{"1": {"fulltext": "", "height": "3587", "width": "2221", "jp2-path": "rhinologylaryng00frie_0001.jp2"}, "2": {"fulltext": "LIBRARY OF CONGRESS.\\nChap. Copyright No.\\nShelf T^E^^Yq\\nUNITED STATES OF AMERICA.", "height": "3448", "width": "2136", "jp2-path": "rhinologylaryng00frie_0002.jp2"}, "3": {"fulltext": "", "height": "3448", "width": "2220", "jp2-path": "rhinologylaryng00frie_0003.jp2"}, "4": {"fulltext": "", "height": "3468", "width": "2096", "jp2-path": "rhinologylaryng00frie_0004.jp2"}, "5": {"fulltext": "", "height": "3464", "width": "2152", "jp2-path": "rhinologylaryng00frie_0005.jp2"}, "6": {"fulltext": "", "height": "3492", "width": "2092", "jp2-path": "rhinologylaryng00frie_0006.jp2"}, "7": {"fulltext": "", "height": "3448", "width": "2172", "jp2-path": "rhinologylaryng00frie_0007.jp2"}, "8": {"fulltext": "", "height": "3468", "width": "2088", "jp2-path": "rhinologylaryng00frie_0008.jp2"}, "9": {"fulltext": "Rhinology\\nLaryngology and Otology\\nSIGNIFICANCE IN GENERAL MEDICINE\\nBY\\nE, P* FRIEDRICH, M,D.\\nPRIVATDOCENT AT THE UNIVERSITY OF LEIPZIG\\nButborl3eD translation from tbe \u00c2\u00a9erman\\nH. HOLBROOK CURTIS, M,D.\\nCONSULTING SURGEON TO THE NEW YORK NOSE AND THROAT HOSPITAL\\nAND TO THE DIPHTHERIA AND SCARLET FEVER HOSPITALS\\nPHILADELPHIA AND LONDON\\nW, B. SAUNDERS COMPANY\\n1900", "height": "3376", "width": "2156", "jp2-path": "rhinologylaryng00frie_0009.jp2"}, "10": {"fulltext": "47545\\nl-ibrkit y of Co\u00c2\u00bbim\u00c2\u00bb \u00c2\u00ab\u00c2\u00abs\\nSEP 15 1900\\nCofyri|*\u00c2\u00ab try\\nSECONO COPV.\\nORDtR DtVISION,\\nSEP 20 I9UU\\n800/ 2\\nCopyright, igoo, by W. B. Saunders CoMPA^", "height": "3468", "width": "2088", "jp2-path": "rhinologylaryng00frie_0010.jp2"}, "11": {"fulltext": "EDITOR S PREFACE\\nAt the present time, when it is the fashion for almost every\\nspecialist to pad his individual work and announce a book\\non the ear, nose, and throat, which upon perusal is gener-\\nally found to cover ground already occupied, it is certainly\\nwith pardonable enthusiasm that we greet a masterly treatise\\nof a thoroughly original type, the intrinsic worth of which\\nwarrants its appearance in our own language. Friedrich\\nhas realized that the general practitioner must acquaint\\nhimself with the rapid advances in the modern teaching of\\notolaryngology, and he has constructed a book so rich in\\nstatistics and reference, so learned in its argumentative\\ndeductions, and at the same time so convincing in the man-\\nner of conservative presentation, that no specialist can afford\\nto neglect the opportunity of acquainting himself with the\\nsubject-matter of his work. The results of the vast clin-\\nical experience of the author, the detailed reports, and the\\nextensive bibliography make the volume valuable alike to\\nthe specialist and the general practioner.\\nFar too little attention has been paid in the past to early\\nsymptomatic manifestations in the respiratory tract nor\\nhas sufficient study been given to the reflex neuroses of the\\near and air-passages and their diagnostic significance.\\nOne can not read the book without admiration for a\\nphysician who is able at once to be observant of the\\nminutest detail of constitutional disturbance, and also to\\npossess so intimate a knowledge of the specialties whose\\nreciprocal relations he so ably defines.\\nThe chapters treating of nervous diseases are most inter-\\nesting and rich in new material, as are also those upon\\nthe exanthemata and their sequels.\\nIn the translation there has been no effort made to ren-\\nder into elegant English the characteristic construction of\\nthe German text. To preserve the exact meaning of the\\n5", "height": "3456", "width": "2164", "jp2-path": "rhinologylaryng00frie_0011.jp2"}, "12": {"fulltext": "O EDITOR S PREFACE.\\nauthor and his individual style of expression has been our\\naim, and the work is reproduced from a strictly scientific\\npoint of view.\\nThe attention which has been given to the morbid anat-\\nomy and pathology is exceptional, and the book as a whole\\nranks among the most progressive works of to-day.\\nThe editor has no hesitation in indorsing the book as the\\nbest treatise upon the relationship of general diseases to\\nthose of the ear, nose, and throat that has appeared up to\\nthis time.\\nH. HoLBROOK Curtis.\\niiS ]\\\\Ia iison Avenue, New York City.", "height": "3468", "width": "2096", "jp2-path": "rhinologylaryng00frie_0012.jp2"}, "13": {"fulltext": "PREFACE\\nIn these days of specialism there is a laudable tendency\\nto tighten the bonds that unite the daughter to the mother\\nscience. On every hand we see the publication of works\\ndestined to show the correlation between various branches\\nof medicine, and to awaken the interest of representatives\\nof the various specialties for one another s work by defining\\nthe lines where their respective provinces meet.\\nThe present book belongs to this category, and the\\nauthor s object has been to point out the interdependence\\nbetween diseases of the entire organism and diseases of the\\nnose, pharynx, larynx, and ears.\\nIt is a somewhat hazardous experiment, this attempt to\\nunite the three specialties rhinology, laryngology, and\\notology in a single treatise, and I am well aware of the\\nopposition it is destined to meet from the extreme advocates\\nof specialism. But let us examine the relation between\\nthese three specialties. A study of the history shows us\\nthat rhinology was added to laryngology in response to\\na practical demand, and that recent developments have\\nshown that otology stands more and more in need of rhi-\\nnology so much so that a distinction might be made be-\\ntween rhino-laryngology and rhino-otology. But we ought\\nrather to oppose this subdivision, since the study of rhi-\\nnology is as important for the successful practice of laryn-\\ngology, as a knowledge of nasal affections is indispensable\\nin the practice of otology in other words, one specialty\\nencroaches on the domain of another, and it is impossible\\nto establish definite boundaries.\\nWhenever it becomes necessar to examine more care-\\nfully certain regions of the body, anatomically and physi-\\nologically distinct, the natural result is the growth of a\\nspecialty.\\nAs experience shows that certain portions of the organism", "height": "3456", "width": "2164", "jp2-path": "rhinologylaryng00frie_0013.jp2"}, "14": {"fulltext": "5 PREFACE.\\nwhich, owing to their position and function, can not be\\nreached by ordinary methods of examination practised in\\ngeneral medicine, demand the development of special\\nmethods to enable us to examine new regions both in the\\nhealthy and in the diseased state, and as with the growth\\nof our knowledge additional facts are discovered, the field\\ngradually widens, and new departments spring into exist-\\nence, which are only too often regarded by both physicians\\nand laymen as isolated domains of the general science.\\nThere must, of course, be a period in the development\\nof a specialty during which those who practise it devote\\ntheir entire energy to the study of the anatomy and\\nphysiology of the new regions, and to the creation of a\\nspecial pathology and method of treatment adapted to the\\npeculiarities of the parts concerned. Once this foundation\\nis established, however, it becomes important to incorporate\\nthe new discoveries in the scheme of general medicine.\\nA specialty should not be regarded as a thing apart and a\\nkind of appendage it should take an active part in all the\\nproblems with the solution of which general medicine is\\nconcerned. To do this an active cooperation between\\ngeneral medicine and every one of the various specialties is\\nindispensable. Whenever it is lacking, the specialty is in\\ndanger of becoming a mere source of revenue and of losing\\nits scientific significance while, on the other hand, the\\ngeneral practitioner will fail to recognize special symptoms\\nwhich might have been of the greatest importance to him\\nin the recognition and treatment of his cases.\\nIn taking this standpoint and in describing the relations\\nwhich manifest themselves as disturbances of the general\\norganism in disease of special parts, or as disturbances of\\nspecial parts in general disease, I lay no claim to origin-\\nality, for several works on our specialties have appeared\\nwith a special reference to general medicine. Moritz-\\nSchmidt, in his excellent book on Diseases of the Upper\\nAir-passages, has followed the same Hues, writing from\\npractice for practice Lori discusses Alterations of the\\nPharynx, Larynx, and Trachea due to Other Diseases\\nwhile Moos and Haug discuss The Diseases of the Ear\\nin their Relation to General Diseases, one in his chapter\\non the Etiology of the Diseases of the Ear in Schwartze s\\nHandbuch der Otologic, the other in a special mono-\\ngraph.", "height": "3496", "width": "2092", "jp2-path": "rhinologylaryng00frie_0014.jp2"}, "15": {"fulltext": "My undertaking a new work on this theme merely shows\\nthe abundance of material accumulated during the last few\\nyears, and the development of new points of view that\\njustify the publication of another book on the subject. It\\nhas been my endeavor to confine myself to the positive,\\nand, disregarding speculation, to present to the reader\\nnothing but exact and well-established information.\\nThe treatment of the subject is purposely succinct,\\nespecially the description of the commoner diseases. A\\ndetailed description of special symptomatology is not\\nwithin the scope of this book, which does not pretend to\\nbe a special text-book in the ordinary sense, being intended\\nto awaken the interests of both the general practitioner\\nand the speciaUst in certain matters which appear to me to\\ndemand special attention and further elaboration. As I\\nhave drawn freely from the entire literature, bibliographic\\nnotes seemed to me indispensable. They do not pretend\\nto anything like completeness, but I have, I hope, cited the\\nmost important works, a reference to which will enable the\\nreader to elucidate any doubtful questions that may present\\nthemselves.\\nE. P. Friedrich.", "height": "3392", "width": "2168", "jp2-path": "rhinologylaryng00frie_0015.jp2"}, "16": {"fulltext": "", "height": "3336", "width": "2168", "jp2-path": "rhinologylaryng00frie_0016.jp2"}, "17": {"fulltext": "CONTENTS.\\nI. DISEASES OF THE RESPIRATORY ORGANS.\\nPAGE\\nGeneral Remarks on the Relations Existing between the Nose,\\nPharynx, and Larynx 17\\nRelations Existing between the Nose, Pharynx, Larynx, and Lungs 19\\nSignificance of the Upper Air-passages in the Physiology of\\nBreathing 19\\nDiseases of the Lungs Due to Disturbances- of the Physiologic\\nFunction of the Upper Air-passages 26\\nDiseases of the Lungs in Morbid Conditions of the Upper Air-\\npassages 28\\nAlterations in the Upper Air-passages in Diseases of the Lungs 31\\nAlterations in the Upper Air-passages in Diseases of the Medi-\\nastinum\\nRelations between the Upper Air-passages and the Ears 35\\nThe Effect of Disturbances of the Normal Function of the Eu-\\nstachian Tube 36\\nDisturbances of the Function of the Eustachian Tube Due to\\nAlterations in the Upper Air-passages 40\\nDiseases of the Middle Ear Due to Infection from the Post-nasal\\nSpace 43\\nThe Effect of Various Diseases of the Respiratory Organs on the\\nEars 47\\nII. DISEASES OF THE CIRCULATORY SYSTEM.\\n1. Diseases of the Heart and Blood-vessels in Their Relation to the\\nNose, Pharnyx, and Larynx 52\\n2. Diseases of the Heart and Blood-vessels in Their Relation to the\\nEar 59\\nIII. DISEASES OF THE DIGESTIVE SYSTEM.