 PAN-AMERICAN MEDICAL CONGRESS. With these facts before us, the destruction of blood corpuscles by a foreign serum has assumed a greater importance. Recently this property, which has been called the globulicidal action of blood serum, has been studied by Buchnerº and by Darem- berg.t These observers have independently found that this property was destroyed by heating to 55 to 60° C. for some time, or by dialysis. Buchner further states that this property is lost by preserving the serum for some time outside the body. All these observations, together with those of Maraglian of on the globulicidal action of the blood serum in different pathological states, were made on the field of the microscope. - The experiments presented in this paper were made as follows: The blood serum was obtained (except from man) by introducing, with antiseptic precautions, into the blood vessel a carefully sterilized long glass canula. By this means the blood was received directly into a sterilized glass flask. From man the blood was obtained from the arm after it had been carefully cleansed and washed with antiseptics. The blood was then set aside in the ice chest and allowed to clot. The clear serum was then injected either intravenously or subcutaneously into another animal, by means of a sterilized burette and canula. There was no bacterial contamination in the handling of the serum. The effect upon the blood of the animal thus injected was determined by means of the Thoma haemocytometer, the diluting fluid being usually a 2.5 per-cent solution of bichromate of potash. The variation between different counts of the normal blood with this instrument is very slight, being on the average not over 200,000 or 300,000. The normal was obtained by counting the corpuscles twice before the injection. After the injection the counts were made as often as possible, or as often as seemed necessary. As each counting occupied considerable time, the condition of the blood could not be determined as often as desirable. The counting and diluting were always done by one person. The experiments were made chiefly on dogs and rabbits, and the blood was obtained from these animals by sticking their shaved ears. Of course by manipu- lating the ear so much, the number of leucocytes must of necessity vary greatly, and so great is the variation between different observations in the normal state that unless there be a pronounced and constant clange in their number, it can not be ascribed to the injection. In a few instances frogs were used, but it was found that the blood could only be obtained with such difficulty and the number of corpuscles varied so much, normally, from the admixture of lymph, that it did not seem desira- ble to continue experimentation in this direction. Besides the numerical observations. it seemed also desirable to examine into the kinds of leucocytes. For this purpose cover-glass preparations were made, fixed, and then stained by eosin and haematoxylon. Five hundred leucocytes were counted at each observation and divided into the following classes: (a) Lympho- cytes, (b) large mononuclear, (c) transitional, (d) eosinophiles, and (e) multinuclear, HUMAN SERUM IN DOGS. In three experiments in which the human serum was injected in large quantities into the veins of dogs there was no appreciable alteration in the number of the red or white blood corpuscles. Neither was there any alteration in the proportion of the different kinds of leucocytes which were examined in Experiment II. Experiment I (dog; weight, 5.3 pounds).-12. M.: R. B.C., 6,550,000; W. B. C., 15,000. 12.30: R. B. C., 6,900,000; W. B. C., 31,000. , 12.45 P. M.: Injected, per jugular vein, 125 c. c. human serum, 48 hours old, taken from an Italian, aged 48, with aneurism; no symptoms after injection. 2.30 P. M.: R. B. C., 6,800,000. 4.30 P. M.: R. B. C., 7,120,000; W. B. C., 54,000. 6 P. M.: R. B. C., 7,020,000; W. B. C., 37,000. Next day, 10 A. M.: R. B. C., 6,980,000; W. B. C., 25,000. 3 P. M.: R. B. C., 7,000,000. * Sitzungsberichte des AErztlichen Verein, München, II, 1892. f Arch. de Méd. Expér. et d’Amat. Path., Paris, 1891, Vol. III, 720. ; Berl. Klin. Woch., 1892, 765. PAN-AMERICAN MEDICAL CONGRESS. 12 19 Experiment II (dog; weight, 15 pounds).-3 P. M.: R. B. C., 7,300,000; W. B. C., 20,000. 3.30 P. M. : R. B. C., 7,125,000; W. B. C., 20,000. 3.45 P. M.: Injected, per jugular vein, 100 c. g. human serum, same as in Experiment I; no symptom. , 4.45: R. B. C., 7,700,000; W. B. C., 7,500. 6: R. B. C., 7,050,000; W. B. C., 7,500; urinated freely during night; albuminuria. Next day, 10 A. M.: R. B. C., 8,070,000; W. B. C., 40,000. 3 P. M. : R. B. C., 8,010,000; W. B. C., 45,000. Ea:periment III (dog; weight, 16.5 pounds).-3 P. M.: R. B. C., 4,400,000; W. B. C., 10,000. 3.30 P. M.: R. B. C. 4,375,000; W. B. C., 6,250. 4.35: Injected, per jugular, 125 c. c. human serum, 6 hours old, from healthy young man, aged 20. 5 P. M. : R. B. C., 4,200,000. 5.45: R. B. C., 4,700,000. Next day: R. B. C., 4,675,000. Normal : Lymphocytes, 7 per-cent; large mononuclear, 1 per cent; transitional, 2.5 per-cent; multinuclear, 89.5 per-cent. Two and one-quarter hours after injection of 125 c. c. human serum, 6 P. M.: Lymphocytes, 9.5 per-cent; large mononuclear, 2 per-cent; transitional, 4.5 per- cent; multinuclear, 84 per-cent. - In one experiment (II) albuminuria was observed. The urine did not show any haemoglobin by Tinct. guiac and peroxide of hydrogen. The kidneys were cut in this experiment and on microscopic examination show the uriniferous tubules filled with granular matter, the outline of the cells showing indistinctly, while the nuclei still take the stain. In order to see if human serum had any toxic effect on dogs, a blood pressure experiment was made in which 100 c. c. of serum from a healthy young man was used. Immediately after the injection there was a slight lowering of pressure, followed by a marked rise to above the normal. The pulse and respira- tion were at first slowed but soon returned to normal. From these experiments it would seem that human serum has neither a toxic or globulicidal action upon dogs. IIUMAN SERUM IN RAI313ITS, Emperiment IV (small rabbit).-1 P. M. : R. B. C., 4,750,000; W. B. C., 9,250. 2 P. M. : R. B. C., 4,200,000; W. B. C., 7,750. 3.14 to 3.25: Injected, per vein, very slowly 12 c. c. serum from man with aneurism, act., 51. 3.26 P. M.: R. B. C., 3,062,000. 3.30 to 3.45: 12 c. c., injected very slowly. 3.50: Paraplegic. 4: R. B. C., 1,070,000. 4.10: Comatose. 4.20: Died in convulsion. Experiment V (large rabbit). —3 P. M.: R. B. C., 6,850,000. 5.33: 12 c. c., human serum twenty-four hours old, rapidly. 5.40: Paraplegic. 5.42: General convulsion. 5.42: R. B. C., 2,900,000. 5.43: Died in convulsion. Experiment PI (large rabbit).-2.30 P.M. : R. B. C., 5,510,000. 3.10 to 3.16: Injected per jugular vein, 19 c. c. serum forty-eight hours old, from young man. 3.16: R. B. C., 2,025,000. 3.16: Died of cardiac failure; no convulsion. Experiment VI+.-11 A. M.: R. B. C., 4,475,000; W. B. C., 6,250. 11.30: R. B. C., 4,680,000; W. B. C., 17,000. 12.27 to 12.31: Injected rapidly, 5 c. c. serum twenty- four hours old; man with aneurism. 12.35: R. B. C., 2,150,000; W. B. C., 25,000. 12.35: Died, heart failure; R. W. distended; no antemortem clot. Experiment VII (medium-sized rabbit).-3 P. M., R. B. C., 5,250,000; W. B. C., 6,000. 3.30 P. M.: R. B. C., 5,000,000; W. B. C., 7,500. 4.10: Injected slowly per jugular vein, 3 c. c. serum twenty-six hours old, from young man. 5 P. M.: R. B. C., 3,875,000. 5.25: Injected 6 c. c. slowly. 5.30: R. B. C., 3,500,000. Does not seem sick. Next day: Seemed very sick; incoërdinate movements; did not seem to have control of posterior extremities; R. B. C., 3,000,000; killed. Ea:periment VIII (medium-sized rabbit). —4 P. M.: R. B. C., 5,000,000; W. B. C., 6,250. 4.30 P. M.: R. B. C., 5,275,000. 5 P. M.: Injected slowly per jugular vein, 3 c. c. serum two days old, from young man. 5.05: R. B. C., 3,375,000. 5.10 to 5.12: 3 c. c. 5.20: 3 c. c. 5.25: R. B. C., 2,400,000. 5.30: 4 c. c. Slowly. 5.35: Slight convulsion; respiration labored; R. B. C., 1,450,000; died. Ea:periment IX (rabbit).-A. M.: R. B. C., 6,925,000; W. B. C., 10,000. 8.30: R. B. C., 6,100,000; W. B. C., 40,000. 10 A. M.: Injected per jugular vein, 3 c. c. serum seven days old, from young man, aged 31. 10.30: Breathing rapidly. 10.50: Purging, lying on side. 10.56: R. B. C., 3,075,000. 10.57: Convulsion. 11: Died. Experiment X. —8 A. M.: R. B. C., 6,650,000. 8.30: R. B. C., 6,500,000; W. B. C., 6,250. , 9.30 to 9.35: Injected per jugular 10 c. c. human serum, eight days old, heated up to 55° C. for a moment. 9.45: R. B. C., 3,550,000. 10.10: R. B. C., 3,570,000. , 10.30: R. B. C., 4,150,000; W. B. C., 10,000. 10.58: Slight convulsion. 11: Died in convulsion; heart beating on opening chest; right ventricle dis- tended with dark inlood, which shows R. B. C., 4,740,000. Erperiment XI (large rabbit). —12 M.: R. B. C., 6,825,000; W. B. C., 5,000. 12.30 P. M.: R. B. C., 6,000,000; W. B. C., 9,250. 2.08: 15 c. c. human serum eight days * 1220 PAN-AMERICAN MEDICAL CONGRESS. old, heated to 56° C. for five minutes. 2.20: R. B. C., 4,900,000; W. B. C., 3,000. 2.40: R. B. C., 5,400,000; W. B. C., 3,100. 3: R. B. C., 5,125,000; W. B. C., 9,000. 4.30: R. B. C., 5,275,000; W. B. C., 12,000. No symptoms; complete recovery. Experiment XII.—9 A. M.: R. B. C., 7,120,000; W. B. C., 7,700. 9.30: R. B. C., 7,025,000; W. B. C., 7,500. 3 P. M.: R. B. C., 7,450,000; W. B. C., 5,000. 3.15: Injected 25 c. c. human serum four days old, from man with aneurism. 4.15: R. B. C., 6,570,000; W. B. C., 6,250. 5.30: R. B. C., 6,950,000; W. B. C., 4,800. 6 P. M.: Urine contained albumin. 6.30: R. B. C., 6,500,000; W. B. C., 13,000. 8: R., 5,400,000; W., 4,700. 9.30: R. B. C., 5,540,000; W. B. C., 7,700. 12, midnight: R., 5,550,000. Next day, 8 A. M. : R., 5,975,000. Eaperiment XIII.-12 M.: R. B. C., 6,000,000; W. B. C., 20,000. 12.30: R. B. C., 6,300,000. 1 P. M.: 20 c.c. human serum, eighteen hours old, subcutaneously. 4 P. M. : R. B. C., 6,800,000. 6 P. M.: R. B. C., 6,450,000. Tumor at seat of injection same size as at 2 P. M. Next day, 11 A. M. : R. B. C., 7,350,000. 4 P. M.: R. B. C., 6,000,000. - From these ten experiments it is seen that when human serum is injected slowly into the veins of rabbits the red blood corpuscles are destroyed rapidly, sinking from 5,000,000 or 6,000,000 to 1,000,000, or to one-fifth their number. This destruction occurs within one hour from the time of the injection and during this time the animal usually has several convulsions, frequently dying in one. Palsies sometimes appear—usually a paraplegia. The pupils are dilated and there is a peculiar exoph- thalmos just at death. The respiration is at first slowed and then becomes labored and the animal usually dies of respiratory failure. When the injection has been rapid death comes on in a few minutes. In these cases there is a rapid destruction of the red blood corpuscles, but never to such an extent as if the injection had been made slowly. The number of corpuscles in these experiments were never reduced below one-half their normal number. In these cases the convulsions are often absent. The disturbance of respiration and the exophthalmos are also present here but the animal dies of cardiac failure. Recovery has taken place after the injection per vein of 9 c. c. slowly, with the corpuscles reduced to one-half their normal, while on the other hand death has taken place after the exhibition of 3 c. c. of serum several days old, the destruction of corpuscles being very little greater in the latter case than in the former. With subcutaneous injections there is a very slow absorption and the destruction is very slight and comes on late. There are no toxic symptoms from the use of 25 c. c. in this way. The globulicidal action of human serum was not lost after the serum had been standing seven days, in Experiment IX. In fact, it seemed more toxic, prob- ably on account of some putrefactive process, although there was no bacterial con- tamination. Momentary heating of blood serum to 55° C. does not lessen the toxicity or destroy the globulicidal action, but when heated for some minutes the blood serum had no effect. There does not seem to be any great change in the number of leucocytes. When there is a great destruction of red blood corpuscles there is also a paucity of leucocytes. There is a slight alteration in the number of lymphocytes when the corpuscles are destroyed. In Experiment IV there was a slight increase in the number of lymphocytes, while there is a corresponding decrease in the number of the multinuclear form, while in VI; there was no alteration. Experiment IV. [Kinds leucocytes.] Just before Normal. death (could only find 50). Per cent. Per cent. Lymphocytes. . . . . . ----------------------------------------------------------- 40. 6 40 to 80 Large mononuclear. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ------- -------------- 3 Transitional - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 2 OT Multinuclear ----------------------------------------------------------------- 53. 4 - Eosinophile * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 1 10 to 20 PAN-AMERICAN MEDICAL CONGRESS. 1221 Experiment VI+. Normal. Just at death. Per cemt. Per cent. & 38. 3 Lymphocytes---------------------------------------------------* - - - - - - - - - - - - - 39 Large mononuclear ----------------------------------------------------------. | 6. 3 2. 3 Transitional -----------------------------------------------------------------. | 5. 3 4 Posinophile------------------------------------------------------------------- 1 -------------- Multinuclear ----------------------------------------------------------------- 48. 3 55 C. Albuminuria was present after the subcutaneous injection, but no hamoglobinuria. In the other cases there was no opportunity of examining for the wind. The kid- neys show a very marked structural change; the whole renal tubule seems filled with granular matter and even the nuclei do not take the stain. It is also interest- ing to note that in these experiments, in which a destruction of red blood corpuscles was taking place, there was a peculiar grouping of those cells and in the field one can see many corpuscles which have lost their color and are very in distinct. In the fixed preparations made for examining the leucocytes, the red blood corpuscles stain very poorly with eosin when they are being destroyed. HUMAN SERUM IN FROGS. Experiment XIP (medium-sized frog). —11 A. M.: R. B. C., 425,000. 12 M. R. B. C., 416,000. 1 P. M.: Injected 5 c. c. human serum 3 days old subcutaneously. 7 P. M.: R. B. C., 200,000. 12 midnight: R. B. C., 232,000. Next day: R. B. C., 217,000; seems very sick. Ea:periment XV (large frog).-3 P. M.: R. B. C., 552,000. 4 P. M.: R. B. C., 438,000. 5 P. M.: 10 c.c. human serum 3 days old. 12 midnight: R. B. C., 310,000. Next day, 3 P. M.: R. B. C., 320,000. Experiment XVI (medium-sized frog). —10.30: R. B. C., 200,000. 11.30: 5 c. c. human serum heated to 55° C. 7 P. M.: R. B. C., 260,000. From this it would appear that human serum has a distinctly globulicidal action upon the corpuscles of a frog when injected subcutaneously. DOG's SERUM IN RABBITS. Experiment XVII (big brown rabbit).-12 M.: R. B. C., 5,260,000; W. B. C., 7,000. 3 P. M.: R. B. C., 4,970,000; W. B. C., 4,500. 3. 48: 3 c. c., dog's serum 4 days old injected rapidly. 3.50: Breathing slowly. 3.55: ‘Slight convulsion and died. Experiment XVIII (white rabbit).-12 M.: R. B. C., 5,600,000; W. B. C., 12,500. 1.49: 1. C. c. dog's serum, 1 day old, injected in jugular vein. 2.10: 1 c. c. 2.20:1 c. c. 2.25: R. B. C., 4,200,000; W. B. C., 12,000. 2.38: 2 c. c. 2.45: R. B. C., 4,680,000; W. B. C., 6,200. 3: 2 c. c. 3.05: R. B. C., 4,960,000; W. B. C., 6,250. 3.30: 6 c. c. slowly. 3.35: 2 c. c. 3.38: Died; slight convulsion. Experiment XIX. —1.30: R. B. C., 5,066,000; W. B. C., 7,600. 2.29: 3 c. c. slowly injected into vein. From dog forty-eight hours before 2.42: R. B. C., 5 000,000; W. B.C., 4,000. 3.10 to 3.15: 3 c. c. 3.25: R. B. C., 5,083,000; W. B. C., 4,000. 3.48 to 4: 3 c. c. 4.05: R. B. C., 4,750,000; W. B. C., 3,000. 4.28 to 4.40: 4 c. c. 4.45: R. B. C., 4,880,000; W. B. C., 1,600. 4.55 to 5.38: 9 c. c. 5.40: R. B. C., 5,043,000; W. B. C., 2,100. 6: R. B. C., 4,428,000; W. B. C., 1,170. 6.10: Convulsion; respiration rapid. 6.17: Died in convulsion. Experiment XX.-3 P. M.: R. B. C., 4,640,000; W. B. C., 12,000. 3.30: R. B. C., 4,400,000; W. B. C., 5,000. 4 to 4.45: 8 c. c. injected into vein, very slowly, dog's Serum 4 days old. 4.50: R. B. C., 5,040,000; W. B. C., 10,000. 5.10: R. B. C., 4,800,000; W. B. C., 10,000. 5.15 to 5.40: 7 c. c. 5.40: R. B. C., 5,200,000; W. B. C., 11,000. 5.45 to 6.25: 13 c. c. 6.10: R. B. C., 5,400,000; W. B. C., 7,700. 6.27: 5 c. c. 6.30: R. B. C., 5,400,000; W. B. C., 12,500. Next day: R. B. C., 5,200,000; W. B. C., 9,375. Next day: R. B. C., 5,800,000. Experiment XXI.-3. P. M.; R. B. C., 5,700,000; W. B. C., 5,600. 3.30: R. B. C., 6,022,000; W. B. C., 3,800. 3.52: 5 c. c., dog's serum, 1 day old, subcutaneously. 4 P. M.: 5 c. c. 4.15: R. B. C., 6,000,000. 4.45: 15 c. c., subcutaneously. 6: R. B. C., 1222 PAN-AMERICAN MEDICAL CONGRESS. 5,360,000; W. B. C., 8,600. 6.30: R. B. C., 6,100,000; W. B. C., 9,000. Next day: R. B. C., 4,460,000; W. B. C., 4,300; albuminuria and hamoglobinuria. Next day: R. B. C., 4,170,000; W. B. C., 6,500; urine as yesterday. Next day: R. B. C., 4,690,000; W. B. C., 8,300. - Earperiment XXII.--10.45: R. B. C., 6,400,000; W. B. C., 1,500. 12.30: R. B. C., 6,840,000; W. B. C., 11,000. 2.06: Injected 20 c.c. dog's serum, 4 days old, subcu- taneously. 3: R. B. C., 7,500,000; W. B. C., 1,500. 4: R. B. C., 7,112,000; W. B. C., 10,000. 6 P. M.: R. B. C., 8,380,000; W. B. C., 6,200. Next day: R. B. C., 7,280,000; W. B. C., 7,000. - Experiment XXIII.-10.30: R. B. C., 6,010,000; W. B. C., 3,300. 12.30: R. B. C., 6,400,000; W. B. C., 6,000. 1,50: injected 15 c. c. dog's serum subcutaneously (sey- eral days old). 2.45: R. B. C., 6,030,000; W. B. C., 10,000. 4: R. B. C., 6,300,000; W. B. C., 18,000. 5.45: R. B. C., 6,200,000; W. B. C., 13,000. Next day: R. B. C., 6,100,000; W. B. C., 9,100. Experiment XXIV.-2 P. M.: R. B. C., 5,630,000; W. B. C., 7,000. 2.30: R. B. C., 5,320,000; W. B. C., 7,600. 4.45: 25 c. c. dog's serum, 1 day old, subcutaneously. 9: R. B. C., 5,400,000; W. B. C., 7,800. 12: R. B. C., 5,500,000; W. B. C., 7,400. Next day, 6 A. M.: R. B. C., 5,400,000; W. B. C., 13,000. 9.A. M.: R. B. C., 5,960,000; W. B. C., 16,000. 12 noon: R. B. C., 5,400,000; W. B. C., 10,000. 7 P. M.: R. B. C., 5,060,000; W. B. C., 6,600. Next day: R. B. C., 5,500,000; W. B. C., 10,000. Earperiment XX V.-2.30: R. B. C., 6,500.000; W. B. C., 14,000. 5.15: 25 c. c. dog's serum, 1 day old, subcutaneously. 9 P.M. : 5,800,000; W. B. C., 9,500. 12 midnight: B. B. C., 6,800,000; W. B. C., 6,250. Next day, 7 A. M.: R. B. C., 6,520,000; W. B.C., 16,000. 12 noon: R. B. C., 5,800,000; W. B. C., 12,000. 7 P. M. : R. B. C., 6,800,000; W. B. C., 9,200. Next day: R. B. C., 6,400,000; W. B. C. 9,000. With dog's serum, as with the serum of man, the rapid injection by the vein causes death in few minutes, often without convulsion. When the injection is made slowly, however, large quantities can be used, convulsions and death coming on late, or there may be entire recovery, even after 33 c. c. lhas been injected, as in Experiment XX. The toxic effect is not noticed until just before death, and is not as great as in rabbits injected with the serum of man. The globulicidal action is not very pronounced, the corpuscles never being reduced below four-fifths the nor- mal quantity, and in several experiments there was scarcely any destruction. The diminution was no greater in the fatal cases than in those terminating in recovery. The white blood corpuscles did not undergo any decided numerical change, but there was a distinct alteration in the proportion of the different kinds. There was a distinct increase of the lymphocytes or the youngest leucocytes and a correspond- ing reduction of the multinuclear form, or the oldest leucocytes. By the subcu- taneous injection there was in one case a decided diminution of red blood corpuscles to four-fifths their normal quantity, and at the same time albuminuria and haemo- globinuria (Experiment XXI). The effect came on the day after the injection. I repeated this experiment four times, in apparently the same way, and even using larger quantities, but never obtained similar results; the only result of the injec- tion in these cases was an albuminuria. The kidney of the rabbit injected with serum from dog a shows decided structural change, being similar to that resulting from the injection of serum of man, but not so severe. Ten c. c. of dog's serum one day old was injected subcutaneously in a frog, and the frog was found dead six hours later. The results of injecting dog's serum into rabbits are different from those obtained by others in mixing dog's serum and rabbit blood. Landois, Buchner, and Darem- berg all found dog's serum very destructive to the corpuscles of the rabbit. My experiments seem to warant the conclusion that dog's serum is toxic, but much less so than the serum of man, and that it is scarcely at all globulicidal. The globulicidal action certainly could not explain the toxicity, for in the cases ending in death there was no greater destruction of corpuscles than in those ending in recovery. 12AN-AMERICAN MEDICAL CONGRESS. 1223 Varieties of leucocytes, dog's serum in rabbit. EXPERIMENT XVII. Just at Normal. death. Per cent. Per ent. Lymphocytes. -- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . --- 44 77 Large mononuclear----------------------------------------------------------- 3 6.5 Transitional. ----------------------------------------------------------------- 3 2 Eosinophile------------------------------------------------------------------- . 5 ... 2 Multinuclear ----------------------------------- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 50 14.3 EXPERIMENT XIX. Normal. 2.45 P. M. 3.45 P. M. Per cemt. Per cent. Per cent. Lymphocytes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... --- 21.6 18.2 Large mononuclear ---------------------------------------------- 3.3 4.4 4 Transitional.----------------------------------------------------- 4.4 3.4 1. Eosinophile ------------------------------------------------------ 1.2 1.4 I Multinuclear---------------------------------------------------- 69. T 7.2. 6 56 EXPERIMENT XXI. p. Next day, 4 days af. Norrmal. 5 P. M. 3 P. §y terwards. Per cent. Per cent. Per cent. Per cent. Lymphocytes. -- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 29 42 62 Large mononuclear---------------------------------- 15 8 2 3 Transitional----------------------------------- ----- 5 7 3 3 Eosinophile. ----------------------------------------. 2 2 ------------ ... 6 Multinuclear---------------------------------------- 50 54 53.5 30 HORSE'S SERUM IN RABBITS. Experiment XXVI (large rabbit).—4.30: R. B. C., 5,742,000; W. B. C., 5,800. 5.30: R. B. C., 5,960,000; W. B. C., 6,500. 8.08 to 8.10: 12 c.c. horse serum 3 days old, injected per jugular vein. 8.10 to 8.18: 14 c. c., slowly. 8.30: R. B. C., 5,166,000; W.B.C.,31,500. 8.40 to 8.45: 10 c. c. 8.45 to 8.55: 15 c. c. . 9 P. M.: R. B.C.,5,085,000. W. B. C., 8,200. 9.16 to 9.40: 25 c. c., slowly. 9.45: R. B. C., 4,810,000; W.B.C.,6,600; 6,600. 10.45: R.B.C.,4,910,000; W.B.C.,8,000. 12.30: R, B.C.,4,550,000; W.B.C.,27,000; urine contained albumin. Next day: R. B. C., 5,320,000; W. B. C., 9,800. Ea:periment XX VII.—5 P.M. : R. B. C., 5,360,000; W. B. C., 9,375. 5.30: R. B. C., 5,600,000; W. B. C., 5,000. 5.55 to 6.19; 10 c. c. horse's serum 48 hours old, injected slowly per jugular vein. , 6.20: R. B. C., 5,160,000; W. B. C., 11,000. 6.25 to 6.47: 17 c. c. 6.50: R. B. C., 4,720,000; W. B. C., 12,000. 6.55: 5 c. c. , 7 to 7.30: 15 c. c., slowly. 7.30: R. B. C., 4,080,000; W. B. C., 7,500. 8.30: R. B. C., 4,200,000; W. B. C., 20,000. 9.30: R. B. C., 4,150,000; W. B. C., 10,000. 11.30: R. B. C., 4,825,000; W. B. C., 18,000. Next day: R. B. C., 4,125,000; W. B. C., 25,000. Experiment XXVIII (large rabbit). —3 P. M.: R. B. C., 5,800,000; W. B. C., 5, 250. 3.20: R. B. C., 5,700,000; W. B. C., 4,000. 5.45: Injection, subcutaneously 30 c. c. horse's serum 24 hours old. 8.15: R. B. C., 5,800,000; W. B. C., 6,700. 10.30: R. B. C. 5,820,000; W. B. C., 6,400. 1 A. M.: R. B. C., 5,720,000; W. B. C., 2,200. Next day, 10 A.M. R. B. C., 5,900,000; W. B. C., 10,000. 3 P. M.: R. B. C., 5,800,000; W. B. C., 5,000. 10 P. M.: R. B. C., 5,850,000; W. B. C., 8,500. Experiment XXIX (small rabbit).-4 P. M.: R. B. C., 4,680,000; W. B. C., 7,500. 4.30: R. B. C., 4,960,000; W. B. C., 10,000. 5.15: Injection subcutaneously 20 c.c. : horse's serum 1 day old. 8.15 P. M.: R. B. C., 4,680,000; W. B. C., 5,000. 10.30 P. M.: R. B. C., 5,240,000; W. B. C., 6,250. Next day, 1 A. M.: R. B. C., 5,080,000; W. B. C., 6,250. 10 A. M.: R. B. C., 6,040,000; W. B. C., 5,000. 3 P. M.: R. B. C., 5,600,000; W. B. C., 9,000; urine contained albumin. From these experiments it will be seen that serum of the horse has no toxic effect upon rabbits. Although large quantities were injected directly into the veins of the rabbit (76 c. c. in one case and 47 c. c. in another), the number of corpuscles were not 1224 PAN-AMERICAN MEDICAL CONGREss. reduced below four-fifths their normal quantity. It is probable that the dilution caused part of this reduction, for in the experiments in which horse serum was injected subcutaneously into rabbits there was no change in the number of cor- puscles. There was no alteration in the number of leucocytes, but with intravenous injections there were fewer lymphocytes, while the multinuclear leucocytes were increased. With subcutaneous injections there was no alteration in the proportion. Albuminuria, but no hapmoglobinuria was produced. Varieties of leucocytes, horse's serum injected into rabbits. EXPERIMENT. XXVI 10.45 P.M., *...*. 76 C. c. had Normal. hour after |*...*|12.30 A.M. Next day. first inje. jected 1 ...' our be- - & fore. L h Per cent. Per cent. Per cent. | Per cent. Per cent. ymphocytes ---------. . . . . . . . . . . . . . ---- 25 19 15 14. 2 14 Large mononuclear --------------------. 2 7 . 5 1.5 4. 2 Transitional ---------------------------. 2 5 1. 2 3.1 Eosinophiel ----------------------------- 1 1 . Tº • 3 |------------ Multinuclear---------------------------. 70 68 83 82 78.6 EXPERIMENT XXVII. 6.20 P.M., 6.50 P.M., 7.30., 47 Nº. 10 c. c. in- 27 c.c. in-l c. c. in- 11.30. * ” jected. jected. jected. y. Per cent. | Per cent. | Per cent. | Per cent. | Per cent. | Per cent. Lymphocytes. -- . . . . . . . . . . . . . . . . . . . ----- 23.4 § 26. 15 7 9. 1 Large mononuclear --------------------. 2. 2 2, 6 2.5 1, 5 1.3 l Transitional---------------------------- 2. 5 2, 3 3.4 2 1. 6 1.5 Eosinophile. ----------------------------|---------- 1. 5 • 6 -------------------- ... 1 Multinuclear --------------------------- 71.3 67. 6 67 81. 5 90.1 87 4 |EXPERIMENT XXIX. 10 tº: C. A. M. p M Normal. subcutaneous- || 10 A.M. next | 10 P. M. next ly, 5 hours af. day. day. ter injection. Per cent. Per cent. Per cent. Per cent. Lymphocytes. -- . . . . . . . . . . . . . . . . . . . . . . . . 22.8 23.4 26 30 Large mononuclear--------------------. 1. 9 1 1 1. Transitional. --------------------------- 1.7 2.4 2.4 1.5 Eosinophile ---------------------------- . 7 1.6 .4 |-------------. Multinuclear --------------------------- 73 71.6 70 67.5 CAT’S SERUM IN RABBITS. Earperiment XXX (large rabbit).-3.30: R. B. C., 5,625,000. 4: R. B. C., 5,850,000; W. B. C., 7,500. 4.45 to 5: Injected 10 c.c. cat's serum one day old, per jugular vein. 5.15: R. B. C., 5,140,000. 5.35: R. B. C., 5,100,000. 6: R. B. C., 5,500,000; no symp- toms. In this one experiment in which 10 c.c. cat's serum was injected intravenously into a rabbit, there was neither toxic or globulicidal action. SHEEP'S SERUM IN CATS. Experiment XXXI (medium-size cat).-3.30: R. B. C., 5,200,000; W. B. C., 29,000. 4: R. B. C., 5,125,000. 4.05 to 4.10: Injected per jugular vein, 20 c. c. sheep's serum 1 day old. 4.15: R. B. C, 5,020,000; W. B. C., 11,000. 4.35: R. B. C., 4,500,000; W. B C., 12,000. 5: R. B. C., 5,000,000; W. B. C., 12,000. No symptoms; cat killed. PAN-AMERICAN MEDICAL CONGRESS. 1225 In this one experiment, in which 20 c.c. of sheep's blood was injected into the vein of a cat, there was neither toxic or globulicidal action. To recapitulate. Human serum injected into veins of rabbits was found most toxic and most actively globulicidal. When injected rapidly it causes death in a few minutes, the corpuscles falling to one-half or one-third their normal number. When injected slowly death comes on much later, the number of corpuscles sinking to one- fifth the normal. In these latter experiments there were convulsions, paralysis, and great disturbance of respiration, and finally death by respiratory failure; but in the former, death came on rapidly by cardiac failure and without the toxic symptoms. With dogs, human serum has neither a toxic or globulicidal action. With frogs, human serum is both toxic and globulicidal. Dog's serum is toxic when injected rapidly into vein of rabbits. When injected slowly in some cases death comes on with slight diminution of red blood corpuscles while in others recovery occurs, even after as much as 30 c. c. has been injected, with but slight reduction in the number of corpuscles. With frogs, dog’s serum is toxic. The serum from the horse is neither toxic or globulicidal to rabbits. Cat's serum in rabbits is neither toxic or globulicidal. Sheep's serum injected into the cat is neither toxic or globulicidal. Heat destroys both the toxic and globulicidal action of human serum. Standing in a cool place for seven days did not cause the serum to lose its globulicidal action; but the toxicity was increased. There was no constant alteration in the number of white blood corpuscles, but when the red corpuscles are destroyed there is also a paucity of leucocytes. When human serum or dog's serum was injected into rabbits, the number of lymphocytes was increased while the proportion of multinuclear leucocytes was decreased. Horse's serum injected into rabbits increases the multinuclear leucocytes and diminishes the lymphocytes. From the fact that the serum of the dog injected into rabbits is toxic without having any globulicidal effect and also from the fact that human serum injected rapidly into the veins of rabbits causes death in a few minutes, before the corpuscles are reduced below one-third their normal, while the slow injection causes a reduction to one-fifth their normal before death, it seems probable that the toxicity of serum is not dependent upon its globulicidal action and rather indicates a multiplicity of poi- sonous substances in the serum. The fact that heating destroys both the toxic and globulicidal action shows their albuminous nature. Buchner has also found that diluting the serum with water causes the globulicidal action to disappear, but it reippears on the addition of sodium chloride. Maragliano “ has found that in a number of diseases in man, in which the blood is altered, the globulicidal action is greatly increased, destroying not only the corpuscles of other species, but also those of healthy men. He further found that the haemoglobin was destroyed and did not remain in solution as when destroyed by other agents. He also noticed that the globulicidal action was greatest in the case containing the least sodium chloride in solution in the serum. When this salt was increased, the globulicidal property was lessened and the patient recovered. From the experiments detailed in this paper it will be seen that the corpuscles of an animal are not destroyed by every foreign serum. The serum of man and of the dog, two flesh-eating animals, is toxic and globulicidal to rabbits, while the serum of the cat had no effect upon the rabbit. The serum of man had no effect upon the dog. In studying the subject of transfusion it was found by Panum and by Ponfick and others that sheep serum in large quantities is toxic to dogs. Lamb's serum has been injected into human beings suffering from tuberculosis without any unpleasant result. - * Loc. cit. 1226 PAN-AMERICAN MEDICAL CONGRESS. Rummo “ has studied the toxicity of different serums, but my observations seem to show that the toxicity is greater than stated by him. He found the toxicity increased enormously in acute infectious diseases. In those cases where death occurred from the injection of either human or canine serum, I never found a chicken-fat clot in the heart. The ventricles were distended, the left with fluid blood, while the right often contained a soft, non-adherent, very dark clot, such as is formed just in the agonic period. DISCUSSION. Dr. HoDGE. I have been greatly interested in Dr. Carter's paper, but, unfortu- mately for this discussion, have not worked in this department of physiology. I am glad to say, however, that we have a member present who has worked extensively in the related field of the germicidal properties of blood and serum, and Dr. Beyer has kindly consented to open the discussion. Dr. H. G. Beyer, U. S. Navy, discussing Dr. Carter's paper on the globulicidal action of certain blood serums when injected into different animals, asked whether Dr. Carter had taken into close consideration the relative proportion of leucocytes to the red globules, as well as the absolute number present of each, For, inasmuch as any error creeping into the count of the red in case of an increase of the leucocytes would give rise to errors being multiplied by as many times as 1 cubic millimeter is contained in 6 liters of blood. Dr. Carter stated that while the leu- cocytes of the different classes changed in number and in their relations to them- selves, their relative proportion to the red globules had not changed, and through- out his experiments remained the same. Dr. Beyer was satisfied. Dr. Macallum objected to the term “globulicidal.” It would appear that Dr. Carter's results might be very well explained as due partly to physical and partly to physiological processes. It is well-known that the isotonic coèfficient of the red corpuscle of the animal is different from that of the red cell in another animal. When, therefore, the serum of one animal is injected into the blood of another the physical equilibrium is overthrown and red corpuscles disintegrate. This result, therefore, is a physical one. On the other hand, that serum of some animals when injected into those of another species, gives toxic effects seems to be definitely proved by the results of the experiments described by Dr. Carter. Dr. Macallum took exception to the view enunciated by Dr. Beyer, that observations tend to show that red cells originate partly from the white corpuscles. If the results of experi- ments of the last five years show anything at all, it is, that white cells never give origin to the red cells and, from the embryological point of view, the white cells never give origin to the red. Dr. Beyer, continuing the discussion in answer to Prof. Macallum, stated that the literature within the period stated showed apparently, without doubt, that there are leucocytes that change into red corpuscles, namely, those that come from the bone marrow and a part of those coming from the spleen; those coming from the spleen are transformed into red partiy within the spleen itself, partly after entering the blood current. - - Dr. W. S. Carter said: In reply to Dr. Beyer's question I would say that there was no alteration in the proportion of white and red blood corpuscles. With horse's serum in rabbits there was scarcely any alteration in the number of corpuscles of either kind, but there was a distinct change in the proportion of leucocytes. With dog's serum in rabbits there was scarcely any distinction of corpuscles, but when there was a distinction both kinds were affected so that there was change in the proportion of red and white * Trans. Tenth Internat. Med. Cong., Vol. II, p. 198. PAN-AMERICAN MEDICAL CONGRESS. 1227 corpuscles. In these there was a distinct alteration of the proportion of the differ- ent kinds of leucocytes. Human serum in rabbits caused rapid distruction of both kinds of corpuscles, there being no alteration in the proportion of white and red corpuscles. Here there was apparently an alteration in the proportion of eucocytes. In reply to Dr. Macallum's remarks I would say that the term “globulicidal” seems a good term. It is used both by Daremberg and Buchner, and, as Buchner remarks, it is a property of the “half-living serum ” and not a physical property. Certainly the corpuscles are greatly concerned in metabolism. There is a destruc- tion of both red and white corpuscles, and under the miscroscope the changes of necrobiosis are seen in the white corpuscles when exposed to certain foreign serums. For these reasons it seems that “globulicidal” best describes the action of the serum. THE EFFECT OF LESIONS OF CERTAIN PARTS OF THE BRAIN UPON THE HEAT PROCESSES. By EDWARD T. REICHERT, M. D., Professor of Physiology, University Pennsylvania. In an article on thermogenic centers, read before the last meeting of the American Society of Physiologists and subsequently published in the University Medical Magazine for March, I briefly reviewed the experimental work thus far published which seemed to bear directly upon the nerve centers specifically concerned in the production of heat, and reported a new series of investigations, showing the location of the automatic thermogenic centers. The chief conclusions arrived at were (1) that the automatic thermogenic centers are located in the spinal cord; (2) that the cruciate and Sylvian centers in the cortex cerebri are thermo-inhibitory; (3) that the caudate nuclei and medulla oblongata contain thermo-accelerator centers; (4) that no specific heat centers probably exist in the optic thalami; (5) that specific thermotaxic centers, i. e., centers having a common control over heat production and heat dissipation, do not exist. - A number of points in connection with that study obviously needed further inves- tigation, as, for instance, the conflicting statements of White as opposed to those of all other recent investigators relative to the physiology of the brain cortex in connection with the heat mechanism; the assertion of Ott that injury of the white matter immediately in front of the caudate nuclei is followed by a marked rise of temperature; the conflicting beliefs regarding the existence of heat centers in the optic thalami; the effects of injuries of the cerebral peduncles upon the heat pro- cesses; the effects of injuries of the pons upon the heat processes; the effect of pyretic and antipyretic drugs upon the heat functions after injuries of certain of above parts. These, together with other suggestions of seemingly minor importance, lead me to begin several series of investigations. In the present inquiry two classes of experiments were performed; in one, com- plete transverse sections of certain parts at the base of the brain were made, and in the other the same parts were punctured. Sections were made with the idea of cutting off the influences of higher from lower parts and punctures were made for the purpose of definite localization of heat centers, or bands of heat films. I have not attempted localization by means of the injection of caustic solutions because such a method is generally far inferior to puncturing. Unfortunately, I have not been able to complete this work in time to report the results in full and in the present communication I can only offer the records of a series of sections. In the study of the effects of lesions of the nerve centers upon the heat mechan- ism it is necessary to keep in view the fact that injury of almost any part of the cerebro-spinal axis may be followed by a more or less marked rise of temperature, 1228 PAN-AMERICAN MEDICAL CONGRESS. which may continue for hours, or even days, and which is particularly likely to occur, if the injury is complicated by much haemorrhage, the pressure of a clot, shock, laceration of the tissues, etc. Besides this, a fertile source of error may exist in the marked and unaccountable fluctuations which occur under perfectly normal circumstances in the bodily temperature of rabbits, cats, guinea pigs, and dogs—the animals almost solely employed in this sort of investigation. The heat processes in dogs seem to be of greater stability than those in the other animals referred to, and on that account chiefly I have chosen them for this research. The mere fact that the heat mechanism may be materially influenced by injuries of any part of the nerve centers renders it evident that no portion of the brain or spinal cord should be concluded to be specifically concerned in the heat processes unless the phenomena produced by operations upon it are distinctly more marked than those which are observed when other but different parts are affected and unless the results are fairly constant and positive and the lesions properly localized. In some of the experiments in the present series, observations were made only of the temperature; in others, records of temperature, circulation, respiration, and motor reflexes were obtained, while in others the method was calorimetrical. In all of the experiments strong healthy dogs were used. The technique of the operations was in all cases the same, unless specifically noted. The animals were anaesthetized with ether, chloroform, or a mixture of both ; a small trephine opening was inade in the side of the skull opposite to and on a level with the upper surface of the struc- tures to be cut; the membranes were punctured; a slightly bent probe, 1 mm. thick and 2 mm. wide, was inserted horizontally and pushed across the brain until the skull on the opposite side was reached, and then with a downward sweeping move- ment all the cerebral mass below the probe was completely severed. A certain amount of haemorrhage always occurred, but this was always very slight, and by properly inclining the head for a few minutes immediately after the operation drain- age was facilitated and the pressure from a clot in a large measure prevented. Temperatures were seldom taken before the operation because the struggles of the animal, as well as the direct influences of the anaesthetic, so affect the heat pro- cesses that the record as a standard is more or less of a fictitious value. By means of sensitive thermometers, temperatures were obtained within three to five minutes after the section. With the exception of the calorimetrical experiments the ther- mometer was retained in the rectum throughout the entire periods of observation. The experiments may be divided into six classes, distinguishable by the region of section (1) the frontal lobes just anterior to the caudate nuclei; (2) the corpora stri- ata; (3) the optic thalami; (4) the crural cerebri; (5) the pons. For many reasons it would have been desirable to have included a number of experiments upon the cortical heat centers of Eulenberg and Landois, and of Ott, especially so since White, in a recent communication (Journal of Physiology, x11, 1891, p. 233), gives results which lead him to reach conclusions in opposition to those of all other recent investigators upon these parts. White believes that lesions of the cruciate centers (Eulenberg and Landois) do not, or but slightly, alter rectal temperature. Regarding the Sylvian center (Ott), he concludes that its injury may cause irregular rises of temperature, which are quickly produced aud last but for a short time; sometimes 'several rises and falls occur after one operation. He was induced to believe, considering the irregular variations and rapid claracter of the changes of temperature following these lesions, that certain parts are concerned in maintaining the balance between heat production and heat dissipation; in other words, of the nature of the hypothetical thermotaxic centers. White's results and conclusious do not, however, seem to be in entire accord. Thus, in his experiments on the cruciate region a rise of temperature occurred in every instance after the operation, varying from 0.4° to 2.8° F.; and in those on the Sylvian areas, in 18 out of 21 there was a Rise—in 6 of less than 19, in 3 between 19 and 29, in 9 from 29 to less than 3°, and in 3 from 3° to 49; the average rise being 1.62° and the greatest 3.6°. PAN-AMERICAN MEDICAL CONGRESS. 1229 It seems, therefore, that White's results are rather in accord than conflicting with those of other investigations. There is, consequently, at the present time no suffi- cient evidence to weaken the belief that there are specific heat centers in the cruci- ate and Sylvian regions, and that both are thermo-inhibitory. My experiments show that sections of the basal parts of the brain, even though the animals are thoroughly anaesthetized, generally severely affect the thermal, circulatory, respiratory, and motor reflex functions, and that, in a majority of instances, the shock to the respiratory centers is so great that the animals succumb within a few minutes to failure of the respiratory movements. If, however, arti- ficial respiration is maintained the immediate effects of the shock pass off and, within a period varying from less than a minute to an hour or more (usually from five to ten minutes), automatic respiration is regained. The respiratory centers generally show for hours that their operations are disturbed, as is evident in irregu- larities in the depth and frequency of the respiratory movements, which frequently occur throughout the successive hours of observation. Indeed, it is not uncommon for spontaneous respiration to cease and after a time to be resumed, only again to cease and be resumed, and so on many times during the four or six hours after the section. As a rule, it seems that the nearer the sections are to the medulla oblongata the more profound and lasting the effects upon the respiratory centers. The circu- lation is always sooner or later materially affected. Sometimes the heart's action, immediately after the operation, is completely inhibited, the arrest usually lasting for but a few seconds, although in one experiment it was for thirty-seven seconds. I have never seen death result from permanent inhibition. That this inhibition is due to influences exerted through the inhibitory centers is evident in the fact that it was never present after section of the pneumogastric nerves. In some experiments these nerves were cut before the brain section was made, and in others during the existence of the inhibition. In the former, inhibition did not occur; and in the latter, it at once ceased. - In many of the experiments, sudden changes in the rapidity and force of the heart's beat occurred during the successive hours of observation, and without obvious cause. Sometimes within a second or two the heart's action would become enormously altered, thus in one case it fell from 264 to 192 beats per minute within a few seconds; shortly after this it suddenly increased from 153 to 240. The arterial pressure is variously affected, generally showing a tendency to slight increase dur- ing the early period of the experiment and to a decrease later. But there is a great lack of uniformity. Owing to the sensibility of the respiratory centers to the injury to the parts subjected to section, it was my practice, after anaesthetization, to insert a tracheal tube, and as soon as any sign of failure of respiratory movements occurred, to begin artificial respiration, maintaining this until spontaneous respiration returned with sufficient strength to carry on the function. - After these operations the dogs usually remained in a condition of stupor and seldom lived for more than six or eight hours, many of them succumbing in less time and some living from two to three days. (1) LESIONS OF THE FRONTAL LOBEs JUST ANTERIOR TO THE CAUDATE NUCLEI. Ott states (Therapeutic Gazette, September 15, 1887), apparently from the results of a single experiment on a rabbit, that transverse section of the white matter 1 mm. anterior to the ends of the caudate nuclei is followed by a rapid rise of tem- perature, which lasts until the third day. This, he also states, is the most anterior part of the brain, which will give a marked rise of temperature when injured. On the other hand, the experiments of Aronsohn and Sachs (Pfluger's Archiv f. Physi- ologie, LVI, S. 237), and White (Journal of Physiology, x1, 1891, and XII, 1891), lead to the belief that injury of this portion of the brain is not followed by a rise of temperature. 1230 PAN-AMERICAN MEDICAL CONGRESS. In two experiments in which I made section just in front of the ends of the caudate nuclei, barely escaping them, the temperature fell in both. Records were made of temperature, pulse, arterial pressure, and respiration, which will be found in the following tables. In experiment 1 the section was less than 1 mm. from the nuclei, and in experiment 2 just 1 mm. in front of them. While both circulation and res- piration were materially affected in both there is no apparent connection between the effects on them and the fall of temperature. If, however, the section involves even the tips of the nuclei the effects on temperature are very different, as are illustrated in experiments 3, 9, and 10, in which from 1 to 2 mm. were cut off, in every one of which a rise of temperature was recorded. The evidence, therefore, seems to point conclusively to the belief that the rise of temperature noted in Ott's experiment was due either to injury to the ends of the caudate nuclei or was an exceptional result. (2) LESIONS OF THE CORI’ORA STRIATA. Thé experiments of Ott (Journal Nervous Diseases, April, 1884), Aronsohn and Sachs (loc. cit.), Girard (Archiv. de Physiologie, VIII, 1886, p. 281), Baginsky and Lehmann (Virchow's Archiv, CVI, 1886, S. 258), and White (loc. cit.) all indicate that lesions of the striated bodies are generally followed by a marked increase of bodily temperature, and some of the observations show that this increase is due to increased heat production consequently leading to the belief that these structures contain thermo-accelerator centers. The most extensive of the above investigations is by White embracing 23 experiments in his first paper and 4 in his second. In 3 of the 27 no rise occurred, and in 2 there was a fall; in the remaining 24 the temperature reached as high as from 1049 to 106.89; in 7 it was 106°, or over. In my own investigations section was made through these bodies in 12 experiments, in 6 of which calorimetrical methods were employed. In the first 6 the sections were made at the following levels from the anterior extremities of the caudate nuclei: Experiment 3, 2 mm. ; experiment 4, 5 mm.; experiment 5, 6 mm. ; experiment 6, 9 mm. ; and in experiments 7 and 8, 12 mm. A rise of temperature occurred in every experiment, although the alterations were by no means uniform in general charac- ters or in degree. The rises were, respectively, 0.36°, 0.98°, 4.379, 3.49, 3.08°, and 2.29. Possibly in experiment 8 the rise might have been greater had not 3 grams of phe- nocoll hydrochlorate been intravenously injected, although this is not probable judg- ing from the results of other experiments in which antipyretics were administered. In experiment 3 the increase of temperature passed away within twenty-five min- utes after the section, and was followed by a marked fall, which progressed until the end of three hours, showing a decrease of 2°. In experiments 4 and 6 there was a primary fall followed by a rise; in the former the rise was followed by a fall, and in the latter it continued to increase until death. In experiment 5 the rise set in at once and steadily continued until death, the temperature increasing within four hours from 39.689 to 44.059. In experiment 7 there was a slight primary rise; then a slight decline, but not to the normal; then a marked rise followed by a fall. In experiment 8 the temperature rose steadily for one and three-quarter hours, and then slightly declined. What influence the injection of the phenocoll had is not positive, although as before stated, it is doubtful if it at all affected the results. The average rise of temperature in the 6 experiments was 2.39°, the minimum being 0.36°, and the maximum 4.379. In the remaining 6 experiments the hourly records of bodily temperature are, of course, insufficient to show the maximum and minimum fluctua- tions, but in every case an increase was noted, varying from 0.34° to 4.19. Doubtless, with but a single exception, the rise was materially greater. The calorimeter and methods employed were described by me in the University Medical Magazine for January, 1890 The sections were at the following levels from the anterior margins of the caudate nuclei: Experiment 9, 1 mm. ; experiment 10, 2 mm. ; experiment 11, 6 mm.; exper- iment 12, 8 mm. ; experiment 13, 10 mm.; and experiment 14, 14 mm. PAN-AMERICAN MEDICAL CONGRESS. 1231 A study of these results shows as important facts (1) that there is in the different experiments no general uniformity in the alterations in heat production, heat dissi- pation, and bodily temperature; (2) that both heat production and heat dissipation are more or less independently affected, although the alterations in the latter are largely dependent upon those in the former; (3) that in every experiment there occurred at Some period an increase of bodily temperature; (4) that the rise of tem- perature was due to an increase of heat production. In 4 experiments (Nos. 9, 11, 12, and 13) heat production was increased during the first hour after the section; heat dissipation was also increased in each, but, with a single exception, to a far less degree than heat production, thus indicating that the alterations in dissipation were of a compensatory nature. In 2 experiments (Nos. 10 and 14) both heat production and heat dissipation were diminished during this period, heat production being more affected than dissipation, this again indicating that the alterations in dissipation were dependent. During the subsequent hours the rela- tions between the curves of production and dissipation were of an uncertain char- acter and indicate that during this period the alterations in dissipation were in a measure independent of those in heat production. In 2 experiments (Nos. 11 and 13) the maximum rise of temperature was noted at the end of the first hour, the increases being respectively 0.82° and 1.88°; in 1 (No. 9) the highest temperature was noted at the end of the third hour, the increase amounting to 0.54°; in 2 experiments (Nos. 10 and 14) the maximum was noted at the end of the fourth hour, the rises being 0.48° and 2. 199, respectively; and in experiment 12 the increase amounted to 3.43°, recorded at the end of the fifth liour, the average time of the occurrence of the maximum increase being two hours and fifty-three min- utes after the section. . Therefore, in every one of 12 experiments in which the corpora striata were cut, the level of the section varying from 1 to 14 mm. from the anterior extremities of the caudate nuclei, an increase of temperature occurred, the minimum being 0.369 and the maximum 4.379. In the first six of the series, in which temperature records were frequently taken, and in which these records are more valuable for showing the maximum effects, the average rise was 2.39°. A careful comparison of the records of the different experiments leads to the belief that the temperature is most profoundly affected when the section was located from 6 to 12 mm. from the anterior extremities of the caudate nuclei. (3) LESIONS OF THE OPTIC THALAMI. Both Ott (loc. cit.) and Baculo (La Riforma Medica, 1890, pp. 1568 and 1574) state that lesions of the optic thalami cause a rise of temperature, and believe that these ganglia contain heat centers. Ott's experiments were made by puncture or section, while those of Baculo were by the injection of bismarck brown and bichromate of potash, etc. White (loc. cit.), however, has obtained different results. In his first paper he reports 9 experiments made by puncture, in every one of which there occurred a rise of temperature; but in his second contribution, as a result of fur- ther and more cautious study, he reaches the conclusion that the thalami possess no power to cause an increase of temperature, and that when they have apparently done so, it has been owing to involvement of the corpus striatum. My own experiments seem to be in accord with White's conclusions. In 2 experi- ments, in both of which the sections were in the posterior half of the thalatni, the striate bodies not being injured, a slight but transient rise of temperature occurred, which was followed by a marked fall. In experiment 15 the section was through the middle of the ganglia; the tempera- ture rose only 0.149, and then rapidly fell. In experiment 16 the temperature increased during the first eleven minutes 0.19 and then declined. In this experi- ment the section was 3 mm. from the posterior extremities of the thalami. 1232 PAN-AMERICAN MEDICAL CONGRESS. In one calorimetrical experiment, in which the section was 4 mm. from the pos- terior extremities of the ganglia, a decided fall of temperature, heat production, and heat dissipation was noted. Heat production was affected more than heat dis- sipation, so that the fall of temperature was doubtless due to a diminution of heat production. - The results of these three experiments are in striking contrast with those in which the striated bodies were cut. (4) LESIONS OF THE CRURA CEREBRI. There are extremely few experiments on record in which the temperature altera- tions were studied after section of the cerebral peduncles. Pflüger (Pflüger's Archiv. f. Physiologie, XII, 282, 333) states that after section of the crura behind the cor- pora quadrigemina, the temperature is sometimes increased and sometimes dimin- ished. In one experiment by Wood (Fever; A Study in Morbid and Normal Physiol- ogy, Smithsonian Contributions to Knowledge, No. 357, 1880), partial section was followed by a rise. Fleishmann (Wien. Med. Woch. 1871, Nos. 6, 7, 8, 9,) found a diminution of 39 F. within a half hour. In 2 experiments by White (loc. cit.), a marked rise was noted in each, amounting to 3.49 and 2.29 F., respectively.9 Of 20 experiments which I performed, in which special study was made of the temperature, the results of which will be found condensed in the following table, a rise was recorded in 16 and a fall in 4. The increase varied from 0.049 to 3.649. In 12 it ranged from 0.04° to 849, and in 4 from 1.29 to 3.649. In 10 out of the 16 it was very transient. The region of section does not seem to exert any special influence; in experiments 18, 19, 20, and 25, the sections were close to the thalami, and the rises were 0.049, 0.14°, 0.25°, and 2.949, respectively; In experiments 24, 32, and 33, the sections were in the middle, and the rises amounted to 1.2°, 0.129, and 0.49, respec- tively; and in experiments 21, 22, 23, 26, 27, 28, 29, 30, 31, 34, 35, 36, and 37, the sec- tions were all within 3 mm. of the pons, the rises being 0.84°, 0 12°, 0.08°, 0.650, 0.54°, 0.55°, 1.3°, 0.079, and 3.649; in experiments 34, 35, 36, and 37, the tempera- ture fell from the first. - - Besides these, 28 experiments were performed by means of the calorimeter. In 5 (experiments 39, 40, 41, 42, and 44) the sections were within 4 mm. of the pons; in experiment 43 it was midway between the pons and optic thalami; and in experi- ments 45 and 46 it was close to the thalami. In 4 of the 8 a slight, transient rise of temperature occurred immediately after the section, which was followed in every instance by a profound fall. In the other 4 a fall set in immediately after the oper- ation. A study of calorimetrical records renders it evident that the fall of tempera- ture was due to diminished heat production. - (5) LESIONS OF THE PONs. Tscheschichin (Dw-Bois Reymond's Archiv. für Physiologie, 1866, s.) in a single experiment records that division of the medulla oblongata from the pons was fol- lowed at once by a marked increase of bodily temperature. Bruck and Günter (Pflüger's Archiv. f. Physiologie, III, 1870, s. 578) in 23 experiments in which the pons was severed at its junction with the medulla, or in which it was punctured, state that in 11 an increase of temperature occurred, and in 12 a diminution. In 11 experiments by Ward (loc. cit.), in which partial or complete section was made, an increase occurred in 8 and a decrease in 3. In 2 of the former the rise amounted to 3.25° and 4.889, respectively. Of 7 experiments (Nos. 47 to 53 inclusive) in which I made section at this point, in 6 the temperature was increased, and in 1 it was diminished. Two of the experiments were calorimetrical. In experiment 47 the animal lived for less than one hour, and the temperature fell steadily from the time of the section. In experiments 48, 49, 50, and 51, the rises were, respectively, 3.48°, 0.27°, 2.87°, and 4.34°, an average of 2.74°. In the two calorimetrical experiments PAN-AMERICAN MEDICAL CONGRESS. 1233 (Nos. 52 and 53) the maximum increases were 0.61° and 0.76°, although the figures doubtless do not represent the full degrees of actions. The results of the latter experiments show clearly that the elevation of temperature in this series, as in the others in which this change was noted, was due to an increase of heat production. In conclusion, an analysis of the results of those experiments of the different series in which the temperature alterations were specially considered, gives the following data: i ; , ºv, , * ~ * | sº Section of stri- Section ſof optic'Section of crura | Section of bodies. ated bodies, thal. cerebri. p011S. Number of experi- ments ------------- 2 6 2 16 5 Average duration of observation - - - - - - - 2 hrs. 50 Inins. 3 hrs. 43 minis. || 2 hrs. 45 Inins. 2 hrs. 34 mins. | 3 hrs. 19 mins. Average rise of tem- perature - - - - - - - - - - O 2. 390 0. 120 (). 80 2. 740 Average time of oc- currence of maxi- mum rise of tem- * perature - - - - - - - - - - 0 || 2 hrs. 53 Inins. 8% mills. 1 hr. 20 Luilus. 4 hrs. By comparison and direct results, these figures clearly indicate that the striated bodies and pons are in some important way connected with the heat mechanism, either of the nature of nerve centers or nerve tracts; and, moreover, the fact that the increase of temperature is due to increased thermogenesis, and this to excita- tion and not loss of inhibition, leads inevitably to the belief that the formation is thermo-accelerator. It is obvious that much work remains to be done before we are in a position to definitely state the meanings of the records of these important experiments, but the records, as far as they go, fully substantiate the claims made by me in a recent com- munication, to the effect of the locations and functions of specific heat centers. THE RELATION OF THE NERVOUS SYSTEM TO HEAT PRODUCTION. By ISAAC OTT, M. D. In the Journal of Nervous Diseases I have classified the centers concerned in heat regulation as thermotaxic, whether concerned with thermogenesis, thermolysis, or thermo-inhibition. In some experiments just made with atropine it was found to act upon the cerebral thermotaxic centers and not on the spinal. It occurred to me that perhaps the heat was nearly all generated in the tissues. To determine this, it would be necessary to remove so much of the nervous system as possible and then determine the amount of heat produced. Cats were selected for this purpose. They were put into the calorimeter for two hours, when they were removed, etherized, and portions of the spinal cord destroyed. The calorimeter employed was the one improved by me, and whose error is only 5.4 per cent. After the animal was under the ether an opening was made into the vertebral canal in the upper dorsal region and the cord destroyed downward by means of a stiff wire as far as the lumbar vertebrae, where a second opening was made in the vertebral canal and the remainder of the gord destroyed. Then the animal was immediately returned to the calorimeter and the heat production studied for four more hours. After this he was killed with chloro- form. It was found that sections below the fifth dorsal were nearly always followed by recovery; if above, near the last cervical vertebra, there was often arrest of the heart, and death. It was found that after sections above the fifth dorsal that the heat produced fell to nearly 1 or 2 units, but afterwards rose to about one-third to one-half of the normal output (experiment 1). If, however, the section was just at S. Ex. 36—78 1234 PAN-AMERICAN MEDICAL CONGRESS. the fifth dorsal, then nearly always the heat production remained but little below the normal amount (experiment 2). In one case (experiment 3) it exceeded the nor- mal amount. Eleven experiments were made and they confirmed the preceding statements. The inquiry now arises, how are they to be explained? It is known if you divide the spinal cord between the fifth and sixth dorsal nerves, that is, where the splanchnic fibres divide from the cord, then the blood vessels of the skin and of the abdomen dilate and the blood-pressure falls greatly. If the section is made above the level of the second dorsal nerve, then in addition to the above vaso-motor paral- ysis there is a dilation of the vessels of the face and head which still further reduces the arterial tension. The cardiac accelerator nerves also leave the spinal cord by the second and third dorsal nerves and possibly to some extent by the fourth and fifth. While the vaso-constrictor centers of the body are in the dorsal cord, the vaso-dilators centers are spread throughout the cord. When I destroy the cord below the fifth dorsal vertebra, I cut off vaso-constrictors, the splanchnics, and also annihilate the vaso-dilators, mainly going to the muscles below this point. This section causes a loss of muscular tonus and a great fall of arterial tension. If I destroy the cord about the first or second dorsal, then all the vaso-constrictors are destroyed and nearly all the vaso-dilators. The animals who died seemed to be shocked, probably by the reflex cardiac inhibition and partly by the great vaso-motor paralysis. In cats I made some blood-pressure experiments, and found that the above-mentioned sections and destructions of the cord greatly reduced the blood-pressure. Now, it seems to me, that the spinal thermogenic centers play but a small part in the heat production of these experiments. In an animal, after death, I made a transverse section of the whole body at the fifth dorsal verte- bra, and the weight of the body anterior to this section was 3 pounds, while the body weight posterior to the division was a little over 5 pounds. In this case there could be no spinal thermogenic centers connected with the posterior part of the body, hence we can only have their effect upon the anterior part of the body— that is, the 3 pounds or three-eighths—while the five-eighths have only the tissue heat without any nervous action. Now, if we assume for the sake of argument that the heat produced after a section at the fifth dorsal is greatly due to spinal centers, then we must assume that the normal three-eighths of the body can produce as much heat as the normal eight-eighths of the body with an intact nervous system. This, to my view, is an absurdity. It seems to me much more rational to assume that the heat is nearly all produced in the tissues of the body and that the spinal thermo- genic centers are of small value. That after the animal is greatly shocked by the section above the fifth dorsal it is easily understood that thermogenesis is greatly arrested. Admitting these facts, it is readily seen that the heat is mainly produced in the tissues and that the whole nervous system concerned in heat regulation is thermotaxic. If the temperature falls below 98.4°F., then impulses are sent by the cerebral centers to the spinal centers and more heat is generated. If the tempera- ture is above 98.4° F., then the thermo-inhibitory centers of the cortex act or the tuber cinereum may be stirred up, and thermolysis be increased by augumenting the rate of respiration. Dr. B. Baculo, of Naples, holds that the thermo-inhibitory centers act directly upon the basal thermogenic centers. While I have published experiments support- ing this view, I think there is little doubt but that they also act directly upon the spinal thermogenic centers. Dr. E. T. Reichert believes the spinal thermogenic centers to be of a high value, and played upon by cerebral centers, like the heart is played upon by the cerebral nerves. But these experiments show that the cerebral centers are of high value and the spinal thermogenic, per se, are of little value. Dr. Baculo, of Naples, noted an increase of temperature after the injection of an irritant into the corpora quadrigemina. Baculo believes these bodies contain ther- mogenic centers like the tuber cinereum of the midbrain. The experiments in this PAN-AMERICAN MEDICAL CONGRESS. 1235 paper show that the arterial tension can be greatly lowered and heat production not be affected. In a previous paper I explained this rise of temperature after injury of the corpora quadrigemina as due to lessened tension and changed rate of respiration, but these spinal experiments have changed my mind. What the correct explanation is of this rise after an injury to the corpora quadrigemina remains to be worked out. That the tuber cinereum contains thermogenic centers is shown by the experiment where, with a fine dental drill, I punctured the tuber through the mouth, and obtained a temperature of 109° F. It should be remembered that what I have described as the thalamic heat center and the heat center about Schiff’s expiration crying center, as well as the thermo-polypnoeic center are all seated in the tuber cinereum. One of the most certain signs that you have punctured the tuber is the accelerated respiration, accompanied with a considerable and rapid rise of tempera- ture. In puncturing through the mouth the fibre theory of some writers is demol- lished, as you injure no fibres in this operation. That transverse sections in front of the caudate nucleus, or of the caudate nucleus itself, producing a rise of temperature and increased heat production, will show the presence of heat centers is conceded; but posterior to the corpus striatum no trans- verse section, even if accompanied with rise of temperature and increased heat production, will localize any heat center in the pons or medulla, as you have removed part of the heat-regulating apparatus anterior to the section, and very naturally the temperature rises and heat production is increased. It is only by well-localized punctures into gray matter, producing considerable rise of temperature and augmen- tation of heat production, that you can infer the presence of a thermogenic center at the base of the brain. That injury of the crura will cause a rise of temperature is true, but here you may, by puncture, injure both thermo-inhibitory and thermo- genic fibers, so that no localization of a thermogenic center can be inferred. It seems to me that in the cortex the cruciate center of Eulenberg and Landois, and the Sylvian, are thermo-inhibitory; that the basal thermogenic centers are located (1) in the caudate nucleus; (2) in the gray matter beneath and in front of the corpus striatum; (3) in the tuber cinereum, and that these centers act upon the tissues through spinal centers when the metabolism needs to be accelerated or retarded in activity, to develop the amount of heat necessary to keep the tempera- ture at 98.49 F., and this is an act of thermotaxis. Therefore I believe the function of all these centers, thermogenic and thermolytic, to be lieat regulating or thermo- taxic. & EXPERIMENT I. [Cat; weight, 3.34 pounds; section of cord at seventh cervical and destruction below this point.] R. T. D H. P. H. D. Beginning | Ending of of hour. hour. First period before section - - - - - - - - - - - - - - - - - - - - - ... • - - - - - - - - - - - 30. 88 || 30.34 102.3 102.8 Second period before section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22.35 | 22.35 102.8 102.8 First period after section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ---- 1. 36 || 19. 03 96.6 90.2 Second period after section . . . . . . . . . . . . . . . . . . .-----...------- 10. 54 || 13. 34 90. 2 89 Third period after Section. . . . . . . . . . . . . . . . . . . . . . . . . . . . . -----. 12.42 | 12.96 89 87 Fourth period after section. . . . . . . . . . . . . . . . . . . . . . . . . . ... -- - - - 92.1 11.93 87 8t; Eifth period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 10. 53 || 13. 57 86 84.9 EXI’ERIMIENT II. [Cat; weight, 7.28 pounds; section of cord at fifth dorsal and destruction of cord below this point.] First period before section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24, 99 || 27. 89 101.1 100. 5 Second period before section . . . . . . . . . . . . . . . . . . . . . . . . . . . . ---. 28. 26 || 32.25 100.5 99.8 First period after section. -----------. . . . . . . . . . . . . . . . . ------. 20. 56 26.86 99.5 98.4 Second period after section. --...-- - - - - - - . . . . . . . . . . . . . . . . . . . . . 26.44 31.42 98.4 97.5 Third period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 22. 38 || 24.04 97.5 97.2 Fourth period after section. -- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 17. 03 || 22.75 97.2 96.2 1236 PAN-AMERICAN MEDICAL CONGRESS. EXPERIMENT III. [Cat; weight, 5.52 pounds; section at fifth dorsal and destruction of cord below this point.] R. T. * Ty | * FI. P. H. D. Beginning Ending of of hour. hour. First period before section. ---------------------------------- 23, 53 26.68 104. 6 103.9 Second period before section. -------------------------------. 23. 53 26.68 103.9 103.2 Tirst period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 26. 34 || 32. 70 103 101.6 Second period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -. 32 34, 73 | 101. 6 1 ()1 Third period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 22, 33 25. 06 101 100.4 Fourth period after section ------------------------------.... 25. 49 || 24, 94 100. 4 100.5 EXPERIMENT IV. [Cat; weight, 4.68 pounds; section of cord at fifth dorsal and destruction of cord below this point.] First period before section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 27.36 28. 81 101. 2 101.6 First period before section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 28. 90 29.77 101.6 101.4 First period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 24.20 | 26, 10 96. 5 96.2 First period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 25, 23 24.46 96 96.2 First period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 20. 20 22.85 95.2 95.5 First period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -. 24, 96 || 26, 80 95.5 95 |First period after section - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 24, 28 28. 29 95 94 DISCUSSION. Dr. Beyer said that there was no room for further doubt of the existence of specific heat-producing, heat-dissipating, and heat-regulating centers in the brain as well as in the spinal cord. In the case of the heart and its accelerating and inhibi- tory centers in the medulla, we have quite an analogous condition only, that work is produced by these cardiac centers which are definitely located, and in the case of the heat centers heat is produced under normal condition, which is only another form of the same energy. In one case we obtain work by the peculiarity of the con- nection of these centers with peripheral organs; in the other case we attain heat for similar reasons. Dr. Macallum observed that in experiments on the central nervous system much more happens than what appears on the surface, as is shown by the condition called “shock.” This complicates the results obtained, although the experiments of Ott, Reichert, and others show distinctly that there are “centers” whose function is that of controlling the production and dissipation of heat. All who have studied the history of our knowledge of the vaso-motor centers will remember the discussions on the question of the existence of subsidiary vaso-motor centers in the cord, and even along the blood vessels. Many of the results which have been obtained in those experiments have been due to “shock.” If we bear in mind, then, that a similar condition occurring after experiments on the central nervous system should manifest itself by some results which possibly have been attributed to influencing the central heat “centers” one may, for all this, well believe in the existence of such centers, although we may further allow that their delimitation and localization have not been exactly determined. PAN-AMERICAN MEDICAL CONGRESS. 1237 HOW DOES ATROPINE ELEVATE THE TEMPERATURE OF THE BODY } By ISAAC OTT, M. D. If atropine is given to an animal it will cause a rise of temperature varying from 1.59 to 6.8° F., provided the temperature of the ambient air is elevated. If, during the elevation of temperature, the sciatic is electrically irritated, a greater rise ensues. This rise after sciatic irritation is not sudden as normally takes place, but rises grad- ually and continues after the irritation for two hours, after which it gradually falls. It was found that while the temperature was rising the arterial tension was falling. When it was determined by the calorimeter, it was found that the increase of tem- perature was accompanied by an increased production and augmented dissipation of heat. I have heretofore, on account of the spinal stimulant action of atropine, inferred that the elevation of the temperature was due to spinal stimulation. To experi- mentally determine the seat of action I have used cats which are well suited to show the elevation of temperature. Thirteen experiments were performed. When the cord was cut at the atlas and atropine injected per jugular there was no rise of tem- perature. Several repeated experiments demonstrated that the rise was not spinal. The next experiment was made after a transverse section, just in front of the medulla oblongata, the carotids being previously ligated; then a rise of temper- ature ensued, after the use of atropine, of about 1°. But normally a rise of temperature ensues after section in front of the medulla, because the great regulating centers of the brain have been cut off. How are we now to differentiate between the normal rise and that rise after the drug? After the atropine the rise is only 19, but when the animal's nervous system is intact the rise is often 6.8° F. I have also made some sections in front of the pons varolii and given atropine. Here we also have a rise of temperature without atropine. With the atropine the highest rise was 2.29 F., after section in front of the pons, which is not more than would be expected normally. After careful consideration of the results, it seems to me difficult to speak accurately as to the cerebral center affected. The slight rise of temperature after puncture of the medulla or pons varolii in the rabbit have not led me to believe in the existence of thermogenic centers in these bodies. Until we have definitely determined the existence of heat centers in these organs it seems to me useless to assume that atropine acts upon them. Although not directly connected with this subject, yet I hope it will not be a miss to speak of the value of atropine in shock, as in the preceding paper I have demonstrated that during the first hour of shock heat production is nearly zero, and as atropine is an augmentor of heat production we have an additional proof of what is practically known, that atropine is of great value in shock. Cocaine is also an accelerator of heat production and would without doubt be of great utility. TSXPERIMENT I. [Cat; tracheotomy; spinal cord cut just below atlas.] - i R. T. A. T. - IR. T. A. T. * --~~. | P. M. P. M. 2.55 ------------------------------ I ()3 90 || 3.20 (; gr.of atropine perjugular). - . . . . . . . . . . . . . . 3.00 ------------------------------ 102 |. . . . . . . . 3.34 ----------------------------- | 101 - - - - - - - - 3.05 (35 gr.of atropine per jugular) . . . . . . . . . . . . . . . . 4.03 ----------------------------- 100. 4 ||-------. 3.08 -----------------------------. | 101.8 90 || 4.05 (3H gr.of atropine perjugular) 100.4 . . . . . . . . 3.25 -----------------------------. 101 - - - - - - - - 4.45 ----------------------------- 99 |- - - - - - - - EXPERIMENT II. [Cat; tracheotomy; spinal cord cut at second cervical vertebra.] P. M. - P. M. 1.15 ------------------------------ 103 98 || 2.26 -- . . . . . . . . . . . . . . . . . . . . . . . . . . . 104.5 ! . . . . . . . . 1.40 ------------------------------ 103.2 - - - - - - - - 2.33 (3's gr. of atropine). . . . . . . . . . | 103.6 !------ 1.58 ------------------------------ 103.6 |- - - - - - - - 3 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 102.7 . . . . . . . . 2.07 (#; gr.of atropine perjugular). . . . . . . . . . . . . . . . 2.53 ----------------------------- 102.7 |. . . . . . . . 2.20 ------------------------------ 5 !-------- 3.23 ----------------------------- 100. 1 |..... --. | 1238 PAN-AMERICAN MEDICAL CONGRESS. JEXPERIMENT III. [Cat; carotids ligated; tracheotomy; transverse section of brain just in front of medulla oblongata.] R. T. A.T IR. T. A. T P. M. P. M. 2.58 ------------------------------ 103.4 81 || 3.27 ----------------------------- 103.2 - - - - - - - - 2.54 (ºn gr. atropine per jugular)---------|-- - - - - - - 3.37 ----------------------------- 102.1 ! -- - - - - - - 3.00 ------------------------------ 103. 6 82 || 3.47 ----------------------------- 102. 1 . . . . . . . . . 3.11 ------------------------------ 104.2 . . . . . . . . 4.15 ----------------------------- 100.6 . . . . . . . . . 3.19 -----------------------------. 103.8 82 || 4.33 - - - -, -----------------------. 100, 1 |- - - - - - - - 3.20 (; gr. atropine per jugular). . . . . . . . . * * * * * * * 4.55 ----------------------------- 99 |- - - - - - - - EXPERIMENT IV. [Cat; carotids ligated; tracheotomy; section just in front ef medulla oblongata.] A. M. A. M. 0.17 ----------------------------- 104. 6 90 || 11.07 ---------------------------- 105.2 |- - - - - - - - 10.18 (3% gr. ofatropine perjugular)|........|- - - - - - - - 11.18 ----------------. . . --------. 104. 6 96 10.22 ----------------------------. 1()4, 7 92 || 11.19 (#5 gr, per jugular) - - - - - - - . . . . . . . . . . . . . . . . . 10.27 ----------------------------- 105. 1 94 1.25 ---------------------------. 104 - - - - - - - 10.33 ----------------------------- 104.8 |- - - . . . . . 11.30 ---------------------------. 103.4 . . . . . . . . . 10.44 ----------------------------- 105 95 || 11.35 ---------------------------. 103, 5 96 10.57 . . . . .---------------------. . . 104.9 |. - - - - - -. | EXPERIMENT W. [Cat; carotids ligated; tracheotomy; transverse section of brain just in front of medulla oblongata.] M [ (before section) (after section) * * * * * * * * * * * * * * * * * * * * * * * * * * * * * P. 2.00 (before section). -- - - - - - - - - - - - 2.25 2.34 • * * * * * * * IXPERIMENT WI. [Cat; carotids ligated; tracheotomy; transverse section of brain just in front of medulla oblongata.] A. M. A. M. 9.50 ------------------------------ 104.3 90 || 10.13 ---------------, ------------ 104. 6 - - - - - - - - 9.57 ------------------------------ 103.8 - - - - - - - - 10.17 - - - - - - - - - - - - - - - - - - - - - - - - - - - - 104. 6 90 10.03 ----------------------------. 103.8 |- - - - - - - - FXPERIMENT WII. [Cat; carotids ligated; tracheotomy; transverse section at anterior edge of pons varolii.] A. M. A. M. 9.28 (before section). . . . . . . . . . . . . . 102.4 75 || 10.37 ---------------------------- 100.4 86 9.37 (after section) - - - - - - - - - - - - - -. 101.6 |- - - - - - - - 10.43 ---------------------------- 100.3 |- - - - - - - - 10.24----------------------------- 100. 4 83 || 11.10 ---------------------------. 100. 7 90 10.81 ----------------------------. 100. 2 85 || 11.30 ---------------------------. 100.8 88 10.32 (3% gr. atropine per jugular). --------|-------. 11.40 ---------------------------- 100. 5 86 EXPERIMENT VIII. [Cat; carotids ligated; tracheotomy; transverse section at anterior edge of the pons varolii.] P. M. P. M. 1.30 ------------------------------ 102 7 || 2.35 ----------------------------- 103.2 92 2.13 ----------------------------. 102.2 97 || 2.44 ----------------------------. 103.2 | . . . . . . . . 2.20 ------------------------------ 102.6 95 || 2.53 ----------------------------- 104.2 90 2.27 ------------------------------ 102.8 94 || 3.20 ----------------------------. 105 90 2.28 (3% gr. atropine per jugular) -|--------|-------. 3.27 ----------------------------- 105 | . . . . . . . . 2.30 ------------------------------ 102.8 93 || 3.30 ----------------------------- 105 94 PAN-AMERICAN MEDICAL CONGRESS. 1239 NOUVELLES RECHERCHES SUR LES CENTRES THERMIQUES AU SUJET DE LA THERMOGENESIE THERMODYNAMIGUE. Par le Dr. B. BA CULO. Institut de Pathologie Générale de l'Université Royale de Naples. Gf NEI:ALITÉ SUR LA THERMOGf NESIE. Les manifestations thermiques sont liées aux phénomènes bio-chimioues qui se prodursent dans la texture intime des tissus. L'influence dinamogène du systeme nerveux, qui est le premier facteur dans le mécanisme de la régulation de la chaleur, est souveraine sur ces phénomènes. La temperature des organismes s'élève sans cesse selon le progrès des pécilother- mes aux oméothermes; dans ces derniers il V a la régulation de la chaleur. Cette fonction n'apparait dans les organismes animaux si le système nerveux n'a pas atteint une perfection, soit dans l'aggrégation des éléments istogénétiques, soit dans sa structure intime. Tout cela est bien clair en considérant le développement du système nerveux dans les pécilothermes, et mème dans les oméothermes, en regard du progressif perfec- tionnement que ce systeme acquiert dans la période de développement des mêmes, car pendant que se développent les pouvoirs qui causent la thermogénésie animale se perfectionne la thermo-régulation, et la temperature des animaux adultes s'égale au degré qui appartient à la classe et à l'ordre. La régulation thermique est donc liée au développement et au perfectionnement du système nerveux. » Mais cette fonction le système nerveux l'explique en toto, ou par centres et par voies nerveuses spéciales, ou mieux par des mécanismes spéciaux? Existe-t-il une régulation thermique indépendante du système vaso-moteur? EXISTE-T-IL DES CENTRES THERMIQUES? Voilà les questions que je me suis proposé de résoudre après des recherches expé- rimentales. Sur la première. Dans les névroses de l'isthme en bas l'existence de centres ther- miques est beaucoup douteuse, cari'opine que les phénomènes d'élévation ou d'abais- sement de la temperature jusqu'à présent remarqués sont liés à des désordres vaso- moteurs. L'existence au rebours des mémes centres dans les névroses de l'isthme en haut est un fait positif, assuré par des recherches expérimentales. TECHNIGUE EXPERIMENTALE. J'ai cherché à conduire mes recherches sur ce sujet dans les conditions les plus physiologiques que possible de l'animal: en localisant exactement la lésion par une technique spéciale; “ en marouant de courbes thermiques après une longue periode d'observations; et en usant des propres appareils thermo-électriques, dont l'un a été construit à dessein. Vraiment Je n'ai pas usé dans la technique expérimentale la trépanation et la chloroformisation en choisissant des lapins très jeunes, et en ayant auparavant bien étudié le rapport topographique entre les ganglions à la base du cerveau et la surface externe de la téte, j'ai pu léser les mêmes ganglions par diverses manières, dont la plus simple est avec une subtile aiguille de Pravaz, colorée à la pointe avec une solution de méthyl violet très saturée et séchée rapidement. Lorsqu'elle parcourt son trajet à travers les tissus, cette aiguille ainsi apprétée les colore, et à l'autopsie de l'animal on peut ainsi voir le point d'arrèt de l'aiguille, et son tra jet. * Voyez: Nota preventiva “Centri Termici,” Luglio 1890. Tip. Salvati o seguente edizione della Riforma Medica, e l'altra pubblicazione col titolo “Se esistano Centri Termici e se esiste una regola- zione termica indipendente dai vasomotori. 1240 | PAN-AMERICAN MEDICAL CONGREss. C'est ainsi que j'ai cru avoir bien localisé la lésion en la limitant à des points déterminés, sans causer de graves lésions collatérales, et en suivant, selon mon avis, la méthode la plus propre pour expérimenter dans les conditions de l'animal les plus physiologiques que possible. Pour les mesures thermo-électriques j'ai usé les aiguilies d'Arsonwall et construit en outre un galvanomètre spécial, qui par le courant thermo-électrique qui se déve- loppe d'une de ses aiguilles mise en un medium à 38º, donnait un arc impulsif de 209. COROLLAIRES EXPÉRIMENTAUX. Les résultats expérimentaux que j'ai obtenus sont : (1) En lésant le thalamo opti- que, on observe une élévation thermique générale avec prépondérance à la moitié correspondant à la lésion et à l'artum supérieur. (2) En lésant le tuberculum qua- drigeminum antérieur, on observe une élévation thermique générale avec prépondé- rance à la moitié correspondant à la lésion et dans l'artum inférieur. (3) L'injec- tion dans les ventricules latérales cause un abaissement de la température. (4) J'ai produit des lésions corticales, soit après piqûre (toujours à l'obscure), soit en faisant une fenêtre au crâne et en injectant dans les lacunes ipoméningées de l'eau distillée colorée avec le méthyl violet, pour connaître l'extension de l'irritation corticale. Les courbes thermiques sont signées par les apparats thermo-électriques, et ont démontré constamment un abaissement de la température qu1 dure pendant plu- sieurs jours. CENTRES THERMO-INHIBITOIRES CORTICAUX ET CENTRES THERMOGÈNIES BASILAIRES. Les centres thermiques sont donc distingués en thermo-inhibitoires, qui sont les corticaux, et dans le lapin se trouvent dans le lobe fronto-parietal ; et en thermo- · moteurs ou dynamo-thermiques ou encore thermogènes, et se trouvent dans les ganglions basilaires. Je ne peux entrer dans l'étude critique des centres thermiques, et par suite, malgré mon désir, je ne peux énoncer les autres faits qui rendent positif leur existence. Je suis convaincu que le secret pour déceler les fonctions du cerveau (du grand coordinateur de tous les centres réflex ordonnés) consiste à expérimenter dans les conditions les plus physiologiques que possible. OÙ EXISTE LE MÉCANISME RÉGULATEUR DE LA CHALEUR ? La mécanisme régulateur dans la production de la chaleur ne réside pas dans la moëlle épinière. Ici existent vraiment dans les colonnes latérales les fibres thermi- ques qui partent des centres thermiques encéphaliques, pendant que la fonction thermo-inhibitoire appartient sans doute à l'écorce cérébrale, qui a de même la fonc- tion d'inhibition des autres mécanismes réfléchis et ordonnés. RÔLE DES VASO-MOTEURS DANS LA RÉGULATION DE LA CHALEUR. Pour répondre à l'autre question : * Existe-t-il une régulation thermique indépen- dante du système vaso-moteur ?" il faudrait l'éprouver expérimentalement : (1) Quelle importance a le système vaso-moteur dans la thermogénésie et dans la régulation thermique ? (2) Sl l'activité des centres thermiques agit directement ou par les cen- tres vaso-moteurs ? Pour résoudre la première question, j'ai fait plusieurs recherches, qui m'ont donné les résultats suivants : (a) L'élévation thermique qui suit la neuro-parésis ou la nevro-paralisis vaso-motrice ne surpasse nullement la température moyenne du sang. (b) En excitant, ou en coupant le filet cervical du sympathique, dans le lapin, après avoir lié l'artère carotide, on n'observe pas de faits d'ipothermie, ou d'iperthermie locale. (c) Nulle quote-part d'élévation thermique n'est causée par la coupe du Sympathique qui ne soit en rapport direct : avec une plus active circulation, avec le –s, º. 4. e 5. G, Ay. 3. OR O RE, 6 RE. º e o e 2o. orro8 RE J.22º 2 l.07T08RE.722. 22.orrog.rzs 23. orros r32 24 orroarza 2S orro6.7; 2. l.ſº 2 6. O7 rog,7 23. A –N A- - a - v, –. /7. A ORE. 3 º M, 08E, le oas. O Rt. .. ORE D e «S. vS. | 2.| S. | D. oRR. - oRe. GR3. bRE. ORE. pnº - Q Re. ORE . o Rs. 7esra 4 0.4 S. 4/o S 3 o S 20 S' fo ORT 0 SUAo V, A0, Za 4/o & OA 7 o //yAr 2 a «5 4 o sº N. B.–A. Dopo preparazione della carotida sinistra. B. 6 minuti dopo puntura del talamo ottico sinistro. C. Allacciatura della carotida sinistra. D. 5 minuti dopo allacciatura carotida sinistra. a) Inizio del dissanguamento. e E. Dopo " 2 grammi di sangue da ambe le orecchie. F. Dopo tolti 13 grammi di sangue dalla giugulare destra. H. Dopo tolti 11 grammi di sangue dalla carotida destra. I. Dopo tolti 13 grammi di sangue dalla carotida sinistra (in sotto al punto d'allacciatura). D. Metà destra ... ... . Temperatura della ferita al collo per la preparazione della carotida simistra 28°. T. Temperatura dell' ambiente. O. La temperatura in questi 2 punti è pressa dopo lavaggio dell' orto. - S. Metà Sinistra - Temperatura della ferita al collo per la preparazione della carotida sinistra 22°. +–+ Nei tratti così segnati manca l'osserva- zione della curva termica. - - - - - Morte dell' animale. Manca l' ultima temperatura di tutta la metà destra. PAN-AMERICAN MEDICAL CONGRESS. 1241 degré de la chaleur accumulée dans le sang, et avec la différence de la température entre le sang même et le corps ambiant externe. (d) Les phénomènes de neuro-para- lisis vasculaire ne modifient pas la courbe des variations ascensionnelles ou de des- cente de la température locale (oreille du lapin) qui suit, au contraire, l'allure ther- mique générale causée par l'offense des centres thermiques encéphaliques. LES VASO-MOTEURS SONT LES DISTRIBUTEURS HYDRAULIQUES DE LA CHALEUR. Le système vaso-moteur règle donc la distribution de la chaleur dans l'organisme, puisqu'il règle l'activité du cœur et le ton des vaisseaux. * Aussitôt qu'il règle l'hydraulique de l'organisme, il régle pareillement la disper- sion de la chaleur. RÈGLE EN MÉME TEMPs LA DISPERSION DE LA CHALEUR. J'appelle cette régulation du nom de périphérique pour bien la distinguer de l'au- tre régulation que je nomme centrale. La première est sous le gouvernement direct du système merveux de la vie végétative, tandis que l'autre est sous le gouvernement du système nerveux de la vie animale. Le système vaso-moteur est néanmoins un facteur principal de la nutrition des centres thermiques, car il règle la circulation du plasme nutritif dans ces centres en réglant le ton des vaisseaux. ACTIVITÉ DIRECTE DES CENTRES THEIRMIQUES. J'ouvre la deuxième question : Les centres thermiques mettent-ils en exécution leur activité directement ou par les centres vaso-moteurs ? J'ai fait pareillement des recherches expérimentales pour résoudre cette question. Pour ôter tout doute, il fallait séparer l'élément vaisseau de l'élément nerf (je demande pardon de cette manière de m'exprimer) pour démontrer l'activité directe des centres thermiques. EXPÉRIENCES. J'ai pratiqué mes expériences de la manière suivante : Après avoir noté la tempé- rature du lapin avec les appareils thermo-électriques, je le lie dans la douche de Schwann et bientôt l'animal entre dans un calme parfait; je note encore la tem- pérature dans les mêmes points qu'auparavant; de suite je prépare la carotide et je note de nouveau la température de l'animal; je lie ensuite le thalamo optique par la méthode que j'ai exposée dans les précédentes publications, et j'observe, pendant un certain temps, la courbe de la température de l'animal dans les divers points notés précédemment, et après qu'elle s'est élevée, je lie l'artère préparée et j'observe ensuite l'allure des courbes thermiques dans les mêmes points qui ont été établis des le comInencement de la recherche. Les planches I, II, III appartiennent à d'autres expériences que je n'ai pas publiées dans les précédents écrits, et tendent à rendre plus évidentes les inductions que j'ai faites sur cette deuxième question. Expérience C, (Série V.) Lapin rougeâtre, du poids de 11 grammes. Je fais la piqûre du thalamo optique avec une aiguille de Pravaz teinte jusqu'à moitié de sa longueur avec une solution alcoolique très saturée de méthyl violet. L'aiguille est enfoncée de 3 mm. de la suture interpariétale, et à 2 mm. de la bramche gauche de la suture lambdoïde, en enfonçant l'aiguille de 2.05 cm. environ, jusqu'à faire paraître des petites secousses convulsives. Je laisse l'aiguille ainsi pendant 5 minutes seulement, en donnant à la pointe des petits mouvements latéraux. * L'existence des ganglions idio-vasculaires d'Huizinga est bien connue. Les recherches de Ludwig et Mosso sur les vaisseaux des chiens récemment extirpés et parcourus d'un courant de sang ; la restriction du calibre des artères jusqu'à l'occlusion complète de la lumière après des stimulus directs (Ludwig); la poursuite de la pulsation des veines dans la membrane volitante des chauve- souris après la recision de tous les nerfs (Luchsinger) ; tous ces faits affirment I'innervation locale des vaisseaux par ces ganglions idio-vasculaires. 1242 PAN-AMERICAN MEDICAL CONGRESS. Arrêté les premières secousses, qui durent environ 6 minutes; aucune autre ne paraîtrait pendant toute l'observation, et pareillement nulle vascularisation ne paraîtra dans les deux pavillons des oreilles du lapin. L'observation sur ce sujet dura 8 jours, après lesquels il fut tué en lui ôtant le sang. Voir la planche I pour l'allure de la courbe thermique et pour les autres remarques de la recherche. Autopsie.—Lésion du thalamo optique gauche jusqu'au # de son épaisseur. Dans les autres organes on n'observe rien d'anormal. Résultat expérimental.—La courbe thermique nous montre qu'après avoir lié la carotide gauche et pendant les jours successifs la température de la moitié gauche (côté correspondant à la lésion du thalamo) est restée en général plus élevée du côté droit, quoiqu'elle ait suivi la courbe thermique, ou l'allure propre aux lésions du thalamo optique. - Dans l'expérience suivante l'animal a été en observation pendant 34 jours, et la carotide a été liée 7 jours après la lésion du thalamo optique. Expérience L, (Série F.) Lapin gris du poids de 1,150 grammes. Je fais la piqûre du thalamo gauche comme il a été décrit ci-dessus, Le lapin n'est pas pris de secousses convulsives, mais seulement d'hyperesthésie dans l'artum inférieur gauche, parce que l'animal crie avec force lorsque j'enfonce l'aiguille. La perte de poids de l'animal est remarquable.* Pour la courbe thermique et pour les autres remarques de l'expérience voir planche II. Le lapin fut tué, en lui ôtant 1e sang. . Autopsie.—Lésion très évidente du thalamo optique où la course de l'aiguille était tracée au milieu des tissus de la peau en bas. Dans les autres organes nul fait anor- mal n'est observé.f 4 La persistance de la coloration du méthyl violet après un temps aussi long est due à la technique expérimentale que j'ai suivie. Le résultat de l'expérience confirme tout ce que j'ai observé dans l'autre recherche susdite. L'expérience suivante n'a pas été suivie de l'autopsie car le lapin vit encore. ! Expérience M, (Série P.) Lapin noir du poids de 1,700 grammes. Je fais la piqûre du thalamo optique gau- che comme il a été décrit ci-dessus. Après la piqûre, un mouvement de manège à droite est évident, lequel persiste pendant 11 jours et peu à peu diminue d'intensité, et le vingtième jour le lapin est en état de calme parfait, mais si on effarouche l'animal en le mettant en fuite, le mouvement de manège se reproduit de nouveau. Nous rencontrons dans cette recherche un seul fait nouveau : c'est le mouvement de manège. Mais ce symptôme est dû à la lésion des fibres du pédoncule par la poussée de l'aiguille dans sa course. En examinant la courbe thermique, planche III, on voit qu'à gauche, où a été liée la carotide, la température s'est élevée jusqu'à 129 au-dessus de l'état normal, et a suivi les modalités des courbes thermiques dans les lésions du thalamo optiqu.e. RÉGULATION DES OBJECTIONS PAR DEs AUTRES RECIIERCHES EXPÉRIMENTALEs. Dans ces recherches je crois presque du tout éliminée l'activité vasculaire, puis- qu'en ayant essayé ce sujet avec des autres expériences de preuve pour répondre à des objections scientifiques ou expérimentales, qui peuvent être mises en évidence en regard j'ai observé : (a) Que les effets de la blessure au col pour lier la carotide * J'ai remarqué ce fait même dans les autres expériences déjà publiées. Voir page 47 de la Mono- graphie " Centri termici e Centri vaso-motori in ordine alla termodinamica regolarizzatrice in condi- zioni normali e patologiche. Napoli : Tip. Salvati. Marzo, 1871. f Dans cette expérience, comme dans les autres déjà publiées, j'ai remarqué seulement tout ce qui touchait à la région encéphalique parce que je n'ai rencontré aucune lésion dans les autres organes. Pour cette raison les autopsies sont complètes. # Le défaut d'autopsie ne diminue pas l'importance de cette recherche, parce qu'en suivant la techni- que expérimentale ci-dessus décrite, dans de longues séries de recherches, j'ai pu acquérir une sûreté technique dans les lésions des ganglions à la base du cerveau. Comme j'ai pu le démontrer à une commission de cette faculté de médecine, composée des professeurs de Martini, Antonelli, Armanni, qui furent présents à une des expériences dans laquelle l'autopsie du lapin fut pratiquée par le Prof. Armanni, et où la lésion du thalamo optique que j'avais produite en leur présence fut rencontrée parfaite. 2 . l. 3. 2 4 2 S 2 o -7 / ?. veApe. 7 2 o. 2 O./V6/2A I 2 o. 2 l. N G RE 7 17 ºi. fv Sºfº a . Aveº e . . . Av6 Re A & Ré. si e vhke vie. vºie. pine piae eia e eshe pike º a –N , Tv, 8. T / ſi 7 /3.5 7 / 7. 7 i 7. r 17. r / 9 7. /7 r 19 T 17. T. /6-3 - D o R E A 8 C 2 a) a –s a \ a s –N –N - - - - - - - . 7 /g. 5 7 19 T. 19 7 /º - raro r S- r- 4 dº dº –N o a- e Cre a ra de fo ore 9 or º ore ore orº l or o or e or e orº , ore or 9. or 9 o re o re o re ove e or Se or o O 3 v o pa 2. / P Na it si 9 ? 4 lo 6 r e re a ore o rap re sra x o As 0. S | p. S | D | S | D. 5 | 2 | S | 0 | S | 0 | S S. | D | S S | D.| S.| D | S | O] S | D | S | A | S. 2| S A)| S | 0 l, l0 - - º • I vio, A) t/t, º 5 /2/lºt e vro. / 7. Se º/e 3. / 7 /VAG /PA . / 8 9/. o Rro , . P 7ul D JA voz ap. G. orro in F. la Dl -5 N. B. –A. Ore 1.18 p.m. Puntura del talamo ottico sinistro. B. Dopo 7 minuti dalla puntura del talamo. C. Ore 8.30 p, m. allacciò la carotida sinistra. D. 10 minuti dopo l' allacciatura della carotida sinistra, (t). Dopo l'allacciatura l'orecchio sinistro è piu vascolarissato del destro. - D. . . . . . . . . . . Mietà destra, T. Temperatura dell' ambiente in cui si sperimentava t Temperatura della metà destra in tal giorno. S. – – Metà sinistra. o. Temperatura della metà sinistra in tal giorno, In detto sperimento l' operazione della curva termica è durata 29 giorni. L'animale vive tuttora. a º º 2 e. a r 2 7, 2. 2 J. N BRt, NBne, N 8 a E si N i v3 0. º, º r q ſo r º - dº o Rg. N. 8 RE e Re . 0 B 5 B RE , iS 5 RF t l 8, N8Ri T: 14,5 14.N8Rt.T 2.0 T. 20 T. 18 T I8's 25. N 8 RE . T IT gº: gi i gºff : ii, T. I 3, 7, 20 :: º": 2v, D BAE, 7 /// E a Al - rim –v,-N –. r- B C - - - A-NA-N s - f) AS o Re ore. ore. ore. Ore, opee. o;-g ore. 0 -6, o ore ORE ore Orº Orº 0p e Org 9 ºr tp o) - 2 - re r uno ºss 3 na .hn re M 3.75 13 orº 0ro 0 -o ore è 6 ae S TEsrA AD S | Z) | S. S | D | S | D | S. D | Sl D. S. A) D | S. AD A), S | 0. s . - º S | A) 42 42 | S. Sl vo N È 5 ù S0 Si s È 29 è 4' S| lo A SAA: AP/A/ATA/7 o Z. SARA'/A do S 30 5 “n o S O oaro / va 4/o S N. B.–A. Dopo 5 minuti dalla puntura del talamo ottico sinistro. B. Sette ore 1.35 di tal giorno allacciò la carotida sinistra. C. 6 minuti dopo l' allacciatura della carotida sinistra. a). Inizio del dissanguamento. a D. Dopo tolti 5 grammi di sangue dalla carotida destra. E. Dopo tolti 31 grammi di sangue dalla carotida destra. I). . . . . . . . . . . Metà destra. T. Temperatura dell' ambiente in cui si sperimentava. S. – – Metà sinistra. in detto sperimento l'allacciatura della carotida si pratico dopo 7 giorni dalla puntura del talamo ottico. L'osservazione è durata 34 giorni. L' animale perdette di peso (dopo 11 giorni dalla puntura gia 80; dopo 14 giorni 180 ore). 13 ottob. r. 2 oº ce Ayr iº Orroe. r 2 o 5 e 1bprt T , or oRe , oas 0 E. 0RE. 0 AE 0RR 0RE. T 0RE ORE . ORE gra 0RE, 0Ri. 2 ORE. P. Ma 2. 5 3.5 i 35 6,35 i fa 7 lo 145 2.15 3. J.16 pra 2,2 5 0AFdChf/0. - Ao S. Zo S. Zo . ſ. 3 o7 7 o 3/7e. A & 9/. . Va vota . 4/º. N. B.–A. Ad ore 1.35 s'allaccia la carotida sinistra. B. Da questa misura in più furon sospese quelle della metà destra, osservandosi solo le sinistre per ragioni facili ad intendere. e s e º a s e a º º e Metà destra. S. – metà sinistra. s T. Temperatura dell' ambiente in cui si sperimentava. 4 S ſºf S. SAAere.v. (lºt. orro e Rs. sa t.) Javount. li:ºrrosREr 2 o 5.º cenr e orros rasº Gaa, 0ſt I°8, N. B.–A. 20 minuti dopo l' allacciatura della crurale sinis- tra. S. metà sinistra. T. Temperatura dell' ambiente in cui si sperimen- taVa. PAN-AMERICAN MEDICAL CONGRESS. 1243 n'altèrent pas les résultats expérimentaux de la recherche parceque la ligature de la carotide a été pratiquée immediatement après la piqûre du thalamo optique, en certaines expériences, autrefois après plusieurs jours, et les résultats de la recherche (en regard des courbes thermiques) sont restés identiques. (b) En ayant lié la carotide et la sous-clavière, et en ayant ensuite coupé encore le filet cervical du sympathique dans le lapin. Je n'ai pas observé d'élévation thermique dans l'oreille du lapin. Ces expériences vont même à l'encontre de l'objection : que les anastomosis terminales des artères puissent réintégrer la circulation dans le champ des occlusions des artères, et même la température. Les faits expérimentaux démon- trent sans doute le contraire de l'objection susdite, parceque la température dans le champ d'occlusion de la carotide est plus élevée que dans le côté, oîi la circulation est normale. Cette élévation 1nême est évidente; soit après l'occlusion de l'altère, soit dans le parcours de plusieurs jours successifs (trente et plus encore). (c) Est-il 2nême éliminé ? Sans doute que l'anémie du centre lésé, en opérant comme une exci- tation, eût pu causer l'iperthermie parcequ'une ample vascularisation est établie pour le cercle artérien de Willis, et les phénomènes d'iperthermie sont continués pour plusieurs jours, après l'occlusion de la carotide. (d) Est-il éliminé encore ? Sans doute que l'élévation de la température, après l'occlusion de la carotide, est causée par l'anémie des tissus (pour la ligature des grosses tiges artériennes) dans le côté de la tête répondant à la lésion, parceque, quoiqu'il soit bien connu que dans les par- ties de l'organisme où la circulation du sang est supprimée, la température s'abaisse rapidement, les expériences que j'ai faites ont démontré assurément un abaissement de la température dans les côtés où était close la circulation des grosses artères (carotide, etc.). s， Voici les remarques expérimentales : Expérience R, (Série V.) Je note la température des oreilles et des deux côtés de la tête d'un lapin. Je clos ensuite la carotide gauche, et je note pour trois jours l'allure de la courbe ther- mique des mêmes places. La température (voir planche IV) reste toujours plus basse qu'avant l'occlusion de l'artère. Expérience S, Série V. En un lapin je note la température de l'artuna postérieur gauche, et ensuite je clos la crurale. La température s'abaisse, comme il est remarqué dans la planche IV, où on voit l'allure des courbes thermiques des deux rocherches susdites, qui démontrent préci- sément la faiblesse du doute sus-énoncé : Que l'élévation thermique qui suit aux légions des centres thermiques ne puisse pas se rapporter à la fièvre de réaction du traumatisme cérébral, parceque le trauma avec la méthode que j'ai suivie est ramené aux limites les moindres que possibles. C'est une piqûre avec une mince aiguille de Pravaz, parce que j'ai banni de la technique la trépanation, la chloroformisation, etc. A la fin on ne peut pas mettre au nombre des fièvres de réaction les élévations thermiques remarquées au-delà de 30 jours. Ces élévations thermiques sont plus remarquables parce que l'aiguille est enfoncée dans le tissu cellulaire sous-cutané, qu'à une température moins élevée que les autres tissus. ENCORE SUR L'ACTIVITÉ DIRECTE DES CENTRES THERMIQUES. L'activité dynamogène directe des centres thermiques est manifestée aussi par un autre fait : - Souvent il arrive dans les observations thermo-électriques que le galvanomètre ne marque pas le même arc, quoique avec la même vitesse on enfonce l'aiguille dans les tissus, on l'approfondisse pour la même longueur et on l'enfonce encore dans la même fenêtre cutanée pour observer la température de la même place. Ce fait est-il causé par les oscillations de l'activité dynamogéne directe des centres thermiques ou par les actions vasculaires ? 1244 PAN-AMERICAN MEDICAL CONGREss. Pour résoudre ce doute j'ai expérimenté ainsi : J'ai enfoncé l'aiguille thermo-elec- trique, trempée dans la paraffine et gardée à une température constante avec l'étuve de Meyer, et j'ai toujours noté un arc galvanométrique constant. Bien, pourquoi dans les observations de la température de 1'animal dans les condi- tions susdites, avons-nous des arcs galvanométriques qui varient de l'un à l'autre moment ? Voici les recherches que j'ai faites : Ayant, sur le thorax d'un lapin, appliqué le cardiographe, je recueillis sur un cylindre mu par le régulateur de Foucault le cardio- gramme (le cylindre achevait un tour pendant 3 minutes). Sur le cardiogramme je remarquai que l'intervalle entre les deux ordonnées systo- liques était en moyenne presque 3 mm. C'est pour ça qu'ensuite je disposai le signal électrique de Depretz en le réglant avec un métronome de telle manière qu'il traçat sur le même cylindre une courbe (parallèle au cardiogramme) avec une série d'interruptions qui se suivaient à 3 mm. d'intervalle, c'est-à-dire la distance qui était entre les deux ordonnées systoliques du cardiogramme. Ayant ainsi disposé les choses, j'enfonçai sous la peau l'aiguille thermo-électrique dans le même moment complétant le circuit électrique entre le métronome et le signal électrique. Il est bien évident qu'ainsi les interruptions du signal électrique étaient marquées sur le cylindre, que de systoles du cºeur du lapin, toutes les fois que l'activité car- diaque ne variait pas pendant l'expérience. Bientôt je pus remarquer que le cardiogramme, en plusieurs rencontres, coïncidait (pour la série des ordonnées systoliques) avec les interruptions du signal électrique, et en de tels rencontres l'aiguille thermo-électrique notait de très rapides oscil- lations de la température, rendues très évidentes par des arcs galvanométriques très variables sur le champ. Quoique dans cette expérience les activités vaso-motrices ne soient pas tout à fait éliminées, néanmoins en la comparant avec les autres énoncées ci-devant, je crois qu'on peut en inférer que de telles variations si sensibles de l'aiguille thermo-elec- trique sont causées par l'activité dynamogène directe des centres thermogènes basilaires. •s La très sensible variabilité des températures locales est un fait que j'ai remarqué autrefois. La variabilité des arcs galvanométriques est évidente en passant de l'une à l'autre observation thermo-électrique, quoiqu'elles fussent environnées de toutes les finesses qui sont ordonnées par l'électro-technique. Cette variabilité varie en certaines limites, qui suivent en général la courbe ther- mique ascensionnelle ou de descente que l'animal montre pendant l'expérience. Par les expériences susdites et par les autres que j'ai publiées auparavant, je crois avoir des bases solides et je suis à la fois autorisé à confirmer tout ce que j'ai publié dans les années précédentes sur la fonction thermique spéciale des centres nerveux. COROLLAIRES SUR LA RÉGULATION DE LA CHALEUR. Ayant démontré l'inhibition thermique corticale sur les centres basilaires, de même que le manteau cortical a l'inhibition sur tous les centres automatiques et ordonnés, qui sont au-dessous dans la névraxe, il est bien claire : (1) Que la régula- tion de la chaleur est due à l'équilibre entre des forces opposées qui s'expliquent entre les centres thermo-basilaires (thermogènes) et les centres cortico-inhibitoires- thermiques. (2) Que selon la prépondérance de l'activité fonctionnelle des premiers sur les autres il y a hyperthermie ou hypothermie. (3) Que la somme des tensions dynamiques, thermiques et partielles, causées par l'excitation de chacun des centres thermiques, doit être égale à la tension de tous les centres à fonction homologue. PAN-AMERICAN MEDICAL CONGRESS. 1245 Voici l'effet utile qui résulte de l'énergie de tels centres, symbolisé avec la formule : ou CT est le symbole d'un centre thermique, et a, b, c sont les symboles de chacun des centres susdits (corps striatum, thalame, etc.). Voici la régulation que je nomme centrale, dans le domaine du systèn1e nerveux de la vie animale. MÉCANISME DE LA RÉGULATION DE LA CHALEUR. Physiologiquement la fonction régulatrice de la chaleur est une, mais pour en entendre la mécanique j'ai divisé les deux principaux mécanismes (qui sont tout-à- fait sous le domaine du système nerveux) en les contre-signant avec le nom de régu- lation centrale et de régulation périphérique. Ceci, bien plus, est un système de compensation physiologique très important qui arrive pour faire acquérir à la température animale (dans les homéothermes) une moyenne constante. La régulation automatique des vaisseaux influe indirectement sur la fonction des centres thermiques, pour l'influence qu'a sur la nutrition des mêmes. Voici un lien nutritif entre régulation centrale et régulation périphérique; c'est le lien harmonique entre le système nerveux de la vie anormale et l'autre de la vie végétative. Mais il y a encore un autre lien, le fonctionnel. C'est précisément ce lien là qui exerce l'écorce cérébrale avec son activité cortico- inhibitrice aux centres thermiques, basilaires, (ou thermogènes) et cortico-inhibitrice aux centres vasomoteurs. Puisque ies voies réfléchies des arcs diastaltiques thermiques doivent être tout-à- fait distinguées par les autres aussi réfléchies des arcs diastaltiques vasomoteurs corticaux. Tandis que les premières vont aux centres basilaires thermogènes, les autres vont aux centres vasomoteurs du bulbe et de la moelle épinière. IPLANCHE EXIPLICATIVE DE TIEL MÉCANISME. Tous les deux systèmes d'arcs diastaltiques, quoiqu'ils aient tel lien intime, · jouissent d'un automatisme fonctionnel dans le domaine de l'activité cortico-inhibi- trice de l'écorce cérébrale. C'est pour de tels mécanismes que la faculté d'équilibre entre la production thermi- que et la dispersion a des limites physiologiques très amples dans les animaux et plus encore dans l'homme, qui a le système de coordination le plus parfait, dans tous les mécanismes réfléchis ordonnés. La planche V rend bien clair la dynamique de tels mécanismes. Il faut à la fois dire que chaque centre thermique (thermogène ou cortico-inhibitoire), comme tous les centres nerveux, est centre d'un arc diastaltique avec des voies incidentes et des voies réfléchies. Les incidents sont les thermo-sensitives et elles vont avec les voies de sens,* les refléchies sont bien distinguées, selon qu'on traite des centres thermo- inhibitoires corticaux, ou des centres inhibitoires corticaux aux vasomoteurs, ou après tout des centres thermogènes basilaires. Les voies réfléchies de ces derniers ont été demontrées expérimentalement, tandis que les voies réfléchies aux centres de l'écorce cérébrale sont admises avec assuré jugement et,sont les mêmes voies par lesquelles se transmet la inhibition des centres corticaux aux centres automatiques ordonnés mis dessous, savoir : les thermogènes basilaires et les vasomoteurs. * Ces voies de sens encore, comme les voies motrices ont la décussation dans les pyramides, et forment ainsi le croisement pyramidal supérieur de Meynert. Voir page 56 de ma publication, 1ère édition, 1891 : " Se esistano centri termici e se esista una regolazione termica indipendente dalsistema vasomotore.'' 1246 PAN-AMERICAN MEDICAL CONGRESS. Pour tels mécanismes la production thermique est réglée par le système d'arcs diastaltiques thermiques, qui ont leur centre dans les cortico-inhibitoires thermiques et dans les thermogènes basilaires, tandis que la dispersion est réglée par l'autre système d'arcs diastaltiques, qui ont pour centres les cortico-inhibitoires aux vaso- moteurs, les centres vasomoteurs et la série ordonnée de ces derniers. (Voyez plan- che V). Les mécanismes de tous les deux régulations sont activés en conditions physiolo- giques par stimulus réfléchis constants. ENCORE SUR LE MÉCANISME SUSDIT. L'harmonie de la production thermique avec la dispersion physiologiquement subite des oscillations, qui trouvent leur interprétation dans la variabilité des stimulus de l'ambient externe (dans le sens le plus large du mot). La régulation de la chaleur en conditions physiologiques ne pourrait s'activer sans les voies incidents et sans les stimulus du monde externe (dans le sens plus large du mot) sur telles voies. La température des homéothermes subira des graves oscillations, ne garderait nas la température media physiologique constante à chaque ordre et classe. C'est pour ça que la nature a multiplié les voies incidentes* sur les motrices (les réfléchies). Il est bien clair, qu'il existe une apperception thermique liée aux activité cortico- thermo-sensorielles. Parce qu'étant le sensorium commun avisé de toutes les variations des stymulus périphériques (dans les sens plus large du mot) tout à la fois excités même les centres régulateurs du dynamique termique, qui sont activés physiologiquement par excitation réfléchie et constante, car l'excitation authocthone, n'est pas le stimulus ordinaire. Dans un champ si vaste de centres d'arcs diastaltiques, thermiques et vasomoteurs les stimulus authocthones ne peuvent être portés que par le plasma qui les arrose. THÉORIE SUR LA FIÈVRE. C'est pour ça que l'abnorme crasis du plasma, le chimisme altéré du plasma qui les arrose, vient traduit en faits de dynamique thermique altérés par imparfaite fonctionalité de la série ordonnée des mécanismes thermiques et dispersifs. Altérée de cette façon la nutrition de tels centres nerveux, l'organisme est en proie du procès fébrile. La voici la cause unique productive du procès félbrile : C'est la crasis du plasma altérée pour changement chimico-moléculaire du même, qui influe directement sur la nourriture des centres des arcs diastaltiques thermiques et des arcs diastaltiques Va,SOmOtelll'S. : - - En conséquence il y a la rupture des harmoniques rapportés (lien nutritif et fonctionnel sus-énoncé), par lesquels vient accomplir la fonction thermo-regula- trice physiologique. Par l'altérée nourriture des centres des arcs diastaltiques susdits en suit une faiblesse dynamogène nerveuse, qui se traduit sensiblement en une moindre célérigé de vibrations de l'éther nerveux. - La diminution de la quantité de mouvement de l'éther nerveux en telle rencontre est telle que ne peut pas modifier l'extension, la célérité, la direction des vibrations de l'éther, traduit sensiblement en chaleur par les activités chimiques des tissus. Elle est parétique sans doute dans le système nerveux l'activité qui rend har- monieuse les vibrations de l'éther nerveux à l'état de vue des éléments cellulaires. Est-elle paréthique précisément l'activité apte à traduire la chaleur chimique en chaleur organique vitale, c'est-à-dire : **Telle qui ne puisse altérer la vie des pro- toplasmes cellulaires.'' * Les Physiologistes opinent que les fibres de sens soient presque deux fois autant que les fibres motrices. Voyez Paladino, 1885, Instit. Physiol. et des autres Traité de Physiologie. PAN-AMERICAN MEDICAL CONGRESS. 1247 L'organisme ainsi est en proie des activités chimidues, qui s'exagèrent méme pour les changements chimioues moléculaires du plasma, qui influent à son tour sur la nourriture des autres protoplasmes cellulaires, en rendant anormale la nutrition, et en accelérant en plusieurs rencontres la totale désagrégation moléculaire. La doctrine physio-pathologique de la fiºvre, comme j'ai déjà publié depuis long- temps dans mes précédents ouvrages, doit être fondée sur l'altérée nourriture des centres de la série ordonnée des arcs diastaltidues thermiques et vasomoteurs pour l'altérée crasis du plasma, et en conséquence, sur l'alterée mécanique régulatrice thermique, rendue anormale dans les fonctionnements des deux mécanismes susdits: le central pour la production de la chaleur, et le periphérique pour la dispersion. - CENTRES THROPHIQUES. Sur la question : Si les centres thermiques soient méme centres throphiques, je crois pouvoir donner aussi des modestes résultats. Les recherches expérimentales m'ont démontré que les animaux lésés en tels cen- tres perdent du poids. Ce fait, je l'avais déjà remarqué à page 53 de ma dernière publication.” Le lapin de l'expérience S (Série V), 4 Mars 1891, perdit en 10 jours 60 grammes de son poids, et la temperature fut toujours au-dessus de la normale. Le lapin de l'expérience L (série V), 18 novembre 1891, perdit de poids après 11 jours de la lésion encéphalique 80 grammes, après 14 jours 180 grammes. Donc une preuve presdue directe pour infrer que les centres thermiques soient mêmes des centres throphiques, Tout ceci est bien en harmonie avec les vues que nous avons déjà sur la nourriture de l'organisme. Il est bien connu que le mouvement thermique organigue est lié intimement avec les acts nutritifs de l'organisme. THEORIE SUR L'INFLUENCE DU SYSTÈME NERVEUX SUR LA CHALEUR ORGANIQUE. En ayant démontré que dans la régulation thermique le système nerveux n'agit pas en toto, mais par mécanismes réfléchis ordonnés, par centres thermiques et vaso- moteurs, par centres et par voies spéciales, je dois conclure, quant à l'influence du système nerveux sur la production thermique, en opinant: que l'activité dynamogène nerveuse avec son mouvement vibratoire, modifie la célérité, l'extension, et la direc- tion des vibrations de l'éther, mis en vibration par les actes chimico-biologiques, qui arrivent dans l'intime texture des tissus, avec phénomènes d'interférence de mouvement vibratoire, et avec modification dans la direction de la propagation de tel mouvement. Le voici précisément dans la vie nutritive physiologique comment la chaleur chi- mique se traduit en chaleur organidue vitale, c'est-à-dire en parfaite harmonie quant à son degré avec les conditions de vie des protoplasmes cellulaires. Dans la vie nutritive pathologique, dans la fiºvre, c'est-à-dire dans l'inanition pathologique désignée par des changements chimidues-moléculaires du plasma, la chaleur organique vitale, dans le sens susdit, se traduit en chaleur chimioſue, pour l'activité dynamogène affaiblie du système nerveux, ou mieux, pour la célérité vibratoire affaiblie de l'éther nerveux, qui pour cela n'a pas tout à fait la quantité de mouvement, telle qu'elle puisse modifier la célérité, l'extension et la direction des vibrations de l'éther, mis en vibration calorigène par les échanges chimico-biologi- ques des tissus. - Comme j'ai déjà précédemment publié, il serait bien banal de songer que les cen- tres thermiques (les thermogènes basilaires) soient producteurs de la chaleur. Celle-ci est produite dans l'organisme par actions chimigues qui se produisent dans l'intime texture des tissus. * Voir Monographie “Centri termici e centri vasomotori in ordine alla termodinamica, ecc., 1891. Tip. Salvati: 2°. ediz. 1248 PAN-AMERICAN MEDICAL CONGRESS. Cette chaleur, ce mouvement vibratoire de l'éther, est modifié par l'activité dyna- mogene du système nerveux, par les vibrations de l'éther nerveux. Les centres thermiques étant centres d'arc diastaltiques sont des voies de conduc- tion des vibrations de l'éther nerveux. Telles vibrations sont excitées par les stimulus du monde externe (dans le sens plus large du mot), qui agissent sur les extrémités des voies incidentes de la séria- tion ordonnée des arcs diastaltiques. Les mêmes vibrations de l'éther nerveux se propagent ensuite du centre de l'arc diastaltique par la voie réflechie, lorsque tels stimulus sont physiologiques, mais si au contraire ces stimulus sont abnormes, il se renverse la direction des vibrations de l'éther nerveux, il y a alors un transfert d'activité dynamogène, de la branche réfléchie dans les voies incidentes des arcs diastaltiques, et ainsi sont altérés les mécanismes ordonnés, par lesquels la vie s'explique. RÉFUTATIONS DE QUELQUES EXPÉRIENCES DE HALE WHlTE. Je ne puis pas clore cet argument sans discourir d'une récente recherche d'Hale White publiée dans le Journal of Physiology, Vol. xII, Nov. 3 de 1891. L'assemblée opine que la température des inguinées dans le lapin soit plus éle- vée que celle du rectum. De ces résultats expérimentaux il infère des conclusions sur les ablations de l'écorce cérébrale, quant à l'influence de la même sur le rapport entre la température vitale et l'inguinale. White expérimente ainsi : avec le même thermomètre mis dans le rectum, il passe à mesurer la température de l'inguinée. Il a remarqué dans cette rencontre que la colonne de mercure monte encore de quelque dixième pour 3 ou 4 minutes. J'ai expérimenté même de cette façon, et d'avantage j'ai fait des autres recherches en observant la température avec des aiguilles et des sondes thermo-électriques, et j'ai eu des résultats opposés : la température anale a été toujours supérieure à l'in- guinale. C'est pour ça que je n'ai pu pas suivre White dans ses vues sur l'influence de l'écorce cérébrale. EXPLICATION DE LA PLANCHE V. M. C. Manteau cortical. C. S. Corps striatum. T. O. Thalamo optique. M. A. Moelle allongée. P. C. Périphérie du corps (au sens large du mot. ) C. V. Appareil cardio-vasculaire. 1. Centres thermo-inhibitoires corticales. 2. Centres inhibitoires-vasomoteurs corticals. 3. Centres thermogène basilaires du corps striatum. 4. Centres thermogènes basilaires du thalamo optique. 5. Centres vasomoteurs de la moelle allongée (coordinateurs des autres centres ordonnés vaso- moteurs périphériques et de la moelle épinière). • 6, 6'. Extrémités terminales des voies nerveuses à la périphérie du corps et dans les systèmes cardio-vasculaires. a. Voies thermo-sensitives (incidents au centre 1 ). b. Voies thermo-motrices (réfléchies des centres (1) c'est-à-dire : voies inhibitrices de l'écorce cérébrale aux centres thermogènes basilaires). c. Voies thermo-sensitives (incidentes au centre 4.) Elles parcourent le cin gulum thalamicum. d. Voies thermogénes ou thermo-motrices (sont démontrées expérimentalement et abornent dans l'intime texture des tissus, c'est pour cela que modifient les actions bio-chimiques). . e. Voies sensitives (incidentes au centre 2). Jf. Voies motrices, inhibitrices aux vasomoteurs de la moelle (réfléchies des centres 2). g g'. Voies incidentes de la périphérie ou du système vasculaire au centre (5) et sa dépendance (centres vasomoteurs de la moelle). h h'. Voies motrices (réfléchies des centres (5) et ses dépendances à l'appareil cardio-vasculaire, PLANCHE V. PAN-AMERICAN MEDICAL CONGRESS. - 1249 a 1 b. Symbolise le système des arcs diastaltiques thermo-inhibitoires corticaux A. c 4 d. Symbolise le système des arcs diastaltiques thermogenes basilaires B. e 2 f. Symbolise le système des arcs diastaltiques corticaux inhibitoires au centres vasomoteurs de la moelle allongée C. . g 5 he g’ 5 h". Symbolise le système des arcs diastaltiques vasomoteurs de la moelle et périphé. riques P. - La mécanique thermique régulatrice des conditions physiologiques s'accomplit par deux systèmes d’arcs diastaltiques Sériès entre eux: Les systèmes A. et B par lesquels est accomplie la régulation centrale; et les systèmes C et I) par lesquels est accomplie la régulation périphérique. - La mécanique des deux régulations est activée par stimulation réfléchie constante. Tous les deux ont entre elix des liens intimes: Ile nutritif et le fonctionnel. Tous les deux jouissent d'automatisme fonctionnel, sous le domaine de l'activité inhibitrice corticale. (V. la Monographie au titre “Centri Termici,” inillet, 1890, Tip. Salvati, et les autres successives.) THE A BSORPT'I()N OF IRON IN THE ANIMAIL BOI)Y. By A. B. MACALLUM, M. D., Professor of I’hysiology, University of Toronto. The author's observation on the distribution of iron in the animal and vegetable cell have resulted in determining that the chromatin of every species of cell is an iron-holding compound and that this substance gives origin to the lasmoglobin in the animal body. It follows from this that the iron of inorganic preparations in the food, if it is assimilated at all, must go directly to the formation, not of haemo- globin, but of chromatin—a conclusion which necessitates a revision of the com- monly accepted views as to the physiological relations of iron, and which at the same time suggests two interdependent questions: (1) Is chromatin formed in the animal body, or is it formed in vegetable organisms only 3 (2) What is the true explanation of the beneficial effects of the administration of iron salts? In an attempt to answer these questions, various compounds of iron have been administered to animals (guinea pig, rabbit) in order to determine by micro-chem- ical and histological methods their action in the intestine. The investigation has yielded results which may be summarized thus: (1) The chloride, phosphate, and sulphate of iron and certain organic prepara- tions of iron are absorbed by the epithelial cells of the villi and by the siderophi- lous cells surrounding the lacteal vessels. (2) When given in large doses, certain preparations of iron have, upon the absorbing elements, especially the siderophilous cells, an effect similar to chemotaxis. (3) The absorption of iron compounds occurs chiefly in the upper and middle por- tions of the small intestine. The beneficial effects of the administration of iron in anaemia Inay, in large part, be explained on the view that iron salts increase the absorptive activity of the intestinal mucosa. Other investigations on the absorption of chromatin tend to support this view and to indicate that inorganic and albuminate compounds of iron are not assimilated in the animal body, or, in other words, iron-holding nucleo- albumins are products of vegetable metabolism only. The bearings of these observations on the pathology of simple anaemia and chlo. rosis and on the subject of nutrition is discussed at length in the original paper. 1250 PAN-AMERICAN MEDICAL CONGRESS. ON THE PROTEOLYSIS OF CRYSTALLIZE I) PHYTO-GLOBULIN OR WITELLIN. * & By Dr. R. H. CHITTENDEN. The study of digestion is interesting and important in its chemical as well as in its purely physiological aspects. In the performance of the natural functions of the body these two phases are everywhere closely related. The phenomena to which each gives rise are dependent upon those of the other to a very great extent, and the normal or abnormal manifestation of the one series of actions always has a decidedly modifying influence upon the conditions of the other series. It is in its chemical aspects, however, that the basis of a correct interpretation of the digestive processes lies, and since proteid foods are essential to the very existence of the body the study of the chemical changes which these undergo in digestion is of great sig- nificance to the physiologist. Considerable was known in a general way, previous to Meissner's work, regarding the greater solubility and diffusibilty of the end products of proteolytic action; but this investigator and Brücke were the first to advance more definite views as to the nature and reactions of these products. Their opinions, however, differed somewhat; the discordance being often due doubtless to a difference in the arti- ficial conditions of their experiments and in the interpretation of their results. The more recent discoveries pertaining to the proteoses and true peptone are especially responsible for the present theories of the chemical physiology of proteid digestion. At the present time the study of the cleavage products resulting from the action of the gastric and pancreatic proteolytic ferments has been extended so as to include practically all of the common forms of proteid matter. All of the results obtained lend favor to the theory that in digestive proteolysis the large proteid molecule undergoes a series of progressive changes, resulting in a cleavage into relatively smaller molecules, representing bodies more soluble and more diffusible; thus they better fulfill the physiological requirements of absorption and an example is afforded of how important a part chemical transformation plays in the functional activity of the system. - The advances in the methods of separating the individual albuminoses or proteoses have given an added impetus to the study of the products obtainable from different proteids, especially in view of the natural diversity of proteid food stuffs. The resulting proteoses and peptones, as might be anticipated from their varied origin, show some noticeable differences in their reactions, as well as in their composition, although certain marked characteristics are common to all of a given series. Blood- fibrin, myosin, paraglobulin, egg albumin, elastin, gelatin, casein, and gluten- casein have all been investigated, and their digestive products carefully examined. This, to be sure, has extended our knowledge of the individual proteoses and given us much valuable information, but in order to understand thoroughly the precise nature of the digestive processes we need to be very sure of the exact nature and chemical composition of the proteid undergoing digestion. In any exact study of the relationship between the various products resulting from ordinary proteolytic action and the mother proteid, the purity of the latter must first be assured. Obviously the colloidal or amorphous character of ordinary proteids is a great obstacle to chemical purity. In crystallized phyto-globulin, however, we have a form of proteid matter, the crystalline character of which offers a comparatively easy means of insuring reasonable purity. These crystalline proteids have, indeed, been known for a long time, and Neumeister, f as well as the writer, f has previously *Abstract of a paper by R. H. Chittenden and L. B. Mendel. fUeber Vitellosen; Neumeister, Zeitschrift für Diologie, Pand 23, p. 402. :Crystalline globulin and globuloses or vitelloses. Chittenden & Hartwell, Journal of Physiology, vol. ii, p. 435. PAN-AMERICAN MEDICAL CONGRESS. 1251 reported on a few experiments designed to throw some light on the character of their digestive products. Hitherto, however, the great difficulty attending the preparation of large quantities of these crystalline proteids, and the somewhat vague ideas as to their nature, have constituted obstacles sufficiently great to inter- fere with their use in digestion experiments. Within the last two years Osborne,” making an extended study of the crystalline vegetable proteids, has called attention to the relative abundance of a beautifully crystallized globulin or Vitellin in hemp seed. This proteid we have been able to isolate in a state of perfect purity in quantities sufficient for all practical pur- poses, and with this product have attempted a further study of the proteoses and peptones obtainable by the action of both pepsin and trypsin. The hemp seed proteid crystallizes in the form of clean cut octahedra with some hexagonal plates. Under the microscope the crystals are seen to have as sharply defined edges as crystals of arsenious oxide freshly sublimed, thus showing the absence of amorphous impurities. It is a typical globulin, or phyto-vitellin, prac- tically insoluble in water, but easily soluble in 10 per cent salt solution, especially when warm, and crystallizing readily from a hot saturated solution as the fluid cools. Further, when a salt solution of the proteid is dialyzed the vitellin frequently sep- arates in crystalline form as the salt diffuses. In fact, it is a globulin exceedingly prone to crystallize, even under what might be termed unfavorable circumstances, a peculiarity which tends to give an assurance of purity. It is readily soluble in 0.2 per cent hydrochloric acid and in 0.5 per cent sodium carbonate, being readily converted, especially with the aid of heat, into acid albumin and alkali albumin, respectively. Like all globulins, it is more or less coagulable by heat, but is peculiar in that the coagulation point is exceedingly high; thus, a 10 per cent sodium chlo- ride solution containing 0.5 per cent of the proteid does not show any signs of tur. bidity until a temperature of 79° C. is reached and flocks do not appear until the temperature rises to 91° C. Even then, and indeed on boiling the solution, coagula- tion is very incomplete. A quantitative experiment tried in this connection is interesting as showing how little confidence can be placed in separations made solely by heat precipitation. Thus, 10 grams of the pure crystallized proteid were dis- solved in about a liter of 10 per cent salt solution and the fluid heated to boiling and kept at that temperature for thirty minutes. The flocculent coagulum result- ing was filtered off, washed, and weighed. It amounted to just about 50 per cent of . the original proteid. The filtrate from this heat-precipitate was then dialyzed until the greater portion of the salt was removed, when the remaining globulin separated out in the original crystalline form, thus showing that it had not been altered by the prolonged exposure to the high temperature. Again dissolved in salt solution and exposed to 100° C., another coagulum gradually formed; and doubtless if this process had been repeated a sufficient number of times the entire quantity of glob- ulin would have been coagulated. Evidently, however, this vegetable globulin is very slowly coagulable by heat. The composition of the crystallized proteid is much the same as that of the more frequently analyzed squash seed globulin, being especially characterized by a high content of nitrogen and a correspondingly lower content of carbon. Thus, the average composition of several distinct preparations shows 51.58 per cent of carbon, 6.88 per cent of hydrogen, 18.80 per cent of nitrogen, 1 per cent of sulphur, and 21.65 per cent of oxygen. Like all proteid bodies, this phyto-vitellin is laevorotary; dissolved in 10 per cent §-–53.8°. Haas has determined the spe- cific rotation of serum globulin to be . –59.7°. Dissolved in 0.2 per cent hydrochloric acid, the proteid is readily attacked by pepsin, and is gradually transformed into proteoses and peptone, while a small amount is simultaneously converted into an salt solution it has a specific rotation of *American Cheru. Journal, vol. 14, p. 675, 1252 PAN-AMERICAN MEDICAL CONGRESS. insoluble anti-albumid-like body, which may be appropriately termed anti-vitellid. It is needless to say that in these digestion experiments the pepsin employed was a carefully purified preparation of the ferment, as free as possible from all traces of adhering albumoses, etc. It is unnecessary to weary you with details of separation and methods of purification; suffice it to say that two pepsin digestions on a large scale were carried out, 150 grams of the pure crystallized proteid bein g used in each digestion. In the first experiment the mixture of proteid, pepsin and hydrochloric acid was warmed at 40° for seventy-two hours. In the second digestion, a somewhat stronger pepsin solution was employed and the mixture was kept at 40° C. for ten days. The first point to be noticed in the results obtained is the relative formation of proteoses and peptome under these somewhat widely divergent conditions. The accompanying table brings out the differences with sufficient clearness: - - Digestion. 2 hours. 10 days. - - - - - -------- I’e” cent. Per cent. Vitelloses------------------------------------------------------------------------- 36 33 Peptone -------------------------------------------------------------------------. 63 66 Vitellid --------------------------------------------------------------------------- 1 I These figures are to be considered simply as an approximation inerely, since con- siderable loss naturally occurs in the separations. They illustrate, however, a fea- ture of gastric digestion which I think has been already clearly demonstrated with other proteids, both in natural and artificial digestions, viz, that under no ordinary circumstances do we have a complete conversion of the proteid undergoing digestion into peptone. There always remain a residue of proteoses, which are very slow to undergo further transformation into peptone, even though the period of digestion be greatly lengthened or the strength of the ferment solution be greatly increased. The initial action may be rapid up to a certain point, beyond which further conver- sion into true peptone is slow and finally comes to almost a complete standstill. Thus, in the two experiments above quoted continuation of the digestion for ten days resulted only in the formation of 3 per cent more peptone than in the shorter digestion of seventy-two hours. It must not be assumed, however, from these figures that the ferment was wholly inactive during the greater portion of this second digestion period. This certainly was not the case, for analysis of the proteoses obtained from the two digestions shows plainly that in the longer and more active digestion the proteoses are represented by a far larger percentage of secondary pro- teose, the primary products being correspondingly diminished in amount. This is clearly shown in the following table: Digestion. 72 hours. 10 days. –– - S5 Per cent. 21 Per cent. Proto-Vitellose.------------------------...-----------------------------------. 35 1. Hetero: Vitellose--------------------------------------------------------------. 2 1 Mixed Vitelloses (CH3-COOH p. p.)------------------------------------------- 47 49 Deutero-vitellose-------------------------------------------------------------- 16 29 Total ------------------------------------------------------------------. 100 100 These results, then, are fully in accord with the view that in digestive prote- olysis we have to deal with a series of progressive changes resulting in the formation of a series of soluble and diffusible bodies known collectively as proteoses and pep- tones. Hitherto we have been wont to limit our ideas of the proteoses to the primary bodies proto- and hetero-proteose and the secondary proteose, known as deutero- proteose, each of these being considered as existent in both the hemi and anti form. A fourth body, known as dysproteose, is simply a coagulated form of hetero-proteose. The writer, however, has had for some time a growing couviction, based upon the PAN-AMERICAN MEDICAL CONGRESS. 1253 many results obtained in this field of work, that digestive proteolysis is still more complex than we have been wont to consider it. The proteoses may, perhaps, be com- pared to the many more or less isomeric dextrins formed in amylolytic digestion, a given proteose, for example, being considered not necessarily as a single substance but rather as a representative of a group of closely allied bodies representing differ- ent stages in the proteolysis. We have been led to consider the possibility of this view because of the apparent lack of agreement oftentimes noticed in the compo- sition of a given proteose when repeatedly separated from different digestive mix- tures. In other words, the composition of a given proteose appears to vary more or less with variations in the extent of the proteolytic change by which it has resulted; that is to say, the length and intensity of proteolytic action appear to exert a modi- fying influence upon the composition of the resultant proteoses. It was especially to test this point that the present experiments with pure crystallized phyto-vitellin were undertaken. In proteolytic digestion it has always been noticed when careful analyses of the products have been made that the proteid undergoing digestion loses carbon as the hydrolytic change proceeds, so that each successive product of prote- olysis contains less carbon than its direct antecedent down to true peptone, the final product of gastric digestion, which latter body may contain two-fifths per cent less carbon than the mother proteid. Thus proto- and hetero-proteoses, as primary prod- ucts, contain, as a rule, only a little less carbon than the proteid from which they are derived; while deutero-proteose, a secondary product of hydration, always contains still less carbon; and true peptone, the final product of the hydrolytic change, a still smaller amount. Now, whatever the conditions under which these several bodies are formed their general characters are always the same; their chemical reactions and general properties, so far as we are able to recognize them, are always essentially constant; but their chemical composition shows marked variation. Further, this variation is something more than a mere variation such as might be attributed to lack of complete purification, etc. It is a variation which shows a certain degree of constancy, pointing in a certain direction, and, if the results are to be trusted, indi- cates that the composition of a given proteose, as now defined, is variable within certain limits, the exact composition being dependent upon the length and intensity of the proteolytic action. This point is well illustrated by the present series of experiments. . Thus, in the two digestions already described, both conducted under exactly the same conditions, excepting that one was continued for seventy-two hours and the other for ten days, and the latter with a somewhat stronger pepsin solution, proteoses of essentially the same general character were separated, but with the following variations in composition : C H N. S () | l | Vitellin ----------------------------------------------------- 51. G3 6.90 18.78 , ſº 31.7% Proto-vitellose, first digestion. - - - - - - - - - - - - - - - - - - - - - - . . . . . . . . 51.55 6.73 18.90 | 1.09 21.73 I’roto-vitellose, second digestion . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50. 45 6.68 17. 10 1. 28 24. 49 Mixed vitelloses, first digestion - - - - - - - - - - . . . . . . . . . . . . . . . . . . 50, 85 6.68 18.94 1. 10 22.43 Mixed vitelloses, second digestion . . . . . . . . . . . . . . . . . . . . . . . . . . 49.43 6.77 18.37 1. 29 24. 14 I)eutero-vitellose, first digestion. . . . . . . . . . . . . . . . . . . . . . . . . . . . 49. 7.3 6.73 17. 97 1. 08 24. 44 1)eutero-vitellose, second digestion . . . . . . . . . . . . . . . . . . . . . . . . . . 50.03 6.70 18.93 1. 53 22, 81 I’eptone. ---------------------------------------------------. 49. 40 6. 77 18. 40 . 49 24.94 i ! If this was the only series of results of this nature that we had to offer I should hardly think it worthy of calling attention to, but results along the same general line have been cropping out continually and to my mind they have some signifi- cance. Thus, the proto-vitellose separated from the two digestions shows a variation of 1 per cent of carbon, and it is to be noticed that the lower content of carbon belongs to the body resulting after ten days' digestion at 40°. C. Further, with the mixed proteoses, the acetic acid precipitate, or a mixture of proto- and deutero- vitellose, the same result is to be noticed. Further, in looth instances the nitrogen likewise shows a diminution as an apparent result of the longer proteolytic action. 1254 PAN-AMERICAN MEDICAL CONGRESS. With deutero-vitellose and true peptone the final products of the proteolytic change there is less tendency for this variation in composition; it is usually more apparent in the primary proteoses. - . I am well aware that these results are open to criticism; that it may be said they are the result of mere accident; that if they imply anything they testify simply to the general lack of definiteness of this class of bodies. But to this I answer that it is comparatively easy to obtain these bodies with like composition over and over again by simply keeping the conditions under which they are formed fairly constant. It is only when the conditions are changed; when the first-formed bodies are exposed to renewed ferment action that changes in their composition begin to appear, although the general characters of the bodies, the reactions on which their identification and separation depend, remain constant. Other forms of proteid matter have given these results and, now that they are likewise obtained with this, a purer form of proteid matter, we are convinced that they have some real significance, a significance that may be interpreted as furnishing additional evidence that the proteolytic process considered from the chemical standpoint is one of gradual, successive changes, resulting not only in the formation of a series of well-defined bodies such as the proteoses and peptone; but that these, especially the primary proteoses, may be represented by a class of semi-isomeric bodies showing only slight shades of differ- ence yet each standing for a definite step in the proteolytic process. CHANGES IN GANGLION CELLS FROM BIRTH TO DEATH FROM OLD AGE; PRELIMINARY COMMUNICATION. By C. F. HODGE, Ph. D., Assistant Professor of Physiology and Newrology, Clark University. Whatever may be true of the protozoa and certain of the lower metazoa, which multiply by fission, undoubtedly for all higher animals the process of growing old, of senescense, is a normal physiological process. It is manifested, probably, in all tissues, from the bones, which lose their animal matter; the muscles, which waste away; and the glands, which sclerose, to the brain, which becomes enfeebled, inca- pable of thought or will. Dr. Holmes may take exception to this last statement, and he has good right to ; but for the general run of old men and old dogs that can . not learn new tricks the above holds true. In fact, it is such shining examples as the one just named that urge to a physiological study of ageing that all may grow old as gracefully as Dr. Holmes. Search should be made through all the tissues for the cause of somatic death. This cause may lie equally in blood, muscle, gland, and nerve; and the intricate interdependence of organs and functions which constitute the circle of an animal's life would support this view. My own previous work makes it expedient for me to begin the search with the nerve cell; and besides, there are reasons for believing that this element plays a prečminent rôle in the determination of somatic life. It is true, muscle and nerve are often referred to as “master tissues” of the body. But muscle is certainly a poor sort of a slave to be called a master. Whenever bidden by a nerve impulse, it contracts. Otherwise it lies quiescent and fails even to nourish itself, shriveling in atrophy if cut off from its nerve supply. The relation of gland to nerve is in general similar; and thus the nervous system may indirectly deter- mine the nutritive constituents of blood and lymph. It is a remarkable and sig- Inificant fact in this connection that in the embryo the nervous system develops so far in advance of the other organs, and that a lesion here during embryonic life so often causes arrest of growth in corresponding parts of the body. It is not the place, however, to discuss the trophic influence of nerve centers. PAN-AMERICAN MEDICAL CONGRESS. 1255 In speaking of normal death and in searching among the cells of the various tis- sues for its cause, I refer, of course, to theoretically physiological dying. Where death is complicated with disease of kidney, or lung, or heart, examination is made of these organs and their pathology gives us the cause of death. Even here, it should be remarked aside, the real cause often lies behind the organ itself in the nerve centers which furnish it control. With man the process of physiological decline often reaches the stage of senescence, but rarely the point of actual death. The fact that it is a normal process renders search for its cause none the less legiti- mate and only enhances its scientific significance and interest. The above may serve to indicate the point of view from which I have undertaken a study of the problem. The present paper can only be put forward as a prelim- inary communication, embodying a year's work in a field to properly cover which must require the united efforts of a number of workers for many years. At any rate a sufficient number of animals should be studied, in all tissues, to enable us to dis- tinguish special from general results. Changes in the walls of the blood vessels within the brain and spinal cord of the aged, as well as sclerosis of the nerve tissue itself, have already been described. Although related, these are aside from my present purpose, which is to confine attention entirely to intracellular phenomena. The exact question is, What differ- ences in the cells themselves can be discovered by comparison of similar nerve cells from the young and the old? In this field Schultze” has attempted to prove that pig- mentation of ganglion cells increases with age, and this has been associated with pathological pigmentary degeneration. Schäfer f opposes the idea of any such con- nection, maintaining that pigment everywhere in the body is evidence of functional activity and not of decay. Observations which I wish to report at this time have been made upon the follow- ing material: First, the cerebrum, cerebellum, cervical cord, and first cervical ganglia of a man dying of old age at 92 years. So far as could be observed or ascertained, cause of death was not complicated with disease of any sort. During the last two years he came gradually to require more and more sleep, considerably more in winter than in summer. At last it became difficult to awaken him for meals. Finally this became impossible and after six days of inanition respiration and pulse grew weaker and weaker and finally ceased without the slightest struggle or even movement to mark the point of death. The above-named parts were removed 11 hours post mor- tem, and were prepared by methods to be presently indicated. Second, the first cervical ganglia of a male footus killed by accident of birth. Third, portions of cerebrum, cerebellum, and first cervical ganglia of a man killed by accident at the age of 47. Fourth, superoesophageal ganglia of 21 old honey bees prepared side by side with brains of the same number of young bees taken as they emerged from the brood cells. In the human cerebrum at 92 years of age no pronounced abnormality has been detected by methods thus far employed. By the osmic acid-bichromate method of Ramón y Cajal, both as to size of cell and number of processes, neurons, and den- drons, everything appears Inormal. The alcohol-magenta, mercuric chloride, and long osmic acid methods show usual appearance of protoplasm, with considerable pig- ment, nuclei full and clear and nucleoli prominent. If degenerative changes are present, they do not involve a sufficiently large proportion of cells to strike one in the ordinary study of the sections. The cells of Purkinje appear considerably shrunken, both nucleus and protoplasm; though not more so than in normal daily fatigue. There are also 25 per cent fewer, by count, than in sections of cerebellum of the middle-aged man, cut at the same stroke of the knife. This difference may * R. Schultze. Ueber Artificielle, Cadaveróse und Pathologische Veränderungen des Rickenmarks. Neurol. Centralbl. Bel. UI, S. 529–536, 1883. f Schäfer. The Nerve Cell as a Basis of Neurology; Brain, 1893. 1256 PAN-AMERICAN MEDICAL CONGRESS. not be abnormal, Most striking differences occur in the cells of the spinal ganglia. Possibly the most important of these is a failure of the nucleolus to stain with osmic acid in cells of the old man. Considering the rôle which this organ plays in proc- esses of reproduction, and it possibly plays no less a rôle in subsequent physiological functions, this fact may have a wide significance. Coupled with this is the condition of the nucleus, considerably shrunken and with irregular, jagged outline. In case of fatigue the nucleus shrinks and at the same time grows dark. In the old-age speci- mens the nucleus has shrunken and remains light, not taking the stain more heavily than the cell protoplasm. Nucleoli are large and densely stained in corresponding cells of the foetus, and nuclei are large, round, and clear, not a single one being at all shrunken or dark. Camera drawings of the two are shown in figs. 1 and 2. The protoplasm in the old man is seen to be largely filled with pigment and fat, both substances appearing black in osmic acid specimens, the pigment being yellow and the fatty masses being represented by large vacuoles in sections by the corrosive sublimate method. The cells of the foetus contain almost no pigment at all. The above comparison may best be expressed in tabular form as follows: TABLE I. Nucleoli | | i Volume of Pigment. Pigment ºf oilºje "º", "ºº". | in nuclei. •-m-m-m--------------~~~~ – - – -- ~~. ----------- - - --— -- –- - - - - - - - - - - - T - T -- “ ” — - - - - – - - – -—--— –— — - | –---—----— ----------— | | I’e, cent. I’ey cent. J’e) cºnf. I’e)' cent. Foetus ----------------------------------------------- 1 ()() In 53 - - - - - - - - - - - - - - - - - - - - - - - - Old man --------------------------------------------. (54, 3 In 5 (37 33 It was not found possible to gain much light upon exactly the point in question from the brain of the man killed by accident. This was a disappointment; since if was hoped that it might furnish a specimen of human brain in prime of life not complicated by pathological conditions, something quite difficult to obtain. The man was, however, a confirmed alcoholic, and by the osmic acid method, upon results of which my comparisons were in the main founded, fully nine-tenths of the ganglion cells in cerebrum and spinal ganglia stained as black as fat cells, showing no structure whatever. Whether the alcohol habit has anything to do with this result remains for further experiment to decide. The rest of the cells stained darkly and were considerably filled with pigment and fat, but showed large, clear nuclei and normal nucleoli. - With the honey bee, experiments could be far better controlled, and results are accordingly more definite. The young bees were caught in the act of crawling out of the brood cells. They are at this time practically ready to begin their life work. The fact that in all cases the honey sac was found moderately (listended with honey will serve to indicate a uniform nutritive condition. Old bees were chosen by “age signs,” worn and frayed wings, abraded hairs, and general behavior. This last was of special use. When a hive is opened, all the able-bodied bees are alert and active in protecting the combs or in securing what honey each can carry. Here and there, generally off in some corner, you may observe a bee quietly humped up, taking neither part nor interest in the general commotion. Such a one is likely to bear the signs of extreme age. The experiments were made in August during a period of honey dearth, while the bees were “loafing,” in order to obtain results as free as possible from complications with fatigue. This matter will require consideration further on. The young and old bees were beheaded, the front and side portions of the skull quickly pared away with a sharp scalpel so as to expose the brain, and both were placed in the same watch glass of 1 per cent osmic acid for two hours. From this they passed, with the old and young always in the same bottles or dishes, through the usual steps to hard paraffin, where young and old were cut side by side with the Same stroke of the section knife. In no case were specimens to be compared sepa- rated in passing from the living bee to the microscope slide. While paring off the PAN-AMERICAN MEDICAL congress. 1257 Scull caps I was struck by a remarkable difference in size between young and old brains. The young brains fill the skull so full that it is difficult to lift off the chitin without injuring the parts below. The old brains are shrunken into a flat cake fill- ing not half the cavity of the skull. It is easy to observe this with the unaided eye. Reasons for the above will appear when examination is made of the sections. These were cut with a Minot microtome, new model, 2 and 6 ſu thick. Sections of the 21 young brains appeared under the microscope as much alike as though they luatl been successive sections cut from the same brain. The nuclei are large and clear. They are, in fact, so large in proportion to size of cells that they often crowd one another into polyhedral shapes. This is shown in fig. 3, drawn from the anten- nal lobe of young bee No. 1. Protoplasm appears dense and evenly granular. In the old brains protoplasm is all but absent, being reduced to a few shreds and granules between the large vacuoles which fill the cell. The nuclei are shriveled in many cases almost beyond recognition. Here, too, as we found in the human ganglion cells, the nuclei in Senescence decrease in size, but do not grow dark and granular as in fatigue. This general result is not so uniform for old as for young brains, and natu- rally so; because it is of course impossible to obtain old bees of uniform age. The age signs by which they were chosen are no more uniform than the appearance of the brains. The above description applies literally to the extreme cases; and not one of the old brains ſailed to show differences of the character indicated by which they could easily be distinguished from young brains. (Compare figs. 3 and 4.) In addition to the above, the most noteworthy result furnished by the bees is that the cells are much more numerous in the young than in the old. A count of 22 groups of cells taken as nearly alike as possible in old and young give an average of 1 cell in the old to 2.9 cells in the young. In all cases the cells were fewer in the old. In a former series of experiments * bees were killed morning and night, in order to demonstrate, if possible, changes in brain cells owing to fatigue of a day’s work. Differences in appearance of cells were found which could not be accounted for on grounds of daily fatigue, and it was then urged (p. 155) that the only variable which could account for them must be a difference in age. The present series confirms that opinion so strongly that in future no study of nerve-cell fatigue can be considered final until just allowance has been made for differences due to age. Daily fatigue in bees must be worked over again with this point in view; and just how far results as obtained in diurnal fatigue of birds may have been complicated by age can only be determined when changes due to aging have been studied in some one, at least, of this class. This brings us back to our first experiments, in which corresponding cells of the same animal were compared. Here no complication of age can have influenced results. It was demonstrated that in fatigue the cell protoplasm became vacıiolated, the nucleus shrunk and came to stain more darkly, and the nucleolus showed a tendency to decrease in size, although this is not constant. Testimony from all sides points to the nucleolus and nucleus as the source of origin of the pro- toplasm. In extreme age we find protoplasm vacuolated in bees, pigmented in man, nucleus shrunken, but not dense, as in fatigue, and the nucleolus absent from a large proportion of cells in man. The nerve cells of the honey bee do not possess a sharply defined nucleolus like that of vertebrates. If anything of the kind exists in these cells, it must be represented by irregular granules, as indicated in fig. 3. These, as may be seen in fig. 4, are largely absent from nuclei of aged cells. The nucleus being the source of rejuvenation for the cell protoplasm, the above would seem to indicate that age is of the nature of final fatigue, final, because the source of energy for the nerve cell has dried up at the fountain head. Decrease in number would intimate that the young bee commences active life with a full quota of nerve cells. Filling the skull as they do, it is difficult to conceive, since the * Hodge. A Microscopical Study of Changes due to Functional Activity in Nerve Cells. Journal of Morphology, Vol. VII, Boston, 1892. 1258 PAN-AMERICAN MEDICAL CONGRESS. adult bee does not moult, how these cells can increase much in either size or num- ber in subsequent life. To start with there is, in brief, a superabundance of cells which furnish the animal not only energy to maintain vital processes necessary to life, but in addition to this, energy for the performance of work. As the work of life is being performed, the cells, one by one, are worn out. A stage is reached when only enough cells remain to barely support processes requisite for continuance of life, no extra work being possible. Finally this number fails, and the functions of life must cease. - - In the above I do not wish to be understood to insist that nerve tissue is of any more importance in relation to physiological dying than any other tissue. Just the position held by each tissue in this regard must clearly be determined by experiment. The working out of age changes in the tissues of a series of animals is something which clearly requires, above all things, time for its consummation. The above is put forward in the hope that valuable material which might otherwise go to waste may be utilized in this connection. (Illustrations not furnished.) A MICROSCOPICAL STUDY OF THE NERVE CELL DURING STIMULATION. By C. F. HODGE, Ph. D. EXPERIMENTS ON SPIN A I, AN I) SYMPATHETIC GANGLION CEI.LS OF FROGS. The purpose of the present series of experiments is to observe continuously the process of fatigue in the nerve cell. Up to the present series. my method has con- sisted in studying the cells at the end of a period of fatigue and only after the tis- sue had passed through the usual processes of preparation for the microscope. From the first it has been my desire to study the process continuously in the living cell. A report of former work upon the subject of changes in ganglion cells due to electri- cal stimulation and daily fatigue may be found in a previous number of the Journal of Morphology." Method. At first an attempt was made to observe the cells in situ with circulation dis- turbed as little as possible. This was done by removing the viscera from in front and a portion of the spinal column, muscles, etc., from the back, tying all blood ves- sels, thus leaving the pleuro-peritoneum with its blood vessels and the sympathetic chain intact. Small frogs were used, but the large pigment cells in the pleuro-peri- toneum itself, and especially along the blood vessels and sympathetic cord, made it impossible to get a clear view of the sympathetic ganglion cells. I was obliged to abandon the method. It thus became necessary to remove the ganglia from the body and free them from their pigmented capsules. In consequence of this the fol- 1owing method was adopted, and it has proved more serviceable than was anticipated. Special apparatus employed can best be understood in connection with a typical experiment. A pair of spinal or sympathetic ganglia is quickly excised from a freshly pithed frog. Each of these is placed immediately in a drop of normal salt solution on a “stage-electrode” of the following construction (fig. 1): A plate of thin clear glass (A), of shape indicated in figure and of a size to be conveniently clipped to stage of a Zeiss microscope stand, larger size, has two grooves cut in its under sur- face from margin to near center. These are made deep enough to conceal two fine platinum wires, which are cemented in them (B). A half centimeter beyond central * Hodge. A Microscopical Study of Changes due to Functional Activity in Nerve Cells. Journal of Morphology, Vol. VII, p. 95. Boston, 1892. /((ſºn). FIG. 1.-Microscope stage electrode. A. Glass plate. ** - B. Two platinum wires laid in grooves on under side of plate and rising through plate to be exposed on upper surface to serve as stimulating tips at— C. Exposed portion of electrodes. D. Platinum wires to support cover slip. E. Wires to induction coil. F. Trough ground in glass plate.to carry off stream of normal solution. * Yº - \'l- - U \t C , 2 A . * # § {\\\\\\apº ºff. * * i * : : ; III" º' * & __----------- Tri-E ==TE=- FIG. 2. —Setting of apparatus for garglion cell stimulation. 1. Flask of normal solution. , 2', Glass siphons which lead solution to edge of cover slip 2 , 3’. Beaker to catch drip. 4'. Stage electrodes in position. 5. Drawing stand to hold card at level of stage. 6. Wires from right-hand microscope to secondary coil. a ; * PAN-AMERICAN MEDICAL CONGRESS. 1259 end of grooves the platinum wires are brought to upper surface of glass through two needle holes about 2 millimeters apart. The ends of the wires are then bent down into needle-hole pits in the upper surface of the plate about 2 millimeters beyond the first perforations. Shallow grooves in the upper surface are made to connect the holes of each pair, so that the platinum wires come to lie half exposed on the upper surface of plate for a distance of 2 millimeters (C). They are then filed off level with surface of glass. This portion of the wires, of course, acts as the electrode, and the preparation is arranged so that either the ganglion lies between the elec- trodes or its nerve lies over them. The other end of each platinum wire is soldered to an insulated copper wire, which goes to a secondary coil. Two other platinum wires (D) support the cover slip. These, for convenience, are hooked into pits in the glass, and are so bent and adjusted as to direct the stream of normal salt solution over the specimen. With the plan of this simple electrode understood, the remainder of the method may be seen at a glance at fig. 2. Each electrode is clipped to its microscope and a stream of normal salt solution is drawn from flask (a) by means of glass siphons (b and b), which end in finely drawn nozzles. These are placed at edge of cover slip opposite trough (F), fig. 1. The stream from (F) drips into beaker (c). Other parts of figure need no explanation. We now have, living in the same fluid, corresponding ganglia of the same animal. A group of cells as nearly alike as possible is sought out in each preparation and brought to center of field. A cell, or several cells in each, are measured and outlined with aid of camera, and then electrical stimulation is applied to one of the preparations and not to the other. Both are Watched and at intervals measured and drawn. Two cameras, each attached to its microscope, were used at first (as shown in fig. 2). To render the two pictures more comparable, avoiding thus any difference in the angle of the mirrors, a camera was clamped to the eye- piece, with mirror firmly set, and eyepiece and camera were lifted together from one microscope to the other. Stimulation was interrupted, fifteen seconds' work alter- nating with forty-five seconds' rest, the primary circuit current being made and broken by a “Lombard clock interrupter.” Four Daniel cells, supplying current of .2 ampere, were used throughout. The induction coil used was one of Krüger's (10305 U). Aside from the electrode and device for supply of normal salt solution, the apparatus was made as similar as possible to that used in my earlier experiments and fully described in the paper just cited. At end of desired time both control and stimulated ganglia were placed together in osmic acid and teased in glycerin for further study and preservation. In all, 33 experiments have been made. These have varied in duration from fifteen minutes to six days. They were divided into a winter series, made between November 25, 1892, and December 24, and a summer series, made from June 14 to Sep- tember 3, 1893. Since no marked difference in results has borne out this division, I have substituted for it a grouping of the experiments according to their purpose and nature. It is intended to give in the following table a condensed statement of the whole research. Each experiment bears its date, but for convenience of reference the numbers have been given to the experiments as they stand in the table. The time of day is written as an exponent of the date, and since all experiments were made during daytime, no designation of “A. M. " or “P. M.” is required. As in the previous work, interest centers chiefly about the nucleus. Change in this is expressed in percentage of loss or gain, using the original volume as 100 per cent. Time in hours and minutes from beginning of experiments is written as an exponent of the shrinkage per cent. Where several cells were watched, each bears its proper number throughout the experiment. Controls enter the table only in case some change is noted in them. No significant change in size of cell body was observed, hence their omission from table. Experiments 1 and 2 were made with cells of sym- pathetic ganglia. In all the rest the spinal ganglla were used. 1260 PAN-AMERICAN MEDICAL CONGRESS. Table of all experiments. Posi- * .. r ... 1-3 No. Date. º Normºution Shrinkage in volume of nucleus. coil. - C’)??, . 1 | Nov. 26, 3.45 . . 10 | NaCl 0.65 per 45 m., 33 per cent; 1 h., 33 per cent; 1 h. 30 m., 33 per CéIlt. ('ent. 2 | Nov.30, 11.05 - 10 - - - - - tio ---------- 55 m., 52 per cent; 23 h. 25 m., 53 per cent. 3 || Dec. 7, 12- - - - - - 10 - - - - - do ---------. 3 h., cell 1, 52 per cent; cell 2, 64 per cent. 4 || Dec. 16, 2, 25. . . 10 - - - - - do -----. . . . . Cell 1: 20 m., 0 per gent; 3 h. 5 m., 20 per cent; 20 h. 45 m., 20 per cent. Cell 2: 20 m., 0 per cent; 3 h. 5 m., 20 per cent; 20 h. 45 m., 20 per cent; stimulus too strong, lost. Cell 3: 20 m., 0 per cent; 3 h. 5 m., 14 per cent. 5 | Dec. 17, 4 - - - - - - 10 - - - - - do ---------. 1 h. 45 m., 53 per cent. 6 || Dec. 20, 2, 55. . . 13 . . . . . do ---------- Cell 1: 1 h. 40 m., 56 per cent; 2 h. 40 m., 68 per cent; 3 h. 5 m., 74 per cent. Cell 2: 1 h. 40 m., 18 per cent; 2 h. 40 m., 32 per cent; 3 h. 5 m., 32 per cent. Controls shrunk f not enough to measure. 7 || Dec. 21, 9.50... 13 . . . . . do ---------- Cell 1: 1 h, 25 m., 28 per cent; 23 h. 15 m., 54 per cent. Cell 2:1 h. 25 m., 30 per cent; 23 h. 15 m., 45 per cent. 8 || Dec. 23, 9.30. . . 13 - - - - - do ---------- 40 m., 30 per cent, control, 8 per cent; 1 h. 40 m., 42 per | cent; 2 h. 40 m., 44 per cent; 4 h. 40 m., 62 per cent; 22 | h. 40 m., 62 per cent; control, 8 per cent. 9 || Dec. 24, 9.45. . . 13 . . . . . . do ---------- 1 h., 18 per cent, control, 0 per cent; 2 h., 27.1 per cent, control, 11 per cent; 3 h., 40 per cent, control, () per cent: 4 h. 15 m., 65 per cent; 5 h. 15 m. to 7 h. 15 m., 68 | per cent, control, 8 and 19 per cent. 10 | Jan. 14, 10. . . . . 13 . . . . . do ---------. 30 m., 39 per cent. ; 1 h., 44 per cent. 11 || Jan. 15, 10. . . . . 13 - - - - - do ---------- 5 h., 30 per cent. Cell injured. 12 || Jan. 19, 10. 30. . . . . . . . . . . . . . do ---------- No nucleus or nucleoli visible in cells. Not stimulated. 13 | Jan. 19, 10, 55. . . . . . . . . . . . . . do ---------- Frog similar to one used in 12. No nuclei or nucleoli visible in any of the cells, although they appear clear and free from pigment. Stimulation applied and in 20 minutes faint outline of nuclei became visible. After 4 hours and 30 minutes stimulation, faint irreg. j ular outline of nuclei visible. No nucleoli to be seen. 14 || Aug. 14.2.15 ... 10 ...... do ---------- 30 m-, 46 per cent. 15 Aug. 14, 5 . . . . . * -- . . . do ---------- 30 m., 24 per cent; 1 h., 42 per cent. 16 || Aug. 21, 11.05. 10 IRinger's solution 1 h. 20 m., 48 per cent. 17 | Aug. 30, 10. 25. 30 . . . . . do ---------- 10 m., 35 per cent; 20 m., 58 per cent; 30 m., 61 per cent; 50 m., 65 per cent; 1 h. 20 m., 69 per cent,; 2 h. 45 m., 74 per cent. 18 Aug. 30, 9 . . . . . 13 - - - - - do ---------- 23 m., 23 per cent. 19 Aug. 30, 2.22 .. 13 - - - - - do ---------- 10 m., 26 per cent; 10 m., 42 per cent; 40 m., 51 per cent; 2 h. 45 m., 65 per cent. .* 20 Aug. 31, 9.33 .. 13 . . . . . do - - - - - - - - - - 12 m., 25 per cent; 35 m., 45 per cent; 50 m., 54 per cent; 1 h. 50 m., 64 and 54 per cent. 21 | Sept. 2, 11.10 - - 13 . . . . . do ---------. 15 m., 22 per cent; 30 m., 37 per cent. 22 || Sept. 2, 11.45 . . 13 . . . . . (lo - - - - - - - - - - 1 h. 30 m., 48 per cent. 23 Sept. 3, 10, 29 - - 12 . . . . . . do ---------. 30 m., 18 per cent; 1 h., 29 per cent; 1 h. 30 m., 43 per cent; 2 h., 43 per cent; 4 h. 44 m., 69 per cent. EXPERIM. EN 'I'S WITH DISTA I, STIMULATION. 24 Aug. 5, 3.30. . . 13 Salt solution. -- . 15 m., 17 per cent continuous stimulation. 25 || Aug. 13, 5- - - - - 10 . . . . . do ---------- 15 m., 33 per cent. Same cell as 24. EXPERIMIENT'S WITH CENTRAL STIMUI, ATION. 26 Aug. 13, 4, 40 ... 10 | Sait, solution . . . . 15 m., 12 per cent continuous stimulation. 27 | Aug. 5, 4.45 . . . 10 | . . . . . do ---------- 15 m., 0 per cent continuous stimulation. 28 || Aug. 13 - - - - - - - 10 | . . . . . do ---------- 15 m., 30 per cent continuous stimulation, ganglion almost touching electrode. - 29 Sept. 2, 9.45... 13 | Ringer's solution | 15 m., 0 per cent continuous stimulation. 30 Sept. 2, 10.30-. 13 | . . . . . do ---------- 15 m., 0 per cent continuous stimulation. EXPERIMENTS WITH P()TASSIUM TARTRATE SOLUTION. 31 Aug. 28, 10. 50. 10 Salt solution 0.65 20 m., 14 per cent; nucleolus moved aboutt in nucleus per cent, satu- with continuous change of shape, and finally frag- rated with eai- mented and disappeared. Nucleolus of normal con- cium phos- trol was seen at first to change from crescent-shaped phate + 0.1 to round, in which condition it remained. per cent potas- sium tartrate. 32 || Aug. 28, 1.36... 10 ...” do ---------- 30 m., 39 per cent. Behavior of nucleolus similar to 29. 33 || Aug. 28, 2.45. 10 ..... do ---------- 30 ºd 30 per cent. Behavior of nucleolus same as in 29 and 30 i ! Oo 9/o "N TN "|NN > 60 % N S. 50 °/o NHSE TIMETIO’T 2.0" 3|0° t; 0° 50” 6|D” FIG. 3.-Curves showing shrinkage of nuclei in experiments 18 to 21. PAN-AMERICAN MEDICAL CONGRESS. 1261 The most striking feature of the table is perhaps its great irregularity, the lack of any apparent relation between amount, duration or intensity of stimulation, and effect in change of nucleus. This is in apparent disagreement with results of former work, in which a quantitative relation between stimulus and shrinkage of nucleus was evident. It is, however, easy to show that the lack of agreement is only apparent. In the former experiments we were dealing with definite amounts of stimulus given in the same way to corresponding nerves, which in turn led the stimulus to corresponding ganglion cells. The point to be emphasized is that the cells were in position in the body under practically the same conditions of blood supply and nutrition and in similar relation to the stimulus. In the present series the cells are removed from the body, placed in a stream of solution, which it is impos- sible to make equal to the different cells, and in an electric field, the intensity of which in any point it is impossible to regulate or even estimate. Taking these important variables into account, the evidence for quantitative relations between stimulus and effect is, possibly, as strong as we should expect to find it. The measure- ments from which the percentages in the table were computed were made long and short diameters of nucleus as usual, with no thought beyond accuracy of each measurement. Differences and similarities between different experiments may be seen more clearly by plotting the percentages in the table in the form of curves. This was done for all the experiments. Four of the most comparable of the curves are reproduced in fig. 3, drawn from experiment 18 in 21 minutes. Position of coil and solution are the same in these experiments, yet the course run by each in its fatigue is distinct, though similar in character. By far the majority of the curves are of the same general form. They show that the cell tires rapidly at first, then more gradu- ally to a condition of fatigue, complete, at least, so far as our present method is able to indicate. This is also in apparent variance with curves derived from a for- mer series of experiments, in which fatigue was rapid at first, then gradual, then more rapid again. A slight tendency to this form of curve is found in experiments 6, 8, 9, 18, these all showing slight secondary acceleration. Considering the circum- stances of the two series of experiments, no correspondence can be expected. In the present series the cells are not living in a nutrient solution, but in a normal non- nutrient solution, which is able, in all probability, to carry off by diffusion the waste matters of the cell’s metabolism. Consequently the nucleus shrinks more rapidly and also more continuously to a condition of complete fatigue. As more fully dis- cussed in a previous paper, there are reasons for believing that cells in presence of nutriment carry on the processes of anabolism and katabolism at the same time. Under the conditions of our present experiments, analoolism is impossible, while katabolism is, possibly, unimpeded or accelerated. Note the slight shrinkage which occurs in a few of the control ganglia. Shrinkage in nuclei of control cells probably occurred to a slight degree in all exper- iments where simple sodium chloride solution was used. It never reached the point at which the nucleus began to show indentations. In Ringer's solution, or in salt solution saturated with calcium phosphate, no change in this respect could be detected, even for long periods. This agrees in the main with recent work by Locke” upon the influence of so-called “normal” solutions on the form of curve of muscle contraction, salt solution making the curve higher than normal. A slight effect tending toward that produced by stimulation is no more than we should expect in transferring ganglion cells from blood to any normal solution. In experiment 9 the control nucleus takes a peculiar course. It is seen to swell slightly for the first two hours, then comes back to normal and continues to shrink, until in seven hours it has lost 19 per cent of its original bulk. I have, as yet, no adequate explanation for this case. It stands alone, so far as my observations go. Upon diluting a normal solution with distilled water, I have observed similar swelling of nuclei. This fact, however, throws little light on the present instance. *Locke, Die Wirkung der Physiologischen Kochsalzlüsung auf querges treiſte Muskeln, Pflüger's Archiv., Bd. LIV, S., 501–524, Bonn, 1893. 1262 PAN-AMERICAN MEDICAL CONGRESS. Experiments 1 to 23 were all made with the single purpose of observing clanges which might occur in ganglion cells during stimulation. But few in this group require fuller statement than is already given in the table. In experiment 3 the cells were kept under observation, at intervals, for six days. Camera drawings were made, at least one a day, during the whole time. Measure- ments were taken to begin with, and at the end of three hours. As the mirror of camera was moved, it is not possible to compute volumes accurately beyond this time. Measurements were omitted under the impression that camera drawings would serve instead. This necessitates a brief description by way of supplementing the table. The experiment was begun at noon, December 7, and during the first five hours the nuclei decreased in size and became irregular in outline. By the next morning, the nuclei had somewhat regained their rounded outline, though remaining small, and the appearance of both protoplasm and nuclei showed little or no change beyond the retraction of the protoplasm from capsule to closely envelope the nuclei. During the fourth day granules in protoplasm and nuclei appeared to be in violent commo- tion. My notes for this day contain the words, “ cells alive with bacteria.” An incrustation of salt had formed around edges of cover slip, in places. In washing this off with distilled water, a little ran under the cover slip, and the nuclei were observed to swell. It was expected that the “bacteria” would leave little of the cells to be seen next day. On the contrary, by the morning of the fifth day, all move- ment of granules had subsided and nuclei and protoplasm had regained, to all appear- ances, their former condition. Upon the morning of the sixth day, however, the nucleoli of two of the cells had entirely disappeared, and the outline of the nuclei in these cells could scarcely be distinguished. In the third cell the nucleus was visible, though faintly, and contained a small speck of still highly refractive nucle- olus matter. On tapping the cover slip lightly to dislodge a mass of débris which had floated out so as to obscure some of the cells, they all flew to pieces and the experiment was at an end. Experiment 4 also deserves a word of explanation. An attempt was made in this case to obtain, by showing the secondary coil to O, the greatest possible effect in the shortest time. Contrary to expectation, however, no change could be observed at first. Very little occurred during the first three hours, and the nuclei remained round and clear during nearly twenty-one hours of this extreme stimulation. Three more experiments, not given place in the table, were tried with coil in same position and with the same result. Motile protozoa were next submitted to the same stimula- tion. Paramecia were found to be killed almost instantly. At least they showed no signs of movement after a few, less than fifteen, seconds' exposure to the current, and speedily disintegrated. Large vorticellae were able to endure more; but after two or three exposures of fifteen seconds each, they invariably succumbed. A num- ber of similar tests were made with gradually decreasing strengths of current, and it was found that with the secondary coil at 10, paramecia, although considerably startled, did not appear to be injured. No relation necessarily exists between strength of current injurious to paramecia and to frog's spinal ganglion cells; however, 10 centimeters was decided upon as the limit of stimulation for remaining experiments. Experiments 12 and 13 are anomalous. In perfectly clear unpigmented ganglion cells no nucleus or nucleolus is to be seen. This is not peculiar to the June experi- ments, for even during the winter several cases of the kind occurred. They were, at the time, discarded with the note, “ cells not clear, no nuclei visible.” The two instances, 12 and 13, are too pronounced to leave unrecorded. They force upon one comparison with the apparently similar disappearance of the germinal vessicle in the ovum at maturation. The fact that on stimulation traces of nuclei but none of nucleoli became visible, is also of significance. But whatever this may be, is at present a matter for experiment rather than discussion. In subsequent experiments, 14 to 33, made upon young frogs, R. temporaria, which had just passed the tadpole stage, left nothing to be desired in way of clearness of lauclei. ) . -' FIG. 4.—Camera outlines of cell, nucleus and nucleolus in experiment 23 (Zeiss, oc. 6, obj. 4-mm., x 375.) Time is given in hours and minutes. 3. $4. FIG. 5,-Camera outlines of changes in nucleolus in experiment 31 during 22 minutes stimulation in 0.1 of potassium tartrate added to normal solution, a -c. occurred in 4 minutes. Zeiss obj. 4.0, oc. 6, x 375. “so toº PAN-AMERICAN MEDICAL CONGRESS. 1263 A fair picture of an experiment can hardly be given in a table or by curves. It requires a series of plates drawn from the living specimen. This has not been done, because I do not feel that my study of cell granulation and its changes during fatigue is at all complete. Hence, for the present, the following outline drawings, reproduced from camera outlines made during the experiment, may suffice. Fig. 4 represents experiment 23, to 7 being successive drawings of the stimulated cell. To begin with, we have a typical spinal ganglion cell, with nucleus situated eccentrically. The nucleus is clear, slightly oval in shape, but with perfectly even contour, as seen in optical section. After thirty minutes' stimulation, *, fig. 4, the side toward center of cell has changed, the outline here having become faint and indented. In 4, the other side has begun to cave in, and so on to 7, where we see a shrunken, jagged nucleus", its original size. It has come to lie a little closer to the cell capsule, and the cell scarcely decreased in size to a measurable amount. To enter here more into detail would be to repeat a former description. The experi- ments are, in fact, repetition of former work under conditions varied so that we see continuously and in a single cell what we were able to find in a series of different animals and months of experimentation before. Placed in osmic acid, the nuclei retain this appearance, which fact completes the connection with former work done by the osmic acid method. It should be added, however, that the characteristic darkening of the nucleus as it shrinks does not occur in these experiments. Considerable attention was directed toward studying changes in the granulation of protoplasm during stimulation. Some of the cells became lighter and clearer, while in others this was not so manifest. In experiment 3 the cell under observa- tion contained several prominent oil droplets. During the first two hours one of these was observed to become smaller and smaller, and at last it disappeared. Two more, observed at first to be separate, were seen to have moved together and coa- lesced. Teased in glycerin, after treatment with osmic acid, the cell protoplasm is seen to be pervaded with large, irregular, light spaces, probably the vacuoles observed in sections. The entire cell is, however, too thick for such study. It was impossible also to detect indications of vacuolation in the living cell. During the whole time nucleoli were also subjected to closest scrutiny, in the hope of seeing pos- sibly the movements described by Svierczewski,” and of gaining some light as to the function of this organ outside of strictly reproductive processes. While in nor- mal salt solution or Ringer’s solution no movement of any sort, or only slight changes of shape and position, such as are indicated in fig. 4, could be observed, together with a gradual decrease in size. Connected with this latter it was possible to make out granules in the nucleolus, which moved slowly about, and in ser, ºral instances were seen to be extruded into the nucleus. Confirmation of the above was immediately sought in sections of spinal ganglia already in my possession, and was found in abundance in osmic acid specimens stained in safranin. The granules here were stained a brighter red than the body of the nucleolus, and several were found partially extruded. In this connection I may briefly refer to experiments 31 to 33, although they belong properly to a subsequent paper. Potassium tartrate was (1 per cent) added to sodium chloride and calcium phosphatesolution, with a view of giv- ing the cells a trace of potassium and more oxygen in case there was not enough accessible in the plain liquid. The somewhat unexpected result may be seen out- lined in fig. 5. The different stages represented in (small type) 1–4 were actually observed and camera outlines made in twenty-two minutes. The movement of the nucleolus in this case had every appearance of being amoeboid. The nucleolus of the control cell changed shape somewhat, but retained its size, whereas the frag- ments of the stimulated nucleolus had all dissolved in thirty minutes. Experiments 32 and 33 gave exactly similar results, except that the control nucleoli were not observed to move. * Swierczewski. Zur Physiologie des Kerns und Kernkorperchens der Nervenzellen des Sympathet- icus. Centralblatt f. d. Med. Wissensch., Berlin, 1869, p. 641. 1264 PAN-AMERICAN MEDICAL CONGRESS. A number of the briefer experiments were made with the special purpose of testing upon frogs certain results which Vas * has recently reported from experiments upon the sympathetic ganglion cells of the rabbit. Among these results Was describes a swelling of the cell and especially of the nucleus upon continuous stimulation for fifteen minutes, the electrodes being applied to the cervical sympathetic 3 centime- ters below the Superior cervical ganglion. The nuclei of these cells became swollen and clear, exactly the reverse of my results for spinal ganglion cells after a longer period of intermittent stimulation. If is of interest to note that this diametrically opposed result is obtained by stimulating the nerve in the reverse direction to that of the normal passage of the nervous impulse. Hence in these experiments stimu- lation was applied to the dorsal root between cord and ganglion. Of the seven experiments under this head, 4 showed no change in the appearance of nucleus; 2, slight change, 7 to 12 per cent; 1, marked change, of about 30 per cent. All change observed was toward shrinkage, with no tendency to swell. It should be added, however, that the present method affords no adequate test of Was's results, since (if stimulation the reverse way tends to produce swelling, and if this be ana- bolic in character) no anabolism would be possible in a non-nutrient solution. In the two experiments with slight change the ganglia were near the electrodes; in the one with marked effect it almost touched one electrode, so that the change produced was in all probability due to irrradiation of stimulus. In the present series no attempt has been made to do more than test under new conditions the validity of previous work. A method has been devised by which a much easier and more complete and satisfactory demonstration of fatigue changes in ganglion cells may be made. Former work has found confirmation, with the addi- tional result that the effect produced by hours of stimulation of a nerve in the body may be obtained in a few minutes by removing the cells to a non-nutrient solution and placing them between the electrodes. In concluding I may call attention to the fact that with the above method we have a means of studying the action of any chemical substance, medical or nutrient, upon the nerve cell itself. With modifications for temperature, it may serve equally well for mammalian tissue. It is intended to make these the next steps in the work, DISCUSSION. Dr.MACALLUM.