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MEDICAL MEMORANDA.

Syrup of Figs and Elixir of Senna.-With a view to making a name of this excellent laxative more expressive, the manufacturers of "Syrup of Figs" have decided upon the above title. In speaking of the subject, Mr. Queen says; "In order to make the name of this laxative more fully descriptive of it, the California Fig Syrup Company has made an addition to the name, as you will see by the new advertisement, and in future, the full name, which will be printed on the wrappers and labels of every bottle, will be "Syrup of Figs and Elixir of Senna," which is what the remedy really is; its special excellence being due to the original method of obtaining the laxative properties of the plant. The original method of the working formula is known to the California Fig Syrup Co. only. We think that the new name will be more acceptable to physicians, as it describes the laxative more fully than the shorter name of Syrup of Figs."

The sample of resinol ointment which came into my hands to-day jogged my memory in regard to your preparations, and reminded me that I have been intending to write you for some time. During the past six months I have twice found it very efficacious. A young lady patient of mine had a very troublesome and unsightly eruption on the back of her neck extending up behind the ears on both sides. She informed me that she had been receiving treatment for it to no effect for over a month and I advised her to use resinol ointment. The result was a cure in a very few weeks, and three months have passed with no recurrence.

Several months ago I extracted some teeth for some boys and their father, and in a couple of days their mouths and chins were covered with eruptions, much to my discomfiture. Prescribed resinol and resinol soap and the recovery was remarkably prompt. I could not account for causes in these cases for I did the work in an antiseptic manner, but will say that I regard resinol ointment as an exceptionally valuable preparation.-A. S. Wolff, D. D. S., 2100 N. 11th St., St. Louis, Mo.

The Card System for Keeping Records and Accounts.-The keeping of records and accounts is a most irksome duty to the active practitioner. No matter how busy or

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exhausting the day, they still remain to be attended to. Sooner or later they are slighted, and slipshod methods and confusion follow. The "Card System" revolutionizes this state of affairs. eliminates all the disadvantages of books, and makes each record so comprehensible and easy of reference as to give it a new value. In lieu of the physician's memorandum book, case history book, cash book, ledger, and what-not, the card system substitutes two cards-case history card and ledger card. One card is used for each patient. Impressed with the worth and practicability of these cases, the Angier Chemical Company has developed a complete case, designed especially for physicians, and so arranged as to take care, in the best possible manner and with the least trouble, of his records and accounts. The first of January is the most convenient time to change from books to the card system, and as the Angier Chemical Company (Allston District, Boston, Massachusetts) is making a special advertising offer and low price for these history and ledger card outfits, we advise our readers to write them (mentioning this journal) for sample cards and details regarding their attractive offer.

Hemorrhoids. (By Elmore Palmer, M. D., Buffalo, N. Y., Ex-President of the Western New York Medical Society.)-Without any comment on the nature, causes, varieties or pathological conditions found existing in rectal ailments, I will transcribe from my records two cases of hemorrhoidal troubles that I have treated within the last two years with glyco-thymoline: Case 1. Mr. B. O. H., age 29, had been ailing several years with what he called piles. A careful examination revealed the follow ing condition: On the margin of the anus were three strangulated tumors about the size and color of a Concord grape. On continued pressure the tumors would empty themselves almost entirely but refill again in the course of an hour. Several similar tumors about the size of a pea were found just inside sphincter. Anal moisture and pruritus vere very troublesome, but singularly enough little pain was complained of. The bowels were somewhat constipated. Regulated the diet and secretions, gave an enema of two ounces of a fifty per cent solution of glyco-thymoline every night and morning quite warm, held in until absorbed, and applied gauze to anus on lamb's wool during the night and as much of the daytime as he could spare from his office. A decided improvement was noted in a week, and three weeks later he was cured. That was nearly two years ago and there has been no trouble since. Case 2. Mrs. R., consulted me regarding "bleeding piles," which had been gradually growing worse for three or four years. At every stool she would bleed two or three tablespoonfuls. She had become quite anemic. No external tumors. A corroding ulcer as large as a

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nickle was diagnosed just inside of the internal sphincter.

Washed out the rectum three times a day at first with a warm solution of boric acid and then gave an enema of one ounce of glyco-thymoline full strength hot, held in until absorbed. After four doses only two enemas a day were used as no blood was passed. At the end of two weeks time a careful examination of the rectum showed it to be perfectly normal. She was cured. No return after eight months.

