(A) THE PERITONEUM.

The majority of authors attribute an extensive rôle to the peritoneum in the suspension of the uterus. Practically, the peritoneum applies, insists itself on the corpus and fundus only of the uterus, not on the cervix. The peritoneum is elastic, and to a certain degree counterbalances the intra-abdominal pressure. In 1887 Walcher denominated the peritoneum as a "peritoneal diaphragm," indicating that the peritoneum acts as a marked support of the uterus. I mean by the peritoneum the thin layer of endothelial cells, not the subperitoneal tissue. If the peritoneum should fix the uterus, it would be required that it should be firmly fixed to the pelvic brim; however, we know it is not firmly, but loosely, fixed to the peivic brim; hence, can be but a moderate support to the uterus. peritoneum can suspend the uterus only to a limited degree, and that for a short time only, as it distends, elongates, yields. The insufficiency of the peritoneum as a uterine support is evident, for, in abdominal distention, the peritoneum easily shifts and experiences new locations, yielding the original ones and assuming new ones with facility. The peritoneum maintains visceral relations in orderly plans for function (motion, nerve and vascular supply) as partitions in a home, as the intersections in netting, as the equalizers on a threshing machine, as the governor on an engine; however, as a uterine support, the peritoneum is meager, insufficient, unstable, distensible, yielding. On account of its distensibility, yielding character, it is irrational to employ it as a uterine support.

(B) LIGAMENTS.

The majority of authors attribute to the so-called ligamenti uteri a maximum rôle in uterine support. A noted exception to this view is the Russian anatomist Lasshoft. The primary structures usually included in the uterine ligaments are (1), ligamenta lata; (2), ligamenta rotunda; (3), ligamenta sacro-uterina. The secondary structures involved are: (4), ligamenta pubo-vesico-uterina (Hyrtl 1811-1894); (5), ligamentum cardinale (Kock's, 1880); (6), ligamentum transversum coli (Mackenrodt, the Berlin gynecologist). The majority of authors view the uterine ligaments as independent anatomic structures, and, as such, represent suspension agents for the uterus. The minority of authors view the uterine ligaments as reinforcements of the peritoneal diaphragm, which serve principally as uterine supports or fixation apparatus. Practically limited. signification should be attributed to uterine ligaments, whether they be independent anatomic structures or so-called reinforcers of the peritoneum diaphragm.

From the uterus radiate muscle strands in many directions, and, in fact, the uterus is not sharply bordered from adjacent structures, as its gross anatomy would indicate. The so-called uterine ligaments belong to the uterus, not the peritoneum. The ligamenta rotunda uteri belong

exclusively to the uterus as to blood and nerves-innervation and nourishment. They hypertrophy with advancing gestation and belong to uterine peristalsis.

Ziegenspeck claims that the ligamentum uteri contract with the contracting uterus and hypertrophy with the progressive gestating uterus. Hence, the so-called uterine ligaments functionate with the uterus in peristalsis and hypertrophy during gestation. The ligamentous apparatus of the uterus is best studied during parturition from complete gestation, when its hypertrophy is at a maximum. During parturition it doubtless aids the uterus to retain its relation to adjacent viscera holotopically. It may be noted here that different authors have attributed different viewsmaximum and minimum fixation capacity-to each individual ligament. However, in my opinion, among all errors of the uterine ligaments, no one has resulted in such unnecessary and harmful surgery as the erroneous views that the round ligament is a uterine support. Nearly twenty years ago I studied the anatomy of the round ligaments of the uterus, and was then convinced that the employment of the round ligaments for uterine supports was marked for oblivion.

COUGHS OF EXTRA-PULMONARY ORIGIN.*

BY OSCAR F. BAERENS, M. D.,

Professor Diseases of the Throat, Nose and Ear in St. Louis College of Physicians
and Surgeons, St. Louis, Mo.

Cough as a symptom is of such frequent occurrence, and is diagnostic of so many varied conditions, that its study is both necessary as well as interesting to the student physician. The majority of coughs are due to causes outside the lungs; in fact, ninety per cent of all coughs are extrathoracic in character.