—Dr. Hodge's observations are extremely interesting and instructive. It would be interesting also to determine the micro-chemical changes that occur in the nerve cells. Lelleneld and Monti have shown that the cytoplasm of the nerve cell contains more phosphorus than the nucleus of the same, and if we could parallel Dr. Hodge's observation by observations with the method used by those observers we might gain a full history of the changes of the nerve cell under stimulation. I)r. Hodge's observations on the amoeboid properties of the nucleolus under the influ- ence of potassic tartrate solutions show that these bodies exhibit under certain conditions properties which are not usually attributed to them. The speaker him- self observed in the gland cells of young amphibia the amoeboid movement of the nucleolus, and regards this as a normal property. Bütschli found that drops of a mix- ture of salt, old olive oil, and albumin exhibited amoeboid properties, and it is not surprising that such a body as the nucleolus, so closely connected and associated with the vital properties of the cell, should exhibit movement. It is more reasonable to believe this than to believe that because a nucleolus-like body exhibits movement as it does in certain cancer cells, that it is therefore a parasitic organism, a conclu- sion which some pathologists have adopted. As to the question whether pigment indicates decay or activity, Dr. Macallum thought that both views are partly true. * Was, Ferd. Studien über den Bau des chromatins in der sympathetischen Ganglieuzelle. Archi v. f, Mik. Anat. Iłd. 40 S., 375, 1892. PAN-AMERICAN MEDICAL CONGRESS. 1265 Pigment is chemically melanin, an iron-holding derivative of chromatin, like haemo- globin and as chromatº n, as shown in the nucleolus, disappears in old age and activity, it is but natural to conclude that the abundance of melanin is an indication of past activity on the one hand and on the other of how far the cell has progressed toward decay. The nucleoli are reserve chromatin, which, in young and resting cells, is more abundant than in those of old age. This fact explains the disappearance of the nucleoli in the nerve cells of old age. With the diminution of the chromatin there must be a diminution in the number of cells holding it, and therefore Dr. Hodge's observations on the great diminution of the number of nucleoli and of the nerve cells themselves is in accordance with the speaker's observation on other cells. Dr. Hodge has done work whose value in understanding certain psychological plenomena is inestimable. ON THE RESPIRATORY CENTER IN THE MEDULLA. OBLONGATA. By J. GAD. The number of muscles taking part in every normal respiration is very large; larger than would generally be supposed. It is an old and unfortunately wide- spread idea that the diaphragm alone is sufficient for the carrying out of a normal inspiration. It is, indeed, possible by suitable sections of the spinal cord to reduce an animal to the necessity of ventilating the lungs by means of the diaphragm alone and the degree of ventilation in such an animal will be found, at least at first, not to |be below the normal. If, however, the movements of the thorax be observed, it will be seen that it now neither widens, as in the thoracic type of respiration, nor remains of unaltered diameter, as in the so-called diaphragmatic type, but that the lower and lateral regions are drawn sharply inward. And when the exposed diaphragm is watched, it is seen to descend much farther, i. e., to work much harder than before. The diaphragm requires therefore, even with the apparently purely diaphragmatic breathing of the rabbit, the continual assistance of the thoracic muscles, simulta- neously stimulated with corresponding intensity, if it would not be exhausted by excessive and unsuitable exertions. - We see from this example very clearly the need for the proper coördination of a great number of respiratory muscles, whose motor roots are distributed over a great part of the spinal cord from the fourth cervical to the twelfth dorsal segment. The necessary number of functional combinations of respiratory muscles is, however, far greater, as is shown by observations which can not be cntered into here. On them is based the view that a normal respiration can only take place when the intensity of stimulation of each respiratory muscle is brought into proper relation with the others. The immediate innervation areas of these muscles reach from the nucleus of the nervus facialis in the medulla oblongata down to the lumbar plexus. The siimplest way of getting such a coördination is seen in the case of the muscles of the eye. The nerve cells which supply the muscle fibers of the rectus internus are found partly in the nucleus of the oculo-motorius and partly in the abducens nucleus of the opposite side, so that when the left internus acts together with the right, as in bringing the point of regard closer, a different portion of its muscle fibers are engaged than when it acts with the right abducens, as in glancing to the right. Every stimulus which reaches the right abducens nucleus finds here motor nerve cells not only of the right abducens, but also of the opposite internus, and every time the right abducens is stimulated the left internus is also stimulated in correspond- ing degree. In this example the coördination of two muscles is accomplished by bringing together a part of their motor nerve cells. This will not serve in the case of the respiratory muscles, neither the inspiratory nor the expiratory, for we have seen that their motor nerve cells are distributed through a long series of segments. S. Ex. 36—80 1266 PAN-AMERICAN MEDICAL CONGRESS. If we take for granted that similar ends are reached in similar ways, we may here. use to some advantage our knowledge of the coördination mechanism of a certain group of movements in the frog. A very important coördinated movement in the frog is the taking of the spring position, for only from this position can he make the spring which is often his one chance for life. The spring position is assumed by: bending all the joints in the hind limbs, and the motor nerves of the flexor muscles. carrying out these movements have their origin in the great motor ganglion cells of: the anterior horn in a series of segments of the distal portion of the spinal cord. Evidence has been brought forward that in the proximal portion, from the fourth spinal segment upward, the coördination of the muscles taking part in the assump- tion of the spring position is effected through small ganglion cells of the posterior horn. Anatomically expressed, the axis-cylinder processes of the small ganglion; cells, together with their collaterals, stretch to the motor ganglion cells of the flexors of the hind limbs and embrace these cells with their terminal branches. Each individual ganglion cell in the first category can in this way occasion a simul- taneous excitation of a number of distant motor cells, and acts as a coördinating: mechanism for them. We may say that the elements coördinated by this apparatus: are subordinate to it, or that the latter is a prečrdinating apparatus for these elements. The small ganglion cells, which coördinate the flexor muscles for the assumption of the spring position, are placed together in the proximal part of the spinal cord. They are connected in space and have a common function, and for this reason may be termed a “center,” and more particularly a “coördinating center. for the flexor muscles.” The combination of motor nerve cells, in the nucleus of the facial nerve or of the vagus or in the individual spinal segments, which supply the muscles taking part, in respiration may be called the “respiratory muscle center,” and what we have: learned concerning the flexion center in the frog warrants us in assigning to some complex of nerve cells the function of bringing the bulbar and spinal respira- tory muscle centers into orderly, related activity. Such a coördinating “respira- tory center” would be sought, according to the usual experience concerning the location of higher coördinating functions, not in the mammalian spinal cord, but in the more proximal portions of the central nervous system. Legallois, indeed, was, able to show rabbits which continued to breathe regularly after the removal of the cerebral hemispheres together with the pons as ſar down as the vagus roots. Death followed the removal of more distal parts, a circumstance attributed by Legallois, to destruction of the vagus roots. Flourens, however, who pointed out that vagot- omy was not immediately fatal, ascribed the result to the extirpation of his moud. vital at the point of the calumus scriptorius. It is certainly true that the destruction of a comparatively circumscribed area in this region will cause a sudden arrest of respiration and speedy death, and this spot may therefore be picturesquely called a vital knot; but that this place is not the seat of the respiratory center, as defined. above, has recently been shown by me and Marinesco. Brown-Séquard in France, and later, Langendorff in Germany, have long contended that the result of Flouren's experiment is not to be explained by the non-stimulating removal of the only place. of origin of the respiratory excitation, but by the strong stimulation of an inhibi— tory path. To the authors just named the respiratory muscle centers are places where the respiratory excitation develops under the stimulus of the blood, but where it may be repressed by the nervous excitation transmitted by the vagus, trigeminus, and other nerves which play a reflex part in the normal regulation of the respiration. Lan- gendorff based his opinion on highly interesting experiments of Rokitansky’s on new-born animals, which Langendorff was able to confirm, namely, that such ani- mals, if they are previously given a little strychnine, continue to breathe sponta- heously some time after decapitation. It appears to me, however, that these experiments can not be made of general application with regard to the functional PAN-AMERICAN MEDICAL CONGRESS. 1267 independence of spinal respiratory muscle centers in fully grown animals, for it has often been shown that the spinal cord of newly born and of lower animals possesses a greater independence of the higher parts of the central nervous system than in the fully grown, in whom alone the changing conditions to which the respiration must be adjusted have reached that complexity which makes the mechanism of its regu- lation so interesting a problem. The logical development of the idea of the essential independence of the spinal respiratory muscle centers must lead to experiments which were made by none of the original representatives of this idea, but were first done by Wertheimer. Wertheimer took fully grown or nearly grown dogs, carried them with long-continued artificial respiration over the immediate consequences of section between cervical cord and spinal bulb and noted the behavior of the animals when artificial respiration was stopped, three-quarters to two hours later. Besides other movements, his animals showed also such as caused a circulation of air in the trachea and sufficed to prolong life three-quarters of an hour without artificial respiration. Not much weight, to be sure, is to be laid on the last circumstance, for the animals must have become cold-blooded under his method, and may have acted like hibernators, who also can live with a minimal circulation of air in the trachea. The form of the movement was the important question and concerning this four experiments of my own have given me an opinion. I used young, scarcely grown dogs and began artificial respiration directly after but not sooner than the stopping of spontaneous breathing after the separation of the spinal bulb. In order to avoid excessive cooling of the animals, I experimented on warm summer days and looked out for plenty of covering. About an hour after the operation the animals behaved like admirable reflex prep- arations; when they were raised by the neck they attempted to lift the head, show- ing that shock had passed off; the heart beat was strong; the rectal temperature indeed had fallen. When the artificial respiration was interrupted, the animal lying upon its side, it continued at first to lie quietly, then began irregular movements in which thorax and abdomen took part, but not to a pronounced degree. From time to time the diaphragm contracted independently and alone, while between times muscles of inspiration and expiration showed a highly disordered activity. These could not possibly be termed coördinated respiratory movements, such as an animal that has not been made cold-bloodied needs to make in order to preserve life. These phenomena were repeatedly observed in the same animal and showed themselves in essentially the same way in all four animals. I got the impression that the spinal respiratory muscle centers did all they were capable of doing after separation from the respiratory center; they fell into activity with the increasing accumulation of carbon dioxide, just as did the spinal nerve cell groups which call forth other move- ments, for example those of a limb; this activity also found rhythmical expression and could be increased reflexly like the movements of a limb; but there was no indi- cation present that the spinal respiratory muscle centers possess a specially strong sensibility towards the stimulus of the blood. This perhaps might be due to the cooling—scarcely to be avoided in this method of experimentation—so that I can give these experiments no deciding power in any direction. The idea of the dependence of spinal respiratory muscle centers on a coördinating respiratory center in the spinal bulb was not strictly demonstrated, but, on the contrary, was not shaken; rather strengthened. The efforts to localize the respiratory center in one narrowly circumscribed place in the spinal bulb have (as is known) led only to contradictions. Flourens, Longet, Scheff, Gierke, Mislawsky, and Hohn, have each given a different bilaterally sym- metrical area whose destruction on both sides should be followed by permanent stopping of the respiration. This result is indeed to be had at each of these spots, if a coarse section is Imade, so that the surrounding tissue is much shaken by the instrument itself or by hamorrhage following the section. The areas lying superficially, for example that given by Gierke, as often fail to show the result 1268 PAN-AMERICAN MEDICAL CONGRESS. when the section is made without shock to surrounding parts and when the haem- orrhage happens to be absent. In such experiments, however, a transient interrup- tion may occur, but is indeed to be referred to the stimulation of an inhibitory path, for it passes off without any treatment. Too little attention is paid to the danger of being deceived by stimulation of inhibitory paths in the attempts to localize the bulbar respiratory center, although Brown-Séquard pointed out this dan ger long ago, a service for which we may give him credit without assenting to his conclusions. Finally, it results from these several experiments that the attempt to confine the respiratory center to a narrowly circumscribed seat has no prospect of success. It must, indeed, excite surprise that the possibility of doing this should have been held to be so important; in fact, far more important than the demonstration of nerve cells at the place in question. We could not, indeed, expect that nerve cells which carry out a defined coördination should be irregularly strewn about in the central nervous system; on the contrary, they should be united in a well-defined anatomical system. There need, however, be no limit to the separation in space of the elements of this system, except that set by the common requirements of the cells of the center in respect of their food and their blood and lymph supply. It was not probable that further progress in the solution of the problems we have been discussing could be made without a method by which extensive extirpations could be carried out, step by step, in such a way that each individual procedure should cause the smallest possible inhibition stimulus; that each further procedure should be made only after the effect of the stimulus of the preceding had died out, and that each successive act should permit as sure a localization of its effect as the previous one. I had seen that cauterization by laying on Small pieces of blot- ting paper just saturated with nitrate of silver fulfilled the conditions of the above- mentioned method and I had often, before my classes, thus eaten holes in the medulla oblongata of rabbits, which included all the places given as the seat of the respira- tory center, without the respiration stopping. But time was lacking for the sys- tematic employment of the method and I was accordingly much pleased when Mr. Marinesco, who had been present at one of these demonstrations, declared his will- ingness to investigate the matter in my laboratory. Mr. Marinesco learned first to do the fundamental experiment, which had to be learned less on account of the requisite nicety of manipulation than to acquire a conviction of the absolute neces- sity of going very slowly, step by step. In these preliminary experiments Mr. Mari- nescu found a still better method of extirpation; burning by means of glass pearls the size of a pin's head, made by melting the end of a fine glass thread. These glass pearls are very light, and thus all pressure, all shock, and all bleeding are avoided, and the operation field is always quite clean and clearly visible. And this procedure also makes much easier the interpretation of the sections of the suitably hardened tissues in respect of the extent and the boundaries of the extirpation. The long continued exertions of Mr. Marinesco furnished us a great number of preparations from animals who either had continued to breathe in spite of exten- sive extirpations in the spinal bulb, or whose often inllibited and as often recur- ring respiration had finally ceased after the last slight extension of the extirpation. I lay the most weight on preparations from animals in whom the extirpation was done only on one side. Such animals breathed on uninterruptedly and sufficiently with the uninjured side. They lost by far less heat than in the Wertheimer experi- ment, because artificial respiration is avoided and the division of the medulla, even in deep extirpations, does not take in too large a part of its cross section. When in such animals a unilateral extirpation causes the respiration to stop on the operated side and there is no return during hours of observation, in which the animal is Imeanwhile breathing sufficiently with the intact side, the conclusion is certain that the effect of an inhibition stimulus has passed away and that the phenomena remaining are purely the expression of a loss of function. We have had frequently the opportunity of observing such animals. The unilateral breathing may with a PAN-AMERICAN MEDICAL CONGRESS. 1269 little practice be recognized with a fair degree of certainty, even with unopened abdomen. We finished the observation, however, by opening the abdomen, after time enough had passed for the effect of the inhibition stimulus to have disap- peared, and determining with all certainty and by direct inspection of the dia- phragm that the respiration was one-sided and that the passive half of the diaphragm did not become rhythmetically active even when the nostrils were closed by pressing them together. As asphyxia comes on, indeed, even this portion of the diaphragm may be drawn into the widespread irregular clonic convulsions. Observations of this sort on rabbits, cats, and dogs of different ages have fully per- suaded me of the incorrectness of Brown-Séquard’s, Langendorff’s, and Werthei- mer's views; the spinal respiratory muscle centers are not, in my opinion, relatively independent of the bulbar respiratory center but, on the contrary, are wholly dependent on the latter in their functional activity. Although a transient disturbance of the respiration follows even a narrowly cir- cumscribed and careful extirpation at most points on and beneath the floor of the fourth ventricle, yet a difference is to be noted. After some extirpations, as soon as the effect of the inhibition stimulus has passed off, the respiration comes back as strong as ever; but in others a noticeable weakening of the respiration remains even when it does not amount to positive failure. The areas giving the latter result lie in the formatio reticularis, whose nerve cells, therefore, are at least in part in rela- tion to the bulbar respiratory center. In human anatomy, as is well known, the median part, or formatio reticularis alba (from the hypoglossus root to the raphé), is distinguished from the lateral formatio reticularis grisea. In man, and also in the rabbit, many more nerve cells are strewn through the lateral than through the median part of this formation, while in other animals, for example the cat, the number of nerve cells in the median part is very large. Corresponding to this, extirpations in the cat between the hypoglossus root and the Taphé, when sufficiently deep and long, seriously impair or wholly stop the breathing, while in the rabbit the formatio reticularis lateralis must be removed in some extent in order to finally stop the respiration. That the stopping of respiration after removal of the respiratory parts of the forma- tio reticularis was not due simply to the section of intra-central conducting paths leading from a more proximally situated respiratory center, but was the result of the removal of cellular elements influencing the respiratory rhythm, was shown by stimulation experiments on rabbits. In order to make a circumscribed electrical stimulation in the depths of the tissue we used very fine insect needles, which were covered to the points with a thin coat of varnish. These were united with the sec- ondary coil of a Du Bois Reymond inductorium by means of very thin, soft, flexi- ble conducting wires and a friction key. At the selected place the needles were passed close together through the floor of the freely exposed fourth ventricle into the bulb. The places which we desired to stimulate lay at such a depth that the needle electrodes were sufficiently fixed by the tissues through which they had been thrust, and the thinness and softness of the conducting wires permitted the needles to follow every movement of the animal, without the slightest displacement in the wound. In by far the greater number of cases the introduction of the needles and their continued presence, so long as the current did not flow through them, caused no alteration in the respiratory curve written with the respiratory volume writer (ağroplethysmograph). In two animals, however, very interesting attacks of cough- ing were observed, each attack being preceded by an interval of quiet, and it was found later that exceedingly minute harmorrhages had taken place into the substance of the formatio reticularis lateralis. The electrical stimulation was made with the secondary coil as far from the primary as possible, and while the respiratory curve was being written with the aëroplethysmograph. The first results which appeared with the smallest effective stimulus were seen when the needles were in the formatio reticularis lateralis, and only then, and con- 1270 . PAN-AMERICAN MEDICAL CONGRESS. sisted of an inspiratory change in the breathing, namely, a quickening of the respir- atory rhythm. Electrical stimulation below the point of the calamus scriptorius, and especially further distal (but still at a sufficient distance from the phrenic roots to prevent their excitation by the very weak current we were using), also affects the respiration. Here were observed, even with the weakest stimuli to which the res- piration is capable of reacting, only tetanic contractions of the inspiratory muscles, on which were superposed the respiratory movements in their previous frequency and depth. Here, therefore, we have to do only with the cerebro-spinal motor conduct- ing paths from the respiratory center to the spinal respiratory muscle centers, and this holds essentially true for the noud vital also, while in the former case, where alterations in rhythm were observed, we must suppose that nerve cells were in action, and these nerve cells must belong to the respiratory center itself. The descending motor conducting paths were localized by Schiff in the lateral columns of the spinal cord. Mr. Marinesco was able to confirm this statement by the use of his method of progressive cauterization. He made this extirpation on one side between the first and third spinal root, and we considered the path in question wholly interrupted when the respiration on the same side did not return after an hour's interval nor in dyspnoea (the diaphragm being exposed for inspection and the animal continuing to breathe with the uninjured side). Mr. Marinesco was able to give the situation of this lateral path more exactly: In the processus reticularis, or lateral column at the base of the anterior horn. This is very satisfactory, for the reason that the bulbar continuation of the lateral column is to be sought in the formatio reticularis, whose cells are concerned in the function of the respiratory center. I hold this result to be indeed specially satisfactory, because the demand that a center subserving a definite function shall be a demonstrable group of nerve cells, for example, a group like the nucleus of a motor cerebral nerve, appears to me to rest on a preconception wholly without foundation. A coördinating mech- anism of the highest order for such an extensive motor apparatus as that for respir- ation requires too large a number of nerve cells to make the realization of such an idea possible. All that can be demanded is that the nerve cells which subserve the function of the respiratory center shall be so arranged that they may be brought into relation with the respiration without conflicting with the histologically grounded conception of the systematic structure of the central nervous system. It is exactly here that the coincidence between the localization of the spinal path and the bulbar cells becomes so satisfactory. There are physiologists who refuse all conceptions of a respiratory coördinating mechanism founded on an anatomical basis. A representative of this school (Lan- gendorff) has recently expressed his views on this question as follows: “By respiratory center should be understood the sum of the individual centers of the respiratory nerves, which must be conceived as united in a physiological union.” The fact of the common harmonious working of nerve centers widely separated from each other and supplied with blood under different conditions can not, how- ever, be explained by the existence of a fixed chain of ideas in the head of a physi- ologist. In order to reach a scientific explanation, from which we are, indeed, still very far off, we must make an earnest attempt to get a definite idea of an anatom- ical connection between these centers which can serve as a basis for exact physico- chemical conceptions. Only such hypotheses can point the way to fruitful experi- mentation, and only such (not metaphysical dicta) can be matter for scientific dis- cussion. An hypothesis permitting such discussion has been recently advanced by Exner and Grossmann. They also believe that they can do without a coördinating center which shall prečrdinate the respiratory muscle centers. Grossmann attempted to separate the bulbar respiratory muscle centers (facial nucleus for the respiratory movements of the nose and vagus nucleus for those of the glottis) from each other and from the spinal respiratory muscle centers by successive sections. He believed PAN-AMERICAN MEDICAL CONGRESS. 1271 he could establish the law that so long as any two of these centers were in connec- tion they continued to functionate, but that each ceased to functionate as soon as it was completely isolated from the other. Grossmann found that a section between the facial nucleus and the vagus nucleus stopped the respiratory movements of the nose, while those of the glottis and thorax still continued. He found further that a section between the vagus nucleus and the spinal cord stopped the thoracic movements, while those of the nose and the glottis continued; and, finally, he observed, on the other hand, that the movements of all three, nose, glottis, and thorax, ceased after two sections were made, the one between the facial and the vagus nucleus, the other between the vagus nucleus and the spinal cord. These experiments led Exner and Grossmann to the conclusion that the motor nerve cells of the various respiratory muscle centers must be united with each other by nerve conducting paths in such a way that each of these nerve cells communicates its excitation not only centrifugally to the muscle fibers dependent on it, but also within the center (intracentral) to the nerve cells of other respira- tory muscle centers. Against this hypothesis is to be nrged that the only test which the authors’ experiments have undergone from other hands has failed to con- firm in the most important particulars the observations on which the hypothesis is based, Frederic and Bienfait declare that they have seen the respiratory move- ments of the glottis continue after complete isolation of the vagns nucleus by section between vagus nucleus and facial nucleus, as well as between the vagus nucleus and the spinal cord, while the movements of the nose and the thorax stopped. This announcement is the more worthy of attention for the reason that after the above-mentioned sections have been made only the vagus nucleus remains in connection with the respiratory center demonstrated by Marinescu and me, in the formatio reticularis. But a serious mistrust of the Exner-Grossmann hypothesis can be justified even without a repetition of their experiments, for their hypothesis is grounded on the assumption that the motor ganglion cells can send an impulse in two directions. - Each motor cell possesses, as a rule, only one axis-cylinder process, and we know with certainty that the excitation is sent out of the cell by the way of this process. Impulses reach the cell, in all probability, by means of protoplasmic processes, and we know no histological difference between the protoplasmic processes that justifies us in selecting some for afferent and others for efferent impulses. That the cell would receive and send out impulses by the same path appears improbable when the classical experiment of the centripetal stimulation of the severed anterior spinal roots of the frog is called to mind. The fully demonstrated power of nerves to trans- mit impulses in two directions requires that the impulse arising from this stimulation should reach the motor nerve cells. As, however, it is known that the stimulation has no visible effect, the impulse can Inot have been transmitted over intracentral conducting paths. It is most probable that it does not pass the motor ganglion cells or, perhaps, does not even enter them. These reflections, indeed, rest on too uncertain a basis to themselves overthrow the hypothesis in question, but they at least point to experiments by which it may be tested. The hypothesis was born of section experiments and must withstand the test of stimulation experiments. If the Exner- Grossmann hypothesis is correct the isolated stimulation of a single respiratory muscle center should strengthen the respiratory movements depending on the remain- ing respiratory centers. If our conception of a prečrdinating respiratory center in the formatio reticularis is correct a narrowly circumscribed stimulus can influence in the same way, respiratory muscle centers lying far apart from each other only when the stimulus reaches the formatio reticularis. Mr. Arnheim undertook the experiments in my laboratory in Berlin. We first devised a method for writing the respiratory movements of the nose on the kymo- graphion simultaneously with the respiratory volume curve. When the stimulation experiment described above was repeated with this method, it was seen that when 1272 PAN-AMERICAN MEDICAL CONGRESS. the points of the two needle electrodes were passed into the formatio reticularis lateralis the quickening in the frequency, which we already know to be a certain indication of a minimal, i.e., barely effective, stimulation, was not limited to the respiratory movements of the thorax, but those of the nose were influenced in the same way. This result would not oppose the hypothesis under examination, pro- vided it is accepted that our stimulation current reached the vagus nucleus. We ourselves believe that this possibility can be excluded with certainty, but it is diffi- cult to furnish evidence that will convince others of this. The above-mentioned result of the minimal stimulation of the processus reticularis in the proximal part of the cervical cord, consists in an increased tonus of all the thoracic muscles of respiration without any alteration in the frequency and depth of the individual respirations, a fact that was interpreted by us to mean that we had to do here not with a center, but with an intracentral motor path. This path might lead from the facial nucleus through the vagus nucleus to the spinal respiratory muscle centers (Exner-Grossmann), or might connect over respiratory center with the spinal respiratory muscle centers. According to the Exner-Grossmann hypothesis we must expect that the stimulation of the path would influence the nasal and the thoracic breathing in the same manner. The experiment, lowever, shows very decidedly that this is not the case. As the stimulus in creases to the point at which the increased tonus of the thoracic muscles of inspiration is produced, and alteration indeed appears also in the nasal movements, but is of quite another character and differs especially from the reaction of the thoracic inspiratory muscles in that it outlasts the stimulation. This and other of its remaining peculiarities characterize it as a reaction to a painful stim- ulation, which reaction appears always much earlier in the nose than in the thorax. We have never seen an increase of the tonus of the inspiratory muscles of the nose caused by stimulation of the spinal respiratory path, and we believe, therefore, that this path connects our respiratory center in the formatio reticularis with the spinal respiratory muscle centers, and that its excitation produces a visible effect only at one end of the path. An analogous path must exist, according to our conception, between the respiratory center in the formatio reticularis and the facial nucleus. The result of the stimulation of this path must be limited to the nasal movements. In fact, we have succeeded, with the aid of the needle electrodes, in finding places at the distal end of the facial nucleus whose stimulation to the effective point causes only increased tonus of the nasal muscles, in which the thoracic muscles do not participate. The existence and meaning of this path may fortunately be still more clearly shown by a combination of the stimulation and the section experiment. It is well known that Martin, Booker, and Christiani have found places in the neighbor- hood of the Aqueductus Sylvii, at which different and well characterized reactions in the breathing can be produced. However slight are the reasons for calling these places “centers,” after the example of their discoverers (they are probably only points in an important conducting path), the phenomena described by the authors named can always be reproduced with certainty. Christiani’s “Inspiration center” has especially helped us to instructive reactions in the study of the more distal respiratory centers and paths. These reactions have a very clearly marked char- acter, the same both in nasal and thoracic breathing. If an unilateral section is made between the facial nucleus and the vagus nucleus and the Christiani “ center,” stimulated on the opposite side, the nasal and thoracic reactions do not appear, while on stimulation of the injured side they appear as before. It follows from this experiment that we have to do here with crossed paths, and that the influence which the “center” exercises on the facial nucleus is not transmitted to it by the shortest path. If this were the case only those sections which are proximal from the facial nucleus would prevent the reaction. As distal sections also do this, the impulse can not pass by the shortest way, and an explanation of the circuitous PAN-AMERICAN MEDICAL CONGRESS. 1273 path is required. An explanation indeed can at once be given on the basis of our conception that all impulses, which affect all the different parts of the respiratory motor apparatus in common, reach them only by the agency of a coördinating res- piratory center, which is prečrdinating to all respiratory muscle centers. The experiments recently made by me in association with Mr. Arnheim, as well as those first described (Gad and Marinesco), show that the seat of this center is the formatio reticularis lateralis. Our efforts to define the upper boundary of this center were at first not wholly successful, but we are now able to state that the center does not reach up to the facial nucleus, basing our statement on the previously mentioned result of the stimulation immediately distal from the facial nucleus. We see that this stimulation influences only the nasal breathing, and does not, as does the stimu- lation of the respiratory center, affect the nasal and thoracic breathing at the same time and in the same way. We have made good progress towards giving the pre- ordinating respiratory center a definite place among objective things. DISCUSSION. Dr. Reichert said that the paper was one of considerable interest to him because his work is a practical demonstration of what Dr. Reichert has taught for years to the students in the medical department of the University of Pennsylvania, i.e., that the various motor nerve centers which are concerned in the complex coordination movements of respiration are undoubtedly governed by a pre-coordinating center. Dr. Beyer, discussing Professor Gad's paper, said that the highest credit was due to the Professor for his work on the innervation of respiration; the formatio retic- ularis was always considered among nerve anatomists and physiologists as a very dark knot. Its connection, therefore, as a preijrdinating center of respiration is to be welcomed very heartily. AUTOMATISM IN NERVE CENTERS. By SAMUEL WOLFE, A. M., M. D., Clinical Professor of Nervous Diseases in the Medien-Chirurgical College, Philadelphia (formerly Pro- fessor of Physiology). The so-called stage of rest in any physiological unit should be considered when regarding its total functional activity. This stage in the nerve cell must be con- tinually influenced by impressions on the peripheral nerve endings sending impulses over fibers, which impressions arise in the external world, within the body from similar causes, and as the result of metabolic processes in the various tissues. The intimate connection by fibers of all the nerve cells makes it probable that no func- tion of the cell is independent of impressions arising outside of the immediate cell concerned, hence not automatic in any absolute sense. A stability which prevents activity independent of excitation transmitted through a fiber is essential to the normal condition of most of these cells, and most probably of all of them. INNERVATION OF THE VENA PORTA. I3y FRANKLIN P. MALL. M. D., of Chicago, Ill. It has been known for a long time that when the splanchnic nerve or cervical spinal cord is irritated the arterial pressure rises. During the irritation of these nerves it has also been noticed that the smaller arteries of the mesentery as well as others contract. The mechanical explanation of the rise of the arterial pressure was therefore quite simple. When the volume of the blood in the arteries, as well 1274 PAN-AMERICAN MEDICAL CONGRESS. as that thrown from the ventricle, is taken into consideration, it is at once seen that the simple contraction of some of the smaller arteries is not sufficient to explain the rise of arterial pressure after splanchnic irritation. It has been found that when the aorta is tied just below the left subclavian artery (and the femoral artery opened to prove that the arterial pressure is reduced to zero), irritation of the splanchnic nerve causes a decided rise of pressure in the carotid artery. Moreover, it is found that with the aorta open or closed splanchnic irritation causes an increase flow of blood to and from the heart, thus showing us that the real cause of arterial pressure is due to an increased amount of blood being thrown into the aorta. A similar rise of pressure can be produced by injecting a quantity of fresh blood either into the jugular vein or into the carotid artery. In a dog of average size splanchmic irrita- tion causes an increase of about 100 c. c. of blood to be thrown into the aorta. Transfusion of the same quantity from another animal causes an identical arterial CUITV6. - The first and most important experiment is the proof that when the splanchnic or the cord is irritated the vena porta contracts, often completely emptying its lumen. That this is not primarily due to a contraction of the smaller mesenteric arteries is proved by the fact that the contraction of the vein is most marked when the pressure in the abdominal aorta is reduced to zero. Moreover, with the aorta open and the vena porta closed, it is quite easy to cause the portal pressure to exceed that of the arterial by splanchnic irritations. We therefore conclude that the rise of arterial pressure, after splanchnic irritation, is due in great part to an increased quantity of blood being thrown from the heart; this, in turn, is caused by the contraction of the veins, and especially the vena porta and its branches. (See Archiv. für Anat., und Physiol., Paynol, Abt., 1892.) In the demonstration to be made a ligature staff is applied to the aorta just below the origin of the left subclavian, and on the splanchnic is armed with an electrode. The portal vein is exposed, and after the artery is closed the splanchnic is irritated. The portal vein will contract and the arterial blood pressure will rise. HIBERNATION AND ALLIED STATES IN ANIMALS. By WESLEY MILLS, M.A., M. D., Professor of Physiology in McGill University, Montreal, Canada. In a paper read on this subject before the Royal Society of Canada in 1892 I made reference to the views entertained in regard to the winter sleep of a number of animals, which will, however, be omitted from this paper in order to shorten it. My own studies were conducted chiefly on our American marmot or woodchuck (Arcto- mys monaz), and of these I now give some account, together with details of some cases in man of hibernation or an allied state, one of these being, I think, about the most remarkable on record. The object of my investigations being to ascertain not only the nature of the winter sleep, but the character of its variations under a changing environment, especially as regards temperature and meteorological conditions generally, I kept the animal in different rooms of the houses in which I dwelt successively through the creature's lifetime, and also in different parts of an outhouse in which my dogs, fowls, etc., lived. It would take up too much space and prove rather wearisome to attempt to reproduce here the records which I have kept in detail. It will be both more prac- ticable and more profitable to give the general results of studies on this one specimen for the four years during which he lived, and then refer to the unexpected result of the study of another specimen during the past winter. PAN-AMERICAN MEDICAL CONGRESS. 1275 I think the following life periods were recognizable in the specimen I had under observation: (1) A period characterized by either drowsiness or sleep or profound torpor, lasting from about November to April; (2) a period of perfect wakefulness immediately following, during which the animal was emaciated, in poor coat, and with a general low vital capital, lasting for some weeks; (3) a period of improving condition, with good health and a desire to get free, which latter was also noticeable in the preceding period; (4) a period of maximum weight and vigor, with perfect coat and an abundance of fatty tissue. But little need be said about any of these life periods except the first. During the second the emaciation increased rapidly at first on waking, and was equally marked by voracious feeding. The meaning of this will be referred to later. It is plain that the organism entered on its long period of diminished vitality with a large stock of reserve material, and it is equally clear that this was drawn upon to the full. I now turn to the peculiarities of the sleeping or torpid condition. I have char- acterized the first-period as one of drowsiness, or sleep, or torpor, because there are subdivisions of the first period, during which the animal was found in a condition that was characterized by drowsiness, and no more; again, it was plainly only sleeping, while again it was as profoundly torpid as it ever became. The period of most profound sleep was never reached all of a sudden, but was preceded by the two states referred to above. Moreover, as the depth of winter approached the sleep became more profound, and the reverse with the approach of spring, so that we might represent the depth of the sleep by a rising followed by a falling curve with a rather long flattened top. During the whole of the first period the animal nestled in the straw, with which he was always provided, and when he was most profoundly unconscious but little of him could be seen often, so completely was he covered. Another important matter. The amount of food consumed was directly proportional to the depth of his sleep. Not only did he eat less frequently, as a matter of course, but the quantity taken at one time was less. Occasionally when fully hibernating he would awake to fall asleep again, merely after gathering the straw about him a little closer, and not eat at all. His cage always being sup- plied with food, there was no doubt about his ability to provide himself when so inclined. His excretions were also in proportion to the amount of food consumed, and especially to the depth of the sleep. The less he ate, and particularly the more profoundly he slept, the less were his evacuations when he awoke. He never befouled his bed, but always left it to void urine and fees. During the period of mere drowsiness the animal would be awakened by a gentle rustling against its cage, and even when asleep a noise would always arouse it; but when in a torpid condition it could not be thus aroused, but might be handled without being brought to the natural condition, though handling and much less disturbance always caused movement—a phenomenon to be discussed later. In the spring of 1891 my woodchuck came out of his winter sleep in a very emaciated condition, and this, as usual, increasing after his awakening, he was in a doubtful state; but the case was soon decided against the animal in consequence of my serv- ant having left him for some time fully exposed to the sun's rays. An autopsy revealed the fact that the animal (a male) was the subject of tuberculosis of the lungs, though possibly but for this exposure he might have lasted another year. Through the kindness of Mr. R. F. Rorke, an undergraduate in medicine of McGill University, I became possessed of two specimens of the marmot in the latter part of the summer of 1891. One of these was very large and in fine condition, and his escape soon after arrival has been a frequent subject of regret by me, as I hoped to be able, not only to continue the observations, but to make them comparative, as it was my intention to keep both under the same conditions, in fact, in the same cage. But the curious part remains to be told. Though I kept the remaining woodchuck under exactly the same conditions as the animal I had so long had, he did not hibernate for an hour during two winters, though he drowsed and slept enough. 1276 PAN-AMERICAN MEDICAL CONGRESS. It has been generally considered that the hibernating condition of animals was dependent above all else on the temperature of the surrounding atmosphere. My experiments on bats seemed to warrant this conclusion, for whenever the temperature reached the neighborhood of 45° F. to 40° F., the other conditions being favorable, my specimens began to hibernate. It was also true that my woodchuck was in the deepest sleep during midwinter, when the cold is greatest. Whether a bat could be put into a state of torpor during summer by exposing it to a lowered temperature I do not know. However, Marshall Hall maintained that the diurnal sleep of the bat (“diurnation”) was exactly the same phenomenon as the winter sleep. The same writer maintained that hibernating bats always awoke when the temperature fell below freezing point, and his observations showed that the temperature of the animals was always a few degrees above that of the surrounding atmosphere. Probably Hall is correct in the main, for my bats when the temperature sank during the night much below freezing were always found dead in the morning. Whether they awoke first or simply passed from torpor to death I do not know. However, for the marmot I can assert positively that this rule does not hold, for frequently the water was found frozen in the apartment in which the animal was kept, yet he was undisturbed. Nevertheless, I came to the conclusion that this exposure is injurious to a hibernating animal, and that it had something to do with the poor condition in which my specimen was found in the spring of the year in which he died. Before discussing the true nature of the phenomena of the winter sleep, I call atten- tion to certain cases of allied nature. Such frequent references as we find to the hibernation of swallows deserve some consideration. It is also stated that in Scot- land sheep have been found alive after being buried for weeks beneath the snow; and Dr. Frank Miller, of Burlington, Vt., reported when a student, to the Society for the Study of Comparative Psychology, at Montreal, that hogs had been found alive after being accidentally imprisoned below the surface for several weeks; longer than it seemed possible for them to survive under ordinary circumstances, so that it would appear they had been in a condition of hibernation, or some such state. Turning to the human subject: We have all read of instances in man of “sus- pended animation” or “trance.” The case of fakirs in India having been buried alive, exhumed and resuscitated after months is attested by such evidence as it is difficult to set aside, however hard to credit. Mr. D. W. Ross, a student in medicine of McGill University, has gathered the facts of a peculiar case in so far as they are now obtainable. The individual in question was known as “Sleepy Joe,” a farmer by occupation. He was married and had several children, one of whom, a girl, had the same drowsy appearance as her father. This man would sleep almost constantly for several weeks, awakening, however, to attend to nature's calls and to take food. He would at times awake more fully and then set to work, whether it was day or night, and almost incessantly labor as if to make up for lost time. He was rather weak mentally, but appeared ashamed of his sleepy tendencies, which seemed to get worse as he grew older. He lived to be about 60 years of age. Dr. Aug. Robinson, of Annapolis, has kindly given the following notes of a unique Cà SG - John T., son of a pensioner, is now about 62 years old. When he was 28 years of age lis father committed suicide by cutting his throat in a fit of insanity. Before his father's death John had shown symptoms of melancholia. He would sit by the hour over his father's cobbler's bench laughing and talking to himself and working himself into a frenzy, fighting imaginary foes, and going into immoderate fits of laughter. I can not ascertain, after much inquiry, how long this condition of things lasted before he lapsed into his present state; but this much is certain, for the last thirty years or more, about the end of September every year he falls into a deep sleep or stupor, and, as his present condition is a fair sample of the manner in which his winters have been passed since he was first attacked, I will describe him as I found him on Monday, December 10, 1888, and repeat what I was told by his friends regard- ing his attack this autumn: About August 31 Jack went to bed after eating his evening meal as usual, without exhibiting anything out of the common in his manner or otherwise, or giving any SUBJECT IN HEALTH. SUBJECT IN A STATE OF LETHARGY. PAN-AMERICAN MEDICAL CONGRESS. 1277 4 reason for the supposition that he was out of sorts in any way. On the following morning he did not get up, nor has he shown any more vitality than any sleeping man up to this time. His sleep is very quiet, without any stertor; indeed, it is as calm as that of a child. Twice in every twenty-four hours he is taken up, a person sup- porting him on each side, holding a vessel for his convenience. He knows enough to voluntarily empty his bladder. The urine is high in color and scant in quantity. About 11 o'clock every night he seems to show rather more life than at any other time, and advantage is taken of this to pour a little thin oatmeal gruel, beef tea, or soup down his throat, he opening his lips to allow them to do so, and slowly swal- lowing it. He only takes a very little each time, and if urged to take more simply keeps his mouth shiut. About once in everythirty days, not exactly at regular intervals, during the evening generally, the family will hear a peculiar chattering noise. They never take any notice of it, for they know it is Jack going down to the otithouse to empty his bowels. He then returns to his bed and sleeps. He knows enough to throw a quilt over his shoulders at such times. At the time of my visit I found his temperature 96° F.; pulse 60, regular, though not strong; respirations 14, easy and quiet; skin cool. A pin stuck into his arm caused no apparent change, and he might be pinched until black and blue without its causing him the slightest uneasiness. My first visit to Jack was about twenty years ago, when I first came to live and practice in this vicinity, and it came about in this way. Of course there was a talk about the new doctor and what he could do, so I was called to see this queer case. I got all the particulars from the friends and neighbors, and what means had been tried by other doctors, and then I promised to try what I could do. On the follow- ing day I went again, accompanied by my brother, also a physician. We took with us a good galvanic battery. One of the handles was placed in each hand and bound closely to the fingers with wet bandages. We then put on the full power of the instru- ment. Poor old Jack was out of bed in an instant, and I shall never forget his look of astonishment and horror as he yelled out, “Damnation, What's that?” I can also well remember my own feelings of satisfaction and complacency when the natives congratulated me on my success in this, my first case. I walked off as if saying to myself, “I knew I could do it.” Well, Jack remained awake about three days and then I got a message that my patient was off again. I went up and tried the battery a second time. with only the effect, however, of making him open his eyes and grunt out “Eh,” in a querulous manner, and after looking about him for a half hour or so, he lapsed into his former condition. Next day I again tried the battery, but without the slightest effect, so I gave it up as a hard case. . This is all I have to say about this singular object, except that, of course, he becomes very thin and haggard before he rouses finally in the spring, and he does not fairly waken until the end of May or first of June. During the summer months Jack does exactly the work he is told to do, but he must be told over again every day; for example, if desired to bring the cows from pasture, he will do so, but will not milk them until told to, nor will he turn them afield again Without being desired. He does not seem to know what to do next, even though the same routine is carried out every day. An exception, however, must be made in one respect. He does not require to be told when dinner or tea time arrives, and is blessed with an excellent appetite. Jack is always ready for his food, and is not particular about quality, so that quantity is there. He will talk quite rationally on any subject when spoken to, and recollects distinctly most of the incidents of his childhood. He will hold animated confab with the cows, dogs, trees, wheelbarrow, or any other object which happens to be in his way, and may be noticed sometimes lecturing a tree for some time, breaking out occasionally into uproarious fits of laughter. When visiting in 1890, Dr. C. K. Clarke, superintendent of the Asylum for Insane in Kingston, he happened to make reference to a peculiar individual known to a few as “the sleeping woman.” It at once occurred to me that her case would prove a study of great value if it could be carried out, and I suggested to Dr. Clarke that he endeavor to supplement such facts as we could learn and such observations as we were able to make by a joint visit to the subject of this peculiar condition by a careful study of the case. He succeeded much beyond my expectations in doing this, and has published the results of his investigations in the American Journal of Insanity for October, 1891, under the title, “A case of lethargy,” and from that paper I extract the principal facts in regard to this case, which is so remarkable that it may be well to state them somewhat fully. Several seasons ago I heard that there was a patient who had been in a trance for years, and from time to time word was brought to the effect that the condition still persisted, and that all efforts to rouse the woman were without result. A little more 1278 PAN-AMERICAN MEDICAL CONGRESS. than a year ago I obtained permission to visit the patient, but was not allowed to make any extended examination. On entering the room. I found a thin, old woman in bed, apparently fast asleep. Her respirations were irregular, and varied much during the visit (lasting almost half an hour), running all the way from 24 to 44 per minute. The pulse quickened in a marked way during my stay, and ran up from about 80 to 120. The woman had her eyes half closed, and to all appearances was oblivious to everything that was going on. The nurse gave many details regarding the patient, and made a number of statements, some of which I shall repeat in a few minutes. Many of these statements we were able to verify at a subsequent period; others were undoubtedly inaccurate. Before going into details regarding the every- day life of this case of lethargy, as we saw it, perhaps it would be well to give a brief outline of the history of the patient. Unfortunately, it has not been found possible to get as many important facts as could be desired in connection with this history, but great care has been taken to eliminate all doubtful points. The patient was born in 1820 or 1821, and when she came under observation was almost 69 years of age. The neurotic history was pronounced on “both sides of the house,” evi- dence going to show that her father had suffered from melancholia. A reliable per- son states that the father died from “softening of the brain”—possibly general paresis. The patient's mother was subject (a member of the family states) to attacks of partial loss of reason, which could only be cured by change of air and surround- ings. It has not been possible to get an accurate account of these attacks of “par- tial loss of reason.” The patient’s early history is not well known, but it has been stated on good authority that she was “peculiar,” and in childhood complained of some head trouble that caused her to keep her hair cropped short. She was married when very young, probably when 17 or 18 years of age, as she was but 21 when her third child was born. Three years after the birth of her last child she was noticed to undergo a change in disposition and acted “strangely.” She could not be depended on, was untruthful and whimsical, and worried a great deal about trifles. It is from a subsequent period (three years later) that the history of this case must be dated. The son, the youngest child, says: “The first recollection that I have of mother's sickness was when I was 6 years old. My little sister had died, and I was just recovering from an attack of scarlet fever when she was taken down. I think the attack was caused by grief over sister's death, and overexertion and want of rest. I do not remember how long she was sick at that time, but I recollect that her left side was completely paralyzed, and that after a time a strong liniment was used, which partially removed the paralysis, and when she went to the country for several weeks she came back well. The second time that she was taken sick was when I was 12 years old. She felt poorly for some time, and was then taken with fits, or convulsions, which lasted for, I think, three days, having sometimes four or five in an hour. She was confined to her bed for, I think, about two years, in very much the same condition as at present. I do not know what curative means were employed, but she gradually improved a little, and was again sent out into the country, where she seemed to recover. She enjoyed pretty good health for about six years, but had to be very careful; she never drank tea or coffee, and always had to have the hair on the back of her head cut short. About this time her father was taken sick and we moved into his house to take care of him. This seemed to affect mother and after a short time she was again taken with fits and soon went into her former condition. During this sick- ness, which lasted about two years, she used to sit up a great part of the time and appeared to be perfectly conscious. She knew father and those who waited on her; used to call me her boy, but appeared to be in a sort of a stupor most of the time. She was again sent into the country, and came back well. Then ensued a brief interval of about two years, during which time she was in fair health, but was again taken down as before, and was sick for nearly seven years. During part of this time she was very low and we watched day after day at her bedside expecting each day would be the last; but she again rallied and gradually her bodily strength and reason returned to her. She was well for about five years, when she seemed to be taken with a low fever and gradually went down to her present condition.” Such is the son's account of the case, and from it we learn that the history of nervous trouble dates back at least forty years, and the inference is that the first indications of lethargy then made their appearance. The details of the conditions that existed during the different attacks are almost entirely wanting and it is unfortunate that we are left almost completely in the dark regarding the nature of the convulsive seizures that occurred. Subsequent history would lead us to believe that these were in all probability hystero-epileptic in origin. About the year 1862 the patient fell into a state of lethargy that lasted for seven years or more. The condition was not one of complete unconsciousness and, although the woman appeared to sleep almost continually, occasionally she would wake up for a minute or so at a time and converse in a rational manner. It is not possible to make more than general statements in regard to these attacks, but it is beyond doubt that the PAN-AMERICAN MEDICAL CONGRESS. 1279 conditions were not identical with those that characterized the last attack. Evidently the condition of lethargy was not so profound. The announcement of the death of a warm friend was the immediate cause of her awakening. The return to even an approach to a normal condition of health was a very gradual process. She was lachrymose and childish for some time, and could not use her limbs properly for months; in fact, had to learn to walk again. During the period of wakefulness that now ensued—seven years or more—the patient, to a certain extent, interested herself in the affairs of every-day life. She went about the house; but was very quiet and did not seem able to concentrate her mind on anything. Her memory was markedly deficient, and she seemed astonished to find people and places changed, and could not realize the fact that she had been asleep for such a long time. When waking up from her long sleep one of the first requests Imade was for beer, and, strange to say, the same want was expressed many years after when arousing from a subsequent attack. About thirteen years ago the patient gradually passed into the condition in which we saw her. At first she spoke occasionally, but in a childish manner, and often made a request for meat and potatoes, invariably using the following words: “Meat and potatoes; a plate all full up to the top.” Before giving the details of the case as we saw it, it will be well to repeat, in a general way, the statements made by the nurses who had the care of the patient before she came to the asylum: She seems to exercise a certain amount of discrimi- nation regarding her food and will eat enormously or not at all and when her appetite is not lost does not seem to know when she has had enough. Her diet is made up of minced meat, potatoes, soft toast, milk, etc., and she is particularly fond of meat and potatoes—in fact will not touch anything until meat and potatoes are provided. She does not like sweet things. When not suffering from diarrhea, she eats three times a day. She eats as much as any healthy, active woman of her age. She objects to nauseous drugs and endeavors to push the spoon away with her left hand. The attitude during the day is quite different from that assumed at night, and the patient undoubtedly sleeps more soundly at night than during the day. In the daytime her legs are extended; at night drawn up. In the daytime she is put either on her back or right side, at night on her left side, and remains in this posi- tion until morning without moving; in fact she can not roll over. She will not settle down for the night until a drink of cold water is given. In the daytime, sometimes for an hour or so at a time, she appears to be nearer a condition of consciousness than at any other time. This occurs generally after breakfast, but she has to be roused for her meals. When heavy coverlets are put on the bed, she attempts to shove the blankets off with her left hand, apparently preferring to be very lightly covered. The eyes are three parts closed during the day and completely closed at night. The face sometimes becomes flushed. She never speaks and, in fact, has spoken but once in eleven years or more and that was quite recently (1890), when she said, “I am not asleep.” Her appetite has been better since she has been in the long sleep than it was before and she eats things she would not touch when awake. At least once during the present attack she has, unassisted, got out of bed and there is reason to believe she has done the same thing several times, but not within three years, as her physical condition renders it impossible. Several times the nurse fancied the patient was moving about the room at night, but for some time could not actually prove that such was the case. At last, however, a fall was heard in the middle of the night, and the patient was found lying fast asleep at the bottom of the stairs, down which she had fallen. During the present attack she has fasted on several occasions, and once went fifteen days without food. It must be remembered that the nurses were speaking of the last attack and at a time when the patient had been in a state of lethargy for more than eleven years. In September, 1890, I saw the patient with Dr. Clarke. This was my first, but Dr. Clarke's second visit. We found the patient, an old woman, in bed. She was lying on her back with her eyes half closed. Her face when we first entered was somewhat flushed and respiration rapid. When respirations were closely observed it was noticed that they were most irregular and at times ceased for several moments. They averaged 22 per minute. Pulse was 104, fairly strong and regular; arteries almost free from rigidity. Axillary temperature,98.6°. The nurse stated that ordi- narily the patient's bowels moved but once in three days, but latterly she had devel- oped a tendency to diarrhea and since that had evinced a sense of discomfort until the bowels were relieved. This sense of discomfort was evinced by whining like a dog. Ordinarily she would not give any indication that she wished to relieve her- self, but the presence of the bedpan would excite the reflexes. She does not soil the bed. The statement of the nurse in regard to the amount of urine passed every day was that a little more than half a pint would be a fair average. A physical examination of the patient was made. The left foot was drawn as if there were a contracted tendo-Achillis; right foot drawn down, but not in such a marked manner as the left. Marked rigidity of the right knee and leg; left leg and knee not rigid. 1280 PAN-AMERICAN MEDICAL CONGRESS. Right ankle easily Imoved; left rigid. Patellar reflexes absent. Tickling the soles of the feet did not cause any evidence of sensibility. Each great toe was drawn under the second toe, this condition being especially marked in the left foot. When the soles of the feet were tickled it was thought that the respirations were slightly deepened, but on account of the irregularity of the breathing it was difficult to determine this point and it was considered undecided. Patient's hair gray; nails healthy and not abnormally brittle. Facial reflexes better than reflexes in any other part of the body. Orbicular reflexes good even with air; at the same time it was noticed that flies crawling over the face did not excite the reflexes. Pupils responsive to light. Small bedsores found on hips and evidence of former deep- seated bedsores plainly visible. While we were present the nurse endeavored to arouse the patient and tried to get her to take some food. A protest was made (whining), the patient winked for a few moments, and then went off to sleep again. Bread was put in her mouth, but remained there without any effort being made to swallow. On October 9, 1890, the patient came under Dr. Clarke's care, and a series of observations of the most complete character was made. The patient, a thin old woman, apparently not weighing more than 60 pounds, was carried into the infirm- ary from the ambulance, and placed in bed. She was asleep and did not seem dis- turbed by the jolting to which she had been subjected. Her temperature was 97.2°, pulse 107, and respirations 20. Efforts were made to arouse her, but without avail. Friends stated that she had been in her present state of lethargy for more than eleven years. Her eyes were half closed, and it was found almost impossible to get her to swallow anything. Next morning her temperature was about normal; pulse 117, respiration 18; still asleep with the eyes half closed, as she remained nearly the whole time she lived. She was under observation from October, 1890, until February, 1891, when she died. In these four months she was closely watched and until the last week of her life gave little indication that she had the slightest knowledge of the fact that she lived. She would remain in any position in which she was placed in bed, and if not fed would undoubtedly have died without making any sign that she required or desired food. Her temperature was almost invariably subnormal, sometimes falling to 95°, although occasionally it would rise to nearly 102°, without any cause that could be determined. Her appetite was capricious, although she undoubtedly had decided likes and dislikes in regard to food. She preferred beef and potatoes to anything else. The process of eating was very slow, and sometimes it would be more than an hour before she could finish a meal. When she drank anything milk was evidently preferred. She was very clean in her personal habits, and never soiled the bed. The quantity of urine passed was very small, not averaging more than one-seventh of normal. The bowels moved but seldom, sometimes only once in six or seven days. It was possible to rouse her for a moment or so, to the extent of making her open her eyes, but beyond this she would give no indication of con- sciousness, and went to sleep again immediately. Her legs were nearly always drawn up, although when the patient was admitted it was stated that she always straightened her legs at Inight. Her feet were almost invariably very cold and the hands sometimes so. Occasionally her eyelids would tremble and quiver, just as they will in a patient suffering from hysteria. Generally when much bothered she would for a few moments make a sort of whining protest. The facial expression was quiet, almost deathlike, under ordinary circumstances, but sometimes when under- going examination an expression suggestive of pain would appear; at the same time it is questionable if pain was really experienced, as the heart and respirations did not show the least disturbance. A large amount of food for one so frail was con- Sumed in a day, although on some occasions the appetite was completely lost. Some- times when suddenly disturbed she would start nervously, and her hands would tremble. Trained Nurse Osborne, who was with her very constantly, seemed to think that there were times when she was nearer a condition of consciousness than at others and as this statement was also made by the former Inurses, possibly it is correct. Occasionally she would push down the bedclothes with her hands and the history of the case would go to show that heavy coverings were always objectionable. Nearly every day she was propped up in a chair for half an hour. This did not seem to have any effect on her general condition. The account of her last days are interesting. Early in February, 1891, a marked change took place in the patient’s condition. Diarrhea developed, and the woman was evidently suffering pain. On the 4th of February she was undoubtedly awake, and in the evening spoke in a hoarse whisper asking for a sour drink. This was the second time she had spoken in thirteen years. On the morning of the 5th of Febru- ary again asked for a drink, yawned twice, and fell asleep again. In the afternoon Was again awake, fed herself in an awkward way, and in the evening spoke again in a natºral manner. I sent for her friends, and they endeavored to get her to take notice of them, but she did not appear to know them, and went to sleep as usual. The trained nurse's notes for the next few days are as follows: PAN-AMERICAN MEDICAL CONGRESS. 1281 February 6.-Will feed herself with bread or anything dry. Hand shakes too much to use a cup or spoon. Will ask for anything she wants, but will not speak at any other time. Always uses her left hand. February 7.-I was called in about 4 A. M., and found her lying on the floor; she would not speak, but from all appearances no one had touched her; she had evidently gotten out of bed herself. At 9:30 A. M. she was cold and very pale; about fifteen minutes later her face was flushed and moist, body warm, hands, knees, and feet cold. This soon passed off, leaving her in her former condition. Temperature was 95.4°, lower than at 8 o'clock. This afternoon asked for a sour drink and a big cake. Spoke hurriedly, but quite loudly and distinctly. Kissed the nurse twice when asked to do so. February 9.-Has not been well at all to-day. Moaned when disturbed. Has eaten scarcely anything, but has taken more milk than usual. Has had slight diarrhea since last Tuesday; worse to-day. e I'ebruary 11.--Asked frequently for drinks to-day, and last night said her throat was burning. Does not appear to recognize any of her friends nor to realize that she is among strangers. So long as her wants are attended to she seems quite unconscious of anything else; not exactly unconscious either; but as though she took no interest in what went on around her. February 13.-Is better this morning; had no diarrhea during the night. Has asked three times for something to eat, which sounds like meat, but when I get it for her she will not eat it. February 13.—Diarrhea much worse to-day. February 15.-Diarrhea, somewhat better. On the 16th she was slightly better, and asked for beer and cocoa, and said she felt as if she were burning up. From this time she steadily grew worse, and died on the 26th. Dr. Ruttan, professor of chemistry, McGill University, made elaborate analyses of urine sent to Montreal from time to time, and without offering any detailed state- ment here, I may say that the general conclusions arrived at were as follows: The whole of the urine passed in six days was sent, and he says the total amount, if representing six days' urine, is about one-seventh the normal. This contains all constituents in about normal quantities in relation to the volume of the urine, except the phosphoric acid, which is about one-third what it should be. - AUTOPSY. Inspectio cadaveri...—Nutrition poor; body much emaciated; apparent age 65 to 70; weight about 50; rigor mortis complete. Ante mortem staining on hands and feet; post mortem staining on back of trunk; bedsores on Sacrum, t1p, and ball of great toe; feet and ankles edematous; legs flexed on thighs by contracted tendons; no teeth, and jaws much absorbed. Sectio cadaveri.-Head: Scalp thin and easily dissected; calvarium of average thickness; tables thin, however, diploë being in excess; dura mater not adherent to the skull, slightly opaque at vertex; one slight adhesion to brain at margin of longitudinal fissure; ante-mortem clots in longitudinal and lateral sinuses, the clots in the lateral sinuses being particularly well organized. Brain: The brain weighed about 35 ounces; macroscopically, it was healthy in appearance; in fact in asylum experience I have never seen as healthy a brain in the post-mortem room. Convolutions well marked and sulci deep; gray matter abundant; brain substance firm; ventricles free from evidence of disease; brain not examined microscopically. - Thorax: Substernal adhesions. Emphysema of cellular tissue beneath sternum; cartilages not ossified. Heart: Small; weight, 3% ounces. Pericardial fluid in average quantity; blood in ..great veins, and right auricle fluid; walls of right auricle and ventricle unusually thin; valves normal; small postmortem clot in left ventricle; walls of left ventricle hypertrophied; left auricle normal; valves of left side normal. Aorta: Ascending aorta dilated into a fusiform aneurism; capacity about twice that of normal; arterial coats not thinner than normal; no evidence of atheroma; no pressure effects noticed; varicose veins on posterior walls of the heart; abdominal aorta atheromatous; antemortem clots in abundance. Lungs: Right, very adherent at apex; small adhesions all over surface of lung; apex, a mass of tubercle; in fact, tubercles were found scattered throughout the whole lungs, and in the apex a small cavity existed; hypostatic congestion marked. Left, in this lung a certain amount of hypostatic congestion was apparent, and an occasional tubercle was found; otherwise the lung was normal; cord-like adhesions of pleura on surface. - - Abdomen: Liver adherent to chest walls and diaphram; whole capsule tore off in taking out and remained attached to diaphragm and abdominal wall; weight, 20 S. Ex. 36 81 1282 PAN-AMERICAN MEDICAL CONGRESS. ounces; three vertical furrows present on anterior surface of right lobe; these fur- rows were about 2 inches in length; center one distinctly marked; nutmeg condition present. Stomach: Large; about 2 inches from pyloric orifice was a constricted portion. This condition was undoubtedly not the result of any inflammatory action, but the natural shape of the stomach, giving rise to an āppearance suggestive of a rudi- mentary second stomach. Intestines: Small; evidences of an old peritonitis; adhesions every where; there were several constricted portions from 3 to 6 inches long; in no place was there com- plete stricture, and no scars were present; above the constricted portions the intes- time was much distended. Caecum : Walls much thickened and much venous congestion; inner surface dark red, and roughened; had appearance of numerous varicose veins in wall. Ascending colon: One portion constricted, and part preceding dilated; transverse colon, normal; descending, slightly dilated. Kidneys: Right, very small, about 2+ inches long; apparently normal; left, about an inch longer than right; apparently normal; capsules non-adherent. We may sum up the case by saying that in the subject under consideration we have a woman inheriting from parents an intensely neurotic organization, in conse- quence of which she showed many indications of an ill-balanced and unstable nature culminating in various vital crises, including periods of stupor. In fact, this woman seems to have spent nearly one-third of her whole existence in an unconscious condi- tion, being then a purely vegetative organism. At one period of her life, she was a veritable Rip Van Winkle, finally sinking into a long lethargy from which there was only a brief consciousness prior to the final stoppage of the vital mechanism. But it is to be noted this curious condition was not the result of any gross lesion of the brain, but of hidden molecular peculiarities, which reſiders the case to my mind all the more instructive when considered in connection with all those states I am now considering. II. I propose now to discuss the real nature of hibernation and kindred states. In the paper on squirrels, read before the Royal Society of Canada in 1887, I said, speaking of hibernation : I think it is very probable that, when the matter has been fully investigated, all degrees of cessation of functional activity will be found represented, from the daily normal sleep of man and other animals, to the lowest degree of activity consistent with the actual maintenance of life. As a matter of fact this is the conclusion toward which all my investigations since that time have tended. Though some maintain that in true hibernation there is cessation of respiration, it would be hard to prove this; for, as Hall showed, the circulation continues and the very beating of the heart against the lungs displaces a certain amount of air, and in any event We can not leave out of account diffusion of gases which in all cases of animals with lungs plays an essential part in the pro- cess of respiration. It would be interesting to know the condition of the heart in a hibernating frog or turtle, but in such creatures the skin, as also probably in snakes, has a respiratory function. Live frogs will stay for hours at the bottom of a tank in winter provided fresh water is flowing over them constantly. In fact, winter frogs kept under these conditions respire largely by the skin. So far as the bat is concerned it is difficult to observe any respiratory movements, but in the wood- chuck I never fail to notice them at considerable intervals, say once in five to nine minutes, even when hibernating most profoundly. The respirations were peculiar. Sometimes one deep inspiration, preceded by a sudden relaxation of the enlarged chest, would be succeeded by a long pause; again, there would be a series of very slight respiratory movements. It was always possible by the respirations alone to predict when the animal was approaching the waking state. The awakening was Inever sudden, but gradual, often extending over hours. I have seen something like this, though less remarkable, in the bat. This is no doubt protective to the vital machinery, for when Hall maintained that bats suddenly awaked from the hiber- nating condition died speedily, he was in the main, if not entirely, correct. A brief consideration of natural daily sleep will throw light on winter sleep. Sleep is favored by moderate exhaustion, a good condition of nutrition, and the PAN-AMERICAN MEDICAL CONGRESS. 1283 absence of all sorts of peripheral stimuli. The case of the youth having but one good eye and one hearing ear who could be put to sleep by closing these up is very instructive. This lad did not, however, continue to sleep indefinitely, but awoke after a number of hours, showing that though there are certain conditions in the environment that favor sleep, the latter is essentially a condition of the central nervous system and dependent on laws governing the latter. This view makes it clear that sleep is naturally a nocturnal condition for most animals, owing, no doubt, to the evolution of life in relation always to the environment. The fact is we can not conceive of life except in and by reason of, in a sense, some environment. The change of the seasons, day and night, and all the periodicities of the inorganic world have as a natural consequence stamped themselves on living things, plants as well as animals. Sleep, then, is essentially a rhythmic diminution of the activities of all the tissues, but especially of that one, which controls all others, the nervous. Rhythm seems to be at the basis of all things organic and inorganic, but has not been enough considered in our explanation of living cells. It was long the custom to explain sleep by anaemia of the brain, whereas the very anaemia was due to a con- traction of the blood vessels of the part accompanied by the diminution of the heart beat, both of which are periodical and dependent on the rhythm of the nervous system itself. Of course, temporary anaemia of the brain favors sleep, though it is not the essential cause. As a natural consequence of the decline in the activity of the great controller of the cell activities (metabolism), i. e., the nervous centers, it is found that all the functions of the body, without exception, perhaps, are dimin- ished during sleep. Marshall Hall and others since his time have shown that the gaseous interchange in a hibernating animal is greatly lessened. This diminished metabolism explains why the animal does not require to eat, or but little. It explains the diminished excretions, etc., etc. This being understood, it is not sur- prising that hibernating animals may be kept underwater for long periods, as is the case with newly born mammals, as kittens and puppies, whose vital machinery as yet works very slowly, which are in fact in a condition but slightly more advanced physiologically than the uterine, which is a sort of a reptilian prenatal state, as regards the circulation and respiration. As the metabolism of reptiles and amphibians is of a much slower kind than that of mammals it is not surprising that their winter sleep is more profound. But it is to be observed that the change from their most active to their most sluggish condi- tion is not probably relatively greater than in the case of mammals. All forins of profound winter (or summer) sleep are protective, both of the individual and the species. Manifestly amphibia, reptilia, and other groups of the animal kingdom must have utterly vanished from the face of the earth but for such a power to adapt to conditions. Probably many individuals, if not some entire groups, have, through more or less complete failure to adapt, disappeared before this habit of the inervous system and of the whole organism became perfect enough. It is equally clear, from the investigation given to the subject, that hibernation, like daily sleep, is not a fixed and rigid thing, but just as it has been the result of adaptation to the environment by virtue of the plasticity of function of all living cells, so the power to modify still remains. It is possible to conceive of its being lost in certain groups of animals; indeed, this phase of the subject has been as much impressed on me as the other. Sleep, hibernation, and all such states are not invariable, but to a certain extent so dependent on the surroundings that, as in the case of my last marmot, also of turtles and frogs kept within doors, there may be an omission of that condition which is habitual under the normal environment of the animal. I would like to emphasize these facts, for they seem to me to throw great light on the evolution of function at all events, and on those changes which may become so great as to lead, we can hardly say, to what, in the lapse of time. For years I have had turtles, and especially frogs, under observation during the winter months. Our frogs for laboratory use at McGill University are kept in a tank in which the water 1284 PAN-AMERICAN MEDICAL CONGRESS. is being continually renewed by a slow stream. They are not fed. None of the frogs seem to pass into a condition of true hibernation, but they descend to the bot- tom of the tank and remain quiet, as if asleep or partially torpid, as indeed I know they often are for hours. In this is an interesting modification of that most profound torpor which they experience when buried in the mud of ponds. Even in the winter life of a creature like the marmot we may have all degrees of drowsiness or torpor, as I have shown; and it is not to be forgotten that our own daily sleep has its degrees, so that the night's sleep may be represented by a curve with a sharp rise and very gradual fall, which may, as we all know, be greatly modified by circumstances. The same laws seem to apply to all the known cases of human lethargy, hiberna- tion, sleep, or whatever the state may be called. In the case of the buried sheep and hogs the protective value of the condition is evident, as also in the case of the lethargic woman. This individual, with so ill-balanced and unstable a constitution, would probably have been carried off by some form of actual disease long before had she remained awake. She could exist as a mere vegetative organism, but not as a normal human being in the ordinary struggle for existence. One thing which has been much impressed upon me by my studies of this whole subject is the varying degrees of Sensitiveness to temperature and meteorological conditions in different groups of animals and different individuals of the same group. The bat as com- pared with the marmot, for example, may be worked like a machine by varying the temperature. On the contrary, the degree to which the woodchuck is independent of temperature was a surprise to me after my experience with the bat. But the woodchuck answered like a barometer to predict storms; in fact, I am satisfied that many wild animals have a delicate perception of meteorological conditions which man has not, and which in a sense makes them wiser than our science and wiser than they know, for they act reflexly, as it were. Often my marmot would be heard in the night Scraping the straw about him prior to a storm that did not reach us for many hours after. Marshall Hall laid it down as one of the principal conclusions that in hibernating animals “muscular irritability” is increased. If the term reflex be substituted for muscular I believe the conclusion is correct. I found as a result of scores of trials that when the marmot was hibernating he was more sensitive to slight stimuli, such as blowing on the hairs of the skin, than when merely sleeping. Plainly this was not a case of muscular irritability at all, but it does indicate that the reflex mechan- ism is more excitable as it is, for example, in an animal under the influence of strych- Inine and as it is in animals from which a portion of the cerebrum has been removed. It may be because the unconsciousness is so profound, i. e., the brain so far from its ordinary functional activity, for it is well established that the brain inhibits the spinal cord normally to a certain extent. Apparently this increased reflex excitability must be to the advantage of a hibernating animal, for the cord and medulla oblongata are the parts of the nervous centers that especially preside over the functions of organic life which are necessary to maintain a mere animal existence. All problems of a biological kind must ultimately be referred to cells, and so with this of hibernation. Indeed, it would seem that unicellular animals pass into a condition which is related to that of hibernation. The so-called encysted stage of protozoa is perhaps analagous and similarly preservative of the individual and the species. - The study of a subject like the present one gives rise to many questions. Can the molecular machinery of life entirely stop and yet be set in motion again? We know that cold-blooded animals may be frozen and completely restored to a natural con- dition. This and the encysted condition of protozoa are suggestive of such a pos- sibility. Yet in insects a condition of perfect quiescence is accompanied by the most wonderful changes. The wormlike caterpillar becomes within its cocoon the butterfly with locomotive powers immeasurably greater. For myself the more I study biological problems the less am I inclined to subscribe to rigid formulae of PAN-AMERICAN MEDICAL CONGRESS. 1285 being. The study of a single group of animals from a physiological point of view, much less that of a single individual, does not suffice to enable one to lay down laws that will apply to similar processes in other groups of animals except in the most cautious way. I can never forget the lesson of my marmot that did not hiber- nate at all, and What modification of present views more extended study of this sub- ject of sleep in all its phases will produce, it is impossible to say. All my own studies have greatly impressed me with the plasticity of living things, their power to adapt themselves to altered environments; and if I might suggest one of the great changes that is likely to come over the biology of the future, it is a recognition of the above fact; so that we will cease to generalize so widely from such narrow data, or rather, perhaps, we will be ready to believe that phenomena very different from those we know may be possible in the realm of living things. It has often occurred to me that possibly if such considerations were kept in mind we should not be disposed to assume that the conditions under which life now exists are precisely those under which it always did exist. Would not a little more biological agnosticism help such sciences as geology and paleontology? PATHOLOGICAL ANATOMY OF YELLOW FEVER. By JOSEPH JONES, M. D., LL.D., Professor of Chemistry and Clinical Medicine, Medical Department Tulane University of Louisiana, Visiting Physician Charity Hospital, New Orleans. I shall now direct your attention to a subject of great importance to all students of medicine and of transgendent importance to the practitioners of medicine in tropical, semi-tropical, tetmperate, and insular America, -the pathological anatomy of yellow fever. - If you will examine carefully the systematic treatises in the theory and practice of medicine, you will find but little of value relating to the pathology of yellow fever; in fact, you will find the statement in some of your text books that “yellow fever has no pathology.” I shall deal solely with the results of my clinical studies, post-mortem examinations, and micro-chemical investigations of the past thirty years, and I feel assured that you will agree with me that yellow fever has a distinct pathological anatomy, wholly different from that of malarial fever, and as distinct- ively characteristic as the pathology of typhoid or enteric fever. It is of the utmost importance that the Southern physician, as well as the practi- tioners in all the maritime cities, should be able to diagnose accurately the various forms of fever. The report of a case of yellow fever in any city within the bounds of the United States excites wide speculation. The people flee from the infected spots and rigid quarantines are rapidly instituted against the suspected locality. If an error is made in diagnosis, if it be not yellow fever, great damage results to the commerce and to the happiness of the suspected people. If, on the contrary, the disease be allowed to spread, through the failure of the medical profession and of the health authorities to correctly and promptly determine its existence, the epidemic may gain such headway that it can never be arrested and thousands of lives may thus be sacrificed. In the United States yellow fever is limited to certain months of the year and never prevails during the winter months. Even here in New Orleans the epidemics have been bounded by sharp lines. In Cuba, Havana especially, and in Mexico, Vera Cruz especially, the disease may prevail through the entire year. I call your attention to the following table, which I have constructed for the pur- pose of illustrating the relations of yellow fever to climate in this city. 12 PAN-AMERICAN MEDICAL CONGRESS, 86 Monthly deaths by yellow fever during a period of thirty-two years, 1847–1878.* Date of first case. Year. May. |J ºne's uly. Aug. 1 Sept. Oct. Nov. Dec. Total. 1847------------|------|------ 74 965 1, 100 | 198 || 33 |... . . . 2,306 1848. ----------------- 4 || 33 200 || 467 226 20 | . . . . . . 808 1849------------'------|------ l 17 || 314 || 416 ill2 9 || 769 1850------------ 1 ------ 4 62 33 4 ------|------ 107 1851------------'------'------|------ 8 6 2 | 1 |------ 17 1852. -----------'------ '...... 2 8 91 || 198 || 105 || 11 || 456 1853-----------. 2 31 |1, 521 5, 133 982 || 147 28 4 7, 849 1854. -----------|------ 2 29 532 | 1, 234 || 490 131 7 2, 425 1855. ----------------- 5 382 | 1, 286 874 97 19 7 2,670 1856.-----------'------'------|------ 14 40 | 16 4 7 74 10 years 3 42 2,046 8,225 || 5,041 1,794 || 453 || 55 |17,481 1857------------|------ | 1 1 1 8 || 98 || 82 8 || 200 1858------------|------ 2 || 132 1, 140 2,204 |1, 137 224 5 || 4,845 1859. -----------------------|------------- 1 i 59 || 28 3 91 1860------------------------ 3 7 5 |------|------|------ 15 1861. -----------------------|-------------|-------|------|------|------|------- 1862------------------------ 1 ------- 1 ------|-----, ------ 2 1863------------|------------|------|------- 2 ------|------|------ 2 1864. -----------|------ ºl.” |-------------- 4 l 1 6 1805------------|------ a sm º ºr - - - sº - - - sº º 1 -------|------|------|------ 1. 1866. -----------------------|------ à 56 | 89 || 31 4 192 10 years. . . . . . . . 3 || 137 1,154 2,277 |1,387 366 21 5,354 1867. -----------|------ | 3 || 11 | 255 1,637 |1,072 | 103 || 26 3, 107 1868. -----------|------ -------------------------- 5 |------|------ 5 ſ 1869------------|------ ------ 1 ------- | * * * * * * * 2 ------|------ 3 1870------------|------ 1 ------ 3 || 231 242 106 5 588 1871. -----------------------|------ 2 | . 22 19 2 54 1872------------------------|------ l 5 24 7 2 39 1873------------|------------ 3 19 || 208 || 79 || 17 | . - - - - - 226 1074------------|------------|------------- 2 6 2 2 11 1875------------'------------|------ 5 24 | 20 9 3 61 1870------------'------------|------ l 19 || 17 4 1 42 10 years..". - - - - - 4 15 286 2, 135 |1, 489 || 267 | 40 4, 136 1877------------ − - - - - - - - - - - - - - 1 ! ------ 1 1878. ----------- 2 ------ 50 974 1,893 1,044 90 3 4,056 2 years---| 2 ||------ 50 || 974 1,893 |1,044 || 9 || 3 || 4,057 32 years...| 5 || 49 2,248 |10,639 11, 346 5,714 |1, 177 | 119 |31, 028 1879. -----------------------|------|------- e - - - - e - I - * * * - - - - as - - - - - - - - - - - 19 1880. -----------------|------ 1 ------ - - - - - - - 1 ------|------ 2 1881. -----------|------|------------|-------|-------|------|------|------|------- 1882. -----------|------ 1 1 2 -------|------|-- * -------- 4 1883------------------------|-------------|-------|------ 1 ------ 1 Total . . . .] 5 ** won hºusins 119 |31, 054 July 6. June 21. July 28. 1 death January; 2 March; 1 May. July. May 22. First death June 12. June 19. June 28. 1 death reported in Jan- uary. 1 death reported January 10. June. About 100 cases in United States river fleet. About 200 cases and 57 deaths, United States gunboats and river fleet. One death August 10. One case died June 10. October 5, died in Char- ity Hospital. July 17. May 26. July 30. August 28. July 9. August 19. August 8. August 11. November. May 25. * Reports of Joseph Jones, M. D., President of the Board of Health, State of Louisiana, 1880, 1881, 1882, 1883. From the preceding table it is evident that, as a general rule, the great epidemics, as those of 1847, 1849, 1853, 1854, 1855, 1858, 1867, and 1878, commenced early in the hot months (May, June, and July), and attained their maximum intensity in August and September. Thus, during the period of thirty-two years the deaths from yellow fever in New Orleans were as follows: January, 6; February, 0; March, 2; April, 0; May, 5; June, 49; July, 2,248; August, 10,639; September, 11,346; October, 5,714; November, 1,177; December, 119. The curve of yellow fever, therefore, corresponds, to a certain extent, with the curve of temperature. Thus, from the records of thirty- eight years, which I have consolidated and calculated from the most reliable data, the mean temperature of New Orleans is as follows: January, 56.289; February, 58.03°; PAN-AMERICAN MEDICAL CONGRESS. 1287 . March, 64.279; April, 69.410; May, 75.90°; June, 81,359; July, 83.219; August, 83.14°; September, 79.64°; October, 70.279; November, 62,800; December, 56.439. Averages: spring, 69.56°; summer, 82.539; autumn, 70.750; winter, 56.919; year, 69.519. The origin and spread of yellow fever, therefore, depends absolutely upon an elevated temperature, ranging from 70° to 859 F., and its decline depends upon a mean tem- perature ranging from 65° to 56° F. These figures, of course, relate to the mean or average monthly temperature, the extremes being much higher or lower, ranging during the year in New Orleans, as shown by meteorological observations extending from 1817 to 1878, from 17° F. to 1000 F. Seaports liable to the infection of yellow fever should be carefully inspected and in the event of the appearence of the disease, the case or cases should be at once isolated and the surrounding houses, yards, and streets thoroughly cleaned and disinfected. Fight the enemy immediately on sight, vigorously, continuously, and with the best-known agents and appliances. PATIIOLOGICAL ANATOMY OF Y ICI, LOW FEVER. Exterior.—Generally full and much reduced in flesh; features may even present a swollen and bloated aspect; skin of face and upper portions of trunk of a golden yellow color. The dependent portions of the body are of a mottled purplish and yellow ecchymnotic appearance. Black vomit frequently otzes from the corners of the mouth and trickles down the face and neck. When the muscles are cut a large quantity of dark blood escapes, which, upon exposure to the atmosphere, changes to a bright scarlet hue. Putrefactive changes take place rapidly after death. In some cases of yellow fever, especially when the functions of the kidneys have been arrested . for some time before death, the putrefactive changes take place with great rapidity and energy, and sometimes even appear to commence before death, the body exhal- ing a disagreeable odor. Cerebro-spinal nervous system; 8ympathetic nervous system.—The post-mortem exami- nations of the brain, spinal cord, and sympathetic system have thus far yielded no characteristic lesions to which the aberrant nervous symptoms of yellow fever can be referred. Beyond congestion of the capillaries of the cerebro-spinal and sympa- thetic systems, which congestion appears to be referable to the same cause as that producing capillary congestion in the internal organs, I have observed no structural or hacmorrhagic lesions, as fibrinous effusion or softening of the cerebro-spinal and sympathetic nervous structures. Chemical analysis revealed the presence of urea, bile, and leucin in the brain, and the effects of these substances, as well as to the direct action of the yellow-fever poison, must be referred the aberration of intel- lect, the restlessness, convulsions, and coma. The amount of congestion of the blood vessels of the brain will, to a certain extent, vary with this stage, and with the conditions under which the death takes place. Thus, when the functions of the kidneys are greatly impaired or wholly suppressed, owing to the retention of the watery elements of the blood, the vessels throughout the entire system are filled with blood to repletion, and the brain is, especially from its soft structure and the character of its circulation, the most affected. In such cases the blood is seen issuing from the cut surfaces of numberless vessels when sections of the brain are made. Under the microscope the three sections of the brain reveal a state of great hyperamia, the minute capillaries being filled with colored blood corpuscles. The golden hue of the brain substance and membranes, as well as most of the tissues generally, is due to the presence of the coloring matter of the bile, and also to the escape of haematin from the blood vessels. When death occurs after profuse haemorrhages from the stomach and bowels the cerebral structures present less evidences of congestion than when these symptoms have been absent or present to a smaller degree. It is probable that the cerebral ganglia and commissures, as well as those of the spinal cord and sympathetic nerv- ous system, are affected with the same chain of chemical reactions, which result in the formation and accumulation in the blood of oil, and also of this product in the 1288 PAN-AMERICAN MEDICAL CONGRESS. heart, liver, and kidneys. Fatty degeneration has been observed in the nuclei of the minute vessels of the pia mater venules, as well as arterioles. In many vessels the Inuclei had disappeared, leaving fat globules in their places. With reference to the brain the most prominent observation thus far made is the existence of fatty degen- eration of the blood vessels of the cortex cerebri, similar to that observed in the vessels of the pia mater, together with degeneration of the ganglionic bodies of the cortex. If these observations should be confirmed by further research, and especially by chemical analysis, determining the exact proportion of the oil in the brain in health and various diseased states, it will thus be shown that the nervous system, both cerebro-spinal and sympathetic, is involved in a similar series of changes as the other organs. The universality of these changes point to the blood as the great medium and source of the chemical actions and we have a confirmation of this view in the fact, which I have determined by chemical analysis, that the oleaginous con- stituents are greatly increased in the blood of yellow fever. That the mere presence of oil in increased amounts in certain organs during yellow fever is not the cause of the gravest symptoms is evident from the rapidity of the convalescence in many cases and also from the well-known fact that in many cases the general health is greatly improved by an attack of yellow fever. The gravest symptoms of this disease must be sought not merely in the structural alterations of certain organs, but in the initial chemical changes induced by the poison, and which precede the final lesions discernable after death. Heart: Pale yellow and brownish yellow, as if undergoing fatty degeneration. Structures of the heart flabby and somewhat softened; numerous oil globules depos- ited within and around the muscular fibrillae of the heart. The appearance of the heart in a case of yellow fever (Edward Griffin, who died in the Charity Hospital of yellow fever November 9, 1876, on the sixth day of the disease, after the ejection of large quantities of black vomit) is represented in the following colored figure (No. 1). Heart yellow and softened. Under the microscope transverse markings of muscular fibres indistinct, and much oil and granular matter deposited within and around the muscular fibres. The appearance of the muscular fibres of this heart are represented in Fig. 2. One thousand parts of the muscular structure of the heart contained water, 786.44; solid matter, muscular fibre, etc., exclusive of oil, 267.06; oil, 46.50. In this case the left ventricle was dilated and hypertrophied, but this condition appeared not to have affected the health of the patient before the advent of fever. In the case of Samuel Rinsley, aged 23, who entered the Charity Hospital Novem- ber 14, 1873, in the fourth day of an attack of yellow fever and who threw up black vomit on the 16th and 17th and who died at 1 o'clock P. M. on eighth day of dis- ease, the autopsy was made eight hours after death. Weight of heart, 9 troy ounces; great congestion of blood vessels of pericardium, resembling the appearance of the pericardium of a case of yellow fever which died on the sixth day of the disease, August 5, 1871, represented in Fig. 3. The blood vessels of the heart were distended with dark-colored blood; the cavities of the heart contained about 3 fluid ounces of blood and golden-yellow clots; vena cavae and pulmonary veins filled with fluid blood. When washed the muscular structures of the heart presented a distinct yellow color, similar to that of the heart delineated in Fig. 1, and was readily mashed between the fingers. Under the microscope the muscular fibrillae presented indis- tinct transverse striae and contained numerous oil globules and much yellow gran- ular matter, resembling the fibres of the heart of a case of yellow fever depicted in Fig. 2. One thousand parts of the muscular structures of the heart contained water, 736.65; solid matter, exclusive of oleaginous matters, 186.80; oil, 76.59. In the preceding case oil or fat was present in abnormal quantities in the muscu- lar structures of the heart, the fat being deposited within and around the muscular fibrillae in the form of minute globules of various sizes. There is also an obliteration or obliterations of the muscular fibrillae of the heart, leading to a disappearance of the muscular striae. - //zzº-ſºwrººſ”. %%. ºwoº/ou/ºver ///zºº/Zºrrº */zzazzº */.3///zrº A/º/ow/?” ºf fºº ºftºre. // 2.//zºo//zºº/A6% zºwo/X//ww/* *2%aºs. //zºº/” zºº” //w/ ºzºrºa'ºzzº seeken-waheim-ush-tº- PAN-AMERICAN MEDICAL CONGRESS. 1289 The removal of the particles of oil from the muscular structures of the heart by sulphuric ether did not restore the obliterated striae, neither did this agent remove all the molecular particles, a portion at least being insoluble in ether, alcobol, and’ chloroform, and having an analogous constitution to albumin and fibrin. It would without doubt be a matter of great interest to medical science to establish clearly the exact physical and chemical changes which result in the final transformation of the muscular structures of the heart and secretory and excretory structures of the liver and kidneys into fat. The difficulties of such an investigation are very great, especially as the chemical research can be commenced only in fatal cases and after death. The complete investigation of this subject should embrace the following inquiries: (1) Is there an actual increase of the entire amount of fat in the blood organs and textures in yellow fever? (2) Is there any movement of the fatty matters from the positions in which they are chiefly accumulated in health, as in the adipose tissue, the marrow of the bones, the brain, spinal cord, and nerves generally, during the febrile stage of yellow fever? (3) Are the heart, liver, and kidneys simply infiltrated with fat conveyed by the blood during fever? (4) Is there an actual conversion of the fibrin and albumin of the blood and the albuminous elements of the heart? (5) Does the accumulation of fat in certain organs in this disease result from chemical changes directly excited by a specific poison, or from imperfect oxida- tion, or perverted nutrition? (6) Has the perversion and arrest of the functions of the liver and the retention in the blood of the constituents of the bile any relation- ship to the deposits of fat or oil in the various organs? As the acute fatty degeneration of yellow fever is in nowise dependent upon the food of the patient during the fever, the change occurring with rapidity during absolute starvation, it is evident that the only possible sources of the oil or fat are those indicated in the preceding inquiries, namely, the prečxisting sources of fat in the transformation of the heterogeneous and albuminous constituents of the blood and organs. The cavities of the heart in many cases are filled with dark fluid blood, yellow fibrous clots sometimes present. The yellow-fever blood contains abnormal amounts of urea and extractive matters and ammonia. By testing blood greatly diminished in amounts I have determined both by chem- ical analysis and microscopical examination that the heart undergoes fatty degenera- tion in yellow fever. As far as my observations have extended, the heart undergoes more rapid and extensive degeneration in yellow fever than in an any other acute dis- ease. The acute fatty degeneration of the heart in yellow fever should not be con- founded with similar changes observed in spirit drinkers and in certain cases of chronic disease, but is more probably dependent upon the same or some chemical actions as those leading to a similar result in phosphorus poisoning and in typhoid and typhus fevers. In yellow fever the fat is deposited within and around the muscular fibrillae of the heart in the form of minute globules of various sizes. There is also an alteration or degeneration of the muscular fibrillae of the heart, leading to a disappearance of the striation. The removal of the particles of oil from the muscular structures of the heart by sulphuric ether does not restore the obdurated striae, neither does this agent remove all the molecular particles, a portion at least being insoluble in ether, chloroform, and alcohol and having an analogous constitution to albumin and fibrin. Fatty degeneration of the heart is, therefore, not the sole state of this organ in yellow fever. The molecular change has taken place in the substance of the muscu- lar fibers and this change affects the albuminoid or nitrogenous constituents, and most probably represents one of the stages of acute fatty degeneration. The peri- cardium in yellow fever presents a congested appearance. Under the microscope the minute blood vessels appear to be congested with colored blood corpuscles. The pericardial fluid is of a deep yellow color. The appearance presented by the peri- cardium of a case of yellow fever which terminated fatally in New Orleans August 5, 1871, is represented in Fig. 3. The pericardium was put upon a glass slide and 1290 PAN-AMERICAN MEDICAL CONGRESS. preserved in Canada balsam. The drawing represents the natural appearance as injected with blood. Lungs: Dependent portions greatly congested, otherwise normal. In some cases circumscribed effusions of blood in structures of lungs. I have in a few instances observed pneumonia as a supernumerary disease in yellow fever. In such cases the sputum consisted of almost pure blood. The Supervention of pneumonia causes a continuation of the febraile phenomenon beyond the usual period of the uncompli- cated disease. Stomach: Mucous membrane of the stomach in many cases internally congested, softened, and eroded. Stomach often contains large quantities of black vomit. Reaction of black vomit often alkaline, from the presence of ammonia, resulting from the decomposition of urea, eliminated by the gastro-intestinal mucous mcm- brane. Ammonia and urea present in the black vomit ejected during life, and also when examined almost immediately after death. The presence of ammonia in the stomach and black vomit was not the result of post-mortem putrefactive changes. In many cases ammonia was present in such large amounts that when a rod dipped in hydrochloric acid was held over the mucous membrane of the stomach or over the black vomit, dense fumes of chloride of ammonium were found, as if the rod had been held over a bottle containing liquid ammonia. Chemical analysis revealed the pres- ence of ammonia, and also of urea in the black vomit. Under the microscope the black vomit is seen to contain colored blood corpuscles, and cells of the mucous mem- brane of the stomach, and broken capillaries. In some cases fungi and fibrin were numerous in the black vomit, in others they were absent. That the stomach suffers and suffers severely in yellow fever is evident from the fact that in the great majority of cases the stomach is finely injected with blood and exhibits, even when examined immediately after death, abrasions of the mucous membrane in pit-like folds and furrows. In some cases the whole surface of the stomach is affected, and in others the effusion and injection is confined to the cardiac or pyloric portion, but in Some rare instances the stomach, duodenum, and intestines have been said to present au almost entire absence of apprehendable lesions. I have not myself, in post-mortem examinations, observed the absence of lesions in the gastro-intestinal mucous membrane. The congestion of the stomach is to a certain extent due to the disturbance of the circulation in the line, but not wholly to this cause. We must, after careful chemical and microscopical examination, admit the existence of irritation, desquamation, and hamorrhages. The congested appearance of the mucous membrane of the stomach after death from yellow fever is represented in Figs. 4 and 5–Charity Hospital, October, 1871, and Charity Hospital, November, 1876. These illustrations must be regarded as exhibiting the extreme conditions of congestion in the mucous membrane of the stomach in yellow fever. In many cases the stomach after death presents less con- gestion, and in some portions of the mucous membrane different degrees of conges- tion are manifested, being much greater in some portions of the mucous membrane of the stomach than in others. Intestines: As a general rule these viscera are dark colored and distended with gas. In some cases the reaction of the ill testinal contents was strongly alkaline from the presence of ammonia. Hamorrhage from the intestinal mucous membrane has been observed during life, and in such cases, as well as in others in which no blood has been discharged previous to death, the intestines have been found, in post-mortem examinationis, distended with blood. A remarkable feature in yellow fever is the fre- quent occurrence of intussusception of the small intestine. The quantity of intes- time invaginated sometimes exceed a quart. The large intestine and the lower por- tion of the small are not so often found congested as the stomach and duodenum, yet such a condition is by no means rare. Congestion of the veins, venules, and mucous membranes generally in yellow fever has been referred to the anatomical distribu- tion of the veins, which like those of the stomach are tributaries to the portal veins, Aºz 4 A/ºzzaszewºzórzne of 5%zzzzzzzzzºomººrer //zºº///cºw/memºrrºwe o/.5/ozozººnºomººrer: sacketlawunemauhoco- Yellow Fever. º Azzº wºoezºzºwerzzz Jºur/ºwer º % ºxazer/37/ - - Afz.7 ºzyżºsé/ºzezzerzºzowo/Zºzz- ºnzøøya Zºº. %zºzoº/* /* /2 *7.4%zzzzzz/ºr. Azzºzo”/3/aºzz. sacken-whelm-Lahoton- Malarial Fever. % /2. Zºrzºwer - - - - /2/3/ºzz//* ºwº/”/ø/º ... /º/, , , .5ºzºwo/Zºrºazza//* 3%mºnºzº” Zºº” ºz/ sackeu-Wuhansu-tax- PAN-AMERICAN - MEDICAL CONGRESS. 1291 but we have been inclined in many cases to regard the congestion as active and not passive. During life the rectum in yellow fever presents an intensely red and con- gested appearance, and some cases of yellow fever in 1878 were followed by irrita- tion and fissure of the rectum. The demonstration which we have given, illustrating the changes of the nervous structures and of the heart, blood, and alimentary canal, under the action of the yel- low-fever poison clearly establishes the fact that yellow fever has a distinctive pathol- ogy. It is necessary that we should pursue this subject to the end, and indorse our proposition by an appeal to the results of microscopical and chemical investiga- tions of the pathological lesions of other organs, as the liver and kidneys in yellow fever. An accurate comprehension of the pathological anatomy of the liver in yel- low fever is especially important, as we are enabled to establish in the clearest man- ner the most marked differences between the pathological anatomy of yellow and malarial ſevers. Liver: Yellow in color and bloodless, resemblin g this organ in fatty degeneration, but firmer and denser in structure. Fig. 6 presents the general appearance of the yellow- fever liver. The specimen was taken from a subject in the Charity Hospital in 1871. Fig. 7 illustrates the appearance of the liver in a case of cirrhosis, induced by spirit drinking, which died in the Savannah Hospital in 1856; there was not only cirrhosis, but also fatty degeneration in this case. Fig. 8 represents the appearance of the liver in a case of yellow fever ingrafted on malarial fever. Fig. 9 represents a por- tion of a section of the liver figured in No. 7, magnified, showing congestion of por- tal capillaries with pigment deposits, and the yellow, fatty, and degenerated central portions of the lobules of the liver. Fig. 10 presents the appearance of the liver in yellow fever ingrafted on malarial fever. The black, pigmentary matter alters the yellow color characteristic of the yellow-fever liver. The preceding figures, representing the appearances of the liver in yellow fever, should be compared with the following figures representing the appearance of the liver in malarial fever. Fig. 11, appearance of the liver in the acute stage of malarial fever, bilious remittent. Fig. 12, appearance of the liver in malarial fever of longer standing. Fig. 13, appearance of malarial liver loaded with pigment particles. Fig. 14, section of malarial liver, showing pigment deposit, magnified by 1 inch objective, 1871. In all the different forms of malarial fever—intermittent, remittent, and congestive—which have continued longer than five days, and in which there have been no previous alterations of the structures, as in cirrhosis and fatty degeneration, I have found the exterior of a slate and the interior of a bronze color, as shown in figs. 11, 12, 13, and 14. Fig. — represents a magnified portion of the section of a malarial-fever liver, showing a deposit of pigment chiefly in the portal capillaries in the periphery of each lobule. Under the microscope the textures of the yellow-fevor liver are infiltrated with much oil. The secretory cells of the liver are thus shown by microscopical examina- tion to contain much oil. The liver of uncomplicated yellow fever, as far as my observations extend, and according to the observations of Louis and many others, is of a bright yellow color. It is probable that this color, as in the case of the mala- rial liver, varies with the length of the attack and the effects of previous diseases. Thus, Dr. Samuel Jackson, of Philadelphia, found the livers of those who had died in the early stages engorged with blood. The ducts of the yellow-fever liver are of a golden yellow color, while those of the malarial liver are of a brownish-yellow color. The golden yellow color of the yellow-fever liver can be abstracted both by alcohol and water. The yellow-fever liver is firmer and harder than that of malarial fever, contains much less blood, and is much less readily acted on by liquor potassae and mineral acids. Liquor potassae readily dissolves the malarial-fever liver, the decoc- tion presenting the appearance of venous blood, while no such effect is produced by this alkaline solution upon the yellow-fever liver. 1292 PAN-AMERICAN MEDICAL CONGRESS. Chemical analysis reveals the presence of urea and fat in abnormal amounts. Ani- mal starch and grape sugar are also present in the yellow-fever liver. As a general rule, grape sugar is absent from the malarial liver. In some cases the deposit of oil is confined to certain portions of the lobule, and may even differ in amount in dif- ferent portions of the liver; but in the majority of cases the fatty infiltration and fatty degeneration of the protoplasm of the hepatic cells extends throughout the whole organ. The oil is deposited both within and around the hepatic cells. Fig. 15 gives the appearance of the hepatic cells and oil globules in the liver of yellow fever (case of Griffin, November, 1876). This figure should be compared with Fig. 16, repre- senting the appearance of hepatic cells and pigment particles in the liver of malarial fever. Careful observations of the relations of malaria to yellow fever, and an extended examination of the statement of various observers, have convinced me that the apparent contradictory statements made by various observers, as to the presence or absence of the yellow color of the liver, which Louis regarded truthfully as the characteristic lesion of the disease, has arisen from two sources, namely, errors of diagnosis and failure to detect the preceding concurrent and subsequent action of malaria on this organ. In uncomplicated yellow fever, fragmentary particles, so uni- formly present in the malarial liver, are uniformly absent. When yellow fever is engrafted on malarial fever, the preceding changes brought by the paludal poison alter and mask those developed by the yellow fever. Hence, the mingling of the yellow color of acute fatty degeneration with the dark bronze and slate of the malarial liver may produce a color very closely resembling the Spanish brown of the healthy liver. Careful scrutiny and examinations of the organs under the microscope will reveal both the oil globules and pigment particles. The distinction has been made by pathologists between fatty degeneration and fatty infiltration, the first being a process of true degeneration, with a tendency to the disintegration of tissue; the latter we observe as a simple definition of fat, in various cells and tissue, without any chemical alteration of their constituent elements. In fatty degeneration there is a conversion of the protoplasm of the cells into fat, which accumulates in the cell body, and as the albuminoid principles disappear they are replaced, pari passu, by fatty particles. It is thus assumed that the nitrogenized albuminoid and proteid particles are converted into fat. The fat is usually present in the cell in very small particles or droplets, and these may coalesce and form larger drops. The protoplasm may even be almost entirely replaced by fat. In fatty infiltration cellular protoplasm is displaced; in fatty degeneration it is replaced ; in the former the corpuscular organisms suffer mechanically; in the latter the cells suf- fer chemically, and are ultimately destroyed. Fatty infiltration of cells is a common occurrence in the normal as well as pathological condition; but in this case the fat appears to originate outside of the cells and simply accumulates in them, causing a passive atrophy of the protoplasm. In general, the fat droplets are larger in fatty infiltration than in fatty degenera- tion, and yet to this there are many exceptions. In spite of the differences just con- sidered, it is often practically impossible to separate one process from the other micro-chemical tests, and histological appearances are not always sufficiently reliable for exact differentiation. The efforts of some writers to discard the terms “fatty degeneration” and “fatty infiltration,” and to substitute the words “fatty meta- morphosis,” simply expresses the theory that the two processes are one and the same. In the case of the liver, both, in health and in disease, we meet with great difficulties in separating the two processes. Fatty infiltration may occur as the efforts of the excessive ingestion of oleaginous food, in chronic alcoholic, phospho- rus, and arsenic poisoning, in certain exhaustive diseases accompanied by malnutri- tion, and in pulmonary plathisis, chronic dysentery, and in various conditions which are not fully understood. Fatty degeneration of the liver in many cases can not be morphologically distinguished from fatty infiltration. The fat is believed to be Aºz/Z Mºzzzzz//zºo/ºr º/Zoº /***ay, wºº, Aºz/6/zizzzzzzºzººnºozzº Zºº”///a/azzaſ/ºzzzzza”zºzz From Nature by Joseph JONES, M.D. Sack-whelmsuhocanº ſ tºº º * {4 A 2 º a º ºr 48 º º- ſºg§ \ & #33 º ičğ. %iº - FIG./8, Illustrating the pathological anatomy of specific contagious yellow fever. Comparison between ordinary fatty degeneration of the liver, and fatty infiltration of the liver in yellow fever. Section of the gastric mucous membrane in yellow fever. Fig. 17 represents a magnified thin section of a fatty liver, in a moderate degree of advance- ment of fatty degeneration. The cells containing oil are seen to be distributed for the most part at the periphery of the lobules, in the vicinity of the branch of the portal veins. Fig. 19. Section of a yellow fever liver magnified 275 diameters, show- ing the presence of oil globules. The capillaries still contain blood corpuscles. The group of cells above the figure represent the hepatic cells undergoing fatty infiltration and degeneration. Fig. 18. Section of a yellow fever stomach, showing the conges. tion of the veins, the infiltration of haemoglobin, and the extravasation of blood caused by a rupture of the minute veins or larger capillaries. The glandular (A) and muscular layer (B) of the mucous membrane, and the subcutaneous connect- ive tissue (C) are shown. The congested vessels descending through the glandular layer represent those straight vessels formed by the various radicles arising from the network of large capillaries beneath the epithelium, and surrounding the orifices of the gastric glands. The dots seen throughout the muscular layer repre- Sent transverse sections of muscular fibrillae (magnified 50 diameters), after H. D. Schmidt, M. D. - PAN-AMERICAN MEDICAL CONGRESS. 1293 formed by a transformation of the protoplasm of the liver cells. The fat droplets are, for the most part, very small and abundant, though this is by no means con- stant. Fatty degeneration of the liver cells frequently follows, and is associated with cloudy swellings in the varying conditions in which they occur, or it may appear in profound anaemia, and in the exhausted condition of the human system consequent upon the prolonged action of the malarial poison. The accumulation of fat in yellow fever appears to be due both to the degenera- tion of the protoplasm of the liver cells and to infiltration of fatty matter. My researches upon the fatty degenerations of the liver in yellow fever have led to the following conclusions: (1) The muscular tissues of the heart show under the micro- scope, and under the proper chemical tests, rapid molecular change and fatty degen- eration; (2) the liver cells exhibit rapid degeneration of the protoplasm of these cells and rapid increase of fat; (3) the albuminoid elements of the blood undergo rapid degeneration and rapid transformation into fat, under the action of the yellow- fever poison; I use the term “rapid” in contradistinction to the slow process of the development of fat in the normal condition; (4) it follows from the preceding propositions that the accumulation of fat droplets in the heart and liver in yellow fever may arise from a chemical change of the albuminoid protoplasm of the blood and of the cells; (5) the increment of fat (oil droplets) in the blood in the heart and in the liver of yellow fever is due to the direct chemical action of the poison of yellow fever in the albuminoid protoplasm; (6) the fatty degeneration caused by the yellow-fever poison ceases with the cessation of the action, and elimination and destruction of the morbific agent. The degeneration of the protoplasm excited by the yellow-fever poison is tempo- rary and not permanent; (7) if the fatty degeneration caused by the yellow-fever poison were permanent, and if the changes thus induced by the yellow-fever poison were an abiding and progressive degeneration, we would witness the effects, and the continuous and destructive effects, of fatty degeneration of the heart tissue as the sequelae to many cases of yellow fever. In our experience such effects are readily traceable to the yellow-fever poison. - Gall bladder: The gall bladder in yellow fever is, as a general rule, contracted, flaccid, small, and contains little or no bile. The amount of bile does not generally exceed 100 grains. In malarial fever, on the other hand, the gall bladder is, as a gen- eral rule, distended with dark greenish black bile. In yellow fever the vomiting is rarely bilious, unless in the commencement of the disease, and the black vomit con- tains little or no biliary matter. The small intestines are rarely, if ever, discolored by bile in yellow fever, while in malarial fever it is common to find the gastric mucous membrane discolored by bile. I have observed cases in which the gall bladder con- tained only a serous liquid coagulable by heat. In two cases a decided haemorrhage had taken place into the gall bladder, which was distended with black blood. The bile in yellow fever contains numerous cells from the mucous membrane of the gall bladder and casts of the hepatic ducts. Spleen: As a general rule this organ is but slightly enlarged; in many cases normal in size and appearance. In many cases of yellow fever the spleen is neither enlarged, softened, or altered in appearance either upon the exterior or within. There appears to be no special alteration or destruction of the colored corpuscles in the spleen of yellow fever as in that of malarial fever. The enlargement of the spleen in fevers does not, from these observations, depend upon the diminution of fibrin, because this element of the blood is diminished to a much greater extent in yellow fever than in malarial fever, and at the same time the spleen is enlarged to a greater and more marked degree in the latter. Another fact worthy of consideration in this connec- tion is, that in yellow fever the blood corpuscles are not specially diminished in amount, while in malarial fever they are rapidly destroyed, and this destruction seems to be greater in the liver and in the spleen. In malarial fever both these organs are loaded with altered blood corpuscles and with the pigmentary granules 1294 PAN-AMERICAN MEDICAL CONGRESS. resulting from the alteration of the colored blood corpuscles, while neither the spleen nor the liver in yellow fever afford any evidence of the alteration of the colored blood corpuscles. Suprarcnal bodies: These bodies appear to be subject to similar changes with the liver and the heart, and oil is increased in amount in the cells of the cortical and medullary substances. I(idneys: These organs in yellow fever as a general rule present a brownish-yellow color, much lighter than that of health. The kidneys, in common with the heart and liver, contain much free fat. Fig. 20 represents the appearance of the kidney in yellow fever, and Fig. 21 represents the appearance presented by a section of the same kid- ney. These figures may be regarded as representing the more decidedly morbid kidneys in this disease, for in some cases they present greater degrees of congestion and deeper coloration from the presence of blood in the capillaries. - In the case of Griffin, who died of yellow fever in the Charity Hospital November 17, 1876, sections of the kidneys, made with Valentine's knife, revealed under the microscope increase of oil globules and granular matter. Many of the tubuli urini- feri presented a thickened and altered appearance, as if undergoing the changes characteristic of cirrhosis. One thousand parts of the kidneys contained, water, 800.33; solid excretory, molecular, and fibrinous matter, 158.39; oil or fat, 40.88. In the case of Samuel Kingsley, who died of yellow fever in the Charity Hospital, November 17, sections of the kidneys under the microscope presented the appear- ance usual in yellow fever, namely, Malpighian corpuscles, tubuli uriniferi filled with oil globules, yellow granular matter, and detached excretory cells. One thousand parts of these kidneys contained water, 798.90; golden-colored oil and 'fat, 57.77; cellular tissue, bloodless excretory structure, etc., 143.33. When these sections of the kidneys are xamined under the microscope, the Malpighian corpuscles and tubuli uriniferi are found to be filled with granular albuminoid and fibroid matter, detached excretory cells, and oil globules. As far as my observation extends, these structural alterations of the kidneys have escaped the notice of preceding observers. The importance of these changes in the kidneys can not be overestimated, for upon them apparently depends the suppres- sion of the urinary excretion, which is an almost universally fatal symptom. The changes in the kidneys may depend on some causes, annong which may be men- tioned as of prime importance, the alterations induced in the albumin and fibrin of the blood by the felorile poison, and the congestion of the capillaries, caused by derangement of the vasomotor system of the nerves, and by the altered blood. This condition of the kidneys is preceded by capillary congestion, as has been shown by the results of post-mortem examinations at different periods of the disease. The same observation applies to the liver. The fatty degeneration and structural lesions are presented by hyperamia; but neither in the kidneys nor in the other organs can the mere stagnation of the blood in the capillaries be regarded as the prime cause of the subsequent degeneration or disintegration of the textures, and more espe- cially of the secretory cells. The chief cause is the action of the yellow-fever poison on the blood and textures. The yellow-fever poison excites a train of chemical changes, the final result of which is fatty degeneration. Thus, in the case of the muscular fibres of the heart, there is fatty degeneration, although from the struc- ture and action of this organ there could be no such passive congestion as we have in the liver and kidneys. It is probable that the fatty degeneration extends to all the unstriped muscular fibres, and may even disable the muscles of locomotion and animal life. The granules of the cells of the epithelium of the uriniferous tubules, set free by the disintegration of the protoplasm, oil globules, detached cells, and albuminous matters and mucus, form opaque granular masses which block up the tubuli uriniferi. We have in these structural alterations of the kidney, which vary in kind and degree according to the stage of the disease, an explanation of the fre- /* */?”//w/ºzz- ***. Q 4%% ºozoº/ſº Jº/or /ºzz: *zºº -------- FIG, 25, º §: -t ; § {34 º * * . *. * , f.", § º * * & §§ tº: º º §§: tº & { *NFIG. 22. Sº . * ºº:: §§ º PATHOLOG|CAL ANATOMY OF THE KIDNEY IN BRIGHT’S DISEASE AND YELLOW FEVER. PAN-AMERICAN MEDICAL CONGRESS. 1295 quent occurence of albumin, casts, detached cells of the epithelium of the urinif- erous tubules, and oil globules and granular matter in the urine of yellow fever. Fig. 22. Inflammatory division of Bright's disease. Bright's disease, first stage. Section of inflamed kidney, Bright's disease. Tubules with epithelium in situ with cloudy swelling, well shown in transverse section, Malpighian body large and opaque, magnified 450 diameters. The inflammatory form of Bright's disease may be divided into three stages, each characterized by very distinct anatomical characters: (1) that of inflammation; (2) that of fatty transformation; and (3) that of atrophy. Fig. 22 represents an enlarged view of the tubules (450 diameters) in the stage of inflammation in Bright's disease. In this stage the kidney is of normal size, or somewhat larger; its capsule is unaltered, and strips off readily; its surface is smooth, more or less congested, often pink; it is sometimes of a dark purplish color, sometimes mottled, pale, and purple. On section the cortical surface is relatively increased in volume. It is often congested, the Malpighian bodies standing out prominently from the surrounding tissue and the congested vessels separated by a varying amount of white (somewhat opaque deposits, composed of the altered tubules). The vascular spaces between the cones and the cortical substance are uniformly distended with blood; the cones are usually redder than the cortical sub- stance, and from the engorgment of these vessels, and the altered condition of these tubules, they present a series of alternating red and white lines converging to the apex of the cone, at which point the white distinctly predominates. The pelvis of the kidney is natural. On microscopic examination with a low power, the con- gestion of the vessels and the alteration of the tubules becomes more distinct; the vessels are for the most part engorged with blood. The Malpighian bodies appear as if injected with red material, or, what is more common, they appear dense and opaque, of an ashen gray color. In the earliest period of the inflammation the former condition occurs; in the more advanced period, the latter. Many of the tubules, especially those of the cortical. Substance, appear darker and denser than natural; they sometimes appear as Solid bodies, sometimes as tubes, with thickened and somewhat opaque walls. In the groups of tubules passing down toward the cones, and in the cones themselves, individual tubules here and there are affected like those of the cortical substance, and contrast strikingly with their neighbors which are unaffected. On examination with a power of from 300 to 400 diameters, the Malpighian bodies appear dense and granular, and when the tubes expand to receive the tuft of vessels, swollen and granular cells may be seen. The tubules are more bulky than natural, their epithelium is swollen, granular and dense, the cell wall indistinct, and the nucleus frequently imperceptible. On examining a trans- verse section the enlargement of the epithelium becomes very apparent, for the cells are large and granular, and the lumen is greatly reduced or altogether lost. In the tubules, so altered, a transparent homogenous material is frequently seen, which fills up the lumen of the tubes, and binds together, so to speak, and cakes into one mass the epithelium of these tubules; not unfrequently blood corpuscles are asso- ciated with this exuded matter, as is slown in Fig. 22. - Fig. 23. Bright's disease. Inflammatory form second stage. Section of kidney in second stage, inflammatory form, showing the fatty Opacity in the tubules and Malpighian bodies. Fatty tubules and Malpighian bodies in stage of fatty degener- ation magnified 350 diameters. In the stage of fatty degeneration or transformation, to which term “large fatty kidney” is commonly applied, the inflammatory process has passed away, or, as is more common, has become chronic. But its effects remain. The organ is enlarged; the capsule is natural, easily stripped off; its surface is smooth, or slightly depressed here and there. It is pale and fatty in color and on its surface stellate vessels are frequently conspicuous. The color is peculiarly mottled from the mingling of opaque sebaceous-looking fatty portions with the whitish, more translucent tissues natural to the organ, On Section the cortical substance is pale, of a yellowish white color, 1296 PAN-AMERICAN MEDICAL CONGRESS. and increased in volume, while the cones are pink, and of natural color and size. The Malpighian bodies do not project prominently, as in the first stage. On closer inspection the sebaceous-looking parts may be seen to correspond to distended con- voluted tubules, and not infrequently lines of this material may be seen running between the small arteries toward the cones. On microscopic examination with a low power (50 diameters), the tubules are seen in many parts distended with a black untransparent material; this is most marked in the convoluted tubules, but in the straight tubules, here and there, individuals or groups may be found affected. The Malpighian bodies are enlarged, but not prominent, and while they may be finely granular never present any black appearance of the tubules. Under a high power (300 to 400 diameters), the distended tubules are found to be filled with fatty granules, which for the most part are contained within the walls of epithelial cells, which again are embedded in a material that blocks up the tubules. The tubes, however, are found to be irregularly distended, in some parts much dilated and in others narrow and of the natural caliber. In the Malpighian bodies oil and fatty cells are frequent, but the capillary tuft is unchanged. The parts in which the fatty condi- tion is revealed by the microscope correspond to those in which the dense-looking material is seen by the naked eye, as in Figs. 22 and 23.” Fig. 24, a vertical section of a yellow-fever kidney from near the surface. (a) Albu- minoid cylinders. The epithelium of the uriniferous tubules, the basement mem- brane, and the granules embedded in its albuminous substance, are also displayed, magnified 275 diameters.f Fig. 25, fine uriniferous tubules containing different kinds of infarctions of the yellow-fever kidney. (a) Albuminoid cylinder with epithelial cells, and the remaining fragments of broken-down cells embedded in the albuminoid substances; (b) epithelium; (c) basement membrane; (d) empty portion of the tubule with cellular tissues; (e) remains of nuclei and cells magnified 235 diameters. In the yellow-fever kidney we observe a degeneration of the protoplasm of the epithelial cells lining the uriniferous tubules. This degeneration of the protoplasm of the renal excretory cells is, without doubt, preceded by hyperamia; but this hyperaemic condition of the renal capillaries must not be regarded as the primary or the sole cause of this condition. The primary cause is to be found in the action of the septic agent or ferment of the specific contagium of yellow fever upon the proto- plasm of the blood and of all the active cells of the organism, including those of the liver and the heart. In fatal cases of yellow fever the hyperamia of the renal vessels has become greatly diminished at the time of death by the degeneration of the protoplasm of the excretory structures, by the loss of blood through the stomach and bowels, and by the slow but progressive accumulation of the great. mass of blood in the large central blood vessels during the last hours of life. When death occurs in the active stages of malarial fever the kidneys, on the other hand, presents, most generally, a hyperamic condition and are without the fatty degeneration of the parenchyma, so strongly marked in the yellow-fever kidneys. The degeneration of the kidneys taking place in the renal parenchyma during yellow fever does not resemble in all respects the fatty degeneration of the kidneys observed in parenchymatous nephritis. A number of infarctions found in the uriniferous tubules during the course of yel- low fever represent albuminous cylinders, while others consist of the remains of disintegrated epithelial cells, or are composed of both. They are met with in all portions of the uriniferous tubules, and vary in thickness in correspondence with the diameters of their canals. The largest are found in the convoluted portions, the so-called tubuli contortae, and in the intermediate canals, which they frequently fill up through their entire length; in the descending and ascending body and in the collecting tubules they are generally smaller. The number of these casts and the *Bright's disease of the kidneys. J. George Stewart, M. D., F. R. S., 2d ed., p. 12-16, 1 After H. W. Schmidt, M. D. PAN-AMERICAN MEDICAL CONGRESS. 1297 extent of their function, as well as the extent and nature of the pathological changes of the kidneys, will depend upon the length and relative severity of the disease. Urinary bladder: As a general rule the bladder contains little or no urine in yellow fever. The urine is of a light yellow color, without any crystalline bodies, and loaded with albumin, granular fibroid matter, urate of ammonia, casts of the tubuli uriniferi and excretory cells of the kidneys. In some cases the urine is entirely suppressed for as long a period as forty-eight hours before death. So long as the kidneys per- form their functions freely and regularly the patient may recover, even though black vomit may have appeared; but if the action of the kidneys has been arrested by structural changes, death is inevitable. The mucous membrane of the bladder is often congested, and in some cases ecchymotic. THE NUMBER OF THE RED GLOBULES. By Dr. JOSE G. HERNANDEZ, Profesor de la Universidad de Caracas. The classical works on physiology fail to mention the influence of latitude upon the number of red corpuscles. The author has endeavored to study this question in the tropics. He started to find the physiological mean of the number of red cor- puscles in the habitants of Caracas. The latitude of the city and elevation above sea level are given. Healthy individuals, medical students between the ages of 16 and 20 years, were chosen. Twenty-five counts were made with the apparatus of Nachet. The mean obtained per cubic millimeter was 3,247,000. The minimum was 1,900,000, and the luaximum 3,840,000. The amount of urea secreted in twenty- four hours was also investigated in six cases, obtaining a mean of 21 grammes, with extremes of 15 and 25 grammes. This olygocythaemia is explained by the theory that the function of the red-blood cells is respiratory and that the process of oxida- tion is necessary to keep up the bodily temperature, a function that must be less active where the surrounding temperature is uniformly high. The diminished oxida- tion of the tissues results in a diminished secretion of urea. The statement, often repeated, that the climate of the tropics is a producer of, anaemia, is thus confirmed. LA FORCE MUSCULAIRE CHEZ LES INDIENS. Par le Dr. J. B. D.A. LACERDA, Rio de Janeiro, Brazil. L’on croit généralement que les Indiens sont pourvus d’une très grande force mus- culaire. Nous avons eu une excellente occasion de vérifier combien était inexacte cotte supposition. Pendant l’exposition anthropologique de 1882, a Rio, ce sont réunis, au Musée National, des représentants de diverses tribus, arrivés de l’intérieur du pays. Sur eux nous avons institué des expériences nombreuses et répétées, par suite desquelles il nous est resté la conviction que les Botocudos et les Cherentes ont une force musculaire inférieure à la moyenne des individus adultes de la race blanche et de la race noire. Nous avons employé le dynamomètre de Mathieu pour enregistrer la force musculaire; et nous me l’avons enregistrée qu'après une longue série d’essais. Les plus forts des Indiens n'ont pu emporter l'aiguille au-delà de 120. Sous le point de Vue du développement des muscles il est encore notable l’infério- rité de ces Indiens, comparés aux mègres. Leur agilité est à peine remarquable pour certains groupes de muscles, longuement édugués dans l'exercice de certains actes qui font pour ainsi dire une partie intégrante de leur vie sauvage. C'est pour cela qu'ils sont très agiles dans le maniement de l'are. En dehors de ca, ils ont des mouvements lents, paresseux. Nous n’avons pu essayer sur eux la course; malgré cela nous ne doutous pas qu’il seraient aisément vaincus par le premier venu d’au- tre race. - S. Ex. 36—82 1298 PAN-AMERICAN MEDICAL CONGRESS. · Leur mémoire auditive, en ce qui se rapporte aux sons musicaux est d'une infério- rité extrême. Ils n'ont pas arrivé jamais à retenir une phrase musicale des plus simples, même après avoir été répétée devant eux une dizaine de fois. Ils sont peureux lorsqu'ils connaissent le péril; de plus ils comptent davantage , sur la ruse que sur le courage. SUR LES TROUBLES FONCTIONNELS DUS À LA CHALEUR. Par le Prof. J. B. DA LA CERDA, Rio Janeiro, Brazil. C'est assez important pour nous, habitants des pays chauds, de savoir comment agit la chaleur sur l'organisme, et de quelle nature sont les troubles fonctionnels . qu'elle produit. A ce sujet nous avons des expériences commencées il y a déjà quel- ques années avec la collaboration de mon regretté collègue, le Dr. Couty, et qui sont restées inédites. Nous en allons faire un résumé, qui doit être présenté au Congrès. Les anciennes expériences de Cl. Bernard ont été trop artificielles; elles ont été faites dans des conditions qui ne sont pas ceiles de la nature. Nous n'avons pas eu recours aux étuves, et nous en avons eu pas même besoin, parce que nous pouvions profiter de la chaleur naturelle. A Rio, durant l'été, nous avons souvent dans la journée des températures variant entre 30° et 36° C., les effets de la chaleur étant encore accrus par la saturation hygrométrique de l'air et les calmes de l'atmosphère. Quand ces conditions sont réunies, on sent une défaillance considérable des forces musculaires; l'activité nerveuse reste abattue; la peau sécrète énormément; les reins tarissent; le cerveau sommeille. Nous avons cherché savoir dans quel état se trouvait la circulation, et quelles modifications se passaient dans l'activité des nerfs sous le coup des grandes chaleurs, en faisant des expériences sur les animaux. En prenant la tension artérielle sur les chiens, avec des températures variant entre 309 et 359 C., nous avons toujours trouvé la tension très basse. Celle-ci variait entre 12 et 15 cent. c. de mercure, tandis que dans l'hiver la tension était entre 19 et 21 cent. c. de mercure. Deux facteurs physiologiques nous ont paru contribuer pour ce résultat; la dilatation paralytique des vaisseaux périphériques et l'affaiblis- sement du cœur. $s - Une étude, aussi comparative, appliquée aux nerfs, nous a fait constater que ceux-ci, actionnés par la chaleur, étaient devenus trop épuisables. Après quelques excitations graduées de la machine électrique, ils restaient inertes. Il fallait alors attendre quelques minutes pour voir les nerfs réacquérir leur excitabilité perdue. Nous avons aussi étudié les effets de l'insolation. Les chiens exposés au soleil, immobiles, ont crevé au bout de 50 minutes tout au plus. Les troubles du commen- cement ont été d'excitation : accélération cardiaque, respiration pressée; pupilles rétrécies ; abondant écoulement de salive. Cela durait une quinzaine de minutes. Ensuite il commençait la période paralytique : le cœur s'afflaiblissait beaucoup ; les pupilles étaient larges; l'écoulement de la salive cessait; la respiration s'arrêtait pour recommencer après. Lorsque la température rectale arrivait à 449 centigrades le moment de la mort était près. Celle-ci venait par arrêt respiratoire définitif, le cœur continuant à battre, sans pousser, pendant encore quelques secondes. Tout de suite après la mort on constatait la perte de contractilité des muscles, du moins pour les muscles respiratoires et pour le cœur. Le sang était noirâtre, assez fluide; le cœur portait des taches hémorrhagiques sous l'endocarde; les poumons étaient engoués avec des plaques hémorrhagiques parsemées. Sous la peau on remarquait un pointillé hémorrhagique, quelques fois suivi par des suffusions san- guines noirâtres. Les modifications créées dans la circulation par l'action de la chaleur, lesquelles nous avons ci-dessus rapporté, doivent créer nécessairement deux autres conditions, -APPARATUS FOR THE EST|MATION OF THE AMOUNT OF GAS EL|M|NATED FROM FOOD. FIG. 4.- : PAN-AMERICAN MEDICAL CONGRESS. 1299 qui n'ont pas Été encore démontrées par l'expérience, c'est-à-dire, la lenteur des phénomènes d'absorption et la diminution de l'activité des échanges dans les tissus. Maintenant il sera facile à comprendre comme ces conditions secondaires peuvent concourir à aggraver certains états pathologiques dans les climats chauds; et pour- quoi, dans ces climats, on ne doit compter beaucoup sur l'absorption rapide des médicaments. THE ANALYSIS OF THE GASTRIC JUICES FOR SOME DISEASES OF THE STOMACH. By HUGH HAMILTON, M. Sc., M. D., of Harrisburg, Pa. The accurate information gained by analysis of the contents of the stomach fluids in their normal condition, when the stomach is empty or in functional activity, is attractive to the physiologist because it places his work in a practical field; of benefit at once to the physician and his patient. One of the first indications of disorder of the stomach is the distension of the organ until the fermentive gases force their way through the cardiac orifice, sometimes carrying portions of the fluids or semidigested food with it. The flabbiness of the stomach walls themselves might be a cause of distension, but the ingestion of an abundance of easily fermented food only emphasizes the condition. The object of this thesis is to apply absolute methods to these phenomena, such as the exact volume of the organ, a way of deter- mining the fermentive capacity of the food as a factor; the estimation of the HCl in its several combinations; the intermittent (functional) or continuous emission of stomach juices. The volume of the stomach measured by means of its capacity to contain a given almount of air at a pressure until it gives way has taxed the ingenuity of those interested. A recent simple apparatus is that of Dr. Kelling, of Dresden. (See Fig. 1.) In his investigations he elaborately entered into the details of the difference of water volume exceeding that of the air volume capacity of the stomach. In his cases the average was 72.3 per cent. FIGURE 2, Case. Age. Height. Weight. Volume of water. | Pressure. c. m. l Ims. Rilos. Lbs. | c. c. Qts. | Pts. | c. m. | Inch. 1 --------------------------- 19 117 50 69 151 1, 500 1 20 >8 K 2--------------------------- 30 168 67 805 177 1,400 1 >1 22 >9 A 3 --------------------------- 28 || 173 69 695 154 | 1, 200 1 || >1 17 | >7 || R. 4--------------------------- 18 182 72 76 167 1, 560 1 <1 22 >9 || IF 5 --------------------------- 39 171 68 85 187 1,600 1 <1 20 >8 L 6 --------------------------- 40 165 66 55 121 1,300 1 || >1 21 >9 Z 7 --------------------------- 35 165 66 62 135 1,860 1 <1% 16 < 6 || C 8--------------------------. 60 165 66 73 146 1, 250 I <1 17 >7 | H 9 --------------------------. 50 167 67 65 130 1, 100 I <1 20 >8 F 10-------------------------- 56 173 69 87 165 1,700 1. <1% 19 >9 G. 11 -------------------------- 47 183 73 100 200 | 1,300 1. 9 || Tº 12 -------------------------- 40 160 64 170 140 1, 200 1 9 || L REMARKS.–7, 8, 9, 10, 11, and 12 are my own observations. To estimate the fermentive conditions, a portion of the stomach contents is with- drawn after definite meals, in periods ranging from one to four hours, then the ingesta placed in a bottle and raised to the temperature of the person's body, kept there until fermentive action ceases, or for a given time, when the oven into which the bottle has been placed indicated the average proper body temperature of the particular individual. The bottle or flask is connected with the following shaped apparatus (Fig. 4), and the amount of gas eliminated from the food mixture read off at desig- nated intervals. The abscissa of a scale may indicate time, while the ordinates will show the number of cubic centimeters of gases that may be caught over mercury 1300 BAN-AMERICAN MEDICAL CONGRESS. or water, depending in some cases upon the nature of the principal gases forming the volume of the effluvium (Fig. 5). 7. P. M., May 24, 1893, case (BR) of continuous secretion of the 8tomach juices. –The organ at rest contained about 1,300 c. c. After a mixed diet of meat, bread, and milk, 100 c.c. of this food was withdrawn, with the following results. Meal was taken between 6 and 7: At 7 hours— - c. c. At 7 hours— C. C. 5 minutes -------------------------- 40 minutes -------------------- 20. 7 10 minutes -------------------- 3.4 45 minutes -------------- , ºr º & tº º tº 22, 8 15 minutes -------------------- 6, 5 50 minutes -------------------- 24.5 20 minutes ------------------- 9, 6 55 minutes -------------------- 26. 7 25 minutes -------------------- 12, 6 60 minutes -------------------- 28 30 minutes -------------------- 16 June 9 --------------------- ------- 26. 1 35 minutes -------------------- 18.4 J tune 18 --------------------------- 32, 5 Various diets affect the amount of gas production. Remedies for interrupting fermentation and scale of their value. . Cubic .# Cubic .# º t; timeters o timeters O In 12 hours— fermentive In 12 hours— fermentive gases. - gases. Acid, salicylic, emitted.-------------. 0.0025 || Carbolic acid emitted................ 0.01 Natrium salicylate emitted.---------- 0.0025 || Creosote emitted ------------------`-- 0.05 Natrium benzoate emitted.----------- 0.03 Boric acid emitted.------------------- 1. 00 Saccharin emitted -------------------. 0.05 Alcohol emitted --------------------. 5. 00 In these experiments it has been found that one drop hydrochloric acid added to 10 c.c. milk gave 9 c. c. of gas in 12 hours due to fermentive action. Hours. Gas. 2--------------------------------------- 9 C. c. 3--------------------------------------- 9, and with Congo paper showed 4.2 per cent acidity. 4--------------------------------------- 5.75, and with Congo paper showed 8.6 per cent acidity. 8--------------------------------------- None in 3 to 4 or 12 hours afterwards. The remedies here are obviously salicylate and benzoate of soda, and in certain conditions small quantities of hydrochloric acid. The acidity of the stomach juices and its proper therapeusis is a fertile source of discussion. The mere fact of its presence by its effect upon certain “indicators” is at best of a qualitative index. The best methods of quantitative estimation are rapid volumetric ones, they give most conclusive results. We first find the total acidity by triturating 5 or 50 c. c. of the stomach contents with a ºn normal alkaline solution. With an indicator this will give you, for example, 0.182 “A.” The total acidity, if made up of the free and organically combined HCl would be exactly the same as the sum of these fac- tors; but the amid-group acids qualify it at different times so that the factors vary considerably during digestion. This may be deferred until later. The factors of investigation are— * - A. Total acidity. T. Total HC1. F. Fixed HCl (salines). C. Organic combinations of HC1. H. Free HC1. ſº a = value of amid-group acids. Fifteen cubic centimeters of the filtered contents of the stomach are divided into three portions, the first of which (a) is dampened with a clear, saturated solution of NaOCO, and dried with the other portions (b) and (c) over a water bath. Then (a) is taken out, exposed one minute to a weak red heat, taking care that the sub- Voz. aſ aajj. Wol or sas: Gueſe cars. I 50 3 &evas. 6 7 3. .2 /0. f/ * f2 Zºe’s 32 cc. 4/o / GO - - - - -/--/ — 2.0 / O /0 0 || 7 -2. 9. *A. JT < || Z--|--|--|--|º. FIG. 5.-PROGRESSIVE FERMENTATION OF FOOD. The volume of gas in c.c. formed from the contents of the stomach taken at three periods, being subjected to a temperature of 38.8° C. from hour to hour upon 100 c.c. of the fluids. PAN-AMERICAN MEDICAL CONGRESS. 1301 stance is heated until totally colorless and white. After cooling, dissolve in dis- tilled water and add a little clear NOs to drive off the CO2; dry and neutralize with CaO or NaOCO2; then filter and wash the residue with boiling water, and triturate with ºf normal solution AgONOs, indicating by KOCrO3, known as “T” = total chlorides. (b) This portion is dried an hour (per se) at 100° to 110°. When totally dry, the resi- due is wet with a clear saturated solution of NaOCO2, and treated as in (a). This is considered the combined chlorides = organic and fixed chlorides “C” + “F.” (c) This portion is dried and burned; the HCl found in ash is considered fixed chlorides. “F.” Portion (a) is designated as total chlorides, A, (b) is designated as the mixed chlo- rides of organic substances and fixed chlorides; hence (a) — (b) = free HCl as differ- ence known as “H; ” and (c) is known as the fixed chlorides, i.e., salts, as “F;” then (b) — (c) == organic chlorides known as “C.” * * Chloro-hydria or Qualitative jº. glandular re- changes in pep- * | active process. tonization. T.; F.; C.; H.; A.; a.; T. C F. H C I. H + C greater than normal =# = Hyperpepsia. II. H + C normal = # = Normal. III. H + C less than normal = H = Hypopepsia. This is the best explained by the following tables: H=T— (F-H C) *=A=_i or less than I. te Total ciº Free, Organic | Tºº! | value 30 255 182 0 73 75 102 60 321 109 44 168 189 86 90 284 164 14 106 126 105 e C I. Hyper-pepsia------------------------------------------------------- # 8 + T 6. General--------------------------------------------------- F=4.5 tº T b. Chloro-organic -------------------------------------------- F=3.1 T 0. Hyper chlorhydria ---------------------------------------- F=3. II. Normal ------------------- tº tº gº º sº º ºs º ºs e º e º 'º º sm sº º ºs e º ºs º ºs º ºs º ºs º ºs º ºs º sº º sº * * * * # } == C III. Hypo-pepsia----------------------------------------- # – to O. A = < 1 or 1 or O * =3.7 0. E" -- tº T b. * = F – 1.5 T te F=1.4 1302 PAN-AMERICAN MEDICAL CONGRESS. A. Normal acidity—0.1 to 0.2 per cent HCl, Nervous dyspepsia. A. Sub-normal. Below 0.1 per cent HC1. Sub-acute Chronic Ectasie or atony of the organ. Carcinoma A. Supra acidity or abnormal above 0.2 per cent, likely ulcer, HCl, Gastritis— Differential Diagnosis: Cancer the A. < O. Ulcer A. X 1 | cells. ... dance of HC1. Glandular or parenchym- . irritation of ! Hypo-pepsia with a-pepsia. (Irritation of the upper } Hyper-pepsia with supra abun- atous gastritis. great cells. Atropy of glands, a-pepsia. Simple, glandular atrophy, in whol g * Imple, g º: º y, In Wnole Hypo-pepsia to a-pepsia. Mixed irritation with glandular ; Decided hyper or hypo- disturbances. - pepsia. To sum up the matter in the increased size of the organ, its capacity to endure strain shows the reasons for its dilatation are either a yielding of the walls or the continuous fermentive process. After defining these facts by absolute methods we have a means of relieving the disease with the action remedies, other things being equal, with comparative certainty from the information gained respecting anti- fermentives, as sodium salycilate or benzoate. - Respecting various painful dyspepsias it is important to fill the organ (it should not be overstrained), discover its weak and tender spot, and test the contents for acidity, A., which to a degree fixes the sort of soreness you have to deal with, whether benign or otherwise. The use of remedies such as pepsin or hydrochloric acids are matters that are exhibited with accuracy in the formulas shown respecting the dif- ferent states of HCl in the contents of the stomach, as in the hyper, hypo, or a-pepsia States. I trust that these few demonstrated clinical certainties may lead to a more sure method of treatment. Interstitial gastritis. RECENT LITERATURE. Books: Du Chimisme Stomacal. By Profs. Hayem and Winter. Paris, 1891. Magen-Krankheiten, Wols. I and II. Prof. Med. Doct. I. Boas. Berlin, 1891–1893. Practice of Med. Osler, Phila., 1892. Deutsche Med. Wochenschrift, Bd. XVIII, 1892. - Articles—Deutsche Med. Wochenschrift, 1893: Secretio Hydrochlorica Ventriculi Continua. Schreiber. No. 29, 20th July; No. 30, 27th July.—Ueber die Continirliche Magensaft-Secretion. Riegel. No. 31, 3d August; No. 32, 10th August. Proc. Edin. Med. Chir. Soo. Dr. Gillespie, 1893. PRELIMINARY NOTE ON THE PHYSIOLOGICAL ACTION OF LANTHANUM, THORIUM, ITTRIUM, PRASEODYMIUM, NEODYMIUM, AND ZIRCONIUM. By ISAAC OTT, M. D., of Easton, Pa. The salts of these metals were procured from the Welsbach Incandescent Light Company, of Gloucester City, N. J. The nitrates were the combination used, and were soluble in water. The two bodies, neodymium and praseodymium, are two new elements separated from the old dedymium body by Dr. Van Welsbach in 1885. Their atomic weights were determined by Bunsen and Welsbach. The experiments were made upon frogs and rabbits. PAN-AMERICAN MEDICAL CONGRESS. 1303 The first element I shall take up is lanthanum, which was combined with ammo- nium to make it soluble in water. In the frog in one-half grain dose subcutaneously it increased the respirations and caused a feebleness of movement with a tetanic action, and finally all sensibility is lost whether the artery is ligated in one leg or not. Motor nerves when exposed are irritable; chest opened, and heart beating 34 per minute. In the rabbit, when a grain is gradually injected per jugular the pulse rate is hardly altered, but the arterial tension falls. The respirations continued after the heart stopped, while in another instance the heart was beating feebly five minutes after the respiration ceased. THORIUM NITRATE. A frog received at various intervals 20 grains subcutaneously. It caused increase of respiratory movement, then convulsive movements of the posterior extremities. There is a feeble response to strong irritation of the skin. The animal died in an hour and twelve minutes, heart beating 36 per minute. Sciatic irritable. A small rabbit received one-half grain thorium nitrate per jugular. Respiration at first accelerated. In two minutes after spasmodic movements of the posterior extremities the breathing ceased, heart beating 100 per minute. When a rabbit received an eighth of a grain at various intervals, it did not alter the pulse rate to any great extent, but depressed the blood pressure. ITTRIUM NITRATE. A frog received subcutaneously 12 grains of ittrium nitrate. In twenty-three minutes he sits in a stupid condition, with eyes closed, but jumps when his legs are irritated. Lies with mouth open; finally does not respond to irritation, heart beating 40 per minute. Has convulsive movement of legs. Sciatics irritable. In the rabbit one-eighth of a grain per jugular lowered the pulse rate and pressure. ZIRCONIUM NITRATE. After injection of 38 grains of zirconium subcutaneously the frog crawls in a weak manner when irritated. Chest opened, heart beating feebly at 36 per minute; sciatics irrital)le. - In rabbit zircon did not perceptibly alter pulse rate, but depressed arterial tension. PRASEODY MIUM. A frog after he received 24 grains of praseodymium had increase of respiration and jumped about convulsively. When 12 grains more given subcutaneously he had convulsions, and at length responds very feebly to strong irritation. When 6 grains more were injected he died; chest opened, heart beating strongly 44 per minute; sciatics irritable. In the rabbit # grain per jugular caused no marked alteration in pulse beat, but a depression of arterial tension. Praseodymium is stronger than neodymium. NEODYMIUM. In the frog 20 grains subcutaneously soon caused loss of movement; severe irrita- tion produces convulsions and death; heart beating 34 per minute; sciatics irritable. In the rabbit 4 grains per jugular caused depression of pulse and arterial tension. The following conclusions can be drawn from these experiments: (1) That in cold-blooded animals they cause loss of motility and a loss of sensi- bility, which is in part cerebral. - (2) That they all depress arterial tension and not markedly alter the movement in warm-blooded animals. (3) That in cold-blooded animals the heart continues to beat after death, but at a lower rate of speed. (4) That praseodymium is a more toxic agent than neodymium. SECTION XI.-DISEASES OF CHILDREN. Honorary Presidents. Dr. S. S. ADAMs, Washington, D. C. Dr. A. D. BLACKADER, Montreal, Canada. Dr. SAMUEL C. BUSEY, Washington, D.C. Dr. CHARLES WARRINGTON EARLE, Chi- cago, Ill. Dr. F. ForcHHEIMER, Cincinnati, Ohio. Dr. L. EMMET Holt, New York, N. Y. Dr. A. W. MEIGs, Philadelphia, Pa. Dr. W. P. North RUP, New York, N.Y. Dr. J. O'Dwyer, New York, N.Y. Dr. C. I. PUTNAM, Boston, Mass. Dr. T. M. ROTCH, Boston, Mass. Dr. J. LEwis SMITH, New York, N.Y. Dr. Louis STARR, Philadelphia, Pa. Dr. J. E. WINTERs, New York, N.Y. Dr. JESUS WALENZUELA, City of Mexico, Mexico. Dr. I. N. LovE, St. Louis, Mo. Eacecutive President. 'Dr. John M. KEATING, Colorado Springs, Colo. Secretaries. Dr. F. M. CRANDALL (English-speaking), No. 113 W. Ninety-fifth street, New York, N.Y. Dr. LARGUIA (Viannont 332), Ayres, Argentine Republic. Dr. ENRIQUE HERTzog, La Paz, Bolivia. Dr. CARLOSA. MONCORVO DE FIGUEREDO, Rio de Janeiro, U. S. of Brazil. Dr. ANTONINo GóMEz CALvo (Carrera 5 No. 92), Bogota, Republic of Colombia. Dr. JoAQUIN L. DUENAs (San Miguel 75), Havana, Cuba. Dr. DOMINGO ALVAREZ, Guatemala City, Guatemala. Buenos Dr. DAMASO LAINſ (Spanish-speaking), Media, Pa. Dr. SAINT LEGER-PERRIER, Prince, Haiti. Dr. F. L. MINER, Honolulu, Hawaii. Dr. ANDRES LOPEZ MARTINEz, Teguci- galpa, Honduras. Dr. RAMóN ICAZA (Ratas 9), City of Mex- ico, Mexico. Dr. CARMEN BENGOCHEA, Managua, Nic- aragua. Dr. PEDRO CASTRO (18 de Julio 422), Mon- tevideo, Uruguay. Dr. LUIS A. IBARRA, Caracas, Venezuela. Port au ADDRESS OF THE PRESIDENT OF THE SECTION. WHOOPING COUGH AS SEEN IN THE ROCKY MOUNTAINS. By J. M. KEATING,” M.D., LL.D., of Colorado Springs, Colo. President American Pediatric Society; President Section of Diseases of Children, Pan-American Med. ical Congress; Fellow of the American and British Gymecological Associations, Etc. The honor which was conferred upon me by the request to organize this section carried with it a responsibility which I fully realized, and, under other circum- stances, I would have hesitated in accepting the trust, living, as I do at present, in a section so far removed from those who would be my active coöperators. But, with the aid of one so efficient, so energetic as our secretary-general, Dr. Reed, and with the active assistance of our secretary, Dr. Crandall, I felt that our meeting was bound to be a successful one, and I was proud to be its standard bearer and to give all the aid of my enthusiasm in the good cause. What more attractive study is * Since deceased. 1304 PAN-AMERICAN MEDICAL CONGRESS. 1305 there than that of pediatrics? What more interesting theme than that which relates to the growth and development of the healthy babe, who will in future bear upon his shoulders the responsibilities of the world—those that relate to family and to government? What more satisfactory study than that of disease at an age when all natural processes are in our favor? The very subjects of which we write are those that are nearest and dearest to us in our individual homes. for they touch our love as well as our sympathy. They teach us how to defend those little ones from the aggressive influences of diseases which luxury and avariciousness have brought into our midst. They teach us the cause and, by knowing it, we learn its cure. The object of this congress has been to bring together all the workers in the vast field of medicine in this great hemisphere, and we hope by the happy associa- tion of scientific meeting and social gathering to learn more of the effects of climate on disease, both in its causative and curative relations; to study also the effects of individual resistance through racial peculiarities probably due to climatic influ- ences—a subject which is looming up as one of vast importance. I desire to call your attention to the subject which I have chosen for a few remarks to-day, hoping that it will bring forth some discussion and that the investigation which I have undertaken may prompt others to follow out this same line of thought in connection with other diseases of children in the various sections of this great country. Since living in Colorado, after having had quite an extensive practice on the Atlantic Coast, I have been very much struck with the differences in various affec- tions of childhood with which I had been previously very familiar. These differences certainly were not due to peculiar conditions of the individual, which might be said of those who are phthisical and who had congregated in large numbers at certain fav- orable places and where certain common symptoms might depend upon the disease and not the climate; but in children who, as a rule, are healthy subjects, peculiar manifestations of disease undoubtedly depend upon local influences, which may be either those of soil or those of climate. For this purpose, I addressed myself to a number of prominent physicians of Colorado and New Mexico, and have collected considerable data, from which I take the material for the paper that I present you to-day. It is not necessary for me to dwell at any length upon the subject of whooping cough. You will find all that I have to say upon this subject in the article in Pepper's System of Medicine and in a recent publication, Mother and Child. I may say that I believe the disease to be microbic in character and capable of being influenced by treatment that will reduce the attending laryngeal and tracheal catarrh and act as sedative upon the nervous system. We have all noticed that children do best with whooping cough who live in the open air and, for that reason, it is always recommended, when possible, to send our cases to the country or to the seashore, to dress them in flannels so as to prevent the catching of cold, to let them lead lives which are invigorating and which will tend to fortify their digestive proc- esses; in other words, that with fresh air and tonic influences the disease will run a mild course and terminate in recovery. The great question which has often attracted attention is whether the violent paroxysms which one so often sees attending this disease, and which result in haem- orrhages, at times most alarming, are productive of organic changes in the heart and lungs which will seri ously impair them as to growth and development. It must be said that at times we do meet with cases of this character, and possibly for years these little ones will be affected with evidences of cardiac strain or emphysema that will require the most careful attention to overcome so as to bring them to the standard of a healthy adult. But if that is so for those who live upon the sea level, how is it for those who live upon the vast slopes of the Rocky Mountains over one mile high? It is not necessary for me to go into the dynamics of altitude. The writings of Denison and Solly in this country, and Theodore Williams in England, have proved conclusively that the attenuated atmosphere, or, in other words, the relief from atmospheric pressure, has a marked influence in increasing the necessity for pulmonary activity and influencing the heart to a very great extent. The respira- 1306 PAN-AMERICAN MEDICAL CONGRESS. tions are either increased in rapidity or rendered deeper and the pulse rate is quick- ened until an equilibrium is maintained. The necessity for a larger supply of air naturally lays a greater strain upon the beart and lungs upon exertion, and one would imagine that where any interference would take place through spasms of the glottis the force of the expiratory effort would be intensified under the conditions named. We find also in studying disease in the adult in high and dry localities that the bracing winds and remarkable electrical phenomena of the atmosphere produce a nervous condition which seems to intensify those affections which have in them more or less of a marked nervous element. Of course one finds that the so-called nervous temperament which is associated with anaemia is benefited by an out-door life, which gives appetite and helps to increase the blood, both in its amount and richness, and such cases seem to do well. But the essentially neurotic type of individual—and I am speaking more especially for the women, as they form the larger part of my practice—are apt to suffer from insomnia, irritability, and all such evidences of excitement. I have also noticed in a few cases that children are more or less subjected to the same influences, and certainly with them we must be able to study more satisfactorily the effects of climate, because they are less influenced by what they hear and by dissatisfaction with their surroundings. I have had two most interesting cases of spasmodic asthma—one in a child born here, who is ten years old, but who developed the dis- ease in early childhood, and who became more and more affected as she grew older. She was highly excitable, intelligent beyond her years, and of an essentially neurotic type. The parents were both perfectly healthy. Exposure to the wind when driving would bring on the most severe attack of asthma I ever saw in any individual, which would last for several days. She would become highly cyanotic, the pulse would become extremely irregular and intermittent, the respiration very frequent and very shallow, and, indeed, on two or three occasions I felt that it would be impossible for her to survive the attack. Upon removal to the Atlantic Coast the child has remained perfectly well for now a year. One would then natur- ally suppose that in this section of country the spasmodic element of pertussis would be much increased; in other words, that the nervous system would be ren- dered more susceptible to the influences of the disease. One of the most interesting descriptions—and from my long residence in the locality I can vouch for its accuracy—is the paper on “High altitudes and their cli- mates” by Theodore Williams, read before the Royal Meteorological Society of Lon- don January 18, 1893. In the description of the climate of Colorado taken from this paper we find that in regard to rainfall it varies from 8.71 to 22.30 inches; at Den- ver, 14.17; Colorado Springs, 15.17; Santa Fé (the capital of New Mexico), 14.17 inches; at Gunnison, which is 7,680 feet, 10.02, and at Leadville, 10,200 feet, only 12.80 inches. Throughout Colorado scarcely any rain falls from October until May, and during the months of July and August most of the precipitation occurs, at which times thunderstorms are of frequent occurrence. Snow, which occasionally falls in the autumn and winter, rarely does so to the depth of more than a few inches, and only in the mountains does it remain for any length of time. The relative humidity, of course, varies with the season of the year. For two-thirds of the year it is remarkably low; for the other third, when the rain storff's are frequent, the average is brought up so as to bring a percentage varying from 46 to 58. As the number of days in the year in which rain falls is calculated to be about 85, and on most of these there is simply a thunderstorm and the rest of the day perfectly fine, the amount of sunshine is simply remarkable, and permits one to remain out of doors practically most of the year. One of the results of this out-of-door life is the remarkable resistance to attacks of bronchitis, which seem so prevalent in the East, as the result of exposure to sudden changes. Children rarely take cold, and yet the changes are remarkably sudden. At Sundown in winter the mercury may fall within an hour or so 30°, 40°, or 500; but probably the excessive dryness of the atmos- phere is in itself the cause of the immunity to the acute catarrhs, both laryngeal PAN-AMERICAN MEBICAL - CONGRESS. 1307 and bronchial, so prevalent in a moister and lower place. In order to find out what influences, if any, these atmospheric peculiarities and also altitudes had upon a disease like whooping cough, I have collected and present to you the experience of a number of physicians, who have kindly replied to my circular letter. give, as follows: These I Name. Place. Altitude. Experience. P. J. McHugh.---------- Hubert Work..... ----- J. M. Sleicher ---------- John Symington. ------ B. P. Anderson Le Kuhn. -------------- & gº tº E → * * * E. Stuver.------------- A. T. King------------- Frank Tinny----------. James Wroth. --------- P. D. Wrathwell....... N. Wiest.....---------. N. W. Bellrose......... John Gaw-------------- Francis H. Atkins..... F. H. Lay-------------. J. N. Hall.------------. N. D. Estes * * * * & & E tº ſº º e s Jesse Hall ------...----- F. Bancroft ------------ J. H. Finfrock......... Charles Denison....... Fort Collins, Colo....... Pueblo, Colo. -- - - - - - - - - - Waisenburg, Colo ------ Santa Fé, N. Mex - - - - - - - Colorado Springs, Colo.. Leadville, Colo s & gº gº ºr sº ºn as a Fort Collins, Colo....... Breckinridge, Colo...... Denver, Colo-...-------. Boulder, Colo Rawlins, Wyo Pueblo, Colo La Junta, Colo--------.. Albuquerque, N. Mex... ge is sº sº e s is e g º ſº gº tº gº ſº e is Eaton, Colo------------. Leadville, Colo. --------- Las Vegas, N. Mexi-...-- Colorado Springs, Colo.. Denver, Colo............ Sterling, Colo-...--------. Alamosa, Colo ---------- Greeley, Colo. ---------- Denver, Colo tº e s is gº tº e º ºs ºn tº Laramie, Wyo ---------- Denver, Colo-----------. Colorado Springs, Colo. Feet. 6, 275 4,600 6,275 5,000 5,000 4,822 10,000 6,450 6,000 5,000 3,900 7, 584 4, 750 5,000 7, 400 5,000 James A. Hart---...--. 6,000 No special change from text-book ac- Count. No special data. Great many cases terminated in pneu- monia following measles epidemic. Mild; rarely complicated. Attacks mild. In something like 20 per cent of cases have noticed some heart strain, and in about 5 per cent have detected val- Vular trouble, though in most cases it is not severe. Have had one case only of pulmonary emphysema following whooping cough, and that was a child of 5 years. Have never noticed asth- ma as a consequence of whooping cough. Nothing to note: Whooping cough more mild, with rather an extended period of catarrhal symp- toms. Whooping cough cases are mild, with few complications or sequela. Whooping cough I find more fatal, through complications and neglect upon the part of parents, than one ought to expect. Pneumonia, progres- sive; emaciation and cerebral conges- tions. We only had one epidemic last winter; disease severe; quite a number of young children died. hooping cough less severe; compli- cations about average; sequelae less grave. More severe than in eastern Kansas. Whooping cough much milder; only fatal case a child two weeks old, disease appearing first week of life. Our fatal cases complicated with pneu- monia. . Iſave had great many cases in private and hospital practice in Denver; find the disease milder by far, but very persist- ent. No important complications or sequelae. Only one case—boy of 4; good, recovery. Generally mild, without complications or sequélae. No variation from standard of sea-level types has been observed; no sequelae. Havelived 20 years in the great plains, 13 in New Mexico, and 8 in Las Vegas. Nothing peculiar in its clinical course. Mild complications and sequelae rare: Saw an extensive epidemic in Sterling, with no death or serious complications. Whooping cough has been mild, unat- tended with complications; no deaths. Very mild; few cases; no sequelae. Whooping cough (last epidemic) very severe one; 8 to 10 years age quite Severe. ** Nine months winter and three late in fall.” Whooping cough common and mild; never knew of a death; often pro- longed; complicated, with bronchitis. Worse in some cases because of mechan- ical effect of rarified air favoring em- physema. Have practiced twenty years in this locality, and found the disease about as represented in the text-books. Some epidemics severe and some mild. 1308 PAN-AMERICAN MEDICAL CONGRESS. We have thus endeavored to ascertain the views of those who are pretty well scattered throughout this section at various altitudes, and though it is absolutely impossible to give a positive reply to the questions asked without a record being kept of cases, as should be done if scientific work is to come from our daily expe- rience in the future, every man is impressed more or less with the character of the cases which have come to his notice, and these statements which I have just quoted possibly represent the facts as they really exist. We may then conclude that there is very little difference in whooping cough as seen in this section from what we have been accustomed to note on the Eastern coast, and that the little difference is possibly dependent upon epidemic influences. The most serious com- plication certainly seems to be pneumonia, and though this is a complication which is to be feared everywhere, it has the greatest significance in an altitude where pneumonia as a rule is a very fatal disease. In New Mexico, according to Dr. Fran- cis H. Atkins, who is a well-known writer on the climatology of that section, sequelae are rare. Dr. James Wroth, of Albuquerque, whose experience is most reli- able, also dwells upon the extremely mild character of the disease. Dr. John Symington, of Santa Fé, whose practice has been an extensive one for many years, speaks of the disease as being mild and rarely complicated, and this at an altitude of over 7,000 feet. But that mildness of climate has very little to do with this result is shown in the statement of Dr. J. H. Finfrock, of Laramie, Wyo., at an altitude of 7,400 feet, who quotes Bill Nye's description of their climate as “Nine months winter and three late in the fall,” in which he notes that whooping cough is common and mild, but that it is frequently complicated with bronchitis, which could be expected in so rigorous a climate. ge In summing up we may therefore conclude that as the cases of whooping cou gh receive their greatest benefit from living in the fresh air on the sea-level, so possi- bly it is the amount of fresh air and outdoor life which mitigates its severity on these mountain slopes; that in children who are healthy altitude of itself does not seem to influence to any very great degree the strain of the cough in the production of heart trouble or seriously impair the lung structure; that the robustness and resiliency of youth soon combine to maintain the balance of the circulation, and that also the nervous system of the child, though more impressionable to reflex irritations, does not seem to be so susceptible to climatic influences as that of the adult. PAPERS READ BEFORE THE SECTION. THE INSANE DISORDERS OF CHILDHOOD. By JOHN MADISON TAYLOR, A. M., M. D., Professor of Diseases of Children, Philadelphia Polyclinic; Professor of Diseases of Children, Medico- Chirurgical College; Assistant Physician to the Children's Hospital, Assistant Physician to the Ortho. pedic Hospital, Newrologist to the Howard Hospital, Fellow of the College of Physicians, Secretary of the Philadelphia Newrological Society, etc. It comes in the way of those who see much of children's diseases to meet with many cases of what I prefer to call insane disorders. A consideration of these, rather in the line of their nature and requirements than elaborate speculation as, to causa- tion and phenomena, may prove of use to the practical physician. Insanity arising from the same sources whence it comes in the adult is rare in childhood, but mental defects are only too common, and grow worse with startling rapidity unless most wisely handled. Minor mental deflections or shortcomings which may escape attention form the fertile ground for ineradically evil mental atti- tudes to take ready root. Active disease frequently disturbs the cerebral functions, PAN-AMERICAN MEDICAL CONGRESS. 