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which it is impossible for him to check until he gets rid at last of a seemingly insignificant quantity for such a great and tumultous effort. I once knew such a case in an old man who was the terror of some ladies in church, for when he began, he soon entered upon a run of rapid little squeaks, which with his swaying body and blackening face sug gested some fearful catastrophe, until a final sort of halleluljah in his throat | told the hearers that the phlegm had arrived.

With these preliminary observations we now pass on to the different varieties of non-expectorant coughs; the first we would mention is due to simple inflammatory irritation without secretion of some portion, or the whole, of the respiratory tract from the epiglottis down to the third division of the bronchi. A typical instance of this is to be found in the purely hyperamic stage of acute bronchitis when, with a turmefied and dry state of the bronchial mucous membrane, we find the patient much oppressed for breathing and constantly tormented with a frequent short and hacking cough, each act of coughing evidently increasing his sense of soreness and tightness of the chest. The prevailing sound of his cough I need not say is of the non-expectorant variety, variety, while auscultation reveals a number of dry whistling rales often more pronounced on expiration. The indication here is to turn the cough as soon as possible into the expectorant variety by nauseant expectorants which will start secretion. For this purpose I use a grain of tartar emetic dissolved in a teacup of water and direct the patient to take a teaspoonful every ten minutes until he begins to feel a little sick. When he does so the dyspnea usually vanishes, easy

on and the

expectoration comes separate husky coughs stop.

A much more common example of this cough, however, occurs in the course of ordinary bronchitis, both acute and chronic, where, owing to the fact of the co-existence of secretion and more or less free expectoration, its presence may be over-looked and it be confounded with the expectorant cough. In these cases the patients have a number of distressing and painful separate hacks without bringing up anything, their cough, however, every now and then terminating in the continuous expectorating kind. In all such cases, though there may be considerable secretion yet it is unequally distributed in patches of viscid coating with inflamed spaces between, and particularly if the dry surfaces are about the bifurcation of the bronchi. We need not say that these cases of mixed expectorant and non-expectorant coughs are especially frequent in the course of phthisis, as we then have ulcerated conditions in the track of decomposed pus expelled from vomicae or from pouches of dilated bronchi. I am particular, therefore to listen to the patients coughing in order to determine the ratio between the expectorant and the non-expectorant sounds, and if there be a considerable number of the latter, to add the sedative neuroties to the cough mixture. Of these I most prefer a small dose of chloral with a small dose of morphia, than a full dose of either separately with the addition of aconite in febrile cases. Eight grains of chloral and one-eight of a grain of morphia, for an adult, are quite sufficient.

But what we would particularly desire to emphasize at this juncture is that these neurotics are to be given for the

non-expectorant element in the cough, exclusively. So far as expectoration itself is concerned they are drawbacks and not helps. I have seen therefore much harm from the routine use of neuroties in coughs given apparently because, in some cases they are so markedly beneficial. In the passive bronchorrhoea of the aged with dilated hearts, in chronic bronchitis with bronchiectasis and emphysema, in capillary bronchitis, in pneumonia, and lastly, in all conditions in which there is abundant secretion, they are not only useless, but may be quite mischievous. and, as before remarked, they have no place in a cough mixture unless the sound of the cough betrays much useless irritation, as a complication.

The second variety of useless cough which we would mention is pure inflammatory irritation of the pharynx. This is common enough in ordinary colds and not infrequently the precursor of laryngeo tracheitis by extension. It is, however, one of the most obstinate troubles of advanced phthisis, giving rise to a constant tickling sensation in the throat which has been wrongly ascribed to reflex irritation from ulcerated surfaces lower down. Kohts found that a few separate coughs could be induced by electrical or mechanical irritation of the posterior surfaces of the palate and uvula and also of the pharynx, and that most violent and prolonged paroxysms could be induced by pulling the pharyngeal nerve. These facts explain the use of throat demulcents and for the same distress in phthisis I have found Sidney Ringer's recommendation to apply a powder of one grain of morphia to five of starch, with a brush, low down in the throat, often enables patients to get a night's rest from

the arrest of the prolonged paroxysms of coughs, which otherwise would rarely stop until vomiting changed temporraily the sensation of the throat.

