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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 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 epiglotti larynx or even trachea.

Within the confines of the upper ph the pathologic changes, namely, hyper and granular pharyngitis, atroph gitis, enlarged pharyngeal tonsil

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 upoL the degree of disturbance inflicted to the highly sensitive epiglottis.

A causative factor sometimes overlooked hypertrophy of the lateral pharyngeal wall or so-called pharyngitis lateralis, which some instances is productive of distress harassing symptoms. The faucial tor in my experience have always been 11 cent offenders so far as related to co

Cough from the epiglottis may be 1 for in edema, ulceration and inflamma In the larynx, in benign and m growths, edema, foreign bodies, ule formation of scar tissue, in acute and inflammation, cough is usually a nr feature.

Treatment consists in opening
air passages, removing obstruc
lishing free and easy physiolo
lessening secretion, and
sources of direct irritation
means accessible and indica
tions confronting the opera.
Acknowledging the valu...
induces me to append b:
following cases: Nove:..
L. age 9. Referred by

amination of the nose
ment if necessary.
the past two months
unsatisfactory. Pre
mal pulse
breathe th

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All patients and many physicians believe. that the cough symptoms should vanish immediately on establishing nasal respiration, overlooking the fact that the symptom no doubt in most instances is a long time in developing. However, the time for recovery usually takes days, weeks or months, depend. ing upon the degree of irritation set up in the lower respiratory tract.

REPORT OF TWO CASES OF CANCER TREATED WITH TRYPSIN INJECTIONS AND LOTIO PANCREATIS LOCALLY.

ROBERT H. DAVIS, M. A., M. D.

ST. LOUIS.

Case I.-Mrs. F., age 47, came under my care April 26, 1906. History.-The cancer, which was of the rodent ulcer type, began about twelve years ago as a small papule situated at the hair line, immediately above the right eye. The papule remained quiescent for ahout one year, and then broke down, and grew slowly, for a second year before any treatment was instituted. Then it was treated locally by various physicians, for a period of three years, with no improvement. This was followed by about one year's local and gen. eral (tonic) treatment, also without improvement, the lesion slowly growing worse all the time. It extended chiefly down the forehead, and the edge had, by this time, reached the right eyebrow. She was now put on X-ray treatment, and followed this line of procedure faithfully under two competent physicians, successively, for a period of five years in all. The exposures were three times a week. The technique of them is unobtainable, but, as stated, they were given by experienced rayists. The cancer, however, continued to grow, and becoming discouraged, she discontinued treatment six months agc. After remaining at home about three months, with local dressings, tonics and anodynes as the measures employed, she came under my care, as stated, on April 26th of this year. Her condition then, both local and general, was very bad, and no permanent improvement could be hoped for. The lesion involved almost the entire right cheek, the upper twothirds of the nose, the forehead on the right side, the scalp for about one inch beyond the hair line, and the inner half of the left eye. The right eye was entirely gone, the globe hanging as a small necrotic mass in the orbital cavity. The discharge was profuse and the odor very offensive. The patient had been confined to bed for almost a year, and was greatly emaciated. Her temperature, on April 26, was 100.6 deg. F., pulse 96 and very weak. All of the usual antiseptic solu

tions were reported as too painful, even in very weak solution, for local application, so, for several weeks previous to her admission to the hospital, only sterile water had been used locally. She was subject to frequent attacks of great pain, and slept consequently but little. Her appetite was poor, and attacks of vomiting frequent. The latter were probably due to the discharge running down the throat through a sinus that existed between the lesion and the posterior nares.

The patient was put on local applications, once daily, of lotio pancreatis 3ss, sterile water 3iss, on April 30th, and injections, once daily, of injectio trypsini gtts. v, sterile water gtts. v, on May 1st. The injections were at first made in the face, at various points near the edge of the lesion, but, after several weeks, this was discontinued, on the theory that absorption was poor in this locality. The injections were, thereafter, given in each arm alternately. The injection of the trypsin solution was preceded ten minutes by the injection of ten minims of 1% solution of eucain hydrochlorate. After the local application, above mentioned, the lesion was covered with a wet pack (2% borosal), and this alone was used at night. Injections were given daily to the present time (July 5th) except during the periods from May 8th to May 15th, May 19th to May 27th, and June 13th to June 20th, when difficulty was experienced in getting a supply of injectio trypsini. The injection was increased to R injectio trypsini gts vii, sterile water gtts. vii, on May 15th, and to R injectio trypsini gtts. viii, sterile water gtts. viii, on May 30th; and finally to injectio trypsini gtts. x, sterile water gtts. x on June 20th, which dose has been since continued. The strength of the borosal solution was increased to 6% on May 10th, but this caused considerable pain, so so it was reduced to 4% on May 15th, and continued at this strength till May 24th, when a saturated solution (12%) was first applied. This was, then, well borne, and was, accordingly, thereafter used. The strength of the lotio pancreatis application was increased to, R Lotio pancreatis 3ss, sterile water 3i on May 22d, and this strength was used till July 1st, when, & Lotio pancreatis, sterile water aa 31, was applied, and has been since in use. From May 21st on, irrigation with sterile water alone was made each morning. This was followed by the application of the pancreatic solution, and the wound covered with a dry dressing. At night, this was removed, and a wet borosal pack applied, and covered with rubber tissue. The pack was moistened with borosal solution, of the strength indicated above, once during the night.