1309 and these may not recover with the subsidence of the acute process, even though the structural damage be small. When this occurs, it is important carefully to direct even the simplest educational and disciplinary measures in order to inhibit further lapses and regain healthy tone. In a long experience in dispensary work among children such cases have occupied much of my attention and certain principles of guidance have become formulated in my mind, which may be trite enough, but nevertheless prove of service to others. My purpose is to call attention to the casual factors which should be scrutinized by the physician so soon as the least ground for apprehension arises, and after a general consideration of these point out how to deal with suspicious phenomena. The causes of these states are many and of wide reach. Some are the outcome of depressed physical powers due to want and misery; many more, however, are the result of careless usages, complications, and vice. In certain parental tendencies there lies danger. Vitiated appetites, as for alcohol, opium, or even tobacco, inter- lace with other, or are themselves a ground for, diseases of body as well as of mind. Tuberculous families frequently present instances of acute nervous diseases, termi- nating in swift fatalities, and offer also little resisting power against exciting causes. Then there are families of notably unstable nervous equilibrium in whom acute dis- eases or overwrought emotions work sad havoc. Cultivation of the emotions in the way of mundane or heavenly things, or, per contra, an undue asceticism or self- repression, may exercise a hurtful effect upon the offspring. When these various causes thus sketched out, and of limitless scope and variety they are, become super- added, one to the other, by the marriage of a tuberculous father to an hysterical mother, or an alcoholic father to an overconscientious, highly spiritual mother, disaster may be predicted for the issue. Again, upon the impressionable nature of developing nervous tissues of a child hypersensitive by heredity, exciting causes act only too overwhelmingly. Influences capable themselves of disturbing even a healthy-minded child are many. Acute felorile diseases produce commonly delirium, which is itself a transient insanity, and this may pass utterly and quickly away, or leave an indelible stain on the cerebrum. That surprising condition which we regard as accidental, because as yet we do not know how to explain its origin, known as precocity, is a source of peril if not an evidence of mental unsoundness. It is almost never a ground for parental gratulation, and only rarely fulfills youthful promise and not seldom predestines its possessor to neurosis. The clildish brain is very vulnerable at all times, and demands for its best devel- opment slow and undisturbed opportunities and wholesome conditions. Very much mental stimulus is always hurtful, although pure intellectual pushing is said by Charcot to be in itself incapable of harm, provided other wholesome physical and moral conditions are maintained. The emotions evidence themselves first in mere animal delightedness, even then running along the lines of ancestral traits. Here the parental coloring of mind, habit, or exterior is shown in curious faithfulness of detail. I’ven at this stage bad habits may become sketched in upon the impres- sionable receptive centers, which, either encouraged or neglected, form the ground for future calamitous happenings. The exciting cause of mental disturbances differ in some respects from those of the adult. One of the most serious is rapid alterna- tions of temperature. Children notably bear heat and cold less well than grown folk, and a baby laid with its head defencelessly toward a hot stove has in several instances been driven into acute mania. Children bear pain unusually well so far as mental distress goes. Much attention has been drawn of late by rhinologists to adenoid growths of the naso-pharynx as a cause of mental degeneration. Disorders of the digestive organs may form fundamental perversions which result in a series of reflex irritations, setting up, usually, only transient disturbances of mind. The cause being removed, recovery ensues. Intestinal parasites cause a variety of nervous troubles, but very rarely actual insanity. Hurtfully directed moral causes are very efficient factors in disturbing the mind, both temporarily and more seri- ously. The shock of fright or overwhelming dread is powerful for larm even in 1310 PAN-AMERICAN MEDICAL CONGRESS. children perfectly healthy. Religious teachings of a lurid hyperbolic type act as a lever by which great harm is wrought. As a potent accessory factor superstition has in all times been an agent to dethrone unstable minds. Acute disease is a fertile source of harm; a scarlet fever, or typhoid, especially if accompanied by hyperpyrexia, very often reduces a perfectly healthy, vigorous child to an imbecile or a maniac. Masturbation was credited with overmuch power for mental harm, but is certainly responsible for some. A brutal, drunken father, aside from prenatal conditions, causes terror and woe to young children, as well as perverted morals. Example is almost as powerful for harm as ancestral traits. Children subjected to long periods of want and exposure are certain to fail of right development and to bear some stain in the moral senses if not in mental acuity. Hence, the waifs and strays gathered up by the municipality or by philanthropic Societies are of questionable mentality and demand unusual care in implanting the seeds of morality and right conduct. These must receive a more primitive form of instruction than others who have enjoyed a better start in life. The fundamental concepts being at fault, too advanced instruction only confuses. To come at a statistical knowledge of the prevalence of mental disorders in chil- dren will always be hedged about with grave difficulties. Parents are not usually watchful as to these states, and are even more rarely competent observers to inter- pret mental deflections and shortcomings. Moreover, if a suspicion arises in a mother's breast as to the mental soundness of her offspring, it is likely to be tight locked therein and shared with no one living, until the conviction is reluctantly forced upon her consciousness from repeated overt acts. Moreover, it is rare to meet a mother capable of rightly training a child not altogether wise. Some, happily, are admirably gifted in this respect, and if the mother is capable of being or will sub- mit herself to be carefully instructed how such a case shall be managed sometimes the very best results come from home care. It has been my experience to see some excellent instances of these mothers. and I am inclined to believe that this particular possibility may be very much amplified. Again, I have found immediate relatives who both could and would undertake this care, and bring about excellent results. As a rule, the mother is so hampered by her emotional view that her judgment is not good in respect to her own child. Then, the problem arises to whom it may be com- mitted. It has been my custom, and I think from it some excellent results have come, to always search about among the home possibilities of such a case, and not seldom there has been found some good maiden woman, or widowed aunt, or child- less person, who could be taught to do what the same child's own mother might be able to do for some other woman's child. We have before us always the admirable example of the insane colonies of Europe, where such excellent results come from treatment in private houses, and whenever this can be accomplished it is better so to do. The well-regulated asylum is abundant for good, and of the excellent specially instructed folk who rule therein I have little to say but of praise. .. My theme here is the conduct rather of those who may not enjoy these advantages, either because they are not adjudged fit subjects or whose people decline to send them there. Moreover, the great body of mental suspects who escape statistical record is at the mercy of the family doctor, and upon him lies the responsibility of directing their care and teaching. Hence the bulk of these are to be treated at liome and the average medical man enjoys a grave privilege. In questioning, examining, and otherwise dealing with the child as a neurotic patient, success in arriving at right conclusions depends as much on the demeanor and conduct of the physician as on his knowledge. With the adult this may possi- bly not be true, but in respect to the less differentiated mental organization my proposition will hold. Skill born of much experience is needed to win the confidence of a child, and to this must be added tact and gentleness. Here again, gentleness should not lack a strong infusion of firmness and decision. If the patient be one whose mind or disposition is disordered it is of double importance to approach the PAN-AMERICAN MEDICAL CONGRESS. 1311 problem aright, either to learn essential facts or to apply remedies. Medicines will often be quite needless, but moral control and tactful domination must be ever forth- coming. The physician should succeedin impressing his personality upon the patient. He must represent embodied power, helpfulness, and justice. In some instances he may be of loving manner, pleading with the obstinate but sensitive nature. More often he needs to pose as a kindly yet overmastering being, to whom confession must be made soon or late. Again, over voluble, highly graphic confessions must be dis- counted too. Always obedience must be exacted, but tempered by due consideration of immediate necessities, and no more. Gradually simple yet systematic measures may be given shape and pushed steadily to an end. Much tactful shifting of unes- sential measures are at times demanded, patience and firmness always. The insane disorders, as the term is used here, is meant to include not only insanity, but that mixture of insanity and hysteria which is ofttimes indistinguishably blended. Nor must hysteria in the larger significance of the word be excluded. Hysteria in imitating as it does all neuroses yet never presents a picture faithful in essential details. It offers the more superficial appearances, but is wanting in the testamentary clinical findings. The faults have especially to do with the phenomena of onset; also with the basal symptoms such as evidence structural change and with the true course of the disorder imitated. Hysteria, while prečnlinently an imitation, is not all, nor nearly all, true simulation. In children it is rarely suspected, but always possible so soon as the receptive faculties and power to form concepts are fairly established. The heedless examiner will often give to the shrewd observation of the hysterical or insane child leading points on which to fashion its symptom groups by his idle words and leakage of thoughts while thinking aloud, and may be thus misled afar. Moreover, the distinction between these closely resembling con- ditions is oftentimes a purely relative matter, to be decided partly by the personal factor of the observer or the social or individual standard of the patient. Again, hysteria and organic brain disease may coèxist, not often in the child, 'tis true, but will there prove most puzzling. Moral perversions are hard to distinguish from merely evil and vicious tendencies which are acquired by a stupid, impressionable subject. The moral imbecile is inherently bad. He is an instinctive liar and thief, cunning and skillful in mischief- . making, and if in other ways seemingly competent, yet unspeakably provoking to the parent or teacher. To know how to best deal with such is generally condi- tional upon a clear decision as to whether one has to do with an ineradicable vice or disease, here probably synonymous, or a possibly removable disorder. The main thing is not to attempt too elaborate a plan of improvement, and when he be under favorable surroundings to exercise infinite patience and use abundant time. He is to be made to know that while not to be trusted or believed the utmost encourage- ment will be enjoyed so soon as evidences of improvement are shown. Along with obviously wicked acts coèxist often evidences of disease process as convulsions. It is often most difficult to determine if these be epileptic or hys- terical. These may be in combination, too; hysterical attacks in an epileptic sub- ject is a blending to which there is no key. Typical clear-cut cases of neurotic maladies are none too common, and ordinarily it is only by the after fruits of treat- ment that they shall be determined. A large familiarity with hysterical states increases ones respect for the difficulties of differentiation. Charcot's diagnostic powers of hemianaesthesia, affections of sight, hysterogenic Zónes, the effect of asthesiogenic agents upon sensibility and motility, many times can not be readily or promptly applied. Then collateral evidence must guide the physician. Hysteria must have some sort of audience always, and wherever vanity can be detected, or gravely suspected, it will help to determine the nature of attack. The instinct of the physician is also a help, but must not be masked by prejudice. In the management and moral training of children of hysterical or maniacal tendencies the first step to be gained by physician or care taker is to win their 1312 PAN-AMERICAN MEDICAL CONGRESS. confidence. The best method to pursue is to show and preserve a frank, quiet, yet persistently friendly, demeanor. In first interviews it is wise with all children to avoid a too direct and impulsive approach. Childish concepts come slowly; con- clusions which are being formed with no great promptitude should not be hurried. Overprecipitancy offends, and the result is negative. Very much the same courteous, straightforward methods win a child which prevail with the elder. I have else- where emphasized this (I, Univ. Med. Mag., Aug., 1891), and am more than confirmed in my views. It is well to efface as nearly as possible the differences of age or posi- tion between the patient and physician. Assume both to be on the same plane, the one simply taking the initiative. It is inscrutable to me how those who talk baby talk, as it is ludicrously miscalled, to children, ever succeed in rendering themselves otherwise than most offensive. There is nothing winning to the feeble intelligence in being treated as an animal. So, thrusting of thumbs in the unprotected abdomen, chucking under the chin, etc., may convulse the infant with reflex laughter or at the grotesque figure of fun cut by the one so acting, but does not inspire confidence or admiration. It is like well-meaning folk who attempt to converse with a for- eigner by using broken English. This is no light matter here discussed. Knowl- edge of the mental processes of the patient one must have, and accurate information only comes through intelligent questioning. I have repeatedly been able to secure the attention and frank answers of a child which my assistants had utterly failed to get, by conveying the impression that I was just such a person as themselves, who asked straightforward questions and fully intended to obtain equally candid replies. And if this be true of the medical man, in rare interviews, how much more needful is it that those who watch and direct the daily progress of the child shall proceed in the same frank, honest fashion ever. Punishment is sometimes needed; sharp corporal punishment, too. Some children of low tone or vicious hysteroidal char- acter are amenable to no other argument. Who shall administer this and when is of the gravest importance, and only harm comes of lack of judgment here. More often gentle domination or kindly encouragement will suffice. A jocose, bantering tone also offends. Begin by questioning the attendant, parent, or nurse, thus allowing the child to take bearings and see you are not an ogre; then proceed to gently draw out the childish thoughts by speaking of perfectly comprehensible subjects first and others indirectly, and finally directly question. It is often most difficult to convince people who assume the care of poor children, and who are themselves simply well-meaning philanthropists uninstructed in matters of mental development, ‘that the morally or mentally infirm should not be allowed the same measure of privilege and responsibility permitted to others. This over- confidence many times leads to disaster for which the society may be held to account. The members of such societies should inform themselves carefully not only upon the subject of the varying capacities of the individuals entrusted to their charge, but in a general way the proper means of managing those whose mentality is either essentially below par or undeveloped through vicious suppression and perversion. It has been my privilege to be connected with such in an advisory capacity, and it grieved my heart frequently to see glaring mistakes made partly through well- intentioned ignorance and not seldom from vain self-sufficiency. I could relate instances of moral imbeciles shrewdly manipulating the good ladies for their own selfish ends and becoming irretrievably ruined themselves, for nothin § so permanently destroys all remnant of moral sense as the exercise of thieving and lying propensities upon credulous philanthropists. But if this is bad for boys, how much worse to allow girls to grow up through the critical periods of puberty unguided in the essentials of self-respect and purity, and become exposed by their deficiencies in moral restraint to the many temptations offered by too great liberty of speech and action. Several lamentable instances of sexual per version and social destruction have come my way even after I had clearly pointed out the danger. The component members of these societies too often forget that human children vary PAN-AMERICAN MEDICAL CONGRESS. 1313 widely, not only in mental capacities, but in degrees of moral stain from ancestry and training. It is too often assumed that, given reasonable opportunities, all chil- dren will tend steadily to improve. The children of pauper and criminal classes need most careful watching and unusual training in the fundamental principles of morality. Instead of this they usually get too much liberty and far too much reli- gious teaching. The training in religious thoughts and observances has a tendency to foster an exaggerated emotion, which is in some ways closely allied to sexual excitement. Let the moral instruction always precede the religious. Appended are the notes of three cases—two of no great interest, but one rather unique. Several such of the deepest interest have come under my observation, but I am not permitted to use them freely. One I give in illustration of a vicious tendency, but large gen- eral intelligence. A girl born of vigorous parents, but on the mother's side fre- quently recurring valvular leart disease. The child had a congenital aortic insuffi- ciency so grave as to create astonishment in the minds of physicians who examined her to believe that life should continue. Here was a very great amount of physical and mental activity constantly maintained and unchecked by the parents. Death occurred at about 9 years. This was an instance of great precocity—especially volu- ble and shrewd in recognizing with unerring certainty the foibles and weaknesses of whomsoever slie came in contact, managing those about her with a tact and adroitness to which too high admiration could not be conceded. Large judgment was here exhibited in manipulating others, but lier purposes were often unclear. Long before it would have seemed possible for the small creature to learn bad lan- guage, for the father was peculiarly free of such habits, the skill and vigor of her profanity would have put a Texas cowboy to the blush. The calm effrontery of her lies were only equaled by the adroitness which was exhibited in covering up her discovered errors and mischievous ſailures. I have amused myself and indeed gathered much instruction in listening to her caustic critical remarks, when about 5 or 6 years old, on the personal characteristics of those whom she knew. Moreover, she never erred a second time, if once the error was committed, of exceeding lier privileges overmuch, especially when swift punishment ensued, but would persist- ently drive a timid or undecided person, as her own grandmother, to the verge of distraction by a well-planned system of petty annoyance, skillfully pursued. I could relate many instances of all these and other vagaries, but need not. The child was morally insane, but of such rare wit and intelligence, showing such tact and wisdom at times, as to convey the impression of her being (in sharp antithesis to case I) possessed of the arch fiend, whereas case I might be deemed of angelic descent. Here was an extremely bright, intelligent child—selfish, cunning, untruth- ful, cruel, and profane—a perfect picture of an almost hopeless mental invalid. Should such children as this receive the thorough systematic training upon the lines laid down by Fröebel, involving a gradual awakening of the dormant faculties, I am confident great gain might be hoped for. It is Iny desire yet to see this kinder- garten system thoroughly and persistently tried by fully competent teachers on unpromising cases. The limitations as sketched out herein must form a serious barrier to satisfactory results in most instances. Another case to which I may only briefly allude: One in whom since babyhood a second personality or companion constantly accompanied the child, to whom all mat- ters of doubt were referred. If asked a question this being is consulted by a side speech and the answer then given, or perhaps a difference of view arises and disputes ensue. Again, sometimes the child comes to parents or others and announces that “I have been to see B., and he and I talked over this or that,” and arrived at cer- tain conclusions which served as an imperative rule of guidance. There are other evidences of a very exuberant imagination, of a possibly hysterical nature, but no distinct signs of insanity except the delusion out of which the child can not be reasoned. My opinion is that as time advances and educational measures are pur- sued this will pass away. S, Ex, 36 83 1314 PAN-AMERICAN MEDICAL CONGRESS. Case I.-Helen Foulke, aged 9 years; first child of healthy parents; family history good for physical vigor; on the mother's side a great deal of neurosis with a dis- tinctly religious coloring, coming of a race of Quaker preachers; one uncle, a man of large general intelligence, regarding himself as definitely under divine guidance, even in the matter of catching trains, for which he refuses to consult time-tables, etc., acting perpetually upon this heaven-sent impulse, yet falling into very few catastrophies. H. F. healthy as a baby in all respects. At 18 months had whooping cough, during which asthma developed, and, while very restless always, is very bright and intelligent, but even at that early age showed a marked ability to amuse herself, rather resenting outside interference. At 3 years of age had a sharp attack of pneumonia, which was probably, from the description, bronchitis with asthma; evidently extremely ill; for a time lay unconscious; some cerebral excitement even then, starting up suddenly and crying out loud for no known cause. During this winter there were three attacks similiar to this. On recovery, began to have imagi- nary playmates, whose names were “Dewey” and “Gee.” These were distinct per- sonalities, apparently sexless, with whom she had long systematic conversations, arranged the disposition of her day, and these shared with her in all pleasures, which were largely solitary. Occasionally other imaginary people were introduced into this coterie, of different names. These frequently assumed the individuality of various pieces of furniture, which acted as a sort of negative background for the more active characters, “Dewey ’’ and “Gee.” As time wore on these inanimate objects were given human names and regarded as regular companions, with whom long hours of perfectly cheerful play were passed. Her family assumed this to be merely the play of a rather exuberant imagination, because the child could be readily diverted from these to ordinary practical affairs. She was otherwise entirely cheerful; indeed, rather of overexcitable spirits, and in most matters quite rational. The two regular companions and herself held long conversations, and when other children would come in to play with her, the two imaginary ones were brought into the conversation as much as possible; at least, to the extent to which the other children were capable of comprehending. Child playmates were comparatively rare in the isolated home, and therefore this imaginary couple were regarded rather as a boon than otherwise by the parents. The curious fact was observed by neighbors and visitors that Helen would almost never take hold of any object, even those which she had endowed with names and individualities, and with whom she conversed most freely. At 4 years of age she went to a kindergarten, and while there it was almost impossible to make her enter into the regular methods of the school, but on coming home, she would go through the entire performance with the utmost accu- racy, showing there was no lack of comprehension. Also, the child failed to recog- nize orders of the teacher for a long time, simply ignoring them, but gradually got in the habit of submission. At 7 years of age she went to a regular day school and gradually got adjusted to regular discipline. She finally became interested in school work and distinctly overwrought herself, occasionally falling into hysterical condi- tions. About this time, also (between 7 and 8 years) she had an attack of influenza, which recurred three or four times, accompanied by a good deal of psychical disturb- ance, and after this fell back into a condition of physical apathy. There no longer appeared the active excitement, the voluble conversations, and such like, but she dreamed dreams both sleeping and waking, the results of which were related, not very frankly, to her mother. For some time she exhibited great slowness in everything, physical and mental, though all this while a moderate degree of intelligence was main- tained in practical matters. She gradually grew more talkative and argumentative, discussing most exhaustively the pros and cons of the smallest matter. Gradually religious ideas became prominent; she became sleepless, lost appetite, etc. Then a period of three weeks intervened of very great excitement, coupled with terror. The house was peopled with wild animals, of definite kind and of aggressive fierce- ness, which kept her in a state of perpetual consternation. She frankly admitted to her mother about this period that she knew she was crazy, declared herself to be the victim of imagination, or worse, and would endow the pictures of living objects on the wall with malignant tendencies, and beg her mother to turn them face down. At 84 years of age she suffered an attack, rather prolonged, of fever with menin- geal Symptoms—pain in the back of the neck, constipation, and finally, troublesome diarrhea. At one time a collapse occurred for twenty-four hours, when she was thought to be almost dead. During convalescence there occurred a period of intense exciteemnt for ten days, with active imaginings, and then suddenly intervened the former state of apathy. A period of complete mental deafness occurred for about five months. - This girl came under my observation in June, 1892. There had then occurred an attack of chorea, which in all ordinary respects seemed true chorea. The child Seemed rather stupid, filled with sudden fears and certain definite weaknesses which prevented her from walking straight, and also hallucinations of fanciful nature. I found a good deal of irritation about the nasal passages which it seemed necessary PAN-AMERICAN MEDICAL CONGRESS. 1315 to cure, and, not to prolong the account overmuch, in two or three weeks this was accomplished very nearly. There were no adenoid growths of the pharynx. I directed that she should spend the summer at the seashore, where she improved greatly, the asthmatic attacks disappearing, and the slight naso-pharyngeal catarrh subsiding almost entirely. The mental condition improved very much. In the autumn, her physical condition being enormously better, and her general intelligence, too, giving great hope of thorough repair, there then intervened a period of extraordinary religious exaltation of a very picturesque kind, and just such as I imagine would convince people of strong religious convictions that this child had been breatlled upon directly by the Spirit of God. She had been under the immediate influence of an overreligious servant, who had played upon the impres- sionable nature of the little girl, had taught her all manner of religious phrases, and done just as much mischief as she could possibly contrive. Thereupon, her pupil proving extremely apt, there transpired a large series of interesting religious phases: One while she would eloquently expound her view of passages of Scripture, her views upon the condition and appearance of heaven, what people should do to enable them to secure residence in the abodes of bliss, etc. There were vouchsafed to her glimpses of heaven, which she described most graphically and charmingly. There finally grew in her the overmastering desire to die and be a blessed angel. As to what she should do and where she should live, how conduct herself, etc., no devotee of the Middle Ages brought up in a nunnery could have more vividly portrayed; indeed, she exhibited a grasp of knowledge of the details of ordinary religious teach- ing which was out of all proportion to what her previous training would have war- ranted, giving any casual observer the impression that much of this was actual rev- elation. Her mother says that this was a feature frequently repeated in various members of her own family, who would fall into ecstatic states, during which astounding revelations were made to them. What might have transpired had not these good people been bound down by the conventionalities of the Society of Friends it is impossible to estimate. In October, 1892, Helen had an attack of typhoid fever, not over severe. During this time the delirium was of a talkative character, and she readily fell into conver- sation with whomsoever came near, relating her dreams, intermingled with the con- stant complaint of the same pain in the back of the head as in her former illness, but with almost no trouble with the digestive functions. After the convalescence from this was safely established, she was brought to me in the city and placed in the hands of two professional nurses of large intelligence, and her condition more closely watched. The improvement in all particulars was steady and admirable. The imaginative tendencies showed themselves occasionally, and were quietly argued away or ignored. The desire to do bizarre and silly things was likewise dis- couraged, occasional tendencies to soil herself and the bed were promptly nipped in the bud, not too roughly, and a general measure of systematic education in the decencies instituted, which very soon had an excellent effect. From being carefully directed by kind, gentle, tactful personalities, the imagination was clipped, reduced to normal proportions, and a large amount of residual common sense allowed to come to the surface. Undoubtedly much harm had been done unwittingly by the mother in unconsciously encouraging some of these poetic flights, and causeless apprehensions were not judiciously explained away; obedience was not demanded to practical matters at home, overindulgence probably given to vagaries of thought and act, and, in short, parental discipline, never the best in cases such as this, was probably rather worse than usual from a mother who was oversolicitous. July 10, 1893, my last report from this case is most favorable. Case II.- Bessie A., aged 6 years, came under my care February 11, 1889. Family history good; third child; one dead of cholera infantum. B. was perfectly well in every respect until at 5 years of age had scarlatina very severely; mouth, nose, and eyes seriously affected; vomited constantly for a long time; was ill two months; the vomiting continued until quite recently, at intervals; toward the end of the illness the child was paralyzed, involving the left side. This came slowly on until com- plete helplessness resulted; eyes were crossed and capacity to swallow almost lost. In two months more began gradually to walk. The power was not especially less- ened on either side. Five months after the first attack a convulsion occurred of a tonic character. The body twisted steadily to right, the eyes staring and fixed; the whole person rigid for nearly two hours; the eyes remained fixedly open until the following night; could not speak. A few hours after the beginning of this attack there was a clonic convulsion in which the head moved both ways; pupils at the time were widely dilated. The health slowly mended, until about three months ago began to have attacks of frenzy, complaining of a fear, as from some sudden noise, usually accompanied by the hallucination of seeing a cat. These increased in fre- quency until a dozen a day occurred; at other times almost none. Now the mind seems distinctly impaired in certain ways; tries to run away from home; on two occa- sions was lost. The body is miserably ill-nourished; the worm-eatentongue of mucous 1316 . PAN-AMERICAN MEDICAL CONGRESS. disease, consideralle nasal irritation, the right lid eroded, slight ptosis; heart sounds muffled and distant, and slightly irregular pulse. She is very excitable; tries to romp and play with children, but needs to be controlled. ... I asked my friend, Dr. Raudall, to examine the eyes, and he reported as follows: Left eye shows considerable H. As., but no gross lesions in the fundus. The right eye has corneal cicatrix. Right ear shows retracted membrane; the left almost complete destruction of mem- brane and a trace of left-sided facial paresis. This child was kept under observation and treatment for over a year, steadily improving in respect to nervous excitability and physical lealth. The screaming spells steadily lessened. The following January considerable accession of trouble arose from being severely whipped. At that time the heart action was very irreg- ular, and she needed constant systematic treatment of a tonic character, as well as tranquilizing measures. A year after being first seen had a fit, and soon after escaped from the house and disappeared for a day or two. In a year and a half a very severe convulsion occurred confined to the right side, chiefly in the fingers and eyes and mouth. No evidence of palsy followed. The knee jerk was found to be normal on both sides. May 22, 1891, it was found necessary to place her in the Home for Feeble-minded Children. Is much more rational in many ways, but explosively emotional, and at such times uncontrollable by her mother, and a very great nuisance to the family and neighbors. Under the admirable care which she received at Elwyn, steady improvement took place, until to-day (May 10, 1893) she presents the appearance of an admirably well-grown, splendidly developed girl of 9. I have seldom seen a more perfect physique. The shape of the limbs and quality of the muscles are extraordinary. There appears to be no trouble with any of the organs, except still in the right eye. The intellectuality has not improved to any very great extent; takes some interest in sewing and land work, such as kindergarten studies; can sing correctly; has a vile temper if aroused, which occurred rarely of late, and is then said to fight like a maniac; at times is rather destructive, but on the whole is a very good girl, obedient to teachers, and talks affectionately of them. She, cur- iously enough, has a very kindly regard for myself, probably because I was the only one, until she went to the home, who dominated her sharply, and even now con- stantly talks about me, and promises her companions that I shall be brought to see them. To-day the only peculiarities in her nervous state are slightly excessive knee jerks in both legs and a slight clonus in each of two or three beats. Case III.-A. B. Female, aged 10 years. No insanity in the family. Parents living, one brother. Previous health of patient good, but always nervous and with weak digestion. One year ago and again six months later had a convulsion following an indiscretion in diet. These convulsions passed off without leaving any apparent permanent injury. About three months ago she had a series of convulsions lasting five hours, and accompanied by fever followed by a trance-like state lasting for two days. Since then she has continued in her present state. Expression vacant, indif- ferent, demented. No sign of affection. Habits, filthy and shameless. Irritable, but never weeps. Rarely quiet. Lies in bed, rolling rythmically from side to side. This movement is apparently automatic. At other times she will pace the floor like a caged beast. Makes no attempt to speak, but hums a luonotonous tune. Does not like to be touched. Hearing is good. Appetite is fair. Puts any object given her in the mouth. There are no palsies. The reflexes are normal. Abdominal and thoracic organs normal. Urine normal. Pupils at times dilated and react to light and accommodation. There is marked pallor and emaciation. After a year her physical condition had much improved. Mentally she is in a condition of dementia. ARTIFICIAL ALIMENTATION OF CHILDREN IN MEXICO. 13y Dr. J. R. ICAZA. GENTLEMEN: This is a subject that was proposed to me by the honorable Dr. Keating, worthy president of this Section of the Diseases of Children, and of which, counting upon your good will, I am going to briefly treat. According to him, it is not my part to busy myself with the different branches that may be allied in a general way to the alimentation of children, nor is it even my duty to make an analytic study of the different methods, more or less worthy of recommendation, that are employed to raise them, when, by some circumstance, they are deprived of their natural food. My mission is reduced, I believe, to telling what is done in my country in such cases, Nevertheless, although it may be a few words, I will say PAN-AMERICAN MEDICAL CONGRESS. 1317 something of the course pursued by the Mexican physicians in directing the alimen- tation of children in the first epoch of their lives; that is, from birth until the first dentition is over. -- In Mexico, gentlemen, it is the general rule that the mothers nurse their children, and it is the truth that we physicians never have to tell Mexican women of the obligation they have of suckling their offspring. There they are dedicated com- pletely, and perhaps to an exaggerated degree, to the domestic duties, and the priva- tions and annoyances of raising children to full age matter little to them and prove a pleasing task. But when the children are left orphans, or when the mothers are unable to nourish them because of lack of health, because they have not sufficient milk or because the milk is bad, then we recommend a wet nurse, taking precau- tions, you understand, before trusting the child to her care, to examine her thor- oughly to see if she is healthy and if her milk is abundant and of good quality. It is worthy of remark that the wet nurses always live in the house and are under the direct vigilance of the family. But if the poverty of the family or other cause pre- vented the employment of a wet nurse, there is no other remedy than to resort to artificial food; but we never advise this course, so troublesome and full of difficul- ties and obstacles, to be followed, except when we see ourselves forced to do so by exceptional circumstances. I express myself so, because the direct lactation by females of animals is very rarely done. However, in some cases goats are used, because, as is well known, they are better adapted to the purpose, as much on account of the form of their mammae and the abundance and quality of their milk, as that they easily become accustomed to take care of the children. We now arrive at the first question: What do we do in my country to artificially nourish children? Generally milk of the cow, goat, or ass is given them. That of the cow is the most used because it is cheaper and more easily obtained. It is scarcely ever given in its crude state. It is customary to use it skimmed and boiled mixed with an infusion of yerba buena, orange leaves, tea, or some other aromatic plant, or boiled water in order not to change the taste and not to diminish the original nutriment. This mixture is made in various proportions; for children under six months, two parts of water or of the infusion are mixed with one part of milk; from the sixth to the ninth month, equal parts of milk and water; from the ninth to the twelfth month, two parts of milk and one of water; after one year, three-fourths milk and one-fourth of water, and after fifteen months pure milk is given. In administering it the bottle is often used. We have many models on the market, but the most accepted for its simplicity and for the ease in cleaning it, a most essential condition in order that the milk may not be altered in its constitu- tion, consists of an ordinary bottle of 300 grams, approximately, the mouth of which is made of gutta percha. In the first six months a half bottle is given every three hours and after that age a full bottle in the same intervals. At times it hap- pens that children refuse cow's milk or digest it badly and it is then given them mixed or boiled with flour, corn, wheat, or rice and it is often greatly improved by the change. - Ass’s milk and goat's milk are also employed, especially the first, whose composi- tion, as is well known, resembles that of human milk. It is more difficult to obtain and costs more. Families that are able to enjoy some conveniencies have the ass in their own yards so as to be able to order milk for the child when needed, which is then taken warm and without any adulteration. I could cite many cases in which ass's milk has given positive aid in raising children. A chemical analysis shows that it is more easily digested than that of any other animal. Some families give their children artificial preparations, such as Nestle's Lactated Food, which is composed, principally of toasted bread dust, wheat flour, and milk dried in a vacuum; Hagner's Food, Liebig’s Extract, or other similar mixtures. The poor often use atole, a drink that consists of a paste made of ground corn which is diluted with water and milk and afterwards boiled. This is a food less wholesome and nutritive than milk but easily digested. 1318 PAN-AMERICAN MEDICAL CONGRESS. The truth is, it is necessary to vary the food for it happens that children, like adults, have different individualities and what is acceptable to some proves nau- seous to others. I have already indicated that in Mexico it is vary rare that a child is given milk or any of the preparations I have mentioned. These preparations are used more especially for mothers and wet nurses, when the milk becomes scarce, and for motherless children—in a word, for variety's sake. However, among the poorer classes, the children are often denied the breast and are given all kinds of food. If artificial feeding, conducted with great care, is always perilous, it is much more so if not done in an intelligent manner. As proof of this assertion I will say that we see every day among poor families more or less grave disturbances of the digestive organs in children prematurely weaned which are quickly cured by a return to the breast; and we see also that the children of poor nurses, badly nourished and im- properly fed, nearly always perish. THE GENERAL PRINCIPLES UNDERLYING ALL METHODS OF INFANT FEEDING. By T. M. ROTCH, M. D. Professor of Diseases of Children, Harvard University. Jºst as the highest aim of medical art should be directed to the province of pre- ventive medicine, so the highest and most noble branch of preventive medicine should consist in the study of the best means and the most practical methods for starting young human beings on their life race; for preserving them from the perils which surround the early hours of existence; for giving them strength and vigor to resist the attacks which, greater and more dangerous in inverse proportion to their age, must inevitably be made upon their vitality. The preventive medicine of early life is prečminently the intelligent management of the nutriment which enables young human beings to breathe and grow and live. In fact, it is a proper or an improper nutriment which makes or mars the perfection of the coming race. Infant feeding, then, is the subject of all others which should interest and incite to research all who are working in the preventive medicine of early life. The subject is a great one and is worthy of the attention of the greatest minds of the age; worthy for the dis- cussion of the leaders in medical thought of our Western Continent. The responsi- bility of introducing such a serious question before such an assemblage of advanced medical thought is a grave one. It should be taken up carefully—it must be dealt with broadly. We must acknowledge for the present, and in fact it is true, that in the status of infant feeding as it has existed up to the last few years, the average human breast-fed infant is more likely to live, the other factors of the life problem being equal, than the infant which is fed by any other method. But we must remem- ber that the latest scientific work on this subject shows very clearly that it is not breast milk as a whole which is prečminently good, but that there are definite known reasons inherent in the different elements of the breast milk which make it the best known food. It is our province as scientific workers in this most important branch of practical medicine to year by year elucidate and make use of these elements, once covered by a somewhat mysterious veil, but now rapidly being laid bare by the search light of patient and laborious investigation. A great advance has been made in our knowledge as to what we are to copy from human breast milk and what we must achieve in preparing a substitute. The very essence of this practical information which we have gradually acquired lies in the discovery that there is no one perfect nutriment for young human beings as a whole, but that it is the changes in the various elements of the breast milk which satisfy the demands of the individual, and thus in time suits the many to such PAN-AMERICAN MEDICAL CONGRESS. 1319 a degree that this protean food has erroneously come to be looked upon as one especial, unchanging nutriment. To thoroughly understand and successfully solve the feeding problem of the early months of life, a knowledge of the changes which take place in the mammary gland from many causes must be clearly kept in view. Again, the methods of modifying the milk in the human mammary gland, however limited in their scope they may be, should be practically investigated and carefully adapted to the individual according to its age and size and general physical condi- tion. The mammary gland in its perfected state, uninfluenced by disease or nervous disturbance or by the improper living of its owner, is a beautiſully adapted piece of mechanism constructed for the elaboration and secretion of an animal food. When in equilibrium it represents the highest type of a living machine adapted for a special purpose, both mechanically, chemically, physiologically, and economically. When for any cause this sensitive machinery is thrown out of equilibrium its prod- uct is at once changed, sometimes but slightly, but again to such an extent that the most disastrous consequences may follow when it is imbibed by the consumer. To state then, concisely, what I have already referred to, we should, in studying the form of nutriment which shall be suitable for the early months of life, manifestly be guided by what nature has taught us throughout many ages. : The researches of science are, indeed, especially in the subject of infant feeding, wisely directed to learning to read the truths which nature presents to us. Great progress has been made in reading these truths; what we are at present endeavoring to do is to copy them. The constituents of the nutriment which nature has provided for the offspring of all mammals is essentially animal and never vegetable. Human beings, therefore, in the first twelve months of life are carnivora. It is therefore evident that an animal food entirely and always free from amy vegetable constitu- ents has been proved to be the nutriment on which the greatest number of human beings live and the least number die. Where good breast milk, or rather one that is fairly adapted to the individual infant, can not be obtained, or, if obtained, can not be regulated by modification, it is desirable to combine the elements which good breast milks represent. For perfecting this, what best may be called substitute feeding, we must have a material which, while as closely as possible approaching the analyses of good breast milks, is also easily accessible. There is no mammal whose milk production corresponds sufficiently to human milk to render a direct substitution safe or wise. If, therefore, milk is used, the problem demands for its solution a modified milk. The mammal whose product representing a carniv- orous food has been proved from the earliest ages to best satisfy this demand is the cow. Certain breeds of cows are better adapted than others to produce milk which can be used for copying human milks. For the use of this continent these breeds are the Durham, Ayrshire, Holstein-Friesien, American grades, and common natives. The infant at the breast receives for its nutriment a fluid which is fresh, sterile, neutral or faintly alkaline in reaction, which has a temperature of 989 to 100°F., and which is furnished in an amount proportionate to its age and size. It is this fluid which we should copy in every possible detail when we undertake to pre- pare a substitute food. We should also consider as foreign matter to be rigidly avoided, any element which we know is not to be found in the fluid which we are copying. Thus, and thus only, can we finally arrive at the proper solution of this intricate feeding problem. It would seem hardly necessary to suggest that the proper authority for establishing rules for substitute feeding should emanate from the medical profession and not from nonmedical capitalists. Yet, when we study the history of substitute feeding as it is represented all over the world, the part which the family physician plays in comparison with the numberless patent and proprietary foods administered by the nurses is a humiliating one and one which should no longer be tolerated. I would plead in the name of common humanity, as well as in that of the intelligence and scientific reputation of our profession, that this representative body of American physicians should in its endeavor to advance 1320 PAN-AMERICAN MEDICAL CONGRESS. the general subject of infant feeding record itself as opposed to the use of patent or proprietary foods of every description. If we are abreast of the times, if we will but recognize and do justice to the work which has lately emanated from our own profession, we surely will not hesitate to boldly relegate to oblivion the statements of the food proprietors, which on box and can, on bottle and on printed circular, attempt to stem the slow but inevitably progressing wave of scientific investigation. It may be well to bear in mind that the attempts which in the past have been made to manufacture cheap foods have been markedly failures. We must first, regardless of expense, learn to produce by modification a perfected substitute food before we should endanger the success of our undertaking by allowing the mercan- tile side of the question to cripple us in the use of costly methods which, however, we know to be the best. We should, in fact, remember that the nutriment which we are endeavoring to copy, far from being a cheap product, is, on the contrary, a very expensive one. It is the knowledge of how to determine the best combinations of certain elements and the best methods of accomplishing these combinations which has in the last year or two especially claimed our attention and in which we have met with signal success. There is no doubt but what one of the most important questions connected with the preparation of a substitute food is the proper control of the primal milk supply. What that control shall be and how it shall absolutely be kept in the hands of those who by education and unselfish interest are most fitted to use their power wisely is a matter worthy of your deepest thought. The state control, as repre- sented in Denmark, is indeed a brilliant example of what can be accomplished in this direction. Whether a similar method would prove to be the best for us to adopt has not as yet by any means been proven. The political clouds which contin- ually obscure the highest scientific aspirations on this contiment make it probable that for the present, at least, the primal milk supply can best be perfected by indi- vidual enterprise and enthusiasm. Finally, I would call your attention and consideration to the great capacity of different infantile digestions for assimilating a variety of proportions of the same nutritive elements, and hence when introducing new methods for preparing a sub- stitute food the necessity for providing for many prescription possibilities. The latest researches on human breast milk show that the albumin of the milk is not merely an exudation from the lymph vessels supplying the mammary gland, but that it is actually modified in the breast. We thus see that the mammary gland, besides being an elaborator and a storehouse for infant nutriment, is also a modifier. Following, therefore, nature again closely, we learn that the precise modification of an absolutely pure and fresh primal milk supply is the vital principle which should at present underlie our efforts to perfect substitute feeding, and I trust that those who will to-day take part in the discussion of this very important subject will especially enlighten us on two matters of extreme interest. First, what is the best method of obtaining a stable and perfect primal milk supply? Second, when this Supply is obtained how shall it best be modified? STUDIES IN INFANT FEEDING. By HENRY DWIGHT CHAPIN, M. A., M.D., Professor of Diseases of Children at the New York Post-Graduate Medical School and Hospital. There are certain requisites for an infant's food before it can be recommended for general use. Thus, it must be readily procurable under the common and ordinary conditions of life; it must be digestible, nourishing, and fairly cheap. The mixing or preparation of such a food must not be too complicated. The conditions here mentioned can only be met by employing cow's milk, more or less diluted or altered, according to the necessities of the case. The following paper contains no new prin- PAN-AMERICAN MEDICAL CONGRESS. 1321 ciples, but is rather a record of experience in the simplest manipulation of cow's milk to make it most acceptable to the infant's stomach and digestion. The clinical experience has been principally derived from the babies' wards of the New York Post- graduate. Hospital, where the infants are subjected to close scrutiny and constant weighing during periods Varying from several days to as many weeks and sometimes even longer. Those who have had a large dispensary and hospital experience in artificial infant feeding among the poor can not have failed to notice the frequent tendency to atrophy. This is often so extreme as to cause death. Even in cases not so marked there is almost universally present a condition of underweight. Many unfavorable hygienic conditions favor this deplorable result, but the principal cause is the nature and quality of the food that is administered. This grave tendency toward atrophy should constantly be borne in mind in all studies bearing on artificial infant feeding. The milk as ordinarily delivered on a given morning in New York, and doubtless in other large cities, consists of a mixture resulting from the milkings of the previous morning and the night preceding, thus being from 24 to 36 hours old. If the milk dealer knows his farmers he can sometimes induce them to put the 24 hours' milk in a can by itself, which is a gain as regards infant feeding. What is urgently needed is more scrupulous cleanliness in the handling of the cows and milk upon the farm, and quicker and more frequent methods of transportation of the milk to town in order to represent a real gain in the feeding of infants. It need hardly be mentioned that the average milk from a herd of cows is better and safer than the traditional one cow's milk. As soon as the milk is received in the early morning it is put in a tin pail or wide-mouth vessel that is covered and allowed to stand in a cool place for 3 hours. The top half only of this milk is to be administered to the infant, as advised by Dr. Meigs. This top portion is best separated by being carefully dipped off by a cup or ladle. If decanted both layers of the milk will become mixed by the lower part rising when the vessel is tipped. At the babies' wards a long glass cylinder is employed, which is graduated and furnished with a stopcock at the bottom. After standing the required time a distinct difference is noted in the two portions of the milk, which are easily separated by drawing off the lower half and reserving the remainder for the infant's use. In order to learn exactly what differ- ence the simple process of standing would make, the two parts of the milk were analyzed, with the following results: One gallon was drawn from the bottom of the cylinder, well mixed, and a sample taken which showed: Total E'at. solids. Per cent. | Per cent. - t 1.--------------------------------------------------------------------------------- 3 12. 29 2---------------------------------------------------------------------------------- 3 12.44 3---------------------------------------------------------------------------------- 3. 1 ||---------- Mean ----------------------------------------------------------------------- 3.03 12.36 . 3. 03 Solids not fat---------------------------------------------------------------|---------- 9. 33 The upper portion of the milk, 1 gallon, was well mixed and a sample showed: Total Fat. solids. Per cent. | Per cent. 4. 9 1--------- ------------------------------------------------------------------------- 14. 01 2---------------------------------------------------------------------------------- 4.8 14. 02 3---------------------------------------------------------------------------------- 5 |---------- Mean ----------------------------------------------------------------------- 4.9 14. 015 4.9 Solids not fat-------------------------- a s = e s is as e s = a, sº sº me a s = e = * * * * * * * * * * * * * * * * * * : * * * * * * * * * * 9. 115 1322 PAN-AMERICAN MEDICAL CONGRESS. This analysis shows that practically the only change on standing is a rise of fat. This, of course, slightly raises the percentage of other solids in the lower portion, since the abstraction of any constituent from a mixture raises the percentage of all the remaining constituents. The upper portion contains, roughly, 5 parts of fat for every 3 parts contained in the lower portion. The minimum of fat allowed for genuine milk is 3 per cent. The increased amount of fat thus procured, in the part of the milk to be used, represents a real gain in feeding the infant. The newer analyses of milk do not confirm the older view that cow's milk contains more fat than human milk, but rather the reverse. Thus Prof. Leeds found, upon analyses of 43 samples of woman's milk, an average of 4.013 per cent of fat, while upon analyses of 11 samples of whole market milk the average percentage of fat was only 3.75 per cent. König finds the average of ſat in woman's milk to be 3.90 per cent, and in cow's milk 3.66 per cent. Prof. Rotch places the average of fat in both cow's and woman's milk at 4 per cent. As cow's milk has to be more or less diluted before being administered to the infant, the necessity of starting with a preparation that is rich in fat will be apparent. The next step to be taken is to see that all fermen- tation in the milk is stopped. - Cow’s milk, as ordinarily procured, must be treated for its biological as well as its chemical properties. The well-known process of sterilization aims to fulfill this object. Partial sterilization, or pasteurization, to the point of killing the germs only, is necessary and desirable. The high and continuous temperature required to destroy spores produces various unfavorable changes in the milk. Practically, all that is required is to submit the milk to sufficient heat to destroy the bacillus of lactic-acid fermentation which causes the souring of milk. This bacillus has been described as of small oval form, occurring singly and in pairs. It is easy, by pro- longed and repeated applications of high temperature, to keep milk indefinitely from souring. By reheating once or twice, it can be kept for months without any sign of acid fermentation. Such milk, however, is by no means ſit for administra- tion to the infant, as the fat collects in masses and changes have taken place in the albuminoids. The casein is altered, the milk remaining more or less liquid in the stomach, as the action of the stomach acids and of the lactic ferment on the casein of sterilized milk is incomplete. Analyses of excrement show more nitrogen and more fatty acids after feeding with sterilized milk than with raw milk. Not only is the digestibility of the milk diminished by long heating, but the necessity for it indicates so much bacterial impurity that their excreta, which can not be rendered harmless by heat, may cause poisoning. It has been found that milk well sterilized will, after a certain interval of time, undergo a species of decomposition with an alkaline reaction. Dr. Koplik States that the alkaline fermentation has not been investigated to such an extent that we can with certainty pass upon the deleterious or non-deleterious effects upon infants of the products of this decomposition. It is enough to know that it takes place, and certain alkaloidal elements are very slowly but surely produced. Accordingly, this writer condemns the storage of sterilized milk and its subsequent use after prolonged periods, and I concur with this opinion Simply sufficient heat must be applied to the milk to keep it sweet until the next supply can be procured. An ordinary double boiler, such as is found in every kitchen, will meet all the requirements of average heating. The Arnold steam. cooker may prove more convenient, and Freeman's pasteurizer is handy and efficient. As a rule, 15 minutes' heating is sufficient with the bottles well plugged with cotton. The addition of a 1 per cent solution of peroxide of hydrogen is a safe preservative of milk for some hours, when heating is undesirable or not convenient. If more scrupulous care were exercised at the source of the milk supply, and the impurities completely separated by the centrifugal process, in the great majority of cases no means at all for preservation need be employed, and an advance in this direction is urgently needed. - We still have facing us the old and difficult problem of how to act best upon the PAN-AMERICAN MEDICAL CONGRESS. 1323 tough, leathery curds of cow's milk as to make them most acceptable to an infant's weak digestion. Not only are the albuminoids much greater in amount in cow's milk, but the portion coagulable by acids is greater than the non-coagulable part, while in woman’s milk the non-coagulable part much exceeds the coagulable portion. Hence the dilution of cow's milk, while reducing the albuminoids to a proper per- centage, does not necessarily render the clot sufficiently soft to be readily digested by the infant. The question whether the size of the curd stands in any relation to the substance used as the diluent has been disputed. It has been taught that by adding gruels of the cereal grains to the milk the clot is mechanically attenuated. Dr. Rotch states, on the contrary, that practically the size of the curd depends simply on the dilution of the albuminoids and not upon the particular menstruum used. Clinical results, however, point plainly to the utility of diluting with barley water, except in very young infants, and I believe the beneficial effects are, to a certain extent, due to a lessening of the compact character of the clot. In order to test this, the following experiment was made by Dr. Eiloart: Equal parts of milk and barley water were taken, and 0.1 gram of hydrochloric acid was added to 100 c. c. of the mixture. This strength was employed, as in gastric juice there is 0.2 gram of hydro- chloric acid to 100 c.c. of fluid, which, on dilution by the contents of the stomach, is weakened somewhat, so that 0.1 gram is a fair estimate for the experiment. Some albumins require 0.2 per cent hydrochloric acid added to pepsin in artificial digestion to obtain the best results, but casein and vegetable albumin are digested best by 0.1 per cent of hydrochloric acid.” This experiment showed the casein formed in finely divided clots. Next, equal parts of plain water and cow's milk were taken and 0.1 gram hydrochloric acid added to 100 c.c. of the mixture. This showed larger clots than before. A number of repetitions gave similar results, using various coagulating agents when plain water and thin gruels were used as comparative diluents. When rennet alone was used as the coagulating agent, the results were so different from those obtained when hydrochloric acid was used with the rennet that recourse was had to the stomach itself, with results given in the accompanying paper by Dr. Eiloart. The disadvantage in the employment of wheat or barley flour consists in the large proportion of starch contained in these grains, which may be great in very young infants. This starch may be rendered more soluble and easy of assimilation by heat or diastasic action. In many cases the effect of prolonged heating upon barley and wheat flour seems to have a beneficial effect, particularly when there is a tendency to diarrhoea. The good results of the old flour ball, made by prolonged boiling of the wheat flour in a bag, have long been recognized. But the heat so applied does not produce its beneficial effect by chemically changing the starch, but probably from some physical alteration which renders it more effective as a diluent. The effect of dry heat upon starch is to produce changes into soluble starch, retro- dextrin, achroödextrin, and finally a small percentage of dextrose and maltodextrin. f The higher dextrins are more soluble. Starch does not begin to dextrinate until 250°F, is reached, and this temperature should be maintained for several days if there is any quantity to be changed. At between 350° F. and 400° F. dextrination may take place in a few hours. It is evident that such a high temperature can not be maintained by any domestic process. If put into an oven the flour will soon be scorched or burned. An interesting experiment was made by Dr. Eiloart upon bar- ley flour that had been heated for a week in an ordinary double boiler. The water in the under vessel was allowed to boil for a week, with the exception of a few hours at night, the dry flour in the upper vessel being thus exposed to as high a constant tem- º perature as possible under the circumstances. An analysis of the unheated meal taken from the same barrel yielded two-thirds more sugar and one-quarter more dex- trim than the heated meal. The cause of this is that the diastase, whose function it is to convert starch into sugar and dextrin, is partially paralyzed by heat, the fer- * Hammarsten. Lehrbuch der Physiologisehen Chemie, 1891. f Stohmann and Kerl. Muspratt's Chemie, Bd, 11, Braunschweig, 1889. 1324. PAN-AMERICAN MEDICAL CONGRESS. ment undergoing this change at about 175° F. This method of acting upon the starch was accordingly abandoned, and the necessary change effected easily and quickly by means of diastase. Starch treated with diastase is split up quickly into maltose and dextrin, and the longer the action is continued the higher dextrin will be formed, such as achroijdextrin and maltodextrin. After a number of experiments and analyses, Dr. Eiloart devised a receipt, for which I am indebted to him, and which has been used at the babies' wards, consisting of a mixture of barley or wheat flour treated with diastase,” the temperature of digestion being regulated by the addition of hot and cold water in proper proportion. The complete description of the process will be found in the accompanying paper. A FOOD FOR INFANTS, WITH EXPERIMENTS, CHEMICAL AND PHYSIO- LOGICAL. By ARNOLD EILOART, Ph. D., Director of the Chemical Laboratory, New York Post-Graduate Medical School and Hospital. The experiments here described were intended to throw light upon two problems. The first was the formation from cow's milk of a curd resembling in fineness that from woman’s milk. The importance of this seems evident,f and Uffelmann f has shown that in artificial digestion the proportion of peptone formed was greatest when the curd was loosest. He recommends mixing cow’s milk with three-fourths its volume of 0.2 per cent hydrochloric acid in order to make the casein like that of human milk. Munk, ) having tried Scherff’s process of sterilization (heating to 1000 C. under 3 atmospheres pressure), states that milk so treated clots in the stomach itself in flocks like woman’s milk, not in compact masses like ordinary cow’s milk. It seems unlikely, however, that these methods will come into general use, and the fol- lowing work has been confined to testing diluents which are everywhere available. The result of a preliminary investigation was surprising, for it appeared that the fine- ness of the curd depended more on the curdling agent than on the diluent mixed with the milk. Thus, with rennet, mixture A curdled finer than mixture B, while with hydrochloric acid, 1 per cent, mixture B curdled finer than mixture A.] Hence the test-tube experiments, which have constantly been quoted to show the effect of vari- ous diluents, must be abandoned and the infant's stomach itself must be consulted to decide what mixture will curdle finest in that stomach. Accordingly, the mixtures to be tested were administered to infants, and after a short interval withdrawn by means of the stomach pump. I am indebted to Dr. Chapin for the opportunity of carrying out these tests in the babies' wards of this hospital. In the following table I have used figures to indicate degrees of fineness of clot, calling the finest curd 1: ‘Maltine was the preparation here yielding the diastase. - flellenberger and Hofmeister, however, object to the fine curd of sterilized milk, because it may pass too quickly through the system and thus escape complete digestion (Molkerei Zeitung, 1892, 6). ;Pflüger's Archiv, 29, 399. §Deutsche Med. Woch., 1881, No. 36. |Mixture A was milk and water, àā; mixture B was milk and barley water, àā. With a mixture of hydrochloric acid and rennet the result was the same as with the acid alone. In every case the volume curdled was 100 c.c.; very small quantities fail to show the differences in the curd. |Fresh milk was used except where sterilized is mentioned. Throughout this work the regularly prescribed malt TABLE I.—Showing fimeness of clot and acidity of stomach contents after feeding with milk and various diluents. + means a small dose, -i- + a full dose.] preparations were used as the source of the diastase. Acidity Taken. Time Fine calculated as HCl. y Age before Quantity — -------------- INo. Date. Name. (months). Health. g Barley | Wheat Wheat, Dias |pumping pumped. ". of Quantity Milk. Water. ºf ºl. * | tase * Total ||. - €. C. Per ct. | Per cent. 1 Feb 15 George Carlson. . . . . 8 | Good (adenitis) - - - - - - - - - - - - 50 50 - - - - - - - -|--------|--------|-------. 1 117 3 . 050 . 0427 2 ....do ....| Stella Morris . . . . . . . 2 | Bad (syphilis) - - - - - - - - - - - - - 50 50 --------|--------|--------|-------- I 12 3 | . 0109 09 3 |...do ....] Annie Riker.....--- 6 || Medium (inanition) ... . . . . . 50 - - - - - - - - 50 --------|--------|-------. 1 109 2 | . 047 04:38 4 Mar. 4 || Ed Scores ---------. 1% | Good (eczema) - - - - - - - - - - - - - 100 ................l................ + 1 15 1 i--------|---------- 5 ...do …. Stella Morris....... 2} | Fair (syphilis) - - - - - - - - - - - - - 30 . . . . . . . . 30 I.-------|--------|-------. 1 7 2 . . . . . ---|---------- 6 Apr. 25 || Ab. Sayres;.......... 2} | Good (cured) - - - - - - - - - - - - - - - * 100 100 --------|--------|-------. + 10 124 3 137 , ().905 7 '...do . . . . Henry Hasbrook.... 68 ||------ do--------------------- * 100 100 --------|-- - - - - - - - - - - - - - - - - - - - - - - 10 140 1 ()65 . 0.467 8 Apr. 29 | Ab. Sayres----------|----------|----------------------------- * 100 100 - - - - - ---|----------------|-- - - - - - 10 108 3 | . 093 . 086 9 |...do ----| Henry Hasbrook. ---|----------...------...----...------------ * 100 100 ----------------|--- - - - - + 10 97 2 | . 061 063 10 | May 3 | Ab. Sayres----------|----------|----------------------------- 7ſ) 70 - - - - - - - - - - - - - - - - - - - - - - - - + + 20 28 2 | . 017 . O6() 11 |... do ....] Walter Grandman .. 6 | Good (cured)... ---...------ 100 100 --------|-- - - - - -]. -------|-------. 15 0. 5 2 0087 . 092 12 May 8 Ab. Sayres--------------------|----------------------------. 51 51 --------|--------|--------|-------. 15 86 3 | . 063 . ()73 13 ||---do ----| Walter Grandman --|----------|............................. 60 do [..............I.I.I.I.I. + + 15 44 3 | . 0289 . 066 14 |... do ....] Frances Collins. . . . . 13 || Marasmus ----------------- 35 35 --------|--------|-------- + + 20 65 3 | . 052 083 15 . . . do ----| Louisa Bechl....... 8 || Good (gastro enteritis) . . . . . 54 54 --------|--------|--------|-------- 20 59 3 | . 031 . ()53 16 || May 19 Joseph Kelo -------. 3 | Good (phimosis) . . . . . . . . . . . 71 --------|--------|-------. 71 -------. 2 70.5 3 | . 046 ()66 17 |...do ----| Joseph Lobe.------. 2} | Fair (erythema). ----------- 65 - - - - - - - - 65 |--------|--------|-------- 2 65 2 | . 031 . 047 18|-3; do . . . . Frances McIntyre.. 3 ||----------------------------- 45 -------. 45 --------|--------|-------- 3 67 2 | . 046 . C69 19 May 22 |. . . . . . 0 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 85 --------|--------|-------. 85 -------. 2 60 1 |------------------ 20 ---do ----| Joseph Lobe--------|---...-----|------------------------..... 100 --------|--------|-------. 100 |-------- I 135 2 --------|---------- 21 |---do ----| Mary Bailey........ 3 | Marasmus - - - - - - - - - - - - - - - - - 75 --------|-------- 75 l.-------|-------- 14 59 2 . . . . . . . . . . . . . . . . . . 22 |---do ----| Joseph Kelo --------|------------...------------------...... 75 --------|-------. 75 --------|-------- 4 7 3 - - - - - - - - - - - - - - - - - - * Sterilized. 1326 PAN-AMERICAN MEDICAL CONGRESS. The figure 4, indicating the very coarse clot sometimes obtained with hydrochloric acid (0.1 per cent), is absent from the record of stomach clots, although the per- Centage of acid in the stomach, calculated as hydrochloric, sometimes rises almost to 0.1 per cent. The chief conclusion to be drawn from the stomach experiments is that the coarseness of curd increases with the percentage of acid. Thus the finest curd (called 1), which was only once obtained, occurred when the acidity was 0.0467 per cent; the curd next in fineness occurred in 6 cases in which the mean acidity was 0.062 per cent; whereas for curd 3 (rather coarse) the acidity averaged 0.072 per cent (mean of 9 cases). So far we have left out of account the diluent used. If we arrange the results so as to show the number of times a given diluent produced a curd of the second or third degree of fineness, we find that water gave clot 2 once, clot 3 four times; barley water gave clot 2 three times; diastase, with or without cereals, gave clot 2 twice, clot 3 four times. So far the results proclaim barley water to produce the finest, and water the coarsest curd. But when we take into account the acidity in the dif- ferent cases, we find it to average in the three barley-water experiments only 0.053 per cent, while in the four water experiments it is 0.077, and in the case of the diastase preparations, which yielded curds almost as coarse as the water mixtures, the acidity is nearly as high, viz, 0.071 (average of the 6 cases). The good results apparently due to the barley water may, therefore, be due in reality to a low per- centage of acid. On the other hand, further experiments may show that barley water itself causes the low percentage of acid. The influence of the concentration of the curdling agent is well seen in the fol. lowing experiment made with an adult: A mixture of 500 c. c. milk with 500 c. c. water at blood heat was taken. Two minutes afterward 360 c. c. were pumped out from the stomach; 6 minutes later 400 c. c. were removed; 8 minutes later the rest was removed. The first portion was curdled so fine that close examination was needed to see that it was not homogeneous. The second portion was fine, but coarser than before. The third portion consisted of yellow liquid with some quite coarse clots; the gastric juice was no longer diluted by excess of milk. EXPERIMENTS WITH CEREALS. Whatever be the part played by barley water in the stomach, it has made good a place in infant feeding, which indicates that benefit is derived from its use. But it seems probable that any such benefit is largely neutralized by the great proportion of starch which all cereals contain and which the infant economy is ill adapted to digest. It is true that infants’ food may be bought in which the starch has been dextrinized by heat; but these are expensive. The object was then to devise a household process for preparing at a minimum cost, and with materials every where available, a digestible food containing with the albuminoid constituents of the grain, carbohydrates in a soluble form and but little of the insoluble starch. At the same time excess of sugar was to be avoided. This necessitated the conversion of the starch into dextrin, or into dextrin with a moderate proportion of maltose. Attempts to dextrinize the starch by heat showed that this method is not adapted for household use. Barley cakes baked many hours yielded only 23.3 per cent of soluble matter. Rusks (“Zwieback”) as bought were further baked, but only 16 per cent could be made soluble. To facilitate the dextrinization by providing an acid, barley cakes were made with buttermilk and well baked, but the soluble mat- ter was then only 20.07 per cent. Rusks moistened with buttermilk and baked at 120° C. yielded 18.88 per cent of soluble matter. These results necessitated a resort to diastase as the converting agent. O'Sullivan has shown that maltose and dextrin are the only products of the action of diastase on starch, and that the proportion of maltose to dextrin depends on the temperature. This proportion may be kept down to about 18 per cent by employing a temperature just below that which destroys the diastase and by stopping the action before the diastase converts the dextrin first PAN-AMERICAN MEDICAL CONGRESS. 1327 formed into maltose. To adjust the temperature, hot and cold water were mixed in varying proportions. The temperature of the hot water was the highest which can be attained in the inner vessel of an ordinary double boiler of tin or enameled iron when the water in the outer vessel is kept boiling; this temperature does not vary much with the size of the boiler and is about 91° C. The diastase was allowed to act on gruels made with starch, with wheat flour, with barley meal, and with oat- meal. The line of action, the quantity of water, and the temperature (proportion of hot to cold water) were varied, and more than twenty analyses were made to determine the proportion of soluble matter and maltose formed in each case. As the result of these experiments a most simple process was arrived at, by which in any kitchen a cereal food may be made containing three-fourths of the solid matter in a soluble form and having more or less sugar (maltose) as desired. For a food containing about one-third of the solid matter in the form of maltose, the following recipe may be used: - Recipe I.-Materials: Wheat flour or barley meal, 2 ounces (2 tablespoonfuls heaped as high as possible); water, 56 ounces (a quart and three-fourths); extract of malt, half a teaspoonful or a small teaspoonful. Process: With 30 ounces (a scant quart) of the water make the flour into a gruel, boiling 10 minutes in a double boiler. Take out the inner vessel and add the rest of the water cold, the malt extract being dissolved in the last few ounces added. Let it stand 15 minutes. Put back the inner vessel and heat again in the double boiler 15 minutes. Strain through a coffee strainer of wire gauze. If for any reason it is desirable, and in cases of diarrhoea, to give a smaller pro- portion of maltose, the following recipe is used, and we get a food containing only one-fourth of the solid matter in the form of maltose: Recipe II.-Materials as in Recipe I. Proceed as before, but reserve only 1 pint of the water for adding cold. After adding the cold water with the malt extract dis- solved in the last few ounces of it, let it stand only 3 minutes instead of 15 minutes. Then heat 10 minutes in a double boiler and strain. To make the gruel well and quickly, beat the flour with very little water. A little beating with little water is better than much beating with much water. Beat smooth, therefore, while the paste is still almost a dough; then add cold water to make a thin paste, and to this add the rest of the first part of the water boiling hot, with stirring. If these direc- tions are followed, very few lumps will remain on the strainer; in fact, only about 5 per cent of the meal need be lost in this way. The water in the outer vessel of the double boiler must be kept boiling throughout. Whichever recipe is followed, the food should be taken mixed with milk. Digestion tests: Cateris paribus, the more of a food is dissolved in the stomach, the more digestible is that food said to be. Therefore if we find in the stomach con- tents, after giving milk with malted food, a larger proportion of soluble matter than when milk is given with unmalted food (due allowance being made for the larger proportion of soluble matter in the malted food itself), then we may say that the malted mixture is the more digestible of the two. In order to test this, experiments were made with three infants and the following results were obtained: Ičatio of soluble to total matter in stomach contents. in , , With malt- || With un- Subject. ed food. malted 1-----------------------------------------------------------------------------. 0.65 0. 58 2------------------------------------------------------------------------------ . 74 . 61 3------------------------------------------------------------------------------ . 58 . 64 The difference is appreciable (later results indicate that this was due to the short time allowed for digestion, which never exceeded a few minutes in the above cases). A comparison was next made between the two foods without admixture of milk, 1328 - PAN-AMERICAN MEDICAL CONGRESS. The process now followed was this: The stomach of a healthy man was washed clean with lukewarm water—i.e., the washing was continued till the water from the stomach ran perfectly clear. Then a definite measure of gruel containing a known weight of solid food was drunk in five equal draughts with an interval of a minute between each draught. After a certain time the stomach was again com- pletely washed; the washings were made to a given volume. The total solid matter . and the dissolved matter were determined; the difference gives the matter undis- solved. Experiments were made with 3 men, all free from any disorder of the stomach. The food prepared with diastase was given one day and the plain gruel the next. Although the amount of either food disappearing in a given time varied considerably, the results were sufficiently concordant to decide the questionat issue. PAN-AMERICAN MEDICAL CONGRESS. 1329 {ķ§§98 ° 1368 "I†8 ^9E#}}ģ$$$::::::::::::::::::::::::::::::}} ● ● ●8#9 º88 °6′I99 º1,6 °į，！4000 ºz Arup ------------------------------ 8’on ſoºſq ms {| '';3. ‘OIZ6 ° 18gg "Z8ý ’6•93000 ‘Izz kimp |------------------------------ lt 93Z6 °880 ºg383 "ºLZ '9+93000 ‘IOz Ķīnp |------------------------------gr |Offș†3 "8%Ț90 'ſ,-->93000 ‘Igz stup |------------------------------ gt |Oý99 "† ’9† I •09 "I+9%000 ‘Igz. 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'qų5ț9 AA | ‘ouampo A |*SYJutttøyI��-Sppuſ Q., ! — ºr ~ A*9ņēCI*JºquIn N. * \,*Uſºx{8ļ p00）{ *pºureuſ 9uu!!! Jº!Jº qobuſtoqs U Į punoſ‘uoſeļ p0o）{ ['9đ1991 otų uț (IoAȚā uoņiođorđ aqq uſ posm sºa qoeryxo oſsensep aqq qeųq soqºoppuſ (+) v ruoaſă sexa ouou qeųą sø, doſpuĮ „øseqsepp, Iapun (–)w) ‘woņ806yp fo spoļ.tød 8m04.000 dò4 (o q0pwoņ8 uțpunoſpoof fo woņatođo.!d.Guſmous—IIĀTavL —84 S. Ex, 36 1330 PAN-AMERICAN MEDICAL CONGRESS. Experiments 1 and 2, which were made without previous washing of the stomach (no food having been taken since the night beſore), agree fairly well with the others, showing that the digestive process is not rendered abnormal by previous washing. In the case of subject No. 1 the amount found in the stomach was constantly greater when the diastase was omitted; the percentage of food taken which was left in the stomach after 40 minutes being, without diastase, 52.02; with diastase, 29.2. This means that of 100 parts of food taken, 100–52.02, or 47.92, were absorbed in the one case, and 100–29.2, or 70.8, in the other; so that with the diastase nearly half as much again was absorbed as without it. Of the solid matter found in the stomach more than twice as much was found to be undissolved when the diastase was omitted as when it was used. With subject No. 2 a shorter time (24 minutes) was given for digestion and no marked difference appeared between the two foods; but when the time of digestion was extended to 40 minutes the malted food again asserted its superiority, the amount of this unabsorbed by the stomach being only one-third the amount of plain food unabsorbed. In the case of subject No. 3 the difference in favor of the malted food was made manifest in 25 minutes. In every case, therefore, digestion was more rapid with the malted than with the unmalted food. Thus the physiological evidence confirms the chemical evidence in favor of the food prescribed. Finally, clinical experiments with the soluble food, made according to recipe No. 1, have given as good results as any system of feeding employed at the babies' wards of the Post- graduate Hospital, as detailed in the accompanying paper by Dr. Chapin. It is intended to employ the method of quantitative stomach washing in other cases, as it seems adapted for testing foods and digestive ferments in general. This food can be easily and cheaply prepared in any household and while the starch is changed to more soluble forms, there is not an excess of sugar. Herein it is superior to the various Liebig’s foods. The nutritive value of the albuminoids is likewise not lost sight of. Either barley, wheat, or oatmeal may be thus treated, the principal difference being the varying proportions of fat contained in these grains. According to Dietrich and König, the percentage of fat is as follows: Barley, 2.09; wheat, 1.55, and oats, 6.09. This may be borne in mind in prescribing for diarrhoeas and the various forms of indigestion. The effect of malt upon milk is to favor its digestion and assimilation. Garup Besanez, a German authority on malt, has found a ferment in the germinated seed of vetches, hemp, flax, and barley, which very energetically converts starches into grape sugar and albuminous sub- stances (fibrin) into peptones. It was afterwards found that diastase has no action upon albuminoids; but peptase, which is generated in germinating grain at the same time and under the same conditions as diastase and practically they can not be separated, acts upon proteids slowly at low temperatures. This substance is an analogue of the vegetable proteolytic ferments found in pineapple juice and the papaw plant. The actual results obtained from the use of food thus prepared in the babies' wards have been good, considering the class of cases treated. During May, June, and early July, 37 infants suffering from various degrees of gastro-intestinal irritation and inflammation and from 1 to 10 months old, were thus fed. Seventeen increased slightly in weight after a week or so, 16 lost a little in weight, and 4 remained stationary. As is well known, the loss of weight in gastro-intestinal affections during infancy is usually well marked, and is exceptionally rapid in hospital and institution infants. So extremely susceptible are young infants to hospitalism that they inva- riably lose weight after a certain interval of time, and will die of inanition under any system of artificial feeding unless removed in season. A baby admitted May 26, 1 month old, having had convulsions from gastro- intestinal irritation, exemplifies this fact. The weighings are registered as follows: On admission, 6 pounds 1 ounce; May 30, 6 pounds 4 ounces; June 2, 6 pounds 6 ounces; June 6, 6 pounds 8 ounces; June 9, 6 pounds 5 ounces; June 13, 6 pounds 2 PAN-AMERICAN MEDICAL CONGRESS. 1331 ounces; June 16, 5 pounds and 10 ounces; discharged. The gastro-intestinal irrita- tion subsided and the baby did well on its food, but at the end of two weeks it began to show the effects of hospitalism, although there was no vomiting or other sign of indigestion. When sterilized milk, diluted to the proper point with water, limewater, or plain barley water, has been used, there is almost invariably a steady and slow loss of weight from the first, So that the change so often noted upon malt- ing the preparation can not fail to be gratifying. Dr. Judson C. Smith, who is the district visitor for the hospital, seeing a certain number of the cases after they have been discharged, tells me he has used the extract of malt to peptonize milk about one year, both for infants and adults, with very satisfactory results. Babies from 4 months to 1 year old, when losing weight on other methods of feeding, have usually gained flesh and improved in every way on milk prepared with malt. One tablespoonful of malt is added to a pint of milk, which is heated from 20 to 30 minutes and then brought to the boiling point. The milk is then diluted with water according to the age of the infant. THE PRODUCTION OF COW’S MILK DESIGNED FOR INFANT FEEDING. By HENRY L. COIT, M. D., of Newark, N. J. Science is about to conclude that the accidental impurities in milk, together with the defects in its nutritive values, are among the greatest causes of death to man- kind. Milk, as a food, seems to be indispensable to the human race, supplying, with water, both meat and drink in early life. It is therefore of the greatest importance that we, as physicians and sanitarians, should establish a strict surveillance over the sources of supply. The perils growing out of a defective food supply appeal with special force to the physician and, through his clinical observations, are usually first apprehended by him. The great importance of cow's milk as an article of food, its universal use in all periods of healthy life, its necessary use in the sick room, its rapid deterioration at ordinary temperatures, its liability to absorb, develop, and convey the material causes of disease, make it imperative that its production and its sale be subject to the most careful scrutiny, and that measures be adopted whereby qualified persons shall enforce a proper care of the animals, prevent unsanitary surroundings, the gross neglect of cleanliness, and the fraudulent prac- tices which, in many instances, characterize its production. If physicians were more generally informed concerning the need for concerted action in this matter, we believe it would not be long before the now fatal results to man from impure, infected, and defective cow's milk would be greatly limited; and the mortality from tuberculosis, so largely due to our association with the bovine species, and the fearful havoc among infants would be narrowed within bounds which would not strike terror to our hearts. In the present state of affairs it has become necessary that the medical profession should resort to active measures to protect their own interests and those of their patients against the horde of dangers which menace the life of our race through this one product alone. This is evident in the United States at least, from the fact that the larger and more powerful commercial interests are so closely bound up with the 4,000,000 dairy farmers, three-fourths of whom contribute something to our milk supply. That a very radical reform is needed in the production of cow's milk is conceded by all who, by their clinical experience, have been obliged to solve the problem of artificial infant feeding. This is also shown by a careful study of the mortality rates from among children under 1 year of age, a very large proportion of whom die of nutritional disorders, directly traceable to unwholesome milk. When it is considered that this infant mortality comprises about 30 per cent of that occurring in all ages and from all causes, we can not escape the conclusion that the 1332 PAN-AMERICAN MEDICAL CONGRESS. medical profession, and especially those who are equipped for the warfare, have an important duty to perform. Were it not that the foregoing was a sufficient reason for instituting a change in dairy methods, the fact that cow's milk is so generally employed for clinical purposes would amply justify such a course. Physicians very often fail to secure desired results in their work because of impoverished milk; it is therefore no less an important medical feature of the subject that so large a propor- tion of those under our care must be fed upon this article alone. The current injurious practices which are common at the dairy are very numer- ous and are found at every step of the production from the breeding of the animal to the delivery of the product. Chief among them are those pertaining to the housing and care of the animals, the feeding of the same, the careless methods of collecting, handling, and cooling the milk, together with the total disregard of its delicate nature in transportation. It is difficult to understand why the dairy cow, which is so universally employed for human food, should receive relatively so little care when other domestic animals are so cautiously guarded. It is a practice so rare as to be remarkable that the milch cow is housed and kept as comfortably or groomed and cleaned as carefully as the horse. As to the feeding, the cow, the most valuable domesticated animal from an economic point of view, is the only one that is fed on refuse materials. The injurious and fatal consequences of this universal custom are too apparent to require comment; and to those who are not familiar with the facts the prevalence of these evils is astonishing when inquiry is made. As to the expedients resorted to by those who for commercial ends would utilize the waste byproducts, nothing too strong can be said in condemnation of their methods. By far the most prominent substance of a questionable character used for feeding cows to-day, especially near cities, is brewers' grains, known as beer or ale grains. There are probably few dairymen near large cities who do not use it to some extent. It is supposed to increase the flow of milk, which it does by augmenting the bulk of the output about 30 per cent. The cost is small, being in summer about $3 a ton, and on this account it is employed. It is wet when sold, contains 80 per cent of moisture, easily undergoes putrefactive fermentation, and is often given to the cows in this condition. The original 70 per cent of starch and dextrin has been removed from the barley in the malting process, leaving nothing of a nutritive value but 10 per cent of proteids (the gluten) together with the cellu- lose. The effects of this diet are to impair the digestion of the animal, lower her nutrition, and probably to render her an easy prey to tubercle. On the milk the effect is a product which has poor keeping qualities and when it is used in large Quantities materially alters its constitution. We are convinced that our failures with this milk in infant feeding are due to the rapid changes which uniformly occur in it and which are probably due to the unstable character of the fats which it con- tains. These volatile fatty principles, being easily broken up in the alimentary canal of the child, liberate the fatty acids which act as irritants. There is no dearth of suitable feed and fodder for the milch cow and a synthetical mixture made of waste materials is not calculated to appeal to the ordinary ideas of correctness and is certainly not permissible when the object is the production of food designed for the most delicate human organism. - Playsicians can not afford to make concessions in these matters; that which they require can not be gained in this way; any indorsement of the use of waste byproducts for reasons of economical expediency, even when modified, would be mis- construed by milk producers and interpreted to palliate their use in any condition. Between production and transportation a host of evils have arisen; yet none are more flagrant than the neglect of those commissioned to guard this all-important dairy product at our door. The milk inspector, with his local board of health behind him, are not, we think, efficient. With all their autocratic powers they do little to improve the milk supply in large cities. While these officers are handicapped by the lack of a proper State supervision at the Sources of supply, yet they could set a safer PAN-AMERICAN MEDICAL CONGRESS. 1333 and more rational guard against impure milk than simply its specific gravity and its total solids. Milk must be poor in the extreme, in appearance, keeping qualities, and nutritive values to be quarantined by the inspector in our cities. Indeed, a large part of the milk now received passes without question the blockade of the local officer and yet it is positively unfit for the diet of the infant. For unexplained reasons, the advance in civilization has been coincident with the failure of the race to nourish its young, and to-day artificial feeding has become an important factor in the work of the clinician. When we remember that an infant consumes during its first year about 500 quarts of milk, and that it requires but a slight variation in the conditions of milk to determine many of the fatal diseases incident to this period, not only are clinical standards essential, but a direct rela- tion is established between the character of the food and infant mortality. Hitherto there have been no uniform clinical requirements of cow's milk from the standpoint of infant feeding. Physicians have been too much occupied through the literature of the manufacturing vender with problems of dextrose, maltose, saccharose, uncon- verted starch, vegetable fat, and disintegrated milk fat to give serious attention to more rational methods. If we would obtain uniform results in the nutrition of the young, certain condi- tions of purity in milk are demanded and must be maintained without variation. It is well, therefore, that we should consider our needs as touching this basis for rational infant feeding, since it is a matter which affects our interests at so many vital points. We are on the threshold of a revolution in infant feeding, and while for several years the manufacturers of artificial infant food have been engaged in efforts to humanize various elements of the lower kingdoms, the profession have been chiefly occupied in trying to harmonize all the discordant views arising from the horde of irrational methods that have thus been foisted upon our attention. This state of things is fortunately being changed. More rational and scientific inquiries are now in progress; so that to-day those who have followed the more recent workers in this field and have adopted the results of their laborious work have been amply repaid. In order to fulfill the needs of infancy and childhood in the present state of our knowledge, three conditions of purity in cow's must be unfailing. First requirement.—Absence of microorganisms in milk, especially of the pathogenic varieties. This may be easily accomplished so far as disease-producing bacteria are concerned, but germ-free milk has never yet been made practicable. When it is brought about it will be through a reform in the collection and handling of milk, and will include not only the pèrsonal cleanliness of those who draw it, but scrupulous care in sterilizing all utensils and milk containers, together with an atmosphere made clean by freeing it from the dust derived from the animal or her immediate surroundings. Microörganisms are found in all milk after it is drawn. Over forty varieties have been isolated from a single specimen of otherwise normal milk. They are never present in the udder except as found when the animal is diseased. Therefore they have their origin in outside sources, namely: The hands of the milker, the udders of the cow, the dust from hay or straw under the animal's feet, the loft and ceiling above, from the air which is constantly in motion, and the dirt left in improperly cleaned milk containers. These bacteria could not have a more favorable medium for their growth and multiplication than fresh milk. The conditions of warmth, moisture, and an animal secretion combine to favor their development. Along with the poisonous ptomaines they are capable of producing, these bacteria are, by their presence and growth, the cause of the various fermentations which occur in milk. Ordinary cow’s milk of fair keeping qualities contains about 4,000 bacteria in a half cubic centimeter; ordinary store milk from cans has been found to contain from 38,000 and upward in the same amount of fluid. It will be a great achievement if these can be eliminated from the milk and we can obtain that which will keep without extraordinary care. Surely infant mortality must thereby be materially decreased. Pathogenic bacteria are often conveyed through the medium of milk 1334 PAN-AMERICAN MEDICAL CONGRESS. and it is probably true that no agent carries a greater variety. In this way tuber- culosis is spread and the extent of the havoc with life from this source will probably never be known. This particular danger assumes greater magnitude when we remember that probably 30 per cent of the dairy herds in this country have one or more tuberculous cows among them. It is likewise clearly established that scarla- tina, diphtheria, and typhoid fever are brought from persons who, either recovering from the disease or associated with it, are at the same time engaged in handling milk, or from untidy milkmaids who, between the milkings, are attendants on persons sick of these disease while they are prevalent. Second requirement.—A constant and unvarying resistance to change during the first sixty hours after it is drawn. The changes occurring in cow's milk are determined by conditions surrounding the collection, handling, cooling, and care of the milk at the dairy farm, and while the lactic fermentation can not be long delayed, even by the greatest care, yet it is a want of proper precaution that brings about these early changes. The normal temperature of the cow, and therefore of fresh-drawn milk, is about 100°F. To insure its keeping qualities is to prevent the growth of bacteria. This is best done by quickly reducing its temperature with ice to about 45° F. and maintaining it at this point until used. Thus treated in clean vessels, milk will keep several days. Several samples of ordinary superior milk submitted by myself to Prof. Albert R. Leeds, Ph. D., were kept by him in his laboratory refrigerator for eleven days without change, the temperature of the chest ranging from 349 to 549 F. Where well-water only is available for cooling purposes, the above conditions can not be brought about, since well-water has an average temperature not above 489 F, and with it milk can not be reduced and maintained below 54°F. The cooling of milk immediately after it is drawn is probably the most efficient means known for retard- ing its fermentations, and it follows that since cold prevents the growth and the activity of bacteria, the earlier the cooling is effected the longer the milk will remain without change. Third requirement.—A constant and unvarying nutritive value of known composi- tion. This can doubtless be realized through an intelligent feeding of the animal, based upon chemical researches, conducted with a view to an adjustment between breeds, their feeding and the product required. The diet of the milch cow in its bearing upon the constitution of her milk has been studied chiefly with reference to the economical side of dairy farming. At agricultural experiment stations the objects have been to determine the cost of foods. Little has been done with refer- erence to the effects of various foods upon the ultimate nutritive values of the milk. That due atteution must be paid by the feeder to the particular purpose for which the cows are kept is conceded by all who are familiar with the subject. Thus for butter, for cheese, or for infant feeding, a special and accurate adjustment of nitrog- enous substances and the carbohydrates must be observed with reference to the product required. This is accomplished by a proper admixture of grass, hay, fod- der corn, and various tubers with solid cereal grains of different kinds ground into meal. The cheap and exhaustive foods used so largely to increase the milking capac- ity of the cow do not even approximately fulfill these requirements. The most variable constituents of milk are the fats. The sugar and albuminoids are the most constant elements of its composition, so that in looking for dangerous modifications in milk chemists would do well to examine more closely into the nature of its fatty compounds, especially the volatile principles which so easily undergo changes. Although the sugar and mineral salts are quite uniform in all milks, the remaining serum solid known as casein may in different breeds vary as much as 24 per cent, which would seriously affect its value in infant feed- ing. The high percentage of albuminoids has been the chief obstacle in the way of a more general use of cow's milk in feeding. The methods in vogue for diluting it in order to make it correspond to woman's milk are somewhat difficult When these elements are higher than 4 per cent. It seems, therefore, that any PAN-AMERICAN MEDICAL CONGRESS. - 1335 method that promises to maintain the ſat and sugar percentage, and yet reduce the casein, is desirable when the milk is to be used for infant feeding. The writer has had an opportunity of demonstrating the utility of a method which we commend to your careful attention. The reported analysis of milk from the breeds usually employed show the albuminoids to be uniformly in the proportion of from 4 to 5 per cent. By making a combination of a thoroughbred Jersey, a thoroughbred Holstein, and two common American grades, the first giving a milk rich in fat, the second a milk rich in sugar, and feeding the animals with a view to reduce the albuminoids, we obtain a result when the milk is mixed which we believe to be valuable. The following analysis made for the writer by Prof. Albert R. Leeds shows that the combination in this instance reduced the albuminoids to 3.36, while the ſat and sugar are maintained at a normal high standard. A good feature of this milk is that it approximates more closely to woman’s milk in its color, its total solids, its taste, and its reaction, which is neutral. The results of the experiment are offered as a basis for future observations, and also suggestive of a possible means of securing an ideal milk for infant feeding. The analysis as made of 24 samples, sub- mitted on June 7, 1893, was as follows: Color, white; smell, sweet; taste, sweet; reaction, neutral; specific gravity, 1.030. Water, 86.88 per cent; total solids, 13.12 per cent; fat, 4.39 per cent; sugar, 4.42 per cent; albuminoids, 3.36 to 3.60 per cent; ash, 0.71 per cent. In seeking a remedy for the difficulties which surround the milk supply, especially in large cities, we find that it must lie within three possible lines of action. Legislation.—This is a common channel through which to appeal for reforms; with the question before us, however, our efforts have hitherto been unavailing. Legal enactments will not afford us the needed relief, since their passage have so often resulted in their being embalmed in the statute books. These laws would be suffi- cient if they were administered; but that they are not effectual is apparent to all. Our legislative bodies seem helpless when their dictum runs counter to commercial interests. Public opinion.—This is always variable and capricious and through the influence of the public press is largely molded by vested interests. As a force to be used for reform, it is therefore unreliable. Moreover, the public are proverbially lax and indifferent with reference to matters connected with sanitation and hygiene. Destruction of property arouses alarm, but a sacrifice of life on the altar of greed or ignorance is not sufficient to awaken the concern of the masses. Medical supervision.—The physician is the proper custodian of matters effecting public health; he is also the only proper agent to meet the conditions which menace human life. His knowledge of the causes and sources of danger best equip him with the means of warfare against current evils of this class. The feeding of the young in infancy and childhood, the approach of infection, which in many instances calls for unusual judgment in the selection of their food, and the many clinical relations of the milk supply, all combine to impose upon the physician important responsibilities, and to make him the proper supervisor of milk production where it is designed for his purposes. In order to secure all that we desire in cows' milk for dietetic purposes, namely, freedom from bacteria, reliable keeping qualities, and uniform nutritive values, we propose the following plan, whereby the above-mentioned conditions may be acquired under our own supervision. This plan, which is now about to be put in practical operation by a medical commission organized by the writer in Essex County, N.J., includes three general requirements, each of which is essential, and we believe, if taken together, will establish a reliable safeguard: (1) That physicians give their practical encouragement and support to labors con- ducted by a commission of medical men, selected from their own number, who shall endeavor to secure a supply of milk produced under such regulations that purity may be assured. 1336 PAN-AMERICAN MEDICAL CONGRESS. (2) That approved and trustworthy dairymen, possessing honor, financial ability, and dairy facilities, shall be induced, by reason of promised medical support and the increased price of their milk, to conduct their dairies, and collect and handle the product in conformity with a code of requirements made by the aforesaid medical commission and imposed by them in due legal form. This contract between the com- mission and the dairyman under their patronage shall be stringent and binding. It shall include ample sureties for its fulfillment, the necessary forfeiture clauses, a territorial limit for the sale of the product, provision for the compensation of experts employed by the commission, which shall include a chemist, a bacteriologist, and a veterinary surgeon. It shall also control the location and character of the land employed for pasturage or for the cultivation of materials for fodder. It shall deter- mine the construction, location, and drainage of buildings in so far as construction, location, or drainage may effect the health of the dairy stock, the removal of waste, or the character and conditions of the milk. It shall provide for an abundant and pure water supply, and prevent the use of water from shallow wells or springs holding surface drainage, or the use of any well or spring located within 300 feet of the stable. It shall include the protection of the stable and stock from a want of cleanliness and order; eliminate dirt, Tubbish, and decayed animal or vegetable waste from the premises; and disallow the keeping of fowls, hogs, horses, or other live stock, except the cow, within 300 yards of the buildings used for dairy purposes. It shall regu- late the health and breed of the animals, and exclude from the herd any animal that is judged by a competent observer to be tuberculous in any organ or part, or any animal with fever or disease proceeding from or associated with parturi- tion, or found to be in a state of ill health prejudicial either to the herd or to the Čharacter of the milk, or any animal that was bred through close consanguinity within a period of three generations, or that was not kept sterile during the first twenty- seven months, or any phenomenal milker except that glandular disease or tubercle has first been excluded by a competent observer. It shall provide for the proper housing and care of the animals and their shelter from the influences of weather and climate detrimental to their health; their grooming and treatment; the prompt removal of waste products from the stable, and its freedom from animal odors by proper ventilation; the absence of conditions which would make the animal nervous, and prevent their use for milking purposes when in a state of excitement, either as a result of or during the period of estrux. It shall regulate the feeding, both as regards the materials which will determine the desired result in the product, as well as restrain the use of questionable or exhausted materials employed to increase the milking capacity, or that will result in impoverished milk. It shall govern the col- lection and handling of the milk, and insist upon a proper regard for cleanliness, as it is viewed from the Standpoint of a physician and sanitarian and as it relates to the animal and her surroundings, the milker, the vessels, or to the association of persons handling the milk, with sources of infectious disease. It shall also govern, in minute requirements, every step in the cooling and preparation for shipment, and add to the product every known detail of care that will promote its keeping quali- ties and favor its safe transportation. (3) That the commission shall carry on its work without pecuniary compensation. They shall endeavor to establish, from data gathered in clinical observations, cor- rect standards of purity for cows' milk. They shall be responsible for a periodical and personal inspection of the dairy or dairies under their control. They shall pro- vide for a bimonthly expert examination of the dairy stock-by a competent and approved veterinarian, who shall be subject to a consulting and a supervising officer. The milk produced shall be subjected to chemical analysis and to bacterio- logical tests, made by experts under the direction of the commission, at such times as in its judgment is desirable, the cost of which shall be defrayed by the dairyman. The chemist, the bacteriologist, and the veterinary surgeon shall be selected by the commission; and when so requested, either periodically or otherwise, they shall * PAN-AMERICAN MEDICAL CONGRESS. - 1337 render their reports in writing. After receiving these reports the commission shall send a certified copy of the same to the owner or agents of the dairy under its super- vision. This triple certificate, duly signed, shall constitute the product of the dairy “certified milk,” provided it shall be sealed in separate quart containers marked “Certified milk,” and bear the name of the producer, together with the date of milking. Being designed especially for clinical purposes, it should be subject to the following restrictions in its sale, namely, that when at any time the demand should exceed the supply, and the milk is required by a physician, either for infant feeding or the diet of the sick, the holder of a physician's order shall be regarded as a preferred purchaser. The reports of the experts, although designed for certifi- cates, may also be used for the information of the medical profession in the localities where the milk is sold. Duplicate printed copies, bearing the signatures of the experts and the names of the commission, should be sent out at such times as may be agreed upon, and the circulation should, for obvious reasons, be limited to the physician. APUNTES SOBRE LA ALIMENTACIÓN EMPLEADA DURANTE LA PRIMERA INFANCIA EN LA ISLA DE CUBA. Por el Dr. JOAQUIN L. DUEÑAS, Habana, Cuba. Este trabajo, escrito con el objeto de satisfacer en lo posible los deseos manifes- tados por los Dres. Keating y Crandall, de los Estados Unidos, servirá para dar una idea general sobre el régimen alimenticio seguido durante la primera infancia en los niños de la Isla de Cuba. Una información rápida, practicada en diferentes localidades de la Isla, me ha permitido reunir datos de algún valor y complementar los conocimientos prácticamente adquiridos durante mi vida profesional en la Habana. Desde un punto de vista general, puedo decir que la alimentación de los niños pequeños no está sujeta entre nosotros, sino con raras excepciones, á los sanos pre- ceptos de la ley natural ó á los prudentes dictados de la ciencia. En cada provin- cia, en cada pueblo, en cada familia, existe un modio de criar distinto, impuesto por los hábitos heredados de varias generaciones. El destete lo realiza cada uno á su manera, casi siempre sin consultar la opinión del médico, sin cuidarse para nada de la trascendencia del acto que va á realizarse, ni de los peligros á que se expone la vida del niño, que atraviesa ese período crítico de su desarollo, con más ó menos for- tuna, según su resistencia individual. En las poblaciones de alguna importancia, en la Habana, por ejemplo, se vé por todas partes el abandono hasta de los más elementales preceptos. Lo arbitrario es la línea de conducta, que se sigue. En los campos no existen costumbres más sanas, y á cada paso tienen que luchar los médicos con los resabios de la ignorancia. Con objeto de contribuir á la desaparición de hábitos muy generalizados, cuyos efectos se reflejan en la estadística de mortalidad, publiqué el año pasado de 1892 una serie de artículos sobre el “ destete” en La Higiene, periódico de vulgarización científica que dirige mi amigo el Dr. Delfin. Alimentación natural.—La lactancia materna, se emplea en toda la Isla, pero de dis- tinto modo y con diferente resultado, según se considere en las capitales, en los pueblos de más ó menos importancia, ó en las viviendas rústicas. En la Habana las condiciones del medio, densidad de población, calores excesivos, humedad, á las que se agregan otras muchas causas de orden biológico ó sociológico, contribuyen á debilitar la constitución de nuestras mujeres, y por lo tanto muchas de ellas no pueden resistir, sin peligro para la salud, las pérdidas que ocasiona una lactancia prolongada. Salvo relativas excepciones de señoras que tienen todo el vigor necesario para soportar una lactancia hasta los dos años del alumbramiento, la mayoría de las habaneras se resiente al cabo de cierto tiempo del gasto orgánico 1338 PAN-AMERICAN MEDICAL CONGRESS. empleado en beneficio do la criatura, viéndose precisada á acudir á la lactancia mixta artificial. Es muy general ver que los niños de pecho se mantengan con bue- nas apariencias de salud y lozanía á pesar de alguna decadencia de fuerzas en las madres, pero no es raro, por otra parte, observar en los niños la dispepsia por alte- ración cualitativa de la leche, la debilidad constitucional, la atrepsia. En tales casos lo más provechoso para ámbos organismos sería, ó la lactancia mixta femenina, en la que una nodriza mercenaria alterna en sus funciones con la madre, ó el cambio definitivo de nodriza, según lo exigieren las circunstancias. La lactancia mixta feme- nina no deja de emplearse algunas veces, pero las familias optan con más facilidad por la alimentación artificial por ser muy común la repulsión que se tiene á las nodrizas mercenarias, la mayor parte de la raza de color, dadas las pésimas condi- ciones en que se encuentra el servicio doméstico á consecuencia de tantos factores sociológicos como han contribuido fatalmente á su desorganización. Si á las defi- ciencias morales del servicio se agrega el elevado precio (330 á $85) que exigen las nodrizas en la ciudad, se acabará de comprender porqué casi siempre se prefiere la lactancia mixta artificial. Esta determinación se realiza frecuentemente del quinto al noveno mes de la vida del niño, algunas veces antes, pero deja probada invaria- blemente la virtuosa disposición de la mujer cubana á amamantar sus hijos, á pesar de no permitírselo en muchas ocasiones la pobreza constitucional de su organismo. En cuanto á las condiciones orgánicas de las nodrizas mercenarias, debo agregar que las mejores son las de raza negra; poséen una leche más rica, más nutritiva y soportan varias crías consecutivas, sin resentirse apenas en su salud. También son buenas las nodrizas de Canarias y las peninstilares, en su mayoría gallegas, cuando traen sus hijos; pero la regla general es que emigren dejándolos en su país y expo- niéndose á perder considerablemente la secreción lactea depués de una larga y penosa traversía. En la Casa de Maternidad se emplea la lactancia natural como alimentación exclusiva de los niños de pecho. Los siguientes datos me han sido suministrados por mis distinguidos amigos, el Sr. Coppinger, celoso director del establecimiento, y el Dr. Montalvo, médico de la Maternidad. Cada niño tiene su nodriza destinada á cuidarlo y attenderlo á la vez que amamantarlo. Se le abonan $30 mensuales, sufragándole los gastos accesorios de lavado de ropa, alimentación, confeccionada en una cocina especial, alimentos especiales, chocolate, etc., lo que hace aumentar el presupuesto para cada una á $47 mensuales. Para saber lo que cuesta el sosteni- miento de esa sección, basta saber que anualmente ingresan de 27 á 28 niños por el torno destinado á recibirlos. El destete se realiza gradualmente bajo la directa inspección del Dr. Montalvo, y se da el caso de ver niños de cerca de dos años que ya toman otros alimentos y todavía tienen una nodriza que les brinda maternal- mente el pecho á ciertas horas. En el interior de la Isla se emplea generalmente la lactancia materna para alimen- tar á los niñitos, pudiendo asegurarse que casi todas las madres dan exclusivamente el pecho á sus hijos durante los tres ó cuatro primeros meses de la vida y luego alternativamente con otros alimentos hasta una edad avanzada (dos años). El modo de administrarlo no está sujeto á otra regla que al capricho ó los hábitos de cada, familia, siendo muy frecuente causa de trastornos intestinales la costumbre de amamantar con exceso al niño, ya durante el día, ya en las horas de la noche. Alimentación artificial.—En la Habana se practica el destete prematuramente, pero por lo común de un modo gradual. La época, que se escoge para empezarlo es la que trascurre del cuarto ó quinto mes al noveno, ya bajo pretexto de nuevo emba- razo ó porque la madre cree debilitarse sosteniendo el niño á pecho solo. En muchos casos el empleo de la alimentación artificial obedece al deseo de fortalecer y engor- dar niños que no lo necesitan, que viven saludables y se hallan en buenas carnes, logrando con esto volverlos dispépticos y delicados ó enfermarlos gravemente. Esa es una tendencia bastante generalizada en nuestro país. PAN-AMERICAN MEDICAL CONGRESS. 1339 El alimento á que se dá la preferencia por su abundancia y baratez es la leche de vaca. Casi siempre se la administra hervida, en la proporción de dos partes de leche por una de agua, esto es, terciada, asociándole agua de cal ó de Vichy, bicar. bonato de sosa, amis, cebada, té, con objeto de prevenir los trastornos que su digestión pudiera ocasionar. Sin embargo todas esas precauciones son inútiles para conjurar los peligros que resultan de las alteraciones que sufre la leche ya por la mala calidad de los pastos al entrar la primavera, ya por las múltiples causas de que he hablado en mi trabajo sobre las entero-colitis. En el empleo de la lactancia mixta artificial se cometen las mismas faltas que en la lactación materna. Es raro que se sujete al niño á un verdladero régimen basado en una higiene alimenticia bien entendida. No hay técnica, sino en los casos en que interviene para dirigirla el médico de la familia; por consiguiente la única precaución de asepsia que se toma es la consagrada tradi- cionalmente por el uso, de hervir la leche varias veces al día, sobre tode en los meses calurosos del verano. Desde el año de 1890, en la misma época en que comenzó á hacerse uso de la leche esteriiizada en el extranjero, los Dres. San Martín y Fors empezaron sus ensayos de esterilización por un procedimiento especial en el Laboratorio de la Crónica, Mé- dico-Quirúrgica, y utilizando poco tiempo después la leche de excelentes vaque- rías situadas en el occidente de la Isla, proporcionaron al consumo en los mercados, una magnífica leche esterilizada al vapor bajo presión en el autoclave, á una tempera- tura de 115º á 120ºC. Esta leche que se vende desde entónces á 10 centavos la media pinta, ofrecía una buena garantía para la salud, siendo acogida favorablemente por el público que llegó á consumir desde que se implantó la mejora, unas diez mil botellas mensuales. Leche buena, superior á todas las que se expenden en la Habana, y además aséptica, estaba llamada á influir poderosamente en la conserva- ción de la salud infantil, si la técnica especial que requiere para su administración fuese escrupulosamente practicada por las familias. Desgraciadamente no da resulº tados seguros mas que en aquellos casos en que la cultura individual se halla dis- puesta á comprender los trascendentales beneficios del progreso. Recientemente el Dr. Delfin lna ideado un pequeño aparato cuyo uso empieza á generalizarse, y que tiene por objeto esterilizar la leche que ha de consumirse durante el día, por medio de un sencillo procedimiento puesto al alcance de las familias. El uso de la leche de burra en la Habana está restringido á un número menor de niños, y puede decirse que solo se toma por prescripción facultativa. La leche no es generalmente de buena calidad por deficiencia en la conservación y sostenimiento del ganado, y su precio no está al alcance de todas las fortunas. La leche de chiva 6 cabra es muy poco usada, lo mismo que la de yegua cuyo empleo es excepcional. Los alimentos que se preparan en el país para ayudar el régimen lacteo ó para sustituirle por completo, cuando el destete es definitivo, consisten en atoles ó papillas que se confeccionan con diversas harinas á las cuales se adiciona caldo más ó menos desgrasado, ó leche y azúcar. Este es el modo más común de comenzar la alimentación. La harina de trigo, de sagú, la Imaicena, la tapioca, la galleta pulve- rizada, la bananina ó harina de plátano, son las sustancias de uso más frecuente. También se emplean las migas, que se lmacen con pan mojado en agua ó leche y un poco de sal, echando el todo en manteca hirviendo con ajos, hasta obtener una pasta de cierta consistencia, que los niños toman con agrado. Las sopas de pan, las de leche, á la que se agrega azúcar y canela, las sopas de fideos ó tapioca, las patatas, el arroz con leche, son los primeros y más usuales alimentos, dejándose para más adelante los huevos, ciertas viandas, el pescado, ave ó carne. Aunque este es el modo habitual de comenzar la alimentación de los niños en las familias habaneras, se dan casos no raros de trasgresiones ligiénicas que consisten en hacer ingerir prematuramente sustancias de difícil digestión, incompatibles con el estado de desarrollo de los órganos digestivos. Legumbres diversas, frijoles y 1340 PAN-AMERICAN MEDICAL CONGRESS. judías principalmente, guisos variados como el de maiz, que los niños no mastican bien, quesos, dulces y golosinas de todas clases, que suelen producir gravísimas indigestiones y enteritis consecutivas. Los alimentos artificiales que se importan del extrangero pueden ser colocados, según el diverso consumo que de ellos se hace, en el orden siguiente, teniendo en cuenta los datos que he recogido en diversas droguerías importadoras de la ciudad: leche condensada americana y suiza, harina lacteada de Nestlé, fosfatina Fallieres, • alimento de Wagner, de Mellin, de Savory y Moare, harina malteada Defresne, grano imperial. De todos ellos se hace un uso variado como alimento supletorio 6 adicional, ateniéndose á las indicaciones expresadas en los prospectos para su modo de administración y dósis. El que más se emplea es la leche condensada americana y muchas veces como alimento exclusivo, manteniéndose los niños en regulares con- diciones de salud. Su poder nutritivo está subordinado en gran parte á la constitu- ción del niño que lo toma. Los niños fuertes que no necesitán de rica y abundante alimentación para reparar sus pérdidas y desarrollarse, se encuentran bien con su uso, pero en la mayoría de los niños habaneros que utilizan la leche condensada de un modo exclusivo, la nutrición se hace con languidez, los colores son pálidos, las carnes blandas, revelan en suma, los atributos del linfatismo y de la anemia. La leche condensada representa, sin embargo, un papel importantísimo en la higiene terapéutica de ciertas dispepsias y enteritis. Cuando no hay el recurso de una buena nodriza y las demás leches no se toleran bien, constituye un alimento precioso para modificar con rapidez el aspecto de las deposiciones. En el resto de la Isla la alimentación artificial varía según se la considere en las poblaciones de más ó menos importancia, ó en los pueblos pequeños, caserios, hacien- das de labranza, sitios, etc. En las capitales de provincia, según los informes que acabo de recibir de varios compañeros, se observan costumbres análogas á las de la Habana. La leche de vaca es generalmente la base de la alimentación de los niños y suele adulterarse en los puntos en que escasea, con agua, leche de boniato ó grasas. En algunos lugares, como en Matanzas, en que no hay leche buena y abundante por haberse convertido muchas haciendas y potreros en colonias para la explotación de la caña de azúcar, ha subido el consumo de la leche condensada americana, el cual aumenta todavía en la estación de la seca, á causa de la muerte de muchas reses y por deficiencia de la secreción en las restantes. En algunas provincias en que existen numerosas vaquerías, predomina el empleo de la leche de vaca, porque existe en Cuba la costumbre de repartir el ganado entre los vecinos ó sitieros con el objeto de conservarlo en el tiempo de la seca. Así cada familia puede disfrutar por cierto tiempo de la leche que le produce la vaca que se le entrega, pero desde hace poco los potrereros tienden á restringir dicho reparto en muchos lugares porque las vacas con- traen el hábito de destruir las cercas que separan las fincas colindantes enseñando á rompedoras á las otras. De todos modos, es costumbre muy seguida en los campos dar á los niños, que care- cen del pecho de la madre leche de vaca, que se administra casi siempre hervida, pero las más de las veces pura y desordenadamente. También está muy generalizado el empleo de la chiva criandera, concordando en todos sus detalles, los numerosos informes recibidos de toda la Isla respecto al modo que se tiene de aprovechar este animal para la lactancia. Se habitua al niño á practicar la succión directamente y al cabo de poco tiempo la cabra aprende y ejerce sus funciones como una verdadera nodriza, acudiendo solícita al llamamiento de la criatura y acomodándose de la mejor manera posible para facilitar al niño la succión. La cabra se aprovecha en toda la Isla, pero muy particularmente en todo el Occidente, provincia de Pinar del Rio y en algunas comarcas del centro y el Oriente. En ciertas localidades de la provincia de Santiago de Cuba, en las haciendas de Bayamo y Tiguauí, en que existen grandes vaquerías, se aprovecha para alimentar á los niños el suero obtenido por expresión de la leche, coagulada por medio del cuajo, para la elaboración del queso. PAN-AMERICAN MEDICAL CONGRESS. 1341 Respecto á la leche de burra y la de yegua, se usan con rareza, cuando el faculta- tivo la prescribe ó el niño no digiere bien alguna de las leches anteriores. Hay un hecho que debe fijar mucho la atención y que por sí solo básta para juzgar del pésimo estado en que se encuentra la alimentación de la niñez en toda la Isla. Lo defectuoso del régimen consiste en no someter exclusivamente á leche á los niñitos. El acuerdo, en la opinión de todos los médicos que me han escrito, es uná- nime. Ya disfruten del seno materno en toda su abundancia, ya de una lactancia mixta más ó menos impropia, lo frecuente es que desde el tercero 6 cuarto mes, bajo pretexto de que se crian débiles á leche sola, se les pone en la boca primero el pedazo de pan, luego el boniato salcochado, el plátano verde frito ó asado, é insensiblemente se vá desde la sopa de pan 6 de fideos á la de arroz, ca8abe, carne ó tasajo para que lo chupe, concluyéndose por saber que el niño, sin haber terminado el período den- tario, come ya de todo como los mayores de la casa. Las papillas que se usan al comienzo del destete, entre los campesinos razonables, se preparan lo mismo que he dicho antes, con caldo ó leche, á los cuales se agrega harina de trigo, de sagú cosechado en el país, ó maicena (fécula de maiz). La harina de maiz también se emplea muchísimo, pulverizando el maiz en un molino de piedra cuyo diseño adjunto. Y º. Se echa el maiz por el ancho orificio situado en el centro del disco superior, y por medio de un movimiento giratorio impreso al mango de madera, se tritura el grano entre las dos piedras, las cuales van dejando escapar poco á poco las partículas por el intersticio que las separa. El producto así obtenido se llama rollón y con él se prepara la papilla, agregándole leche hervida y un poco de azúcar. Con el plátano verde frito, machacado en un mortero, se fabrica también una harina que sirve para hacer papillas, cuyo empleo es general en toda la Isla. Dotada de alguna consistencia ya sóla ó unida á otros alimentos, se deposita, en la boca del niño después de haber amazado cierta cantidad entre los dedos. Este pro- cedimiento del bocado tiende á sustituir en muchos puntos del campo al antiguo proceder del mascado, que consiste en introducir en la boca del niño el alimento préviamente masticado é insalivado por otra persona. El alimento empleado por algunas familias campesinas bajo esta repugnante forma, es el plátano verde frito, transversalmente cortado en angostos discos, ya sólo ó mezclado con pequeños peda- zos de carne de puerco 6 chiclmarrón, que no es otra cosa sino la piel del puerco unida á cierta cantidad del tejido celulo-grasoso que la sustenta y que se fríe y achicharra al fuego. También se asocia la carne de puerco al boniato ó al plátano maduro, constituyendo un alimento muy agradable al paladar. El proceder de la tetera está asimismo muy generalizado. Consiste en colocar un pedazo de pan, de galleta, de panetela 6 cidra dentro de un pequeño trapo, sujetán- dolo después con un hilo, á la manera que se dispone la gasa para el taponamiento intracervical del útero. Hecha la tetera se sumerje en un poco de agua, sola ó con vino ó leche, y se da á chupar al niño, remojándola las veces que sean necesarias. De los alimentos importados, la leche condensada americana y la harina lactea de Nestlé, son los que únicamente se emplean, siempre en mayor proporción en las capitales de provincia ó en las poblaciones de cierta importancia, que en los pueblos, 1342 PAN-AMERICAN MEDICAL CONGRESS. caseríos, colonias ú otros conglomerados humanos, donde puede calificarse de insig- nificante ó nulo el consumo que de ellos se practica. Sería prolijo insistir ahora en los resultados de tantas trasgresiones higiénicas como se cometen al alimentar viciosamente á los niños, del mismo modo que al sujetarlos á la ingestión de aguas de pozo ó manantiales sin filtrar ni hervir. La dispepsia, la dilatación del estómago, las enteritis, los vermes, la eczema, son las enfermedades más comunes en los campos y en los poblados del interior. Los bebés de vientre grueso se ven por todas partes. Las infecciones de todo género por el tubo intestinal, encuentran un terreno preparado de antemano para realizar cori más facilidad sus terribles estragos. En resúmen: en la Isla de Cuba la alimentación de los niños de la primera infan- cia no está sujeta á los preceptos higiénicos sino en las poblaciones de cierta impor- tancia y entre las familias de cierta cultura intelectual. El modo más frecuente de alimentar á los niños es por medio de la lactancia, materna durante los primeros meses de la vida. De un modo general puede decirse que son buenas las condiciones de la mujer cubana para el amamantamiento de sus hijos, siendo menos numerosas las buenas nodrizas en las ciudades y debilitándose más pronto que las campesinas. - La tendencia de nuestras madres en toda la Isla es destetar prematuramente á sus hijos sujetándolos, en las poblaciones, á la lactancia mixta artificial; en los campos á una alimentación viciosa, pero sin dejar de darles el pecho á veces hasta los dos años ó más. - La leche á que se dá la preferencia de ordinario es la de vaca por su abundancia y baratez (5 centavos la pinta); en segundo lugar, la de burra en la Habana ú otras poblaciones importantes; la de chiva en los campos, usándose en último lugar la de yegua. La leche esterilizada no se consume más que en algunas capitales de pro- vincia, sobre todo en la Habana y alrededores. La leche condensada americana y suiza, pero sobre todo la primera, son de uso muy general en ellas, desconociéndose su empleo casi en absoluto entre los campesinos ó guajiros. Los demás alimentos artificiales que se importan del extrangero son escasamente administrados aún en las capitales, á excepción de la harina láctea de Nestlé. La primera alimentación, confeccionada por el arte culinario en las ciudades, con- siste en el empleo de papillas ó atoles de sagú ó trigo con caldo ó leche, las migas, bananina, sopas ligeras de pan y luego de fideos, tapioca ó revalenta. En los pueblos de campo se usan las mismas papillas de sagú ó de trigo, pero sobre todo las de harina de maiz y las de plátano verde. Se anticipa el empleo de otros feculentos, como el boniato, las patatas, la malanga, el arroz, etc. La alimentación viciosa cousiste en el uso más frecuente en los campos, pero limi- tado en las ciudades á las familias de poca cultura intelectual, de sustancias inade- cuadas á la edad y desarrollo del niño: ciertos feculentos, como el ñame, la yuca; leguminosas como frijoles, judias, frutos diferentes, algunas veces verdes, dulces de todas clases, helados, quesos y productos más complexos del arte culinario. No debo levantar la pluma sin dejar consignada mi más profunda gratitud á los dignos compañeros que han querido favorecerme con sus instructivos informes. Los primeros ejercen su profesión en las distintas localidades de la Isla que se expresan; los segundos, residentes en la Habana, han permanecido más ó menos tiempo en el campo: Dres. Carbonell, Fors (Mántua, Pinar del Río), Perez (de Guane), Valdes Brito (de San Luis), Madan, Cuní, Tomás, Valdés, Anciano (de Matanzas), Cadenas (de Remedios), Cuervo, Garcia Rijo (de Santi Espíritu), Tristá (de Sta. Clara), Betancourt (de Puerto Príncipe), Guimerá (de Santiago de Cuba), Meneses (de Baracoa. Delfín, Grande Rossi, Borrero, Saenz Yanes, San Martín, Tamayo, Albarrán, y Quiñones de la Habana. 13 bis. %0 C C, C t & * : Ns J. to º, “, § S. § º S.S. Nº ** S. S. *. e Q '', * * Sº º fe * •. **--------.. - - - - ** * * * * ~ * º º ** * * * * * * * * * * *** -- ... * * * * * * * * * ºff. *: 53. #. - '.. ...---" " ; § . : § ; S, ...--"\;i. 4ezera/ J/fo/* 4% An A4e až%reza wazºº, ºražič, ...tzwałzza','ezz, yºeze Az/; era& *ze” artzi erºezºs, cºrrerº 4e year /922, //ºrla. t - .." ZŽe /* zo/torceeze **eeze A/ºe Asºo ora!erv º, ......” % care, ºr 24e zzwºozzº e^ wera, tº werſ?/2 ... • - - -- * PAN-AMERICAN MEDICAL CONGRESS. 1343 A CONTRIBUTION TO THE STUDY OF PRIMARY ENTERO-COLITIS IN EARLY INFANCY. By J. L. DUENAS, M. D., of Havana, Cuba. In Havana, as in all populous cities of either hemisphere, the proportion of cases of and deaths occasioned by intestinal diseases among infants reaches a very high figure. Besides simple diarrhoea and Hayem's green diarrhoea, many cases of acute entero-colitis occur of greater or less intensity, which are either cured by an appro- priate treatment or pass into a chronic state, attended sometimes with secondary ailments, which are but the consequence of neglected intestinal troubles. In order to have an idea of the damages caused by enteritis among the children of Havana it is only necessary to direct one moment's attention to the demographic charts so scrupulously figured out by Drs. Delfin and Laguardia since 1890. Thus, the mortality from enteritis in that year (1890) included 417 children under 2 years of age, equivalent to 5.71 per cent of the total of deaths (7,298) in the entire popula- tion. In 1891, out of a total of 7,030 deaths, 1,556 were children under 2 years of age, 566 of them (36.37 per cent) having died of diarrhoea. In 1892 a total of 6,963 deaths were registered, 1,535 of which belonged to early children, 399 (26.99 per cent) having been occasioned by diarrhoea, so that each year between 400 and 550 little children are carried off in this city by acute diarrhoea, equivalent to a maximum of 2.75 deaths per 1,000 inhabitants. If the above figures be compared with those given by Dr. Smith concerning the city of New York during the year 1892 a marked difference will be observed against the Havana mortality, for in New York the mor- tality annong children under 5 years of age only represented 2.90 per 1,000 inhabi- tants, from which it must be inferred that for children under 2 years of age the mortality would have given a figure much lower than ours. Such results are most harassing in a city which barely contains 200,000 inhabitants, and where the propor- tion of births to deaths presents an alarming balance against the population. The important factor that we are considering well deserves, therefore, to be taken into account in order to lessen as much as possible its fatal influence. The observations which I shall present concerning the intestinal troubles of early infancy refer exclusively to the acute primary entero-colitis. No account will be taken of catarrhal diarrhoeas or simple diarrhoea, such as rapidly disappear under the use of simple remedies, nor shall I include in my statistics all the cases observed by me in the course of my thirteen years' practice, but only those that I have attended in 1891 and 1892, all of which have been carefully examined and analyzed with the aid of previous experience acquired in the observation of infantile diseases. Before proceeding any farther I must observe that, not occupying any official post in the public institutions where sick children are admitted, the corroboration of pathological anatomy will be wanting in my observations, owing to the insur- mountable difficulties in the way of obtaining autopsies in private practice. This paper must therefore be understood to be written only from an etiological, clinical, and therapeutic point of view. My cases from a total of 155 children attended with acute primary enteritis during the period of first dentition. They are distributed as follows: Boys, 93; girls, 62; total, 155. Brought up entirely or partially on the bottle, 114; brought up entirely on mother's milk, 41; total, 155. Twenty-five of the former (21.93 per cent) and 3 of the latter (7.32 per cent) died. Total of deaths, 28, equivalent to 18.05 per cent. The same cases, classified according to the age at which the disease was contracted, give the following order: 1344 PAN-AMERICAN MEDICAL CONGRESS. Age. Cases. || Deaths. | Mortality. l’er cent. 1 month.-----------------. 11 l 2 months.------------------ 11 3 3 months.------------------ 16 4 25 4 months.----------------- 15 5 5 months.------------------ 11 4 6 months.------------------ 11 2 7 months.----------------- 6 l 8 months.------------------ 7 2 9 months.-----------------. 11 0 9 10 months.------------------ 6 0 11 months.------------------ 4 0 12 months.------------------ 9 1 Second year *-------------- 37. 5 13.51 Total ---------------- 155 28 ------------ * Almost all the cases here included in a single group occurred between the twelfth and fifteenth months. The 155 cases distributed according to the months in which they occurred appear in the following order: January-------------------------------------- 13 | August -------------------------------------- 16 Tebruary ------------------------------------ 15 September ----------------------------------- 4 March --------------------------------------- 16 October ------------------------------------. 5 April ---------------------------------------- 15 | November------------------------------------ 13 By - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - 11 | December ------------------------------------ 10 June ----------------------------------------- 21 * July ----------------------------------------- 16 Total.---------------------------------. 155 Classified according to the form of the disease, they consisted of— Cases. | Mortality. - Per cent. Types: 12 66 Cholera infantum ----------------------------------------------------------- 143 13.99 Acute entero-colitis--------------------------------------------------------- Total.---------------------------------------------------------------------- 155 Forms of the entero-colitis: Common--------------------------------------------------------------------- 68 5, 88 Thoracic -------------------------------------------------------------------- 25 7. 69 Cerebral--------------------------------------------------------------------- 22 22.72 Typhoid--------------------------------------------------------------------- 4 15 Choleraic-------------------------------------------------------------------- 23 26.08 Total ---------------------------------------------------------------------- 143 |------------ Etiology and nature of the disease.—The following causes are reckoned among those that most commonly bring about the acute infantile enteritis in Havana: (1) Expos- ure to cold; (2) premature weaning; (3) indiscriminate use of cow's milk in the feeding of infants; (4) the use of food not adapted to the child’s age; (5) the effect of high temperatures during the summer months, which is also our rainy season; (6) various infectious influences which habitually prevail in this locality. These various etiological conditions generally combine in many ways to produce the intes- tinal troubles. Most of them, however, only deserve to be considered as occasional factors, modern investigations having conclusively demonstrated the important rôle that belongs to infection as the primordial pathogenic agent in these diseases. (1) Children are quite as liable to catch cold among us as they are in cold climates. The special construction of our houses, the constant breeze which prevails during the hot season, the common habit of opening doors and windows to mitigate the oppressive heat, the sudden fall of temperature after heavy showers, are frequent occasions of catching cold for the children of this country, generally very lightly PAN-AMERICAN MEDICAL CONGRESS. 1345 dressed, especially when suddenly exposed to drafts after awaking from their sleep, or after taking their milk, which frequently provokes perspiration. (2) Premature wealing must also be considered as one of the predisposing causes of enteritis. The bad conditions of many of our wet nurses, their ignorance or low social grade, etc., induce many mothers to wean their children prematurely, thereby exposing them to the dangers of the following etiolºgical agencies: (3) The expenditure of cow's milk to the public is carried on under the most deplorable conditions for the feeding of infants. The rules of sanitary police are utterly disregarded. The cows, mostly attenuated or diseased, insufficiently fed, or supplied with a bad quality of pasturage, are led through the streets of Havana, frequently lying down, so that their udders come in contact with a goil infected to the highest degree with organic detritus of all kinds. The consequence is that even when milked before the very eyes of the consumer the milk is liable to be contam- inated with pathogenic germs, putting aside the readiness of the milkman to adul- terate the article by the addition of large quantities of water, in which Dr. Davalos has bacteriologically demonstrated the presence of various microbes, and in particular of the bacillus coli communis, so well known for its pathogenic properties. As to the milk which is sold in coffee-houses, milk depots, etc., it is often brought from considerable distances, and consequently delivered many hours after it has been milked. It is conveyed in tin cans so constructed that they can not be thoroughly cleansed, being greatly shaken before reaching its destination, and, moreover, adul- terated, to say the least, with impure water, such as until the present year has been drunk in this city. All the above circumstances combine to produce the fermenta- tions so well studied among us by Dr. Delfin, author of several important papers on that subject. In one of them” our colleague has called attention to the frequency and death rate of cholera infantum and to the fermentations developed in the milk under the influence of our high summer temperatures. If in addition to all these circumstances we take into account the carelessness with which artificial lactation is carried on in the households of Havana, the importance of this factor in the devel- opment of infantile diarrhoea will be readily understood. Many of my colleagues have come to identical conclusions. Drs. Madan and Garcia Rijo, f in particular, have carefully studied the etiological influence just pointed out. The best testimony that I can adduce to prove the dangers of lactation carried out under such unfavorable conditions is the fact that in the course of my thirteen years' practice I have only met with a comparatively small number of cases of enteritis among children exclusively fed from mother's milk, and such cases as did occur have afforded a more favorable termination (a mortality between 5 and 7 per cent). (4) The use of improper food, of indigestible substances, of sweetmeats made with milk, cheese, ice cream, fruit, and other delicacies too early granted to chil- dren, have been in many of the cases observed by me the occasioned cause either of severe enteritis or of the clinical syndroms known as “cholera infantum.” (5) The injurious influence of heat is very remarkable in Havana, and has long since been pointed out. Even in the cooler season from December to March, when the average temperature ranges between 649 and 68°, there are days when the ther- mometer rises as high as 82° or 86°, and the enteritis is again observed. In mid- summer the temperature rises as high as 90°, 939, and 979, the number of intestinal disorders increasing with the intensity of the heat, as shown in the tables of com- parative mortality for the period 1888–1892, given further on. * La Leche en la Habana (Primer Congreso Medico Regional), p. 481. Habana, 1890. f Garcia Rijo. A pantes clinicos sobre el envenenamiento por la leche en los recien-nacidos y fiebres de la la infancia (Primer Congreso Medico Regional, p. 212. Habama, 1890). Madan. Con- sideraciones sobre las diarreas graves dela primear infancia (Cron. Med. Quirung.) Tomo i 6, p. 476 y 545. Habana, 1890. * S. Ex. 36—85 1346 PAN-AMERICAN MEDICAL CONGRESS. The 155 cases noted down in my own case book for the two years of 1891 and 1892 present the following monthly distribution: - - January -------------------------------------- 13 July ---------------------................. . . . . 16 February ------------------------------------- 15 August ------------------------.......... . . . . . 16 March ... -------------------------------------- 16 September ---------------------...--.......... 4 April -------------------------------- --------- 15 October -----------------------------.......... 5 May ------------------------------------------ 11 | November. . . . . . . . . . . . . . . . . . . . - - - - - - - - - - - - - - - - - 13 June ------------------------------------------ 21 | December ------------------------------------- 10 The highest morbidity corresponds to the months of June, July, and August, and it is particularly to be noticed that in the months of March and November, which are frequently warm, a corresponding increase occurs in the number of cases, a fact also observed in the general demographic statistics for the years mentioned above. Inasmuch as the summer heat by itself can not be regarded as capable of producing the diarrhoea, I shall consider in the next paragraph what seems a plausible expla-. nation of the anomalies offered by the curve of morbidity and mortality. - (6) Three infectious diseases, which prevail endemically or epidemically in Havana, deserve to be particularly considered, owing to their primary localizations in the intestinal tract. They are typhoid fever, paludism, and grippe. There is besides, a numerous group of fevers, not yet etiologically classified, which may for the present be included, so far as their clinical features are concerned, among the typhoid fevers. They constitute toxi-infections originated in the intestinal tract, bearing great resemblance to the incomplete forms of typhoid fever, their duration being more or less prolonged and likely to be modified by the appropriate employ- ment of purgatives and intestinal antiseptics in their treatment. The etiological conditions that preside over the development of all these fevers are to be sought partly in the composition of the soil, in the quality of our water supply, such as it has been until last year, and also in the well-known disregard of everything appertaining to public hygiene. The collection of garbage is very deficient; the streets are badly paved, and in main wards not properly swept, whereby infec- tious foci of every kind are formed all over the city during the rainy season. The sewerage is as bad as can be; it is not carried out on a general system, but only consists of very poor drains, deficient in size, declivity, and workmanship, and scarcely calculated to prevent the filtration or accumulation of corrupt matter in the soil of the city. In addition to this a most defective system of cesspools is used in our houses, and the municipal ordinances are often infringed, the privies being surreptitiously connected with the sewers which run along our streets. From this it will be readily understood that the muddy soil of Havana, lying as it does upon an impermeable subsoil, must be completely saturated with infection. Accord- ing to the calculations of our engineers, Messrs. Gonzalez and Amigo, every year 79,200,000 kilograms of fecal matters find their way into the soil around the cess- pools and sewers. It is no wonder, therefore, that in a dense city like ours, where all the etiological elements favorable to organic decomposition are present, heat and moisture in particular, the air should be greatly contaminated with impurities, and charged with deleterious effluvia and microbes which being deposited on the walls of the pharynx, are afterwards swallowed with the food and drink, thereby producing many kinds of infection in the intestinal canal. All that Dr. Lewis Smith has writ- ten in lais book on Diseases of Infancy regarding the causes of enteritis is verified in Havana upon an enlarged scale, and if the results have not been worse it is undoubtedly due to the influence of the winds which constantly purify our atmos- phere, and to the copious rains that wash out our imperfect sewers. The etiological conditions already described affect all the inhabitants of the city, but as will be readily understood, their influence is more disastrous upon infants, principally upon those that are badly lodged and improperly fed. In more advanced cliildhood, in youths, and even in adults, the infection is apt to assume another 27.4 A4s ſºozze &/24ezz!/&eer .22 2// 2.Éev 2%zz ZZ &e zzezz: 7. Zea/o Arezze ex/ezzzzº crºcºſ' cºgee cºzzzzzé &e Jazzee 3/eºz. ZŽe Jazzz's 22 c. 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(aunque este síntoma no lo busqué en algunos casos. cuando aún no pensaba en esta complicación), viva inyección de la conjuntiva alrededor de la córnea ó en toda su extensión, dolor más ó menos agudo, limitado al ojo ó extendiéndose á toda la rama oftálmica, dilatación pupilar, lágrimas, enturbiamiento de los líquidos intraoculares, disminución de la vista, y dificultad para mover el ojo. e - Pero estos fenómenos, aunque alarmantes al principio, se disipan en el transcurso de algunos días. En otros casos el glaucoma ha sido agudo, y tan característico que me ha decidido á ser sobrio y muy prudente en la práctica de esta operación. Referiré á grandes rasgos la observación 16, en que un glaucoma fulminante produjo rápidamente la atrofia de la pupila en medio de agudísimos dolores. A un individuo blanco, de 57 años, artrítico, muy grueso y de cuello corto, le extraje la catarata de un ojo sin accidentes, y curó pronto dejando una secundaria bastante tenue. A los 32 días la operé con un cuchillete de Knapp, desgarrándola en dos direcciones y obteniendo inmediatamente una hermosa pupila negra, á traves de la cual vió claramente el enfermo. Esta operación se hizo con todo rigor antisép- tico, y se usaron instrumentos nuevos. Después de terminada se aplicó un vendaje protector. A las 24 horas de la operación se declaró dolor fuerte en el ojo que se irradiaba á toda la rama oftálmica, con sensación de tensión, con edema de los párpados y de la conjuntiva, con oftalmoplegia, exoftalmos, pupila dilatada, abolición de la vista y gran dureza del ojo. A las 40 horas tuvo escalofríos y vómitos repetidos y agrava- ción de los síntomas antes indicados. El dolor se mostraba por punzadas intermi- tentes intensísimas. El quinto día el quemosis conjuntival era aún mayor, y el enfermo en el colmo de la desesperación rehusó más obstinadamente que al primcipio la iridectomia que le propuse como único remedio que podía curarle con éxito. Al cabo de una semana, remiten todos los síntomas, pero persisten T > In, anestesia de la córnea, disminución de la vista y enturbiamiento del humor vítreo. HDesde esta época, el glaucoma ha tenido accesos con intervalos variables. Al fin la cesación de los fenómenos agudos se ha debido á la distensión de la cicatriz de la primera operación, que á los 150 días parecía no existir en ella más que una ectasia formada por el iris retenido por algunas fibras córneo-esclerales. La pupila estaba en esa fecha muy dilatada, los humores intraoculares algo turbios y T > n, aunque menos duro que en el principio. La opacidad había quedado definitivamente recha- zada al tercio inferior de la pupila. A traves de esta, se veía la pupila atrofiada y totalmente excavada. El campo visual estaba muy reducido en todas direcciones (aunque con la particularidad de hallarse casi abolido del lado externo), y la vista había quedado reducida á la percepción de la luz. Es indudable que este ha sido un caso típico de glaucoma agudo y que no tuvo otra causa más que el traumatismo operatorio. - Entre los ojos de tendencia glaucomatosa y otros refractarios á esta complicación hay una gradación que depende de la intensidad de la reacción uveal, y de la anchura de las vías excretorias. PAN-AMERICAN MEDICAL CONGRESS. 1391 Pero, ¿cómo puede la discisión producir el glacoma cuando en tantos otros trau- matismos operatorios no se le vé aparecer? Veamos primero lo que es el glaucoma. Lo considero como una consecuencia de la hipersecreción de la glándula uveal, si afecta la marcha aguda; y en la crónica lo creo debido á la deficiencia de las vías excretorias, haya ó no aumento en la producción de los líquidos intraoculares. Partiendo de este principio me explico la génesis del glaucoma después de la discisión del modo siguiente: Al desgarrar la cápsula con cualquier instrumento que sea y con cualquiera forma que se dé al corte, se determinarán tracciones sobre la opacidad. Estas se trasmiten al ligamento suspensorio del cristalino, que por sí y mediante numerosas fibrillas zonulares adhiere á la glándula uveal. Sufre, pues, esta glándula en el acto de la discisión una fuerte irritación que se traduce por hipersecreción brusca de humor acuoso, y desde ese momento se habrá originado un ataque de glaucoma agudo, con todo el cuadro de síntomas que desa- rrolla, el aumento de la tensión intraocular. Esto, en efecto, es lo que pasa casi siempre que se practica la operación. Si las vías excretorias son amplias no llegará á constituirse el estado glaucoma- toso; sí son normales aparecerá el ataque, pero al cabo de algunos días se restable- cerá el equilibrio de la tensión, y el enfermo habrá dominado la crísis. Pero en indivíduos predispuestos al glaucoma, como en los artríticos, ateromatosos y otros en quienes no sabemos sospecharlo, pero que consideramos que tienen todos de común la insuficiencia de las vías de excreción, el ataque puede llegar á ser brutal, y la vista quedará perdida 6 gravemente comprometida. ¿Puede evitarse la aparición del glaucoma en las operaciones de secundaria? Se logra ciertamente suprimiendo las tracciones de la glándula uveal. Desde luego creo más conveniente desgarrar la opacidad con dos agujas, de las cuales una sirve de apoyo mientras la otra desgarra. De este modo se evitan al menos tracciones violentas. Sin embargo, en el cuadro que incluimos figuran casos de glaucoma siguiendo este procedimiento, de modo que no es grande la superioridad que ofrece sobre el empleo de una sola aguja. Respecto al instrumento que ha de usarse me parece preferible un cuchillete puntiagudo á las agujas, aunque estoy seguro que ni con ellos se evita el traumatismo del epitelio de los procesos ciliares. Soy parco en el uso de la discisión, sobre todo en los casos de secundarias espesas que necesitan fuertes tracciones para ser desgarradas. La capsulotomia ó la irido-capsulotomia, en cambio, no ejerce la menor acción sobre los procesos ciliares. Así no debe extrañarse que á pesar de ser con ella mayor el traumatismo nunca dé lugar á un verdadero ataque de glaucoma. Esta operación, aunque en extremo delicada por la destreza que necesita la intro- ducción y corte de la pinza-tijera, tiene en cambio la gran ventaja de formar anchas pupilas y no tener complicaciones serias cuando se han empleado instrumentos asépticos. Gracias á esta operación no tengo el disgusto de presenciar ataques de glaucoma. Cierto es que por lo común provoca una reacción moderada que se reconoce por la tumefacción del iris y por enturbiamiento del humor vítreo, y á veces inyección de los vasos subconjuntivales, pero con poco ó ningún dolor. La herida de la córnea cicatriza rápidamente, y el humor vítreo recobra su transparencia al cabo de algunos días. Terminaremos proponiendo que se emplee contra las secundarias muy tenues la discisión con una ó dos agujas, prefiriendo esta última. Contra las secundarias espesas debe emplearse siempre la capsulotomia. 1392 PAN-AMERICAN MEDICAL CONGRESS. Operación. Resultado. •gº Días E e Núnn. ¿y Diag- depº IPr o c e di- 3 E Complicaciones. nóstico. ex # miento. # # CIOLl , s C 1-----. H.55 1 E. 15 2 agujas ... º R. IR. Glaucoma agudo desde las 4 horas, con dolor, inyección conjuntival, pupila dila- tada, humor vítreo turbio, T > n. 2------ BI. 58 E. 60 2 agujas . . lè. IB. Inyección vascularemoderada, poco dolor. 3.----- E.95 E. 78 2 agujas ... It. ------ Glaucoma, agudo, intenso el primer día; desapareció lentamente. 4.----- V. 52 E. 180 2 agujas -. R. ------ Reacción “moderada. r 5------ V. 49 . E. 55 1 aguja -.. - lè. º MI La opacidad se desprendió de parte de su inserción sin desgarrarse. Cicletis con dolor, inyección y tumefacción conjunti- val y palpitación, enturbiamiento lhumor, acuoso y vítreo. 6-----. V. 42 4 T. 44 1 aguja ... º B. R. Reacción inflamatoria moderada: dolor. 7------ H, 56 lº. 17 1 aguja. -- l3. ------ Reacción moderada. 8------ H. 70 E. 20 1 aguja . . . B. Glaucoma agudo, intenso durante 5 días, desapareció después de un mes. 9------ V. 40 E. º 42 1 aguja ... M. M. Reacción glaucomatosa moderada. 10.----- V. 49 l. º 41 1 aguja . . . M. M. Reacción glaucomatosa moderada. El re- sultado fué nulo por las abundantes masas corticales que había detrás de la cápsula. 11. ----- H. 60 E. 360 1 aguja --- l3. I3. Reacción glaucomatosa de mediana ínten- sidad. 12------ V. 58 E. 37 1 aguja -.. B. R. Ciclitis moderada. 13------ E. 56 I. 190 1 aguja - . . I3. 13. Reacción moderada; dolor muy fuerte la primera noche. 14-----. V. 42 E. 130 1 cuch - - . . B. IB. Ciclitis moderada; poca reacción y escaso dolor. 15------ V. 48 T. 26 1 cuch . -- . B. R. Dolor, congestión, disminución de la vista, etc. 16-----. V. 54 T. 32 l cuch - -.. J3 M. Glaucoma sobreagudo. 17------ V. 55 E. 27 | 1 aguja -.. - B. R. Glauconna de mediana intensidad, declarado á las 10 horas; duró 4 días. 18. ----- V. 57 E. 20 1 aguja -.. B. lB. Glaucoma, moderado con dolor durante tres días. 19. ----- V. 48 E. 2 1 cuch - ... I3. -----. Glaucoma moderado. 20. ----- V. 65 E. 22 | 1 aguja ... - B. B. Glaucoma; dolor intenso de la primera rama por 9 días. p • 21. ----. V. 54 T. 12 1 cuch ---. I3. R. Ciclitis; cámara anterior profunda; dolor. 22.----- V. 54 l. 10 || 1 cuch ---. l3. B. Glaucoma de 6 días; ataque á las 10 horas. 23. ----. V. 62 E. 82 agujas -. B. R. Apenas hubo reacción; sin dolor. 24-----. V. (32 E. º 31 2 agujas -. IB. 3. Indolencia. 25. ----. V. 65 "I'. 30 2 agujas -- B. I3. Glaucomasmoderado. 26. ----- V. 65 T. 30 2 agujas -. I3. l3. Glaucoma, moderado. 1 Espesa=E. * IRegular = lè. 3 Malo=MI. 4 Ténuc=T. 6 Bueno= I3. El exponente en la cuarta columna indica el número de secundarias practicadas en la misma persona. THE ETIOLOGY AND EARLY MANAGEMENi' Oirº GLAUCOMA. By G. E. DEAN, M. D., of Scranton, Pa. Although much attention has been given by authors to the subject of glaucoma, a great deal of the mysticism of the past has clung to it, causing most observers to class it with the inscrutable, while the few ventured to explain it by fine-spun theories. Believing that the theories of the causation of this important disease of the eye, which I learned from the text-books of a dozen or more years ago and which I heard taught in Vienna in 1887, must, from their very nature, be noth- ing better than fragmentary, I have been making some observations independent of theory, either dignified by age or newly preconceived. If the conclusions arrived at should, as I venture to hope, throw some light upon the etiology of the disease, give definite aim to the labors of the pathologist, and lead up to a more rational plan of prophylaxis or treatment than has prevailed in the past, I shall feel more than repaid for the effort expended in the researches. PAN-AMERICAN MEDICAL CONGRESS. 1393 My first observation was that the theory given in the excellent treatise of Soel- berg Wells—mostly quoted from Graefe and which we may call the anterior inflam- mation theory—however attenuated, would not apply to all cases and was, therefore, untenable as a general theory. My next observation was that the theory taught us in the clinic of the celebrated Prof. Stellwag, by his first assistant, and which we shall call the choroiditis theory, while approaching a little nearer the bottom facts, did not at all cover the ground. It is evident that while degenerative choroiditis might be present in a good many cases, it was as likely to be a part of the patholog- ical process as to maintain the higher relationship of cause to effect. Then I observed, year after year, that, with few exceptions, the cases of decided glaucoma, of threatened glaucoma, and of glaucomatous cupping without active symptoms, were in persons affected with astigmatism (frequently conjoined with hypermetro- pia); and it seemed to matter little how small the degree, 0.25 of a diopter being a not infrequent showing. Later I began to observe that the exceptional cases were myopes in whom a more or less similar condition of back pressure existed; or what is relatively the same, posterior weakness of the eyeball. My next investigations led me into a study of the so-called “physiological cupping,” and I found it such an elusive subject that I at last concluded that it was to a very considerable extent a delusive one. Perhaps the fairest explanation of it in all respects that can be given in brief, is to compare the whole subject with the inguinal canal in its healthy state, and its possibility of acquiring inguinal hernia. The conditions are analogous in the main, except as to size and the possible difference in time required to produce a similar effect from a similar cause. In both instances we have a point of weakness about certain vessels and subjected to more or less pressure from within. In each we may have this weakness exaggerated, it may be anywhere from a slight to an extensive degree, by a funnel-shaped depression or cupping outward which may be either congenital or produced. . It is easy to under- stand that a tolerably constant undue pressure may gradually increase the depth of this cup or broaden it, and thereby gradually increase the element of weakness; or it may yield suddenly at the base and admit of a hernia de facto. In the case of the optic disk, we have in perfect health, as it appears, an exceed- ingly slight depression about the vena centralis retinae, and also some less rigid tissue there, apparently intended by nature to afford greater safety to the vein. Now in the highest state of nature this slight depression has an area of elevation around it which acts as an excellent bulwark of protection; but let it be subjected to a con- tinued excess of pressure, slight though the accretion may be, as in the eye strain of defective refraction, and we may observe that the interfibrillar substance of the nerve is absorbed, leaving a broad, shallow cup (the atrophic cup of Fuchs), or, apparently independent of that, we may notice in other cases quite deep retrocession at the temporal side of the central vein without any very noticeable lowering of the general surface of the optic disk. In the former cases (atrophic) there is apt to be also atrophic change at the periphery of the disk, while in the latter cases this factor is at least not so noticeable. I am disposed to regard both these conditions as inter- mediate stages between a healthy condition of the nerve on the one hand and glaucoma on the other, more especially as I have seen inflammatory glaucoma in an eye with one of the deep narrow cups and a decided tendency toward glaucoma simplex in another, and because it appears that atrophy of this kind favors the developing of glaucomatous cupping. The optic nerve is placed very much like the cork in a wine bottle, i. e., as if forced in, so that outward and inward it is larger than in the middle; hence an atrophy which reduces its diameter tends to make it push out more readily, thus displacing the lamina cribrosa backward and admitting of the well-marked glaucomatous cupping. Having given a brief résumé of the course of utterly unbiased reasoning which led up to the conclusion, though without introducing the cases, which would be interesting enough if time permitted, we shall unhesitatingly announce the prime underlying cause of the disease. S. Ex. 36 S8 1394 PAN-AMERICAN MEDICAL CONGRESS. The keynote of glaucoma is eye strain and that usually from some defect of refraction. There is no need to make a great mystery out of glaucoma any longer. If it were possible to correct all the errors of refraction in a given community, cor- rect them early, and keep them continually corrected by suitable and absolutely accurate glasses, then, in that community, glaucoma, apart from a few secondary and traumatic cases, would disappear. We speak advisedly in saying a few, for it is highly probable that these cases have largely been predisposed to by eye strain. We apprehend that the elucidatiºn of this subject has been delayed somewhat through reverence for the opinions of the immortal Graefe. It is indeed a high tribute to his genius that his doctrine on the subject should have been accepted as the law governing research almost up to the present time. Graefe did wonderfully well, as well as it was possible to do in his day, but the age is progressive and the greatly improved refraction work, at least of some of the more careful men in this country, makes it possible to take a deeper and more comprehensive view into the etiology of this and certain other diseased conditions of the eye. Our object should not be to combat the theory of this or that individual, but to lay a foundation under them. Some of them at least, and perhaps most of them, contain good material and make such a presentable showing that they deserve to have something better than mist to stand upon. While we have already been laying considerable stress upon back pressure, and while we believe that in the average case the posterior portion of the eye earlier receives the impression which tends in the direction of glazıcoma, we must never lose sight of the general truth that eye strain, the cause, is bipolar in its action; hence we must comprehend the effects produced both posteriorly and anteriorly and must not be surprised nor disconcerted by the variations in type met with in studying the disease. It is but natural that when a force acts in more directions than one, the manifestations produced may vary in character. Of course, in speaking of posterior strain, we are referring to that which takes place in and about the optic disk; and of anterior strain, referring to that which occurs in and about the cilliary region, including a tolerably large and important area. We further must not ignore the fact that there is lateral pressure as well, and that the venae vorticosae are important elements in the circulation of the eye. And perhaps there has not enough stress been laid upon the ease with which the retrochoroidal lymph space may become affected. Concerning the effects of anterior pressure, it is not necessary to say much here, for the reason that it is so well described in the text-books. Most of them doubt- less attribute undue importance to disturbances in Schlemm's canal, as etiological factors; they are important enough to be sure, but it should be borne in mind that there are other and larger lymph channels in the eye. A close observer may notice that in a great many cases interference with filtration in that direction is the final act of a rather long ocular tragedy. A strong argument that the early pressure effects are not so much forward as backward, is that so little scleral congestion is observable in the inflammatory cases compared to what is seen in iritis, cyclitis, etc. No wonder the scientist looked in vain for the cause during the attack, when the cause has been acting more or less quietly for years until the attack obscured it, and rendered critical study impossible. It should be remembered that in thousands of non-glaucomatous cases the same cause (eye strain) is acting, but finds enough resistance to prevent a glaucomatous effect from being prºduced. The optic nerve often withstands the strain so long and with so little local deleterious effect that we can but marvel at its power of endurance; and even when some retrocession has occurred, oftentimes no startling symptoms arise until the lamina cribrosa has been forced back to such an extent that the press- ure in part is applied in a lateral direction almost directly upon the nerve sheath, upon the lymph channel surrounding it, and only less directly upon the posterior cil- liary circulation. Likewise forward pressure in the ciliary region (i. e. practically in the opposite pole) is endured fairly well until it causes an impingement upon the PAN-AMERICAN MEDICAL CONGRESS. - 1395 absorbent angle of the anterior chamber. But it will be observed that these are only climaxes in a process long since begun. It is highly probable also that in a considerable percentage of cases, strain at one pole is endured until too much strain is applied at the opposite pole; then the patient, suffering eye succumbs to over- whelming forces. In another of the diseases to which flesh is heir, viz, peritonitis, we have what may answer as an example in some respects of what is meant. So long as a peritonii,is (nonpurulent) remains localized, it may seem comparatively insignificant, but let it assume a general form and all will admit its gravity. Space will not here admit of going exhaustively into the subject of eye strain, but a few points may be briefly touched upon. We shall premise by saying that the term has too often been restricted in many minds, almost entirely to the appa- ratus of accommodation, rather ignoring the important part played by the recti muscles. It is true that, apart from myopic eyes, a large percentage of the strain comes from near work, and hence glaucoma as a fully developed disease is largely confined to persons of more or less mature years, when the eyes find some added resistance to the efforts of accommodation. It accounts also for its relatively greater frequency in hypermetropes. We should not be surprised to find, if sufficient sta- tistics were available, that the average onset was a little earlier in hypermetropes than in some other classes of cases, just as we notice in them the relatively earlier necessity of wearing glasses for reading. A very possible reason why myopic eyes are less frequently glaucomatous arises from the fact that many of them do not find much difficulty of accommodation. Another factor is found in the general weakness of the posterior wall of the globe, making the excess of pressure relatively less felt at the disk than in hypermetropic cases. Understanding that astigmatism is one of the greatest causes of eye strain, we must consider that the ideal eye for the production of glaucoma would be one with hypermetropic astigmatism. It is known to be rather frequent in such eyes, and doubtless a great many glaucomatous eyes classed simply as hypermetropic really had a slight astigmatism which was undiscovered. Statistics show that very few emmetropic eyes have been affected with glaucoma, so few indeed that it is exceed- ingly probable that they were cases of mistaken diagnosis. If space permitted, we would refer to general conditions of the circulation and the system at large; to tonic spasm of the ciliary muscle, intra-nasal pressure, etc., as possible etiological factors. I'or the reason indicated it is impossible here to give a detailed explanation of our views regarding the mechanism of eye strain. If the pathologist will take his cue from the clinical facts that eye strain is the general underlying cause of glaucoma, and further, that the earlier effects, so far as tending towards glaucoma are concerned, may be exerted backward quite as fre- quently as forward—perhaps far more frequently—he will soon find that the study of this disease does not lead him into such a mystical field as it has been pronounced by most of our authors. If then he will turn his attention to the admirable schematic cut in Fuch's Textbook of Ophthalmology, page 251, showing the lymph passages of the eye, and, observing how extensive they are, decide to make a gen- eral study of them in connection with glaucoma, he may find a rich field for investi- gation and produce some decidedly definite results. IZARLY MANAGEMENT OF GLAUCOMA. It has been thought best to refer to the plan of treatment provisionally adopted as the “early management of glaucoma,” for the reason that it applies primarily to those cases of glaucoma and threatened glaucoma which early come under the observation of the oculist; and it would be manifestly unfair to apply it only to a few neglected and desperate cases found in metropolitan hospital practice, and then reject it as unworthy. Of course, in this disease even more than most others, prevention is better than cure. The chief measure of prophylaxis is the early use of accurate glasses; but medication is also useful in that direction. The medica- 1396 PAN-AMERICAN MEDICAL CONGRESS. tion must, however, be followed up by glasses and no pains must be spared to make them exact. Of therapeutic measures perhaps the best we have as yet found are acetanilid internally, pilocarpine solution instilled into the eye, and the hot solu- tion of boracic acid applied externally. The acetanilid has mostly been given in 8-grain doses, three or more times a day to the average adult, and 4-grain doses to specially susceptible females. Its action should be watched so that it shall not cause too great depression; and if the temperature is found subnormal, the dose should be lessened. My reasons for preferring pilocarpine to eserine are twofold; first, that while it may not be so strong a myotic, it seems to have a better effect in reducing ciliary congestion; secondly, it allays pain instead of causing it, as eserine does. We know of no reason why the strength of the solution should not be increased in critical cases; but 4 grains to the ounce is as strong as we have used. Whether the salicyllate of sodium does good of itself, we can not say positively, but at any rate it preserves the solution, and we have sometimes fancied that the pilocarpine solution was more efficacious when combined with it. So we invariably use it at the rate of 10 grains to the fluid ounce. Very possibly it may be found that hypodermic injections of pilocarpine (one-sixth grain) may be of service, but I have thus far never used them in this connection, preferring to rely upon aceta- nilid as internal treatment. Unless the patient was kept in a recumbent position and the circulation and temperature noted it would not be safe to make use of both these depressing agents at once. Perhaps we may find cases wherein this, as in so many other diseases, the recumbent position is highly advisable; but oftentimes the pain is of such a character as to make the patient restless instead of causing him to seek repose. For the hot external applications the patient was allowed to make an extemporaneous solution of boracic acid, but the mode of applying was as specific as possible. The applications were made with soft cloth dipped fre- Quently (once a minute), kept at about the highest comfortable temperature, and continued twenty minutes each time. The frequency of repeating them varied with the case, from once a day, to every three hours, or oftener. We had hoped to obtain favorable results from the use of gelsemium, but, at least in the dose employed, it did not yield as favorable results as acetanilid. The early employment of temporary glasses is a measure not to be neglected in certain cases, for in these irritable eyes a sensible man will not attempt a great amount of subjective testing for glasses; and we doubt if many cases retain the same refraction when the acute and the subacute symptoms have passed that existed during those stages. Regarding iridectomy in this disease, we are confident that it is an operation which will fall more and more into disuse. It was an empirical operation at best, and though it served a very useful purpose in its day it has comparatively little place in attending to the better-cared-for eyes of the present. While it may still remain a desirable procedure for certain urgent and neglected cases, it does not always produce satisfactory results, and should by no means be lightly adopted as routine practice. BISCUSSION. Dr. McFARLANE. I am glad to know that some one has had such universal good fortune following operations for glaucoma. It has not been my fortune, nor the fortune of those with whom I have been most familiar, except in acute or subacute forms of the disease. I would refer to the report of a group of cases by Dr. C. S. Bull, of New York, in which the results were far from satisfactory. I think medica- tion valuable as well as iridectomy, which can not be discarded. Dr. TIFF ANY. In my first years of practice in Kansas City I had frequent cases of acute glaucoma; of later years they have been less frequent. . I attribute this to the fact that the cause has been largely removed by the universal correction of low PAN-AMERICAN MEDICAL CONGRESS. 1397 forms of ametropia, as of hyperopia, of astigmatism, and of hyperopic astigmatism in particular. - Dr. REDMOND. I speak more through observation here and abroad, as these cases are not by any means common, yet in my experience I have found that surgical interference is almost always necessary. Cases in which I have seen iridectomy fail have been generally attributed to corneal vision instead of Scleral. Dr. ALT. Dr. Dean claims that eye strain is the cause of glaucoma. If it was the cause a great many more people would have glaucoma. There must be something else behind the eye strain, which even this paper on the etiology of glaucoma does not clear up, and for which no theory has yet fully accounted. Dr. BAKER. The last case but one which I operated upon for glaucoma was in an old lady 74 years of age. If glaucoma is due to eye strain, as stated by the essayist, how would you explain it in such a case as this? Dr. SAVAGE. Yes. In the old there is no ciliary strain; but strain of the recti or obliques can exist at 120, or any age. Such strain begins in infancy and ends only with death, unless relieved by treatment. Dr. S. S. HOSER. I am loath to believe that these cases come to us sufficiently early to make out with exactness these low grades of refraction. Certainly those who come to me are. And as to therapeutic management, I have not seen much success therefrom. On the contrary, rather let us operate early, while it is yet possible to do an iridectomy neatly, and not wait until the iris is so degenerated that an equally clean operation can not be done. Dr. TYNER. I have my doubts as to the existence of chronic glaucoma and to eye strain. They rarely ever come to us in time for correction. Most of my cases have been in persons who were poor and did not use their accommodation. That a real and timely-made iridectomy is mostly successful I am sure. Dr. J. J. CHISOLM. While an iridectomy is the only reliable treatment for glaucoma, especially the acute forms, I have sometimes derived such excellent results from eserine as to do away in some instances with the need of the operation. Only to-day I saw a case in a gentleman whom I had first seen in August, fifteen days since. He was 62 years of age and had been suffering intensely for ten days with inflammatory glaucoma in the left eye. The eye was much injected, pupil enlarged, anterior chamber obliterated, tension marked, and sight reduced to counting fingers. The cornea was too steamy to give the fundus definition with the ophthalmoscope. He had walked the floor all night from severe pain. I determined to prepare the eye for operation by trying to establish an anterior chamber by use of a 1-grain solution of eserine instilled upon the cornea six times a day, and advised the use of the Japanese hot box for dry heat. The temperature of about 1159 was kept up for two hours at a time and was ordered three times a day. The heat relieved the pain and by the next day I found the pupil contracting. The eye steadily improved until at the end of a week all congestion had disappeared, and with it all pain. Sight had returned as the congestion subsided, and to-day when I saw him there was no need of an operation at present. Sight is normal, congestion all gone, and, with the exception of a much-contracted pupil, the eye looks quite as well as the other, which was not affected. How soon there may be a repetition of the glaucomatous attacks in this individual case I am not able to say. I have other cases of two years' stand- ing that I have relieved as promptly as in this instance and they remain cured. I am beginning to have so much confidence in the eserine and dry heat for the relief of acute glaucomatous attacks that I am quite ready to advise this treatment as a prepa- ration for an iridectomy should the relief not come in a few days' use of the remedies. For convenience, cleanliness, and the very great advantage of keeping up the same temperature, I would call the attention of the section especially to the Japanese hot box, which is in universal use in Japan to relieve pain in all cases in which we apply moist heat. They can be found at all stores selling Japanese goods. The boxes, as we find them, not made for eye work, are about the size of the hand in length, breadth, 1398 PAN-AMERICAN MEDICAL CONGRESS. and thickness. A charcoal fire is used for heating. Under the slow combustion of the box it will burn for about two hours and will keep up a temperature of from 1159 to 120°. I have had them in general use, both at my hospital and in private practice, for fully three years, and I know no substitute for them in any case of severe eye con- gestion, especially in glaucoma. Patients who have once used it fly to it for relief with confidence whenever the pain recurs. In closing the discussion Dr. Dean said: I am very glad that so much discussion has been elicited. And it was not to be expected that so learned a group of scientific gentlemen would accept all the ideas advanced unchallenged; it is not in the nature of things. My object was to start up trains of thought that might lead to useful results. My leading idea was to explain the underlying or predisposing cause of glaucoma; not to combat the opera- tion of iridectomy as such. I believe in iridectomy in suitable cases, where the rapid reduction of tension is an urgent necessity. What I meant was that, by begin- ning early with suspicious cases, its application might be gradually circumscribed. I also ventured the prediction that it would be less often required in private practice as the people learned to take earlier and better care of their eyes, aided by the painstaking efforts of skilled oculists. CATARACT EXTRACTION WITH THE IRIS RETRACTOR. By FRANCIS WALK, M.D., Instructor, Diseases of the Eye, New York Post Graduate School and Hospital, etc. Since the early part of 1887, I have performed the operation for the removal of cataract by a method somewhat different from that usually adopted. This I have placed before the profession at the Post-Graduate School, at the State society, and also at the meeting of the New York Academy of Medicine, but, owing to unforeseen circumstances, there has been no opportunity for my colleagues of New York City to criticise or to discuss the merits or demerits of the retraction of the iris, and the removal of the lens at the same time. I have, therefore, asked the honor and the privilege of bringing this matter before the congress, that it may meet with a full and a fair discussion. I shall always highly appreciate the opinions and suggestions of those who have entered this special branch of surgery, before I attempted to step on the first round of the ladder of fame, as well as the remarks of those who are working side by side with me in trying to advance this noble art, even though our efforts may not meet with the approval of all, still we hope these are but steps for- ward, if I may call them such, that they may some day fall into the hands of men who may so improve them as to produce far better results. I do not propose to discuss the merits of the different methods for the removal of the sclerosed lens, which intercepts the rays of light, nor the special features of an operation with or without an iridectomy, as the advantages of a round and normal pupil are well known and obvious. Nor yet do I believe there will ever be a day when the conscientious surgeon will adhere strictly to only one method of operation, but will always adopt what he thinks best for the ultimate good of his patients. Therefore it is my intention in this paper to suggest some thoughts and methods that have occurred to me in the course of my limited number of operations and to explain the uses and advantages of the simple little instrument, “the iris retractor,” that I have used whenever possible during the past four years. As regards the time to operate. I think that this should be decided, when we find the cataractious lens sufficiently hardened to admit of its ready removal, without any reference to what the vision in the other eye may be. If our patients are willing to have an operation performed, even though the vision may be good in one eye, say #3, then you are justified in taking the slight risk there may be of failure for the PAN-AMERICAN MEDICAL CONGRESS. 1399 benefit of the improved binocular field of vision. The blindness on one side renders our patients at a disadvantage, as some of my cases will show; at the same time we make a useless eye ready for practical vision, when its fellow lens become opaque. Preparation for the operation.—We may do nothing as regards the ultimate success, except so far as we may have the minds of our patients completely at rest. In the light of the present statistics, the chances of failure in a healthy eye, if a cataractous eye can be healthy, are very small, as you may see by the reports of cases lately published. So I do not in any way prepare my cases beforehand, and particularly avoid the use of atropine before the operation. Operation.—At the time when I am ready for the operation, I instill a sufficient quantity of a solution of cocaine, 4 per cent., to render the cornea anaesthetic, but not to dilate the pupil. The patient is then placed on a steady table or bed with a good clear light on the eye, and the lids opened with the speculum. The eye is then washed with a solution of boracic acid while my instruments are all placed in boil- ing water and then on a clean towel and covered until wanted. - Section.—This I consider the most important part of the operation, as upon a good section, I believe, depends the ultimate success. This should be in the same plane, except at the finish, as I shall describe. I wish to avoid the conjunctival flap, and by the perfect coaptation of the wound in the cornea we may avoid slow healing, septic infection, and prolapse or incarceration of the iris. I make the section either upward or downward, according to the eye to be operated upon, as upward in the right eye, downward in the left eye, or, if the operator is ambidextrous, then both sections may be made upward, as I consider the upward section preferable. I prefer, in making my section, to cut always towards myself, for in so doing we produce a much smoother and clearer cut. I always make the puncture and counter puncture wholly within the corneal tissue, through its transparent margin, about 1 millimeter from its periphery and so that the cutting edge of the knife will just cover the pupillary edge of the iris on the side toward which I propose to make the section. If possible Irapidly make the section of the cornea with three distinct cuts; first, carrying the point of the knife, as soon as the counter puncture is made, upward and forward, cutting one side of the cornea; then the heel of the blade is drawn upward and backward, so cutting the opposite side; then turning the knife on its long axis, the section is completed with the third cut by pushing the knife steadily forward until released. I think De Wecker, of Paris, first suggested this method, and I prefer it to all others. As I complete the section in the above manner the knife comes out some distance from the scleral junction, leaving room for the iris to be tucked in, when drawn back by the retractor. At this time we may have prolapse of the iris; if so, it must be returned with the spatula, if we wish to save the iris; but if not, then it may be drawn out and cut off, if we decide that an iridectomy is best. Another complication that may occur at this stage, particularly in very old people, is the rupture of the capsule or the zone of Zinn, with the presentation of the lens at the section; if so, it must be removed at once by pressure on the cornea. I am inclined to think that should there be any tendency to prolapse at this stage, it is better to perform an iridectomy at once, to prevent any future prolapse as the healing process proceeds. If no com- plications arise I then proceed to open the capsule by a peripherial incision, passing the cystitome inward to the pupillary space, then under the iris, and sweep it around beneath the edge, so as to cut the capsule in more than one-third of its peri- phery on the same side that the section has been made. My next step is the draw- ing back of the iris and the extraction of the lens. At this point I wish to say a few words in reference to my method of the retraction of the iris with the little instrument called the “iris retractor,” which I now pre- sent, claiming that I first adopted and practised this method. In the Archives of Ophthalmology, May, 1888, page 60, Dr. Herman Knapp states that, before and since I read my first paper on this subject, he had drawn back the iris toward its periphery when he found that membrane somewhat rigid, using the small wire 1400 PAN-AMERICAN MEDICAL CONGRESS. loop, but he does not state that he held the iris drawn back until the lens was removed, so I infer that he simply drew it back to relieve its rigidity, or to break up any adhesions that may have formed between the iris and the anterior capsule. Again, I find in an article by Dr. Barton Pitts, of St. Joseph, Mo., in the Medical Record of October, 1890, wherein he claims a method of operation by which he draws back the iris with the same wire loop which Dr. Knapp used, and held it there until the lens passed out by pressure on the cornea. In the same paper Dr. Pitts criticises my retractor, when, according to his own admissions, he has never seen my instrument, nor does he even know its construction, but has simply followed out my ideas of drawing back the iris and holding it tucked back until the lens is removed. He does not give me the credit of having first adopted that procedure, though his ideas may be original with himself. I will quote Dr. Pitts’s words: By Dr. Walk a distensible shield with two knobs is proposed. The method of its manipulation is to insert through the corneal wound, cover the surface of the iris, and by the knobs holding in the pupil, retract the iris upward as far as necessary and slide the lens over the front surface of the shield. Dr. Walk reports good results with it. I have not tried it, nor am I familiar with its pattern except from description. I should think, however, it objectionable, on the score of occupying considerable space, already too limited. Its insertion, moreover, I think awkward, and in the event of sudden movement of the eye under operation its presence in the anterior chamber especially dangerous. * * To overcome the resistance of the iris and frequent rigidity of the pupil, I have for two years resorted to the same instrument recently mentioned by Dr. Knapp as used by him; that is, a fine wire loop attached to a delicate handle. This instrument, which can be easily and thor- oughly sterilized, I insinuate through the corneal wound into the pupillary space and retract the iris into the superior triangular space, and by a gentle pressure backward and upward of a strabismus hook applied against the lower edge of the cornea, I have little difficulty in the delivery of the lens and without material injury to the iris, and in no instance accompanied by loss of a single drop of vitreous, or followed by septic infection of the eye. I have quoted his remarks thus fully, that you may note the different methods, and also if this little instrument is at all objectionable because it occupies too much Space, or is especially dangerous in any sudden movements. I have never found it So; and in reality this retractor of mine does not take up any more room than the Wire loop, Inor is it “awkward” in any sense, as it can be easily removed from the eye by simply tipping up the ends of the blades, thus instantly releasing the iris. It seems to me that the construction of this little instrument is extremely simple, having only two small smooth knobs on the ends of a pair of forceps, with crossed action, and the size of the ordinary iris forceps. These little knobs, standing at right angles to the axis of the ends of the blades, and pointing downward, simply hold the iris tucked back in the superior triangular space until the lens passes into the corneal wound, when the iris is at once and easily released. When we consider the ease with which the lens passes out and the slight pressure required on the cornea, so much less than in the simple extraction universally adopted at the present day, I feel justified in claiming some merit and originality for this little retractor. The eye being now ready for the extraction of the lens, it is grasped by the fixa- tion forceps directly opposite the section, and held steady by a careful assistant. I now take the retractor in the left hand and with the blades closed and the set-screw so arranged that the blades will open to about the diameter of the pupil, I insinuate the ends through the section to the pupillary space. The blades are now opened by pressure and the iris drawn back and tucked beneath the edge of the lower corneal Section. Holding it steady in that position, a slight pressure is made on the oppo- site side of the cornea, by a spoon or hook, causing the lens to rise up and easily pass out over the ends of the blades. As it does so, and as soon as the lens presents itself at the section, the retractor is pushed slightly inward, at once releasing the iris. The retractor is then generally removed, with the lens lying in the concavity of the blades. As the lens clears away we find the iris back in its position, not injured in PAN-AMERICAN MEDICAL CONGRESS. 