Out of 184 cases of asthma operated on, there were 157 instances of nasal disorders, or of infection of the accessory sinuses; and of these cases, 104 had reported themselves as more or less relieved, the degree of benefit being in proportion to the thoroughness of the operations. Inasmuch as all the 157 patients had purulent or seropurulent secretions in the sinuses or pent up in the nasal passages, Matthew is of the opinion that the asthmatic symptoms were manifestations of anaphylaxis from absorption of bacterial protein. Of my own cases, let me cite briefly two or three. A lady physician, seen last October, had suffered from asthma in an aggravated form for a number of years. In accordance with my suggestion, she consulted a nose and throat specialist gestion, she consulted a nose and throat specialist who discovered and drained an infected antrum. Relief from asthma was experienced for three months thereafter. She then had coryza with swelling of the middle turbinal and stoppage of the drainage from the sinus, and quite promptly her asthma returned. A young woman who had suffered from asthma and hay fever since early childhood was found to have a double ethmoiditis and an infected antrum. Curettage of the ethmoid cells on one side and removal of the polypi were followed by partial relief. Circumstances prevented a more complete operation, and so Dr. E. P. Norcross decided to try the effect of mixed vaccines from a well-known pharmaceutical house. Reaction. was pronounced, but improvement began at once, and now this patient says she has her asthma only in so mild a form that she experiences only a feeling of stuffiness when the air is unusually damp or foggy. It may be added that the vaccines cleared up the antrum. Dr. George Paull Marquis has narrated to me the case of a man sent to him from out of town with a double hyperplastic ethmoiditis. His asthma had been so bad for many years as to necessitate an annual change of climate during the winter months. Radical operation on his ethmoid cells completely cured his asthma. Dr. C. was a sufferer from asthma for a number of years and was forced to spend his winters in Florida to the great injury to his practice. Five years ago he discovered he had gall-stones and last fall was induced to submit to their removal and drainage of the gall-bladder. The result on his asthma was surprising. His operation occurred last December, and he has written lately that for the first time in years he has been able to spend the winter at home and engage in practice. In the course of time the symptoms of anaphylaxis become practically constant, and the sufferer is rarely free from his asthma, which torments him daily, or, as in one instance I have notes of, many times each day. With the increased severity and frequency of the paroxysms, chronic bronchitis and emphysema become established and then the asthmatic is never wholly free from dyspnea. It seems to me that this same explanation holds with regard to Dr. C., whose asthma appears to have been greatly ameliorated, if not cured, by drainage of his gall-bladder. Sensitization to foreign protein is just as possible in chronic infection of this viscus or of a pus-tube as in any other structure, and apropos of this latter condition may be cited the following case: A woman, under the observation of my assistant, had suffered from hay fever for a number of years, but not from asthma. Some five or more years ago she got an infection of one fallopian tube, and now has a chronic pyosalpynx. But singularly enough, she states that with the infection of the tube she began to suffer from distinct paroxysms of asthma, and now her dyspnea displays the features characteristic of the second form as I have designated it. Nevertheless, although anaphylaxis appeals to me as the cause of asthma in chronic hyperplastic ethmoiditis and other sinus infections, we yet are confronted by the query, why does anaphylaxis manifest itself as asthma in one individual and not in another? In the present state of our knowledge we cannot answer unless we assume an underlying neurosis or inherited predisposition. Doubtless, there are individual peculiarities, just the same as in animals of different species. Why does the guinea-pig show anaphylaxis in the form of bronchial stenosis and extreme dyspnea, while the dog, e. g., shows pronounced disturbance of the nounced disturbance of the gastro-intestinal tract? Hay fever, according to Vaughan, is à local anaphylaxis, but why does one hay fever sufferer have asthma in addition or develop asthma in the course of time, while another does not? As yet we cannot answer satisfactorily, and yet the theory of anaphylaxis is a long step in advance of the old and purely conjectural hypothesis. Just here some one may ask, how can you explain the relief occasioned by remedies employed for that purpose? The relief from hypodermic injection of adrenalin is due probably to the increase in blood-pressure it occasions, since anaphylaxis is said to be attended with diminution of blood-pressure. But I cannot explain the modus operandi of morphin and various asthma powders, unless in the same way as with whisky and ether. Desredka states that alcohol and ether prevent the phenomena of anaphylaxis for a time, and in this connection I might state that I once knew an old asthmatic who found relief from a stiff drink of whisky reinforced by the smoking of strong tobacco, two remedies in which he never indulged except during his paroxysms. A patient of mine had been suffering from extreme dyspnea and asthmatic exacerbations for four months when I first saw him. Suspecting some infection in the upper air tract he was advised to see a nose and throat specialist. This he did, with the result that a pair of old