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Dr C. P. Linhart, Columbus, closing discussion: will try to reply to the discussion in an inverse order. do not believe that it matters so much what you use in the Eustachian tube or the nose tube so that you use something that will stimulate the parts to assume a normal secretion and condition.

Dr Ingersoll has spoken about the variation in the hearing. My attention was once called to this in a manner which I shall never forget. I was trying to learn French and got to a point where I could understand it somewhat and went to church to hear French sermons, sitting pretty well back. You know when you are listening to an address in a large room, if you only hear one-half of what is actually said you can by the context understand the other half, but if the occasion arises in which it is necessary that you hear every word in order to know what is said, you can understand the circumstances in which a deaf person misses so much. I had to change my position in the church because I could not hear the phrases. I could hear the majority of the words, and after changing my position I could catch the individual words. That drew my attention to the variation in hearing, how one might hear many individual words and yet fail to understand the phrases.

In reference to the method using the electric bougie, I would say that I use the method advised by Duel very closely. I use from 25 to 35 volts of the Edison current running that through an amperemeter. I do not use over 5 milliamperes, to start with using 2 milliamperes, and sometimes do not run it up over 4 milliamperes. I use rubber tissue to insulate the Eustachian catheter. I also have a sponge electrode in contact with the hand, the positive pole, and have that immersed in a salt solution. I introduce the catheter and then push the bougie up into the Eustachian tube as far as it will go easily. We find obstructions in these tubes anywhere from one-fourth to one-half of an inch from the orifice. Where the cartilage and the bone join there is of course a natural narrowing. As soon as the obstruction is reached I turn on the current, as I said 2 milliamperes at first, and as a rule patients do not notice that much. Patients tell me that the pushing of the bougie into the tube hurts them more than the electricity, even when a strength of 5 milliamperes is used. I continue the treatment for from five to eight minutes, in some cases

have continued it for ten minutes, but I think good results can be obtained from five-minute applications. Then the bougie is slowly withdrawn having passed up through the tube and the strictures, if you get through them the first time. If you run into a stricture leave it there until it dissolves so the bougie will easily come out, then the bougie is withdrawn into the catheter before the current is turned off. In regard to the treatment of these cases I think the general practician is coming more and more to realize the importance of keeping the nose clean and in a normal condition and carrying the treatment back through the tubes into the middle ear, and this is a field for the general practician as well as the specialist.

CHAPTER VI-PATHOLOGY

A Case of Diaphragmatic Hernia-Death from Acute Distension

BY T. L. CHADBOURNE, M. D., GALLIPOLIS

[From the Pathologic Laboratory of the Ohio Hospital for Epileptics]

On July 23, 1902, E. L., an inmate of the Ohio Hospital for Epileptics, died rather suddenly with a syndrome of symptoms consisting of pain in the stomach region, dyspnea and abdominal distension. The patient's illness dated only from the previous day. Soon after a dinner consisting for the most part of vegetables and unripe fruit he became qualmish and vomited; after this he was noticeably short of breath and complained of pain in the abdomen. For this deodorized tincture of opium was given in water, which he had no difficulty in retaining, as there was no further vomiting. He remained sitting or lying on a cot until eight o'clock in the evening when he was able to walk a short distance to the hospital ward, and afterward to the watercloset where his bowels moved once. He was then put to bed, and, still complaining of pain in the belly, was given one-fourth of a grain of morphin hypodermatically. The abdomen was still greatly distended. Following the injection the patient slept rather uneasily until five o'clock in the morning. He died about an hour later with a continuance of the symptoms already noted.

The patient was a male 30 years of age, an epileptic, with a marked infantile paralysis of the whole left side with contractures of the hand. The palsy and the grand mal seizures to which he was subject dated from an attack of meningitis in his eighteenth month. He is said to have been a normal and healthy infant and aside from his epilepsy and palsy to have been, as a rule, well throughout his life. He was always a voracious eater but never had any vomiting attacks. His relatives do not recall that he ever complained of his chest, and no suspicion of

there being anything unusual in this region was ever entertained. During the patient's residence in the hospital of about a year he was always well and cheerful, although his simple mental condition and his lameness quite incapacitated him.

The necropsy was performed July 23, four hours after death. There was enormous distension of the abdomen which was everywhere tympanitic. There was marked soft edema of the scrotum. Incision of the abdomen allowed the escape of a small amount of gas and a little slightly cloudy fluid. The intestines were much blown up and greatly congested. When the sternum was removed the left side of the thorax was seen to be occupied to the level of the second rib by a part of the abdominal viscera. There was a large defect in the left half of the diaphragm, through which had passed the whole stomach, the omentum, and part of the large intestine beginning about three inches above the caput and including a portion of the descending colon. The caput coli with the sound appendix occupied the stomach region. About three inches above the ileocecal valve there was a small adhesion causing a kink in the bowel which was, however, still patulus. The stomach was of normal color but the large intestine was rather dark. No obstruction other than that possibly caused by the hernial ring could be found. The heart was displaced toward the right so that its border was in the right sternal line. This organ opened in position showed no change beyond a slight increase of the pericardial fluid. After allowing the escape of the gas, the abdominal viscera could be replaced in the abdomen. without much difficulty, as there were no adhesions about the ring and they slipped through the large opening easily.

The following measurements, taken after the hardening in formalin, are of course only relative, but indicate the comparative sizes of the two lungs. The right one is 22 x 18 cm., and the left one is 141⁄2 x 8 cm. This latter organ lay close against the spine, it was much compressed, but both lobes contained some air. The left lung presents the following anomaly: a horizontal fissure extending about two-thirds of the way to the root, divides the lower lobe into two parts, the upper division being about onehalf as large as the inferior. The opening in the diaphragm cor

responds roughly to the position of the left tendinous leaflet and measures about 8 x 12 cm. Its edges are quite firm and sclerotic. The esophagus can be traced downward through its proper foramen; it bends sharply upward just at the cardiac end of the stomach to pass through the hernial opening.

The accompanying photograph, which shows the organs from behind, will serve to give an idea of the relations of these structures to each other and to the orifice in the diaphragm. Legend. An untouched photograph. Upon the right are shown the right lung (r) with the corresponding half of the diaphragm (rd) beneath it, and opposite, the compressed left lung (11). Above the left segment of the diaphragm (1d) lie the organs; the stomach (s), the omentum (o) and the colon (c) that have passed through the hernial ring. This orifice is not well shown but the posterior part of its rim is indicated by the sharp line (r) just behind Lower down is the free border

of the mesentery, (m) the intestines having been removed. cut end of the esophagus is at oe..

The

Sections of the left lung show areas of collapse of the alveoli alternating with portions where the lung is air-containing. The vessels are engorged, especially the capillaries of the alveolar walls. The bronchi in the compressed areas are collapsed and desquamating. There are a few small areas of round-cell infiltration. Many of the cells of the alveolar walls are vacuolated and some of them desquamating. There is everywhere a great