1401 any way, nor has it been exposed to the air, as may occur in simple extraction. In case there should be any cortex remaining, which I do not think will be absorbed or will interfere with the vision, I have reintroduced the retractor, and, drawing back the iris again, these masses are easily pressed out with the spoon. This completes the operation, and the section being in perfect opposition, the speculum is removed, the eye gently closed, and the bandage applied. After treatment.—There seems to be as much diversity of opinion as regards the method of after treatment of an operation at the present day as there is in the methods of operation, even so far as not to use any bandage or dressings of any kind. I note that Prof. Knapp does not close the eye until about half an hour after the operation, in order to see if there is any tendency of prolapse. He only applies the cotton and isinglass slips, while Chisholm, of Baltimore, does not even apply any cotton; but as I have watched the healing process of my cases and noted the differ- ent conditions under which my patients have, from necessity, been placed, I am inclined to think that it is best to take a happy medium with a decided modifica- tion of the old strict method in use some years ago. Our first gonsideration must be the ultimate success of the operation and next the daily comfort of our patients as the healing process proceeds. Bearing these two points in mind, it seems to me that there will be fewer movements of the eye, and consequently less pressure on the sclera by the straight muscles, if we close both eyes with a meat-fitting flannel band- age with pads of absorbent cotton over the eyes. The slight restraint of a day or two in bed will not cause any distress, while the rest and quiet will assist in the rapid healing of the large corneal wound. I do not doubt but that those who use modified dressings have as good success as can be wished for, though the above ideas Seem to me the best that we may employ to complete the healing of our patients, according to the old motto Tuto, cito et jucunde. I remove the bandage from the eye not operated upon at the end of forty-eight hours, or on the second day, as I do not wish, nor do I see any need, to keep these old people in the dark any longer than is absolutely necessary. - In my last four cases I have tried to carry out my ideas of non-interference still further, as I sometimes think that atropine may irritate an eye which has been operated upon for cataract, and lately I have not used this drug unless necessary; that is, when there were indications of commencing iritis; but I have changed the bandage every twenty-four hours, washing the lids carefully and gently with warm water, applying a little vaseline to the edges of the lids, and then replacing the bandage. - Now I wish to make another suggestion in reference to that desire which we per- haps all have, to look at the eye and to see the result of our work. Is it not better to leave the eye alone until all possible danger of complications has passed? Some of us have noted an opening of the wound or prolapse of the iris as late as the sixth day after the operation. Therefore I have decided to simply change the dressings every day for about ten days, unless there are some indications otherwise, and then open the eye in a darkened room, gradually accustoming it to light by the use of smoked glasses. Prof. P. D. Keyser, of Philadelphia, and Dr. W. Buss, of Bradford, Pa., have used my retractor in several cases, and have reported to me good results, each being pleased with the easy exit of the lens and the rapid healing of the wound in the COTIle:Ø. . In conclusion, I do not think that the surgeon who considers the best interests of his patients and the various conditions that may arise during an operation for the removal of cataract will persistently adhere to any one method of operation. In my own cases I have been compelled to lay aside the retractor in four cases out of thirty-three. So the surgeon must adopt that method which to him at the time seems best for the success either with or without an iridectomy, but we can adopt some method and endeavor to carry it out, unless we find it will endanger the final results. 1402 PAN-AMERICAN MEDICAL CONGRESS. Some of my cases have required a subsequent discussion, but as each case of that kind requires special study and method in itself, I will not make any particular refer- ence to it, except so far as I consider Dr. Knapp's remarks as to the operation, deliv- ered at Detroit, as the best and giving the final results required. In the following table I give the histories of 29 cases in which the retractor was used: No. .: º N sº g O ; § al]] e. 9. * | • • • • - - - - - - - - - • •sºſeuue）{ SºſºVN. :9p：BJ 3 q\， InOJI - - - - - - - - - - -sºſeuue）{ - - - - - - - - - • • • • •SøſæIN :9pt; I3 q\ļț¢I - - - - -，SðIGUÐIÐ „H SºſºVN. :ºpe.Užſ ĻļxţS • • • - - - - - - - -> • <- • • • - - - •~~~~ sa ſuureſ SaſeJÄI :øpſb.I:3 qąttº A9S - - - - - - - - - -sº ſeuIÐJI ------------- sºțeſ :øpe. Lº qļų3țGI * CIGI?ŁO’TOO QUIQO IQ&{ • - - - -[8ąOļ puſē.ī£) g Co- Av- AS- Am & nus Grades examined. erage the- bly- cºa Or . q- Em ... [H. ret.) M. gl. M.ret. ai Em H. M. age. |nopia. Op1a. . DOleIl ST1g. & about disk. COLORED–cont'd. Second grade: . Per ct. ..] Per ct. No. | Per ct. | No. Per ct. Males ------------- * !-------|-------|-------|------- 2 20 || 0. 666 8 2 | 1 |------- 0.666 || 8 || 0.266 || 2 0.066 Females----------- * -------|--------------|------- 2 24 0.800 6 ? -------|------- 0.800 || 6 || 0.200 || 0 (). 000 Total.------------ 9;al--------------|-------------- 4 (). 733 14 4 | 1 |------- 0.733 14 || 0.233 2 0.033 Males: th Total.--------------| 210 |------ 5 | 2 ||------- 2 26 || 198 |169 |_ _ _ _ _ _ _ _ 3) 22 8 |169 |- - - - - - - - 32 ||-------- 9 |-------- Per cent ----------|------|------ 0.002 || 0.009 |- - - - - - - 0.009 || 0.12 0.804 0.14 0.10 0.04 0.804 || - - - - 0.152 |_ _ _ _ ] 0.042 Females: Total.--------------| 210 |------ 16 || 0 ||------- 0 35 | 181 | 154! -------- 39 19 || 8 || 23 |154 - - - - - - - - 39 -------- 17 -------- Per cent ----------|------|------ 0.007 || 0.000 |- - - - - - - 0.000 || 0.16 (). 733 0.19 0.09 0.10 0.733 |--|--| 0, 185 |. -- 0.080 Grand total.-----| 420 ------ 21 2 ------- 2 61 || 379 |323 |_ _ _ _ _ _ _ _ 69 41 21 (323 |-------- 71 -------- 26 -------- Per cent -------- * * * * * * 0.05 || 0.004 - - - - - - - 0.004 || 0.14 (). 769 0.16 0.09 0.05 0.769 |_ _ _ _ (). 169 |- - - - || 0.063 PAN-AMERICAN MEDICAL CONGRESS. 1421 FURTHER STUDIES OF THE CYCLOPLEGIC VALUE OF HOMATROPINE AND COCAINE DISKS, AS ATROPINE, DUBOISINE, AND HYOSCINE SUBSTITUTES. By CASEY A. WOOD, C. M., M. D., Ophthalmic Surgeon Alescian Hospital, Oculist and Awrist Cook Cownty Hospital and to the Emer- gency Hospital, Chicago Post Graduate Medical School. Nearly three years ago, in an article contributed to the American Journal of Ophthalmology, I gave the results of some experiments I had made with mixtures of homatropine and cocaine, and with solutions of atropine and duboisine, for the purpose of comparing their relative merits as cycloplegics. The conclusions I then arrived at were these : (1) In the shape of watery solutions probably less than 10 per cent of the dis- solved alkaloid becomes absorbed in such a way as to affect the eye, the remaining 90 per cent being carried off into the nasal duct or flowing over the cheek with the tears. (2) Mixtures prepared with vaseline, sanitas jelly, lanolin, and similar men- strua, or, as in Lang and Barrett's" experiments, castor oil, are much longer retained in the conjunctival sack. The drugs thus longer kept in contact with the Ocular and palpebral surfaces undergo, as Green suggests, a much more extensive absorption and produce a still more pronounced effect. (3) They are absorbed by the blood vessels and other absorbents of the cornea and conjunctiva, and not by those of the nose and throat. But such oily and greasy mixtures have this serious drawback : They leave a thin film upon the corneal surface which interferes with the examination of the eye, especially when One wishes to determine the refractive condition. (4) The form of gelatin lamellae or disks appear to be the most useful one in which to apply agents to the eye for the purpose of securing their fullest mydri- atic and cycloplegic action. These undergo a slow, regular, and complete absorp- tion when put into the conjunctival sack. (5) The addition of cocaine to almost all the alkaloids used in ophthalmic prac- tice undoubtedly increases their peculiar effects. (See also the reports of Malakoff and the experiments of Lang and Barrett beforementioned.) (6) From the foregoing results, and after much experimentation on the subject, I concluded that the most decided cycloplegic effects of homatropine are obtain- able from its employment in the gelatin disk form, associated with cocaine. In its most convenient and stable shape these disks can not be made to hold more than gr. ºs of these alkaloids, hence I was necessarily restricted to the use of gr. #5 each Merck's homatropine and cocaine. Since the publication of my original paper I have not lost sight of the purpose I originally had in view, viz, the attempt to find some cycloplegic less objection- able than atropine for the measuring of refractive errors. I happen to be a firm believer in the doctrine that it is necessary to know the absolute refractive condi- tion before one can intelligently prescribe glasses, and I further believe that it is requisite to paralyze the accommodation as the best means of obtaining the informa- tion in the majority of cases under, and in some cases over, 40 years of age. For the past year I have been engaged in this line with the gelatin disks aforesaid, with disks containing gr. ºr of homatropine alone, and with various solutions in water tropacocaine, homatropine plus cocaine, duboisine Sulphate, atropine sulphate, hyoscine hydrobromate, and hyoscyamine sulphate. Without troubling you with details, I may say briefly that for the determination of the refractive condition, and with the idea of making the conditions of the comparative test *Lang and Barrett: The Action of Myotics and Mydriatics. Oph. Hos. Reports, Vol. x1, 130 and 219, * 1422 PAN-AMERICAN MEDICAL CONGRESS. as constant as possible, I chose those patients in whom I could employ a number of agents at proper intervals, and whose refractive state would be most likely to afford reliable tests. These were put under the influence of the particular cycloplegic and their refractive state determined by retinoscopy. Every case was carefully worked out by my assistant, Dr. T. A. Woodruff, who is an expert skio- scopist. Sometimes one agent was used first, sometimes another, but in every instance the effect of the previous cycloplegic was allowed to pass off before the second was employed. Using all possible care to avoid sources of error, the refrac- tion of 34 selected eyes, furnishing 68 principal meridia, was thus determined. The results I have here drawn up in chart form. EI. and C. Number. Atropine. Hyoscine. Hºlo. Number. Atropine. Hyoscine. discs 1 -------------- +3. +3.25 —H3. 35 ------------- +5. —H. 50 * 2-------------- —H1. 75 ––1, 75 +1.75 || 36 ------------- +6.50 +6.50 +6.50 8-------------- —H2.75 +2.50 +2.50 || 37 ------------- +5. +5. 5 4-------------- —H1.50 +1.50 +1.50 || 38 ------------- +6. +5.50 5-------------- +0. 75 –H0. 50 +0.50 || 39 - - - - - - - - - - - - - +5, ------------ 4. 5() 6-------------- 4 +4.25 –H4. 40 ------------- +8. ------------ 8, 7-------------- +2.25 +2.25 —H2. 41 ------------- +4.50 |------------ +4. 8-------------- +3.25 +3. +3.25 || 42 - - - - - - - - - - - - - +6. ------------ +6. 9-------------- +1.25 —H·1. 75 +1.50 || 43 - - - - - - - +8. ------------ +8. 10-------------- +2.50 +2.75 +2.75 || 44 ------------- +9. ------------ +9. 11 -------------- +1.50 —H·1.50 –H1.50 || 45 - - - - - - - - - - - - - +10. ------------ +9.50 12 -------------- +2.75 + +2.75 || 46 ------------- +11. ------------ + 10.50 13-------------- +2.75 |------------ +2.50 || 47 - - - - - - - - - - - - - +1.25 ------------ —H1.25 14-------------- +2.75 |------------ +2.50 il 48 - - - - - - - - - - - - - +1.50 ------------ +1.50 15 -------------- +2.75 ||------------ —H2.50 || 49 - - 2. ------------ +1.75 16 -------------- +2.75 ||------------ —H3. 50 ------------- +2.25 ||------------ +2 25 17 -------------- +5. +5.50 –H5. 51 ------------- +2.25 |. ----------- +2 25 18 -------------- +5. —H·6. +5.50 || 52 ------------- +2.25 !------------ +2.25 19 -------------- – 6.25 –H5.50 –H5 53 - - --7. * * * * * * * * * 7 20 -------------- —H7. +7. +6.50 || 54 - - - - - - - - - - - - - +11. ------------ +11 21 -------------- +1.75 |------------ +1.25 || 55 - - - - - - ------- +6.50 |- - - - - - - - - - - - * * -------------- +1.25 ||------------ +1.25 || 56 ------------- +10 |------------ +9. 50 23 -------------- +1.50 |------------ +1.25 || 57 -------- - - - - - +3.25 |. ----------- +3 * -------------- +1.75 |------------ +1.50 || 58 - - - - - - - - - - - - - +8. ------------ 3 *5 -------------- +3.75 —H3.75 +3.75 || 59 - - - - - - - - - - - - - +3.25 ||------------ +3 25 26 -------------- f; 50 +5. –H5. 50 || 60 - - - - - - +3. I------------ 27 -------------- 2.50 +2.7 +2.50 || 61 ------------- +1.50 ||------------ +1, 50 38 -------------- i; +3.25 –H3-50 || 62 - - - - - - - - - - - - - +3.50 |. ----------- +3.50 29 -------------- 5. ––7. +6.25 || 63 - - - - - - - - - - - - - +3.75 ------------ +3.75 30 -------------- +6.50 +7 +6. 50 || 64 ------------- +2. ------------ 2 31 -------------- +2.25 ||----...------- +2 65 ------------- —1. —1 —1 33-------------- +3. I.----------- +1.50 || 66 ------------- +1.25 —H·1.25 +0.50 33-------------- +1.50 * * * * * * +1.50 || 67 ------------- +4.50 –H4. +4.50 34-------------- +1.50 - - +1.50 || 68 ------------- +5.50 +5.50 —H3.75 In these observations (166 in all) 2 drops of 1 per cent solution of atropine sul- phate were dropped in each eye 3 times daily, after meals, for 2 days, and the examination made in from 1 to 3 hours after the last instillation. Of the hyoscine and hyoscyamine 2 drops of a 4-grain solution were instilled into each eye 3 times at intervals of 20 minutes, and the examination made in from 1 to 2 hours after the last dose. The disks were employed as hereafter described. Every precaution was taken to prevent poisoning by the hyoscine and the disks were used for the exami- nation of the same merida in 30 instances. In 16 of these the refraction was exactly the same, or the highest differed from the lowest not more than 0.25 D. In 10 instances the difference was 0.50 D. In only 2 instances out of the 30 was there a greater difference than 0.50 D., a case to be afterwards referred to. In these 30 cases atropine showed the highest refraction or was one of the highest in 19 instances; hyoscine in 22 instances, and homatropine and cocaine disks in 15 instances. Coming now to the tests of atropine and H. & C. disks we found that they were the same, or did not vary more than 0.25 D. in 58 out of 68 meridia. Of the remaining 10 the result varied 0.50 D. in 8 cases, and in 2 instances there was a radical difference, to be again referred to. Speaking generally, atropine showed a higher refractive condition than the disk in 21 out of the 68 cases, while the disks showed an increased refraction over atropia in 4 instances. In a single instance of mixed astigmatism, before referred to, did the refraction of 2 prineipal meridia PAN-AMERICAN MEDICAL CONGRESS. 1423 amount to more than 0.50 D., viz, 0.75 D. and 1.75 D. greater in the case of atropine than that shown by the disks. In this case the disks were first used. That this may happen in a second trial of any cycloplegic, in relieving a spasm of the accommoda- tion, is well known. I have recently had a case which well illustrated this fact, where a second trial with atropine showed a much greater difference. A boy, aged 16, with marked astigmatism in each eye was atropinized in the usual way with 1 per cent solution, and the skioscopy and result was 2.75 D., 3.25 D., 2.50 D., 3.25 D. A week later he was found to have withfull correction nearly in either eye. My sus- picion being aroused by this early acceptance of his glasses I again atropinized his eyes and the result was -H4 D. and +4.75 D., +4.50 D. and +5.25 D., i. e., an advance of between 1.25 D. and 2.00 D. in the 4 meridia. Ten days afterwards he obtained V.- : — in either eye. A month afterwards his W. in each eye was $ -- with all symptoms relieved. - As a result of these and other experiments I have reached the following con- clusions, some of which are modifications of the propositions contained in my first article: (1) If two gelatine disks containing gr. tº each of homatropine and cocaine be placed in the conjunctival sac at an interval of 20 minutes, the eye being all the while kept closed, the ciliary muscle will in most instances be found to be fully paralyzed in from 70 to 100 minutes after the introduction of the first disk. (2) In persons under 25 years old, or whenever ciliary spasm is suspected, the best results are obtained by the use in another 20 minutes of a third disk or one containing gr. sº of homatropine alone, the examination in that case being best made between 90 and 120 minutes after using the disk. The first two disks con- taining cocaine are sufficient to furnish the chief advantage which, in my opinion, resides in that alkaloid, viz, of increasing the absorbing powers of the cornea for agents combined with it, while the increased dose of homatropine produces a more thorough relaxation of the ciliary muscles. An eserine disk (gr. rººm) inserted the following morning will enable the patient to do near work within an hour or two. (3) The disk should be inserted in the eye on the tip of a damp camel's hair brush and should always be applied to the ocular conjunctiva at its inferior and outer surface, the patient looking up and in while the lower lid is drawn down. Any adherent or sticky gelatine may be easily wiped off the pal- pebral edges with a damp cloth or a piece of wet absorbent cotton. In my preference for these disks over any solution of atropine I wish to state that I do so only on the grounds of the quicker and more evanescent cycloplegic action of the former. I always use atropine whenever I possibly can, and particu- larly if in my judgment the patient would be benefited by ciliary rest, as many of our cases are. But for the business man, the clerk, the bookkeeper, the lawyer, the doctor, the school-teacher, et hoc genus omme, ten days of ciliary or any other kind of rest is usually impossible. It is with them either an examination for glasses of the optician and jewelry store order or a transient cycloplegia. In the list of dangerous cycloplegics I would place duboisine, hyoscine, and hyoscyamine. They are all, especially the last two, much prompter and more fiercely active cycloplegics than atropine or these disks. If hyoscine and hyoscya- mine are used in solution and in doses strong enough to insure ciliary paresis, i.e., in disks Somewhat less than atropine and duboisine, they are certain to produce toxic symptoms more or less pronounced in about one-quarter of the cases. If used at all they should be instilled in the oculist's office, and in my experiments I found this to be the only safe plan to pursue. If this be done, the refractive con- dition can be readily determined in one day, the ciliary paresis passing off in from 72 to 96 hours. Upon their cycloplegic action single disks of eserine have little or no permanent effect. Tropacocaine has, so far as my experiments went, no cyclo- plegic advantages over cocaine, while its mydriatic action seemed to me to be less than that of cocaine. 1424 PAN-AMERICAN MEDICAL CONGRESS. THE NECESSITY FOR COMPLETE SUSPENSION OF ACCOMMODATION BY MYDRIATICS IN THE ADJUSTMENT OF GLASSES. By G. C. SAVAGE, M. D., Professor of Ophthalmology, University of Nashville and Vanderbilt University, Nashville, Tenn. If the accommodation could be suspended instantaneously and then, after the work of refraction has been accomplished, could it be as speedily restored to the normal, who and where is the oculist who would not exercise such magical power in all his cases of refraction? If the exercise of this supposed magical power would be justifiable, then there must be some strong reasons for using the means, really at Our Command, for putting at rest the ciliary muscle when a focal error, what- ever may be its nature, is to be corrected. It is the object of this paper to give the reasons that not only justify but actually demand the use of the mydriatic in refractive work. In presenting the numerous reasons for the use of the mydriatic in the work of refraction all the reasons against its use will be met. While in Some cases glasses may be prescribed simply to sharpen vision, it must be con- fessed that the greater number of cases coming under the observation of the oculist are persons.who suffer because of strain. This leads us to inquire, what is eye-strain A clear understanding of what the answer to this question should be will go far toward settling the question of the proper line of practice intended for its relief. None will controvert the statement that eye strain is muscle strain, and that the muscles concerned in the visual act are; first, those regulating the quantity of light admitted into the eye and the direction of its rays, these are the two sets of fibers in the iris, and the ciliary muscle; second, the extrinsic muscles, the recti and the obliqui, which are concerned in directing the visual axes and in keeping the naturally vertical meridians of the corneae so related that images may fall on corresponding parts of the two retinae. Muscular action is not muscle strain, unless the action is either too prolonged or too great for the inherent power of the muscle. Some, by their teaching, would show that only the ciliary muscle is susceptible of strain, and that ciliary strain alone is capable of bringing into existence that long train of nervous phenomena with which the oculist and, of late years, the neurologist are so well acquainted There are others who are accused of believing and teaching that the extrinsic muscles are alone susceptible of that fatigue which brings discomfort, in varied forms, to our patients. There are not a few, however, whose practice is governed by the sounder doctrine that both the intrinsic and extrinsic eye muscles may be put to the necessity of doing more work than their strength will bear, and that the consequent strain, whether in the one set or in the other, or in both at the same time, will develop headache, vertigo, confusion of thought and a host of other phenomena. While glasses prescribed for the correction of focal errors were once thought capable of curing all symptoms dependent on eye strain, the time is now when no such claim can be sustained. Lenses that give a perfect correction of existing focal errors may, in some instances, augment rather than allay the suffering due to eye strain. Such patients would be better without lenses until the chief cause of suffering, in the individual case, has been found and, by the proper treatment, cured. But I am not one to cry out against the prescribing of glasses. My wearing lenses is sufficient evidence of my regard for and my appreciation of them. Properly determined, scientifically prescribed, and correctly worn, they do only good. But in prescribing glasses we must take into consideration both the focal error and the muscular adjustment, particularly the adjustment of the internal and exter- nal recti. Since glasses can do more than relieve ciliary strain; they can, if prop- erly selected, relieve strain of the internal and external recti independent of pris- PAN-AMERICAN MEDICAL CONGRESS. 1425 matic effect;* also strain of the oblique muscles in cases of oblique astigmatism; they should be scientifically prescribed, after a most painstaking study of the focal error and the muscular adjustment. For the present, fixing our attention on focal errors, we find that there are these: myopia, hypermetropia, and the several kinds of astigmatism. In emme- tropic eyes there is no strain, in the proper sense, when used in moderation. In simple myopia of 3 D. or more the ciliary muscle is never calleſl into action and, therefore, can never be strained. If such eyes give annoyance, other than dim- ness of distant vision, the cause must be sought, and will be found in the relation- ship of the extrinsic muscles. In simple hypermetropia the ciliary muscle, during waking hours, is ever acting until quieted by age. Any action of the ciliary muscle for sharpening distant vision is strain, and in such eyes overaction (strain) is necessary in order to good near vision. In some of these cases the ciliary muscle is hyperdeveloped, the center controlling it has an abundant supply of nerve force and there are no symptoms resulting from the strain. Other hypermetropes are not so fortunately constituted, and the ciliary strain, caused by the refractive error, is felt in some form or other. In astigmatism, of whatever kind, with the principal meridians in the vertical . and horizontal, or if oblique the obliquity is in the same direction and at the same angle in the two eyes, the astigmatic refraction also being equal in the two eyes, there is ciliary strain directed against this refractive error. As to the character of the effort made by the ciliary muscle there is some difference of opinion. What- ever may be the nature of this strain it is capable of correcting wholly only the lower degrees of astigmatism, and only a small part of the higher degrees of this error; but that the effort is being continually made for distant and near vision, in cases of hypermetropic and mixed astigmatism, also in myopic astigmatism, when near vision is attempted, there can be no doubt. This effort is strain if the action is equal and simultaneous in all parts, holding the focal interval on the retina, or adjusting the rays of first one principal meridian and then those of the other, as vertical or horizontal lines may be viewed; it is strain if the ciliary muscle acts, as described by Martin, in sections the One opposite the other, thus, by altering curvature, developing a lenticular astigmatism correcting in whole or in part the corneal ; it is also strain if the longitudinal fibers of Bowman are alone concerned in the effort of correcting the astigmatism by tilting the lens on an axis in a plane with the corneal meridian of greatest refraction, thus producing a lenticular astigmatism counteracting to some extent the corneal. In oblique astigmatism, as usually encountered, there is demonstrable necessity for action (strain) on the part of the obliques, which, in these cases, is a factor added to the ciliary strain excited by the astigmatism. The strain caused by astigmatism is nearly always a source of annoyance to the patient and should, in all cases, be fully corrected, regardless of any and all other conditions. Ciliary strain is an effort on the part of the ciliary muscle to increase the refract- ive power of the lens, as in hypermetropia, or to render it astigmatic, by tilting or otherwise, for the correction of a corneal astigmatism. This action, or these actions, of the ciliary muscle is from necessity brought into existence in very early life, and because of daily repetition becomes a fixed habit of the muscle, a habit whose existence continues in nearly all cases for a time after the cause for it has been taken away by properly adjusted lenses. If this is true who knows that his work has been correctly done, when he undertakes the correction of a refractive error while the ciliary muscle is allowed to continue at its old work? That glasses thus fitted often (for a time) give satisfaction is but a verification of the old adage that “guesswork is as good as any when it hits.” - *See Ophthalmic Record, No. 11, vol. 2. f See Ophthalmic Record No. 1, vol. 1, S. Ex. 36—90. 1426 PAN-AMERICAN MEI) ICAL CONGRESS. How often do we find ourselves declaring what is a truth, that ophthalmology is more nearly a pure science than any other department of medicine? And is not this true mainly because of our perfect knowledge of the refraction of the eye and the conditions that result from errors of refraction? If there were no modifying condi- tions nothing could be more scientific than the full correction of errors of refraction, which could not be done accurately without first putting at rest the self-correcting power, the ciliary muscle. Since these modifying conditions are known and can be removed, it is the plain duty of every oculist to determine, by a most thorough and painstaking examination under the only favorable condition, suspension of accom- modation, what the refractive errors are, even though, because of the existence of some known muscle error, he might know that it would not be proper to give fully correcting lenses at that time; for having cured the muscle error his record would enable him later to give the full focal correction. There is no condition of the extrinsic muscles which would be disturbed by a full correction of any astigmatic error: there is no astigmatic error which may not be partly concealed by ciliary strain. In the work of refraction how fortunate for science and practice, for patient and practitioner, that we have at our command mydriatics, whose effect is to tem- porarily suspend the self-adjusting power of the faulty eye, during which period artificial correcting means may be accurately determined. While a mydriatic does not, in the least, interfere with any of our objective methods of examination, it gives greater accuracy to most of these. All must confess that the ophthalmo- scope can measure more correctly the refractive error of an eye, when under the influence of a mydriatic than when it is not. The man most skilled in estimat- ing the refraction of eyes by means of the ophthalmoscope must confess that it took both time and practice to enable him to voluntarily suspend his accommo- dation, with his eye on the dark side of the instrument; then how can he expect the patient, whose eye is on the light side of the instrument, to learn in a minute to suspend an involuntary power, one that is being stimulated into activity by the light that is thrown on the retina? When there is forced suspension of accom- modation (by a mydriatic) in the patient’s eye and acquired suspension of accom- modation (by practice) in the observer's eye, then there can be some degree of accuracy in the measurements of the ophthalmoscope; otherwise there can not be. The valuable objective examination of skioscopy could not be so well made nor could the results be so accurate, if done when the eye is uninfluenced by a mydri- atic. Properly practiced, under favorable conditions, skioscopy, in addition to detecting and measuring myopia and hypermetropia, shows quickly the existence of astigmatism, the kind and the quantity, and approximately the location of the principal meridians. A method capable of doing so much should not be inter- fered with by an active ciliary muscle and a contracted pupil. When we come to the method of Ophthalmometry we find that an active accom- modation neither hinders nor helps. Since the ophthalmometer deals only with the cornea, we know that its findings must be the same both with and without a mydriatic; for a mydriatic can effect no change in either the corneal curvature or the corneal reflection. If no effort on the inside of the eye was ever made for the correction of corneal refractive errors, as is true in the aphakial eye, and all errors of refraction existed in the cornea alone, we would then have, in the ophthal- mometer, an instrument infallible in its findings; and the mydriatic could be sent into immocuous deswetude. Although ciliary action prevents our relying implic. itly on the ophthalmometer, it is, nevertheless, a great aid in refractive work. Those who bought this instrument and then consigned it to the attic, if they will only bring it down again and cultivate its acquaintance a little more closely, will find in it a worthy friend. Those whose enthusiasm has led them to trust this instrument implicitly will, on more careful study, find themselves victims of PAN-AMERICAN MEDICAL CONGRESS. 1427 misplaced confidence, for the reasons already given in this paper. The great sin for which the ophthalmometer will have to account is that its introduction led to a vigorous renewal of the effort to discard the mydriatic in the work of refraction. If the mydriatic is an aid in objective examinations, and ought not to be dispensed with, it is still more essential when the subjective methods are to be resorted to, as they must be, if we aim at accuracy in our work. In our subjective tests there are causes for error, other than activity of the accommodative muscles, but unfortunately none of them are so easily removed as the latter. For the stupidity of the patient under examination there is no perfect remedy; for the carelessness and haste of the operator there is a cure in the com- bination of knowledge of the conditions under study and a determination to do the best possible under the circumstances. When we resort to the use of the lenses of the test case our aim is to prove the “findings” of our objective tests. If the fixed habit of strain is not suspended by a mydriatic, though we labor long and earnestly, we can never be certain that what we have done is absolutely correct. No one has ever yet learned the art of coaxing the ciliary muscle into a state of rest. When capable of acting it is always trying to correct the error which your lenses are searching out. This subjective test, when unopposed by ciliary power, is soon satisfactorily ended. If the need of a sphero-cylinder has been determined, and yet there is a “modicum of doubt” as to whether the spheri- cal part should be diminished and the cylindrical increased in strength, or vice versa, the confirmatory agency is the Jackson sphero-cylinder, the use of which can be depended on Only when there is suspension of the accommodation. If a perfect knowledge of the full error of refraction in every case is necessary, and this knowledge can be attained only by the suspension of the accommodation, then the reasons against the use of the mydriatic can be easily disposed of. As to the interference with the business of the patient, superinduced by the mydriatic: He comes to the oculist because of the fact that his eye strain inter- feres with his business in one way or another. Relief is what he needs, and what he should have, relief in the fullest sense of the word, not present relief only, but relief for the future as well. When told that his trouble is due to eye strain he naturally infers that if the cause of that strain is removed freedom from trouble will follow. He comes, possibly, from a great distance, and, though his business may need him at home, he is off seeking comfort, worth more to him than gold. He is a willing subject, and complains at nothing that is needful to be done. He is a young man—old men may suffer with eye symptoms brought on by strain of the extrinsic muscles, but not from ciliary strain—and his accommodation is active. This must be suspended if the full error is to be known. If he is left to choose, after a fair statement of his case has been made, he will agree to the loss of time that must follow the use of the mydriatic, for he wants the work done cor- rectly. Methods and means that are correct for patients from a distance are correct for home people. As to the amount of interference with business, the difference is decidedly in the favor of the home man. Besides, the business man being a sensible man, will not complain at loss of time necessary in order that relief may come, for he remembers how his troubles have, at times, incapacitated him for effective work. There are few whose work in bank, store, or elsewhere can not be done for a reasonable time by a substitute. What is true of the man of busi- ness is true of all patients, lawyers, doctors, school-teachers, artists, sewing girls, etc. But the necessary loss of time from the proper use of a reliable mydriatic need not exceed twenty-four to forty-eight hours. If it were necessary, the patient might be sent at once from the doctor's office to the countingroom, or wherever his duties might call him. Of course, near seeing so quickly done would have to be effected by means of a temporary pair of lenses. The mydriatic whose power is effective and yet, as compared with atropine, 1428 PAN-AMERICAN MEDICAL CONGRESS, evanescent, is the one that should be chosen. There are few ciliary muscles that will not respond to a solution of hydrobromate of homatropine of the strength of one-third grain to 20 drops of water, 10 drops of which, drop by drop every five minutes, should be put in each eye. In ten minutes after the last instillation the study of the refraction can be confidently commenced The work completed by both subjective and objective tests, within an hour and a half all told, a few drops of a one-five hundredths solution of eserine may be used, the same to be repeated the next morning early. The patient may then be sent about his busi- ness. By the next morning the effect of the mydriatic is entirely gone. As to the general inconvenience to the patient, this can be readily borne or modified by Smoked glasses, etc. Systematic effects are rare, and can be combated by appro- priate remedies, brandy and morphine. As to loss of time to the operator, this is a myth. While the muscle test and the correction of the refractive errors must be done by the operator, he can safely commit the use of the mydriatic to the office girl, whose time is not so valuable as his own. This method, too, is restful both to the doctor and the patienf; for the muscle tests should always be made when the eyes are uninfluenced by a mydriatic. After the eyes are brought under the influence of the mydriatic the subjective and objective examinations of the focal errors are soon over, and the patient does not have to be reëxamined on the next day, nor at any other time, as a rule. As to the objection that the mydriatic may increase tension to the point of exciting an attack of glaucoma : this objection can weigh but little when we consider that this danger exists only in persons beyond middle life; and that in these patients the ciliary muscle has lost more or less of its power, and a weak mydriatic serves to completely suspend what remains. In these cases, especially if the patients are beyond 55 years, the prime object is not to act on the ciliary muscle, but to dilate the pupil, in order that a thorough examination of the fun- dus may be made for the detection of central choroiditis so common in old peo- ple; also that the periphery of the lens may be examined for beginning opacities. When these conditions are detected early, as is well known, proper therapeutic means may check their progress, and make it possible for the patient to have comfortable vision during the remainder of life. Through the Small pupil of the old these changes could not be readily detected. After the proper glasses have been determined and the fundus and lens have been thoroughly investigated the myotic should never be omitted if the patient is beyond middle life. While advocating the complete suspension of the accommodation, that full knowledge of the refractive errors may be attained and made a matter of record, I would not be understood as advocating that the myopic and hypermetropic refraction should always be fully corrected in every patient at the beginning. On the contrary, in the light of our present knowledge, such practice should be avoided, not only for the comfort of the patient, but also for the credit of the practitioner. In the present state of our knowledge there is not a single reason for not correcting fully all the astigmatism that may be found in any case; but not so with the hypermetropia and the myopia that may complicate it. The rela- tionship between the external and internal recti should always be known before prescribing convex or concave spherical lenses. This should be determined when the eyes are uninfluenced by a mydriatic.” The superior and inferior recti and the obliques may not be consulted when glasses are to be prescribed. In prescribing spherical lenses for esophoric cases there is an absolute need for the mydriatic in its full power, regardless of whether the refraction is hyperme- tropic or myopic. If hypermetropia is associated with esophoria, the accommoda- tion should be fully suspended, not only that the whole of the refractive error may * See Ophthalmic Record No. 11, vol. 2. PAN-AMERICAN MEDICAL CONGRESS. 1429 be known, but that it also may be corrected fully. Such glasses will cure a part (the pseudo-esophoria) of the esophoric condition, if not all. As I have been ablé to show in a former study, the esophoria associated with uncorrected hypermetropia is not all due to the intrinsic power of the internal recti. Further observation leads me to suggest that, for every diopter of hypermetropia in each eye, there is a half degree of pseudo-esophoria (1 D. of H. in each eye would give 1 degree). What esophoria is left after giving a full correction of the hypermetropia must be cured by operation or exercise, or by both. A full correction of the hypermetropia should always be given in cases of internal squint. When esophoria is associated with myopia the mydriatic should be used to full suspension of accommodation, that the very great error of giving an overcorrec- tion of the myopia may be avoided. The exact correction should be known and recorded. The same may be prescribed for distant seeing without risk of adding a pseudo-esophoria to the true muscle error; but the fully correcting concave lenses should not be prescribed for near use, for the reason that the muscle error would be thereby increased. When the esophoria has been cured the full myopic correc- tion should be worn for all distances. In prescribing spherical lenses for exophoric cases, there is an absolute need for the mydriatic in its full power, whether the refraction is hypermetropic or myopic; for it is in these cases that the true error of refraction is most likely to be concealed, because of the spasm of accommodation caused by the exophoria. Exophoria often causes emmetropic eyes to appear to be myopic. It renders latent the greater part of a hypermetropic error, and adds a pseudo-myopia to the real myopia. The mydriatic alone is able to show the refraction of exophoric eyes in its true state. Without it, concave lenses will be selected by emmetropic eyes, not infrequently, under these conditions, hypermetropes choose concave lenses. While an overcorrection of myopia should never be given, the full cor- rection of a myopia associated with exophoria should always be prescribed, and the patient should be directed to wear these lenses for all purposes of vision. While the hypermetropia associated with exophoria should always be known and recorded, the full correction should not be given, often no correction, until the muscle error has been cured by means at our command. - Orthophoria is rare, but when it exists a full correction of any and all refractive errors should be given. That an overcorrection of myopia and an undercorrec- tion of hypermetropia may be avoided in these cases, the full suspension of accommodation is essential. Instead of using the mydriatic once in 46 cases, have we not strong scientific reasons for using it 46 times in 46 cases 2 The human eye remains a human eye under the influence of the mydriatic, except as to its focal adjustment. In this respect it is no more than a machine, and is susceptible of perfect measurement by means of our several objective and subjective methods. In no other way can accuracy be attained. The unscientific cry of honest but misguided occulists against the use of the mydriatic is to the ear of the quack spectacle vender a sweet sound which he attunes to his own profit, and to the detriment of the unsus- pecting public. May it soon be heard no more in the land. * 1430 PAN-AMERICAN MEDICAL CONGRESS. ASTIGMATISM FOLLOWING CATARACT EXTRACTION AND OTHER SECTIONS OF THE CORNEA. By EDWARD JACKSON, A. M., M.D., Professor of Diseases of the Eye in the Philadelphia Polyclinic; Surgeon to Wills Eye Hospital. In his work on the anomalies of accommodation and refraction of the eye, Don- ders stated, “To the very ordinary causes of altered and consequently irregular arching of the cornea belongs the extraction of cataract. Especially when pro- lapsus iridis or threatening prolapsus has existed, whereby the pupil has lost its central position, or where, with forward projection of the flap, the wound sur- faces do not perfectly correspond, we seldom obtain a completely normal arching of the cornea. If the deviation is slight, the power of vision may still be quite sufficient ; but on accurate investigation it now appears that the acuteness is defective, and the astigmatism is in this instance also partly capable of correction by giving an oblique position to the convex glass, or by combination with a cylin- drical one.” Since the publication of Donders's work almost every text-book upon the refraction or diseases of the eye has contained an allusion to the subject, but these allusions little more than call attention to the existence of such astigma- tism. A few papers upon the subject have appeared from time to time, but, so far as I know, only one in the English language—namely, that by Dr. Swan M. Bur- nett, in the American Journal of Ophthalmology for 1889, page 361. In view of this, it seems worth while to here record some observations as to the clinical his- tory of such astigmatism. Frequency.—It appears to occur almost universally after cataractextraction. In a few of my earlier cases my notes do not show that it was detected. But in none of these cases was full vision, or nearly full, vision obtained; and they were not subjected to careful study with the ophthalmometer or the shadow test, so that their negative evidence is not conclusive. In 48 cases that have been carefully studied the amounts of astigmatism present were : Less than 1 D. in 5 cases, 1 to 1.75 D. in 6 cases, 2 to 2.75 D. in 18 cases, 3 to 3.75 D. in 10 cases, 4 to 4.75 D. in 4 cases, 5 D. in 2 cases; 6, 7, and 8 D. each in 1 case. From these statistics I am inclined to think that those who have found it frequently absent have failed to note it, as I did, in the cases previously mentioned, because it was not looked for carefully enough. It would appear from these figures not only that it is present in an amount that can be detected, but also that in a great majority of cases it is present to such a degree that its correction is a matter of considerable importance. Direction of the principal meridians.—All writers who have alluded to this sub- ject have noted, what is shown in my own cases, that, contrary to the rule, the principal meridian of greatest hyperopia was at or near the vertical, the section being made either upward or downward. This has been so generally observed that we may take it as settled that the meridian of greatest hyperopia is usually or always perpendicular to the center of the corneal incision. In many of my own cases the slight difference in height between the puncture and counter puncture clearly influenced the inclination of the principal meridians. The greatest depar- ture from such a position of the principal meridians was in the cases presenting low degrees of astigmatism. In one case of astigmatism, 0.5 D., the flattest meridian was found 55° from the vertical. As to the explanations of the direction of the astigmatism, as well as of its occurrence, more will be said later. Seat of astigmatism.—After cataract extraction this can only be in the surface of the cornea, and in cases of iridectomy, also, the ophthalmometer has invariably revealed that the asymmetry had a similar location. Time of appearance and clinical history.—The first application of accurate methods for the measurement of refraction subsequent to the operation has inva- riably revealed the astigmatism present, and in the highest degree exhibited at PAN-AMERICAN MEDICAL CONGRESS. 1431 any time in that particular case. Inspection of the cornea, with or without the use of the Placido disk, from the date of operation shows that after the effects of cocaine have passed away and the humors have replaced the extracted lens the form of the cornea remains normal, although subject to changes by changing pressure from the lids, until the interior chamber is reëstablished. Then in the course of two or three days, or sometimes in a few hours, the corneal asymmetry becomes evident and quickly reaches its maximum. From this time on the tend- ency is for the astigmatism to diminish, until at length a permanent condition is reached. This diminution, however, is not always regular or constant, as was well illustrated in many of the cases. For example : Mrs. J. M., aged 54 : iridectomy for subacute glaucoma, corneal section upward, well back in the sclero-corneal junction, involving one-fifth of its circumference. The eye was operated on May 14, 1883. It had previously been carefully examined and found hyperopic 2 D. and free from astigmatism. The astigmatism was evident shortly after the operation. In five weeks it had markedly diminished, and +4 D. cyl. axis 25°, gave vision equal four-sixths. At nine weeks there had been no change whatever in the refraction, and the above cylinder was ordered for dis- tance, with +3 sph. added for reading. Sixteen days later the patient wrote me com- plaining that the glasses had begun to hurther eyes, and was instructed to discontinue their use. At fourteen weeks the refraction was again carefully tested and found to require for its correction +2 sph. C ––2.50 cyl. axis 20°, giving the same vision. At eighteen weeks the same correction was required, but fearing further diminution of the astigmatism she was ordered for distance +2.25 sph. C ––2. cyl. axis 20°. Four years later she required -|-2.75 sph. C ––2.50 cyl. axis 13°, and with it obtained a vision of four-fourths, partly. There was no further change in the refraction when last seen, more than eight years after the Operation. In watching cases from week to week with the ophthalmometer, it has repeatedly happened that for some weeks the change in the astigmatism would be but slight, and then there would suddenly appear a rapid change to what proved to be the permanent condition. On the other hand, there will in some cases be a steady diminution of the astigmatism from the time it is first measurable until the per- manent condition is reached. Thus: R. C., aged 63, after simple extraction, upward section in the margin of the cornea had at 14 days, astigmatism 15 D. convex cyl., axis 155°; at 21 days, 13.5 cyl.; at 40 days, 11 cyl.; at 54 days, 7.5 cyl., now axis 157° ; at 61 days, 7.5 cyl.; at 75 days, 5.75 cyl.; at 78 days, 5 cyl., axis now 158°; at 90 days, 4 cyl., axis 158°, giving a vision of four-fifths, mostly. In nearly half of my cases capsulotomy was performed while the patient was under observation. No effect from it upon the astigmatism present could be noticed. Final amount.—The amount of astigmatism remaining when its condition had become permanent is indicated in the table given in connection with its frequency. It should, however, be noted that all cases in which the astigmatism is given as over 4 D. were cases that have not been seen more than five months after the date of operation, and of the cases showing 4 D. but two were seen more than-six months after the operation; so that it is uncertain whether in any case more than this amount of astigmatism has remained permanently. Although some of these cases are known to be within reach, and all were directed to report if their glasses became unsatisfactory, the one in which the astigmatism was 8 D. was seen only one month after operation. It is certain that in the large majority of cases the amount of astigmatism diminishes to less than 3 D. before it becomesfixed. Andin a given case where it was necessary to adjust glasses within the period of probable change of astigmatism it would be safer to prescribe for this average amount than to take the measurement of the eye at the time if it indicated a higher amount, even though this might have been almost or quite constant for days or weeks. When it ceases to change.—The period during which the astigmatism continues to diminish varies widely. In two eyes it decreased from 4 D. to 2.25 D. after a 1432 PAN-AMERICAN MEDICAL CONGRESS. period of six months had elapsed. In another case it had fallen to 2.25 D. by the twenty-second day, and no further change occurred, although the eye was seen for more than a year afterwards. In another case it diminished to 1.25 D. by the twenty-fifth day, and remained without the slightest change five years later. In still another, it fell to 1 D. by the twenty-third day. In about 60 per cent of the cases the change continued between two and three months, with perhaps a very slight diminution after this. In 15 per cent permanence was reached in the second month; in 20 per cent change continued after three months. Where the amount remains high at the end of this period, even though it has been for a con- siderable time stationary, there is strong probability that it will further diminish later. All of the cases long under observation, two of them for ten years, seem to show that after a certain period, limited apparently to the first year, or possi- bly a little longer, the amount of astigmatism becomes quite fixed and is as little liable to change as in cases of moderate astigmatism not due to operation. Influence of complications.—The occurrence of prolapse of the iris or of incarceration, or even of close adhesion of the iris to the corneal stump, notably influences for a time the amount and delays the diminution of astigmatism, but these conditions appear to produce but little effect upon the final amount and permanence. The influence of prolapse in this direction, unless it be so extensive as to cause great displacement of the corneal flap, is not greater than the influence of incarceration or of adhesion of the iris to the cornea. In either case the influ- ence appears to be proportioned to the extent to which the corneal wound is involved. Thus, a large incarceration is worse than a small prolapse. In the series of cases upon which this paper is based, there occurred two of extensive pro- lapse of the iris allowed to shrink without excision or other operative interference. W. J., aged 70, by a sudden movement of the eye during the corneal section, caused a doubling of the incision that left about one-third of the margin of the flap hanging as a shaving of corneal tissue, almost completely severed from its connections. This underwent partial absorption, delaying the healing of the wound, and the restlessness which had caused the original accident Secured an extensive prolapse of the iris. On the twenty-sixth day he still had 10 D. of astig- matism, which, however, had diminished to 3.50 D. by the seventy-seventh day, and after that underwent no change. J. W., aged 42, had a bit of steel lodged in the lens four months previously. The lens was much swollen, and in order to make sure of the removal of the foreign body, a long incision well back in the sclero-corneal margin was employed. Pro- lapse of the iris occurred and extended until it occupied the whole length of the wound. It reached its maximum in a few days, and then remained without nota- ble change in bulk for thirty days, after which it flattened rapidly, and by the forty-fifth day had gone down entirely to the level of the cornea. On the fifty- first day the astigmatism was 20 D. ;* on the fifty-eighth day 11 D., at sixty-five days 9 D., and only after five months has it reached 5 D. In contrast to this is the course of the astigmatism in the following case: Mrs. J. G. B., aged 64; simple extraction, normal healing; on the twenty-fifth day, astigmatism 26 D. : on the twenty-eighth day it had fallen to 23 D., and in two months and a half to 0.75 D. Nature of the change in the cornea.—The readings of the ophthalmometer show, first, that the corneal curvature is actually diminished in the meridian of least refraction, usually vertical, or nearly so, and that this meridian is flattest at the first examination and becomes more convex as the astigmatism diminishes; second, that the meridian of greater curvature, usually horizontal, or approxi- *The numbers of diopters in this and the following case are, what was indicated by the Javal ophthalmometer, considerably higher than the convex cylinder accepted. Thus when the olph- thalmometer showed 11D. the 10 D. cylinder was chosen. When it showed 23 D. the 18 D. gave the best vision. This is partly because of the distance of the cylinder in front of the eye, and *; because the constants taken as the basis of the graduation of the Jayal instrument do not hol for the eye rendered aphakic by cataract extraction. (See paper by Dr. Carl Weiland, Archives of Ophthalmology.) PAN-AMERICAN MEDICAL CONGRESS. 1433 mately so, presents an actual increase over the previous curvature of the cornea, which increase is greatest at the first examination and diminishes with the astig- matism; sometimes, but not always, passing away altogether by the time the con- dition of permanency is reached. To explain these corneal changes, the pressure of the lids, the displacement of the flap, and the action of the extra-ocular muscles upon the globe have all been invoked, but the astigmatism occurs, typical in form and course, when the flap and stump unite in perfect coãptation; and the pressure of the lids and action of the extra-ocular muscles have not been shown to differ essentially from their pressure and action on the normal globe. It seems to me that the explanation of the phenomena of post-operative astigmatism is to be found in the essential fact of an incision through the resisting coat of the eye, temporarily entirely destroying its resistance along a certain line, and that.the necessary effects of Such an incision, irrespective of any outside influences, are just such as we have observed in cases in question. With the incision the resistance of the sclero-corneal coat to the intraocular tension along the line of incision drops to zero and remains there until the flap and stump adhere. During this time that the wound remains open the intraocular tension also remains at zero, and no displacement results. When, however, the wound is closed the intra- ocular tension is immediately renewed and the adhesions uniting the flap and stump become a portion of the sclero-corneal coat, which has to resist this tension. Throughout most of this coat the power of resistance is normal, the adhesions possess comparatively little power of resistance, and the changes in the neighbor- ing margins of the flap and stump incident to the process of repair materially diminish resistance. It follows, therefore, that we have along the line of incision less resistance to the intraocular pressure than at any other portion of the sclero- corneal sac: necessarily the parts where the resistance is less protrude. This protrusion causes great increase of curvature in the direction perpendicular to the incision at the line of incision ; and this increase of curvature must necessarily be made up by an equal amount of flattening of the neighboring portions of the cornea and Sclera. In the Sclera, this flattening being of no practical importance, remains unnoticed. In the cornea it causes the flattening of the vertical meri- dian. So much for the flattening in the meridian perpendicular to the incision. It is noticed that the change of outline that occurs is dependent on the bulging of the point of least resistance. The maximum of this bulging will be at the center of the corneal incision; that is, the center of the corneal imcision is more pushed out from what would be its normal relation to the center of the globe than any other point of the sclero-corneal coat; and the whole area of the central part of the flap shares more or less in this bulging. We have, therefore, the center of the upper part of the flap bulging forward. If other parts of the circumference of the cornea remain fixed, as the whole cornea does outside of the region of incision, and as the angles of the incision do, to a less extent, because of the sup- port they receive from neighboring firm tissue, this bulging at the upper margin of the cornea causes the cornea to assume more or less the form of a vertical ridge, comparatively flat in the direction of its length, but with increased curva- ture from side to side. And in this increase of curve, to get over the ridge as it were from side to side, we have the cause of increased curvature in the meridian of greatest curvature. This explanation is put forward not as an hypothesis, but as an application of perfectly understood physical laws to the special case of intraocular tension, resisted by the sclero-corneal coat, weakened along a certain line of incision, and seems to me entirely adequate to the requirements of the phenomena in question, rendering unnecessary any appeal to other special causes to explain post-operative astigmatism. As the resistance along the line of incision increases with the return of the tissues to normal, the tendency of intraocular pressure is to reproduce the 1434 PAN-AMERICAN MEDICAL CONGRESS. normal spherical curves, or the spherical curves of the normal eye. That it should fail of doing this completely is not to be wondered at when One considers the existence of the permanent scar and the comparative rigidity, on account of the age of the patient, of the tissues in which this process generally occurs. The influ- ence of such complications as prolapse or incarceration of the iris is clearly trace- able to the fact that they produce softening in the adjoining margins of the flap and stump, and delay their return to the conditions of normal corneal tissue. Choice of operation and after treatment.—The hope has been expressed that with an increased knowledge on the subject of post-operative astigmatism, we would be able to choose or devise some special form of operation that would reduce it to a minimum or prevent it entirely. But if the cause lies in the essential fact of an incision into the cornea that necessarily lessens its resistance, this hope will have to be abandoned. All we can do in the choice of an operation will be to keep the incision out of the visual zone of the cornea, and to secure prompt and Com- plete healing. The thought will occur that if the bulging could be prevented by the proper outside pressure, the astigmatism would be prevented. But, as I have already urged in a paper before the American Medical Association, in 1891, any such application of pressure is impracticable and the attempt certain to be inju- rious. Where prolapse or incarceration of the iris has occurred, the removal of the involved iris may hasten the condition of permanence, but will not diminish the ultimate amount of astigmatism sufficiently to justify a resort to it on that account. The correction of post-operative astigmatism.—Many of those who recognize its existence speak of it as unimportant, or to be corrected not by a cylindrical lens, but by the placing obliquely of a spherical lens. The need of the improvement of vision gained by the correction of 1 or 2 or 3 D. of astigmatism is as great for a patient who has undergone cataract extraction or iridectomy, and so speedily acquired the astigmatism, as for a patient in whom the astigmatism is congenital, or of slow development. Theirmperfect visual acuteness often presentin the former class of patients is, I believe, more than balanced by the fact that astigmatism is new to them. Even if its correction will not give as good vision as may be obtained by the correction of some case of congenital astigmatism, the fact that the patient has been accustomed to seeing without astigmatism will cause him to appreciate as highly the relief afforded. In any case of cataract extraction that can be properly classed as successful, it seems to me important to correct the astigmatism. Now, as to the method of correction. Theoretically, it is true that by looking obliquely through a strong spherical lens regular astigmatism may be corrected, but, as I pointed out in a paper read before the American Medical Association, in 1887, on the effect of obliquity of correcting lenses, such a correction is far less sat- isfactory and far less beneficial than the correction by the ordinary cylindrical lens. The proper cylindrical effect is only obtained at a certain angle and at an angle where the slightest deviation either way produces a perceptible change in the cylindrical effect, so that the patient who gets his cylindrical effect by looking obliquely through a spherical glassis constantly getting, instead of the proper effect, not enough or a little too much. On the other hand, with the cylindrical lens, and the visual axis perpendicular to the lens, there is a considerable angle to either side of the perpendicular through which the change of cylindrical effect is imper- ceptible; and on this account, if the lenses are properly mounted, it becomes diffi- cult for the patient to get a cylindrical effect which will be seriously incorrect. One other point. The reason urged for not employing a cylindrical surface upon the cataract glass is that it renders necessary the use of a more convex spherical surface, increasing the weight of the lens and the amount of spherical aberra- tion. The increase of weight in a plano-spherical over a double convex that is absolutely necessary is so slight as to be of no practical importance. The increase that happens in the use of such lenses in practice depends on the inferior selection PAN-AMERICAN MEDICAL CONGRESS. 1435 and grinding of the lens by the optician. The spherical and chromatic aberration of even a strong cataract glass, especially through the small pupil obtained by simple extraction, are not the most serious defects in a strong lens. The effect of looking obliquely through the lens is of much greater practical importance. And by placing the spherical entirely on one surface, if convex, the surface away from the eye, we secure an approximation to the ideal periscopic lens, one which should have the center of its refractive surface at the center of rotation of the eyeball, and reduce to the minimum the effects of looking obliquely through the refract- ing surface. Indeed, so important is this matter that where the cylindrical lens was to be employed in connection with the strong spherical, I have used the con- cave cylindrical with the convex spherical, turning the former toward the eye, the latter from it, and have found such a lens as satisfactory or more satisfactory than those made with both spherical and cylindrical surfaces convex. The teaching of the non-correction of astigmatism after cataract extraction seems to me utterly opposed to good sense, and practice based upon it is only excusable on the ground of an insurmountable constitutional indisposition to do thorough work. * A FEW THOUGHTS ABOUT OPHTHALMOMETRY: AS TO WHAT THE JAVAL INSTRUMENT WILL DO, AND WHAT IT WILL NOT DO. By LOUIS J. LAUTENBACH. A. M., M. D., Ph. D., of Philadelphia, Swrgeon to the Pennsylvania Eye and Ear Infirmary, Chief of the Eye Clinic of the German IHospital, etc. The value of the ophthalmometer as a factor in the determination of the axis and amount of astigmatism has for the past few years given rise to considerable controversy. According to some it would seem as though the ophthalmometer had supplanted the subjective test, rendering the use of mydriatics unnecessary, and those who used them liable to be considered old fogies, too “sot” in their ways to appreciate the value of the more perfect and scientific method. Others con- sider it little more than a toy whose popularity will be ephemeral, and content themselves with the assurance that it, like many other medical fads, rests on an insecure foundation and will therefore soon be a thing of the past. Again, there are those who consider the instrument a scientific One, constituted on proper prin- ciples, and not a toy; yet know that the scope of its work is limited, and have endeavored to get from it all that is possible, and while acknowledging its great usefulness, realize its limitations. Those who have used the ophthalmometer, in other words, those who from experience know something of it, naturally belong either to the first or third group. Originally the larger number of them belonged to the first class; but the third or conservative class has been steadily growing, and now contains quite a respectable number of the thinkers, or, in other words, it contains the workers and reasoners, and not the enthusiasts. The main reasons for this difference of opinion consist, firstly, in a faulty construction of the instrument; secondly, to a faulty use of it; and thirdly, a wrong interpretation as to what can be accom- plished with it. Glancing for a few moments at the different ophthalmometers, we have to con- sider, first, the original instrument constructed by Helmholtz in 1853. This instrument is really perfect in construction, giving us most accurately the radius of curvature at any part of the cornea desired. Its results are accurate, but its use entails the expenditure of a large amount of time. To thoroughly measure the cornea at any point necessitates at least sixteen separate readings. It has been used by Knapp, of New York, and Strawbridge, Wieland, and others, of Philadel- 1436 PAN-AMERICAN MEDICAL CONGRESS. phia. All testify to its accuracy and perfectness, but consider it more valuable in the laboratory than the office. The ophthalmometer of Le Roy and Dubois has the disadvantage of being poorly constructed, the hinge and other joints being loose; in fact, nearly all the fittings are inaccurate. There is no means of steadying the head so that the eye may be fixed while being measured; the scale is inaccurate; the bar on which the mirrors or reflectors ride is straight, whereas it should be an arc of a circle with a radius equal to the distance of the Scale from the eye being examined. It has no means of artificial illumination, while requiring for its proper use a very strong light. Some pretend that by its use the refraction of the eye- ball can be determined. The claim is, however, too absurd for discussion, as it must be evident that it is a physical impossibility to determine this objectively. The Javal-Schiotz ophthalmometer of 1889, if mechanically well constructed, is a good instrument. Its most frequent defects are a displacement or a malposition of the Wollaston bi-refrangent prism, a displacement of the arc upon which the scale is constructed and the mirrors move, the want of a means of keeping the patient’s head fixed while under examination, and an insufficient illumination. In the Javal instrument (model of 1889), of French construction, the base is too light, it does not keep the telescope and head rest in a fixed relation to each other, and in the general workmanship itismarkedly inferior to that of American construction. A malposition or displacement of the Wollaston prism is frequent. Instead of the primary image revolving about its center with the revolution of the telescope, it has, in addition, another motion about an imaginary center, the secondary image in either case moving about the primary one. This double motion of the primary image is due to a faulty position of the prism, and before using such an instru- ment it should be carefully overhauled, as all results obtained under these con- ditions are absolutely worthless. If the arc be not in proper position, if it is not at all points exactly the same distance from the eye, again are the results value- less. The screws by which the arc is fastened to the barrel of the instrument must be very carefully adjusted. In order to test the arc a lens with a refractive power of its anterior surface of about 32 diopters should be placed at the rest of the instrument. If, as the telescope is revolved, there be the slightest break in the continuity of the black lines of the mires, it indicates that the arc is still improp- erly adjusted. With a properly constructed instrument, a good illumination (four incandescent lights of 16 candle-power each being undoubtedly best), the apparatus firmly secured to a good stout table, and the patient's head firmly fixed (strapped in the head rest), the results will be trustworthy and accurate. It is for us to interpret the results. Here let us pause and inquire as to what has been expected of the instrument, and how far our anticipations have been realized. There are those who have assured me that it would measure the refraction in any meridian. It is with this idea in view that the scale of the Le Roy-Dubois instrument is constructed. Physically, as before mentioned, this is an impossibility and can not be accom- plished. Others consider that it will invariably give both the axis and entire amount of astigmatism of the eye. This it will do only in such cases where the astigmatism is confined to the anterior surface of the cornea ; but the astigma- tism may not be confined to the cornea, and therefore lenticular astigmatism must be considered, as must also the fact that the posterior surface of the cornea may not be parallel with the anterior; if this be not so, it will influence the astig- matic refraction. In other words, ophthalmometers deal with the cornea only, and are therefore, strictly speaking, keratometers and any knowledge of other parts of the eyeball that they may reveal to us is obtained by a comparison of our other studies with those of the keratometer. In fact, all we obtain is a knowledge of the anterior surface of the cornea, its radii of refraction, its irregularities, and some idea of the transparency and nutrition of its superficial layers. When once this fact PAN-AMERICAN MEDICAL CONGRESS. 1437 is thoroughly realized there will be fewer disappointments, as well as fewer enthu- siastic outburststhan have up to this time characterized the progress of these studies. By means of the keratometer we can measure the corneal area, its curvature at any or all parts, and learn the angle of the axes of the principal meridians at the part under examination, as well as the difference between the radii of curvature at these Or any intermediate points, and can thus determine in diopters, the dif- ference in corneal refraction at these points. In addition to this, the instrument has in my hands proven valuable in determining problems as to the nutrition of the cornea, and as to increase or decrease of the intraocular pressure. My first keratomic work was done with a Helmholtz instrument, but I am now using the Javal instrument entirely, and with it have examined over 1,800 eyes of over 900 patients. In all cases of refractive errors or diseases of the eyeball or its appendages (with the exception of a few cases of acute inflammation of the iris, cornea, and conjunctiva), in addition to the routine examination, a kerato- metric examination is invariably made. Of these over 1,400 eyes have been thoroughly examined and tested while under the influence of a mydriatic, either atropine or homatropine. As a result of these examinations I have found that the axis of astigmatism, as determined by the keratometer, corresponded to the axis as determined by the mydriatic in 88 per cent of the cases, while the degree cor- responded (after making the correction of 0.37 diopters, subtracting it when the astigmatism is with the rule and adding when against the rule) in 45 per cent. It is an admitted fact that the astigmatism of a ball is not always confined to the cornea; that not infrequently it is lenticular. Of this we have two varieties, the static and the dynamic. In the dynamic variety, supposed by some to be a compensatory effort to overcome the effects of the corneal astigmatism, usually all that is necessary is to carefully correct the corneal astigmatism, the dynamic lenticular astigmatism then disappearing. In the static variety, the ophthalmo- meter can not give us the total astigmatism. In these cases we must proceed to the estimation and correction of the lenticular astigmatism as well. It is these cases that in the whole range of refraction work gives us the least satisfactory results. In the examination of corneae which have been subjected to weakening of struc- ture in consequence either of local inflammations or systemic disorders; cases where the results obtained by glasses while under mydriatic influence are either indifferent or nil, because of irregularities in curvature or in the transparency of the corneal layers; we can often get very good results through the aid of the ker- atometer. By instilling a few drops of castor oil on such corneae we are often enabled to get very clear images, and can thus determine the axes of the princi- pal meridians and the difference in diopters between their refractive powers. The approach, advance, and subsidence of glaucoma has been made more noticeable and marked by the changes in the axis and curvature of the cornea and changes in the brillancy of the keratometric images than by any other method of examination. - In developing myopia it will soon show the suspicious nature of the case, and in progressive malignant myopia the changes are frequent and marked. I have often noticed that irritable retinas are associated with corneae whose axes and curvature vary, and now I always seek for the latter whenever I find the former. In corneal malnutrition dependent upon syphilitic disease the changing of the axes and curvatures, with a loss in the brilliancy of the reflex, precedes an inflam- matory attack, and if this condition be appreciated, serious results will, often be avoided. In refracting cases of aphakial eyes, and in refracting shortly after injuries of the cornea, and after operations involving the cornea, its value must be evident to all, giving us results which often we could not obtain without incurring possible danger from irritation and subsequent inflammatory action. Some of the intricate problems regarding the construction of the eye, its depth 1438 PAN-AMERICAN MEDICAL CONGRESS. and diameters, its lens astigmatism and refraction, can be determined by means of calculations from the data as furnished by this instrument, as compared with those as furnished by the subjective examination under full mydriasis. Now, briefly outlining, we find that the ophthalmometer will not give us the refraction, nor will it give us the total astigmatism except when this is confined to the cornea, or any knowledge as to whether there is or is not lenticular astig- matism. It will give us the axis and degree of astigmatism when this is corneal. Practically we find that it gives us the axis in 88 per cent and the amount of astig. matism in 45 per cent. It reveals to us a knowledge of diseased conditions of the eyeball when the disease is of such a nature as to interfere with the corneal nutri- tion or to increase or decrease the Ocular tension. It will, in connection with other methods, allow us to calculate the lenticular refraction and astigmatism as well as the depth of the eyeball, and thus puts within our grasp a new method of more thoroughly studying its functions and anatomy. smmam-m-m-mºms DISCUSSION. Dr. Risley said: I congratulate myself on the fact that the task before me is a pleasant one, since I am in practical agreement with the views expressed in the several valuable papers presented. I am much interested in Dr. Belt's researches regarding the eyes of white and black school children. He had kindly referred to the Philadelphia school examinations. In that work the main endeavor, however, was to show that the universally recognized increase of myopia during the School life was due in large measure to existing astigmatism, which seemed to be confirmed by the fact that in astigmatic eyes, it was shown, were discovered the commencement of those pathological states of the choroid which, in their Imore advanced states, were characteristic of the myopic eye, while in emmetropia Or simple permetropia or myopia, not Only were these changes absent, but the eyes were comparatively free from asthenopia. In the management of refractive errors I feel it important, first of all, that emmetropia should be accepted as the model eye and all departures from this accepted as defects, and when pressure in asthenopic eyes should be corrected by glasses. As to the methods to be pursued in the management of these cases, it should differ widely in different cases when the choroid and retina are practically healthy; in many instances approximate corrections will secure the comfortable use of the eyes, and may be made without the use of a mydriatic, or with the careful use of homatropine; but in cases of retino-choroidal irritation, with their woolly or “ripe-peach * eye grounds, time is an important element in their treatment; hence any endeavor at rapid correc- tion was liable to prove futile. In late years a very large percentage of the cases I have seen had bad eye grounds and needed the mydriatic, not only to paralyze the accommodation, but as a therapeutic agent. In such cases the drug should be employed until the turgid state of the intraocular tunics subsided, when the correcting glasses would be chosen with but little difficulty. It required time to accomplish this, and while the same end could be reached with the employ- ment of homatropine it should be applied more frequently and must be used longer than the stronger mydriatics. For this end he preferred hyoscyamine, and although the resulting effort was more enduring than that of homatropine, the total time of detention from work was no longer, and on the whole more satisfactory and less annoying to the patient than the prolonged and frequent instillation of homat- ropine. Regarding the use of the alkaloid disks, after a persistent trial he had returned to neutral solutions in water. When combined with cocaine they caused increased lachrymation and the tears either diluted the alkaloid or washed it away. Then, too, the cocaine lessens the intraocular tension and often disturbs PAN-AMERICAN MEDICAL CONGRESS. 1439 the corneal epithelium. Solutions in oleaginous substances, he quite agreed with Dr. Wood, were inadmissible for the reasons stated, as he had ascertained by trial in 1875. Nomention had been made of the later chemical results in the manufacture of the mydriatic alkaloids. If the alkaloid is extracted from atropa belladonna in the presence of an alkali or of great heat the product is atropine, but if no alkali is employed and only low temperatures used, hyoscyamine is the result- ing product, while, on the other hand, in the presence of high temperatures and an alkali, atropine is the product, even from hyoscyamus migra. It was important, therefore, that in dispensing hyoscyamine sulphate that the solution should be neutral and made at low temperatures. Recently, preparations of sulphate of atropine and sulphate of hyoscyamine were given by me to Dr. Marshall, of the University of Pennsylvania, and neither of the drugs showed any paralyzing power, hitherto the only means, except their physiological properties, of differentiat- ing them. It would therefore appear that the products now in the market, certainly those from Merck's laboratory, are both hyoscyamine, and that we get atropine only through the careless manipulation of the druggist. A 1 per cent solution of duboisine to hyoscyamine was too strong to use in the manner suggested by Dr. Wood and would in many cases give rise to toxic symptoms. In reply to Dr. Savage's paper I would say that I am in full accord as to the urgent necessity for mydriatic corrections if we are to secure any but the barest approximations to the static refraction of the eye. I can not, however, agree on the statement that old men do not suffer from eye strain. The ciliary muscle is still present and susceptible of contraction however futile its efforts may be over the now flat and inelastic lens. This is frequently demonstrated in the irritable eyes and headache of old people, reading or working with an improperly adjusted glass. In these conditions a mydriatic often gives as great relief from these asthenopic symptoms as in younger people. The pin-point pupils of people at 50 years reading without glasses, or with too weak glasses, demonstrates still further the existence of eye strain, and hence the frequent need of a cycloplegic after 40 years of age. I have no fear of the glaucoma ghost which has been held up before us from the use of mydriatics in middle life. I have used them in thousands of people beyond the mydriatic dead line, and no harm has ever followed. It would, of course, be folly to use them in cases where glaucoma was imminent, or in sus- picious cases. These should be excluded. I do not believe the spasm of accom- modation is by any means confined to cases of exophoria, as I have frequently seen marked spasm which has disappeared under prolonged use of mydriatic and no exophoria was demonstrable. My own experience is in accord with the teachings of Dr. Jackson's paper. The astigmatism following operations which opened the anterior chamber, I believe, occurred quite uniformly. I have recently performed extractions in two cases in which the existence of astigmatism has been demonstrated before extraction, the axes of the correction cylinder being required at 90°. After extraction a much higher grade of astigmatism was pres- ent with the axis of the correcting cylinder at right angles to its former position. My experience also showed a more or less rapid diminution of the astigmatism found to exist two weeks after extraction. The permanent degree probably aver- aged about 1.25 D. and the axis of the cylinder was ordinarily required approxi- mately parallel to the line of the cicatrix. I was much pleased with the admirable statement by Dr. Lautenbach of the proper values of the ophthalmometer. I use it quite constantly as an addition method, but I can not trust it sufficiently to justify me in ordering cylinders by its readings since, in a careful analysis of 200 eyes, subsequently corrected under mydri- atics by subjective examinations, 25 per cent showed important discrepancies. Dr. Burnett said: I was interested in the statement of Dr. Belt that he had found approximately the same number of squints in the white and colored children. 1440 PAN-AMERICAN MEDICAL CONGRESS. My Own experience in clinical and private practice has been that squint, especially of the concomitant form, is very rare in the negro. I coincide fully with Dr. Jackson, since the results as reported by him as to astigmatism following cat- aract extraction are in accordance with my own, published three or four years ago. He did not think that on the average the eye regained its final shape after an extraction, on an average, under two months. I think Dr. Lautenbach's estimate of the ophthalmometer just. It would give us only the astigmatism of the cornea, but is, on the whole, one of the most valuable instruments we have, and if once used understandingly would never be given up. It did not give us the lenticular astigmatism directly, though it had done more than any other instru- ment to demonstrate its existence. (He gave the history of a case examined that morning which showed that neither the ophthalmometer nor the shadow test could be relied upon implicitly). In this case the shadow test showed those inter- nal shadows of which I have spoken at a late meeting of the Ophthalmological Society, and whose presence indicates, in my mind, some irregularity in the refrac- tion of the lens, and made the findings of the shadow test unreliable. I am of the opinion that in some particulars the old instrument of Javal is the better, particularly as to its prisms. Dr. Gould thought that in the great majority of cases of eye strain without com- plicating disease, the long-continued use of a mydriatic as a therapeutic agent was an unnecessary tax on the patient. The glasses are the therapeutic agent. Physiologic action, not paralysis, is true therapeutics. He finds that homatropine and cocaine in pure solutions, properly exhibited, give perfect mydriasis. Dr. Snellen said: Dr. Jackson stated this morning that operations for Cataract or iridectomies are always followed by astigmatism. I quite agree with him that this is due to the loosening of the tissues and the bulging of the Sclerotic. The more the wound is in the sclerotic the more astigmatism one gets. After a para- centesis of the cornea no astigmatism occurs. Up to now no one knows to what the good effect of iridectomy is due. My father, Professor Snellen, started the idea that it was due to this astigmatism, or rather to the cause of it; the bulging of the Sclerotic which opens the perilenticular space. Priestly Smith, of Birmingham, Sought the cause of glaucoma in closing of this space. Dr. Hansell said: My experience in refraction of aphakial eyes agrees in the great majority of cases with the observations made by Dr. Jackson, that astigmatism diminishes during the few months following the cataract extraction. I have had, however, a case which has proven an exception. Four weeks after operation I prescribed --12 c +4 cyl. ax. 180°. Four months later Ireéxamined and discovered that the astigmatism had remained unchanged but that the Hypermetropia had increased to 16°. Dr. Baker, of Cleveland, Ohio, said: I am pleased with the conservative char- acter of the papers read; and yet I suppose that every ophthalmic Surgeon is at liberty to use his own judgment and experience as to the choice of mydriatic, and the method of examination, either objective or subjective. When a patient pre- sents himself at my office complaining of eye trouble, immediately after making a few general inquiries I take him into the dark room and examine him with the retinoscope. This examination should be made in a large dark room and without a mydriatic. Many of the difficulties complained of by Dr. Burnett in his case this morning will not be met with in the undilated pupil. The inability to dis- cover the point of reversal in retinoscopy with the dilated pupil, I think, is often due to an irregular refraction at the margin of the lens. I then test the patient with the Snellen test type and trial lenses and if I get the same result as in the retinoscopic examination 1 feel perfectly justified in prescribing lenses without resorting to mydriatics, and I think these include fully one-half of my refractive cases, not including presbyopic ones. My cases do not all come to me because of PAN-AMERICAN MEDICAL CONGRESS. 1441 pain and eye strain; in fact, a large percentage come for imperfect vision, and if I can improve the vision without using mydriatics I see no occasion to subject the patient to the inconvenience of their use. I frequently make an exception in cases of low degrees of myopia. An overcorrection in these cases would prove disastrous. There is no danger of overcorrecting hypermetropia, and an undercorrection is not objectionable ; and the amount of astigmatism can be accurately measured by retinoscopy. In low degrees of myopia I frequently use homatropine. I thoroughly believe with Dr. Risley in the therapeutic value of atropine in cases of eye strain, even though no pathological changes can be discovered in the fundus. These overworked eyes need rest, Frequently it is impossible to send these cases to the mountains or seashore, and the best substitute I can subscribe is absolute rest for two or three weeks under atropine, and I frequently prescribe it for this purpose. Parents often will not remove their children from school, and I take this method of enforcing my demands. I find the presoptometer of the late Dr. Culbertson of much use to me in cases of amblyopia in young children who can not read and in ignorant, dull people as a substiute for the test type. Dr. Kollock, of Charleston, S. C., said: My experience with the negro shows a much greater percentage of corneal disease than has been incidentally men- tioned by Dr. Belt. In my practice among the negroes more than 37 per cent of all diseases were corneal. With regard to strabismus in the negro I agree with Dr. Burnett that it is never seen in the pure-blooded negro except in cases of corneal defects, paralysis of the Orbital muscles, cataract, or disease. In the mulatto it is not uncommon, though not as frequent as in the white. I think in testing these troubles in the negro care should be taken to state whether they were mulattoes or pure negroes. The mulatto has all the refractive troubles seen in the white, though not as common ; the pure-blooded negro has little refractive trouble, slight hyper- opia, and rarely myopia. With reference to Dr. Jackson's paper, I have seen an interesting case of corneal astigmatism following a corneal section for glaucoma. This section was made with a lance knife. The anterior chamber filled with blood, and tension instead of being reduced became of strong hardness. This con- tinued for two days and vision was nil. Weak solutions of eserine failed to reduce the tension and the 4-grain solution was used with the result of rapidly reducing tension and restoring vision. This vision was 15, and no glass or combination of glasses would improve, but the stenopoeic hole gave #5. About a month later vision was brought up to this point by a compound lens. - Dr. Tiffany, of Kansas City, said: Dr. Belt in his report of the examination of school children, white and colored, says that he notices that some of the hyperopes after a few years increased in their hyperopia. We can readily understand how an eye can appear or even become emmetropic. My examinations of school chil- dren and students show many pupils of 10 to 12 years with a fraction of 1 to 2 dioptres become at 18 or 20 absolutely emmetropic or even myopic, but never more hypermetropic. When we speak of hypermetropia we mean the static refraction and not the dynamic. The dynamic conceals the hypermetropia to a great degree. I remember one patient, a young lady of 20, a teacher, who came to my office with #}, but, with the dynamic set aside, her vision was sån requiring a +6 D. to gain #}. The fact is that hypermetropia does not increase but myopia does. Dr. P. D. Keyser, of Philadelphia, said: I regret that I was obliged to leave this morning before hearing all the papers read, my duties requiring my attendance in the section of hygiene for the time, but to the remarks of Dr. Kollock in relation to the negro never having myopia I must say that there must be a difference in the eyes of the black race in the South from those in the North, although our confrères of the South have much greater advantage in seeing more eyes of the negro than in the North, but in my experience of more than twenty years in the Wills Eye Hospital, of Philadelphia, I have found several that we call pure negroes suffering S. Ex. 36 91 1442 PAN-AMERICAN MF.DICAL CONGRESS. with well-marked myopia as well as compound myopic astigmatism. One case, near my office, of a very dark coachman of a well-known physician of our city wears 6 spherical, and only last week I fitted a compound myopic astigmatism. Really, in my experience I find as the negroes are being educated to read that their attention is being called to the defectin vision and they seek assistance, and in proportion as these educated persons come to my clinic I find almost an equal defect as in the white. In relation to Dr. Jackson's paper on astigmatism following cataract extraction, I desire to state that v. Graefe in 1883–84 called attention to the defect after his modified linear incision, and I have noticed it in all extractions by any form or place of incision, as well as in iridectomy. I look at it being caused by the Swelling and thickening of the cicatricial edges of the corneal incision in the process of healing; always soon after the healing of the wound the irregular curv- ature of the cornea is much greater than is found after several months. It is very frequent that it is necessary to change the cylinder six, twelve, and twenty-four months after from the change in the cornea caused by the shrinkage of the cicatrix. It is very rare that astigmatism is not found in operations on the cornea which requires correction for good vision. I agree with T)r. Savage in the necessity for complete paralysis of accommodation in many cases of examination and adjust- ment of glasses; especially is it necessary in small children who have strong mus- cular power and unable to aid the examiner. Homatropine and such remedies do very well in adults and are mostly sufficient, but are not so in children. With them atropine to complete suspension of accommodation gives the best result in many cases. But judgment is necessary in making a full correction. I find many cases in which it is impossible to put on the glasses found correcting the defect. A cer- tain amount of play of accommodation must be allowed to relieve the patient from discomfort. Dr. Dean, of Scranton, Pa., said: I have not, during this discussion, heard any one raise the question of the mydriatic producing a low grade of hypermetropia during its action in an eye otherwise emmetropic; therefore I rise to bring for- ward that subject. In my experience the mydriatic often produces 0.50 to 0.75 of a dioptre. Dr. Savage did say that he did not always fully correct the hyper- metropia. I have had a few cases where I had glasses made with the correction with the mydriatic to change to the correction without a mydriatic. Dr. Allen, of Pittsburg, Pa., said: I advise simple and direct methods for the examinations of the refraction of the eyes, employing the test case and test card, not regarding retinoscopy and ophthalmometry as of the greatest practical use. I examine the eye under the full effect of atropine. I have the patient wait until the effect of the atropine has passed off before the glasses are prescribed. Dr. Zeigler, of Philadelphia, Pa., said: Referring to Dr. Jackson's paper on astig- matism following cataract extraction, I wish to place on record two cases of very high astigmatism, amounting to C+6 D. ax. 180° in one patient and C-H.8 D. ax. 10° in another. These cases occurred during my service as house surgeon at the Wills Hospital, and, notwithstanding Dr. Love's remarks I do not think there is more astigmatism under the use of the simple dressing of court-plaster, Suggested by our president, and I strongly prefer the lighter dressing. I have recently refracted two presbyopes in whom the astigmatism was irregular. The last case showed C+2 D. ax. 180°–C–1.25 D. ax. 30°. I desired to order S-1-3D. in the bifocal slip, and have had both these cylinders ground on one side of glass, leaving the other side plane for the application of the bifocal sequent. This was ground on the principle of the “tonic ’’ lens, by Borsch of Philadelphia, and I herewith show such a lens. My habit is to use complete mydriasis for all cases under 45. The stronger solutions of atropine are used before 40 and hyoscyamine sulphate after that age. I can not rely on homatropine, and only use it when I can not avoid it. I use a solution of 16 grains to the ounce. In a recent case, aged 49, I was not PAN-AMERICAN MEDICAL CONGRESS. 1443 satisfied with the homatropine, and changed to hyoscyamine. While the result in one eye was the same as in the previous test, the other one showed a change in cylinder and a change in the axis. It is these occasional failures that shake our faith in the weaker mydriatics. Dr. Young, of Burlington, Iowa, said: I desire to remind the section that twelve or fifteen years ago when I, with possibly some others present, began the study of ophthalmology we had no ophthalmometer, no skiascopy, no phorometer, no homa- tropine, no cocaine. We had only the ophthalmoscope, the trial case, and atropine; and yet we did creditable refractive work, creditable to ourselves under modern standards and satisfactory to our patients. Now we have all the advantages and have more trouble. Is it not due to a mistaken idea of our duty, a confusion of which we ought to know, and which we ought to do (satisfactory to the patient)? Dr. Risley properly sets up the emmetropic eye as the normal eye, but an eye artifi- cially made emmetropic will not necessarily be a satisfactory organ practically. We should know as much as possible about it and do our work within these lines. As regards mydriatics I use the mydriatic, weak or strong, according to peculi- arity of the case, to secure paralysis of the accommodation. Patients complain of discomfort from disks. I find astigmatism after extraction and have used cross cylinders in some cases for the flatter field. Dr. Chisolm said, in response to Dr. Belt's paper, that the colored race in America was only exempt from refractive errors by absence of eye tax. Prior to 1885 colored public schools in the South were very rare. Colored children up to 15 years of age were comparatively unemployed. To eat, sleep, and play, and look after the smaller children was their occupation. So that through the growing stage there was no eye tax whatever. They escaped the dangerous period of school life which starts or develops refractive trouble. Now the colored children have all the advantage of education, and the results of their new period of eye work is that they are requiring the need of glasses also, showing conclusively that it is a fault of education more than one of race. Squint in the colored race is rarely met with. In response to Dr. Wood as to the value of mydriatic disks he would say that from neutral solutions he gets all the good and prompt action that could be desired. He uses homatropine grs. vi to 1 ounce, puts a few drops into the cul-de-sac formed by drawing the lid downward, and makes a small cup as it were, requesting the patient to look downward at the same time, so as to submerge the cornea in the liquid. He secures full action of the drug in 30 to 50 minutes. In his expe- rience the effects begin to pass away at the expiration of an hour. Rarely does he find it necessary to use the stronger mydriatics, nor has he found any especial advantage in combining them with cocaine. In answer to Dr. Savage, he does not think it necessary to paralyze completely the ciliary muscle in his refractive work and, hence protects his patients from the annoyance of atropine instillation. He makes it a rule to cover always by glasses the entire amount of astigmatism found, but does not find that patients desire to have all hyperopia cov- ered by plus glasses. He does not succeed in keeping his patients under observation for one or two weeks. With many of them he can only retain them twenty-four hours until the action of the homatropine has passed off, and some are not seen again after the first visit. He uses homatropine in about 30 per cent of the refractive cases. When sharp answers are elicited in reference to the astigmatic charts no myariatic need be used. When the patient is not sure of lines or angles, or when the angle differs in the two eyes homatropine instillation is used to verify the examination. In the weaker forms of simple astigmatism, when patients have acute normal vision, but can not use their eyes with comfort, he often found that an astigmatism of 0.25 D.—would be converted into one of 0.25 D. -- at right angles by the mydriatic. As soon as the mydriatic effects have passed off the myopic cylinder would be accepted as the most restful glass, and that one would be pre- 1444 PAN-AMERICAN MEDICAL CONGRESS. scribed. In quite a number of instances he has had to change the plus cylinder, given by others under the mydriatic, and worn with no comfort, to the minus cylin- der, which was immediately restful. In the mixed cases in which normal vision without the mydriatic may be reduced to #95, showing + 6-i-hyperopia and an astigmatism of not more than 0.25+D. When the effect of the homatropine has passed off they would need only a small part of the spherical strength with the cylin- der, probably not half of it. I prescribe accordingly, and give much more com- fort to patients than if I forced them to try to accustom themselves to the latent amount of error. In answer to Dr. Jackson he agrees with him fully that the exten- sive opening of the cornea for cataract extraction will in the healing act so change the corneal curvature as to cause more or less astigmatism. Most of this irregu- larity passes away in the course of time, so that glasses given at the end of a fort- night, the time that most of our cataract patients are dismissed, need changing in a few weeks or months. Dr. Love thinks that his patients escape these irregulari- ties of the healing of the corneal wound by the peculiar manner of his eye dressing regulating the eye pressure and tightening the bandage after the third or fourth day after the operation. He has for many years considered the typical dressing of an eye after cataract extraction simply the closed lids, the cartilage of the upper lid acting as a splint for perfect adaptation of the corneal wound, held in position by the tonicity of the palpebral muscles. Formerly a piece of adhesive plaster per- fected this result, and he still considers this the very best of eye dressing. In the past year he has laid this aside, as he found it interfering with the daily examina- tions of the eye, which he thinks the simple cataract extraction of the present day requires to reduce hernias of the iris should they occur. His present dressing is a single Lebright bandage to cover only the eye operated upon, to hold in position a thin pad of absorbent cotton, which makes no pressure. At the time that Dr. Love is tightening the bandage he himself removes it altogether, leaving the eye free and open. He bandages over five days, and has released the eye after two days' closure. He finds the astigmatism, nevertheless, neither more nor less than those who use much more 1manipulation and restraint than he does. He covers only the one eye operated upon, leaving the patient the use of the other. With Dr. Lautenbach Dr. Chisolm agrees fully as to the restricted value of the ophthalmometer. He had found it useful, and again very disappointing. The only concise work that he secures is by the trial lenses and astigmatic card, and we all acknowledge that they alone are reliable. He proceeds to their use at once, and only uses the other means and apparatus to aid should difficulties arise in the irregular responses of patients. With intelligent patients he rarely finds trouble; with the ignorant and timid we must use all the means at our hands for securing the best aid for them. There is no doubt that constant practice with any method of investigation will enable one to derive much more information than those who only use the method incidentally, and yet he feels assured that the few enthusiasts who profess to get everything out of the ophthalmometer of Javal, much more even than Javal himself contends for, are misleading the younger members of our body. - Dr. Hubbell, of Buffalo, N. Y., said: I think that most of us will agree that astigmatism almost always follows cataract extraction. How to make it as slight as possible is the question. My experience is that the greater the pressure from , the dressing the greater the astigmatism that results. I aim simply to keep the eyelids closed without any pressure. I use a bandage consisting of a piece of flannel six inches long and two inches wide with a piece of tape three-fourths of an inch wide Sewed to each end. One of the tapes is carried around the head over one ear under the Occiput to the other tape as Ioosely as can be done and be kept in place. This is comfortable, very easily readjusted, and produces no pressure. I cover both eyes for the first four or five days, but do not restrict the freedom of the PAN-AMERICAN MEDICAL CONGRESS. 1445 patient. In the correction of refractive errors I combine the use of Javal's ophthal- mometer, pattern of 1889, skiascopy, and the trial lenses. The trial lenses is the final resort in all patients who can read. The ophthalmometer has its drawbacks. A slight variation from the position of sharpest focalization, which is not always easy to determine exactly, correspondingly changes the readings on the minus. An error of 0.25 D. to 0.50 D. can thus be very easily made. Again, with the most accurate focal adjustment possible, the readings in the great majority of cases show greater refraction in vertical, or nearly vertical, meridians of the eye as compared with any other test, objective or subjective. This difference, also, is not a fixed quantity, but varies in different patients. In a very few cases by most careful use of the instrument I have been surprised to find the other tests placing the astigmatic meridian directly at right angles to that which it had indicated. The cases in which discrepancies are great are comparatively so few and positively misleading that I consider the ophthalmometer a most useful instrument, gen- erally giving an approximate degree of astigmatism and a tolerably sure position of the meridians of greatest and least refraction. The shadow test is to me an invaluable objective method of examination. But this, too, has its weak points, although not as various as those of the ophthalmometer. In some patients the pupillary shadows do not move normally, so to speak. They either move instan- taneously or irregularly, with or against the movement of the mirror when the glass is placed before the eye, which seems to be the nearest to the proper correc- tion, and even without any glass, or, as in one case, which I recall, where the shadows moved normally in one eye, but in the other eye no shadow could be produced in any direction with or without any plus or minus glass, although the fundus could be distinctly seen with the ophthalmoscope and appeared normal, and the refraction nearly emmetropic. The vision in this eye was very amblyopic. I have no explanation for this anomalous response to the shadow test, although I studied the case carefully and with the eyes under the influence of homatropine. Again, the movements of the shadows when normal will sometimes indicate a spherical glass weaker and sometimes stronger than the patient will see best with by the subjective test. With normal shadows, however, the degree and direction of astigmatism can be quite accurately determined. The cases in which, with normal movements of the shadows, this method of examination gives results at variance with that by the subjective method are so very few that I rely upon it with great confidence, and it is most helpful, even indispensable, to me, in amblyopic patients and in children, and in others who can not read. The first thing I do in a case of suspected refractive error is to ascertain the acute- mess of vision. If, without or with concave or convex glasses, I find vision equal five-fifths or better, I do not use the ophthalmometer, as I do not expect to find sufficient astigmatism for the readings of the instrument to aid me. But if the vision is below normal, especially if much below, in spite of spherical glasses I at once place my patient before the instrument with the expectation of getting some light as to whether astigmatism or some other condition is the cause of the reduced vision. If it shows astigmatism, this may be the cause, although there may be associated amblyopia; if it shows no astigmatism, I look for some other cause. If astigmatism is present, the direction is indicated and I can esti- mate its degree approximately. In short, in one moment it tells me in what direc- tion to work. Its use takes so little time that I am always glad to avail myself of such suggestions as it may give, and I therefore use it constantly in the cases indi- cated. In testing for refraction I almost constantly use homatropine, 8 grains to the ounce of water. I always use it in practicing skiascopy, and generally in young people, even up to 48 years of age in cases of special importance. I instill a drop or two at intervals of three or four minutes for three or four times. I expect to get the full cycloplegic effect in twenty to forty-five minutes, when I proceed with 1446 PAN-AMERICAN MEDICAL CONGRESS, my examination. I do not believe longer time is necessary. I get such satisfac- tory results with homatropine in refractive work that it is very seldom, indeed, that I resort to atropine. I use the latter only in suspected cases of accommodative Spasm, or in rare cases of apparent inability of homatropine to sufficiently suspend the accommodation. Iconsider it unnecessary, and therefore unjust and unfeeling, to inflict upon a patient the prolonged inconveniences and distresses of atropin- ization when the transient effects of homatropine serve the desired purpose. I determine the axis of astigmatism by using the single set of three parallel lines of proper size placed in the positions selected by the patient, and the degree of least and greatest refraction by finding the spherical glass which gives the best vision for such lines in corresponding positions. I then combine the cylin- drical glass representing the difference in the two meridians with the proper spher- ical for one of the meridians and then direct the attention of the patient to the test letters. I seldom have occasion to modify the combination or the axis of the cylinder to secure the most acute vision. This method of determining the astig- matism is more rapid, and not less certain in its results, than any other which I have tried. In patients who give doubtful information or none at all, or who make con- tradictory statements as to how they see, the ophthalmometer gives some light and skiascopy affords most important and usually reliable aid. My practice is to cor- rect all astigmatism, even small degrees in Sensitive eyes, all of myopia, unless there is some special contraindication, and all of the manifest and one-half to three-fourths of the latent hypermetropia, excepting the few cases which seem to require, for various reasons, a full correction, or a few others which insist, at least at first, on greater undercorrection. In all my refractive work I do not forget the changed relation between accommodation and convergence produced by wear- ing glasses. Dr. Wood, of Chicago, said: There are several points elicited by the discussion of my paper which I desire to further elucidate. If it betrue, and I do not think that the statements have been successfully controverted, (a) that solutions of the cyclo- plegic alkaloids in water are less effective than the same agents in oily suspension, or Solid form, it must follow that homatropine disks are more effective than that drug in solution; (b) likewise if the effect of the ordinary alkaloids on the eye is increased by the addition of cocaine to them, homatropine plus cocaine is a more effective cyclo- plegic agent than the former alone; (c) the disk form, with cocaine, is the best one in which to exhibit homatropine when we desire to obtain its fullest effects for the determination of refractive errors. To prevent the deleterious action of the cocaine on the cornea it is absolutely essential that the eye be kept closed during the whole time that elapses between the use of the first disk and the beginning of the exami- nation proper. The omission of this important detail is responsible for many of the failures to obtain satisfactory results with these agents. Not only is the ephithelial disturbance thus reduced to a minimum, but the Scleral congestion and the foreign-body feeling and smarting shortly disappear when the eye is thus kept in a state of rest. Regarding the different effects upon the symptoms expe- rienced in the case of hyoscyamine by Dr. Risley and myself, I can only attribute them to differences in the samples supplied by our different druggists. This alka- loid in my hands has proven so uncertain and so toxic that I have entirely dis- missed it from my armamentarium as a cycloplegic. Dr. Hiram Woods, of Baltimore, said: Refractive test for ciliary paralysis after the use of a mydriatic, which I have used for some time, is to get the best distant vision and then add a weak concave glass. Myopic refraction must be previously excluded. If the best distant vision is retained with a concave glass as strong as 0.5 to 0.75 D., I do not trust the cycloplegia. I have seen total dilatation of the pupil from homatropine, and an accommodative range left of 1 D. Dr. Jackson, of Philadelphia, said: Some accommodation may in a few cases PAN-AMERICAN MEDICAL CONGRESS. 1447 remain when the refraction is quite fixed. This can only be discovered by pro- longing the mydriasis. When there remains voluntary accommodation, the most valuable means of detecting it is by skiascopy. The test with lenses either at a distance or near is liable to the fallacy that one part of the pupil may have one degree of ametropia and another part may have a different degree, allowing distinct vision with different lenses, although no accommodation is present. As a mydriatic I use habitually duboisine and homatropine. The former I prescribe for use in the patient's home; the latter I always instill myself, placing a drop of the 24 per cent solution at the upper margin of the cornea. Under these circumstances, I see fail- ure to produce complete paralysis more frequently with the stronger mydriatic. It is extremely important that the instillation should be made effectually. With reference to postoperative astigmatism, Dr. Snellen raised the point of the influence of the position of the incision. In the cases on which my paper was based, no such influence could be determined. About one-half were cases of sim- ple extraction with the incision in the clear cornea. One-third were cases of extraction with iridectomy with the incision in the sclero-corneal junction. The remainder were cases of iridectomy for glaucoma, the incision in the extreme periphery of the anterior chamber. They were carefully studied as to the influ- ence of the incision and the amount of astigmatism, and gave only negative evidence. The increase of hyperopia during cicatricial contraction, referred to by Dr. Hansell, was noted in a number of cases, in one the hypermetropia rose from 7 to 11 D., the astigmatism remaining 3 D. throughout. The ophthalmom- eter indicates that this change is mainly due to a strengthening of the antero-poste- rior diameter by retraction of the cornea. High tension after iridectomy, as referred to by Dr. Kollock, must be due to jamming of a large lens into the ciliary ring, and can not affect the anterior chamber while the incision remains open. Dr. Corr said: There are three or four points in the discussion on errors of refraction and their mode of detection and correction that it seems have not been quite fully enough dwelt upon. The first of these I will put in the form of a ques- tion: Has anyone, in books or otherwise, given a standard of relaxation of the ciliary muscle or gauge by which we may know that we have obtained the desired cycloplegic condition of the ciliary muscle as a prerequisite to determin- ing refractive errors? Dr. Wood and all others, so far as I know, who have spoken here, have referred only to the dosage, and taken into consideration, with- out regard to the patient's ability to, in a greater or less degree, manage or Command the use of the muscle. A moment's thought will lead you to say that this can not be so implicitly relied upon. Hence some systematic plan ought to be agreed upon by which the proper condition of the muscle may be determined. Until this is done the controversy between the relative value of homatropine and atropine will be continued. I suppose each one has established some standard or gauge for his or her self, but the trouble is they do not agree; hence our results and conclusions do not agree when they should, for we are striving for the same thing amid condi- tions that are very similar. I will not impose on you details of varying procedure, but give my gauge or standard. After running over the case in a Superficial way so as to determine the W. and the accommodative power, determining finest print the patient can read, I begin my dosage, usually homatropine 1 per cent Solution, which I instilla drop every five or ten minutes for three times or oftener, after which Iwait a variable time, half to one hour; then I present him a card with grades of fine print. While the patient could read medium or fine print before, he will usually say: “I can’t read any on the card.” Then I take a 2% or 3 D. lens and place before his eyes, when, if that or a stronger lens only enables him to read as he read before mydriasis, I conclude that the muscle is fully relaxed. From this as a standard or gauge, I proceed to determine the error of refraction. The next point is the one of so-called “mixed astigmatism.” Iagree with all who may assert 1448 PAN-AMERICAN MEDICAL CONGRESS. it, that there are many cases of apparent mixed astigmatism, but I have never met With a case that did not, under proper mydriasis, restore itself into some simple variety or compound variety of astigmatism. The third point is the one referred to by Dr. Chisolm ; that of prescribing minus cylinders axis horizontal in cases of hypermetropic astigmatism. I suspect these are the cases of mixed astigmatism referred to, and involves the question as to whether you would prescribe a minus cylinder axis horizontal in a casewhere there is simple hyperopicastigmatism in hori- Zontal meridian. Another point that I think should be emphasized more definitely is that, according to circumstance, of requiring the patient to wear a full correction. I think this ought to be insisted upon in many cases as importunately as is agreea- ble. As is well known, the distant vision is not so good for a variable length of time with the full correction. Of this the patient ought to be advised, that the medicine must be taken for awhile, bad as it is, and soon it will taste better. Here another point suggests itself, that of whether we should lead our patients to expect a cure of their eye discomfort, or headache, or whatever led them to seek advice except amblyopia, so they will not always need to wear the correction. I have Seen cases of perpetual and torturing headache for many years so far cured that they could leave off the correction, still pursuing their studies or business with immunity for years. - Dr. Savage, of Nashvillee, Tenn., said: My advocacy of the complete suspen- Sion of the accommodation of the operator, as well as of the patient. A full knowledge of the error should be had, not that in all cases a full correction should be given, but that a correct record should be made. The “balance” of the lateral muscles should determine if no correction, a partial, or a complete correction of the focal error is to be made. And let me insist that these cases be tested when the eyes are uninfluenced by the mydriatic. As to the correction of astigmatism, this can be done in any case by either plus or minus cylinders, the One increasing the refraction of the least refractive meridian, the other decreasing the refraction of the greatest refractive meridian, and in either case the astigmatism is corrected. Knowing the existence of a lateral muscle error, but ignoring its treatment, we should be guided by this knowledge in prescribing plus or minus cylinders. If there is hypermetropic astigmatism associated with exophoria a minus cylinder correcting the astigmatism would add to the patient's comfort, while a plus cylinder would increase his discomfort. If the hyperme- tropic astigmatism should be associated with esophoria it would be folly to correct the astigmatism with a minus cylinder, for it would make the patient worse. The correct thing to do would be to treat the muscle error and cure it, either by operation or exercise, and then prescribe the lenses indicated by the state of the refraction. I am asked if a mydriatic is not necessary in our study of cases of mixed astigmatism? It is, but not more so than in the other forms of astigmatism. We may have a case appearing to be mixed astigmatism, which the mydriatic will show to be hypermetropic, simple or compound. On the other hand, we may have a case of apparently myopic astigmatism, simple or compound, which the mydriatic would show to be mixed astigmatism. . Mixed astigmatism is so rare that a man's reputation may suffer who fails to find it when it exists, or supposes he has found it when it does not exist. The mydriatic can alone make him certain. If he should find it he should tell the patient of it; and if he does not give the mixed correction he should give his reasons to the patient. Otherwise when the patient drifts into the hands of some confrère, he may remark: “I have always considered Dr. — a competent man, but he missed it badly in your case.” It is always best to know the refractive error and to correct it, or give the patient some good reason for not prescribing a full correction. To the question just asked by Dr. Corr, “Do glasses scientifically prescribed relieve the symp- toms, headaches, etc., commonly attributed to eye strain,” I will answer by report- ing a case that has come under my observation. The patient not only suffered PAN-AMERICAN MEDICAL CONGRESS. 1449 with headache but was also an epileptic. I was asked by the physician in charge of the case to examine the eyes and correct any error found, with the hope of a cure. It was agreed that the patient should not be told that we suspected that anything like a causative relation existed between the eyes and the epileptic attacks. I found 4.50 D. hypermetropia in One eye and 5 D. in the other, with slight astigmatism in each. This was seven years ago, when I was not a believer in muscle troubles, hence did not then know that this patient had an esophoria. I fortunately prescribed a full correction. The glasses were worn more or less con- tinuously four years, with relief from headaches and epileptic seizures. Not hav- ing been impressed that the glasses had brought this relief, the patient began to leave them off, and finally ceased wearing them. The epilepsy returned and, strange to say, the glasses were still neglected. Four months ago the new family physician in getting a history of the case, learned of the wearing of the glasses and the coincident immunity from suffering. He sent the case to me for investigation again. I did not reëxamine the focal condition. Having in the meantime learned something of heterophoria (thanks to Dr. Stevens who made this study a possi- bility, and thanks to my good fortune that I stumbled into this study even as early as I did), on investigation I found 4 degrees of esophoria about the same for near and distant vision. On placing the full focal correction before the eyes I found that both the focal and the muscular error was corrected by them. This I expected from my knowledge of the relationship between the centers of accommodation and con- vergence. For the first time I told the patient that the epilepsy was due to errors of the visual apparatus which the glasses corrected; and I gave assurance, based on four years of relief by wearing the glasses, that these would cure in that they would remove the cause. There have been no other attacks nor do I expect any so long as the glasses are worn. - Dr. P. Lagleyze, replying to Dr. Savage, said: Algunos Oculistas emplean indif- erentemente los midriáticos para la corrección de cual(Illier vicio de refracción. El diámetro de la pupila ejerce una acción considerable sobre la agudeza visual, porque las dimensiones de los circulos de difusión están en relación directa con el grado de dilatación pupilar. El diámetro de la pupila no influiría mucho sobre la nitidez dela imágen, à pesar de la aberración de esfericidad y de refrangibilidad que poseen todos los ojos, si la côrnea fuera esférica. La córneatiené una forma elipsoidaly Según lastiltimas medidas practicadas por Sulzer, resulta que si se pasa del centro à la periferie, la curvatura disminuye irregularmente, no solo à lo largo de los dos meridianos principales, sino aſſin à lo largo de las dos mitades del mismo meridiano. Esta dis- posición es causade diferencias entre la refracción central y la de las partes perifé- ricas. Se concibe, pues, que la atropina, permitiendo que las partes periféricas de Ia córnea participen en la visión, produzca variaciones, y por consiguiente que el vidrio corrector elegido en estas condiciones no sea el mās conveniente. En los hipermétropes, en general, no debe recetarse lentes bajo la acción de la atropina; el hipermétrope, por el habito de ačomodar constantemente ha estable- cido una armonia difícil de alterar entre su convergencia y su acomodación, empleando una parte 6 toda su amplitud relativa de acomodación positiva bino- cular. Sin embargo, no debe desecharse en absoluto eluso de los midriáticos; hay casos, en que llena una indicación, por ejemplo, cuando Se Sospecha una contracción irregular de la acomodación y tambien en los espasmos ciliares de todo el masculo. Some oculists employ indifferently mydriatics for the correction of any vice of refraction. The diameter of the pupil exercises considerable action on the visual sharpness, because the dimensions of the circle of diffusion are in direct relation with the degree of dilatation. The diameter of the pupil would not influence much the clearness of the image, notwithstanding the spherical and refractive observa, tion that all eyes possess, if the cornea was spherical. The cornea has an ellip. 1450 PAN-AMERICAN MEDICAL CONGRESS. soidal form, and according to the latest measurements practiced by Sulzer, it results that if it passes from the center to the surface the curvature diminishes irregularly, not only in length of two principal meridians, but also in the two halves of the same meridians. This arrangement causes the difference between the Central refraction and that of the peripheral parts. We conceive, then, that atropine, allowing that the peripheral parts of the cornea participate in the vision, produce the variation and therefore that the correcting glass selected in these con- ditions is not the most convenient. In hypermetropia in general, glasses must not |be prescribed when under atropine influence. The hypermetropia, by the habit of constantly accommodating has established a harmony difficult to change between its convergency and accommodation, employing a part or the whole of its relative ampleness for positive binocular accommodation. Yet, the use of mydriatics must not be put aside absolutely. There are cases, for example, when an indication has been filled, when we suspect an irregular contraction of accommodation and also in ciliary spasm of the whole muscle. Dr. Belt, of Washington, D. C., said: In reference to Dr. Jackson's paper on astigmatism following cataract extraction, I am inclined to think that a large amount of astigmatism is due in our prescribing glasses and allowing the use of the eyes for reading too soon after the extraction. The patient having been blind for some time is impatient to see to read and work, and wants his glasses as soon as possible, and when he gets them he thinks he should be able to read with as great facility as ever, and when he finds he can not do that, by great effort tries to bring to his aid the external muscles and lids, and this great pressure on an eye- ball, still weak and pliable when the corneal section was made, cause the astig- matism. This is probably counteracted later by contraction of the wound by cicatrization, thus decreasing theastigmatism. However, astigmatism may develop a year or two after extraction ; e. g., in a case operated upon by me about two years ago, three months after extraction vision was #} with 10 D., three months later a 1 D. cyl. ax. 180° was required to give that vision, and a year later a 2 D. cyl, ax. 180° was required. In reference to the disks of homatropine and cocaine as recommended by Dr. Wood, I tried disks of homatropine, thinking they would be convenient for the patient to use an hour before coming to my office so I could proceed at once with the examination, but usually found as a result conjuctival irritation sufficient to interfere with the examination, so I have gone back to the use of solutions. I think the combination with cocaine objectionable, owing to its causing dryness of the epithelium, which prevents clear perception. Dr. Kollock called attention to the cases of corneal disease found by me among the colored pupils. Knowing its prevalence generally in the race, I can only account for it by the carelessness of negro parents in allowing children, even with slight troubles, to remain at home. I did not pay especial attention to the ques- tion of whether the cases of strabismus found in the colored pupils were among the mulattoes or the pure-blooded negroes. Dr. Chisolm said: To-day we take up the subject of muscle errors. We have been a long time finding out that the extraocular muscles, numerous and large as they are, should necessarily play a very important rôle in the comfort and dis- comfort of eye work. I can not say that we have devoted too much time to the study of refractive errors, for ciliary muscle action is undoubtedly the pivot for acute. But to keep the fovea centralis in its proper place, to secure binocular vision, is the duty of the recti and oblique muscles. It requires that these six pairs of muscles be nicely adjusted and always alert, for they are in perpetual action during our wakeful hours. Lately I have been devoting much more time in exploring the individual functions of each of these muscles, and am quite sure that results are against my former neglect. I hope that the discussion will elicit much knowledge for our future guidance in a class of cases which becomes quite numerous the more carefully we seek them. PAN-AMERICAN MEDICAL CONGRESS, 1451 A CLINICAL STUDY OF HETEROPHORIA. By Dr. HIRAM WOODS, of Baltimore, Md. I fear my paper may seem to some surgeons too elementary ; reactionary rather than progressive. Most of the articles one meets nowadays in journal literature on heterophoria show, it seems to me, a tendency toward a refinement of diagnosis and treatment, proper enough in itself and under certain circumstances, but not reaching the question which daily puzzles an oculist in office work. “What is the significance of the heterophoria in the case before him * Text-books of eight or ten years ago give little or no information. Those by American authors of more recent date discuss the subject more or less fully; but I doubt if Dr. Noyes, or Dr. de Schwenitz, or other recent book writers, would claim that their chapters on Imus- cularas thenopia are more than pointers for original investigation. The more I See of heterophoria the more I appreciate the truth of a recent remark by Dr. Stevens (Ophthalmic Record, January, 1892): “One will find himself too often in the face of serious embarrassments to believe that he has arrived at the knowledge of an easy system in which all the ultimate facts are at his command.” I am often in doubt whether to lay stress upon the refraction and accommodation or upon the muscular anomaly; whether to regard the latter as really the cause of the asthenopia headache or other disturbance which has brought my patient to me, or as only symptomatic and secondary, a guide, so to speak, to the real cause. This question lies at the bottom of every case. It can not be answered by the amount of equilibrium error; for, if my experience has taught me correctly, fractional degrees sometimes cause trouble, and high grades frequently do not. I wish to present in this paper a few clinical observations in the hope that they may call from those better acquainted with the subject a profitable discussion. I have noth- ing new to offer; only a study of the findings by methods in common use. For four or five years I have realized the importance of examining the condition of the extrinsic eye muscles. Cases of asthenopia I could not relieve, no matter how carefully I corrected the refraction. I consulted others with the same result. I first turned my attention to the subject in a practical way. I began work by causing diplopia at 20 feet by holding a square prism in front of the eye. For two years or more I have used Maddox's double prism, with a colored glass before one eye, and more recently his rod. Before examining the muscles, I correct the refraction, giving as nearly the full correction as is consistent with the best visual acuity. I note abduction. If the equilibrium test has shown Orthophoria and abduction is 10° or 12°, I suspect “ latent” exophoria, as it has been called. If it is below 5°, I suspect “latent” esophoria. I am skeptical about adduction. In the first place, as has been pointed out by others, it is a distance test only so far as con- vergence can act independently of accommodation: i. e., to the extent of the posi- tive portion of the relative range of convergence for infirmity, Dr. Randall (Trans. Am. Ophth. Soc., 1889) says: “Adduction can be made almost anything, if the patient and examiner have patience.” It is striking how rapidly adduction increases as soon as the patient learns how to fuse images of unequal clearness. I have seen adduction of 48°, while the balance test showed exophoria of 10°. Its determination is not, in my opinion, important unless one is contemplating an internal tenotomy for esophoria, when it is well to know that adduction can be developed to a point higher than the normal relation to abduction.—7 or 8 to 1. Unless the equilibrium test has shown hyperphoria, I do not, as a rule, examine the power of the vertical muscles to overcome opposing prisms. I look upon com- parison of the distance and near equilibrium as very important. Except in the case of presbyopia, or where there are, in myopia, conditions which demand spe- cial modification of the glass for near-work, the near test should be made with distance glasses. What relation should the near equilibrium bear to the distance? 1452 PAN-AMERICAN MEDICAL CONGRESS. Dr. Noyes (loc. cit.) says that “most commonly there is a deviation (from the ver- tical) in the sense of abduction of about 5° which can not be called abnormal.” Dr. Randall (loc. cit.) thinks that insufficiency of convergence for the near is the rule among hypermetropes, because the hypermetrope can avoid excessive conver- gence only by utilizing and developing the negative part of his range of relative convergence and * * * the correction is overdone.” Again, two years later before the same society, in discussing a paper of Dr. Theobald's, he said that while this convergence insufficiency at the near was the rule rather than the exception, he could not accept it as normal any more than he could “accept as normal the hypermetropia which is present in the majority of eyes.” As to the frequency of this near divergence, compared to the distance balance, 100 consecutive cases from my case book show: Equilibrium the same at 13 inches as at 20 feet, 16; comparative divergence at 13 inches, 81; comparative convergence at 13 inches, 3; total, 100. The distance equilibrium of the 100 was, orthophoria, 39; esophoria, 29; exo- phoria, 28; hyperphoria, 3; hyper-exophoria, 1. This condition was noted in 23 of the 39 with distance orthophoria; 26 of the 29 with esophoria; all the 28 with exo- phoria; and the 4 with vertical deviation. I do not think another 100 would differ materially from this. It is clear that the condition is so very frequent as to be almost constant, and is not confined to any form of distance equilibrium. Regarding the associated refraction of these 82 cases, 54 were hypermetropic ; an apparent confirmation of Dr. Randall's statement that it occurs most frequently in hypermetropic refraction. Myopic refraction was noted in 21 of the 82, with near divergence. Of the entire number (100) 66 showed hypermetropic and 26 myopic refraction. Thus a divergence at 13 inches, relative to the equilibrium at 20 feet, was noted in 81.8 per cent of persons with hypermetropic and 80.8 per cent of persons with myopic refraction, a difference of 1 per cent only. These figures would seem to indicate that divergence at 13 inches is seen most frequently in hypermetropia, because hypermetropia is the most common form of refractive error. Is this divergence at the near compared to the balance at 20 feet normal? Can we make any useful inference from a departure from it? In my opinion we can, and I daily use it as a guide in my refraction work. - Dr. Samuel Theobald presented a paper to the American Ophthalmological Society in 1891, entitled: “Subnormal accommodative power in young persons a not infrequent cause of asthenopia.” The objective point of the paper was to show that young persons often became asthenopic without refractive or muscular error; that others continued so after the correction of these errors, and that the cause lay in a subnormal accommodative power, whether a weak ciliary muscle or a lens incapable for one reason or another of responding to ciliary action. It was pointed out that the usual symptoms of presbyopia did not exist in this con- dition, but that the diagnosis lay in the relation of the equilibrium test at 13 inches to that at 20 feet. He looked upon a comparative divergence at 13 inches of 2° to 5" as normal. The near balance might depart from this in the direction of excessive or deficient divergence. Excessive divergence might come from myopia through the correlation of the functions of accommodation and convergence. Dr. Theobald thought that low exophoria which appeared as orthophoria at 20 feet could cause the same excessive divergence at 13 inches. The exclusion of this, I think, would be very easy. There are cases of exophoria which for a time appear as distance Orthophoria, but they generally are accompanied by abduction of 10° to 12° or the retention of the orthophoria balance at 20 feet with an abduct- ing prism. The third cause of comparative divergence over 5” was a hypersthenic ciliary muscle, calling for less nerve force, and so causing less nerve force to the internal rectus. Departure from this “normal * comparative divergence of 2° to 5° in the direction of deficient divergence could come from any condition which might call for excessive nerve stimulation to the ciliary and so to the internal PAN-AMERICAN MEDICAL CONGRESS. 1453 rectus muscle. Uncorrected hypermetropia, a weak ciliary Inuscle, or an unre- sponsive lens, demanding more than normal ciliary action, are such conditions. Hypermetropia can easily be excluded. Esophoria, by lessening the amount of opposition to the interni, might also cause it; but if the esophoria is not disclosed by the equilibrium test at 20 feet low abduction or the retention of Orthophoria with an adducting prism would lead us to suspect it. Thus we are left with the sub- normal accommodative power. The conclusions drawn by Dr. Theobald are (1) comparative divergence at 13 inches of 2° to 5’ is normal ; (2) in the absence of the other possible causes, which can be excluded, a comparative divergence greater than 5° means hypersthenia of the ciliary muscle, less than 5° subnormal accom- modative power. A word concerning this near test as modified by refraction correction. (1) The relation holds only when the near test is made with the eyes behind the same glasses worn during the distance test. In compound hypermetropic astigmatism, for instance, after Inydriasis has disappeared the hypermetropia, often becomes latent, the cylinder alone being accepted. The addition of a spherical, correcting any part of the latent hypermetropia, increases the comparative divergence. A case in point: - March, 1893; Mrs. C., 22 years old; eye pains and headache on reading. Under homatropine right eye attained #} with + 1.5 S.; left eye attained #} with + 1.25 S. c + 0.75 C. 90°. Three days later right eye, Hm. -- 0.75;}; left eye, As. Hm. + 0.75 C. 90° #}; muscle 20 feet, esophoria, 3°, Ab., 5’, near esophoria, 3”; no com- parative divergence at all at 13 inches. By adding the spherical equivalent to the latent H., near Orthophoria was obtained, but distant vision was reduced to #}. A message from this lady two weeks ago was to the effect that these glasses had completely relieved her. My reason for neglecting the esophoria in treatment was the nearly normal abduction (5°). I felt reasonably sure that it was secondary to the uncorrected refraction error, which was of such a nature as to cause excessive internal rectus action. In this comparative divergence I find a guide to the cor- rection of latent hypermetropia. I believe that the nearer we come in our refrac- tion work to an emmetropic correction, the more positive and permanent will be the relief. But the correction of latent hypermetropia often relieves distant vision, and, in low compound hypermetropic astigmatism, especially, the correction of the astigmatism alone frequently relieves. While these are exceptions, I believe a safe rule is to correct enough latent hypermetropia to produce at 13 inches a com- parative divergence if 2° or 3°. - (2) In myopia of 3 or 4 D., if the correcting distance glass be employed at 13 inches, there will nearly always be deficient comparative divergence, disappear- ing when the strength of the concave is reduced, I believe this is due to the habitual non-use of the ciliary muscle. I have for the past two or three years been in the habit of training young myopes with normal visual acuity and good fundus to wear their total correction, pro- vided it does not exceed 5 or 6 diopters. Reading for a time is difficult, but the ciliary muscle soon learns to work, and the usual comparative divergence at 13 inches develops. Esophoria contraindicates the use of the strong concaves for near, I think, because of the necessarily increased ciliary, and so internal rectus activity. But esophoria and myopia of any degree are not frequently associated. I have dwelt thus at length upon the relation of the near to distance equilibrium |because I am inclined to think there is a tendency to underrate the value of the near test. It is useless as a test for muscular equilibrium ; but if its relation to the distance balance has such significance as Dr. Theobald has given it it is useful not only as a diagnostic sign of subnormal accommodative power, but as a guide in the treatment of at least one form of heterophoria, viz, esophoria. If this condi- tion occurs, as it usually does, with hypermetropic refraction, the indication would be to correct all or nearly all of the hypermetropia, and the more nearly the 13 1454 PAN-AMERICAN MEDICAL CONGRESS. inches balance corresponds with that at 20 feet the more of the hypermetropia should be corrected. I have already spoken of esophoria contraindicating strong concaves at the near. When there is no refractive error, and the esophoria is to be attacked independently, an excess of near divergence indicates a weaker adduct- ing prism than if the comparative divergence is of the usual degree or deficient. In esophoria, prisms, according to my experience, give us their best results, and this - guide to regulating their strength is with me not a mere theory. Contradictory findings by the various tests are a common cause of perplexity. Different results may be gotten at different sittings; the equilibrium tests and the power of the muscles to overcome opposing prisms may not harmonize. Such things Dr. Stevens has attributed to hyperphoria. That this variety of hetero- phoria does influence the others can not be doubted. I want to mention two or three cases, however, which show, I think, how close the connection is between anomalies of the ciliary muscle and anomalous heterophoria. * Mr. G., 28 years old, consulted me in April, 1890. He was unable to work com- fortably at his desk in the post-office. He was wearing – 0.25 C. 180° with #4 D. V. He rejected all convex glasses. He had orthophoria at 20 feet with ab. of 12°. A near test was not made at that time. Under atropine his apparent low M. As. was turned into compound H. As., each eye accepting +1 S. c +0.5 C.90°. As mydriasis wore off, convex glasses reduced vision to about #. Minus cylinders at once cleared vision, but he found he could work better with the convex glasses. For a year or so he called to see me occasionally. He always had orthophoria and high abduction 10 to 12°. He gradually got #} with his glasses and still more gradually developed an exophoria, which in the end amounted to 6°. He has since then worm prisms 2°, bows in, combined with his refraction correction, and is comfortable. This seems to me to be a case of exophoria concealed by an excessive innerva- tion of the weak muscle, associated with ciliary spasm. An abduction too high for the equilibrium was the only indication. The exophoria was, I believe, a factor in producing the ciliary spasm. My assistant at the Presbyterian Hospital called my attention a few months ago to the case of a seamstress 23 years old who had had only ## V. when he first examined her. Improved by minus glasses. Homa- tropine gave her ##, and atropine, used for several days, had brought her to +3 with a +0.75 S. The girl had persistent headaches and the refraction did not account for either them or this ciliary condition. The equilibrium test at 15 feet showed exophoria of 9° with abduction of 10°. The explanation seemed clear; exophoria with secondary ciliary spasm. I have seen several such cases as these, but it is useless to narrate them. - The points I desire to make are that a contradiction between equilibrium and abduction requires careful investigation ; that a weak internal rectus may produce ciliary trouble, and this contradiction be the only clue to the real cause. Neither of these cases had any manifest or latent vertical deviation. A second anomalous finding I have met at 20 feet is exophoria, with normal abduction. Mr. W., 22 years old, student, was first seen in 1887. He was unable to work Over half an hour without pain. Glasses had so far failed to relieve him, though Selected by a competent man. His refraction under atropine was, right eye, #}, with — 2.25 c – 0.5 C. 45°; left eye, #}, with — 4 S. c — 0.75 C, 180°. The müs- cle test at 20 feet was exophoria 4”, ab. 6°, ad. 24° ; at 13 inches, exophoria 4°, Same as at 20 feet. The amplitude of accommodation was only 2.5 diopters. He was given the full correction for the right eye for distance, with the same spherical correction over the astigmatism for his left. On account of his weak accommoda- tion, only the cylinder was ordered for his best eye º right), the cylinder and — 0.75 S. for left. He read at 13 inches with these, either eye. For a time he was better, and then the old symptoms returned. Not to prolong the case, after two years of tonic, electric, and other time-wasting methods of treatment, advised by myself and others, it was decided to get rid of the exophoria. I did external tenot- Omy. At first an esophoria of 3° resulted, but in a few days orthophoria was found. The therapeutic results were absolutely nil. Work over 15 minutes was an impossibility. In a year (1890) there was the old muscular condition. PAN-AMERICAN MEDICAL CONGRESS. 1455 At my suggestion Mr. W. went to New York in the fall of 1890 and consulted Dr. David Webster. Dr. Webster expressed the opinion that everything had been tried except to make the accommodation work. He advised full correction on both eyes for all work. Mr. W. put on his glasses, and for nearly two months held his reading (when he did any) at arm’s length. His discomfort was greater than ever. Still he persevered, and gradually his p. p. came within respectable limits. His condition now is, to use his own words, “as good as it probably will ever be.” He can read and write for several hours, and follows his occupation of civil engineer. His exophoria has disappeared at 20 feet and his abduction is 6° at 13 inches; he has 1° to 2° of exophoria. Here, it seems to me, was a case of weak ciliary muscles. Because of the myopia they did not receive the extra nerve force spoken of, and so the internal recti did not receiveiteither. The result was pseudo- exophoria, and the normal abduction should have been a clue. A third anomalous finding at 20 feet, which I have noticed in connection with hypermetropic astigmations, especially against the rule, is esophoria with normal or even high abduction. Time will not allow me to cite the cases in detail. Suffice it to say that they usually show deficient comparative divergence at 13 inches, and that the esophoria nearly always disappears after the correcting cylinders have peen worn for a time. Their explanation is to be found, I believe, in the exces- sive and irregular action of the ciliary muscle called out by the uncorrected refrac- tive error. I would not be understood as expressing a doubt that all kinds of heterophoria. can cause distressing asthemopia; that even when refraction errors exist, the mus- cular error may be the most important element. I have had, myself, a personal experience with esophoria, and know how to appreciate the value of adducting prisms, and later, the internal tenotomy which my friend, or Harlan, did for me last March. But in the cases such as I have narrated, where one test contradicts another, I believe it behooves us to move slowly; to find the underlying cause by patient, repeated investigations before we put on prisms, except for diagnosis; proceed with exercise, or do tenotomy. I believe this cause is found in the accom- modation or the associated refraction error more commonly than is generally thought, and that frequently muscular perplexities will clear up behind spherical or cylindrical glasses. When there is nothing found of importance except the muscular error, it is foolish to delay. I should like to discuss some other points, but I can do nothing more than mention them. I have not met hyperphoria as often as some others seem to meet it, but I have seldom seen it exist to the extent of 13° or 2° without requiring treatment. I have had in a few patients to correct, by prisms, as little as #" or #’, and with good results, after refraction correction had failed to relieve. Again, I believe there is a good deal in the association of certain refraction errors and different forms of heterophoria. Hypermetropia and exophoria, myopia and esophoria, low degrees of heterophoria and astigmatism against the rule, have seemed to me specially troublesome combinations. There are certain symptoms which I think characteristic of muscular astheno- pia. They are mentioned in Dr. Noyes's book, and in my own case I have noted them, I am sorry to say, in an emphatic way, a sense of tension while reading, occasional paroxysms of pain in the eyeballs, lasting sometimes two or three hours, pain on awakening in the morning, and an indefinite, but, as I know by experience, positive symptom which a gentleman a short time ago thus described to me: “My eyes just won't work any more,” i.e., a sudden collapse while at work. Such symp- toms, I believe, are usually due to the muscular anomaly. To review the entire subject of heterophoria in one paper is an impossibility, and Imust leave the question of treatment almost untouched. By exercising the weak muscles with prisms I have gotten good results in a few cases of exophoria, but in the other forms of heterophoria I have found it useless. I am now trying Dr. Savage's “rhythmical exercise,” but can not yet say much about it. Prisms have 1456 PAN-AMERICAN MEDICAL CONGRESS. given me best results in esophoria and very low degrees of hyperphoria. never done tenotomy for less than 6° of esophoria, 4° of exophoria, and 2° of hyper- phoria. Ihave always done complete tenotomy. The operation, in some instances, where the error was low, was undertaken only after other treatment had failed. It was “complete” only because repeated examinations during the “partial” stage failed to show any equilibrium gain. I know it is behind the times to say So, but I have never noted any change in the equilibrium test at 20 feet until I thought I had severed the entire tendon. I meet cases in practice where prisms are not tolerated. Evidently the muscular anomaly is causing the trouble, and I know there is not room for a complete tenotomy. I hope to get some light on this question to-day. I have AN ANALYSIS OF FIFTY SUCCESSIVE CASES OF INTERNAL SQUINT. By HOWARD F. HANSELL, M. D., Chief of Ophthalmic Clinic, Jefferson Medical College Hospital; Adjunct Professor of Diseases of the Eye, Philadelphia Polyclinic. TABLE OF CASES. No. Sex. Ag e. * Fixing Ronacº ºlerºyd) Refractiºn ºler myd.) viºn viºn noticed. eye. OI right. €IU. right. left. 1 | Fle 17 3# L. + 4 c + 2 c. ax. 900 - - - - - + 4 c + 1.75 c. ax. 900 - - & 7 'so 2 F. 25 12 R. + 1 <> -- 3 C. ax. 80°- - - - - + 1 <> -- 3 C. ax. 100°- - -. § # 3 || F. 23 # R. + 3 --------------------- + 3 (estimated). - - - - - - - - § é, 4 || F. 8 1% L. + 4 c + 1 C. ax. 135°. - ... + 4 S + 1 C. ax. 45° - - - - || 7 ºn 7#w 5 | F. 3} | (1) R. + 2. -------------------. + 2--------------------- (?) (?) 6 || M. 45 (3) R. -- .25 c + .50 c. ax. 90° - + 3 (estimated). . . . . . . . . # tº 7 || M. 22 4 L. + 1.75 c + 3 c. ax. 709. . – 3 c + 1 c. ax. 1102 . . . &; # 8 F. 13 3 L. + 3--------------------- + 3.25 c + .25 c. ax. 900 # # 9 || M. 14 4 {. -|- 1.25 c + .25 c. ax. 900 || -- 1.25 c -i-.25 c. ax. 909. § # 10 || M. 10 6 R. + 3 c + 3 c. ax. 802 - ... + 3 (estimated) - - - - - - - - #: t’s 11 F. 6 3 R. + 1.25 c + .50 c. ax. 90° Irregular astig -------.. zºo &; 12 F. 6 2 R. –H 2.50 * * * * * * * * * * - - - - - e º 'º' + 2.50 - - tº * * * * * *- - sº tº e s - - - - ** # 13 F. 4 3 R. + 2--------------------. + 2--------------------- 74's rºo 14 | F. 15 6 3. + 4 c + 2.25 c. ax. 180°. -- 4 c + 1.25 c. ax. 1359. § #-H 15 || M. 74 6 IR. or L. + 4 c + 1 C. ax. 45°..... } + 4.75 - - - - - - - - - - - - - - - - - - #, #5 16 || M. 8 (1) R. + 3.50 -----------------. + 6--------------------- # & 17 | F. 9 2 || R. or L. + 4 c + 2 c. ax. 100°. . . .] -- 4 c + 2 c. ax. 909. . . . . rºo 7#5 18 F. | 8 2 R. or L. -|- 2.50 c + .50 c. ax. 90°. -- 2.50 c + .50 c. ax. 90° zºo 7#so 19 F. : 17 6 R. -H 5 c + 1.25 c. ax. 902 . . -i- 5 O -H 1.25 C. ax. 90°. - 7% o 3% 20 | F. : 10 (2) R. or L. — .50 c — .25 c. ax. 180° — .50 c – .25 c. ax. 180° É # 21 | M. 9 (2) R. or L. + 1 <> -- .25 c. ax. 90° - ...| + 1 <> -- .25 C. ax. 90°. -- § # 22 F. 18 3 R. + 1 c + 1 c. ax. 90° - - - - - + 2 (estimated). ---- - - - - É #; 23 || M. 15 4 L. + 6 c + 2 c. ax. 135° + 7 c + 1 c. ax. 1809. --. #: 7#5 24 || M. 4% 2 B. + 5.50 c 1 c. ax. 909. . . . . + 5 --------------------- (4) (4) 25 | E'. 40 (2) R. or L. — .25 C — .50 c. ax. 1350 | — .25 c – .50 c. ax. 159 - § # 26 F. 38 (2) &. or L. + 5.50 c + .50 c. ax. 750 | + 5.50 c + .50 c. ax. 750 # # 27 | M. 27 (3) L. + As ------------------- + As ------------------- # 7#o 28 || F. 20 4 || R. or L. + 3 c + .75 c. ax. 45°.. 2.25 ------------------ ; # 29 || M. 25 (2) R. + 1.75 ------------------ 2--------------------- § tº, 30 | M. 25 (2) R. or I. + .50 c + 2.50 c. ax. 110° -- .50 c + 2.75 c. ax. 800 zºn r:#;" 31 || F. 19 3 R. + 2.25 ------------------ + 3.50 ------------------ § tºo 32 || M. 28 3 R. + 4 ~ + 3 C. ax. 75°. . . . . + 4 C -H 4 c. ax. 909-...-. #. & 33 F. 9 5 L. + 1.75 ------------------ + 1.75 ------------------ § # 34 M. 25 {2} R. + 4 c + 1.50 c. ax. 90°.. + 4 (estimated). - - - - - - - - # th 35 | F. 28 (2) L. + .75 C -- 1.50 c. ax. 450 + .75 c -|- 1.75 c. ax. 1350 * * + 36 | F. 8 * L. + 5.50 ------------------ + 7. -------------------- 3% # 37 | F. 12 (1) L. +4.50 ------------------ + 3.50 ------------------ th # 38 || F. 6 L. + 3 --------------------. + 3 --------------------- dº Éa 39 || M. 36 (2) R. or L. + 4 c + 2 c. ax. 130°. ... + 3 c + 2.50 c. ax. 1159 - || 7-#5 7#t, 40 || M. 19 (?) L. – 6 --------------------- + 1 --------------------- th * 41 | F. 13 (3) L. + 3 C -- 2.50 c. ax. 1200 - || -- 2 C -- 1 c. ax. 60°. - - - - tº, # 42 | M. 34 (1) L. + .25 C — 1.25 c. ax. 1202 — 1.50 c. ax. 750 - - - - - - - - - # # 43 | F. 14 4 L. + 2.50 c + 3 c. ax. 200 ... -- 3.50 c + .50 c. ax. 1800 * # 44 || F. 11 (2) It. or L. + 5 c + 1 c. ax. 459. . . . . +4.50 C –H .50 c. ax. 135° #: # 45 F. 8 1. L. — 1 --------------------. + 2 --------------------- (2) (2) 46 | F. 5 2 R. + 2.50 ------------------ + 3 --------------------- # #, 47 | F. 30 (3) R. + 4.50 c + 1.50 c. ax. 300 + 4.50 c + 1 c. ax. 1500 - § #: 48 F. 36 (2) L. + 2.50 c -i-.50 c. ax. 9730 –– 2.25 c + .50 c. ax. 90° 77 ºn # 49 || M. 25 (2) R. or I. + 1.25 c + .25 c. ax. isº –|- 1 c + .25 C. ax. 1359 - # É 50 | M. 7 6# L. + 4 c : - .50 c. ax. 90°. -- + 4--------------------- #'s # 1 Birth. * Unknown. 3 Childhood. 4 Illiterate. PAN-AMERICAN MEDICAL CONGRESS. 1457 Inspection of the series of cases shows: 1. That convergent strabismus is most common between 2 and 4 years of age (36 per cent). The earliest age at which it was noticed was at birth (4) and the latest at 15 years (1). 2. Females preponderate over males as 31 to 19. 3. The right was the fixing eye in 20, the left in 18, and either eye was used indif- ferently in 12 cases. 4. The refraction was hypermetropia in 92 eyes; 2 had myopia, probably acquired through corneal inflammation; 4 had comp. M. As, with full acuity of V.; 2 had hyperopic astig. with one-half V. The fixing eye showed simple H. in 16; comp. H. in 21 cases. Of the former H. was less than 2 D. in 3; between 2 and 4 in 10; between 4 and 6 in 2, and above 6 in 1 case. Of the latter the comp. H. As. was less than 2 D. in 4; between 2 and 4 in 7, and higher than 4 in 10; defect unre- corded in 1. The squinting eye showed simple H. in 18, comp. H. As. in 15. The former H. was less than 2 D. in 1; between 2 and 4 in 12; higher than 4 in 5. Of the latter comp. H. was less than 2 D. in 1; between 2 and 4 in 2; higher than 4 in 12. Twelve cases used either eye indifferently for fixation; of these there was no case of simple H. in both eyes; 2 had comp. M. As. of low degree; 3 had comp. H. As. of less than 2 D.; 3 between 2 D, and D., and 4 between 4 D. and 6 D. 5. Vision in the fixing eye after correction equaled 1 in 21, 3 in 9, 4 in 4, and # in 2 cases; unknown in 2. V. in the squinting eye after correction equaled 1 in 2, # in 4, § in 8, # in 2, in 3, 4's or less in 10 cases; unknown in 2. Of the 12 cases in which either eye was used indifferently V. =1 in 7, 3 in 3, 4 in 1, 4 in 1 Ca,S62. An examination of the notes of 200 consecutive cases (400 eyes) of H. and H. As. greater than 1 dioptre abstracted from my private case book, uncomplicated by disease and without squint, in relation to the degree of ametropia and to the vision obtained by full correction (under mydriasis), shows: H. and comp. H. As., between 1 D. and 2 T). in 98, between 2 D. and 3 D. in 40, between 3 D. and 4 D. in 17, between 4 D. and 5 D. in 13, higher than 5 D. in 9 cases. Also 23 cases in which H. of one eye exceeded that of the other by 1 dioptre or over, with a difference of one- third or more in the aculty of vision. V. = 1 in 310, 3 in 24, 4 in 11, in 12, # or worse in 43. My purpose in this brief analysis and comparison is to prove clinically that : 1. H. is found in nearly all cases of internal squint. Ninety-two eyes of the series had hypermetropic refraction. 2. H. is not essential to convergent strabismus. Two cases, Nos. 20 and 25, had low myopia. 3 Congenital amblyopia is almost uniformly present in constant internal squint. Amblyopia in this connection means decidedly diminished vision from no known cause without pathological changes and not correctible by glasses. In 38 squint- ing eyes V. = 1 in 2, 3 in 4, , in 8, § in 2, # or less in 19 cases; unknown in 3. The exceptions—where V. = 1—were Nos. 9 and 33, evidencing no reason why one eye should invariably be used for fixation. - 4. Amblyopia is not essential to squint, either constant or alternating. Cases Nos. 9 and 33 are illustrations of constant squint without amblyopia, and Nos. 20, 21, 25, 26, 28, and 49 of alternating squint with full V in each eye. - 5. Amblyopia is found in H. without squint. Among the 200 cases of H., V. was equal to one-half or less, without known cause in one eye and normal in the other in 9. Two cases serve to illustrate this statement : No. 1. Female, age, 46: R. -- 7 c + .50 c. ax: .45° = }; L. -- 7 c + .50c. ax: 135° = %. No. 2. Female, age, 45. R. -- 3 c + 2 c. ax: 35 = }; L. -- 3 c + 3 c. ax: 90° = #. Instances of nearly identical ametropia with amblyopia among the cases of squint Nos. 23 S. Ex, 36—92 1458 PAN-AMERICAN MEDICAL CONGRESS. and 32 are forcible arguments in favor of the causative influence of monocular defective vision in the production of squint. 6. Amblyopia is not a condition of alternating Squint. Of the 12 cases in which either eye fixed, V. was equal in the two eyes with one exception, No. 44, where the difference can be accounted for by the higher optical defect. Its action, then, must be negative in the causation of alternating Squint. - 7. Amblyopia precedes the appearance of abnormal convergence and is not the result of monuse. We have no means of determining with any degree of accuracy the inception of amblyopia, but that it is congenital, and hence antedates the squint, would seem reasonable, because: (a) The duration of time after the squint was noticed until examination of the acuity of vision is, in the great majority of cases, too short to admit of the possi- bility of the development of the loss of vision from disuse. At no other time of life than in early childhood, and under no other conditions than those of functional internal squint, do we find examples of this kind of amblyopia. The retina may be shut off from participation in vision for many years by an opaque lens and retain acute sensibility. Other illustrations of this fact are not wanting. If squint causes amblyopia, amblyopia must always be associated with squint and should be cured after the axes are made parallel by operation. Neither of these assumptions is true. (b) That binocular fixation secured after tenotomy is retained in a small propor- tion of cases, and in the great majority the result of operation is cosmetic only. (c) Amblyopia does not follow, at least within several years, paralytic devia- tion of one eye. The image seen by the deflected eye is after a time consciously suppressed, but visual acuity does not degenerate into amblyopia. 8. The degree of H. does not determine the squinting eye. The table of cases shows the same error of refraction and in constant Squint in 14; the higher defect in the fixing eye in 3, and lower H., but higher As., in the squinting eye in 4 cases. 9. The degree of H. does not determine amblyopia. A majority of cases shows practically the same degree in both eyes; a minority anisometropia; but similar differences are found in an equal number of cases which have never squinted and which have no amblyopia. 10. H. may be the determining cause of squint, since (a) all the cases with two exceptions were hypermetropic; (b) the relation of accommodation to converg- ence in H. encourages abnormal convergence; (c) convergent Squint is sometimes cured during paralysis of accommodation and by wearing correcting lenses. There must, however, be other causes than H. in the majority of cases of squint, since— I. H. is exceedingly common. - II. The proportion of cases of squint to cases of H. without squint does not exceed 1 to 50. - III. While squint is most common in H. of 2 D. to 4 D. (20 per cent), the ratio of cases of H. between 2 D. to 4 D. without squint to H. of other degrees is nearly 25 per cent. IV, Internal squint is found in myopia. 11. H. As. must be considered equally with H. as a refractive cause of squint, and it may be, in some cases, the more important factor in determining the squint- ing eye. Astigmatism of 1 dioptre or over was present in the fixing eye in 21, in the deflected eye in 18 cases. The latter number should be modified by 5 cases in which, on account of amblyopia, it was not measured, but was probably present. In the 400 hypermetropic eyes without squint the number of eyes with As. of 1 D. or over was 49–124 per cent. Hence As. is relatively more common in H. with squint than among those without squint. The axis of the correcting cylinder was vertical or within 10° in the deviating eye in 8, symmetrical in the two eyes or PAN-AMERICAN MEDICAL CONGRESS. 1459 within 10° in 6, and unsymmetrical in 4 cases. The remainder had As. of less than 1 D. or its degree was unknown. Among the cases of H. without Squint 152 had As. in both eyes. Of these, 59 had axes vertical or within 10°, 33 had axes symmet_ rical or within 10”, and 50 had axes unsymmetrical. From these figures it is diffi- cult to ascribe any importance to the direction of the axis of AS. as a factor in the production of Squint. - The second part of the proposition was true, in cases No. 7, As. 2 D. higher in the squinting eye; No. 23, 1 D. higher; No. 32, 1 D. higher; No. 41, 1.50.D. higher; No. 43, 2.50 D. higher; No. 50, .50 D. higher. In several cases where V. was decid- edly bad and glasses made no improvement, it must be remembered that the As. was not recorded. If these eyes had been examined by the ophthalmometer it is probable that they would have been added to the list. On the other hand the fix- ing eye had the higher As. in Nos. 14, 24, and 47. It was practically the same in both eyes in Nos. 1, 2, 4, 9, 19, 27 (?), 35, 42, and 48. In the cases of alternating squint As. was 1 D. or more higher in only 1, and less than 1 D. in 11 cases (Nos. 17, 18, 20, 21,25,26, 28, 30, 39, 44, and 49). - 12. A considerable difference in the degree of H. in the two eyes may not cause squint. Among the 200 cases of H. the total defect differed by 1 D. or more in 24, and in some (12) of these cases there was decided inferiority of V. in one eye. 13. Amblyopia determines which eye shall squint, and in its absence either eye fixes indifferently without regard to the degree of H., although it is unlikely that the difference in the ametropia exceeds 1 D. - A consideration of the preceding thirteen propositions leads logically to the con- clusion that the generally accepted theory that functional internal squint depends upon hypermetropia must be greatly modified, and hence that our present method of treatment is unscientific and ineffective. We should look rather to the follow- ing conditions as likely to cause internal squint: Hyperphoria or hypertropia; con- genital amblyopia; hypermetropia, heredity. I have not discussed the complication which I believe to be most common in unilateral convergence, namely, a want of balance of the vertical muscles, since my data are too insignificant to be of service. My recent experience, however, leads me to believe that constant internal squint is almost uniformly associated with an upward or downward deviation, but whether as a cause or sequence I am not in a position to state. My statistics are incomplete also in that the results of treatment are not tabulated. This is not an accidental Omission. Permanent results are difficult to obtain. If the patient is cured by one or more tenotomies he does not return. If he is not cured he consults another surgeon. The few cases of constant squint in which I can state the final result of tenotomies have shown little or no improvements, either in appearance or vision, and I candidly confess I had more failures than successes until 1 sought and found other causes than hypermetropia. SOME CONSIDERATIONS RESPECTING EXAMINATIONS AND TREAT- MENT IN HETEROPHORIA. By GEORGE T STEVENS, M.D., of New York. Perhaps I may be pardoned, in consideration of the subject assigned for this day’s discussion, if I indulge in some satisfaction when I contrast the sentiments prevailing among oculists at the present time regarding that subject with those which prevailed only a few years since. At the meeting of the Ninth Interna- tional Medical Congress, held in this city in 1887, just six years ago, I read before this section—the same gentleman presiding who now occupies the chair—a paper 1460 PAN-AMERICAN MEDICAL CONGRESS. with the title, “Some important problems respecting insufficiencies of the ocular muscles.” Directly after the publication of this title in the medical journals I Was violently criticised in some of the leading medical journals, not for the special views contained in that paper, for it had not yet appeared in print, but for the presumption and folly of suggesting that there were any problems regarding What were then known as insufficiencies of the ocular muscles. The public was emphatically informed that all the problems in this department of science had long ago been solved, and that there was nothing more for me to suggest nor for the profession to consider. * The writers undoubtedly voiced the prevailing sentiment of the profession at the time. Otherwise, had they expressed only their individual views, there would be no occasion for recurring to the incident here. To-day, six years later, this Sec- tion of this great congress assigns one entire day to the study of the very problems which, six years ago, we were told had already reached a final solution. When, at the request of the president of this section, Iconsented to participate in this discus- Sion, I was in doubt what I could best offer for your consideration. In reply to my appeals to the president to tell me what part of the subject he wished me to present, he gave me the whole field to discuss, but he did not give me more than One day in which to do it. At the last hour I have determined to speak, not of new things, but to direct your attention to some things of which I have already Spoken, but placing them in a light which may possibly encourage some inquirer. If I shall be able to accomplish that, I shall be glad that I have chosen this course. In the first place, I venture some words in regard to examinations for hetero- phoria. Perhaps the suggestions that I am to make are needless repetitions; yet I am led to the belief, by examining much of the current literature of the subject, that it may not be out of place to call attention to the fact that views from many points and much careful and logical thinking are essential elements in the mak- ing of these investigations. It is not, in the brief time allotted to me, possible to go into any details of examinations, but permit me to suggest an order and some important points which may be brought out by an orderly examination. The facial expression of our patients will often give us strong hints of what we may expect to find. Indeed these expressions are so well marked in their rela- tions to the condition of the ocular muscles that one who has had considerable observation and who is withal a close observer will rarely fail to make a general diagnosis of his case without the aid of his instruments. Of course, this is not a working diagnosis, but it is a valuable aid to that which is to follow, and often serves to direct the attention to slight inconsistencies in the instrumental examina- tions which otherwise might escape notice. A glance at the eyes themselves and at their movements prepares us, after we have learned what is necessary of their refractive condition, for the more exact examination. First in order, after considering well the facial expressions and the movements, the phorometer is brought into use and its results recorded. If other instruments than the phorometer are employed for the purpose of indicating the manifest heterophoric tendencies, either by induced diplopia or by contrasting images, let me repeat what I have already said elsewhere, that no instrument of this class which is held near the eyes, or the correcting prism of which is brought close to the eyes, can be relied upon for such exact examinations as should be obtained if we are to make a critical study of our case. Some of the instruments which are in common use will give us false information to the extent of many degrees. The tendency to overcome a deviation of the images from the vertical or the hori- Zontal lines is similar if not as strong as the instinct to unite images by overcom- ing prisms. If the phorometer is placed at the distance of from 4 to 6 inches in front of the eyes these adjustments, which are so naturally made, are either TAN-AMERICAN MEDICAT, CONGRESS. 1461 entirely or in large measure neutralized. In whatever way we ascertain the pho- rometric measurements, we must bear in mind the important fact that we have arrived at Only a single stage of the examination, and that other classes of facts must enter into the question of interpretation of the ocular adjustments. We must ascertain the abducting and the circumducting ability, and perhaps, also, the adducting ability. We are to observe the action of each eye when temporarily excluded from fixation and when it returns to fixation. If, assuming the stand- ard abduction to be 8° at 20 feet, a standard adopted by myself many years ago, and which experience has shown to be a correct one, we find that it corresponds to the record of the phorometer, and if the circumduction right and left also cor- responds to the indication of the phorometer, we may fairly assume that we have an uncomplicated case in which the reading of the phorometer may be taken as an index of the actual condition, so far as the kind of tendency is concerned. But if, as often happens, the records of the various tests; for example the phorometer, the abducting ability, the deviation in exclusion ; are not in harmony, we are to search for the cause of this want of correspondence. For example, if by the phorometer we find esophoria 2° and abduction 6°, or even 5°, with equal circum- duction and no hyperphoria, we arrive at the conclusion that we are dealing with a case of simple esophoria, 2° of which is now manifest. On the other hand, should we find esophoria 2° with abduction of 10°, or exophoria of 2° with abduc- tion of 6°, we may at once conclude that we have a complicated case, even although there is no manifest hyperphoria, and one which must demand the most careful attention before any radical measure of treatment is adopted. There are so many forms of these contradictory indications that I can only allude to them as a class as indications for the most careful study of the cases and as warnings that we must in no case assume that one class of testing tells us the whole truth. We should note the facial expression, test by the phorometer, try the ability to overcome prisms, examine carefully the rotating ability of each muscle and the action of one or other eye when excluded from fixation. These and often many other points are to constitute elements in our examination. And here let me add that if we are at the present stage of knowledge of this subject to pub- lish our case the bare statement that the patient had an abduction of only 5° or that the phorometer showed a certain degree and form of heterophoria will not suffice for critical readers. Such readers must know all about that case. They have seen too many instances in which an abduction of 12° with an actual converging squint to accept such a bare statement as having any scientific value. Moreover, such a statement leaves in the mind of the critical reader the impression that the writer had not himself ascertained the remaining facts necessary to a just conclu- sion in regard to the nature of his case. A single word more regarding these examinations. Contrary to the general impression and contrary to my own teach- ings of many years ago, the correction of the refractive anomalies by glasses during an examination of this kind is not only in the vast majority of cases unnecessary, but positively detrimental, as the glasses themselves often lead to error, and their absence does not as a rule influence the muscular conditions. And now that we have, in the few minutes, gone over the examinations in hetero- phoria, a subject which for its proper consideration would require the patient study of many months, let us as briefly sketch an outline of some of the methods for the management of the defects which we may have discovered. Let no one suppose that this sketch can be in any degree more than suggestive. One of the first of the elements in the management of these cases is patience. The oculist who imagines that he can measure and correct his cases of hetero- phoria in an Offhand manner has not reached an understanding of the first prin- ciples of the subject. A case which at first appears quite simple and easy to handle 1462 PAN-AMERICAN MEDICAL CONGRESS. may prove to be one which, for its best correction, may demand the exercise of great skill and of unwearied patience during many months. We can not know When we begin the treatment of a case of heterophoria the full meaning of the indications which we then discover. One who thinks that he has found an instru- ment which will reveal latent heterophoria is surely laboring under a misapprehen- Sion. As we go on in the treatment of these cases new difficulties may arise and new efforts may be demanded. This is no reason for not beginning the work and less for abandoning it before completion. I have sometimes illustrated these pro- gressive difficulties by recalling the experience of one who climbs a mountain. He sees before him a height which appears to him the summit which is to reward him for his effort, but when he reaches it he sees before him another even higher than the one which he has surmounted. He ascends higher, and when at length he attains to the second height, the real summit is still far above him. Is he therefore to say there is no end of this, and one might climb indefinitely without finding the summit? There is a summit, and one may reach it if he has the need- ful strength and courage. I am sometimes asked by my colleagues if there is no end to the treatment of these cases. Does not the condition which has been apparently removed return? Must the treatment not continue as long as the patient will continue to submit to it? The heterophoric condition which has been in any measure properly corrected does not return, but that part of the original defect which was at one time latent may at a subsequent time become manifest. There is as surely a limit to this work as there is a final summit to the mountain, and when one reaches that limit he has an infinitely greater satisfaction than he who finally gazes upon the grand stretch of hills and plains and lakes from the great elevation which he has earned. Many who do not care to take the trouble to climb decline to accept the reports of those who do; and many an eminent man who has lingered about the foothills of this work is incredulous because he can not obtain the same grand view that has been described by someone who has gone beyond. An essential to success in this work must be a thorough knowledge of the principles governing the tensions of the muscles with which we work. Instru- ments can not know these principles. They are only to be learned by long and patient research on the part of the oculist. But what immediate steps are we to take for the relief of our patient with heterophoria? We may give him prisms. Will they help? Sometimes, and to a very limited extent. In the large majority of cases they will serve little purpose or perhaps produce decided annoyance. In the cases in which they afford relief that relief is in no sense the effectual degree of comfort and the absence of reflex trouble which may be expected from the more radical relief of abolishing the heterophoric condition. Then we may give to the muscles the gymnastic exercise which may be accomplished by the overcoming of prisms. That good may be accomplished in this way I have long ago demon- strated. The fact remains that the method is but tentative. The anomalous con- ditions remain, and the unpleasant symptoms will probably return. A vast expe- rience with these two methods enables me, I believe, to speak of them with some degree of authority, and I do not hesitate to say that while they have much value to recommend them, and while no one can afford to overlook them, they fall far short of the more rational measures of actual adjustments by means of equalizin 8. the tensions in such a way as to establish practical orthophoria. We may accom- plish this by graduated tenotomies and tendon contractions. Are we then to operate for all cases of heterophoria? By no means. The surroundings of the patient, his methods of work, the importance of the case, and many such consid- erations must enter into the question of treatment. The best judgment of the experienced surgeon is here in demand. In most cases, however, in which impor- tant reflex disturbances are the result of heterophoria we shall find operative meas- ures imperative. PAN-AMERICAN MEDICAL CONGRESS. 1463 How are we to operate? I must reply first in the negative. How are we not to operate? We are not to operate by the methods described in the text-books which I have seen. Indeed, if I may be permitted to diverge from our strict line of thought in a single sentence, I will add we should never for any condition of heterophoria, strabismus, or paralysis perform any tenotomy after the manner thus described. We should never operate in such a manner as to disable our muscle in its function of rotating the eye. We are told of tenotomies which are so far in excess as, after the relaxation, for example, of a single external rectus, to leave the patient with homonymous diplopia for some months. It is true that single vision may return and that even a condition of exophoria may succeed, but if the ability to rotate that eye well to the temple has been lost at the moment of the operation it will never return without a readjustment of its insertion. Let me impress this important fact upon the mind of everyone who operates for hetero- phoria, that whatever may happen in regard to phorometric indications, the rota- tion of an eye after tenotomy does not undergo any very important change and that we can not at the time of the operation disable this function in the expecta- tion that the tendon will readjust itself. We should never attempt a complete and final correction on a single lateral muscle. If we have even a low degree of heterophoria we should proceed on the assumption that when we have finished the work we shall have relaxed the lateral muscle of one eye exactly, or as nearly exactly as we are able to determine, as much as we have that of the other. There is an important consideration too often overlooked in operations for hyperphoria, and especially for hypertropia, that the gaze of the great majority of our patients must be habitually directed downward. Hence a tenotomy of an inferior rectus is, as a rule, to be avoided, unless there are positive indications for selecting that muscle. Before any operation, even in well-defined cases, more than one, and usually many examinations should be made. Prismatic glasses, usually less than a nominal correction of the manifest heterophoria, should be given, and the patient should be charged to use them continuously during waking hours. From time to time, during the use of these glasses, examinations may indicate a greater degree of defects than was at first found and the prisms may be strengthened. The use of temporary prisms which are kept by the oculist, as suggested by me some years ago, has now become somewhat general. After a time, varying from a few days to a few weeks, we have either found such a degree of heterophoria as would be all that wenight reasonably expect to relieve by a single operation without risking a restriction of the rotating power of the muscle to be operated upon, or there has been a halt in the further manifestation of heterophoria. We may now proceed with an operation. I have already more than once described this operation, but I will venture to do so again in order to introduce some details concerning which inquiries have often been made. - Let us suppose the operation to be done for esophoria, and that we have deter- mined to do a graduated tenotomy of the right internal rectus. The speculum being in place, the patient directs both eyes well to the right. The surgeon takes with his fine forceps a minute fold of conjunctiva at the center of the insertion of the tendon. Drawing the little fold of conjunctiva slightly away from the eye- ball, with the extreme points of his tenotomy scissors he snips the fold transversely so that an opening about one-half of a millimetre in extent is made through the membrane. Now the forceps, the points being closed, is pressed into the little opening and slightly backward, when the points are permitted to spring apart, after which they are again closed, this time holding a small fold of the tendon just behind the insertion. This little fold of tendon being put on the stretch, the fine- pointed scissors, by little snips, dissects the tendon from the eyeball between the layers of the capsule (which should remainintact) toward one border of theinsertion. The sense of feeling of the fingers against the rings of the scissors will, in the hands 1464 PAN-AMERICAN MEDICAL CONGRESS. of one skilled in this operation, inform him of his approach to the border and warn him against its destruction. In extreme cases, like strabismus, the surgeon may determine to continue his section through the border, leaving uninjured as far as possible both the anterior and posterior lamellae of the capsule as well as the expan- Sion at each border to hold the muscle in its relation to the eye. Turning the scis- Sors then in the direction of the other border, this portion is dissected with equal care. With as little delay as possible the patient is placed in the examination chair and the test by the phorometer and by prisms is made. It is safe in very moderate cases, by the first operation, to carry the correction to 0° and the abduc- tion to 10° or 11”: for at the moment there is likely to be a greater nervous relax- ation than will be found an hour or more later, and it may be reasonably expected that within a few days there will still be a manifest esophoria sufficient, especially if the temporary prisms were again brought into use, to permit of a relaxation of the corresponding muscle of the left eye equal to that now being done on the right. Such an extent of relaxation may, however, be counter-indicated should it be found that the rotation, which should always be tested before the patient leaves the operating chair, is in danger of being unduly restricted. Perhaps we find that esophoria is still manifest. The patient returns to the oper- ating chair, when the surgeon, introducing the slender, blunt hook, feels for the point to which the section has been made either above or below. He soon finds, if he is expert, whether the section has been carried far enough in that particular direction; and, if so, he searches at the other extremity. If he now finds room for carrying the section further, he, using the slender hook as a guide, increases the effect of the tenotomy by carefully executed Snips of the scissors, and after an examination this process may be renewed if required. If by chance we find that we have erred in judgment and have gained an exophoria with abduction exceed- ing 11°, we must at once introduce at the exact center of the free end of the tendon a very delicate suture, carrying it through the cut edge of the conjunctiva at the corneal side. There is an occasional exception to this rule, in which, if we permit the patient to wait for an hour or less, the exophoria and excessive abduction dis- appear spontaneously. We make this suture to include as little as possible of either tissue, and then draw it with great care until we have overcome the exo- phoria, as shown by the phorometer, when the knot may be made fast. This proc- ess, although sometimes demanded in the practice of the most skillful, is always unfortunate. Those who tell us that we should cut the tendon across and then introduce the suture are laboring under a serious error. Should it be found on the following day that the result is not what could be desired, the suture may be renewed, or by removal an increased effect of the original operation may be obtained. There are conditions which render it almost imperative in a certain small pro- portion of cases to make adjustments in lateral tendencies which, although not more than nominally correct at the time of making, are such that the experienced surgeon feels almost sure that when he is better able to adjust for a supposed hyperphoric condition will at length prove overcorrections. Such overcorrec- tions, when they become manifest, must be restored to equilibrium. Now, it should be an axiom, a rule never to be forgotten, that we have no right in any case to weaken a muscle because we or someone else has weakened the opponent of that muscle. For example, if, as the result of a tenotomy of the internus of one eye, we have as a result an exophoria of even as little as a single degree, it is inexcus- able to cut the externus in order to relax that muscle equally with the excess of relaxation of the other. Let me repeat we are not to correct an overcorrection by a new tenotomy. In all such overcorrections we should resort to tendon shortening or tendon advance- ment of that muscle which has been too freely relaxed. If the original tenotomy 12AN-AMERICAN MEDICAL CONGRESS. 