cheesy tonsils were removed. Ether was the anesthetic, and for three weeks thereafter he was entirely free from his asthma. Then he contracted what he called a "cold in the head," and promptly his asthma returned. The practical application of the foregoing is this: In every case of asthma search for some focus of chronic infection in the nasal accessory sinuses, in a chronic hyperplastic ethmoiditis, or in some closed cavity in any other part of the body, and finding it, advise its removal by surgical interference. If the absorption of a foreign protein can be prevented in this manner, it is likely that the asthmatic seizures will be prevented or greatly ameliorated. Of course, in cases of asthma traceable to animal or vegetable emanations or to some article of food to which the person has become sensitized, we can do no more than advise avoidance of exposure to the exciting cause. Nevertheless, the understanding of the etiology of this distressing malady certainly gives us a basis for rational and effective therapeutics in many instances that otherwise might go on unrelieved. PHLEBOSTASIS; A NEW TREATMENT FOR BROKEN-HEART COM PENSATION* S. LILIENSTEIN, M.D. BAD NAUHEIM, GERMANY Every medical man who is called on to treat chronic heart cases knows how thankful these patients are for new means of relieving their distressing disturbances. So I hope that my apparatus, the "Phlebostat," which I am going to describe, will be a valuable adjunct in the treatment of weakened heart action. It consists of two hollow cuffs, as they are used with a tonometer; of a manometer and a rubber bulb. A cuff is placed around each upper arm. These cuffs are connected by a tube and into them air is pumped by means of the bulb. A pressure of 80 to 100 mm. mercury is usually sufficient. At this pressure the pulse is not entirely obliterated, only the venous flow from the arm is retarded, with the result that a peripheral congestion ensues. After one or one and one-half minutes, the air is allowed to escape, and this procedure is repeated four or five times in succession, so that the treatment takes about ten minutes. The "Phlebostat" may be applied, according to the condition of the heart, every day or every other day. In patients suffering from cardiac dyspnea, dull feeling in the head, feeling of oppression, etc., a marked improvement is immediately felt. The patients assert that they breathe more freely, that they feel lighter, the oppressing feeling in the head disappears, etc. These results I happened to obtain accidentally in a patient of mine, and they prompted me to experiment, at first with insufficient means, until I had constructed and perfected this apparatus, which has proved its efficacy in practice. During the past two years I have used it over five hundred times in more than one hundred cases with the usual good effects described above. The amount of relief obtained, however, varies with the nature of the heart lesion and the degree of compensation. I will now give a few typical cases from the great number which I have observed. CASE 1.-F. K., a man aged 70 years, had had a stroke five years before, and since then had had paralysis of the left side. The face was very congested, he slept badly, frequently suffered from diarrhea and was Besides excitable and depressed. marked arterio * Paper read before the Chicago Medical Society, Jan. 15, 1913. sclerosis and myocarditis, he had a feeling of intense oppression and slight dyspnea. Heart normal in size, no murmurs, the second aortic sound distinctly accentuated. The temporal and radial arteries felt rigid and were very tortuous. Pulse slightly arhythmic, with a frequency of about 88 per minute. Blood-pressure was 160 mm. Hg. After the third application of the phlebostat the patient felt much easier, more comfortable and could breathe better. He felt as if a great weight had been taken from him. I assumed that the relief was at any rate partly due to suggestion. But the improvement persisted. His condition never again became so serious as it was before, and he improved considerably after each phlebostasis during ten days, treatment being given every day. The patient has had no further strokes, more than six years having now elapsed. Psychically he is calmer, less excitable, less depressed and without difficulty follows his business as manager of a large factory. CASE 2.-Patient L., aged 35 years. Mitral insufficiency. Complains of extraordinarily violent palpitation and dyspnea, particularly when climbing stairs and during a physical examination. The pulse is 140. When I observed the patient from another room by means of the cardiophone, the pulse in five minutes dropped to 120 and remained there during the subsequent observation. Immediately after phlebostasis the patient felt much better, said that he could now take a deep breath. The patient, usually very much depressed, actually became enthusiastic about the procedure. "It has done me good. This is really excellent," were his words and he came again the next day and many more times without being asked “to be blown up," as he expressed it. The pulse did not diminish in frequency, but the subjective symptoms and dyspnea were much improved. The apex beat became less violent. CASE 3.