Internally, the patient was put on holadin grs. v. t.i.d., on April 29th. This was increased to ten grs. t.i.d. on May 6th, and continued at this for one week. It was then discontinued till May 28th, after which from 10 to 20 grs. were given daily, divided into two doses, one at 4 p.m., and one at bedtime. The morning dose was omitted, because of an occasional attack of nausea at that time. The patient was also put on various tonics, at different times, but all were discontinued after a few days' to a week's trial, as they seemed to occasion attacks of Vomiting.

Results of treatment were as follows: (a) A decided decrease in the discharge after a few days; (b) a marked lessening of the fetor. This at times is entirely removed; (c) a great relief from pain, and a consequent ability to sleep, with improvement of the pulse, appetite and spirits; (d) the cancer remained practically stationary from the time of the commencement of the treatment until about June 26th. Since then it has slowly spread and deepened; (e) there has been no untoward symptom of any sort, either local or general, from the applications or injections. The amount of discharge of course, varies from day to day, but is, as stated, much less on the average, than before the treatment was instituted. There was, also, a decided increase of the fetor during those periods when the local trypsin applications were unobtainable. Occasional attacks of pain were controlled by B Phenalgin grs. 23, morphine sulphate gr. 1.1.

Case II.-Mrs. T., cancer of the peritoneum, the whole peritoneal surface being involved. This lady, a patient of Dr. E. W. Saunders, was also hopelessly ill when the treatment was first available, an amelioration of symptoms alone being hoped for. Local applications being impossible, trypsin injections, and holadin interally, alone were used. The trypsin injections were preceded ten minutes, as in the previous case, by an injection of 10 m. of a 1% solution of eucain hydrochlorate. The trypsin dose was 10 m. with sterile water 10 m. from the beginning. These injections were begun April 24th and continued until June 26th, a period of 63 days.

During this time 56 injections were given. They were never given more frequently than once a day. Holadin grs. v, t.i.d., was given during this period, except for one or two short intermissions, necessitated either by the difficulty of obtaining the drug, or a transient objection of the patient to taking anything. The injections were discontinued on June 26th, as increasing weakness made giving them too great a strain on the patient's strength.

The results were: (a) decrease of pain; (b) no ill effects either local or general.

Pusey (Jour. A. M. A., June 9, 1906) reported a series of seven cases of inoperable carcinoma, and one inoperable, round celled sarcoma of the thigh, treated by this method. He had one apparent cure. In the other cases he believed appreciable harm was done, as either abscess resulted at the site of injection, or cachexia developed rapidly, or both these harmful effects were produced. None of these results occurred in the cases repcrted, and I believe Dr. Pusey's trouble was due to a too rapid increase of the amount of injection, or to setting the dose limit too high. In several instances he injected 60 m. daily. He does not give his technique in detail as to dilution of the injectio trypsini before administration. Both he and I used Fairchild's sterilized trypsin solution, with the commercial name of injectio trypsini.

In a subsequent case, now under treatment, I find that the preliminary injection of eucain is unnecessary.

It seems that the method carried out as above reported, is harmless, and affords considerable relief to the patient. Of course, with the present meagre evidence before us, it should be used only in inoperable cases, or in conjunction with the X-ray, and should, in no case, be relied upon as a means of cure where a radical operation is possible.

The salicylate of strontium is an intestinal antiseptic and anti-rheumatic, dose 10 to 15 grains.

NEW BUILDING FOR INSANE HOSPITAL OPENED. The second new building at the North Texas Hospital for the Insane, Terrell, was opened June 28. The building is in. tended for white male patients exclusively, and will accommodate 250. The third additional building will be ready in a few weeks, and will furnish accommodations for 500 additional patients.