Suggestions in the Treatment of Diseases of the Respiratory Tract.-(J. F. T. Jenkins, Ph. G., M. S., M. D., Los Angeles, California.)-A marked advanced in therapeutics has taken place in the last few years and many new remedies have been introduced which after careful clinical tests have been found to be vastly superior to former methods of treatment. A drug which has attracted considerable attention is the new morphine derivative heroin It has been brought before the profession for the purpose of allaying cough and to take the place of codeine as a more efficient substitute. Its action in relieving cough and dyspnea is much more prompt and decided, and the frequent deleterious after-effects of codeine and morphine-nausea, vomiting, headache, constipation, gastric pains, tinnitus, and visual hallucinationshave never been observed during its administration. Results are equally as good with children as with adults, and it has now taken a permanent place in the armamentarium of the physician. Some time after the introduction of heroin, while I was acting assistant surgeon in temporary command of the station for the United States Marine Hospital Service, I had a number of government patients, sailors of the merchant marine, at the Los Angeles Infirmary (Sister's Hospital) under my professional care. In one case of persistent cough, which was extremely distressing to the patient and harrassing to his friends, I tried everything I had heretofore used, without obtaining even partial relief. The then resident physician, Dr. M. M. Kannon, urged me to try a new combination of heroin with other drugs, known as glycoheroin (Smith), made by Martin H. Smith Company, of New York. Acting upon upon this suggestion, I gave a prescription for a few ounces of this preparation to be given in teaspoonful doses every for to six hours until relieved. The good effect was immediate and pronounced, and from that time to the present I have had positive results in relieving cough that I had failed to obtain in my previous experience of a quarter of a century in the active practice of the medical profession. Before giving it in the case mentioned I was inclined to be sceptical, notwithstanding the frequency of favorable reports in regard to it by respectable medical journals and leading professional men. I had tried without satisfactory results the usual mixtures, “heroin comp.," of which there are so many without merit, failing entirely to accomplish all that heroin can shown to do in using the preparation indicated. To satisfy myself still further and to remove a doubt in my mind that this might be an exceptional case or a mere coincidence, I was induced to give it a trial in a series of selected cases of a similar character. The result was so satisfactory that I feel constrained to add my testimony to that of others. Glyco-Heroin (Smith) is a true solution of heroin in glycerine; each teaspoonful represents one-sixteenth of a grain of heroin, with ammonium hypophosphite, hyoscyamus, white pine bark, balsam of tolu, with glycerine and aromatics. A glance at this formula shows a happy selection of drugs adding to the palliative effect of the heroin and each possessing decided curative properties of its own. It gives the physician an elegant pharmaceutical preparation, strictly ethical in character, a trial of which will satisfy him that it excels any single drug or combination of drugs in the materia medica. Limitation of space prevents an exhaustive consideration of the individual therapeutic virtues of the ingredients mentioned. With the exception of heroin, all are so well known that a very minute detail of their virtues is not necessary. It is important, however, to notice that the value of each seems to be increased tenfold, and the special sedative action intensified in the uniformly exact proportions adhered to by Martin H. Smith Company in its manufacture. So much for heroin, with a great deal left unsaid which might be justly stated in its favor. The ammonia hypophosphite and hyoscyamus each speak for itself. The peculiar virtues of white pine bark in checking night sweats and in allaying all inflammatory conditions of the bronchial mucous membrane, need only to be mentioned to be appreciated. That pleasant and palatable aromatic stimulant, balsam of tolu, together with glycerine, completes the prescription known as glyco-heroin (Smith), now so well established by the evidence of experience.

The striking and surprisingly good results so uniformly obtained in the administration of this remedy can be fully verified by an unprejudiced trial in which it is tested. Such a trial may be made without hesitation, for notwithstanding its therapeutic advantages it possesses the virtue of absolute harmlessness. When physicians of the professional standing of Francis W. Campbell, M. A., M.D., D.C.L., L.R.C.P., London, Dean and Professor of Medicine, University of Bishop's College, Montreal; and Dr. J. Leffingwell Hatch,late Professor of Laryngology in the New York Clinical School of Medicine, Pathologist to the Philadelphia Hospital and formerly Sanitary Inspector in the Marine Hospital Service, give this preparation their unqualified endorsement, their opinions founded on the actual treatment of a large number of cases, it is apparent that these positive, unlimited, and clear results must gain for this remedy a still fuller recognition, and lead ultimately to its universal acknowledgement as the best remedy of its class for the purposes indicated in these reports and in clinical reports of prominent medical men in England and her colonies,in addition to the favorable testimony of many American physicians from Canada to Mexico and from Maine to California.