The third variety of useless coughs is from irritation of the pleura. The importance of recognizing a pleuritic origin or element in a cough can scarcely be overrated. I believe that many cases of permanent damage to the lungs, including the induction of phthisis itself, might often be prevented if the frequent origin of a chronic cough in a pleuritic adhesion was more commonly recog nized. A valuable monograph might be written indeed on the theme that "Serous Inflammations are always serious," not so much from their immediate effects, though often that is the case, as from the far reaching consequences on the affected viscera of the glueing together of the two surfaces of their serous coverings. How long, for example, will it be that the brain or spinal cord will be as good as ever, after a meningitis, how-ever slight? When will the heart be quite free from the effects of a pericarditis? How often do we find sequelae of a long antecedent peritonitis manifest themselves in some complication in the abdominal cavity? But post mortem revelations show us that of all serous inflammations, those which lead to pulmonary adhesions are the most common, often where they had not been › at all suspected. Repeatedly, on the other hand, I have found that patients who come to me with a chronic cough,. some with the diagnosis of chronic fibroid phthisis, others as cases of chronic bronchitis, and others as instances of constitutional irribility of the respiratory passages, others again as asthmatics, have proved on examination be suffering from chronic

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there- uneasiness, very soon reconcile the patient to the trouble of wearing the straps. There are, however, many other conditions besides simple pleurisy where these considerations will apply. Whenever patients come to me with the ordinary signs of phthisis, I ask if they have been troubled with rheumatic pains about the shoulders. The answer is frequently in the affirmative, with often a pain behind the scapula worse in stormy weather. These pains are sure to give rise to useless cough. It is the familiar dry hacking cough of early phthisis. As a means of diagnosis, laying the cold hand on the infra clavicular space over the affected part will immediately elicit several sharp hacks, when the same procedure tried first on the unaffected side will not do so. But a still more decided example of this kind of cough, and with much more injurious effects, is when a womica has contracted extensive adhesions in front. The patients often then complain of an acute incisive pain through the lung which constantly excites more coughing. Now in both the early stages, and still more, in vomical, this pleuritic cough cannot be otherwise than harmful and provocative of increased inflammation in the

fore were most benefitted by measures directed to that condition. Nothnagel, it is true, failed, he says, to induce cough by irritation of the pleura, but other experimenters, and especially Kohts found the case to be directly the reverse; the latter observer noting it as invariable if the irritation was sufficient to cause inflammation. I am sure, however, that all clinicians will testifiy to the prolonged tendency to short hacking cough, after a patient has recovered from any attack of severe pleurisy. I myself have never found it absent in any such patients that have been under my observations for a year after their attack. The only exceptions, which in truth are only apparent exceptions, are of hydrothorax with renal disease, for in them the effusion is often too watery to leave adhesions, after absorption. These patients are specially prone to have their cough return with changes of the weather, a common source of aggravation of all symptoms due to ad- | hesions of serous membranes, as in pachymengitis, for example, but, because their cough returns, then they are apt to ascribe it to their catching a fresh cold. My rule, therefore, is to strap the whole affected side for six months or more after every attack of general pleurisy, explaining to the patients the necessity of the procedure to allow of as perfect rest as possible to this unresting respiratory surface, as otherwise the embers of the original in flammation will not go out and a permanent source of pulmonary mischief remain. The immediate relief to the constant sense of uneasiness in the side, and the cessation of the useless ominous hacking cough which accompanies that

surrounding parts. When, therefore, the phthisical process is limited to one lung, I invariably strap that side and keep it so for months together. Some writers, on theoretical grounds,object to this procedure. I believe that if they took careful clinical notes of the cases in which strapping is tried, they would come to a very different conclusion.

The fourth variety of useless cough is the spasmodic cough of pertussis. This cough is specific in its kind and not due to bronchitis. It may therefore be wholly suppressed in less than a week

as I have done repeatedly, and not return, though the disease remains and runs its natural course, and may remain as infectious as ever without there being ily cough present.

If, however, the patient contract a cold before the six weeks is over, the whooping cough at `once comes back and is 'then quite intractable to the ineasures which at first arrested it, showing that the irritation, of simple bronchitis plays the same role in inciting the nervous irritability of pertussis that bronchitis does in exciting asthma. My plan for arresting the cough of pertussis is to bring the patient as rapidly as possible fully under the influence of belladonna. Nothing short of doses which will produce the physiological effects of the drug should be tried. In children the dose should be enough to produce flushing of the skin, and repeated every two or three hours, night and day, for a week, after which the intervals of the doses may be gradually lengthened. Five grains of chloral may be added if after the third day, the belladonna does not seem to have the full desired effect.