1465 has been done in the manner I have just described there will be little difficulty in performing a correction which shall leave nocicatricial bands to interfere with the freest action of the muscle. - We begin in this operation, as in that for tenotomy, by making a transverse slit of one-half millimetre in extent over the point of insertion of the tendon. Then lifting the border toward the cornea by the fine forceps, a little pocket is made by the points of the scissors, extending under the conjunctiva, more or less toward the cornea in proportion to the greater or less effect which we propose to induce. The pocket having been made, the forceps seize the central portion of the tendon, and it is dissected from the eyeball entirely or partially, as the case may be. If it is entirely dissected, then by means of the scissors points acting as a probe, or by means of the lance probe, the tendon should be absolutely freed from any attachment to the surrounding tissues. The fine tendon crochet now catches it at the center and a little behind the section and draws it forward, or if the hook proves to be ineffectual to hold it during the next stages of the operation the fine fixation forceps with catch may be used. The tendon is drawn forward through the little conjunctival opening, when one of the needles from a thread of silk armed at each end with a needle is passed through the central part from one-half to a full millimetre, or even more, behind the cut extremity. Bringing the needle forward until the two extremities of this thread are about equal in length, an assistant carries the lance probe into the pocket already made, and one of the needles, passing by the side of this probe, which acts as a guide, is made to pene- trate the conjunctiva at the extreme end of the pocket and the thread is drawn through. The other needle and its thread are managed in like manner, the second needle penetrating a little to one side of the first in order to allow, between the two threads, a little bridge of tissue. Now, the assistant holding the conjunctiva at the border of the wound by means of fine forceps, the surgeon draws upon the ends of the thread, forcing the cut end of the tendon into the little pocket, and when he has thus advanced it to his satisfaction he fastens the threads by tying them across the little bridge. No cover and no especial care are required beyond that needed for perfect cleanliness, and on the third or fourth day the suture may be removed. The greatest danger in these cases arises from the use by the patient of a soiled handkerchief with which he rubs the eye. Against this danger the strictest injunctions are to be enforced. This operation, with such modifications as may be required, I have performed during the past five or six years in many hundred cases, and it has been witnessed by some scores of my colleagues. sºmsºmºsºssmººsºmº DISCUSSION. 1)r. Burnett, of Washington, D. C., said that in view of what had already been said in this discussion it did not seem necessary to insist upon the importance of muscular errors in the production of symptoms referable to the eyes, head, and even remote localities as due to these defects. Probably no one present ever doubted the existence of grave muscular errors and the necessity for their cor- rection. The problems before us, then, would seem to be the best and readiest methods for their detection; the muscle or muscles involved, their extent of involvement, and the treatment necessary for relief. And the further we go into the study of the question the more complicated it becomes in all these partic- ulars. Formerly the dot and line test of Graefe was considered all that was neces- sary for determining muscular insufficiencies, but now no one of a half dozen or more methods is deemed infallible; and in some cases all seem to fail, and it is only by the exercise of great patience that the absolute power of the muscles 1466 PAN-AMERICAN MEDICAL CONGRESS, involved can be determined, if at all. I would dwell more particularly upon the difficulties in determining hyperphoria. As we know from the teachings of our physiologists the interni and externi move the visual axis in what is approxi- mately a horizontal plane. Their simple action gives no vertical or rotary motion to the eyeball. So the problem in exophoria and esophoria, pure and simple, is a comparatively easy one. I would call attention to the remark made by Dr. Stevens that a complete tenotomy of the interni, for example, might, by a faulty union, give rise to a pathological rotation of the eye. This he did not think was liable to happen if the muscle was allowed to go free, as when it was sutured. But if this is to be feared so much as the result of the operation, how much more should we consider its possibility as a primary condition. We must remember that the upward and downward movement of the eyes is an exceedingly compli- cated one and is not made by one set of muscles. The superior and inferior recti and the obliques which make these movements have also a lateral and rotary movement each, and as the recti and obliques are astigmatic in this portion of their action we should in every case of hyperphoria be able to put our finger On the faulty muscle. If we can not, our therapeutics, whatever it may be, must be, in a measure, blind. So far as I am aware, no effort has yet been made to detect and measure this error of rotation in hyperphoria, and yet it must exist in some degree in every case, and it will be different according as the obliques or recti are involved. There is every reason for supposing that the effort on the part of the eye to overcome this faulty rotation and to bring the inclined line of one eye into the plane of the straight line of the other eye lies at the bottom of the trouble in hyperphoria quite as much as the vertical deviation. And it probably also accounts in no small degree for the unsatisfactoriness of the vertical diplopia which we find mentioned not infrequently. It is fortunate, however, that as far as surgical therapeutics goes, there is this correlation in the action of the recti and obliques, for it will enable us when an error is clearly diagnosticated to correct it by an operation on the associated rectus. My friend, Dr. Savage, is the only one who seems to be working on these lines, and I hope his sanguine expectations may be realized. Two years ago I reported to the Ophthalmological Society my expe- rience in tenotomies, and from the favorable opinions there expressed I have had, from my subsequent experience, no reason to recede. Dr. Gould, of Philadelphia, said that according to Dr. Burnett, who undoubt- edly represented the general consensus of feeling of ophthalmologists, the well- recognized treatment in decided cases of heterophoria was that of tenotomy, either partial or complete, according to the circumstances. This to the speaker seemed to be a true tenotomomania, and one illustration of the general surgical debauch of these days, which has also been so well illustrated in gynecology. It should be remembered that surgery is not medicine, that it is the despair of med- icine, and a dernier ressort. The true physician only proceeds to Surgery when medicine is no longer able to bring relief. The speaker believed that in a very few years from the present time there will be little or no tetonomy in cases of insuffi- ciency of the extraocular muscles. He protested that the whole muscle question is not a muscle question at all; that the origin of the trouble is not in any periph- eral organic defect, but that it is almost entirely of central Origin or nature, and that it is functional and not organic. A large number of cases of course are to be Set aside as due to general disease and abnormal conditions existing in other parts of the system. If this is the true view, the cure must therefore be a cure, not of the peripheral organs, which are not at fault, but of the nerve centers controlling the extraocular muscles, because in uncomplicated cases the disease is a disease, if it may be so called, of the nerve centers and not of the muscles themselves. The essence of the diagnosis consists in the relation between adduction and abduction. Leaving out cases of heterophoria, if we have an adduction of 25° PAN-AMERICAN MEDICAL CONGRESS. 1467 or 35° and an abduction of from 4° to 8°, there is certainly no insufficiency and no demand for interference with the muscles of the eye. The secret of the whole matter is to reinstate such a proper relation between adduction and abduction. Every case of heterophoria not traceable to general disease, malnutrition, ametro- pia, etc., the speaker believed to be curable without any operative interference, by a course of gymnastic exercises with the object of developing the strength of the innervational centers. In all other cases of incoördination of the muscles of the body we do not cut a strong muscle or group of muscles in order to strengthen a weak muscle or group of muscles, but instead of that we endeavor to develop the strength of the weak muscles. And so in heterophoria, the true therapeutic meas- ure is to develop the weak muscles. The speaker had discovered by experiment a method of developing these weak muscles, which he believed might be of service, and which had proved very successful in his hands during the last year. In all cases of insufficiency that had not proceeded so far as strabismus, there is during convergence singleness of the images in vision and an increased ability or strength of the coördinating muscles brought into play. The problem then simply consists in carrying this power, developed at the near point of vision, to the far point; in other words, of so developing the nerve centers that the stimulus of converging power shall be enlarged until the same power exists in the distant vision. To illus- trate the method the speaker cited a number of cases, in which there was exo- phoria at 20 feet of from 5° to 15°, and adducting power of from 10° to 20° only, and an abducting power somewhat in excess of that needed. By placing prisms before the eyes, base out, twice as powerful as the patient could fuse at 20 feet, and beginning with the stimulus of convergence at the near point, the object could be very soon carried beyond the near point without producing diplopia, and in a very brief period of time the internal recti muscles had gained their normal strength, the adducting power had increased to 30° or 35°, and the reflex symptoms had entirely disappeared. A number of cases of this kind were cited, in which the cure had been brought about within a few weeks in young people, and in the more neurasthenic or older patients if the insufficiency had not been made to entirely disappear there was a great improvement in this respect, which was first demon- strated by the disappearance of the reflex symptoms. As the weak muscles regain their power stronger prisms may be used, and there is a perfect coordination and proper relation between adduction and abduction. The speaker especially referred to a case in which there was 18° of esophoria. The patient was operated upon, the tendons of both internal recti being completely severed, producing tempora- rily slight exophoria. To the astonishment of the surgeon the original condition was reinstated within ten days, and the patient's original 18° of esophoria had completely returned. If such a result as this could arise (and the speaker con- tended that there was a tremendously large element of doubt as regards the results of operations upon the muscles of the eyes) what, then, could be said as regards the infinitesimal delicacy and minutiae of operations when surgeons speak of correcting half a degree, or one or two or three degrees of heterophoria of any kind? Such a result also conclusively proved that it was not a case of peripheral lesion, but that the trouble lay in the central nervous system, a theory moreover which was proved by the subsequent history of this patient, who refused to submit to further opera- tion, and upon whom the principle of gymnastic exercises of the weak muscles, according to the plan described, was undertaken. Although the 18° of esophoria had remained permanent for some months after the first operations, within a week or two after these gymnastic exercises had been undertaken the patient's esophoria had been reduced to 12 degrees, with a cessation of many of the reflex symptoms. The case is still under treatment and progressing favorably. It would seem, therefore, that as conservative and wise physicians we should not longer indulge in this glamor of surgical procedure, but with more conserv- 1468 PAN-AMERICAN MEDICAL CONGRESS. atism that we should seek to remedy defects by physiological and medical methods rather than by surgical methods. The success that in the speaker's practice had attended this plan during the last eight months had been so remarkable as to con- vince him that the method of carrying the convergence stimulus into the distant vision and the developing of the weak nerve centers was the true and rational method of procedure in these cases. Dr. Savage said: I am exceedingly sorry that Dr. Stevens is not here, since it is my purpose to controvert Some of the thoughts set forth by him in his discussion this morning. I agree with him in many of the views he holds, but I consider that he is wrong in his teaching as to some very important practical points. I agree with the Doctor that associated with muscle errors and depending on them there are peculiar facial expressions. I wish I was as able to interpret these as he is. But he stated that Sometimes the facial expression clearly indicated the existence of a certain muscle error which is not at once shown by the tests at our command. In connection with that statement he did not tell us his method of dealing with these cases. We may reasonably infer from what he said further on in his discussion that the facial expression having indicated a hyperphoria, but not finding it with the phorometer it was found by means of prisms in position of rest for the sus- pected weak muscles, of action for the supposed strong muscles. Continuing this for a few days the latent error begins to be manifest, and the tests begin to harmonize with the facial expression. I believe the facial expression may some- times be misleading, and that, as an index to a muscle error, it can be proven false or true by our muscle tests. I believe further that means should never be resorted to, under any circumstances, for making manifest any supposed lateral error. If we have a “hint" that we are about to deal with a left hyperphoria and a right cataphoria, it is clear to my mind that we should direct our efforts toward curing the slight manifest error, rather than add to it by bringing out a latent error. If a prism be placed base down before the left eye and another prism base up before the right eye, in the supposed case, the strong muscles will be made stronger and the weak muscles weaker, in comparison. This work could be car- ried on, up to a certain point, and thus a greater or less quantity of a supposed latent error may be manifest. How much better it would be to reverse the order and make it possible for the error already manifest to become latent by being cured. Place the prisms in position to strengthen the weak muscles, regulate the exercise as to intensity and time, and they will grow strong. The only object we could have in view in increasing the hyperphoria is that a sufficient quantity may be shown to justify operative interference. This seems to me to be a very round- about way to effect a muscle balance; and I believe it to be a very incorrect method. If one believes the operations alone can correct muscle errors, then he must of necessity often resort to the work of making manifest much that is latent, so that an operation might be indicated. I must dissent from another thought which Dr. Stevens emphasized this morning. He plainly stated that he did not believe the accommodation has any- thing to do in the way of causing or curing any form of muscle error. In this I believe him to be wrong, so far as the latent muscles are concerned. As evidence, I want to introduce one of his own cases. A few years ago In One of his publica- tions he gave the history of a patient who, when a little girl, had an Internal squint; later in life there developed a slight deviation outward, but now, on instilling atropine, she suddenly developed her old internal squint. He published a picture of this patient, representing her as a little girl with an internal squint ; also a picture representing her as a woman approaching middle life, with eyes comparatively straight; and still another picture, showing the same woman, at the same age, under the influence of atropine, which had excited a high degree of internal strabismus. He states that the squint disappeared when the effect of the PAN-AMERICAN MEDICAL CONGRESS. 1469 atropine passed away. Having had patients like this One, I am sure I do not err in the statement that she was hypermetropic, though the Doctor's report did not give her refraction. Early in life, where she had full ciliary power, the activity of the centers controlling the ciliary muscles excited a tendency to activity in the centers controlling the converging muscles that would not be restrained by the guiding sensation, and one eye turned in. Later on the ciliary muscles having lost much of their power, the centers controlling these became less active and cor- respondingly there was less excitation of the converging centers, so that the guiding sensation again assumed control of the internal recti, the Squint disappearing simultaneously. Atropine suspended what ciliary power remained and, as a consequence, very imperfect images were formed on the retinae. The guiding sensation, not being satisfied with these images, called on the accommodative centers for help. In response to the call, these centers generated an impulse and sent it out to the ciliary muscles, but they were not aroused. Another com- plaint went forth from the guiding sensation, more urgent than before, and by it a greater degree of activity was excited in the accommodative centers; but every impulse, though increased in intensity, found the ciliary muscle unresponsive. In this manner the calls and responses were kept up from hour to hour. This activity of the accommodative centers was attended by a corresponding tendency to activity on the part of the converging centers, which tendency having thrown off the restraining influence of the guiding sensation, became unrestrained action, developing the internal squint. As demands on the accommodative centers ceased, the unusual excitation of the converging centers passed away, and with it the muscles again became obedient to the restraining commands of the guiding Sen- sation, and the squint was no more. I have had numbers of just such cases, and have often amused myself by satis- fying the guiding sensation with sharp images by placing correctly centered lenses before the eyes, when, as if by magic, the squint would disappear, only to appear again the moment the glasses were raised. For this there can be but one explana- tion ; the sharp images (made so by the lenses) satisfied the guiding sensation, which instantly ceased its calls on the centers of accommodation, and as a con- sequence both the centers of accommodation and convergence became quiet. We need no stronger evidence that the centers of accommodation have the power of changing the “balance” between the external and internal recti-muscles. If this relationship can develop a squint, certainly it can cause an esophoria, which is a “latent ’’ squint. If glasses, properly centered, can cause a squint to vanish, is it incredible that glasses can cure an esophoria which depends for its existence on an uncorrected hypermetropia In a recent publication I have termed this a pseudo- esophoria and distinguish it from intrinsic esophoria, which can not be cured by convex lenses. The two may be associated in a case of uncorrected hyperme- tropia, while the intrinsic form can only exist in cases of emmetropia and myopia. In volume 2, No. 11 of the Ophthalmic Record, this whole subject is dealt with at length. While glasses have the power, when properly adjusted and properly cen- tered, to cure some pseudo-muscle errors, they have no power at all over intrinsic het- erophoric condition. As pseudo errors may be classed those muscle anomalies dependent on decentration of the muscles, and these can be cured, and ought to be cured, only by prisms in position of rest, or, what is the same thing, by decen- tered lenses. Since focal corrections can do nothing for the cure of intrinsic muscle errors, and since prisms in position of rest should never be prescribed for a correction of these errors, the question naturally arises, “What shall we do for their relief?” There are two plans of treatment, each appropriate in its place: Rhythmic exercise for developing the weak muscles; operations, partial tenotomies for weakening the strong muscles, and shortenings for giving greater power to the weak muscles. 1470 PAN-AMERICAN MEDICAL CONGRESS. The indications for the one or the other are clear to my mind, and my practice is governed by these indications. When there is exophoria of any quantity in the near but none in the far, the case does not admit of operation. The plan of rhythmic exercise which I have introduced will cure the exophoria in the near and allow orthophoria for distance to remain. An operation in such a case would give as much esophoria in the distance as it cures exophoria in the near; therefore it should not be thought of. Again, when there is esophoria for distance and ortho- phoria in the near, the error for distance can be cured by gymnastic exercise allowing the orthophoria in the near to remain. An operation would give as much exophoria in the near as it cures esophoria in the far; therefore it should not be done. A hyperphoria of less than 14 degrees should be cured by gymnastic exer- cise. When there is exophoria both in the far and near, that for distance should |be corrected by a partial tenotomy of one or both external recti, and later the exophoria remaining in the near should be cured by developing the internal recti by exercise. When there is esophoria both in the near and the far, that in the near should be relieved by operating on one or both internal recti, and the eso- phoria remaining in the distance should be cured by developing the external recti by exercise. When there is hyperphoria of more than 14 degrees an operation on the tendon of the superior rectus should be done to effect a part of its cure. Bather than overcorrect, it is far better to fall short of a full correction, and cure the remaining part by developing the weak muscles by rhythmic exercise. No muscle should be operated on more than once. If an exophoria for distance can not |be corrected by a partial division of the tendon of each external rectus, the balance should be accomplished by shortening one or both internal recti. Reversing the Order, the same course should be pursued in very high grades of esophoria. If in a high grade of hyperphoria there should be more than 14 degrees of the error after a partial tenotomy has been done on the strong superior rectus, a sim- ilar operation should be done on the strong inferior rectus of the fellow eye. Shortening or advancing a superior or inferior rectus will not often be neces- sary ; I have never seen a case requiring it. - When I am about to operate I decide beforehand what I want to accomplish, and do what I undertake without resorting to tests during the operation. I always aim in exophoria and esophoria to divide the effect between the corresponding muscles of the two eyes, but as a rule do not operate on the second muscle within four weeks. Not infrequently I find that my first operation has accomplished all I desired. Never has the first, and in only two instances has the second, operation accomplished more than I wanted, and my operations run up into the thousands. Before devising the rhythmic exercise treatment I did desire, not being able to do better. to give by my operation some esophoria for distance in relieving some of the exophoria in the near, and vice versa. With Dr. Gould, I agree that unneces- sary operations have been done on the ocular muscles, and that bad results have followed, all of which is to be regretted. These errors can be, and should be, avoided. The fact that bad results have been seen should not and, I dare say, will not drive all thinking men from acting on sound prinicples. These opera- tions can not be called surgical debauchery when carefully and skillfully done. There is nothing under the sun more sure than that there are intrinsic errors of the ocular muscles, errors the nature of which may be clearly understood, errors that can not be cured by any and all medical means at our command, or that may be at our command in the future. Even glasses, purely surgical appliances, can not alter the true nature of inherent muscle troubles. Glasses and medicnes, I grant, may so act on the nervous system as to make these errors more tolerable, at least for a time. But the errors are there still in spite of all these means. As they can be made more tolerable by improved sys- temic conditions, they can, on the contrary, be rendered less tolerable by sys- PAN-AMERICAN MEDICAL CONGRESS. 1471 temic derangements and extraneous causes that disturb mental equilibrium. The fact remains, and will always remain, that intrinsic muscle errors; errors due to hyperdevelopment of the too powerful muscles, or to a more favorable attachment of these muscles to the globe, or to their having inherently and per- sistently a too abundant nerve supply; can be cured by any one of two means, both Surgical in their nature ; first, operation on the strong muscles; second, development of the weak muscles by proper gymnastic exercise. The indications for the one or the other of these, or for both combined, are clear in most cases. Surgery is not the despair of medicine, but medicine's hope. As to ocular troubles, medicine does not appeal to surgery in vain. The two forms of ocular surgery applicable to the ocular muscles will go locked hand in hand down the ages, each to do its own proper work and ever ready to call on the other for aid in time of need. No. the days of well-done partial tenotomies are not over, nor will they end with the hundredth generation of oculists to follow us. Dr. Risley remarked that heterophorias declared themselves in the facial expres- sion of his patients. He was sure that those who devote themselves to the study of this complicated and intricate subject must sooner or later exhibit the results in their anxious and haggard faces. The gentleman who had preceded him had been preserved from the gray hairs, so numerous in the section, by the buoyant faith in his methods. For his part, the gloved hand of conservatism was controlling more and more his management of the errors of muscular balance. ..While the careful study of the relation between convergence and accommodation was of great importance, no study of these cases was complete which did not take for its starting point the etiology. The proper dynamic relation between the interni and externi was as 3 to 1 determined at 6 m. This was based upon the careful study of a very large group of corrected eyes in which no muscular anomaly existed, and astenopia was absent. When this relation does not obtain errors of muscular balance may be assured. The etiology of such disturbance is important and should control the management of the case. Some cases are unquestionably congenital and possibly due to errors of development; in others, seen in adult life, the esophoria is a residuum of periodical converging. - Strabismus in childhood.—This could in some cases be demonstrated by the study of photographs taken in childhood. Foreign irritations were not infrequently the cause of trouble in ocular muscles. He related the history of a casein which a pessary had removed the heterophoria, which had seemed to require tenotomy. The ocular muscles were subject to disturbance by general diathesis as are the other muscles of the body, rheumatism, gout, etc., and a heterophoria might, therefore, be due to a rheumatism of one of the muscles or the residuum of a palsy. It was prob- able that a muscle once the subject of a palsy, whether peripheral or central, never entirely recovered its original efficiency. Disturbance in Ocular balance was often the initial symptom in babes, or dis- use at the origin of one or more of the nerves supplying the ocular muscles, and error was very liable to creep in at this point. He could not agree with the dic- tion of Dr. Stevens regarding the refractive errors in relation to muscular trouble, since, in his judgment, the two were inseparable in that group of cures of periph- eral Origin. Dr. Baker, of Cleveland, said that he thought Dr. Gould would have little occasion to regret his strong condemnation of the promiscuous snipping and cut- ting of the tendons of the ocular muscles now indulged in by certain ophthalmic surgeons. He said that for many years we have been endeavoring to so perfect our means of correcting errors of refraction as to be able to cure cases of strabismus without resorting to tenotomies, and now that we had about succeeded in curing most of these cases without operative interference in which there is a positive rational indication for operation. These fellows come along and tell us that we must 1472 PAN-AMERICAN MEDICAL CONGRESS. operate in every case where there is the slightest deviation. He believed division of the tendons in most cases to be unnecessary, and he thought partial tenotomies unscientific and unsuccessful, that a partial tenotomy eventually shortened instead of elongated the tendons, and that when a tenotomy was performed a complete division of the muscle should be made and controlled by a suture, if necessary. Dr. Woods, of Baltimore, said: The entire discussion seems to point to the fact that the Oculist in treating heterophoria must remember that he is a doctor; that he is investigating a condition sometimes troublesome, sometimes not; some- times intrinsic, sometimes Secondary; that the primary cause is sometimes in the eye, sometimes elsewhere. As Dr. Burnett has said, we are to look into the etiology. If we are not capable ourselves of meeting the remote conditions, we should seek help rather than do a doubtful operation. Dr. Risley has, I think, given, as nearly as they can be given just now, the correct principles. I have had a case similar to the one he mentioned; a young woman employed in a store, whose head and eyes pained almost constantly. Correction of myopic astig- matism against the rule failed to relieve her; so did prismatic correction of an exophoria. An operation to remove a uterine defect and some menstrual dis- turbance cured her, eyes and all. I have a patient, a lady, who does a great deal of eye work, and who for several years has obtained relief from headaches by wearing cylinders; yet she has a hyperphoria of 24”. Surgical interference in this case would have been bad. In the first, it could not have reached the real cause; in the second, there could be no reason for correcting a “tendency” which was doing no harm. On the other hand, when the heterophoria is intrinsic, and really causing the disturbance, results are brilliant. The gratitude of patients thus relieved, so well presented by Dr. Risley, shows what great good can be done. The question is to determine what cases need operation. There are a few points in the papers of the morning, and remarks made at this session, about which I should like to say a word. Dr. Stevens's advice for journal writers to give all the details of a case in reporting, and not simply say “such and such an error of so many degrees,” should be followed. Such reports of cases, in the present state of heterophoria, are useless. I wish very much Dr. Stevens was here this afternoon to explain why correcting glasses should not be worn during the muscular examination, as he stated this morning. This contra- dicts all his former teachings, as far as I know, and opposes all the recognized principles of refraction. According to my way of thinking, an examination of the muscles without refraction correction would be valueless. Dr. Savage has said he “would not develop the interni out of a near exophoria,” and “would corr rect the esophoria up to its amount at the near.” If the principles I advocated in my paper this morning are correct the former might be a normal condition, and it might indicate either hypersthenic or weak ciliary muscle. The clinical signifi- cance of the esophoria at the near would dependentirely on what had been found at 20 feet. If more esophoria, how much more? I do not believe that any valuable information about the intrinsic strength of the recti muscles is to be gotten from the near equilibrium. This is gotten at 20, and the near test is made for an entirely different purpose. It seems to me Dr. Risley has underestimated the normal proposition of adduction to abduction. I am inclined to think that it is more fre- quently 5 or 6 to 1 than 3 to 1. The cross shown by Dr. Zeigler this morning for the near test seems to me too large to bring out exact accommodation. The smaller the object, the better. Again, it should be mounted on some sort of a rod which would keep it at a fixed and definite distance from the eye. Dr. Zeigler said: I hereby agree with what Dr. Woods has said in regard to the interrelation of the distance and near test. This is illustrated by an anomalous case I related in which the esophoria for near was 6°, while for far it was only 2°. I was compelled to bring the eye to orthophoria for near, with the accompanying transfer to exophoria of 4° for distance, before I could secure comfort in the near PAN-AMERICAN MEDICAL CONGRESS, 1473 work. I do not find that the record of muscular power bears any important rela- tion to either operative or prismatic correction of heterophoria, although we should have an accurate knowledge of it for other purposes. Dr. Stevens, I believe, said that he did not believe in the statement that the ciliary muscle may disturb the condition of the extrinsic muscle of the eyeball. I think we have all seen tempo- rary heterophoria from ciliary spasm, and per contra ciliary spasm from functional muscular errors. The relation between accommodation and convergence is cer- tainly an intimate one. Relying on this fact, I always adjust the proper constant correction in my trial frame, and place in front of patients’ eyes in both opera- tive and monoperative cases. In fact, a test with and without the refractive cor- rection will show different results, just as a test under mydriatic is only a matter of interest, and not to be relied on, because the accommodation is suspended. Dr. Stevens referred to a case in which I overcorrected the exophoria 5°. It was a case of esophoria of 20° reduced to orthophoria by the total tenotomy, which had receded to 10° base out. A complete tenotomy was made on the internal rectus of the other eye, overcorrecting 10°, and again it slid back, coming to orthophoria or 1° beyond. I think the history of this and similar cases justified me in doing as I did ; and five months of comfort for the patient goes to prove the same. In regard to advancement I prefer the capsular advancement in heterophoria and the muscular advancement in heterotropia or squint. To get the best effect in the latter cases the adhesion should not be loosened but drawn up with the muscle. In regard to covering the eye: I am a firm believer in light dressings. In cata- ract extraction and other operations requiring corneal incision I use two strips of plaster in the shape of a cross, one from the upper to lower lid. But in these walk- ing cases exposed to the weather and having considerable bloody ooze I prefer a light compress and Lilbright patch for the first day and night. I have seen one case in which an exposed eye was lost from diphtheritic infection, and I have had one case in my own practice where, in facing a cold wind on the Second day, the eye became inflamed and presented a most beautiful picture of culture of staphy- lococcus pyogenes aureus. While no harm came to this patient I still consider it good judgment to adhere to a light dressing in a certain portion of my cases. I never have used them in every case. In regard to failure to correct cases of internal squint I think we frequently overlook the capsular adhesions which, when cut, may allow the eye to turn from 5 to 10 degrees. They particularly amount to a shortening of the muscle. I think we all use muscular gymnastics with great relief in some cases, and none in others. I agree with Dr. Risley in regard to uternie irritations. I remember a very hopeless case of heterophoria in a woman whom I referred to a gynecologist, who was wholly relieved by an ovarian operation. Replying to Dr. Woods, I would say that I have generally used a smaller cross for the near test, but the engraver has made an error in making this larger cross. The card I presented is the first proof. I do not, however, hold the near- test object at a single point, but take the range. TREATMENT OF OPACITIES OF THE VITREOUS HUMOR WITH PILO- CARPINE HYPODERMATICALLY ADMINISTERED By Dr T. J. TYNER of Austia, Tex. I will not take up your time by giving the anatomy and physiology of the “corpus vitreum ” further than to say that it is without either blood, nerve, or lymphatic circulation This opinion is I believe, now accepted by most, if not all, recent authorities and my clinical experience is in accord with it. It would be a pleasure to give a satisfactory theory as to how these opacities clear up under the influence of this drug (pilocarpine). That it differs from all other drugs in its physiological action there is no doubt, and that it is a specific in this S. Ex. 36 93 1474 PAN-AMERICAN MEDICAL CONGRESS. disease, or rather condition, I have demonstrated, at least to my own satisfaction. That there is ever a primary inflammation of the vitreous I can not believe. How- ever ingenious some writers have been in the opposite theory, for the most part, in their conclusions, they have been forced to regard these opacities as the result of some previous inflammation in the uvea. It is most generally believed that a cure is impossible, except in recent cases. This is only in part true, and true only for the reason that the previous inflammation in the adjacent tissues, espe- cially the retina, and from which these opacities or exudates enter, has been such as to permanently affect vision. This is clearly proven by the disappearance of the opacities, without corresponding improvement of vision; and when the media become sufficiently clear to see the fundus the ravages of a preceding choroiditis or retinitis is revealed. The iris, especially in old persons, is frequently atheromatous, the pupil responding to atropine only in part. Such cases are rarely met with, except where they are of long standing, and generally in elderly persons. I treated a gentleman 72 years of age whose vision began to fail six years previ- ously; the media became perfectly clear and vision improved very much, as much as was possible, so far as the vitreous was concerned, but with the ophthalmo- scope the scars of a preceding inflammation of both the choroid and retina were made manifest. However, such cases do not detract from the efficacy of pilocar- pine in rendering the vitreous clear of opacities. As to how it does it, as before stated, we can not say. That it is not by absorption is almost certain, for so far as is known the vitreous is devoid of absorbents. I will, however, venture the hypothesis that through the lymph channels endosmosis is probable, and that the opacities are disrupted and resolution takes place. I could not do better than refer you to a paper read at this meeting by Dr. J. W. McLaughlin on “The philosophy of drug action.” However much we would like to know the process by which a thing is accomplished, yet the practical fact that we know the agency by which it can be done should be sufficiently satisfying, and my clinical experience warrants me in saying that the hypodermic injections of pilocarpine is a specific in opacities of the vitreous humor. In support of this statement, since the beginning of 1887 I have treated about 31 cases in which there was not one that failed either to fully recover or to be greatly improved. Those only improved were the cases already referred to, in which a precedent destructive inflammation in the uvea had existed. It will not be amiss to state here that in one case in which the opacities had appeared only ten or twelve days before, V-#}, at the end of the first week of treatment it fell to ſº, showing the inflammation in the uvea to be at its height, but thirty days later V=}}. The oldest case treated was 91 years of age ; the youngest, 18. The age most suscepti- ble is about 50 or say between 45 and 55. The case of longest standing was eight years, the shortest twelve days; but for the most part between one and two years when the patients present themselves for treatment. Sex, 27 males; 4 females. (Noteworthy.) Of the 31 cases, 4 were colored, 1 mulatto. In administering the drug, I proceed with extreme caution, beginning with about the one-sixteenth of a grain twice daily, increasing the dose as rapidly as possible until the full physi- ological effect is reached, then continue. Generally though, after this, only once daily. A larger dose can be given at the patient's home and with much more com- fort than at the office. The reason is obvious. As a rule, the greater the effect of the drug the more rapid the improvement. DISCUSSION. In discussing Dr. Tyner's paper, Dr. Chisolm said that he had for many years used pilocarpine by hyperdermic injection for the relief of recent cloudings of the Vitreous and with excellent results. He usually commences with a really stronger PAN AMERICAN MEDICAL CONGRESS. 1475 dose than Dr. Tyner ends with. He injects one-fourth grain and usually obtains free sweating in a few minutes, with salivation and at times emesis. He had seen no bad effects from these doses. The more prompt and excessive the skin action the more prompt the clearing of the clouding. ORBITAL TU MOR.S. By WALTER B, JOHNSON, M. D., of Paterson, N. J. Exophthalmus, from any cause, is unsightly, and when it is produced by the pres- ence of some variety of orbital tumor is always to be regarded as an extremely grave condition, for the presence of a growth behind or within the eyeball is serious, and may, even if a suitable case for operation, result in loss of the eye if, as in many cases, it does not terminate in the death of the patient. The histories of the cases of the tumors of the orbital cavity here presented, which differed in their composition and had their foci of development in various localities, are reported, without any special effort at classification, for the purpose of placing them on record, and for the consideration of the interesting features always pre- sented in the study of cases of so grave a character. Protrusion of the eyeball when presented, as a symptom, for examination should be carefully considered from every standpoint, and the diagnosis and treatment of the possible condition only suggested after deliberate inquiry and investigation and a thorough study of the probable prognosis and requisite medicinal or oper. ative treatment. The important factors which present themselves for consider- ation, are: The presence of an orbital tumor, and the character of the growth whether benign or malignant. The previous and family history of the case is important, special inquiry being made regarding the affection of any family con- nection by malignant disease. The physical condition of the patient (cachexia) will frequently indicate the probably malignant form of the disease, although many cases of positively malignant growths have occurred without any apparent physical or constitutional infection. The age of the patient may indicate possible malignancy, a high percentage of malignant orbital tumors occurring early in life. The time of onset is important in indicating the character of the disease, a tumor recently appearing, which has attained great size in a comparatively short time, being much more apt to be malignant than one of slower growth, although even a malignant tumor may be of slow growth, while it remains in the posterior portion of the orbit behind the globe and ocular muscles. When the surrounding tissues have been involved in the orbital growth or have become a part of it, the question of its malignancy is almost settled, as a benign tumor rarely, if ever, extends. The presence of pain is more common in malignant disease but may be present in any case providing the growth has attained sufficient size to cause pressure upon the eyeball and stretching of the nerves. The character of the pro- trusion and its extent is, if a tumor exist, generally more marked in a given direc- tion, and not directly forward and uniform, as is frequently the case in other con- ditions. The mobility of the eyeball is more extensively impaired in tumor than in other conditions, and in malignant disease is frequently affected very shortly after the onset, even before the proptosis is marked, while in other conditions presenting excessive exophthalmus an almost normal muscular action may be present. The location of a tumor within the eyeball, or attached to it or to the optic nerve, is an indication for immediate operation before the disease spreads to the surrounding tissues or cavities; the attachment to the eyeball or to the optic nerve is indicated by the proportionate ratio of mobility to the protrusion, the mobility in malignant dis- ease being much more impaired than would be indicated by the amount of the prom- inence of the eyeball. The condition of the eyeball itself, even when not diseased, 1476 PAN-AMERICAN MEDICAL CONGRESS. may be an indication for immediate interference, as frequently the pressure effect is cause of excessive pains, congestion, edema, inflammation, and strangulation, endangering the integrity of the globe from malnutrition or induced disease. The effect of the stretching of the optic nerve upon the vision varies with the different cases and conditions; the sight is, however, always more or less blurred, and may be nearly, if not entirely, lost. Although it can not always be deter- mined positively that an orbital tumor exists, and especially what the probable variety of the growth may be, the diagnosis may be made more readily after the exclusion of any possible cause for the condition other than some variety of abnormal growth. - - - The presence of a tumor of the orbital cavity having been ascertained, the first and most important consideration is, has it a benign or malignant character? While surmise is profitable and a probable diagnosis may be made, certainty can only be acquired by a microscopical examination of some portion of the growth itself. The diagnosis is rendered more difficult in consequence of the location of these tumors, which is frequently, in the early stages at least, so far back in the orbit that thorough digital examination is not possible. The point of origin is most important, not only in indicating the probable character of the tumor, but also in determining the proper course of the operative treatment to be pursued. The rapidity of the onset of the growth is of great importance, especially if it be accompanied by excessive pain, with extensive protrusion of the eyeball and if the mobility of the globe and the vision be decidedly impaired. The invasion of, or the Onset in, any of the surrounding cavities is extremely serious, probably indi- cating the impossiblity of the removal or evisceration of the growth in its entirety. The operation indicated, in nearly all cases of tumor of the orbit, is the removal of the entire growth ; if the location of the tumor will permit it the operation may be made from behind the eyeball, leaving the organ in situ after the proced- ure. If the tumor involve the eyeball itself, or is so extensive that it precludes the possibility of its complete extirpation without the removal of the eyeball, the entire mass must be removed. If any portion of the tumor remain after operation the cavity must be thoroughly cauterized with the galvano-cantery or the application of a strong caustic paste. In advising operation the most impor- tant considerations are: If the tumor is benign ; is it endangering the integrity and vision of the eye? Will it possibly disappear without operation? May it be a benign tumor which presents the symptoms and character of a malignant growth? If the tumor is decidedly malignant the important question is the probability of its complete removal, for if not likely to succeed in the entire eviscer- ation of an orbital tumor (and some of the malignant tissue may remain within the orbit or surrounding cavities and can not be removed or destroyed), it is almost certain that the growth will recur with marked rapidity and much more extensively than if it never had been operated upon, and that the patient will suc- cumb much sooner than would otherwise have been the case. The tumor, even if malignant, if confined by the presence of the eyeball and the surrounding tissues will be of comparatively slow growth. Even though there is progressive protru- Sion, loss of motion and sight, irritation, inflammation, edema, strangulation, and perhaps subsequent disintegration, a tumor which can not be entirely removed should not be operated upon unless the unbearable pain, distressing discharge, and bleeding compel it; for the condition is generally much worse very shortly after the operation has been performed, and the death of the patient is hastened with- Out compensating benefits. SMALL. SPHEROIDAL AND OVOIDAL CELLED SARCOMA OF THE ORBIT. Case No. 1.-B. D., age 6, August 3, 1886. A strong, well-developed boy, giving a previous history of good health, no cachectic appearance, and no history of malignant disease, either in the paternal or maternal ancestors. One year previ- sº i - Ø ſ % ;." - $ .*.* s * t - ** - .* - ; jº * A §§2% * 2 * Z. 9 * * * FIG. 3. —Capillary blood vessels with hyalin degeneration of the walls. CASE No. 2.--MYXO SARCOMA OF THE OPTIC NERVE WITH HYALIN DEGENERATION. PAN-AMERICAN MEDICAL CONGRESS. 1477 ous to the present visit he had an abscess, which broke and discharged at a point 1 inch below the left eye, over the superior maxillary bone. The discharge continued for three days, and was estimated to have been about one-half teacupful in all. The abscess healed kindly, the swelling diminished, but for some time the cicatrix adhered to the bone. At present theskin is movable, and a very small scar marks the point of rupture. Eight months ago the mother first noticed a prominence of the left eyeball, which has gradually increased until the present time; the increase having been much more rapid during the past three months. There is a slight pain occurring once or twice a day; at other times the patient has no discomfort, and does not suffer from headache. The examination discloses the left eyeball dis- placed forward, downward, and inward, one-half inch anterior to its normal posi- tion; the corneal sensibility is not diminished; the pupil is slightly contracted, but responsive to light; the eyeball is reddened ; there is considerable lachrymation and some mucous discharge. Above the eyeball and to the temporal side, pal- pation reveals a somewhat movable dense mass, apparently about the size of a Brazil nut; the mobility of the eyeballis only slightly impaired in some directions; the vision equals: R. V. =#}; L. V. =#3 N. I. with glasses. Ophthalmoscopic examination reveals a normal fundus. August 17: Dr. H. Knapp examined the case in consultation, and advised imme- diate operation. Since last record the growth has developed rapidly, and during the past five days an increasing haziness of the lower quarter of the cornea has appeared, with a markedly roughened and yellowish area near the limbus and also considerable conjunctival chemosis. - August 23: Operation under ether; a crescentic incision, 14 inches long, was made through the upper lid, just below the eyebrow ; the dissection was continued with the handle of the scalpel, and the tumor peeled out readily; the bone on the temporal side of the orbit was rough, as though it were denuded of its periosteum. The tumor, a dense inelastic mass, was 13 inches long and three-quarters of an inch in diameter in its widest part; it was somewhat lobulated, having an anterior and a posterior portion and decreased in size as it was more deeply seated in the orbit. The wound was closed, several stralids of catgut being placed in the cavity to facilitate the drainage. August 24: Since the operation constant but slight oozing has continued ; the lids are edematous, the conjunctiva less chemotic than before the operation, the cornea is still hazy, but the roughness and yellowish appearance is improving. August 27: The stitches were removed ; the wound had healed exceptat the most dependent point kept open by the catgut drainage. There had been but little pain following the operation, and the temperature varied from 99° to 103°; the conjunc- tival ºnosis continues to grow less and the appearance of the eye has decidedly 1I]]|Ol'OVéC1. º 28: The discharge from the wound is of dark color, but not at all odor- ous; the catgut drainage was removed and a small rubber drainage tube inserted in its place; a pressure bandage was then applied for the night, hot-water appli- cations having been used continually previous to this time. September 8: The patient has improved steadily since last record, the wound having healed kindly from the bottom and entirely closed, the eyeball being nor- mal and in its proper position, and the vision perfect in each eye; the patient was discharged cured. December 12: Three months after the patient left the hospital apparently cured, he returned with a growth evidently of the same character as the one removed, but much smaller, situated below the eyeball and to the nasal side. An immedi- ate operation was advised. The patient, however, passed from observation and unfortunately no subsequent history of the case could be obtained. Dr. T Mitchell Prudden, of New York, made a microscopical examination of the growth, and his report is as follows: “The tumor is of an irregular ovoidal shape about 2 inches long and 1 inch in diameter in the thickest part ; its texture is firm and dense. Microscopical eacamination.—The tumor mass consists for the most part of spheroidal and elongated cells. These cells are in most places closely packed together, but in Some parts narrow bands and fascicles of fibrilated basement sub- stance run between and among them. . The cells are all small, and the prevailing form is the spheroidal; the tumor is but moderately vascular. The anatomical diagnosis is accordingly: small spheroidal and ovoidal celled sarcoma. MYXO-SARCOMA OF THE OPTIC NERVE WITH HYALINE DEGENERATION. Case No. 2. —C. A., aged 22. . When 12 years of age she was operated upon for tumor of the optic nerve, which had been first noticed six years before. The case, which was very interesting and unusually rare, was reported in the Archives of 1478 PAN-AMERICAN MEDICAL CONGRESS. Ophthalmology, Volume XIV, Nos. 2 and 3, 1885, with illustrations and micro- scopical examination, by Dr. T. Mitchell Prudden, of New York. The child, when first examined in 1883, had an exophthalmus of 13 '', with accompanying inability to close the lids and many disturbing symptoms, which had gradually increased during the past six years, although pain and increasing discomfort had not appeared until the past year. The eye had been sightless for five years and Six months; the general health of the patient is and always has been extremely good. The case is again mentioned to record the fact that at this time, ten years after the removal of the growth, there had been no return, even though it had been considered possible that all of the structural material had not been entirely removed at the operation. . RECU RRENT CARCINOMA OF THE ORBIT FOLLOWING ENUCLEATION. Case No. 3.-S. F., 2 years; March, 1892; United States. The child, of Irish and Scotch parents, had enjoyed good health until 1 year of age. There was no his- tory of malignant disease either in the family of the mother or father. One year ago the mother first noticed eye trouble, which she considered an inflammation of the eye, probably caused by cold. When carefully questioned, however, she stated that the eye had not appeared just right from the time the child was 3 months old. She described the pupil as widely dilated, stating that the blue part was absent and that the eye looked peculiar. During the last year the eye has increased in size gradually, until about four months ago, when it commenced to enlarge more Tapidly, and the child began to complain of pain. Enucleation was advised by an eminent oculist of an adjoining city, but was not permitted until January 5, 1893, when the eyeball had protruded excessively. Bleeding had occurred, and there was a constant discharge of ichorous pus. The enucleation was delayed so long, in consequence of the objections of the parents, that a successful operation was doubtful. It was, however, performed by the physician above alluded to. For three weeks the orbital cavity seemed to be in a perfectly healthy condition, and the parts appeared to have healed kindly; after this time the orbit began to fill up again, and from that time, about February 1, until March 9, when first seen, it increased very rapidly until it finally emerged from between the lids. The tumor bled frequently and constantly discharged a bad-smelling, ichorous pus. The child was in an extremely restless and enfeebled condition and it died of haemor- rhage and exhaustion three days after. ORBITAL SARCOMA ORIGINATING IN THE NASAL CAVITY. Case No. 4.—Miss V. R.; aged, 22; November 15, 1890. First saw patient on above date; at that time she had slight ptosis and a very little paralysis of the left side of the face. She had constant lachrymation from the left eye; was rather delicate ; although not frequently ill, was thin and somewhat anaemic. Bowman's operation for opening the lachrymal sac and subsequent probing was advised. The operation was performed in the usual manner and a No. 8 Bowman's probe introduced. For the first four weeks after the operation the patient was seen and the probe passed twice each week; from that time until the 5th of September, nearly one year, she was seen every week or two and the probe passed, with tem- porary relief, but the lachrymation always persisted to some extent. There was never any unusual bleeding from the nose after probing. The probes were increased in size gradually to No. 13 Bowman's. On September 5, 1892, she first complained of difficulty in breathing through her nostrils. Examination disclosed a complete occlusion of the left nasal passage; the inferior turbinated bone was covered with hypertrophied mucous membrane and the post pharynx on the left side was apparently filled and closed, so that she could not inspire or expire with the right nostril closed. The removal of some of this hypertrophied tissue was advised, and the operation performed without having inflicted unbearable pain ; it was followed by excessive haemorrhage; the amount of tissue removed was not great; the canulated knife of Dr. Smith was used in operating. There was constant oozing from the nose, and on the second day after the operation severe inflammation accompanied by excessive swelling and violent pain supervened; the inflammation extended to the antrum, the frontal sinuses, and also through the Eustachian canal to the ear. This inflam- mation subsided very slowly and was attended by severe pain. The patient was treated by local applications and warm douching. In about two weeks the trouble had practically subsided, there was but slight improvement in the nose, although a partial inspiratory effort could be made, but expiration was completely sus- pended. The peculiar friable feel of the membrane of the nose suggested the pos- Case No. 3.-RECURRENT carcinoMA of THE ORBIT FOLLOWING ENUCLEATION. Case No. 4.-ORBITAL SARCOMA ORIGINATING IN THE NASAL CAVITY. PAN-AMERICAN MEDICAL CONGRESS. 1479 sible malignancy of the growth and the patient was referred, with a history of her case, to Dr. F. H. Bosworth, of New York, who made further operations upon the nose which on each occasion was followed by extremely excessive hemorrhages, although his opinion was at that time that the tumor was of a non-malignant type. One month later, in a letter written to Dr. S. F. Wiley, who originally had charge of the case, Dr. Bosworth stated that he then considered the growth to be possibly a myxo-sarcoma and thought it probable that the tumor might have been induced by the probing of the lachrymal duct, although he was not able to locate the point of origin at a point near its opening. The Doctor also suggested the possibility of the excessive pain in the ear being due to pressure on the spheno-palatine nerve, although the inflammation of the middle ear by extension had been considered sufficient to produce the pain. The patient passed from observation from October, 1891, U.I:til June, 1893, about eighteen months, when she again presented herself for treatment, enucleation of the left eye having been advised in consequence of an exophthalmus which had gradually increased during the past year and had devel- oped to such an extent that the proptosis of the left eyeball was equal to about 1 inch. The eye was entirely sightless; the cornea in a semi-sloughing condition; there was constant lachrymation and purulent discharge and at intervals distress- ing pain in and about the eye. The right eyeball had also recently increased in prominence and its vision decidedly diminished, the nose was completely occluded, no inspiratory or expiratory effort being possible through either nostril. The patient seems also to have lost somewhat in mental power and at times is consid- ered by her family to act in a very peculiar manner. In consequence of the extent of the disease being so great and the possibility of a radical operation so slight, any operation was not considered advisable and the patient returned home. TRAUMATIC EXOSTOSIS OF THE ORBIT. Case No. 5.—M. E. M., colored, aged 25, married. A strong, healthy woman, with a good family history, and her husband well and free from specific taint. She has had two children, one of which was stillborn and the other died in ten or fifteen minutes. There is no indication of, and she denies, specific disease. Three years and six months ago she was kicked on the left side of her face, causing a con- tused wound of the left upper eyelid and a general swelling and ecchymosis about the left eye; the wound healed and the swelling entirely disappeared in about a month Six months after this time her attention was called to a “swelling ” on the left side of her face, at the edge of the orbit near her nose, which she had failed to notice. This tumor has slowly increased in size, absorbent and alterative med- ication apparently having no beneficial effect. Two months ago she first noticed pain in the growth, which has at intervals been so severe as to prevent sleep. She also suffers from occasional frontal headaches. The patient has no tenderness in the region about the growth, but immediately over it pressure produces some pain; she has an epiphora, but no inflammatory disease of the eye; the nasal passages are free and clear. The tumor, which is hard and immovable, is situated over the edge of the orbit and extends from the nasal bone, covering part of the anterior surface of the Superior maxillary. The tumor was about 13 inches in length, and in size and shape very much like a Brazil nut; a linear depression could be felt between it and the nasal bone, the surface was slightly nodular, the skin was not adherent to it, there was some swelling of the adjacent soft parts. Operation was advised and performed. A T-shaped incision was made just below the lower eyelid, over the tumor, 14 inches in length, and at right angles to this an incision three- quarters of an inch in length just over the linear depression between the tumor and the nasal bone; the periosteum was stripped off and disclosed the growth, which was somewhat cancellous in some parts, while in others it was compact and dense. The growth could not be separated en masse, and in chiseling was broken off in many pieces, as shown in the specimen herewith presented. The edge of the orbit and anterior surface of the superior maxillary bone were thoroughly cleared down to the healthy bone with a pair of sharp-cutting gouge forceps. The wound, which was antiseptically dressed, healed kindly, a slight purulent discharge occur- ring on the fifth, sixth, and seventh days from the most dependent portion of the wound, its edges having been separated for the purpose. The deformity was removed, a slight Scar only being left, which after cicatrization adhered somewhat to bone; there has been no pain and no subsequent increase of bone tissue to pres- ent time, six months after the operation. SPONTANEOUS HAEMATOMA OF THE ORBIT. Case No. 6.—Miss Z., aged 14, November, 1892. Was first seen November 12, 1892, having been referred by Dr. George T. Welch, of Passaic. The right eye was 1480 PAN-AMERICAN MEDICAL CONGRESS. excessively protruded, the exophthalmus being so great that there was severe pain. The eyeball was displaced downward, forward, and outward, fully three-quarters of an inch in front of its normal plane, a tense swelling resembling a malignant tumor of the orbit was situated above and to the nasal side of the eyeball. Three days before her first visit she suddenly felt a severe pain in the right eye, which was immediately followed by the tumefaction. There was no ecchymosis present; the mobility of the eyeball was greatly impaired. An exploratory puncture was advised and performed with a hypodermic needle, which was thrust into the tumor; a syringeful of dark-colored, liquid blood was withdrawn. The pain was relieved at once and the subsequent absorption was very rapid, the exophthalmus having entirely disappeared in about two weeks. There was no subsequent ecchy- mosis or pain. The removal of a portion of the extravasated blood by an hypodermic needle in such cases would seem to be very desirable, as the process of absorption is ºed and can not be satisfactorily established until the excessive pressure is I'êII6 V 601. " CARCINOMA OF THE NASAL FOSSA EXTENDING TO THE ORBIT AND SURROUNDING CAVITIES. Case No. 7.-Mrs. M., aged 63, a strong, healthy woman, presented herself at the Paterson Eye and Ear Infirmary for treatment. For the past two months she has suffered from inability to breathe through her nose, and for the past ten days she has had violent pains over the frontal sinuses which were very sensitive to the touch. She has no knowledge of any malignant disease in any member of her family or relations. On examination both the right and left nasal passages were found to be filled with masses of a new material which was friable, nodular, and bled profusely when touched. The point of origin seemed to be from the vicinity of the turbinated bones and vault of the nasal passages. The growth was consid- ered malignant. The pain had, during the next two weeks, increased to such an extent that an operation was performed for its relief. The operation consisted in the cleaning out of all the tissue possible from each side of the nose with a Snare and the forceps. A large quantity of tissue was removed, including the turbinated bones which were within the tumor mass. The bones were very brittle and the growth came away readily, one large mass from each nostril, and many Small pieces. There was considerable haemorrhage, and oëzing continued for three days, after which time the irritation of the operation gradually subsided, the swelling and pain over the frontal sinuses was relieved, and the patient remained very com- fortable for five weeks, during which time the growth had gradually increased until finally it became more painful than ever before, and a marked prominence of the right eye began to develop. The growth was examined microscopically by Dr. J. W. Williams, who submitted the following report: “I have made and examined sections of the growth which you sent me, removed from the nasal fossa of Mrs. M., and found it to be carcinoma, the cells being for the most part of the squamous type.” The patient desiring further operation in consequence of the unbearable pain was referred to the New York Cancer Hospital, where her right eye and part of the bones of her face were removed, but the growth returned. She was operated upon three times in all, and she finally died, six months after her first visit, from a recurrence of the disease and exhaustion. A CASE OF ENOPHTHALMUS TRAUMATICUS. By LOUIS F. LOVE, M. D., of Philadelphia, Pa. Ophthalmic Surgeon to St. Mary's Hospital, etc. I wish to present to the attention of the Congress the description of a case of enophthalmus traumaticus. The right eye presents the appearance of being sunken in the orbit. The under lid, with its loose and baggy folds, shows an almost complete absorption of the underlying fat; and that this condition of absorption extends to the whole cushion of fatin the orbit is evident from the fact that the ball is retracted from 6 to 7 millimetres. The retraction gives the eye the appearance of an artificial eye, an appearance which is enhanced by the apparent smallness of the globe. The globe is in reality, however, the same size as its fel. low. Microphthalmus was absolutely excluded. The old scar, which is visible on TRAUMATIC ENOPHTHALMIA. TRAUMATIC ENOPHTHALMA. PAN-AMERICAN MEDICAL CONGRESS. 1481 the nose, has nothing to do with the present disease. The history of the case is as follows: P. McC., age, 35, was struck with the fist in the right orbital region in March, 1893, the blow being quite a severe one and causing a large swelling of both lids. There was no external wound. The swelling remained for about two weeks and was not treated except by domestic remedies. After the subsidence of the swell- ing he noticed that the eye appeared smaller than its fellow, and this condition had continued up to the time he presented himself for treatment, three months after the date of the injury. At no time had he suffered pain in the eye itself, and vision was excellent. O. D. V. =# 22 D. =0.50 186. 46c. O. D. W. =#? D. =0.50 20c. 48c. On examination the globe is found to be retracted 6 or 7 millimetres, but is normal in size; there is no apparent paralysis of any of the ocular muscles, but the movement of the globe was markedly limited in all directions. The lower lid is thrown into folds and presents a flabby appearance. There is no ptosis, and the patient states that at no time was double vision present. The right pupil is about 2 millimetres in size, the left about 24, both actively responsive to light. Ophthal- moscopic examination showed media clear, disk oval, axis 90°, good tint, vessels normal in size and carrying good blood. In a word, there was apparently no gross pathological changes. The case which I have thus briefly presented appears to be almost unique. The cases heretofore reported have almost invariably been connected with fracture of some of the bones of the orbit, or were the result of age or disease. In this case there was no evidence whatever of fracture, and all the circumstances pointed to its having resulted from direct violence in a young and healthy man. The liter- ature upon the subject is exceedingly meagre. Dr. Hansell, in reporting a case to the Philadelphia County Medical Society” in which a fracture of the orbital plate of the ethmoid bone existed, has collected what little there is. The older authors are silent on the subject of traumatic enophthalmus, with a few exceptions, and only refer to enophthalmus produced by disease in an incidental manner. Two cases reported by Gessner (Archiv für Augenheilkunde, Bd. XVIII, Hft. iii), and quoted by Dr. Hansell, are similar to mine. In both of these cases the orbital region was lacerated by injury, and a few weeks later enophthalmus of the ball was noted. In both cases the condition remained permanent. A plausible explanation of the con- dition is that a cicatricial contraction of the retrobulbar fat and cellular tissue occurs as the result of inflammatory reaction, following a wound in this neighborhood. In the case I have the honor to report there was no evidence of wound or deep-seated lesion, though whether the inflammation of the cellular tissue about the eye could have extended to retrobulbar tissue and could have been followed by cicatricial con- traction, or more probably by absorption, can not certainly be stated. It is possible that the injury caused a general infiltration of inflammatory products throughout the Orbital tissue, and that when these products were removed by absorption, that much of the normal tissue was absorbed with them. But what should cause such an abnormal absorption, and, if such should be the cause, why do we not see more of such results following a blow in this region? We know very little of the trophic nerve system, or even of the normal method of absorption in the orbital region, yet physiological investigation has furnished some facts which may bear upon this case. I am indebted to Dr. Charles K. Mills for literature which he has placed at my disposal. Claude Bernard called attention to the fact that the contraction of the pupil after division of the sympathetic is constantly accompanied by retraction of the globe of the eye, flattening of the cornea, and decrease in the size of the pal- pebral fissure. The same phenomena he saw also after division of the anterior roots of the two first dorsal nerves and after section of the spinal marrow at the level of the first and second dorsal vertebrae. Irritation of the divided sympa- thetic or of the peripheral ends of the several anterior roots gave opposite results, prominence of the globe, bulging of the cornea, and enlargement of the palpebral fissure. H. Muller (1musculus orbitalis—smooth muscular fibres found in the * Proceedings of the Philadelphia County Medical Society, Vol. XI, 1890. 1482 PAN-AMERICAN MEDICAL CONGRESS, Imembrana orbitalis)* discovered in the anterior orbital fissure a reddish gray mass consisting of bundles of unstriped muscular fibre with elastic tendons analogous to the Orbital membrane of the mammalia. He supposed that its action is to pro- trude the eyeball. It is supplied by fibers from the sympathetic, and irritation of the latter in the neck has been found to cause -protrusion of the eye, perhaps through the action of this muscle. Sappey has described similar muscles in the orbital aponeuroses, f The well-known experiments of Euhlenberg and Guttmann on the cervical sympathetic may also be referred to. § In conclusion, I will state that the case has been kept under observation and any further changes will be noted carefully. The condition is, of course, irremediable by Surgical or other Iſlea, IlS. FURTHER OBSERVATIONS ON THE EYE OF THE NEGRO. By CHARLES W. KOLLOCK, M. D. of Charleston. S. C. In a former paper on this subject it was concluded that the eye of the negro had deteriorated since he became free, and that this was due to the following causes: (1) Syphilitic infection; (2) lack of good and sufficient food and clothing; (3) total disregard of sanitary and hygienic surroundings; (4) frequent Sexual intercourse with whites of low condition which has produced the mulatto, who inherits the weaknesses of both races, and therefore is rarely healthy, but generally syphilitic, scrofulous, and tuberculous; (5) education implanted upon such a rotten founda- tion has produced its ill effects, such as myopia and attendant evils. Syphilis has caused widespread destruction among them, and it is not an exaggeration to repeat that but few remain who do not show symptoms of infection. The eyes, especially, have suffered from this disease, and blindness is increasing rapidly. Ignorant and careless of consequences, they rarely consult a physician when the disease is in its incipiency, so that when seen iritis is usually well advanced, synechiae firm, pupils occluded, and general inflammation of the uveal tract and choroid is not unusual. When there is keratitis, and this occurs in 37 per cent of all their diseases of the eye, ulcers have extended over the cornea and eaten into the layers proper, and perforation is the rule. When it is realized that so large a per- centage have keratitis in some form, and that they rarely seek advice until serious injury has been done, it is not difficult to understand how fast impaired vision and blindness are increasing. Kerato-malacia associated with xerosis of the conjunctiva is a frequent and interesting condition seen in negro children, and more com. monly among the blacks than mulattoes. It is not often found in adults, and in Charleston has never been seen among the whites, though there are many who live in similar conditions and who have like surroundings. There can be no doubt but that the disease is due to a lowered vital condition, and it usually occurs in weakly children from one to eight years of age. Some show undoubted signs of inherited syphilis, others are scrofulous, and some tuberculous, with cavi- ties in their lungs and deposits in the mesentery, while others do not appear to have any bodily affliction; but all are night-blind, and this more than any other symptom induces the parents to bring them for treatment. It has been thought that perhaps malaria was a factor in its causation, but examination of the blood so far has not proved anything worthy of note. The existence of a bacillus| has been suspected. The negro lives commonly on hominy (grits), rice, fish, and *Billings's National Medical Dictionary, Vol. II. + Soelberg Wells by Bull, A Treatise on Diseases of the Eye. † Sappey's Anatomy, 1876–1879. § Journal of Mental Science, Vol. xxx III, 1883. | It is stated that the bacillus has been found by Dr. Weeks, of New York. PAN-AMERICAN MEDICAI, CONGRESS. 1483 bad hog meat, and it is possible that the kind of food may have something to do with the condition. The whites do not eat as much fish, and the quality of hog meat is better than that used by the negro, who will frequently buy strong smelling meat in prefer- ence to that which has no odor. Treatment does much for those in whom the cornea is slightly affected. but it has been the experience of the writer that when the entire cornea breaks down and suppurates it avails nothing and the patient soon dies. Malaria is undoubtedly a cause of keratitis among them, and when such is the case there will be periodic exacerbations. These cases are rapidly improved by large doses (gr. xx) of quinine given at short intervals for several days in succession. But in all these cases of corneal trouble specific treat- ment will be of great value. The negro is a curious being; he will sit, ax in hand, on a pile of wood and freeze to death, and he will hold a prescription which can be procured free of charge, and yet not have it filled, so that treatment is not always satisfactory, nor can one depend upon him to carry it out. But for certain things he has a predilection, and one of these is for “salves.” Any greasy dirt that he can rub in will afford him pleasure. Therefore, taking advantage of this weak- ness, it is best to begin treatment with mercurial inunction; than which there is no better. He will faithfully rub a drachm of this into his skin twice a day, and the results are magnificent. It is food and medicine; he responds beautifully, and the efficacy of drugs seems assured. They seem to bear mercury better than the whites, and inunction may at times be continued for two weeks or longer. Conjunctival inflammation of a mild character is more frequently seen among the mulattoes, but this may be due to the fact that refractive errors are more common with the latter, and also that they use their eyes more for trying work than the blacks do. Trachoma is equally rare among both blacks and mulattoes, but undoubtedly occurs. Strange to say, ophthalmia neonatorum is not very common among them. The gentlemen who have done the practice for the poor in Charleston say that it occurs in the blacks less frequently than among the whites. Certainly gomorrhoea does not seem a very prevalent disease with them. Recently two cases of leprosy have been seen in mulatto men by the writer. One man was about 60 years old and the other 25. No other members of their families were affected, nor were they related. Both had the nodular infiltration along the eyelids and the ciliaº had dropped out. In the older man the diffused progressive opacification described by Hulanicki was shown. It extended upon both corneae from the upper margins to about the centers. The surfaces were smooth, there was no inflammation or photophobia, and the haziness was either between the conjunctival layer and Bowman's mem- brane, or involved the latter. In the younger man was seen the other mode by which the disease affects the eye—the nodular infiltration of the cornea. This, Hulanicki says, is seldom a primary affection of the cornea, but usually extends from the sclera. This patient had also some signs of syphilitic affection, as the bones of the nose had been destroyed by ulceration, but leprosy and syphilis sel- dom coèxist in the same person. Refractive errors are met as commonly among the mulattoes as the whites, but as yet myopia is not quite as frequent in occur- rence, though it is undoubtedly increasing. In the pure black, refractive errors are the exception; myopia has never been seen by the writer, but as their education advances they will at no distant date have the civilized eye. DISCUSSION. Dr. Burnett, of Washington, said he had been interested in the eye of the negro for many years; had published at various times papers on the subject since 1876, and he was glad to find that the experience of Dr. Kollock agreed in all essential 1484 PAN-AMERICAN MEDICAL CONGRESS. particulars with his own. His experience in Washington, however, has not shown that syphilis is yet so destructive as it appeared to be in Charleston. . Dr. Belt, of Washington, D.C., said that he had seen many cases of ophthalmia neonatorum among the negroes, and that it was not uncommon. He thought it more severe among the whites and mulattoes than among the pure-blooded negroes. He had foundiritis very common and nearly always from syphilis, but it usually responded well to treatment. Dr. Chisolm said that Baltimore, the city in which he lived, had a colored popu- lation of 45,000, and that in the books of the Presbyterian Eye and Ear Charity Hospital he has recorded upward of 8,000 cases of disease. These he had not yet collated, but would do so at some early day. Syphilitic troubles were commonly met, especially as iritis, and often with gummata. He thinks glaucoma more com- mon among them than in the whites. Purulent ophthalmia of the newly born he does not often see among the blacks, notwithstanding their general disregard of cleanliness. As to the two cases of leprosy which Dr. Kollock had met with, he would state that in his earlier medical career when he practiced medicine in Charleston for fifteen years he knew of five cases of leprosy, some of whom had been his patients. They were all whites, all relatives, all sporadic cases in large families; most of them among the best people and occurring in early adult life. These cases ran through all the peculiar phases of the disease, with eye, throat, and bone complications, terminating fatally. They were usually members of large families, from healthy parents, with no history of leprosy in the family. During the years that the disease was running its course these persons were in no way isolated, but lived on the most intimate relation with the other members. Some were old enough to be married before the leprosy was developed. Contagion was never considered in the house nor has any case ever shown itself from these constant and close intimacies. The leprosy in these families began and ended with the isolated case, and hence established in my mind the belief that the dis- ease was not contagious. In closing the discussion Dr. Kollock said that undoubtedly the large percentage of corneal cases seen in Charleston was due to the carelessness upon the part of the negroes in not seeking medical advice earlier. That he found the negro responded well to treatment, but it was difficult to make him carry it out thoroughly. THE TREATMENT OF TRIQUIASIS AND DISTRIQUIASIS BY LIFTING - THE EYELID. By JUAN SANTOS FERNANDEZ, M. D., of Havana, Cuba. Triquiasis and distriquiasis are generally the results of prolonged irritation of the free borders of the eyelids; they are consequently most commonly observed in ill-accommodated persons who are more or less exposed to granulations and other inflammatory diseases of the eye that are due to lack of hygiene. This disease has been studied sincelong ago and many methods of treatment have been proposed againstit; epilation and application of calcium sulphite have been employed together with the ablation of the free border. These procedures are, however, of little value, the first being too long and the second non-physiological. A change of direction in the eyelashes is to be preferred. This method, advised by Celsius, which has been since modified by Sorelle, Knapp, and others, is not acceptable on account of the great number of eyelashes which may necessitate the procedure. Moreover, the results only last three months, when it is necessary to perform a new operation. It has been considered better to change the direction of the implantation area of the eyelashes. The methods of Arlt and others have been devised with the view of real- PAN-AMERICAN MEDICAL CONGRESS. 1485 izing this suggestion. The methods that I propose do not interfere either with the eyelashes or with their implantation area. I only endeavor to change the position of the border of the eyelid by placing a wedge of tissue under the external corner of the eye and maintaining it in position by means of a suture. I desire to expose briefly the facts that induced me to devise this procedure. - - The 2d of July, 1891, I was visiting the ophthalmic clinic of the faculty of Lyons under the direction of Prof. Gayet. He stopped before one of the beds and said: “This is a countrywoman of yours on whom I have performed tarsoplasty as a remedy against entropion.” It was a girl of Cartagena, who had contracted granu- lations and entropion in Algeria. I became greatly interested with the new oper- ation, which attempted to resolve the treatment of a disease which I had been sometimes unable to master ; and at other times, after having succeeded in remov- ing the symptoms, I had seen them reappear after a year or two. I begged Prof. Gayet for a demonstration, which was accorded, and he recommended to me his work on the matter.” Gayet supposed that the diseased tissue being a scar, the transplantation of a flap of skin would reinove all trouble. He desired to cover with skin the internal or posterior surface of the superior eyelid, and he expected that the eye would perfectly tolerate the contact of the new epithelium. His object was, therefore, to lift the border of the eyelid in a way to prevent the eye- lashes coming in contact with the cornea. I endeavored to perform Gayet’s method, but I met too many difficulties in keeping the sutured flaps in place and I devised the new method. The observations that I have made prove that in many cases the flap failed to heal and occasionally was destroyed by gangrene. The troubles disappearing even under these conditions, I consequently came to the conclusion that success might be obtained even without complete healing of the sutured flap. I thought it would suffice to slit the external canthus of the eye, dissect the superior border 1 centimetre high, and place underneath a small flap of skin dissected from the tem- ple, and then restore the canthus with a suture. The superior eyelid would thus be increased in thickness and its free border would be situated at more distance from the cornea. The method is based on the anatomy of the obturator muscle of the eyelids. This muscle is provided with fixed and movable insertions. The first are attached to the base of the orbit by means of four portions which embrace the lachrymal bag. The second (movable) are fixed in the deep surface of the skin which is situated in the external portion of the orbital region precisely at the exter- nal angle of the eye. These fibers are curved and their concavity is directed toward the palpebral opening. But few fibers of the superior eyelid continue to the infe- rior one without becoming adhered to the external portion of the region. This con- dition renders possible the section of the angle without interfering with the func- tions of the sphincter. This change in the position of the border of the eyelid is the basis of the method performed in the cases that I am going to relate. Mrs. M. P. G. was seen on August 26, 1880, suffering from granulations and triquiasis. Epilation was tried without success. She was operated on May 22, 1892; a frontal lambeau 4 cm. long was placed under the eyelid after section of the external canthus having revived the mucous surface. To-day she is completely relieved, and no difference is to be detected between this eye ºnd the healthy one. Mrs. S. B. P., at. 61, applied on September 8, 1892. She has suffered for thirty- one years. The corneae were opaque on account of pannus, which had resulted from the contact of the superior eyelids. Tarsoplasty was performed on October 11, 1892, according to Gayet’s method. A flap of skin was dissected from the temple and sutured to the posterior aspect of the eyelid. Five days after the stitch at the end gave way, the flap becoming free. Two days after some more of the suture gave Way, and the flap being imperfectly attached it was decided to excise it. This was done, and only 2 cm. were left. Twenty days after the patient was greatly relieved. ****-mºr * Annales d'Oculistique. 1486 PAN-AMERICAN MEDICAL CONGRESS. S. H., aet. 30, had from childhood a deviation of the eyelashes, which was the result of traumatism. He had submitted to several operations without success. Ectropion of the lower eyelid was resorted to; tarsoplasty being afterwards per- formed with the view of preventing lagophthalmus. Operation was performed as usual, the suture being partially made with metallic thread. AEsthetically con- sidered, the result was not a very good one, but the troubles were removed enough to allow of rude work. E. J. A., Chinese (No. 25708), had granulations and distriquiasis, with pupillary atresia. Tarsoplasty was performed by Gayet's method and antiseptic bandage was placed and the flap healed in position, but a little too high. The border of the eyelid was not, therefore, sufficiently raised, and the eyelashes continued to disturb the cornea. A new operation was proposed and was not accepted by the patient. - - A. C., Chinese, September 16, 1891; totalleucoma, atrophy, chronic conjunctivitis, caused by distriquiasis. Tarsoplasty was performed. A flap was dissected from the temple, the external comisure incised, and suture applied. Three days after the flap was still adherent, but in March the patient was newly examined and but traces of the flap were found. The troubles were, nevertheless, relieved. C. G. P., of Canarias, aet. 22, May 14, 1888—granular conjunctivitis, triquiasis, and distriquiasis of both eyes. She has applied daily for five years. Epilation and other treatments proved unsuccessful. February 9, 1892, I resolved to perform the operation which I had devised instead of that of Gayet. I accordingly dis- sected a small flap from the temple, which I placed under external angle ; several points of suture finished the operation. Immediately after operation the free border of the upper eyelid was seen to be a little before the lower one. Later, however, this condition became less marked, sufficient difference remaining how- how—just enough to prevent any trouble arising from the contact of the eyelashes. C. G. P. is the same person, the operation involving the left eye. The opera- tion was the same, though greatly simplified. The flap was 3 cm. long and was sutured to the eyelid after incision of the angle. The success was as complete as in the other eye. From the perusal of the foregoing chapter it will be seen : (1) That the sur- gical operation that I propose is designed for the correction of triquiasis, distri- quiasis, and entropion of the upper eyelid. (2) I reached this object unexpectedly whilst trying to perform tarsoplasty according to Professor Gayet's method. (3) I find the reason of the success in the absence of fixed insertions in the external extremity of the orbicular muscle. (4) In certain cases of distriquiasis, the eye- lashes grow in a wrong direction, and, when fully developed, they rest against the border of the inferior eyelid. (5) Patients with granulations who had not been able for a long time to perform their duties are enabled after the Operation to resume their work. (6) I feel satisfied that a greater number of operations will bring new modifications to the preceding, which is already greatly simplified. A CASE OF CYSTICERCUS OF THE WITREOUS. By W. CHEATHAM, A. B., M. D., of Louisville, Ky. This affection being so rare in America, England, France, and countries other than Northern Germany, I feel justified in reporting a case that has come under my observation this week. - Mrs. F., aged 42, of Irish parentage, consulted me May 22, 1893, concerning her left eye. January last she had some severe acute inflammation of her left eye in which there was intense pain and edema of the lids, which lasted for some weeks. She now has vision of left eye ##, with no improvement by glasses. She has some scars of upper part of cornea simulating those found in trachoma, with slight pannus. I was surprised on everting the lid to find no indication of her ever having had trachoma. Vision right eye sºn, and eccentric. She said her right eye had been blind (following a spell of sickness) since she was 15 years old, or twenty-seven years. She did not come to consult me concerning her right eye, yet as a matter of routine I examined it. Ifound all the media perfectly clear. , Just at or over right macula, I discovered a sac or cyst, pedunculated, the pedicle being attached to the retina above and external to the macula, the body of the Sac PAN-AMERICAN MEDICAL CONGRESS. 1487 extending down and in over the region of the macula. The sac with its pedicle appeared a bluish gray and opaque, except a part of the wall toward me about the size and shape of the optic nerve entrance, which was transparent and through which the deeper or other wall could be seen. The eye was emmetropic with the ophthalmoscope. The highest or most prominent part of the sac, just at the transparent part referred to, could be seen best with a + 10 D., showing an eleva- tion of about 2.3 mm. The other cyst wall could be seen through this trans- parent portion best with about a + 2 D., showing an elevation of about 0.52 mm. The sac was ovoid in shape with the edges at some points serrated, and at one point down and in there was quite a projection. Over this sac small blood ves- sels could be seen, one up and in could be traced to a large retinal vessel close by. No motion could be discovered in this opaque cyst. Forming something of a crescent from the lower and outer part of this sac was a transparent, reddish cyst; at the upper part of this cyst could be seen two spots looking like air bubbles, which were no doubt the parasite's suckers. This cyst when watched closely could be seen to have a distinct rhythmical motion; a spot of pigment beneath it would appear and disappear; the motion was perfect. Above the attachment of the pedicle of the cyst could be seen two white, crescent-shaped spots, no doubt the points of entrance of the parasite. The retina between the cyst and optic nerve presented the appearance of a recent detachment. Several large vessels ran from the nerve direct to the sac, some of them disappearing under it and reappearing on the other side. There were many more large vessels taking this course than usual. This would probably indicate that the trouble is of long standing. The vitreous seemed to be detached over the optic nerve entrance. I called Drs. Dabney and Pusey, of this city, to see the case, on account of its rarity and interest, and to confirm my diagnosis, which they both did. Mrs. F. gives a history of several serious attacks of what she called congestion of heart and lungs, Several years ago. For six or seven years up to January last, when her left eye was so badly inflamed, her health had been very good. She thinks she is going through her “change.” Left eye usually inflamed some every four weeks. This case, besides being the second, so far as I know of, reported in America, presents other points of interest. Could this parasite possibly have been the original cause of the loss of vision of right eye twenty-seven years ago? I think this possible and quite probable. The vitreous is clear and but little dam- aged, but a small part of the retina and choroid are damaged. The parasite, from the appearance of the parts, seems to have left its old bed, and is migrat- ing, Mrs. F. does not remember of ever having had any pain in her right eye. Could the disease she has had in her left eye be sympathetic? Sympathetic affections have their exacerbations and their times of quiet, as we all know. Foster, Encyclopedic Medical Dictionary, page 1237, says: Cysticercus cellulosa is the larval stage of taenia solium. It has a quadrangular head, a long cylindrical body, and an elliptical, caudal vesicle, and is from 10 to 15 mm. in length. Manthuer describes the animal as follows: The worm is provided at its posterior end with a round cyst-like formation which acts as the receptaculum scolicis, into which the animal can withdraw, presenting when in this position the appearance of a round, whitish body. A small hole marks the mouth of this small receptacle. When the animal protrudes its head and neck out of the receptacle its body appears to be sprinkled here and there with calcareous deposits, and presents sometimes a smooth and sometimes a wrinkled surface. The body decreases in size toward the neck, to which is attached the head, with its four flattened down but angular projections. A round- shaped snout can be projected by the animal from the center of its head, and this latter is provided at its base with a double row of hook-like tentacles, which are capable of retraction. Each of the angular projections of the head is, moreover, provided with a rounded sucking apparatus. Schmidt-Rimpler, page 276, says: The embryo enters the stomach of the suitable host in the food or water, loses its covering through the action of the gastric juice, bores into the blood vessels with its hooks, and begins to wander. Finally it becomes settled, and now begins the second stage of its development in which it is known as cysticercus. It is con- verted into a vesicle with fluid contents. All authors agree that the embryo tarvels by the blood current, Cysticerci may occur in any part of the eye or orbit. They have been seen in the Orbit, lids, conjunctiva, iris, lens, vitreous, choroid, and retina. They are found more often in the posterior part of the eyeball than in the 1488 - PAN-AMERICAN MEDICAL CONGRESS. anterior. They are quite common in Northern Germany, where uncooked meats are eaten; less often in Southern Germany, France, and Italy. There have been. three cases reported in Austria. Brudenell Carter says none have been seen in England, but Soelberg Wells reports a case in his book, page 328. In Northern Germany, Graefe, saw 80 cases in 80,000 patients, or 1 in 1,000 in the deeper tis- sues of the eye, 3 in the anterior chamber, 5 beneath the conjunctiva, and 1 in the orbit. Hirschberg in six months saw 2,100 new patients, in 5 of which he saw cysticercus, or 1 in 420 cases of eye diseases. Of the one other case seen in this country, reported by Dr. Minor, Loring, on page 188, says: From the opthalmoscopic appearances there was reason to believe that it was a true case of cysticercus, although it was not absolutely proved to be so. Yet, from Dr. Minor's description of the case and the ophthalmoscopic appear- ances (page 193, Loring), I do not think there can be any doubt of its having been a case of cysticercus cellulosae. How long a cysticercus can remain in an eye is in doubt. Cases of two and four years’ standing are common. Von Graefe saw a casein 1856, which was twenty years afterwards seen intact by Hirschberg. Others have reported cases of long standing with vision nearly perfect. My case, as I stated before, is possibly of twenty-seven years’ standing. Usually, though, in from fifteen to twenty months, irido-cyclo-choroiditis follows, and sometimes pano- phthalmitis, with total loss of the eye. Von Graefe and Hirschberg state that there is not much danger of sympathetic inflammation, although sympathetic irri- tation is often present. Jacobson reports sympathetic amblyopia. Two cysts have been seen in one eye, but no case has been reported of both eyes being involved. Patients with cysticercus do not have tape-worm. The presence of this parasite in the eye is so dangerous to the vitality and the usefulness of the organ that its removal has been undertaken and with success, but not with very flattering after results when it is located in the posterior part of the organ. When in the iris a section of this membrane that holds the parasite can be removed. -** =----- RELACIONES IDE LA OFTALMOMETRIA CON LA SKIASCOPIA. Por el Doctor PEDRO LAGLEYZE, Profesor de Oftalmología en la Facultad de Buenos Aires. Kohlrausch, en 1839, propuso determinar el sitio del astigmatismo mediante las medidas comparativas de las imagenes reflejadas por la côrnea. Senff, en 1846, emprendió este estudio, pero es en realidad Helmoltz quien, en 1854, demostró la importancia de este método midiendo las curvaturas de la côrnea y del cristalino. El oftalmómetro de Helmoltz, precioso instrumento matemático para las medidas fisiológicas, no es aplicable en la práctica diaria de la clinica. Javal y Schiótz, en 1881, construyeron un aparato basado sobre los mismos principios, adaptăndolo à la clinica por un fåcil manejo y haciendo innecesarios los Cálculos matemáticos que exije el oſtalmómetro de Helmoltz. La oftalmometria descubre astigmatismos que escapan almas prolijo exãmen por los métodos ordinarios, y cuando se ha usado durante algun tiempo el oftalmómetro de Javal, es difícil hacer optometria sin este precioso instrumento, que sin titubear, y con gran exactitud nos indica el rayo de curvatura de los meridianos principales de un astigmatismo en menos de un minuto. Este instrumento es casi imprescindible para el clínico, pues sin 6], no es posible descubrir en elastigmatismo total, la parte de refracción astigmática, dinámica. 6 estática, que pueda corresponder al cristalino; cuestion importante para la prescrip. ción de lentes. Cuando elastigmatismo total sea igual al corneo, no debe titubearse en indicar el cilindro que haga la corrección total. Si clastigmatismo total es mayor que cl de la córnea, deberá tenerse en cuenta para la prescripción del cilindro no S6lamente la PAN-AMERICAN MEDICAL CONGRESS. 1489 º relación entre la diferencia refringente, sino también la dirección del meridiano córneo de menor rayo con la dirección del astigmatismo total. De igual modo se procederá cuando el astigmatismo total sea menor que el indi- cado por el oftalmómetro. Débese siempre buscar con cuidado si estas diferencias son debidas á contracciones parciales del músculo ciliar, y guiarse para la corrección de tal manera que el vidrio no sea causa de que esta contracción irregular se man- tenga, debiendo, por el contrario, dirigir todos los esfuerzos á fin de que desaparezca. Cuando estas diferencias sean pronunciadas y principalmente si la mayor refrin- gencia tiene lugar sobre el meridiano horizontal, será conveniente medir la refrac- ción total bajo la acción atropínica y comparar el resultado. Algunos autores sostienen que los resultados obtenidos por el oftalmómetro de Javal y Schiötz señalan vidrios superiores al exámen subjetivo. Oswalt es uno de los que sostienen esta tesis, pero su trabajo carece de valor porque no se basa en la práctica y porque parte de una premisa falsa sobre el valor dióptrico del ojo. Los doctores Motais, Pflatz y G. J. Bull dicen igualmente que en la gran mayoría los pacientes no admiten el cilindro indicado por el oftalmómetro, sino solamente un cilindro más débil. Story dice que los vidrios indicados por el oftalmómetro son media dióptria más fuertes que el astigmatismo subjetivo. Chibret sostiene lo con- trario diciendo que, según sus trabajos de control por la skiascopia, el oftalmómetro da numeros menores en lugar de aumentarlos. Tscherning y Javal han demostrado, el primero científicamente y el segundo por la clínica, que en los fuertes grados el astigmatismo subjetivo es generalmente superior al indicado por el oftalmómetro. No se pueden hacer conclusiones generales sin indicar la dirección de máxima curvatura de la córnea, pues el astigmatismo total varía según esta inclinación. Javal ha estudiado desde 1880 hasta el año 1887 las relaciones que existen entre el astigmatismo total y el astigmatismo de la córnea, habiendo llegado á las siguientes conclusiones: El astigmatismo regular comprende á lo menos tres especies distintas. Una de ellas se presenta en general en los ojos cuyo meridiano vertical presenta la mayor curvatura. La segunda se encuentra habitualmente en aquellos en que el astigmatismo está colocado en una dirección perpendicular á la del caso precedente, En fin, la tercera variedad se encuentra más amenudo en los ojos en que los meri- dianos están situados en 45 grados. En la primera de estas variedades, la más ordinaria, la totalidad del achaque reside en la córnea, ósea el astigmatismo total difiere poco del astigmatismo córneo. En la segunda, la deformidad reside principalmente en el cristalino, de tal manera que el astigmatismo total es superior al astigmatismo córneo. Desde luego, cuando tengais que dar vidrios á enfermos de esta categoría, no debeis sorprenderos de encontrar a menudo una ó dos dióptrias de astigmatismo cris- taliniano estático. Es entre los ojos de esta categoría que se reclutan en masa el glaucoma y la catarata. La tercera variedad que se encuentra más amenudo en los ojos cuyos meridianos forman ángulos de 45º con la vertical, no se asemeja á las precedentes. Se acompaña de una descentración del globo que puede llegar hasta 20 y 259. Aquí los vidrios correctores no corrijen sino mediante una visión oblicua. (Soc. franç. d'opht. Congr. de 1887. Sess. 2 mai.) Swan Burnet, dice que el oftalmómetro da cifras mayores para el astigmatismo según la regla y más débiles para el contrario á la regla, creyendo que esto último es debido á una inclinación del cristalino. El error en ambos casos, dice, que es de 0.50 D. y que una diferencia mayor entre el exámen oftalmométrico y el subjetivo indica la instilación de un midriático para deslindar las contracciones parciales del músculo ciliar del astigmatismo estático. (Washington, Congr. Soc. médica ameri- cana, Mayo, 1891.) La corrección útilmente aplicable al astigmatismo está generalmente comprendida entre las indicaciones oftalmométricas y skiascópicas. El resultado subjetivo se acercará lo más amenudo al astigmatismo oftalmométrico en los casos de astigmatismo según la regla, y al astigmatismo skiascópico en los casos que el astigmatismo sea contra la regla. S. Ex. 36—94 1490 PAN-AMERICAN MEDICAL CONGRESS. No debe pedirse al oftalmómetro más de lo que puede dar. Si el vidrio se llevara pegado sobre la córnea, y si no se tuviera en cuenta al agente cristaliniano, que en general no altera en mucho el resultado, el oftalmómetro indicaría la prescripción del vidrio. Pero no debe olvidarse lo que para muchos observadores ha pasado sin importancia, que él oftalmómetro indica el astigmatismo córneo y no el vidrio cor- rector; para hallar su justo valor es necesario tener en cuenta la distancia que separa al anteojo de la córnea. Esta distancia negligible para los débiles grados, y en general para los astigmatismos simples, debe de tenerse muy en cuenta para los astig- matismos compuestos. Esta es una de las causas que debe señalarse como una de las más frecuentes y poderosas en las diferencias del astigmatismo total y córneo. A continuación presento una série de cuadros comparativos que demuestran las diferencias indicadas entre el exámen oftalmométrico y skiascópico, correspondientes á cada grupo, y ordenados según la variedad del astigmatismo y la dirección del meridiano más refringente. Los signos (——) y (—) indican la relación del meridiano más refringente entre las medidas encontradas por el oftalmómetro y la skiascopia. El signo (—-) señala el exceso oftalmométrico sobre el skiascópico, y el signo (—) el de la skiascopia sobre el oftalmómetro. - Este trabajo se basa sobre el estudio analítico de 1,230 ojos examinados durante el año 1891. En todos he medido la refracción total por medio de la skiascopia, y el rayo de curvatura de la córnea con el oftalmómetro de Javal y Schiötz. El aparato que he usado para la medida de la córnea es el ejemplar No. 123, cons- truido por A. Goubeaux, con las últimas modificaciones de Javal, es decir, con el raro grado de perfección que posee desde el año 1889. Diferencia entre el astigmatismo indicado por el oftalmómetro y la 8 kia8copia. . ASTIGMATISMO MIÓPICO SIMPLE. Meridiano ver- Meridiano obli-Meridiano hori- | Meridiano ver- Meridiano obli- Meridiano hori- tical más Cu o más zontal más tical más Guo más zontal más refringente. refringente. refringente. refringente. refringente. refringente. r T. No. Diferen- No. Diferen- No. Diferen- No. Diferen- No. Diferen- No. Diferen- de cia de cia de cia de cia de cia de cia OJOS. e OJos. o ojos. dº, e ojos. 4U e ojos. º OJos. / a D. JD. D. D. JD. 53 0.00 4 0.00 8 0.00 17 —0. 50 —0. 50 1 —0.75 6 --0. 25 l —-0. 25 3 —0. 25 1 —0. 7 1 —0.75 1. —1. 25 5 --0. 50 1 —0. 25 2 —0. 50 4 —1.00 —1.00 1. —1.50 2 +0.75 -------------------------------- 2 -2.00 -------------------------------. 11 -0.25 -------------------------------- ASTIGMATISMO MIÓPICO COMPUESTO. 66 0.00 12 0.00 26 0.00 5 —1. 25 2 —0. 75 8 —1.00 4 + 0.25 1 —-0. 25 5 —- 0.25 17 —1.50 2 —1.00 3 — l. 25 7 --0. 50 1 —-1.00 4 —0. 25 14 —2.00 2 —1.50 3 —1. 50 2 --1.00 4 —0.25 16 —0. 50 6 —2.50 1 —2.50 2 —2. 00 2 --1.50 4 —0.50 1 —0. 75 1 —2.75 l. --------------. 1 —2.50 1. H-1, 75 -------------------------------. 3 -3.00 l. ------------------------------- 10 -0.25 -------------------------------. 3 -3.50 -------------------------------- 41 -0. 50 -------------------------------- ll -4.00 -------------------------------- 7 -0.75 -------------------------------- 1 -5.00 -------------------------. . . . . . . 26 -1.00 -------------------------------- ASTIGMATISMO HIPERMETRÓPICO SIMPLE. 68 0.00 8 0.00 6 0.00 8 —0. 25 1 —0. 50 1 —0. 50 11 --0. 25 1 —- 0.5) 2 —0. 25 5 —0. 50 1 —0.75 i --------------- 4 --0.50 1 0.25 ---------------- 2 —l. 25 ------ -------------------------- 1 + 1.00 ------ -------------------------- PAN-AMERICAN MEDICAL CONGRESS. 1491 Diferencia entre elastigmatismo indicado por el oftalmómetro y la skiascopia—Continuia. ASTIGMATISMO HIPERMETROPICO COMPUESTO. | Meridiano ver- Meridiano obli- Meridiano hori- || Meridiano ver. Meridiano obli. Meridiano hori tical mas cuo mas zontal més tical mas Cuo mais zontal mas refringente. refringente. refringente. refringente. refriugente. refringente. No. Diferen- No Diferen- No. Diferen- No. Diferen- No. Diferen- No. Diferen- . . de || “...i. de cia de cia de cia de cia de cia ojos. º ojos. * ojos. * ojos. & OJOS. tº OJOS. e D. I). I). D. * e 69 0.00 11 0.00 11 0.00 9 —0. 50 4 –0. 25 4 —0.50 17 +0.25 1 +0.25 1. +0.25 3 —0.75 2 –0. 50 1 —0.75 15 +0.50 2 +0.50 2 +0.50 10 —1.00 l –0. 75 2 —1.00 1. +0. 75 1. +1.00 3 —0.25 2 —1.50 3 —1.00 ------|---------- 5 +1.00 ------|----------|------|---------- 1 –2.00 ------|----------|------|---------- 17 —0.25 |------|----------|------|---------. 1 —3.00 ------|----------|------|---------- ASTIGMATISMO MIXTO. 28 0.00 9 0.00 2 0.00 1 —1.25 1 —1.00 1 —1.00 2 +0.25 1 +1.00 2 +0.50 4 —1.50 ------|---------- 1 —2.00 1 +0.50 ------|---------- 1 —0. 50 12 —2.00 ------|---------. 2 —2.50 1. +1.00 ------|---------. 1. –0. 75 1 –2.25 |------|---------- 1 —3.00 2 –0. 25 |------|----------|------|---------- 2 –2.50 ------|----------|------|---------- 11 –0. 50 |------|----------|------|---------- 1 —3.00 ------|----------|------|---------- 2 –0. 75 l------|----------|------|---------- I –4.00 l. -----|----------|------|---------- 15 -1.00 l------|----------|------|---------- El oftalmómetro no indica astigmatismo y la skiascopia, 8i. EN OJOS HIPERMETROPES. Meridiano ver- || Meridiano obli- || Meridiano hori- || Meridiano ver- || Meridiano obli- || Meridiano hori- tical mas cuo mas zontal mas tical mas CuO más zontal mas refringente. refringente. refringente. refringente. refringente. refringente. No. Diferen- No. Diferen- No. Diferen- No. Diferen- No. Diferen- No. Diferen- de Cia de Cia do cia do Cia. de cia de Cia ojos. § ojos. ſº ojos. & OJOS. g ojos. e ojos. e * L). I). s D. D. 2 –0. 50 ------|---------- 2 —0. 50 5 —1.00 || ||---------. 2 —1.50 2 —0.75 ------|---------- 1 –0.75 || ------|----------|------|---------- 1 —2.00 * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * * 2 —1.00 * EN OJOS MIOPES, 1 —0.75 3 —1.00 1. —0. 50 1 –2.00 ------|---------- 4 —1.00 7 —1.00 ------|---------- 3 –0. 75 El oftalmömetro indica astigmatismo y la skiascopia, no. EN OJOS HIPERMETROPES. Meridiano ver- || Meridiano obli- || Meridiano hori- || Meridiano ver- Meridiano obli- | Meridiano hori- tical mas cuo mais zontal més tical mais cuo mas Zontal mis refringente. refringente. refringente. refringente. refringente. refringente. *: Diferen- . Diferen- . Diferen- Nº. Diferen- . Diferen- *: Diferen- ojos. C13. ojos. C13. ojos. Cla. ojos. Cla. ojos. Clà. ojos. C13. D. D. D. D. D. D. 44 -H.0.25 3 +0.25 3 +0.25 4 +0. 75 2 +0.50 2 + 1.00 31 +0.50 |------|---------. 2 +0.50 8 +1.00 ------|----------|------|- sº ºr * * * * * * * EN OJOS MIOPES. 29 --0. 25 1 +0.25 2 4-0.25 4 +0. 75 1 +0.75 1 +0.75 14 +0.50 6 --0. 50 6 +0. 50 | 3 -- 1.00 3 +1.00 1 +1.50 t | - - - - 1492 PAN-AMERICAN MEDICAL CONGRESS. EL OFTALMÓMETRO Y LA SKIASCO PIA NO REVELAN ASTIGMATISMO EN 153 OJOS AMETRóPICOS. Lo que más resalta en estos cuadros es que el valor del astigmatismo indicado por la skiascopia prevalece sobre el valor refringente correspondiente á la medida de la córnea, principal sitio del astigmatismo. - El cuadro que sigue demuestra el término medio para cada variedad de astigma- tismo. Todos representan una cantidad.negativa para el oftalmómetro con excepción. del último grupo, en el cual el astigmatismo córneo se halla corregido por un astig- matismo inverso del cristalino, ocultándolo por completo. Relación media entre la oftalmometría y la 8kia8copia 8egún la variedad del astigmatismo y la dirección del meridiano más refringente. No. e No. de Media. de Media. OJos. OJOS. Astigmatismo miópico simple: D. Astigmatismo hipermetrópico com- D. eridiano vertical -.. -----.. ... - 101 —0. 14 puesto: s Meridiano oblicuo---. ---------- 12 —0.35 Meridiano vertical ... ... --.. ... 150 —0. 07 Meridiano horizontal. ---------. 16 —0.32 Meridiano oblicuo. ..... ... --... 25 —0.14 Astigmatismo miópico compuesto: Meridiano horizontal... -----.... 24 —0. 17 Meridiano vertical ... ... --..... 217 —0. 67 Asº mixto: Meridiano oblicuo-------------. 29 —0.37 eridiano más refringente ver- Meridiano horizontal... -.. --.... 69 —0,45 tical------------------------- 84 —0. 78 Astigmatismo hipermetrópico simi- Meridiano más refringente obli- ple: Clu0 --------------------------- 11 . 00 Meridiano vertical ...... ---.... 99 —0. 01 Meridiano más refringente ho- Meridiano oblicuo. --.. --------- 12 —0. 08 rizontal . . . . . . . . . . . . . . . . . . . . . . 11 —1.02 Meridiano horizontal... ... ... -. 9 —0, 11 El oftalmómetro no indica astigmatismo y la skiascopia, sí. No. de g ojos. Media. Hipermétropes: Meridiano más refringente— ID. Vertical--------------------------------------------------------------------- 9 —0.83 Horizontal. ----------. . . . . . . . . . . . . . --------------------------- º si se e s y es º a 8 —l.09 Miopes: eridiano más refringente— Vertical--------------------------------------------------------------------. 9 —1.08 Oblicuo ----. ----------- dº a = = = es = - º s as e = = es º s e» = • º se a s = º s a = s s- = s es º s º s as e º es es es e es º e - = = • = 3 —1.00 Horizontal ----------------------------------------------------------------. 8 — 0.84 El oftalmómetro indica astigmatismo y la skiascopia, no. Rº Media. Hipermétropes: Meridiano más refringente— D. Vertical--------------------------------------------------------------------- 87 —-0.43 Oblicuo -----------------. . --------------- ---------------------------------- 5 —-0.35 EIorizontal ------------------- . . . . . . . . . . . . -------------------- . . . . . . . a s es e º es s se 8 —-0.53 Miopes: Meridiano más refringente— Vertical. ------------------------------------------------------------------- 50 +0, 40 Oblicuo --------------------------------------------------------------------- 11 —-0. 63 Horizontal ------------------------------------------------------------------ 10 —-0.57 El estudio de este cuadro demuestra que cada grupo presenta sus meridianos oscilando próximamente al rededor de una misma cifra. El meridiano oblicuo del astigmatismo mixto hace excepción á esta regla general. Dice Javal que cuando subjetivamente existe astigmatismo y el oftalmómetro no lo revela, el astigmatismo es contrario á la regla. Mis resultados no están contestes con los de Javal. Tanto el meridiano horizontal como el vertical se hallan casi en PAN-AMERICAN MEDICAL CONGRESS. 1493 igual número en ojos miopes como en hipermétropes; el meridiano oblicuo solo en muy pequeño número de miopes y en ningún hipermétrope. He aquí, para cada grupo, el valor medio de las diferencias entre las medidas oftalmométricas y skiascópicas: - No. de e ojos Média. D. Astigmatismo miópico simple. . . . . . . . . . ....... .... .. .... ... .... ... s st se se º a en a n a da º a se se se 129 —0. 18 Astigmatismo miópico compuesto ... -- ---------------------------------------. ----- 35 —0. 6) Astigmatismo hiperimetrópico simple. ---. . . . ..... ... --.----------------------. ----- 120 —0.02 A stigmatismo hipermetrópico compuesto. ----------------. -... -- ... -.. ------.. ----- 199 —0.09 Astigmatismo mixto. --------------------------------. ---.. ------ . . . . . . . . . . . . . . . . . . . 106 —0.72 El oftalmómetro no indica astigmatismo y la skiascopia sí, en 37 ojos; media —0.96 D. El oftalmómetro indica astigmatismo y la skiascopia, no en 171 ojos; media —-0.44 D. Los valores de la diferencia media según la inclinacisn del meridiano más refrin- gente, incluyendo todas las variedades del astigmatismo, son: - ID. En 806 ojos con el meridiano vertical más refringente--------.. ... ---.. -..---.. -----. --.. .... ... —0.28 En 108 ojos con el meridiano oblicuo más refringente ......... .... ........... ...-........... -... —0.12 En 163 ojos con el meridiano horizontal más refringente ..... --------...... ..................... —0.35 Si de los 1,230 ojos descontamos 153 ametrópicos, en los cuales el oftalmómetro y la skiascopia no han revelado astigmatismo, tendremos 1,077 ojos de un astigmatismo próximamente de 0.25 I). no verificado por el oftalmómetro. Proporción centecimal del número de astigmáticos 8egún su variedad y meridiano de mayor refringencia en el astigmatismo total. Vertical. Oblicuo. Horizontal. Total. Astigmatismos indicados por el oftalmómetro y la skiascopia en el meridiano: Astigmatismo miópico simple --------------------. . . . . . . 9.38 1.11 1.49 11.98 Astigmatismo miópico compuesto.- - -.. ------.. --. ------ 20. 15 2.69 6.41 29.25 Astigmatismo hipermetrópico simple. --.. -.. . . ... -- ... --. 9. 19 1.11 0.84 11. 14 Astigmatismo hipermetrópico compuesto. --.. .... . . . . ... 13 92 2.32 2. 23 18.47 Astigmatismo mixto .. . . . . . . . . . . . . . . . . . . ...----. . . . . . . . . . . 7, 80 1. 02 1. 02 9.84 Astigmatismos no indicados por el oftalmómetro y sí, por la skiascopia: Astigmatismos hipermetrópicos ------------------------- 0.84 ---------. 0.74 1.58 Astigmatismos miópicos. -------------------------------- 0.84 0.28 0.74 1.86 Astigmatismos indicados por el oftalmómetro y no por la - r. skiascopia: Astigmatismos hipermetrópicos ... ----------------------. 8. 08 0.46 0.74 9. 28 Astigmatismos miópicos. . . . . ----------------- . . . . . . . . . . . 4. 64 1. 02 0,93 6, 59 Total.------------------------------------------------- 74.84 10.03 15. 13 100, 00 Estos números comparativos han sido deducidos de una cantidad de 1,077 astig- máticos totales, ellos demuestran proporcionalmente sobre cada cien casos, la relación de las diversas variedades de astigmatismos y de la inclinación de los meridianos de mayor refringencia. Las cifras de este cuadro conducen á las siguientes conclusiones: 1º. Las sumas de astigmatismos simples descubiertos por el oftalmómetro y la skiascopia, revelan entre sí una diferencia tan pequeña que, sin gran error, pueden considerarse iguales. Descomponiendo el astigmatismo simple según los meridianos de mayor refrin- gencia, tendremos: - - (a) El meridiano vertical presenta un número igual de astigmatismos simples hipermetrópicos y miópicos; - 1.494. PAN-AMERICAN MEDICAL CONGRESS. (b) El meridiano oblicuo se manifiesta en una justa é igual cantidad; (c) El meridiano horizontal acusa una notable diferencia en favor del astigmatismo miópico simple, siendo casi dos veces más numeroso que el astigmatismo hiperme- trópico simple; - (d) Las sumas del astigmatismo hipermetrópico y miópico simple en sus meridianos oblicuos, lo mismo que en el horizontal, se presentan en igual número de casos. siendo la suma del meridiano vertical de ámbos astigmatismos simples ocho veces más frecuente que la suma de cada uno de los otros dos meridianos. 2º. Las sumas de astigmatismos compuestos, indicados por el oftalmómetro y la skiascopia, se hallan en la proporción de cien astigmatismos miópicos compuestos para cada 63 astigmatismos hiperimetrópicos. - Los meridianos del astigmatismo compuesto entre los miópicos é hipermatrópicos, se encuentran en la siguiente proporción: (a) El meridiano vertical prepondera en los miópicos, siendo de casi 3 la propor- ción de astigmatismos miópicos compuestos con relación á los hipermetrópicos; (b) El meridiano oblicuo ligeramente superior para los miópicos da más ó menos en la proporción con los hipermetrópicos, exceso que puede negligirse aceptando como conclusión: igual número de astigmatismos compuestos miópicos é hiperme- trópicos para el meridiano oblicuo; (c) El meridiano horizontal tiene en el astigmatismo compuesto una diferencia, más notable que la indicada por el astigmatismo simple, siendo tres veces más fre- cuente en el astigmatismo miópico compuesto que en el hipermetrópico; (d) La relación de los meridianos según su inclinación no es igualmente propor- cionada en el astigmatismo miópico compuesto que en el hipermetrópico. El meri- diano vertical del astigmatismo miópico compuesto es poco más de siete veces más frecuente que el oblicuo, y solo tres veces más frecuente que el horizontal. El meri- diano vertical del astigmatismo hipermetrópico compuesto es seis veces más nume- roso que el oblicuo y también que el horizontal; - (e) Las sumas de los meridianos correspondientes del astigmatismo miópico compuesto é hipermetrópico da para el meridiano vertical una frecuencia dos veces y media mayor que los otros dos meridianos juntos. Siendo el meridiano vertical casi siete veces más numeroso que el oblicuo, y cuatro más que el horizontal. 3º. El astigmatismo mixto, descubierto por el exámen oftalmométrico y skiascópico ha revelado que el meridiano vertical más refringente se presenta siete veces y media más frecuentemente que cada uno de los otros meridianos, hallándose los meridianos oblicuo y horizontal en igual número de casos. 4º. El oftalmómetro no ha revelado astigmatismo mientras que la skiascopia ha indicado asimetría en la refracción ocular, provocada por el cristalino solamente, en un caso para cada 29 astigmatismos: ºr (a) La cantidad de astigmatismos hipermetrópicos, pueden considerarse como igual á la de astigmatismos miópicos indicados por la skiascopia y no por el oftalmó- metro. (b) El meridiano vertical se ha presentado igual número de veces en los ojos hiper- metropes y miopes, lo mismo lha sucedido con el horizontal. (c) El meridiano oblicuo no se ha manifestado en ningún astigmatismo hiperme- trópico, y tan rara vez en ojos miópes (1 por 359 astigm.), que puede darse como regla general la falta de astigmatismo cristaliniano en los meridianos oblicuos. (d) El meridiano vertical es veces más frecuente que el horizontal. 5º. El oftalmómetro ha indicado sin que la skiascopia revele astigmatismo un núImero de ojos cuatro y media veces mayor que en el caso anterior. La skiascopia no descubre la asimetría porque el astigmatismo córneo se halla corregido por un astigmatismo inverso del cristalino: - (a) La cantidad de astigmatismos hipermetrópicos es de 3 con relación al número de astigmatismos miópicos. - (b) El meridiano vertical más refringente se presenta en mayor número en los astigmatismos hipermetrópicos, siendo casi el doble de los miópicos. PAN-AMERICAN MEDICAL CONGRESS. 1495 (c) El meridiano oblicuo es la mitad menos frecuente en los hipermetrópicos. (d) El meridiano horizontai se presenta en los 3 de hipermetrópicos con relación al mismo meridiano en los miópicos. 6". La relación de los meridianos entre sí, de la suma total de todos los astigma- tismos clasificados en el cuadro centecimal, es: Para el meridiano vertical ----------------------------------------------------------------------. 74. 84 Para el meridiano oblicuo. ----------------------------------------------------------------------. 10.03 Para el meridiano horizontal--------------------------------------------------------------------- 15. 13 De tal manera, que el astigmatismo según la regla, es decir el vertical, es siete veces y media más frecuente que el oblicuo, y cinco veces más que el llamado con. trario á la regla, ó sea el horizontal, siendo este último una vez y media más frecuente que el oblicuo. SECTION XIII-LARYNGOLOGY AND RHINOLOGY. Honorary Presidents. Dr. HARRISON ALLEN, Philadelphia. Dr. FRANCKE H. BOsworth, New York. DR. J. SOLIS-COHEN, Philadelphia, Pa. Dr. D. BRYSON, Delavan, N. Y. Dr. J. F. DICKSON, Portland, Oreg. Dr. STEPHEN DODGE, Halifax, Nova Scotia. Dr. W. C. GLASGOw, St. Louis. Dr. FREDERICK I. KNIGHT, Boston. Dr. GEO. M. LEFFERTs, New York. Dr. ALVARO LEDAN, Villa Clara, Cuba. Dr. JOHN N. MACKENZIE, Baltimore. Dr. DAVID MATTO, Lima, Peru. Dr. P. EMELIO PETIT, Santiago, Chile. Dr. JOHN O. ROE, Rochester, N. Y. Dr. FEDERICO SEMELEDER, City of Mex- ico, Mexico. Dr. CHAs. J. SAJOUS, Paris, France. af Eacecutive President. Dr. E. FLETCHER INGALs, 34 and 36 Washington street, Chicago, Ill. Secretaries. Dr. T. MoRRIS MURRAY (English-speak- ing), Washington, D. C. Dr. OVEJERO (Piedad 22), Buenos Ayres, Argentine Republic. Dr. H. GUEDES DE MELLO, Rio de Ja- neiro, United States of Brazil. Dr. G. W. MAJOR, Montreal, Canada. Dr. FELIX CAMPUzANo (Virtudes 33), Havana, Cuba. Dr. LUIS FONNEGRA (Calle 10, niãmero 263), Bogota, Republic of Colombia. Dr. J. MIDENCE, Leon, Nicaragua. Dr. F. MARRON Y ALONZO (Spanish- speaking), Las Vegas, N. Mex. Dr. FABRICIO URIBE, Guatemala City, Guatemala. Dr. HENRI GOULDEN MCGREW, Hono- lulu, Hawaii. Dr. ANGEL GAVINO (Cocheros 15), City of Mexico, Mexico. Dr. EUGENIO CASSANELLO (San José 119), Montevideo, Uruguay. Dr. NAPOLEóN F. CORDERO, Merida, Venezuela. ADDRESS BY THE PRESIDENT OF THE SECTION, E. FLETCHER ING ALS, A. M., M. D. GENTLEMEN AND COLLEAGUES: In calling to order the laryngological section of the Pan-American Medical Congress I take the opportunity to congratulate you upon the number and excellence of the papers which have been secured for your consider- ation. I feel that there is a special reason for felicitation upon the propitious cir- cumstances under which we have convened, because of our successin spite of many obstacles. The laryngologists of this country, as well as those who would have visited us from abroad, have been called upon for more than the usual amount of work during the past few months. Early in May the American Laryngological Association met in New York and was largely participated in by those who other- 1496 PAN-AMERICAN MEDICAL CONGRESS. 1497 wise would have been free to aid us. Shortly afterwards the American Climato- logical Association met in Philadelphia, taxing the energy and taking the time of many of the laryngologists of this country. And only three weeks subsequently the American Medical Association met in Milwaukee, with a large attendance upon the laryngological section. In addition to these, the various State medical societies called out a considerable number of papers upon diseases of the throat and nose. Besides this, many laryngologists who contemplate going abroad have undertaken to prepare papers for the International Medical Congress, which was to have met in Rome shortly after the close of this congress. When the American Laryngological Association held its first annual meeting in 1879 there were, all told, less than thirty men in the United States sufficiently interested in the subject to be counted laryngologists. But the ranks have been added to rapidly year by year, until now there are probably not less than four times that number who are well equipped; and in all of the cities and larger towns throughout the country are others more or less qualified who are doing considerable work in this special line, and it is probable that to-day 500 men could be found in the United States who might present something of interest to this body, though I have been able to discover only about 200 of them. Nearly a year ago I opened correspondence with the physicians of Central and South America and the West Indies, hoping to get them to join us in this con- gress, but I regret to say that in only a few instances have I been able to obtain replies to my letters, and that only two or three of our colleagues in those coun- tries have promised papers for this occasion. Considering the limited intercourse which has always existed between the United States and the Latin Americas, this is not a matter of surprise, but it is hoped that this congress will be a beginning of a closer alliance and personal friendships, which will, in coming years, bring us often together, and build up a powerful International Congress in this Western Hemisphere. The railroad already projected through Central America, which will connect with various railroad systems in South America, and increased means of commu- nication by sea, will, it is believed, ere long, open up to the physicians of the United States many new and valuable resorts whose climatic influences may be made subservient to our patients in their search for health. When this has been brought about it is obvious that our acquaintance with the physicians in these southern climes will be of the greatest advantage to our patrons. We welcome you one and all to our national capital. We ask of each your hearty coöperation in the work before us, and we believe the final results will justify the large amount of labor and anxiety which have been expended in this undertaking. 1498 PAN-AMERICAN MEDICAL CONGRESS. PAPERS READ BEFORE THE SECTION. REFLEX EPILEPSY FROM INTRA-NASAL DISEASE. By JOHN O. ROE, M.D., of Rochester, N.Y. The existence of reflex neuroses has been known since the earliest period of med- ical history. In an excellent historical study on this subject, read before the Amer- ican Laryngological Association in 1887, Mackenzie' traces the general history of such neuroses from the time of Plato and Aristotle to that of Bostock, in the sec- ond decade of this century. Of the neuroses that may be excited by peripheral irritation probably epilepsy is the most important; for, as Watson” very truly says: While it is a disease probably not painful in itself, seldom immediately fatal, often recovered from altogether, it is yet apt, in many cases, to end in fatuity or insanity, and carries perpetual anxiety and misery into those families which it has Once visited. It was called the “sacred” disease by the ancients—“either,” as Aretaeus” says, “from its magnitude (for what is great is sacred) or from the cure not being in the power of man, but of God, or from the notion that a demon has entered the patient, or from all put together.” The earliest conception of the malady was that it is a disease of the brain, and incurable. Aretaeus seems, however, to have recognized that the exciting cause may reside in other parts, for he says: Occasionally the malady is fixed in the head, and that is the starting point of the paroxysms; in other cases it begins in the nerves which are most remote from the head and which sympathize with the part affected. The nose seems to have been the part of the body which was first recognized to be so vulnerable to external influences as to excite epileptic attacks. Mackenzie says that among the older writers many cases are recorded in which the odor of various substances was known to result in epilepsy; and Salmuth," in 1648, called attention to the fact that paroxysms of epilepsy are often relieved by the eruption of blood from the nose. Since that time, irritation of nearly every part of the body has been observed to be the cause of epileptic convulsions. The first scientific light was thrown upon this subject about forty years ago by Brown-Séquard," who showed by a series of carefully conducted experiments on animals that epilepsy could be produced by the artificial irritation of the peripheral nerves in almost any part of the body. The first experimenter, however, to formulate a distinct physio- logical theory of epilepsy was Marshall Hall." According to Marshall Hall the seat of epilepsy is in the medulla oblongata. To fully understand his system one must remember that this medulla oblongata, the seat of reflex or excito-motor movements, has the power of receiving impres- sions conveyed by the sensory nerves, which act as centripetal conductors, and also possesses the power of transferring them to the muscular system by the *Transactions of American Laryngological Association, 1887, p. 102. * Practice of Physic, Philadelphia, 1853, p. 379. *Causes and Signs of Chronic Diseases, Liber primus, cap. IV. *Transactions of American Laryngological Association, 1887, p. 106. g *Observationum medicarum centuriae tres posthumaº, Brunsvigiae, 1648, cent. II ; obs. 13, p. 65; and obs. 60, p. 87. & *Researches on Epilepsy; its Artificial Production in Animals, etc., Boston, 1857. 7 See T. Fairet, Théories Physiologiques de l'Epilepsie; in Archives général de Médecine, February to May, 1862. PAN-AMERICAN MEDICAL CONGRESS. 1499 motor nerves, which act as centrifugal conductors. If the medulla oblongata, being morbidly excited, experiences a stimulus either from the brain or periphery, such stimulus will be abnormally transmitted to the muscular system, and reflex movements of greater or less irregularity and violence will be produced. Brown-Séquard accepted Marshall Hall's theory in general, and developed it with remarkable ability in a large number of papers. Accordingly it was gener- ally received until 1870, when the question assumed another aspect. It was in that year that Fritsch and Hitzig' published their first researches upon the motor centers of the brain. By them it was demonstrated that mechan- ical irritation of certain regions of the cerebral cortex caused convulsions similar to those of epilepsy. Hitherto the most eminent physiologists had unanimously held that the brain was functionally homogeneous, and that stimulation of neither surface nor deeper parts would be followed by any motor reaction. The observa- tions of Fritsch and Hitzig were, however, soon confirmed by a large number of experimenters. Without depriving the medulla oblongata of the function attrib- uted to it by Marshall Hall and Brown-Séquard, it is thus clearly established that it has not the exclusive power of provoking epileptic convulsions. Thus we im- mediately have the question brought before us, Is there a difference between con- vulsions of cortical origin and medullary origin, and why are sometimes the for- mer, sometimes the latter, produced? It is this question that Hughlings Jackson” endeavors to answer in the Lumleian Lectures for the year 1890. According to Jackson the central nervous system is composed of three superimposed levels, representing degrees of evolution more and more advanced. In each of these levels, the lower, middle, and upper, there is a set of cerebral convolutions. The lower level consists of the spinal cord, the medulla, and pons, and represents the simplest movements of all parts of the body. The middle level of the cerebral system is composed of centers in the Rolandic region (so-called “motor region” of the cerebral cortex), and possibly of the ganglia of the corpus striatum also. It represents complex movements of all parts of the body from eyes to perineum. The upper level of the cerebral system is made up of centers of the prefrontal lobes. This represents the most complex movements of all parts of the body and presides over “ epilepsy,” properly so called. These three levels are all sensori- motor, and in each of them convulsions are produced by the same mechanism. To these anatomical classifications there is a corresponding classification of con- vulsions. These convulsions constitute genuine epilepsy only when they are of cerebral origin; that is, when they originate in the highest level; otherwise minor convulsive movements are manifested, such as petit mal. In order to explain the mechanism of the convulsion, Hughlings Jackson adopts Schroeder van der Rolck's 3 idea of comparing the nerve center to a Leyden jar, the convulsion to the discharge of the jar. He starts with this principle—that all nervous phenomena are to be traced to a nervous discharge, or liberation of the energy of the nervous elements. This discharge takes place in all healthy operations. When produced abnormally there results a discharge by explosion, and as a result convulsive move- ments of certain portions of the body that are in direct connection with the por- tion of the cortex irritated. Hence this form of epileptic manifestations, or hemi- epilepsy, has been distinctly characterized as “Jacksonian epilepsy.” The irrita- tion in this case may be applied to the brain center itself, or may be reflected to it from some distant part. Hughlings Jackson goes so far as to say that there is “in every case of epileptic seizure a persistent discharging lesion,” and that he would advise cutting out that lesion, whether it was produced by tumor or not. 1 Reichert and Du Bois-Raymond's Archiv, 1870, No. 3. 2 British Medical Journal, 1890, Vol. I, p. 703. 3 On the Minute Structure and Functions of the Spinal Cord, etc.; translated by W. D. Moore. London, New Syd. Soc., 1859. - 1500 TAN-AMERICAN MEDICAL CONGRESS. Hughlings Jackson's theory of cortical irritation has since been fully sustained by the brilliant achievements in brain surgery of Victor Horsley and Schäfer, Mac- ewen,” Ferrier,” Keen,* Lloyd and Deaver," Mills," Leo." Bennett and Gould,8 Barker," Park, 10 Oliver,” Seguin and Weir,” and Harrison.” As the most usual peripheral causes that may excite cortical irritation, manifested in epilepsy, may be mentioned diseases of the ear, teeth, eyes, uterine appendages, and the nose. Disease of the external or middle ear may in some cases be associ- ated with reflex epilepsy, entirely independent of any direct involvement of the brain itself. Moos "reports a case of middle-ear disease which resulted in epileptic Seizures. A large number of similar instances are recorded elsewhere by various Writers. Elaborate researches on the relation of epilepsy to ear disease, when the disease acts as a causative factor, have been made by Boucheron " and Ormerod.” Ormerod tested the ears of 200 epileptic patients, and found that 31 of them had a previous history of suppurative otitis, past or present. As a counterstudy, 100 patients with ear disease were examined for epilepsy. Seven cases were found. Brubaker” has reported 16 cases of epilepsy due entirely to the presence of decayed teeth, and an interesting instance has also been reported by Schwartzkopff. 18 Other references to similar cases are given by Hare.” G. Sous” reports a case in which relief from epileptic convulsions was obtained by the removal of a cataract, and Galezowski” records a case of epilepsy that was due to the reflex irritation produced by inflammation of the stump of an optic nerve after the eye had been removed. In 1876 Stevens,” of Albany, N. Y., said that in 70 cases of epilepsy examined by him only 3 were free from refractive lesions, and in 2 of these deep excavation of the optic nerve existed, a condition liable to give rise to a most troublesome form of asthenopia. At the same time he presented a table showing the refractive condition of the eyes in 54 cases of epileptic insane persons and in only a very small proportion of these cases was the vision normal. As far back as 1698 Eickmeyer” published a work on uterine epilepsy, and two quartos appeared in 1764 on the same subject, one by Polex * and the other by Schneider.” In 1859 Eagon” reported a case of epilepsy succeeding the suppression * Phil. Trans. Royal Soc. of London, Vol. CLXXIX (1888), B, p. 1. The cases reported by Horsley individually are to be found in his brochure on Brain Surgery, from British Medical Journal, 1886, Vol. II, p. 670, and 1887, Vol. I, p. 863. *Lancet, London, 1888, Vol. II, p. 254. 3Functions of the Brain. 4American Journal of the Medical Sciences, 1888, Vol. XCVI, p. 329. *Ibid., p. 477. *Transactions of Congress of American Physicians and Surgeons, 1888, Vol. I, p. 185. 7 American Journal of Neurology and Psychiatry, 1883, Vol. II, p. 38. 8British Medical Journal, 1887, Vol. I, p. 12. 9Ibid., 1888, Vol. I, p. 777. 197'ransactions of Congress of American Physicians and Surgeons, 1888, Vol. I, p. 324. 11 British Medical Journal, 1888, Vol. 1, p. 236. 12 American Journal of the Medical Sciences, 1888, Vol. xCVI, p. 219. 18 British Medical Journal, 1888, Vol. I, p. 848. ** Allgem. Zeitschrift f. Psychiatrie, Bd. xxx II, S. 5. * Revue de Thér. Méd. Chir., September 1, 1886., 1* Brain, 1884, p. 37. 17 Medical and Surgical Reporter, Phila., 1888, Vol. LVIII, p. 67. ** Deutsches Monatshefte f. Zahnheilk., Heft 3, September, 1885. * Epilepsy, its Pathology and Treatment, Philadelphia, 1890, p. 126. *Journal de Médecine de Bordeaux, Tom. xvi I, p. 202. * Revue de Thér. Méd. Chir., 1886, ** Medical Record, New York, 1876, Vol. x1, p. 567. ** “De epilepsia uterina.” Traj. ad Rhenuim, 1698. * “De epilepsia uterina.” Jenae, 1764. * “De epilepsia uterina.” Erfordiae. 1764. ** American Journal of the Medical Sciences, 1859, n.s., Vol. xxxv III, p. 569. PAN-AMERICAN MEDICAL CONGRESS. 1501 of the menstrual discharge and cured by the restoration of the catamenia. Cur- ran and Terrillon 2 have each recorded notes of cases of uterine epilepsy, and Thomas & has described a case of ovarian Origin. In the instance mentioned by Engelmann 4 the epilepsy was dependent upon erosions of the cervix uteri, and the convulsions described by Carstens’ were due to uterine stenosis. Of instances of epilepsy whose origin may be traced to intra-nasal disease, 3 cases have been reported by De Vilbis." In each of these cases the epilepsy was the result of so-called “nasal catarrh.” Fincke gives a full and very interesting report of a case in which the removal of nasal polyps gave complete relief from epileptic attacks, and Schneider * has cured 6 cases of epilepsy by the treatment of nasal disease. In some of the instances mentioned by Schneider, the epilepsy was complicated with attacks of asthma ; in others there were no complications of any nature. Erlenmeyer * reports the case of a physician, 25 years old, who had an attack of influenza. About a month later he suffered from epileptiform convulsions, which Erlenmeyer believed to have resulted directly from the attack of influenza. Abramson" cured a girl who was suffering from nightly epileptic attacks by cauterization of hypertrophic rhinitis and enlargement of the tur- binated bodies. Two cases of a similar nature are reported by Crossfield." Griffin 13 removed a shoe button from the left nostril of a young girl suffering from epileptic convulsions, thus affording her instant relief. The button had become incrusted with the saline portions of the serum, and formed the nucleus of a rhinolith. The calculus was the size of a hazelnut. No medicine whatever was administered, nor were there any recurrences of the convulsions. Hinsdale 18 reports a case, given to him by Dr. Weir Mitchell, in which epilepsy was cured by the removal of a bean from the nose of the patient. In each of 2 cases observed by me and herewith reported, the epilepsy was the result of turbinated exostosis and hypertrophy, causing pressure on the septum. Case 1.—Miss M., aged 23, was brought to me by her family physician, Dr. Townsend, of Bergen, N. Y., July 30, 1889. Her case presented the following his- tory: One morning in February, 1888, she was found just recovering from a convul- sive attack. Dr. Townsend was immediately summoned. As no one was present at the time when she was supposed to have fainted, the nature of the attack could not be made out. She was then well-nourished, had good color; all her functions, so far as could be ascertained, were normal. Suspecting that Miss M. had had a convulsion, Dr. Townsend instructed her parents to watch her closely. After the girl had three similar attacks alone, the fourth attack was observed by her mother, who described to the doctor the phenomena so well that there remained no doubt in his mind as to the true nature of the malady. It appeared that the patient was aware for many minutes previous that an attack was coming on, and could call her mother, who, in this instance, reached her before any convulsive effort had taken place. From March, 1888, to January, 1889, her attacks increased in fre- Quency, from one in two weeks to two and sometimes three a week. On consider- ing the long interval of consciousness after an attack was felt to be coming on before the stage of rigidity and unconsciousness occurred, the doctor thought that the case might be one of focal epilepsy. He finally took her to an oculist for an examination into the condition of her eyes, but nothing abnormal was detected 1 Medical Mirror, London, 1870, Vol. VII, p. 128. 2 Annales de Gynecologie et d’Obstetridue, Paris, 1881, Tom. xv, p. 401. ° Medical and Surgical Reporter, Philadelphia, 1879, Vol. x L.1, p. 206. 4 St. Louis Clinical Record, 1878, Vol. v., p. 28. * Detroit Lancet, 1879–80, n. S., Vol. III, p. 153. * St. Louis Medical and Surgical Journal, 1884, Vol. xlv.1, p. 14. 7 Deutsche Medicinische Wochenschrift, 1885, No. 4, S. 50. 8 Berliner Klinische Wochenschrift, 1889, No. 43, S. 934. 9 Ibid., 1890, No. 13. 10 Proceedings of the Kovno Medical Society, 1889, p. 36. 11 Journal Of American Medical Association, 1890, Vol. xiv. p. 111. 12 Medical Record, 1888, Vol. xxxiv, p. 65. 19 American Journal of the Medical Sciences, 1889, n.s., Vol. xC v1.1, p. 587. 1502 PAN-AMERICAN MEDICAL CONGRESS. in the examination. The doctor then took her to his own residence, and as the attacks nearly always occurred at night, after one nap, he had her sleep in an adjoining room. About five minutes before the attack she would call him, and having time to dress himself partly, he would go almost immediately to her. At no time during nearly two months and a dozen seizures could he discover any rigidity of any muscles or set of muscles, fingers or toes, in advance of the general muscular convulsion. He, therefore, gave up the supposition that it was a case of Jack- Sonian epilepsy. . The case was, therefore, unquestionably one of typical epilepsy, and it was attended by nearly all the customary phenomena. There were convul- sive movements of all the muscles, frothing at the mouth, biting of the tongue, and a period of unconsciousness, followed by a condition of languor. A complete history of the patient was gone into by the doctor. He found that she had experienced two falls, one from a horse and one from a step-ladder. He could not learn, however, that there was any interval of unconsciousness after either, nor could he discover any mark or asymmetry of the cranium, nor that she had any disease or lesions about her, with one exception—she had suffered from nasal catarrh for quite a long time, and there was obstruction to nasal res- piration. For the purpose of investigating the latter condition, the doctor brought her to me for an examination. There was found considerable inferior turbinated hypertrophy on both sides, and in the right nostril there was an exostosis of the middle turbinated bone which pressed firmly against the septum. Pressure against this region with the probe produced the sensations which she experienced just previous to the occurrence of an epileptic convulsion. The nasal obstructions A. therefore, removed, together with the exostosis in the middle turbinated OT162. For some time previous to the date when I saw her she had become very rest- less, and had much mental depression, particularly for a time after each attack. This condition speedily disappeared after the removal of the intranasal abnormal- ity, and she has had no attack of epilepsy since, That this improvement is due Solely to the operation in the nose, both Dr. Townsend and myself unqualifiedly believe, for the reason, as he states, that the patient had not taken for months before the operation, nor has she taken since, any medical or other treatment, except an antiseptic solution that I gave her to be used in an atomizer for spray- ing and cleaning the nose for a time after the operation. Case 3.−Master A. B., aged 14, was referred to me September 16, 1891, on account of a persistent headache, associated with more or less nasal obstruction, attended with frequent convulsive attacks, the nature of which had not been definitely determined. About a year and a half before I saw him he began to have very Severe headaches, confined mainly to the frontal region. This was increased by study in school, by exposure to the sun, or any excessive heat. The first convul- sive attack occurred one year before I saw him. He became much heated after rid- ing a bicycle, became dizzy, and had a short convulsive attack, falling to the ground from his wheel. This was followed by a dull pain and a very uncomfortable sen- sation, confined to the frontal and nasal region. This pain was much aggravated by stooping. After this first attack they were repeated at frequent intervals, but were usually excited by active exercise, exposure, or any condition that would naturally excite nasal turgescence. The parents became alarmed about the condi- tion of the lad, but no direct connection had been thought by them to exist between the nasal condition and the convulsive attacks, nor by the family physician, who referred the boy to me for treatment of the nasal obstruction. On examination the left middle turbinated bone was found to be very markedly hypertrophied, pro- jecting in the form of a sharp bony ridge against the septum. On the right side the turbinated body was very much hypertrophied, being pressed firmly against the Septum. The whole interior of the nose was very vascular, much congested, and very sensitive to slight irritants, although the patient had not suffered from hay fever. The treatment required was clearly indicated; the removal of this intra- nasal pressure in both the nasal passages—the hypertrophied tissue in one and the hypertrophied middle turbinate bone in the other. After the removal of this pres- Sure not only did the headaches cease, but there were no further indications of any epileptic seizures, and the lad has remained entirely free from them since, now nearly two years having elapsed. He has regained the brightness that he partially lost, and at the present time enjoys a condition of perfect health. The richness of the nasal region in sensitive nerves makes it possible for us to understand how it is that the nose is one of the organs that most frequently causes neuroses of reflex Origin. By no means, however, let us on this account attribute all neuroses to intra-nasal disease, for it is a fact which should never be overlooked that identical nasal lesions can produce with different persons different neuroses, PAN-AMERICAN MEDICAL CONGRESS. 1503 In one instance we may have epilepsy, in another vertigo, in another chorea, in another supra-orbital neuralgia, megrim, or persistent headache, and in another asthma, while in other cases there may be no reflex at all. As I have elsewhere stated, the explanation seems to be that the nervous force is like an electric cur- rent and travels in the line of least resistance. In One case the line of least resist- ance may be in one direction and in another case in another direction, and thus the manifestations vary according to the anatomical or physiological conforma- tion or variation in different subjects. - As to the influence of the condition of the nervous system in cases of epilepsy, it can not be denied that the ganglionic centers of persons having a susceptible nerv- ous organization are more readily affected by local or reflected irritation than those having a less susceptible organization; but it is by no means true that such natural susceptibility is necessary in order that the neurosis may be excited by the peripheral irritant. A long-continued nasal disease may, and in the majority of cases does, lower the tone of the nervous system and the inhibitory power is thereby lessened. Thus with the continuance of the affection a neurosis is devel- oped that is as much secondary to the primary disease in the nose as the nervous disturbance resulting from an abscess in the ear is secondary to a diseased tooth that may have been the direct cause of the abscess by the irritation of the otic ganglion. In one of the cases reported by Crossfield, referred to above, the patient's habits. were faultless, but he was very much emaciated, with a sallow complexion and a hacking cough, associated with night sweats. His appetite was varying, but generally poor. In the second case the young man was well nourished and full- blooded, rather large for his age, 17. In the second case reported by Schneider, the young woman, aged 24, was strong and well built, and engaged in active out- door life, being a haymaker. In the fifth case the man was strongly built, but suffered from a number of nervous troubles. Fincke says that the man treated by him was strong and active. The girl cured by Abramson from nightly epileptic attacks, resulting from hypertrophic rhinitis and enlargement of the turbinated bodies, was the daughter of a hysterical mother. The two cases that have come under my observation were by no means of a neurotic habit. As might be inferred then, a severe attaca of epilepsy often results from a disproportionately small irritant, owing to the condition of the central nervous system having been previously lowered. With reference to the supposition that natural susceptibility is necessary for a peripheral irritant to produce a marked neuroses, it may be interesting to note that in about one-half the cases of epilepsy cited above as being the result of intra-nasal disease the reporters have mentioned the fact that their patients were naturally well nourished, strong, and active. The portions of the nose of which a diseased condition seems most liable to occasion epileptic attacks are the septum and the middle and lower turbinated bodies. The etiolog- ical factors most frequently met with are turbinated hypertrophy, exostosis, and polyps. In the case reported by Fincke, nasal polyps were found in the right fossa. Of the cases reported by Schneider, in two there were polypoid growths, with exostosis of the septum ; in two other cases the lower turbinated bodies were hypertrophied, and in the remaining two cases the affection is described merely by the indefinite term “swellings on both sides. * Chronic hypertrophic rhinitis, with enlargement of the left two lower and right middle turbinated bodies, occasioned the epilepsy in the case recorded by Abram- son. In the first case reported by Crossfield there was found on the right side marked hypertrophy of the inferior turbinated body, causing almost complete *__ 1 New York Medical Journal, Vol. XLVI, p. 257. 1504 * PAN-AMERICAN MEDICAL CONGRESS. stenosis. On the left side there was marked deviation and exostosis of the septum, while the inferior turbinated body was hypertrophied. In case No. 2 there was absolute nasal stenosis, both the right and left inferior turbinated bodies being hypertrophied. In both of the cases that I have reported the convulsive disturb- ance was due to the pressure from turbinated exostosis and enlarged turbinated bodies against the Septum. From a careful study of all the cases of reflex disturbance from nasal disease coming under my observation, I have come to regard the Septum as the center from which these disturbances most often radiate, and not the sensitive areas in the turbinated bodies, as has hitherto been regarded. Starr has recently stated that in all cases where local irritation is sufficient to cause epilepsy the patient will have his attention sufficiently directed to this localized disorder to cause the local disturbance to be discovered. In this respect I do not agree with him. Many cases of neurotic disturbance have come under my observation where it was only by the merest chance that the local cause was discovered. Hence we can not emphasize too highly the importance of examining the nose in all cases where the cause of epileptic attacks is at all obscure. That epilepsy has other causes than nasal irritation goes without saying, but that nasal disease is a factor of prime importance in its production has also been fully proven. d SOME FORMS OF NASAL REFLEXES, WITH REPORTS OF CASES. By Dr. S. K. MERRICK, Professor of Diseases of the Nose, Throat, and Chest, Baltimore Medical College. While a few are still skeptical as to the connection between the treatment of intranasal diseases and the cure of certain so-called “reflexes,” located in some more or less remote portion of the body, I take it that the great body of medical men, especially among throat specialists, believe the connection to be close. To mention the names of all who have contributed to our fund of knowledge would lead us far beyond the limits of this paper, but it may not be amiss to refer to a few whose labors have thrown special light upon this interesting subject. Voltilini” seems to have been the first writer to bring the question of the nasal reflex to the attention of the profession when he reported a case of spasmodic asthma, due to a nasal polypus, cured by removal of the growth. This observation has since been verified by others. - Seiler,” Hack,” and John N. Mackenzie" subsequently published cases of reflex cough, due to morbid conditions within the nasal cavities. Hack" in his mono- graph reports a large number of reflexes, among them are gastralgia, dyspepsia, cardiac palpitation, tumefaction and redness of the skin of the nose, salivation, neuralgia of the first two branches of the trigeminus, cephalalgia, migraine, ciliary neuralgia, Scotoma, photophobia, vertigo, exophthalmic goitre, and others. Elsberg," Salinger,” and Bosworth" have reported cases of chorea, due to hyper- trophic rhinitis. Cases of epilepsy, due to intra-nasal disease, have been reported 1 Medical Record, New York, 1890, Vol. xxxv II, p. 1. 2 “Die Anwendung der Galvano-Kaustik.” Vienna, 1872. 8 Arch. of Laryngology, Vol. III, No. 3, p. 240. 4 Berlin. Klinische Wochenschrift, 1882, No. 25. 5 Amer. Journal of Medical Sciences, July, 1883. • Wein. Med. Wochenschrift, 1882–83. 7 Trans. Amer. Loryngological Asso., 1883. 8 Polyclinic, Phil., June, 1887. * Deformities of the nasal septum, Nº. Med. Record, January, 1887. PAN-AMERICAN MEDICAL CONGRESS. 1505 by Salinger, Fincke,” and Bosworth,” while T. A. McBride * reports a case of psychical epilepsy. Ziem " reports a case of nocturnal enuresis, while North " thinks most cases of neurasthemia will be found to have intra-nasal disease. Two cases of salivation of reflex origin are reported by Bosworth and one by E. Frankel, and cited by Rualt.* and Bosworth, were cured by treatment of intra- nasal conditions, upon which they were dependent. The question of Ocular dis- turbances of nasal origin was forcibly brought to the attention of the profession by Dr. Gruenning,” of New York, in a paper read before the Academy of Medi- cine, in January, 1886. Beverly Robinson," Cheatham,” and Bettman” report cases of many forms of eye troubles dependent upon intra-nasal conditions. Many names might be added of those who have reported nasal reflexes affecting divers organs, but the foregoing, in view of their eminence and respectability, are quite sufficient to emphasize the fact that nasal reflexes are not uncommon, nor Con- fined to a very limited portion of the economy. The moral effect has been invoked to explain the action of treatment in effecting cures. I, however, agree with Bosworth that, while “it may have some force,” it is purely secondary and adventitious in the great majority of cases, but in a small per cent of them I am constrained to believe it is the chief if not the only factor in achieving the result. Bosworth believes that the successful results are due primarily and mainly to the removal of local intra-nasal disease. In this view I can not fully concur. While this is so in most cases, there remains a small num- ber which are relieved before the morbid condition in the nose is cured, and must be explained on the theory of counter-irritation, which was sufficient to excite healthy action in the nerve centers, presiding over the site of morbid action, before it effected a cure at the site of application. There are three prominent or chief views held as to just how these reflexes are cured, viz: (1) By moral influence; (2) by counter-irritation, and (3) by removal or cure of the morbid causative condition within the nose. That no one of these theories will adequately explain the modus operandi of the curative agent in all cases, I firmly believe; and that all three of them may be necessary to do so, the following cases will, I think, prove : Case 1.--G, S.; male; aged 28; native of Baltimore, Md. ; merchant; , parents living and well; one brother died of pulmonary tuberculosis, and a sister is suffer- ing with a chronic cough. , Patient consulted me November 5, 1892, complaining of intense headache and vertigo, which had persisted, in spite of all remedies, for the past six months, until life had become a burden and he feared sometimes he would “lose his mind” if he did not get relief. As his nose had become more or less obstructed and a sense of pressure over bridge of same was nearly always pres- ent, he had concluded that nasal catarrah might have something to do with his distressing headaches and vertigo, and had accordingly come to consult me. An examination revealed in both nasal fossae, highly inflamed and senitive turbinates, which were the seat of both false and true hypertrophy. At the second visit, November 7, the inferior turbinate on one side was cauterized, and on the 9th he told me his headache and vertigo were much improved. On the 14th the cautery was again used on the other inferior turbinate, and at his next visit, on the 18th, he told me he was entirely relieved and delighted beyond measure with my treat- 1 Loc. cit. 3 Moniteur de la Polyclinique, June 7, 1885. 8 Loc. cit. 4 N.Y. Record, Vol. XXIX, p. 137. * Monatsschift für Ohrenhielkunde, Nos. 8 and 9, 1886. ° Med. Register, Philadelphia, May 14, 1887. 7 Dis-ef- a.I] roat, Vol. I, p. 190. 8 Loc. cit. ° N. Y. Med. Record, January 30, 1886. 10 Med. Record, April 3, 1886. 11 American Practitioner and News, Louisville, April 2, 1887. ** Journal of the American Medical Assoc., May 7, 1887. S. EX. 36 95 1506 PAN-AMERICAN MEDICAL CONGRESS. ment. Beyond a slight shrinking of the inferior turbinates I could see little improvement in the intranasal conditions. The marked relief which my patient had experienced seemed out of all proportion to the slight changes effected within the nose. This, together with the fact that a severe rhinitis was still going on, forced me to the conclusion that the nerve centers, responsible for the head symp- toms, had been stimulated into healthy activity by the first cauterization, and that the marked improvement which took place within two days could not be due to improvement in the intranasal morbid condition, which was not sufficient to be noticed on the closest inspection at that date. This patient did not return for fur- ther treatment after his head troubles, vertigo and headache, were relieved, although his rhinitis was still uncured. Case 2. —A. E. M., male, aged 30, native of Pennsylvania, station agent Penn- sylvania Railroad (family history not known), consulted me June 15, 1888. The right nasal fossa was nearly normally patulous, there being slight hypertrophy of inferior turbinate and chronic rhinitis. The left fossa, however, was nearly com- pletely obstructed by a deflected septum and an exostosis which rose up from the inner side of the floor of the nose, half inch from its anterior opening, the two deformities leaving a small triangular opening for respiration. Both fossae were in a high state of inflammation, and after about two weeks of soothing treatment I operated on the deflection and a week later upon the exostosis. The catarrhal proc- ess began to improve rapidly after free respiration and drainage were established. A few days before I was ready to discharge him, he told me one morning with evident delight that the cocaine which I had been using in his nose had restored his eyesight. This was the first intimation I had had that he had defective vision, although I had observed that he wore glasses. He had discarded them the night before, finding he could see better without them. I found upon inquiry his was a case of asthenopia of several years’ standing. I of course explained to him that the real cause of the restoration of normal and painless vision was the removal of nasal obstruction and cure of his catarrh, and that the cocaine played no part in it, except as a local anaesthetic during the Operation. Case 3.—Miss L. C. B., single, aged 27, born in Montgomery County, Md., weight 145 pounds, above the medium height. Parents living and healthy; six sisters and three brothers, all strong and healthy. She was referred to me by Dr. William P. Chunn, of Baltimore, Md., who thought she had some nose and throat trouble which needed attention. March 1, 1893, Imade an examination of patient's nose and found a badly deflected septum of traumatic Origin, dating from a fall on the ice, in girlhood, while skating. The knuckle of deflected cartilage was trans- verse and firmly adherent to the inferior turbinate of the left side, involving the sutural junction between the bony and cartilaginous septum. The middle turbinate was much hypertrophied and pressing down on the knuckle of deflected cartilage, but not adherent to it. The left nasal fossa was, by these deformities, almost com- pletely closed. The inferior meatus of the right fossa was completely filled with an hypertrophied inferior turbinate, which on close examination was found tightly bound down to the floor of nose by adhesions, the result of an operation done by a physician in a neighboring Virginia town, just before she had the grip. Both nasal fossae were operated on—one with scissors and cautery and the other by means of the saw and cautery, and free respiration and drainage were established. Owing to ha-morrhage from the sawing I found it necessary to plug and replug daily for three days the fossa with cotton wool, and an interesting and instructive fºre of the case hangs upon this circumstance, which will be referred to pres- ently. Twenty-four hours after the cotton tampon was dispensed with my patient returned to my office, telling me I had cured her of a most serious and distressing eye trouble of long standing. I then elicited the following history of her case, as nearly as possible in her own words. Eight years since, she began to have head- ache and the first disturbance of vision. It became impossible to place a book at the proper distance for reading. When she thought it was right it would imme- diately get wrong. This difficulty increased, and seeing double and often triple, with blurring, jumbling, and half blotting out of words, constantly harassed her efforts at reading. By the end of six months she could not see well enough to paste pictures in a blank book for a child, and had to desist on account of imper- fect and painful vision. She then consulted a prominent oculist of Washington, D. C., who gave her three pairs of glasses, which she wore as directed. These made her condition more tolerable and improved the painful vision, until two years since when she had the grip, followed by measles, when it became necessary to again consult an oculist, who was also a distinguished specialist of Washington, D. C. After some treatment of the eyes, the right eye was operated on for slight external strabismus. Vision after this was easier, somewhat, but reading and PAN-AMERICAN MEDICAL CONGRESS. 1507 writing were impossible, and vision at all times remained painful, and dread of light was always present. She was to return after a month or two and have the other eye operated on for a similar condition, but fell into my hands before the time arrived for her next visit... I was entirely ignorant of the foregoing history of her eye trouble until she related it to me, four days after 1 had operated upon her nose. As long as the cotton tampon remained in the nasal fossa after the operation no improvement in her vision took place, but six hours after it was removed she suddenly discovered that she could read by gaslight with perfect comfort, and at once seated herself and wrote a letter to her mother, without glasses, telling her of the “glad news.” She had been unable to write for several years. It was the following morning she informed me of the result of the operation upon her eyes. She remained under my care for about two weeks, during which time her vision remained easy and good, and I have a letter dated July 29, 1893 (about four months after the operation), in which she tells me she has just paid a visit to Dr. M., of Washington, D. C., and he frankly admits that my treatment of nose has rendered it unnecessary to operate for strabismus on the other eye, and that there is not the least doubt about the benefit which resulted from the operation. Case 4.—J. S., male, aged 45, married, engineer, enjoyed good health until six weeks previous, when he was compelled to stop work On account of great pain in right thigh and hip. Patient consulted me October 12, 1887; at that time he was walking with a cane and limping badly. It transpired that he had been relating his case to a neighboring barber, who was under the impression that nearly all ail- ments were caused by catarrh, and insisted that my patient should consult a throat specialist at once. I learned the names of two reputable physicians who had been treating patient since his trouble began, but no relief was realized. The man had become convinced that all his trouble in leg was dependent upon “masal catarrh,” and that when the latter was cured he would get well of the former. I frankly told him that there was no connection between the two affections. I found on examination a mild chronic rhinitis, most marked in left inferior turbinate, which I told patient I would operate on, and did with the galvanie cautery. Two days later patient returned, walking without a cane and with a very slight limp, saying he began to get better on leaving my office at his previous visit. At his next visit he declared himself well, and has remained so to this date. No one can convince him that he was not cured by the electro-cautery. I saw little or no change in the intranasal condition, and it is possible that it had no connection with the sciatica, with which the man was suffering on his first visit, but that the case was one similar to that of Bouchard, referred to by Bosworth in his book, volume 1, page 197, where a case of sciatica was cured by cauterizing the lobe of the ear. The description which he gave to the barber of the operation, and of his feelings during the progress of the same, lead me to the conclusion that the “moral influence” was the chief if not the only factor in effecting the cure. - This case, however, is reported to invite the Opinions of others and some rational explanation of the connection which exists in such cases between the cauteriza- tion and the morbid action so remotely situated, and not with the view of express- ing any very definite opinion of my own. The following deductions, I think, may be fairly drawn from the foregoing cases, viz.: (1) That distressing headaches and vertigoes, apparently dependent on chronic rhinitis, may yield to intra-nasal cauterization before the catarrhal process is appreciably improved. (2) That the most serious ocular disturbances may be due to intra-nasal disease, and that presure irritation may be the chief factor in such conditions, and that removal of same may yield the most brilliant results. (3) That pathological processes or symptoms, remotely situated, are, occasionally, unexpectedly relieved by cauter- izing the turbinates. In the preparation of this paper I have freely consulted Bosworth (Diseases of Nose and Throat). 1508 PAN-AMERICAN MEDICAL CONGRESS. DISCUSSION. Dr. PRICE-BROWN, Toronto. I can not say that in my experience I have seen any cases of epilepsy that I could trace to neurosis of the nasal cavities, although I have certainly seen some exceptionally nervous patients with neurotic Symptoms of that nature that might possibly develop into an epileptic form. A case of that character came under my observation recently. It was that of a lady, about 50 years of age, who had been troubled with sore eyes for several years. There was a good deal of discharge and a constant running of tears over the face, so that she had, on a number of occasions, gone to an ophthalmologist, who had passed an instrument down the nasal duct in order to free the passage to the nasal cavity. Although this was done repeatedly, she still had the same trouble of tears running over her cheeks, and finally she came to me. I examined the nasal passages, the left one in particular, and found there was a large hypertrophy of the middle turbinate of the left side pressing against the septum. This hypertrophy, from which a discharge of pus took place, was very painful. I operated upon it with the galvano-Cautery, and removing the hypertrophied tissue I discovered that the middle turbinated bone itself was pressing into the septum. I sawed a portion of it off, with the result that there has been a complete cessation of the eye symptoms. There is no more running of tears over the face, there is no tendency to conjunctivitis, and the associated ophthalmological neuralgia has passed away. Of course, the discharge of pus from the antrum still continues. It may be possible that the pus, not escaping sufficiently, might give rise to the other symp- toms; but as the occlusion was only on one side, while both were affected, it Seems to me to be largely a reflex condition. Another case was that of a young lady who had hay fever for fourteen years; she is 25 years old now and she has had the disease since she was 12. Hay fever in her case had the peculiarity of commencing in June and ending about the 1st of August. On examination I found the columnar cartilage completely filling in the right nasal cavity, pressing against the septum ; of course she could not breathe on that side. I cut through the mucous membrane and with saw and scissors cut out one-half of the columnar septum and by means of a tampon kept the nares open. The result was that all the symptoms of hay fever which she had when she came to Ime passed away and she has had none since. I think the symptoms of hay fever in her case arose principally from the pressure of the columnar cartilage against the ala of the nose. Dr. S. SOLIS-COHEN, Philadelphia, Pa.. I have been much pleased with the mod- erate tone of the paper read and the judicial nature of the conclusions arrived at. I suppose some members of the section at least are familiar with the position I have taken, opposing the extravagant assertions made by men of insufficient experi- ence in describing a large variety of diseases as solely due to morbid conditions of the nasal chambers, it having been my fortune to meet with many cases of such conditions in conjunction with diseases of the nasal chambers, in which I purposely refrained from local treatment in order to test the dependence of So-called reflex symptoms upon the nose or upon constitutional conditions. The cases stated by Dr. Roe are, however, beyond criticism. The epilepsy in these cases, so far as I am able to judge, must have been due to the conditions of the nose which he relieved. I have no criticisms to make of Dr. Merrick’s cases. Scattered throughout the literature here and there are such undoubted cases, and there must be others unpublished. I am inclined to believe, however, that many of the cases reported of reflex disturbances due to nasal conditions are not depend- able. Some of the cases appear to have been insufficiently studied, in others the conclusions are not justified by the reported facts, and in some instances with PAN-AMERICAN MEDICAL CONGRESS. 1509 which I am personally acquainted the reporters have not had sufficient acquaint- ance with general medicine to be able to exclude the general causes. In this connection I would like to differ somewhat with Dr. Roe as to the necessity of the neurotic substratum for these manifestations. I believe such neurotic dis- position to be essential. It may not, however, give rise to marked phenomena in the absence of peripheral irritation in the nose or elsewhere. I have recently investigated a number of cases presenting certain neurotic phenomena in the domain of the vaSO-motor system. In some instances there is apparently a very slight departure from normality. It would not attract attention unless sought for, yet when the cases come to be studied and investigated from all standpoints the evidences of instability in the circulatory mechanism will be found. I should not be at all surprised if in 1many cases of reflex disturbances from nasal irritation the patients would, upon investigation, be shown, as some of my hay-fever patients have, to have this neurotic instability of circulation, which would account, when mechanical causes are insufficient, for the vertigo and for the disturbance of vision. In some of my cases ocular disturbances have been quite prominent, and even epileptic attacks are among the phenomena associated with this condition. I find the same thing existing in several members of a family, and in someinstances there has been marked heredity. I would ask Dr. Roe and the members of the section, in future cases of apparent nasal reflex neurosis, to investigate especially two features of the case. First, whether cardiac action can be disturbed by slight causes, causes that in a thoroughly normal individual would not be adequate to effect such disturbances; and, second, whether the phenomenon called dermo- graphism can be produced. The test is made by writing with a probe upon the skin of the patient at any point, say on the inner surface of the forearm, the skin having been made tense by clinching the fingers. Light pressure is used. In a very few moments the device traced will stand out in bright red characters, and in some patients in a few minutes large welts will appear resembling the welts of urticaria ; in others deeper pressure is required to produce this factitious urticaria, and in some who are still less susceptible the additional application of cold. I do not know that these conditions are present in nasal reflex, because, unfortunately, in the 50 cases I have studied there was none in which I was able to discover any condition in the nasal chambers which I would consider adequate as a source of peripheral irritation. The cases reported by Dr. Mierrick of ocular disease are certainly interesting; and conversely to them are the cases stated by Gould, in which correction of ocular defects cured nasal catarrh and hay fever. The question of moral effect, raised by Dr. Merrick, is most surely one which can not be excluded in considering some of these cases. In Dr. Roe's cases of epilepsy there was hardly room to suspect merely moral effect. In the cases of sciatica reported by Dr. Merrick, and in some others, moral effect must, however, play a large part. I remember having reported to the American Laryngological Association some years ago a case of Obstinate sneezing in a patient who insisted upon having her nose cauterized in order to cure it. I did not cauterize it, but she did not get well until I said I would apply an electric current. I applied a constant galvanic current, and thinking it was the cauterization which she had insisted upon having applied, the patient promptly recovered. That surely points to more than a suspicion of moral effect. In conclusion, I would allude to a class of cases, one of which has but recently been under my care, in which with marked intra-nasal exostosis there coéxists headache asseeiated—with a sense of T jFēššūrā āf the root of the nose, and with sensitiveness to pressure over the intra- orbital and supra-orbital foramina. In about half a dozen such instances I have seen the headache, which occurred periodically, disappear upon treatment with quinine hydrobromate, administered four to six hours before the attack in order to have its maximum effect at the time of the expected paroxysm. This drug is 1510 PAN-AMERICAN MEDICAL CONGRESS. usually administered in conjunction with ergot in order to prevent any bad effect of the quinine upon the ear. The combination of quinine hydrobromate and ergot having relieved these headaches while I have left the nasal deformity untouched, and on the other hand, as in a case specially reported, skillful treat- ment of masal conditions at other hands than mine having failed to give relief to headaches that afterwards yielded to medication, I am constrained to minimize the nasal factor in many cases. I believe there must be quite a large number of such cases. Others probably see many more of them than I do, because, being in general practice, the number of nasal cases I see is not so great as that seen by other members of this section. Dr. A. W. DE ROALDEs, New Orleans. I fully agree with Dr. Cohen and Dr. Mer- rick when they call attention to the fact that persons affected with reflex troubles from intranasal disease are not always to be looked upon as belonging to the con- stitutionally neuropathic class of patients. In order to emphasize this point allow me to refer to a case which came under my observation a few weeks ago. The subject was a country girl of about sixteen years of age, who was brought to my office for some aural trouble on one side. She was a fine specimen of country life, in exceedingly good health, of strong nerves; could ride a horse, fire a gun, and feared nothing. Menstruation was normal. The drum on the affected side was opaque and somewhat retracted, the hearing having diminished considerably on that side in the last eighteen months. Mouth breathing was observed, due to intranasal obstruction, the result of an Osteo-enchondromatous deviation of the septum on side of the affected ear. I suggested an operation to relieve at once the nasal trouble, which would allow me afterwards to treat the ear. Cocaine was applied, and the obstruction mostly sawed off, when all at once, as the instrument reached the upper and posterior part of the bony ridge, the girl complained of a severe pain in the head, especially in the supraorbital region, with a marked disturbance of respiration. The pulse rose to about 118, she was pale and fainting; whisky had to be administered and the operation hurriedly finished. At the time I attributed these symptoms to the effect of cocaine, for I had used it in a rather strong solu- tion. All at once the patient began to cough and she coughed for two hours, one of those harrowing, incessant, short, expiratory Coughs. Everything was tried to relieve this painful symptom. Primary anaesthesia with chloroform, pushed even to the point where the eyeballs were made insensible to the touch, would but par- tially relieve the cough. I had finally to resort to a hypodermic injection of one-third of a grain of morphine, which allowed her removal to her home. That condition kept up for three days, when to procure rest the family physician had to resort several times to the use of morphine hypodermically. After three days the cough had mostly disappeared and the condition much improved, when she reported to the office in Iny absence. My attendant, Dr. Scheppegrell, had scarcely inspected the intra-nasal wound and resorted to a very gentle mopping when the girl began to again complain of pain in one side of the head, with irritation behind the ear and in the neck, and the same violent cough returned. This time electricity was resorted to, with temporary relief. The cough nevertheless returned after she had reached home, lasted a whole week, giving the young woman only three or four hours of sleep, depressing her, and interfering seriously with nutrition. A third attempt to clean out the nasal passage, on the eleventh day, brought about the same state of affairs, lasting about twenty-four hours. After such an expe- rience the parts were left undisturbed and the intra-nasal wound left to heal up naturally ; henceforth the girl's condition improved, and she has never had a recurrence of the cough, which, as a result of the operation, had for fourteen days rendered her life miserable. The second and third attempts at treatment were made for the sake of clearing a possible doubt without the use of cocaine. This is as marked an example as I have seen of a nervous trouble, set up evidently * PAN-AMERICAN MEDICAL CONGRESS. 1511 as a reflex by the traumatic effect of the operation, in a strong and healthy young woman, devoid of any neuropathic taint. In such cases the reflex troubles are, I think, better explained by some direct nervous communication, especially when developed in the area of innervation of the exciting intra-nasal disease, or in its immediate vicinity, where nervous anastomoses or continuity of tissue can be invoked. Suggestion will be of no avail in the relief of such cases. On the other hand, I am inclined to accept its good effects in cases of neurasthenic patients, in whom the reflex troubles are developed at a distance. Dr. F. C. COBB, Boston. I would like to ask how long relief lasted in these cases, the epileptic ones especially? I have found in cases of vasomotor rhinitis that when the obstruction was removed the asthmatic symptoms were very much relieved for a time, but in a year they almost always returned, yet the nose remained almost clear. It seems to me that time is a great factor in deciding how much is suggestion and how much cure. .* Dr. S. K. MERRICK, Baltimore. I should like to ask Dr. Cohen in the cases he referred to with vertigo and headache where there was pressure over the bridge of the nose similar to one of the cases I reported, what doses of hydrobromate of quinine he gave, and whether or not the cure in these cases was permanent. Dr. COHEN. The dose varied from 10 to 30 grains, the 30 grains being given in two doses. The cure in two cases was permanent ; in one case the gentleman came under treatment but a short time ago and I am unable to say what the result will be ; the other case I have been unable to hear from since. - Dr. MERRICK. In the case I reported there was a great deal of sensitiveness and both false and true hypertrophy were present. It seems to me that anything that will control the circulation or get possession of the nervous system is desirable. I think quinine exercises a great deal of influence in hay fever, and that condition is simulated in many of these cases such as Irelated. Ergot also controls the cir- culation, but it simply emphasizes the fact that if the circulation is controlled and the pressure relieved that it will not militate against the idea or assumption that the case was originally one of reflex origin, reflected from that point of irri- tation ; simply controlling the circulation by hydrobromate of quinine does not show that it was not originally caused by pressure irritation within the nose. One point I would like to answer that refers more especially to Dr. Roe's paper; that is in regard, to time. I stated that in one of my cases the man had remained well since 1887, and he is still well. One of the eye cases I followed for six or seven months, the case that believed himself cured by the use of cocaine. In the last case of ocular disturbance it has been about four months, and the patient is now using her eyes as well as ever. Dr. John O. ROE, Rochester, N. Y. In regard to the points raised by Dr. Cohen as to the uncertainty of this condition being due to local irritation as a primary factor, or to a constitutional condition, I think it would be difficult to establish that fact, as we have no means of estimating exactly how much general disturb- ance the local irritation has caused. We can not say that the general disturbance has not been the result of the local irritation or that the general constitutional impairment of the system has not caused the present susceptibility to this local irritation. We know that if we have so simple a disturbance as a toothache for a short time we become very much depressed, our inhibitory powers are lessened, and the circulatory system much disturbed. So any local irritation in any por- tion of the body may manifest itself in a general neurotie-eondition Or a disturbed ition of the circulatory system. In a great many of these cases we find a primary weakened condition, causing a proclivity for these disturbances which a local irritation readily develops, but we can not say positively that in a great many cases the local irritation has had a great deal to do with bringing about a condition that may be the exciting cause of epilepsy. In regard to the general * 1512 PAN-AMERICAN MEDICAL CONGRESS. treatment of these cases, invwhich we have a central disturbance induced by a local cause, it may be said that the administration of drugs, such as those that will quiet the nervous excitability or will so deaden the afferent nerves that the local irrita- tion ceases to be communicated to the brain centers, will have the Same effect as if we remove the exciting cause. Consequently, the medication has but the effect of stopping the paroxysm for a certain length of time, or during the continuance of the effect of the drug. It is, however, of the utmost importance to resort to restorative and supporting measures, for in all of these cases, whether due to a primary central disturbance or a local cause, there is always a lowering of the tone of the general system, in very much the Same way as a short-circuited elec- tric wire will prove a marked drain upon the main electric current. In regard to the length of time these patients were under observation, in case 1, four years have elapsed since the patient was under treatment, and she remains at the present time perfectly well. In case 2, two years have elapsed since treatment was dis- continued, and the patient is in perfect health. v IMPORTANCIA DEL ESTUDIO MICROSCÓPICO DE LAS MUCOSIDA- DES LARINGEAS, PARA DESCUBRIR OPORTUNAMENTE LA INFEC- CIÓN TUBERCULOSA LARINGEA É INSTITUIR UN TRATAMIENTO CONVENIENTE. Por el Dr. ANGEL GAVIÑO, Profesor adjunto de Higiene, Profesor de Bacteriología de la Escuela de Medicina de Méacico, Médico del Consultorio Central de Beneficencia y Secretario de la Academnia de Medicina de Méarico. SEÑORES: Todos vosotros que habeis observado la laringe en numerosos casos, podreis haber comprobado el hecho de que en general la mucosa laringea no presenta caracteres especiales en el principio de la tuberculosis de este órgano. Xierto es que la hinchazón y la palidez de los cartílagos aritenoides y de la epi- glotis en la tisis laringea son un buen signo de presunción, sobre todo cuando existen en el enfermo otros del lado de las mucosas ó de los pulmones; que los antecedentes de la familia, que la proximidad de personas tuberculosas, y otros elementos, pueden hacer suponer que haya una tuberculosis laringea, si el funcio- namiento del órgano se modifica y los síntomas de inflamación crónica se acentúan. También puede ser casi indudable el diagnóstico cuando se han demostrado degeneraciones necrósicas tuberculosas, ulceraciones clásicas, en las encías ó en la faringe. Estas degeneraciones, estas ulceraciones de pequeñas dimensiones y 1muy numerosas, con tendencia á la reunión y á extenderse en superficie más bien que cn profundidad, son ya un signo demasiado elocuente para que el clínico ponga en duda la infección tuberculosa de la laringe; sin embargo, algunos prácticos muy notables han incurrido en error cuando se han fijado solo en el aspecto de las pequeñas ulceraciones y en otros de los signos reputados como casi inequívocos, ejemplo de ello es Heinze, quien habiendo observado en 1876 á 50 enfermos en el Hospital Jacob, los cuales fueron elegidos entre los que presen- taban todos los caracteres de la tuberculosis pulmonar, declaró ser las ulceraciones laringeas tuberculosas, convenciéndose después de que de estas ulceraciones solo el 83 por ciento lo eran y el 17 por ciento no lo eran, Esto significa que aún en el período de ulceración ó cuando este se inicia, es algo inseguro el diagnóstico y que en estos casos como en aquellos de presunción, y aún en los que se reputan como simples laringitis catarrales crónicas, es necesario otro elemento que como el microscopio ayude á aclarar cuanto ántes la naturaleza de la afección. Pues bien, en varios enfermos que se me han presentado pidiendo tratamiento de su laringitis crónica, y en los que solo existía enrojecimiento é hinchazón de PAN-AMERICAN MEDICAL CONGRESS. 