\\n1. Diseases of the Digestive System in Their Relation to the Upper Air-\\npassages 68\\nDiseases and Changes in Form of the Oral Cavity in Disturbances\\nof Nasal Respiration 68\\nDiseases of the Digestive Organs in Relation to the Nose,\\nThroat, and Larynx 70\\n2. Digestive System and Diseases of the Ear 76", "height": "3464", "width": "2176", "jp2-path": "rhinologylaryng00frie_0017.jp2"}, "18": {"fulltext": "CONTENTS.\\nIV. DISEASES OF THE BLOOD.\\nPAGE\\n1. Anemia 8i\\n2. Leukemia 83\\nAlterations in the Upper Air-passages in Leukemia 83\\nThe Manifestations of Leukemia in the Ear 86\\n3. Hemorrhagic Diatheses 89\\nV. CHRONIC CONSTITUTIONAL DISEASES.\\n1. Rachitis 92\\n2. Acromegaly 95\\n3. Diabetes Mellitus 96\\n4. Gout 102\\nIctus Laryngis Occurring in the Course of Obesity, Gout, and\\nDiabetes 104\\nVI. ACUTE INFECTIOUS DISEASES.\\n1. Measles 108\\n2. Scarlatina 112\\n3. Varicella I20\\n4. Variola 121\\n5. Typhoid Fever 123\\n6. Iniiuenza I32\\nAural Complications in Influenza 134\\n7. Parotitis Epidemica (Mumps) 138\\n8. Acute Rheumatoid Arthritis 139\\n9. Diphtheria 142\\n10. Erysipelas I47\\n11. Malaria 148\\nVII. CHRONIC INFECTIOUS DISEASES.\\n1. Tuberculosis and Lupus 15 1\\nTuberculosis of the Nose 158\\nTuberculosis of the Pharynx 161\\nTuberculosis of the Larynx 162\\nTuberculosis of the Ear 169\\nLupus 174\\n2. Leprosy 177\\n3. Malleus Humidus (Glanders) 183\\n4. Foot-and-mouth Disease 184\\n5. Anthrax 185\\n6. Actinomycosis 185\\n7. Rabies 186\\n8. Trichinosis 187\\nVIII. DISEASES OF THE KIDNEY.\\nEdema of the Pharynx and Larynx 188\\nHemorrhages in the Pharynx and Larynx 189\\nNephritic Aural Diseases 189", "height": "3464", "width": "2176", "jp2-path": "rhinologylaryng00frie_0018.jp2"}, "19": {"fulltext": "CONTENTS. 1 3\\nIX. DISEASES OF THE SKIN AND OF THE SEXUAL\\nORGANS.\\nPAGE\\n1. Diseases of the Skin 193\\n2. The Influence of Normal or Pathologically Altered Sexual P unctions\\non the Upper Air-passages 197\\nRelation of the Sexual Organs to the Upper Air-passages 197\\nRelations between the Sexual Organs and the Ears 201\\n3. Gonorrhea 203\\n4. Syphilis 205\\nX. DISEASES OF THE EYE.\\n1. Relations between the Eye and the Nose 224\\n2. Relations between the Eyes and the Ears 234\\nXI. INTOXICATIONS.\\nAcids and Alkalies 242\\nlodids 243\\nArsenic and Lead 245\\nMercury 246\\nCopper, Phosphorus, etc 247\\nQuinin, Salicylic Acid, etc 248\\nChloroform, Tobacco, Alcohol 249\\nXII. NERVOUS DISEASES.\\n1. General Remarks on Diseases of the Larynx in Diseases of the\\nCentral Nervous System 251\\nDiseases of the Sensory and Motor Nerves of the Larynx 251\\nLocalization of Centers for Movement of the Vocal Cords in the\\nCentral Nervous System, and the Effect of Diseases of the\\nCentral Nervous System 258\\n2. General Remarks on the Aural Disturbances Produced in Diseases of\\nthe Central Nervous System 263\\nThe Mechanism of Functional Disturbances in the Ear and the\\nElectric Reactions of the Auditory Nerve 263\\nThe Localization of the Ear in the Central Nervous Organs 270\\n3. Nervous Diseases which Produce Definite Alterations in the Nose,\\nPharynx, and Larynx, and in the Ears 275\\nDiseases of the Spinal Cord 275\\nTabes Dorsalis 275\\nMultiple Sclerosis 289\\nDiseases of the Medulla Oblongata 291\\nSyringomyelia 29I\\nProgressive Amyotrophic Buliiar Paralysis 292\\nNeuroses 293\\nParalysis Agitans 293\\nEpilepsy 294\\nChorea Minor 295\\nHysteria 295", "height": "3464", "width": "2180", "jp2-path": "rhinologylaryng00frie_0019.jp2"}, "20": {"fulltext": "14 CONTENTS,\\nAPPENDIX.\\nPAGE\\nNasal Reflex Neuroses 306\\nThe Significance of Some of the Cranial Nerves in Rhinology and Otology, 314\\nThe Trifacial Nerve 314\\nThe Chorda Tympani 320\\nThe Facial Nerve 323\\nDiseases of the Meninges and of the Cerebral Sinuses 325\\nTheir Significance in Connection with the Nose, Larynx, and Ears 325\\nDiseases of the Meninges in Nasal Affections 328\\nDiseases of the Meninges and of the Cerebral Sinuses in Ear\\nDisease 330\\nINDEX 337", "height": "3320", "width": "2096", "jp2-path": "rhinologylaryng00frie_0020.jp2"}, "21": {"fulltext": "RHINOLOGY\\nLARYNGOLOGY AND OTOLOGY\\nAND THEIR\\nSIGNIFICANCE IN GENERAL MEDICINE", "height": "3360", "width": "2172", "jp2-path": "rhinologylaryng00frie_0021.jp2"}, "22": {"fulltext": "", "height": "3424", "width": "2152", "jp2-path": "rhinologylaryng00frie_0022.jp2"}, "23": {"fulltext": "DISEASES OF THE RESPIRATORY ORGANS.\\nJ. GENERAL REMARKS ON THE RELATIONS\\nEXISTING BETWEEN THE NOSE,\\nPHARYNX, AND LARYNX.\\nThe upper air-passages, comprising the nose, pharynx,\\nand larynx, present a canal of varying form and diameter,\\nlined in its entire extent, except where the respiratory and\\nalimentary tracts cross each other in the pharynx, by mucous\\nmembrane covered with ciliated columnar epithelium so\\nthat nose, pharynx, and larynx imperceptibly merge one\\ninto the other without the interposition of a sharp line of\\ndemarcation. It follows that pathologic changes in any\\nportion of the upper air-passages are not sharply limited in\\ntheir local effects and ultimate consequences, but invade\\nadjacent areas quite irrespective of the anatomic boundaries\\nof nose, pharynx, and larynx.\\nIt is well known that catarrhal affections of the upper\\nair-passages are not limited to a circumscribed area they\\ndisplay, on the contrary, a peculiar descending character,\\nas it is called, beginning in the nose as an acute rhinitis and\\ninvading at certain definite intervals the pharynx and the\\nlarynx.\\nThe comparative immunity enjoyed by the larynx as\\ncompared to the pharynx is not altogether accidental,\\nalthough to a certain extent dependent on accidental\\ncauses, for it is generally admitted that progressive morbid\\nprocesses meet with a certain resistance wherever the char-\\nacter of the epithelium changes, which resistance may be\\nsufficient to arrest their further advance. Now, the ciliated\\ncolumnar epithelium of the nose and nasopharynx is re-\\nplaced in the oral pharynx by squamous epithelium, which\\nextends as far as the upper border of the larynx but at\\nthis point the epithelium returns to the ciliated columnar\\ntype of the higher air-passages, and this type is retained\\n2 17", "height": "3456", "width": "2084", "jp2-path": "rhinologylaryng00frie_0023.jp2"}, "24": {"fulltext": "1 8 THE RESPIRATORY ORGANS.\\nthroughout the interior of the larynx with the exception\\nof a zone of squamous epithehum extending over the\\ninterarytenoid notch to the posterior wall and to the vocal\\ncords. Hence we can readily understand that the boun-\\ndaries between these various kinds of epithelium oppose to\\nthe progress of an acute catarrh a barrier more or less\\ninsurmountable, according to the intensity of the process\\nand the disposition of the individual. In the comparatively\\nrare cases where the larynx becomes involved in a de-\\nscending catarrh, the laryngeal symptoms develop several\\ndays after the first appearance of the nasal and pharyngeal\\nsymptoms, or even after convalescence has begun in the\\nhigher air-passages.\\nAscending catarrh, on the contrary, differs diametrically\\nfrom the descending form in the matter of frequency, and it\\nseldom or never happens that an acute pharyngitis or laryn-\\ngitis spreads to the higher portions of the respiratory tract.\\nWith the infectious diseases, especially diphtheria, the\\ncase is quite different they may originate either in the\\npharynx or in the nose, although, as a matter of fact, they\\nusually appear first in the pharynx, and spread from that\\nregion either upward into the nose or downward to the\\nlarynx.\\nThe relation between the nose and the nasopharynx\\nis a particularly intimate one, so much so that only very\\nfew diseases are limited to one or the other of these two\\nstructures. Any chronic condition leading to obstruction\\nand to the passage of morbid products such as mucus\\nand pus into the nasopharynx exerts an injurious effect\\non that structure and, conversely, any disease of the\\nnasopharynx, by causing chronic enlargement of the phar-\\nyngeal tonsils, thereby obstructing the nasal passages and\\ninterfering w ith nasal respiration, sets up a congestive\\ncatarrh the secretions accumulate as the expiratory blast\\nis no longer able to remove them, and a hyperplasia of the\\nmucous membrane eventually results.\\nIf, on account of obstruction, the nasal secretion is unable\\nto make its escape outward and flows back into the nasor\\npharynx, the harm which results is not confined to this\\nlocality the discharges trickling down along the posterior\\npharyngeal wall accumulate in the oral pharynx, and the\\nsubsequent course of the disease then depends on the", "height": "3500", "width": "2100", "jp2-path": "rhinologylaryng00frie_0024.jp2"}, "25": {"fulltext": "SIGNIFICANCE OF THE UPPER AIR- PASSAGES. 1 9\\nquantity and consistency of the morbid secretion. If the\\npatient is unable to remove it by hawking and coughing, it\\nwill adhere to the posterior pharyngeal wall in the form of\\na thick, tenacious coating, and thence will gradually spread\\nto the posterior wall of the larynx. This mode of spread-\\ning from the nose to the pharynx and larynx is especially\\ncharacteristic of certain definite diseases, the most typical\\nof which is atrophic rhinitis with fetor and crust formation.\\nThe greenish-yellow, foul-smelling crusts with which the\\natrophied nasal cavities are covered as the walls of a room\\nare covered with wall-paper are also found clinging to\\nthe roof and posterior wall of the pharynx, while in the\\nlarynx a tenacious material accumulates on those parts\\nwhich are least concerned in the movements of phonation\\nand respiration, especially in the region below the glottis.\\nSimilar consequences attend any chronic inflammation of\\nthe nose, accompanied with copious secretion and suppura-\\ntive processes in the tributary cavities of the nose, whenever\\nthe position of their openings permits a backward flow of\\npus.\\n2. RELATIONS EXISTING BETWEEN THE NOSE,\\nPHARYNX, LARYNX, AND LUNGS,\\nSIGNinCANCE OF THE UPPER AIR-PASSAGES IN THE\\nPHYSIOLOGY OF BREATHING.\\nLeaving the description of the interdependence of nose,\\npharynx, and larynx, which really belongs to the domain of\\nspecial pathology, we now turn our attention to the influence\\nexerted on the lungs by disease of the upper air-passages.\\nThe first requisite for a thorough understanding of this\\nsubject is a knowledge of the physiologic significance of the\\nair-passages in the act of respiration. They should not be\\nviewed merely in the light of canals for the transmission of\\nthe inspired air for each segment has a special function of\\nits own and contributes to the preparation of the air for\\nreception in the lungs, and this function can not remain in\\nabeyance without detriment to the organism.\\nWe begin with the consideration of the upper air-passages\\nas the respiratory pathway and with the changes experienced\\nby the inspiratory air-current during its passage through\\nthe nose.", "height": "3440", "width": "2088", "jp2-path": "rhinologylaryng00frie_0025.jp2"}, "26": {"fulltext": "20 THE RESPIRATORY ORGANS,\\nI. The Nose as the Respiratory Pathway. The nose\\nis the portal through which the air gains admittance to the\\nbody, and it has certain special functions to perform which\\nlend to it a greater importance than belongs to the pharynx\\nand larynx. It is charged with the duty of preparing the\\nair for its entrance into the deeper air-passages, in the fol-\\nlowing ways\\n1. By removing foreign substances as much as possible.\\n2. By warming the air.\\n3. By imparting to the air the requisite degree of\\nmoisture.\\n4. A subordinate function consists in protection of the\\norganism by means of the sense of smell and the nasal\\nreflexes.