were disclosed. Then it was suggested there was a special secretion of something like diastase or vegetable pepsin. which the microbe didn't like, and so he quit. Then the idea was advanced that the germs administered to themselves the penalty for being such gourmands upon the tissues of their host, and that their own excrementitious products were their undoing. The latest word that I have heard-some of you may have heard later is that the antitoxin neutralizes the toxin much as an alkali neutralizes an acid. That probably there is some such relation between them appears to be evidenced by the fact that, while the mixture of a toxic and an antitoxic liquid in a test-tube results in a neutralized compound, the toxin is not destroyed. Let the mixture be heated to 68 degrees Centigrade, the antitoxin will be coagulated and its influence will disappear, while to the toxin will be restored all its former virulence. Healthy blood, owing to its alkalinity, is a germicide, and thus affords immunity against ordinary onslaughts of disease; while the person suffering from reduction of vitality, on account of low alkalinity of the blood, will readily catch anything, from a bad cold to the spring fever.

But whatever may be the how or the why of the operation of antitoxin, we all may be thankful for the benefactions it has brought already, and for the still greater things it promises. With kingdoms and republics declaring fears that the race may run down if not out, because of reduction of the birth-rate, it is reassuring to know there are processes afoot which mean also reduction of the death-rate. If there were marked increase in longevity of human lives, and at the same time no diminution in the primary supply of population, the struggle for existence of course would be greatly intensified, and life might be made much less worth living.

In conclusion, I desire to express my thanks to the Medical Society of the Missouri Valley for the privilege of honorary membership therein, and for the unique distinction of having been permitted as a layman to have my name appear upon your programme.

TREATMENT FOR RELIEF OF NASAL REFLEXES WITH REPORT OF CASES.

F. W. Dean, M. D., Council Bluffs, Ia.

Y nasal reflexes I mean those neuralgias and muscular spasms that are caused by abnormal conditions in the nasal chambers. We often

find large spurs projecting from the septum, the inferior turbinates hypertrophied to the extent that respiration through the nose is impossible and the nasal chambers crowded with polypoid growths, still there is an entire absence of any reflex pains or muscular spasms. Again the septum may be normal, the nasal chambers free from polypi and the respiration through the nose unimpeded, at the same time the patient is a constant sufferer on account of these reflexes.

The reflexes may take the form of asthma, sneezing, or neuralgic pains; the pains being supra-orbital, temporal, over the malar bone, over and back

of the mastoid, or in the ear of the affected side. These symptoms are aggravated by anything that will cause irritation and congestion of the nasal mucosa, such as dust, irritating fumes or exposure to cold. The headaches are apt to be worse on rising in the morning than in the afternoon, while the reverse is the rule with headaches from eye strain, and they are usually one-sided.

If we irritate the anterior end of the middle turbinated body with a probe we can produce sneezing and the reflex pains. Conversely, when we find these symptoms we must look for the cause in that part of the nasal mucosa.

In examining the interior of the nose the first abnormalities we observe are spurs and deflections of the septum, and congested or hypertrophied inferior turbinates. Much unnecessary and often harmful surgery has been and is being done to these parts.

If deflections and spurs of the septum do not obstruct the passage of air or impinge on the opposite structures causing an irritation their correction while not harmful is, I believe, unnecessary. The mucous membrane which covers the inferior turbinate is necessary for the furnishing of moisture to the inspired air. If too much of this membrane is destroyed by cauterization or removed by scissors or snare, the result is a dryness which is more disagreeable and harmful to the patient than the congested condition. If cauterization is necessary it should be deep in order to form a good escar, but the cicatricial line must be narrow preserving as many of the mucous glands as possible.

On examining the middle turbinates, we may find the anterior end of the bone itself thickened and pressing against the septum or inferior turbinated body. Again, the bone may be normal. but covered by hypertrophied or edematous tissue. Either of these conditions is almost certain to cause constant or intermittent reflexes.

The reflexes are also caused by polypi behind the middle turbinate, crowding against it or crowding it against the septum, but the symptoms are not as certain to follow as they are in the case of abnormal conditions of the middle turbinated body itself.

The treatment for these conditions is surgical. To treat these hypertrophies with sprays, snuffs and nebulae is at best only palliative. There is a sense of relief as long as the nasal chambers are kept free from mucous, and the patient believes that he is being benefited. The hypertrophies remain unchanged, however, and must be treated surgically if permanent improvement is to be secured.

It is impossible to rid the nasal mucosa of bacteria by the use of the spray, hence the spraying of the nose immediately before operation is useless

If the middle turbinated bone itself is not thickened or twisted and crowding against adjacent parts, but simply covered by hypertrophied tissue, its reduction can be accomplished by the use of the cautery, either chromic acid or the galvano cautery, personally I prefer the latter, or the tissue may be removed down to the periosteum with a cutting forcep. When the bone is thickened it should be amputated, but it is almost never neces

sary to remove more than the anterior end of the bone. I do this under cocaine or eucaine anesthesia and adrenalin chloride, and with a pair of Noyes' alligator cutting forceps, punch out as much of the bone as seems desirable. Only in exceptional cases is it necessary to remove more than an eighth of an inch of the anterior rim of the bone, and if there is no more than that removed there is no danger of any atrophic changes or a disagreeable dryness following the operation.

The adrenalin makes the operation almost bloodless and the majority of my patients have had very little after hemorrhage, though a few have given me no little trouble to stop a profuse and persistent bleeding.