The fifth variety is a tracheo laryngeal cough in children, occurring mostly at night and due to malarial infection. It is quite paroxysmal and strongly suggestive of whooping cough. In one family I had a younger child begin with such pronounced symptoms that I was fearful that it was true croup. The next day, however, three more of the children were down with the same croupy cough and each with considerable fever. The occurrence of so many cases of croupy cough together was a great relief to me, for I soon found my suspicions confirmed as to the nature of the trouble by a sign on which I place a good deal of reliance as diagnostic of a

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malarial infections in 4-KiNIPER, Daniely the presence of odorpusele in the urine der the microscope Children with these malarial coughs often fish the morning tired and fretful? With appetite, with brownish yellowedating of the tongue and considerablepharyngual redness; but during the day they scared

cough at all. If a few bloot corpuscles are found in the urine, a few dosás of quilineare sufficient to arrest the cough." yitva tapaus

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The sixth variety is familiar to phyas the nocturnal cough of sicians children from some irritation "ii" the alimentary canal, such as from indigestion, the presence of worms, etc., and should be treated accordingly.

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The seventh variety is that with which we are all familiar and which is often termed the uterine cough. If it be meant by this that it is associated with disorder of the female generative functions or organs it is correct enough, but the starting point of the irritation may not be from the uterus, but rather from some of its accessories. This cough is often the loudest of all coughs, as in some hysterical women. other accompaniments of hysteria, I have succeeded best in its treatment with purgatives like caseara, ales and rhubarb, with intestinal antiseptics like benzoate of soda, salol and camphor, with the usual adjuvants of myrrh, and the assafoetida and valerian, bromides. On the other hand in women more advanced in life we may find a local cause in the cervix uteri, the removal of which may be all that is necessary. The cough of chlorotics which so often excites alarm as likely to befrom phthisis, is doubtless of the same general character.

Very different of course is the next

variety, namely the aneurismal cough. The diagnosis may be facilitated by listening carefully over the trachea to the persistent croupy sound of the breathing, no matter how quiet the respiration be. I have suspected aneurism in a case of laryngeal phthisis, by this sign, where the co-existence of pronounced laryngeal ulceration made the case otherwise very obscure, and the autopsy proved the correctness of the surmise. This cough is best relieved by morphia, but it is surprising how often its most distressing paroxyms can be warded off by a couple of leeches to the notch of the sternum.

tion may not have happened in cases of this kind. Of course this kind of vomiting with hoarseness in phthisis is wholly different from the same symptoms later

on.

Another example of purely reflex coughs is mentioned in all our text books on diseases of the ear. Foreign bodies in the external auditory canal are especially prone to occasion it, and if we cannot find the reason for paroxysm of apparently causeless coughing we had better look for plugs of hardened wax as a possible explanation.

Finally we have the coughs of mitral insufficiency and of cardiac dilatation, which are too familiar for us to detain the society with. Also the cough from irritation of the phrenic nerve in perihepatitis, and even in abscess of the liver, as well as in some cases of splenitis, each of which is to be recognized by its sound as having nothing to do with expectoration of matter from the lungs, each also requiring its own and not a routine treatment. There remains one cough however which is always of grave import; namely the cerebral cough. In a few cases of epilepsy it may indicate nothing but a functional irritation, but when associated with symptoms of cerebral mischief it points to organic changes or irritative lesions affecting the cough center in the medulla oblongata. This is apparently located in the rhomboid groove on both sides of the raphe, just above the calamus scriptorious, and is particularly apt to be excited by affections of the under surface of the cerebellum, or by effusion, abscesses or tumors pressing the cerebellum down upon the medulla.

Similar in its genesis but of widely different import, is the cough produced by enlarged bronchial glands pressing upon the pneumogastric. This may be one of the earliest signs of phthisis, but if so it wholly differs in its nature and associations from the early pleuritic cough. It is almost invariably accompanied by excessive sensitiveness of the pharynx. Very often this goes along with hoarseness or even aphonia and intractable vomiting, although there be no vomica or scarcely any pulmonary symptom present. At other times there is a good deal of palpitation of the heart. In these cases the normal bronchial breathing between the scapulae is much intensified. You can promise the patients that their hoarseness and vomiting, will both cease after a while, which it usually does with softening of the implicated glands, but all the symptoms, including the cough, can meanwhile be greatly relieved by repeated dry cupping between the shoulders. I have wondered whether some of the good results reported from the old practice of a seton between the shoulders in the treatment of consump-irritative coughs, because they are all of

I have spent so much time in referring to these various kinds of simply

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