Vol. XXX

ST. LOUIS, DECEMBER 25, 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.
M. V. BALL, M. D., Warren, Pa.
FRANK BILLINGS, M. D., Chicago, Ill.
CHARLES W. BURR, M. D., Philadelphia.
C. G. CHADDOCK, M. D., St. Louis, Mo.
8. SOLIS COHEN, M. D., Philadelphia, Pa.
ARCHIBALD CHURCH, M. D., Chicago.
N. 8. DAVIS, M. D., Chicago.

ARTHUR R EDWARDS, 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. HARE, M. D., Philadelphia.
CHARLES JEWETT, M. D., Brooklyn.

THOMAS LINN, M. D., Nice, France.

FRANKLIN H. MARTIN, M. D., Chicago.
E. E. MONTGOMERY, M. D., Philadelphia.
NICHOLAS SENN, M. D., Chicago.

FERD C. VALENTINE, M. D., New York.
EDWIN WALKER, M. D., Evansville, Ind.

REYNOLD WEBB WILCOX, M. D., LL. D., New York
H. M. WHELPLEY, M. D., St. Louis.

WM. H. WILDER, M. D., Chicago, Ill.

LEADING ARTICLES

FOREIGN BODIES IN THE LARYNX and TRACHEO-BRONCHIAL TRACT.*

L. D. BROSE, M. D., PH. D.

EVANSVILLE, Ind.

THE entrance of a foreign body into the air passage, is an exceedingly grave accident and usually productive of a symptomatology, distressing to the patient and highly alarming to his family. I cannot better enter upon this subject than through the relation of the three following cases, two of them illustrating the gratifying result of successful operative interference, the other an unsuccessful operative interference with subsequent coughing up of the foreign particle, after the patient had been dismissed from treatment:

CASE I.--J. F. W., aged eleven years, was sent to me June 21st by Dr. E. G. Lukemeyer, of Huntingburg, Indiana. The history obtained, was that while whittling a trigger on a piece of wood four days previous, the severed particle of wood was drawn into the wind-pipe, calling forth a severe attack of strangulation. After regaining his breath he found himself unable to speak

Read before the Ohio Valley Medical Association, November 15, 1906.

No. 12

above a whisper. At my examination I noted stridor in breathing, hoarse cough, aphonia, and slight temperature elevation. With the laryngoscope, the obstruction was easily recognized lodged between the true and false vocal cords, and extending transversely across the glottis. After the use of a spray containing cocaine, several attempts were made at extraction with forceps, but without success. A long bent probe was then hooked from behind forward under the obstruction, and by sudden traction, it was readily brought up into the mouth, and thence extracted by the patient. The boy returned to his home the same day, and a later report from his family physician stated complete voice recovery in five to six days. The piece of wood measured 15 millimeters in length and 9 millimeters in width.

It

CASE II. Agnes, the eight-year-old daughter of Mr. A. E., of Owensville, Indiana, while at school October 11th, 1904, and eating an apple during recess, bit off a large piece which in hurriedly attempting to swallow found its way into the wind-pipe. Alarming symptoms of suffocation at once followed, and Dr. M. Montgomery was immediately sent for. By the time the doctor reached the patient the suffocative attack in a measure had been recovered from. Acting upon the advice of the physician the child was brought to my office by its father. With readily seen lodged in the upper part of the the laryngoscope, the piece of apple was trachea, just below the true vocal cords. was deemed inadvisable to attempt its removal by instruments introduced through the mouth, for fear of its becoming displaced and perhaps lodging deeper in the air passage and causing death ere the trachea could be opened externally, so the child was sent to St. Mary's Hospital, where with the assistance of Dr. P. Y. McCoy, preliminary tracheotomy was made, a tube inserted and the patient returned to its bed without making an attempt at removing the obstruction until the following day, when chloroform was again administered through the tracheotomy tube, and then by use of a probe passed from below upwards, it was sought to bring the particle of apple into the pharynx. Not succeeding in this, a small intubation tube was passed from above in the usual way, and the portion of apple pushed down and removed through the opened trachea. The external wound was at once closed by four deep interrupted sutures,