1513 la mucosa con lijero enronquecimiento de la voz, he hecho el exámen microscópico de las mucosidades adherentes tomadas con un pincel fino en los repliegues de la mucosa, ya en la base de la epiglotis, en su cara laringea ó en los antros de Mor- gagni, y he encontrado en algunos el bacilo de la tuberculosis, siendo así que por el exámen laringoscópico no estaba autorizado á dar un diagnóstico seguro y no podía inclinarme á la existencia de una laringitis tuberculosa. El conocimiento de la naturaleza de una afección cuando aún no se encuentran comprometidos órganos importantes ó que la infección no se ha generalizado, es de todo punto necesario si se quiere obtener un resultado con los elementos médico- quirúrgicos de que actualmente disponemos. Esta idea muy general ha sido reforzada en su importancia, con el importante estudio previo de las mucosidades faringeas de los supuestos difteríticos, pues ha venido á enseñarnos que cuando el clínico aún no puede pronunciarse por el diagnóstico de la diftería, ya el microscopio y las culturas en suero, denuncian la presencia del bacilus de Löffler, y proporcionan al práctico un conocimiento de colosal importancia que le permite combatir la afección en su principio, y por consiguiente multiplicar las proba- bilidades de éxito. Si en la difteria se alcanzan hoy brillantes resultados, como pasa en el Hópital des Enfants Malades de Paris en el servicio del Dr. Simon, ¿porque no aplicar el mismo medio en todos los casos en que una laringitis comienza á hacerse duradera, y refractaria á los medios terapéuticos comunes en las afecciones catarrales? Siempre recuerdo, para enseñanza, de lo que reputo como necesario del exámen microscópico en todos los casos ligeramente sospechosos, á dos enfermos, uno hombre, el otro mujer, quienes durante algún tiempo fueron tratados como afec- tados de un catarro crónico simple laringeo, por presentar un lijero edema glótico con enrojecimiento de la mucosa y una ronquera y afonia incompleta, intermitentes y que al cabo de nueve años han caido en mis manos, y he podido demostrar en el hombre una necrosis tuberculosa de los cartílagos aritenoides y de la epiglotis y la destrucción del ligamento ventricular izquierdo y de la cuerda vocal izquierda, y en la mujer un inflamamiento considerable al nivel de los aritenoides, más el del lado derecho, y una ulceración irregular y granulosa en el repliegue inter-aritenoideo derecho. En ambos casos la demostración del bacilus tuberculoso no dejó lugar á duda respecto al diagnóstico. No es indudable que si en estos casos ó en otros semejantes, se demuestra con tiempo la naturaleza específica de las lesiones, se podrán evitar, retardar, ó disminuir los terribles destrozos que pueden sobrevenir posteriormente, En los enfermos en los que bien temprano he podido demostrar la presencia del bacilus de FKoch he instituido el siguiente tratamiento que me ha dado muy buenos resultados: (1) Inyecciones intra-laringeas, tres veces por semana de la siguiente solución : Gramos. Aceite de almendras dulces ------------------------------------------------- 100 Creosota de haya ---------------------------------------------------------- 3 Salol ----------------------------------------------------------------------- 3 Salicilato de bismuto ------------------------------------------------ - º --º -- º º - º 2 S. Inyección intra-laringea. (2) Aplicaciones con el pincel en los repliegues de la mucosa laringea de una solución de cloruro de zinc y sublimado: Cloruro de zinc----------------------------------------------------------- 5.00 Sublimado --------------------------------------------------------------- 0.05 Agua destilada ----------------------------------------------------------- 90.00 Glicerina----------------------------------------------------------------- 10.00 S. Toques para la laringe. 1514 PAN-AMERICAN MEDICAL CONGRESS. (3) Tres pildoras diarias de la siguiente fêrmula: GramOS Creosota de haya ---------------------------------------------------------- 1.00 Guayacol ----------------------------------------------------------------- 1.00 Extracto de Opio ---------------------------------------------. sº.A. º. * * * * * * * * * * 0.15 P. Píldoras No. 50. Tanto las invecciones de un gramo, como los toques laringeos, los enfermos los toleran muy bien, y he podido continuarles el uso cuotidiano de las pildoras de creosota durante muchos meses sin el menor inconveniente. - Periódicamente he estudiado las mucosidades laringeas al microscopio y he podido notar la diminución progresiva de los bacilus. En tres enfermos han desaparecido casi completamente se puede decir, pues con trabajo Se encuentra uno que otro en la preparación, y los sintomas se han mejorado en dos de éllos al grado de no presentar molestia y de haberse reducido la hinchazón laringea sin que aparezca el aspecto pâlido opaco de una mucosa tuberculosa. Creo portanto necesario el que en ningún caso, por poco Sospechoso que Sea, Se deje de recurrir à este medio diagnéstico que oportunamente permitirá al especia- lista instituir un método curativo tal vez eficaz. THE TREATMENT OF CERTAIN CASES OF CHRONIC CATARREH. By Dr. ANGEL GAVINO, City of Mexico, - [Abstract given by Dr. A. W. de Roaldes.] Dr. Gavião wishes to call attention to some cases of apparently chronic catar- rhal affection of the larynx; those cases which after having been treated prove rebellious to the treatment. He calls attention to the fact that, in his opinion, from his experience, in some of these cases it is advisable to examine the laryngeal secretions microscopically; that is, in those cases where nothing objectively in the larynx or chest would permit one to suspect any tubercular affection. In such cases he has had the laryngeal secretions examined and has even gone so far as to scrape the mucous membrane ; but only in cases where there is no infiltration or ulceration that might lead to the suspicion of tuberculosis, and in such cases he has found in the secretions or the scrapings, Koch's bacillus. This has been a sufficient reason to him to carry on that practice systematically and he has been able in that way to diagnose laryngealtubercular trouble and to institute the proper treatment in time and long before the objective symptoms, either of the chest or the larynx, would have led him to believe that he had to deal with tubercular trouble. Accordingly, he suggests the advisability in those cases of making a microscopic examination of the secretions and even scrapings of the mucous membrane of cer- tain parts—the arytenoid cartilages, false folds, ventricular bands, and epiglottis. The treatment he suggests is laryngeal injections of an oily substance containing creosote, salol, and salicylate of bismuth, local application of bichloride of mer- cury and chloride of zinc, and creosote given internally. His conclusion is that even in apparently healthy mucous membrane, where nothing attracts the atten- tion but the rebellious condition of the part to treatment, microscopical examina- tion of the secretions and scrapings of the mucous membrane will often reveal the bacillus tuberculosis when we least expect it, and we are in that way able to insti- tute early germicidal treatment, especially creosote. PAN-AMERICAN MEDICAL CONGRESS. 1515 DISCUSSION. Dr. D. BRYSON DELAVAN, New York City. This is certainly a most interesting paper. The plan proposed is a decidedly new departure, different, so far as I am aware, from any we have heard of before. There are without doubt instances in which tubercular disease seems to develop primarily in the larynx, more probably than we are aware of, because of the difficulty of the diagnosis. If this means could be carried out, with reasonable skill on the part of the practitioner, it would seem, as the writer of the paper has indicated, that in a certain number of cases at least an early diagnosis might be reached. I hope that the paper may be trans- lated and We may have the pleasure of reading it in English, as it seems to me to embody a very valuable suggestion. ALUMNOL, ITS EXCELLENT PROPERTIES FOR USE IN THROAT AND NOSE PRACTICE: A NEW ANTISEPTIC AND ASTRINGENT. By J. MOUNT BLEYER, M. D., of New York City, Visiting Laryngologist to the West Side German Clinic, etc. * Following upon the discovery of kairin, the first of the series of synthetical sub- stitutes for chinin, and that invaluable one, antipyrin, together with naphthol, resorcin, urethan, methylene blue, benzoinol, and others of the same group intro- duced to us by those excellent chemists, Meister, Lucius & Bruning, of Hoechst, Germany, comes another of their preparations for which, after careful trial and investigation, I predict a long career of usefulness. I refer to alumnol, which only recently was isolated and prepared by Drs. Heinz and Liebrecht also, those chemists who first demonstrated the possibility of building up alkaloids in the laboratory, and were the ones who gave to us the new synthetical medicaments now passed beyond the stage of experiment, whose value as combatants of disease can not be underrated. Kairin, for a long time after its discovery, was regarded as one of the many curiosities that are born in the chemical laboratory, only to remain as such ; and so, too, was the early fate of its successor, antipyrin, which, as we all know, has since become one of the most valuable therapeutical agents in our pharmacopoeia. It is only since the days of Dalton, Gay-Lussac, Dulong and Petit, Mitscherlich, Berzelius, Avogado, Faraday, Whöler, and others that the chemist sees in the past course and present tendency of organic chemistry the strongest proofs of the influence and value of the doctrine of Dalton and of these other scientists. Within the past few years many of the new synthetical rem- edies have found their way into our materia medica, and a knowledge of their nature, history, and properties is essential to every progressive medical man whose aim it is to keep abreast of the rapidly developing pharmacology of the age. My object is, before entering upon the discourse regarding alumnol, etc., which is also one of these synthetical compounds, to trace historically part of the development of synthetical chemistry, in order to make it clear to those not so thoroughly versed in this branch of science. As far back as 1823 Gay-Lussac and Liebig clearly recognized the existence of isomerism.” It is in the domain of organic chemistry that isomerism finds its numerous and most striking examples. Isomerism, after its recognition, sho ... ----------------" the faet—that-the-same-e its māy combine together in the same proportions and yet give rise to totally distinct compounds, and also that fact that it must i Synthesis—meaning in chemistry the uniting of elements into a compound. *In chemistry this term means: Identity or close similarity of composition and molecular weight with difference of physical or of both physical and chemical properties. 1516 PAN-AMERICAN MEDICAL CONGRESS. ultimately depend on difference in the mode in which the atoms of the constituent elements are combined. The discovery of the identity in qualitative and quanti- tative composition of silver fulminate and silver cyanate by these chemists was in reality one of the most momentous discoveries of the century. These were followed quickly by new discoveries in that direction by other chemists. As these many facts were born and made known to the science of chemistry they profoundly influenced chemical thought by demonstrating that the attributes of |bodies depend not merely on the nature and number of their components, but also on the mode in which these components are arranged and distributed. Chem- ists for the first time clearly recognized that their business was not only to deter- mine the quality and quantity of the various atoms in a compound, but also the manner in which those atoms were grouped and held together. This, indeed, is the great problem of modern chemistry, and each successive theory of the last half century may be valued in proportion as it has ministered to this end. The idea of atomic grouping lay at the basis of the doctrine of radicals, by means of which the chemists of sixty years ago sought to make evident that organic com- pounds are fundamentally similar to organic substances. It lay, too, at the basis of the unitary views, which, with the discovery of the principle of substitution by Dumas, began to gain ground in organic chemistry. The fact of substitution, indeed, is as inexplicable as the law of multiple proportions, except upon the atomic hypothesis. The nucleus theory of Laurent and the different type theo- ries of the French school, and of their successors in England, all tacitly recog- nized the existence of atoms. - The limits of this paper preclude the possibility of the attempt to show how these various theories have given place to more rational modes of viewing the structure of organic compounds. Unquestionably the two most powerful factors in determining the present character of organic chemistry have been : firstly, the recognition by Frankland, 1852, of the fact that the atom of every element is inherently endowed with a specific combining power, varying within certain limits, whereby it is able to unite with a definite number of atoms of other ele- ments; and secondly, the hypothesis of Hekule and Couper, which graft them- selves directly on Frankland's discovery, concerning certain peculiarities in the mode of combination of the element carbon, the Organic element par excellence. Although nothing is known as to the real cause of valency, that is to say, of the cause which enables the atoms of carbon to take to itself and hold in stable union four atoms of hydrogen or of chlorine, and no more than four, and which forbids the atom of hydrogen or of chlorime to do the same thing as regards carbon, it will be obvious that the fundamental idea of valency is essentially atomic in con- ception. From this time the attempts of chemists to unravel the internal structure or constitution, to use the term first introduced by Butlerow, of organic compounds, took a new departure. Great numbers of compounds hitherto unknown and undreamt of were prepared because theory indicated their existence. The mode of genesis and the nature of the transformations of these bodies threw fresh light on the manner of the grouping of the atoms in bodies already known; and the knowledge thus gained enabled chemists to conceive the methods by which such bodies might be synthetically prepared. Indeed, it may be safely asserted that whenever the constitution of an organic substance is clearly made out the synthet- ical formation of that body comes within the sphere of practical chemistry. It may not be uninteresting in this connection to take a short survey of the progress which has been made in synthetical chemistry during the last fifty or sixty years. Such a survey, however rapid, will take us into every department of the organic world. During the past half century the chemist has succeeded in forming the active principles or characteristic products of many plants; he builds up sub- stances which have hitherto been regarded as made only by the very process of PAN-AMERICAN MEDICAL CONGRESS. 1517 living of an animal; and he has formed substances which were thought to be pro- duced only by changes in organized matter after death. That particular day in 1828 when Wöhler first observed the transformation of ammonium cyanate into urea should be accounted a red-letter day in the history of science. This discovery virtually gave the death blow to the notion that the operations which are concerned in the formation of the chemical products of the organic world are fundamentally different from those which take place in the inorganic world. Urea, or the final product of a series of tissue changes, is pre- eminently a typical product of animal life; no more characteristic example of a substance formed by the action of the so-called vital force could possibly be adduced. By demonstrating that urea can be made synthetically by ordinary laboratory processes and from substances inorganic in their origin, Wöhler proved that vital force is only another name for chemical action, and that an ani- mal is nothing but a laboratory in which a multitude of chemical changes, similar to those which occur in our test-tubes and controlled by essentially the same con- ditions, is continually taking place. Since the date of Wöhler's discovery, urea has been synthetically prepared by many reactions. Thus it was obtained by Natanson and Basarow by the action of ammonia on carbonyl chloride. This and the other reactions have a special interest from the circumstance that all the sub- stances taking part in them can be formed directly or indirectly from their ultimate elements. Associated with urea as a product of the oxidation of the nitrogenous compounds in the organism are uric acid, xanthin, and sorcin. These bodies are met with in greater or less quantity in urine and in certain forms of urinary cal- culi, and they are invariably present in the blood and muscle juice. In chemical composition they differ from each other simply in the amount of oxygen they con- tain. Urea was first artificially transformed into uric acid by Horbaczewski. Its synthesis has also been effected by Behrend and Roosen. Closely related in chem- ical composition to these bodies are theobromine and caffeine, the active princi- ples respectively of cocoa, coffee, and tea. The widespread use of caffeine-con- taining products is undoubtedly of great physiological import, and its interest is enhanced by the intimate relationship which is now shown to exist between caffeine and the products derived from the oxidation of nitrogenous matters within the organism. Xanthin, indeed, has been recently transformed into theo- bromine by Emil Fischer. Of late years much attention has been paid to the study of the putrefaction of albuminous substances of animal origin with the result that a considerable num- ber of basic nitrogenous bodies, some of which are highly poisonous, have been isolated. These compounds were classed by the Italian toxicologist Selmi under the generic name of ptomaines. They are the products of the vitality of the micro-organisms which are concerned in setting up the putrefactive change. Their discovery has greatly modified our views as to the mode of action of pathogenic organisms, and it is now regarded as not improbable that the disturbances are due rather to the presence of these poisonous compounds. It ought to be stated, however, that the attempts hitherto made to isolate the toxic substances which may be formed by the growth of pathogenic organisms have been attended with only partial success. Thus Nencki was unable to detect any toxic substance among the products of anthrax and staphylococcus aureus, a common organism in abscesses which yields only a nonpoisonous base. On the other hand Briegger, to whom we owe the detection of a large number–of–these—se-eałłed-eadaveric atka- loids, has found that the typhoid bacillus yields a poisonous substance which he has named typhotoxine; and he has also discovered that the bacillus of tetanus forms a base now called tetanine, which gives rise to symptoms which have a strong resemblance to those occasioned by the inoculation of the bacilli. 1518 PAN-AMERICAN MEDICAL CONGRESS. All the ptomaines hitherto isolated are comparatively simple in composition and not very complex in chemical constitution. Some of them have been shown to be identical with bodies already known. Thus choline, a nonpoisonous alkaloid found in bile by Strecker, in the brain and in the yolk of egg, and now known to be the productof the putrefaction of meat or fish, has been synthesized by Wurtz; whilst neurine, a derivative of brain substance, originally confounded with cho- line, but differing from it in composition and in possessing intense poisonous properties, has been artificially produced by Baeyer and Hofmann. Choline and neurine are closely related substances, and can be readily transformed into each other. AImother of the so-called corpse alkaloids, cadaverine, has also been syn- thetically formed by Ladenburg. * In 1870 Schmiedeberg and Koppe isolated the poisonous principle of the fungus Agaricus Muscarius, which they named muscarine. Subsequently muscarine was obtained synthetically. It is,however, among the products of plant life that some of the most valuable syntheses of modern times have been effected. Tartaric acid, the characteristic acid of unripe grapes, and citric acid, the acid which gives sourness to limes, lemons, and oranges, have each been artificially prepared. Many attempts have been made at various times to effect the artificial formation of vegetable-alkaloids, such as quinine, morphine, Strychnine, etc., but as yet with only partial success. There is little doubt, however, that such synthesis will be accomplished when the constitution of these complex substances is better under- stood. Up to the present time only two alkaloids have been synthesized, one completely, viz, comine, and atropine. A considerable number of the odoriferous principles of plants have been obtained artificially, such, for example, as bitter- almond oil and oil of mustard. Salicylic acid, vanillin, and alizarin are now also synthesized. The remarkable industrial results which followed Graebe's and Liebermann's discovery from coal-tar derivatives, which completely destroyed a staple trade of France, Holland, Italy, and Turkey, naturally roused chemists to attempt the artificial formation of a dyestuff not less important, viz, indigo. This has been accomplished, independently, by Baeyer, by Heumann, and by Heymann. No synthesis of recent years has created a keener or more widespread interest than that of the sugars, dextrose and laevulose, which has been recently effected by Emil Fisher. It is interesting not merely as an instance of the arti- ficial production of well-known substances, but also on account of the light it is calculated to throw upon the origin and mode of formation of the sugars in the vegetable kingdom. This has been accomplished through the medium of glycerin. The advance in every section of chemistry during the latter half of it has literally been by leaps and bounds. Although practically a creation of our own time, no branch has been more fruitful in result, in suggestion, or in possibility than that of organic synthesis. The mere gain in the knowledge of fact is immeas- urable; it is even more impossible to gauge the profound effect of that knowledge on other departments of human effort and intellectual activity. Past history shows only too well that there is a tide in the affairs of Science, as in all other things, that constitute affairs of men. There are periods of ebb and flow, of advance and retrogression. But of this we are certain : in chemistry the flood has only just set in, and it is still very far from high-water mark. - Alumnol is a remedy to which I desire to call the attention of my colleagues, the laryngologists, on account particularly of its antiseptic, astringent, and highly non-poisonous properties, which, by the way, are its marked characteristics, and which alone must give it prominence as one of the most useful agents in our branch of practice. In looking up the pharmacological literature in relation to the sub- ject, I find that many different preparations of aluminium have been used as anti- Septics, particularly the acetate and aceto-tartrate, both of which are freely solu- ble in water and possess the advantage over the others of being devoid of poison- PAN-AMERICAN MEDICAL CONGRESS. 1519 ous effects. But, like all our therapeutical investigations, we continually are brought to realize that even among good remedies some are decidedly better than others. It is like the Irishman's whisky. And so it was with solutions of alumin- ium salts; while good in Imany ways, their demerits far outweighed their merits. In the first place, the stability of the solution could not be relied upon, and that, in conjunction with other chemical disadvantages, such as throwing down a pre- cipitate of an insoluble base, proved to us that they were not safe agents to employ in daily practice where an unshaken confidence in the evenness of a preparation is absolutely essential. These are among the more important reasons that are given us for introducing an aluminium preparation, perfectly stable when in solu- tion and capable of retaining an evenness of strength, yet possessed of all the advantageous principles which we look for in aluminium. Such a preparation, I unhesitatingly say, we find in alumnol. Chemically speaking, alumnol is the aluminium salt of a napthol-sulphionic acid, containing 15 per cent of sulphur in the form of the sulphon group and about 5 per cent of aluminium. It assumes the form of a fine-grained white powder, which may readily be dissolved in cold water to a strength of 40 per cent, this enabling us to make any strength of solution without the danger of separation of the salt from its solvent. It is also soluble in glycerin and hot alcohol. In the latter solvent it exhibits a beautiful blue fluorescence. It is insoluble in ether. Heinz and Liebrecht, its discoverers, tell us that it possesses reducing properties, which they say is evident from its behavior with nitrate of silver, especially when warmed. As a result of this fact alumnol undergoes a change by long exposure to the air, becoming darker. This change, however, does not affect any of its prop- erties and stabilities. Like all the solutions of aluminium salts it has an acid reaction. These salts will precipitate albumin, but differ in this respect from other astringents in that the precipitate immediately redissolves in an excess of albumin. This very behavior of alumnol makes it doubly valuable, enabling it to mix with the fluids of the body rich in albumin and thus enter into the tissue substance. Alumnol will be found to be a most powerful astringent. This prop- erty I have tested in many ways, viz: If applied to the tongue in solutions of 0.01 per cent in strength patients have readily become aware of the astringency of the the remedy. Much milder solutions, such as 0.0025 to 0.005 in strength, give me like results. I made several experiments on the vascular membranes of animals, and in each case the peculiar astringent property of the alumnol became evident. It was an astringency unlike that of the astringents commonly used by us. In solutions up to 5 per cent in strength there was not the slightest sign of irritation to the membranes experimented upon. Let this suffice for a brief description of the more important chemical features of alumnol; and now a word about its therapy as I know it. - In speaking clinically of alumnol I shall give, in brief, cases in which 1 found it possessed of advantages above those of other astringents I have used. One of the first cases in which I had an opportunity to use aluminol was a case of epistaxis. Here the epistaxis was due to an erosion of the membrane covering an arterial twig in the cartilaginous septum, and in one or two other varieties much like that form which we so often find associated with cirrhosis of the liver in its early stage, where rupture of the capillaries of the nasal fossae occur. Here the application to the membrane of a solution of 0.25 to 1 per cent in strength con- trolled the haemorrhage in short order. A tamponade saturated with a solution of the same strength is equally efficient, and I have not the slightest doubt that insufflations of powder in the same proportion may be used. I also treated sev- eral cases of simple and chronic rhinitis of the form that comes under the observa- tion of the rhinologist almost daily in the following manner, with exceptionally good results: First, I carefully cleansed the passages with a warm solution of 1520 PAN-AMERICAN MEDICAL CONGRESS. Sodium bicarbonate, 1 dram to 1 pint of water. This was followed by the injection of one-fourth per cent solution of alumnol. The cases all showed signs of improvement after a few applications. I also tried the efficiency of alumnol in cases where I had operated for nasal polypi. For several days after the removal of the growths I used an alkaline wash, alternating with injections of a one-half per cent solution of alumnol. In two out of four cases thus treated no recur- rence of the trouble followed. The other cases passed from my notice, and hence I am not able to acquaint you with them. In two cases of ozena, one of syphilitic and the other of constitutional origin, both were treated with alumnol with most gratifying results. The nostrils were ordered washed twice or thrice daily with a copious application of sodium bicarbonate, one-half teaspoonful to the ounce of warm water, which was followed by a one-half per cent solution of alumnol. After the last daily washing, a powder containing one-half per cent of alumnol was insufflated. Where abrasions of the mucous membrane were discovered they were covered over with lanolin, containing 5 per cent of alumnol. Often when the incrustations were extensive I applied a cotton wool tamponade, moistened with a very weak solution of alumnol, which I left in the situ from two to three hours, leaving the patient to remove them according to instructions. In these cases the discharges became less offensive, and if we can have such good results I can not praise alumnol too highly. In two cases, when I curetted to remove post- nasal adenoids, I used a mild solution of alumnol, from 1 to 2 per cent, both as a disinfectant and astringent. In one case where the haemorrhage was excessive the flow was immediately controlled by a 1 per cent solution of alumnol. Not long ago Ihad occasion to see several cases of syphilis. One was of the bullous variety, with laryngeal complication. The ulceration implicated a large area of both the pharynx and the larynx. In these cases I used douches of alumnol, 1 per cent, after cleansing the parts with an alkaline Solution. The antiseptic and healing properties of the alumnol were marked by the fact that the ulcerations healed up in from eight to ten days. In tonsilitis, where the glands are inflamed symmet- rically, and which varies much in severity and should not be confounded with suppurative quinsy due to Septic causes, often attacking several members of one family, and frequently concomitant with Scarlatina and diphtheria. In short-lived outbreaks of so-called infectious sore throat, occurring from bad sanitary sur- roundings, etc., I have secured very good results from gargles and irrigation with a 2 per cent solution of alumnol. Alumnol is undoubtedly a nonpoisonous antiseptic and astringent, acting not only superficially but also upon the deeper tissues, owing to its ready diffusibility. The tonsils, we know, are absorbant glands, and their function not improbably may be connected with the absorption of certain elements of these poisonous bacteria which enter the system through this channel. The great advantage of alumnol in this instance seemed to be its power to disinfect the channels without occluding them. This is mainly due to the extreme readiness with which alum- nol disfuses itself. I was not long ago told that one bacteriologist who used it found it to be a bactericide of high grade. In 1most cases of acute and chronic laryngitis, where we are prone to lay much stress on the application of astrin- gent solutions, alumnol in 1 per cent Solution gave a good account of itself, especially in those instances where there was a congestion of the vocal bands, the arytenoid cartilages, or interarytenoid folds. I can not conclude this paper without saying a few words about the action of alumnol upon mucous plaques of the tongue of specific origin, in the treatment of which we have not had much to encourage us until lately. I need not dwell upon the many local applications that we have been in the habit of using from time immemorial, but I will say that none gave me such results as alumnol or chromic acid. By vigorously push- ing the alumnol application I soon found that it suited patients far better than chromic acid. PAN-AMERICAN MEDICAL CONGRESS. 1521 In conclusion let me say that in alumnol I find a remedy which is soluble in water, has a penetrating action which makes it specially active, not only against recent inflammatory affections, but against those chronic forms in which infiltrations and induration have occurred. For the latter a higher concentration of the remedy is necessary (from 5 to 10 per cent). Another great advantage is that it can be worked up into various forms, as with glycerin, lanolin, vaseline, gelatin, etc. My short experience with alumnol has been very gratifying. I must ask you to try its efficacy, which I know will not disappoint you. DISCUSSION. Dr. D. BRYSON DELAVAN, New York City. I have been using alumnol for six months and find it a remarkably good astringent, although I have not proved in my own practice all that has been said of it. EXHIBITION OF INSTRUMENT FOR FINDING LOST INTUBATION TUBE. By Dr. J. MOUNT BLEYER, of New York City. This is my first model of an instrument, which I please to call an electrical probe searcher, for the discovery of a lost intubation tube within the lower air passages. The usefulness of this instrument was practically demonstrated several months ago upon such a case. This accident has befallen me only once in over 540 of my cases which I had operated on from the year 1886 to 1892. Nevertheless such another may happen again to me and others who operate. The diagnosis of a lost tube can be made by means of this searcher without delay and anxiety, which I believe is worth the price of its cost. The apparatus consists, as you see, principally of three parts: (1) The battery; (2) the alarm; (3) the bipolar needle-pointed searcher; contained, with their acces- sories, in a box 4} inches by 3 inches, and is complete in itself, requiring no external supplies. The battery is made up of a carbon cell, with zinc electrode, S. Ex. 36 96 1522 PAN-AMERICAN MEDICAL CONGRESS. and is charged with bisulphide of mercury, made ready in a moment's notice by adding a teaspoonful of water to one-fourth teaspoonful of the mercury powder. The alarm is a buzzer. The searcher is a bipolar electrode, with two fine-pointed needles of 1 inch long. The method in using the instrument is very simple, the probe or searcher being handled in the same manner as a pen. It is held in the right hand, and with the left the skin over the trachea, or in the suspected location of the tube is made tense by an assistant. The needles are thrust in between the rings of the carti- lages of the trachea, and explored until the contact is made between the searcher and the tube. Both points of this needle probe usually touch the metal tube at once, and a bridge of contact is formed, which obtains a signal from the buzzer. The location of such a tube is determined beyond a doubt, and preparation for its removal is next in order. This method of searching does not hurt the child, A CASE OF ELONGATION OF THE EPIGLOTTIS REDUCED BY OPER- ATIVE MEASURES. By PRICE BROWN, M. D., of Toronto, Canada. In the treatment of the case I now report I am much indebted to Dr. Rice, of New York, for a paper read by him last year at the annual meeting of the Amer- ican Laryngological Association, entitled “The troublesome symptoms caused by the enlargement of the epiglottis, and the advisability of reducing the size of the cartilage by operative measures.” I was much impressed by the article when I read it, as I had on several occasions treated patients for laryngeal dis- ease, in whom the epiglottis presented either an abnormal development or some unusual feature in reference to position. In no case, however, up to the time of writing, have I found it advisable to operate, except in the one which I have the honor to report to you to-day. And in this case, owing to its being more One of malposition than malformation, I was obliged to resort to the method which Dr. Rice, at the time of the preparation of his paper, considered inadvisable, namely, the galvano-cautery. On February 27, 1893, Miss M., ast., 23 years, tall and slight in figure, presented herself for treatment. Family history was not good. Although both parents were living and healthy, yet on the father's side there was extensive tuberculosis. Two of her brothers likewise had died of consumption, between the ages of 20 and 30 years. The patient herself had been delicate from infancy; and according to the statement of her family physician the apex of her left lung had already, upon two distinct occasions, been diseased. During early childhood her respiration had been of a whistling character; and throughout life she had been subject to throat colds, attended by marked hoarseness, sometimes amounting to complete aphonia, and lasting for a period of one or two weeks. One other interesting feature was the difficulty the patient had always experienced in freeing her throat from mucus. Two years prior to consulting me her physician sent her to Colorado Springs for six months. She returned much improved in general health, but with little amelio- ration of the throat symptoms. When she came for advice she had been free from cold for several weeks. Laryngoscopic examination revealed a healthy larynx, so far as could be seen. The epiglottis, however, was long and narrow, with the end turned up, and it occupied a completely horizontal position. During ordinary respiration the whole of the free end pressed against the posterior wall of the pharynx; while during forcible inspiration or expiration it was raised slightly, seemingly enough to admit the passage of a narrow knife blade. The whole larynx was deeply seated, and it required 2+ inches from the right angle of the laryngeal probe to reach the tip of the epiglottis. Fortunately the patient was tractable. The manipulation of the parts was tolerably easy ; and, as a good view could be obtained, I considered the case a favorable one for operation. On March 1, after applying a 15 per cent solution of cocaine, I made the first tentative touch with the galvano-cautery, and for the next two days watched care- PAN-AMERICAN MEDICAL CONGRESS. 1523 fully for pseudo-membranous inflammation or edema, as the possible results of the operation. The reaction, however, was slight, and on the 4th, during forcible breathing, I slipped the galvano-cautery blade between the epiglottis and the post- pharyngeal wall. Then drawing the former forward by means of the instrument so far as to free the pharyngeal surface, I cauterized the central margin and also the left side of the tip. The operation was followed by sloughing and acute con- gestion of a mild type, but no edema. I operated upon the remaining portions on the 18th and the 29th. Throughout the treatment, simple albolene sprays were made to the throat several times a day. At no time was the reaction very strong; and owing to the effect of the cocaine the operations were not only pain- less, but the epiglottis itself remained immobile during the cauterizations, ena- bling the operator to limit, as he might choose, the amount of work done. During the whole course of treatment the deglutition of fluids was not interfered with to any marked degree. . Of course solids were interdicted for several days after each application of the galvano-cautery. The shortening of the epiglottis amounted to about one-quarter of an inch, leaving as a result a permanent niche of about half that width. On April 1, as the patient was in need of general recuperation, I allowed her to return home to a town 100 miles distant. There was still a protruding corner that I did not like, so I arranged for her to come for further treatment later on. Accordingly, she visited my office again on June 6. The epiglottis during the interval had entirely healed, and although she had suffered once or twice from cold this had not, as formerly, been attended by hoarseness. I found, however, as I expected, a little projecting nodule on the left side. This I touched twice with the galvano-cautery at an interval of three days. The healing was more rapid than formerly, and in ten days the young lady was well enough to return home. On final examination before her departure the sloughs had separated, the epiglottis was uniform in length and regular in outline, and although the Organ was still and probably ever would be in the horizontal position, the vocal cords could both be distinctly seen, something that was quite impossible previous to the cautery opera- tions. Six weeks later I heard, directly from my patient's mother, that physically much progress had been made, and that the throat itself was now quite well. In reference to the advisability of using the galvano-cautery in the treatment of cases of this kind, it must be said that the experience gained by the history of one case is not sufficient to establish a rule. Malposition to the extent and in the form described is probably exceedingly rare. It was fortunate that the epiglottis was both narrow and thin, facilitating operation and reducing to a minimum the probability of edema. If, on the other hand, the Organ had been broad or thick or hypertrophic, caustic treatment would certainly have been more dangerous in view of possible pseudo-membranous inflammation or edema of the inner surfaces of the larynx. I have, on several occasions, seen severe temporary edema of the palate and uvula following galvano-cautery operations on the tonsils; and if a like result should occur to the ary-epiglottis folds or ventricular bands from similar treat- ment of a thickened epiglottis, the end would scarcely justify the means. In well selected cases, however, there are several facts in favor of this method of operat- ing which would seem well worth considering. First of all, sufficient time for thorough and careful treatment is in every way essential for a successful result. Then the operations can be performed bit by bit, and by having the patient under daily observation the parts can be kept under perfect control. There is no bleed- ing to interfere with examinations, and when cocaine of sufficient strength is applied, we have not only immobility of the epiglottis, but likewise freedom from pain during cauterization. To this might be added that the chiseling may be done so perfectly as to challenge comparison with the normal epiglottis. For cases in which, for various reasons, the galvano-cautery might be unsuitable. I would suggest the construction of a rectangular epiglottome, in which the teeth would merely transfix the epiglottis, without drawing it further into the ring, as in tonsilotomy. The amount cut off by the blade would thus be under the com- plete control of the operator. If trimming of the margins was still deemed nec- essary, this could be accomplished by the galvano-cautery after the healing of the primary wound. 1524 PAN-AMERICAN MEDICAL CONGRESS. DISCUSSION. Dr. E. FLETCHER INGALS, Chicago. I have had no experience with the gal- vano-cautery in such Operations as this, nor indeed with any instrument, but the thought suggested itself that if the tissue could be removed by a cutting instru- ment, such as is suggested in the paper, or a punch forceps, the treatment could be carried out much more expeditiously and perhaps with less danger and dis- comfort to the patient. The galvano-cautery when used by an experienced person like the author of the paper, is perfectly safe and is of great value, but the result- ing reaction is always more than if a simple cutting instrument had been employed; therefore the latter would seem better. I do not know that there are any instru- ments made for the purpose, but it would be easy to devise one of proper angle with a cutting punch or scissor blade. - Dr. PRICE-BROWN, Toronto. I do not think it would be wise to operate in cases of this kind without you can have the patient remain constantly under your care. Then, if the throat was in that condition, you could treat it as you wished. I know there is danger in using cautery instruments of this sort. Some years ago I used the galvano-cautery in removing the tonsils. After operation the patient went out of the city for a week; when she returned she was completely aphonic, respiration strong, temperature 101°. I examined the throat and found inside of the epiglottis a coating of pseudo-membrane, and I thought at the time it was diph- theria, as there were some cases in the neighborhood. The healing of the throat had gone on continuously; there was no pseudo-membrane in the fauces or larynx, only on the inside of the epiglottis. The vocal cords were congested, also the ventricular bands, and there was a certain amount of edema. I treated the case with inhalations of steam and the patient recovered in a few days, but having that case in mind and believing now that it was traumatic instead of diphtheritic, made me particularly cautious as to the manner in which I operated upon the case I have reported. I think you can operate so that there need not be any danger if you have sufficient care of your patient afterwards; but if not, I think it would be dangerous to operate. THE SIMPLEST AND MOST PRACTICAL ELECTRIC APPARATUS, ESPE- CIALLY FOR GALVANO-CAUTERY OPERATIONS. By ARTHUR. G. HOBBS, M. D., of Atlanta, Ga., Member of the American Medical Association and the Pan-American Medical Congress, Ex-Presi- dent of the American Rhinological Association, Member of the Georgia State Medical Association, and Fellow of the Atlanta Society of Medicine, etc. The little apparatus that I am using especially for galvano-Gautery operations is the only perfect appliance for that purpose in my knowledge. It has been used in my own and assistants’ rooms perhaps a thousand or more times during the last year, and in no instance has it ever failed us or caused us any care or trouble. Indeed, no thought of its presence is ever suggested until it is needed for actual use, quite unlike any of its predecessors, even the best of which required an occa- sional charging. It is small and compact, contained in a mahogany box 8 inches long, 4 inches thick, and 4 inches deep, and is securely screwed to the wall at a convenient distance from the operator's chair. The wires from an alternating cur- rent of 52 volts, the most generally used circuit, particularly in the medium and smaller cities, are brought into the operating room from the street wires and attached at each upper corner of the little box. The conducting wires are simi- larly attached to the lower corners. The apparatus is now ready to be used for the cautery, the magnet, or for the small incandescent lamp, and it remains always PAN-AMERICAN MEDICAL CONGRESS. 1525 and ever ready. When the moment for using it arrives it is only necessary, first, to turn a screw, projecting from its nearer surface, with the left hand, while the instrument is held with the right. It thus serves as a gauge for measuring out the exact quantity of electro-motive force in the form of heat, magnet power, or light by modifying the 52 volts, conducted to it from the nearest street transformer, to an alternating current of the fractional number of volts that may be required for the occasion. As both the force and ampèreage in actual use with this transformer are acquired by induction, and are not in direct contact with the initial current, there can be no possible danger to either the patient or operator, even if the initial wires should by accident come in contact with more powerful wires. The electro-motive force can be gauged between 1 and 16 volts by a screw, and the ampereage is determined by the resistance of the conducting wire. The cost of the electric supply is very small, perhaps $2 or $3 per month for all ordinary purposes, including the rent of the meter. It is quite easy, by modifying the force with a slight turn of the screw, to adapt it to the forehead lamp in ear operations, and to the still smaller lamp used for translucent and direct illumination in the small cavities, as in antrum diag- noses. A much smaller cautery handle than the conventional one is more con- venient for actual use, while in addition to this it may be permanently attached to the conducting cord, where it is always at hand, requiring only to change the point to suit the occasion. The larger handles are necessary, however, for the wire loop Operations. The needle and a narrow blade are the only cautery points used in my rooms, and in all cases they are made to enter at the most prominent part of the hypertrophied tissue, penetrate down to the bone with white heat, and then withdrawn through the same puncture while the point is hot. In no case is a wholesale destruction of the mucous membrane ever produced by applying the flat surface of the blade to the protruding part. The needle and the narrow blade produce little or no pain when an application of a 10 or 20 per cent solution of cocaine has been locally applied on a cotton probe ten minutes before the operation. The annoying constitutional symptoms, that not infrequently follow even a weak spray, are rarely encountered when a many times stronger solution is applied to a limited area of mucmous-embrane surface. Its easy control renders it the most reliable and certain means for making cautery operations on the cornea, because of the small amount of electro-motive force required to heat the fine points used for this purpose. This means of treating corneal ulcers, and, I may also add, of reducing the corneal part of a pterigium, is not only less painful than any other, but the resulting cicatrix is more transparent, provided the cautery is not allowed to touch the healthy cornea. A pterigium will in some cases need no further. operative procedure, although it will occasionally be necessary, in addition to the cautery, to sever the vascular supply, without excising any part of the hypertro- phied conjunctiva except when it is decidedly thickened. The magnet in general use is constructed for the continuous current, yet it can be charged for the lighter uses with the alternating current. My electrician is now adapting one of these magnets to the alternating current for this apparatus. The electric motors hereto- fore used for fans and drills were supplied with the continuous current only, but some are now being adapted to the alternating current as applied by the trans- former. In addition to these varied purposes that this little apparatus may be called upon to serve, the current that supplies it may be still further utilized before its entrance. For example, it will light two incandescent lamps, and at the same time turn two fans or drills where the motors are suitable, and still supply the transformer with sufficient force. While the volume of the current, or ampereage, is large, the electro-motive force can be reduced sufficiently for therapeutic uses where the alternating current is advisable. In short, it is safe; it is inexpensive; 1526 PAN-AMERICAN MEſ) ICAL CONGRESS. it is always ready; it is reliable; it exacts no time or attention; it dispenses its force and volume in many practical ways: it occupies but little room and is not unsightly; it does its work perfectly, and if it once gains an entrance to the con- Sultation room of one who resorts to electricity in many of its varied forms it will become a fixture. T)ISCUSSION ON INJUDICIOUS NASAL OPERATIONS. In opening the discussion Dr. Hobbs said: If our friends, the gynecologists, have their nymphomaniacs, I think we, too, may have our rhinomaniacs. We have a class (and it is a rapidly increasing class) of patients who consult us with the avowed purpose, to use their own language, ‘‘ of having their noses burned out.” In some respects these two classes are analogous in that the neurotic factor is often present also in our rhinomaniacs, as it is always present in nymphomaniacs. My point is that we may, without much exaggeration, lay the blame of the injudicious, or at least the unnecessary, opera- tion, when we make it under such circumstances, upon the patient himself, unless we place it upon a higher plane, and refuse in all such cases even the pretense of an operation as a placebo or for its moral effect when its necessity is not indi- cated. While judicious and properly executed rhinal Operations have done and are doing an immense amount of good, for this very reason the temptation is increased in many instances to do operations that were better not dome, par- ticularly by the younger men just making their entrée into this special line of work. They are loath to allow an opportunity to pass to saw a septum, to drill an exostosis, or to cauterize a protuberance or an enlarged turbinate. The mere suggestion of a septum spur, or a bony protuberance, Or an enlarged turbinate is too often deemed a sufficient reason for a surgical procedure, even though no subjective or other objective symptoms may exist. When we are reminded of the large area of nasal mucous membrane its functions should at Once be sug- gested. The nasal space was intended to breathe through, and only secondarily to serve as an olfactory organ. As this great expansion of mucous surface, twice that of the so-called “ throat,” is intended to perform the important functions of moistening and warming the inspired air, the necessity of its preservation should never be lost sight of. Hence any nasal operation made without reference to the mucous membrane preservation is not only injudicious but harmful, provided the nature of the case does not necessitate its destruction. And again, where no operation can be made without resulting in a large cicatrix, the question may arise, “Would it not be better left undone?” In cases where chromic acid or any other escharotic would seem to be more appropriate on account of the timidity of the patient, or for any other reason, the toxic sequence should always be considered ; otherwise the operation may prove to have been an injudicious one. Septum deflections, spurs, and exostoses should always be carefully measured before any operative procedure is resorted to, else a perforation may result that would be worse than the primary condition. The drill is, in my opinion, almost always an injudicious device, for the reason that it necessarily destroys so much mucous membrane and leaves a rough cicatricial surface, although I find myself resorting to it in some cases of prominent exostoses. To attempt to generalize upon the injudicious external operations that are resorted to most frequently in malignant growths, and occasionally in large benign tumors, would require too much of your time, since each case of so serious a nature is a law unto itself and should always be so treated. ^ 3 | . = Engine Jºng-Arn l Aſr-º'ſ/ ^a rºofer. Cate/orº (3) § zºrea's (?vrreº. º Faradic. & © Zºra', ozºo, /or Zanz2. & © Miſſ Ampere. @ R (2) V O or || 6 || or || ,-º-Fºn- Šl G. W &=-3 ! N Moſor. Zynamo. F’ 3. A 1. --- Yº - /* 3./_2& J. J Fc/dº-Magne / - * arºls ºf Effshare; #: * * * * * * * *-* * ğäfisälii Zſ ºf V Il-TEß 32 vº. §xºs - †-A-É - —º y— X. E Z. * | Z _2? \A 2.97arro A2 ozo r Arma/iere. Arzrra /t/re Fig. 2. s N Moſor Dynamo. J/ 1 4. 3./_S J. 3 |77e/cy Magner. A’ •X. =#=#|-TF FE-F-I- [SHFº * * *m, º. º. - - - -* = HH-H = -7-- E-F-U--|--|-|E||== º === 2 F. 6 * 52 -—# - - mº sº me 2 [e -A- A- Z \ 7– * _Z3. Al . Zynarra o ZM o Aa r" Arizza/iere. A rrr, a /7, re Fig. 3, PAN-AMERICAN MEDICAL CONGRESS. 1527 AN IMPROVED MOTOR. DYNAMO AND ELECTRICAL CABINET FOR THE ADAPTATION OF THE STREET CURRENT TO OFFICE PRACTICE. By A. W. DE ROALDES, M. D., Surgeon in Chief of the Eye, Ear, Nose, and Throat Hospital, and in Charge of the Ear, Nose, and Throut Department . Professor of Otology, Rhinology, and Laryngology in the New Orleans Polyclamic : President of the Orleans Parish Medical Society; Fellow of the American Laryn- gological Association, etc. With a view of facilitating the application of electricity for medical and sur- gical purposes, and at the same time economizing in the cost of using this agent, I have had constructed an improved electrical cabinet, for which I claim, after one year's daily use, the following advantages: Reliability in its action, pre- cision in its application, convenience in the varied uses for which it may be adapted, and economy in the motive power. Although primarily constructed for my needs in the treatment and investigation of diseases of the ear, nose, and throat, it may, without any change in its mechanism, be adapted to all the pres- ent requirements for which electricity is used in medicine and surgery. The cabinet contains arrangements for generating the current required for heating electro-cauteries of all sizes, for operating the drill motor, for lighting up Small lamps of all kinds, and for applying the various forms of faradic and galvanic currents. In the application of each of these methods there are new and special features, which render the cabinet of more than ordinary importance. The cabinet very much facilitates the use of the electro-cautery. Instead of using the direct current, as is almost universally the case, an alternating current of low tension is used, as will be explained later, which adds considerably to the life of the cautery point. By means of the rheostat M (fig. 2) the current may be regulated for cauteries of all sizes, and the heating and cooling of the cautery points are regulated by pressure on the foot piece. The drill-apparatus also has special features which make it valuable to the surgeon. The capacity of the motor, being one-quarter horse power, will give sufficient power for operating in all kinds of surgical work for which the drill and trephine are adapted, and the working of the motor may be so adjusted that a speed of from 1,500 to 6,000 revolutions per minute may be attained. Of special value is the power of the foot piece to control the operations of the drill, as, by means of an automatic brake, the drill may be instantly started or stopped at the will of the operator by a simple movement of the foot piece. The current for lighting up miniature lamps, such as Vohsen's, Trouvé's, Trautman's, and Heryng's, etc., is controlled by a rheostat, so that lamps of either higher or low resistances may be used. By connecting wires with the binding posts of the cabinet the current may be conveyed to a specially designed “dark room,” where it may be controlled by a simple switch. This method I have adopted in my office, and find very convenient in the examination by trans- illumination for diseases of the maxillary sinuses. The induced currents which may be obtained from the cabinet are six in number : The primary (induced), the secondary, the combined primary and secondary, the alternating primary, the alternating secondary, and the combined primary and secondary alternating. Any one of these currents may be obtained by a movement of the lever of the current selector E (fig. 2), the strength of the current being regulated by means of the lever R. in connection with the indicator. The variety of these currents and their range of strength allow a wide latitude for their adapta- bility in electro-therapy. The galvanic current supplied by the cabinet con- tains in its circuit a water-rheostat, a milliampèremeter and polarity-changer. By means of a special device the current supplied is protected from the danger- ous influence of high currents potentiality from outside wires, which may acci- 1528 PAN-AMERICAN MEDICAL CONGRESS. dentally fall across the wires which furnish the current to the cabinet. This device also allows of delicate adjustment of the current, so that a strength of from one-tenth of a milliampère to 500 milliampères may be used. The impor- tant mechanism of the cabinet is a motor-dynamo, upon the action of which much of the capacity of the cabinet depends. As the name implies, a motor-dynamo is both a motor and a dynamo. Its special function is to transform an available existing condition of direct electrical pressure and volume into another ratio of pressure and volume which may be required for special work. This motor-dynamo was adopted for several reasons, prominent among which is that of obtaining cur- rents of low potential, free from the dangers and cost of using a 110-volt current from the Edison mains direct. - There is a great loss of energy to use a current having a potential of 110 volts in cautery work, when a 5-volt current will do the work, the ratio being 5 to 110; that is, we are wasting ### of the total energy passing through the circuit, and utilizing only +} p in the heating effects upon the cautery. The manner in which we economize energy by means of the dynamo-motor is very simple. By its agency we take, for instance, a current of two ampères at 110 volts pressure, and trans- form it into mechanical energy (loss about 10 per cent during conversion) or rotary motion similar to that of any ordinary motor, which motion, being trans- mitted to a shaft carrying another armature of similar construction, but wound differently, enables us to obtain a corresponding reduction in electrical pressure and an increase in the volume of currents flowing in direct proportion to the decrease of this pressure. On this principle, if we take a current of 2 ampères at 110 volts, and reduce this to 5 volts by conversion, we obtain 44 ampères of current at 5 volts, with no greater expenditure of mechanical energy than is represented in the first case, except such losses caused by friction in the parts, self-induction, and eddy currents, which do not exceed 10 per cent for each conversion, making a total of 20 per cent for the whole apparatus. Although in the construction of the motor-dynamo 2 independent armatures, 110 and 5 volts, respectively, are used, yet there is but one pair of field magnets, which envelop both armatures at the same time, which is a saving in the first cost of the apparatus, and likewise econo- mizes the amount of current required to excite them. The side marked A (fig. 3) represents that part of the field magnet covering the motor armatures, and to the right of this is the commutator, by which the Edison current at 110-volt pressure is admitted. This causes the motor to revolve and thus gives the shaft a definite rate of speed. The dynamo armature, being attached to this shaft, is caused to rotate at the same rate of speed as the motor armature, and also in a field, always of the same strength. The dynamo armature, by its rotary speed and power, generates a current of low pressure and great quantity, such as is necessary for cautery work, and this current is delivered to the commutators, B', B*, and B3, the first two being alternating currents and the last a continuous current, all having the same potential. Bº therefore gives a continuous current that is available for operating the induction coil with the interrupter in circuit, and from the commutators, B' and B”, we draw an alternating current which is here used to heat the electro-cauteries, and also to operate the induction coil without the use of the interrupter. It has hitherto been the practice of different makers when constructing dynamos of low-tension currents to generate and make use of those currents flowing in one Specific direction called ‘‘ continuous; ” but in this apparatus this process is reversed, a current which alternates about 6,000 times per minute being used. This current, on account of the rapid change of polarity, secures a longer life to the electro-cauteries than when they are heated by a continuous current. It is a well- known fact that the side of any incandescent conductor through which the posi- tive enters will waste away more rapidly than the negative side, and for this reason it is desirable to equalize this action in using the electro-cauteries. The PAN-AMERICAN MEDICAL CONGRESS. 1529 principal reason, however, for employing the alternating current in this connec- tion is that it enables us to use a commutator having no openings or divisions in its periphery, thereby excluding the possibility of sparking, a point of great impor- tance, as it concerns the life and correct working of one of the vital parts of the apparatus. Sparking is one of the great causes of cutting and destructive wear- ing of motor and dynamo commutators. For this reason carbon brushes are used throughout the apparatus to the entire exclusion of copper, experience having taught that mothing can equal carbon for this purpose in the present state of our knowledge. The objection to copper brushes lies in the fact that both the commutators and the brushes being metallic, the current (especially such a heavy current) has a tendency to fuse their surfaces together; as the continual rotation will not permit this, particles are torn off continually, causing what is known as “cutting,” which in some cases may become so great as to wear out a new commutator in a few hours. Carbon, being nonmetallic, can not be fused to the rotating commutator, hence its superiority for this purpose. There are 14 brushes used in this appara- tus, and were they of copper there would always be difficulty in getting the machine to work smoothly and successfully. The motor-dynamo ef this cabinet is capable of furnishing mechanical energy to the extent of one-quarter horse power. At the end of the shaft F (fig. 3) there is a small apparatus called an “automatic brake,” the object of which is to start and stop the power from the motor-dynamo to the belt G, which operates the drill engine at the will of the operator, and is controlled by what is called a “foot piece.” The automatic brake consists of five essential parts, marked, respectively, 1, 2, 3, 4, 5 (fig. 3), of which 1 and 2 are electro-magnets; 3 a keeper actuated by them ; 4 a sleeve carrying a pulley at one end and the keeper 3 at the other and free to move longitudinally on the shaft F within a limited scope; 5 is a friction cone fastened permanently to the shaft F, and therefore rotating with it. H is an outboard bearing made of hardened and accurately ground tool steel, and is put there for the purpose of steadying the shaft F and to prevent undue side strain from the action of the belt G. J is a hardened and ground steel collar and washer which receives the thrust due to the pressure of the brake magnet (2). On exam- ining the top board of the apparatus (fig. 2) there will be seen a set of three |binding posts called “foot piece,” and marked 2, 0, 1 ; they serve for the double purpose of actuating the brake by means of the foot piece and controlling the cautery current, both being operated with the same foot piece. In this connection the current selector is used. This has eight contacts, marked respectively, “Engine,” “Cautery,” “Interrupted primary,” “Interrupted sec- ondary,” “Interrupted primary and secondary,” “Alternating primary,” “Alter- nating secondary,” “Alternating secondary and primary.” The connections are so made that when the handle of the current selector is placed over the word - “Engine,” the cautery and induction-coil currents will be antomatically cut out and can not be used while the engine is in operation. This provision is necessary because the engine may be run at a variable speed by means of the Switch K, but these variations would seriously hamper the use of the cauteries and induction coil. To illustrate this, suppose two operators desired to use the engine and cautery at the same time, and let us suppose that the apparatus were so con- structed as to permit of such use. If, then, the operator using the engine adjusted the engine at the lowest speed, and the other operator at the same time employed a small cautery, which he brings to the proper degree of heat by means of the switch M-if, now, the first operator desiring to increase the capacity of his drill, increases the speed of his engine by moving the lever at K, the dynamo will simultaneously increase the strength of the current supplied to the electro-cau- tery, which would probably be at once burned out. When the apparatus is used 1530 - PAN-AMERICAN MEDICAL CONGRESS. for cautery purposes it is requisite that the starting switch K should be at full p0Wer On Contact 5, and the current selector must be on contact marked “Cau- tery,” and when in this position the foot piece attached to the binding posts 2, 0, 1 Will be cut out from operating the brake and the engine belt G, but will simply put the current on or off the cauteries attached to the cautery binding posts. A forward motion of the foot will turn on the current, and a backward motion will cut it off. The action of the foot piece is the same when the selector handle is on contact marked “Engine,” but instead of operating the cautery it clutches in or out the brake pulley or shaft F, causing the cable with its drill to rotate or stop instanta- neously, according to the will of the operator. In the automatic brake this is accomplished by means of the magnets 1 and 2 (fig. 3). When the current is turned on the magnet 1 it is at the same instant cut off from magnet 2, the result being that the sleeve carrying the pulley 6 is attracted toward magmet 1, and pressed firmly against its surface with a tension of about 50 pounds. When the foot piece is pressed forward the current is cut off from magnet 1 and is trans- ferred to that of 2. This causes the sleeve to press forward, but this time it does not reach the face of magnet 2, being arrested by the pulley 6 coming in contact with the friction cone 5 fastened to the shaft F. This at once causes the pulley to acquire the speed of the shaft, to be again checked when the foot piece is depressed backwards and the keeper 3 is brought in contact with the face of magnet 1. The binding post O is common to both magnets 1 and 2, and therefore there are but three wires in the foot piece. The current which operates the electro-cauteries does not pass through the foot piece, as this extra resistance would be important to a current having a potential of only 5 volts. Instead of this, the constant current from the dynamo is passed to the foot piece, which operates a magnetic circuit closer, through which the alternating current which heats the cauteries, is passed. When the foot piece is pressed forward the constant current passes to the electro-magnet of the circuit closer and the switch is drawn down, allowing the alternating current to pass to the cautery. When the foot piece is depressed backward, the switch of the cir- cuit closer is released, and the alternating current no longer passes to the cautery. The foot piece thus serves a double purpose, that of controlling the engine and the cautery, and either one may be used according to the position of the current selector E (fig. 2). The cautery can, however, be used at the same time as any of the induction coil currents, and the cautery may still be used when the selector handle is over any of these contacts. The only time that the cautery can not be used is when the engine is used, for the reason already explained. When the motor dynamo is used to operate the engine, it may be used at any speed within the limits of the rheostat K, but when it is used to operate the cautery, or induction currents, it should be used at full speed, the lever of the rheostat K being on the point 5. The cautery currents are taken from the bind- ing posts marked “Cautery’’ on the top board of the apparatus, and the faradic currents from the binding posts marked “Faradic.” There are six forms of fara- dic currents generated in this apparatus, all of which are available from the same pair of binding posts, thus avoiding the inconvenience of selecting a new pair of binding posts each time that a different current is required. The current that the operator desires to use is carried to the binding post by means of the lever of the current selector E, which is placed over the contact marked “Primary,” “Sec- ondary,” etc. The indicator for faradic currents (fig. 2) is operated by the small handle, R, in front of the apparatus, and its object is to indicate the relative immersion of the primary into the secondary coils of the induction coil proper, which is made up of a number of coils so as to permit of the use of simple and com- plex currents. This indicator serves for all six currents, and, by means of a handle, R, the strength of the current can be very accurately graded to suit the require- PAN-AMERICAN MEDICAL CONGRESS. 1531 ments of the case. Although the scale is an arbitrary one, still it enables the operator to keep a record of the number of degrees required to give the best. results to the patient, and enabling him to use the same strength that was found efficient on a former occasion, Pis the rheotome, and is so arranged that it can be adjusted to coarse or fine vibrations by turning the screw of the contact point. Y X are oil cups on the 111otor-dynamo, which require filling regularly. The com- mutators should be kept clean, and a little vaseline rubbed on the wearing sur- faces as a partial lubricant and to deaden the vibrations of the brushes. The motor-dynamo is held down to the bottom of the cabinet by its own weight only, and it rests on six gum washers so as to prevent undue vibrations of the floor and surroundings. The belt G, after leaving the pulley of the motor-dynamo, travels upward and passes over the pulleys marked 1, 2, 3, 4, 5, the pulley 5 being the one attached to the regular S. S. White engine cable and hand piece, the general design of which is shown in the plan (fig.2). The pulleys 2 and 3 are attached to the slid- ing arm, and serve the double purpose of taking up the slack of the belt when the arm is slid in or out, thus preserving at all times the same degree of tension in the engine belt G. The engine arm S is capable of turning on a center, from side to side, and the center of motion is so adapted that the belt is always in its radius, and thus never suffers any distortion or strain and can not fall off unless it is loose. Whenever the belt is too loose for proper work the small sliding head, to which the pulley 4 is attached, may be moved forward until the belt has the proper degree of tension. The engine cable head, marked 6, can also be rotated on a com- mon center to the extent of half of an arc of a circle. The cable itself has all the movements commonly given to these devices by the S. S. White Dental Company. V, V, V, V, V are drawers for instruments, electrodes, flexible cords, etc. T is a quick break-switch which cuts all the current from the apparatus when not in use. The engine switch K is also fitted with a quick-breaking attachment, so that as the lever leaves the last contact the circuit is broken with a quick snap, thus preventing the possibility of arcing and its consequent injury to woodwork and the metallic contacts forming part of the circuit. The miniature lamp switch U (fig. 2) receives its current directly from the Edison mains, and is not depend- ent upon the motor-dynamo for its energy, and the current from this is conveyed to the binding posts marked “Lamp.” This lamp circuit is so arranged that the current is drawn from the Edison mains in shunt, and not in series, as is usually done. For this purpose the current from the Edison mains is passed through wire resistance of great length and fastened in coils to the back part of the cabinet. By tapping this wire at different points of the circuit by means of lamp switch U (fig. 2) we obtain a current of sufficient intensity to produce incandescence in the miniature lamp connected with the binding post marked “Lamp” (fig.2). By means of this shunt system we avoid the sparking incident to using the cur- rent when the lamps are placed in series. Z Z are the binding posts, to which are attached the wires leading to the Edison mains. The action and details of the foot piece used in this apparatus are shown in the plan (fig. 2), and require no extended description here. T is the main switch of the galvanic current. As the tension of the Edison current (110 volts) is too high to make it conven- ient for the delicate adjustments required for galvanism, and as, moreover, the direct current is not free from a certain element of danger, such as the crossing of the wires with an outside wire carrying a current of high and dangerous potential, I have introduced into the cabinet an arrangement devised by my assistant, Dr. Scheppegrell (New Orleans Medical and Surgical Journal, January, 1893). In this arrangement the direct current is passed through a number of lamps, which divide up the difference of potential, and by means of a volt selector a shunt cur- rent is taken from the lamp circuit, varying in strength according to the position of the volt selector. If, for instance, the current be passed through four lamps 1532 PAN-AMERICAN MEDICAL CONGRESS, of equal resistance the tension of the current will be divided into four equal parts, and by adjusting the lever of the volt selector we may make use of a current of 27}, 55, 82}, or 110 volts, respectively, thus allowing of more accurate adjustment of the current. As there will be less resistance through the lamp than through the water rheostat and patient, this shunt arrangement forms a safeguard to the patient from extraneous currents. The current, after being adjusted by the volt selector, is regulated by means of a new Bailey rheostat, the strength of the cur- rent being shown by the milliampèremeter. A polarity changer is used for reversing the polarity of the electrodes. In regard to using the motor-dynamo for heating the electro-cauteries it has not only the advantage of convenience and economy over using the Edison cur- rent direct, but also the importantitem of safety. Let us suppose a case where the surgeon has a patient in his chair and is operating on any part of the body with a cautery electrode carrying a 110-volt current, and while doing so a wire in the street, carrying a current of from 500 to 2,000 volts, should become accidentally detached and fall upon the lines leading to the office. This would injure the patient severely, and is an accident that happens quite frequently to all electric-light Cir- cuits, the central-station dynamos being sometimes burnt out from this cause. By the use of the motor-dynamo system the patient is not brought into contact with the Edison circuit direct, and should any outside wire fall on the wires, as described above, it can only result in blowing out fusible plugs by which the motor- dynamo is protected from heavy currents. Another element of danger to be con- sidered lies in the use of a current of such a high potential as 110 volts for cautery work, Outside of any consideration of the question of cost. Suppose you have an electrode in the circuit that requires a current of 22 ampères; this will, at a pres- sure of 110, consume an energy of over 3 horse power. Now, should the cautery suddenly break from any cause, while it is being used, there will be formed a heavy arc, which would destroy all tissue within one-quarter radius of the arc so formed. A current of 22 ampères at 5 volts, such as is supplied by the motor-dynamo, could not give rise to an arc that would in any way be dangerous to the patient. The engine can be operated at from 1,500 to 6,000 revolutions per minute; is adapted for using all kinds of drills and other attachments, and can be stopped within the One-tenth part of a second while making 6,000 revolutions per minute." DISCUSSION. Dr. E. FLETCHER INGALs, Chicago. I would like to ask Dr. de Roaldes how much his apparatus costs, and I would put the same question to Dr. Hobbs. I would also like to ask Dr. Hobbs if his apparatus can be applied to the powerful currents we havein the larger cities, as well as to those in the smaller ones. I would like to ask Dr. Hobbs whether his instrument allows him to use the current for anything else except the galvano-cautery. Dr. D. BRYSON DELAVAN, New York City. This is one of the most important subjects that could be brought before us, because one of the newest, and while I fully sympathize with those who have spoken of the expense and extravagance of experimentation in electrical matters, I still think we are advancing in that line and that our trouble in past years has not been thrown away. We seem to have arrived at this basis, viz: That the street current is available for our uses. This has been shown for several years and every season brings up some new and * I take great pleasure in thanking publicly the Messrs. Buchel Bros., of the Buchel Machine Works, New Orleans, who have exercised the greatest mechanical skill and technical knowledge in constructing this apparatus. PAN-AMERICAN MEDICAL CONGRESS. 1533 improved plan, device, or apparatus by which the street current can be utilized. The great desideratum in regard to it is, first, that we shall be allowed to use it with safety; second, that we shall be able to adapt it to the widest variety of uses; and, third, that in the adaptation of it to this variety of uses we shall not be put to too great expense. The addition of a single department of electricity, the faradic current, for instance, will materially increase the cost of such an apparatus as this, and so with the addition of any other distinct branch. For a man of small means, who has not a very large practice, it becomes a question whether it would pay to try to combine all the uses of electricity in one apparatus, or whether, on the other hand, it would not be more economical to combine several immediate uses in one instrument, perhaps, and supplement that apparatus by other independent instru- ments. For instance, if we wish to employ a galvanic current for electrolysis or the simple therapeutic use of galvanism, it might be much better to purchase an ordinary galvanic battery and use that, depending upon the street current for other uses. It is extremely difficult to advise others as to what electrical apparatus to purchase. - In my office, while using the street current for lighting, I have an arrangement made by the Edison Company, a series of primary cells, the so-called “Edison- Lalande,” which work well, are economical and durable, and on the whole are the most satisfactory of the kind I have ever seen. However, when that happy day comes, and let us hope it is arriving now, that we can convert the street current to all uses at not too great an expense, it will be a desirable thing to do away with all subsidiary apparatus and confine ourselves to one source of power. There is only One serious objection, aside from the expense, to these complicated instruments, and that is every additional complication, every additional connection, switch, etc., put upon a given instrument is liable to increase by So much the possible chance of acci- dent, and unless the instrument is very well constructed and access may be had to the services of a thoroughly competent electrician, the more complicated instruments are not so desirable. The others certainly have a place with residents of the smaller cities and places remote from the centers of electrical information. Although I have the greatest admiration for the instruments that have been presented this morning, it seems to me that as yet the universal electrical apparatus has not been presented. By universal I mean adapted to the largest number of purposes and brought within the means and easy handling of the largest number of men. It is certainly a cheering fact that we have had this morning brought before us two instruments which suggest so much that is valuable and which have gone so far toward solving the large number of difficulties which we encounter. It is to be hoped that before long, from these ideas and those that have gone before, an instru- ment may be evolved which will answer all purposes for all men. Dr. A. W. DE ROALDES, New Orleans. I think Dr. Cohen can rest assured that from this time on if he wants to procure either one of the two apparatuses which have been described here, he will have no cause for investing further in electrical instruments that will have to be put aside after spending a great deal of money on them, as has been the experience of all of us for the last ten years. The motor- dynamo and very complete electrical cabinet which I to-day bring before you can not be said to be a cheap apparatus, Owing to the fact that a good deal of money was expended on it for experimental work. But now that this experi- mental stage is over and the mechanical work well defined, this apparatus could, I believe, be duplicated for much less money, say a sum between four and five hundred dollars. Such an outlay, made by a specialist who has a large prac- tice, and consequently reason to make use daily of the different parts of the cabi- net, will, in the long run, be found to be a profitable investment. The cost of run- ning is so insignificant that I have found the electrical company which supplies. the direct current for the motor unwilling to furnish me with a special meter. I 1534 PAN-AMERICAN MEDICAL CONGRESS. had, therefore, to submit to a minimum tariff of $3 a month, which, however, includes the current for the illumination of several rooms. Of course my apparatus is much more costly than the One described by Dr. Hobbs; but remem- ber also that, besides a galvano-cautery, it embodies, in a neat and compact cabi- net, a drill, as well as all the different forms of currents for medical use and for electrolytic work. In addition, with theingenious little apparatus of our colleague, Doctor Hobbs, there is a considerable loss of energy, even when using only a Current of 52 volts. This has been obviated in my cabinet by means of the motor- dynamo, as already explained. When considering the cost of the apparatus one must also consider the wide range of electrical applications which it furnishes in a neat, compact, reliable, and economical (as to running expense) form. You have first an electrical drill as a part of the apparatus, with such an arrange- ment as no other electrical drill offers, an automatic brake that will allow you to start or stop the drill almost instantaneously (within ten seconds). Its power is equal to one-quarter horse, which is sufficient to do any kind of surgical work. The galvano-cautery is so arranged as to heat at will the smallest cauteries for ear work to the heaviest knives, the control of the current being transferred from the han- dle to the foot piece. You have in addition all the varieties of the faradic current, With an improved scale of measurement, and a finely graduated galvanic current available for medical use or for electrolytic purposes. This apparatus with its dif- ferent combinations will allow you to utilize the current of the street for any pur- pose in medicine and surgery, and while it was originally designed solely for my special work, it is practical for the general surgeon. If the different parts con- tained in this cabinet were to be obtained as separate electrical apparatuses I doubt very much whether the aggregate expenditure of money would not be as great. The running expenses would certainly be greater. As to the reliability of this motor-dynamo and electrical cabinet I will only say that the guaranty of one year has expired without having to call on the expert electrical engineer who built it. The apparatus was so well constructed that at no time in eighteen months of daily use has there been a single part out of order. The only attention it requires is on the part of my office nurse, who keeps the cups properly supplied with oil. Dr. Arthur Hobbs, Atlanta, Ga., in closing the discussion, said: Yes. It will charge a magnet ; it will give a light to the small incandescent lamps, either for direct or translucent purposes, which could not be gotten directly from the street wire. Electrolysis can not be obtained from an alternating cur- rent; it would neither reduce the electro-motive force nor the ampèreage suffi- ciently for this purpose. The cost of the cautery through this little apparatus is practically nothing; possibly as much as 10 cents per month. The only cost is that of the wire, which you would already have in your office for light and power before attaching the transformer. I am not sure of the cost of this transformer. My electrician has, however, assured me that it will not cost over $30 or $35. The only transformers now in use are the three in my own and assistant's rooms. I think $35 will be its probable cost. I would not sell mine for $1,000 if I could not duplicate them. The current must be alternating. The one best adapted to it is the 52-volt, but the 120-volt will do, or even the high power of 500 volts may be used by first distributing the force through five or ten lamps and motors before the current is carried through the transformer, provided it is the alternating cur- rent and the magnet and motors are properly adapted to it. PAN-AMERICAN MEDICAL CONGRESS. 1535 SOME OF THE THROAT CONDITIONS OBSERVED IN GOUTY SUBJECTS. By SOLOMON SOLIS-COHEN, M. D., Professor of Clinical Medicine and Applied Therapeutics in the Philadelphia Polyclinic; one of the Physicians to the Philadelphia Hospital, etc. The term ‘‘gouty subject,” as used in this paper, has perhaps a somewhat wider range of meaning than can strictly be ascribed to it, if only those are to be termed gouty who have suffered with articular inflammation, or who exhibit character- istic deposits. In this country, at least, a much larger number of persons suffer with other than articular manifestations of the uric-acid diathesis, their symp- toms being varied, and often obscure, until the cause is discovered upon examina- tion of the urine, which shows more or less constantly an excess of urates and uric acid, and often contains calcium oxalate and excess of phosphates. In both classes of patients the upper air passages are frequently affected, and while the gouty diathesis can not be affirmed to be the sole cause of the local manifestations, it doubtless acts as both a predisposing and a modifying influence. g Harrison Allen' has sharply discriminated between gouty sore throat and the lithemic throat, and has reported a number of instances of the former condition. He has also given such references to literature as are of value in this connection. I am not inclined, however, possibly because of a more limited experience, to make equally sharp distinction with Allen. Sir William Roberts * has well shown the important difference between uric-acid gravel and gout, the offending materials in the latter case being deposited in combination as urates in the true interior of the body, while in the former they are deposited as uric acid, on a doubling of the exter- nal integuments; yet even headmits that the underlying conditions are virtually the same. Reasoning upon clinical analogy and without direct histologic evidence, it seems to me that cases of the class treated of in this communication occupy what may be termed a middle position, the phenomena depending in large part upon irritation due to offending materials in the circulation, but in less part upon actual deposition in the fibrous tissues. A large number of cases would have to be recorded in detail by different observers, and a careful analysis made, before characteristic signs of throat gout could be laid down. Reference should be made to the valuable studies of Hinkle,” with whom, however, I can not agree in assuming that the cases reported by Ingals as instances of rheumatic sore throat were of a gouty nature. This paper does not aim to present more than the general results of personal observation extending over a number of years, but necessarily dealing with a limited number of cases. The condition, depending as it does upon a permanent error of metabo- lism, is probably in most, if not in all, instances a chronic one, with a tendency to paroxysmal exacerbation, under the influence of extrinsic or intrinsic exciting causes. Among the most frequent of such exciting causes are exposure to cold or to wet and indiscretion in diet. The frequent dependence of chronic sore throat on diathesis has been recognized by systematic writers. Thus, concerning the causation of “chronic catarrhal sore throat,” J. Solis-Cohen says : * The disease is not usually a sequel of acute sore throat, but becomes gradually developed without attracting much attention. It may exist with any diathesis. Sometimes it is a mere manifestation of disorder in the intestinal tract. 1 The Medical News, Philadelphia, June 16, 1888. 2 Sir William Roberts, on the Chemistry and Therapeutics of Uric-acid Gravel and Gout, p. 56. London, 1892. 3 Trans. Am. Laryngological Association for 1889, p. 124. New York, 1890. 4 Diseases of the Throat and Nasal Passages. Second edition, p. 178. New York, 1879. 1536 PAN-AMERICAN MEDICAL CONGRESS. And again, concerning treatment, he remarks: As this affection may coéxist with a variety of diatheses, the systemic treat- ment will vary in accordance with the constitutional requirements. Alkaline laxatives are usually indicated. Attention being as a rule first directed to gouty sore throat during a paroxysm, its diathetic origin may be overlooked; and the case may be mistaken for one of the ordinary forms of acute inflammation. Inflammation, however, is not a necessary feature of the disease, and in my own experience the most prominent symptoms have been sensory ; pains and perverted sensations of various kinds being referred to circumscribed regions, often described as “spots,” in which no structural alteration adequate to explain the symptoms can be discovered. In one of the most marked cases that has come under my observation, that of a mar- ried lady, some 45 years of age, who is of a gouty family and has gouty deposits in the finger joints, the spot most frequently pointed out as the seat of the discomfort isin the left pharyngeal angle just behind the free border of the soft palate. This, however, is not the only location of pain, which is variously described as stinging, burning, pressing, or like that caused by the presence of a foreign body. Some- times the discomfort is referred to the neighborhood of the epiglottis; sometimes to the side or the base of the tongue; sometimes to several points at once. These spots are often painfully sensitive to the touch, and can thus be accurately local- ized. The patient has an idiosyncrasy to cocaine, and it could not therefore be determined whether or not the application of this drug would abolish the locali- zation of pain. Similar localization is found in many, but not in all cases, and usually fails when cocaine has been applied, though this is not invariable. I have been of the opinion that when sensitiveness persisted after application of cocaine the trouble was deep-seated in the fibrous structures. In some cases pain is referred to a part apparently unrelated with the one touched, but the association is constant, and the impression left upon the mind of the observer is that the error is in the reference, few persons being able to describe accurately the exact seat of a sensation in the throat. Sometimes, and more especially during an acute paroxysm, visible alterations of structure are manifested at the painful spots. The most usual appearances are the presence of dilated blood vessels; veins or capillaries, several of which may cross one another at such a spot. Sometimes a single large blood vessel is found ; sometimes there is a dusky coloration of the mucous membrane; Sometimes an enlarged and reddened follicle. Often, however, there is no apparent difference from the surrounding membrane, which sometimes presents general congestion, and sometimes nothing out of the ordinary. When congestion exists it may be patchy or uniform. Usually the coloration resembles that of corned beef; some- times it is dusky red, or even purplish. In the larynx, the epiglottis and the arytenoid eminences seem the favorite seats of morbid Sensation, the former usually exhibiting a network of dilated vessels resembling a veil, the latter a slight tumefaction and reddening. In two cases, in young men, I have seen what appeared to be inflammation limited to the neighborhood of one crico- arytenoid joint There was pain on respiration and phonation, vaguely referred to this region. I have frequently seen similar appearances at the inception of an attack of acute rheumatic tonsilitis. In some cases there is during the more acute stages a characteristic diffuse laryngitis, much resembling, and perhaps identical with, the form described by J. Solis-Cohen' as Occurring in young adults addicted to overfeeding and the abuse of condiments. In these subjects the tongue is red or reddish-LTown, thick, puffy, with promi- ment papillae, with a somewhat thick coating at the base, extending in streaks 1 Diseases of the Throat and Nasal Passages. Second edition, p. 474, New York, 1879. PAN-AMERICAN MEDICAL CONGRESS, 1537 toward the tip. The mucous membrane of the pharynx, palate, and palatine folds is relaxed, puffy, and usually congested. The mucous membrane of the larynx, and especially of the arytenoid eminences, and of the ary-epiglottic folds, is similarly puffy and always congested; the vocal bands are pink or red, the color being deepest at their posterior insertions. A pellet of mucus is usually adherent to the meso-arytenoid fold, and as a rule mucus is found in other por. tions of the larynx as well. The voice is hoarse; the hoarseness is greatest in the morning and after meals. There is a constant desire to clear the throat of mucus; the expectoration is greatest in the morning. The patients often com- plain of a feeling of fatigue after slight use of the voice. This sensation of tired- ness may be referred to the larynx or to the pharynx. The conditions described may pass off in a few days; they may persist for ten days or a week; or they may merge with the chronic symptoms. In the pharynx, the tonsillar and peri-tonsillar structures and the angles of junction of the posterior and lateral walls have seemed to be most frequently affected. There may be enlarged glands. The tongue and its glands are often involved. The mucous membrane of the tongue or of the cheeks sometimes pre- sents whitish patches of cornified epithelium (leukoplakia buccalis). When the distressing sensations are referred to the rhino-pharynx, Luschka's tonsil may be tumefied and reddened. In young patients the pharynx and larynx are often covered with grayish, tenacious mucus; in those past middle life the pharyngeal and palatal membrane is often dry and pale, exhibiting a network of enlarged and tortuous vessels, or mottled with livid patches. - Relaxation of the palate is common, and in some subjects paroxysms of nasal obstruction, with or without coryza, are met with. This was noticeably the case in a man aged 54 years, a neurasthenic, with gouty deposits in the drum mem- brane, and in whom at other times nasal respiration was perfectly free; there being no structural deformity that would impede the passage of air. During these paroxysms of obstruction the turbinates would be puffy and pasty looking; the posterior wall of the pharynx would be apparently bulged forward, and the soft palate would likewise appear puffy and pale. There would be an annoying sensation of a foreign body between the throat and the nose, and efforts at hawk- ing, though ineffectual, would be continually repeated. Examination would not reveal sufficient accumulation of mucus in this region to account for the sensa- tion. In this case the hard and soft palate were occupied almost constantly with a network of large, bluish vessels, which during the paroxysms referred to became still more tortuous and darker in color. Upon one occasion I proposed scarifica- tion, but the patient—perhaps wisely—would not consent. In some cases tubal catarrh exists and sensations of distress are referred to the ear. In a case similar to the one just cited, pain was referred to a point marked externally by pressing the finger just behind the angle of the jaw, whence it radiated into the ear. In a few cases spasmodic choking in swallowing and spasmodic obstruction of respira- tion, laryngeal and bronchial, have been observed. In One case an attack almost resembling croup was followed by an outbreak of articular gout. The diagnosis in these cases, while suggested by local appearances and symptoms such as have been described, depends upon recognition of the constitutional con- dition, and can not be affirmed in the absence of the ordinary evidences of such constitutional disorder. Urinalysis gives the most important evidence in cases in which there has been no articular inflammation or deposit. Local treatment is palliative only and it should be sedative and protective; irri- tating and stimulating applications are counter-indicated. Astringents may be cautiously employed during exacerbations. For this purpose I have found the glycerole of tannin applied by cotton wad, or a spray of zinc sulpho-car- bolate in rose-water (5 grains to the ounce), the most useful. Cocaine is badly S. Ex. 36 97 1538 PAN-AMERICAN MEDICAL CONGRESS. borne by some patients, inducing spasmodic phenomena. When well borne it is useful to relieve pain. Applications of fluid extract or concentrated infusion of coca will at times be feasible and useful in cases in which the alkaloid can not be employed. I have likewise found aconitine oleate (2 per cent in oleic acid, freshly made and flavored with oil of almond) a useful analgesic application. Menthol (from 2 to 5 per cent in liquid petrolatum, as a spray; from 5 to 10 per cent topi- cally by cotton wad) is occasionally of great service; in Some cases, however, it can not be tolerated. Bromoform (topically by cotton wad) has given relief in one or two cases in which other applications were inadmissible. In chronic cases solution of iodine and carbolic acid in glycerin (of each 1 grain to the Ounce, with 14 grains of potassium iodide to facilitate solution) applied to the spots of painful sensation, or brushed over the entire pharyngeal wall, is of Service. Before making any of these topical applications, whether in acute or chronic cases, the parts should be cleansed by an alkaline and aromatic spray. In quite acute pharyngitis a gargle of hot milk and borax, or of plain hot water, or hot alkaline solution, often gives great relief. Guaiac is likewise of benefit. In acute laryngitis alkaline sprays, followed by the inhalation of the vapor of hot water impregnated with benzoin and paregoric, are useful. For permanent relief, of greater or less degree, dependence must be placed on dietetic, hygienic, and medicinal measures appropriate to the uric acid diathesis. It is unnecessary to detail these here, but I would like to record my favorable experience in this con. nection with strontium bromide. ILLUSTRATIVE CASES. Case 1.-Mrs. L., aged 50, for some years has had attacks of tingling and sensa- tions as of the presence of dust (hardly intense enough to suggest the presence of a feather) at the left side of the throat. When this feeling is experienced she is forced to cough, and with the cough comes a Sensation of strangling. The cough is short, at first sharp, afterwards, with the strangling sensation, muffled. There is never any expectoration. The pharyngeal mucous membrane is irregularly. reddened and thickened, and there are a number of prominent follicles, surrounded by reddish whorls of dilated vessels. The larynx is diffusely congested, the color being deepest over the arytenoid eminences. There is no mucus in the larynx or pharynx; Luschka's tonsil is reddened and prominent. There is no turbinate engorgement, and though the septum is slightly deflected to the left, nose breath- ing is, and has always been, free. The patient has frequent attacks of shooting pains in the finger joints and about the knees. There are gouty changes in the last joints of the ring and middle fingers of the left hand. For some years she has been compelled to rise at night to urinate. The urine at times is burning. The patient belongs to a family of good livers, some of whom have had articular gout. She is very stout and has a sallow and flushed complexion. Urinalysis showed the presence of free uric acid, as well as excess of urates and calcium oxalate. The specific gravity was high. No Sugar or albumin was found. . A spray of liquid petrolatum, with 5 per cent of menthol and 2 per cent of cocaine, was prescribed to be used three times a day and whenever the unpleasant sensations were expe- rienced. The diet was carefully regulated, outdoor exercise directed, and stron- tium bromide given in doses of thirty grains three times a day before meals. Under this treatment the patient rapidly improved, and up to date (ten months) there has been no return of the paroxysms. Case 2.—Mr. M., aged 52, of full habit, sallow and flushed complexion, com- plains of ringing in the ears, of a pain darting from the ear to the throat, and from the throat to the ear, sometimes felt externally behind the angle of the jaw. There is a constant desire to clear the throat, but very little mucus is ejected. The nose feels stuffed up. At times there is a burning sensation referred to a definite spot in the pharynx. The palate is relaxed and covered with a network of bluish vessels. There are a number of enlarged follicles in the pharynx, which is irregularly streaked with red and bluish patches; between these the interven- ing membrane is quite white. A sensitive spot is found just beneath one of the enlarged follicles on the posterior wall. The patient recognizes this as the seat of the burning. There is considerable tumefaction of the posterior wall of the pharynx toward the lateral angles. The septum is slightly bent, though not suffi- PAN-AMERICAN MEDICAL CONGRESS. 1539 ciently to obstruct respiration, and the lower and middle turbinates are red and swollen. The tongue is heavily coated, and the papillae are prominent. Some accumulation of thick, tenacious mucus is seen in the vault of the pharynx. The mouths of the Eustachian tubes are widely open, and the whole structure appears much larger than normal. No mucus is detected in the Eustachian tube and air enters it freely. The drum membranes are opaque and show gouty deposits. The patient is a dyspeptic; his urine shows excess of urates, calcium oxalate, no albumin, no sugar. A spray of menthol and cocaine in liquid petrolatum was prescribed, but the strength had to be reduced to 2 per cent of menthol. The rhino-pharynx was wiped clean every morning with a cotton wad, saturated with a 2 per cent solution of cocaine. Counter-irritation over the mastoid processes with tincture of iodine was from time to time employed, and iodine, carbolic acid, and glycerin solution applied twice a week by a cotton wad to the nasal passages. Regulation of diet and antilithic treatment internally were kept up. The patient slowly improved and was dismissed from treatment in the course of three months, He had become largely rid of his distressing symptoms, though not altogether of the roaring in the ears. Once in a while he returns for local treatment, which seems to give him relief. Case 3.-Mr. C. H., aged 30, a traveling salesman, for a year or more has had frequent attacks of hoarseness, with a feeling of “rawness” in the throat. There is no pain in swallowing. The attacks last about a week. The intervals of free- dom vary from a month to six weeks. The present attack has lasted longer than usual—some ten days. There is a slight, hacking cough and a desire to clear the throat. There is no trouble in breathing, nasal or otherwise. The tongue is heavily coated, the pharynx congested in streaks, the larynx slightly congested, the epiglottis flaccid, the arytenoid eminences puffy. There is pain referred to the upper part of the chest, but no physical sign of pulmonary lesion. The heart is normal. The patient is a very stout man. He uses tobacco largely and drinks |beer moderately. He is a hearty eater and a gourmet. The urine is 1.034 in spe- cific gravity, of acid reaction, and contains urates, uric acid, and calcium oxalate in excess. Diet was regulated. A Solution containing strontium bromide and strontium lactate, 15 grains each, was given in water, before meals. The patient was ordered to drink hot water one hour before meals. Zinc sulpho-carbolate spray was applied locally. Relief was reported in four days. There has been no return of discomfort as yet. tº DISCUSSION. Dr. JAMES E. LOGAN, Kansas City, Mo. I was very much interested in the paper, as I have given the subject some consideration within the last few years, and especially the relation the general practitioner should bear toward the throat specialist. I have found some cases very interesting in their nature that were only remediable through agents of general medication. Where I had tried local treatment, where examination revealed very little, if any, active inflammation in the pharyngeal cavity, there were possibly some little inflammatory points refer- able to the follicles of the tongue, especially where they come in contact with the anterior and posterior faucial pillars. That is one of the most aggravating of the painful points these patients complain of. There is another, to me, pathognomonic symptom in these cases; that is, a complaint of a tired sensation in the throat, and especially is this tired feeling experienced after a little excitement. In all these cases I have made the urinary analysis the Doctor speaks of and found the condi- tion as he represents it. Not more than five weeks ago I had an elderly lady in my office who gave every evidence of this condition from the urinary analysis. I found her very apprehensive. The pain was so excessive and aggravated that she could hardly realize that it was other than the most malignant type of disease. I assured her this was not the case, and put her on an antigout treatment and a mild astringent—the sulphate of copper—for its moral effect more than any- thing else. The patient was relieved in a little while. She had had one or two previous attacks, but not so severe, and she and her family got the idea that it was some malignant disease. I reassured her on this point, and found the case reme- diable through Inedicinal and not through local means. - 1540 PAN-AMERICAN MEDICAL CONGRESS. Dr. J. H. Low MAN, Cleveland. I think the subject of paraºsthesia of the pharynx and larynxis interesting, because instances of that kind do come under one's obser- vation where it is impossible to make a diagnosis. The question of paraesthesia of the pharynx in tuberculosis and paraesthesia of the larynx in gouty conditions may be distinguished by the color perhaps, but they run into one another so closely sometimes it is difficult to make a distinction. Not infrequently I have seen people who have complained of pains in the limbs and of a sensation as of a foreign body in the throat, where I could find nothing in the throat to explain the phenomena and could find absolutely nothing in the constitution to explain it, but have been able to trace it to tuberculosis later, the paraºsthesia, by some accident in the career of the individual, manifesting itself first. It strikes me that paraºsthesia in the gouty subject may be the same ; the system is ready, and by some accident it appears. I remember an instance where the individual had this congestion and disease of the pharynx with occasional pains in the limbs and paraºsthetic sensa- tions, and then he had gouty urine, etc., and after any little excess of eating or drinking he would have most intense edema of the uvula ; it would become as large as his thumb, and this would last from one to three days, then the throat would go back to the normal condition again. The edema of the uvula would be so great that it would have to be clipped; no remedies would have any effect upon it. I think the diagnosis is very difficult in paraºsthesia. Dr. S. SOLIS-COHEN, Philadelphia. Of course I did not go into the great subject of the diagnosis of parapsthesia ; I recognize its difficulty. Nor would I be under- stood to imply that all cases of paraesthesia of the pharynx or larynx are gouty. I simply recorded my experience with a number of cases as being related with a uric-acid diathesis, and have confessed my inability to make a positive diagnosis by local signs in affirming that it can only be made by a recognition of the constitutional condition. A CASE OF ANGIOMA OF THE NASAL SEPTUM. By FREDERICK C. COBB, M. D., Assistant Physician for Diseases of the Throat at the Massachusetts General Hospital and Physician to the Throat Department of the Bostom Dispensary. The patient, Lizzie B., 15 years of age, came to the Out-Patient Throat Depart- ment of the Massachusetts General Hospital in October, 1892, complaining of obstruction of the right nostril and epistaxis from the same side. The duration of these symptoms was about six months. There had been no sneezing, and only occasionally a yellow, thick discharge from that nostril. She was anaemic, always subject to headaches, and exhausted by the least exertion. Her previous history, with the exception of an attack of Scarlet fever six years ago, was negative. Examination of the anterior mares showed them to be normal on the left side. On the right side the nostril was wider, the turbinates slightly atrophic. Hanging from the septum by a thin pedicle inserted near the junction of the skin and mucous membrane, above the end of the lower turbinated bone, was a small growth divided into two lobes by a constriction about its middle. It was soft to the probe, moved backward and forward on inspiration and expiration, but was not seen to pulsate. At its lowest portion were a few small, black blood clots. The posterior nares, pharynx, and larynx were normal. With the aid of Hooper's Snare and écraseur the growth was removed with very slight hapmorrhage. The base was not cauterized, the patient was given an alkaline wash, and returned two or three times until the site of the pedicle was completely healed, which occurred in about ten days. She was examined in August, 1893, and has had no recurrence. The growth was submitted to Dr. Whitney, the pathologist to the hospital, and the following report PAN-AMERICAN MEDICAL CONGRESS. 1541 was received from him : “Growth with large vascular sinuses with more or less round cells about ; cavernous angioma.” In looking over the literature of nasal angiomata one is struck by the lack of pathological accuracy shown by the reporters of cases. If we inquire what is the structure of angioma, we find, according to Bosworth, that it is composed almost entirely of blood vessels held together by a slight network of connective tissue. Sutton, Ziegler, Birch-Hirsch- feld, and other pathologists agree with this definition. Now, if the reported cases of angiomata be judged by their pathological examinations, we shall find, I think, that a pure angioma of the nose is very rare. The importance of pathological accuracy will be evident when we remember that the prognosis may depend upon it. Sarcomata and epitheliomata may contain small portions of nearly pure angio- matous tissue, and if such portions alone are removed for examination they may lead to very erroneous conclusions. The cases reported are those of Verneuil,' Wagner,” Steinbrügge,” Seiler," Richet," and 13 Roe," Jarvis,” Vanderpoel,” Burck- hardt,” Nelaton,” Huguier," Panas,” Guyon,” Dumenil,” Delavan,” Luc,” and Bellows.” There were in all twenty-one cases. There was no microscopical examination in 7 cases, viz: Those reported by Dumesnil, Verneuil, Seiler, Panas, Guyon, Vanderpoel, and Burckhardt. In 5 cases the growths contain myxomatous tissue and are not therefore pure angiomata. These cases were reported, 2 by Wagner, 2 by Luc, and 1 by Delavan. Three cases, those of Richet, Huguier, and 1 of Nelaton's reported by Beuf, were prob- ably fibromata rather than angiomata. We have then left the cases of Richet (reported by Bazy), Roe, Jarvis, Steinbrügge, and Nelaton's other case. Roe's case was, by microscopical examination, an angioma, but it subsequently degenerated into an angio-sarcoma. Nelaton and Richet's pathological descrip- tion is not characteristic enough to class their tumors among the angiomata, while in the case of Jarvis no pathological description, but only the diagnosis was given by the microscopist. Steinbrügge’s case was evidently an hypertrophy. Bellows's case was, by the microscopical examination, a pure angioma. As a further proof of the rarity of this affection, I would say that in an exami- nation of 7,429 cases in the Massachusetts General Hospital records I have found no other case. With regard to the symptoms the only two of importance are haemorrhage from and occlusion of one nostril. In all the reported cases a mere examination of the growth with probe or finger caused extensive haemorrhage. As regards prognosis it is evident from Roe's case that a pure angioma may degenerate into a malignant growth. 1 Annal, des Mal. de l'Oreille, Vol. I, p. 169. 2 Diseases of the Nose, N. Y., 1884, pp. 149, 150. * Zeit. für Ohrenheilkunde, Vol. VIII, p. 110. 4 American Specialist, Phila., 1881, Vol. II, p. 7. 5 Cited by Débrie, Thése de Paris, No. 5, 1882. *Trans, of the Amer. Laryngological Assn., 1885, p. 94. 7 International Journal of Antiseptics, Vol. I, p. 1. 8 Cited by Jarvis, loc. cit. 9 Bericht tiber die Chirurgische Abtheilung des Ludwigs-Spitals, Charlottenhilfe (1884), 1885, II. 10 Cited by Beuf, Thése de Paris, No. 69, 1857, pp. 21, 25. - 11 Bull. de la Soc. de Chir, de Paris, 26 s., I, p. 7; Séance of January 4, 1860. 1” Bull. de la Soc. Anat. de Paris, 1872, Vol. xlvi.1, p. 435. 13 Bull. de la Soc. de Chir. de Paris, 3e s , Vol. II, p. 356; Séance of June 25, 1873. 14 Ibid., p. 339, Séance June 18, 1873. 15 Cited by Débrie, op. cit. 16 Arch. of Laryngology, Vol. III, p. 174. 17 Myxome Télangiectasique, France Médical, Paris, 1890, xxxvii.1, pp. 723, 725. 18 Ophthalmology, Otology, and Laryngology, October, 1892, p. 330. 1542 PAN-AMERICAN MEDICAL CONGRESS, The diagnosis of pure angiomata can only be made by careful microscopical examination. In the treatment of these growths we are met with less difficulty since all the recent authors seem to consider the Snare, if used slowly, as the safest instrument. The length of time to be consumed in removal should depend upon the thickness of the pedicle. In Roe's case three hours were consumed in removal of the growth, the haemorrhage being very slight. Jarvis and Luc got no ha-mor- rhage with slow smaring, but considerable from more rapid use of the instrument. The former used his own snare and écraseur, the latter the galvano-cautery wire. In my own case I attribute the slight haemorrhage to the thickness of the pedicle. - DISCUSSION. Dr. John N. MACKENZIE, Baltimore. I thoroughly agree with what Dr. Cobb has said in regard to the rarity of these tumors. They seem to me to be extremely uncommon. In my experience I have only seen one case of true cavernous angioma: that was a case which occurred last year at my clinic, at the Johns Hopkins Hos- pital. It was operated upon by one of my assistants with the snare, and consider- able haemorrhage followed. It is singular, but comparatively few of our amato- mists are intimately acquainted with the structure of the nasal mucous membrane, that is to say, its cavernous structure ; in a great many works on anatomy it is entirely overlooked. In the transition stage of simple inflammation to hypertrophy men have mistaken the large network of cavernous spaces for cavernous angioma and I think a number of the cases in literature are none other than portions of the hypertrophied membrane in the stage which represents the transition period from simple inflammation to the hypertrophic stage. There is one condition, too, that may be mistaken for true angioma, a condition I described some years ago before the Laryngological Association, namely, a pendulous prolapsed condition of the turbinated bodies. The turbinated body sometimes assumes a pendulous form and may even hang out from the exterior of the vestibule, presenting all the appear- ance of a true angioma, and that might very readily be mistaken for an angioma- tous tumor. Dr. F. C. COBB, Boston. I agree with what Dr. Mackenzie has said, but in this individual case the tumor grew from the wall of the septum itself and contained no glands or any other signs of hypertrophy; the pedicle was verythin and small. AN INTERESTING CASE OF MYXO-SARCOMA, WITH GENERAL SAR- COMATOUS INFILTRATION. - By CHARLES S. RICHARDSON, M. D. During the early part of October, 1892, there came under my observation a child, 5 years of age, presenting quite an interesting clinical history. This child had previously been under the care of Dr. Bayne, who referred him to me. The patient was born to parents of unusually good health and free from any heredi- tary physical defects or vice. The child was strong and apparently in perfect health until the end of his second year. At this time his parents noticed that he sniffled and that his nasal breathing was somewhat impaired. This difficult nasal breathing became slowly but progressively worse, and was followed by a train of symptoms due to imperfect nasal respiration. He became restless at night; snored and caught his breath; would wake up crying, as though frightened; would breathe with his mouth open; and on awakening in the morning would be cross and irritable. About six months before coming under my care the parents PAN-AMERICAN MEDICAL CONGRESS. 1543 noticed that his voice was muffled and had lost nearly all its nasal quality. The child now began to lose flesh, showing but a slight desire for food. A growth now developed upon right side of neck, and it was also observed that something was protruding from the left nasal cavity. Discharge from nasal cavity was thin and watery, never sanious, nor was there ever any free bleeding. Shortly before con- sulting Dr. Bayne dysphagia was added to the child's already pitiable condition. At this time the inability to ingest food was confined to solids, liquids being taken with some degree of ease Dr. Bayne removed the mass protruding from the nose, and then referred the parents to me. - On presentation he was noted to be a well-formed boy of average height ; body and face extremely emaciated ; nasal breathing entirely annulled; Oral breathing distressingly loud and unpleasant. He was very weak; voice almost absent and unintelligible; was drowsy, and if held quiet for a few moments passed into a deep sleep. Externally his nose was well formed and showed no deformity. On the right side of neck there was a tumor of about 3 centimetres in diameter. The mother stated that for about three days the child had found it almost impossible to ingest food, either liquid or solid, and she feared that he would starve if some- thing were not done immediately. I found her statement to be absolutely correct, as the child could not swallow water when offered. Both nasal cavities were filled with a grayish white mass which protruded slightly. The mouth was in a horribly offensive condition ; the lips were fissured and covered with dry crusts and the teeth with sordes. The tongue was dry, horny, and deeply congested along its free borders. The hard palate was covered with dark brown deposit and the soft palate pushed forward until the uvula rested on the center of the dorsum of the tongue. The whole pharynx was filled up with a dirty grayish white mass that extended to the larynx below and pushed forward the soft palate until it extended well into the mouth. This mass was more or less lobulated and its lower borders were hornified. I appointed the next day for operation. Suspecting that the growth was malignant, I prepared for considerable haemor- rhage. I operated without the use of an anaesthetic. Dr. Balloch assisted me. I removed the mass from the nose, first with the cold snare, attended with only moderate bleeding. The pharynx was cleared with the finger and post-nasal for- ceps. The haemorrhage from the whole operation was much less than ordinarily attends the removal of post-adenoid hypertrophies. - - - The child was greatly improved by the operation and gained strength and flesh very rapidly. On the fourth day after the operation I observed a large mass of mottled grayish black tissue in the left nasal cavity, which I removed with the snare. This mass was slightly necrotic, and I supposed it was a piece that I detached and failed to remove during my first operation. Four days later, on the child reporting, I found the cavity again filled out with a mass similar to the one removed at the previous sitting. This mass was about 3 centimetres long by about 1 centimetre in diameter; softer and more pultaceous than the first tissue removed. Bleeding was also more active. I was now firmly convinced that the growth was a myxo-sarcoma. In four days there was a greater reproduction, extending even into the pharynx. On this day Dr. Balloch confirmed my diagnosis by telling me that the tissue originally removed was from a myxo-sarcoma. I now consulted with Dr. Bayne as to the advisability of doing a more formidable operation. The excision of the superior maxilla met with his approval and the day was appointed for its removal. The child's condition on the day of the operation, although only six days since my last interference, was quite as bad as previous to any operative interference whatever. The attachment of this growth seemed to be about midway of the under surface of the middle turbinated bone. With the assistance of Drs. Bayne, Van Rennselear, and Luce, I did Billroth's operation for resection of the Superior maxilla. Chloroform was administered. An 1mcision 1544 PAN-AMERICAN MEDICAL CONGRESS. was made from the root of the nose, extending in the median line to its top through the soft tissues and into the nasal cavity, upon the side to be operated upon. From the root of the nose an incision was carried outward to the malar prominence. In making this latter incision care was taken in carrying the knife along themargin of the orbit to avoid theinfra-orbital foramen from fear of dividing the artery issuing from this canal and thereby cause troublesome haemorrhage. An incision parallel to the second incision was carried from the ala of the left nasal cavity to the border of the masseter muscle. The nasal bones were now dis- articulated and the flap containing the left nasal bone was rapidly separated from the left maxilla and thrown outward. Bleeding vessels were taken up as divided and consequently only a very slight amount of blood was lost. The whole nasal cavity was now exposed and filling out this space was seen the same character of growth that had been so often removed. The growth was traced under the middle turbinated bone, from whence it seemed to have its origin by a broad base. The body of the superior maxilla was now separated by sawing outward, in the lines of the skin incisions, and after the mass had been separated it was pried out of 1ts position and turned outward upon the cheek. As the growth now could be seen to involve the antrum, probably secondarily rather than primarily, I decided to remove the bony mass entirely, and therefore separated it from the pterygoid proc- ess. A part of the palate bone and the pterygoid process were torn away by the forceps. The whole cavity was now free of growth. Rough edges were curetted away and the cavity having been packed with iodoform gauze, the skin flap was brought into position and carefully united. Haemorrhage was quite free, but to no alarming degree. The patient bore the operation well and rapidly recovered from the shock. There was no bleeding after reaction set in. The patient was in good spirits and quite hungry the next morning and had no fever. On the fourth day the iodoform dressing was removed, coming away quite clean, and new gauze introduced. On the fifth day all stitches were removed and union found to be perfect. On the seventh day the gauze was finally removed. There was no fever throughout. There was only a slight difference to be noticed in the prominence of the two sides of the face. At the end of the third week, as the child seemed to be in a perfect condition, I discontinued my visits. Five weeks later the mother requested me to see the child on account of the rapid increase in size of the tumor on the right side of the neck, and, if possible, to relieve the child from the great pain that this rapid increase in size had occasioned. The growth had now assumed enormous proportions and filled out the whole left cervical region, extending from the mastoid to the clavicle. I also noticed a smaller growth on the left side, just above the clavicle. During the following week new growths appeared in lateral walls of the pharynx and in left cervical region; there was no recurrence in nasal cavity. Four months after the operation the child died from inanition and exhaustion. In looking over the histories of some 60 cases of nasal and naso-pharyngeal sar- comata, many of the latter no doubt having their origin in the nasal cavity, I find several that correspond in their description very much to the case above given. In these extensive growths I find that the patients were quite young, but none So young as the case herein presented. Rapid reproduction is common in Sarcomatous tissue, but the rapidity of regrowth in this case was of a startling nature. To have all evidences of a growth removed in one day, and within six days thereafter to have it nearly reproduced in its original magnitude, is sufficient to excite the admiration of any pathologist. We have all been taught that haemorrhage is quite a necessary attendant upon malignancy; especially is this stated in regard to sarcoma. It therefore appeared to me to be quite remarkable that this little one had had no trouble of this character, and that the various operative procedures were attended with so little bleeding. The micro-pathological PAN-AMERICAN MEDICAL CONGRESS. 1545 find was that of a most typical and exquisite myxo-sarcoma, and even here we have an interesting feature to call to your attention. As you will observe, here and there disseminated throughout this mass of tissue are single fibers of striated muscular tissue. The section which shows these muscular fibers in the most pro- nounced manner was obtained from a mass removed from the nasal cavity. There are several points in connection with the operative interference that require consideration. In a case of this character where operative interference was not so immediately demanded to relieve the urgent symptoms, I think it would be wise to first ascertain the character of the growth before resorting to any instrumental interference. It seems that all interference, excepting that it be of radical character, intensifies the rapidity of growth and its malignancy. One well knowing the nature of the growth can consider, from its seat and attach- ment, whether it is possible to remove it in its entirety and more thoroughly by the snare, or whether it will be necessary to resort to one of the more formidable operations. Growths so extensive as the one outlined above should, if any operation is attempted, be dealt with in a most liberal manner. The reason the above case was not so treated at first was on account of the desperate condition of the child and the necessity for immediate action. A positive diagnosis could not be made out from its clinical history alone. It is also a question whether even the latter operation would have benefited this patient, as no doubt a general sar- comatous infiltration had already set in when he was first brought under my observation. - SARCOMA OF THE NASO-PHARYNX, WITH REPORT OF A CASE. By J. E. LOGAN, M. D., of Kansas City, Mo. J. N. T., age 44 years, a teacher by profession, consulted me in June, 1888, pre- senting the following history: Up to the age of 40 had always been a strong, healthy man; in the autumn of 1884 he was taken with a severe attack of typhoid fever, which lasted for many weeks, convalescence being very slow. Upon recov- ery, or shortly thereafter, he noticed what he termed “quite a fullness in the upper part of the throat,” which was accompanied by considerable secretion of saliva and some interference in breathing, especially noticeable when in a recumbent position. This condition grew steadily worse, so much so that within a few months he was unable to breathe through the nose, could scarcely talk, and had frequent sensations of impending suffocation. He applied to a local practitioner, who examined histhroat and found a tumor large enough to be easily seen, low down in the pharynx. The general health of the patient had now become greatly impaired, the discharges being very profuse and extremely offensive. The physi- cian, not feeling flimself able to cope with such a disease, and not being properly equipped to perform the necessary operation, referred the man to a surgeon in our city. As nearly as I have been able to learn by questioning the patient, this gen- tleman pronounced the growth a fibroid tumor. He at once removed it, and dis- missed the patient, leading him to think or at least to hope himself cured. His general health did improve immediately. He breathed easily, and his appetite returned. This improvement, however, was of short duration. Very soon there was a return, and a rapid and aggravated return, of all of his former symptoms. In six weeks from the time of the operation he was utterly unable to breathe through the nostrils, the discharges were fetid, the hapmorrhages were frequent, and for the first time there was considerable pain, referable principally to the left ear. The surgeon again examined him, and found to his great surprise that the growth had returned. He now gave it a more careful examination, though not, I believe, with a microscope, and pronounced it malignant. A tonic course was 1546 PAN-AMERICAN MEDICAL CONGRESS. prescribed in order to build up the patient's general health before venturing upon a second operation; but the tumor grew with such rapidity that he was forced to remove it while the man was still in a very weakened condition. During all this time there were no glandular complications and comparatively little pain. The second growth was removed by means of a wire écraseur, and the patient reports the operation as very bloody, though I am inclined to think that a very little blood would impress him greatly. He rallied from this second operation very slowly, but for five months he enjoyed comparative immunity from his trouble. At the expiration of this period the old symptoms reappeared, but in a modified form. The discharges were profuse and offensive, but the difficulty in breathing was not so marked. Profiting by past experience, he lost no time in having the new growth removed; but his promptness availed him little. The tumor again appeared in a few weeks and another operation became necessary. This went on until he had submitted to nine such operations. The frequency of these dis- couraged him greatly, and he finally concluded to seek the aid of a throat special- ist. He applied to my friend, Dr. Schauffler, for advice in the selection of a physi- cian, and Dr. Schauffler brought him to me for treatment. Examination of the case revealed the presence of a tumor perhaps twice as large as a partridge egg, situ- ated for the most part upon the roof of the pharynx, with attachments along the post-pharyngeal wall for the distance of one-quarter to half an inch. Digital exam- ination provoked profuse haemorrhage. The tumor appeared slightly lobulated and was firmly attached to a large base. The patient's general health was much much below par. He was somewhat cachectic and was suffering considerable pain in the left ear and in the back of the head. Profiting by the experience of the other operator, I concluded to remove the tumor by another method. Tying back the soft palate, I applied a 10 per cent solution of cocaine to the growth and the surrounding tissue until complete anaesthesia was established. My first step in the operation was to cut the tumor into three sections with galvano-cautery knife, continuing the cautery from the surface to the base. My object in so doing was to cut off the blood supply as much as possible. I next insinuated a curved, flat Knife under one section and removed it without much difficulty. Very little haemorrhage attended this operation. I applied persulphate of iron to the cau- terized base and sent the patient back to the hospital. I saw him each day, but applied no treatment except a warm spray of Dobell's solution. A week from the day I first operated he came back to my office, and I proceeded to remove the remainder of the growth. Upon examination I found this had been much reduced; in fact but one section of it remained, the other having sloughed away and been expectorated by the patient. The remaining portion was hanging by a few attach- ments to the base. I introduced my curved knife as before and easily severed the growth. The hamorrhage was hardly perceptible. I continued to keep the patient in the hospital for a few days, using no application save the warm Dobell spray. At the end of two weeks the surface had completely healed; so perfectly healed that scarcely any induration could be detected by digital examination. Ihad the growth examined by several most competent pathologists, and all agreed in pronouncing it a round-cell sarcoma. The patient immediately began to improve in health under the administration of tonics and outdoor exercise, and is living to-day, as fine a specimen of manhood as one would care to see. Repeated examinations have failed to reveal the slightest evidence of a return. One of my neighboring medical friends saw him just a few days since and carefully examined him, with negative results. So far as I have been able to find in looking over the literature of this particu- lar subject, this is about the twentieth case on record and about the second of well-defined recovery. Some are reported as recovering from the operation and continuing in good health during the period of observation, such observations PAN-AMERICAN MEDICAL CONGRESS. 1547 admitted by the operators to be of limited duration. Dr. Bosworth’s case is one of well-known recovery, since the patient is to-day within the limits of this beau- tiful city, with no intimation of trouble from the disease. The case reported by Dr. Lincoln was probably one of recovery, but his period of observation was too short to enable him to say certainly that there was no return. We see enough after looking into this matter to prove that sarcoma of the naso-pharynx is a very rare disease, and in a largemajority of cases is fatal. Just why a few of these cases have recovered while the others have died we can not, of course, explain. But might 1t not be well to observe that of all the cases operated upon those removed by the simplest means have shown the greatest tendency to recover? In writing upon this subject Dr. Bosworth says in his monograph in Wood's Medical and Surgical Monographs, Vol. XI, p. 256: Various operations were resorted to in these cases, such as the galvano-cautery, curette, the Spoon, and the cold snare manipulated through the natural passages, while some of the cases were subjected to radical operations, such as excision of the jaw, etc. There certainly seems to be something of consideration in the fact that the only successful case was cured by the use of the cold snare operated by the natural passages; and moreover that in this case the use of the galvano-cau- tery was attended with most unfortunate effect, indicating here also, as in the nasal cavity, that this disease is to be treated with great gentleness and any dan- ger of injuring neighboring parts avoided. The truth of his last proposition I think beyond question, but the opinion which Bosworth expresses of the galvano-cautery is scarcely borne out by the facts pre- sented by my case nor by those in the one reported by Dr. Lincoln. The inflam- matory reaction following my operation was inconsiderable—so slight indeed that the Eustachian tubes did not even show any signs of participation, which they would naturally have done had there been any such condition. Had the growth been of such a size as to have made necessary the application of the cautery for an indefinite period, I should probably have resorted to more rapid means; but when one is able to accurately define its outlines in the vault and can apply the galvano-cautery without danger of injury to other tissue, it seems to me to be the most simple and effective measure. DISSCUSSION. Dr. JOHN O. ROE, Rochester, N. Y. One case of myxo-sarcoma of the nasal cav- ity came under my observation about six years ago. I was requested by a physi- cian in Cayuga, N. Y., to go there and remove a growth from the nose of an old lady. I found a lady about 65 years of age, with the nose so dilated and face so disfigured as to have a frog-shaped appearance. What annoyed her the most was the projection of so much of this tumor into the throat as to nearly choke her. I was not prepared to operate upon such a formidable growth, but with the instruments I took with me I succeeded in removing the greater portion of it. I passed a wire loop down through the nostril along one side of the growth, brought it out of the mouth, and passed it up along the other side of the growth. Then, with the finger in the mouth, I engaged the greater portion of the mass in the loop and removed it. The amount removed nearly filled an ounce quinine bottle. I did not remove the whole of it, however, as the base was attached to the ethmoid and the middle turbinated bones, but the patient was very much relieved by this oper- ation. As she was much reduced in strength and quite anaemic, we built her up as best we could, so that in a few weeks she was able to come to Rochester, when I proceeded to remove the base of the growth as thoroughly as possible. She stood the operation very well, but in a few days she sank and died from asthenia. The 1548 PAN-AMERICAN MEDICAL CONGRESS. portion I removed first showed it to be a myxoma, ; but the latter portion that I removed, the base, showed it to be a sarcoma, so that very likely it started with the Outer portion a myxoma and the base a sarcoma. Dr. E. FLETCHER ING ALS, Chicago. I am interested in this matter, having seen a number of cases of malignant growth of the nose, though I can not now state whether they were sarcomas or epitheliomas. I now recall four cases. One, in a lad twelve or thirteen years old, was shown by careful microscopical examination to be a mixed sarcoma, and partially fibrous, but with enough of it of the sarcomatous element to ensure its malignancy. In that case the reaction following the use of the galvano-cautery increased the rapidity of growth, and I obtained much bet- ter results from operations with the knife, snare, or forceps. The growth was carefully removed two or three times, and the boy lived for at least two years how much longer I do not know, as he passed from my observation. I once saw such a tumor in a gentleman of advanced age, where the nose was so full, the patient so debilitated, and his age so great that I could not conscientiously advise any operation. He lived but a short time. In another case upon which I operated two or three times with the snare and cautery, the patient was considerably relieved and lived for five or six months. I saw such a tumor recently in a gentle- man 63 years of age. The right nasal cavity was distended by the growth, there was abnormal prominence of the right cheek, and considerable protrusion of the right eyeball. The patient suffered greatly from pain through the right side of the head. Some part of this growth, which had been termed a polypus, had been removed a little while before. He and his family were very anxious to have another operation. Believing that extensive operations for malignant growths in this locality in aged people are seldom justifiable, I did not decide upon a surgical procedure until after consultation with Dr. Senn and weighing all the circumstances in the patient's history. Removal of the superior maxilla was considered inadvisable in a man of his age, so I decided to remove the growth by the cold wire snare and a sharp spoon. The patient was given ether and the cold wire snare intro- duced in a manner I thought likely to remove the attachments of the tumor with- Out causing much bleeding. I was unable to ascertain the exact attachments of the tumor before operating, therefore I passed a special canula through the upper and Outer part of the nasal cavity, keeping it as far to the right as possible, and brought it into the naso-pharynx. Through this I passed a small catheter, the end of which was caught by forceps and brought out of the mouth; through this 1 passed one end of a steel wire 3 to 4 feet long, bringing it out through the nostril. Another catheter was passed in beside the lower outer part of growth and the other end of the steel wire was pushed through this until it came out of the nose. The ends of the wire projecting from the nose were then drawn upon and at the same time the catheters were removed and the loop drawn in through the mouth up to the outer side of the tumor, as the upper part of the tumor was likely to be adherent. Another catheter was passed through the canula, through which I had returned the end of the first wire; the end of the catheter was brought out of the mouth and the end of a second long wire passed through it and out of the nose. Another catheter was then introduced and brought out the mouth as high up as possible on the left of the tumor and through it the other end of the second wire was passed; the catheters were then withdrawn, the wires pulled out, and the loop passed in at the mouth and inclosed the upper attachment of the tumor. I put a snare on each of the wires and cut off the growth, which proved softer than I had anticipated. There was practically no bleeding. My reason for using the Snares was that I expected much bleeding when the growth was attacked and felt that if I could get out the major part of it without much loss of blood I could then Curette rapidly and pack the nose to stop the ha-morrhage. I pulled out the PAN-AMERICAN MEDICAL CONGRESS. 1549 piece which had been separated with the forceps and then scooped out the remain- der of the growth rapidly with a sharp spoon. There was but little haemor- rhage. The patient was a large man, which made it easy after the removal of part of the growth to introduce my little finger into the nasal cavity. I could feel the granular surface of the malignant tissue, and I scraped it out until the walls of the antrum and the vault of the nasal cavity were perfectly smooth. The floor of the orbit having been absorbed I could feel the under surface of the eyeball, sep- arated from my finger only by a granular tissue which could not easily be scraped away and was finally concluded to be adipose tissue. The tumor seemed to have been as thoroughly removed as it could have been if I had removed the superior maxilla. The next morning the temperature ran up to 103", and for seven or eight days the patient complained of pain in the eye, which was much swollen. A large diffused induration just back of the angle of the jaw was also swollen during this time. About the eighth day the fever went down, the swelling subsided, the pulse became nearly natural, and the patient became comfortable ; but before another day had passed he had a chill, the temperature rose to about 104", and twenty-four hours later he became paralyzed on one side; an extravasation of blood into the brain had occurred, from which he died three or four days later. Dr. C. W. RICHARDSON, Washington. The consensus of opinion seems to be in favor of the milder operations. Of course, when they are attended with the best results in a nasal case such should be the course to pursue, and such would be the course I would pursue in many of these cases if the growth was small and did not infiltrate neighboring tissues, but as the general surgeon deals with sarcomatous infiltration in other portions of the body in the most liberal manner, so it seems to me that in many of these cases of sarcomatous infiltrations of the nose and pharyn- geal cavities that have resulted fatally, when the growth was small if they had been dealt with in a more liberal manner and the growth removed in its entirety they would probably have resulted differently. In the case I reported I do not think anything was to be done except in the most generous manner. The case was a good one for such operation if there had not been the probability of secondary infiltration. It had already involved the antrum and the posterior portion of the antral cavity. To have attempted to remove this with snares would have been useless, as five or six operations previous to removing the maxilla proved. Of course in a case of that kind where the patient is in such an emaciated condition, and in fact demanding interference to save the life if possible, the particular opera- tion I did was the one that should be done. The rapid reproduction of the case was something very startling. Within four days after the removal of the tissue, both with snare and forceps, the patient returned and I found a great mass filling out the left nasal cavity. I could hardly believe it was a reproduction until after I had got my snare on it and tore it away. When I removed it the posterior portion was somewhat necrotic ; that was evidently where the growth had formerly been removed, and tissue above it had been pushed down as reproduced. There was reproduction again in four days, which was very remarkable, and each time the growth was removed the tissue was of a more malignant character. I did not refer very much to the gland that was situated on the right side; the growth was on the left. When I operated upon the case the patient seemed to be in a pretty fair condition, and Iwasin favor of removing that gland, or rather the tumor, but the gentleman who was with me in the case seemed to think it was an enlarged gland. Within three months that growth had assumed enormous proportions. Dr. Baynesaw the case before me and thought he detected fluctuation, and opened it, thinking it was an abscess. I removed some of the tissue from this opening and found it to be sarcomatous. Before the child died the whole left side was filled out the same as on the right and the condition was one of the most marked general sarcomatous infiltration that I had ever seen. 1550 PAN-AMERICAN MEDICAL CONGRESS. Dr. JAMES E. LOGAN, Kansas City, Mo. About three years ago I had sent to me a case of sarcoma of the nasal cavity, which was so complicated that the patient was completely depressed and very anaemic. The sarcomatous infiltration extended into the eyeball socket and upper eyelid, so much so that the lid was thickened and protruded out from the man's face. From my previous experience in operations upon the superior maxillary, I decided to remove this growth, which I found situ- ated upon the turbinated bone, filling almost the entire antrum, with the galvano- cautery by piecemeal, if I could get the patient to live long enough. I was satisfied the infiltration was so great the patient would die anyway. I removed about one- third of this growth. This patient while in the army had received a chest wound in the right side just above the nipple. He began to sink rapidly after the opera- tion and died from ha-morrhage from the lungs. Imade an autopsy and found that this sarcomatous infiltration had gone to the seat of the wound he received some thirty years previously, and from that center had extended over the whole lung surface. As regards the use of the galvano-cautery in these cases, so far as I have been able to see, operative procedures of a severe type have never been followed by evidences of even partial recovery, and in these cases the only operative procedure I would recommend would be a partial removal, at repeated sittings. I do not think anything other than the galvano-cautery or the cold snare should be used under any circumstances; that the results in these cases do not warrant a more thorough operation. DISCUSSION ON TREATMENT OF HAY FEVER. Dr. D. BRYSON DELAvAN, New York City. No greater task could be imposed upon one than to open a discussion upon the subject of hay fever. It is desirable, however, to obtain the sense of this meeting on the treatment of hay fever, and I hope that the discussion will be strictly confined to this department. There are two conflicting opinions regarding hay fever. One is that it is essentially a local condition; on the other hand, it is held by a far greater number that however much local influence may have to do with its production there is, broadly speak- ing, in the majority of cases at least, an underlying condition of some sort which tends to the production of this disease. Accepting the latter view, it is necessary that the treatment should be conducted in accordance with it. If it is conceded that there are general causes underlying hay fever, then reliance can not be entirely placed upon the treatment of local conditions. The general as well as the local state of the patient must be attended to. It is necessary therefore, in order to treat hay fever successfully, to look into the general well being of the patient and find whether he is suffering from lithemia, malaria, or any serious disorder of the heart, lungs, or kidneys, and to investigate the condition of his digestive tract. These, or any other general or diathetic states which could cons, tribute to the local trouble, must, as far as possible, be improved. The local treatment of hay fever may be broadly summed up under two distinct heads. Under the first plan are used various heroic therapeutic and surgical measures. Under the second are employed general therapeutic measures which are not heroic, the chief object of which is to subdue local irritation, and there are also surgical means which have exactly this same end in view. I believe that where conditions exist in the nose which contribute directly to the irritation of the nasal passages, such for instance as distinct organic occlusion of the nose, then Surgical means may be of great use. On the other hand, nasal surgery in this department has often been carried too far. It is extremely unwise to interfere in a case in which we can discover no good cause for interference, simply because the patient desires to be cauterized or to have a spicula of bone removed which PAN-AMERICAN MEDICAL CONGRESS. 1551 he supposes is there. Where there is not present a condition which distinctly calls for surgical interference it is wrong to advise the removal of apparent obstructions, and to practice the use of the galvano-cautery as often applied to the nasal mucous membrane in such cases. It may be unnecessary to state here that wholesale destruction of the nasal mucous membrane is not a good means of curing the dis- ease, yet there are some who, in a case of hay fever, will destroy it far and wide, by means of caustics or the galvano-cautery. With regard to the use of cocaine; every good thing seems to have its negative side. Thus, the most valuable of drugs, opium for instance, may become the most dangerous; and So it is with cocaine. This drug is doubtless a great blessing to persons suffering from hay fever. Its indiscriminate use, however, in this disease is productive of serious evils; indeed, in these cases cocaine improperly used will do vastly more harm than good, and I would like to go on record as dis- tinctly and vigorously opposing its indiscriminate use in these hyperesthetic patients. To recapitulate: If the discussion be confined to a few of the points here with raised we shall have enough to do. I would like to call attention especially to the question of the recognition and treatment of coéxisting conditions. I would also call attention to the abuse of surgical interference and to the proper and improper use of cocaine. The discussion should include the best means of treatment; that is, the means which are the most practical, the least theoretical, and most successful. The discussion seems opportune here in view of the fact that this meeting repre- sents such a wide diversity both of territory, experience, and thought. Dr. PRICE-BROWN, Toronto. I suppose I am particularly qualified to speak on hay fever, as I have been subject to it for the last ten years. I do not know in my personal history that I have suffered organically any other way; I do not know that my system has been deteriorated; I do not know that my kidneys, or lungs, or organs generally have been at all out of order, but I know that periodically, about the middle of August, I have an attack of this disease. I may say, however, that before I ever had hay fever, frequently with the slightest cold I suffered from closure of the nasal passages to a certain extent. I would find the greatest diffi- culty in breathing through the nose in cold weather, and this finally developed into an attack of hay fever. For two or three years I did nothing special for it; then I used a little cocaine; but four years ago the attack I had was most intense. I remember that it did not seem as if I had the power of thinking or feeling any- thing, except the intense sensibility produced by the disease, and I determined to operate upon myself, if I could find the part of the nasal cavity where the thing originated. I felt the indications in the back part of the left naris. After sneezing about one hundred times I sprayed the left maris with a 10 per cent solution of cocaine, and passed a probe into the passage. I found at the back end of what I assumed was the inferior turbinated bone a sensitive spot, with another about the middle of the passage. I then passed the cautery blade to the posterior spot and turned on the electricity and singed it; then to the next spot and singed that. The result was that for the rest of that year my paroxysms of hay fever were not so severe. The following year the trouble commenced in the back of the right nostril, and when most intense I operated in the same way. I might say in pass- ing, that I have had many cases of hay fever under treatment at different times; and one of the prominent symptoms has been exceeding irritation of the palate, particularly the uvula, the patient desiring to scratch the uvula and rub his tongue over it. The result is there is great elongation of this organ. The fol- lowing year I amputated half of my uvula, which resulted in great benefit. Last year my attack of hay fever was not very severe. This year it has been less than ever, and I have had no operation. It came on about the 24th, instead of the 14th, and I had no hay fever of any account until I started from Toronto, but on 1552 PAN-AMERICAN MEDICAL CONGRESS. my first night in the hot, dusty car coming South the attack became intense. I got alumnol the moment I heard of it. The treatment I generally use is a light solution of cocaine, giving it myself. I use the cocaine first, and afterwards men- thol in albolene. It seems to me the action of menthol in from 5 to 10 or even 20 grains to the ounce has the effect of lengthening the action of the cocaine. Latterly I use menthol more than I do anything else in my cases; this year I personally used no cocaine whatever. I find it more beneficial to apply the menthol to the throat, and have the patient breathe in through the mouth and out through the nose. In regard to any occlusion producing hay fever, I mentioned a case this morning where the columnar cartilage pressing against the wall of the nostril caused hay fever, and the removal of that cartilage removed the hay fever. From the effect that alumnol has had upon me to-day I think it will prove a good thing, and I shall try it in future. Dr. JOHN O. ROE, Rochester, N. Y. In every case of hay fever there is more or less disease of the nasal mucous membrane, and the more I see of hay fever the more I am convinced of the correctness of this assertion. I have yet to see a patient in whom disease of some portion of the nasal mucous membrane does not exist, and when I hear a case reported in which the patient suffered intensely from hay fever but without any local disease in the nose I think that the doctor is in error and did not discover the local lesion, perhaps on account of making only a cursory examination. When we consider that the nasal mucous membrane in adults covers a region of about 26 square inches it is not surprising that disease may lurk in some portions and remain there undiscovered unless a most thorough examina- tion is made. Hay fever may be considered a neurosis (pardon me for an allusion to the neurotic theory), but we have a great many neurotic people who do not have hay fever, and there are a great many people who have a great deal of disease in the nose who do not have hay fever; but when a person who is intensely neu- rotic has a great deal of trouble with his nose he is quite sure to have hay fever. There are a great many, as in Dr. Brown's own case, who have fever when there is apparently no neurotic element, and in such cases the disease is, I believe, as much a local disease as any disease can well be. Disease in the nose that may be the seat of the irritation is not necessarily confined to any One region, as it has been believed to be confined to the region of the inferior turbinated bodies, either the anterior or posterior end. The part that I have found to be most sensitive in these cases is the nasal Septum, and this undue sensitiveness has been usually excited by an intermittent or constant pressure of the turbinated bodies. The exciting cause of these neurotic conditions I believe to be in nearly all cases intranasal pressure, either from intermittent or constant contact between the different portions of the interior of the nose. It is, however, not necessary for this pressure to exist between the turbinated bodies and the septum, for it may exist between the turbinated bodies themselves or the inferior turbinated body and the floor of the nose. In the latter instances the extreme sensitiveness is confined to these bodies. The galvano-cautery in the treatment of these cases is frequently the most serv- iceable agent we have, but there are many conditions of the nose in which its use is not advisable. It is useful in vascular turgescence, but can not be employed to advantage in firm hypertrophy or Osseous excrescences. It is usually not advis- able to institute treatment during the attack, although in Some instances the abnormal conditions in the nose are emphasized during the attack and should be attended to at that time. + The beneficial effect of local treatment can not be better illustrated than by the case of a young lady whom I treated last summer one year ago. She was about twenty-three years of age, distinctly neurotic and neurasthenic, and her mother was also neurotic. She had suffered from hay fever severely for seven years, and was willing to have anything and everything done that would relieve her of this distress- PAN-AMERICAN MEDICAL CONGRESS. 1553 ing complaint. As it was so near the time of her attack I advised her to have the nostril in which she had the most difficulty treated, as she was unable to go through the necessary treatment for the removal of the difficulty from both sides at the same time. There was pressure of both the inferior and middle turbinated bodies against the Septum. This I relieved and carefully treated the nose. The result was that she passed through the summer without any trouble in this her left nostril, while in the right nostril, which had not been treated, she suffered from hay fever quite severely, although, the left nostril being free, respiration remained unobstructed and she did not suffer the distress experienced when both nostrils were completely blocked up. Later in the season, after the hay-fever period had passed, I treated the other side carefully, and she has passed through the hay-fever season this year without any disturbance from hay fever. In all cases of hay fever, more or less constitutional treatment is advisable, 8,S the local disturbance has a marked effect in lowering the tone of the system, inde- pendently of the neurotic trouble with which it is frequently associated. The tonics proposed by Dr. Mackenzie are excellent and I have found them of great Service. One thing that is of importance is nutriment to build up the system, and One of the best nutriments I have found to be eggs. By breaking an egg into a glass and having the patient swallow it whole he will take from five to ten eggs, or even twenty, a day. Many patients will be very much improved and their attacks somewhat modified by increasing the resistance of the system to local irritation, or frequently by the employment of a sedative that will abolish to a great degree the response of the nervous system to the local irritation, but in addition to this there is in all cases some localized disease, which should be found and carefully treated. Therefore, however much you treat the person generally and build up his nervous system, or however much you may improve the condi- tion of the vascular system, you must attend to the local condition in the nose, be it ever so severe or ever so slight, if you wish to relieve your patient positively and permanently from hay fever. Dr. S. S. KOSER, Williamsport, Pa.. I am glad to note on the part of this section the deprecation of the free and undue use of cocaine. It was only a week ago that a pharmacist of my city mentioned to me that he had regularly several customers for cocaine, and added that he was quite sure that the habit was first contracted in all of them from using the tablet at home, that the market is now flooded with, for these nasal cases. I believe the position taken this afternoon in the matter of prescribing cocaine, not permitting the patient to use it at home, is wise. It is a terrible thing to be the means of establishing cocaine inebriety in any case. In conneetion with this discussion I wish to call attention to a couple of articles that have done me good Service as temporizing agents in mitigating the severity of hay fever. One is terebene. I have certainly found it quite valuable as a mitigat- ing agent. I would also like to call attention to an old remedy, but one that has not been referred to in this discussion, and that is the inhalation of a strong solu- tion of carbolic acid, camphor, and chloroform, in the proportion of about a dram of the crystals of the acid and 13 drams of the camphor to 2 or 3 drams of chloro- form, used in a Smelling bottle. In fact, these cases come to us at such a stage that I rather prefer to palliate them first. I do not believe it is good surgery to rush into an Operation on the nose when the engorgement is so great. That is, I do not believe proper conditions exist for good surgical repair. I would rather say it is good practice to first palliate the case and watch for one of those opportunities which the gentleman from Toronto (Dr. Price-Brown) referred to as the conditions present prior to developing hay-fever symptoms, and to operate on the turbinates at Some time other than during that attack. Prečminently, in my experience, the Operation that does the most good and which is more perma- ment is to gently clip the lower ends of the turbinated bone. This, in my hands, .S. Ex. 36 98 1554 PAN-AMERICAN MEDICAL CONGRESS. yields the most lasting benefit, and I have frequently preceded an operation with the use of the cautery, so that there might be less tendency to haemorrhage follow- ing the operation itself. The point, then, I wish to make is that in my experience I have had better results in operative procedures if I deferred the operation until the intervals of the attack. I believe, then, that the permanent results are better, the parts will heal kindlier, and in all respects will do our patient a greater good. Dr. JAMES E. LOGAN, Kansas City, Mo. I wish to confirm Dr. Roe's experience in hay fever. Living in a country where hay fever is prevalent, I have seen a great many cases, but I have yet to see a case uncomplicated with hypertrophic rhinitis or rhinitis in some form. I read an article before one of our medical Soci- eties in 1886 in which I made the statement that I did not believe hay fever could exist without a previously existing rhinitis of some form, and after years of expe- rience I am willing to support that statement to a considerable extent, for I have never seen a case where there has not been some such trouble, either from a deflected septum, exostosis, hypertrophic rhinitis, or Some disease where there was a soil in which this idiosyncrasy was produced. The treatment I have used for the last few years has been the cautery. I begin the cauterizations about a week previous to the first attack and continue them at intervals through the period of hay fever, and by continuing these cauterizations after the period has passed, relieving whatever condition, mechanical or otherwise, that existed there, and in succeeding year continuing a mild course of cauteriza- tion through the period of hay fever, I have relieved quite a number. I have recorded some cases of very pronounced recovery in this respect. A lawyer who has an office next to mine, who was a constant sufferer for sixteen years, suffering the tortures of death almost from hay fever, and who had travelled the world over seeking relief, is a standing monument of the efficacy of the treat- ment of hay fever as I have suggested it. To-day he has no trouble whatever from it, and there are a number of cases of a similar nature. The neurotic ten- dency, which I believe exists in nearly every one of these cases, whether it be perceptible to the physician or the patient, is a latent element which must be corrected by medicinal means preceding the hay fever period. Beginning a week previous to the attack, I administer a preparation of nitrate of sodium with a half grain of camphor, continuing that six weeks after the attack has passed; I have found it to be an admirable sedative, and can heartily recommend it. My mother was a great sufferer from hay fever and asthma, and in 1885 I removed from her right nostril a large tumor, after which she had no trouble from hay fever or asthma until two years ago, when I found there was considerable hyper- trophy existing in the left nostril, also in the right, together with a deflected septum, that by reason of my position in the family I had to refuse to operate on. About six weeks ago I removed an exostosis of considerable extent, and she writes me she had had no hay fever this season so far, and no asthma. I think there is great progress yet to be made and many things to be found out in the treatment of hay fever. Dr. F. C. COBB, Boston. I would like to know whether in hay fever the writer includes vaso-motor or hyperaesthetic rhinitis? I have had some cases of that kind, and although in a good many of them I could not find any very marked nasal- obstruction, yet cauterization, not of a very wide area, but usually over the lower turbinated and points opposite to it on the septum, which seemed to be especially hyperaesthetic, appeared to give great relief, and a year later I heard from these cases that they had had very little, if any, hay fever. But those cases which were complicated with asthma still had asthma ; there was very little relief from that. These were hospital cases operated upon year before last and they all had a great deal of trouble; some were complicated with polypi, which, of course, were removed. But all to whom I wrote, reported very little nasal trouble, so I believe that cauterization, at least to a limited extent, is of considerable value. PAN-AMERICAN MEDICAL CONGRESS. 1555 Dr. J. H. BRYAN, Washington, D. C. I think there must be two conditions or else we would not have such diametrically opposite ideas, one of which is due to a morbid condition of the nose, which of course is relievable, but those cases in which in the interval of attacks there is no Inorbid condition I do not believe can be cured by local treatment, yet the symptoms can be greatly palliated. I think in this locality we have as much hay fever as anywhere in the country and I have seen quite a number of cases. Those which have been dependent upon exostosis or pressure of the turbinated bodies have been easily relieved and have not returned, but those which are entirely neurotic in character, where in the interval of the hay fever attacks, as far as observation goes, it is impossible to see any mor- bid condition invariably return, in this part of the country, about the 15th of August. I can not understand why there should be a discrepancy of opinion. Dr. Roe and Dr. Logan are positive the condition is not due to anything but intra- nasal disturbance, but I have two cases in which I think it is impossible to find anything existing in the nose in the interval of the attacks. Dr. E. FLETCHER ING ALS, Chicago. I did not intend to say anything upon this subject, but I am so heartily in accord with the last speaker that I wish to amplify and support what he has said. I have thought for a long time that where there is nothing discoverable in the nose during the interval, treatment of the nasal cavities is useless. Where there is something discoverable that gives the patient discomfort, treatment of the nasal cavities may be valuable. I have seen several cases where there was no hypertrophy or other form of obstruction, in which there was hypera-sthesia, and in these cauterization has been beneficial. As to the time of cauterization, my plan is to complete it at least two or three weeks before the attack is expected, so as to allow the mucous membrane to become healed before the ontset of the disease. The cauterizations are rarely made oftener than once in five days, and cover an area of not more than a centimeter in diameter. The burn is superficial, never destroying the mucous membrane. Such cauterization has an effect similar to that of a blister on the skin, and after the treatment it is impossible to find cicatricial tissue. In some cases where there is much swelling, deeper linear cauterizations are necessary. I do not favor removal of the turbi- nated bodies in the way suggested by one of the speakers, believing that it is not best to destroy so much of the mucous membrane. If I wished to remove the turbinated bone I would run a trephine or burr through it, beneath the mucous membrane, thus removing enough of the bone so the soft tissue would fall to the side and be out of the way. - I have seen one case in which daily soothing treatment alone, carried out by the patient for a period of two years, prevented recurrence of the attacks. I have seen one case in which no topical or general treatment was employed, in which the patient, when the attack came on, by force of will never sneezed if he could possibly avoid it and persistently refrained from blowing or wiping the nose. As a result of this course he had only a slight attack the first year it was tried, and the next year practically none. I hope some of the other gentlemen will tell us what can be done by general treatment. It seems to me that half of the cases can be relieved, perhaps cured, by local treatment during the interim ; but if the patient comes to us after the attack has been established local treatment is not important excepting to soothe the parts. A day or two ago a physician who has |been troubled with hay fever told me that he has a rheumatic diathesis for which he has recently taken a few grains of salicylate of soda, which he feels confident is preventing him from having hay fever this season. It may be that the gouty condition causes hay fever in many cases, the rheumatic condition in others, and I have no doubt that digestive disorders have much to do with it. For my own part, I rely much upon a general tonic and sedative treatment sim- ilar to that recommended by the late Morell Mackenzie, consisting of the phos- 1556 PAN-AMERICAN MEDICAL CONGRESS. phate of brucia combined with camphor, hyoscamus, salol, and sometimes with valerianate of quinine. I have used this treatment for two or three years, I think with much advantage. I begin the treatment three or four weeks before the attack is expected, and have the patient continue it throughout the season. Dr. JOHN N. MACKENZIE, Baltimore. I have been very much interested in the discussion and I am very much pleased that the word pollen has not occurred 1n the remarks made. The day is dawning when we will find a solution of this prob- lem in the study of pathological law and not in an inquiry into the processes of plant reproduction. It is difficult to disassociate the pathology of hay fever from its treatment, because the latter depends upon what is conceived of the former. The pollen theory I regard as the greatest bar we have had to the march of therapeusis in this disease, and next to that I am afraid we are having another barrier set up in the too exclusive theory of the nasal nature of the malady. If we view it from the higher vantage ground of general pathology and laws of health we may catch a very much broader glimpse of the protean aspects of the problem and be in a much better position to relieve our patients than if we follow the beaten track of the pollen theorists. I certainly see cases in which there is no respiratory lesion whatever during the interval between the attacks. When I first began to investi- gate this matter I was allured by the new theories concerning the disease and for a long time was completely under their dominion, but further examina- tion and broader conceptions of the disease have taught me the lesson that in a goodly proportion of the cases there is no appreciable local respiratory lesion what- ever. Another point: It is not in the nose alone that these lesions are found; the area in which the nerve storm breaks will depend upon the seat of the local patho- logical process. For example, take a neurasthenic with a polypus in the rectum, the nervous disturbance produced by the polypus would be referred to the lower bowel, whereas in the case of a polypus in the nose the impressions would be referred to the upper respiratory tract. These lesions, when they do exist, as they undoubtedly do, may exist in the nose, pharynx, retro-pharynx, larynx, bronchial tubes, and trachea even. The point I wish to make is that the nose alone is not the only part of the respiratory tract that is responsible for the outbreaks of the disease falsely called hay fever. A great deal has been said in recent years about pressure irritation, but it seems to me that instead of producing hypertrophy it is more likely to produce atrophy. Take as an illustration cases to which the middle turbinated bone is enormously developed; as it gets larger and larger instead of producing hypertrophy of the septum it produces atrophy, and goes through to the other side. Dr. Cobb has brought up the question of the identity of these different forms. They are all blood relations—coryza, vas-omotor hay fever, rose cold, June cold— and if we should classify them as one disease it would simplify matters very much. As to the plan of treatment, my rule has always been to examine the patient, going over him from head to foot, finding out any peculiarity, any disease, gen- eral or local, that might be the source of any systemic, local, or remote irritation. They are all different, like the stars, and in that way you get at a more rational plan of treatment. Having done that, I look carefully after any disease, either gross or microscopic, in the respiratory passages, not in the nose alone, but all through the tract, from the tip of the nose to the bronchial tubes. After having found the general condition I treat according to the circumstances of the case. Dr. Ingals wishes to know about the general tonic treatment. I can not give any rule. I feed the nervous system; it is always broken down. We do not always find conspicuous nervous phenomena among hay-fever patients, but there is always a nervous organization—a screw loose somewhere in the nervous mech- anism. I generally start out with a pill containing about one-sixteenth of a grain of phosphide of zinc, about 2 grains of quinine, one-fourth grain of extract of PAN-AMERICAN MEDICAL CONGRESS. 1557 nux vomica, to be taken before meals, and after meals 3 to 5 drops of Donovan's or Fowler's solution in water. Very frequently I have to substitute some other nerve tonic, but the main point is that the nervous system must be braced up. If there be disease of the respiratory organs, remove it if possible. If there be no apparent disease, and if upon experimental stimulation of different portions of the mucous membrane no sensitive areas are to be found, let it severely alone. But if, on the contrary, as is frequently the case, we can localize these areas I treat them by cauterization, and for this purpose the galvano-cautery transcends all other methods. We find these sensitive areas not only in the places where I have located them in the nasal passages, but also in other portions of the respiratory tract, in the posterior wall of the pharynx, in the arytenoid commissure, and the posterior wall of the trachea. Why is it that the removal of a nasal polypus, for example, will dissipate hay fever permanently 2 The explanation, it seems to me, is this: Take an illustrative case; the patient consults his physician, perhaps suffering from violent paroxysms of Sneezing, obscure cough, and other symptoms referable to some reflex producing agency. The patient goes on unrelieved day after day. Asthma is finally added to his symptoms, and finally he blooms out into a regular hay-fever patient. If it is summer the physician tells him he has hay fever; if it is winter he is told he has asthma. At this stage of the disease a polypus is dis- covered and removed and the reflex symptoms are dissipated, and the patient gets well. What is the explanation of that? No attention has been paid to the cen- tral nervous apparatus; simple operative work in the nose has secured the result. In this class of cases the way in which the nervous system is influenced is through the constant irritation by the foreign body in the nose; the irritation of the nerve centers, the weariness they experience at being forever called upon to discharge their functions. With the removal of the polypus the irritation is taken away and physiological rest secured for the centers, and in that way the patient gets well. If the polypus remains unrecognized the condition goes on for years, other organs are included in the arc of reflex disturbance, changes occur in different organs which are impossible of eradication, and local treatment alone will lead to tem- porary relief, but will not effect a permanent cure. In regard to surgery; it is called for when surgery is necessary, and it is only necessary when there is some- , thing pathological to be removed from the respiratory apparatus. Dr. JOHN N. MACKENZIE, Baltimore. I omitted to make an important point, and that is that hay fever does not exist only at one time of the year. I believe it is like epilepsy, with you day and night, Summer and winter. One of the wo.st cases of hay fever I ever saw was a lady in Baltimore, whom I treated for four suc- cessive Januarys. She never had it in any other month ; it was a marked case of hay fever, with asthma. My plan is not to commence with a tonic at the period of attack, but I commence from six to eight weeks, sometimes three months, before the expected attack, and I feed the nervous system for all it is worth during that time; and I not only do that but I treat the patient through the year at certain intervals, depending upon the patient, the character of the case, etc. I treat them during the entire year as if they were just on the verge of a paroxysm, and one of the chief difficulties I have is to follow my patients. They will get apparently well, and will think “this is all humbug; I don’t feel nervous; I am not going to have a paroxysm for six or eight months, and I will let the thing drop.” Dr. D. BRYSON DELAVAN, New York City. The Doctor has referred to one of the most important points in view in bringing forward this discussion. It can not be too vigorously emphasized. We so often see patients and physicians put- ting off treatment of this disease until the attack begins. The golden opportu- nity for treatment, according to my experience, 1s the interval between the attacks, especially in those cases where there is present any nasal or constitu- tional trouble. I have seen cases in which during the Intervals between the 1558 PAN-AMERICAN MEDICAL CONGRESS. attacks the nasal condition seemed to be normal, and although I have used my best endeavor to find an abnormality, I have not succeeded. However, we com- monly have hypertrophic conditions, catarrh, exostosis, nasal polypus, and various other deformities present, and these conditions persist, to a greater or less degree, throughout the year. We can all agree to the following propositions: First, that the general condition of the patient should be kept up to the best possible limit; second, that the best opportunity for relieving the patient will be found between the attacks, when abnormal conditions of the nose should be treated, whether by Surgical or therapeutical measures to be determined by the nature of a given case; and, third, that during the attack the treatment applied should have for its prime object the alleviation of the existing symptoms. In regard to treatment during the attack, I think it would not be unwise for this body to place itself on record as distinctly opposed to the indiscriminate and careless use of cocaine. What one of the gentlemen said with regard to this mat- ter in his locality might have been said, I think, by everyone present. We all find it commonly used and commonly abused. It is a source of a great deal of injury, and I wish we might go on record as opposing the evil. Finally, the fact has not been touched upon, although we all recognize it, that when our therapeutical and surgical means are exhausted certain relief may be obtained by placing the patient in a proper climate, where he may enjoy immu- nity from his attacks. I believe that in this class of cases, where the patient can be sent away during the time he is having his attack, and where he can be treated between the periods of expected attack, in time the attacks may be entirely done away with in a fair proportion of instances. Dr. JOHN N. MACKENZIE, Baltimore. I wish to indorse what Dr. Delavan has said in regard to the use of cocaine. I have long since given it up in the treatment of this disease except as a purely palliative measure. At a meeting of the Laryngo- logical Association some years ago in Detroit I called attention to the fact, shortly after the drug was brought over to this country, that the time came sooner or later when cocaine dilated the blood vessels in the mucous membrane of the throat and nasal passages, and Ithink that point is now perfectly well established, and Dr. Dela- van's denunciation of its indiscriminate use is correct. But there is another point not generally known, namely, the evil effect menthol sometimes produces. I know of two cases in the practice of a fellow practitioner in which menthol has given rise to brain symptoms similar to those cocaine produces. The patients were both sing- ers and had learned that a little menthol squirted into the nose with an eye dropper just before they were going to sing would make their voices more resonant, so it had become their practice every time they were to sing to drop in a little of this seemingly harmless thing, and finally the friends of one of them noticed that she was having hallucinations and that her mind was becoming otherwise affected. This was spoken of to a physician, and when she ceased taking the menthol all her bad symptoms disappeared. The other case was affected in the same way and on discontinuing the use of menthol became well again. THE ULTIMATE PROGNOSIS IN NEGLECTED ADENOID HYPERTROPHY. By D. BRYSON DELAVAN, M. D., of New York. The effects of adenoid hypertrophy upon the general well being of the patient have been so thoroughly exploited during the past ten years that they are, or should be, abundantly recognized and understood by all practitioners of medicine. To discuss the injury to the hearing, the deformities of the jaw, the nasal cavities, the face and the thorax, the defects of speech, or the impairment of nutrition due PAN-AMERICAN MEDICAL CONGRESS, 1559 to adenoid hypertrophy would be to present facts which are already sufficiently familiar. It will be the object of this paper to avoid the above considerations, and to invite attention to a series of important conditions which, in the opinion of the writer, are more or less the result of neglected adenoid enlargement, or of incom- plete removal of it during attempted operation, but which have not always been recognized as bearing direct relation with that disease. The existence of the conditions which we are about to consider must depend upon the oft-repeated question: Does adenoid hypertrophy, if left to itself, tend to disappear, leaving the pharyngeal vault in a normal, healthy state 2 By a uni- versal consensus of opinion, founded upon common observation, the reply is nega- tive. Adenoid hypertrophy, if left to itself, will seldom result in spontaneous cure, no matter what modifications it may undergo, but will usually leave behind it local pathological conditions which may continue for life, to the permanent inconvenience and detriment of the patient. This is proved by the frequency with which the history of prečxisting adenoid hypertrophy is traceable in these cases. The conditions above alluded to are the direct outcome of the structural changes which occur in the third tonsil, as elsewhere, as the result of long-con- tinued inflammation. They may be classified broadly under two heads: (1) A condition of permanent enlargement or thickening. (2) A condition of genuine atrophy. (3) Finally, as a probable subdivision of class 1, we may have the con- dition known as “Thornwaldt's disease.” Class 1.-The existence of this class of cases is proved without difficulty, since they are commonly met with in practice and easily recognized. Belonging to it are several varieties, which may be summarized briefly as follows: (1) Cases in which the hypertrophy of childhood remains, with slight diminu- tion in size, until past middle life. Examples of this form may be found in per- sons well along in life. Indeed, Dr. J. Solis-Cohen has reported one case occur- ring in a woman of over seventy years of age. Cases are often met within singers and speakers whose voices show distinct evidence of the pharyngeal disease, and who often fail to obtain satisfactory relief until the offending tissue has been thoroughly removed. The hypertrophy is seldom as pronounced as in childhood, but a sufficient amount remains to constitute a well-marked projection from the pharyngeal vault and a consequent interference with the normal amount of space required for that region. (2) Cases in which, with considerable diminution in the size of the original growth, a moderate enlargement remains, which in some cases is subject to acute attacks of swelling, during which may be developed, temporarily, a well-marked pharyngeal tumor. In this condition of the vault there often appears, upon exami- nation, to be nothing more than a simple thickening of the mucous membrane without especial significance. In reality, it is the remnant of an early hypertrophy, and constitutes in itself a morbid state, attended with annoying symptoms. This particular class of cases presents several interesting features. Often the usual appearance of the vault differs little from the normal, excepting that the color may be darker than usual and the surface of the mucous membrane somewhat less smooth. The application of the finger tip, however, or of the end of a probe, will demonstrate the presence of a distinct thickening which may be so slight and so generally distributed as to be overlooked, although overlying the whole vault. (3) The so-called “Thornwaldt's disease” is described as being a chronic inflam- mation of the “pharyngeal bursa,” accompanied with some enlargement, and a discharge from one or more of the crypts or folds at the pharyngeal vault. It appears to be nothing more than a chronic condition resulting from long-standing hypertrophy. Certainly it is best treated by the same means which are successful in cases of ordinary hypertrophy, namely, by the removal of the offending tissue. 