\\nIn order to gain a full understanding of these various\\nfunctions let us examine the path followed by the air in its\\ntransit through the nose. Even at the present day we\\nfrequently hear of the division of the nasal cavity into a\\nrespiratory and an olfactory region, the former correspond-\\ning with the maxillary, and the latter with the ethmoidal,\\nportion. It should follow from this subdivision that the\\nlower half of the nose, as far as the middle turbinated bone,\\nis concerned exclusively in the act of breathing, while the\\nremaining upper half subserves solely the sense of smell.\\nExperimental researches prove, however, that such a\\ndivision is not justified, either by the nature of the respira-\\ntory air-current or by the distribution of the nerves, to\\nwhich we shall return later. Experiments have been made\\nby Paulson, Kayser,^ Franke,^ and Scheff,^ and those of\\nScheff have recently been repeated and confirmed by\\nDanziger.* The perfect agreement of these experiments\\nand the convincing care with which they were performed,\\njustify us in rejecting the older theory, according to which\\nthe respiratory air-current passes only through the lowest\\nsegment of the meatus nasi communis that is, the space\\nbetween the inferior turbinated bone and the septum. The\\nmost important fact brought out by recent investigations is\\nthat the respiratory current passes principally through the\\nmiddle and upper parts of the nose, and hardly touches the\\n1 Zeitschr. f. Ohr., vol. XX, p. 96.\\n2 Arch. f. Laryng., vol. I, p. 230.\\n3 Klin. Zeit- u. Streitfr., Vienna, 1895, vol. IX, part U.\\n4 Mon. f. Ohr., 1896, p. 331.", "height": "3468", "width": "2088", "jp2-path": "rhinologylaryng00frie_0026.jp2"}, "27": {"fulltext": "THE NOSE AS THE RESPIRATORY PATHWAY. 21\\ninferior meatus under normal conditions. As the entrance\\nto the nose is in the horizontal plane, the current of air, on\\nentering, rises in a line parallel to the dorsum of the nose\\nit is then deflected backward in the region of the agger\\nnasi (which in man is rudimentary), describing a curve, the\\nconcavity of which faces downward, while its apogee may\\nproject above the superior, and never falls below the middle\\nturbinated bone, and passes out through the upper half of\\nthe posterior nares. According to Franke, the air-current\\nalso forms an eddy somewhere in the region of the inferior\\nturbinated bone. During expiration the curve is flattened,\\nits elevation being in direct proportion to the depth of the\\ninspiratory movement.\\nWhile we must accept this as the type of nasal respira-\\ntion to be considered in judging of pathologic conditions,\\nwe must also take into account the shape of the external\\nnose, the position of the anterior nares, and the width\\nfrom side to side of the internal openings which depends\\non the prominence of the plica alaris. The significance of\\nthese factors was shown by Kayser in his experiments to\\ndetermine the manner of aspiration in variously shaped\\nnoses. In the narrow, aquiline variety of nose, in which\\nthe external opening is horizontal and the inner opening\\nusually small, the air-current follows the direction which\\nhas been described on the other hand, we have the testi-\\nmony of various authors that in the broad, turned-up, so-\\ncalled pug-nose, in which the space between the septum\\nand the plica vestibuli is large, the air-current enters in a\\nmore horizontal direction, and is directed toward the lower\\nportion of the nose.\\nThis apparently complicated arrangement enables the\\nnose to fulfil the three different functions which pertain to\\nit in the preparation of the respiratory air-current, by in-\\nsuring the greatest possible extent of contact with the walls\\nof the nasal cavities.\\nI. Removal of Foreign Substances from the Respira=\\ntory Air=current. When we consider the great variety\\nof conditions with which we are surrounded, it is self-\\nevident that the purity of the air, which depends on the\\npresence or absence of dust and gaseous substance, is sub-\\nject to considerable change. Under the head of dust we\\nhave to consider solid particles of a mineral or vegetable\\nnature and microorcranisms.", "height": "3456", "width": "2088", "jp2-path": "rhinologylaryng00frie_0027.jp2"}, "28": {"fulltext": "22 THE RESPIRATORY ORGANS.\\nThe nose is provided with various means of defense\\nagainst the entrance of these deleterious substances the\\nvibrissas which hne the inner margin of the nostrils, the\\nmoist surface of the mucous membrane, the reflex act of\\nsneezing, and, lastly, a bactericidal property which probably\\nresides in the mucous secretion.\\nThe vibrissae act like a coarse filter which arrests the\\nlarger particles. The moist surface of the mucous mem-\\nbrane attracts and holds fast any foreign substances in the\\nair-current as it passes through the narrow and complicated\\npassages of the nose. This occurs especially at certain\\npoints where the current impinges on the surface of the\\nmucous membrane and is deflected, necessitating a certain\\namount of friction between the air and the walls of the\\ncavities. In consequence of this friction, the dust particles\\nsuspended in the air-current are brought into close contact\\nwith the mucous membrane, and stick fast to its moist\\nsurface, later to be swept out by the outward current\\nof the ciliated epithelium. One important region of this\\nkind is found on the cartilage of the septum, at the level of\\nthe inferior turbinated bone, at the spot where the inspired\\ncurrent, after being deflected inward by the plica vestibularis,\\nstrikes the septum another corresponds to the posterior\\npharyngeal wall, opposite the posterior nares. The purifi-\\ncation which the air undergoes in the nose does not, how-\\never, entirely prevent the inhalation of dust into the lungs,\\nas we know from the occurrence of anthracosis and other\\nforms of pneumoconiosis. A similar resistance is offered\\nby the tissues of the nose to the entrance of microorgan-\\nisms. Considering the number of bacteria contained in the\\nair, and the great quantity of air that passes through the\\nnose, we would expect to find a very large number of\\nmicroorganisms in the nasal chambers, as it is probable\\nthat they do not penetrate into the deeper air-passages.\\nOpinions are divided on the fate of germs introduced into\\nthe nose, both as to the depth to which they penetrate into\\nthe nose and as to their behavior therein. While some in-\\nvestigators state that the nose is a playground for all kinds\\nof bacteria, others, like Thomson and Hewlett, have\\nrecently advanced the theory that the germs are arrested\\nin the vestibule, and only in exceptional cases and in\\n1 Medico-Chirurgical Transactions, vol. LXXVni, 1895.", "height": "3468", "width": "2080", "jp2-path": "rhinologylaryng00frie_0028.jp2"}, "29": {"fulltext": "THE NOSE AS THE RESPIRATORY PATHWAY. 23\\nsmall numbers penetrate into the deeper portions of the\\nnose.\\nThe question whether the nose contains germs under\\nnormal conditions has a practical bearing. There have\\nbeen found the staphylococcus pyogenes aureus, the pneu-\\nmococcus of Friedlander, the streptococcus, the diplococ-\\ncus of Frankel-Weichselbaum, diphtheria bacilli, and count-\\nless other bacteria of less importance, and Straus has\\nshown that tubercle bacilli are frequently present in the\\nnoses of healthy individuals living among phthisical patients.\\nBut it is a matter of everyday observation that injuries or\\noperative wounds in the nose usually heal without causing\\nany, or at any rate very little, general disturbance, in spite\\nof the apparent danger from infection which should result\\nfrom the presence of such large numbers of bacteria. The\\nexplanation of this want of virulence on the part of the\\ngerms in the nasal cavities has been sought in a bactericidal\\nquality of the mucous secretions. This was assumed by\\nWurtz and Lermoyez.^ but Thomson and Hewlett found\\nthat the nasal mucus is not directly bactericidal, although\\nit arrests the growth of germs to a certain extent. It is\\nidle, in the absence of exact proofs, to discuss this question\\nof the bactericidal powers of the secretion. The most that\\ncan be said is that it is not a favorable soil, and hinders the\\ndevelopment of the microorganisms more or less. The\\nconditions in this respect are evidently analogous to those\\nfound in the oral cavity, which contains even a greater\\nabundance of bacteria. The mere presence of germs is not\\nin itself injurious to the nose other factors must be taken\\ninto account the number and virulence of the pathogenic\\ngerms which gain entrance the disposition of the individ-\\nual and the presence of other bacteria, which either assist\\nor retard the growth of the pathogenic varieties.\\n2 and 3. Warming and Saturation of the Inspired Air.\\nIt has been proved by the experiments of Aschenbrandt\\nand of R. Kayser,^ that the temperature of the air-current\\nduring its passage through the narrow chambers of the\\nnose is raised to from 25\u00c2\u00b0 to 35\u00c2\u00b0 C, depending on the\\nexternal temperature. It would, however, be wrong to\\nsuppose that this function of the nose is indispensable\\nfor breathing Kayser has shown that the inspired air is\\n1 Ann. des mal. de I oreille, 1893, p. 661.\\n2 Pfliiger s Arcliiv, vol. XI.I.", "height": "3452", "width": "2092", "jp2-path": "rhinologylaryng00frie_0029.jp2"}, "30": {"fulltext": "24 THE RESPIRATORY ORGANS.\\nwarmed only half a degree less in mouth-breathing than\\nin nasal respiration, and that after tracheotomy the trachea\\nand bronchi are quite capable of warming the air to 30\u00c2\u00b0\\nC. the average temperature imparted to it in the nose\\nwithout injury to the lungs. Gaule suggests that the\\nabundant supply of blood-vessels in the nose, and the\\nproperty possessed by them of changing their volume,\\nenable them to adapt themselves more easily to the ther-\\nmic changes of the outside air.\\nA far more important function of the nose is to supply\\nthe necessary moisture to the inspired air a function which\\nthe mouth is unable to perform. The nose thus relieves\\nthe bronchi and lungs of an onerous duty, which falls on\\nthem to a much greater degree if respiration is performed\\nthrough the mouth.\\nTo enable it to supply the required amount of moisture\\nthe nose is endowed with unusual secretory activity. The\\nlatter is derived in part from the abundant supply of serous\\nand mucous glands and from an extensive system of lym-\\nphatics also in part from an irrigation-system, which\\nkeeps the epithelium constantly supplied with the necessary\\namount of moisture. The source of this special system\\nis to be sought, according to Schieffendecker, not in the\\nlymphatic vessels, but in the lymph-spaces of the tissues,\\nthe moisture making its way to the surface through the\\nbasal canaliculi, which pierce the basal membrane and\\nemerge between the epithelial cells.\\n4. In addition to these functions of the nose, there are\\nother protective contrivances of less importance in the\\nupper air=passages, which prevent the entrance of deleteri-\\nous substances into the lungs. Thus, the sense of smell\\nserves to protect the organism by testing the inspired air\\nand guarding the lungs against the entrance of substances\\nwhich can be recognized by their odor. This protection\\nis, after all, a faulty one, as there are many odorless gases\\nwhich are injurious to the lungs and can not be detected in\\nthe inspired air by the sense of smell.\\nIn the physiologic reflexes the body possesses another\\nmeans of ridding itself of coarse particles of matter that\\nhave gained entrance to the nose with the inspiratory air-\\ncurrent, the mucous membrane bringing the sneezing reflex\\ninto action.", "height": "3468", "width": "2076", "jp2-path": "rhinologylaryng00frie_0030.jp2"}, "31": {"fulltext": "PHARYNX AND LARYNX AS RESPIRATORY PATHWAYS. 