present as in several other renal affections. Periodical attacks of hemorrhage, with frequency of micturition, often with passage of clots, seem characteristic. These clots sometimes block the ureter, cause diminished urine, and the pain is referred to the corona glandis. Between the attacks of bleeding there is fairly constant pain in the back. fresh hemorrhage relieves the pain, thus contrasting with pain and bleeding connected with the passage of stone. PATHOLOGIC SPECIMENS. Professor J. H. Larkin, of Columbia University, presented some pathological specimens of great interest and gave the history of each, in so far as he was able to obtain it. The first were of diseased appendages, a field of surgical research which is becoming more and more important. Until a few years ago it was supposed that lesions of the pancreas, as found at post-mortem examinations, were fairly well understood, but little was known of the etiological significance; but now pathologists are able to show the causative factor. Its close relationship to cholelithiasis and other diseases of the intestinal tract has been understood for some time. The clinical histories in these cases are very similar. There is usually a severe onset of gastric pain that at times is almost diagnostic to the surgeon of appendicitis or intestinal obstruction and many patients have been operated on for one or the other of these conditions. In the majority of cases, stone in the ampulla duct has been a very common factor. The specimen presented was mounted so as to preserve its normal color. On the right side was a portion of the duct and on the left a portion of the pancreas. It is presumed that one or more stones had been passed in this case, because of the immense dilatation of the common duct. The lesion is easily explained, and experiments have reproduced exactly the same condition. The stone passes down into the common duct and is impacted at Bardes' ampulla, and this leaves a continuous passage from the common duct to the ampulla, and the bile, instead of going down, is sidetracked and goes directly into the pancreas, and this produces hemorrhagic pancreatitis. This can be reproduced by putting bile into the pancreatic duct, or a solution of hydrochloric acid will produce the same re sult. The next specimen presented also showed the connection of the pancreas with the duct, and also showed the gall-bladder with an immense amount of stone. Several interesting brain specimens were presented, but no clinical histories would be obtained. One specimen had been taken from a patient who had been under observation for some time, and a diagnosis of cerebral abscess had been made. The specimen showed one side of the brain, with the cerebellum and 1 cc. of hemorrhagic blood which had been removed at time of operation. FOURTH OF JULY EYE INJURIES.-R. L. Randolph, Baltimore (Jour. A. M. A., July 7), has collected over 500 cases of eye injury occurring from fireworks during the last few years, some variety of fire crackers being usually responsible for the injury. He gives the result of work in stirring up public sentiment showing a decided decrease of such injuries in Baltimore. He laid the statistics before the leading newspapers and before the police, and secured the publicaticn of strenuous articles on the subject and also the issuance of stringent orders to enforce the laws. He believes that much can be done in other cities by ophthalmologists in the same way, and that in due season we may be able to educate the public and to accustom it to a quiet and sensible celebrations of the holidays. THE INTERNATIONAL POSTAL CONGRESS.A congress of the greatest importance to the world in general has been conducting its deliberations modestly and quietly in the Italian capital. We refer to the International Postal Congress, whose conclusions have been a useful and practical contribution to internationalism. In the first place the international letter weight unit has been raised from half an ounce to an ounce, making the rate five cents (or the equivalent in the money of other countries) for the first ounce and three cents for each additional ounce. There is also to be the equivalent of an international stamp, in the form of an international postal order, for five cents, which will be exchangeable for a stamp of the same value in any country of the unionthis for "return" postage. A number of proposals were made to reduce the unit from five cents to four (the British "tup-pence"), but these were defeated. Our own currency system prevents our taking much interest in this proposal, since a nickel is a much more convenient unit than four cents. The new regulations will no doubt result in a great extension of the postal business throughout the world, and will in all probability thereby increase the revenues of the post offices in all civilized countries. The international postal exchange order marks an interesting advance in the peaceful business relations between nations. In all probability it will prove the germ of international currency of the future. -American Monthly Review of Reviews. THE MEDICAL FORTNIGHTLY A Cosmopolitan Biweekly for the General Practitioner The Medical Fortnightly is devoted to the progress of the Practice and Science of Medicine and Surgery. Its aim is to present topics of interest and importance to physicians, and to this end, in addition to a well-selected