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BY DR. S. P. Mengel, Parsons, Pa.
READ MAY 25, 1910.

Master T., aged 61⁄2 years, during the afternoon of September 5, in an attempt to escape being caught stealing plums, jumped down from the roof of a small building and was beating a hasty retreat toward home, when in some way a plum stone became lodged in his throat.

He immediately began coughing and before he reached home, distance of probably eighty to one hundred yards, he fell to the sidewalk exhausted. He was carried into the house and placed upon a sofa. His coughing soon ceased but he complained of severe pains in his throat.

I saw him with Dr. Heslop about an hour after the accident. He was quiet then, did not cough, but had rather an anxious look, had perspired rather freely, was weak, and insisted on remaining quiet.

Examination of the throat was negative. Later, during the evening, he was examined by a specialist, and I was much relieved when the dector called me up by 'phone and told me the examination showed nothing and that the boy had evidently swallowed the stone.

The following morning-September 6-I again saw him. He was a rather sick little fellow; temperature 101 2-5, pulse 120, and showed the usual physical signs of pneumonia of right lung, upper lobe, posteriorly, expectorated blood or mucous and blood.

September 7 and 8 he ran a temperature of 101 to 101 3-5, and was constitutionally sick, but there was very little cough and no evidence of any foreign body lodged in the trachea except the pneumonia, and this I rather hoped might have been caused by exposure during the excitement at the time of the accident.

On the 9th he was much improved and sat up in his bed. At 2 a. m., September 10, he began coughing and continued until he became unconscious. The father and mother thought

him dead. About this time the paroxysm of cough was suddenly relieved and the lad soon regained consciousness. During the day he was again taken to a throat specialist, who with one of his colleagues again examined the child and advised an X-ray examination. The plate showed no foreign body in the trachea.

The little fellow had two paroxysms on the 10th, one on the 11th, and three on the 12th. During these spells he would cough until he became livid, relaxed and unconscious, then after a time he began breathing again, and in a short time, with the exception of the exhaustion, one would think there was nothing wrong with him.

During the afternoon of September 12 I was hastily summoned to the house. When I arrived I found the child lying quietly on a couch, quite weak, but he was breathing naturally. The father told me he had just had a coughing spell-the paroxysms, he said, were so severe and the dyspnoea so great that he took the child and rolled him on the grass in the yard, when, after a time, he again began to breathe.

Dr. Heslop, who was also present at the time, and I advised the removal of the boy to the hospital, where he could be closely watched and tracheotomy performed in case it became necessary.

A few minutes after we had left the house we were again recalled, the boy had taken another coughing spell.

When we got to the little fellow he was still coughing violently. An attempt was made to dislodge the foreign body with a finger in his throat. This proved futile.

The little fellow, now unconscious and practically moribund, was placed on a kitchen table, and with a pocket knife (which fortunately was a new one and the blades sharpe) I opened the trachea. There was little or no blood, and, on account of the condition of the child, no pain.

When the trachea was elevated into the wound by means of a haemostatic forceps which Dr. Heslop had with him, the child gasped, after which, by means of artificial respiration, he was soon breathing nicely and regained consciousness.

The trachea was stitched on either side to the sides of the

wound and held in this position until a tube was procured and placed. A professional nurse was placed in charge of the case.

The following morning, on entering the patient's house, I found every one in good spirits and happy, and on inquiry I found the little chap had during the night dislodged the foreign body and the nurse found it lying on his pillow.

The tube was removed the following day and the child made an uninterrupted recovery.



BY DR. M. A. MURRAY, WILKes-Barre, Pa.
READ JUNE 8, 1910.

The whole nervous system, the peripheral as well as the central, is, like all other tissues of the body, built up of anatomical units, and although varying much in shape and size, are notwithstanding to be regarded as highly differentiated cells. But, unlike other tissues, nowhere in the body is there a group of nerve cells completely disconnected from other nerve tissues of the body, as muscle or glands are disconnected, as they would be without physiological significance.

