I was conversant with the requirements and procedure in the performance on dogs; I was supplied with the apparatus, and I at last obtained a suitable patient upon whom to operate.

“At 12.30 A. M. Saturday, July 23d, 1887, I was called to attend Mr. Patrick Burns, book-keeper, residing at No. 49 Morgan street. I found the patient in a semi-conscious condition. His wife reported that he had been drinking heavily for a week past, and had been in the habit of using alcoholic liquors to excess for ten or twelve years. His present excesses induced him to try chloral to produce sleep, but finding that unsuccessful, he added twenty grains of morphine (approximately) with the following results:

"According to his statement he had taken the drug late on Friday afternoon, so that sufficient time had elapsed to permit complete absorption. When first discovered by his wife he was breathing stertorously, and was with difficulty aroused. A draught of black coffee was given, which produced vomiting. On my arrival I supplemented this with one of mustard, sodium chloride, and water, which effectually emptied the stomach. This produced no farther effect, as the patient, left to himself, immediately passed into the deep, narcotic condition of opium poisoning. The pupils were markedly contracted, and it was evident a serious case was in hand. At this time I administered two cathartic pills which I had with me, and, at different times, minim doses of fluid extract of belladonna: sent for some atropia, and frequently administered the onesixtieth of a grain hypodermically. To keep the patient awake he was dressed and two attendants walked him around the block in the cool, pare atmosphere of the early morning. At each round I examined him and administered more atropia. The fourth or fifth time round, when within one half block of the house, his limbs gave out, and while being tugged and jerked along, stertorous breathing began again; he was carried into the house and laid on the floor, as I believed, to die. This was about 3.30 A. M. As the respirations failed, and the intervals between them lengthened, Sylvester's method of artificial respiration was employed, and kept up at intervals long after I had given up any hopes of the man's recovery and until I was thoroughly exhausted, and, farther, with out apparent benefit to the patient. In the meantime, I notified the family that the patient could not live.

"At this juncture Father Grant, of the cathedral, appeared, and performed the last rites of the Catholic Church. At my suggestion, a bed was prepared in the front parlor of the house, and the patient laid upon it. From Mrs. Burns I obtained the data for the death certificate, which I confidently expected to fill in the morning. I then took a last look at the patient, only to confirm my opinion that death was imminent, and then thought nothing more could be done. I was too thoroughly fatigued to think of forced respiration. The pulse, before Father Grant came, had registered as high as 180, and before I left the house it could

have been counted with difficulty: I considered it 200 or more. The respirations at four o'clock in the morning were five per minute, and, when I left the house for home, were intermittent, or with a long intermission, followed by a few spasmodic respiratory efforts, and then apparent inanition for a time. I left for home a little after five o'clock in the morning, went to bed, and, after a sound sleep, was awakened by a call about eight o'clock.

"Dr. F. R. Campbell, who, through illness, had been unable to respond to an early summons from Mrs. Burns, called about 8 A. M. and finding Mr. Burns still alive, sent for me. I promptly repaired to the house, and indeed the patient was alive, with respirations, however, not more than one per minute, and the pulse with difficulty to be detected at the wrist. The extremities were quite cold; the face had assumed a cyanotic appearance; pupils still contracted. The doctor suggested that more atropia be given hypodermically, to which I assented. Together we repaired to the drug store near by, had some powders prepared, and on our return were surprised to find the pupils widely dilated; it is needless to say no more atropia was administered. The sudden dilatation of the pupils was undoubtedly caused by the paralysis of the nerve centers controlling the iris, and is one of the frequent conditions in the last stages of opium-poisoning, and indicative of general muscular paral ysis; it is also known as the 'dilatation of asphyxia'.

"Dr. Campbell made the remark, we can do nothing more now.' I agreed with him; but recalling the case of Mr. Dyke, and my views then entertained, I mentioned to Dr. Campbell my conviction that Mr. Burns' life might be saved by opening the trachea, placing a tube in it, and with suitable apparatus, keeping up the respirations until the poison could be eliminated. I informed him that I had the apparatus used on dogs in the laboratory of the college at my residence near by. He offered to assist if I would make the experiment. With the aid of a gentleman stopping at the honse, I obtained the apparatus. On my way I asked Dr. G. H. McMichael to assist in the operation.

