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ALBERT ABRAMS, M. D., San Francisco.
M. V. BALL, M. D., Warren, Pa.
FRANK BILLINGS, M. D., Chicago, Ill.
CHARLES W. BURR, M. Ď., Philadelphia.
C. G. CHADDOCK, M. D., St. Louis, Mo.
8. SOLIS COHEN, M. D., Philadelphia, Pa.
N. S. DAVIS, M. D., Chicago.
ARTHUR REDWARDS, M. D., Chicago, Ill.
FRANK R. FRY, M. D., St. Louis.
Mr. REGINALD HARRISON, London, England.
RICHARD T. HEWLETT, M. D., London, England.
J. N. HALL, M. D., Denver.
HOBART A. HARÉ, M. D., Philadelphia.
CHARLES JEWETT, M, D., Brooklyn.
THOMAS LINN, M. D., Nice, France.
E. E. MONTGOMERY, M. D., Philadelphia
NICHOLAS SENN, M. D., Chicago.
EDWIN WALKER, M. D., Evansville, Ind.
H. M. WHELPLEY, M. D. St. Louis.
WM. H. WILDER, M. D., Chicago, III.



Probably there is no symptum more frequently met with, aside from pain, that causes more distress than cough. Cough is an indication of some irritation or disturbance in the upper or lower respiratory tract. I believe, that in the vast majority of instances, the actual disturbance to be extra-pulmonary in origin, and quite innocent in its nature, contrary to the conviction of the patients, who often insist that the seat of the trouble must be in the chest Extrapulmonary cough has been ascribed to almost as many causes as there are organs in the body. Various theories as to the production of reflex cough formerly enjoyed a wide recognition among physicians. However, by a thorough and accurate examination, the extraneous cause will usually be found to be due to some pathologic change in the nose, naso-pharynx, oro-pharynx, palatal region, glosso-epiglottic fossae, larynx, or upper third of the trachea.

Cough is usually spoken of as direct or reflex. It is a direct cough when there is irri. tation from congestion, edema, inflammation, pressure, swelling, or from foreign substances, such as mucus, pus, eto., within the respiratory tract. Cough is a reflex phenom. enon when due to some pathologic change in the respiratory organs.

Apparently there exists among various ob. servers more or less confusion as to the mutual understanding of the reflex cough. There are those who consider all cough due to altered functions of the upper air passages as reflex, while others classify it a direct cough.

From a physiological sense, all coughs are reflex, that is, we have an exciting organ, a central organ, and this united in turn with an executing organ. An admirable example and interesting source of reflex cough is exhibited by irritation in the external auditory canal by the presence of a foreign body, impacted cerumen, inflammation and irritation in the cerumen secreting area, the osteo-cartilaginous junction of the auditory canal and the drum membrane. Illustrated in this ty. pical case: Three years ago, Mr. A., age 38, consulted me for tinnitus in the right ear, slight impairment of hearing and occasional pruritis in the external auditory canal. On introducing the aural speculum in the auditory canal, a most persistent and violent cough was induced. An inspection of the canal showed it to be covered with dark, dry, scaly lardaceous substance extending to the depth of the drum, which was hyperemio and

the phpbborn, harassithose types be chest


ST. LOUIS, MO. ONE of the diffioult problems confronting

ho didint neoblema confronting the physician is to find the cause of and cure for stubborn, harassing and persistent cough. This paper refers to those types of cough in wbiob pathologic changes in the chest can be excluded. This class of cases have usually run the gamut of the whole pbarmaco. piea. Yet, aside from temporary relief, the cough lingers, causing greater or less annoy. ance and concern to the patient, family and friends.

The assurance that the cougb is quite in nocent in character, that no lesions or evi. dence of tuborculosis are present, offers the patient little comfort. The physician often finds it difficult to retain the confidence of the patient, to passify him and prevent un due and unnecessary worry, partioularly so in this time of enlightenment on and crusade against tuberculosis.

* Read before the Missouri State Medical Association, Jef. ferson City, May 16, 1906.


tbiokened. The patient remarked that he in so far as the condition is productive of bad been troubled with this troublesome partial or absolute stenosis, or in proportion cough for years. This paroxysm was likely as the hypersecretion from this region proto come on at any time. During the last vokes irritation to the sensitive areas well eighteen years he has consulted physicians supplied with peripheral nerve blaments, will who have prescribed various remedies with cough follow. little or no benefit to the cough. He has In the lower pharynx cough is induced by been advised to leave this climate, that his elongated uvula, low hanging uvula from lungs are affected. However, the patient re. relaxed palate, edematous uvula from contact mained in St. Louis, continuing to cough, with the epiglottis. but took on weight.