and the patient made a rapid recovery, notwithstanding a tedious tracheotomy, due to its being performed at night with the child struggling violently against the anesthetic, and becoming early semi-asphyxiated, so that it had to be placed in a sitting posture, partially revived and the wind-pipe opened with the trachea violently rising and falling with each respiratory act. The piece of apple removed was nine-sixteenths of an inch long and five-sixteenths of an inch wide, of firm and solid consistency.

CASE III. The five-year-old daughter of Mr. H. J. was brought to my office January 23, 1906, by Dr. W. G. Hopkins, of Fi. Branch, Indiana, with the statement that on the previous afternoon while playing with a bean in the mouth, she had a sudden attack of violent coughing and strangling. After a time, the breathing became easier, and as soon as the child was able to talk it informed the mother that it had swallowed a bean. An examination of the larynx with a throat mirror proved negative. It was noted by inspection that the breathing was labored, and upon auscultation dry sonorous rales were heard with very feeble respiratory murmur over the right lung. Vesicular murmur clearly heard over the left lung, and the normal pulmonary area, either side of the chest, was without dulness anywhere upon percussion. Patient was sent to St. Mary's Hospital, where an examination of the thorax by the Roentgen ray was made, but the foreign body was not detected. Never theless, it was decided to attempt recovery of the bean through an external opening in the trachea, and with Dr. J. N. Jerome administering the anesthetic, a low tracheotomy was made, but all our efforts at extraction or expulsion with instruments, or through eversion and succussion of the body, failed to recover it.

The tracheal incision was stitched to the skin, and on the two succeeding days renewed attempts were made to recover the bean, but resulted in failure. Purulent bronchitis, fever, with circumscribed pneumonic consolidation ensued, and only the use of hypodermic injections of strychnia, apparently on several occasions sufficed to keep the child alive. February 5th, at the earnest solicitation of the parents, permission was granted to remove the patient to their home in a neighboring county. The purulent bronchitis and expectoration continued, with remissions and exacerbations, until some two months later during a violent parox. ysm of coughing, the bean was expelled by the mouth, after which gradual recovery ensued.

The various substances that have at one

time or another found entrance into the larynx, are too numerous to mention, and in a general way may be classed under both solids and liquids. The latter, such as blood, or pus evacuated through bursting of a peritonsillar abscess, will not be farther considered, since the fluid is either coughed out or produces death before the arrival of the medical practitioner. Foreign bodies may enter the air passages through the nose and mouth, from the stomach during vomiting, or through wounds or fistulous opening in the neck, chest wall, or bronchial tract. In most cases, however, the accident occurs during unconscious, thoughtless, surprised or frightened forcible inspiratory effort, in conjunction with a reflex swallowing impulse. Loss of sensibility of the laryngeal mucous membrane, which attends bulbar and diphtheritic paralysis, favors the entrance of foreign bodies into the larynx. Foreign bodies in the air tract are much more frequently met with during child life, than during adult life. The symptoms that follow depend somewhat on the size, consistency, shape and place of arrest of the body, and may be designated primary and those which develop subsequently. Of the former reflex cough and spasm of the larynx are at once manifested. The spasm may be severe and cause death in a few moments or pass off and be succeeded by hoarseness dry cough and pain. Excitement and distressed feeling is shown save when the accident occurs during the unconscious state or when person is deeply intoxicated. Small round bodies may lodge in one of the ventricles of the larynx and occassion very mild or no symptoms. Should the body be of large size and sufficiently occlude the air passage unless speedy relief is given death early occurs. Sharp or pointed bodies may perforate the walls of the air tube and then injure an im. portant blood vessel and through hemorrhage occasion death. After a time the parts acquire more or less tolerance for the foreign body and the primary symptoms in part or wholly subside. Where the foreign body remains movable and alters its position with the respiratory act or the body suffocative attacks are apt to recur at irregular intervals. The subsequent symptoms are largely of an inflammatory nature laryngo-bronchitis developing with fever expectoration of blood or pus, fetor of the breath perichondritis, pleurisy, pneumonia, abscess formation and gangrene. Pulmonary emphysema may result through bronchial obstruction and inability to expel confine air when coughing.

