That you may understand my description, perhaps, more readily, my son* has kindly made these enlarged drawings (Fig. 1 and Fig. 2) from my original clinical sketch. Right upon the vocal glottis, the respiratory portion being comparatively uninvolved, was fixed the cockle-burr (which I show you, in this bottle). It lay (See Fig. 1) antero-posteriorly, its long axis-almost exactly corresponding with the median line of the rimaglottidis. Its base was directed backwards. The point of the sharp spine at its apex was

6

son, 4 and 5 Dr. Sajous, and our esteemed townsman, Dr. Wm. C. Glasgow, and Dr. E. H. Gregory with him,-will appreciate the problem presented: to remove this cockleburr with least possible injury to the larynx. The one great immediate difficulty with which one may have to contend, in attempting forcibly to remove a foreign-body of this character from this stronghold, is, that, of the intense reflex laryngeal spasm which may be excited thereby, against the sharp spines and tenacles of the cockle-burr.

imbedded, anteriorly, apparently just above the commissure of the vocal cords, in the lower curve of the cushion of the epiglottis. From its position, it seemed as if the tips of some of its tenacles must necessarily be in the ventricle of the larynx, upon either side.

Those of you who have met with cases of cockle-burr in the larynx, or have read the literature on the subject-such as the reported experiences1 of Dr. Max Thorner of Cincinnati, Dr. Crawley, 3 Dr. J. F. Thomp

McClelland Barclay.

1 Burnett's System of Diseases of the Ear, Nose and Throat, J. B. Lippincott Co., Phila., 1893, Vol. II, pp. 525-526.

tissues of the larynx; after which, the patient was instructed as to her part of the procedure. She was directed, upon the word, to take a slow, very deep, forced inspiration; and then, at the words, "Say 'A' (not "Ah!"), to attempt to phonate that vowel. She was directed to prolong this sound, "A!", however much it might tax her to do so at the end of her breath, until I should give her the command, "Breathe!", when she was to take a sudden, quick, full breath. Having demonstrated this cn myself, several times, to her entire comprehension, I introduced the laryngeal mirror and the Fauvel forceps. Passing the forceps, at the proper! moment, behind the cockle-burr, the blades were gently separated, and the body of the cockle-burr was seized firmly, (Fig. 2,) just as the patient responded to the command to "Say 'A'!"' It was held immovably, as the urgent command was loudly repeated, again and again, to "Keep on saying 'A'!!"—until I saw that she was growing desperate for "air;" when I gave her the order, "Breathe!".

The larynx at once relaxed into the position of forced inspiration; and, as it did so, a slight wig-wag motion of the forceps instantly brought away the entire cockle-burr, without the loss of a single one of its tenacles, and without wounding any of the laryngeal tissues.

The patient forth with returned home with Dr. Schroeppel; who subsquently reported her prompt and uneventful recovery.

3894 Washington Boulevard.

POINTS FROM GENERAL PRACTICE.

M. E. FITCH, M. D.

PHILADELPHIA, PA.

THE impression is too prevalent that irregular hemorrhages at the menopause are of little consequence. Generally all such cases where the patients had complained of excessive loss, the cause is attributed more or less confidently to a disturbance 'natural" to the period of the climacteric. From these a group can be isolated in which an obvious gross lesion, such as carcinoma of the cervix, a fibroid, etc., can be easily detected. There then remained a large number where the cause of the hemorrhage is not so readily explained.

Here, if anywhere, ought to be found the material to justify the view that at the menopause frequent and excessive hemorrhage is to be expected. Yet it was discovered that, with one or two doubtful exceptions, every one of the so-called functional hemorrhages

could be referred to a definite though perhaps relatively slight structural cause, upon the removal of which the hemorrhage ceased. Among such causes are such conditions as small polypus of the cervix, fungoid hypertrophy of the uterine mucosa, multiple adenoma of the same structure, retroversion of the uterus, and the early development of carcinoma or sarcoma. These considerations are of the utmost importance in order to secure the early diagnosis of cases of serious trouble.