In the glosso-epiglottic fossae from vari. Diagnosis.-Eczema of the external audi. cosity and hypertrophy of the lingual or tory canal. Treatment directed to the der tongue tonsil, the cough is depende matitis stopped the cough, the itching, the the degree of disturbance indicted to the tinnitus, and restored the hearing to por higbly sensitive epiglottis. mal. To the present the introduction of a À causative factor sometimes overlooked is speculum or probe evokes the same old hypertrophy of the lateral pharyngeal walls, cough.

or so-called pharyngitis lateralis, which in It occurs to me that undue stress has been some instances is productive of distress and laid on nasal and naso-pharyngeal reflexes barassing symptoms. The faucial tonsils as a causative factor in the production of in my experience have always been innocough. It is a term misapplied.

cent offenders so far as related to cough. My experience has been that almost every Cough from the epiglottis may be looked case of cough due to some disturbance in for in edema, ulceration and inflammation. the upper air passages, rather than a reflex In the larynx, in benign and malignant cough, is a cough due to direct mechanical growths, edema, foreign bodies, ulcers and irritation of either the epiglottis, lateral walls formation of scar tissue, in acute and chronio of the pharynx, sensitive areas in the larynx, inflammation, cough is usually a prominent in the trachea and bronchi. I hardly believe feature. that too liberal construction can be given the Treatment consists in opening the upper importance of nasal and naso-pharyngeal ob. air passages, removing obstructions, estab. struotion and its interference with proper res. lishing free and easy physiologio respiration, piration, causing periodic or absolute mouth lessening secretion, and obliterating all breathing. Mouth breathing is a course pro. sources of direct irritation by or through ductive of many bad results, and harmful in means accessible and indicated by the condi. proportion, as the air inspired is impure, tions confronting the operator. charged with dust, not sufficiently warmed, Acknowledging the value of clinical data, and humidified before reaching the epiglottis, induces me to append brief notes from the larynx trachea and broncbi. In consqeuence, following cases: November, 1905, Elizabeth direct mechanical irritation is set up with re. L. age 9. Referred by Dr. Kennedy for exsultant direct cough.

amination of the nose and throat, and treatIntra-nasal factors, which may induce ment if necessary. Complained of cough cough fronu indirect irritation through mouth the past two months. Internal medication breathing or from hyperseoretion in the unsatisfactory. Present state; no fever, norpharyngeal space, may be menticned as mal pulse, appetite good. Patient appears to chronio rhinitis, intumescent and chronic breathe through the nose freely. Mother bas hypertrophy of the middle and inferior tur. never observed that the child breathes binate bones and of the mucous pembranes otherwise. Inspection of the nose, naso. in general, posterior hypertrophies, polypi, pbarynx, oro-pharynx and larynx did not deflected septum, spurs, ridges or other ab. revel any abnormal alterations, aside from normalities of the septum and floor of the some slight bogginess of the lower margin of nasal fossae.

the inferior turbinates. The mother was in. Mention should be made of necrotio, puru. structed to note breathing during sleep. The lent, sypbilitic, atropbio rhinitis and sinusi. report next day confirmed my belief that restis causing stenosis or profuse secretion piration was carried on at night, when recumwhich trickles down the pharyngeal walls to bent, through the mouth. Diagnosis.-Inirritate the sensitive areas of the epiglottis, tumescent hypertrophy of the inferior tur. larynx or even trachea.

binate bodies. Within the confines of the upper pharynx Treatment.—Locally, every tbird day at the pathologic changes, namely, hypertropbic office, spray in the nose 2% cocaine solution and granular pharyngitis, atrophic pharyn- to lessen irritation, induced by the applicagitis, enlarged pharyngeal tonsil or adenoids, tion of a 1% copper sulphate solution. This

was followed by an oily spray of menthol gr. sis of the vomer. Treatment: Internally, 3, camphor gr. 2, oil eucalyptol gtt. 3, in syrup stillingia comp. one teaspoonful three vasenol oz. 1, to the nose, naso-pbayrax, and times daily; ten gr. kali iod. three times by deep inhalations into the larynx, trachea daily. Locally: Curettement of the necrotio and bronobi. At home, oil vasenol comp. bone with subsequent application of 20% oz. 1, with instructions to instil 10 drops in solution silver nitrate for several weeks. eacb nostril every three hours. Results.- Cleansing douche with an alkaline solution, The nasal congestion soon disappeared, result and spraying with an astringent oily spray. ing in re-established nasal respiration at Results. — Tinnitus ceased. Hearing innight. Within three weeks the cough was creased to thirty inches by the watch. In cured.