25\\nIt is thus seen that under normal conditions respiration\\nis effected through the nose, the hps being closed and the\\noral cavity occluded anteriorly and posteriorly by means\\nof the tongue. The latter completely fills the oral cavity\\nduring nasal respiration, its tip being pressed against the\\nupper teeth and the dorsum and edges fitting against the\\npalate and alveolar processes, while the base of the tongue\\narches upward and is closely applied to the soft palate, so\\nthat the oral cavity is hermetically closed and shut off\\nfrom the pharynx.\\nThe question presents itself, whether the mouth is capa-\\nble of supplying the functions of the nose in preparing the\\nair for respiration, or whether mouth-breathing is injurious\\nto the organism and the answer must be that the oral\\ncavity is not in any way adapted to replace the nose in the\\nact of breathing. The width of the oral cavity is such\\nthat the air-current encounters no resistance, and conse-\\nquently its progress is not retarded, as it is in the narrow\\npassages of the nasal cavity, and no time is afforded for\\npurification and saturation. The less abundant vascular\\nsupply and the absence of cavernous tissue (the amount of\\nblood in which is regulated by the external temperature,\\nand thus tends to maintain the required degree of tempera-\\nture in the nose) the absence of an abundant watery secre-\\ntion in the oral cavity the nature of the epithelium in the\\nmouth, which is of the squamous variety, and therefore in-\\ncapable, in contradistinction to the ciliated epithelium in\\nthe nose, of removing automatically any deleterious sub-\\nstances in the air-current all these structural differences\\ncombine to make the mouth unfit to supply an air-current\\nwhich would be other than injurious to the organism.\\nII. Pharynx and Larynx as Respiratory Pathways.\\nWhen the air reaches the pharynx and larynx, after\\npassing through the nose, it has undergone the necessary\\npreparatory changes for its entrance into the lungs, and\\nneeds no further alteration of any moment. If any par-\\nticles of dust enter the larynx with the inspired air, they are\\npromptly expelled by the ciliated columnar epithelium.\\nBut the pharynx and larynx are nevertheless supplied with\\na protective apparatus capable of preventing the passage of\\nforeign bodies in either direction into the postnasal space\\nand the nose, or into the trachea and deeper air-passages\\nand it is called into activitv whenever food is taken, to", "height": "3448", "width": "2084", "jp2-path": "rhinologylaryng00frie_0031.jp2"}, "32": {"fulltext": "26 THE RESPIRATORY ORGANS.\\nguard the air-passages against the invasion of food par-\\nticles. The oral cavity is completely shut off from the\\nrhinopharynx by the application of the soft palate against\\nthe posterior pharyngeal wall, but the larynx is not entirely\\noccluded during deglutition, the bolus of food gliding easily\\ninto the esophagus over the arching dorsum of the tongue\\n(which guards the entrance to the larynx), so that the\\naction of the epiglottis in closing the larynx is not abso-\\nlutely indispensable. If a foreign body, however, does get\\ninto the larynx, the glottis immediately closes,- as it does\\nalways at the slightest touch, and the offending particle is\\nexpelled by coughing.\\nDISEASES OF THE LUNGS DUE TO DISTURBANCES OF THE\\nPHYSIOLOGIC FUNCTION OF THE UPPER AIR-PASSAGES.\\nIn returning from this physiologic digression to the dis-\\ncussion of the influence exerted on the respiratory organs\\nby disease of the upper air-passages, I shall adopt a classi-\\nfication in which the first place is accorded to those diseases\\nof the lung that develop in consequence of disturbances\\nof the function of the upper air-passages.\\nSuch disturbances may arise because the respiratory air-\\ncurrent can not make its way through the nose, so that\\nmouth-breathing becomes necessary. The obstruction may\\nbe situated in the nose or in the postnasal space. Any one\\nof the following conditions may be present, and necessitate\\nmouth-breathing Hyperplasias and tumors in the nose\\nstructural anomalies in the framework of the nose obstruct-\\ning the lumen, caused by deviation of the septum, by\\nridges on its surface, or by abnormal bulging or cystic\\nformations in the muscles occlusion of the posterior\\nnares by tumors in the postnasal space, and especially by\\nadenoid growths on the vault of the pharynx. The evil\\neffects of mouth-breathing first manifest themselves in the\\nmucous lining of the pharynx and larynx, which becomes\\ndry because the air has not been properly prepared and\\nsaturated. Dust particles are deposited first on the mucous\\nmembrane of the mouth and oral pharynx which is cov-\\nered only with squamous epithelium and later make their\\nway into the larynx and deeper air-passages. The con-\\nstant irritation of the dry and unpurified air coming in\\ncontact with the mucous membranes of the upper and lower", "height": "3468", "width": "2084", "jp2-path": "rhinologylaryng00frie_0032.jp2"}, "33": {"fulltext": "DISEASES OF THE LUNGS. 2/\\nair-passages gives rise, as we can easily understand, to\\nchronic catarrhal conditions. Thus it is found that mouth-\\nbreathers, as represented typically by children in the early\\nstages of enlarged tonsils, are prone to become the subjects\\nof catarrh of the upper air-passages, of recurring pharyn-\\ngeal and laryngeal catarrh, and of acute bronchial catarrh\\nwhile if the condition continues, they usually develop\\nchronic bronchitis, which can be permanently cured only\\nby restoring nasal respiration.\\nIn this way we can frequently explain the chronic catarrh\\nwhich is seen almost constantly in children of scrofulous\\nhabit, in whom the hypertrophy of the lymphatic elements in\\nthe postnasal space is followed by occlusion of the posterior\\nnares. Mouth-breathing is, however, not the only pre-\\ncursor of chronic catarrh in the deep air-passages the\\ncondition frequently develops as a sequel to pathologic\\nalterations in the nose itself, provided they are sufficient to\\nrender it unfit to afford the necessary protection to the lungs.\\nIn atrophic conditions of the nose, coupled, as they are,\\nwith metaplasia of the epithelium, foreign bodies contained\\nin the inspired air cling to the walls of the cavities, and\\neventually penetrate into the deep air-passages. In examin-\\ning persons afflicted in this way, whose work obliges them\\nto breathe impure air, a mere inspection of the nose, pharynx,\\nand larynx shows the dust-particles, whether mineral or\\nvegetable, as, for instance, coal-dust and flour, clinging to\\nthe mucous surface, and it is easy to understand that these\\ndust-particles may be carried down with the inspiratory\\nblast and settle in the bronchi. Suchmorbid changes must\\nnecessarily favor the development of the various forms of\\npneumoconiosis, especially anthracosis and chalicosis.\\nDisturbances of the sensibility and of the reflex activity\\nof the pharynx and larynx have an important bearing on the\\nlungs and bronchi, as they facilitate the development of\\ninspiration pneumonia. If there is anesthesia of the pharynx\\nand larynx, and the cough reflex is diminished, it is easy for\\nparticles of food to enter the larynx and when from\\nanesthesia of the larynx the glottis fails to close, and\\nthere is no reflex cough, the offending body readily finds its\\nway into the lower air-passages. Hence an inspiration\\npneumonia frequently complicates nervous affections, which,\\nlike diphtheria, are accompanied with disturbances of sensi-\\nbilitv\\\\ or, like bulbar disease, witli loss of reflexes.", "height": "3456", "width": "2092", "jp2-path": "rhinologylaryng00frie_0033.jp2"}, "34": {"fulltext": "28 THE RESPIRATORY ORGANS.\\nOn the other hand, it is worthy of remark that ulcera-\\ntions and disturbances of mobihty in the epiglottis do not,\\nas a rule, interfere with deglutition, and therefore are not\\nfollowed by inspiration pneumonia. Motor disturbances of\\nthe epiglottis are usually mechanical, being due to inflam-\\nmation and swelling of the member, while ulcerations,\\nwhich may be so great as to destroy the entire organ, usu-\\nally result from syphilitic or tuberculous lesions. When\\neither of these conditions is present, we should naturally\\nexpect that food particles would penetrate into the air-\\npassages, the entrance to the larynx not being sufficiently\\noccluded by the epiglottis. The fact that it does not hap-\\npen is proof that the epiglottis is of no great importance as\\na protection to the larynx, its place being easily filled by\\nthe base of the tongue. If, however, the muscles of the\\ntongue are paralyzed or atrophied, as in progressive bul-\\nbar paralysis, foreign bodies find no difficulty in entering\\nthe deeper air-passages.\\nDISEASES OF THE LUNGS IN MORBID CONDITIONS OF\\nTHE UPPER AIR-PASSAGES.\\nDiseases of the lungs may owe their origin to direct ex-\\ntension of disease of the upper air-passages to the trachea\\nand bronchi. The causes are the same as those we have\\nreferred to in discussing the relations existing between dis-\\neases of the upper air-passages, chronic hypertrophic and\\nchronic atrophic catarrh, and suppurative processes in the\\nnose, in its tributary cavities, and in the postnasal space.\\nChronic bronchitis is the most frequent of the various\\nsequels, and proves very obstinate, especially in cases of\\nchronic suppuration in the tributary cavities of the nose,\\nwhere the pus trickles down from the nasal pharynx into\\nthe deep air-passages and sets up a chronic irritation. The\\nquestion of the relation between chronic catarrh of the\\nupper and of the deeper air-passages has not received the\\nattention it deserves it is barely mentioned in the most\\ngeneral terms in connection with bronchitis, and the pos-\\nsibility of emphysema, bronchiectasis or fetid bronchitis\\nbeing due to such causes is usually ignored. A paper by\\nSticker, 1 in which he establishes a causal relation between\\natrophy, or dry catarrh of the mucous membranes of nose\\n1 Arch. f. klin. Med., vol. LVII.", "height": "3496", "width": "2088", "jp2-path": "rhinologylaryng00frie_0034.jp2"}, "35": {"fulltext": "DISEASES OF THE LUNGS. 2g\\nand pharynx, and similar atrophic conditions in the trachea,\\nbronchi, lungs, and pleura, is therefore worthy of notice.\\nGenuine ozena, or rhinitis foetida atrophica, is an atrophic\\nprocess in the mucous membrane, shared to some extent\\nby the skeleton of the nose, so that the turbinated bones\\nare often entirely destroyed, and the nasal cavity attains\\nenormous dimensions. The atrophy affects the glands and\\nthe erectile tissue, partly destroying both structures, but\\ndoes not extend to the blood-vessels, which, on the con-\\ntrary, according to recent investigators, become dilated.\\nAt the same time the ciliated cylindric epithelium is con-\\nverted into horny squamous epithelium, giving the mucous\\nmembrane a dry, cicatricial appearance, which in the later\\nstages also extends to the pharynx and larynx after the\\natrophic process has reached these parts. The disease\\nis regularly accompanied by the secretion of a tenacious\\nmaterial, which dries, forms crusts, and gives off a\\ncharacteristic penetrating fetor. The discharges make\\ntheir way into the pharynx and larynx, and thence into\\nthe deeper air-passages, where they may set up chronic\\nirritative conditions. Sticker has shown that, aside\\nfrom the fact that diseases of the lungs may be caused\\nby disease of the deeper air-passages secondary to a similar\\nprocess in the nose and postnasal space, there is a general\\ncondition of which the atrophy of the mucous membrane is\\nmerely the superficial expression, and this he has called\\nxerosis of the mucous membranes. This condition event-\\nually leads to a wide-spread and more or less complete\\natrophy of all the mucous membranes in the body, and, as\\nold age comes on, to a progressive increase in the size of\\nthe nasal and postnasal cavities, the larynx, the trachea,\\nthe bronchi, and, finally, the lungs. In cases of marked\\natrophy with ozena of the nose and pharynx experience\\nteaches us to expect not only chronic bronchitis, but also\\nemphysema and asthma-like attacks. If such a condition\\nis met with in elderly persons who have all their lives suf-\\nfered from chronic bronchitis due to ozena, it is readily ex-\\nplained as senile emphysema, or as a secondary emphy-\\nsema, such as may develop gradually in chronic bronchitis.