the

Diagnosis-This is easy when we get a clear history of the disappearance in the air passage of a foreign body, followed by

a sudden attack of choking and cough. This, however, is not always obtainable, since the patient may be too young, insane, or his statements unreliable, in case of intoxication. Physical examination is valuable not alone for diagnosis, but in locating the position of the obstruction. By simple inspection with a strong light and the tongue depressor, the extreme upper part of the larynx may be seen. Exploration with the finger or sound, may detect a hidden body, or one that was overlooked by other methods of examination. The laryngoscope is of the greatest value, for withit the interior of the larynx and trachea, and even part of the bronchial tract may be inspected. Unfortunately, just in the child, where we need it most, we encounter difficul. ties in the use of the instrument, such asuncontrollableness and gagging, that rob it often of most of its value. Profuse secretion may so hide a semi-transparent body, as to make its detection with the laryngeal mirror difficult or impossible. When the patient is unruly and will not hold, a general anesthetic may be employed, and after unconsciousness the mouth gag is inserted, the tongue drawn forward with forceps, and the throat mirror introduced. An everhanging epiglottis may be lifted with a slender hook. The recognition through auscultation of diminished respiratory murmur in the lower lobe of the right or left lung, following upon a history of foreign body in the air passages, is strong evidence of obstruction in the corresponding bronchus, and according to statistics and for anatomical reasons, the lodgment happens oftenest right-sided. When the obstructing body is movable, and changes its position with the respiratory act, or upon coughing, auscultation will almost certainly detect either a whistling sound, or flapping noise, or change in the area of diminished respiratory murmur; should the offending body be of solid consistency and of some size, the X-ray may be used in its detection and localization.

Prognosis is always doubtful so long as the foreign body has not been expelled, and even after expulsion death may still occur in cases where grave secondary lesions have been set up. The larger the body and the greater the obstruction, the greater the danger from asphyxia. Lodgment in a bronchus, offers a graver prognosis than when the offending body is arrested in the larynx. Also in the child, our prognosis is more unfavorable than in the adult, not only because operative interference is undertaken with greater difficulty, but also because of the smaller size of the lumen to be obstructed and the greater liability to suffocation by spasmodic contraction.

Treatment may be designated emergency, or that directed toward saving life during impending suffocation, and for this purpose immediate tracheotomy is oftenest done, and measures undertaken for the purpose of expelling or extracting the foreign body. Expectant treatment may be elective from the first, when the body is of small size, of smooth surface, and harbored in a bronchus with a possibility of sponaneous expulsion, or from necessity after unsuccessful operative measure for its recovery. From the larynx our first attempt at extraction as a rule, should be made through the mouth with hook or forceps, after local anesthesia and under guidance of the laryngoscopic mirror. It may happen that the body is impacted between the cords, or so embedded that its removal from above is not feasible, in which case the knowledge derived through the throat mirror may still materially assist us in the choice of external operative procedure. Inversion and succusion of the body may be employed, but it is well always to prepare first for emergency opening of the wind-pipe, since a partial obstruction of the air tract may by these means be suddenly converted into a more or less complete one through the offending substance altering its position. I have never seen the least good result from the employment of emetics. The Killian bronchoscope, is a useful instrument not only for the detection of deep-seated foreign bodies, but likewise for their removal through the natural passages or through the trachea after an inferior tracheotomy. The acquisition of the necessary skill for the successful use of the long bronchioscope requires practice and patience and hence the superior operation must remain a procedure best executed by the specialist. The inferior operation or that through the opened trachea is much easier of accomplishment and in children under six years of age because of the smallness of the air tract it is the procedure of election and in lieu of a more suitable instrument the ordinary cystoscope may be employed.

During a visit to Professor Killian's clinic in Freiburg, Germany the past summer, I had an object lesson of the need of the anesthetic being in the hands of a skilled anesthetizer. The patient in question was one where I had been entrusted with the pulse, and where sudden respiratory failure and collapse occurred during the midst of the operation, and only the most active efforts at resuscitation saved the life of the patient.

Whether superior or inferior tracheotomy, laryngotomy, or pharyngotomy is to be performed will depend upon the size, shape, nature and position of the substance to be extracted, and after careful study and deduction

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