six weeks the cough entirely disappeared. From the case cited, it will be noted that

CASE IV.-September, 1904. Rosie H., it is at night, when recumbent and asleep,

age 10. Complains that for the past two the physiologio function of the nose is arrested

years has been troubled with a hacking by hypostatic congestion of the mucosa.

cough more or less constant and always From mere inspection of the pasal chambers,

worse at night. Many cough mixtures from in many instances, a definite diagnosis cannot

drug stores have been tried and several phy. be made. However, by requesting the pa

sicians bave prescribed without relief. The tient to observe the condition of his mouth

father thinking the trouble may possibly be and nose on awaking in the nigbt and morn.

in the throat brought the child to be exam. ing, and to note the nasal stoppage, and con

ined. Present State: The nose, pharynx sequent parohed, dry, leathery, pasty feeling

and larynx appear normal. The uvula does in the mouth and throat, with other disagree

not appear unduly long on inspecting the able symptoms, as hawking, gagging, retoh

throat with the tongue depressor, however, ing, etc., a definite conclusion can be drawn

by examining without depressing the tongue and diagnosis made.

the soft palate is noted to hang low and the CASE II.-Five years ago, Mrs. L., age 26, uvula elongated. This case demonstrates the consulted me complaining of a lump in the necessity for in examining those obscure oonthroat and for the past two years. Symptoms ditions in highly sensitive throats. Treatwere worse after dining. Present State. - ment: Removal of two-thirds of the uvula Examination revealed a large spur on the cured the cough. septum left paries, moderate pharyngitis and CASE V.-Mr. E. W , age 37, brought to hypertrophy of the tongue tonsil. Diagno. me by Dr. Becker for examination and treat. sis.-Hypertrophy of the lingual tonsil. ment of the nose. Complains of since over Treatment confined to reducing the enlarged two years ago has been troubled with stoptongue tonsil with the galvanic cautery. ping up of the onset, particularly at night. This was accomplished in three sittings when Take frequent colds in the head. Annoyed the symptoms cleared up.

by muous dropping into the throat. For

over a year has been troubled with a cough CASE III.-April, 1904. Mr. G. W. G., paroxysmal in obaracter. The cough is es. age 45. Complains of the nose stopping up pecially annoying about bed time in the night for the past fourteen months, and especially and mornings. Of late the cough has been annoying at night, when he breathes through unusually annoying early in the evenings, the mouth. Always bas a cold in the head. especially when out in company. At times The ears ring and hearing is impaired. Early the paroxysm is so violent the patient is in the mornings is awakened by an annoying forced to retreat to out door air. Mr. W. cough, which is troublesome all day. Has bas never sought relief for the cough, but taken many cough remedies without relief. bas been treated for the nasal stenosis. Present State.-The nose, nares filled with Present State. - On the septum right paris a thiok greenish secretion. The septum is large spur projects impinging upon a hypertbickened narrowing the nasal fossae. The trophio inferior turbinate. In the left naris inferior turbinates are turgescent filling the the upper third of the septum is thickened inferior meatuses. After removing the secre. and blooks that part of the fossae not closed tion and reducing the congestion a fair view by the tumefied inferior turbinate. The of tbe pasal cavities was made possible. On pharynx is chromically inflamed. The larynx the posterior end of the septum a crusty scab appears normal. Diagnosis.—Chronio hy. was clinging. By removing the scab the pertrophic rhinitis, and spurs on the septum. probe came in contact with denuded bone. Treatment.—Removal of spurs and hyper. Questioning the patient brought forth a his. trophies with intranasal saws and scissors. tory of specifio trouble in the family. Ears: This treatment resulted in establishing free Drums normal. Hearing by watch one inch nasal respiration with gradual cessation of right and left. Diagnosis: Syphilitic neoro- the cough.

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