Intermenstrual pain has not received the attention which it deserves, and the consequence is that it is as yet only imperfectly understood. It is not so rare as is generally supposed, and as regards regularity, the pain is apt to appear practically every month. In twenty-one cases studied by Storer occurred on a definite day from the beginning of the last menstruation: in thirteen there was a variation of two days, and in four of four days; in two with irreg ular menstruation it occurred on a definite day before the next menstruation. In reference to the day of appearance from the first day of the previous menstruation, it came on from the twelfth to the sixteenth day in thirty-seven out of forty-one cases. In a large number of cases it was described as paroxysmal, the attacks either coming on at intervals of several hours and lasting from five to fifteen minutes, or the pain being constant, with exacerbations often of the greatest severity and resembling that of labor. In ten it lasted two days; in nine, three; in eight, one; and in four, four or more. In no case was there a discharge like that of menstrua- ! tion, but in two cases one (of bleeding fibroids and the other of hemorrhagic endometritis) there was a slightly discharge; hence the term "intermenstrual dysmenorrhea" is misleading. A marked increase of leucorrhea is spoken of in ten cases, which is evidence of temporary congestion. This pain in most of the text-books is described as ovarian, but it is not always so. In one case it disappeared after the removal of a hydrosalpinx; in another, after the uterus was curetted for endometritis; and in a third, stenosis of the internal os was apparently the only lesion. On the other hand, out of forty cases in which the local condition is stated, more or less of an inflammatory condition of the appendages is described in thirty (ovariis, fifteen; salpingitis, twelve; and hydrosalpinx, three.

Thiel haber believes that more than 75 per cent of the cases of painful menstruation do not depend upon anatomical causes; the pain being due to tetanic contraction of the circular muscle at the os internum, such as occurs in other sphincter muscles in neurotic sub

jects. He opposes Menges' theory that dysmenorrhea is due simply to an exaggeration of the contractions of the longitudinal muscular fibres, which always accompany normal menstruation, for he argues, if the symptom is due purely to mechanical obstrcution it should invariably disappear after childbirth, which is not the case in nervous and hysterical women. Uterine colic cannot be due only to the passage of clots, since in many typical cases of dysmenorrhea there is a free escape of liquid blood. Moreover, the pains often most severe from twelve to twenty-four hours before the flow appears, instead of on the second or third day, when it is most profuse and clots usually are found.

In an exhaustive search by Anton on nerVous and mental affections at puberty he classified 3,720 cases according to age, and the first manifestations of the nervous or mental trouble. The symptoms due to the lack of normal relations between the nervous system, the brain and the rest of the body are important. Hysteria is due to a lack of the normal relations between the dynamics of the cerebrum and the physical body, but these relations differ in the child and in, the adult. The disturbances of puberty are sometimes within or without, or of disturbances in the thymus gland, where treatment should aim to prevent degeneration and to promote hygiene, which should commence before birth be particularly enforced during school life. Sexual morality is an important hygenic institution for the prevention of nervous and mental pathology; watch for the appearance of nervous irritability, for the crisis in the sexual life and for the periodical fluctuations in the mental and moral spheres. Again, disturbances during puberty are frequently due to acquired or inherited intoxication and morbid metabolism. patients re cured by a change of climate, especially to the mountains. The life of the neuron axis being a great chain of simple and complex reflexes, it is possible to therapeutically influence the organisms by systematically eliciting suitable reflexes, for example morbid distress can often be dispelled by application of heat to the back of the neck. Massage of painful nerves in the neck will sometimes banish severe headache. Painful stomachic cramps may be cured by a mild steam douche in the umbilical region, while the sensation of excessive fatigue may sometimes be dispelled by merely tapping the muscle, or nervous vertigo be relieved by energetic compression of the head. The peculiar reflex connections between the nose and the genitalia are well known. All these All these reflex phenomena are subject to individual variations, and the physician, by these sim

Some

ple reflexes, should be able to influence the nervous system, and should utilize this "reflex therapy." Bear in mind that a family is liable to contain some person who has a nerve-racking influence. Homesickness is another frequently overlooked factor; here the physician should bring the subject in normal relations between mind and body. The patient should not be allowed to yield to the impulse for self-isolation, nor to the influence of stronger morbid wills, nor to companionship with degenerates. A primodical fluctuation of the entire nerve condition is frequently noticeable. Anton believes that not until the crisis of puberty is past, final decision is possible as to the definite personal equation of our child patients.