1560 PAN-AMERICAN MEDICAL CONGRESS. In all of the above varieties of pharyngeal disease there is commonly present a remarkably persistent catarrhal inflammation, in some cases much more severe than in others, and attended with greater disturbance to adjacent parts, but in nearly all sufficiently well marked to be the cause of distinct annoyance. It is in Such cases also that progressive loss of hearing is apt to occur. While the habit of mouth-breathing may have been long ago successfully overcome, the effect upon the voice of the interference with the normal contour of the vault of the pharynx, caused by the thickened tissue projecting into it, and of the presence of the unnat- ural Secretions which more or less occlude it, is particularly unfortunate, materi- ally impairing its richness and tone quality even when it does not interfere with pronunciation. * The Second class of cases is one in which the conditions and symptoms are even worse than those of class 1. In them the soft parts of the pharyngeal vault have undergone a distinct atrophy. Their anatomical structures have either been completely destroyed or else so modified that they are no longer able to per- form their normal functions and the physiological activity of the parts has thus been destroyed. Local symptoms of a distressing nature also are set up and a most unfortunate state of affairs is the final result. It is not claimed, of course, that all cases of atrophic catarrh of the vault are consecutive to adenoid hypertrophy. On the contrary, it is not uncommon to find this disease in patients who, to all appearance, and so far as their histories go, have been remarkably free from lymph- oid enlargements of all kinds. Nevertheless, severe degrees of dry pharyngeal catarrh are not seldom found in patients in whom unmistakable evidences of pre- existing adenoids are present. If the conditions described under class 1 are objectionable, those last mentioned are far more so, both with regard to the discomfort and annoyance which go with them and to the extreme difficulty which attends their cure. All, however, are objectionable in a high degree and eminently calculated to add to the burdens of life, while detracting from the comfort and general usefulness of the patient. To sum up, it appears: (1) That there are several pathological conditions of the upper pharynx found in adult life. (2) That these conditions are common. (3) That where they are present the history of preexisting adenoid hypertrophy can often be distinctly traced. (4) That the conditions which are present in these cases of adult disease are such as would have resulted naturally from the effects of long-continued inflammatory action upon the parts concerned. (5) The above premises being true, it is impossible to avoid the inference that prompt and efficient treatment of the original adenoid enlargement would have removed the chief cause of the subsequent disease, and thus have prevented much injury and suffering. The great frequency therefore with which disease of the vault of the pharynx, due to neglected adenoid hypertrophy, is found, the serious character of the con- ditions resulting from it, and the great difficulty often experienced in overcoming them, all bear testimony to the fact that, on the whole, adenoid hypertrophy does not tend to spontaneous cure; that when present, in any marked degree, it demands thorough treatment, and finally that if left to itself in the hope of spontaneous cure the ultimate prognosis is bad. The practical application of the above conclusions is obvious. Adenoid hyper- trophy is a disease which is always likely to be injurious. Its effects are not con- fined to childhood, but may follow the patient as long as he lives; and with regard to its treatment, the greatest amount of evil is to be avoided and a maximum of good obtained by its early, thorough, and complete removal. PAN-AMERICAN MEDICAL CONGRESS. 1561 DISCUSSION. Dr. PRICE-BROwn, Toronto. I would like to ask whether the Doctor finds a greater proportion of cases of hypertrophy in the adenoids in males or females; also whether there is any direct hereditary tendency to the disease? As a rule, I have found a larger number occurring in males than females. In children who have been brought to me for treatment of adenoids, I have frequently found that where the father had the disease, the sons had it also. I would like to know whether there is any connection between the two. Dr. D. BRYSON DELAVAN, New York City. In answer to Dr. Brown. I have not observed any distinct preponderance in either sex. There is no question as to the possibility of heredity. Either the child inherits the adenitis itself or he inherits tertiary syphilis, or tuberculosis, which may develop adenitis, which amounts to the same thing. As to nationality, that nation will have the most adenitis which is the most exposed to damp, changeable, chilly weather, and per- haps to tuberculosis and the various diatheses that accompany bad climatic sur- roundings, although in the healthiest American types adenoid enlargement may be found. The subject of the paper is the tendency of neglected adenitis to con- tinue as a source of irritation and disease during adult life, and it was for that point alone the paper was presented, because I think sometimes this tendency to degeneration and permanent pathological results is not sufficiently realized. THE EFFECTS ON THE VOCAL CORDS OF IMPROPER METHOD IN SING ING. By H. HOLBROOK CURTIS, M. D., of New York. It would be strange indeed if alaryngologist who was daily in the habit of exam- ining very many throats of singers did not have his attention particularly attracted to the difference in the appearance of the glottis as the direct result of different methods of voice production. Several years ago, as early as 1884, I observed that many pupils of a certain pro- fessor of singing presented marked peculiarities in regard to the position of the free borders of the vocal bands. The slightly elliptical shape of the chink of the glottis, which this class of pupils presented in emitting the usual sounds to allow the proper view of the larynx, led me to inquire as to the particular method of teaching which would produce in so many throats a typical appearance. I soon found out that these pupils were in the habit of taking daily exercises almost entirely on a single vowel, and that single vowel being the letter “o.” The vocal cords appeared striated, with frequently a congested area at their anterior attach- ment. Frequently a nodule, more or less defined, would be observed about the center of the free edges on either cord. This is a picture which every laryngolo- gist will recognize. Another type of which the study is most interesting is that of a class of pupils undergoing instruction at a conservatory where that pernicious French method, the so-called stroke of the glottis (coup de glotte), is daily prac- ticed. In this type the writer has observed the middle-third of the cords to be slightly bulged, the cords presenting a convexity in contradistinction to the con- cavity exhibited in the last group. These pupils had been singing chiefly on the vowel “a,” pronounced as “ah” in English, and with the emission of each note the middle portion of the cords would clash, and by constant attrition become hardened and callous. The cords in this particular type do not usually show congestion; their appearance is usually of a 1562 PAN-AMERICAN MEDICAL CONGRESS, good pearl color, and healthy looking in every way. The complaint which they make upon consultation is a difficulty in singing the so-called mezzo voce and a lack of richness of tone and timbre, with extreme weakness of two or three notes in the upper medium register. It was these two opposite appearances of vocal cords, which are every day observed in singers’ throats, that led to an investiga- tion of methods employed by the various schools of singing, and has opened up a field which I think has been entirely neglected, though of the greatest importance to every laryngologist who has to do with singers. - Two names are intimately linked with the traditions of method in singing : those of the elder Lamperti (that illustrious exponent of the best Italian school), and Mandl, who, by his ingenious arguments, though founded on a false physio- logical basis, succeeded in completely overturning the art of voice production which previously had been taught throughout Europe. He substituted in place of the so-called Italian school a method of abdominal respiration which was at Once adopted in the Paris conservatory, and has obtained to within the last three years an almost universal recognition in the best schools of the Continent. It is the writer's purpose, without going too deeply into the history of singing, to discuss the various methods of respiration and initial tone production, and to show by a series of experiments made upon individuals the effects of certain meth- ods of voice building, hoping to arrive at some definite conclusion as regards the proper exercise and position of the larynx, and consequently proper tension of the vocal cords during tone emission. For the brief historical sketch which I shall give I am indebted almost entirely to the able article of Dr. Joal, of Mont-Dore, which appeared in the Revue de Laryngologie d’Otologie et de Rhinologie, Nos. 8, 9, and 10, 1892, Paris. The position which Dr. Joal occupies at Mont-Dore (the favorite resort of almost all the European artists) has enabled him to consult freely for a number of years the most distinguished vocal talent in Europe, and his views upon voice production should be carefully read by every instructor who wishes to profit by the exceptional opportunities which that author has enjoyed. One can not read his able discourse upon the singing voice without feeling that his every utterance is eac cathedra. In 1842 Beau and Maissait divided the respiration of singers into three characteristic types—the superior costal, inferior costal, and abdominal. The superior costal may be illustrated as the breathing of a woman tightly laced, the respiratory expansion taking place chiefly in the cone of the thoracic cavity, the upper ribs, collar bone, and sternum rising and falling during the respiratory act. In the inferior costal type the inferior ribs (commencing with the seventh downward) are rotated and elevated, the sternum moving only in its inferior portion, the abdominal wall being contracted during the inspiratory act. In the true abdominal type, the thorax is supposed to remain completely fixed, the diaphragm, taking the ribs as a fixed point, lowering the abdominal viscera, thus distending the wall of the abdomen in inspiration. It is this latter type of breath- ing which has been taught for the last thirty years in France. Mengozzi, together with the masters of one of the conservatories, determined upon the following rules illustrative of the breathing of singers: The respiratory act in singing differs somewhat from that used in speaking. In-speaking the abdomen is distended in inspiration and recedes in expiration, while in singing the abdomen must be drawn in during inspiration, returning Slowly to its natural state as the chest contracts in expiration; thus retaining as a negative force the air which has been introduced into the lungs. In a revision of this method, published in 1866 by Baptiste, these laws are repeated with the addition of a note by Dr. Mandl (the apostle of abdominal respiration) who advocates the advancing of the abdomen in inspiration. Mandl carried his point, and his ideas became generally adopted by the conservatory. M. Bonheur and Dr. Cheval, of Brussels, advocated the superior costal type of breath- PAN-AMERICAN MEDICAL CONGRESS. 1563 ing in contradistinction to the method of Mandl. Mandl in his work states that the larynx becomes very much depressed and the glottis enlarged in the costal method of respiration. Joal answers him in these words: We do not find this depression of the larynx referred to in any of our classical treatises on physiology, anatomy, nor in any of the numerous works which have appeared since 1855 on laryngology; consequently we suppose that writers do not share the ideas of Mandl on the subject. Besides we have examined a number of persons whom we engaged to breathe alternately from the abdomen and from the shoulders. We ourselves, in singing, have often observed the movement of our larynx and we have never observed that the clavicular inspiration caused the thyroid to fall. Nicaise explains this fact by demonstrating experimentally that during strong inspiration the trachea contracts and becomes shorter, which draws down the larynx.” It is very difficult for a professional man to take cases of distinguished singers in his own private practice and hold them up by name as models of perfection of certain types. Joal made the assertion, in an article published in 1890, that great artists. especially women, used the superior costal method. The distinguished critic of Le Temps challenged Dr. Joal at once to mention some of these artists. The Doctor responded : . I would be happy to gratify Mr. Weber's desire, but it is very difficult for a physician to go into personalities and to say that a certain singer is using a vocal method considered disastrous and execrable by masters of criticism. Melchissedec, however, offered himself as an example of the superior costal respiration, saying that it had enabled him to sing constantly for twenty-five years. Both his strength of tone and his tremendous endurance, with an almos perfect glottis, attest that the method has not been injurious to him. - The abdominal method of breathing has many powerful advocates. M. Obin and M. Faure, for example, speak most highly of it; Shakespeare, of London, Behnke, and Lennox-Brown are also its advocates. The instructors of both methods are very apt to quote great artists as the exponents of their particular school. Joal cites the case of Rubini, the celebrated tenor, whom Massini and his pupils declare originated abdominal respiration. Bonheur, on the contrary, states that he expanded his upper chest, Walshe even going so far as to say that he frac- tured his collar bone in making a violent effort to reach “B flat '' in “The Talis- man of Pacini.” Lablache and Laget acknowledged that in spite of long and attentive observation they had not been able to distinguish in the theater how this illustrious tenor breathed. Joal goes on to state that the famous Lamperti is alternately represented as a partisan or opponent of the abdominal type of breath- ing; but I think that, having treated many of the elder Lamperti's pupils and inter- rogated them very particularly upon this question, I may unhesitatingly affirm that the elder Lamperti was a strong advocate of the lower costal respiration, always arguing that the abdominal wall should remain quiet or be slightly drawn in during inspiration. The evidence of Campanini, Jean de Reszke and Clara Heyen is in support of the above. Joal says if we except the works of Laget and Bonheur, we find nowhere the praise of clavicular breathing in men. The ancient method of the Paris Conservatory and the works of Maunstein, Caruth, and Manuel Garcia all advise thoracic respiration by the elevation of the ribs and drawing in of the abdomen. If we take up any work on the voice and study the photographic appearances of the cords during the emission of certain notes, we remark that the cords are not vibrating longitudinally, but that their free borders approximate, touch, or over- lap, and that the posterior opening of the chink is longer or shorter, and different * Revue de Medicin, 1889. 1564 PAN-AMERICAN MEDICAL CONGRESS. in appearance for each note. I wish to put on record here my opinion of the abso- lute impossibility of photographing the vocal cords during the proper emission of tone, from the very fact that the laryngoscopic mirror placed in the pharynx interferes with the right focus of the respiratory attack, and it is only possible to observe the vocal cords in the photograph when the so-called stroke of the glottis is used in the emission of a note. The photographs of singers' cords and the deduc- tions which have been drawn from their appearance during the emission of dif- ferent notes only demonstrate, in every case that I have ever seen, that the larynx is elevated by the pulling up of the thyroid, the cords relaxed, and the free borders more or less approximated. If we ask a singer who is in the habit of using the so-called “high-chest method” of costal respiration to take a note (the attack entirely taken from the cords and focused in the masque, bringing into play the harmonics lent by the sound waves passing behind the uvula and soft palate), introducing the Smallest possible size of mirror, so that the color given to the note by nature's resonance pipes, the antra and nasal cavities, will be as little as possible interfered with, we are surprised to find that on the emission of every note of the soprano medium register the cords appear equidistant from each other throughout the entire extent that it is possible to see them. r The part which the intrinsic muscles of the larynx play in the tension of the vocal cords becomes an interesting study. It is very easy for us to see by the depression of the thyroid how the cords must be elongated, but it is extremely difficult for us to comprehend the minute differences of tension caused by the movements of the thyro-arytenoid and crico-arytenoid muscles. I have frequently been surprised, upon examination of the vocal cords with the head held down, the chin resting upon the chest, to find the cords present a beautiful pearly appear- ance, entirely homogeneous, but upon attempting to show the patient his own cords by an adjustment of double mirrors, the head being slightly thrown back, upon the same note the cords suddenly have become dusky, semi-congested, and striated. How much of this is due to the slight elevation of the thyroid cartilage, and how much to the intrinsic muscles of the larynx or to the relationship between the chink of the glottis and the trachea, it is difficult to determine. To a careful study of these differences of tension am I indebted for the discovery of a fact which I here write about for the first time, the appreciation of which fact, how- ever, has entirely changed my treatment of the singing larynx, and has caused me to institute a system of tone exercises by which certain intrinsic muscles of the larynx are so strengthened that any medical application through the medium of sprays, probangs, and, I may say, instrumentation, has ofttimes been entirely done away with. - If we take a good-sized laryngoscopic mirror, No. 4, for example, and ask a patient to sing “E” or “Ah,” the cords come into view for two reasons: First, the epiglottis becomes more perpendicular, allowing a better view of the bands, and secondly, the cords themselves are on a more elevated plane, owing to a slight ele- vation of the thyroid cartilage and consequent relaxation of the intrinsic tensors of the cords. In this position we remark that the free borders of the cords come together in the anterior and central portions, and we are able to study the initial tone attack, the membrane separating as the tone bursts through the closed chink. This picture may be said to be an imitation on a small scale of the so-called stroke of the glottis. In this method of producing a tone, the initial attack being upon the cords themselves, the central portions of the cords necessarily touch. The peculiar muscular equilibrium which is employed in this mode of attack invites a reflex elevation of the soft palate, cutting off the oral from the nasal cavities. As we look at this picture our minds revert to the singing teacher who commands her pupils to keep their palates up, sing in the back of their heads and strike the glottis, PAN-AMERICAN MEDICAL CONGRESS. 1565 Could ever villainy be more compounded? Let us take the same patient and require him to sing the same note, but in an entirely different way. We will first ask him to expand his upper chest, not necessarily by respiration, but by elevation of the superior ribs by a muscular effort, at the same time slightly drawing in the abdominal wall. We now introduce the smallest mirror and ask our patient to sing “A,” pronounced as in “law” or “maw.” With this position of the larynx and muscular poise, we observe two things: First, the epiglottis does not assume its most vertical aspect, not inclining as near the perpendicular, and the soft palate and uvula do not Spring upward and backward to make the partition between the mouth and the naso-pharynx. Different in every respect is the tone produced by the cords, which may be assumed to vibrate longitudinally, but never touching each other in the middle portion, even in making the initial attack. The cords appear narrower, tenser, lower anteriorly, equidistant from each other, more homogeneous and whiter in color. These two pictures should be well considered, as they become the basis of criti- cism in distinguishing the correct and eliminating incorrect methods, on the one hand, in singer's voices, and of the greatest assistance to the laryngologist in cor- recting pathological conditions, the result of bad training. The proper apprecia- tion of these opposite conditions and their effect on the quality of tone imme- diately calls our attention to the subject of respiration. Within the past three years the entire theory of musical education has changed in France. The explana- tion of this change being that there is at present a better appreciation of the influ- ences bearing upon the production of tone, and a better understanding of the physiology of the larynx by reason of the advances made in laryngoscopy. Mod- ern teaching tends to cultivate tone harmonies and sympatica in the voice at the expense of brilliancy of execution. The same judgment should be exercised in the training of an individual who proposes to make singing his or her art as should be employed in advising the painter that his special forte lies in landscapes, rich in color, to which he may give expression to his imaginative genius, rather than to the sterner fac simile of portraiture. How many singers we hear whose tech- nique and brilliant staccato in the Bell Song of Lakme calls forth our admiration and amazement, but who are absolutely unable to put any sympatica whatso- ever into the simplest ballad. We should study color harmonies in music in the same way that they must be studied in painting. There is no rule for the palpi- tating sunlight effects and prismatic play of colors in the school of Claude Monet; it is certainly a subtle feeling which is given by an ingenious mingling of pure spectrum colors. In the human voice, that added coloring of tone which appeals to the heart as well as to the ear of the listener must be brought about by the employment of those harmonies which are added to the original tone by intervibrations within the accessory cavities of the nasal passages, To sing dans le masque, as the French say, is to give this added richness to the initial tone; but to sing in this manner requires the soft palate and uvula to be lowered in the production of tone. Like- wise, to make the purest initial tone from the cords we must get the utmost pos- sible tension, which may only be arrived at when the thyroid is depressed; for, in proportion as the thyroid is elevated, the cords tend to assume the base of a right angle triangle instead of its hypothenuse. Several elements beside this enter into the question of greatest possible tension, one of the most important of which is, that the trachea be drawn down to assume the position that it takes when the apices of the lungs are filled to their greatest extent with air. One of the greatest singers that the world has ever known told me that the reason that he adopted a fixed high chest was that he had found, after the removal of a papilloma from one of his cords, that the only way in which he could be at all sure of his voice while singing was the maintenance of the so-called “high-chest respiration.” This is 1566 PAN-AMERICAN MEDICAL CONGRESS. easily explained by the fact that in this position the upper ribs remaining fixed, the apices of the lungs always remain in contact with the thoracic wall, expanded to their fullest extent, the cords being kept in their state of greatest possible ten- sion. In this position the breathing becomes entirely inferior, costal, and dia- phragmatic. The position of the thorax, as indicated above, permits the lungs to expand to their fullest extent, thus adding a secondary resonance to the voice from below—a sort of complementary timbre—the fixed upper thorax allowing of the least possible change of color during tone production. - It is this combination of facial and thoracic tone fortification which gives the enormous carrying power to tones produced by this method. For a number of years, before I made a special study and estimated the great significance of these factors in singing, I have deluged the throats of singers with sedative and astrin- gent sprays when their cords appeared congested and swollen, often presenting nodules in their center which I had never previously recognized as being due entirely to singing with an improperly poised larynx. I may cite several cases to show you the difference, from a medical standpoint, in the treatment of the singer's throat, where I now substitute respiratory and tone exercise for the amelioration of conditions, that I have always been taught were only to be cured by rest and the diligent use of drugs, The cases I cite are typical of a class of singers that I have treated with equally good results since I have made a particular study of the peculiar value of the proper tone production in the human voice. The 1st day of January last I was consulted by Miss F., age 23, who had had a contralto voice of large power, which she had employed constantly for several years, and had finally, after a prolonged concert tour with a well-known Orchestra, entirely broken down. Her cords were dark red, with a slight nodule in the middle of either band. She complained of great pain in producing her notes, and her medium register had no power in it whatsoever. She had been told by two of the best authorities on the throat that she must not sing a note for a year, and must have her cords painted with astringent solutions and tone up her general health. Upon testing her voice, I remarked an extremely breathy tone and clavicular respira- tion. In accordance with the principles which I have attempted to demonstrate, I forbade her speaking a single word for a week, but placed her at once upon the so-called “inferior costal respiration,” maintaining a high chest, and giving her direction to take a medium “C” with the chin almost resting upon the clavicle singing the word “ma” for five minutes of each hour of the day, the tone first to be focused in the face with the mouth closed and the attack to break upon the lips as much as possible on opening the mouth. At the end of seven days the cords, instead of presenting an elliptical appearance, were straight, and the nodule was so far rotated upward on either cord that it did not touch the nodule of the opposite side in the emission of tone. At the end of the week this young lady, who considered her voice hopelessly destroyed, having acquired a new method of respiration, sang in a concert. She has since sung regularly in church, in many oratorios during the winter, and is at present singing three times a week in grand opera, learning new rôles continually, apparently perfectly restored. She tells me her voice is far more powerful than she had ever dreamed of. Case 2. —Miss P. H. consulted me on March 2, in great distress. She was obliged to sing in a comic opera on that evening or close the theater. Examination showed inflamed and bulged cords, with great hoarseness in the speaking voice; middle register impossible, but the high notes obtained with great effort. I sent her at Once to my assistant, who gave her exercises to maintain tension, and at the end of an hour's work with tension exercises and inferior costal breathing the cords responded and she sang with ease. Case 3.-Miss H. B. consulted me in May, having lost her position as prima, donna by reason of loss of voice. Had been constantly treated. Her cords showed the nodules of attrition, the result of the employment of the coup de glotte and faulty respiration. In this case a week's work caused the nodules to disappear. She adopted a proper laryngeal poise and again assumed the leading rôle. Observation.—In this class of cases rest causes a relaxation of the cords and singing becomes impossible for some time, whereas constant work with tension of the cords and nonapproximation of the same gives immediate relief. PAN-AMERICAN MEDICAL CONGRESS. 1567 Case 4.—Fraulein K. consulted me in the spring. Her cords appeared swollen and the membrane was injured but not hyperaemic. Had been obliged to cancel her engagements and return to New York for treatment. I recognized the famil- iar picture and sent her to my assistant, who cured her in a week without other treatment than the establishment of a proper laryngeal poise. With many cases like these which I might cite, may I not be excused in calling attention to what I consider the most important ground principle of the singer's art, namely, the proper employment of the muscles of respiration, the poise given the cords, and the proper use of the intrinsic muscles of the larynx, not forgetting the bringing into play of the accessory resonance cavities of the face, which lend so much color to the tone, removing entirely from the cords the deleterious effects of an improper initial attack? To rehearse briefly the deductions which I have attempted to draw from my argument, I maintain that the best method of respiration is the inferior costal or diaphragmatic, faithfully maintaining the elevation of the upper ribs without raising the shoulders. Next in importance is the depression of the thyroid car- tilage, brought about through the agency of the crico-thyroid muscle, and the pulling down of the trachea by increasing the capacity of the upper lobes of the lung. Be careful that the initial attack is removed entirely from the cords. Lower the uvula and soft palate that the sound waves may obtain their inter- current vibrations or harmonics by partly passing into the nasal cavities from behind. Let us not fall into the error that the roof of the mouth alone is the sounding board of the singing voice, for without that added richness and timbre to be given by calling into play nature's resonance pipes, the nose and its acces- sory cavities, we may sing, but the singing is at the expense of the cords and the life of the voice is necessarily shortened. If I have said enough to arouse a new interest in what I consider a most necessary accessory to laryngology I shall feel amply repaid for my endeavors to set the theme before you in a clear and com- prehensive manner. * DISCUSSION, Dr. JOHN N. MACKENZIE, Baltimore. I have nothing to add to the admirable paper of Dr. Curtis, except to second what he says concerning the vast impor- tance of vocal gymnastic exercises in the treatment of affections such as he describes. In mis office last May I saw a very striking illustration of its power for good in the person of the first case he has reported. I think this whole question of vocal gymnastics is going to play a very important rôle hereafter in the treat- ment of minor affections of the vocal apparatus. Dr. H. HolPROOK CURTIS, New York City. I wish to dwell upon theimportance of this question and the interest it should arouse, because, as Dr. McKenzie has said, it is in the hyperamic conditions where we encounter chronic affections of the vocal cords from lack of tension, the cords with nodules in the center, where the person is hoarse in the morning and hoarse after singing. It is in those cases that gymnastic exercises of the intrinsic muscles do so much good. I took a choir singer in New York who had lost her voice from a papilloma on the cord. After scraping the cord I put her on these exercises, and she recovered her voice with a brilliancy it had never possessed before. She has since adopted this system of teaching for a livelihood, and does nothing else except give these exercises to singers, thereby making a very comfortable income. Professional people who go to her recommend her to others. This has shown me that we have been groping around for a long time in this condition of the cords, trying to cure them by electricity and in various ways, whereas the true principle of treatment should be the cultivation of the proper poise of the larynx, and practicing mild tension 1568 PAN-AMERICAN MEDICAL CONGRESS. of the cords, in order that they do not touch when making the initial tones. By taking these exercises constantly, you pull a cord from a bulging condition into normal straightness without the loss of a day's work, and this is important to singers and actors. You can take a man with chronic laryngitis, who has per- haps been drinking a good deal, and in a couple of days he may be put in good condition, whereas by the old method it would take a couple of weeks, s–––. ...— ...--—-->"ºf ASPERGILLUS MYCOSIS OF THE MAXILLARY ANTRUM. By Dr. JOHN N. MACKENZIE, of Baltimore, Md. I was not aware until I arrived in Washington that a paper was expected of me. This fact, together with the intense heat, compels me to read a paper which I have not yet written. In the early part of last November I presented a case before the Johns Hopkins Medical Society which will furnish the text for my remarks to-day, I wish to call your attention to a new disease of the antrum. As far as I can find from consulting literature the condition was never described until I presented this case, which was that of a young lady who, in 1883, consulted Dr. Theobald, of Baltimore, on account of pain in the right ear, which he said was as well marked a case of pure otalgia as one would ever See. This was the usual Symptom that would bring her to see him from time to time. Often there was nothing wrong to be seen in the ear, but at other times there would be a swelling of the outer third of the meatus and tenderness on pressure. March 4, 1889, a threatening furuncle appeared in the auditory canal; in October, 1887, an abscess of the lobe of the ear, which was opened by Dr. Theobald. There never was at any time asper- gillus in the ear, nor even a condition which would suggest a probability of its presence. Dr. Theobald first noticed-a swelling on the right side of the face Jan- uary 7, 1889, and a week later recognized the presence of a disease of the antrum, she having had a discharge of pus from the nose with relief of pain and diminu- tion of swelling of the cheek in the meantime. February 27, 1891, he noticed some swelling over the root of the nose, with pain over the right eye, and he feared there was trouble beginning in the frontal sinuses. These symptoms disappeared later. Dr. Theobald was disposed to think that the disease in the antrum had something to do with the ear symptom, and perhaps was the chief cause of the otalgia which she had from time to time. About two years ago her dentist brought her to Baltimore in consultation with Dr. James H. Harris, and from the history which Dr. Harris got of her antral trouble he seemed to think that the trouble was due in the first instance to caries of a molar tooth possibly originating as a variety of periodontal inflammation, with subsequent antral trouble. The antrum was opened at that time (the second molar tooth was extracted, and the floor perfo- rated by a large drill) and an immense amount of pus washed out with a syringe. She was seen subsequently by several general surgeons who insisted upon scraping out the antrum. She was a little afraid of the operation and declined it. So things have been going on for the past two years, the antrum being syringed out daily with various alterative, astringent, and antiseptic solutions. The only drug which seemed to give her any relief at all was mitrate of silver in strong solution. This would stop the discharge for a week or two, and then it would become as bad as €Ver. One of the chief points of interest in this case was the passage from the antrum of large quantities of false membrane. You all know that Zuckerkandl, who, above all other German investigators, has thrown light upon antral troubles, says that the structure of the antral mucous membrane is such as to preclude the formation of false membrane; therefore he denies the possibility of any diphtheritic membrane forming in the antrum. This case, of course, overthrows this postulate of Zucker- PAN-AMERICAN MEDICAL CONGRESS. 1569 kandl's. The membrane was a well-formed false membrane and it was passed from the antrum in large quantities during weeks and weeks. I obtained some of the membrane and sent it to Dr. Flexner, assistant pathologist at the Johns Hopkins University. Dr. Flexner has all my preparations, and as he is in Europe now I am not able to show you the beautiful work he has done, but shall have to content myself with a description of the microscopical appearance. The membrane consists of three layers. The first layer consists of a mass of round cells with some loose epithelium of the mucous membrane of the sinus. The second layer is apparently one of pure necrosis, which does not stain. Upon this layer rests a mass of the so-called aspergilli. Dr. Flexner inclines to the belief that it is the aspergillus fulmigatus. The aspergillus sends its spores in two direc- tions, off from the free surface and down into the deep layers. The subject of aspergillus infection is receiving some attention at the present day. Apparently very little is known about it. Of course we are all familiar with the fact that the aspergillus frequently infects the auditory canal and is also found on the cornea. The variety that is found in the auditory canal and on the cornea is the aspergillus niger, which is the least infectious of the three main varieties of aspergillus; these are the niger, the flavus, and the fumigatus. There seems to be more danger connected with the fumigatus than with either of its brethren, the niger or the flavus. Aspergillus infection is quite common among some birds, for example, the dove and various other smaller birds. Flügge states that it is found quite commonly in zoological gardens among the animals, asper- gillus fumigatus being the variety most often met with ; it is inhaled and sets up a pneumonia, which differs from ordinary pneumonia in that it proceeds rapidly to necrosis of the lung tissue. - Aspergilli seem to flourish best on moist soil and on mucous membranes where the epithelium has become moistened and loosened; they are sometimes produced by injections of oily matter. I have very carefully gone into the history of this case and find no reason to believe that at any period of her trouble was fluid injected into the antrum which might have brought the aspergillus spores. They may have lain there dormant for months. According to the natural history of these parasites, they may remain on a membrane a considerable time before evi- dence of their existence is forthcoming. We rarely see parasites in the nasal pas- sages or the accessory cavities in our climate; they are found in southern climates, as you know. As I have not the sections here to show you, I will read a short extract from Dr. Flexner’s report: The thickness of the separate layers did not exceed 3 to 4 mm. and the membrane was found to be very friable. Sections showed on microscopical examination sev- eral layers. The undermost layer was composed of polynuclear leucocytes. This varied in thickness in different parts and formed about one-third of the entire thickness of the false membrane. A few cells of a different type, larger, with more protoplasm and vesicular nuclei, being Sometimes flat and scale-like, and , again narrow, elongated, and columnar, were present in the layer of leucocytic aggregation. These epithelial cells presented evidences of degeneration in the staining properties of the protoplasm as well as in the shriveled appearance and diffuse staining of the nuclei. Above the layer of leucocytes an indefinite sub- stance was found, composed of granules and fiber-like processes which stained poorly in haematoxylin and eosine. But in the specimens stained in Weigert's fibrin stain this layer was seen to be felted and composed in large part of mycelia of a fungus. The uppermost layer of the membrane is composed of branches from the mycelia below, bearing on their summits the fruit-bearing heads. The fungus was recognized as belonging to the aspergilli, and Dr. Lotzy, who examined the specimen, finds it to be the aspergillus fumigatus. This subject which I have brought before you is a twice-told tale; I have pre- sented it to the Johns Hopkins Society and the American Laryngological Associa- tion. As far as I can make out, this is an entirely new disease added to our list of antral affections. - S. Ex. 36 99 1570 PAN-AMERICAN MEDICAL CONGRESS. DISCUSSION. Dr. MERRICK. Dr. Mackenzie has certainly presented a very interesting paper, but I should like to know what means of treatment were adopted and with what degree of success. Dr. MACKENZIE. I only saw the case twice in consultation. The patient lives at a distance from Baltimore, and I have not yet received the final report of her attending physician. All sorts of things were used—nitrate of silver, zinc, iron, iodoform packing, and almost everything you could think of. The only thing that seemed to do any good, and that only temporarily, was the application of a strong solution of nitrate of silver to the antral cavity. Of course the Only way to get rid of the trouble is to scrape the disease out of the antrum, but that she will not have done. HYSTERICAL APHONIA AND DEAFNESS. By E. FLETCHER ING ALS, A. M., M.D., of Chicago, Ill. Hysterical aphonia is so common that little of interest can be said concerning it, but hysterical deafness is comparatively rare. I find reports of a few cases, but have never met with it myself, excepting in a single instance, a brief history of which I think will be of interest to this congress. The case is that of Miss P. A. J., aged 23 years, and a teacher by profession, who recently came to America from Ceylon. She had been annoyed for three years by weakness of the voice, and occasionally by complete aphonia, and had been slightly deaf. About two years ago, while making an Ocean voyage, she was greatly alarmed by a rat springing upon her. Immediately thereafter she lost the sense of hearing, and since that time has been so deaf that she could not hear ordinary conversa- tion, and could only understand when addressed in very loud tones with the person’s lips close to her ear. When she came to see me, in the early part of July, 1893, she was still extremely nervous, and complained of dryness in the throat, inability to speak excepting in a whisper, and deafness so great as to require shouting to enable her to hear. Her general health was good ; there was no history of predisposition to disease; pulse 100, temperature 100 °; no cough or expectoration; appetite fair, and diges- tion normal. The hearing, tested by an ordinary watch, showed that no sounds whatever were appreciated even when the watch was placed in contact with the ear or temporal bones. The left membrana tympani was considerably thickened; the right normal. There was no congestion of the larynx, and the cords were well approximated on attempted phonation; but this condition could not be main- tained. She talked only in a whisper, but upon directing her to sound the letter “a,” while examining her larynx, I found that she could easily produce loudsounds. The excitation of pulse and elevation of temperature were temporary. I applied a mild astringent spray to the larynx and a solution of menthol, 5 grains to the ounce of liquid albolene, to the Eustachian tubes, through the naso-pharynx, the application being made by a long-tipped Davidson's No. 59 atomizer, which was introduced back of the palate, the spray being driven in with an air pressure of 15 pounds, while the nostrils were tightly closed. She was given internally ber- berine muriate, 1 grain ; extract of Valerian, 2 grains, and strychnine sulphate in doses of one-twentieth of a grain, which I proposed to increase rapidly to one- tenth or even one-eighth of a grain. Three days later it was noted that she felt something better, stating there was a “softening” in the ears, and seven days after the first treatment her friends stated that she occasionally spoke aloud, though in a low voice, and that her hearing was decidedly improved. At this time PAN-AMERICAN MEDICAL CONGRESS. 1571 the dose of Strychnine was increased to one-sixteenth of a grain, and three days later to one-twelfth of a grain, four times daily. Four days later it was increased one-tenth of a grain and combined with extract of valerian, 2 grains, and asafoetida, 3 grains, which she took for five days, when (nineteen days after the beginning) One-eighth of a grain of strychnine was ordered in the same combination. This she took four times before the toxic effects of the strychnine became manifest. It was continued, notwithstanding the spasms, for two days subsequently and then reduced to two doses per day for five days. The convulsive movements continued to occur at evening for a couple of days after diminution of the quantity of strych- nine, and then disappeared. The following day the friends reported that her hear- ing was greatly improved. Two days later (one month after beginning treatment) her hearing was apparently much improved for ordinary conversation. She talked aloud much of the time, but occasionally lapsed into whispers. The dose of strych- nine was again increased to one-tenth of a grain four times a day and given in com- bination with extract of valerian, 3 grains. The Strychnine will be continued in sufficient doses to cause slight twitching of the muscles, electricity will be used, and at the same time some simple topical application containing a small amount of menthol, for its physical effect. The case is still under treatment. sº-mºm-tº- DISCUSSION. Dr. S. K. MERRICK, Baltimore. This case is certainly one of great interest, the like of which I have never seen. I have, of course, had cases of hysterical aphonia. I would like to ask whether Dr. Ingals considers this a case of uncomplicated hysterical deafness? I understood him to say there was some reddening of the membrane. It occurs to me the length of time in securing results might throw some doubt upon the question of its being entirely of hysterical origin. Within the last six months a young girl came to my office, accompanied by her sister as spokeswoman. She was unable to speak at all except in a whisper. She said she felt perfectly well otherwise; there was no history of hysteria, nothing to indi- cate that it was a case of hysterical aphonia, yet on closer examination I found the larynx perfectly normal. There is one suggestive point in Dr. Ingals's paper— one remedy I had never used until I used it in this case. I was satisfied of the diagnosis and assured the girl that her voice would be instantaneously cured—it had been three days since she had spoken. It occurred to me menthol would be an excellent thing to use. She took three inhalations with 20 pounds pressure, and immediately spoke, talking as well as anybody, and she has never had any subse- quent trouble. I think we usually get good results very quickly in these cases if there is no other element standing in a causative relation. º Dr. H. HOLBROOK CURTIs, New York City. I have had one case of hysterical aphonia associated with deafness, but it never occurred to me until I heard this paper that there was an association between the hysteria and the deafness. The cure was made in the following way: The lady went out sailing, and in going ashore on a small boat stepped on the rail and went down between the boat and the yacht. She screamed for help, and from that moment she spoke; and, as I remember now, her deafness is much better; in fact, I have not heard her allude to it since. In all the cases I have seen of aphonia which might be considered hysterical, I have observed that there was a thickening of the ventricular bands. Dr. JAMES E. LOGAN, Kansas City, Mo. For the last two weeks I have been attending a câse, not of hysterical deafness, but of hysterical aphonia, which was pronounced, but did not recover as I expected it to, and I simply state the case in order that I may get Some information in regard it. I have made a close examina- tion of the case. I can see the condition of the larynx perfectly, and the only thing 1572 PAN-AMERICAN MEDICAL CONGRESS. I can find there is a considerable thickening of the ventricular bands, but no inflammation. She has spoken in a whisper for six months, but when I ask her to sound the letter “a,” or “ah,” she speaks it distinctly, and she coughs distinctly. She was sent to 1me by physicians in Indian Territory with what they thought was tubercular laryngitis. There is no evidence of bacilli, no enlargement except of these bands. I can look down the trachea and can find no evidence of ulceration. I saw a little granulation in the anterior commissure, but with an application of chromic acid it passed away; but it was above the vocal cords and could have given no trouble in that respect. I can not bring about a relief or cure of her condition. She is now at my home, and I am anxious to find something that will relieve her. This question of hysterical deafness is certainly very interesting. I would like to know the condition of the patient's ear previous to this deafness coming on, as it seems Dr. Ingals found considerable thickening of the left membrane; in that event she certainly could not hear very well out of the left ear, but the right ear being normal makes up for the deficiency, and being so totally deaf I should think was due to the hysterical condition. This question of hysterical aphonia is inter- esting to me, because I have had several cases and have not been able to relieve them as soon as I thought they ought to be relieved. The patient I speak of is a little Indian woman of nervous temperament, with great vitality; she makes every effort to speak, but says it hurts her. Dr. MACKENZIE. I think we cure these cases more by psychical impression than anything else. Dr. LOGAN. I would like to say that I tried that on my last case; I set a day for operation, and told the lady when the operation was performed I would have her speaking. I went down with a long forceps and played around in the larynx for awhile. She was very much wrought up about it. I knew I was not accom- plishing anything, for I had nothing to accomplish. It made no such impression. When I have her go through the scale the ventricular bands do not move at all, but the cords act perfectly ; the bands do not seem to obstruct the action of the cords at all. But the moment she loses sight of my constant effort to have her speak audibly the sound is but little above a whisper, and the ventricular bands approximate within two-thirds of their surface. Dr. PRICE-BROWN, Toronto. I would like to say a word in regard to the treat- ment of Dr. Ingals's cases. As I understand it, he places much more stress upon the importance of strychnine than menthol, but the point I wish to make is the possi- bility of the cumulative effect in giving strychnine in increasing doses for such a long period. I should be afraid to give it in that way and still have the spasmodic effect of the strychnine. I would like to have the experience of others on that point, because we might be inclined to give strychnine in increasing doses in neu- rotic cases, and it is a question with me whether it would be safe to do so. I think in this case the strychnine produced the cure and that the menthol did not have much to do with it. T}r. E. FLETCHER ING ALS, Chicago. The question asked as to whether the case I reported was entirely hysterical I think was answered in the paper. There had been slight deafness before the fright; there was some thickening of the drum membrane. The suggestion that the length of time required to obtain relief threw some doubt upon the hysterical nature of the affection, reminds me that hysterical patients are not always cured promptly. I recall one case of hysterical aphonia that I treated for a year and a half before I succeeded in effecting a cure. She had been aphonic for five years before I saw her. I have seen many patients in whom the hysterical symptoms have not disappeared promptly that were cured by a few weeks of treatment. I suggested placing reliance upon the sulphate of strychnine, which I use, and I am glad to speak of it again, because it is, to my mind, the most important remedy we possess in the treatment of hysterical aphonia, and it was PAN-AMERICAN MEDICAL CONGRESS. 1573 for that reason I gave it in hysterical deafness. It may be given with safety and benefit for a long time and in large quantities. I have given to various patients one-eighth of a grain four times a day for weeks, though I begin with about one- twenty-fourth of a grain and reach the large dose gradually. I do not expect to obtain any decided benefit from it until I get the muscles to twitching. I recently saw a patient who had been under my care two years ago for laryngitis, which appeared to be tubercular. After considerable improvement she went to her home in Iowa, and when she returned recently her larynx was practically normal, but she could not talk aloud, the aphonia being of only about two weeks' standing. I placed her upon the sulphate of Strychnine, running up the dose to one-tenth of a grain four times a day before I obtained clonic contraction of the muscles. A day or two afterwards she had two or three convulsions, which were quite frightful to herself and friends, but which had the desired effect of restoring her voice. As to the danger in continued use of this drug, we may get what is called the cumulative effect, but I think there is no harm from it, so long as we increase the dose gradually and watch the patient. As soon as convulsive move- ments occur the dose is diminished or the remedy temporarily suspended. When a patient has once been brought fully under its influence we usually find that two- thirds of the dose that had been taken previously can not be borne afterwards. My rule is to gradually increase the dose until I get the toxic effects of the drug and then reduce the amount until it causes only slight twitching at times, and to continue this, if necessary, for three or four weeks. This remedy will accomplish more for the cure of hysterical aphonia than any other drug or method I have ever used. A question was raised regarding phonatory approximation of the ventricu- lar bands. I am sure that they are closely approximated in some cases, for I well remember one in which it was impossible to see the tone cords during phonation because the ventricular bands always closed first. ELECTRICAL IDLUMINATOR. ' By Dr. D. BRYSON DELAVAN, of New York City. I have been experimenting for several years with the view of evolving a con- venient and practical electrical illuminator, and have here the product of that experimentation. It has been in use for a year and a half, and with success. The disadvantages of illumination by gas of course are obvious. The fact that gas evolves a large amount of heat and a certain amount of smoke and deleterious vapor, and that we are obliged to stay in our offices many hours each day and may thus suffer directly from its use, is a matter of common observation. It is desir- able that electric light should be utilized, not only for the sake of health, but for the reason that in it we have a light that is manageable, the color of which is stable and uniform, and which in every respect is vastly more convenient than gas. The ordinary incandescent lamp with a single horseshoe loop, the ordinary loop filament, can not be adapted to our purpose by means of any mechanism I have been able to find. The objection to it is that the shadow or form of the loop filament is always in sight, no matter through how many series of reflectors it may be thrown. The reflection of the incandescent filament is dazzling to the eye as one looks into the laryngoscopic mirror, while the region in its neighborhood is in shadow. In order to adapt the light to our purposes it was necessary to make a new lamp and do away with the ordinary loop filaments. Many varieties of lamp were tried, the object of all being to concentrate the light as nearly as possible at one point, instead of distributing it through a long loop. The lamp finally selected is furnished with a single filament which has four convolutions, 1574 PAN-AMERICAN MEDICAL CONGRESS. the object being to collect a strong, uniform mass of light at one point. That mass of light, when the lamp is held horizontally, is distributed with fair uni- formity in the lamp itself; not sufficiently so, however, to serve our purpose. In other words, if this light were to be thrown directly on the head mirror and reflected into the pharynx of a patient, it would be dazzling and uneven. In order to overcome this we throw between the light and the head mirror a small plano- convex lens, such as is used in the ordinary Mackenzie condenser. This materially distributes the light, takes away its dazzling properties, and causes it to be dis- tributed pretty evenly over the surface of the reflector. In order to make the distribution of the rays perfect I used for some time a lamp with a ground-glass shade. This was expensive, however, about 30 per cent of the illuminating power being lost. Instead of this a plain lamp was substituted and the surface of the lens itself was ground. By this means a sufficient distribution of light is obtained to throw it evenly over the surface of the head mirror and to secure a perfect illumination from the latter. In short, a 40-candle-power Edison lamp with a peculiar filament is set horizontally in a hollow cylinder, the latter being merely a case to hold the lamp. The plano-convex lens is fastened to one end of the cylin- der and the electric plug with the lamp to the other end. The current derived from the street is regulated by means of a common shut-off, the whole is mounted upon a suitable stand, and the apparatus is complete. I have used it in one form or another for the last two years, the last year and a half in the shape it is here- with presented, for all my examinations, and since using this particular 4-spiral fila- ment lamp have had no difficulty whatever. One objection to the lamps of other varieties formerly used was that they quickly burned out. I have two lamps now which have been in constant use for over six months and which seem as good as ever, the lights having been in use several hours every day. The apparatus is made by the Edison Manufacturing Company, No. 110 East Twenty-third street, New York. Dr. ING ALS. I would ask whether the rays of light leaving the apparatus are divergent, parallel, or convergent? Dr. DELAVAN. They are convergent. REPORT UPON CASES OF TUBERCULAR LARYNGITIS TREATED IN COLOR ADO SPRINGS. By S. EDWIN SOLLY, M. D. I desire to report to you the general features and results of 45 cases of laryngeal tuberculosis treated by me in Colorado Springs, which place stands at an altitude of 6,000 feet. I have gathered together 250 cases of pulmonary tuberculosis, and the 45 cases are all of these in which there was unmistakable evidence of laryngeal tuberculosis. These 250 cases are not all the cases of pulmonary or laryngeal tuber- culosis treated by me during the eighteen years of practice in this region, but are all that I had opportunity to follow out, and watch, and obtain such knowledge of as would enable me to speak definitely of their progress and results, and in order to allow a reasonable time to have elapsed before reporting I have taken no cases that were seen for the first time in the past two years and only those that were treated by me personally. As far as these conditions allowed the cases were taken as they happened to come and may be considered a fair sample of what the total of the cases would probably show if all the records had been complete, and this opinion as regards the whole 250 cases is confirmed by their similarity in quality and results to the cases reported by other observers treated in this and similar alti- tudes. I could obtain no reports of laryngeal cases alone to compare them with; as to results, reports of cures of laryngeal tuberculosis after treatment are reported, PAN-AMERICAN MEDICAL CONGRESS. 1575 but none that I knew of that have been any length of time under observation. It will be observed that in the duration of the disease there is a relative likeness to reports of cases in low climates as given by others and also a close resemblance in the percentage of laryngeal cases among the whole number of those with pul- monary tuberculosis, while the percentage in whom ulceration was found is close to that from Schroetter's autopsies though smaller than Willigk's or Mackenzie's. It is therefore, Ibelieve, fair to infer that the cases are of an average quality, and this is shown by their resemblance to the reports of pulmonary tuberculosis treated at an altitude made by other observers. While these results could not have been obtained without treatment, yet in many of the cases similar treatment previously used in low climates failed of any such results. Frequency of laryngeal tuberculosis among cases of phthisis. & Laryngeal ulcera- Larynx involved. tion found. Number X. Number of Cases. Per cent. of cases. |Per cent. Mackenzie------------------------------------------------ 100 33 100 13 Louis----------------------------------------------------- 193 39.6 |-----------|----------- Heinze---------------------------------------------------- 1,226 30.6 -----------|----------- Willigk autopsies----------------------------------------|-----------|----------- - 1,317 13.8 Schroetter -----------------------------------------------|-----------|----------- 72: 6 Solly------------------------------------------------------ 25() 28 250 8 Twenty-five of the laryngeal cases showed clear signs of tubercular infiltration, which had not, however, proceeded to ulceration at the time of the first examina- tion, though some of them did subsequently, while 20 cases had ulceration as well as infiltration when first seen. The average duration of the nonulcerated cases from the date of their first symptoms up to the present time or death was 6 years, while of 17 of these cases who improved and are living the average duration is 13 years, and of the 8 who are worse or dead it was but 3 years 10 months. Total average duration of the 20 cases with ulceration was 3 years 2 months; of 5 cases that improved and are living it was 8 years 5 months; while of the fatal and deteriorated cases it was 2 years. Of the deteriorated cases, with and without ulceration com- bined, the average duration was 2 years and 7 months. This is somewhat longer than the 2-years' limit given by Bosworth for all laryngeal cases. With regard to position of the ulcers, dividing them by the situation of the first or most marked ulcer, it was found upon the false cords in 20 per cent, on the corn- missure in 30 per cent, and upon the epiglottis in the same proportion ; upon the arytenoids in 45 per cent and upon the true cords in 50 per cent. Of the non-ulcerated cases 40 per cent were in the first stage, 32 per cent in the second, and 24 per cent in the third. Of those with ulceration 20 per cent were in the first stage, 30 per cent in the second, and 50 per cent in the third; thus showing a close relation between the condition of the lungs and throat. The results are placed under the following heads: Cured, greatly improved, improved, and worse. These terms apply to the entire condition and not to the throat alone. The cured are those from whom all signs of ill health have disap- peared and who have remained well not less than two years. The greatly improved are those who are practically well, but yet show some signs of trifling disability, or have not recovered long enough to be pronounced cured. The improved are those who, while they may have suffered and are still suffering from their battle with disease, yet show a tendency to recovery, but are still on uncertain ground. The worse include all the fatal cases and the few still living whose tendency is downward. 1576 PAN-AMERICAN MEDICAL CONGRESS. Seventy-eight non-laryngeal cases cured, 36 greatly improved, 30 improved, 57 WOTSé. wº - Laryngeal cases.—Non-ulcerated: 9 cured, 7 greatly improved, 3 improved, 3 died, 2 worse. Ulcerated: 2 cured, 2 greatly improved, 1 improved, 10 died. Total laryngeal : Cured 11, greatly improved 9, improved 4, died 16, worse 2. Grouping together the cured, greatly improved, and improved, under the head of improved, we find of the whole 250 cases of phthisis 72 per cent improved. But of the 45 laryngeal cases only 49 percent improved. The non-ulcerated cases, how- ever, showed 68 per cent, and the ulcerated only 25 per cent improved. Taking the condition of the throat without regard to the ultimate fate of the patient, the results were much better, there being local permanent arrest of disease in 64 per cent, besides 5 cases which healed temporarily. Among the non-ulcerated cases, alone, 68 per cent showed a return to normal appearance in the larynx, while among the ulcerated cases, 50 per cent healed permanently and 3 cases, in addition, temporarily. With regard to the position of the ulceration the results were: Com- missure, 33.3 per cent improved ; true cords, 30 per cent; epiglottis, 17 per cent, while of the arytenoids and falss cords none improved. To recapitulate, it may be said that of the whole number of cases, viz., 250, a little more than 2 out of 3 improved. Of the 45 who had laryngeal disease, 1 out of 2 improved. Of the 25 cases in whom there was laryngeal tubercular infiltration without ulceration, a little more than 2 out of 3 improved, while of the 20 in whom there was laryn- geal tubercular ulceration only 1 in 4 improved, but of the 205 cases without laryn- geal disease there was improvement in nearly 3 out of every 4 cases, the exact reverse of the laryngeal ulcerated cases. This shows, as was to be expected, that the laryngeal complication reduces the chance of improvement, and when it has proceeded to ulceration does so to the extent of 3 to 1. But even then, according to the opinions expressed by laryngologists practicing in low climates, these are far better results than have been obtained, and shows, I believe, that similar beneficial, retarding, and often curative effects which have been demonstrated in pulmonary tuberculosis treated in Colorado and other high climates are exhibited in laryngeal tuberculosis. That the results are not quite as good, though rela- tively so, is of course to be expected, as in all of these cases, and I have never seen a laryngeal tuberculosis without an accompanying pulmonary tuberculosis; there was the double disease and therefore the double burden to bear. Moreover, there is little doubt that the laryngeal complication in almost all, if not in all cases, indicates a tendency to a free dissemination of tubercle and generally an absence of any self-limiting tendency. There are undoubtedly some cases in which the laryn- geal tuberculosis is derived from a local inoculation from the sputum from the tuberculous lung lodging on the abraded mucous membrane, but clinical observa- tion leads me to believe that in the great majority of the cases the infection starts from within and not from without. Taking the results upon the laryngeal disease alone, irrespective of the ultimate recovery or deterioration of the patient on account of the accompanying lung disease, we find that in 64.2 per cent there was arrest, and if we consider also the five in whom there was temporary healing, which broke down again under the strain of the last weeks of fatal pulmonary suppuration, we see that the percent. age of improvement in the local laryngeal symptoms is not very far short of that of the simple pulmonary cases. While I believe that, contrary to what was a common impression, viz., that high climates are injurious per se to tubercular laryngitis, they are positively beneficial, speaking as a generality; yet such results as I report could not be reached without in the majority, especially in the ulcerated cases, of careful local treatment. As Bosworth truly writes, after advocating topical measures, “in no ulcerative process, probably, are we able to detect in a less degree any reparatory PAN-AMERICAN MEDICAL CONGRESS. 1577 effort on the part of nature than in tubercular ulceration,” and yet instances of spontaneous cicatrization have been reported by Bouveret, Virchow, Jarvis, and others. With regard to the nature of the treatment, it must vary according to the appearance of the parts from day to day, and all routine treatment is wrong. But in speaking of general principles, it may be said that the first essential is the toilet of the throat; that is, the removal of mucus, pus, etc., and the washing of the membrane, and this is in most cases best procured and with the pleasantest effects by a free spraying with Dobell's solution. The old injunctions were to use sedatives and avoid stimulants to a tubercular larynx. Now, in the majority of cases if the choice lay only between sedation and stimulation, I would say stimu- late, while there is, often continuously and generally at the onset, hyperaemia and hyperaesthesia of some of the parts, yet the underlying condition is an anaemic one, the congestions are chronic, not acute, and the real good of treatment almost invariably comes from stimulation ranging from the mild stimulation of weak menthol and nitrate of silver solutions, etc., to the cauterization with lactic acid, and the scraping with the curette of ulcerated surfaces. Cocaine should of course be used to avoid pain of treatment, while for pain at other times a spray of anti- pyrine will generally give a more prolonged relief. I should extend this paper beyond its proper limit were I to enter further into the details of treatment, but I may mention that astringents, iodoform, etc., are often of service. I believe in using the cotton applicator, the powder blower, and the spray, as the case demands; also, I must mention the valuable aid I derived from the Sass inhaler, particularly with the use of benzoin inhalations. To conclude, it may be said that the foregoing facts would indicate that while tubercular laryngitis is always a grave complication at an altitude, as elsewhere, and when advanced is almost invariably fatal, yet in the earlier and medium cases high climates, with appropriate treatment, afford relatively, though not actually, as good a chance of arrest or delay in laryngeal as in pulmonary tuberculosis. CLINICAL NOTES OF CASES OF TUBERCULAR ULCERATION OF THE LARYNX, TREATED BY THE KRAUSE METHOD AT THE THROAT AND CHEST CLINIC OF THE EMERGENCY HOSPITAL. By T. MORRIS MURRAY. M. D., of Washington, D. C. In 1886, Professor Krause read his now famous paper before the laryngological subsection at the fifty-ninth meeting of German naturalists and physicians at Berlin, in which he asserted that, when great debility was not present, under which circumstances he always advised against the treatment, no tubercular ulceration with which lactic acid comes in direct contact refuses to heal. He reported 14 cases successfully treated in this manner. To Heryng, of Warsaw, belongs the distinction of having first employed effective surgical procedure in the treatment of tubercular ulceration of the larynx. In his book upon the sur- gical treatment of tubercular ulcerations of the larynx he reports 13 cases success- fully treated in this manner alone. Krause has an article in the May number, 1889, of the Therapeutsche Monatschrift, in which he gives the history of 71 cases treated with lactic acid and the curette from 1885 to 1888, inclusive. Of these, up to the time of publication, 1889, 28 remained improved in condition, 7 dead, but not as a result of tubercular laryngitis, 8 the result unknown, 12 still under treatment, 8 sick when treatment was stopped, 8 died unhealed. At the Berlin congress in 1890 a day was given to the discussion of the treatment of laryn- geal tuberculosis, and it was almost unanimously agreed that when properly treated with the curette and lactic-acid applications the disease was curable. 1578 PAN-AMERICAN MEDICAL CONGRESS. The literature upon this subject, particularly in the European journals, is voluminous. In America articles have been contributed by Delavan, Major, Weed, and others. One of the most recent publications is that of Dr. Hèlary, of Paris, in which he contrasts the medical with the surgical treatment of laryngeal tuberculosis. The conclusions at which he arrives are as follows: First. Laryn- geal tuberculosis is not benefited by medical treatment. Second. Surgical treat- ment, on the other hand, ameliorates, in a certain way, dysphagia, dyspnoea, dysphonia. Third. Curetting the larynx causes the disappearance of the troubles of respiration and permits the avoidance of tracheotomy in certain forms of tuber- culous laryngitis. Fourth. The extirpation of the infiltrated arytenoid masses has the most happy influence upon the dysphagia, which it always calms. In per- mitting the patient to eat who is literally dying of hunger it prolongs his exist- ence and contributes to the relief of the general condition. Fifth. Endolaryngeal operations are not followed, save in absolutely exceptional cases, by serious acci- dent. Sixth. They have a happy action upon the ulterior evolution of the pul- monary tuberculosis, the progress of which seems to be retarded. Seventh. Sur- gical treatment does not act as a palliative merely ; it can also, but in rare cases, cure laryngeal phthisis, as is proven by pathologic anatomy and in the clinic. Eighth. Curative treatment can be obtained in three ways: (1) By curetting the larynx, the more ordinary method: (2) by laryngo fissure, a procedure rarely employed; (3) extirpation of the larynx, an operation which has yielded one or two successes, but which must be rejected by reason of its too great gravity. I have given these conclusions in full, because they embody so nearly the results of my own experience. I can not agree with him however if, as I understand him, he means to eliminate lactic acid in the treatment of tubercular ulcerations. I regard it as an indispensable aid in the treatment of many, if not most, of these lesions. Certainly this is true if the operations are done by any but the most skilled in such surgical procedure, and under such exceptional circumstances I think it has its value, producing coagulation upon the cutsurfaces. It does away with reinfection from the pulmonary trouble, which nearly always exists in such C3SéS. In reporting the following cases treated under my direction at the Emergency Hospital of this city, I can claim nothing original in their management, scarcely anything of interest in their history. They are offered as a small contribution to the existing statistics. Case 1.—A. S., white, female. Father healthy; mother died of throat trouble of four months’ duration, and had cough before this developed ; brother died at 16 of phthisis; sister living, asthmatic. Consulted me January 16, 1891. Had always been subject to colds, and in January, 1890, had grippe which lasted three weeks. A slight cough remained, from which she never entirely recovered. The following May the patient was treated by a laryngologist in this city for throat trouble and bronchitis. There was an ulcer which she could see upon leftwall of pharynx; the epiglottis was said to be affected. In July she went to the country, and pharyngeal ulceration was healed in three weeks by application of sulphur. The summer was spent at Cape May. General health much improved; gained 7 or 8 pounds in weight. In September, had an attack of pleurisy which lasted for six weeks, and left her with adistressing cough. January 10, 1891, had pain for first time and difficulty in Swallowing; no night sweats or haemoptysis; no evening elevation of tempera- ture. Appetite and digestion good; sleep disturbed by cough; menstruation normal; voice impaired. Examination of pharynx discovered an oval ulceration upon upper portion of the back wall, on the right; no indication of previous ulceration upon the left side; epiglottis immovable, indurated and much thick- ened; ulcerated nodules over whole of laryngeal surface; large ulceration on right Ventricular band. Ary-epiglottic folds infiltrated; tubercule bacilli found in the pus from the pharynx and in the sputum; the apices of both lungs are consolidated and beginning to soften. Fifty per cent solution of lactic acid was applied to the pharyngeal and laryngeal ulcerations, which relieved the pain. February 22, the pharyngeal ulceration was curetted; application of lactic acid continued; the pharyngeal ulceration entirely healed in two weeks. The epiglottis and right ven- PAN-AMERICAN MEDICAL CONGRESS. 1579 tricular band were curetted March 22, and acid applied: the ventricular band cicatrized, but not the epiglottis; there was no pain on swallowing. In May she was very much exhausted by a profuse and painful menstruation, and was sent to the seashgre for a week. Upon her return an ulceration was seen in the interarytenoid space. This was curetted, and the epiglottis the week follow- ing; the latter was permanently benefited, the former only temporarily so, and it was necessary to operate again June 17. Another confinement to the house greatly weakened the patient and the ulceration increased in extent and activity. Subse- Quent applications again held ulceration in check and relieved pain. The general exhaustion was increased by rapid softening of pulmonary deposits, and death ensued September 3, 1891. Case 2.—James J. White, age 24. Family history good; has had a bad cough for two years: aphonia for six months; for two months has been spitting blood; is very much emaciated, hectic; painful deglutition: all of both lungs involved; cavity in the left lung; ary-aepiglottic folds and epiglottisinfiltrated ; ulceration of vocal cords and ventricular bands; large granulations in interarytenoid space. General treatment : Lactic acid applied to larynx, which relieved pain and les- . sened difficulty in swallowing; owing to extreme debility the patent was unable to come to hospital regularly. He was seen April 7 ; the uvula was then enlarged, of a firm and nodular appearance; this was amputated with snare and the base healed rapidly. May 7, sºuperficial indolent ulceration on the left side of the soft palate; lactic acid applied. May 20, ulceration has spread; soft palate, dotted with small spots ; whole palate edematous and infiltrated. June 12, soft palate a mass of broken-down nodular granulations, with tubercule bacilli in the pus; excruciating pain in Swallowing; left side of palate curetted, followed by applica- tion of pure acid; relief so marked that the right side was treated in a similar manner and lactic acid applied every other day, until the ulcerations were entirely healed. Patient died July 10, 1891. Case 3.—A. S., colored, widow, age 41. Family history good ; had grippe in the winter of 1890; cough began to be troublesome in January, 1891; hoarseness super- vened in March ; no appreciable loss of flesh during the year and strength well preserved; the patient has an annoying cough at night; occasional night sweats; no hasmoptysis; painful and difficult deglutition ; retraction of inferior clavicular region on left side, dullness of both sides; also broncho-vesicular respiration; occa- sional rāles in both inferior clavicular regions, prolonged expiration in left; voice reduced to a whisper. . Examination of the pharynx and larynx showed a large ulceration upon left side of posterior wall of the pharynx extending one-fourth inch above the level of the soft palate, palatine fold very much swollen and inflamed; ulceration in interarytenoid space and upon the right cord; ventricular bands thickened and very much inflamed; tubercule bacilli found in the pus from the pharyngeal ulceration and in the sputum. The patient was put upongen- eral treatment and fuchsin applied to the larynx for two weeks. At the end of this time, the granulations having increased in size, it was replaced by a 50 per cent solution of lactic acid, applied twice a week. October 22 the pharyngeal ulceration was curetted and the acid applied. At the end of the week the tissue had again broken down. October 27 the whole of the pharyngeal involvement was again curetted and entirely healed in seven days and has given no trouble since. December 15, superficial ulceration appeared upon the superior surface of left arytenoid, and sudden increase in edema of the ventricular bands; treatment continued. January 5, ulceration upon the right cord healed; the ulceration in the interarytenoid space is the Only active process remaining. January 13, applica- tion of acid continued. January 21, sudden edema and involvement of left ventricular band, margin of cord, and left arytenoid. February 25, ulceration of ventricular band and arytenoid cicatrized: left cord presents raw, lumpy granu- lations; treatment continued. March 31, no ulcerations visible in larynx; voice much improved; lungs in about the same condition as when first examined; gen- eral health improved and gain in weight; no evening fever. It is now eighteen months since the last operation. There has been no return of ulceration in the larynx. The normal weight has been regained and the patient is apparently in perfect health. The voice, however, is still impaired owing to what I think is an unusual accident in such cases. The vocal cords are united by a thick band of cicatricial tissue for nearly two-thirds of their entire length. This remains owing to a disinclination on the part of the patient to submit to the operation necessary for its relief. Case 4.—S. C., female, colored, age 29. Examined April 25, 1891; pulmonary tuberculosis: deposits in the apices of both lungs: irregular granulations in the interarytenoid space; lactic acid, 50 per cent, was applied twice a week. There was a gradual disappearance of the granulations and cicatrization of the ulcer. 1580 PAN-AMERICAN MEDICAL CONGRESS. During the next month the patient failed rapidly. An ulceration was seen extend- ing down the posterior wall below the cords. No return of the ulceration in the interarytenoid space. The patient discontinued her visits to the hospital, and, as I learned subsequently, died. In this case a severe edema, the only instance in my experience, followed one of the applications of lactic acid. It yielded, however, promptly to scarification. - Case 5–White, male, age 56. First visit, May 6, 1893. Pulmonary and laryn- geal tuberculosis with emaciation, anorexia, night sweats, etc.; both lungs were involved. There was a decided thickening and infiltration of the arytenoids and ulceration of the interarytenoid space. A superficial ulceration was also found on the upper edge of the left ventricular band. Lactic acid was applied twice a week from May 6 until June 3. Both ulcers were healed and there was a marked relief of the subjective symptoms. The patient’s voice was strong and clear; gen- eral health improved. Last visit June 10. & Case 6.--White, female, age 29. First visit, June 26. Pulmonary phthisis; areas of softening in both lungs, with small cavities in right apex. There was an .ulceration a quarter of an inch in diameter, with small granulations springing from its base, in the interarytenoid space. The voice weak and husky; degluti- tion painful. Patient was treated with lactic acid twice a week from June 26 to August 7. On the latter date the ulcer had cicatrized, the voice was clear, and the patient had no pain in the larynx. Last visit, August 7. In three of these cases it can scarcely be claimed that life was much prolonged, but they were spared the terrible suffering always attendant upon this disease under former methods of treatment. In the third case I think it can fairly, be claimed that the patient is cured. It will be observed that in cases 1 and 3 the laryngeal and pharyngeal ulcerations appeared practically at the same stage of the disease. In case 2 the involvement of the uvula and soft palate occurred when the patient was in the last stage of decline; yet in all the ulcerations which could be easily reached and thoroughly treated healed readily, while those in the larynx resisted treatment to a greater or less degree. These observations would seem to indicate that the limitations placed by Krause upon his treatment are unnecessary, and that desirable results in some cases can be obtained even though great debility should exist, whenever lactic acid can be brought in direct contact with the gran- ulations. The management of laryngeal phthisis must always be attended with embarrassment to the laryngologist, owing to the extreme difficulty, if not impos- sibility, often, of reaching the whole of the diseased surface. With pharyngeal and buccal phthisis the case is different. There is now, I think, no reason why these most painful complications of tuberculosis, conducing, as they always do, to the speedy and fatal termination of the disease, should not be completely under the control of the physician. PRELIMINARY NOTE ON THE USE OF THE FORMATES IN ULCERA- TION OF THE PHARYNGEAL AND LARYNGEAL MUCOUS MEM- BRANE. By E. L. SHURLY, of Detroit, Mich. The caustic property of formic acid, whether derived from insects or plants or manufactured synthetically in the chemical laboratory, has for a long time been observed, and also antiseptic properties belonging to it have been noted from time to time, although the literature of the subject is very meager. Theorizing that this agent or its combinations as existing in animals and plants might be a natural chemical agent, in some way designed to protect their bodies from extrane- ous deleterious influences, it occurred to me to test the action of the various salts. of formic acid upon some of the lower animals for the purpose of ascertaining their degree of usefulness in the treatment of general septic diseases, especially the so-called “tubercular diseases.” Accordingly in 1891, in the laboratory of Harper Hospital, Dr. P. M. Hickey made formic acid from oxalic acid and glyc- PAN-AMERICAN MEDICAL CONGRESS. 1581 erin, according to the ordinary process; and directly from this made formate of sodium, formate of calcium, formate of ammonium, formate of barium, formate of copper, formate of iron, and the iodoformates of iron, sodium, calcium, and ammonium. We next tested the effects of these various salts upon such of the lower animals as mice, rats, guinea pigs, and monkeys. The formate and iodo- formate of copper, sodium, calcium, barium, and iron were all found to be poison- ous to mice and rats in the proportion of from one-half to 2 grains when intro- duced by hypodermic injections. They were also fatal, but after a longer lapse of time, when introduced into the stomach of these animals in somewhat larger doses. Rabbits and guinea pigs bore from 5 to 10 grains of formate of sodium, ammonium, and iron, but rapidly succumbed to the same dosage of the copper, calcium, and barium salts. The iodoformate of sodium was also borne in 5 to 10 grain doses by the larger animals. The iodoformate of sodium and ammonium proved to be antitoxic to pus and tubercular sputum in rabbits, as shown by the experiments of injecting these animals with each of these toxic materials, respect- ively, and then a short time afterwards injecting them with the above-named chemicals. One animal only, out of several, died from Ordinary septicaemia. An extract of sputum, obtained by treatment with alcohol and phospho-molybdic acid, when injected into a mouse produced a convulsive chill, lasting until death, which occurred after eight hours. The same extract when mixed with an equal quantity of a 10 per cent solution of iodoformate of soda had no toxic effect. Pure cultures of the staphylococcus pyogenes aureus, when mixed with formate of soda and injected into the perioneal cavity of a rabbit, did not produce any toxic effect. Formate of sodium and ammonium only was given to monkeys by the mouth and by hypodermic injection. It was found that of all these salts formate of sodium and formate of ammonium especially were non-poisonous. A large-sized Rhesus monkey was given 60 grains, by the mouth, of formate of sodium in four doses, during a period of twelve hours, with the effect of redden- ing the tongue only, causing salivation and an inordinate appetite. From these preliminary investigations it was decided to turn our attention to the human sub- ject, confining ourselves to the use of the salts of Sodium, ammonium, and iron. Accordingly these were employed in hospital practice upon various patients, who were suffering from different forms of phthisis, especially laryngeal phthisis. These agents were also used upon a few patients who were suffering from epithe- lioma, lupus, and sarcoma of the throat. One patient (Mrs. C.), who was suffering from general tuberculosis, was given ammonium formate in from 1 to 10 grain doses for over a period of two months, beginning October 28, 1891. It was administered to this woman, both hypodermic- ally and by the mouth, from three to six times daily. Its effects were quite marked, being manifest occasionally by increase of appetite and extra salivation. After awhile its use would have to be discontinued on account of the supervention of stomatitis, but no sensible effect was observed on the general course of the disease. The hyperaemia of the buccal mucous membrane would soon subside upon the dis- continuance of the drug. We also administered to this same patient the formate of iron with decided tonic effects, but its long continuance seemed to produce irritation of the intestinal tract. The same effect was observed from the use of the sodium formate. Another patient (J. N.), suffering from severe tubercular ulceration of the larynx, was treated internally by the administration (as in the former case) of formate of sodium or ammonium, without very much effect upon the local lesion. Internal administration was stopped and the drug was used locally by means of spray and afterwards by insufflation, the insufflating powder consisting of sodium formate and starch, of each equal parts. Under the local treatment there was a marked cica- trization of the more recent ulceration, but among the deep ulcerations which 1582 PAN-AMERICAN MEDICAL CONGRESS. reached the cartilages of the larynx complete granulation and cicatrization could not be brought about. Notwithstanding this was a hopeless case, we observed that at the time of death the laryngeal ulceration was certainly one-half less than when he was “put upon "this local treatment. In a hopeless case of sarcoma (N. G.), where the ulceration of the pharynx was very extensive, formate of sodium was used by insufflation, and spraying three or four times daily for the purpose especially of testing its local action on such extensive ulcerated surfaces. To our surprise, even in this case we found that cicatrization of the superficial ulcerations here and there would take place in spite of the rapid breaking down of the tissues all about this region. Besides this, its effects were so marked in giving ease to the patient that he was constantly besieging the nurses to use it. These three cases cited were treated simply to test, under the most disadvantageous circumstances, the effects, if any, which these salts might have locally and not with any hope of producing permanent benefit. Deriving some encouragement from these observa- tions, we have since used from 5 to 10 per cent solutions of the ammonium and sodium formates in a number of cases of laryngeal and pharyngeal ulceration of a specific, a tuberculous, and epitheliomatous nature. In the more benign cases cica- trization has promptly occurred from the use of these salts, although with many of them, through the unfavorable general progress of the disease, the effect has not been permanent. However, in purely benign ulcerations of mucous membrane these salts have been found very efficacious in producing healthy granulations and prompt cicatrization. It therefore seems to me that these agents are worthy of more extended trial in the treatment of pharyngeal and laryngeal ulcerations. The insufflation of equal parts of formate of sodium and starch seems to produce no direct irritation, unless used more frequently than about four times daily. In ulceration of the throat accompanying scarlet fever, and in diphtheria, formate of sodium or ammonium may be used by spraying or insufflation as often as once in two hours, without producing much if any irritation of the surrounding mem- brane. I think formate of iron deserves a more extensive trial than it has had, for its good effects are certainly equal to some of the other salts of iron, especially in the septic diseases. The application of these salts undiluted to the mucous membrane (with the exception of copper) causes little or no pain. But a 10 per cent solution applied to the larynx, where the membrane is hyperaemic from recent disease, causes a stinging pain for a few minutes. But generally speaking, there is no Smarting as a result of its application in the strength above indicated. However, in some instances where sodium or ammonium formate is applied directly to the mucous membrane it causes considerable sharp pain for a period of from five to ten minutes, but this is not the rule. I do not consider it necessary to weary my hearers by lengthy details of all the cases in which these several salts have been used, because I think that further observation is requisite in order to place a proper value upon them as renuedial agents. DISCUSSION. Dr. JOHN N. MACKENZIE, Baltimore. I have been very much pleased to hear these three papers. We now no longer regard laryngeal tuberculosis as a neces- sarily fatal disease; we are gradually getting to that position where we can tell a patient that in a case of moderate ulceration of the larynx, and especially of the pharynx, we can cure. I was very much interested to hear from Dr. Solly that these cases do so well in Colorado, and I am exceedingly glad to learn of his good results. PAN-AMERICAN MEDICAL CONGRESS. 1583 Dr. PRICE-BROWN, Toronto. I would like to say a word as to laryngeal opera- tions in tuberculosis of the larynx, from my own limited experience. I have in one case, I think, seen a complete cure of infiltration with ulceration of the larynx by operative measures. Briefly, this case was that of a lady who came to me first in June, 1891. She was 27 years of age and unmarried. Her mother died of tubercu- losis. She had been suffering from hoarseness for a year and a half and during the latter months of this time was almost completely aphonic ; her temperature was 100°; she complained of soreness over the apex of the left lung. On examination I found solidification, bronchial breathing, and all the evidence of tuberculosis. Examina- tion of the larynx revealed a large infiltration between the arytenoids with the ulcer projecting toward the epiglottis and extending to the level of the vocal cords. The cords were congested and she could not vocalize because it was impossible to bring them into juxtaposition. I applied a pretty strong solution of cocaine and made two operations with the galvano-cautery upon this growth, at an interval of a week. This did not have as much effect as I desired ; there was some sloughing. During the summer of 1891 I curetted the growth a number of times. I did not use lactic acid, but what was much preferable to the patient, a solution of men- thol in a strength of 5 to 10 per cent in albolene. This was used daily, and about the end of the year; her voice had almost returned, the ulceration had ceased and showed cicatrization. I have seen her often since, and her voice is now entirely restored; there is complete healing of the ulceration; the lung is what I call fibrous, there is a creaking sound Over it; there is no fever, but some cough. I saw her three weeks ago and her voice was clear. I think in this case there was complete cure by operation, but I suppose eventually she will die of tuberculosis of the lungs. Dr. S. K. MERRICK, Baltimore. I am very glad indeed to hear of cases so near home as Washington being cured of tubercular laryngitis. One case in par- ticular related by Dr. Murray, where he is sure the patient is well, I am particularly interested in ; also the one to which Dr. Brown has referred, Per- sonally I have never seen a case of laryngeal ulceration of tubercular origin that was cured. For some years there was a great deal of skepticism as to the possi- bility of such a result, but the cases have so multiplied and cases are so numerous it is now a notable fact that cases of tubercular laryngitis get well, temporarily, at least. It seems to me it is a distinct gain to know that we can do anything in these cases. I have a case of laryngeal ulceration that I saw this morning. When the case presented himself about six months ago there was sim- ply slight swelling of the arytenoids, and there was a cavity in the right lung. The patient was sent to Atlantic City and he took on 12 pounds of flesh there in three weeks; still the throat trouble did not improve. He has been under treat- ment from time to time, and I have been sending him to the country a good deal. I believe to a certain extent, as Osler once said to me he believed, that “the country will do more for phthisis than any doctor can do.” I believe that is certainly the case unless there are laryngeal complications. This patient spends most of the time in the country. All my cases of tubercular laryngitis go on and die. I have tried lactic acid and nearly every drug that has had a reputation for curing these cases. I may say that in the last twelve years I have had about 2,000 cases of pulmo- nary tuberculosis from outdoor clinics and I have never seen a case with tuber- cular laryngitis that has healed where there was the bacillus tuberculosis in the sputum, and I am very glad to find, so near home, gentlemen testifying to facts so favorable that are undoubtedly true. I feel utterly without hope in these cases when I take them. Any advance along the line of even temporary improvement is to be accepted with thanks, and it is to be hoped that reports will be even more favorable in the future as our knowledge increases. 1584 PAN-AMERICAN MEDICAL CONGRESS. Dr. H. Holbrook CURTIs, New York City. I have been extremely interested in this discussion, especially in the remarks of Dr. Solly. I wonder if he realizes the weight of responsibility resting upon him in his peculiar position in the West and his great opportunity for observation in these cases. How excellent are the con- ditions when the patient goes to a mountain resort free from the cares of his busi- ness, where he is buoyed up by the enthusiasm and hope which must be more or less inculcated by association with the large number of patients who are improv- ing. The statistics of his paper are very flattering and must of necessity be a lit- tle more favorable than the statistics we can show. It is very satisfactory to hear of any hope that can be given in cases of laryngeal tuberculosis. I reported four cases a year ago at the Academy of Medicine in which I thought three had made absolute recovery, but another year has passed and two of these cases have gone back; their throats have become reinfected, although they have been very careful in the use of peroxide of hydrogen and kept their throats very well cleansed. The one case I may still claim as a cure was a most peculiar one. This young man was 19 years of age. When he came to me his left lung was consolidated at the apex and his throat had the appearance of three Malaga grapes. The epiglottis was infiltrated and edematous, and both of arytenoids filled up the entire larynx so that I could only get an obscure view of one cord. I gave no hope whatever in this case; never- theless, I scarified and curetted according to the method of Krause, applying lactic acid thoroughly, and to my surprise there seemed to be an improvement. As soon as the edema was reduced I saw that there was entire absence of the left vocal cord. When the throat got a little better he developed a perichondrial abscess, which I opened externally, and nearly one-half of the thyroid cartilage came through as a sequestrum and was removed. I kept a drainage tube there for nearly three months, when the ulceration of the throat entirely disappeared; afterwards the thyro-arytenoid muscle repaired itself and the vocal cord was repro- duced as a flabby band on that side. That was eighteen months ago, and he has had no return of the throat trouble; but I am told that his other lung is affected and that he is running down and losing flesh from pulmonary tuberculosis. I do not think we ought to feel too much encouraged by the reports we have heard read, but we may hope to give patients suffering from this disease some relief. Two years is scarcely enough time in which to decide that these cases are cured. If we took five years our statistics of cure would be very much less. I think the return of the disease is almost inevitable. One per cent would seem to me a very flattering figure to place as the probability of cure in tubercular ulceration of the larynx. - Dr. D. BRYSON DELAVAN, New York City. It is not often that three such papers are brought together at one time. Each is in itself extremely interesting, instruct- ive, and valuable, the one to a remarkable degree offsetting the others, and each representing, as it does, a distinct basis of treatment. With regard to tubercular laryngitis there was formally no hopeful condition. Comparing the prognosis possible in many cases now, and I am not inclined to take a more sanguine view of recent advances than are others, in the last five years progress has certainly been made, although the fact remains that even before these new methods of treatment were proposed cases of tubercular laryngitis were known to recover. I have had several such, in which recovery was due to climatic influences of a favorable nature. Cases have also been seen, although very rarely, where tuber- cular ulceration has been arrested by persistent local treatment; I mean strictly therapeutic treatment. So there were two resources by which it was possible in rare instances to arrest tubercular laryngitis. When Prof. Krause and Theodore Heryng offered their suggestions a new field for research and experimentation was opened. Unexpected success attended their methods in that these patients did get well of tubercular laryngitis. That this is a fact I know, for I have seen PAN-AMERICAN MEDICAL CONGRESS. 1585 Dr. Krause take a case of advanced tubercular laryngitis in which it seemed that no help could be given the patient, and after performing what seemed to be a most severe operation have found that in forty-eight hours the patient was greatly relieved. I have operated upon cases myself where cicatrization has followed the removal of diseased tissue from the larynx and the standard treatment with lactic acid employed. Lactic acid is a good method of treatment, combined with curette- ment, or the extirpation of the diseased tissues. It is efficient in some cases where simple topical treatment would be unavailing. I had the privilege this winter of studying some cases under the care of my friend, Dr. Trudeau, in the Adiron- dacks, which showed very remarkable results in the healing of advanced laryn- geal disease. I saw in the Sanitarium at Saranac five cases in which advanced ulceration had been arrested. The treatment consisted of the injection of a modi- fied tubercular lymph, prepared on a totally different principle from the lymph of Prof. Koch, and practically deprived of the irritating and dangerous qualities of the Original tuberculin. Not only did these laryngeal cases do well under the injection of tuberculin, but cases of pulmonary tuberculosis have done well also. Since the date of the above observation, a period of ten months, all of the above cases have done well, and a number of new and successful ones have been added to the list. Each of these things marks an advance in the treatment of this dis- ease, cases of which are so often set aside as incurable. It is immaterial whether the patient lives indefinitely or not ; it is an immense advantage that he should be left to live out the time allowed him by his tubercular disease without tubercular laryngitis. If we can relieve the patient for a year, a month, or even a week, we are fully justified in bestowing all possible pains and labor in our power to help him. It is not necessary for patients who die ultimately from tubercular disease to have a recurrence of laryngeal symptoms. The reports of Prof. Krause show that a considerable number of his cases have been cured; that is, permanently relieved of laryngeal ulceration and all the attendant symptoms that go with it, although they have finally died of the pulmonary trouble. That is certainly a vastly better outlook than we had ten years ago, and it is certainly a subject of great rejoicing that we can relieve these patients, if only to a limited and very moderate degree. When it comes to the treatment of special cases, Dr. Murray has dealt with such as most of us will have to meet with, namely, those who must remain at home. Unfortunately tuberculosis is a disease which should be confined to the wealthy. The poor man ought not to have it. Unfortunately, he will have it, and we shall have to help him ; and anything that will help him is greatly to be desired. We have the above resources, which can be carried out at home, to the great relief of the patient. The conditions described by Dr. Solly are truly, on the other hand, Utopian. They are the happiest, best, and most favorable conditions the tubercular patient can be placed in, namely, first, to be able to live in the most beneficial climate possible; and, second, in that climate to receive the most skillful and admi- rable treatment that can be given him. Under this second condition 1many of our health resorts are unavailable. We dare not send our patients to them, because there is no one there to look after them, and, if for no other reason, I think the writer of the paper deserves gratitude for the fact that he has been one of the pioneers in establishing the idea that a patient can be sent to a first-class climate and there receive first-class treatment. It is only a question of time when such sanitaria will become more widely distributed, and we can then select the climate most beneficial for a given subject. This experiment, carried out in Colorado Springs, is certainly one of the most interesting and valuable ever attempted in this or any other country. One word about the Krause treatment: While it may not be applicable in every instance, it certainly has a place in our armamentarium, and the successful work of every man in this direction is a benefit to us all. It would be very valuable if in discussing the matter with our patients we could S. Ex. 36 100 1586 PAN-AMERICAN MEDICAL CONGRESS. refer to such excellent work as we have just heard of, not only from one but from a large number of good operators and careful observers in this country. Dr. E. FLETCHER ING ALS, Chicago. Years ago I stated at the American Laryn- gological Association that as a rule laryngeal tuberculosis would get better if the patient's general condition improved, but the reverse was also true. I think the rule is correct, but we have been shown to-day that there are a considerable num- ber of exceptions, more than I had supposed possible. I was particularly struck with the remark that there seems to be something peculiar to the German people that enables them to bear severe treatment better than others, and perhaps the same may be true of negroes. My patients will not usually tolerate such rough handling, but certainly Dr. Murray's results were most excellent. I confess that after Dr. Delavan’s report I had so little confidence in Krause's method that I did not try it, though I used the lactic acid without the curette. I did not fully under- stand whether Dr. Murray meant to fully coincide with the statements he quoted from Henry or not, but for fear he did not I want to say that I think they are not correct. For example, I understood him to say that laryngeal tuberculosis is not benefited by medical treatment. I am quite satisfied from a very considerable number of cases that medical treatment, even internal treatment, but particu- larly topical medical treatment is of very great advantage, and that many cases recover under this course; indeed, I believe many more than would be benefited by any surgical procedure. General treatment I consider of prime importance. Topical treatments have seemed to me of special value in relieving the sufferings of the patient and thus permitting better nutrition. Dr. Shurley, whose paper we have heard, sent me some of the formate of soda to try in laryngeal tubercu- losis. I tried it in two or three cases, but not sufficiently to speak of its efficacy. I have used various other local remedies and have tried lactic acid, but have not used the latter thoroughly. Lately I have been using a remedy which at least in two cases seems to have been of very great value. In one of these cases the patient suffered from extensive tuberculosis of one lung. There were many tubercle bacilli in the sputum, but the larynx was not ulcerated, though both larynx and trachea were congested and there was some infiltration of the larynx. Dnder the influence of this remedy, the terchloride of iodine, he improved imme- diately, and his improvement was so great that the patient, who is a physi- cian, calls himself well, though he occasionally catches cold and then comes in for treatment, one or two applications as a rule being sufficient to make him feel all right for a couple of months. I am satisfied that the terchloride should have the credit, for he says this is the only remedy that ever did him any good. The other case referred to was one in which there was extensive infiltration, and ulceration of the left ventricular band extending down to the cord. Under the use of the terchloride of iodine the infiltration has largely subsided, at least 50 per cent hav- ing disappeared, and the ulcer appears to be healed. There is a small excavation still, but it does not seem to be an open ulcer. The terchloride of iodine is specially valuable for the reason that when applied to a surface on which there is purulent Secretion it becomes decomposed at Once, the iodine being set free in a nascent state which is thought to be more than under other conditions. I use it in the strength of from 1 to 24 grains to the ounce of distilled water as a spray. Dr. Curtis's remark that a patient must remain well from two to five years before he can say he is cured is very true, but if we can cause the ulcer to heal we do the patient a great good, even though a cure may not be effected. º t Dr. SOLLY. I thank the section for the consideration they have given to my paper. What Dr. Curtis said about responsibility I think I feel very fully. One thing that particularly strikes me in regard to this disease and tuberculosis gener- ally is that we have in Colorado Springs the opportunity of observing what may be termed its natural history. So many cases of tuberculosis die in low climates so PAN-AMERICAN MEDICAL CONGRESS. 1587 much earlier than in high, even the fatal cases are usually more prolonged in Colorado, and we have the opportunity of seeing the disease in its various phases, better perhaps than you do at sea level. Also, we are intimate with our patients, we observe them on the street, we know how they are living, what they are doing, and therefore there are many aspects of tuberculosis we see that do not show them- Selves to you. As regards the point of patients being buoyed up by the climate, that is true. Some are extremely hopeful when they come on the high ground. It has a marked effect upon perhaps 50 per cent, but on the other hand an equal num- ber are homesick, suffering from the absence of friends and business; they are worried and fret and often die. Unquestionably two years is too short a time to pronounce any case cured, and in my reports no cases are given as cured in two years although some are reported as greatly improved. I have avoided using the term cured unless at least five years have passed, and in many cases longer than that ; some observations go back seventeen or eighteen years. I could not burden the paper with fuller details of these cases, but I hope to publish them some time in eactenso. Dr. Curtis spoke about the return of the ulceration in the larynx. My statistics cover this point, but what astonished me very much, and Dr. Ingals also referred to it, is the fact that quite frequently when the patient was running down and dying of general tuberculosis the larynx remained healed. My observation has been when the ulceration is treated, getting down to what is called in the West “bed- rock,” there is seldom a return of ulceration in the same spots, though it may occur elsewhere if the patient's general condition deteriorates. Of course healing the throat is not necessarily curing the patient, but he is relieved from one of the most painful deaths, viz., that from tubercular laryngitis. A very interesting case illustrating the difference between healing and cure of the tuberculosis was that of a gentleman whose larynx is now in the Army Medical Museum. He was in the Navy and in good health until he was attacked with an acute laryn- gitis and bronchitis, which became tuberculous. Aphonia continued and a chronic laryngitis, but the bronchitis disappeared. He went on the Greely expedition and improved very much in the dry cold, got strong and vigorous, but his voice did not come back. On his return, finding himself running down, he went again on an Arctic expedition, with the same results, and so came to Colorado. He was brought to me for examination by another physician. His larynx was unquestionably tuberculous, but no ulceration was then visible, although there were some few papillomata on the commissure, looking as if an ulcer had healed. There was consolidation at the apex of one lung; he was somewhat affected con- stitutionally. I did not see him again for about six months. In the meantime he was running about the country and overtaxing himself, and was brought again to me complaining of soreness of the throat and continued aphonia. His physician then placed him in my hands for treatment. There were several ulcers, and one at the base of the epiglottis had perforated. Under radical treatment the ulcers healed, though signs of infiltration remained and the voice was but little improved, the dullness at the apex of the lung cleared up, and his general health became excellent. He started to drive from Colorado Springs to Kansas City in an open gig, and arrived East in fine condition. Dr. Solis-Cohen then examined his larynx and reported it healed. After six months’ residence in Washington general tuber- culosis of the peritoneum and meninges came on and fresh ulcers appeared in the larynx, though not in the old spots. This case shows that there may be very marked local results from treatment even when the general tuberculosis is not cured. It is possible had this patient remained in Colorado, as advised, that he might yet be living. However this may be, all my clinical experience warrants the belief that laryngeal is as well suited as pulmonary tuberculosis for treatment in high climates, 1588 PAN-AMERICAN MEDICAL CONGRESS. Dr. T. MORRIS MURRAY, Washington, D.C. It has been a great pleasure to me to listen to Dr. Solly's paper. The results of the treatment he gives there are by far the best published in this country, and suggest to me what I have thought was perhaps one of the reasons why we get such different opinions as to the value of these methods of treatment in tuberculosis; that is, that the climatic conditions under which the treatment is instituted influence very imaterially the result. As to the medical treatment of which Dr. Ingals speaks, I must confess that having carefully followed the history of the medical treatment of laryngeal tuberculosis it seems to me to be simply a record of disappointment and failure. I may possibly undervalue medical treatment in such cases; I refer to local treatment. While undoubtedly it has its advantages when combined with the removal of the cause of the disease, I think that time is wasted in their employment when it is possible with the curette and lactic acid to destroy the cause of the trouble. It is particu- larly gratifying to me to hear Dr. Delavan speak with enthusiasm upon the surgi- cal treatment of laryngeal tuberculosis. This is so because he was the first in this country to call attention to the subject. His continued enthusiasm is a high trib- ute to the excellency of this method of treatment, which to me certainly appears far superior to any other heretofore suggested. *----- THE UTILITY OF THE ELECTRO-CAUTERY SNARE. By HANAU W. LOEB, M. D., of St. Louis, Mo. Since the introduction of the electro-cautery snare as an agent for remowing neoplasms and hypertrophied tissues in the nose and throat three facts have been well established: (1) One may operate without the occurrence of haemorrhage; (2) One may operate with greater celerity; (3) one may operate with more pre- cision. The first of these stands without an argument ; all must recognize the influence of the red-hot wire in staying the flow of blood. The second, while no less a fact, still admits of some discussion. For while there is no necessity for wasting time in removing an enlarged tonsil by a knife or a tonsillotome, if it is desired to be accurate in removal, in other words, if a certain portion is to be removed, the operation with a snare requires far less time. In removing polypi the most partisan advocate of the cold snare will admit that it consumes far more time than the electro cautery snare. But it is in reference to the last of this trinity of utilities that special stress should be laid, viz., the accuracy of removal. No one can hope, in face of the circumstances attendant upon pharyngeal operations, to be as accurate, with the knife, scissors, or similar instruments as he can with the snare, which limits so exactly the line of removal. A patient may twist and turn as much as he pleases, and may indulge in gagging and the like, but when the snare has once been placed in proper position the operator may feel secure as to the amount of tissue he is going to remove. The cold snare is as accurate an instrument as the electro-cautery, but it does not rise to its plane of equality in so far as preven- tion of haemorrhage and celerity are concerned. To consume half an hour in biting off a growth is by no means pleasant to the patient and is almost as annoying to the physician. There are other advantages of somewhat minor importance, such as greater ease of obtaining patient's consent to a simple oper- ation, less pain, the decreased danger of injuring other organs and tissues, and the ability to perform two operations at the same time, where, under a form of operating without an absolute control of haemorrhage, a second operation, on account of the flow of blood, would be precluded. The electro-cautery snare is therefore of utility in the following operations: (1) Removal of nasal polypi and tumors; (2) removal of redundant mucous membrane; (3) removal of tonsils; (4) removal of the uvula, . - PAN-AMERICAN MEDICAL CONGRESS. 1589 Removal of nasal polypi amal tumors.—Among specialists the removal of polypi by the forceps has long since been tabooed and to the cold smare has been assigned the burden of popularity. As between the cold and the electro-cautery snare, there is to my mind no reason for hesitation in making a choice. The snare prin- ciple is the same in both, the manner of effecting the removal different. Tedious and failing to arrest haemorrhage unless the wire be tightened very gradually, the cold snare is compelled to give way to the electro-cautery, which accomplishes the operation in an instant, Occasions absolutely no hamorrhage, and cauterizes the base of the tumor, thereby exercising an influence which in many cases at least prevents the return of the neoplasm. The application is as easy in one case as in the other, though until one is familiar with the electro-cautery instrument the wires attached to the handle may sometimes interfere. This objection, too, will be dismissed by a new handle which will not require the wires to be attached when applying the snare, a handle which I hope soon to have the pleasure of per- fecting and of presenting to the profession. Far more polypi may be removed at one sitting. The act of removal in the one case requires but an instant, and in the other case from ten minutes to half an hour, depending upon the Operator's other engagements. Less pain is occasioned by the electro-cautery snare, for the cocaine effect will not have worn away before the operation is completed. Far- ther application is accordingly obviated. After effects are no more common or severe than those following other methods of operating. This decision is the out- come of observation of a large number of cases during the past three years. Dur- ing that time in over a hundred operations for nasal polypi no complication beyond the natural consequence of any surgical treatment has resulted, save in one case which was followed by otitis media, with which, however, I can not charge the electro-cautery. The operation was performed early in the morning of the 4th of July, 1893, and the patient carelessly stirred around all day, notwithstand- ing the inclement, damp weather. From this attack he very readily recovered. I do not wish to be understood as advocating the electro-cautery snare operation as a radical cure for polypi in opposition to the method of removing the diseased turbinate which primarily occasions the disease. I have too often seen the good effect of the latter operation. The fact still remains that the polypi are better removed by the electro-cautery snare; the other operation may, if indicated, be performed later. In all pendant nasal tumors, and in all those where it is possible to engage a wire around them, the electro-cautery is to be preferred to the cold snare, the reasons being the same as in the case of polypi, with a stronger argu- ment in regard to its hemostatic power. Such tumors are often very vascular. 2. Removal of redundant mucous membrane.—In regard to the removal of redundant mucous membrane a similar condition of things prevails. As there is greater liability to haemorrhage than in the case of polypi, the arguments urged before are multiplied. So kindly does the mucous membrane respond to this method of removal where it is indicated that I am safe in the conclusion that once tried it is sure to be adopted. 3. Removal of tonsils.--Tonsillar haemorrhages are rare, but they are not so uncommon as to cause those who operate frequently to lose sight of their possi- bility. As the tonsillotome and the knife permit bleeding without restraint, it behooves the operator to lessen the chances if possible. The operation with a tonsillotome is too thoroughly ingrafted in the practice of the profession to expect a sudden change in the use of the instrument; it is too easy of performance to be cast to the wayside for what to many is an unknown quantity, and yet, after an experience not inconsiderable, I feel that my earliest expectations have been more than confirmed; truly no more thorough a realization could be desired. With the tonsillotome, in addition to the probability of haemorrhage, no one can be very accurate; that is to say, the portion of tissue removed is apt to be greater or less 1590 TAN-AMERICAN MEDICAL CONGRESS. than was intended. When the electro-cautery snare, on the other hand, is used, precision is the rule, for the wire marks effectually the tissue desired to be removed. There is no danger of wounding the palate; no necessity of making a hit- or-miss thrust; no sudden action necessary on account of the restlessness of the patient; you may remove as much or as little as you wish. The method of opera- tion is easy; the loop is placed around a pair of forceps, the tonsil is grasped by them, the loop engaged around the tonsils and tightened. The operation of removing adenoids may be performed coincidently with the tonsillotomy, as no haemorrhage interferes with the administration of chloroform or ether; a point of no inconsiderable value. It often happens that a moderately enlarged tonsil is quite impacted between the two pillars of the fauces. In such a case a small portion may be removed with the electro-cautery snare, which will afford a larger loss of tonsillar substance than simple cauterization. Sequences are quite as exceptional as in other methods of tonsillotomy. In the 33 tonsil-removal operations performed last year by this method, no case presented anything beyond pain in the throat and occasionally slight pain in the ear. As is usual in most cases, a mild pharyngitis followed the operation. In one case, that of a young man of 18, otitis media followed eleven days after the operation, which was attended by no unusual symptoms, and hence, I think, not responsible for the Otitis. 4. Removal of the www.la.—In the removal of the uvula the Snare is convenient of application, the uvula being permitted to fall into the loop. The removal is soon accomplished, without any slipping, without pulling down the mucous membrane, and without more or less of the uvula removed than was intended. Of course, as in all electro-cautery snare operations, no haemorrhage follows. The stump is more even and heals far more quickly. There is no such pain upon swallowing follow- ing this operation as after the cutting operations, and, with very few exceptions, patients were able to eat fairly well upon the day of and the day succeeding the removal, comparing very favorably to the after effects of operations performed with a knife, scissors, or uvulatome. Electro-cautery snares which have been in use are open to objections on account of their uncleanliness, on account of the length of wire necessary, and because of the occasional short-circuiting of the current. It is practicably impossible to perform anything like an aseptic operation with a snare of the old make, as when used a single time the discharges so collect upon the silk and cotton insulation as to render it unfit for subsequent use. The snare, however, which I had the honor of presenting before the laryngological section of the American Medical Association in 1892, and which I have been using for two years, negatives these objections. Every portion of the instrument is separable, f’AN-AMERICAN MEDICAL CONGRESS. 1591 the canulae, the copper wires, the ivory tip, and the rubber insulation. It there- fore may be subjected to the ordinary aseptic procedures, the rubber insulation being in this respect far superior to the silk or cotton insulation. By means of the two stout copper wires which are made to pass through the canulae, and which are supplied with an eyelet in the upper end, a substantial loop may be made. I have of late used steel instead of platinum wire for the reason that it is firmer and more apt to remain where placed. It is not so lasting as the plati- num, yet it has never failed to act. Forevery operation a new piece of wire should be used, as it becomes brittle after the current has passed through it. As the eye- lets are very easily rethreaded, this is not a disadvantage. Very valid objections have been urged against batteries of all kinds, whether primary or storage, and this condition of things has had no little to do with the non-adoption of the electro-cautery snare by many practitioners. The great prog- ress of electrical inventions has come to our relief, for we now have appliances for changing the current used for lighting purposes so that it is available for the cau- tery. This supplies the missing link of electro-cautery possibilities, and makes those who use the electro-cautery snare secure in feeling that they have a medium of electric cauterization that is certain. I have during the past year been using for this purpose the converter made by the A. S. Aloe Instrument Company, of St. Louis, Mo., and I can testify that it has not failed me a single time. Finally, and in all confidence, I beg to reintroduce the three postulates of electro- cautery utility in nose and throat diseases, the three desirable ends in the removal of all non-osseous projections: (1) No haemorrhage, (2) celerity of operation, and (3) precision. SECTION XIV.-0TOLOGY. Honorary Presidents. Dr. ADOLPH ALT, St. Louis, Mo. Dr. ALBERT H. BUCK, New York. Dr. GORHAM BACON, New York. Dr. WM. CHEATHAM, Louisville, Ky. Dr. FRANCISCO DE P. CHACóN, City of Mexico. Dr. SEBASTIAN CUERvo Y SERRANO, Sancti Spiritu, Cuba. Dr. WM. T. CARMALT, New Haven, Conn. Dr. J. C. CONNEL, Toronto, Canada. Dr. STEPHEN DODGE, Halifax, Nova Scotia. Dr. J. B. EATON, Portland, Oreg. Dr. A. A. FOUCHER, Montreal. Dr. JoHN F. FULTON, St. Paul, Minn. Dr. J. WILFORD GOOD, Winnipeg, Man- itoba. Dr. FRANCIs B. LORING, Washington, D. C. Dr. HENRY D. NOYES, New York. Dr. ARTURO COSTA PRUNEDA, Santiago, Chile. Dr. CHARLES INSLEE PARDEE, New York. Dr. G. STERLING RYERSON, Toronto, Canada. Dr. D. B. ST. JOHN ROOSA, New York. Dr. W. H. SANDERs, Mobile, Ala. Dr. BELISARIO SOSA, Lima, Peru. Dr. G. C. SAVAGE, Nashville, Tenn. Dr. J. B. B. VERMYNE, New Bedford, Mass. Eacecutive President. Dr. C. M. HoBBY, Iowa City, Iowa. Secretaries. Dr. S. O. RICHIE (English-speaking), Washington, D. C. Dr. FERNANDO PáREz (Juncal 809), Buenos Ayres, Argentine Republic. Dr. ERNESTO MAZIZE, La Paz, Bolivia. Dr. THEODoRo PECKOLT (Jor), Rio de Janeiro, United States of Brazil. Dr. J. H. WISHART, Toronto, Canada. Dr. CARLOS DESVERNINE (Cuba 52), Havana, Cuba. Dr. CARLOS EsgueRRA, Bogotá, Re- public of Colombia. 1592 Dr. H. McHATTON (Spanish-speaking), Macon, Ga. Dr. DEMETRIO ORANTES, City, Guatemala. Dr. H. G. MCGREw, Honolulu, Hawaii. Dr. ANTONIO PENAFIEL (Escuela de Medicina), City of Mexico, Mexico. Dr. MONTENEGRO, Leon, Nicaragua. Dr. N. SURH (Ituraingo 265), Monte- video, Uruguay. Dr. FOCION F. CORDERO F., Merida, Venezuela. Guatemala PAN-AMERICAN MEDICAL CONGRESS. 1593 PROCEEDINGs. ADDRESS BY THE PRESIDENT OF THE SECTION, C. M. HOBBY, M. D., IOWA CITY, IOW.A. GENTLEMEN OF THE OTOLOGICAL SECTION: In opening this otological section of the First Pan-American Medical Congress we can congratulate ourselves that, notwithstanding untoward obstacles, accidents by field and flood, and such finan- cial stringency as perforce in many parts of Our country prevents those that would greatly enjoy participating in this congress from obtaining for use their hard-won increment, long kept for this occasion, we have gathered together in sufficient numbers to assure the permanency of the body, and from a glance behind the veil I have no hesitation in saying that the character and quality of the papers to be presented guarantee for the First Pan-American Medical Congress a higher scientific value than has heretofore been obtained by any general medical assem- blage on this Western continent. The opportunity for interchange of opinions between the North and the South, the more than 100° of latitude that separates our confrères, the plains, table-lands, and the mountains of the tropics, suggest at once a multitude of questions that we of the North look to our brethren of the South for solution; but the story of the mucous membranes is a long one, and we hope that hereafter we may fre- quently share in similar opportunities for comparison. Meanwhile we have assurance of the kindly help of our fellows from the denser populations of Europe; and I congratulate you upon the presence with us of one whom we all reverence as a master; for whether we have been pupils at Vienna, or have through litera- ture gleaned the steps by which otology has advanced since the days of Toynbee, there is not one of us but who acknowledges a debt of gratitude for the landmarks established by Prof. Adam Politzer; and I think I voice the universal sentiment of felicitation that his genius is still active, and that he is here to speak for him- self. I have sampled some of the good things he has brought to you, and I assure you that it will hereafter rejoice you to have been present. I shall detain you but a short time with the topic of my address, not because I do not profoundly believe that the methods of diminution of deaf-mutism are not among the most important considerations to come before you, for I do believe that in this case prevention must take the place of cure, but because I do not desire to encumber an address necessarily statistical with a flood of details. The material I have used, with the exceptions caused by death in the last eight years, is accessible to all for verification, and the facts are presented with the desire that you criticize the conclusions. THE PREVENTION OF DEAF-MUTISM. It has long seemed to me that in this era of preventive medicine, when our outer portals are so rigidly guarded against the admission of diseases like smallpox and yellow fever, which are easily recognized and quickly controlled at least in our Northern cities, that so little attention has been paid to an internal enemy whose permanency robs the State, the family, and civilization in a ten-fold ratio to the infections against which we so wisely and strenuously guard. It is an unfortunate, but undoubted fact, that census reports and governmental inspections in this country reveal only part of the truth. People feel that deformity, incompetency, 1594 IPAN-AMERICAN MEDICAL CONGRESS. disease and the results of disease, carry with them a stain, a disgrace, and, if gem- erally known, a discount upon the family importance which they desire to conceal. Especially is this true among the poor and uneducated, and the census enumer- ator does well if he gathers all the family names and ages and a small part of the truth in regard to the defective classes. In my own State, which probably contains the most prosperous agricultural population in the Union, without large cities, and with the most equal diffusion of education among all the States, I am satisfied that the census of 1880 gave less than 70 per cent of the number of blind or mute. This estimate is confirmed by Dr. Billings's comparison of the reports of deaths by the enumerators in Massachusetts and New Jersey compared with the State reports. This comparison showed that in 1880 the enumerators were deficient in Massachusetts to the extent of more than 26 per cent and in New Jersey to more than 34 per cent, and he remarked that “in no State is the deficiency in the enumerator's returns less than in Massachusetts.” It is not probable that the enumerators were more accurate in regard to defective classes than they were in regard to mortality. We have no means of comparing the two enumerations for 1890, but as the ratio of 68 deaf mutes to the 100,000 population was maintained in 1890, we can say safely that the census report of 41,283 deaf mutes for 1890 represents an actual 50,000 or upward of this defective class. Taking the defect- ive classes together we find that the proportion is as follows: Insane, 37 per cent; idiotic, 30 per cent; blind, 19 per cent; deaf-mutes, 14 per cent. From the nature of the affliction public attention is seldom directed toward the mute. In his early years, no means of communication existing between him and the public, he is not noticed, and the lack of any external mark of his defect leaves him devoid of the sympathy that the people give to the blind. Later on, after he returns from the institution for education, he naturally fellowships with those who talk his language, and is only accidentally recognized by the public as one of the defective class. He is able to labor, to earn his own living, and usually suc- ceeds in so doing ; but without criticising the methods of instruction which are the results of the formulated experience of those who devote their lives to this noble work, with a few exceptions that surmount in an incomprehensible manner the barriers that exist, the great majority of mutes reach the age of 20, able only to converse with their fellows, and those that take the pains to acquire their lan- guage; but with such a limited range of tools of ideation as to make them unable to think or reason other than as a child of 10 or 12, or as a Savage with small vocabulary, the mental action dwarfed, the enormous area of the incomprehen- sible that surrounds them when they reach out toward the public and converse with the slate, makes them seek their own kind for association and segregate them from the world. The mental incompetency so often manifested has in some of the States, I believe, been recognized as irresponsibility, and I believe that a large proportion of the 50,000 are as irresponsible for the results of emotional acts as are the insane or idiotic. Whilefostering every effort and every method that prom- ises amelioration to this unfortunate class, I believe the duty of the medical pro- fession goes further; that upon us rests a responsibility not met by simply using our influence to secure early training educationally, but which will only be accom- plished when we shall have reduced to the minimum the number requiring such training. • . Is any considerable proportion of deaf-mutism preventable? In considering how large a proportion can be so classed, we are met with a professional and pop- ular opinion, which has so dominated the authors upon diseases of the ear that nearly all have contented themselves with accepting the statement of the teach- ers, that one-half of the mutes are “born deaf.” A few have indicated that per- haps the proportion of congenital cases was overestimated, and it was without other preconceived opinion and against all that I had been taught that I was led, f’AN-AMERICAN MEDICAL CONGRESS. 1595 after the examination of the admission papers of more than 1,000 cases, to go into a careful inquiry as to the basis of this general belief that at least one-half of the cases were congenitally deaf. After discovering that in former times, for educa- tional purposes, teachers had classed all pupils that had never learned to talk as “born mute,” and after finding that all cases in which the parents were unable to say when a child became deaf, or simply said, “He never seemed to understand what was said to him,” that the case was almost invariably classed as congenital, I entered upon the investigation that led me to say in a paper on “Cerebro-spinal fever a cause of deafness,” read before the Ninth International Medical Congress (Washington, 1887) : “With a little care in sifting I have found out of 1,111 cases in Iowa, only 13.3 per cent of congenital mutes, and I believe that a majority of those who have investigated the subject practically will agree that even this per- centage is too large.” Since that time a personal and careful examination of 250 cases, followed by correspondence, showed that only 14 per cent could have been born deaf, and the probability is strong that many of these cases have acquired the deafness in early infancy. The analogy existing between the causes of con- genital deafness and pre-natal blindness would lead us to expect something like a parity in proportion; and the absence in statistics of congenital deafness of one ear points in the same direction. When we come to consider that the percentage of deaf mutes is only between 10 and 15 per cent, which is certainly true for the United States, we have left appealing to our art for relief 85 per cent of deaf mutes in whom disease of an active nature has played the devastating part in the early months and years of childhood. While simple middle-ear diseases unaccompanied by suppuration and consequent destruction of parts may produce deafness of so high a grade as to prevent the acquisition of vocal language, my examinations would limit the probability of this to less than 4 per cent. The destructive action of sup- purative disease plays a more important part, reaching probably 10 per cent, and the remainder, nearly or quite 76 per cent, result from intra-cranial causes, and amongst these must be classed many attributed to Scarlet fever, for less than half the cases following scarlet fever, examined by me, have shown marked lesions of the middle ear upon both sides. We hope that the diffusion of knowledge amongst general practitioners and the increased skill and thoroughness with which diseases of the nose and throat are managed by the profession at large will lead to more prompt and efficient treatment of such diseases when complicating the exanthe- mata, and so materially lessen destructive suppurative processes. There still remain the great majority in whom intracranial, especially labyrin- thine diseases produce deafness in the early months of life, and for whom there has seemed no hope. The study of these conditions is surrounded with great diffi- culty. Pathologically, the opportunity for close comparison of the clinical history with the morbid anatomy is extremely rare, and the recorded observations have hitherto given us little of value as to the relation between acute diseases and the development of extreme deafness. Clinically, we are met with the difficulty that only a small proportion of the cases are seen and studied by a medical attendant during the important period when deafness is acquired. A child of a few weeks or months is indisposed, fretful, its head is thrown back, it may decline nourish- ment, an eruption may, or may not exist, the symptoms pass away without any physician being called, and months may elapse before it is discovered that the * child is deaf. Or the medical attendant being called, the disease recognized and recovery taking place to the gratification of the physician, the same delay exists between convalescence and the recognition of deafness; such occurrences are familiar to you all, and should lead to no censure of the attendant, for in the first place it is extremely difficult in infancy to determine whether the hearing is badly impaired or not, and we are not even certain whether the pathological cause of deafness is always or even usually developed synchronously with the acute affec- 1596 PAN-AMERICAN MEDICAL CONGRESS. tion causing it. The fact shown in my former paper that cerebro-spinal fever bears a causative relation to deaf-mutism, in the United States in from 30 per cent to 50 per cent of cases, is now well recognized, and while as a rule admission papers of institutions can be considered of as little except negative value, the exceptions in which the clinical history is developed by a careful medical attendant are sufficiently numerous to make certain that other febrile diseases, especially typhoid fever and mumps, are occasionally followed by deafness from internal lesion; and as indicated before, scarlet fever is a more frequent cause of internal ear deafness than of destructive middle ear disease. * Nothing in statistics or clinical history of the cases personally examined affords anything satisfactory in regard to the relationship of acute inflammations of the pia mater, “leptomeningitis infantum,” “basilar meningitis,” “purulent menin- gitis of the convexity,” “traumatic meningitis,” “consecutive meningitis,” “metes- tatic meningitis,” or possibly “tubercular meningitis,” to lesions producing deaf- ness; although we may believe that through these imperfectly known conditions the results are produced which are attributed to “rheumatism,” “fright,” “con- vulsions,” “hydrocephalus,” “colds,” and the fevers generally. It is unfortunate that the term “epidemic" has been associated with cerebro-spinal fever, because on the part of the profession an erroneous idea has been developed. This disease is epidemic as typhoid fever is epidemic, under special circumstances, but like typhoid it is constantly endemic in all parts of the United States. Its prevalence as a scourge in special localities, and the undoubted fact that in malarial portions of the country many cases of cerebro-spinal fever were supposed to be remittent and other fevers, led to failure to appreciate this endemic character. However, it is in evidence that in Michigan there were reported, in 1873,812 deaths, and in the ten years following a mean mortality from this cause of 178 per annum, the greatest number 330, the least 101, in a single year, and these cases scattered through the various counties and distributed through the twelve months so uniformly as to show conclusively for this State that the cases could all be considered sporadic. The same evidence is furnished wherever vital statistics are published in America. The occasional occurrence of epidemics in restricted localities among men and animals does not lessen the importance of the fact that this disease is always with us. Another important fact in this connectioli is developed by study of the census reports of 1880 and 1890, namely, that there exists a remarkable uniformity in the proportion of deaf-mutes to the total population North and South, East and West, through all the diversities of climate and elevation of this great country, and that the proportion remains nearly the same in the white and colored races; also that while scarlet fever produces its greatest ravages in the densely populated portions of the country and almost disappears as a causative agent in the production of deaf mutism in some of the States of the Mississippi Valley, we find cerebro- spinal fever producing an almost uniform rate of mortality in all parts of the country. In thus presenting the conditions that must be met in efforts at prevention of the deafness of childhood, I wish to reiterate that the conclusions presented in the foregoing, differing in many respects from the accepted doctrines, have been arrived at only after careful clinical study of this helpless class, and I am sure the personal study of these cases in the institutions for education and careful sifting of the clinical histories of patients, with the assistance of those familiar with the incidents of early childhood of the victims, will'lead to similar conclusions in any of the United States. Inherited syphilis, which had sparingly marked the features and teeth of those examined by me, will doubtless in institutions drawing from large cities appear more frequently, and the same is probably true of the effects of suppurative process, but I believe not to an extent to produce material change in the statistics of causation. It is apparent, therefore, that any considerable suc- PAN-AMERICAN MEDICAL CONGRESS. 1597 cess in diminishing the frequency of mutism must have its origin in the study of intra cranial diseases; the specific cause of cerebro-spinal fever remains to be discovered, and with a knowledge of the methods of infection and the reasons for its extensive dissemination the physician will be better prepared to study its natural history. To accomplish this desirable end it is necessary that the attention of the profession at large, the general practitioners of the whole country, be called to the frequency with Which deafness follows apparently slight ailments of chil- dren, and impress strongly upon their minds further the fact that destruction of hearing most frequently takes place without symptoms referable to the ear. Through the public institutions a more accurate history of each individual could |be obtained by correspondence with parents and medical attendants. The amount of energy that has been wasted in the endeavor to prove that deaf-mutism is largely the result of consanguineous marriages would be sufficient to greatly enlarge our knowledge as to the beginning of deaf-mutism. Public institutions can more readily than medical societies appeal to the public for coöperation, and through the public press awaken the people to one of the neglected results of infantile dis- €3,S62. - I am aware that much that I have said is an old story to most of you, but the strong impression made upon my mind by the conflict between the methods of causation as described in literature and the history of the cases studied in institu- tions, and the neglect of writers upon general medicine to afford to the general practitioner due warning of the dangers of the minor as well as the graver cerebral lesions, must be my excuse for appealing to you to investigate for yourselves these important questions, and I feel deeply grateful that I am-enabled to make this appeal to those interested in the diseases of the ear from so many lands, represent- ing all habitable latitudes. PAPERS READ BEFORE THE SECTION. OTACOUSTIC TREATMENT: ITS HISTORY AND RESULTS UPON THE DEAF AND DEAF MUTES. By J. A. MALONEY, M. D., of Washington, D. C. Prior to the year 1886 I devoted a great deal of time to experiment in physics and principally to its branch acoustics; the result of which was the development of the instrument since known as the otophone, which differed in construction from anything previously used for the purpose. It had three chief characteristics: (1) It did not enter the meatus auditorius externus; (2) it was a tube closed at one end by a flexible membrane, and thereby confined a column of air; (3) it was free from reverberation so common to the old forms. Its advantages reached the ears of Drs. S. Wier Mitchell and C. H. Burnett, of Philadelphia, and through them I was requested by the College of Physicians of that city to lay the matter before them and demonstrate its advantages. This was done on April 6, 1887. (See Transactions of the College of Physicians, third series, Vol. Ix, Phil- adelphia, 1887.) Subsequently I was invited to make tests upon deaf mutes at the Pennsylvania Institution for the Deaf and Dumb and a confirmatory test at the National Deaf Mute College, Washington, D. C., and the results were laid |before the American Otological Society, July 19, 1887, New London, Conn. (See Transactions American Otological Society, Vol. IV, Part I.) The cases so tested were classified as follows; (1) Five congenital cases; (2) five who lost hearing between the ages of 1 and 5; (3) five cases of profound hardness of hearing, being 1598 PAN-AMERICAN MEDICAL CONGRESS. educated as mutes, but who hear a little, can talk and understand lip reading, and may be termed “semi-mutes.” After the tests in Philadelphia (the first made), Dr. Burnett expressed surprise at the demonstration of the hearing power in the five congenitals. The results attending these experiments suggested the thought of a new field of treatment in chronic deafness, by means of passive motion, and I turned to physiological acous- tics for light and knowledge, but found the path had been traversed only partially, until the portals of this domain of science had been opened by Weber, Lucac, Hemholtz, Politzer, Rieman, Henke, and in our own country by Blake, Burnett, and Sexton, and the literature upon the subject was sparse and not specialized. Up to this time otology depended upon local applications and “Politzer inflation.” Then came Siegel's otoscope, as a means of passive motion, and later Delstanche's modification of same, but success in their use was rare, why? Because it pro- duced a too violent and anti-periodic motion, and the ear of the lower as well as the higher order of animal shrinks from the same. - As before stated, prior to my discovery local treatment and Politzer inflation were the means most relied upon for success. The aurist in addressing himself to the external canal had light before him, as far as it related to that part. With Politzer inflation he could render the Eustachian tubes more patulous, and by so doing admit more air to the middle ear In an endeavor to bring about that important factor of audition, i. e., equalization of pressure upon each side of the membrana tympani; but should he succeedin getting a normal lumen established, any fixation of the transmitting mechanism prevented further success. This was the status of treatment in chronic deafness up to the year 1888, when I announced the discovery that Sound, arbitrarily applied to meet conditions of each case, was a therapeutic agent of importance in chronic deafness. The indications for scientific passive motion had long been suggested by the well known phenomenon of “paracusis Willisiana.” Hearing better in a noise is an acuteness of audition made so by motion, but entirely different from the natural methodforthe following reason: Hearing better in a noise is a distinct function from that of normal hearing in that there is an antecedent momentum established by the noise through mass vibration, especially in a moving vehicle, and the voice as a superimposed vibration retards or interferes with the existing vibrations. This interference addresses itself to the sensorum as sound. In the normal ear the mem- brana tympani and Ossicula auditus or transmitting mechanism has a direct action in the translation. Having completed the method and means for a system of aural massage, I designated it “Otacoustic treatment,” which covered in its meaning any sound to the ear. In my earlier cases I was struck by the relief afforded as well as the cessation of tinnitus aurium ill imany cases, and upon reflection I turned to my notes of experimentation, in which I tried to produce those sounds mechanically which are set out in my article “ The sphenoid bone; some of its possible func- tions,” (see New York Medical Journal, August 11, 1888). In speaking of tinnitus aurium, I said: I would here state that I have produced the singing sounds by getting a very loose contact in a Blake telephone transmitter, the contacts of which would be for the purpose analagous to the articulations of the malleus and incus, from which I have concluded that singing sounds are due to slight disarticulation of the malleo- incudal joint placed in vibration by Some subjective cause, and continued by reason of the membrana tympani acting as a retractile spring, thus producing the same effect as the “Neff hammer’’ or make-and-break device upon the induction coil. Much time was required in formulating the method of treatment in individual as well as classified cases during the first two years, the work being empirical because I had no rule of procedure based upon an experience by others for my guidance. That partial anchylosis or fixation of the ossicula auditus could be relaxed by this form of passive motion was accepted by some of the most eminent PAN-AMERICAN MEDICAL CONGRESS. 1599 otologists of our day, and I was encouraged by them to persevere. There were some, however, who ascribed my success to education of the perceptive tract, and this alone. e - In the year 1890 I treated a patient, who was then dean of the Southern Homoe- pathic Medical College at Baltimore, Md. At the time of visit he was accom- panied by a T)r. H. F. Garey, professor of otology in said college. Some time after this visit I understood that said Garey had applied the doctrine of “similia similibus curantur” to sound as a therapeutic agent, or, in other words, that the similar sound of tinnitus applied would cure the tinnitus as well as the deafness. Later on I was astonished to find in the lay press such announcements as “New way to cure deafness,” “Deaf hear by phonograph, by Dr. H. F. Garey,” “Sound waves in the treatment of aural diseases, by Dr. H. F. Garey.” Whereupon I sent a protest to the faculty of said college against the unfair assumption upon the part of Garey; they in response indorsed his action. This party used the phonograph and the similar sound (being a homoepath) as the tinnitus, but has since abandoned said instrument, as I did in my early experi- ments years ago. Others have since suggested the use of the telephone, but the use of phonograph and telephone for commercial purposes has produced ear trou- bles, in the latter case known as “telephone ear.” They are frequently met with by otologists of our large cities. “Telephone ear” was first pointed out by Dr. Clarence J. Blake, before and during the year 1888 (see Transactions American Oto- logical Society, Vol. Ix, part 2, 1888) and later by M. Gelle abroad. No man has used the phonograph more, nor had a greater opportunity of testing its efficiency in deafness than its inventor, Thomas A. Edison, yet he has suffered for years from progressive deafness, and I was informed lately that he is profoundly deaf. Thereason for the deleterious effect upon the ear from the use of these instru- mentalities is the shock necessarily created by their sound-producing mechanism. The method and means which I employ in otacoustic treatment are: (1) The tube or otophone hereinbefore mentioned closed at One end by a flexible mem- brane, and confining a column of air; (2) the method, which consists in the use of articulate sounds (preferably) by reading, twice or thrice daily for a given length of time, according to conditions of case; power of voice also being regulated. Such is the history of sound in its application to otology up to this time. The diagnosis in profound deafness requires a knowledge of the history in each case and experience in the application of this method of treatment, based upon a familiarity with physiological acoustics. Strange as it may seem, otology, as taught to-day, ignores physiological acoustics, which, to my mind, is a Sime qua mon to that special branch of medicine and surgery. º I will now call your attention to the class of cases and degree of success obtained by otacoustic treatment: Case 1.—Dr. B., a busy practitioner of this city, had three or four years pre- vious, by diagnosis, Menière's disease. He applied to me for test May 4, 1887. Right ear only involved. He was very much surprised at being able to hear on that side. The next day I received a message, asking me to call at his office and repeat the test. After making the second test he apologized for being skeptical, and said that three of the most eminent otologists abroad had made an unfavor- able prognosis in his case. The following day he commenced treatment, and on July 12 (two months afterwards) could hear unaided voice in a conversational tone a distance of 15feet. He asked at this time what he could do to acknowledge the result, when I suggested that he communicate the facts to Dr. C. H. Burnett, of Philadelphia, which he did in a letter which was read at meeting of American Otological Society, New London, Conn., July 19, 1887. Case 2.—Ralph G., aet. 12; February 12, 1887; diphtheria at 6 years. Before visit to me the boy had been treated in this country and abroad. R. E., destruction of membrana tympani, Save a portion of membrana flaccida; Ossicles absent; L. E., otitis purulenta; exacerbations frequent from exposure: pain relieved by dis- charge; membrana tympani perforated and sclerotic; inflammation with Sup- 1600 PAN-AMERICAN MEDICAL CONGRESS. puration frequently recurring ; slight naso-pharyngeal catarrh : excessive hyper- trophy of tonsils (almost touching each other); loud voice ; L. E. =2 inches, R. E. =0. Diagnosis had been made of paralysis of auditory nerve. The boy was an expert lip reader, and had the “deaf face ’’ well developed. After examina- tion I found after a five-minute test that he could hear, R. E., moderate tone at meatus, and range extended to 12 inches for L. E. I made a favorable prognosis for development of hearing to serve practical purposes through life. The usual local applications were used upon ears; naso-pharynx and tonsils and otacoustic treatment faithfully followed. On May 20, 1889 (a little ovel three months), the hearing power had been brought up as follows: With eyes closed could hear ordinary conversation at 12 feet, and this remained fixed up to time of last visit, August, 1889, his mother having removed to the far West; the deaf face had dis- appeared ; he was ruddy and robust, and I think it would have puzzled an expert to discover that the boy had ever been profoundly deaf. Case 3.-Mrs. W. H. H., act. 46; June 1, 1889; atrophic nasal catarrh : R. E. deaf for fifteen years. W., R. E. = C., L. E. = tº ; B. C., good; M. T., sclerotic, opaque, retracted ; tinnitus very persistent and varying ; E. T. partly patulous. Patient was very skeptical of prognosis made after examination and tests, but her husband, who was present, urged her to proceed with treatment, which she reluc- tantly did. After thirty days the following results were shown : W., R. E., = , ; L. E., #}. Ordinary conversation heard in any part of room with back to speaker; tinnitus very much reduced. This patient was a neurotic and at the menopause. In November, 1890, she called to inform me that she had been ill with typhoid fever, but her hearing remained good. At this time tests showed: W., L. E. = ##, R. E. = }}; tinnitus scarcely perceptible, and then only at times. Case 4.—February 15, 1889, Mr. J. Van S., act. 36;lip reader; atrophic nasal catarrh. This case was sent by specialist, who was treating him for otorrhoea. Deaf R. E. three years, L. E. twenty-five years; had been under treatment for some years; W., R. E. = ſºn, L. E.-C.; V., R. E. –3 feet, L. E. meatus. After four months condi- tions were W., R. E. =##, L. E. = 1%; ; conversational tone of voice heard in any part of room (15 by 15) and low voice at 3 feet with L. E. The deaf face in this case was pronounced at time of first visit. On 1may 19 patient presented an improved appearance, no deaf face, and was bright and cheerful; V., undertone, 15 feet; ... R. E. = }}, L. E. = }}. On May 19 patient presented an improved appearance, }. deaf º: a bright and cheerful countenance ; V. =moderate, 15 feet ; W., L. . = ##, R. E. =#}. Case"#. Miss A "de L., ast. 24; January 16, 1890; expert lip reader: post-scarla- tinal deafness since early childhood; R. E., W. = }, , L. E., W. = , ; B. C. good; chronic muco-purulent discharge from L. E.; M. T., R. E., opaque, retracted, and full of cicatrices, L. E., perforation in inferior posterior, quadrant and tissue bathed in muco-purulent secretion ; E. T., R. closed, L. patulous; treatment for discharge of L. was carried out under otologist who sent the case. I directed Otacoustic treatment to development of hearing in R. E. with disuse of L. E. because of sensitiveness (closing meatus with wool) for L. during medication. At end of thirty days, otacoustic treatment was used on both sides, the purulent dis- charge from L. having subsided. On May 8, 1890, conditions were, W., R. E. = ºr, L. E. =#. October 1, 1891, W., R. E. =##, L. E. =##. - Case 6.-Mrs. E. R., at. 38; September 30, 1890, chronic naso-pharyngeal catarrh; M. T., L. E. opaque, thickened, retracted; E.T. partly patulous; M. T., R. E. opaque upon posterior segment, retracted; tinnitus aurium both sides; unfavorable prognosis by several specialists; had been under treatment for years; W., R. E. tºo, L. E. = O: B. C. good; V., R. E., loud = 6 feet, L. E., loud := meatus. October 30, tinnitus, R. E. seldom noticed, L. E. very much reduced; V., R. E. 10 feet, L. E. 10 inches. December 15. W., R. E. = ºr, L. E. == i , ; V., R. E., conversational tone, 15 feet, L. E., conversational tone, 4 feet. January 22, 1891, no tinnitus; W., R. E. #, L. E. º. May 4, R. E. #}, L. E. ºr ; V., conversational tone, R. E. 20 feet, L. E. 10 feet; no tinnitus. Upon first visit this patient stated ‘‘the deafness is of minor importance compared to the suffering endured from the tinnitus, and will be happy if rid of it within two years.” Case 7.—Mrs. G. B. This case was sent by specialist in another city, August 23, 1890; W., R. E. = ºr, L. E. = C. He reported under different dates as follows: November 19, 1890, “I have seen Mrs. B. but three times since she commenced your treatment. On November 13, she heard W., R. E. = 24 inches, L. E. = 4 inches; compared with R. E. 18 inches, L. E. = } inch. October last, she is delighted, i. ; ” On February 20, 1891, she again reported, W., R. E. =26 inches, L. E. = 1I?ChêS. Case 8.—Mrs. M. H., apt. 40; May 4, 1891; hypertrophic nasal catarrh ; R. E., deaf six months, L. E., deaf eight years; M. T., R. slightly retracted, luster and trans- PAN-AMERICAN MEDICAL CONGRESS. 1601 parency somewhat diminished; L. retracted opaque; W., R. E. = C., L. E. = O; V. moderate, R. E. = 6 feet, L. E. =O ; no perception of quality, as patient expressed it, every sound was “whiz, whiz.” June 2, W., R. E. = ſº, L. E. = *; V. mod., R. E. 10 feet, L. E. 4 feet. June 26, W., R. E. = }}, - E. = 14 feet, L. E. = 10 feet. October 10, W., R. E. = **, E. = 20 feet, L. E. = 17 feet. Case 9–Mr. W. G. P., aet. 25; November 27, 1891; atrophic nasal catarrh ; lip reader; M. T. R. E. = perforated, retracted, opaque, L. E., retracted, opaque, E. L., R. closed, L. partly patulous; W., R. E = tºo, L. E. tº ; V. Loud, R. E. = 12 inches, L. E. = 30 inches. December 24, W. E. ::, L. E. = }}; V. mod., R. E. = 6 feet, L. E. = 8 feet. January 21, W., R. E. =#, L. E. = #; V. low, R. E. = 10 feet, L. E. 10 feet. March 2, W., R. E. = }}, L. E. #}; V. mod., R. E. 16 feet, L. E. 13 feet. April 22, W., R. E. =##, L. E. #; V., R. E. = 18 feet, L. E. = 16 feet. This case was treated otherwise by aurist who sent case to me. Case 10.—Miss H. R. B., aet. 28; January 4, 1892; lip reader; atrophic nasal catarrh, tinnitus aurium ; M. T., R. E. retracted, L. E. retracted, opaque; E.T., R. patulous, L. partly patulous; W., R. E. = ºr, L. E.;; V., R. E. 16 inches, L. E. 3 inches mod. February 14, W., R. E. =##, L. E. ºr ; V. mod., R. E. 5 feet, L. E. 2 feet. April 5, W., R. E. §§, L. E. ºr : V. mod., R. E. 12 feet, L. E. 6 feet. May 7, W., R. E. =##, L. E. 5; V. mod., R. E. =26 feet, L. E. 20 feet; no tinnitus except slightly at period. Case 11.—Miss K. M., ast. 32; February 18, 1892; atrophic nasal catarrh; M. T., R. E. retracted, cicatrix, opaque, L. E. retracted; E. T. partly patulous; W., R. E. = ſº, L. E. =#}; V. mod., R.E. 24 inches, L. E.4 feet. March 28, W., R. E. =}}, L. E.=#; V. mod., R. E. = 12 feet, L. E. 20 feet. May 9, W., R. E.}}, L. E. #; V. mod., 15 feet, L. E. 30 feet. Case 12.—Miss M. R., a t. 15; March 4, 1892; scarlatinal deafness; R. E. only; had been under treatment for years; W., R. E. = }; ; V., R. E. 12 inches, mod- erate; M. T., opaque, retracted ; E. T., patulous. May 27, W., R. E. =#; V., R. E. 12 feet, moderate. June 15, W., R. E. #; V., R. E. 21 feet, moderate. Case 13.—Mr. L. S., at. 68; March 14, 1892; chromic atrophic catarrh; M.T., K. E., retracted, opaque, calcarious deposits, L. E. retracted, opaque deposits; E. T., partly patulous; V., R. E. = 12 inches, L. E. = 24 inches; W., R. E. tºº, L. E. ſº. April 27, W., R. E. = ºr, L. E. : ; V., R. E. = 7 feet, L. E. 13 feet, mod- erate. May 27, W., R. E. = }}, L. E. ##; V., R. E. =9 feet, L. E. 21 feet, mod- erate. Case 14.—Katie J., aet. 8; June 1, 1889; scarlatina at 2 years; a good lip reader for one so young ; profoundly deaf; no supposed hearing; articulation bad; M. T., R. retracted, parchment-like in appearance; L. better appearance; E.T., R. slightly patulous; L. patulous; diagnosis by several specialists paralysis of audi- tory nerve; after test, V. loud, R. E. – 0, V. loud, L. E. = 1 inch. As this was an out-of-town case the mother wrote after six months as follows: ‘‘I find it has been the means of great improvement in hearing and articulation.” The father writing later to the physician who sent the case to me said: “We feel satisfied there is a marked improvement in her hearing ; she now hears with both ears; she fre- quently asks, “Which is my good ear?’” Case 15.-Noma S., at. 6; July 19, 1890; scarlatina at 5 years; W., R. E. tºº, L. E. ſh; W., R. E. loud, 5 feet; B. C. good; L.E. loud, 2 feet. September 16, 1890, W., R. E.-ºff, L. E.E #; V., R. E. 18 feet, moderate tone, L. E. 10 feet, moderate. Case 16.-Miss C. P., aet. 22; February 12, 1889; supposed congenital; sent by a New York specialist for determination of hearing power. Had been educated as a deaf mute by the Bell visible-speech method. Upon examination I found hear- ing upon both sides, and after ten minutes she could repeat the test words nat- urally, conversation upon her part, Owing to system of education, being in a mon- otone. For prognosis I gave improvement in audition sufficient for articulation. I heard nothing from this case until five months had elapsed, when the following reportwassent from the person carrying out my instructions: “In less thana month 74 words and 40 sentences had been learned and were recognized upon day of review (end of month). At end of fifth month she had learned and could repeat many other words, besides figures up to 100.” A physician residing in : “me city, becoming interested in the case, requested a test in his presence. He selected figures up to 100 as test. The teacher then selecting figures here and there within this limit called them to her and they were repeated without a mistake. Her mother could at this time, with unaided voice, pronounce a word close to meatus and her daughter would repeat it. This was the first time she ever heard her mother's voice. I have heard nothing from this case since directly, but under- stand it was laid before the American Association to Promote Teaching of Speech to the Deaf in New York, 1890. It was again referred to by the secretary of the said S. Ex. 36 101 i. º - ## & TY! O d R s º E € }. 6 () 1602 PAN-AMERICAN MEDICAL CONGRESS. association in an invitation for me to deliver a lecture before that body upon the cultivation of hearing at their June meeting, Lake George, N.Y., 1891. Said invi- tation I was forced to decline, owing to affliction in my family at that time. Case 18.-Bessie B., aet. 16; January 10, 1891; scarlatina at 2 years. Her mother stated that an unfavorable prognosis had been made by several specialists. Owing to her mental condition she was at this time an inmate of an institution for feeble-minded children at Font Hill, near Ellicott City, Md. While convers- ing with the mother the girl sat looking at the ceiling, talking to herself and twirl- ing her thumbs. She was very submissive to all tests, but would not allow exam- ination by aural speculum, and never would. I found hearing upon both sides, and with fork test I found conduction per aerial and bone. F. C., aerial, R. E. 2 "" 3 ''', L. E. 2 " " 3 "'; V., R. E. 2 inches, L. E. 0 loud, I made prognosis for improvement of hearing sufficient to improve articulation if she was removed from her environment and taught at home. Upon consultation with the father, subsequently, she was placed under my care. On February 21 the mother reported that her daughter called her attention to the blowing of a distant steam whistle while on the street. March 30 F.C., aerial, R. E. = 11 "h 12 " ", L. E. = 10 "h 12 "I ; V., R. E. = 4 feet, L. E. = 2 feet. Articulation much improved. Patient now left the city with her mother, and under date of July 28, 1891, the latter wrote: “Her health has very much improved, and the general comment of friends is that she has improved in hearing and speaking. I teach her regularly.” November 12, 1892: “She has improved in articulation, and is being educated.” At this date the hearing power was V., R. E. = 6 feet, L. E. = 4 feet. I submit the foregoing cases as typical to show what can be done in many cases of profound deafness without the radical operation now so much in vogue. DISCUSSION. Dr. J. MoUNT BLEYER. New York. The phonograph undoubtedly can be used for the purpose of testing deafness as well as of curing such a malady. The trouble lies not in the phonograph but in the method of handling such an important tech- nical instrument. Otacoustic method of treatment of deafness is the proper and only method of testing and aiding the treatment. Phonograms should be made in different acoustic grades. Tests by means of the phonograph are most reliable tests. Prof. POLITZER. Might I ask Dr. Maloney if he uses inflation with catheter in his cases? Dr. MALONEY. I will state that I am in the habit of using inflation after Prof. Politzer's method, and that I use the catheter only when absolutely necessary. Dr. H. B. YOUNG, Burlington, Iowa. Briefly I wish to add my indorsement to the views expressed by the president in his address. This has recently been added to by a consultation (case cited) in which an unrecognized sporadic cerebro-spinal fever in early infancy was undoubtedly the cause of the deaf-mutism found. The importance of bringing this matter to the consideration of general practition- ers can not be overestimated as a prevention of deaf-mutism. Dr. S. S. BISHOP, Chicago. The showing made by Dr. Maloney is certainly a very favorable one. Respecting the use of the telephone and phonograph, I have never seen any good results to the hearing from their employment, while I have observed many cases of diseases of the ear apparently attributable to the use of the telephone. No cases of diseases of the ear resulting from the use of the phono- graph have come under my treatment; but I do not believe it is in any way bene- ficial to hearing. In my clinics at the Illinois Charitable Eye and Ear Infirmary, Chicago, as well as in private practice, I have seen chronic non-suppurative inflam- mation of the middle ear, chronic suppurative inflammation of the same part, and ulceration of the auricle in persons who constantly use the telephone, either in the telephone offices or in large commercial houses, that I had every reason to believe were due to the irritating effects of the constant use of the telephone. However, I am not prepared to say that this instrument will cause ear disease in DAN-AMERICAN MEDICAL CONGRESS. 1603 those who are not predisposed to such trouble, or who have no preéxisting affec- tion of the ear. The gentleman who was for a number of years superintendent of the Chicago Telephone Company, and whose hearing seemed to be normal, assured me that although he was in the habit of conversing many times a day by telephone no unpleasant results were experienced. I have also questioned quite a large number of people who constantly use the telephone, and who assure me that it produces no bad effect in their cases. But I believe its use by persons whose ears are diseased is positively injurious. The injury following its use may be due to the present imperfections in its construction which allow of the whir- ring and crackling noises that are irritating in character. If the uses of such i stru- ments were beneficial to hearing, why should people become progressively deaf who are constantly subjected to the action of sound waves? They do nothing more than conduct Sound waves to the ear. Notwithstanding the skepticism con- tained in this question, I shall give this instrument a fair trial if an opportunity is afforded. Dr MALONEY. In reply to Dr. Bishop's remark that he did not see why persons should become progressively deaf while sound waves were constantly making impact upon the membrana tympani, it is clear to me why sound waves from unaided voice do not exert a beneficial influence in progressive deafness, because under conditions usually found in progressive deafness there is a resistance to transmission by Ossicula auditus. PATHOLOGICAL CONDITIONS FOLLOWING PIERCING OF THE LOB- ULES OF THE EAR. By MAX THORNER. A. M., M. D., Professor of Clinical Laryngology and Otology, Cincinnati College of Medicine and Surgery Laryngologist and Aurist, Jewish Hospital Consulting Laryngologist and Rhinologist, Oph- thalmic Hospital, Cincinnati, Ohio. The custom of piercing the lobules of the ear dates from the remotest historical antiquity, being first mentioned in the book of Genesis. It was practiced by the people of the Orient and by those of the West, and was transmitted from the races of classic antiquity through the middle ages down to our present times. Ear- rings were held among certain nations in high repute as talismans or amulets. They were, and I believe are still, superstitiously valued as remedies for eye affec- tions. But their principal use was at all times, and certainly is now, that of orna- ments to be worn, generally by women. And thus it happens that mothers, who who would otherwise protect their little ones from every harm and pain, will not shrink from subjecting them to an unnecessary, inexcusable, and painful proced- ure only to adorn them with the coveted jewel. This explains why such a bar- baric custom as that of piercing the ears could have survived to our present times. It is, however, barbaric, not only because of its origin, nor on account of the crude methods by which it is practiced, but more so for the reason that not rarely more or less troublesome, and even fatal, consequences have been observed after this procedure. It is my pleasure to report to you to-day a number of such sequelae of piercing the lobes, some of which seemed to me to be of more than ordinary inter- est, although there are scattered in literature a goodly number of interesting cases. Defore reporting my own it may be opportune to mention a few of the observations made by others. Hufeland saw a child die of trismus following piercing of the lobule of the ear." Severe inflammation of the lobe, erysipelas of the ear, large granulations around the wound, cutting of the ring through the lobule, and hypertrophic thick Scars Cited from Dieffenbach, Die operative Chirurgie, Vol. 11, p. 78. 1848. 1604 PAN-AMERICAN MEDICAL CONGRESS. are some of the possible sequelae mentioned by Dieffenbach. Fibroids (keloids) have been observed by many authors and are mentioned by Knapp, Agnew, Turnbull, Finley, Bürkner, Schwartze, Politzer, Bacon, and others. They occur up to the size of chicken eggs, and are said to be more common among the colored than the white race. Politzer says” they are benign, no recurrence taking place after total extirpation. He refers, however, to the case of Agnew,” in which a tumor originating in a traumatic Scar returned again and again. And, according to Some observers, recurrence of these tumors is not at all uncommon, Knapp has called special attention to the fact that they are liable to recur, and that by fre- quent recurrence they may become malignant.” And in all cases of tumors of the auricle to be reported in this paper recurrence has taken place several times. Sexton * speaks of a cleft lobule from earrings, and saw even a portion of the lobule slough off. Kirchner * says that the lobule is not infrequently the seat of an eczema, Originating by preference in the pierced holes. Altschul has reported a death from gangrene following piercing the lobes in a girl of 9 months; 1 and erysipelas, Sometimes fatal, is mentioned recently by Haug 8 as being occa- Sionally caused by the reprehensible practice of piercing the lobule. It would be easy to multiply these cases, but these will be sufficient to show that there are abundant observations on record to make one reflect why the voices of physicians or at least of otologists are not raised against this “truly barbarous custom,” as Roosa calls it. The following cases have come under my observation: ERYSIPELAS OF THE AURICLE AND FACE. Case 1.—The lobule was pierced in a child 2 years old, and this was followed by a severe attack of erysipelas, involving the whole auricle, auditory canal, and part of the neck. Case 3.−A lady 20 years of age, who had not worn ear-rings for some time, was, on attempting to do so again, obliged to use some force in placing them. Pain, redness, and swelling soon developed in one ear, and the erysipelatous inflamma- tion also involved face and scalp. Case 3.−Also in an adult, and very similar to case 2. In this case the general symptoms were very severe, and the erysipelas, after having spread Qver the face and neck, invaded the pharynx. The patient recovered. DEFORMITIES. Two cases of cleft lobule were seen, caused by the ear-rings cutting through the lobe. In the one case both lobules were torn. The clefts were readily repaired by the operation advocated by Knapp," by paring the edges and stitching the little flap left on the posterior lip over the corresponding portion of the anterior lip, thus avoiding a notch in the lobule. The result of the operation was good. The other case of cleft lobe was peculiar. It was that of a middle-aged woman, in whom the earring had torn through the left lobule about ten years ago. Two years later she got tired of wearing but one earring, and she had the left lobule again pierced close to the old aperture. In the course of time this ring had also torn through, parallel to the old slit, and the woman had now a lobule consisting of three pend- ants. The narrow central strip was removed, and the edges of the remaining parts united in the above-described manner. The cosmetic effect was good. 1 J. F. Dieffenbach. Op. cit. * Lehrb. d. Ohrenheilkunde. 1882, II Bá., p. 720. * Trans. Amer. Otol. Soc. 1882, p. 720. * * Quoted by E. B. Dench, in Burnett's System of Diseases of the Ear, Nose, and Throat. Phila., 1893, Vol. I, p. 157. * The Ear and its Diseases. N. Y., 1888, p. 112. 6 Schwartze's Handb. d. Ohrenheilk. 1893, Vol. II, p. 18. 7 Ibid. 8 Arch. f. Ohrenhlk. Bd. 35, p. 142. * Archiv. of Ophth. and Otol., Vol. III, No. 1. PAN-AMERICAN MEDICAL CONGRESS. 1605 One case of enlargement of the opening made for earrings presented a peculiar and even ridiculous appearance. The hole on one side had gradually enlarged, from the weight of the ring, to the size of a lead pencil, and repair was desired by the patient, a young lady of 19 years, for cosmetic purposes. The edges were pared with a cataract knife, united by one suture, and healed readily. (A similar case is described by Roosa.") FCZEMA OF THE AURICLE. This has been observed in a number of cases to be caused by the wearing of earrings, especially when they had accidentally caused small tears of the cutis, and also after forcible placing of earrings, when the opening had been closed for some time. It was generally the acute form which was seen, causing swelling, excoriation, formation of unsightly crusts, and bleeding, often upon the slightest touch. This form is, as a rule, very painful. Removal of the cause, and treat- ment with ointments (for instance the Ung. Diachylon) were sufficient to produce a speedy cure. In two cases the eczema had reached the chronic stage, in one involving the larger part of the auricle, and more especially the furrow along the insertion of the auricle. These cases were more obstinate, but yielded also finally to treatment. - TUMC) RS OF THE AURICLE. Case 1. Fibroma (fibro-chondroma) of auricle.—The patient, referred to me in August, 1887, by Dr. Wright, was an unmarried lady, 32 years of age, white. Eſad been troubled as a child with painful swellings of both lobules, which caused her to discontinue wearing earrings at the age of 17. At the age of 22 she noticed that the old swelling in the right lobule, which had been pierced higher than is the custom, and very close to the antitragus, began to grow, until it had reached the size of a small cherry. Two years thereafter it was removed, but showed signs of recurrence within a year. Three years ago, and five years after the first operation, it was again removed, but began soon to reappear, until it had reached the size of a small chestnut, involving the whole lobus. Removal was effected by a V-shaped excision, and the edges brought together by sutures. The tumor had not returned two years after the operation, the last time I saw the patient. The microscope showed, within a dense connective tissue formation, the structural elements of cartilage sparingly interspersed. A case of fibro-chondroma of this region has also been reported by Strawbridge.” The appearance of cartilage in a tumor of the lobule finds its explanation in the fact that the lobule is not entirely free of cartilage. There is, as W. His” has shown, an unciform strip of cartilage , below the antitragus called lingua auriculae, which is the cartilaginous support of the lobule of the auricle. ... Case 2. Fibroma of the auricle.—For the history of the following interesting case and the specimen I here with present to you, I am indebted to my friend, Dr. O. Landman, of Toledo, Ohio. Mrs. C. E. J., white, aet. 35. When 15 years old her earrings were caught on a pillow and both forcibly torn out. The wound healed, but later on a “lump began to grow” on both lobules. Two years after- wards both lobules were partially amputated. The left tumor has never returned. The tumor in the right ear returned six times, and reached an operable size about every three years. There were six operations after the first. Two years ago Dr. Landman saw the case for the first time, when the tumor had reached the size of an English walnut, involving the larger part of the auricle. He operated by amputating the entire auricle. About eight weeks ago the lady was seen again. There were at that time no signs of recurrence. The microscopic examination showed the tumor to be a characteristic fibroma, containing possibly a little more yellow elastic tissue than is usual in this kind of tumors, but which might be expected from the structures involved, - - | Case 3. Keloid of the auricle and face.—Miss E. P. H., of Indiana, white, 35 years old, was seen one year ago. When 18 years old a small nodule developed in the right lobule, close to the puncture. This began to grow, was painful, and was excised. Within the following seventeen years the recurrence of this tumor was 1 A Practical Treatise on the Diseases of the Ear. New York, seventh edition, 1891, p. 104. 2 Trans. Of the Amer. Otolog. Soc. 1875. 3 Arch. f. Anat. u. Physiol. 1889, V and VI. 1606 PAN-AMERICAN MEDICAL CONGRESS. the cause of untold misery for the sensitive woman. In the course of time she was operated upon six times with the knife, and caustics of every description and in untold quantities had again and again been used. Electrolysis and hypodermic medication had been tried in vain. The pain produced by these different thera- peutic agencies, especially the caustics, and the frequently unbearable pain within the growth had undermined her health. When Isaw her, a little over one year ago, there was a solid sessile tumor, the size of about a silver quarter, extending from the region below the tragus into the cheek. The lobule and lower posterior half of the auricle were gone, and from the edge of the rest of the auricle a dense and unyielding cicatricial tissue extended into the integument below and behind the ear. The tumor was flat, about one-sixteenth of an inch elevated above the sur- rounding skin, ordinarily pale, and not sensitive to the touch. At the time of menstruation it was usually congested, and slightly more elevated, and caused, especially at such times, but occasionally also during the intervening period, the most intense and lancinating pain. The tumor was removed by an elliptical incision in healthy tissues, care being taken to lift it with a portion of the Sub- cutaneous adipose tissue from its location. After severing, by deep incisions, some of the cicatricial bands behind and below the tumor, I was enabled to close the wound by sutures. Primary union. There remained a thin linear scar, the pain disappeared within a few weeks, and there have been no signs of recurrence as yet, fourteen months after the operation. On former occasions the tumor showed signs of reappearance within six months. The microscopic examination made by IProf. Kramer, of the Cincinnati College of Medicine and Surgery, showed the removed tumor to be a true keſoid. The epidermis was atrophied, and hairs, hair follicles, and glands were entirely absent. The Malpighian layer was distinctly preserved, but there were only scanty traces of papillae. Immediately below them, and arranged in layers parallel to the surface, there was a dense mass of fibrous tissue, in which here and there blood vessels, some compressed, appeared. Among the bundles of fibrous tissue occasionally elastic fibers were noticed, and also fre- quently groups of spindle cells. Below this was a looser connective tissue, with many cellular elements, and a gradual merging into adipose tissue. Of course it is too early as yet to say whether the last removal will be followed by a recur- rence. It is true that most authors insist upon the possibility, and even proba- bility, of a return of these growths after operation. But no treatment has as yet been devised that will actually give better results; while Erichsen,” though ad- mitting their liability to return after excision, calls this their only treatment. And in this case, the almost intolerable sufferings of the patient, whose best years had been sacrificed in the battle with this baneful disfiguration, compelled me to do something that gave her at least a slight chance of a permanent cure. These cases do not demonstrate anything new, but having occurred under my own observation lead me to believe that they are still more frequent than we usually think; and while in most cases no serious consequences result from the folly of piercing the ear lobes, yet there occur from time to time cases where a life is at stake or where the enjoyment of life is seriously interfered with. It is time that this relic of barbarism ought to be relegated where it belongs, to the bygone follies of superstition and fashion. And the day is, I hope, not far distant when it will be considered an evidence of brutality to have a tender and unprotected child subjected to such an unnecessary and mutilating procedure. DISCUSSION. Dr. C. R. HoDMES. I have seen three cases in colored women, which, however, were not operated upon. A fourth case, occurring in a white woman 20 years of age, was operated upon four years ago. The tumor occurred on the left side and - was about the size of a large hazelnut. It was removed by a V-shaped incision, healing by first intention. There is no recurrence up to date. Prof. A. POLITZER. I desire to ask Dr. Thorner how many cases of tumor of the auricle, all told, have been seen by him; whether they were all produced by ear-rings, and whether there were any colored people among his patients 2 * The Science and Art of Surgery, Vol. II, p. 314. PAN-AMERICAN MEDICAL CONGRESS. 1607 Dr. THORNER. The total number of cases of tumors of the auricle seen by me is four. But only in the three reported by me the history of the patients left no doubt that the piercing of the lobe was responsible for the affection. The fourth patient was seen but Once and, refusing any operation, was lost from observation. Although these tumors seem to be much more common among the colored race it was strange that all the patients referred to were white. ON A PECULIAR, AFFECTION OF THE LABYRINTHINE CAPSULE AS A FREQUENT CAUSE OF DEAFNESS. By Prof. ADAM POLITZER, M. D., University of Vienna. The subject of the writer's paper is a peculiar form of deafness, occurring usually in the aged and due to a pathological alteration of the labyrinth capsule. During the examination of a number of temporal bones of people who had suffered from progressive deafness, the author remarked circumscribed bony protuberances in the neighborhood of the niche of the fenestra ovalis. These protuberances were of the size of a lentil, rather flattened toward the edges, and contrasted with the surrounding parts by their yellowish color. The mucous membrane of the tym- panic cavity was generally normal, occasionally somewhat thickened. The fen- estra ovalis was, in some specimens, of normal appearance, in others marrowed by protuberances. The stapes was usually immovable; yet, in very few specimens, slightly movable. In the second edition of the author's text-book on Diseases of the Ear, published in 1887, may be found a drawing of a case of bony anchylosis of the stapes. Besides changes in the stapedio-vestibular articulation, the capsule of the labyrinth shows considerable enlargement of the lacunar medullary spaces. These changes were interpreted by the author, as well as by others who had observed similar condi- tions, as being due to chronic interstitial middle-ear catarrh. The study of the specimens which the author demonstrated to the section showed that this view is not correct, and that these cases which have usually been grouped under dry, sclerotic middle-ear catarrh, are in reality due to a primary lesion in the capsule of the labyrinth. The following are the histological changes observed in the microscopical sections made from the specimens: The parts surrounding the oval window are transformed into a uniform mass of newly formed osseous tissue. The normal articulations between the stapes and oval window have entirely disappeared. The plate of the stapes is frequently thickened, even to five or six times the normal size. The Ossificatory changes begin in the bony labyrinth capsule and extend toward the Oval window and the plate of the stapes, sometimes even toward the cochlea and the vestibulum. Sometimes the Ossificatory changes only produce partial Ossifica- tion of the stapedio-vestibular articulation, so that in the same section we find one portion of the articulation completely ossified and another still membranous. This partial anchylosis explains why the hearing power for a loud voice is still retained in some cases. The newly formed Osseous tissue stains more deeply with carmine, and this difference in color enables us to distinguish the pathological tissue from the normal, even with the naked eye. The number of bone corpuscles is usually increased, the lacunar and medullary spaces are generally larger and contain fibrillar tissue, cells, blood-vessels, osteoblasts, and Osteoclasts. It may be well to assume that the changes are due to a primary inflammatory process in the labyrinth capsule, producing a formation of new and young Osseous tissue, which successively replaces the normal bone, and by extension toward the stapes and other contiguous parts finally causes the important functional changes due to anchylosis of the stapes. These conditions represent one form of progressive deaf- 1608 PAN-AMERICAN MEDICAL CONGRESS. ness. That other pathological conditions, entirely different in character, caused by chronic middle-ear catarrh, such as calcifications and Ossifications of the sta- pedio-vestibular ligament, or adhesions between the branches of the stapes and the lower wall of the niche of the oval window may, and do often, produce similar clinical symptoms is a well-established fact. Very little could be ascertained regarding the etiology of this form of progressive deafness, as the disease was observed in old people from whom it was impossible to obtain an accurate history. In two cases gout maybe assumed as a possible cause. That Syphilis undoubtedly may cause such conditions may be assumed from the investigations made by Moos, who found hyperostotic changes on the labyrinthine wall of the tympanic cavity. [Specimens and drawings were exhibited and explained by the author, illustrat- ing the conditions described.] t In conclusion the writer refers also to the practical bearing of his investigations; inasmuch as these conditions demonstrate to us why our therapeutic efforts are not always crowned with success. An operation can only afford possibilities of success provided the affection in question has not yet caused anchylosis; and that, even should an operation in some cases bring immediate relief, a permanent result can hardly be expected if the anatomical changes which were exhibited in the specimens are only considered, inasmuch as the affection is progressive, and even the extraction of the stapes would not prevent an obliteration of the oval window. ON THE APPLICATION OF STACKE'S METHOD IN CHRONIC AURAL CATARR.H. g By FELIX COHN, M. D., of New York. The results obtained by the method usually employed in the excision of the ossicles have not been very encouraging, so that the author attempted the appli- cation of Stacke's method of operation, which he calls “extra-auricular,” in con- tradistinction to the ordinary method, the “intra-auricular,” in these cases. Although no cases of its application in chronic aural catarrh have been as yet reported, a priori, this method appeared to have considerable advantages over the usual method, chiefly in that the regeneration of the drum membrane might be prevented if the entire tympanum and the limbus be removed; that the external wall of the attic being removed, a larger area for the impact of Sound waves on the stapes and the oval window is provided ; that the intra-auricular method does not permit of thorough asepsis ; and that, finally, the field of operation being larger the successful removal of the ossicles is in all cases certain. As the opera- tion was experimental in both cases only one ear was operated upon. Two cases are reported. Case 1.