-Patient O., aged 59 years, emphysema, cardiac dyspnea, at times slight edema, no murmurs. Rapid, somewhat irregular pulse. Probably weakened heart muscle from coronary sclerosis. First mitral sound muffled and dull. The patient complains of persistent palpitation for the past two years, attacks of dyspnea (angina pectoris) especially at night so that he must get out of bed; easily fatigued, has headaches and general nervous symptoms. A neurologic examination, especially of the reflexes, showed no organic disturbance. The phlebostat was applied three times for two minutes each time, the patient's condition improving after the second application; the palpitation which had lasted uninterruptedly for two years became less and breathing was easier. During the next few weeks the patient improved. With his improvement the relief from each triangular treatment became shorter and shorter, due to the fact that there was more general well-being and of course not so marked an effect following immediately after each treatment. The subjective restlessness in this patient was permanently improved. Nitroglycerin tablets which I prescribed for the hitherto frequent attacks of angina pectoris were not taken during this treatment. Besides the phlebostasis I ordered mild baths and expiration into rarified air. The effect of phlebostasis was particularly noteworthy in the following case: Mr. St., aged 66 years. Advanced myocarditis; arhythmia; heart tones distinct, clear; liver increased in size; ascitis; edema of both legs. For the past sixteen years the patient had derived benefit from an annual visit to Bad-Nauheim. Restricted milk-diet cure (Karell) by which the patient reduced his weight from 219 to 202 pounds was also successful. Slightly alcoholic. Subjective symptoms; dyspnea, pressure pain in epigastrium, insomnia, general weakness. During the phlebostasis, three times one and one-half minutes each, the patient experienced a feeling of relief which lasted one day. He slept much better the following night and insisted on continuation of the treatment. Phlebostasis was made every other day. The pressure pain in the epigastrium, which usually appeared after meals (especially after first breakfast) did not appear if the patient was given a treatment before a meal. The dyspnea also had increased while taking a bath so that the patient was only able to take sitting bath (Sitzbad). After the phlebostasis the full baths were taken without discomfort. The treatment was continued for about five weeks, increasing the good effects at first produced. Professor Treupel (Frankfort a. M.) has tested my method in his hospital on a series of patients. He has requested me to publish the following cases: Mrs. B., aged 55 years. Arteriosclerosis. Rumbling systolic murmur over all the valves. Second sounds accentuated at the base. Heart action rapid, irregular. Blood-pressure, 140-220 mm. Hg. Subjective symptoms: palpitation, pulsation in the arteries, sense of One minute after the pressure in the precordium. phlebostasis the palpitation ceases, heart action becomes more free. Patient feels the good effects for three hours. She had treatment for fourteen days, twice daily, three times, one minute each time. The subjective symptoms decreased, the pulse dropped from 100-110 to 80-90. The patient is discharged very much improved. Miss R., aged 36 years. Mitral insufficiency and stenosis. Myocarditis. Subjective symptoms: palpitation, sense of pressure in the chest. The patient was given phlebostasis treatment twice daily, three times, one minute each time. The subjective symptoms disappeared during the treatment and this improvement usually lasted for two or three hours. Objectively no change was demonstable in the heart during or after the treatment. Dr. Haeberlin of Bad Nauheim and myself obtained a brilliant result in the following case of contracted kidneys with hypertrophied heart, albuminuric retinitis and uremic symptoms: The patient, a man aged 49 years, had contracted kidneys two years. For the past four months he suffered with severe continual headaches, insomnia, disturbances of vision to complete amblyopia and pain around the heart. Objectively, there was increase in dulness to one-half inch left of the mammillary line, heaving apex beat and accentuated second aortic sound. Blood-pressure 220 mm. Hg. Liver dullness increased by the width of two fingers. The ophthalmoscope revealed a marked albuminuric retinitis with numerous blood-extravasations. The patient could count the fingers at a distance of one-half meter. Immediately after the second phlebostasis, which lasted two minutes, the headache decreased, palpitation and pressure sensation around the heart diminished, the patient counted the fingers at a distance of 2-3 meters. His condition became worse in a few days but by the aid of phlebostasis he again improved, at least, symptomatically. In this case the edema of the lungs was postponed for hours at a time. In consequence of my paper (Medizin. Klinik, 1912, Nr. 8) they have tried my method with good results in some other German hospitals. Some of these results have been published by Dr. Dangschat,1 Dr. Grabley1 and Dr. Engel.2 I will not enter on details about the principles of this practically demonstrated method. The venous stasis in the periphery at any rate produces an unburdening of the heart. As is well known in all compensatory disturbances, the heart is overfilled and usually dilated. The action of phlebostasis, as I have called this method, is almost equivalent to a venesection with the difference that there is no loss of blood, so that we are justified in calling it a bloodless phlebotomy. - If the circulation of blood to the capillary system of the four extremities, the portal circulation, or the circulation, for instance, of the central nervous system, is interrupted, the force of the heart that is, the pressure of systole as well as the suction of diastole-is distributed over a diminished vascular area. In this lessened area the strength of the heart can naturally act with relatively greater force, the heart having a chance to work under more normal conditions while the apparatus is applied and while the amount of blood is less. I am aware that my method of treatment will not revolutionize our present therapy of the heart, or that, objectively, we can do more by this method than with the standard chemical heart tonics, digitalis, strophantus and their derivatives, or by physical therapeutic means. My experience, however, leads me to assert that in cases of broken heart compensation indicated, especially in those in which formerly venesection has shown good results, phlebostasis has a rapid, immediate and beneficent influence. THE RELIEF OF METATARSALGIA WELLER VAN HOOK, A.B., M.D. CHICAGO Morton of Philadelphia, many years ago, described a "painful affection of the foot," which we know to be due to recurring traumatism of the branches of the plantar nerve. The improper shoeing of the modern foot is doubtless the remoter cause of those pressures on the nerves as they pass between the heads of the 1. Internat. Kongr. f. Physiotherapie, Berlin, 1913. 