Distinguish between congestive and spas.. modic dysmenorrhea; the former is due to the pelvic congestion which normally precedes and accompanies the early part of the flow, and presents the following characteristics. "It is a general aching diffused over the whole pelvic region-over the lower abdomen, lower part of the back, and often down the thighs. It is often accompanied with aching in the breasts. It is a continuous pain, not one that comes in short, sharp paoxysms. You may be told that it comes and goes, but when you inquire as to the length of each attack and remission, the answer will be that the pain continues steadily for two or three hours at a time, and then remits for an hour or two. It comes on gradually; you are not told of its waking the patient in the middle of the night. It begins from a day or to a week before menstruation, and is not relieved until the flow has become as copious as is customary for that patient. It is always better while the patient is lying down. It is never bad enough to produce objective evidence of severe suffering. The patient is in least discomfort when she is still; she does not writhe with pain, nor vomit, nor perspire, nor faint. She may look languid and tired, but there is no other external sign of suffering. Spasmodic dysmenorrhea is due to painful uterine contractions; this is dysmenorrhea in the literal sense of the word. "The pain of spasmodic dysmenorrhea is far more severe than any other kind of menstrual pain."

SUBSCRIBE for The Medical Fortnightly.

A NOVEL PUBLICATION.-A patient in the Spring Grove Asylum for the Insane (Md.) edits a monthly four-page paper, the Maryland Hospital News. This is probably the only publication edited by an admittedly insane individual.

RADIO-RECTAL DILATORS RADIOURETHRAL SOUNDS.

HEBER ROBARTS, M. D., M E.

Founder and formerly Editor American X-Ray Journal;
First President Roentgen Ray Society of America;
Member Roentgen Ray Society of London;
Late Surgeon to the Northern Pacific
Railway, Etc

THE attention of the medical profession, just now, is particularly directed to radium in medicine. Recent reports of its use with modes of light rays have renewed an unexampled inquiry into its use for internal diseases. Radium is the most interesting agent therapeutics has acquired, but the most alluring part and attractive claim to a medical man, is that radium may restore to health a cancerous patient. The physics and therapy of radium broadens and almost amazes we pursue its study.

as

Roentgen rays and all radiant matter so far known, have a pronounced influence_upon animal tissue. Leonard rays and the Roentgen rays coming from the Crookes tube, furnish much of the same physical phenomena, as is observed in the study of the beta and

gam

Glass tubes not being flexible I felt the necessity in my own practice for some device that would permit radium to reach sinuous cavities. I therefore had made round and flat aluminum receptacles attached to German silver handles. These instruments were fully described and illustrated in the March and April issues of The American Journal of Surgery and Gynecology and in the June issue of the Fortnightly, 1904.

While using aluminum tubes in practice I observed more rapid reaction from them than could be produced with glass tubes. The tissues responded more readily. I observed also that minor radio-activities in aluminum walls would do for human tissue what more costly salts of radium in glass tubes would not do.

The physics of radium had foretold of the alpha rays and of the emanations. It was shown that these agents of radium would not pass through the glass of therapeutic tubes. The most extraordinary revelations of these products was its power to confer radio-activity to animal tissue. These properties are not known to the Crookes tube. This property

ALUMINUM WALL

RADIO-ACTIVE WALL
WALL or 02200

ma rays coming from radium. From either source the effect is nearly identical when applied to the body. It is established beyond controversy now that these rays cause tissue reaction when medically applied. Rodent ulcers, lupus and the semi-malignant sores respond to these rays and it matters not whether the rays are generated by and with cumbersome apparatus through a Crookes tube or through the spontaneous bursting forth of the atoms of radium applied with a small pencil. It is to be observed that when the salts of radium are used in glass receptacles beta and gamma radiations only pass through the glass. When these rays only are needful it is a decided convenience over the X-rays. MackenzieDavidson, of London, makes use of very small glass tubes bound three and four in a row placed in a rubber bag when used for treatment. Dr. Danlos, of Paris, uses the round glass tube and Dr. Freund, of Veinna, was using glass in his clinic.

I have per

sonally witnessed the uses of radium in the hospitals of nearly all the large cities of Europe, having made the trip in 1904 and

1905.

of confering radio-activity was quickly util ized by Dr. Morton of New York City. The repairing influence yellow-green light rays, violet rays and some of the invisible rays have upon animal tissue led Dr. Morton to fluoresce the interior of the body with substances these activities would excite. To get light he used radio-activities-emanations.

For eighteen months I have used Dr. Morton's method with gratifying success. In my articles mentioned above the method of preparation is fully given.

In January. 1904, Sir Oliver Lodge suggested the probable use of radium internally.

Other observers had expressed the same thought, the idea having come from the known physics of the emanations and the alpha ray.

These

In glass wall receptacles two-thirds of the activity of radium is lost. The alpha rays and the emanations are bottled up. are the most efficient agents in repair. It is through these agents that any hope is held out for the cure of cancer. It has been found practicable to use thin sheets of aluminum. There are other metals that permit the trans