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inner canula, so that when the dilator is in position the canula can be corked and the breathing be carried on entirely through the larynx, which assists very materially the dilatation.

Schrötter, however, treats these cases by passing instruments from above into the larynx. His method consists in passing metal or hard rubber bougies a little over an inch and a half in length and of diferent sizes into the constricted glottis by means of a hollow staff, through which a string attached to the bougie passes and is tied at the handle so as to hold the two parts firmly together. After the dilator has been passed into the glottis, and the button on the end of it can be seen in the tracheal tube, it is fastened and held in position by a pair of small forceps which are passed through the canula, or, as modified by Schrötter, by transfixing the dilator by a curved rod a little over an inch in length that projects from the inner canula, which is only about of an inch long. The string is then unfastened from the handle and the latter is drawn away, leaving the string hanging from the mouth or fastened around the ear. The dilator is then allowed to remain in position for 12, 24 or 48 hours, when it can be removed to be cleansed or replaced by a larger one.

Schrötter says that the upward and downward movement of the bougie dilator, which was the greatest objection to the first mode of holding it in position, is obviated by the transfixion that he afterward adopted; but it appears to me that the dilator would occupy a large portion of the lumen of the tracheal canula and interfere with respiration being properly carried on, whereas I have seen persons breathing perfectly comfortably with it fixed by means of the forceps, and no doubt some of you saw in Baltimore last winter the patient upon whom Schrötter had operated, and who had from long practice become an expert in passing and fastening these bougies in his throat, wearing one with apparently but the slightest inconvenience.

The two methods of Schrötter, the hard rubber tubes and the one I have just described, have given almost uniformly good results and are to be recommended, although the dilators of Morell Mackenzie and Navratil have been employed with success in some cases, and in one instance reported by Dr. Morris J. Asch, of New York, flexible metal sounds were successfully used to break the adhesion and dilate the constrictions.

Whenever the adhesions are extensive, however, or if the stenosis is due to membranous webs or bands in the larynx, they should be cut either with the laryngeal lancet or, better still, with the ingenious

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instrument devised by Dr. MacNeill Whistler, of London, which Dr. Morell Mackenzie told me he had used with satisfaction. This instrument of Dr. Whistler's consists of an almond-shaped dilator with a concealed blade which is reversible, and will make a section when it is pushed out by the lever on the handle, either anteriorly or posteriorly, as required.

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WHISTLER'S CUTTING DILATOR.

After Dr. Whistler passes his cutting dilator through the constricted glottis he introduces either his own instrument with the lancet concealed, or bougies, to prevent readhesion, though this would be more certainly ensured, I think, by a thorough cauterization of the cut surfaces before making use of the bougies.

In conclusion I will state that the results obtained by me in the three cases will explain sufficiently my having called the attention of the society to them; for Lennox Browne, in speaking of this condition, says in his work on Diseases of the Throat, published in 1878: "Laryngeal oedema must be met by the prompt performance of tracheotomy, and the same step may be necessary, at least as preliminary to later measures, if stenosis becomes extreme. With respect to the further treatment of this last condition, it cannot be said that any great success has, so far, followed attempts to remove the cicatricial web, or to dilate the narrowed orifice by bougies or analogous measures carried on through the natural passage. It is better, therefore, to warn the patient on whom tracheotomy has been necessary on account of such condition, that he will in all probability be obliged to wear the canula for the rest of his life"; and so eminent an authority as Cohen says in 1880: "I have never been able to induce a patient to place himself under my care with such an uncertain prospect before him, and therefore lack personal experience in the procedure."

In all my cases the difficulty in breathing was relieved by the treatment, and I have shown to-day a patient who was for months absolutely dependent on a tracheal opening for respiration, who wore the tracheotomy tube for one year, and who is now breathing with perfect comfort entirely through the natural passage.

INVITED PAPERS.

THE DIRECT ACTION OF ETHYL ALCOHOL UPON THE

ᎻᎬᎪᎡᎢ.

BY H. NEWELL MARTIN, M. A., M. D., D. Sc.

Professor of Biology in the Johns Hopkins University.

The action exerted by alcohol upon the system is a question upon whose answer depend so many fundamental matters, both social and political, as to make a thorough exact study of the subject eminently desirable. But if that were all, I should not feel justified in discussing it before this Faculty: the action of alcohol has a more immediate interest to the medical man, as medical man. Alcohol in some form or another is a very frequently prescribed drug, administered for some direct power, stimulant or nutritive, which it is believed to exert upon the system in general or upon some special organ. Still more frequently the physician has to deal with pathological states resulting from or modified by the tippling habits of his patient. I believe, therefore, that I need make no apology for bringing before you an account of an experimental investigation as to the direct action of alcohol upon the heart, upon which I have been engaged for some months, in conjunction with Mr. L. T. Stevens, graduate scholar of the Johns Hopkins University.

The literature of the subject is immense; under the heading "Alcohol, Physiological Effects of" I find 160 titles in the Index Catalogue of the Library of the Surgeon-General's office. On looking down the list, however, one soon sees that very many of these papers may be thrown out of consideration from the point of view of the physician or physiologist; they are merely more or less rhetorical essays by persons who contribute no new fact which may aid us in arriving at a deliberate and unemotional scientific conclusion. Then there is a large class of pseudo-scientific writings, of what may be called the "eggalbumin-and-spirits-of-wine" type. That if we place some white of egg

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