2. Berliner klin. Wchnschr., January, 1913, and Kongr. f. inn. Medizin, 1912. The relief of early discovered cases of this disease may sometimes be effected by changing the poor shape and style of shoe to one of a broad, thick-soled, low-heeled type. But the final remedy lies, in difficult cases, in the excision of the branches of the plantar nerve which are affected by the pressure. The excision may be effected by opening over each affected branch of the nerve; but a single incision can sometimes be used for two branches. The writer wishes in this brief paper especially to call attention to the fact that these nerves should be attacked at a point beneath the proximal extremities of the metatarsal bones. A single incision at this point gives an excellent opportunity to attack the nerve before its final major divisions have taken place. Furthermore, the incision at this point does not leave a scar where pressure can subsequently cause irritation and suffering. Hyperesthesia frequently follows these operations for some months. But as a rule the discomfort disappears and comfortable function is restored. 31 North State Street. TOPOGRAPHY OF THE TYMPANIC CAVITY* JOHN A. CAVANAUGH, M.D. The subject which is chosen for this thesis is one which most of our modern text-books touch upon in a general way. I believe it is one worthy of being brought before our readers, and I am especially convinced of its importance from personal observations on wet and dried specimens. most of which are in my possession. Photographs of some of these specimens are shown here. I ask the kind indulgence of my readers if I should tire them with detailed description, but it is necessary for a clear understanding of the subject. I believe that if the general practitioner had a better understanding of this very important organ, he would realize more thoroughly the necessity of vigilance in diseased conditions of this locality. The development of the middle ear should be understood in order to know how the surrounding structures are sometimes invaded by diseases of this cavity; therefore, permit me to give a brief résumé of its development. The temporal bone is developed by ten centers, exclusive of Read before the Chicago Laryngological and Otological Society, Feb. 18, 1913. those for the internal ear and the ossicles. One for the annulus, one for the squamozygomatici, two for the styloid process, four for the petrous and two for the mastoid. Huxley declares the centers are more numerous and gives a little different classification, which I will not enter into at this time. The mastoid and petrous portions are united before birth; however, an imaginary line drawn in a vertical plane close behind the stylomastoid foramen and at right angles to the whole petromastoid portion marks the union between these two portions. We have at birth three ununited portions of the temporal bone. the squamozygomatici, annulus and petromastoid parts, which are held together by bands of connective tissue. Ossification usually takes place between the two upper extremities of the annulus and adjacent portion of the external table of the squama, so that after a certain period the temporal bone separates into two portions, the united annulus and squamous portion and petromastoid portion. During the first year the bony union of these three parts, namely, the annulus, squama and petromastoid, are very imperfect. annulus at birth is like a plain ring; only that the upper posterior part is wanting, leaving a gap which is filled in by the outer table of the squama. As the child develops there is an outward growth of the outer edge to form the future external auditory meatus, and an inward growth from the inner edge to help form the floor of the middle ear. The horizontal portion of the squama divides into an outer and inner table. the outer forming the external wall of the attic. while the inner helps to form a part of the roof of the middle ear. The petrous portion forms. the inner and posterior walls of the middle ear. The The tympanic cavity is the largest cavity of the temporal bone in the larger percentage of cases, but anomalies may exist where an unusually large antrum or mastoid cell is present. I have in my collection a temporal bone wherein there is a cavity in the petrous portion extending from above the inner part of the internal auditory meatus, just internal to the superior and posterior surface extending to the Glaserian fossae; it measures 20 mm. long, 9 mm. wide and from 5 to 10 mm. deep. The tympanic cavity is of a cuboid shape, the walls being very unequal. It is formed by the pars petrosa, pars squamosa and pars tympanici, though the pars petrosa forms the greater part. This cavity contains air, reduplications of mucous membrane, muscles, ossicles and the ligaments of the ossicles. This cavity we describe usually as having a floor, roof, an anterior, posterior, external and |