\\nBut how are we to explain such cases of pulmonary em-\\nphysema in young persons, barely twenty years old, with\\nall the symptoms especially dyspnea and cyanosis which\\nare found only in the severest grades of emphysema? I", "height": "3464", "width": "2088", "jp2-path": "rhinologylaryng00frie_0035.jp2"}, "36": {"fulltext": "30 THE RESPIRATORY ORGANS.\\nremember particularly a healthy young farmer, twenty-one\\nyears old, who suffered from severe emphysema, and the\\nonly explanation that could be found was a marked ozena,\\nwhich the patient said he had had for a long time. Great\\nas was the temptation to establish a causal relation between\\nthe two diseases, there did not seem to be sufficient justifi-\\ncation for doing so, if the lung disease was viewed merely\\nas secondary to the disease in the postnasal space. Such\\ncases confirm Sticker s theory of a general xerosis. The\\ntendency of the finer bronchioles to a dry catarrh, leading\\nto simple increased volume (volumen pulmonum acutum)\\nand pulmonary emphysema, is interpreted by Sticker in his\\npreviously mentioned paper, as an expression of the gen-\\neral xerosis which primarily affects both the upper and\\nlower air-passages.\\nBut how does this xerosis originate? Is it a disease,\\nbrought on by external influences, by bacteria, by suppura-\\ntions or excoriations in the nose, which is hidden under the\\ndisguise of what we call genuine ozena? Every one of\\nthe hypotheses that have been advanced to explain the\\noccurrence of atrophic fetid rhinitis must be rejected as in-\\nadequate. All the various causes, from alterations in the\\nepithelium, glands, and blood-vessels to the latest bacterio-\\nlogic discoveries, to which the symptom-complex known as\\nozena has been attributed, while they may possess some\\naccessory importance, are certainly not the primary etio-\\nlogic factors. The production of a fetid secretion with a\\ntendency to crust formation is not peculiar to ozena. Ex-\\nperience teaches that it may occur in any condition in which\\nthe capacity of the nose is increased, whether from destruc-\\ntion of the skeleton or from too severe treatment with the\\ngalvanocautery, or any form of atrophy of the mucous mem-\\nbrane. There is nothing new about Sticker s suggestion of\\nsyphilis as the cause of his mucous membrane xerosis.\\nStork repeatedly emphasized the probability of a causal\\nrelation between ozena and hereditary syphilis but Sticker\\nput the matter in a clearer light when he showed that the\\nconspicuous local alterations in the nose are comparatively\\nunimportant, and that the general xerosis is the primary\\ncondition, corresponding to a postsyphilitic destruction of\\nthe parenchyma, which may, by becoming complicated with\\nchronic catarrh, give rise to ozena with its characteristic\\nsecretion.", "height": "3496", "width": "2088", "jp2-path": "rhinologylaryng00frie_0036.jp2"}, "37": {"fulltext": "ALTERATIONS IN THE UPPER AIR-PASSAGES. 3 I\\nIt is at least worth while to examine this xerosis of the\\nupper and lower air-passages, in order to determine whether\\nchronic bronchitis and emphysema are really due to the\\nsame cause as the disease of the nose and postnasal space.\\nAmong- pathologic curiosities may be mentioned the\\ncases in which corrosive fluids penetrate into the larynx,\\ntrachea, and bronchi. There have also been reported\\ninstances of fibrinous exudations due to vapor of ammonia\\nbeing formed in the nose, pharynx, larynx, trachea, and\\neven in the finest bronchioles (Hoffmann). Phthisical patients\\nwho had been treated for a long time with local applica-\\ntions of lactic acid on account of tuberculosis of the\\nlarynx have been known to expectorate ribbon-like shreds\\nof mucus from the trachea and bronchi.\\nScleroma of the upper air-passages which, as Schrotter\\nand Baurowicz had occasion to observe, extends to the\\nbronchi and leads to stenosis, is a very rare condition, at\\nleast in this country. Schrotter s patient died of maras-\\nmus and fetid bronchitis Baurowicz s, of asphyxia brought\\non by stenosis of the bronchi.\\nALTERATIONS IN THE UPPER AIR-PASSAGES IN DISEASES\\nOF THE LUNGS.\\nThe most important alterations in the upper air-passages\\noccurring in the course of the various diseases of the lungs\\nare those which are due to the irritation of the mucous\\nmembranes by the passage of the secretions. Any chronic\\ndisease of the lungs in which sputum is secreted is followed\\nsooner or later by chronic laryngeal and pharyngeal\\ncatarrh, the intensity of which is in direct proportion to\\nthe amount and consistency of the expectorated material\\nand to the amount of effort required to effect its expulsion.\\nHence, asthmatic and emphysematous patients, whose\\nbronchi are filled with tenacious sputum which requires\\nsevere coughing and straining to remove, suffer more from\\ninflammatory conditions of the upper air-passages than do\\nthose who have a simple bronchitis with watery secretions,\\nwhich they can expel without straining the muscles of the\\nneck and throat.\\nF. A. Hoffmann, Die Krankh. der Bronchien, in Nothnagel s\\nSpec. Path. u. Therap., p. 135.\\nMon. f. Olir. 1895, p. 149 et seq.\\nArch. f. Laryng. iv, p. 99.", "height": "3448", "width": "2092", "jp2-path": "rhinologylaryng00frie_0037.jp2"}, "38": {"fulltext": "32 THE RESPIRATORY ORGANS.\\nA form of ascending catarrh of the air-passages has\\nbeen described, beginning with bronchitis and terminating\\nin acute larjmgitis and pharyngitis. Emphysematous in-\\ndividuals suffer from congestive catarrh, and are prone to\\nhave hemorrhages.\\nAccording to Heinze and Landgraf,^ croupous pneu-\\nmonia is sometimes followed by laryngeal complications.\\nAmong fifty cases of laryngeal ulceration, Heinze found one\\nin which the vocal cords were ulcerated in the course of\\ncroupous pneumonia, and he states that the ulcerations were\\nnot tuberculous. Landgraf analyzed eighty cases of croupous\\npneumonia, and found two cases of ulceration in the larynx.\\nIn both cases the primary disease was severe, one being a\\nbilious form and the other being accompanied by severe\\nsensory phenomena, and he attributes the ulcers to the\\ndyspnea, interpreting them as decubital ulcers analogous\\nto t} phoid ulcers The closure of the glottis which\\nprecedes the cough in other words, the pressure on the\\nvocal processes and free borders of the vocal cords led to\\nthe formation of ulcers in these situations.\\nThe most frequent complications of lung diseases in the\\nlarynx consist in paralysis, the occurrence of which after\\ndisease of the lungs and pleura is explained by the course\\nof the recurrent larjmgeal nerve. The plications which\\nform in the pleura over the apices in chronic inflammations\\nare very apt to include the nerve, especially on the right\\nside, where such a complication is favored by the relation of\\nthe nerve to the subclavian artery and, on the other hand,\\nindurations of the apex may during cicatrization exert\\ntraction on the nerve. Paralyses of the right or left\\nrecurrent are most frequent in chronic indurative pleuritis,\\nand produce permanent alterations in an acute left pleuritis.\\nSchrotter once observed a paralysis, which disappeared\\nafter ten days, and infers that it was a case of inflamma-\\ntory edematous infiltration of the pleura. Paralysis rarely\\ndevelops in pleural exudations. Moeser claims to have\\nobserved that patients with pleural exudations, particu-\\nlarly when there is a copious effusion of fluid, and oftener\\nDie Kehlkopfschwindsucht, p. 87.\\n2 Charile Ann.. xil, p. 244 et seq.\\n3 Comp. Gerhardt, Virch. Arch., xxvn, p. 76.\\nDie Krankheiten des Kehlkopfes, p. 414.\\n5 Arch. f. klin. Med., XXXVII, p. 570 et seq.", "height": "3496", "width": "2092", "jp2-path": "rhinologylaryng00frie_0038.jp2"}, "39": {"fulltext": "ALTERATIONS IN THE UPPER AIR-PASSAGES. 33\\non the right than on the left side, present peculiar motor\\ndisturbances of the vocal cord on the corresponding side,\\nwhich almost always consisted in diminished power of\\nabduction but his observations are not sufficiently con-\\nvincing, and do not present the typical picture of a pro-\\nnounced paralysis of the recurrent. Nor is there more\\nplausibility in the attempts to explain a paralysis occurring\\nin a left pleural effusion by the downward displacement of\\nthe heart exerting direct traction on the aorta and the\\nrecurrent nerve or one occurring in a right effusion by the\\ndisplacement of the heart to the left and the consequent\\ntraction on the vessels of the right side, especially the\\nsubclavian artery and the recurrent nerve which winds\\naround it.\\nChronic conditions in the apex of the right lung such\\nas tuberculous consolidation or chronic induration from the\\ninhalation of dust may produce recurrent paralysis.\\nCompared to the great frequency of pulmonary tubercu-\\nlosis, paralysis due to this condition is exceedingly rare,\\nJurasy saw only three cases, which he did not describe in\\ndetail, and the diagnosis can not even be established with\\nabsolute certainty during life, for, as will be described later,\\nthe nerve may be pressed upon by swollen lymph-glands\\nwithin the thorax. The same is true of recurrent par-\\nalysis in anthracosis, examples of which are found in cases\\nof Baumler and Kohn,^ in which the cause of the par-\\nalysis turned out to be an adhesion of the recurrent nerve\\nto an indurated, deeply pigmented and contracted bron-\\nchial gland.\\nALTERATIONS IN THE UPPER AIR-PASSAGES IN DISEASES\\nOF THE MEDIASTINUM.\\nBefore closing the section on the respiratory organs,\\nmention should be made of alterations due to disease in the\\nmediastinum and changes in the thyroid gland.\\nThe inferior laryngeal nerves traverse the mediastinum,\\nand are, therefore, exposed to injuiy from disease in that\\nlocality.\\nIn the case of mediastinal tumors the left nerve, on ac-\\n1 Krankh. der ob. Luftwege, p. 476.\\n2 Comp. Baumler, Arch. f. klin. Med., xxxvn, p. 231 et seq.\\nMiinch. med. Wochen., 1895, P- ^^Z^-\\n3", "height": "3424", "width": "2116", "jp2-path": "rhinologylaryng00frie_0039.jp2"}, "40": {"fulltext": "34 THE RESPIRATORY ORGANS.\\ncount of its position in the lowest part of the mediastinum,\\nis most apt to be included within the growth. But it also\\nhappens, as in Michael s case/ that in spite of its more\\nsuperficial course the right recurrent nerve becomes em-\\nbedded in the tumor.\\nParalysis of the inferior laryngeal nerves may follow dis-\\nease of the bronchial lymph-glands, and of the glands be-\\nlonging to the group oi ganglions tracJieo-lath-aiix (Barety),^\\ndesignated as ganglions peiitracheo-laryngiens by Gougen-\\nheim and Leval Picquechef,^ which occupy the groove be-\\ntween the trachea and the esophagus, and therefore come\\ninto close relation with the recurrent nerve, which emerges\\nfrom the mediastinum in the same situation on each side of\\nthe body. 4\\nThese glands often become enlarged in scrofulous chil-\\ndren after bronchopneumonia and other forms of chronic\\npulmonary catarrh they are also found to be enlarged in\\ntuberculosis and in melanotic degeneration. An example\\nof the latter has recently been mentioned in Baumler s case,\\nwhile the literature of tuberculosis of the bronchial glands\\nhas lately been worked up by Fronz.