The bone should be removed in many cases in order to facilitate the eradication of polypoid growths having their attachments behind it. Often it is necessary to do this before their removal can be thoroughly accomplished.

The following were not consecutive cases, but I have chosen them to illustrate the reflexes which occur from irritation of the middle turbinates:

CASE I. Dr. D., a dentist, age thirty-nine; had had asthma occasionally between the ages of nine and twenty, especially during the winter months. Since that time he had had no trouble, until one evening I found him hard at work trying to get air. I gave him a quarter of a grain of morphine with atropine hypodermically for temporary relief. The next day I examined him in my office and found a small, firm polypus behind the anterior end of the right middle turbinate and crowding it against a slight projection from the septum. I removed the polypus with a cold snare and cauterized the base with the galvano-cautery. More than three years have elapsed and there has been no return of the asthma.

CASE II. Mr. B., clerk in the freight depot, age about twenty-three. Had been suffering with an intense left supra-orbital and temporal headache for five weeks. On examination I found what I supposed to be a thickened anterior end of the left middle turbinate. The right was also thickened but not to the same extent. On attempting to remove the hypertrophied portion of the left, I found that the thickening was due to a cell in the anterior end of the bone which, when opened, discharged a drop or two of pus. I broke down the cell walls and in a few hours the headache was relieved. The patient went to Denver on a visit, and while there was taken with a headache on the right side similar to the one he had had on the left. That headache was relieved by an operation on the right turbinate, done by a Denver rhinologist. The young man's father told me about two months ago that his son had secured a position with a western railroad and was feeling well, but later his headache had returned. have not heard from him since.

CASE III. Miss M., a nurse, had been suffering with a severe pain in left ear for one week. All the usual remedies, carbolized glycerine, laudanum and oil, heat, etc., were used with no relief. On examination I found the ear apparently normal. She was subject to attacks of follicular tonsilitis, but at this time I found no inflammation of the tonsils. In

the nose I found on the anterior end of the left middle turbinate a hypertrophy. This I removed with just the edge of the bone. The earache stopped before the patient left the office. Six months have now elapsed without a return of the earache.

CASE IV. Miss P., a school teacher, came to me five months ago for the relief of a pain at the back of her head which she had had almost constantly for months. I found the middle turbinates hypertrophied and covered with crusts. I removed the hypertrophied tissue together with the edge of the bone. The next morning she awoke without her headache and a month afterward, the last time I saw her, it had not returned.

CASE V. Mr. P., a railway mail clerk, came into my office with a severe left-sided supra-orbital headache. He gave a history of having those headaches on one side or the other, or both, for a number of years. I found both middle turbinates hypertrophied, I operated on the left and the pain was relieved at once. Five days later I removed a portion of the right middle turbinate. Two hours after the operation I was called to the patient's home on account of a profuse hemorrhage. The hemorrhage was stopped by placing a pack of gauze wet in adrenalin against the wound. The gauze was removed the next morning and the wound healed nicely without further accident. The patient has had no return of the headaches in the three months since the operations.

I do not claim any originality in the operation on the middle turbinates for the relief of nasal reflexes, but I wish to emphasis the importance of examining these bodies, as I believe that many patients go the rounds seeking relief from headache due, as they believe to eye-strain, and too often we correct any error of refraction and pass them on without even examining the nasal cavities to discover if the cause is not there rather than in the eyes.

A COMMON FAULT.

(Apologies to everybody.)

There was once a doctor who started a " shop,"
On a very elaborate scale.

On corners to talk of his fame they would stop,
And his rivals would gasp and turn pale.

The town was agog o'er the cures he turned out,
All said to be due to his foods.

But through one little flaw his defeat came about
He couldn't deliver the goods.

Not only in practice you'll often behold

The man who with promises fine

Is winning the cheers of the crowd-which grows cold-
When a practitioner new gets in line.

He glitters awhile in a glorious style,

And then he must take to the woods,

There are few, 'mongst the many, who promise and smile,
Who really deliver the goods.

My desire and aim have been to utter nothing but the truth. I have no love for error in any form or in any field of knowledge."-HIRam ChristopHER.

The Medical Herald.

THE PRESENT

ST. JOSEPH, MO., JULY, 1903.

The Editors' Forum

STATUS OF MEDICAL OPINION AS IT RELATES TO THE TREATMENT OF APPENDICITIS.

No more opportune time could well be chosen for the careful consideration of that much discussed, very much abused, by no means perfectly understood subject, appendicitis.

Happily for the patient and equally satisfactory to the physician and surgeon seeking the truth and nothing else, we are no longer confronted by titles not by any means so far in the past as to have grown the least dim, the "ethical means" of advertising in a "perfectly legitimate" way we were taught by the brilliant and tireless investigators who modestly began in a manner akin to these: "My First 100 Cases of Appendicitis;" "47 Cases of Rupture of the Appendix with General Infection of the Abdominal Cavity with recovery in each case showing the value of my method of treating the Stump;" "There should be no Deaths from Appendicitis;" "Appendicitis a Surgical Disease only;" "Free Incisions as first urged by the Author the reason for his success in every case of Appendicitis coming under his care;" "An inch and a half incision, a week and a half in bed."

No one we believe will question that the most brilliant achievements may often, indeed do mark an epoch in medical history, such as the titles. referred to would indicate, but the sound of the gavel will be much in evidence, and there will be seemingly ruthless hewing to the line before the workmanship will find favor with the master builder and be given a