HEALTH PAMPHLET ISSUED BY THE ILLINOIS STATE BOARD.-The Illinois State Board of Health has issued a new pamphlet, written on the same general lines as one published last summer, containing information on how to take care of the babies. Suggestions are given for the nursing mother, artificial feeding is fully discussed, and the advantages and disadvantages of the various infant foods are carefully considered. This pamphlet is issued for gratuitous distribution, and those who wish copies should apply to Dr. James A. Egan, secretary of the board, at Springfield, Ill.

SENILE ARTERIO-SCLEROSIS.

GEO. E. ROSENTHAL, M. D.

QUINCY, ILL.

SENILE ARTERIO-SCLEROSIS is a general systernic disease essentially chronic in character, producing a thickening of the artery wall with secondary changes therefrom in the tissues. Of the viscera, the heart, kidney and brain suffer the most profound impairment.

Etiology.-Broadly as to etiology we may safely include all toxic principles, both autochthonous and exogenous; the poisons of syphilis, of the eruptive fevers, the products of bacterial activity generally, of intoxications and auto-intoxications.

It is undoubted that hard, laborious occupations with attendant exposure are factors of the greatest importance in its development, when occurring in connection with some of the conditions above mentioned. In the twenty-two cases analyzed there were blacksmiths 4; farmers 6; carpenters 4; laborers 4; railway engineers 1; coal miners 2; painters 1. The average age was 71. The oldest individual was 84. The youngest was 56. These are all occupations demanding severe exertion continued over long intervals, pursuits in which the arduous labors developed great appetites for food, drink, tobacco, etc., and these were habitually satisfied to satiation, with certain attendant intoxications and auto-intoxications.

Those suffering from this arterial disease were in middle life almost invariably, largeboned muscular individuals fitted by nature for their occupations, and further developed by them. In their senility they find that they have outlived many of their less rugged companions.

Etiologic factors of senile sclerosis bear not directly, but indirectly upon this condition, they produce arterial neuro-muscular weakness, which permits dilatation of the artery wall. This is the condition which necessitates a compensatory arteritis.

When the system is saturated by toxines instead of the exact reciprocity between the supply of and the demand for the blood stream by means of a varying arterial lumen as required by the activities of the individual, the adjustment shows imperfections. The artery, after an exertion which has demanded the maximum of arterial pabulum, fails to contract promptly when the demand ceases, and after many repetitions a permanent dilatation results. This failure to resume a normal calibre is due to certain toxic principles afloat in the blood stream and influencing the nervous and muscular system of the blood vessel.

When we examine an individual suffering from sclerosis, we find on palpation that the nodules are inore prominent distally than proximally in the extremities, and that this condition, beginning at or near the body where it is of a minor degree, grows progressively more grave until the artery branches for its final ramifications. Thus in the upper extremity the axillary artery may show a mere smoot fibrosis, the bracial exhibits minor prominences along its wall, while the radial is extravagantly beaded.

An artery is, in normal health, a thinwalled elastic tube containing a fluid of a When such specific gravity of 1040-1080.

a tube is swung in an arc of a circle there is a longitudinal and transverse stretching, greatest at its distal end. In an individual performing manual labor the arteries of the extremities are swung through arcs of circles many times daily, and thereupon the above mentioned phenomena of longitudinal and transverse stretching occurs, the stress increasing in proportion to the distance from the trunk..

But with such distortion and increase in endo-arterial area there follows functionally a slowing of the blood stream, a stasis inimical to proper economy results, with organically an arterial rarefaction or thinning which predisposes to aneurism. This slowing of the blood stream is the exciting cause for the compensatory endarteritis. By this process (the endarteritis) the norma[ arterial area for the part is restored through the laying down of new tissue in the intima.

A year perhaps is consumed in the process, but now instead of the straight smoothly lined tube we are confronted with one which is much less perfect. Irregular masses of cells project from its walls into the lumen, causing cross and counter currents and throwing a greater burden upon the left heart which must undergo a compensatory hypertrophy to cope with its increasing labor. In this way compensation is twofold, intimal and cardiac. Eventually as the years go on the expansile artery of health becomes stiff and almost immovable, responding feebly or not at all to stimuli. Its walls are firm and inelastic, its coats are thickened, nodules of lime salts are deposited in its substances, it is incapable of responding to the many adjustments needed by the varying activities of the structures which it supplies.

The nervous governance is seriously impaired, whence comes the vertigo upon suddenly arising from a sitting or recumbent position, the cold extremities, the anginose pains, the dysbasias and dyspragias.

It is generally agreed that arterial sclerosis is a compensatory process, the artery is com

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