^ If suppuration\\ntake place in the glands, the abscess sometimes ruptures\\ninto the trachea, and the pus is evacuated into the larynx,\\nas observed by Massei in several cases.\\nBesides pressing on the nerve-trunk, mediastinal tumors\\nmay push the larynx to one side or the other and compress\\nthe trachea. Such a stenosis from compression of the walls\\nis sometimes seen in the trachea with the laryngoscope\\nrotation of the trachea and larynx may take place, so that\\nthe glottis appears oblique in the laryngoscopic image.\\nStruma is a more frequent cause of tracheal stenosis than\\nmediastinal tumor, a large percentage of all stenoses being\\ndue to goiter. Rosenberg found that out of fifty-four\\ncases of tracheal stenosis, thirty-eight were caused by\\nstruma.\\nThe occurrence of vocal cord paralysis in struma de-\\n1 Die med. Wochen., 1895, No. 25.\\n2 Comp. F. A. Hoffmann, Erkrankungen des Mediastinum, 1896, p. 30.\\n3 Ann. des mal. de roreille, etc., 1884.\\nAn excellent illustration of these anatomic relations is found in Gougen-\\nheim Glover s Atlas of Laryngology, I, xix.\\n5 Jahrb. f. Kinderheilk., vol. XLIV.\\nRev. de lar., d ot et de rhin., 1897, No. 7.\\nHeymann, Handb. der Laryng., i, p. 568.", "height": "3496", "width": "2108", "jp2-path": "rhinologylaryng00frie_0040.jp2"}, "41": {"fulltext": "THE AIR- PASSAGES AND THE EARS. 35\\npends more on the position than on the bulk of the enlarge-\\nment if the lateral lobes are affected, pressure is exerted\\non the nerves, and paralysis frequently results.\\nAmong the structures in the mediastinum which may\\naffect respiration unfavorably the thymus gland must also\\nbe mentioned. In recent times, cases of sudden death in\\nchildren have been attributed to hyperplasia of the thymus,\\njust as the inspiratory stridor of the new-born is now gen-\\nerally acknowledged to be referable to the same cause.\\nSiegel 2 and Avellis have contributed valuable descrip-\\ntions of the clinical picture presented, supplemented with\\nfull histories of the cases.\\nA signal proof of the relation between inspiratory stridor\\nand enlarged thymus is afforded by Rehn s case, reported\\nby Siegel, and by a case operated on by Konig, in which\\nrecovery was brought about by exposing the gland, after\\nresection of the sternum, and fixing it to the cervical fascia\\nin one case, and by extirpating a part of the gland in the\\nother. In the typical case there is labored, groaning res-\\npiration, not occurring in paroxysms but persistent the\\ndyspnea sometimes amounts to violent choking fits with\\ncyanosis, so that the affection (which is also called asthma\\nthymicum) has often been erroneously described as laryn-\\ngismus stridulus. Since the clinical feature is not a spasm\\nof the vocal cords, but a compression of the trachea and\\nbronchi, the term inspiratory stridor is the most scientific,\\nand should be applied at least to cases in which the diag-\\nnosis of a thymic origin for the dyspnea is not quite clear.\\nThis compression, as M. Schmidt observed in a woman,\\ntwenty-five years old, who had suffered from inspiratory\\nstridor during infancy, may be permanent.\\n3. RELATIONS BETWEEN THE UPPER AIR-\\nPASSAGES AND THE EARS.\\nThe interdependence of the upper air-passages and the\\nears depends, in the majority of cases, on the communica-\\ntion established by the Eustachian tubes, which open into\\n1 Avellis, Arch. f. Laryng., vni, p. 159.\\n2 Berlin klin. Wochen., 1896, No. 40.\\n3 Miinch. med. Wochen., 1898, Nos. 30 and 31.\\nCited by Avellis.", "height": "3464", "width": "2108", "jp2-path": "rhinologylaryng00frie_0041.jp2"}, "42": {"fulltext": "36 THE RESPIRATORY ORGANS.\\nthe lateral walls of the pharynx, and their function in con-\\nnection with the middle ear. Hence, to understand the\\nmechanism of secondary ear affections, when the primary\\ndisease focus is in the upper air-passages, the following\\npoints, which will later be described more in detail, must\\nbe borne in mind.\\nThe Eustachian tube ventilates the middle ear, and\\nregulates the tension by equalizing the differences that may\\narise between the atmospheric pressure on the tympanic\\nmembrane in the external meatus and in the postnasal space,\\nand the pressure of the air imprisoned in the middle ear.\\nWhenever the equilibrium is disturbed, auditoiy disturb-\\nances result, which have their seat in the tympanic mem-\\nbrane and in the sound-conducting apparatus.\\nSuch disturbances may follow disease in the upper air-\\npassages, obstructing or occluding the pharyngeal orifice, or\\ninterfering with the action of the palatal muscles which\\neffect the opening and closing of the tube.\\nThe Eustachian tube represents the path by which disease\\nof the pharyngeal vault spreads by continuity to the\\nmiddle ear the mucous membrane of the tube becomes\\ninvolved in any disease affecting the mucous membrane of\\nthe nose and pharynx or, in other words, the tube repre-\\nsents the channel through which infection reaches the mid-\\ndle ear from the upper air-passages.\\nTHE EFFECT OF DISTURBANCES OF THE NORMAL FUNC-\\nTION OF THE EUSTACHIAN TUBE.\\nFor the proper comprehension of this relation a few in-\\ntroductory remarks are required to explain the mechanism\\nby which the normal tube neutralizes the variations in pres-\\nsure of the atmospheric air in the middle ear. The tube does\\nnot keep up a constant communication between the two air-\\nchambers that of the pharynx and that of the middle ear.\\nIn the state of rest its pharyngeal extremity remains closed,\\nand is opened only when the muscles of the palate and\\npharynx, which are devoted to its service, are brought into\\naction. As the opening of the tube is effected by the tensor\\nveli and levator veli muscles, the pharyngeal orifice must be\\nopened whenever these muscles contract, which happens\\n1 Hammerschlag, in Wien. med. Wochen., 1896, Nos. 39 and 40,\\nmakes the assertion that the tube is normally open.", "height": "3496", "width": "2100", "jp2-path": "rhinologylaryng00frie_0042.jp2"}, "43": {"fulltext": "DISTURBANCES OF THE EUSTACHIAN TUBE. 37\\nregularly and frequently, accompanying the act of deglu-\\ntition. The opening of the tube is, therefore, under the\\ncontrol of the will power, and we can equalize any disturb-\\nances of the pressure equilibrium by the simple act of\\nswallowing, which establishes a communication between the\\npostnasal space and the middle ear, through the opened\\ntube. We instinctively take advantage of this phenomenon\\nwhenever a change in the atmospheric pressure takes place,\\nas in climbing high mountains, during explosions and loud\\ndetonations, and, artificially, for therapeutic purposes, by\\nmeans of pneumatic chambers.\\nWhat, then, is the result if the tube fails to maintain the\\nequilibrium What happens when the pressure is greater\\nin the pharynx than in the middle ear, either because the\\npressure of the outside air has been raised or because the\\npressure of the air in the middle ear has been lowered\\nValsalva s experiment, which consists in artificially rais-\\ning the air pressure in the postnasal space by making a\\nforced expiration with the nose held shut, when the pharyn-\\ngeal orifice of the tube is forcibly opened and the air escapes\\ninto the middle ear, would appear to indicate that the\\norifice opens automatically whenever the pressure in the\\npharynx is even slightly increased. This is not the case,\\nhowever. On the contrary, a rise in the atmospheric pres-\\nsure has the efifect of closing the tube tighter than ever, for\\nwe know from practical as well as experimental observation\\nthat increased pressure in the pharynx brings the mem-\\nbranous wall of the tube into closer apposition with the\\ncartilage, thus forming a kind of valve, which shuts the\\ncanal off from the middle ear. The closure effected in this\\nway may be so obstinate that an ordinary act of swallowing\\nis unable to overcome it.\\nA rise of pressure takes place regularly in the pharynx,\\nindependently of changes in the atmospheric pressure, when-\\never the tube remains closed for any length of time, and the\\nair imprisoned in the cavities of the tympanum undergoes\\nrarefaction.\\nIt follozvs, therefore, that a fall in the tympanic pressjire\\noccurs in all diseases in which the pharyngeal orifice of the\\nEustacliian tube is occluded. In explanation of this phe-\\nnomenon we can not do better than quote the words of\\nBezold :i In the middle ear, as in all vascular, air-con-\\n1 Berl. klin. Wochen., 1883, No. 36.", "height": "3464", "width": "2116", "jp2-path": "rhinologylaryng00frie_0043.jp2"}, "44": {"fulltext": "38 THE RESPIRATORY ORGANS.\\ntaining cavities, the volume of air diminishes whenever free\\ncommunication with the atmosphere is interrupted, because\\nthe oxygen enters into chemic combination with the blood\\nand the amount of CO2 given up is not enough to compen-\\nsate for the loss in volume.\\nThese pressure variations give rise to a series of clinical\\npictures which are included under the general term of\\nacute or chronic middle-ear catarrh, and hav^e as their most\\nprominent symptom retraction of the tympanic membrane\\na purely mechanical result of the increased pressure in\\nthe external auditory meatus. In the otoscopic image\\nthis abnormal position and the curvature of the tympanic\\nmembrane find their expression in the absence of the cone\\nof light from its normal situation in the presence of irreg-\\nular reflexes in displacement of the handle of the malleo-\\nlus, which assumes a more horizontal position, or eventually\\neven disappears behind the posterior fold and, finally, in\\na marked projection of the short process and handle of the\\nmalleolus from the retracted membrane. The subjective\\nsymptoms are diminished auditory acuity and tinnitus\\naurium occasionally the patient complains of pain. The\\nquestion whether the occasional occurrence of exudation in\\nconditions of diminished tympanic pressure is due solely to\\nhypcrcEinia ex vacuo can not be answered in the affirmative\\nin every case. Although the possibility of such an origin\\ndeserves consideration, the fact that JiypercEinia ex vacuo\\nis not by any means a regular accompaniment of occlusion\\nof the tube is sufficient proof that other factors must also\\nbe operative to produce an effusion, and it is safe to assume\\nthe occurrence of an irritative inflammation of the mucous\\nmembrane. The idea of hydrops ex vacuo is therefore limited\\nin its application, and must in many cases give way to the\\ntheor}^ of an inflammatory exudate. This view is con-\\nfirmed by clinical experience, since it is found that chronic\\nocclusion of the tube, which produces the greatest dimin-\\nution of density, is not, as a rule, followed by exudation.\\nOn the other hand, in almost all cases of occlusion oc-\\ncurring after acute inflammations an exudate is formed\\nwhich betrays its inflammatory nature in the otoscopic\\nimage by a simultaneous swelling and congestion of the\\ndeeper layers of the membrana tympani, and can be ascribed\\nonly to inflammatory swelling of the mucous membrane of\\nthe middle ear, with secondarv extension to the mucosa of", "height": "3496", "width": "2088", "jp2-path": "rhinologylaryng00frie_0044.jp2"}, "45": {"fulltext": "DISTURBANCES OF THE EUSTACHIAN TUBE. 39\\nthe membrana tympani. It follows, therefore, that the\\nexudate is as much a symptom of middle-ear inflammation,\\nor the time-honored otitis media catarrhalis, as of oc-\\nclusion of the Eustachian tube. The results of bacterio-\\nlogic investigations of this condition are not uniform enough\\nto throw much light on the subject. Kanthack i found a\\ngreat variety of pathogenic organisms in exudations follow-\\ning occlusion of the tube, while Scheibe and Brieger\\ndeny the presence of these organisms, and consider the\\nexudate ex vacuo sterile hence we are not as yet jus-\\ntified either in adducing the finding of microorganisms as\\nproof of the inflammatory character of the exudate, or in\\ndenying it on the strength of a negative bacteriologic result.