Nos. 3 and 4 are photographs of the plate made to fit the pattern of the remodelled cast illustrated in cuts 1 and 2 before the leather covering is applied. The use of rigid supports such as plates has become very much abused not only by the laity but by lay physicians, due to lack of appreciation, I believe, of the demands of the individual case. With the great variety of shapes, sizes and conditions of feet it can be readily understood that a universal pattern can not be adopted which furnishes the reason for our meeting with so many cases where ready made plates were pur another. One can only determine by his own development of technique that form of plate which he can best adapt to the case to be treated. The form represented in a No. 6-FOUR PHOTOS OF PLATE AND MODELED CAST. general way by these photographs, altered to conform to the demands of any particular case, has in my experience been found most serviceable. The steps in the process of making the plate may be briefly outlined as follows: The model of the foot is taken in plaster of Paris with the patient seated and the foot at rest in the panful of the soft mixture of plaster of Paris and water. When the imprint of the sole and the inner surface of the foot is sufficiently set the foot is removed and the mold allowed to dry when it is shellaced and filled to form the working model upon which the outline of the desired plate is drawn to cover the sole and inner surface sufficiently to grasp the arch. The model should be reshaped as the case requires, making the summit of the dome of the arch to correspond to the astragaloscaphoid articulation, which should correspond to the junction of middle and posterior third of the entire length of the plate. From this point the slope should be most decided backward to the middle of the dome of the heel and much more gradually forward and outward, reaching forward to just posterior to the first metatarso-phalangeal articulation, and in width of sole to cover in ordinary cases about three-fourths of the entire width of the sole of the model. In simply pronated feet it is not necessary to cover more than one-half to two-thirds in width of the plantar surface, thus permitting the outer segment of the foot to go unsupported by the plate. The inner surface of the foot in most cases should be covered sufficiently to bring the upper border of the plate above bony prominences and indentations may be made in this surface to relieve somewhat the pressure of these bony protuberances. The plate when made to conform to the outline thus drawn upon the model should when resting upon a flat surface indicate the position the arch will be held in when placed in the shoe. There should be three points of contact with the surface, either two points forward and one at the heel or two points at the heel and one forward, forming in this way a tripod so to speak, in order to maintain perfect stability. Any rocking will tend to continue protective muscle spasm and delay restoration of the foot but where this observation is followed confidence will be placed in the stability with which the arch is held supported and the result attained. Where the transverse arch is flattened and painful the forepart of the plate sole can be elevated just posterior to the painful metatarso-phalangeal articulation and will necessitate extending necessitate extending the sole forward further than is usual when fashioning the same to support the longitudinal arch only. These plates can be made of various substances, preferably of steel sufficiently soft to be malleable and at the same time to preserve the shape when formed. The gauge will depend upon the strain placed upon them. I find 22 to 19 is about the range, 19 being the most employed. Twenty-two yields a very light and easy plate. These plates may be nickeled, tinned, galvanized or japanned and covered with leather, the leather sole extended to form an insole to the shoe, thus keeping the foot from bearing against the hard metal, which is an objection often mentioned. When placed in the shoe and the foot inserted there should be very little reliance upon the shoe to maintain the foot in position in the plate. If otherwise the plate has been improperly modelled or the case is not one suitable for plate treatment. Foot exercise and massage with the corrective shoe will in the majority of early cases suffice. In conclusion therefore I would emphasize that each foot is a law unto itself and to but in the application of our mechanical it does not furnish a rigid passive support treatment we must bear in mind its practical adaptability. In infancy and early childhood our efforts should tend toward toning up the weakened structures by exercises and massage rather than by the use of passive supports. No. 7-ONE PHOTO ILLUSTRATING SUCH A CASE. In older cases while we have the attainment of a permanent cure always in view and where passive supports such as plates but allows freedom in the restoration of the supporting structures. 122 East 34th St., New York, and 234 Main St., Orange, N. J. SURGICAL HINTS. Next to rheumatism, tuberculosis is the most common of all affections of the joints, although in the early stage the symptoms may be so obscure as to make a diagnosis extremely difficult. THE RELATION OF NASAL DISEASE TO HAY FEVER AND ASTHMA. BY CLAUDE G. CRANE, M. D., Associate Laryngologist to the Brooklyn Hospital; Assistant Surgeon, Department of the Ear, Brooklyn Eye and Ear Hospital, Brooklyn, N. Y. By hay fever we intend to include all the various terms which have been applied to a well conceived group of symptoms caused by the irritation of the afferent nerve terminals supplying the nasal mucous membrane, resulting in the stimulation of the nerve center in the floor of the fourth ventricle, and ending in an efferent nerve pulse at the point of origin in the nasal mucous membrane. This briefly is a description of a nasal nerve reflex, beginning in the nasal cavities and ending