Probably the direct cause of cough is irritation of fibres of the pneumo- gastric nerve. This nerve, in many respects, is the most wonderful telegraphic line in our physical make-up. It, of all the cranial nerves, has the most devious course and the largest anastomosis. It has its origin in the medulla oblongata, and is distributed to both voluntary and involuntary muscles, and forms the principal line of communication between the brain and the various viscera contained within the thorax and abdomen. We trace its branches through the respiratory tract and we touch upon them in the ear as well. Its stimulus may manifest itself as hunger, as thirst, or as nausea. Nor is this all. Clinical observation has taught us that any direct stimulus to it or its communicational branches may excite cough. Hence, the statement of the fact that almost any organ within the body may be responsible for the symptom designated

*Read at the Meeting of the Tri-State Medical Society (Missouri, Illinois and Iowa) at Moberly, Mo.

Here

as cough. Cough has for its object, primarily, the expulsion of some pathologic product of disease, which, if permitted to lodge undisturbed, say, in the lung, would ultimately lead to dyspnea and asphyxia. we see the wise provision of Nature in sounding the alarm and facilitating the removal of objectionable matter from the lung tissue. For all clinical purposes we may divide the genesis of coughs into two classes, namely, intra- and extra-thoracic coughs, and inasmuch as the larger percentage of coughs are of the latter variety, I shall consider in this paper some of the varieties met with daily. All coughs depend upon some source of irritation for their existence, and are either useful and protective or useless and irritative. As an example, the coughs of pneumonia or bronchitis belong to the useful variety, and the coughs of pertussis, pleurisy and asthma, cardiac irregularities and the like, are the useless irritative kinds. The former should be encouraged, the latter should be brought under control as speedily as possible. Extra pulmonary coughs must be suspected when a thorough examination of the lungs proves negative— though auscultation and percussion by trained fingers and ears fail very often to reveal intra-thoracic lesions. The character of the cough is usually our best guide in determining the underlying causative factor thereof. We know and speak of various kinds of cough, such as dry, moist, nervous, paroxysmal, hacking, rasping, spasmodic, irritating, persistent, recurrent, intermittent, short, whistling, whooping, barking and the like, and these various characteristics should serve as an index to their etiology.

In the minds of the laity, all coughs are indicative of pulmonary trouble, and to many of them it invariably suggests tuberculosis. To the observing and learned medical mind it is a symptom of interest always, and to him it is the alarm signal sounded by Nature, and means trouble somewhere along the line traversed by the pneumogastric. After satisfying ourselves that the cough is of extra-thoracic origin, we must direct. our search to other regions than the lung for its cause. In my own experience the oro- and laryngo-pharynx have been responsible for the greater amount of extra-thoracic coughs. Perhaps the commonest variety met with is that due to an elongated uvula, which may be hypertrophied and sufficiently long to irritate mechanically by its size the tussogenic zones in the immediate locality. The most severe paroxysms come on when the patient bends his head far forward, or when he assumes the recumbent position. After awhile there will develop a hyperesthetic condition, which will become so great as to cause serious interference with sleep, loss of appetite, even nausea and vomiting, resulting in emaciation and a general depression, which the physician, who sees the patient in this physical state, will most likely mistake for a phthisical condition. Hypertrophied tonsils are responsible for quite a few cases. All enlarged tonsils will not produce cough, but the kind in which the bases of the tonsils are broad

and which extend downwards and backwards, and in those cases in which adhesions exist between the glands and faucial pillars, will usually furnish their quota of coughers. Often we find cholesteatoma of the tonsils and cretaceous matters deposited in the follicles and crypts of the glands which will excite paroxysm of cough, and it is therefore of some importance to thoroughly explore these regions before concluding our examination of the throat. The lingual tonsil, situated at the base of the tongue, occupies a position favorable to the causation of cough, especially when this lymphoid tissue is hypertrophied. By reason of its situation it is often overlooked by the casual observer. The cough, in cases of this sort, is frequent, hard and rasping in character, and usually unaccompanied by expectorate. Posterior lateral hypertrophy is noted as a causative factor in the production of cough, though more infrequently met with. Pharyngo-mycosis will produce cough and is likewise comparatively rare. Varicose veins traversing the walls of the pharynx and ramifying through the lymphoid tissue at the base of the tongue must be included among the causative factors. In the naso-pharynx we find adenoids as the common offenders. I need not do more than mention them, so common is the condition, and every doctor is or should be familiar with the characteristic facies and symptoms produced by their presence.