\\nThere is also a possibility of the pressure equilibrium\\nbeing disturbed by an excess of pressure in the middle ear,\\nmost frequently due to a fall in the atmospheric pressure.\\nIts pathologic significance is slight compared to the oppo-\\nsite condition. The rise in pressure is readily equalized by\\nthe tube, because, as previously described, there is no occlu-\\nsion of the pharyngeal orifice by the air pressure, and the\\nequilibrium is therefore easily restored by the act of deglu-\\ntition. Hence a gradual fall in pressure, such as is ex-\\nperienced in balloon ascensions and in mountain climbing,\\nis easily borne, because the excess of pressure which at\\nfirst occurs in the middle ear soon accommodates itself to\\nthe surrounding conditions. On the other hand, when the\\nexternal pressure is suddenly removed, the excessive pres-\\nsure in the middle ear is very apt to produce disturbances\\nin the auditory organs by rupture of the membrana tym-\\npani. This is apt to occur when men are released from a\\ncaisson without the necessary precautions. Sudden rise of\\npressure in the middle ear is sometimes produced by blow-\\ning the nose, if the pharyngeal orifice is forcibly opened by\\na sudden increase in pressure in the postnasal space, allow-\\ning the air to escape through the tube. It is particularly in\\ncases of nasal obstruction, when the expiratory blast can not\\nescape and becomes imprisoned in the postnasal space, that\\nviolent blowing of the nose is apt to be followed by serious\\nconsequences in the ear, by producing hemorrhages or\\nrupture of the membrane, especially if the latter is diseased\\nor atrophic.\\n1 Zeitschr. f. Ohr., XXI. 2 Zeitschr. f. Ohr., xxiii.\\n3 Deitr. z. Ohrenheilk., p. 59.", "height": "3464", "width": "2108", "jp2-path": "rhinologylaryng00frie_0045.jp2"}, "46": {"fulltext": "40 THE RESPIRATORY ORGANS.\\nIt is still an open question whether the tinnitus aurium\\nwhich occasionally occurs in gradual changes of the\\nexternal air pressure originates within the organ of hearing,\\nor whether it is due to other causes. The subjective noises\\nheard during balloon ascensions and mountain climbing are\\nnaturally attributed to the variations in pressure between the\\nmiddle ear and the external air. But if we study the\\nclinical picture of so-called mountain sickness, we are\\nstruck with the predominance of the circulatory phenomena,\\nthe markedly accelerated pulse, the dyspnea, and local\\nsymptoms of flashes and subjective noises in the ears we\\nare irresistibly led to attribute the ocular and aural\\nphenomena to the vascular disturbances, and not to alter-\\nations of the special sense organs.\\nIt may be well in this connection to call attention to the\\nfact that similar phenomena, though somewhat milder in\\ncharacter, occur in the treatment of heart and lung diseases\\nwith rarefied and compressed air, when the patients are\\nentering or leaving the pneumatic chamber. A certain\\ndegree of caution is therefore advisable in the case of in-\\ndividuals whose hearing is not quite perfect, especially\\nsuch as are troubled with tinnitus aurium.\\nSchwartze s observation that many persons with\\nincurable middle-ear sclerosis experience relief during a\\nprotracted stay in high Alpine health resorts, on account of\\ntheir freedom from the distressing tinnitus aurium, and the\\nmarked improvement in the hearing has not been ex-\\nplained. But is it not permissible to assume that the aural\\nsymptoms are due to circulatory disturbances For if the\\ntinnitus is really a vascular murmur within the ear, would\\nit not be relieved by the beneficial effect of the altitude on\\nthe heart?\\nDISTURBANCES OF THE FUNCTION OF THE EUSTACHIAN\\nTUBE DUE TO ALTERATIONS IN THE UPPER\\nAIR-PASSAGES.\\nThe diseases of the upper air-passages that diminish the\\npermeability of the tubes are principally those which are\\naccompanied by swelling of the mucous membrane. The\\nrelation existing between the nose and the postnasal space\\nis a very intimate one, and very few diseases have their\\n1 Die chirurg. Erkr. des Ohres, p. 169.", "height": "3492", "width": "2068", "jp2-path": "rhinologylaryng00frie_0046.jp2"}, "47": {"fulltext": "DISTURBANCES OF THE EUSTACHIAN TUBE. 4 1\\norigin and exclusive seat in the postnasal space without in-\\nvolving the nose. The great majority of pharyngeal\\ndiseases arise, as we have already stated, by extension from\\nthe nose, so that the importance of rhinology in the study\\nof diseases of the ear is easily explained.\\nAny acute catmn^Ji in the upper air-passages may lead to\\nintumescence and occlusion of the pharyngeal orifice, and\\nthereby produce a fall in the pressure of the middle ear.\\nAs soon as the swelling subsides and the tube again\\nbecomes patulous, the morbid symptoms usually disappear\\nwithout treatment. In chronic catarrh, on the other hand,\\nas the hypertrophy of the mucous membrane does not, like\\nthe hyperemia in acute catarrh, tend to disappear sponta-\\nneously, the changes produced in the middle ear by occlu-\\nsion of the tube are of a more lasting character. The\\ncontinued tension of the membrana tympani leads to\\natrophy, and the persistent retraction disturbs the normal\\nrelation of the ossicles, which then exert a constant pressure\\non the fenestra ovalis.\\nIt is fair to assume that, in consequence, the muscles of\\nthe ossicles the tensor tympani and the stapedius are\\nthrown into a state of permanent contraction, and probably\\natrophy from disuse while, as a result of the hypercBinia ex\\nvacuo, a chronic inflammation of the mucous membrane of\\nthe tympanum develops, giving rise to morbid conditions\\nwhich can not be distinguished clinically from catarrh of the\\nmiddle ear due to other causes. These conditions are in\\ngreat need of anatomic and clinical investigation in fact, the\\nconcept of middle-ear disturbance by occlusion or obstruc-\\ntion of the tube has never been clearly differentiated from\\nthe idea of inflammatory middle-ear catarrh, and the various\\nviews advanced in the text-books descriptive of middle-ear\\ncatarrh of inflammatory and noninflammatory origin merely\\nadd to the confusion.\\nAny and all diseases of the nose and postnasal space\\nwhich are followed by obstruction of the nasal passages lead\\nto passive hyperemia in the mucous membranes, which in\\nturn produces occlusion of the Eustachian canal. The\\nrecognition of this important fact is comparatively recent,\\nand since the causal relation between these disturbances and\\nthe interference with nasal respiration by the presence of\\nadenoid growths was definitely established the attention of\\nclinicians has been directed to tlie significance of nasal", "height": "3424", "width": "2100", "jp2-path": "rhinologylaryng00frie_0047.jp2"}, "48": {"fulltext": "42 THE RESPIRATORY ORGANS.\\nStenoses in occlusions of the Eustachian tube. The inter-\\nference with nasal breathing may be due to a number of\\nconditions within the nose, as hypertrophy of the mucous\\nmembrane, mucous polypi, tumors, syphilitic or tuberculous\\ninfiltrations, foreign bodies, etc. There may be a congeni-\\ntal narrowing of the nasal cavity from deformity, and hy-\\nperplasia of the septum or abnormal curvature of the tur-\\nbinated bones. The obstruction may be situated in the\\npostnasal space, and may take the form of hypertrophied\\npharyngeal tonsils, tumors, syphilis, or tuberculosis occlud-\\ning the posterior nares. Hence the recognition and re-\\nmoval of any obstacle to nasal respiration should constitute\\nan integral part of every examination and treatment of the\\nears. There can be no hope of curing the ear affection be-\\nfore the causes which are responsible for the congestion of\\nthe mucous membrane have been removed and the permea-\\nbility of the tube has been restored.\\nIf I have included hypertrophy of tlie pharyngeal tonsils or\\nadenoid vegetations among the diseases which produce hy-\\nperemia and swelling of the mucous membrane, with occlu-\\nsion of the tube by interfering with nasal respiration, it is\\nbecause I believe the occlusion is due to a general adenoid\\nhabit of the nose and pharynx, rather than to the direct\\nmechanical intrusion of the pharyngeal tonsil. The ade-\\nnoid habit manifests itself in the rhinoscopic image as a\\nhyperplasia of the entire lymphatic ring of Waldeyer the\\nfollicles in the posterior pharyngeal wall and in the longitu-\\ndinal folds on each side of the pharynx are more numerous,\\nand are intensely red and swollen. Hyperplasia of Rosen-\\nmiiller s crypts and of the anterior fold of the tube may\\ndevelop as the manifestation of a general hyperplasia of all\\nthe lymphatic elements entering into the formation of the\\nso-called pharyngeal lymphatic ring hyperplasia of these\\nstructures necessarily favors the occlusion of the tube by\\ncompressing the orifice.\\nTwo forms of adenoid enlargement are distinguished a\\ndiffuse, cushion-like hyperplasia, and a villous variety con-\\nsisting of finger-like projections or true vegetations. Their\\nusual seat is the roof and upper portion of the posterior\\nwall of the pharynx, so that they fill the upper part of the\\npostnasal space more or less completely, and whenever they\\nhang down below the level of the upper margin of the\\nposterior nares, the latter are obstructed and nasal breath-", "height": "3496", "width": "2092", "jp2-path": "rhinologylaryng00frie_0048.jp2"}, "49": {"fulltext": "DISEASES OF THE MIDDLE EAR. 43\\ning is interfered with. As the vegetations usually spring\\nfrom the median line, they are not, when at rest, in contact\\nwith the lateral walls of the pharynx and therefore do not\\nocclude the orifices, as we are frequently able to demon-\\nstrate in the postrhinoscopic image but whenever the\\npalatal and pharyngeal muscles contract, as in swallow-\\ning, retching, and similar movements, the lumen of the\\npostnasal space is constricted and the enlarged growths are\\nforced against the lateral walls of the pharynx, thus giving\\nrise to periodic occlusion of the tube. The adenoid tissue\\nis not the soft, gelatinous mass that it is sometimes com-\\npared to, but is comparatively firm, and returns to its\\nnormal position of rest, dependent on gravity, as soon as\\nthe constrictors of the pharynx and the tensores and leva-\\ntores palati relax and the postnasal cavity regains its normal\\nvolume. But it is not clear to me how a momentary occlu-\\nsion of the orifice can have the same effect as a permanent\\none, and I therefore consider the hyperemia of the entire\\nmucous membrane the most important factor in the produc-\\ntion of aural complications.\\nParalysis of the muscles of the soft palate, especially of\\nthe levator veli palatini and tensor veli palatini, muscles\\nwhich effect the opening of the Eustachian tube, is fol-\\nlowed by permanent occlusion, with the usual appearances\\nof the membrana tympani. The action of the muscles may\\nbe similarly affected by tumors, by syphilitic, tubercular, or\\nother kinds of ulcerations or their scars, and by cleft palate,\\nso that these conditions are also occasionally accompanied\\nby middle-ear disease.\\nDISEASES OF THE MIDDLE EAR DUE TO INFECTION\\nFROM THE POSTNASAL SPACE.\\nThe cartilaginous portion of the Eustachian tube is lined\\nwith ciliated columnar epithelium, the ciliary current being\\ndirected toward the pharynx, which is replaced at the isth-\\nmus by cells of the same type as that of the middle ear.