-Man, aged 21, operated November 21, 1892, on left ear; suffered from . severe tinnitus aurium and progressive deafness. On left ear conversation in low voice not at all audible; loud whisper, 1 inch. Six weeks after operation tinnitus fºrely disappeared in operated ear; ordinary conversation, 3 feet; loud voice, 8 €6215. Case 3.—Girl, aged 16, suffering from sclerosis and of the anchylosis stapes; operated December 15, on left ear. On examination, hears loud voice at 1 foot ; immediately after operation hears ordinary conversation at 14 feet; loud voice, 8 feet. Six weeks later, hearing is reduced to condition before operation. The author does not claim any wide applicability of this operation, or the extra- auricular method, in the present state of our knowledge of chronic aural catarrh. Though the success of the experiment has not been brilliant, it has, however, demonstrated the perfect safety of this method, and its availability in cases in which the intra-auricular method is not practicable. With improvement in diag- nosis and careful selection of cases, the author believes that better results will be obtainable by Stacke’s method than by the intra-auricular method. PAN-AMERICAN MEDICAL CONGRESS. 1609 OPENING THE MASTOID CELIS IN ACUTE INFLAMMATORY MIL)- - T) LE-EAR DISEASES. By L. D. BROSE, M. D., PH. D., Oculist and Awrist, St. Mary's Hospital, Evansville, Ind. Although the indications as laid down in the text-books for opening the mastoid cells in acute inflammatory middle-ear diseases seem well defined, it has neverthe- less been my experience to have met with cases where mastoid swelling and edema were present associated with pain and fever and other symptoms, usually indicative of mastoid cellular involvement, where, owing to failure to obtain con- sent of the patient to an operation or through other causes, delay was encountered, the patients eventually made a perfect recovery under simply local treatment. Dr. Knapp, of New York, seems to have had a similar experience, for in a recent report' of a so-called case of “Bezold mastoiditis with operations,” he states that he is afraid at the present day there is too great a tendency to opening the mastoid and the skull, and that precision in the determination when to or when not to operate can only be obtained by a critical comparison of many fatal cases. As an explora- tory operation, he thinks mastotomy not yet harmless enough to be justifiable in many cases. To more minutely bring up the symtomatology of the subject and describe a method of operation, I will relate several of the cases which, in my opinion, justified opening the mastoid cells. Mr. J. E., 41 years old, came to me early in July, 1891, with right-sided otorrhoea, accompanied by pain in the temple and frontal region. The disease was of ten days duration, and previous to this time he had never had ear trouble. By gentle syringing with warm water the external auditory canal was freed from pus, show- ing slight edema and swelling of its walls and middle-ear pulsation. Pressure over the tragus and mastoid region elicited soreness, but little or no pain. Treat- ment, three Swedish leeches in front of the ear, hot-water instillations of fifteen minutes duration, frequently repeated, and later insufflations of dry powdered boric acid. July 26, otorrhoea cured and patient passed from under observation, complaining still of nocturnal pain. In the following October he had an attack of meningitis, for which he was treated by Dr. A. M. Owen, and finally resumed his business, that of shoe merchant, in December. During the meningeal attack the ear pains returned in severity, but unaccompanied with otorrhoea. Patient con- tinued to complain of earache off and On, and finally again consulted me in March, 1892. At this time there was neither swelling nor tenderness in front of or back of the ear. The drum perforation in the lower and posterior quadrant was almost wholly closed, with the hearing of ordinary conversation fairly good. April 14, consent was obtained, and after shaving the scalp around the ear region and care- fully washing the side of the head with a 5 per cent solution of carbolic acid, an incision was carried down to the bone just upon a line with the ear insertion some 2 inches in length. Strong retractors were inserted and the wound widely separated. The bleeding, which was light, yielded to compression. With ham- mer and chisels a funnel-shaped opening was made into the temporal bone upon a line with the upper border of the external hearing canal and parallel to its axis down to the mastoid cells, and a small quantity of pus liberated. The operation, which had not required more than ten minutes, was terminated by packing iodo- form gauze into the wound and placing over this a pad of absorbent cotton mois- tened in sublimate water and a retaining bandage. After the third day the dress- ings yººwed almost daily until the patient's complete recovery and discharge, May 24, 1892. º A. De F., 71 years old and a practicing physician, came to see me about April 20, 1892, for profuse left-sided otorrhoea, attended with violent pains all over the side of the head. His history was that he went outdoors the last Sunday in March, 1892, a cold, raw day, without a hat or head covering, from which he took severe cold in the head, followed during the night with earache. For several years previous to this he had been hard of hearing in the right ear through dry chronic middle-ear catarrh, which in turn followed chronic naso-pharyngeal catarrh, with which for years he has been afflicted. The present otorrhoea set in five days after * Archives Otology, July 9, 1892. 1610 PAN-AMERICAN MEDICAI CONGRESS. the earache, mitigating but little this terrible pain, for the relief of which he has been daily resorting to powerful narcotics. The region in front of the tragus was swollen and tender and the patient was much annoyed by a “slushing” in the external auditory canal when he moved the jaws in speaking or eating. The dis- charge from the ear was ropy, very copious, without Odor, and the canal lumen so encroached upon by its swollen walls that little could be seen of the drumhead. The mastoid region was not swollen, but tender upon firm pressure. Treatment, hot- water instillations, followed by a 10 per cent solution of cocaine when there was severe pain and large doses of chloral hydrate at bedtime. No improvement result- ing, three Swedish leeches were applied over the tragus, followed by Leiter cold- water ear coil. During the flow of very cold water the pain would almost cease, only to gradually return with increased severity after its discontinuance. The patient, because of his age, was loath to take an anaesthetic and have the mastoid cells opened. Finally, June 2, he consented, and after the usual antiseptic prepa- ration of the field of operation, a long incision along the line of ear insertion was made, the mastoid cavity opened with chisels, considerable pus evacuated, and a communication reëstablished with the middle ear and through the Eustachian tube with the pharynx. After each irrigation with a weak solution of sublimate water, fluid invariably entered the throat. The pain became less, narcotics which had been used for two and one-half months were dispensed with, and recovery slowly followed. July 6, 1892, he returned to his home, the perforation in the drum mem- brane healed and hearing restored to ordinary conversation. Amos W., 28 years old and a farmer, came November 5, 1892, with a history of having used cold salt water as a snuff in the September previous for the cure of chronic catarrh. In a few days left-sided earache resulted, followed by an ear discharge of bloody serum, which later became purulent. He was treated in a neighboring village and cured by boric-acid insufflations of the otorrhoea, but thereupon followed an edematous swelling back of the ear, with at times return of the ear pain. An ointment of mercury and belladonna was prescribed, with frequent poulticing. During the next two months the swelling back of the ear would decrease and again increase, with at times slight otorrhoea. December 6, 1892, mastotomy was performed in the manner described in the preceding cases, and a small quantity of pus found in the mastoid cells. Result, recovery in seven weeks, with hearing improved to watch at 2 feet. In reviewing the indications which lead one to determine whether a mastotomy should or should not be performed in a case of acute middle-ear disease, I can not too strongly advise against permitting the presence or absence of any one symptom to determine the point in every and each instance, but rather to make a study of each individual case in all of its symptomatology, with proper considera- tion of the result of recognized good previous treatment. Schwartze says," at the furthest, after eight days of antiphlogistic treatment, especially ice applications, if the pain, edema, and fever have not ameliorated, the operation is indicated. Further along, though he qualifies this positive assertion somewhat, and says that while in most cases unbearable and uncontrollable pain in the mastoid region, radiating from thence into the head region around, urge One to operation, they are, never- theless, and to a high degree, uncertain in determining suppuration in the mastoid. Redness, edematous swelling, and marked tenderness over the bone on pressure may be due to localized periostitis, not in anyway connected with middle-ear inflam- mation. The most reliable symptom of acute suppurative mastoiditis, in his opin- ion, is stenosis of the external auditory canal through swelling and bulging of the posterior and upper wall, with edematous skin inflammation just below the apex of the mastoid process. Deep-seated furunculosis of the external auditory canal, however, must be excluded. In the course of acute purulent Otitis media without involvement of the mastoid and without retention of Secretion, Dr. Heimann, of Warsaw,” thinks mastotomy indicated if the otorrhoea remains profuse and does not yield after a certain time (two or three weeks) to the usual methods of treatment. Where ear drainage, after perforation of the drum membrane through swelling of the mucous lining of the middle ear or great stenosis of the external auditory canal, is insufficient, * Second volume Handbuch der Ohrenheilkunde, 1893. * Archives Otology, Vol. xx, No. 2. PAN-AMERICAN MEDICAL CONGRESS. 1611 the operation may be indicated as a prophylactic measure, in the prevention of death through imperfect disinfection. Cerebral abscess, brought about by acute, suppurative, middle-ear disease necessitates opening of the mastoid, for without it the termination is invariably rupture into the ventricles, or fatal meningitis. We suspect this condition through pressure symptoms on some of the Cranial nerves, speech disturbances, or by ophthalmoscopic eye examination disclosing changes in the eye ground and vessels, with or without irregular fever, chills, delirium, stupor, drowsiness, and coma. Suppurative phlebitis with thrombosis of the lateral sinus as well as extradural suppuration are in many cases not dis- tinguishable from deeper-seated abscesses and call for operative treatment as well, even if septic or pyaemic symptoms have occurred. When the thrombosed jugular vein can be felt as a hard, painful cord along the sterno-cleido-mastoid muscle, we have all the more reason to suspect involvement of the sinus, but it should not be forgotten that the vein accompanying the lymphatic plexus may, through inflam- mation, likewise occasion this tenderness when the sinus and internal jugular are perfectly healthy. Persistent headache, nausea, vomiting, and dizziness, with diminished, otorrhoea, may signify meningitis. Still the boundary between meningeal irritation superinduced by the middle-ear inflammation and meningitis proper is not at all sharply defined and calls for the exercise at times of unusually clear judgment. Repeated and obstinate attacks of mastoid neuralgic pains, unas- sociated with fever, or even loss of hearing, and which resist antineuralgic treat- ment, can at times be alone cured by mastoid resection. The region for a mastotomy operation may be defined as just under the linea temporalis, above and just back of the posterior wall of the external auditory canal in front ; a layer of bone from one-sixteenth to one-eighth of an inch thick usually separating the mastoid antrum and the inner end of the bony external auditory canal. Following Hartmann, of Berlin, my first incision is from 14 to 2 inches long and just back of the insertion of the ear muscle, with the center cor- responding to the upper edge of the external auditory canal. After thoroughly scraping away the periosteum a funnel-shaped canal is carefully chiseled out of the temporal bone, layer by layer, in a direction inward and forward and parallel to the axis of the auditory canal. Frequent examination with head mirror, ear speculum, and, when in doubt, the ear sound in addition, keep me informed as to the depth of penetration as well as its course. When pus is reached, and there has been no reason for suspecting extensive bone involvement, the operation is terminated with the removal of just enough bone to give good drainage. For more extensive suppuration and where the attic is largely the seat of the disease the posterior wall of the inner end of the auditory canal may likewise be removed and a drainage tube at times carried through the new-formed opening and out of the external meatus. Iodoform gauze keeps the wound open and serves as a dressing next to the bone, and over this a layer of absorbent cotton and a bandage is placed. Good results, however, can be obtained in many cases equally well with drill, chisel, or trephine, more depending upon the operator and his anatomical acquaintance with the neighboring blood vessels, nerves, and cranial contents, with careful and well-regulated after treatment, than upon the instruments with which the operation is performed. CHRONIC DISEASE OF THE MIDI) LE EAR : ITS PROGNOSIS AND SUR- GICAL TREATMENT. By ALBERT H. TUTTLE, S. B., M. D., of Cambridge, Mass. The treatment of the chronic dry form of aural catarrh has always been an unsolved problem with the profession, and even to-day adequate means for its pre- vention or cure are unknown. It was with the hope of relieving the deafness 1612 PAN-AMERICAN MEDICAL CONGRESS. resulting from this disease, sclerosis of the tympanum, that Schwartze, for the first time, removed the membrana tympani and malleus in 1873, and by his prece- dence encouraged others to undertake similar operations. Soon after Schwartze, Kessel took up the subject, and did much to establish the operation. He removed all the Ossicles and insisted that good results in hearing could only be expected when the stapes was removed. In 1880 Weber-Liel reported a case of dizziness, following a destruction of the stapes, with loss of labyrinthine fluid. Bishop Operated 14 times by simply removing a small piece from the membrana tym- pani in 1885. In 1886 Rossi in 2 cases disarticulated the stapes from the incus, and Sexton introduced the operation of removal of the larger ossicles and mem- brana tympani in certain cases of persistent suppuration of the middle ear. In 1887 Baracz removed the membrana tympani and larger ossicles for tinnitus aurium, and the following year Burnett performed the operation for a similar purpose. In 1888 Berthold while operating on the middle ear accidently removed the stapes complete and observed as the result a great improvement in hearing. The cases which were operated upon by removing membrana tympani and Ossi- cles now began to increase rapidly in number ; Stacke reported 10 cases and Sexton 29, treated for chronic suppuration of the middle ear in this manner, and soon after 28 cases were reported by Wetzel, 32 by Ludwig, and 20 by Colles; Schwartze, in two and one-half years, operated on 151 cases; Milligan reported the results of 4 operations. During these later years the operation became lim- ited almost exclusively to cases of chronic suppuration, and it was not until the last (1892) that the operation, in modified form, was revived for its earlier indi- cation, the relief of chronic deafness by Jack, who operated for the simple removal of the stapes. Since then the latter operation has been performed by Blake, Bur- nett, and others. As to the result of these manifold operations, deafness has been greatly relieved in many cases, in others slightly, whereas some have received no improvement or even have been made worse; most of the cases of chronic sup- puration have been cured or greatly relieved; tinnitus aurium and vertigo have been relieved, as a rule, but the accompanying deafness usually has remained unchanged. From this mass of material several facts can be established, viz, that in certain cases of chronic deafness great improvement in hearing follows the removal of the ossicles, in part or whole, with and without the membrana tympani; that, in cer- tain cases of chronic deafness of apparently middle-ear origin, the complete removal of the stapes is unattended with improvement in hearing; that the removal of one or all the ossicles and membrana tympani is not productive by itself of any great degree of deafness;' that incisions in the membrana tympani heal rapidly by first intention, when the ear is properly prepared and prior to the operation is free from suppurating processes; that the operation is attended with but slight inconvenience to the patient, the total disability lasting, as a rule, not over twenty-four hours, and with no risk of life of itself; that the treatment of chronic suppurative otitis media by removal of the remains of the membrana tympani and ossicles for the purpose of eliminating causes, such as carious bone, and establishing free drainage for the discharge of pus is a legitimate and purely surgical practice, which is just as applicable here and is followed by as good results as in most other parts of the body; and, finally, that certain cases of tin- nitus aurium and vertigo are benefited by releasing the stapes from its attach- ment to the incus and surrounding adhesions. With these facts before us it is obvious that in certain cases of chronic deafness there are surgical measures for relief, but the difficulty at present lies in the 1 Würdemann has reported a single instance where total deafness followed the removal of the ossiculae for chronic aural catarrh, which he thought was due to hamorrhage into the laby- rinth, with the formation of a clot and its subsequent organization. PAN-AMERICAN MEDICAL CONGRESS. 1613 inability to recognize, among those who will not, the cases which will yield good results from operation. As it is yet impossible in many cases to distinguish deaf- ness due to middle ear causes from that of central origin, changes in the nerve or internal ear, and as the results of operative treatment in the latter classes must necessarily be of a negative character, it is very important in consideration of the prognosis to study intimately the minute differences in the symptoms of cases which yield unlike results and especially after the successful removal of the stapes, since by this means the contra-indications of the operation can be more clearly determined. The number of cases which the writer has had the opportunity of studying is too small for the basis of a just conclusion, and recourse has been made to a study of the reports of similar cases in the practice of others; however, one thing is very obvious, and it requires very little experience to prove it, i. e., the great dif- ference in the bond of union between the foot plate of the stapes and the margin of the oval window. Furthermore, when the stapes is removed with great diffi- culty, perhaps only after the foot plate has been broken, and in Small pieces, the improvement in hearing is usually great and, on the contrary, when it is easily removed, often by simply pulling on the head with a hook inserted between the crurae, the hearing is usually unchanged by the operation. It would seem, then, that deafness is an indication for operation only in those cases where the stapes is firmly fixed in the oval window, and the firm fixation of the stapes is found especially in chronic dry catarrh of the middle ear, Sclerosis of the tympanum, the principal symptom of which is deafness, of insidious origin, continuous and progressive in character, and the chief pathological changes, that are recognized late in the disease, are a thinness of the membrana tympani, which is usually of increased transparency, often retracted and immobile; a rigidity of the chain of ossicles; an atrophy of the crurae of the stapes, and firm fixation of the foot plate, often by osiffic union with the margin of the Oval window. In making a diagnosis of this trouble the chief considerations to be borne in mind are the history of the insidious onset without suppurative changes and the free- dom of the membrana tympani from old scars or adhesions. Complicated cases can not always be recognized with certainty. In cases of tinnitus aurium, Menière's disease, deafness following acute and chronic suppurative otitis media, also deafness due to senility and calcareous deposits in the membrana tympani, the stapes is easily removed, but in these cases there will be no great improve- ment in hearing as a result of its removal; therefore, the operations should not be undertaken for the relief of deafness. The condition of the hearing after the removal of the stapes is better in recent cases of dry catarrh, where it may become nearly normal, than in the older cases; this seems to indicate that as a result of the long-continued fixation of the stapes certain changes occur in the deeper struc- tures of the ear and gives rise to the question of early operation for the prevention and arrest of the progressive deafness in cases of established dry catarrh, where the diagnosis is certain, but as yet the hearing is not greatly impaired. The writer does not wish to convey the impression that this is the only class of cases where a removal of the ossicles will be followed by an improvement in hear- ing, but that with our present knowledge it is the only class where the diagnosis is fairly certain and the patient can be assured of a reasonable improvement in hearing from a successful operation. When anchylosis of the Ossicles from any cause is broken up the hearing will be improved if there exists no deeper causes of deafness, but here the exact state of affairs can only be determined by the opera- tion, and therefore the result is uncertain. If the stapes is firmly fastened in the oval window by bony deposits, little improvement in hearing can be expected from its disarticulation with the incus, a practice that has been followed by some few operators. In giving a prognosis of an operation for the removal of the stapes 1614 PAN-AMERICAN MEDICAL CONGRESS. an important fact to be borne in mind is the great difficulty of extracting the foot plate in those cases where there is Ossific Union with the margin of the oval window ; where the external meatus is very narrow or the window is concealed from view it may be impossible to extract the Ossicle. In chronic suppuration of the tympanum the continued formation of pus depends chiefly upon the retention of the inflammatory products from want of a proper outlet, granulation tissue, caries of the Ossiculae, or walls of the middle ear, cholesteatomata of the attic, aditus, or antrum, and chronic mastoid inflam- mation, and it is very difficult to determine which of these causes are active in producing the discharge of a given case. Under these circumstances the treat- ment of chronic aural suppuration should be governed by a proper spirit of con- servatism, and, except in certain cases, the older and milder means, such as douches, with the occasional cleansing of the tympanum as well as possible by the physician, removal or cauterization of granulations, and application of mild anti- septic solutions or powders, should be persisted in until it becomes obvious that no result will come from these measures. - & Those cases where in the beginning the diagnosis of mastoid disease is clear form an exception to the above, and as spontaneous cure is rare and considerable danger of cerebral complications exists so long as the suppuration continues, an early operation is advisable. Cases are sometimes presented where the suppura- tion has persisted for years, and under these circumstances it is reasonably assured that there are causes present which require immediate surgical treatment. Many of these cases have only a very small outlet for the discharge, situated in the upper posterior segment of the membrana tympani, and surrounded by thickened edges which increase in size with every acute exacerbation, make smaller the nar- row channel and threaten its complete occlusion. The latter class can be recog- nized at sight by the pathological appearances of the membrana tympani in con- sideration with the history of continued suppuration, and demands early opera- tive treatment. It is the writer's opinion that an ear which has healed without Operation, with the formation of dense scar tissue, and strong adhesions between the remains of the membrana tympani and inner walls of the tympanum, so as to close off completely the cavity of the middle ear from external and atmospheric influences, is less liable to recurrent attacks of suppuration than those where the Ossicles and membrana tympani have been removed. Vertigo and tinnitus aurium when caused by adhesions between the membrana tympani or Ossicles and the inner wall of the tympanum indicate the necessity of surgical interfer- ence, but when the cause of these symptoms are not manifest on examination of the parts treatment of any kind is experimental. There remain for consideration two classes, which Kessel has tabulated among the conditions requiring a removal of the membrana tympani and ossicles, viz, entire calcification of the membrana tympani combined with difficult hearing and a normal acoustic nerve, and cases of incurable occlusion of the Eustachian tube. In the former class it is impossible to determine that the acoustic nerve is in a normal condition, and with a rigid membrana tympani there may exist, without recognition, anchylosis of the Ossicles, or even firm fixation of the stapes. The writer found a considerable absorption of the remains took place after the removal by excision of one-half of a large horseshoe-shaped calcareous deposit, beginning at the line of division and developed by the hyperaemia and other changes inci- dent to the process of repair. Therefore it seems to him that, if the exact condi- tions set down by Kessel could be determined, milder measures than the removal of the membrana tympani and Ossicles, such as simple incision or the removal of pieces of the deposit, might be practiced with equally as good results in these cases. The cases of incurable occlusion of the Eustachian tube are very rare, and none have come under the writer's experience; however, he would suggest as a prelimi- PAN-AMERICAN MEDICAL CONGRESS. 1615 nary operation the production of a triangular-shaped opening in the membrana tympani with the base downward, made from an inverted V-shaped flap, which have been shown by v. Troeltsch and McKeown to remain patent for a long time. From the above it will be seen that the principles governing the operative treat- ment of these middle ear affections are of two different types, and the cases have been divided into two groups accordingly, by Stacke, viz: The first, cases of chronic suppuration, often imperatively demands surgical interference to save life, whereas the second class, cases of deafness, tinzhitus aurium, etc., resorts to surgi- cal treatment merely from the hope of improving hearing, relieving the distress- ing tinnitus, or other conditions of no vital importance. In the first group, imme- diately after the operation severe and even alarming symptoms sometimes appear and depend largely on the condition of the diseased ear, the skill of the operator, the extent to which the parts are removed, and the accidents peculiar to the seat and circumstances of the operation. Nausea and dizziness are the particular symp- toms after the surgical treatment of the second group, and the patient experiences |but little discomfort from the operation. The extent to which the parts have been removed and the method of operating has been varied considerably by different men, and therefore it is important to define the exact limits of the operation necessary in a given case to give the best results with the least inconvenience to the patient. In cases of chronic suppu- ration most operators have found that an improvement in hearing follows the removal of the membrana tympani and larger Ossicles, and that this improvement is partially lost when the membrana tympani re-forms. It is on this account that many operators remove the membranatympani as completely as possible and pre- vent its re-formation by such means as the application of caustics or secondary exci- sion. In the same class of cases there is also under debate the question, what ossicles shall be removed, and here the argument is concentrated especially upon the extrac- tion of the incus. Furthermore, when the disease has extended to the antrum, the simple excision of the membrana tympani and extraction of the larger Ossicles sometimes will not be sufficient to effect a cure, and therefore Stacke devised his method for operating in these cases, by which the bony partition between the malleo-incudal space, the aditus, and antrum and the external meatus is removed and a free communication established between these cavities. In the writer's opinion, deafness is of secondary importance in suppurating cases, and a re-formation of the membrana tympani, which will shut off the deeper cavi- ties of the temporal bone, is of greater value to the patient than the slight improve- ment in hearing that attends its non-development. Therefore in the treatment of this affection it is advised to remove as little as possible of the membrana tympani, that its re-formation will be better assured; the malleus should be withdrawn after cutting close around it to free it from adhesions with the membrana tympani, tak- ing especial care to free the articular head, and the incus should also be extracted when it can be easily without injuring the neighboring parts. The removal of the incus brings with it, as a rule, any remnants of the head of the malleus that may have been left after the latter ossicle has been extracted in the carious condition and makes a free communication between the lower portion of the tympanum and the attic, aditus, and antrum. The ossicle is sometimes the seat of carious changes. The removal of the incus is therefore desirable, since it enables the operator to better cleanse the middle ear, prevents the ossicle from becoming a foreign body, eliminates a possible Source of continued suppuration, and liberates the head of the stapes from part of its attachments. With deep-seated inflammation in the mastoid, the radical Operation proposed by Stacke or some of the various mastoid operations will often be necessary to effect a cure. 1616 PAN-AMERICAN MEDICAL CONGRESS. In the earlier operations for the relief of deafness the removal of all the ossicles was recommended, but later the observations of Jack and Berthold showed con- clusively that in cases where the stapes is removed the hearing is better after the opening in the membrana tympani is closed, and that the removal of the stapes is the essential part of the operation. In removing the stapes, the incus is frequently loosened and can be easily extracted without increasing the reaction or time required for healing. If dislodged during the operations on the typanum it is liable to become a foreign body unless removed. Case 1.--Martin F., aged 23 years, has had chronic otorrhoea of left ear for twelve years. The membrana tympani and malleus were removed February 8, 1891, and the tympanum treated carefully with antiseptic solutions, but the mem- brana tympani quickly re-formed, and it became necessary to repeat the operation. The second excision of the membrana tympaniwas performed by Stacke's method, and at the same time some carious spots on the posterior wall of the tympanum were curetted. The latter operation was performed December 9, 1891, was more thorough than the preceding, was not followed by a re-formation of the mem- brana tympani, and resulted in an almost cessation of the discharge. At the end of three months only a slight amount of moisture could be found in the tympanum after the patient had been lying down for some hours (a symptom of suppuration of the antrum). A great improvement in hearing accompanied the reparative changes of the middle ear. Case 2.—William D., aged 35 years, has had dry catarrh of the tympanum with marked deafness for more than five years. The membrana tympani, malleus, and incus were easily removed September 11, 1892, and resulted in an improvement in hearing. The membrana tympani re-formed in a short time and the improvement in hearing was partially lost. - Case 3.—Mr. F., aged 55 years, has had dry catarrh of the middle ear for twenty years, and at present deafness is very marked. October 24, 1892, the incus was removed, but in attempting to extract the stapes both cruras broke off short, leav- ing the foot plate in the oval window. The incision in the membrana, tympani healed rapidly, but the improvement in hearing was very little and not at all satisfactory. Case 4.—Lydia P., aged 33 years, has had a chronic otorrhoea for ten years, and when examined there was a mass of polypi in the meatus, excessively sensitive to the touch ; a large perforation in the membrana tympani; an entire absence of the malleus and a large opening in the posterior upper wall of the meatus, which extended through the bony wall, formed a free communication with the antrum, and showed the existence of mastoid disease, with an attempt on the part of nature to form a spontaneous cure. The patient was treated in a conservative manner for two months, but showed no improvement, and it was decided to operate Octo- ber 26, 1892. The remains of the membrana tympani, a mass of inflammatory tissue, some carious bone, and several pieces of a cholesteatomatous growth were removed, and the opening between the antrum, tympanum, and meatus enlarged. The patient reacted badly, and there were symptoms of severe meningeal irrita- tion; however, by careful and repeated cleansing and keeping the drainage free, these symptoms abated at the end of ten days, during which time large masses of cholesteatoma were discharged from the meatus. The suppuration entirely ceased at the end of the sixth week, a clean scar formed over the diseased places, and a considerable improvement in hearing followed. Case 6.-Mary C., aged 21 years, has had chronic otorrhoea of both ears for sev- eral years. After treating the parts in the usual way for several months, the membrana, tympani and remains of the malleus and incus were removed from the ear which was most diseased November 6, 1893. The incus was found to be normal but the malleus, which was removed intact, had almost completely ulcer- ated away, leaving but a small portion of the head about the joint. Suppuration entirely ceased at the end of eighteen days, the membrana tympani did not re-form, and the hearing was considerably improved. By continued treatment the discharge of the opposite ear was stopped, but a large perforation remained in the membrane. The hearing is about the same in both ears. During the past six months there have been recurrent attacks of suppuration in both ears. Case 6.-John B., aged 57 years, has been afflicted with non-suppurating disease of the middle ear for ten years, and Menière's disease for five years. The mem- brana tympani and all the Ossicles were removed in December, 1892, and as a result there were severe dizziness, vomiting, and nausea, for nearly a week, the moises in the head ceased for twenty-four hours, and then they returned with PAN-AMERICAN MEDICAL CONGRESS. 1617 increased force. The vertigo returned in paroxysms and was as bad as before the operation. The hearing was unchanged. The operation revealed a small exos- tosis on the inner wall of the tympanum near the round window. Case 7.—John K., aged 30 years, has had chronic suppuration of the left ear for three years. When first seen the patient was suffering from an abscess which pointed in the mouth, on the left side, near the hammular process, and probably found origin in the middle ear disease, from which it descended along the tissues forming the Eustachian tube. The membrana tympani was greatly thickened and contained a large perforation. The abscess healed rapidly after it was freely incised, but persistent treatment failed to stop the Suppuration, and at the end of three months, January 8, 1893, the remains of the membrana tympani and mal- leus were removed. Facial paralysis and free suppuration followed the operation and continued for two months, when the discharge ceased and a recovery from the paralysis SOOn Occurred. The membrana tympani did not re-form and a con- siderable improvement in hearing took place. Case 8.-Samuel J., aged 53 years, has had progressively increasing deafness for twenty-five years, due to dry aural catarrh. The stapes was removed in pieces with great difficulty after both crurae had broken off, and a great improvement in hearing is the result. Operation January 8, 1893. Case 9.—George C., aged 60 years, has had marked deafness, the result of chronic suppurating otitis media, for which the stapes was removed in its totality February 12, 1893. The operation was easy, although the membrana tympani was closely bound to the promotory with old adhesions. The result was entirely negative. Case 10.-Sarah C., aged 24 years, has had marked deafness due to dry aural catarrh, for which the stapes was removed in pieces March 14, 1893, with great difficulty. The improvement in hearing was very great and brought the ear very near its normal ability. The deafness had been very bad for three years only. Case 11.—Mr. B. J. R., age 55 years, has had progressively increasing deafness for twenty years, which was apparently due to a large horseshoe-shaped calcare- ous deposit that partly surrounded the manubrium and occupied nearly the whole of the membrana tympani. March 18, 1893, one-half of the calcareous plaque was removed with very little improvement in hearing; and later, April 7, under cocaine anaesthesia, the stapes was partially removed and followed by consider- able relief of the deafness, *-i-º-º-º-º-º-º- ºr-mº THE INDICATIONS AND PREFERABLE METHODS FOR MASTOID OPERATIONS. By SETH SCOTT BISHOP, M. D., of Chicago, Ill., Surgeon to the Illinois Charitable Eye and Ear Infirmary, etc. When and how shall we operate in mastoid disease? Among American surgeons there is a wide diversity of opinions, especially as to what symptoms constitute a positive demand for opening the mastoid process. My observations leave the impression that the majority of surgeons are too conservative, both as to the time selected for surgical interference and the extent of the operation. While con- servatism is an admirable trait in a surgeon, so long as caution is not merged in timidity, so far as I have seen its influence in this class of cases it has proved det- rimental to the patients. I have seen fatal results follow (1) refusal to allow the operation; (2) after operations too long deferred, and (3) after operations that were performed too timidly to remove all the diseased tissue, but I have never known death to occur as a direct result of the operation itself. We all appreciate the gravity of this undertaking, but in view of the fact that the disease demand- ing it is far more dangerous than the surgical measures for its relief, greater free- dom of action and boldness of methods will add luster to the records of our work. When shall we operate 2 The weight of experience and the testimony of trust- worthy authorities favor early operations. If we wait for the very grave symp- toms; fever, rigors, vomiting, vertigo, widely diffused pains in the head and neck, thickly furred, tremulous, and indented tongue, delirium, etc.; the chances of success are discouragingly diminished. I do not believe it is wise to postpone S. Ex. 36 102 1618 PAN-AMERICAN MEDICAL CONGRESS. an Operation until these symptoms occur, unless the patient is suffering from some other affection that renders recovery hopeless, or unless the prostration is so great as to preclude the possibility of survival. There are tentative methods of treat- ment that are proper and promising in incipient mastoiditis unattended by urgent Or dangerous Symptoms. I have often subdued periostitis by the use of counter irritation, compresses, and the free extraction of blood by leeches and wet warm applications. Many cases of mastoid disease may be cut short by this early active treatment. I have seen very acute attacks with intense pain relieved per- manently in this manner. If there is also acute inflammation of the middle ear, additional leeches should be applied about the tragus and an opiate given. If decided relief does not occur within twenty-four or forty-eight hours we should not hesitate to make Wilde's incision, or if this does not relieve, open the bone. This statement, in my opinion, embodies as great conservatism as our duty to the patient justifies. Obviously, any rules that may be laid down are more or less elastic. For example: A case recently came under my observation in which the mastoid had been opened. Another fluctuation swelling appeared above the auricle. I advised opening it, and pus was liberated. Subsequently the patient was brought to me with this opening almost closed, but pus could be pressed from it. There was severe periostitis involving the whole mastoid, temporal, and zygomatic regions. I advised free incision extending through the two previous openings, but one of my assistants, Dr. Holinger, desired to try the effect of pres- sure with antiseptic compresses. This treatment alone dispelled all the threaten- ing symptoms in less than two days. I have formulated the following six rules by which I have been guided in deciding the perplexing question of an Operation: The mastoid process should be opened (1) when there is acute inflammation of the bone that resists palliative treatment; (2) when repeated swellings and abscesses occur; (3) when there is bulging of the posterior and superior wall of the meatus with middle ear sup- puration; (4) when there is a fistula; (5) when there are severe pains in the same side of the head as the diseased ear, resisting all other treatment (mastoid cell inflammation); (6) when a foul Otorrhoea can not be cured by any other means. These rules may be said to be conservative, and whatever deviation we may indulge in Ought to be at Once favorable to the operation and the welfare of the patient. Too great temporizing favors sinus thrombosis, septicaemia, brain abscess, and meningitis. * What method of operating shall we pursue? I have usually performed Schwartze's operation, but have also used Stacke's method with gratifying results. It is one of the most difficult, delicate, and dangerous operations in surgery. Since one can not know the extent of the pathological process before entering the bone, it does not appear to be advisable to decide upon any special method of procedure in advance save One: Remove all dead and diseased tissue. Whoever does this does best. Stacke's and Bergmann's operations have the advantage of affording the greatest accessibility of the tympanum, so that if it is necessary to remove necrosed ossicles or diseased tympanic tissue it can be done with greater facility and thoroughness. But it is best to guard against collapse of the walls of the meatus and resulting stenosis by inserting a tube in the canal. Schwartze's oper- ation is sufficient for most cases. It is much simpler and leaves a less extensive wound. The operations of Wolf and Kuster through the meatus I have never ventured upon for fear of not possessing sufficient skill to remove all the diseased tissue through such a narrow field of vision. All these operations are described in the admirable monograph on the surgery of the ear by Albert H. Tuttle, of Boston. There are a few points in this connection worth mentioning, for they are closely related to a successful issue. The best illumination is gained by the use of light PAN-AMERICAN MEDICAL CONGRESS. 1619 reflected from the mirror on the operator's forehead. This affords a decided advantage over direct illumination. The light is more intense, can be thrown into the opening of the bone in every direction, and there are no shadows to obscure the field. It is safer not to close the wound entirely until it has healed from the bottom. When the interior has filled with cicatricial tissue up to the surface of the outer table, it is safe to allow it to close. I have had good results after closing the wound completely at the time of operation, but it is certainly not so safe a plan. The best dressing is aristol sprinkled over the wound surfaces to cover them entirely. Then iodoform gauze should be placed lightly in the mouth of that part of the wound chosen to remain open. It should not be packed downto the bot- tom of the wound so as to crowd any discharges inward, but it should extend just far enough inward to keep the cutaneous tissues from closing over the superficial opening in the bone until the deep wound is well. Aristol has two excellent qualities: It is the best cicatrizant we possess, and it has the additional advantage of being to some extent an anaesthetic. While iodoform is irritant and toxic, and boracic acid sometimes produces pain, aristol soothes and heals without any ill effects. After stitching that part of the wound to be closed and dressing the open mouth for drainage, the whole is covered with iodoform gauze, absorbent cotton, and a net bandage. This bandage is made of the common mosquito netting, which, as used in the Northern States, is sized with a preparation of glue. The roll of bandage is dipped in water, just before applying, until it is wet through. Then the water is squeezed out and the bandage applied as usual. When it dries the layers adhere together firmly, so as to retain their position for many days in suc- cession without interference. But the most perplexing question before us is, When shall we open the bone 2 My conviction is that the earlier the operation is performed the better our records will be. We should operate while the condition of the patient favors resolution instead of dissolution, and all dead and diseased tissue should be removed. The safest and simplest rule by which I have been generally guided is this: When there is a fistula, or a group of unyielding symptoms of serious sickness undoubt- edly due to the ear disease, penetrate the bone. Unlock the vault that holds our treasure and the sufferer's doom. Give vent to the pent-up furies of disease, as AEolus loosed the struggling winds. A merciless and unrelenting foe has stormed the fortress of the brain ; the citadel of life. No truce is safe, and now heroic action only conquers man’s great foe. - DISCUSSION. Dr. C. R. HOLMES, Cincinnati, Ohio. I can not agree with Dr. Cohn that the operation by Stacke's method is more aseptic than when the operation is per- formed through the external canal. The results from the operation in chronic catarrh of the middle ear have been anything but satisfactory, and therefore there is little to justify us in making such an extensive operation as proposed. I do not think that drills and trephines, as mentioned in Dr. Brose's paper, should even be considered as a part of the armamentarium of the modern aural surgeon. They are instruments that had their day and defenders, but are, and justly so, relegated to the past. I am not in favor of using the drainage tube, as described by Dr. Brose, passing through the opening in the mastoid into the middle ear and out of the external canal; because, if the disease warranted such an extensive interference with the middle ear, the method of operation is not radical enough ; and if only for the purpose of giving vent to the mastoid cells, it is not good surgery to med- dle so much with the middle ear and endanger the position of the ossicles. I have examined cases where the stapes had been removed; Schwartze's and Lucae's experience have been very unsatisfactory. I read a letter recently received from 1620 PAN-AMERICAN MEDICAL CONGRESS. Prof. Schwartze and another from Dr. Stacke, wherein both spoke unfavorably of the operation; and Prof. Schwartze, referring to the reports by Dr. Jack, declared that the time for judgment upon these cases is entirely too short, and at present he does not believe the results will be what has been claimed. I agree with Dr. Bishop that aural surgeons have been too conservative in operating, and it is especially true that many do operate, but are too timid. If we have once deter- mined that it is necessary to operate, we should use the utmost care to guard against opening into dangerous parts, but we should be bold enough to remove all the diseased tissue. I beg to call the attention of gentlemen to the fact that Wilde's incision should not be practiced. Schwartze has omitted it in his last work because it is painful, and, if the disease has advanced far enough to warrant the operation, the cells in nearly every case are also involved, and the patient can only be benefited by opening the bony cortex. If the flap is formed from the lining of the external canal, according to Stacke there can be no collapse after the opera- tion, and with proper packing stenosis should never occur. In the experience of the speaker, the canal will admit of the largest-sized speculum being used, and every part of the cavity can be freely inspected. We do not expect the cavity formed by the removal of diseased tissue to be refilled with cicatricial tissue; in fact this is the most undesirable thing that can happen. What we do want is a cavity covered with healthy epithelial cells; and this can never be accomplished unless firm and persistent packing is practiced until all of the cavity is covered with epithelium. Prof. N. POLITZER. I never open the antrum in acute cases. The mastoid trouble is, in acute cases, rarely in communication with the antrum, and it is better simply to open the mastoid cells. We have thus a clean wound, which closes rapidly; the suppuration in the middle ear ceases sooner, and hearing returns. Of late I have tamponed the wound for one or two days with iodoform gauze ; in fact I have sometimes closed the wound immediately after the operation by sutures, after hav- ing, of course, scraped away all diseased bone. These patients were able to leave the hospital after one week. In cases of chronic sclerotic middle-ear catarrh, on the whole, I do not expect to get good results from the extraction of the ossicles. In some cases the operation is liable to impair the condition of the ear. In chronic purulent cases I think that we must expect little from extraction of the ossicles alone. I have employed Küster’s method of opening the attic and antrum with good results. - Dr. FELIX CoEIN. I wish again to state distinctly that I am not an advocate of the excision of the Ossicles and tympanum in aural catarrh, no matter by what method, be it extra-auricular or intra-auricular. I also claim no originality, even in the application, as Stacke himself in the first publication of his method at the International Congress in Berlin mentions as one of the indications its appli- cability in sclerosis. Bürkner, in his text-book, as well as Schwartze, in his hand- book, which has just appeared, both refer to the possibility of excision by this method. So far, however, to my personal knowledge, no cases have been recorded. I have reported only two cases, because, not advocating the excision of the ossicles, after having satisfied myself sufficiently of the applicability of the method, I have not yet found a case that, according to the indications enumerated in the paper which I had the honor of reading before you, warranted success by either method. I believe that there are only a few chronic conditions in the tympanic cavity in which excision of the ossicles will produce permanent results; and unless we decide to operate, not to improve the hearing, but, prophylactically, to prevent a progression of the disease or for cases of insufferable tinnitus, we are at present obliged to limit the operations, so that even an otologist commanding a very large materiai will not find occasion to operate upon many cases in the course of a limited length of time. Even, however, from the two cases operated upon and my personal knowledge of the technique of Stacke's method in cases of suppurative otitis, I claim PAN-AMERICAN MEDICAL CONGRESS. 1621 that in suitable cases it would be just as advisable, if not preferable, to operate by the extra-auricular method instead of by the intra-auricular. It is an antiseptic, clean, surgical method. It is comparatively easy and it is safe, Safer than the extra- auricular. Although I fully agree with Dr. Holmes that the wholesale excision of ossicles should be condemned—I have tried to preach restriction of indication in my article—I can not see that the objection of Dr. Holmes to this method, that it is painful, can be at all considered. Both methods are surgical operations, and as long as the operation has been shown to be practically safe, an incision a couple of inches larger than we have been accustomed to make in the common Wilde's incision should certainly not deter us from employing a method which may give better results even if it were more painful. The real fact is that the extra-auricu- lar method is painless, because the operation must be done in narcosis, and pain- less in the after-treatment, since the external wound is sewn up, leaving Only a small catgut drain in the lower portion of the wound as a precautionary measure. Dr. S. S. BISHOP. I do not often insert a drainage tube in the wound of the mas- toid operation. The superficial opening is maintained by the pledget of iodoform gauze until the wound heals from the bottom to the opening in the bone. After Stacke's operation I have been obliged to use a tube in the auditory canal for a short time to prevent stenosis. For this purpose a hard-rubber tube was used for one day, followed by a soft-rubber tube for a few days. Since the discussion has turned upon the question of operating for the removal of the drumhead and Ossicles for dry catarrh of the middle ear, I will add a few remarks to those which have already been made. I have investigated this subject sufficiently to make me very cautious. Four cases have come to my knowledge, in all of which the results were so disastrous as to deter me from operating for this disease. In One instance the operation was followed by total deafness in the operated ear, suppuration, and ver- tigo. The suppuration was cured, but the hearing was not regained. Another case was that of a physician who heard his watch 2 inches with the affected ear before the operation, but was troubled with tinnitis. The Surgeon who removed his Ossicles thought the operation would remove the noises and improve the hearing. On the contrary, when the unhappy man came under my observation he had a suppuration in that ear, seemingly intensified noises, and total deafness. We succeeded in stop- ping the discharge, and a few weeks ago I found that the drumhead had been entirely reproduced. He still suffers from absolute deafness in the operated ear, and says that the tinnitis appears to be worse, for he can hear nothing else. He traveled about 3,000 miles from home for this operation. Two other cases with similar unfortunate results have been recently reported to me by Dr. Walker, of Denver, and a Kansas City physician, both of whom have promised to furnish me with full reports of these cases. I have had correspondence with other physicians who have operated for dry catarrh, and their experiences, together with my observations of the deplorable conditions that have resulted in the only cases I have ever seen after the procedure, have kept me from trying it. I have often opened the drumhead and removed it without any unpleasant results and with temporary benefit; but the discouraging feature of this operation is the difficulty of preventing a closing of the perforation and regeneration of the membrane. The same occurs after removal of the Ossicles. Agentleman has lately consulted me for deafness, saying that an aurist removed his chain of ossicles, but the drumhead would re-form after such operation. The Surgeon instructed his patient to return for operation every time the drumhead was reproduced. This put him to considerable inconvenience, as his residence was about 1,000 miles distant from the aurist. But with the hope of finally regaining his hearing he was willing to take these periodical journeys, for he happens to be avery wealthy merchant. In the reports of these operations I have looked to see if such cases were recorded, but they appear to have been overlooked. In ulceration, Suppuration, necrosis, etc., I do not hesitate to do these operations, and I take it that every Surgeon approves of them as good surgery. 1622 PAN-AMERICAN MEDICAL CONGRESS. THE PHONOGRAPH IN THE TREATMENT OF DEAFNEss. By JOHNSON ELIOT, M.D., of Washington, D. C. Over a year since my attention was directed to the use of the phonograph as a means of treating chronic catarrhal otitis. Many years since we were advised to exercise the muscles of the tympanum by means of sound waves. This performed through the medium of aural tubes proved to be tedious and was abandoned. It was thought that in the phonograph we had an instrument which would yield the desired results. Though the Edison phonograph had been used for various diagnos- tic purposes, the credit of introducing it in deafness belongs to Dr. H. F. Gray, of Baltimore, Md., who has recorded some beautiful results. The most of what follows is familiar, but I think best to incorporate it. Sounds are but a succession of falling waves of air capable of affecting the auditory nerves. Whether they fall regularly or not, they may all be traced to the vibrations of some material body. When a fork is struck the edges are set into vibrations; this vibratory motion is communicated to the air, in which it spreads in waves of condensation and rarefaction having the fork in the center. Where the spherical diffusion is interfered with, as in tubes, the sound is more distinct. Sounds falling upon the diaphragm of a phonograph cause, through its style, a series of minute depression upon a revolving cylinder of wax. Be the sounds composed of many or few vibrations it is analyzed and markings corresponding to the number of vibrations are recorded. From our phonogram thus made we can reproduce the sound time after time. The style drops into the depressions on the cylinder and the diaphragm gives back to the air the vibrations which composed the original sound, though with less intensity. From this we understand that sound is composed of a series of vibrations, and the phonograph is capable of reproducing these and conveying them to the ear. For their effect here we must look toward massage. The vibrations are but a series of taps (tapotement) on the membrana tympani, which are carried by means of the Ossicles to the internal ear. The taps cause, as in other parts where massage is used, increase of the venous circulation, freer absorption, prevents and resolves stiffness and atrophy of mus- cles, and favors the repair of tissues. From this it would seem that the treatment would be successful, but I regret to say my clinical experience does not bear out the claims. Deafness may be divided generally speaking into two classes, where the middle ear is affected and where the internal ear is at fault. Those affections of the auricle and external meatus are omitted as having no bearing. In the middle ear our most common lesions are catarrhal, generally with a thickened membrana tympani, a Sclerosed lining membrane, anchylosis of the Ossicles, and depression of the membrane often by contraction of the tensor tympani muscle; the auditory nerve may be but little affected. In these we have the indications of the massage treatment as applied by means of the phonograph. Could we but limit our action to the middle ear or prevent shock to the internal ear, I would fully concur in this belief. To break the false unions of the ossicles and cause absorption of callus thrown out will require sounds of larger volume than the ordinary speaking voice as recorded by the phonograph; in fact these sounds are often not heard by the patient. To persist in the use of such phonograms I consider harmful, as in the endeavor to appreciate the sound one is kept on the qui vive, and fatigue of the muscles of the tympanum will ensue. This generally passes, but we know per- manent effects may result. In the endeavor to procure sounds of larger volume I had various cylinders made, also making use of musical ones. Intense Sounds imply greater amplitude of vibrations, which in the case of the ear means a strong stroke upon the labyrinthine fluids. Normally the labyrinth is protected from PAN-AMERICAN MEDICAL CONGRESS. 1623 blows and concussions, as, in addition to the yielding which the membranous walls afford, we have a special valve at the fenestra rotunda, the membrana tympani secondaria. This idea is based upon the communication existing between the scala vestibuli and the scala tympani, which is generally admitted. Physiology teaches that when an impulse is received upon the membrana tym- pani it is carried by means of the endolymph to its corresponding organ of Corti, which it stimulates, and sends the impulse to the sensorium. This is true, whatever theory of auditory nerve stimulation we accept, as we know the terminal filaments of these nerves are stimulated by variations in the tension of the fluids of the internal ear. If the impulse is great, Corti’s Organs are protected by the valve action at the round window. This bulging relieves the pressure and prevents over- stimulation of the nerve, but in chronic catarrhal otitis the lining membrane of the tympanic cavity is thickened or sclerosed. These changes, involving the mem- brane at the round window, render it less elastic and less capable of yielding. When this condition is present, we can readily understand that a vibration start- ing at the footplate of the stapes will fall with augmented force upon the terminal filaments of the auditory nerve. But little is known of the pathology of the special nerve trunks. Overstimulation would cause fatigue and loss of irritability; the sensations would be obtunded as in the case of the olfactory nerves in Ozaena. That this is permanent I am unable to say. When deafness depends on labyrinth or nerve changes, can we hope to again bring into activity a nerve by means of mas- sage applied through the ossicles? I do not think it possible; for since phono- graphic massage will lessen the activity of the auditory nerve, we certainly could not by the same means restore the nerve to its original activity. In the following cases the deafness depended more especially on changes in the middle ear, and as many are similar I have selected eight from a series of eighteen, all however proving failures. Case 2.--Adult, female ; health good; applied for relief of tinnitus aurium of two years’ standing, following acute rhinitis; membrane normal but slightly depressed; H. D. R. #}, H. D. L. §§; after first treatment tinnitus abated for one day, then returned; ten further treatments given every other day had no influence. Case 3.—Male, aged 38 years; hearing impaired fourteen years; health good; mem- braneopaque; anchylosis of malleus and incus; adhesion of membrane; history nega- tive; H. D. R. ºr, H. D. L. fºr; tinnitus; treatment every day from June 13 to July 9, then every other day until August 12; the adhesion gave way slightly, but no change was made in audition. Case 4.—Male, 22 years; good health; increasing deafness for four years; mem- brane opaque; firm anchylosis; nerve in good condition ; H. D. R. j. H. D. L. ºr ; under treatment five months, generally three times weekly ; cause stated as repeated colds and tobacco; treatment was of no benefit. Case 8.—Female, aged 40 years; health good; deafness nine years, following typhoid fever; tinnitus; H. D. R. ºr, H. D. L. : ; membrane lusterless; bone con- duction fairly good; anchylosis; treated every third day for four months; audition remained stationary. From a letter received a few days since she states that the phonograph increased her trouble. Case 9.—Female, aged 52 years; seven years’ duration; commenced with abscess in left ear; right ear taking on chronic inflammation. There was constant tin- nitus and post-nasal catarrh ; bone conduction good; treatment about every other day for nearly seven months; H. D. R. ºr, H. D. L. ºr ; no change in the hearing distance. While under treatment this patient suffered from an attack of “nervous prostration.” As there was no exciting cause, it has been a question with me whether my treatment could have had any influence in its production. During the attack the phonograph was not used. Case 11.—Female, aged 45 years; no cause assigned; duration twenty to twenty- five years; H. D. R. gº, H. D. L. ſh; tuning fork faintly heard through the bones of the skull; two and ă'half month; treatment was negative. Case 15.-Male, adult; adhesion of membrane; no nasal or pharyngeal trouble; bone conduction remarkably acute; H. D. R. contact, H. D. L. j. This case I saw but three times and can hardly consider him a patient of mine. He stated that he had been under a five months’ treatment in Baltimore just preceding his visit to me and that his hearing decreased from the beginning of the treatment. 1624 PAN-AMERICAN MEDICAL CONGRESS. Case 16.—Adult, male; health good; H. D. R.3%; H. D. L. §: post-nasal catarzh; Eustachian tubes patent; membrane normal; bone conduction good; applied for relief of tinnitus; treatment for nearly three months proved negative. CLINICAL CONTRIBUTION TO THE STUDY OF AURAL SYPEIILIS. By MAX TOEPLITZ, M. D., of New York. Aural syphilis may be manifested during the secondary and tertiary stages, and some rare cases also even of primary induration of the auricle have been reported. Secondary affections are, as a rule, transmitted through the pharnyx and naso-pharnyx through the Eustachian tubes into the middle ear, or they appear in the external meatus as condylomata or ulcers. Tertiary syphilis is characterized by chronic inflammations of the periosteum of the labyrinth, with subsequent hyperostosis or exostosis of the petrous bone or of the cavities of the labyrinth leading to stenosis, or even occlusion of the latter. All cases, however, exhibiting syphilitic affections of the labyrinth are due to hereditary or to acquired syphilis of long standing. The case which I have but recently observed is remarkable by the fact that the labyrinth was affected primarily in the course of a freshly acquired case of syphilis, and that the aural affection began simultaneously with the appearance of roseola. The patient, a physician, at. 41, married, of excellent repute and standing, pre- sented himself at the aural department of the New York Ophthalmic and Aural Institute on August 1, 1892, with the complaint only of deafness in the left ear, other symptoms being absent. Otoscopy revealed moderate congestion of Shrap- nell's membrane, which seemed to have disappeared on the following day upon application of two leeches to the tragus. Politzerization used for diagnostic pur- poses did not improve the hearing. Hearing power horologium, A. S. =*.* A. D. =#. On August 2, hearing, A. S. =#, improved. August 3, hearing worse; leeches to the mastoid. On the fourth day of observation the right ear, which had been endowed with very acute hearing, had become affected. The examina- tion with tuning forks, which did not give any distinct results in the very begin- ning as to the relation of bone and air conduction and seemed to be leaning more toward a decrease of bone conduction, revealed on August 4 positive Rinné in both ears, but there existed almost as much bone conduction as air conduction, the former being decidedly decreased. My diagnosis of otitis interna was now fully justifiable, on account of the sudden development of deafness and the great difference of the course of the affection from that of middle otitis. In order to ascertain the etiology, I questioned the patient about former attacks of syphilis, but with entirely negative result. After repeated inquiries for fresh lesions, the Doctor presented the middle finger of his left hand, which bore in the center a round, hard tumor of the size of a large cherry, representing a genuine primary chancre, contracted during gynecological examinations. Dr. Sigmund Lustgarten confirmed my diagnosis of syphilis. At the same time pharyngeal mucous patches and a beginning roseola were found. Energetic treatment with inunctions of blue ointment were immediately resorted to and injections of pilocarpine were independently made by the patient. The further course of the affections ran as follows: - August 10: Patient experienced a tendency to fall upon rising in the morning, and espécially when awakened out of sleep. The walls of the building seemed shaking. He felt once or twice, for a minute, as if he would like to put his hands against the wall, but the phenomenon was not very marked. - August 16: H. P. H. A. U. = *.*. Tuning fork perceived as above. Ordi- nary conversation is well understood, but the patient has to pay strict attention. Whisper, A. D. =#, A.S. =; conversation, A. D. =::, A.S. =#. August 17: Result of examination with tuning forks unchanged; Weber's experiment, T. F. perceived in either side equally well; T. F., both high and low, are perceived when placed upon R. mastoid in A. S., but when R. ear is closed in A. D.; R. E. does not hear all the high notes of the piano above g’; R. E. above last i the high notes were perceived as mere taps without the faintest musical SOUIIlOl. PAN-AMERICAN MEDICAL CONGRESS. 1625 October: In the beginning of October the hearing of A. D. was almost normal; A. S. somewhat improved. - November 23: Whisper, A. S. =; watch, A. S. — #: conversation, =#; Rinné, A. S., negative. Weber's experiment: Diapason vortex not perceived in either ear; high and low tuning forks equally well perceived; T. F. placed upon R. mastoid, best perceived in A. S.; hearing for the watch, whisper, tuning fork; conversation was normal in A. D.; musical hearing normal. Mucous patches of the soft palate were not quite healed. The special features of this case are as follows: (1) The affection of the laby- rinth occurred after the appearance of the pharyngeal mucous patches and simul- taneously with the appearance of roseala; (2) the aural lesion took place during the Secondary stage without attacking the middle ear; (3) the diagnosis of syphilis was made from the ear. - It may be doubted that the affection was located in the labyrinth and in its stead the Outer wall of the labyrinth, and more especially the region around the oval window, may be preferred for its location. The entire course of the dis- ease, however, contradicts such an assumption, and also the suddenness of the beginning, the well-nigh entire absence of inflammatory signs in the membrana tympani, the mutual relation of both ears during the attack, the relation of bone conduction and the attack of vertigo ; all speak in favor of labyrinthine disease. The pathological changes produced by the syphilitic poison, which entered the lymphatic and blood current of the labyrinth from the pharynx through the aqueducts and the blood vessels, probably consisted in inflammatory alterations of the membranous portion, the periosteum, and the surrounding lymph of the vesti- bule, and the first turn of the cochlea, with an increase of cellular elements and haºmorrhages. All these changes disappeared after energetic antisyphilitic treat- ment. I have looked over the literature of the subject and have not found a similar case of labyrinthine disease due to secondary syphilis in its earliest stage without implicating the middle ear. Politzer” only mentions in general that in affections of the middle ear due to syphilis the perception of the tuning fork through the skull may be lessened or absent (complication with syphilitic disease of the laby- rinth), a fact which essentially supports the diagnosis of specific aural affection when other syphilitic symptoms are present. THE PRESENT CONDITION OF OTOLOGY IN EUROPE AND THE OPERATION OF EXCISION OF THE OSSICLES IN CHRONIC SUP- PURATIVE OR NON-SUPPURATIVE DISEASE OF THE MIDDLE EAR (PROGRESSIVE OR PROLIFEROUS SCLEROSIS), WITH CASES. By LAWRENCE TURNBULL, M. D., of Philadelphia, Pa. Baving spent the greater part of the years 1892–93 on the Continent and in Great Britain, I made it my business, as well as pleasure, to compare the present posi- tion of otology and note its progress as a special department, as also the character of the representative men who practice it, with that of twenty years ago. I found the advance had been made in several directions. First, a more perfect knowl- edge of the normal, pathologic and microscopic anatomy of the ear both in men and animals. Second, with this precise knowledge of anatomy there followed a more rational use of therapeutics both in their local and general application. No haphazard probing, but definite operative and mechanical methods of treatment, with perfectillumination by gas or electricity. The old empirical use of the syringe *Text-book, first edition (German), p. 693. 1626 PAN-AMERICAN MEDICAL CONGRESS. With hot alkaline solutions, without looking into the ear, has, we are happy to State, even among general practitioners, entirely disappeared. Almost all are pro- vided with an aural and nasal speculum and some form of mirror with a Politzer air douche. Third, the number of good, scientific, yet practical works on the ear and its diseases are numerous, well illustrated, and can be had at a moderate price. Among these are the works of Pritchard, S. MacNaughton Jones, and Barr, of England; Baratoux, of France, and Hartmann, of Germany; while the more elaborate works of Politzer, Gruber, and Schwartze are prized by the aurist, as they are replete with accounts of improvements in this department brought up to date, and even the English translation of these works has passed through several editions, showing the great demand there exists for this kind of knowledge, not only by the student, but by the active medical man. While in Liverpool we vis- ited the learned Dr. Stone, who is recognized as an authority in that city, and who has done himself great credit by his translation of the admirable work of Politzer, describing the technique of the various instruments and apparatus for the proper dissection both of the normal and pathological ear. Another important union has taken place between the laryngologist, the rhinologist, and the otologist, as without the knowledge of the use of the laryngoscope and the rhinoscope complete diagnosis would not be possible, as most aural maladies, either directly or indirectly, are associated with naso-pharyngeal diseases, and are so described and treated in the more recent works on the ear, throat, and nose. This happy combination was well illustrated in the recent meeting of the British Laryngological and Rhino- logical Association, in London, which I attended in June, 1892, when papers were read and discussed on these subjects to the advantage and satisfaction of all con- Cerned. I was also much pleased to find that the sections of otology and laryngology were united at the meeting of the British Medical Association at Nottingham, held from July 26 to 30, 1892, and a large number of interesting papers were read and dis- cussed. There were present a number of distinguished representative men of both departments, among them Profs. von Schrotter and Gruber, of Vienna. Prof. Gruber had the honor of being invited to take a seat on the platform in the general meetings. Prior to my visiting London, Prof. Politzer had made a visit and been the recipient of numerous attentions from both the throat and ear spe- cialists. While in Great Britain I noticed that great attention was paid to the ventila- tion of the Eustachian tubes, the removal of adenoid growths, and the general and special treatment of naso-pharyngeal diseases as causing deafness, but not a word was said of operative measures for the relief of chronic suppurative inflammation of the tympanum, now considered of much importance. It is now recognized in the United States as a measure which is absolutely necessary. (Described in Part II of this paper.) First, in chronic aural discharges, especially those from dis- eased bone or polypi, first proposed and performed by Sexton in 1886. Second, for the relief of vertigo and distressing tinnitus aurium. Third, the cure or relief of deafness, or the prevention of its increase, performed by Schwartze in 1885. Often the slightest improvement in the hearing of the human voice is hailed with delight by the long-suffering deaf person, just as the light admitted by the removal of the cataract, or an iridectomy, is a source of great joy to a sightless patient. Gradually we are improving our methods of diagnosis, the only true method being to discover by the tuning fork whether the seat of the disease is in the middle ear or in the nervous apparatus (inner ear). A series of tuning forks has been devised by Hartmann, of Berlin; his lowest is a C fork registering 128 vibrations per sec- ond; the highest a C fork, 4 octaves higher, registering 2,048 vibrations per second. The intervening forks are also tuned to the note C and vary from each other by an octave in the scale. When not supplied with these refined methods, having PAN-AMERICAN MEDICAL CONGRESS. 1627 only an ordinary tuning fork with a clamp, it is well to remember that a great decrease of bone conduction indicates an implication of the internal ear or nervous apparatus, except in old persons, and in cases of syphilitic bone disease in which there is deposit with thickening. The thanks of every aural surgeon are due to Dr. Sexton, of New York, for his devotion to and careful study of operative measures for the relief of chronic, suppurative, and attic, disease, as also non- suppurative inflammation of the tympanum, in the face of great opposition, even in his own city. Dr. J. Baratoux has performed a few operations in Paris, but in his recent work , Guide Pratique pour le Traitement des Maladies de l'Oreille, 1892, no mention is made of this mode of treatment. The English have ignored the whole subject, except the operation through the mastoid, by Lane. Our German confrères, who first opposed it at the congress, but are now the strongest advocates for its use, especially Kretschmann, Ludwig, Reinhardt, Grunert, and Kessel, endeavoring to show that the credit of the introduction of the operation for the removal of the malleus and incus from a patient suffering from chronic catarrhal inflam- mation of the tympanum was due to Kessel in 1877. The operation was with- out satisfactory results, however, until taken up by Sexton, who proved it not only possible, but advocated the measure and published the first satisfactory results to the world in 1884. It was he who first proposed and performed excision of the membrana tympani and Ossicles for the relief and permanent cure of chronic dis- charges from the ear. I at first was opposed to the operation, but after a consul- tation and conference with Dr. Sexton I was convinced of its value. At the Jefferson Medical College I made my first successful operation February 5, 1892; since which time I have operated in other cases, and my former assistant, now lecturer on otology, Dr. S. MacCuen Smith, has operated in a large number of cases, both public and private, during my absence in Europe. Some forty of these were clinical cases. In the last edition of the work of Politzer, published in Stutt- gart, 1893, on page 276, section 6, “Die Excision des Ganzen Trommelfells und die Extraction des Hammers und Ambouses,” he refers to the subject and concludes with a description of the technique of the operation, but gives no Opinion of the operation or his cases, nor even states how often he had performed it. He says: Simrock states that even after complete extirpation of the membrana tympani and hammer a membranous cicatrix forms andfills out the whole Opening, which frequently adheres to the opposite wall of the tympanic cavity. Kessel” claims through the tendinous ring at the posterior circumference of the membrana tym- pani to have secured a permanent opening. According to the experiments of Schwartze + the cicatrization of the opening results from leaving the limbus carti- lage. In the cases operated upon by him a serous secretion or suppurative inflamma- tion followed the operation, the treatment of which required several weeks. The improvement in hearing seems to depend upon whether the vibrating conduction is impeded by the hammer-anvil joint or by the stapes; in the latter case no hear- ing power is secured. The subjective sounds are often lessened, never aggravated. Lucae removed the membrane and hammer several times; the anvil in 47 cases, 55 times. The result of the operation was in 9 cases a considerable improvement, in 19 a lesser improvement, in 18 a negative result, and in 7 cases an aggravation. Lucaef considers the operation in clinical cases as without danger, but the result so unsatisfactory as to make it advisable to set the procedure aside, pend- ing the establishment of more precise indications. The excision of the whole membrana tympani together with the hammer, or even hammer and anvil, has been more recently advocated by Sexton f on the strength of a considerable number of favorable results at his hands. According to Sexton the operation is indicated in a dry middle-ear catarrh, with a progres- sive tendency, especially when accompanied by tinnitus and vertigo and when the previous local treatment (catheterism, etc.) has been fruitless. The earlier the operation the better the results. * Oest. Arztl. Vereins-Zeitung, 1879; Arch. f. Ohrenh., Bd. 13. + Die Chir. Krankh. d. Ohres. # Archiv für Ohrenheilkunde, Vol. XXII. 1628 PAN-AMERICAN MEDICAL CONGRESS. While in Brussels I called to see Dr. Charles Delstanche, the president of the recent Otological Congress held in that city. He contributed by his generous hos- pitality very much to the happiness and comfort of those who attended it. He stated that his patients still continue to derive much benefit from the use of the massage to the auditory canal and membrana tympani, and uses his condensing Syringe and also pure liquid vaseline, or associated with iodoform, especially in Subacute cases of otitis media.” I returned again to Paris in May, 1893, and visited the distinguished otologist, Dr. Lowenberg, president of the Paris Otological Society. I found that he held With great tenacity to the use of the silyer Eustachian catheter on account of the risk of infection. These catheters are of three sizes, and in a pamphlet given to us he describes a new method of catheterization of the Eustachian tube, as follows: He states the principal difficulty during the first stage of the operation is the horizontal deviation of the septum. This he obviates by using half of a nasal spec- ulum, so as to guide the catheter and press the septum aside. During the second stage, when the point of the instrument leaves the nasal cavity, it is difficult to tell when we are in front of the pharyngeal orifice of the Eustachian tube. When he thinks that his catheter has arrived at the end of the post-nasal cavity he orders the patient to Swallow. If the instrument has not yet passed the nasal cavity the hand holding the instrument feels no shock, but if the instrument has passed into the pharyngeal cavity the soft palate when contracting pushes it sometimes into the tube, or at least displaces it, which movement can be seen and is also felt by the hand. The correct distance once determined, it will be useful to mark it in the instrument. He employs a piece of new rubber tubing for each individual patient to tip the Politzer bag, and inflates the air charged with chloroform vapor. He also adheres to the syringe for the removal of epithelium, scales, etc., seldom employing the probe. He also employs the galvanic cautery for the removal of the polyph and polypoid-like growths. He seldom employs ointments. In this he differs from Politzer, depending chiefly upon alcohol and boracic acid; and he still believes-in the special microbes to be found in the pus of suppurative otitis media, as also in furuncles. He seldom operates for diseased mastoid, believing in the use of local applications in the early stage, leaden tubes for ice water and Subsequent persistent and careful syringing with Hartmann’s intertympanic Catheter. He has as yet not employed operative measures for the relief of chronic Suppurative and non-suppurative inflammation of the tympanum, waiting, as he states, for further trials. - On my visit to Rome I found great activity in preparation for the International Congress of September, 1893,f and numerous valuable papers will be read in the Section of Otology by the distinguished men of that city, more especially Gadnego and De Rossii, who have devoted much labor and careful research to the obscure diseases of the nervous apparatus of the internal ear. Of the whole number (154) of cases operated upon by my assistant, S. MacCuen Smith, at several of which I was present and assisted him, the youngest was 4 and the oldest 81. The number which either had a continuous or recurrent discharge was 85. * In passing it will be interesting to some of my confrères to know that he has since informed me by note that the next Otological Congress is postponed until 1895. t Which has been postponed to April, 1894, on account of the cholera. 1630 PAN-AMERICAN MEDICAL CONGRESS. Table of results from eaccision of the Discharge. Hearing power. - 24 - Gº 3- ;: p --> - C - g C ºf É 5 É c º, ©.S. .8 $– 'E : .8% - §: ~. ot; § | 8 É 5 § 5 ;: £ • g 'E º 3.5 C 50 C Kl) p r- º Q) 3 'S p O 2 |*|| 3 || 3 | tº Q H Pl: P- ſº P- É B | * | Im. 1| 16 M. || Yes | No-- 12 yrs...] No----| No----| No----|Left --- Loud 2 ft. .] (*) | No. |Normal. 2 24 F. No--| Yes | 9 yrs---| Yes ---| Yes ---| Yes ---|---do - . . No -------- No. | No. 1. --do - - - - 3| 36| F. Yes | No--| 19 mos -|Severel No----| No----|--|-do. --| No --------| No. No. 4 normal 4| 9 F. No--| Yes - 7 yrs---| No----|No|--|--| No----| Right--| O. C. 1 ft --| No. No. # normal 5, 81| M. No. - No. - | No----- Severel Severel Yes - - -] Both - - - | No - - - - - - - - No. | No. $normal 6|| 7 F. Yes | No. - 2 yrs. --| No----| No----| No----|---do ---| O. C. 2 ft --| No. No. [...do - - - - 7| 18 F. No--| Yes - 13 yrs. -| Yes...| Yes ---| No----|---do ---| O. C. 3 in...] No. | No. # normal 8| 14 F. Yes | No--|24 yrs--| No----. No----|No----| Right--| O. C. 1 ft. - 2 | No. |-|--do - - - - 9| 7| M. No--| Yes - 43 yrs--| No----| Yes ---| No----|---do ---|--|--do - - - - - - 1 N; ---do ---. 10| 52 F. No. - No--|--------- Severel No----|Severel Both--- L. C. 1 ft.--| No. Nö. Slight .. 11| 12 F. || Yes | No--| 2 yrs---| No----| No----| No----| Right--. O. C. 2 ft 1 | * | Normal 12 12 M. Yes -| No -- 3 yrs ---| No----| No----| No----|---do -- . O. C. 23 ft # - ClO - - 13 54| M. Yes | No. 3 yrs---| Yes ---| No----| Yes - - - - - -do - ... O. C. 1 ft --! No. O. |-|--do ---- 14|45. M. No--| Yes || 7 yrs. --| Severe Severe Severe Left ---| O. C. 3 ft. - No. No. -- do . . . . 15| 80 M. I.------|------|--------- 30 yrs. | No----| 20 yrs. | Both. --| Very L. 1 | No. No. 4 normal Severe. Sever"e. ft. 16| 53. F. - - - - - - - - - - - - - - - - - - - - - - 10 yrs. | No----| 3 yrs. |-|--do -- O. C. 3 ft. - No. No. ---do - - - - |Severe. Sevel’e. 17| 62 F. ------|------|--------- 2 yrs. | No ----| 2 yrs--|---do - - - O. C. 4 ft. -| No. No. normal Seve?”.e. 18, 49. M. ------!------|--------- Severel No. ---| 7 mos.-l---do - - -] O. C. 7 in--| No. | No. | Normal. 19| 57. F. |_ _ _ _ _ _ - - - - - - - - * * * * * - - - Yes ---| No----| 3 mos----do --- O. C. 7 in--| No. | No. ---do - - - - 20| 71 M. |------|------|--------- Severe No. ---| 14 yrs - - - -do - - - O. C. 2 ft. | No. No. # normal 21] 39| M. |------|------|--------- Yes...|No----| 5 yrs--|---do ---|Q. C. 4 ft. 2 |No. | Normal. 22, 29 M. |------|------|--------- 2 yrs. | Slight | 3 yrs --|---do - - -] O. C. 6 ft. 3 | No. ---do -...-- SeV el’e. 23| 47| M. l------|------|--------- --- do -. No----| 6 yrs--|---do - - -] O. C. 13 ft. No. No. ---do - - - - 24, 55. M. |------|------|--------- Yes.--| No----| 12 yrs-|---do ---| O. C. 3 ft --| 24 | No. ---do - - - - 25, 57. M. ------|------|--------- Yes ---|NO----| 4 yrs--|---do ---| O. C. 3 ft - | No. | No. ---do ---- 26, 48. M. ------|------|--------- 12 yrs. | No----| 2 yrs...| Left ---| No -------- No. | No. ---do ---- Severe 27; 37 F. i------------|--------- Yes ---| No----| 1 yr ---| Both. --| O. C. 6 ft. No. 3 in. ---do ---- 28, 35| M. ------|--------------- Yes---i-------- 3 yrs -- Left --- O. C. 3 ft. . 2 | No. ---do - - - - 29| 53| M. ------|------|--------- Yes---|-------- 4 yrs.--|---do - - - O. C. 3 ft. . 3 | No. ---do -- - - 30, 46 F. ------|------|--------- Yes---|-------- 3 yrs -- Both. ..] O. C. 7 ft. . 4 | No. ---do - - - - 31|| 42. F. ------|------|--------- Yes---|-------- 2 yrs do - - - || O. C. 9 ft - . 7 || 7 in. ---do ---- 32| 31| M. |------|------|--------- Yes---|-------- 9 yrs - - - - -do ---|--|- do - - - - - 6 || 2 in. ---do -- - - 33 M. I.------|------|--------- Yes---|-------- 1 yr. --| Left ---| ---do - - - - - 2 | No. ---do - - - - 34 43| M. I.------|------|--------- Yes---|-------- Yes - - - - - - do - - - O. C. 8 ft. 1 || 2 in. ---do --- 35' 62 F. ------|------|--------- Yes---|-------- Yes. - - || Right - -] O. C. 7 ft. 4 || 4 in. ---do --- 36| 48 M. I.------|------|--------- eS---|-------- Yes- - - do - - - || O. C. 12 ft- 3 | No. ---do ---- 37, 43. F. ------|------|--------- Yes---|-------- Yes---|---do - - -] O. C. 6 ft - 2 | No. ---do --- 38' 57. F. ------|------|--------- Yes---|-------- 2 vrs--|--|-do - - - || O. C. 4 ft- 3 | No. ---do - 39| 56 F. |------|------|--------- Yes---|--------| No----| Left ---|--|--do - - - - - #| No. ---do --- 40 47. M. I.------|------|--------- Yes---|-------- No----|--|-do - - -] O. C. 3 ft -- 1 | No. O - - - 41, 64. M. ------|------|--------- Yes---| No----| No----|--|-do - - -] O. C. 5 ft. 2}| No. 1. --do - - - - 42 48| M. ------|------|--------- Yes... No----| 1 yr. --| Right--| O. C. 6 ft- 3 | No. ---do - - - - 47; M. I.------|------|--------- Yes. --| No----| 2 yrs - - Left - - -] O. C. 7 ft- 1 | No. 1.--do 44. 53. M. I.------|------|--------- Yes---| No ----| 3 yrs --|---do - - -] O. C. 3 ft- 4 | #; .do 45, 32. F. ------|------|--------- Yes---| No----| No----|---do - - -] O. C. 11 ft. 3 | # |-|--do 46 34 M. I.------|------|--------- Yes---| No----| No----|---do - - -] O. C. 10 ft- 1 35 |-|--do - 471 39| M. I.------|------|--------- Yes---| No----| No ----| Both - - -] O. C. 7 ft -- 4 | # |-|--do -- 48] 35 F. I.------|------|--------- Yes---| No----| No ----| Left - - -] O. C. 5 ft -- 2 | #6 |-|--do - 49| 47| M. I.------|------|--------- Yes---|No----|3 yrs--| Right--| O. C. 13 ft 7 | # |.--do ---- 50 64. F. ------|------|--------- Yes---| No----| 1 yr ---|---do ---| O. C. 4 ft - 1 | No. ---do - 51, 47. F. ------|------|--------- Yes - - - No----| 4 yrs --|--|-do - - - O. C. 3 ft -- 2 | * |-|--do - - - - 52 54. M. |------|------|--------- Yes---| No----| 12 yrs - Left - - - || O. C. 1 ft. . No. No. . . . do - 53. 45. M. ------i------|--------- Yes---| No----|19 yrs-| Both---|-...-do - . . . . No. | No. |. --do - - - - 54, 57. M. ------|--------------- Yes---| No----| 7 yrs--|---do ---| O. C. 2 ft. - No. No. 1 #11ormal 55 62 M. ------|------|--------- 20 yrs. |No----| 15 yrs-|---do ---| L. C. 1 ft.) No. No. normal |Severe Severe. 56l 53 M. 1------|------|--------- Yes---|No----|Yes---|Left ---|O. C. 3 ft. 3 | f | Normal- 571 43. M. ------|------|--------- Yes---| No----| Yes---| Right--|--|--do - - - - - 4 | #5 |---do --- 58! 39 F. ------|------|--------- Yes---| No----| Yes---|---do ---| O. C. 4 ft -- 5 | # 1---do .-- 59' 40. F. ------|------|--------- Yes---| No----| Yes---|---do - - -] O. C. 12 ft. 8 # ---do --- 60 46 F. ------|------|--------- Yes. --| No----| Yes---| Left ---| O. C. 9 ft -- 4 || 3: ...--do - 61| 54. F. ------|------|--------- Yes---| No----| Yes---|---do - - -] O. C. 11 ft- 9 | No. 1. --do . . . . 62 38 M. |------|------|--------- Yes---| No----| Slight |. --do - - -] O. C. 7 ft.-- 1 | No. normal 63 63 F. ------|------|--------- Yes---| No----| Yes---| Both ---|----do------ 3 | No. |----do --- * Negative, PAN-AMERICAN MEDICAL CONGRESS. 1631 -*. membrama tympani and ossicles. O. C.–Ordinary conversation. L. C. =Loud conversation. Results of operation. Hearing power. * 65 | 3. 3 | * O } & 4 & 3 §§ º à § c 3. | bſ) & • H --> C º: ~. • : .: t : ā 5 tº dº º) º Q 2: ;: +-> Q ; : --> © Ž * ..? º .8 ; # 5 || 3 || 5 : #. c Q P+ H :- : É k É O Q 2. | —— ---, -— — — Im. No----| No----' No-------- No-------- O.C. 19 ft. 11 | }} | 3 yrs...|Scarlet fever Mal. and | 1 111C. No----| No----. No-------- No-------- e Wºº º - - r 7 * * : *- * * * - §: Nº. 3...] §:33:##| || || |}ººl;...":::::::::::: ; No. --- No----| NO-------- No-------- O. C. 10 ft -| 5 || 3 || 7 mos--| Measles------ --do. ----- 4 N3 −. Nº: Nº.: N:|3% ºf , || |º]}...'...}}…] : O - - - O----| NO - - - - - - - - 0 - - - - - - - - tº ºf tº - 4. No----| No-...--| Slight ----| No-------- 3 gº ºf Hºlsºvº:::::::::: ; §:...] §...R.R. 38.3%| |f|##: ;ºsiſ"...] § foLIII] No.l.. Slightim. |No...III.jö, Ö, 3 ft|No||No||34 yrs. Not known. Mai and 16 É.” | | inc. No----| No----| No-------- No-------- O. C.12 ft. 4 || 3 || 4 yrs. --| La grippe ---|--|--do ----- l §§§ {.{##|||}|3.s.º.º.º.; §3...];...]; .......] §........|3:3:#;"|";| || 1:...]...] "...] : No----| No----| No-------- No-------- O. C. 4 ft --| 2 | #; 33 yrs -- Not known --|Inc., and 15 fºrum º intact, No - - - - No----| Slight - No----...-- O. C. 2 ft. - || 1 | #; . . . do . . . . . .-do - - - * * * . “s sm sm ºm as * 16 No----. No----| No-------- No-------. --do. ---- 4 | # 25 yrs. -----do ------------do ------ 17 No----| No----| No-------- No-------- O. C. 12 ft - || 7 | * --------do ------ -- NO----| No----| Slight ----| No-------. ----do----- 6 . §rs. ...i. .#3. # NO----| No----|--|--do ----- No-------- O. C. 16 ft. 3 | ##|...do ...|----do. ------. ----do - - - - - 20 No----| No----|--|--do ----- No-------- Q. C.9 ft. 11 | # 13 yrs...|La grippe ---|-...do ..... 21 No----| No----|--|--do ----- No-------- O. C. 6 ft. - 7 || 3 || 1 vril--|--|-- do....... [...do ...I. ! || 3:5 yr- - - - ------do ------ 22 N:|N:|N::::::N3:33; #| || ||º: Nºnºwº-ºº::::::: N. N. N. N...] §§ 13 || |##...].....................] § No----| No---. But little Little im- |O. C. No --|No||No|| 6 mos...|----do -------- --do ------ 26 * improved.provement No----| No----| Slight ----|No-------- O. C. 12 ft. || 4 || 3 || 7 mos--|--|--do -------- ----do------ 27 No----| No----|-----do ----! No. ------ O. C. 19 ft. 7 Ol 9 mos------do -------. ----do -...----i 28 No----| No----| No-------. No-------- O. C. 5 ft -- 74| #3 13 mos.j.---do -------. --do ------ 29 No----| Slight | No-------- No-------- O. C. 12 ft-| 6 || 3 || 5 mos...|--|--do ------... ----do ------| 30 Slight |-|--do --| No-------- No-------- O. C. 25 ft-| 9 || 3 || 8 mos --|--|--do -------- ---do ------ 31 No.---|---do ... No-------- No-------- O. C. 31 ft - 11 | # | 16 mos. |----do -------- ---do ------ 32 No----|---do --| Slight ----| Slight ----| O. C. 12 ft-| 3 | ##| 9 mos. -|--|--do --------|--|--do -- . . . . 33 No----|---do --| No-------- ---do ------ O. C. 10 ft. 12 ºr 9 mos--|--|--do -- ----do ------| 34 No----|---do --| No-------- --do ------ O. C. 13 ft-| 11 | *, 64 mos-----do - - - - - - - - ---do ------ 35 No----|---do --| No-------- ---do ------ O.C. 27 ft. 7 | # 7 mos--|--|--do -------. ----do ------| 36 No----|---do -. No-------- --do ------ Q. C.9 ft --| 8 || | | 16 mos-----do -------- ----do -----. 37 No----|---do --| No-------- No-------- O. C. 3 ft --| 1 || | | 3 mos--|--|--do ------...----do ------|38 No----|---do --| No-------- No-------- Ö, Ü, Öft| 2 | Sol 3, mos...}.Idol.III. ----do ------| 39 No----|---do --| No-------- No-------- O. C. 7 ft --| 4 || || | 18 mos. ----do -------- ---do --- 40 No----|---do --| No-------- No-------- O. C. 12 ft -| 1 | ## 20 mos-----do -------- --do ------ 41 No----|---do --| No. ------- No-------- O. C. 11 ft. 2 | 3 |19 mos...--do ------...----do ----...] 42 No----|---do -. No-------- No-------- O.C. 26 ft - 13 | #, 19 mos-|--|--do -------- ----do ------ 43 No----|---do --| No-------- No-------- O. C. 3 ft --| 3 || 3 |19 mos-|--|--do -------- ----do ------ 44 No----|---do --| No-------- No-------- O. C. 11 ft -| 7 | #, 3 yrs. --|--|--do -------- ----do ------ 45 No----|---do --| No-------- No-------- O.C. 20 ft -| 9 || || || 23 yrs. -|--|--do ------...- ----do ------ 46 No----|---do --| No-------- No-------- Q. C. 21 ft-| 5 | f | 4 yrs. --|----do - .------|--|--do ------ #7 No----|--...do --| No-------- No-------- O. C. 9 ft --| 17 | #, 24 yrs--|--|--do -------- ----do ------ 48 No----|---do -- No-------. No-------- O. C. 19 ft. 13 | ##| 3 yrs.--|--|--do -------- ----do ------ 49 Slight|---do --| Slight ----| No-------- Q. C. 27 ft. 5 || 3 || 9 mos--|--|--do -------- do 50 Nol---| No----| No-------- No-------- O. C. 3 ft --| 2 | f | 9 mos--|--|--do -------- Idol.III 5i §: §: -- §: * * * * * * * = §§ * * * * * * * * oº:: ; 36 º mos. Idol.IIIdo III 52 O- - - - NO----| NO--------| NO - - - - - - - - * * * * * * * * * * * No----| No----| No-------- §. 6.8% ft. §§4:::::::::::::::::::::::::::::::::::::: No----| No----| No-------- Slight ----| O. C. 7 ft --| 4 || No 4 mos--|--|--do -------- ----do ------ 55 No----| No----| No-------- ---do ----- O. C. 2 ft --| 3 || 4 || 11 * | * * * * * * *...* = &m º ºs & No----| No----| No-------- O- - - - - - - - 3:3:##| || |##::::::::::::::::::::::::::::::::: No----| No----| No-------- Slight ----|O. C.12 ft. 8 || || 9 mos...|...doll...I. Ido III. 58 * | No----| No----| Yes ------- - - - ClO ----- O. C. 16 ft. 9 || #| 7 mos...|ll-doll...I. Idol. 59 No----| No----| Yes ------- No-------- O. C.20 ft. 12 || 3 | 16 mos]...do III. Idol. 60 No----| No----|NQ-------- No-------- O. C.9 ft--| 9 || || 3 mos...|...doll...I. ...do...... 61 No----| No----| Slight --- slºt. ..] O. C. 6ft. 1 | . 2 yrs...]...I do III.I.I.I.Ido...] 62 No----| No----|----do ----. ----ClQ ----- O. C. 8 ft. - 2 | No. 1 yr ----|--|--do -------- ----ClQ - - - - - - 63 1632 - PAN-AMERICAN MEDICAL CONGRESS. Table of results from eaccision of the membrana Discharge. - Hearing power. # --> # P . O g g {A} * 3 35 E | ? .9 p O ČD . . º # | 8 # --> e .89 d5 # 5 GD & 5 ;|g| iſ || 3 | # | # | # | 5 | f | 8 .3 5 || 3 || 5.5 C | 8p || 3 || 8 GD p *t cº GD º O p O 2 | < | dº | j p? | C E- ſh P- º P- # | 3 | tº Im. 64 42 M. |------|------|--------- Yes---| No----| Yes---| Right--| O. C. 5 ft.-- 23| No. |#Inormal 65, 47. M. ------|------|--------- Yes---| No. ---| Slight |...do ---| O. C. 12 ft. 1 | No. | Normal- 66l 51] M. 1.------|------|--------- Yes---|No----| Slight | Left ---|O. C. 1 ft --| 3 | No. ---do---- 67. 50) M. |------|------|--------- Yes---| No----| Slight| Right--|----do - ---- 1 | No. # normal 68 57| M. I.----. -------|--------- Yes---| No----| Slight|---do - - -] O. C. 2 ft.-- 2 | #8 ----do --- 69| 48 F. ------|--|--|--|--------- Yes---| No----| Slight|---do ---| O. C. 3 ft.-- 2 | #5 # normal 70 49| M. |------|------|--------- Yes---| No----| Nol---| Left ---| O. C. 4 ft - . 1 ! :º |-|--do ---- 71 39 F. - - - - - - * * * * * * * * * * * * * m. sº wº Yes---| No----| No----|---do ---|--|--do ----- 4 35 |---do ---- 72. 33. F. ------|--|--|--|--------- Yes---| No----| No----| Right--| O. C. 2 ft.-- 3 | # ---do ---- 73 41. F. ------|------|--------- Yes---| No----| No----|---do ---|--|--do ---...- 5 ºo |---do ---- 74. 44. M. |------|------|--------- Yes---| No----| No----|---do ---| O. C. 4 ft. 2 | #5 |-|--do --- 75l 38 F. ------|------|--------- Yes---| No----| Yes---|---do ---|----do ----- 1 | No. | Normal- 76l 61 M. ------|------|--------- Yes ---| No ----| Yes ---| Left ---| O. C. 4 ft.-- 2 | do | Normal. 77) 58. M. ------|------|--------- Yes ---| No----| No----|---do - - -] O. C. 3 ft. 1 | # |---do ---- 78, 59. F. ------|--|--|--|--------- Yes --- No----| No. ---|---do ---| O. C. 6 ft- 1 &; ---do ---- 79| 491 F. ------|------|--------- Yes ---| No----| No. --- Right--| O. C. 2 ft- 1 | No. 3 normal 80. 44. F. ------|--|--|--|--------- Yes - - - | No----| Yes ---| Left - - -] O. C. 3 ft - 3 | No. | Normal. 81| 35| M. |- - - - - - * = ** * * * : * * * * * * * * * Yes ---| No----| Yes - - -] Right--| O. C. 4 ft -- 2 | No. 4 normal 82| 64| M. - - - - - - - * * * * *- : * * * * * * * * * 10 yrs. | No----| 9 yrs. | Both- - - L. C. 1 ft --| No. | No. ---do ---- Sevel’e. SeVere. 83| 74 M. |------i------|--------- 12 yrs. | No----| 4 yrs. |.--do - - - L. C. 2 ft --| No. No. normal Severe. Sever*G. . 84 67| M. I.------|------|--------- 9 yrs. |NO----| 3 yrs. ---do ---| L. C. 1 ft.--| No. | No. 3 normal Severe, Sevel’e. º 85| 4 F. Yes ------- 1 yr ----| No----|NO----| No ----|---do - - -] O. C. 8 ft- 2 | No. Normal 86| 7| F. || Yes |______ 3 yrs. --| No----|NO----|NO----|--|-do ---|--|--do ----- 4 | No. ---do ---- 87| 9| M. || Yes |______ 2 yrs. --| No----|NO----| No ----|---do ---| O. C. 6 ft- 2 || 3 ||---do ---- 88, 18 F. - - - - Yes - 7 yrs---| No----| Yes --- No ----| Right--| O. C. 16 ft- 9 | #3 ||---do ---- 89; 4 F. || Yes |_ _ _ ___ 18 mos. No----| No----| No ----|---do ---| O. C. 1 ft.-- 4 | No. ---do ---- 90. 5| F. || Yes |_ _ _ _ _ _ ---do ---| No----| No----| No----|---do ---|--, - do ----- 2 | No. ---do ---- 911 23 F. - - - - - - Yes - 17 yrs--| Yes ---| Yes ---| No----|---do ---| O. C. 7 ft. 1 | No. ---do ---- 92. 13| F. || Yes - |_ _ _ _ _ _ 9 yrs---| No----| No----|NO----|---do ---| O. C. 4 ft -- 4 | No. ---do ---- 93. 27| M. - - - - - - Yes -| 12 yrs--| Yes ---| Yes ---| No----|---do --- O. C. 7 ft.-- 8 & |---do ---- 94; 19 M. || Yes - |_ _ _.-- 18 mos-| No----| No----| No----| Left ---| O. C. 4 ft- 1 | # |---do ---- 95 28 F. - - - - - - Yes - 11 yrs--| Yes ---| Yes ---| No----| Right--| O. C. 3 ft.-- 1 | No. ---do ---- 96 22 M. || Yes - - - - - - - 6 yrs---| No----|NO----| No----|---do ---|O. C. 9 ft -- 3 | # |-|--do ---- 97| 7| M. || Yes |_ _ _ ___ 2 yrs---|No----| N9----|No----|---do ---|Q. C. 4ft. 4 | No. ---do ---- .98; 6 F. Yes || ------ 9 mos--| No--...- Slight | No----|---do ---| O. C. 7 ft. 1 | No. ---do ---- 99| 18| M. || Yes || ------ 10 mos-| No----| No.---| No----|---do ---| O. C. 6 ft -- 2 | No. ---do ---- 100 12 M. || Yes -|------ 12 mos-| No----| No----| No----| Both---| Q. C. 12 ft- 7 | # |-|--do ---- 101| 4 M. Yes - - - - - - - 9 mos--| No----| Yes - - -] No ----| Left - - -] O. C. 2 ft.-- 3 O. |-|--do ---- 102 9| F. || Yes |_ _ _ ___ 2 yrs---| No----| Yes ---| No----|---do - - -] O. C. 6 ft -- 5 | No. |-|--do ---- 103| 491 F. - - - - - - Yes - 20 yrs--| Yes ---| Yes ---| Yes ---|---do - - -] O. C. 1 ft.--| No. | No. ---do ---- 104; 27| F. ------ Yes - 17 yrs-- Yes ---| Yes ---| Yes ---| Right... O. C. 2 ft.--| No. No. ---do ---- 1051 12 M. Yes || - - - - - - 4 yrs---| No----|No----|No----|---do ---|Q. C. 4 ft -- 4 # ---do ---- 106; 14 F. || Yes -|------ -- do ---| No----| No----| No. ---|---do ---| O. C. 8 ft.-- 7 | # |-|--do ---- 107] 26 M. Yes |_ _ _ _ _ _ 3 yrs---| No----| No----| No----|---do ---| O. C. 3 ft.-- 5 | # |-|--do ---- 108 M. |Yes -|Yes|-|24 yrs--| Yes ---|Yes---| Yes---| Both--- O. C. 1 ft.--| No. ºr |---do ---- 109| 19| F. ------|--|--|-- 1 yr ----| No----| No----| No----| Left ---| O. C. 9 ft -- 5 | #6 |---do ---- 110 7| M. Yes | Yes - 2 yrs---| No----|No----| No----|---do ---|O. C. 12 ft 8 & |---do ---- 111| 28 F. Yes || Yes - 16 yrs--| Yes--- N: N: ---do ---| O. C. 4 ft- 2 | 36 |---do ---- O- - - - | N O - - - - 112 22 M. Yes |_ _ _ ___ 9 yrs. --| No----| No----| No----|---do ---| O. C. 6 ft- 3 | # |-|--do ---- 113| 31|| M. ------ Yes - 12 yrs--| Yes---| No----| No----|---do ---| O. C. 3 ft- 1 || 3 ||---do ---- 114 26 M. |------ Yes -|---do ---| Yes---| No----| No----| Right--| O. C. 8 ft.-- 7 | #5 |---do ---- 115| 18. F. || Yes -|--|--|-- 4 yrs. --| No----| No----| No----|---do --- O. C. 6 ft -- 9 | # --- do ---- 116 24 M. || Yes -|------ 9 yrs---| No----| No----| No----| Left ---| O. C. 3 ft.-- 2 #: ---do ---- 117. 19 F. Yes -|------ 2 yrs---| No----| No----| No----| Both ---| O. C. 6 ft -- 1 | No. ----do ---- 118 F. | Yes ------- 1 yr----| No----| No----| No----|Left ---| O. C. 11 ft- 1 | No. -|---do ---- 119. 14 F. || Yes -|------ 3 yrs---| No----| No----| No----|---do ---| O. C. 7 ft -- 3 | # ||---do ---- 120 11| F. | Yes ------- 6 yrs---| No----| No----| No----| Both ---|----do ----- 1. O--|---do ---- 121| 71 M. || Yes ------- 5 yrs---! No----| No----| No----|---do --- O. C. 3 ft.-- 1 | No--'---do ----, O. C. = Ordinary conversation, PAN-AMERICAN : MEDICAL CONGRESS. 1633 tympani and ossicles—Continued. Results of operation. Hearing power. ; % --- s g § | ** 2: rº - -: § £ O ; ää ‘5 S : * ſ: 1 – º * =} # | = | # # g | #| 5 | * ; ; ; # # .8 5 # 5 || 3 | # # #| |3 Q 04 H :- *- à || | #. O 5 Z! in. No----| No----| Slight ----| Slight -- ..] O. C. 5 ft -- 1: No 3 yrs---| Not known. . . In c. a n d 64 fºrum IIlúð,C15. No. -- . No----|--|--do ----- Not much O. C. 11 ft. 2 No. 7 mos--|--|--do --------|--|--do -----. 65 - Improve - No----| No. -- O- - - - - - - - ---do ----- O. C. No. - 2 No. 12 mos-----do -------. ----do ------ 66 No----|NO----| Slight ----|--|--do ----- O. C. No. - No No. 3 mos--|----do --------|--|--do - - - - - -| 67 No----| No----| No. ------- O-------- O. C. 2 ft. . . 2 # 3 mos--|--|--do ------------do ------ 68 No----| No----| No-------- No-------- O. C. 4 ft --| 4 #; 4 mos--|--|--do -------- ----do ------ (59 No. ---| No. ---| No-------- No-------- O. C. 3 ft --| 3 #5 || 8 mos--|----do -------- ----do ------ 70 No----| No ----| No -------- No-------- O. C. 6 ft -- 4 ; ; 10 mos-----do -------- ----do ------ 71 No----|NO----| Slight ----| No-------- O. C.4 ft --| 4 ; 14 mos-|--|--do. -------|----do ------ 72 No----| No----|----do ----. O-------- O. C. 8 ft --| 7 || | 18 mos - |----do -------- ----do------ 73 No----| No ----|----do ----- No-------- O. C. 7 ft --| 2 # | 9 mos--|--|--do -------- ----do ------ 74 No----| No----| No-------- No-------- O. C. 4 ft --| 2) # 3 yrs---|--|--do --------|--|--do ------ 75 No----| No----| No-------- No-------- O. C. 4 ft -- 2 No. 24 yrs. -|----do -------- Mal. , and 76 #ºum e IIlta-Ct. No No----| No-------- Slight ----| O. C. 6 ft -- 4 No. 11 mos -|--|--do -------- ----do ------ 7. NO No----| No. ------- 0-------- C. 12 ft.) 5 # 3 yrs---|--|--do -------- Ma 1. and 78 IIlC. No----| No----| No -------- ---do ----- O. C. 1 ft --| 2 #, 1 yr ----|--|--do -------- ----do ------ 79 No----| NO----| No-------- ----do ----- O. C. 8 ft - 4||No|| 2 yrs---|--|--do -------- ----do ------ 80 No----| No----| Slight ----|--|--do ----- O. C. 8 ft --| 3 No 2 yrs. --|----do -------- *::::: drum 81 1I]t 8,0. No. ---| NO----. No-------- ----do ----- O. C. 1 ft, #| No 3 yrs---|--|--do -------- ----do ------ 82 No----| No. ---! No-------- No-------- O. C. 9 ft --| 9 || || 12 mos. ----do -------- Ma 1... and 83 #ºum 1Ilta,Ct. No----| NO----| No-------- Slight ----. O. C. 12 ft - 8. § 9 mos--|--|--do -------- ----do ------ 84 No----| No----| Yes ------- ----do ----- O. C. 16 ft -| 9 || 3 || 7 mos--|--|--do -------- ----do ------ 85 N: - §3. §: - - - - - - O-------- O. C. 20 ft. # § º IOOS - : * * * * * * * * .# * * * * * * ; O- - - -] N O----| NO- - - - - - - - O-------- * * * * * * * * * is 3 IIloS- - - - - - ClO - - - - - - - - ----ClO ------ jº...] No I Šlight III Šlight II. O.C. 6ft. i | . |3:...|Idol....I. ----do ------ 88 No----| No--------do ----- ----do ----- O. C. 8 ft 2 |No|| 1 yr ----|--|--do -------- ----do ------ 89 No----| No--------do ----- ----do ----- O.C. 5 ft. - 1 ||No|| 3 yrs---|--|--do --------|--|--do ------| 90 No----| No----|--|--do ----- iº O. C. 11 ft -| 2 |No|| 7 mos--|----do -------- ----do ------ 91 Improved. Slight | No----| No-------- ----ClO - - - - - O. C. No --| 2 | No. 12 mos-|--|--do ------ - - ----do ------ 92 O----! No----| Slight ----|--|--do ----. O. C. No -- No No. 3 mos--|--|--do. -------- ----do ------ 93 No----| NO----| No-------- NO-------- O.C. 2 ft. - 2 || 3 || 3 mos--|----do -------- ----do ------ 94 Slight | No----. No-------- No-------- O. C. 4 ft --| 3 | #; |4 mos--|--|--do -------- ----do ------| 95 o----| No----i No-------- No-------- O.C. 3ft. - 4 || 3 || 8 mos--|----do -------- ----do ------ 96 No----| Slight | No-------- No-------- O. C.6 ft. - 4 | # 10 mos-|----do --------|--|--do ------ 97 No----| No----| Slight ----| No-------- O. C. 4 ft --| 4 | # 14 mos-|--|--do -------- ----do ----- 98 No----| No--------do ----- No-------- O. C. 8 ft --| 7 || 3 | 18 mos-|--|--do --------|--|--do ------ 99 No----| No----|--|--do ----- No-------- O. C. 7 ft -- || 2 | f | 9 mos--|--|--do -------- ----do------ 10() No----| No----| No-------- No-------- O. C. 4 ft --| 2 | f | 3 yrs-------do -------- ----do ------ 101 No----| No----| NO-------- No-------- ----do ----- 2 |No|| 23 yrs--|----do -------- ----do ------|102 No----| NO----| No-------- Slight ----| O.C. 6 ft --| 4 ||No|| 11 mos-|--|--do -------- ----do ------ 103 No----| No----| No--------| No-------- O. C. 12 ft. 5 | # 3 yrs---|--|--do --------|Mal. and 104 IIIC. No----| No----i No-------- Slight ----| O. C. 1 ft -- 2 | 3 | 1 yr ----|--|--do -------- ----do------ 105 No----| No----| NO-------- ----CiO - - - - - O. C. 8 ft --| 4 ||No|| 2 yrs---|----do -------- ----ClO ------ 105 No----|NO----| Slight ----|--|--do ----- ----do -----| 3 ||No|| 2 yrs---|----do -------- Initiºn 107 1Iltº,CU. No----| No ----. No-------- ----do ----- O. C. 1 ft.--| ||No|| 3 yrs. --|--|--do -------- ----do ------ 108 No----| No---- N9-------- O-------- O. C. 1 ft. - 1 ||No|| 3 yrs---|--|--do -------- ----do ------ 109 No----| No----| Slight ----| No-------- L. C. 3 ft -- 1: No! ---do---|--|--do -------- ----ClO - - - - - - 11() Slight | No----|NO--------|NO-------- O. C. 7 ft. - || 4 || 3 || 12 mos. Scarlet fever Pº mal. 111 àIl Ci 111C -* * * * * No----| No--------| No--------|----do-----| 3 | *; 4 mos--|----do --------|--|--do ------|112 Slight | No----| No-------- No-------- O.C. 12 ft -| 3 | # 8 mos--|--|--do -------- ---do ------ 113 ---| No----| NO-------- No-------- O. C. 27 ft. 11 | #; 2 yrs---|--|--do -------- ---do ------ 114 No----| No-...--| No-------- No-------- O.C. 12 ft. 5 || 3 || 4 yrs. --|----do -------- ----do ------ 115 No----| No----| NO-------- No-------- ----do----- 12 | # |---do---|--|--do -------- ----do ------ 116 No----| No. --- No-------- No-------- O. C. 18 ft - #; 3 yrs. --| Measles ---. - ----do ------ 117 §§ - §3. §§ * * * * * * * * §§ - - - - - - - - 8. § #. º # łyń. sº fever ...; * * * * * * # O - - O----| IN O- - - - - - - - O-------- * * * * - || 7 | #: I'----|----ClO -------- ----ClO ------ No----| No----| No-------- No-------- O. C. 7 ft -| 9 # işinos. ----do -------- ----do ------ 120 No----| NO----' NO-------- No-------- O.C. 6 ft --! 4 | # 13 mos-----do --------'---- do ------ 121 L., C, - Loud conversation, 1634 PAN-AMERICAN MEDICAL CONGRESS. Table of results from eaccision of the membrama Discharge. Hearing power. & ºd * . # | # a 5 §§ 5 || 3 || 5 É | 6. . . . . *; # | 5 | # # ; # d # | 5 || 93 g | H | 3 || 3: $4 § 3. $—t H .3 E | # §§ O || 8f) Gi) p p- º Gº) o: O C tº : |3| 3 || 8 || 3 || 5 E- ſh- P- º P- É | 3 || 3 Im. 122 5|| F. Yes -|------ 2 yrs---| No----| No----| No----| Both---| O. C. 2 ft.-- 2 | No--| Normal- 123| 6| F. || Yes -|------ 14 yrs--| No----| No----| No----|---do ---| O. C. 8 ft.-- 2 | No. -|---do ---- 124 8. M. Yes -|------ 2 yrs---| No----| No----| No----|---do ---| O. C. 1 ft.-- 1 | No--|---do ---- 125] 11| M. Yes ------- ---do ---| No----! No--...] No----| Right..] O. C. 3 ft 3 | # |-|--do --- 126; 16 F. || Yes -|------ 18 mos. Yes---| No----| No----|---do ---|----do----- 4 | #5 |---do --- 127|10| F. Yes || - - - - - - 11 mos-| No----| No ----| No----|-- do ---| O. C. 4 ft -- 2 || 0 |---do --- 128; 8 F. Yes -|------ 16 mos. No----| No----| No----| Left ---| O. C. 2 ft. - 1 --do ---- 129; 6 M. Yes - - - - - - - 22 mos-| No----| No----| No----| Right--| O. C. 1 ft- 6 Nº. --do ---- 130 10| F. || Yes -|------ 23 mos-) Yes---| No----| No----| Left ---4----do - - - - - 4 | No--|---do ---- 131|| 13| M. | Yes -|------ 3 yrs---|No----| No----| No----|---do ---| O. C. 4 ft-- 1 | No--|---do ---- 132 5. M. || Yes -|------ 8 mos--| No----| No----| No----|---do ---| Q. C. 8 ft--| 1 | No--|---do ---- 133| 36|| M. |------ Yes - 19 yrs-- §ºre Yes---| Yes - - -] Both ---| O. C. 1 ft. 3 | No--|---do -- I’S. 134l 16 M. |------|------ 4 yrs---| No----| No----| No----| Right--| O. C. 6 ft -- 2 | # ---do ---- 135| 31|| F. [- - - - - - Yes || 21 yrs-- jº Yes--- §ºre Both ---| O. C. 4 ft -- 4 : ; ---do -- yrs. yrs. 136] 21 M. |------ Yes - 8 yrs---|Severe] Yes---| Yes---| Right--| O. C. 3 ft-- 2 | #6 || --do --- I’S. - 137| 8 M. Yes || - - - - - - 2 yrs---. No----| Yes---| No----| Left - - -] O. C. 1 ft.-- 1 | No. ----do --- 138|| 11| F. || Yes |- - - - - - 4 yrs---| No----| Yes---| No----|---do - - -] O. C. 8 ft.-- 1 | No--|---do -- 139| 9| F. | Yes || - - - - - - 6 yrs---| No----| Yes---|NO----|---do - - -] O. C. 2 ft.-- 1 | No.-1.--do ---- 140| 6| M. || Yes -|------ 1 yr ----| No----| Yes---| No----|---do --- O. C. 3 ft-- 3 || 36 |-|--do --- 141 8|| F. || Yes |- - - - - - 3 yrs. --| No----| Yes---| No----| Right--| O. C. 8 ft.-- 1 Nº. -do --- 142 12| M. || Yes - - - - - - - 8 mos--| No----| Yes---| No----|---do ---| O. C. 2 ft --| No...] No -do ---- 143, 9; M. || Yes ------- 3 yrs---| No----| Yes---| No----|--|-do - - -] O. C. 1 ft.--| No--| No--|---do ---- 144|| 7 || M. Yes -|------| 2 yrs---| No----| Yes---| No----| Left ---|----do ----- No--| 35 |---do ---- 145| 7| M. | Yes - - - - --- 1 yr----| No----| Yes---| No----| Both---|--|--do ----- so...] Nº,...i. 146|| 8 F. || Yes -|- - - - - - 4 yrs---| No----| Yes---|NO----|--|-do ---| O. C. 3 ft--| No--| No--|---do ---- 147| 6 F. || Yes -|------ 3 yrs---| No----| Yes---| No----|---do ---| O. C. 2 ft--| No--| No--|---do ---- 148; 4. M. | Yes -|------ 2 yrs---| No----| Yes---| No----|---do ---|----do ----- No. - No--|---do ---- 149; 3 F. Yes - |- - - - - - 1 yr----| No----| Yes---| No----|---do ---|----do ----- No--| No--|---do ---- 150] 3 F, Yes -|------ 2 yrs---| No----| Yes--. No----|---do ---| O. C. 1 ft.-- 1 | # ---do ---- 151| 5|| F. || Yes -|------ 3 yrs---| No----| Yes---|NO----|---do ---|----do ----- 2 | f |---do ---- 152, 8 F. | Yes -|------ 4 yrs---| No----| Yes---| No----|---do ---| O. C. No -- 2 O--|---do ---- 153| 7| F. || Yes || - - - - - - 5 yrs---| No----| Yes---| No----|---do ---|----do ----- 3 i No. -|---do ---- 154, 6) F. || Yes -|------ 2 yrs---| No----| Yes---| No----|---do ---|----do ----- 2 No. -)---doº---- O. C.- Ordinary conversation. PAN-AMERICAN MEDICAL CONGRESS. 1685 tympani and Ossicles—Continued. Results of operation. Hearing power. ; % tº Q. § # O ..? e § th e 3 #3 º 5 à p & e * | < | #: C 3 ~! gº #3 • Pº Q3 .8 © . Gł) GD cº C : g: --> .9 ;: | *B {ſ} § * ..? º: .8 § S 5 || 3 | : : º O Q ſh- H P- P- É B | #: O O 2, Im. No----| No----| No-------- No-------- O.C. 4 ft --| 2 | dº | 10 mos-| Scarlet fever Pººl. 122 3,1] Ch IIlC. No----| No----| No-------- No-------- O. C. 18 ft -| 5 | }} | 11 mos-|--|--do -------- ----do ------ 123 No----| NO----| No-------- No-------- O. C. 2 ft.--| 4 || 3 || 8 mos. - | Diphtheria.-- Pººh and 124 Iſlä, JićTIS. N: N: N: * * * * * * * * §§ * * * * * * * * 3. 3. #. ; § # IGOl()3 - sellettever ::::::::: - - - - - # O- - - - , INO - - - - | N O - - - - - - - - O-------- * * * - --- 3 mOS-l----do -------- ----ClO ------ No----| No----| No-------- NO-------- öö. §ft| 3 || || |#y.....I. ----do ------ 127 No----| NO----| No-------- NO-------- O.C. 3 ft. -| 6 | #, 2 yrs---|----do -------- ---do ------ 128 No----| No ----| No-------- NO-------- O.C. 2 ft -- 12 | ##| 9 mos--|--|--do -------- ----do ------ 129 No----| No----| No-------- No-------- O. C. 3 ft --| 6 || 3 || 6 mos------do -------- ---do ------ 130 No----| No----| No-------- No-------- O. C. 5 ft, 4 #, 13 mos-----do -------- ----do ------ 131 No---. No----| No-------- No-------- O. C. 9 ft--| 2 | #5 || 1 mo---|----do -------- ----do ------ 132 Slight | Slight | No-------- No-------- O. C. 13 ft-| 12 | #, 3 mos--|----do -------- ----do ------ 133 No----| No. ---| No-------- O-------- O. C. 5 ft --| 2 | #, 20 mos-----do -------- ----do ------ 134 Slight | Slight | Slight ----| Slight ----| O. C. 11 ft-| 3 | * | 7 mos--|----do -------- ----do ------ 135 No----| No----| No-------- No-------- O.C. 7 ft.--| 1 | # | 7 mos--|----do -------- ----do ------ 136 No. ---| No----| No-------- No-------. O.C. 3 ft. 2 |No. 9 mos......do-------- ----do ------ 137 No. ---| No----| No.------- No-------- O.C. 18 ft. 4 | No. 4 mos--|----do -------- ----do ------ 138 N: N: N: * * * * * * * * N: *s ºs º ºr ºs ºs ºn am 9% 6 ft - ; §§ ; II].OS - L Meºles * * * * * :::::::: - - - - - #. O- - - - | N O- - - - | N O - - - - - - - - O-------- ----ClO - - - - - Ol 'ſ IllOS- - - - - - ClO - - - - - - - - ---ClO ------ No----| No----| No. ------- No-------- ---do----- 3 | No 6 mos--|--|--do -------- ---do ------ 141 §§ * * * §. §§ - - - - - - - - §§ &m - sº * * * * * 8. §§: ; § §::::::: Piºneria: ...: - - - - - - #. O. ---| N O - - - - | NO---. - - - - O-------- * *-* * - - IIlCS--|----ClO -------- ----ClO ------ No----| No----| No-------- No-------- öö. Aft| 5 || || |iº...I. ----do ------ 144 No----. No----| No-------- No-------- O. C. 12 ft-| 8 | #3 |-|--do---|--|--do -------- ----do ------ 145 No----| No----| No. ------- No-------- O. C. 4 ft --| 5 | # |---do---|----do -------- ----110 ------ 146 No----| No----| No-------- No-------- O. C. 3 ft.--| 3 | #5 |-|--do---| Mumps------|--|--do ------ 147 No----| No----| No-------. No-------- O. C. 2 ft --| 2 | #; ---do---|----do -------- ----do ------ 14S No----| No----| No-------- No-------- O. C. 6 ft --| 6 ||No|| 4 mos--|----do -------- ----do ------ 149 No----| No----| No-------- No-------- O. C. 10 ft-| 3 | # |-|--do---|--|--do -------- ----do ------ 50 No. ---| No----| No-------- No-------- O. C. 2 ft.--| 8 || #; 9 mos--|----do -------- ----do ------ 151 No----| No----| No-------. Ne-------- O. C. 3 ft --| 7 | #5 || 1 yr----|--|--do -------- ----do ------ 152 No----| No----| No-------- No-------- ----do----- 9 | #5 | 11 mos-|----do -------- ---do ------ 153 No.---. No----| No-------- No. ------- O. C. 4 ft --| 3 | #; 9 mos--|--|--do -------- ---do ------ 154 1636 PAN-AMERICAN MEDICAL CONGRESS. In the foregoing list of 154 operations it will be found that from cases 15 to 84 inclusive we record 691 patients presenting the non-suppurative variety of middle- ear disease. Many of these patients suffered from distressing tinnitus; severe pain, staggering, vertigo, and marked impairment of hearing, while others com- plained of one or more of these same symptoms in a much less degree. Their ages range from 21 to 81 years. The timein which the patients suffered from one or more of these symptoms varies from two to forty years, while the time elapsing since the date of operation is from three months to four years. The improvement in tin- nitus and vertigo has been in many cases most striking and satisfactory, notwith- standing the little hope that could be offered for their relief in some of the cases before operation. The probable improvement of hearing in this class of cases is of course not marked by so many favorable possibilities as in the suppurative variety and yet a perusal of the carefully recorded results will, we think, be convincing that the operation in selected cases is now justifiably demanded. PART SECOND. In chronic suppurative disease of the middle ear, after all ordinary measures have failed, the excision of the membrana tympani and ossicles is resorted to for relief or cure of carious or necrosed bone or diseased tissues, causing mechanical obstruction to the entrance of sound, and is now a well-established rule of prac- tice as well as a decided advance in aural surgery. In non-suppurative or chronic middle-ear inflammation the operation has received the term “otosclerectomy'' (očg, Öróg, ear; alcâmpáç, hard; £któum, excision), or the Surgical removal of all or part of the sclerosed and anchylosed conductors of sound. The operation has received the sanction of the majority of the aurists of the United States and many in Germany for properly selected cases. Now and then we meet with cases of such failures as occur with our best surgeons in the best diagnosed and selected cases. “To err is human,” etc., and in our experience of many years in the practice of the profession we have witnessed some errors and have received authen- tic reports of sad results in general surgery from others. Not only do they occur in the hands of the tyro, but in those of professors and hospital surgeons of our cities. In properly selected cases of non-suppurative or chronic middle-ear inflam- mation our success has been good, when we find a patient with the obstruction anywhere between the thickening and adhesions of the membrana tympani or anchylosis of the malleus with the incus. It is almost always necessary to per- form a preliminary operation by a removal of an oval piece of the drum with the malleus. When we find that this opening improves the hearing or relieves the tinnitus and vertigo, we then complete the Operation by removing the incus. If there be any dry, progressive sclerosis affecting the stapes, it has been advised to make a long incision in the membrana tympani posterior to the malleus, and to use traction on the incudo-stapedial joint. If these are not effectual in removing the annoying symptons, then it will be safe to resort to the full operation, i.e., excision of the membrana tympani and OSsicles. In our hands even sclerosis has been stopped by the operation. See case which stood the test of two years, as fol- lows: The most recent one was a lady of 38 years. She was profoundly deaf, only hearing the watch, of 60 inches, on close contact on either ear. There was pain and great tinnitus, with vertigo. Both ears were operated upon May 22, 1892. The left ear first, the right ear soon after, as at first she did not experience much benefit. The parts continued so patulous that she breathed through her Eustachian tube. In May, 1893, her hearing had improved to 8 inches for the watch on the right and 4} inches on the left. She can hear an ordinary voice, by first calling her attention to it, at 25 feet, and is no longer considered very deaf by her friends. The progress in this case was very slow, being almost one year before decided improvement took place, PAN-AMERICAN MEDICAL CONGRESS. 1637 The following is a much more satisfactory case: Excision of the membrana tympani and handle of malleus in otitis media catarrhalis chronica, with improvement of hearing and removal of the tinnitus and vertigo: E. H. K., aged 46, a daughter of one of our deceased county judges, was left dependent upon her own exertions for a livelihood. When she presented her- self, June 9, 1891, at our office for treatment she was profoundly deaf from otitis media catarrhalis chronica of many years’ duration. She had also suffered from chronic rhinitis, with nasal hypertrophies, all of which had been removed and everything done for her without improving her hearing. On testing her hearing by watch, of 60 inches, it was not heard on close contact on the right ear, and only 3 inches on he left. Miss E. H. K., status praesems, June 18, 1891: Right ear, membrana tympani thickened; the short process prominent; the handle attached to the promontory and the whole malleus was twisted on its axis (torquirt) Gruber ; the air enters the tympanum ; H. W. close (pressed contact); tuning fork, full C; Reiner's test shows the auditory nerve normal ; bone conduction good; tinnitis (from pressure), escaping steam, hissing, and roaring. Left ear the better looking, taking all points in topography of the membrana tympani, etc.; conditions the same as in fellow-ear; air enters the tympanum full and well; but one section (posterior and superior) moves from autoinflation ; H. W. = 3 inches, Reiner's test nega- tive; the auditory canal was relaxed and dry, with a general congestive condition; bled on rough contact of cotton. A radical operation was proposed, excision of the membrana tympani and malleus; and she consented, as she had great difficulty in being understood in her business. After suitable preparation the patient was admitted into the woman's surgical ward at the Jefferson Medical College Hospital on Friday, February 5, 1892. She was operated upon on Saturday, the 6th, Dr. Eads, one of the surgical assistants, administering the ether by carefully dropping it on a folded towel until there had been employed some 4 ounces, but she was not profoundly unconscious. We then directed her to be given a few whiffs of chloroform, which had the desired effect, but in a few seconds respiration became embarrassed, and the chloroform was withdrawn ; artificial respiration was performed, and after prompt recovery the ether was again resumed and the operation performed. The first difficulty was the great relaxation of the lining membrane of the auditory canal, which was pushed before the Gruber speculum. A bivalve was then tried with no bet- ter results. A large-sized ordinary Politzer speculum was then employed with the illumination of the electric light. Another difficulty in her case was that after performing the double incision the canal was filled with blood, which was very much in the way during the whole operation. In cutting around the malleo- incudal joint found it very firmly anchylosed, so that it could not be removed by a strong pair of forceps; so, after using all the force considered justifiable, Dr. Smith, who assisted me, tried to remove it, but he had no better success, although he found the section complete all around the membrana tympani, and also the double incision running up to the membrana flaccida. After removing the mem- brana and handle and part of the malleus and cleansing the parts and blowing iodoform powder into the canal, plugging it with iodoform cotton, the patient was removed from the operating room to the ward. She had considerable nausea from the anaesthetic, but had no bad symptoms, and was able to leave the ward on the ninth day after the operation, greatly improved in hearing, being able to hear with that ear when the other was closed. On examination ten days later she stated that everything sounded loud to her. She also heard the watch half an inch from the ear which before she could not hear on close contact. The following is her own statement, she being well edu- cated and intelligent: “Am both pleased and surprised with the result of the operation, for although I was not very sanguine of deriving much benefit from it, at least I would not let myself hope too much, fearing a disappointment; yet I was willing to try. From the very first day after the operation I found an improve- ment. Voices at the other side of the room were loud and unnatural, but I could not distinguish the words. The footsteps which before seemed to move noiselessly along the bare floors, now seemed like the tread of heavy shoes. I can now hear the voice and speech given in an ordinary tone and without being very near the speaker. The noises of wagons and cars in the street are very loud and sound as if the ground was hollow. All sounds and voices seem loud and unnatural, except- ing music, which has lost none of its sweetness. All my friends are surprised and pleased with the improvement in my hearing, and say it is no effort to make me hear them now. This is all without my ear being entirely healed, and filled with cotton wool. I am now waiting to hear what improvement I will find in being able to hear a sermon or address in public. I have tried to give you a very cor- 1638 PAN-AMERICAN MEDICAL CONGRESS. rect account. I have a sound in my ear like puffing of steam, always worse after coming upstairs, but sometimes it is so faint that I forget it.” The patient presented herself on twelfth day, and we removed considerable dried blood. Tested her hearing and found her progressing most favorably. Again, on February 17, my patient reported as follows: “Hearing continues good and the harsh sounds are disappearing.” Tested her hearing in ordinary conver- i. with her face turned from me, and she heard me distinctly at a distance of 13 feet. Two weeks later she reports: “Yesterday was the first test I have made of my hearing, since the operation, in church, and it was a Complete surprise to me, for I had never imagined that I should find such great improvement. I had no diffi- culty in hearing the lessons read, and in fact all of the service, and I was able to join in myself, and that is what I have not been able to do for a great many years— fifteen or sixteen I think—and the great volume of Sound that came from the organ almost overwhelmed me, I was going to say—perhaps that is almost too strong a word—yet Ihave often been in doubt whether the organ was being played at alſ, it would be so indistinct at times, and yesterday the difference was so great. I find a great improvement in many ways. I get along much better at work, and my friends do not have to strain their voices to make me hear.” .. One month and five days after the operation, since her last visit, she reports: “Have had some pain in the ear, but on blowing the nose forcibly Some blood passed, and the pain disappeared with no return since. Visited a friend in the coun- try on Sunday, who stated that it was like a revelation, the restoration of my hear- ing. At a business meeting I was able to hear all that was going on, when for- merly I heard not a word.”* tº * tº Two years after the operation, June, 1893, hearing continues perfect in the ear operated upon; new membrane formed has been examined by Dr. S. MacCuen Smith, Dr. C. S, Turnbull, and Dr. C. M. Thomas; all confirm the good results in her case. In proliferous disease of the middle ear, and when all ordinary and extraordi- nary measures, as massage, vaseline, Eustachian bougie and catheter, vibratory treatment, etc., have failed, we are fully justified in Opening the drum, and excising the head of or the entire malleus, but it has not always been found nec- essary to remove the incus and stapes. In cases of severe pain in the ear of an obscure nature, with a dreadful feeling of pressure, cases of which have been seen at the aural clinic, much relief of a permanent character has been afforded the patients by opening the drum and disarticulating the malleus. On examination there has been found diseased bony structure which giving no other indication on the surface. We have found similar disease in the mastoid region, where in two cases an opening was found in the bone large enough to admit the tip of the fore- finger. We have never, as yet, known of a death from this operation, but cases have been reported where the hearing power has been made worse. Cases accom- panied with atrophy or paralysis of the auditory nerve should not be operated upon. Again, great care must be taken not to injure the Fallopian Canal with the incus hook. Children can be operated upon, and even old men have had their hearing restored for ordinary conversation, also experiencing great relief from tinnitus and vertigo. As a matter of course, the older the individual, the less chance of restoration to good hearing. Yet cases aged 60 and even 81 years have been oper- ated upon with good success. We are all liable to accidents, yet much can be done to prevent them by great care in our manipulations in so limited a space as we have to operate. The use of antisepsis, a good electric light, and a proper clip for a lens on the back of the forehead mirror; this is necessary for presbyopes. The mobilization and extraction of the stapes was first proposed by Ricardo Botey (Berlin Congress, 1890) and modified and performed by Miot and Boucheron. An incision was made on the outer periphery and the stapes was extracted by a Palet hook. Kessel and Botey employed extraction through the fenestra Ovalis in * Progress of Otology, Annals of Ophthalmology and Otology, April 1, 1892. PAN-AMERICAN MEDICAL CONGRESS. 1639 anchylosed and fixed stapes. Still later, C. L. Jack” reported 16 cases; 5 for chronic middle-ear catarrh, in which there was a remarkable improvement in a number of the cases. Then we have the synechotomy, or section of the stapes sug- gested by Schwartze and published in the transactions of the congress at Basle. (In Politzer's work are figured the instruments for the performance of these opera- tions, pp. 273–275; Figs. 144, 145, and a careful description of the operation.) The most recent report on the removal of the stapes is by Clarence J. Blake (Boston) + of 4 cases operated upon under a solution of cocaine. His results have not been very encouraging; 2 were slightly improved, and in 2 there was no improve- ment. The operation for excision of the stapes has only been performed in a very few cases in Philadelphia, owing to the prolonged staggering vertigo which fol- lowed them. Schwartze's contraindications to operation for removal of the drumhead, ham- mer, and anvil: (1) Excessive deafness so great as to require shouting into the ear of the patient. (2) When inflammation of the middle ear produces not even temporary improvement in hearing or tinnitus. (3) When puncture of the drum head improves neither tinnitus nor hearing, never do a double operation and do the operation only in the worst ear. Operations should only be performed under these conditions. Our Own conclusions are as follows: When a patient is so deaf as not to hear the voice close to the ear or a watch of 60 inches applied in contact, we would reject such as unfitted for the radical operation, but the preliminary one can be performed. If the suppurative process has continued for a very long period, especially in a scrofulous or consumptive individual, it is best to give a guarded opinion of the success of the operation, as structural lesions of the internal ear are apt to OCCur. The demonstrations shown by Prof. Politzer, besides their scientific interest, aid us in understanding why in many cases our therapeutic efforts are not crowned with success. You know, gentlemen, that in recent years various attempts have been made to accomplish the extraction of the stapes for the purpose of diminish- ing the degree of deafness. As a matter of course, such an operation is only pos- sible as long as the affection has not produced a condition of anchylosis. When the plate of the stapes is once fixed to the fenestra ovalis, or even partially fixed, an operation becomes impossible, for the arch of the stapes would break off under the least traction. But even should our operation appear to bring immediate relief we can hardly hope for a permanent result in all cases, if we bear in mind the anatomical changes which we have observed in the specimens shown by Prof. Politzer. As we have seen that the Osseous proliferation originates in the capsule, is progressive, and extends toward the oval window, almost invariably producing complete occlusion of the fenestra, even an early extraction of the stapes would hinder the progress of the disease in the form of anchylosis here described. mºmmºm- DISCUSSION. Dr. M. THORNER. The favorable results obtained by Dr. Turnbull in a number of cases of removal of the membrana tympani and some of the Ossicles are cer- tainly very remarkable. I am inclined to think that in his cases, as well as in those reported by some other gentlemen, conditions prevailed more favorable to obtaining good results than in cases reported by some observers who greatly dis- favor these operations. I think that we may expect, in cases of simple adhesions, *Transactions American Otological Society, 1892. t Archives of Otology, April, 1893, p. 196. 1640 PAN-AMERICAN MEDICAL CONGRESS. better results than in those of complete anchylosis. If the mallelus has been removed, it appears to be rather risky to leave the incus where it possibly might do harm, while its presence can not aid any longer in the mechanism of the sound- transmitting apparatus. As to the removal of the stapes, there is at present scarcely enough evidence to formulate distinct indications for this operation. But it stands to reason, especially if we consider the light thrown upon this ques- tion by yesterday's demonstrations of Prof. Politzer, that in a great majority of cases we can not expect to obtain any permanent results by the operation of stapedectomy. I would like to ask Dr. Turnbull in what position he places his patient during the operation. May not the position, either the sitting or half reclining, have been responsible for the embarrassment of respiration, observed in the one patient, as soon as chloroform was given P Dr. HOBBY. Is it not possible that many of the failures in operations upon the middle ear are due to labyrinthie disease having been previously developed? Dr. MALONEY. I would like to ask Dr. Turnbull whether the two successful cases reported in the paper read by him represented the success obtained in the entire number of operations named by him in the first part of his paper? My method of treatment compels me to admit the necessity for excision of the mem- brana and Ossicles only in cases showing caries, and not as a means of improving the hearing. The limited success following this operation for improving audition I think sustains me in my view. Dr. TURNBULL. In reply to the question of the secretary, I am not sure of the removal of the incus, and therefore did not state that it was removed. I always operate by placing the patient on a bed or lounge on the side. A number of chronic cases are reported in Dr. Smith's table operated at the clinic of the Jefferson Med- ical College Hospital. FOCUSING EAR TRUMPET. By EDMUND D. SPEAR, M. D. The large number of cases of incurable diseases of the ear, accompanied by deaf- ness for conversational tones, makes it necessary for the aurist to prescribe some form of acoustic apparatus as an aid to hearing. The unsatisfactory character of the ordinary mechanical aids is, perhaps, the cause of the negligence of aurists in regard to this matter. In Burnett's recently published System of Diseases of the Ear, Nose, and Throat an article on “Acoustic aid to the deaf '' will be found, in which I make suggestions regarding the use of instruments for patients with defective hearing, and Ishall quote some of them in this paper. The importance of this is not appreciated by aurists as it should be, partly, per- haps, from the fear that the impression might be given that when artificial aids are advised the prognosis is no longer favorable and the case likely to be considered incurable. This fear, together with the general antipathy to the use of instru- ments, continues to prevent encouragement in their use, and may effectively hin- der the scientific study of very interesting acoustic phenomena for the develop- ment of this department of otological research. To paraphrase the words of an eminent writer, “If it were not that the science of acoustics is one of the least per- fect branches of human knowledge, and its practical application certainly the least understood, it would be easy to explain the principles on which perfect ear trumpets should be made.” * - Acousticians and aurists have, up to the present time, failed to furnish any single instrument to suit all cases, or indeed any satisfactory apparatus or mechan- ical means (besides the so-called artificial membranes) for restoring the function of hearing. It is true that a limited number of deaf patients find that some par- ticular device serves to improve their hearing for certain sounds and individual voices, but there is no instrument which can be varied in shape so as to change with the varying character of the sounds desired to be heard. /2 SCHEME OF FOCUSING EAR TRUMPET. FOCUSING EAR TRUMPET. PAN-AMERICAN MEDICAL CONGRESS. 1641 A few principles for guidance in the choice of proper instruments will be here given. The size, shape, and length of each tube, as well as the condition of its interior surfaces, its mouthpiece, and ear tip. are to be first examined and com- pared with those of all kinds obtainable. The size of the internal bore of a tube is of prime importance, as every aurist knows by experience with his “otoscope,” which is usually made of flexible rubber tubing fitted at each end with ear tips. A comparison of tubes of different caliber, though fitted with the same ear tips and of equal length, will quickly show that tubes are resonators for the various tones, and that the same sounds heard through the different tubes appear much varied in character. Cone-shaped tubes without breaks or seams within are best formed to convey the sound waves to the ear. Of the score of forms of ear trumpets offered for the use of the deaf by surgical- instrument dealers, but three or four appear to be constructed with a view to secure the best results with the least expenditure of material. In order to meet a demand for small instruments makers have been led to sacrifice utility for size, and on this account have fallen into error. The ear trumpets which give the most satisfaction are those made on proper acoustical principles without reference to size. These combine the reflecting par- abola with the cone-shaped conducting tubes. All the ordinary ear trumpets consist of large horns with wide extremities, tapering with more or less varied curves or with frustra of cones to the small ends, which are fitted with ear tips intended to fit into the auditory canal. A cone-shaped tube tapering to a point, and with one of its sides partially cut away, is the best kind of instrument for the use of those partially deaf. The cut in the side, as now made, is of service in forming shorter columns of air in the tube, which serve as resonators for tones of high pitch (particals of tones), thus giving a more serviceable instrument than one formed from a plain cone. Research and experiment in applied acoustics will accomplish what I hope to open the way to by the presentation of instruments which in a measure fulfill indi- cations, and the aurists, to whom this work belongs, must undoubtedly profit by the results. To illustrate my improved manner of condensing sound waves I shall present to the section two forms of instrument. Strictly speaking the word “focusing” can be applied as descriptive of the manner in which the sound waves are condensed in referring to what takes place in one only of these forms, though the result arrived at is practically the same in both. In the long axis of a metal reflector, whose sides are parabolic, a short, hollow, metal cone is placed with its large end directed inward. These are relatively so fitted that the cone can be adjusted for the various focal points of the parabolic reflector by being moved nearer to Or farther from the apex of the reflector. To a cone-shaped tube tapering to a point and of a length to correspond with the wave lengths of tones whose pitch is below C, is fitted a small tube within which another tube is made to slide. To this latter tube a small hollow cone is fastened at one end; a short, curved tube is fitted at the other end. This comprises the portable form. By varying the length of the air columns within the cone and adjusting at different points a considerable varia- tion in perception of tones is produced. AN IMPROVED MIDDLE-EAR POWDER BLOWER. By R. D. BARRET, B. S., M. D., of St. Louis, Mo.. Clinical Assistant to the Department of Diseases of the Ear of the Missouri Medical College. The little instrument I wish to describe to you as briefly, yet as clearly as possible, was designed primarily for the purpose of applying directly to the diseased parts any of the various antiseptic powders so often indicated in the treatment of those cases of chronic suppurative inflammation of the attic Space, in addition to the inflammatory process going on in the atrium. But it has proved to be for me the most convenient and perfect universal powder blower I have found 1642 PAN-AMERICAN MEDICAL CONGRESS. as yet, and I hope it may be equally as useful to others in every respect. Its three component parts are the canula, the receptacle for the powder, and the rubber hand bulb. The canula is similar to that of the Blake middle-ear Syringe, 3inches long, one-sixteenth of an inch in diameter, and has an upward curved extremity to direct the powder into the attic. A second canula with a straight point will add greatly to the range of usefulness of the instrument. The receptacle for the pow- der is a metal bulb an inch in diameter. From it projects a tube about three- fourths of an inch in length, and to the end of this the Canula is attached. At a point directly opposite is a short nipple, over which fits the rubber tube leading to the air bag. Over the opening of this nipple within the powder recep- tacle is soldered a wire screen with a mesh so fine that the finest powder will not pass through it unless rubbed, but still it does not interfere materially with the force of the air current. This screen prevents the powder from falling or being drawn into the rubber bulb. The powder receptacle is opened for filling by unscrewing a small segment of it, the center of which is the point of attachment of the canula. The base of this tube is encircled by a milled-edged band to prevent the annoying slipping of the fingers so frequently experienced with such instruments. To the under side of the largest part of this receptacle is fastened a handle in the shape of a loop through which the thumb is slipped in using the blower. The air bulb is the ordinary rubber bulb used for the same purpose On other instruments. The tube leading to it should not be over 3 inches long, and for one with a small hand even that is too long. In using the instrument the thumb is slipped into the handle from behind, the powder receptacle resting On the top of the thumb between the nail and the knuckle, the first finger steadying it by pressing the handle against the ball of the thumb, the rubber tube passing to the Outer side of the thumb–not between it and the first finger—and the air bulb then falls natu- rally into the palm of the hand, when a very slight pressure upon it by the two or three free fingers puffs out the powder. A too forcible compression of the bulb simply blows the powder around the receptacle, but the least bit of force will puff it out readily. The canula is bent at an angle of 130° from the body of the instru- ment, hence it is all that is in the line of vision. The right hand manages the instrument perfectly, leaving the left free to hold the speculum or for any other manipulation that may be necessary. The cannula and powder receptacle are nickel-plated, can be easily and quickly separated, cleaned, etc., and there is nothing about the instrument to break or get out of order every few days. - My sincere thanks are due to the Mellier Surgical Instrument Company of this city for the careful and skillful manner in which they carried out my idea and the perfect instrument they produced. ADENOIDS A CONTRIBUTIVE FACTOR IN AURAL AFFECTIONS. By M. D. LEDERMAN, M. D., Assistant Surgeom, Manhattan Eye and Ear Hospital ; Instructor in Laryngology and Rhi- mology, New York Polyclinic; Assistant Laryngologist and Otologist, Mount Sinai Hospital Dispensary. - Although hesitating before offering an abbreviated paper upon a subject which has generated such universal discussion, the continued appearance of neglected cases permits the expression of pleasant results observed after the removal of this frequent causation of middle-ear disease, especially in children. Realizing that this subject has already commanded the attention of some of my auditors, I con- sole myself with the thought that this field of medicine has been so thoroughly №ģ（{ gº tººt it tº lººt **lintº | AN IMPROVED MIDDLE EAR POWDER BLOWER. PAN-AMERICAN MEDICAL CONGRESS. - 1643 cultivated it would seem impossible to make an absolute discovery. However, I trust you will bear with me, in the hope that there may be a few among those present who have not given this cause its deserved recognition. When we consider the percentage of ear diseases prevalentin early lifeit, behooves us to carefully investigate the observation of clinical experience and test the vir- tues of its information. It is indeed gratifying to reëcho the statements of others interested in this topic, and to conscientiously testify to the delightful benefits derived from the ablation of the hypertrophied lymphoid tissue in the post-nasal space, especially in cases of suppurative otitis chronica. Although appreciating the impression produced in offering statistics upon any given subject, I will not tire you with them, but with your kind indulgence will give later the history of two or three cases that demonstrate these few remarks. In attempting to ascertain the immédiate influence which the hypertrophied pharyngeal tonsil has upon ear disease we are confronted with numerous pro- posed theories. Before giving any of these in detail, I briefly quote the statements of some authorities on the disturbing effects of so-called “adenoids” upon the sense of audition. Woakes * expresses his experience in these words: Interference with the organs of hearing, inducing more or less deafness, is the most frequent and to my mind the most important of the direct lesions resulting from the disease. Not more than 5 per cent of my cases have escaped this complication. Beverly Robinson f mentions the observations of Dr. Swinburne, who states that “in a large proportion, indeed in all cases, of adenoid vegetations the ears were found diseased.” Again, Dr. Robinson adds that “other observers have described the great frequency of aural complications in cases of adenoidvegetations.” Under the symptomalogy of hypertrophy of the pharyngeal tonsil, Dr. Bos- worth'sf experience is so clearly expressed, I can not offer a more weighty thought than to quote verbatim from his valuable work: Probably no symptom of the disease possesses greater importance or requires more thorough appreciation and study than that of ear complications, Occurring, as they do, early in life and at a time when their prompt recognition only may save the patient from permanent loss of this important faculty. In referring to cases of total deafness in children due to this lymphoid swell- ing, Lavrand, § of Lille, considered the growth to be a cause of deaf-mutism, and thought that their removal would act as a possible cure of the latter affection. If we believe that this pitiable condition is contingent upon pharyngeal vegeta- tions, their predominating influence is truly amazing. In a very interesting and instructive brochure | upon Lymphoid Growths in the Vault of the Pharynx, Dr. T. R. French informs us that deafness as a complication of this disease occurs in more than half the cases. With such statements before us we can not lay too much stress upon the immediate relationship the nose and naso-pharynx bear to aural disturbances. - My experience in clinical and private practice certainly proves the immediate influence this disease has upon the production of deafness, be it a catarrhal or sup- purative manifestation. I have watched the progress of young patients under the routine treatment of syringing, peroxide of hydrogen drops, with boric-acid insuf- flations, and though the suppuration ceases for the time the patients would often return with another outbreak. These recurring attacks were promptly overcome by ridding the pharynx of its irritating occupant. We should never consider an * Woakes, Post-Nasal Catarrh. - + Beverly Robinson, Treatise on Nasal Catarrh and Allied Diseases. † Bosworth, Diseases of the Nose and Throat, Vol. 1. § Lavrand, Annual of the Universal Medical Sciences, Vol. 4, 1890. | Paper read before the Kings County Medical Society, August 18, 1893. 1644 PAN-AMERICAN MEDICAL CONGRESS. examination of a patient with ear difficulty completed until the nose and naso- pharynx have been thoroughly inspected. In children we should never hesitate to bring to our aid the proverbial eye at the end of the finger. It is not exaggerating to assert that the majority of running ears in children, together with the depressed condition of their general health, is the consequence of this often-neglected factor. It is not unusual to diagnose the presence of these growths by the child's facial expression alone. The senile appearance of the young one, the drooping eyelids, together with the open mouth, are indicative of the post-nasal obstruction. . As to the theories suggested in the causation of ear disease by these growths, Bosworth supposes the trouble to be due to an interference with the renewal of air in the middle chamber. Any cause which interferes with free nasal respiration, if continued sufficiently long, is liable to produce impaired hearing by creating a stagnation and rarefication of air in the pharyngeal vault. The free action of the levator palati muscles is hindered by the hypertrophied tissue, thus preventing their compensating action. A catarrhal process is incited by this rarefication, an hypera-mia and its consequences appearing in prompt succession. Lowenberg con- cludes that theinflammation is a direct continuation of the pharyngeal involvement. Blake reasons the result to be due to a passive hyperaemia of the middle ear, by interference with the return circulation, owing to the pressure exerted by the post- nasal growths upon the pharyngeal veins. This seems quite a plausible theory, and we can readily imagine that some such effect may be the result if the blood current of the neighboring tissues is materially obstructed. My views incline toward the supposition of some disturbance of the circula- tory function. There can be no doubt that the presence of this foreign element influences the blood supply, thus exciting a congestion of the local tissues, and possibly affecting the vasomotor system of the middle ear as well, thereby giving rise to an inflammatory process. We are yet in the shadow of a revelation which I earnestly hope will soon illuminate the present obscurity. In dwelling upon the immediate relation of this factor in the production of aural complication, it would be unpardonable had I omitted mentioning the deleterious influence that nasal stenosis has upon the organ of hearing. Suffice it to state that in the majority if not in all cases of otitis media catarrhalis chronica in which there exist some obstructing lesion in the nose, we may sincerely expect to improve the patient's hearing by removing the barrier to normal respiration, thus allowing the necessary aeration of the Eustachian tube and middle ear. The proportion of children under 10 years of age that are subject to adenoid growths is so large that I anticipate their presence in almost all cases of middle-ear Suppuration, particu- larly if it be of a chronic nature. The happy results obtained from the thorough removal of the pharyngeal obstruction in such cases permits Irie to cheerfully promise a speedy relief from the offensive discharge and an improvement in the hearing distance, not overlooking the beneficial effects upon the general health of the patient. Very briefly I mention the history of a few cases, in one of which the discharge ceased surprisingly soon after the surgical treatment: Case 1.—Nettie G., 3 years of age, well nourished; mother noticed that the child experienced difficulty in breathing; was restless at night ; tossing about in sleep, snoring loudly; lips were parched and covered with a deposit of dried secretion in the morning ; in short, a mouth-breather. The little one had attacks of fever off and on, in one of which an acute suppurative otitis media developed. There was some pain before pus showed itself, but it was not distressing. The ear was treated by the family physician with hot-water douches and boric-acid insuffia- tions. The suppuration ceased for two months, then reappeared with acute symp- toms. The same treatment was continued, with a cessation of the discharge. With the next appearance of the difficulty the patient came under my care. The history being so pronounced, and the expression of the child's face being quite typical, I immediately examined for adenoids, and found the pharyngeal vault PAN-AMERICAN MEDICAL CONGRESS. 1645 completely filled. The growths were removed under an anaesthetic by means of the curette. On the fourth day following the operation no sign of suppuration was visible. Peroxide of hydrogen failed to reveal any pus. Until the present time (almost a year since the operation) the child has had no reappearance of her trouble. Her hearing has improved considerably, as shown by the voice test. At time of operation watch and finger-nail tests were not satisfactory. The child when last seen affirmed to the watch test at 3 feet and heard the voice in the usual tone. The parents noticed the improvement in hearing three weeks after the operative treatment. Case 2. —The pleasant effect of the surgical treatment in this particular case makes the history unusually interesting. I am indebted to Dr. Alvarez for the following history: J. H., aged 7 years. Mother lived in Florida, and while preg- nant with this child had an attack of chills and fever. The child was born in New York. Three months after his appearance into the world the infant was also attacked with chills and fever. This lasted for a week or ten days, and was treated by the family physician as malaria. Ever since the boy has had period- ical fevers every two or three months. Dr. Alvarez first saw the patient in the spring of 1891. Doubting these attacks to be malarial, yet, unable to ascertain their origin, he recommended a change of climate. The child spent the summer in the Catskill Mountains, but no improvement was noticed. The temperature in these febrile attacks never arose above 101°. In August, 1892, the young lad |became more ill than usual, and Dr. A. discovered that the faucial tonsils were markedly hypertrophied and adenoid growths were present in abundance. He then associated the periodical fevers with his discovery. In November following the little fellow became the victim of an acute otitis media suppurativa of both ears, which failed to get well under the usual treatment. This ear continued dis- charging until February, 1893, when I was requested to see the patient. The removal of both tonsils and adenoids was at once performed. The running ears ceased to flow at the end of two weeks, and up to the present time the periodical fevers have not returned. Through the kindness of Dr. Gruening, I briefly offer the history of an interest- ing case which proves the direct effect this common affection has upon aural dis- ease. A boy 5 years of age had two attacks of double-sided suppuration, compli- cated with mastoid disease, and at each attack the doctor was obliged to Operate upon both mastoids. After the removal of the adenoid vegetations the patient rapidly recovered, and has had no attack since that time. Dr. Gruening expresses his experience in the following words: I have repeatedly observed cases of otitis media purulenta which, though yield- ing temporarily to local treatment, had a tendency to recur, and that the tendency ceased when the adenoids had been removed. These and other cases lead me to believe that adenoid vegetations are a causative factor in purulent disease of the middle ear and the mastoid. Such observationis conclusive evidence of the important relation that this exciting factor bears to middle-ear disease. True, we sometimes find suppurative cases in children in which the adenoids are wanting, but they are indeed very few. It is not in the realm of this brief paper to dwell upon the methods employed in the removal of these growths, but will state that I have found the modified Gottstein's heart-shaped curette, together with the use of Lowenberg's post-nasal forceps, improved by Dr. Gleitsman, of most service. The continued employment of a favorite instrument leads one to become too greatly impressed with its superiority, and we are apt to overlook the good qualities of others. It is therefore necessary to test the merits of the modern modifications and by personal experience select the most serviceable. Dame Nature has considerately supplied some of my esteemed colleagues with strong finger nails, which have been cultivated and used with success in the destruction of the hypertrophied tissue. I doubt, however, whether this natural instrument is as successful as the manufactured curette or forceps, especially if the growths have assumed a fibroid character. The method employed is immaterial so long as the tonsil is completely extir- pated. A small portion of lymphoid tissue remaining may give rise to further difficulties, If we follow the custom of regularly examining the adjacent parts 1646 PAN-AMERICAN MEDICAL CONGRESS. Of patients complaining of aural symptoms, we would frequently discover the origin of their discomfort. In closing I can not offer a more appropriate thought than the one expressed in the words of Hamlet : That we find out the cause of this effect; Or rather say, the cause of this defect, For this effect defective comes by cause. DISCUSSION. Dr. T. V. FITZPATRICK, Cincinnati, Ohio. I most heartily concur in the doctrine set forth in this paper of the necessity of surgical interference in cases of adenoid vegetations or hypertrophy of Luschka's tonsil. Since the paper of Meyer, of Copenhagen, of twenty years ago, but little new has been said in favor of the necessity of surgical treatment of this hypertrophy. The evidence is only accu- mulative. What we need most is investigation of the cause or causes of this hyper- trophy. My own observations are leading me year after year gradually to the conclusion that a state of Suppuration, nasal or pharyngeal, is an essential prece- dent to the hypertrophy. I think we find a very apt analogy in the hypertrophied lymphatic glands in their attempt to carry off suppurative processes. Most of these cases will improve under antiseptic treatment, though I doubt if the true hypertrophy of Luschka's tonsil is ever cured by any antiseptic treatment, cer- tainly not-under many years. Suppurative rhinitis and pharyngitis in children is very common. Its far-reaching influence is probably due to the absorption of ptomaines. Recent investigations have shown in Ozena that when a suppurative process is stopped the anaemia, so often associated with it is arrested. We often find cases of adenoid vegetations of the vault of the pharynx anaemic. This can scarcely be due alone to the obstruction offered respiration by the hypertrophy, but is probably due to suppurative process associated with the disease. The theory of Hill, that this enlargement is due to the arrest of the migration of leucocytes, merits investigation. So far but little light has been thrown upon the cause, con- sequently nothing is done in the way of prevention. - To refer again to the disastrous influence which these lymphoid growths may and do exercise upon the organ of hearing, I can not too strongly advocate the course recommended by the essayist. He is right when he says that in purulent processes of the middle ear the routine treatment is entirely too often carried out, when an examination of the post-nasal space would readily reveal the cause of the recurrent attacks of suppurative inflammations. We must not always expect to find all the typical symptoms of adenoids presented in such children, but we must look for their presence in all cases where recurrent attacks of suppuration take place in young persons. I wish to also emphasize the fact that it has been my experience to find otherwise intractable cases of acute as well as chronic middle-ear catarrh frequently associated with adenoid hypertrophies; and we would probably oftener see speedy and more permanent improvement in such cases if we would establish the rule to always examine the post-nasal space. CRANIOMETRIC MEASUREMENT OF 500 SKULLS IN RELATION TO - AURAL TOPOGRAPHICAL ANATOMY. By B. ALEXANDER RANDALL, A. M., M. D., w Professor of Otology in the University of Pennsylvania and the Philadelphia Polyclinic. Aural anatomy and topography have of late years been the subjects of a number of interesting and valuable studies, stimulated by the increased specialization of otological work and the greater employment of bolder surgical procedures. The PAN-AMERICAN MEDICAL congress. 1647 Question of the topography of the temporal bone has grown steadily more press- ing, for the success attained by surgery in many directions is widening the oper- ative field and urging the surgeon to intervene radically upon less vital indica- tions than were formerly regarded as his sole justification. Especially is this the case in relation to mastoid trephining, which was reintroduced after a century of discredit, as a life-saving operation in cases of empyaema or caries of the mastoid. Now it is coming into use in the group of cases where intractability alone marks the case as dangerous, since the danger to life of skillful operation has come to be smaller than that of timid temporizing. Everything that tends to further lessen this peril constitutes a real step in the advance of otology in this and other directions, and gives promise of making it one of the most successful fields of medical practice, instead of being one that is now often, however unjustly, ad- versely criticised. Notable among these anatomical studies are those of Bezold, Hartmann, Zuckerkandl, Ruedinger, and Leidy, and from each of these we can claim important teachings, the two first having dealt specially with the operative aspect of the mastoid process. Bezold was the first to note a relation of aural topography to the form of the skull, and he pointed out that the lateral sinus was apt to be more forward and superficial, more vulnerable in ordinary mastoid trephining, in the short, broad head. He also laid stress upon the larger size of one lateral sinus, usually the right, because the longitudinal sinus usually passes almost directly into it, while the other receives only the smaller venous trunks. Without giving the statistics for its verification, he estimated that the right sinus is the larger in 70 per cent of instances, although in his 48 pairs of temporal bones there cited the left was larger 9 times and the right but 13. Schültzke gives 40 per cent as his finding in this respect, and among my 50 pairs the right sulcus is larger in 56 per cent. With this larger size there is often a more curved course of the sinus, which hollows a deeper channel forward and outward; and Zucker- kandl called attention to the occurrence of bulbous enlargements upon the vessel, which at times greatly increase its dangerous relations. O. Koerner, of Frankfort, in an article in The Archives of Otology in 1887 (Vol. XVI, p. 281), expanded this view as to the influence of skull form upon the topog- raphy of the temporal bone, finding in his measurement of 60 skulls of various types and races that the brachycephalic crania, those short for their breadth, were distinctly the more dangerous. Hence, the mere measurement of the length and breadth of a patient's head would give strong presumptive evidence of the location of the lateral sinus and the middle cerebral fossa and have important bearing upon the question of the indications and prognosis of operation. So simple a solution of a difficult problem challenged attention and called for the further investigation of the matter, which Koerner invited. Many accepted the clear and plausible showing of his study as conclusive, while others, confirming his results in their earlier measurements, as I did, made clinical application of his rule with apparent satisfaction. Politzer, in his text-book, referred to the rule as likely to be valuable if confirmed by adequate statistics, but regarded 60 measurements as wholly insuf- ficient. Schültzke, in the Archiv fuer Ohrenheilkunde, Vol. XXIX, p. 201, set forth a contrary series of results as his finding in a similar series of 60 skulls, pointed out some fallacies in Koerner's work, and left the problem as complicated as before. Koerner gave his measurements of 27 more crania as confirming his former results, and has since sectioned and remeasured some of the temporal bones previously measured to confirm his results. My studies were begun in 1888; but as I desiréd a wide basis before attempting any generalization, only a preliminary statement of my methods has been thus far published, and ‘I much regret that I can now |bring forward the figures of but one-half of the intended thousand. Craniometry has by no means a settled and fully accepted method of determining even the fundamental points of skull dimension, and some of the discrepancies 1648 PAN-AMERICAN MEDICAL CONGRESS. between various workers lie in the matter of the primary conception of “skull index.” Following some of the older craniologists, Koerner adopted the parietal protuberances as the points at which the skull breadth is to be measured, thereby obtaining figures generally smaller than the maximum breadth of the cranium and having no definite relation to it. Schültzke has followed the more authorita- tive method of obtaining the very greatest interparietal width, just as he takes the maximum length, from the glabella rather than the nasion to the occiputatits most prominent point, whether this be the inion or not. A greater breadth can at times be found between points on the squamae of the temporals, but this may be from the springing of these bones out of place in the process of maceration. This is the method which I have followed, waiving any theoretical advantage which might be gained by measuring in fixed planes precisely at right angles to each other to obtain the length, breadth, and height. The index given is this maximum length divided by the maximum breadth, not the less convenient figures used by Koerner, who divided the breadth into the length. In the classification of the specimens, instead of assuming a geometrical line at the index 1.30, as does Koerner, as sep- arating the long from the short crania, I have followed the best authorities in considering all skulls with indexes from 0.777 to 0.799, inclusive, as mesocephalic and constituting an intermediary type. This makes no little difference in the rating of crania. Thus one of the rare skulls having the transverse breadth at the parietal protuberances equal to the maximum, 134 mm., and a length of 172 mm., would be brachycephalic (with index 1.28) according to Koerner, while rightly rated as mesocephalic (index 0.779) in my tables. Another, 154: 192, would hardly be brachycephalic (index 0.802), although markedly so (index 1.19) in Koerner's notation. Yet further, in the more common instances where the width at the protuberances falls below the true breadth, the rating differs still lmore widely ; and a skull 150:183, instead of receiving its true brachycephalic index of 0.814, would be held by Koerner to be dolichocephalic with index 1.32, because the distance between the tuberosities was only 138 mm. Besides these distinct differences in viewing the fig- ures obtained, Koerner used a method of orthographic projection, rather than direct mensuration, to obtain the height of the floor of the middle cerebral fossa—a method possibly more exact for measuring the minimum distance, but only so after the point of greatest vulnerability has been otherwise determined. It must be admitted that the mensuration by Calipers is almost sure to exaggerate the distances under the circumstances here met, since it is difficult or impossible to avoid slight obliquity in the position of their points. Yet this was fairly constant throughout the similar measurements of the investigation and usually too minute to be worthy of more than this passing mention. Accuracy to a fraction of a millimetre has not been attempted here ; yet comparison with previous very careful measure- ments of the same crania has shown few and minute discrepancies, and only a very narrow margin of error can be conceded. In deciding as to the dangerous relations of the sulcus of the lateral sinus, Koerner lays stress almost solely upon the Superficial position, holding its forward position to be closely commensurate with its proximity to the mastoid convexity. No statistics are given in support of this view which had been set forth by Bezold and Hartmann; and he does not, like the latter, state the position of this thinnest point back of the meatus. Hence he leaves us wholly uninformed whether the temporal bones with the most superficially placed sigmoid sulcus, may not have been absolutely safe, since this portion of the sinus lay far posterior to the field of mastoid operation.’ The orthographic method can be employed only on skulls sagittally or otherwise sectioned, a limitation which Koerner has himself felt ; whereas far larger series of cranial measurements must be secured before any claim to rules of general “SESTINIS O IOW50||S NE EAA. LEE H_1C] | WA E 80SVE W O L _LNE W08_LSN|–* | "Đlº 0|5"/ Oly, Olºf 4º ·• ~º• U • � • „ • • • • • ^ <\• •* --> sº p * - ** * ... → • *- ~~ | | | 4/10 | | m | m () / () #|0 3|0 2. | | | º 3. () / () 3|0 5. 0 Q 70 J. - (a) s \e = * = E —$—= Fig. 2. —DETERMINATION OF THE MOST VULNERABLE POINT OF THE MIDDLE CEREBRAL FOSSA. PAN-AMERICAN MEDICAL CONGRESS. 1649 applicability can be ventured. A method has, therefore, been devised which can be used with apy intact skull, is ready of employment, and yet gives results which are sufficiently accurate for all surgical purposes, for when it becomes a question of a fraction of a millimeter operative skill, rather than anatomical knowledge, must be relied upon to prevent disaster. My procedure in measuring was as follows: With an ordinary pair of calipers the cranial length was taken from the most prominent part of the glabella between the superciliary ridges to the most distant point of the occiput, often above the protuberance. This length was then read off by applying the points to an accurate millimeter scale. The extreme breadth was similarly taken between the parietals, with the calipers held exactly transverse and their points on the same level. The distance between the parietal protuberances was also taken as by Koerner. In like manner was taken the width between the spinae supra meatum and the inter- mastoid distance at an “operation point ’5 mm. behind the spina with the ordi- nary calipers, or the sliding calipers described later. For the maximum width between the sigmoid sinuses a special instrument was employed through the for- amen magnum, a pair of inside calipers as figured in the cut. (Fig. I.) A plain pair of calipers then served to measure the thickness of bone between the sulcus and the operation point, 5 mm. back of the spina, between the sulcus and the back wall of the auditory meatus, and at the thinnest point of the mastoid, where the sinus most nearly approached the surface of the process. The distance of this thin point posterior to the spina was also noted. To determine the position of the most vulnerable part of the middle cerebral fossa, a sliding caliper (Fig. II), like a shoe- maker's measure, was used to take the position and plane of the spinae, and a detached L. scale, as figured (b), was passed through the foramen magnum and applied to the lowest and most external part of the fossa, as determined by sight aided by touch. Its external portion was then brought into relation with the out- side calipers, its rectilinear position secured by application of its mortised block to the lower edge, its relation to the plane of the spinae Secured by apposition of the surfaces (or any deviation from that plane made evident), and then the posi- tion of the point read off as to its height and lateral distance within or beyond the spina. The figure makes clear the manoeuvre, which was really simpler than the description may suggest. The relative size of the lateral sulcus of each side was then determined by the eye and similarly that of the jugular caput and foramen. All the more difficult measurements were made in strong light, generally full sun- shine; and the translucency of the bone permitted much more to be seen through the foramen magnum than might be expected, while it made easy the location of the most superficial portion of the sulcus, and in the dangerous bones made the condition readily manifest. The crania measured consisted of the Hyrtl and other collections in the Mütter Museum of the College of Physicians of Philadelphia, the skulls in the Wistar and Horner Museum of the University of Pennsylvania, about 100 specimens in the Army Medical Museum in Washington, and lastly a number in the Academy of Natural Sciences in Philadelphia. To the curators of these museums and to others who have kindly aided me in my researches, I desire here to tender my grateful acknowledgment. The specimens utilized were unselected in so far that I have pre- sented here the figures of every measurement completed. Adult Caucasian crania were preferred when they were at hand; deformed specimens were excluded, and a number of partially 1measured crania have been omitted from this report because of the incompleteness of the data. At the last, as the 500 was nearly complete, extreme specimens were sought in the rich collection of the Academy of Natural Sciences, in order to fill out symmetrically the groups into which I divided the various types. But no single specimen was introduced or omitted because of any selecting of specimens to point for or against any hypothesis. S. Ex. 36 104 - - 1650 PAN-AMERICAN MEDICAL CONGRESS. In the detailed tables the figures are given for each cranium, and the width at the parietal tuberosities is given for the use of anyone who regards that as the proper position for determining the transverse diameter. Any other employment which can be made of the studies and any other conclusions which can be elicited from them will, I hope, be freely made. In the other tables I have summarized the findings which appear to me to be their most important teachings. TABLE I. 210 dolichocephalic |80 mesocephalic skulls 210 brachygephalic skulls (0.61 to 0.776). (0.777 to 0.799). skulls (0.800 to J.97). OPERATION ROOM. | Right: - Maximum. --------------| 20 !--------|-------- 19 ---------------- 18 ---------------- Average ----------------- 10.8 *65 |-------- II. 79 129 |- - - - - - - - 11.7 *65 ! -------- Minimum - * * * * - - - - - - - - - - - 0.8 ---------------- 6 --------|--------| 1 |--------|-------- € , Maximum --------------- 25 *52 -------- 17 *22 ||-------- 20 360 - - - - - - - - Average ----------------- 11 '92 ||-------- 11.84 129 |-------- 12 *85 -------- Minimum ------...--------- 0 ---------------- 5 ---------------- 0.2 --------|-------- MEATUS TO SULCU.S. Right: Maximum --------------- 21 ---------------- 18 --------|-------- 18 ---------------- Average ----------------- 11.4 *59 |-------- 12.5 *24 |-------- 12.3 *70 - - - - - - - - Minimum ---------------- ! --------|-------- 6 --------|-------- 0.3 ---------------- Left: . Maximum --------------- 25 *57 |-------- & 222 |- - - - - - - - 20 267 - - - - - - - - Average ----------------- 12.5 *94 |-------- 12.8 *34 |-------- 12.4 *73 -------- Minimum ---------------- 0.3 --------|--------| 6 |--------|-------- 0.4 |--------|-------- THINNEST POINT. Back of Back of Back of Right: Spina. Spina. Spina. Maximum --------------- 15 -------- 30 15 ||-------- t 15 162 Average ----------------- 6. 19 166 17 6.17 122 18.3 5.9 |-------- 18.3 Minimum ---------------- 0 -------- 5 1 -------- 4 ! -------- Left: Maximum --------------- 17 251 30 18 216 29 18 251 30 Average ----------------- 6.51 193 16.9 6. 89 142 16.8 6.6 197 17, 5 Minimum ---------------- 0.5 !-------- 5 * !-------- 5 0.2 -------- 1 FOSSA HEIGHT. s Right: - Maximum --------------- 14 1124 -------- 18 --------|-------- 15 ---------------- Average ----------------- 6.7 --------|-------- 6. 27 *41 ! -------- 6.6 1119 |. -- - - - - - Minimum ---------------- () - - - - - - - - , ºs = * - - - - - 0 ---------------- 0 ---------------- Left: Maximum --------------- 14 *48 - - - - - - - - 12 *21 |-------- 15 242 ----. --- Average ----------------- 5.4 *38 |-------- 5.94 *18 |-------- 5.7 *49 |-------- Minimum ---------------- 0 --------|-------- 1 -------- !-------- 0 --------|-------. Sulcus_larger: R. 93; R.40; R.? 12; equal 6; R. 92; R.?.26; equal 26; R.? 15; equallā; L. ? L.? 5; L. 17. L. ? 18; L.48. 24; L. 63. R. 52; R.? 2; equal 7; R. 115; R. 212 equal 31; Jºli. fossa larger: L. : 2; L. 17. L. : 10; L. 42. . 110; R.? 15; equal - 13; L. ? 6; L.66. * Larger. * Equal. PAN-AMERICAN MEDICAL CONGRESS. 1651 TABLE II. 60 extreme dolichoce: * 60 extreme brachy- phalic skulls (0.61 Avºulis çephalic jº. to 0.729). (0.86 to 0.97). opBRATION ROOM. Right: & Maximum --------------- 20 ! -------|-------- 20 ---------------- 17 --------|-------- Average ----------------- 10 4 *18 -------- 11. 3 *159 |-------- 12.1 *16 |-------- Minimum---------------- 0.3 |--------|--. ---- 0.3 --------|-------- 6 ---------------- Left: Maximum --------------- 25 *15 - - - - - - - - 25 *135 |-------- 18 220 | -------- Average ----------------- 11.2 127 | -- - - --- - - 11.8 *206 |-------- 12.6 *24 |-------- Minimum---------------- 0 ---------------- 0 --------|-------- 0.? --------|-------- MEATUS TO SULCU.S. •º Right: Maximum ...-------------- 20 --------|-------- 21 --------|-------- 18 --------|-------- Average. ---------------- 11.2 *14 || -------- 12. 1 *153 |-------- 12.7 '?? -------- Minimum---------------- 0 --------|-------- 0 --------|-------- 7 --------|-------- Left: Maximum --------------- 25 *14 |-------- 25 *146 -------- 18 220 ! - - - - - - - - Average ----------------- 12.4 *32 |-------- 12.5 | 1201 |-------- 12.5 *18 |-------- Minimum---------------- 0.3 |--------|-------- 0.3 --------|-------- * --------|-------- THINNEST POINT. Back of Back of Back of Right: spinct. Spina. Spina. Maximum --------------- 15 -------- 40 20 |-------- 40 15 |-------- Average ----------------- 6.4 117 15. 6 6.1 1151 17.8 6.8 118 18.4 Minimum ---------------- 0.3 |-------- 0. 5 0 -------- 0. 5 3 -------- 11 Left: Maximum --------------- 16 215 35 18 2118 35 18 217 24 Average ----------------- 6.8 128 15.5 6.6 1231 17 7.4 125 17.7 Minimum ---. ------------ 0 -------- 2 0 -------- 1 0.2 |-------- 5 FOSSA HEIGHT. Right: w Maximum --------------- 14 ||-------- -------- 18 --------|-------- 12 ---------------- Average ----------------- 6.3 *30 - - - - - - - - 6. 6 1287 | - - - - - - - - 6.3 *28 |-------- Minimum ---------------- 0 l--------|-------- 0 ---------------- 0 --------|-------- Left: Maximum --------------- 14 *11 |-------- 15 *111 || -------- 14 *12 |-------- Average ----------------- 5.7 119 |-------- 5.6 *102 ||-------- 5.9 *20 -------- Minimum---------------- 0 ---------------- 0 --------|-------- 0 --------|-------- Sulcus larger: R. 29; R. 225; 45 per cent; R. 23; R.? 6; equal 8; R.? 2; equal 3; L. ? R.? 53; equal 47; L.” L. ? 8; L. 15. 4; L. 22. 47; L. 128; 25.6 per | R. 30; R.? 3, equal 13; Jugular fossa larger: Cent. L. 24; L. 10. R. 30: R.? 5; equal 5; R. 277; R.?29; equal 5.1; E. 2 J ; L. 19. L. : 18; L. 125. 1 Larger. * Equal. Summarizing the results gained from these 500 skulls, we find that they furnish us with 80 crania of medium index (0.777 to 0.799) and 210 on each side of this mean, not a few of which are extreme examples of the long and short head, respectively. Tabulating the figures, it is at once manifest that while Koerner's claim is perhaps Sustained, that the right sigmoid sulcus more closely approaches the mastoid sur- face than the left, and is more superficial in the brachycephalic skull; this differ- ence averages but a fraction of a millimeter; and the thin point is a little nearer the field of operation in the dolichocephalic. More important in this connection is the occurrence of minimum results in crania of every type and on either side— the left sulcus being the larger or the more superficial in 25 to 30 per cent. Yet the value of Koerner's measurements, when confirmed, is greatly lessened when we note that the approach of the sinus to the surface is not accompanied by a com- mensurate forward position; for the distance of the sulcus from the back wall of the external auditory meatus averages some 6 mm. more than from the mastoid surface, and holds no constant relation to the other dimension. It is, perhaps, smaller in the dolichocephalic; although in both types rather smaller on the right side. * 1652 PAN-AMERICAN MEDICAL CONGRESS. Still more practical seem the figures indicating the “operation room,” that is, the space intervening between the lateral sinus and the chisel of the Operator when he begins to trephine the bone at a point but 5 mm. back of the Spina Supra meatum. This appears to average nearly the same on the two sides, although more often less on the right; but it is a millimeter smaller in the long head than in the short head, and is sometimes only 1 mm. Or less, so that careful inspection would probably detect the dark sinus close beneath the bared surface. Zuckorkandl has described a temporal bone in the Vienna collection which pre- sented a large dehiscence of the mastoid convexity, where the sinus wall was exposed; and this study cites a specimen in the museum of the Philadelphia Col- lege of Physicians, a Tartar adult male, of 0.68 index, where there were 2 mm. of bone covering the sinus externally, but a large dehiscence into the upper back wall of the meatus. No craniometric finding, therefore, can in any way relieve the sur- geon from the apprehension that, in the case before him, the lateral sinus may be so superficial and anterior as to preclude operation in the usual way. No plan of operation and no instrument will insure safety; and Hartmann's rule is fully jus- tified, always to operate as though the position of the sinus were probably a very dangerous one. This becomes the more clear by study of the second table, where the general averages of all the 500 skulls are presented in contrast to those of the 60 crania at each end of the series, which constitute the extreme examples of the opposed skull forms. Here appears the curious contradiction to Koerner's hypoth- esis in that the extreme brachycephalic skulls presented on the right side no instance of minimum results, gave on the average more Operation room than the dolichocephalic and presented a larger right Sulcus and a dangerous relation less often than the general average and still less often than the Opposite long type of head. Turning now to the second point of danger to be avoided by the operator, the relation of the middle cerebral fossa to the operation field, we find another diamet- rically opposite result from Koerner, in that a precarious position was more com- mon on the left side than on the right in every type of cranium, and in the dolichocephalic rather than the brachycephalic, thus confirming the finding of Schülzke. The extreme types of skull are seen to be closer to each other than to the general average in this regard, each showing nearly the maximum height at times, or again a fossa reaching exactly to the level of the upper margin of the external meatus. In no instance was the middle cerebral fossa found lower than this fairly convenient landmark, and in almost all instances the floor was higher in the operation field farther back; so that a trephining channel which did not go above this level would seem always sure to avoid all danger. This may be consid- ered sufficiently accurate for all practical purposes. Where we come to fractions of a millimeter in dimensions, Safety becomes a question of surgical skill, not of anatomical knowledge. Some description of the instruments devised and their methods of employment should accompany the diagrams and make clearer the measurements taken. The inside calipers (Fig. 1) consist of a crossing pair of slightly curved arms 120 mm. long, pivoted 75 mm. apart, and centrally slotted through about half their length in order to articulate with a graduated rod sliding in a vertical mortise through the center of the base. Movement of this vertical rod forward or backward sym- metrically separates Or approximates the tips of the calipers,.and their distance apart at any moment is accurately shown by the graduation upon the scale. The points can be brought close together for easy introduction through the foramen magnum, there expanded until they mcet the sides of the sulcus on each side, their most external position found and verified by observation through the same opening, and then the distance read off to a fraction of a millimeter. The plane of this measurement is easily determined in relation to that of the spinae, the out- side calipers Serving, at need, to demonstrate its exact distance back, and any lack of symmetry in the height or distance out or behind the spinae. - PAN-AMERICAN MEDICAL CONGRESS. 1653 The instrument for measuring the relations of the middle cerebral fossa consists of a sliding caliper scale (a), with curved points, of sufficient length to embrace the skull from below and close upon the “spina supra meaturm * or the depressions just behind them, where they are readily held by light pressure. The second part of the instrument (b) consists of an L scale with an arm 50 mm. in length and a mortised block sliding upon it so as to furnish an edge at right angles to its length. Introduced through the foramen magnum, the tip of its curved arm easily finds the lowest and most external portion of the middle cerebral fossa or any other point more exposed to injury by proximity to the trephining track, the surface of its long arm is brought into apposition with the external scale, so as to show that the tip is in the plane of the spinae, its sliding block is pressed against the lower edge of the external scale to secure its vertical position, and then the height of its tip above the spina can be read off from the graduation. At the same time, its Outer edge, which is just 50 mm. internal to the tip, indicates upon the Outside scale by what amount the measured point lies within or beyond the spina,-e.g., in the figure it marks 53 less 50=3 mm. within. As the fossa often overhangs the spina, the reading may be negative by as much as the scale shows less than 50 mm. The same measurements Inay then be made upon the other side, without shifting the outside scale, by taking the difference between the two readings on the horizontal scale and subtracting 50 mm. The sliding caliper is made of such size as to serve for taking all the external dimensions of the skull ; but these were quite generally taken with an ordinary pair of calipers, graduated in millimeters. The same were employed, with one branch introduced through the foramen mag- num, to measure the distance between the sulcus and the mastoid surface or the back wall of the meatus—the latter measurement being rarely possible in a hori- zontal plane, as the instrument had to be so inclined that the plane of its tips sloped up and forward about 30°. Similarly the thickness of the bone between the sulcus and the exterior of the mastoid was slightly overestimated through measuring in a somewhat inclined plane. The small errors thus introduced were inconsiderable and fairly constant throughout the series. In the detailed tabulation following, the crania are designated for purposes of identification by their museum numbers. In (C) College of Physicians, Phila- delphia; (N) Academy of Natural Sciences, Philadelphia; (U) University of Pennsylvania; (A) United States Army and Medical Museum, Washington, and (P) private collections. The age, race, etc., are given as far as known, in the column of remarks. # ‘eApSSBUI ‘Ol:3e N. ‘q[mpe ‘enbpg|UIºzoWI ‘OCI *Inpe ‘uboy. ITV ‘O.13e N ‘lāIppoqsbuT.Iaqui eLIe.IqxGI ‘q[npū ‘O.13e N ‘e AISSetu ‘qūmpV. 'eſt?UUI qImpt: "...It:1.It I, ‘UIO]ll CI. ‘qImpts ‘Houeiði ‘OCI ‘eſbut q(mpt, “O.I3e N ‘q[npb ‘O.I.3a N. 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