corps of Department Editors, it has secured correspondents in the leading medical centers of Europe and America. Contributions of a scientific nature, and original in character, solicited. News of Societies, and of interesting medical topics, cordially invited. Advertising forms close on the first and fifteenth of each month. Time should be allowed to submit proof for correction Advertising rates on application. Remittances and business communications should be addressed to the Fortnightly Press Co. Subscription, $2.00 a year, in advance, including postage to any part of the United States, Mexico and Canada. Postage to foreign countries in the Universal Postal Union, including Newfoundland, $1.00 a year additional. Entered at the St. Joseph post-office as second-class matter. The Medical Fortnightly will not be discontinued at expiration of subscription, as many of our readers prefer not to have their files broken on account of failure to remit. Unless we receive a distinct request to discontinue, and payment for all ar rearages, this magazine will not be discontinued. Subscriptions may begin at any time; volumes end with June and December. Contributors should understand that corrected typewritten copy is essential to clean proof and prompt publication, and is much more satisfactory than manuscript. Original articles should be as condensed as justice to the subject will allow. Editorial offices in St. Louis Jacksonville, and St. Joseph, where specimen copies may be obtained, and subscriptions will be received. Contributions and books for review should be addressed to the editors, 319 and 320 Century Building, St. Louis, Mo. FAVORITE PRESCRIPTIONS PURULENT OPHTHALMIA.-Wm. F. Rielly, of Covington, Ky., writes that he has used hydrastine hydrochloride (Merck) in purulent ophthalmia for the past three years, and never yet has it failed him. He considers it the best remedy to give for home use, especially where a trained nurse is not in attendHe prescribes the following formula: Hydrastine hydrochlor. (white crystals)..... ance. B gr. v 3 j Magendia solut. morphine.. gtt. xv Dest. aq... After cleansing, instill two drops in the eye, and repeat every half hour, as long as there is pus.-Merck's Archives. ORCHITIS.-Lutaud combats the pain of orchitis by the administration of cachets containing seven and one-half gr. of quinine sulphate. In the majority of cases pain is arrested after the first dose, and it is unnecessary to give an injection of morphine. At the same time the following is applied locally: R Methyl salicylatis. 3 vj Guaiacoli..... Vaselini,.... aa 3 j M. Sig. Apply locally once or twice daily. -Medicine. EXOPHTHALMUS AFTER ACCIDENTS.-Kiliani states that the appearance of exophthalmus immediately or shortly after the accident is an absolutely reliable sign of a hemorrhage from within, and therefore of a fracture of the base of the skull.-Denver Medical Times. WATER ANESTHESIA FOR REMOVAL OF HEMORRHOIDS.-Charlotte Medical Journal, in discoursing upon the subject, describes Gant's method as follows: The operation is performed by placing the patient in the knee-chest position. The sphincter is graddown." By this means the hemorrhoids are ually dilated and patient is told to "bear brought into view. A large sized hypodermic syringe filled with distilled water is then until the mucous membrane over the pile betaken and the water injected into the pile comes blanched. Then an incision is made through the mucous membrane about the base of the pile, ligature applied and the pile cut away. This is the same as the ligature operation under anesthetic. The clamp and cautery could be used in place of ligature. The patient is allowed to go on about his work, having the parts examined and dressed every other day. They do not complain of any after-pain and ligatures soon slough off and parts heal.-Ex. Vol. XXX ST. LOUIS, AUGUST 10, 1906. Papers for the original department must be contributed exclusively to this magazine, and should be in hand at least one month in advance. French and German articles will be translated free of charge, if accepted. A liberal number of extra copies will be furnished authors, and reprints may be obtained at cost, if request accompanies the proof. Engravings from photographs or pen drawings will be furnished when necessary to elucidate the text. Rejected manuscript will be returned if stamps are enclosed for this purpose. COLLABORATORS. ALBERT ABRAMS, M. D., San Francisco. ARTHUR R EDWARDS, M. D., Chicago, Ill. Mr. REGINALD HARRISON, London, England. HOBART A. HARE, M. D., Philadelphia. LEADING ARTICLES COUGH-EXTRAPULMONARY CAUSES OF COUGH, IN CONSEQUENCE OF PATHOLOGIC CHANGES IN THE UPPER RESPIRATORY TRACT, AND DISTURBANCES IN THE FUNCTION THEREOF.* J. C. BUCKWALTER, M. D. ST. LOUIS, MO. ONE of the difficult problems 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 which pathologic changes in the chest can be excluded. This class of cases have usually run the gamut of the whole pharmacopiea. Yet, aside from temporary relief, the cough lingers, causing greater or less annoyance and concern to the patient, family and friends. The assurance that the cough is quite innocent in character, that no lesions or evidence of tuberculosis 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 undue and unnecessary worry, particularly so in this time of enlightenment on and crusade against tuberculosis. *Read before the Missouri State Medical Association, Jefferson City, May 16, 1906. No. 3 Probably there is no symptom 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 irritation from congestion, edema, inflammation, pressure, swelling, or from foreign substances, such as mucus, pus, etc., within the respiratory tract. Cough is a reflex phenomenon when due to some pathologic change in the respiratory organs. Apparently there exists among various observers 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 typical 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. 