The communication between the sympathetic nervous system and the central nervous system is through the white and gray rami communicantes. All the spinal nerves have gray rami, but only from the first thoracic to the fourth lumbar have white rami; and Gaskell says, "The outflow of visceral nerves from the central nervous system into the so-called sympathetic system takes place by means of the white rami alone." The color of the rami depend upon the preponderance of medullated or non-medullated nerve fibres. The medullary sheath gives the whitish appearance, and this medullary sheath is lost when the nerve communicates with a ganglion cell of the sympathetic system. And according to Piersol: "The splanchnic afferent fibers are the sensory fibers of the splanchnic area, and consist of the dendrites of cells situated within the intervertebral ganglia on the posterior roots of the spinal nerves. While the greater number of these fibers are

found in the white rami, a few are thought to be constituents of the gray rami. Beginning in the viscera they run centrally, without interruption, through the terminal and collateral ganglia, through the gangliated cord and the white or gray rami to the spinal nerves, and thence after coming into relation with the cells of the ganglia of the posterior roots, they pass by way of the posterior roots into the spinal cord."

The efferent fibers, which are very much finer than those of the general nervous system, are the axons of cells situated in the lateral horns of the gray matter of the spinal cord. They leave the cord by way of the anterior horns, and it is now generally believed that all non-striated muscular tissue-namely, that of the intestinal canal and the gland ducts in connection with it-the smooth muscles of the urogenital system, the smooth muscle found in the skin, the eye, and all vessels, receives its nerve supply from the sympathetic neurons. These neurons carry efferent impulses, and their mode of termination may be one of the following: (1) In involuntary muscle tissue. (2) In heart muscle tissue. (3) In glands. (4) In spinal ganglia. (5) In other sympathetic ganglia; but, however, never gain the tissue as a spinal fiber, the last link in the path of conduction being a sympathetic neuron. Langley has shown: "That so far as the skin is concerned, the distribution of all the sympathetic fibers which run to the spinal nerve (gray rami) is the same as that of the sensory fibers of the nerve, and that the distribution of the sympathetic fibers of the spinal nerve can in the main be determined by dissection of the nerve in its course."

Since the sympathetic system is part of the general nervous system, and governed by the same laws, it is only fair to presume that stimulation will produce reflex effects in parts of the body supplied by the nerves stimulated; and this is well shown by the dilated pupil and increased secretion of the submaxillary gland-constriction of the small vessels of the ear, conjunctiva, and other parts of the head on stimulation of the cervical sympathetic. These same changes may be observed on stimulation of the superior cervical ganglia directly, some of the nerves given off from these ganglia, the upper thoracic

nerves in the vertebral canal. And Langley says: "All effects which can be produced by stimulating the sympathetic system in any region can be produced by stimulating the spinal nerves in the vertebral canal, or by stimulating the cord itself."

In 1888 Ross pointed out that disease of the viscera was associated with pain in certain superficial areas or zones. An enormous advance was made when Dr. MacKenzie, in 1892, described the cutaneous tenderness which was so frequently associated with visceral disease. For this is a symptom distinctly more objective, therefore more to be relied upon. Simultaneously Head published the result of his experiments, which were carried on separately and independently, which agree with those of MacKenzie. And he said that the pain of which the patient complains always lies within this area of tenderness and corresponds to the point or points of maximum tenderness in those areas. This tenderness is not deep seated, and is best elicited by picking up the skin gently between the finger and thumb or by using the blunt head of a pin. Head further established the fact that the referred pain and tenderness of diseased or disturbed viscera follow definite lines and bear a definite relation to nerve distribution-a single nerve trunk on a single segment of the cord.

They are referred along the somatic nerves, which come off from the same part of the cord as the sensory sympathetic fibers to the organ affected, but are not always localized over the organ affected. Indeed, while the areas of tenderness always bear a definite relation to the different organs affected, they, in many cases, lie at a considerable distance from the affected organ. The superficial reflexes are also usually exaggerated over the tender areas produced by the visceral disease, and each of these areas have points of maximum tenderness, which in a general way correspond with pain spots.

A few examples from Head's marvellously interesting and instructive articles may show the value of a knowledge of these superficial areas of referred pain and tenderness in visceral disease from a diagnostic as well as therapeutic standpoint.

In disease of the heart and vessels it is easy to get an account

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