In atrophic naso-pharyngitis and rhinitis the dried scales of mucus produce cough of a very irritating nature, though it is more of a hawking than it is a cough, and is usually most prominent in the morning, because of the accumulation and drying of the mucus over night. The nose is responsible for a host of troubles, and cough is one of them. Here we find various forms of pathological conditions, such as hypertrophic, atrophic, simple chronic intumescent and hyperesthetic rhinitis, septal spurs, ridges, exostoses, enlarged and cystic turbinals, polypi and irritative areas, all of which will cause cough, varied in variety and intensity as well as persistency. Going down further along the respiratory tract we look to the larynx intuitively almost, for it is the general impression that this organ has for its most prominent symptom, cough. Yet experience of laryngologists has proven this to be an erroneous impression. While it is true that cough does occur at times, it is not a constant nor a prominent symptom of laryngeal troubles. Just as there are sensitive areas within the nose, so are there sensitive areas within the larynx, which will respond to irritating stimuli, such as gases and dust, and produce cough. These areas are found in the inter-arytenoid commissure and over the ary-epiglottic and the glosso-epiglottic folds. Those of us who are engaged in aural work often note that patients will cough when the speculum is introduced into the auditory canal. This cough is short and of a hacking nature, and sometimes persists until the speculum is withdrawn. Pressure upon the auditory branch of the pneumogastric nerve produces the cough in these cases. It sometimes happens that when the

eustachian catheter is introduced into the tube, that cough is produced by the pressure against the walls of the eustachian tube, which would lead one to suspect that there are hyperesthetic areas met with in this locality.

Among the other remote causes of extra-thoracic cough we must not overlook hepatic, gastric and uterine disturbances, cardiac aneurism, tobacco heart, edema of the glottis, benign and malignant growths of the larynx, foreign bodies and ulcers.

Even in the skin we are told that tussogenic zones exists. These are situated on the anterior surface of the neck following the course of the distribution of the pneumogastric. In these cases of cutaneous cough the paroxysm is induced by playing a jet of cold air over the region, and is often produced by the contact of cold bedclothing with the warm epidermis.

From the foregoing it will be readily seen that the proper treatment of cough will depend largely upon the early recognition of the underlying cause, and the removal of the cause, if it be possible to do so. This is by no means an easy matter, and many cases of extra-thoracic cough will, by their persistency and severity, deceive both the physician and the patient, and lead them to believe that there exists a serious pulmonary affection. It is hoped that the possible causes of extra-thoracic cough enumerated here will be of some benefit to those of you who have given me your earnest attention, for which I thank you.

Commercial Building.

THE TOXIC EFFECTS OF QUINOSOL, CRESOL AND LYSOL.

Th. Weyl has studied the toxic effects of these three substances upon rabbits, and publishes the results of his investigations in the Vierteljahresschrift f. Gerichtliche Medicin. He finds that in the stomach of the rabbit, lysol and cresol are equally poisonous, but when administered hypodermically, quinosol is more poisonous than lysol, while cresol is less poisonous than either of the other two. Injected into the peritoneum, quinosol has a far less toxic effect than lysol or cresol.

Expressed in numbers, the minimum lethal doses were as follows: Introduced into the stomach, cresol is 163% more poisonous than lysol, and 135% more poisonous than quinosol.

When hypodermically injected, cresol is found to be 136% less poisonous than lysol, and 371% less poisonous than quinosol.

The results of the inter-peritoneal injections show that cresol has the same toxic value as quinosol and is 51.5% less poisonous than lysol.

In view of the large number of cases of lysol poisoning that have occurred in Germany within the past year, and the consequent restrictions placed upon its sale by the government, the investigator urges that the sale of quinosol, whose poisonous properties are equal to those of lysol. if not greater, be likewise regulated.-Pharm. Zentralh.