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 hyperemic and On thickened. The patient remarked that he had been troubled with this troublesome cough for years. This paroxysm was likely to come on at any time. During the last eighteen years he has consulted physicians who have prescribed various remedies with little or no benefit to the cough. He has been advised to leave this climate, that his lungs are affected. However, the patient remained in St. Louis, continuing to cough, but took on weight. Diagnosis. Eczema of the external auditory canal. Treatment directed to the dermatitis stopped the cough, the itching, the tinnitus, and restored the hearing to normal. To the present the introduction of a speculum or probe evokes the same old cough. It occurs to me that undue stress has been laid on nasal and naso-pharyngeal reflexes as a causative factor in the production of cough. It is a term misapplied. My experience has been that almost every case of cough due to some disturbance in the upper air passages, rather than a reflex cough, is a cough due to direct mechanical irritation of either the epiglottis, lateral walls of the pharynx, sensitive areas in the larynx, in the trachea and bronchi. I hardly believe I hardly believe that too liberal construction can be given the importance of nasal and naso-pharyngeal obstruction and its interference with proper respiration, causing periodic or absolute mouth breathing. Mouth breathing is a course productive of many bad results, and harmful in proportion, as the air inspired is impure, charged with dust, not sufficiently warmed, and humidified before reaching the epiglottis, larynx trachea and bronchi. In consqeuence, direct mechanical irritation is set up with resultant direct cough. Intra-nasal factors, which may induce cough from indirect irritation through mouth breathing or from hypersecretion in the pharyngeal space, may be mentioned as chronic rhinitis, intumescent and chronic hypertrophy of the middle and inferior turbinate bones and of the mucous membranes in general, posterior hypertrophies, polypi, deflected septum, spurs, ridges or other abnormalities of the septum and floor of the nasal fossae. Mention should be made of necrotic, purulent, syphilitic, atrophic rhinitis and sinusitis causing stenosis or profuse secretion which trickles down the pharyngeal walls to irritate the sensitive areas of the epiglottis, larynx or even trachea. Within the confines of the upper pharynx the pathologic changes, namely, hypertrophic and granular pharyngitis, atrophic pharyngitis, enlarged pharyngeal tonsil or adenoids, in so far as the condition is productive of partial or absolute stenosis, or in proportion as the hypersecretion from this region provokes irritation to the sensitive areas well supplied with peripheral nerve filaments, will cough follow. In the lower pharynx cough is induced by elongated uvula, low hanging uvula from relaxed palate, edematous uvula from contact with the epiglottis. In the glosso-epiglottic fossae from varicosity and hypertrophy of the lingual or tongue tonsil, the cough is dependent upon the degree of disturbance inflicted to the highly sensitive epiglottis. A causative factor sometimes overlooked is hypertrophy of the lateral pharyngeal walls, or so-called pharyngitis lateralis, which in some instances is productive of distress and harassing symptoms. The faucial tonsils in my experience have always been innocent offenders so far as related to cough. Cough from the epiglottis may be looked for in edema, ulceration and inflammation. In the larynx, in benign and malignant growths, edema, foreign bodies, ulcers and formation of scar tissue, in acute and chronic inflammation, cough is usually a prominent feature. Treatment consists in opening the upper air passages, removing obstructions, establishing free and easy physiologic respiration, lessening secretion, and obliterating all sources of direct irritation by or through means accessible and indicated by the conditions confronting the operator. Acknowledging the value of clinical data, induces me to append brief notes from the following cases: November, 1905, Elizabeth L. age 9. Referred by Dr. Kennedy for examination of the nose and throat, and treatment if necessary. Complained of cough the past two months. Internal medication unsatisfactory. Present state: no fever, normal pulse, appetite good. Patient appears to breathe through the nose freely. Mother has never observed that the child breathes otherwise. Inspection of the nose, nasopharynx, oro-pharynx and larynx did not revel any abnormal alterations, aside from some slight bogginess of the lower margin of the inferior turbinates. The mother was instructed to note breathing during sleep. The report next day confirmed my belief that respiration was carried on at night, when recumbent, through the mouth. Diagnosis.