being better relieved by such remedies as the iodides, bromides, etc., while the bronchial catarrh has seemed to yield more readily to the local action of the spray than it would have done to the constitutional remedies if used alone. In ordinary acute bronchitis, several cases of which have been treated, its curative effects have been very striking. We have also used the Evans apparatus in the treatment of several aggravated cases of diffused catarrh of the upper air passages, where the irritability of the mucous membrane of the pharynx, larynx and trachea have been so great as to give rise to frequent attacks of vomiting, particularly with the morning cough. The plan has been, first, to thoroughly wash and disinfect the upper air passages with the coarse spray of the "Sass" tube, thrown in under a pressure of from thirty to fifty lbs. to the square inch, and then have the patient inhale the spray of a twenty per cent solution of carbolic acid from the Evans atomizer for about half an hour. Relief has been obtained much more promptly by this combined treatment than by either method if used by itself. In fact, for nasal and naso-pharyngeal catarrh, where a thorough washing out of the cavities is absolutely necessary to a cure, the apparatus of Dr. Evans is comparatively valueless; but, when the membranes have been thoroughly cleansed, great benefit may be obtained by the prolonged inhalation of the finely nebulized spray. We have further modified the method of Dr. Evans in all cases by causing the patients, instead of removing the finger from the mouth-piece and allowing the breath and spray to escape through it during expiration, to blow the spray out through the nose. This can be readily done by anyone with very little practice, and is of advantage, inasmuch as almost everyone who suffers from catarrh of the larynx or bronchial tubes has also more or less naso-pharyngeal catarrh. This is particularly the case in pulmonary consumption, and the reflex irritation from the posterior nares, and the direct result of the passage of purulent matter through the naso-pharynx downward, is to greatly aggravate the cough. By exhaling the spray through the nostrils, we get simultaneous treatment of the entire respiratory tract. Whether the spray introduced in this way ever permeates to the alveoli of the lungs, is difficult to determine; but we must say, that if it can be obtained by the use of any device with which we are acquainted, it is by that of Dr. Evaus. Much has been said of late in regard to the relative merits of this apparatus and the pneumatic cabinet. It is difficult to draw a comparison between them, except in so far as clinical results are concerned, because the principles involved are quite different. In using the pneumatic cabinet we depend almost entirely upon the effects of differential pressure, that is: upon the difference between the pressure of the air inhaled, and that upon the exterior of the body; while with the Evans inhaler we look for more benefit to be gained through the voluntary effort on the part of the patient, and the deeper penetration of the medicated spray. It is claimed by the inventor of the pneumatic cabinet, that the increased expansion of the chest resulting from the inhalation of compressed air, will carry the spray deeper into the respiratory passages, than it can be by any other means. It has been shown, however, by some experiments which were made by my friend and former colleague, Dr. Isaac Hull Platt, and myself, and which were referred to by him in an able paper upon the Physics and Physiology of Pneumatic Differentiation, read before the American Climatological Association at its last meeting, and published in the New York Medical Journal of Nov. 6 and 13, 1886, that while the respiratory expansion of the chest is increased by the inhalation of relatively compressed air in the pneumatic cabinet, the amount of tidal air passing in and out of the lungs is actually diminished, so that, after the first deep inspiration, the spray would probably not penetrate as deeply, nor would as large an amount be inhaled with each inspiration as if the patient were making strong voluntary effort in the open air. This was ascertained by causing robust men to inhale as deeply as possible, and then exhale through the tube into a jar filled with water. The amount of air exhaled could thus be measured. The subject of the experiment was then placed in the pneumatic cabinet, and under the rarefaction of half an inch of mercury, made the deepest inhalation possible; he then exhaled through the tube into the reservoir, expelling all the air that he could from his chest. It was found on actual measurement that the volume of air exhaled when sitting in the room outside the cabinet was considerably more than while in the cabinet. This will show that the benefit which is undoubtedly derived from the use of the cabinet is not through the introduction of sprays deep into the lungs, but rather through the modification of the circulation in the respiratory organs, resulting from the differential pressure. In practice we have found that patients who are benefited up to a certain point by the use of the cabinet, could then be still further benefited, particularly as regarded the amount and character of the expectoration, and the violence of the cough, by the use of the Evans Inhaler. And we have further found that those who had come to a standstill after both these forms of treatment, had gone on improving more rapidly when