"The tracheal tube was quickly cleaned with a bichloride solution, and the operation of tracheotomy begun at 9 A. M. The hæmorrhage was overcome before incising the trachea. The greatest difficulty was experienced in passing a ligature about the trachea to prevent the air from passing up the throat. After this was accomplished we were ready to begin the respirations. The blood passing from the incision was of a dark coffee color, indicating an extreme venous condition. Having been deeply occupied with the operation I had not noticed the condition of the patient farther than to be able to state that no respiratory effort had been made for some time, and that the dark blue tinge of the face had materially increased.

"We began the forced respirations; and as some interesting physiological changes ensued, it may be well to note them carefully. (See

effects of forced respiration on narcotised human subjects, page 59.) The lungs were inflated; not the slightest expiratory effort was made, indicating not only paralysis of the muscles of respiration, but loss of elasticity in the lung tissue.

"No mention has been made of the difficulty encountered after the patient revived and began to move uneasily about; these movements loosened the tube in the trachea and started hæmorrhage, and as at this time the patient was depending upon the forced respiration for his life, the result was made uncertain. This was the most serious time in the operation. In the house were boarding three soldiers of the U. States recruiting service, who were quickly summoned, and performed efficient service in restraining the patient. At this time, and before the tracheal tube was first inserted, considerable blood passed into the lungs; it was subsequently coughed out at the opening of the valve of the apparatus. At 12 o'clock, mid-day, after the forced respiration had been under way two and one-half hours the ordinary tracheotomy tube was substituted for the tube of the apparatus, and the patient allowed to breathe for himself.

"To add to the uncertainties of this case the night following the operation a bad attack of delirium tremens set in; the patient became quite violent, requiring at times four or five men to restrain him. This condition passed away, and with the exception of abnormalities in the number of respirations, nothing farther happened to complicate the casc." At the close of Dr. Fell's paper of September, 1889, he gave the following resume of all cases reported to date :

"Case No. 1. Dr. Fell, Buffalo, N. Y. Adult. Morphia, grs. xx taken. Forced respiration; two and a half hours, saved life."

"No. 2. Prof. Dr. Boehm, Vienna, Austria. Morphia, grs. 8.24 taken. Forced respiration for four and one-half hours, saved patient." 'No. 3. Dr. Fell, Buffalo, N. Y. Adult. Tr. Opii. 2 oz. taken. Forced respiration for fourteen and one-half hours, saved patient."

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"No. 4. Dr. Fell, Buffalo, N. Y. Adult. Tr. Opii. 2 oz. taken. Anterior jugular vein and trachea cut with a razor. Patient almost exsanguinated. Forced respiration for twenty-four hours,—twenty-one and one-half continuously, with transfusion of 8 oz. of salt solution; saved life."

"No. 5. Dr. Fell, Buffalo, N. Y. Adult, 80 years of age. Tr. Opii. 1 oz. taken. Forced respiration for twelve and one-half hours failed to save the patient."

No. 6. Dr. Fell, Buffalo, N. Y. Infant, eighteen days old. Mcrphia Sulph. 1 gr. taken. Five hours afterward forced respiration kept the child alive for four hours."

"No. 7. Dr. Fell, Buffalo, N. Y. Adult. Morphia, in large but unknown quantities taken. Operation undertaken after pulse at wrist was lost; dilatation of asphyxia had taken place; auscultation failed to

. detect heart action, and blood on tracheotomy was venous. Forced respiration produced return of pulse at both wrists, and clear action of the heart on auscultation. Blood became arterial. Heart ceased beating in about one hour."

"No. 8 Dr. Fell, Buffalo, N. Y. Still-born infant. Compression of brain," caused by laceration and hæmorrhage, as shown by autopsy, prevented forced respiration from proving successful.”