-Intumescent hypertrophy of the inferior turbinate bodies. Treatment.-Locally, every third day at office, spray in the nose 2% cocaine solution to lessen irritation, induced by the application of a 1% copper sulphate solution. This was followed by an oily spray of menthol gr. 3, camphor gr. 2, oil eucalyptol gtt. 3, in vasenol oz. 1, to the nose, naso-phayrnx, and by deep inhalations into the larynx, trachea and bronchi. At home, oil vasenol comp. oz. 1, with instructions to instil 10 drops in each nostril every three hours. Results. The nasal congestion soon disappeared, result ing in re-established nasal respiration at night. Within three weeks the cough was cured. From the case cited, it will be noted that it is at night, when recumbent and asleep, the physiologic function of the nose is arrested by hypostatic congestion of the mucosa. From mere inspection of the nasal chambers, in many instances, a definite diagnosis cannot be made. However, by requesting the patient to observe the condition of his mouth and nose on awaking in the night and morning, and to note the nasal stoppage, and consequent parched, dry, leathery, pasty feeling in the mouth and throat, with other disagreeable symptoms, as hawking, gagging, retching, etc., a definite conclusion can be drawn and diagnosis made. CASE II.-Five years ago, Mrs. L., age 26, consulted me complaining of a lump in the throat and for the past two years. Symptoms were worse after dining. Present State.Examination revealed a large spur on the septum left naries, moderate pharyngitis and hypertrophy of the tongue tonsil. Diagnosis. Hypertrophy of the lingual tonsil. Treatment confined to reducing the enlarged tongue tonsil with the galvanic cautery. This was accomplished in three sittings when the symptoms cleared up. Has CASE III.-April, 1904. Mr. G. W. G., age 45. Complains of the nose stopping up for the past fourteen months, and especially annoying at night, when he breathes through the mouth. Always has a cold in the head. The ears ring and hearing is impaired. Early in the mornings is awakened by an annoying cough, which is troublesome all day. taken many cough remedies without relief. Present State. The nose, nares filled with thick greenish secretion. The septum is thickened narrowing the nasal fossae. The inferior turbinates are turgescent filling the inferior meatuses. After removing the secretion and reducing the congestion a fair view of the nasal cavities was made possible. the posterior end of the septum a crusty scab was clinging. By removing the scab the probe came in contact with denuded bone. Questioning the patient brought forth a history of specific trouble in the family. Ears: Drums normal. Hearing by watch one inch right and left. Diagnosis: Syphilitic necro On sis of the vomer. Treatment: Internally, syrup stillingia comp. one teaspoonful three times daily; ten gr. kali iod. three times daily. Locally: Curettement of the necrotic bone with subsequent application of 20% solution silver nitrate for several weeks. Cleansing douche with an alkaline solution, and spraying with an astringent oily spray. Results. Tinnitus ceased. Hearing in creased to thirty inches by the watch. In six weeks the cough entirely disappeared. CASE IV. September, 1904. Rosie H., age 10. Complains that for the past two years has been troubled with a hacking cough more or less constant and always worse at night. Many cough mixtures from drug stores have been tried and several physicians have prescribed without relief. The father thinking the trouble may possibly be in the throat brought the child to be examined. Present State: The nose, pharynx and larynx appear normal. The uvula does not appear unduly long on inspecting the throat with the tongue depressor, however, by examining without depressing the tongue the soft palate is noted to hang low and the uvula elongated. This case demonstrates the necessity for in examining those obscure conditions in highly sensitive throats. Treatment: Removal of two-thirds of the uvula cured the cough. CASE V.-Mr. E. W, age 37, brought to me by Dr. Becker for examination and treat. ment of the nose. Complains of since over two years ago has been troubled with stopping up of the onset, particularly at night. Take frequent colds in the head. Annoyed by mucus dropping into the throat. For over a year has been troubled with a cough paroxysmal in character. The cough is especially annoying about bed time in the night and mornings. and mornings. Of late the cough has been unusually annoying early in the evenings, especially when out in company. At times the paroxysm is so violent the patient is forced to retreat to out door air. Mr. W. has never sought relief for the cough, but has been treated for the nasal stenosis. Present State.-On the septum right naris a large spur projects impinging upon a hypertrophic inferior turbinate. In the left naris the upper third of the septum is thickened and blocks that part of the fossae not closed by the tumefied inferior turbinate. pharynx is chromically inflamed. The larynx appears normal. Diagnosis.-Chronic hypertrophic rhinitis, and spurs on the septum. Treatment.-Removal of spurs and hypertrophies with intranasal saws and scissors. This treatment resulted in establishing free nasal respiration with gradual cessation of the cough. The |