these were discontinued and older and more ordinary methods of treatment adopted. This would go to show that each method has its advantages, and that the judicious practitioner should not limit himself to the exclusive use of one of these, but should give his patients the benefit, as far as possible, of that one which seems particularly suited to his individual condition, or to the combined or separate use of them as circumstances suggest. For office use, where we wish to use the inhaler to the best advantage, some special contrivance should be adopted by which large quantities of compressed air can be secured at a high pressure. Dr. Evans, we believe, uses a gas engine with an air pump, constructed by the Clayton Air Pump Co. of Brooklyn. He uses a pressure of from eighty to one hundred pounds to the square inch, and has a boiler capacity of six or eight hundred gallons. In our own practice we use a smaller engine and storage capacity, and ordinarily employ a pressure of from fifty to sixty pounds. This smaller engine is manufactured by the National Meter Co., of 252 Broadway, N. Y. THE editor of the Denver Medical Times in an excellent article against abortionists says: "The attitude of the church is very indifferent on this question." Such suggestions do great injustice to both Catholicism and Protestantism. The Roman church as well as the Methodist Episcopal, Protestant Episcopal, Baptist and Presbyterian churches speak with no uncertain sound on this question. We of the medical profession should first thoroughly remove the beam from our own eyes before we tackle the mote that darkens the moral vision of any weak theologian. THE POULLET AXIS-TRACTION FORCEPS. GEMRIG THIS instrument is a modification of the forceps designed by the illustrious Tarnier, to permit of traction in the axis of the superior strait. As you are aware, this is impossible with ordinary forceps; as the axis of the superior strait, and of the upper portion of the true pelvis, passes through the perineum. The effect of this anatomical configuration is overcome by the shape of the tractor of the Tarnier instrument, which curves sharply downward over the perineum. Poullet, of Lyons, has perfected and simplified Tarnier's instrument by attaching the tractor by tapes, which run through holes in the forceps blades, two and one-half inches from the tips. In using Poullet's tractor it is desirable to employ forceps of strong construction, with firm Hodge lock and handles. The cut represents the Poullet tractor fastened to Hodge forceps. The writer has used, with great satisfaction, this tractor attached to Simpson forceps (with Hodge lock and handles). In using this instrument one cannot fail to note the facility with which the foetal head is drawn through a contracted pelvis, and the freedom with which it rotates into the most favorable position for delivery. Acknowledgment is due to Dr. H. A. Kelly, of Philadelphia, who brought the Poullet instrument from Europe, and who is its enthusiastic advocate. THE second annual session of the Association of American Physicians was held in the city of Washington, June 2 and 3, 1887. Dr. S. Wier Mitchell presided. *NARCOSIS FROM COMBINED EFFECTS OF CHLOROFORM AND OPIUM. BY H. G. BRAINERD, A. B., M. D., Lecturer on Diseases of the Mind and Nervous System in the Medical College of the University of Southern California; late Assistant Superintendent of the State Hospital for the Insane, Independence, Iowa. THE subject of this sketch, A. H. W., was a tall, slight blonde, of American parentage, age 28, married. For several months she had been suffering from a mild attack of melancholia, which had not yielded to the treatment of her family physician and she had been brought to the Hospital for the Insane by her husband. She complained of a strange, uncomfortable sensation in her head; that she was unable to fix her 'mind on any subject, and was constantly under the influence of the delusion that she was losing her mind and would soon become totally demented; but in her conversation and her letters she showed no loss of memory or reasoning power, or, in fact, any evidence of dementia which she feared. Her husband assured us that she had never attempted suicide; that she had a scrupulous regard for her word, and could be trusted implicitly to do as she promised, and he wished her to be given all the freedom consistent with the regulations of the institution. Accordingly, on her promise not to try to escape, she was allowed to stroll about the grounds with other patients, and to ride to town a couple of miles away. On one of these occasions, while shopping with a party of fellow-patients, she excused herself from her companions on some trivial pretext, went to a drug store, purchased an ounce of chloroform and a drachm of gum opium. She then went to the parlor of a neighboring hotel, swallowed two-thirds of the opium and washed it down with three-quarters of the chloroform. These facts, however, we knew nothing of till many hours afterward. Whether the chloroform produced a primary stimulation, or the step she had taken caused her to lose her self-control, I can not say, but for some reason she became much excited, prayed, sang and talked in so loud and excited a manner as to attract the attention of hotel employes, who looked up the attendant, in charge of the party of patients that had come to town that morning, and notified her that a lady at the hotel was acting *Read at the June meeting of Los Angeles County Medical Society. |