"No. 9. Dr. Fell, Buffalo, N. Y. Adult. Tr. Opii. 2 oz. taken. Forced respiration, after eleven hours, saved the patient."

No. 10. Dr. Fell, Buffalo, N. Y. Adult. Morphia, grs. v to x, and Tr. Opii. 2 oz. taken. Forced respiration, after fourteen hours, saved life."

Concerning the outcome of these cases in which recovery took place, there can be no question but what forced respiration is alone to be credited with the saving of several, if not all, of these lives, and yet all the cases reported did not terminate so happily.

At just what stage or condition one would be justified in not using forced respiration, Dr. Fell said: "Having now saved five human lives which could not otherwise have been saved, it is difficult to state at what stage preceding death it will not prove valuable. The only safe rule is to make the attempt, and place your patient beyond the question of uncertainty as far as this operation is concerned, and a favorable result will occur in the majority of cases."

Too great publicity of this practice can not be given it. The almost daily occurrence of death from opium poisoning, reported in the public press of the country, from San Francisco to Portland, Me, in which it is asserted that every means was resorted to to save life, but in which forced respiration per tracheotomy was not practical, and in too many cases was probably unknown to the physician, in which a personal correspondence with physicians elicits the opinion not infrequently that cases in their charge could have been saved in that manner, indicates that physicians should not only be forewarned but forearmed.

Since writing the foregoing, in correspondence with Dr. Fell he informs me that he has added another life to the list of lives saved, in which artificial respiration was of no avail. This, his last case, was a young girl who had taken eight grains of sulphate of morphia was treated by a new device for forced respiration,—the trachea not being opened,— which consists of a firm rubber cap fitting tightly over the nose and mouth of the patient, and will answer in some cases. This device I have not yet seen, but I take pleasure in now exhibiting to you such of his apparatus as is required to do forced respiration per tracheotomy. An apparatus for imparting moisture to the air, also for warming it for cases requiring air for inhalation warmer than the surrounding atmosphere, can easily be added to the outfit.

TREATMENT OF HAY-FEVER,-WITH THE REPORT OF CASES.

BY C. E. CHANDLER, MONTPELIER.

An essential, in the successful treatment of hay-fever, is a knowledge of the anatomy of the nasal cavities. Briefly and for our purpose, it may be described as follows: Each nasal cavity is divided into two regions, a superior or olfactory, and inferior or respiratory region. The olfactory region, the function of which is smell, is the upper portion of the cavity, corresponding to the distribution of the olfactory nerve. It includes the superior turbinated and upper third of the middle turbinated bone, and adjacent septum. The respiratory region is the remaining portion of the cavity, and is the only part of the passage that concerns us, in the treatment of hay-fever.

The mucous membrane covering this part is much thicker, very highly vascular, and resembles erectile tissue. This description applies more closely to the membrane covering the inferior turbinated bone. The posterior and middle portion of this membrane is supplied by sensory filaments from the spheno palatine ganglia. The anterior portion derives its nerve supply from the nasal branch of the ophthalmic nerve. The function of this region is to afford warmth and moisture to the inspired air, and free it from impurities before reaching the lungs.

Sensitive areas are certain spots, in the nasal cavity, which are capable of exciting reflex symptoms, from the irritation of a probe or other foreign substances.

Three such areas have been described, one or all being implicated in the production of hay-fever. The first is Hack's, situated over the anterior extremity of the inferior turbinated bone: the second is Mackenzie's, at the posterior extremity of this bone: the third is Sajou's, situated in the vestibule of the nose. A fourth has also been described at a corresponding point on the septum.

In the nine cases of hay-fever, which are reported, Hack's area has been affected, either by hyperæsthesia, or vascular engorgement, sufficient, at times, occlude the nose or true hypertrophy of this membrane. The difference between the two latter conditions is readily shown by the application of cocaine. If hypertrophy exists, there is considerable swelling after the blood-vessels are fully contracted. In only one of these nine cases was there simply a sensitive area at Hack's point and in this case, there was a vascular growth, touching the septum, about the middle of the turbinated bone. In the other eight cases, there was a