in the nasal cavities. In connection with the subject of this paper we intend to consider only asthma. of nasal origin. We have here a group of symptoms of a very definite character. originating in an irritation of the nasal afferent nerve terminals and ending in the bronchial efferent nerve terminals. In hay fever we have an afferent sensory impulse and an efferent sensory and vaso-motor impulse, while in asthma, we have an afferent sensory nerve impulse and an afferent motor and vaso-motor impulse. While in hay fever we can very readily conceive and are willing to accept at once the simple nerve impulse just described; in asthma, on the other hand, we have a more complicated nerve reflex to explain. In both reflex examples the peripheral irritation may originate in and be conveyed to the nerve centers along the nerve of special sense the olfactory-or along the sensory nerves supplied by the trigeminus. That we must have some connection between the sensory nerve supply of the nasal fossae and the motor and vaso-motor supply of the bronchi in order to satisfactorily account for asthma of nasal origin is only too evident. In asthma we have the same origin of irritation in the nasal sensory afferent nerve terminals, but the efferent motor and vaso-motor impulses instead of returning to the seat of their origin, return by the efferent motor filaments of the vagus and the vaso-motor efferents of the sympathetic. This connection has been well established and is regularly described in the text books of anatomy, as through the superior cervical ganglion of the sympathetic. In order to understand how close is the nerve connection along the lines above indicated it may be well to briefly describe the nervous system involved in the parts under consideration. The olfactory or special sense nerve has an intimate connection through the sympathetic system with the gasserian ganglion of the 5th nerve. The second or optic nerve is connected with Meckel's ganglion. The 3rd or motor oculi, and the 4th or trochlear nerve both receive filaments from the cavernous plexus of the sympathetic and from the ophthalmic division of the 5th nerve. The 5th or trifacial or trigeminus, the great sensory nerve of the head and face, and the motor nerve of the muscles of mastication, has its origin or nucleus in the floor of the fourth ventricle and so has the vagus or 10th cranial nerve. It is believed that the nuclei of these two nerves are connected by means of association fibres. This, however, is not essential in order to prove the connection between the 5th and 10th nerves as we have as previously mentioned, a well proven and accepted connection through the superior cervical ganglion of the sympathetic. The gasserian ganglion of the 5th receives branches from the carotid plexus of the sympathetic. The ophthalmic or 1st division of the 5th is a sensory nerve supplying the eye ball, lachrymal gland, mucous lining of the eye, nasal fossae, the integument of the eyebrow, forehead and nose. The ophthalmic is joined by filaments from the cavernous plexus of the sympathetic, and the 3rd, 4th and 6th nerves as well. Connected with the three divisions of the 5th are four small ganglia. With the 1st division, the ophthalmic ganglion; with the 2nd division, the spheno-palatine or Meckel's ganglion; with the 3rd division, the otic and submaxillary ganglion. All four receive sensory filaments from the 5th and sympathetic filaments from various sources. The spheno-palatine is is the the largest of the four and like other ganglia of the 5th has motor, sensory, and sympathetic roots. The nerve supply, motor sensory and sympathetic of the eye, orbit, nasal fossae, palate, pharynx and bronchi is entirely received from the foregoing sources. That they are intimately connected is sufficiently established by the facts just enumerated and need no further elaboration. Now that we have established the undoubted anatomical and physiological connection between the eye, nasal fossae and bronchi, we can turn our attention to the consideration of hay fever and asthma of nasal origin as pathological entities. The etiology, pathology, symptoms, course and treatment do not warrant separate consideration of these two conditions and they will be considered together while at the same time recognizing that either may exist with or without the other. That hay fever and asthma are examples of what we are accustomed to term reflex neurosis there can be no doubt. Volumes have been written and numberless theories have been propounded to account for the etiology of these conditions. After carefully perusing them all we are forced to the acceptance of the term "reflex neurosis" as descriptive of the underlying etiological factors. That this term is not sufficiently specific and descriptive is due to the fact that the proper interpretation of what is meant by a reflex neurosis varies so widely. By reflex neurosis I merely mean the pathological reflex described in the first part of this paper. It is a true nerve reflex and there is no need of the mystifying terms so constantly applied to the phenomena. In hay fever we have a simple nerve reflex, while in asthma we have a complex reflex. Examples of both in other parts of the body are too numerous to require mention. We can well afford to accept an anatomical and physiological basis only too well established and to build up our etiology, pathology and treatment along these familiar lines. The foregoing introduction will serve to elucidate whatever points in this paper may be at variance with the ideas prevalent in the minds of many of the profession, a very considerable number of whom have given the subject careful study. The first mention in literature of hay fever was that of John Bostock, a London physician, who in 1819, read a description of his own case before the Royal Surgical Society. In 1828, he supplemented his first report by reading a treatise on the subject based on 28 new cases. Others |