\\nSince, therefore, the mucous membrane of the tube is a\\ndirect continuation of the epithelium of the postnasal space,\\nwe can readily understand that an inflammatory process\\nbeginning in the latter is not arrested at the pharyngeal\\norifice, but is continued into the tube itself, and may be\\nfollowed by acute inflammation of the mucous membrane", "height": "3456", "width": "2076", "jp2-path": "rhinologylaryng00frie_0049.jp2"}, "50": {"fulltext": "44 THE RESPIRATORY ORGANS.\\nof the middle ear. Next to acute rhinitis and pharyngitis,\\nthe most important inflammations in the etiology of otitis\\nmedia are those which occur in the aaite exanthemata.\\nThese will be discussed elsewhere.\\nIn addition to the ordinary inflammations of the mucous\\nmembrane of the tube and middle ear, we observe acute\\nsuppurative otitis media in the train of acute nasal and phar-\\nyngeal diseases. As we may have either a simple or a\\nsuppurative inflammation without any apparent external\\nreason, we are forced to assume a different behavior of the\\nmucous membrane of the middle ear in regard to the in-\\nvading pathogenic germs to explain the occurrence of sup-\\npuration in the middle ear through the channel of the\\nEustachian tube.\\nIt is well known, as has been mentioned, that the nose and\\npostnasal space harbor a multitude of microorganisms.\\nTheir presence in the healthy organism appears to have no\\nsignificance, perhaps because of a bactericidal property of\\nthe mucous secretion which destroys the virulence of the\\npathogenic germs and prevents their further development.\\nIt may also be assumed and has, in fact, been practically\\ndemonstrated experimentally by Zaufal, Kanthack, Scheibe,\\nand others, in spite of the differences in the individual\\nresults that the middle ear normally contains bacteria\\nwhich may, under favoring circumstances, regain their vir-\\nulence.\\nThe number of bacteria in the middle ear and the liability\\nof the organ to infection depend on the condition of the epi-\\nthelium lining the tube and the size of the lumen. If the\\nciliated epithelium is intact, it enables the tube to rid itself\\nof any deleterious substances, and thus forms a protection\\nagainst invasions from the pharynx. Since any inflamma-\\ntory alterations, be they acute or chronic, which destroy the\\nintegrity of the epithelium tend to remove this natural pro-\\ntection, they will naturally be accompanied by inflamma-\\ntion and suppuration in the middle ear.\\nThe question whether abnormal dilatations of the tube\\nmay produce pathologic conditions in the ear by affording\\nan easier entrance to pathogenic germs deserves passing\\nmention.\\nIn catheterization of the tube the nature of the blowing\\nnoise, and the strength of the concussion-note afford a clue\\nto the size of the lumen. But, in addition to this, other", "height": "3468", "width": "2084", "jp2-path": "rhinologylaryng00frie_0050.jp2"}, "51": {"fulltext": "DISEASES OF THE MIDDLE EAR. 45\\nsigns have been noted, depending on the respiration, which\\npoint to abnormal dilatation and permanent patulousness of\\nthe tube.\\nRespiratory movements have been observed in the tympanic\\nmembrane by Lucae,i Schwartze,^ Wagenhauser, and\\nOstmann the membrane retracts during inspiration and\\nbulges toward the external meatus in expiration. These\\nobservations were, however, always made on atrophic or\\ncicatricially contracted membranes, which respond to a\\nmuch slighter pressure than would a tense healthy mem-\\nbrane. According to Ostmann, it is sometimes possible,\\nwith the aid of a tube inserted into the external meatus, to\\nhear an inspiratory and expiratory murmur, even in healthy\\nindividuals during quiet nasal respiration. Finally, Lucae s\\nmanometric experiments called attention to the occurrence\\no^ pressure valuations in the external auditory meatus synchro-\\nnous with the respiratory movements. Ostmann, it is true,\\nobtained varying results when he tried the same experiments;\\nalthough he observed a constant variation of about of a\\nmm., synchronous with the pulse-beat, he could not demon-\\nstrate a constant coincidence with the respiratory move-\\nments.\\nThe first-mentioned phenomenon respiratory move-\\nments of the tympanic membrane is undoubtedly to be\\nattributed to abnormal dilatation and permanent patulous-\\nness of the tube, while the second is of no value in the\\ndiagnosis of these conditions.\\nAbnormal dilatation of the tube is practically a constant\\nfeature of atrophic catarrh of the nose and pharynx,\\nrhinitis foetida atrophica, and these conditions are regularly\\naccompanied by disease of the middle ear, either in the\\nform of sclerosis of the middle ear or chronic suppurative\\notitis media.\\nSclerosis occurring in atrophic rhinitis is caused by a\\ndisease of the mucous membrane analogous to the dry\\ncatarrh of the upper air-passages. The histologic changes\\nin otitis media sclerotica closely resemble those of xero-\\nsis of the mucous membranes of the upper air-passages\\n(Sticker), so that the middle-ear affection must be interpreted\\nas a process analogous to atrophic rhinitis and pharyngitis.\\nThis was pointed out several years ago by Abel, when he\\n1 Arch. f. Ohr., vol. il. 2 ^rch. f. Ohr., vol. 11\\n3 Arch. f. Ohr., vol. xxi. Arch. f. Ohr., vol. XXXIV.", "height": "3448", "width": "2068", "jp2-path": "rhinologylaryng00frie_0051.jp2"}, "52": {"fulltext": "46 THE RESPIRATORY ORGANS.\\ndemonstrated his bacillus mucosus ozcenae in the middle ear,\\nalthough that discovery seems to me to be of little import-\\nance, in view of the questionable connection between this\\nbacillus and the development of ozena.\\nIt may be said that suppuration in the middle ear is\\nprincipally due to the greater ease with which pathogenic\\ngerms can gain entrance when the tube is dilated, and to\\nmetaplasia of the epithelium.\\nOstmann has called attention to another pathologic\\nchange at the pharyngeal orifice which may produce dilata-\\ntion of the tube. The lateral wall of the tube is provided\\nwith a pad of fat, which normally acts as a natural protec-\\ntion by facilitating the close application of the lateral to the\\nmedian wall and thereby closing the tube. In emaciated\\nindividuals this pad is so much reduced that the tube is not\\nperfectly closed, and there is a greater tendency to infection\\nof the middle ear from the pharynx. Ostmann believes\\nthis to be the explanation of tubercular suppuration in the\\nmiddle ear, which develops in phthisical patients when the\\ngeneral condition is weakened, and in the fourth or fifth\\nweek of typhoid, when the nutrition of the patient is much\\nreduced.\\nFrom a practical standpoint the infection of the middle\\near through the introduction of infectious material into the\\ntubes by therapeutic measures is extremely important. It\\nmay occur by the current of air carrying mucus and pus\\nfrom the nose, postnasal space, or orifice of the tube into\\nthe ear during the performance of Valsalva s experiment\\nor violent blowing of the nose with the nostrils closed,\\nwhich has the same effect, and in Politzer s method of in-\\nflating the tympanum, which consists in blowing air through\\none side of the nose while the nasopharynx is shut off from\\nthe oral cavity and the anterior nares are closed, so as to\\nraise the air pressure in the postnasal space and force open\\nthe pharyngeal orifice of the Eustachian tube. Another\\ndanger of infection of the middle ear from the pharynx\\narises from the use of nasal douches in hypertrophic\\nconditions of the nasal mucous membrane. As the\\nwater enters the nasal cavities under considerable pressure,\\nand can not escape through the nose on account of the\\nswelling of the membrane, it is dammed up in the postnasal\\nArch. f. Ohr., xxxiv, p. 188, etc.", "height": "3468", "width": "2092", "jp2-path": "rhinologylaryng00frie_0052.jp2"}, "53": {"fulltext": "THE EARS. 47\\nspace, and being under pressure, easily makes its way into\\nthe middle ear. This is, therefore, an example of the im-\\nproper use of the nasal douche, being in violation of the\\nprinciple that the use of a nasal douche with low pressure is\\npermissible only when both sides of the nose are sufficiently\\nopen to allow free access to and egress from the nose. Even\\nwhen this rule is carefully observed there is a possibility of\\nwater reaching the middle ear, if during its passage the\\npatient swallows or chokes, or performs a similar act which\\nopens the Eustachian tubes and facilitates the entrance of\\nthe fluid into the middle ear.\\nBut as, in spite of the frequency of these harmful condi-\\ntions and the presence of infectious mucus in the upper\\nair-passages, infection of the middle ear takes place only\\noccasionally and in certain cases, it is evident that the de-\\nvelopment of pathogenic germs is determined more by a\\nfavorable condition in the ear itself than by the fact of their\\ngaining entrance through the tube. Such a condition is\\nproduced chiefly by acute inflammations of the mucous\\nmembrane, and we expect to find suppuration of the middle\\near in acute coryza, in the acute exanthemata which are\\naccompanied by rhinopharyngitis, and in the acute inflam-\\nmation which follows the use of the galvanocautery in the\\nnose and we can not emphasize too strongly that air\\ndouches, as well as the ordinary nasal douche, are to be\\navoided in acute disease of the nose and throat with inflam-\\nmatory changes in the Eustachian tubes.\\n4. THE EFFECT OF VARIOUS DISEASES OF THE\\nRESPIRATORY ORGANS ON THE EARS.\\nPain in the cars or pain radiating from the neck to the ears\\nis a symptom occurring in a great variety of diseases of\\nthe upper air-passages. It occurs with the greatest regu-\\nlarity in all inflammatory diseases of the epiglottis and\\nupper margin of the larynx which are accompanied by\\nswelling, and is met with also in malignant tumors of the\\nThe rule which obtains in our country viz., to introduce the tip of the\\nnasal douche only into the side of the nose most obstructed, to allow free\\nexit of the fluid from the more open side would seem an important sugges-\\ntion. Ed.", "height": "3456", "width": "2076", "jp2-path": "rhinologylaryng00frie_0053.jp2"}, "54": {"fulltext": "48 THE RESPIRATORY ORGANS.\\nlarynx and upper portion of the esophagus. The physi-\\ncian sees many cases of tuberculosis with infiltration and\\nulceration of the mucous membrane covering the cartilages,\\nand perichondritis of the epiglottis and arytenoid and\\ncricoid cartilages, in which the patients complain of violent\\npain radiating to or localized in the ear. The pain is in-\\ncreased by any pressure or movement in the affected region,\\nand usually attains its maximum intensity during the act of\\nswallowing, making it very difficult to feed the patient\\nproperly. The greatest distress is usually complained of\\nwhen the patient invoknitarily goes through the act of\\nswallowing, just as in any form of angina, and especially in\\ntonsillar abscess, while the swallowing of slimy, semisolid\\nfood is a little less painful.\\nIn carcinoma of the larynx pain radiating to the ears is\\npractically a constant symptom it is usually of a paroxys-\\nmal character, like the lancinating pain of neuralgia. In\\nthe early stages of the growth the pain is dull and localized\\nin the larynx, but radiates to the ears when the ulcerative\\nstage is reached.\\nSince the sensory nerves at the entrance to the larynx\\nand in the deeper portions of the pharynx are branches of\\nthe vagus, and the external auditory meatus receives\\nsensory fibers from the same trunk through the auricular\\nnerve, the vagus must be the channel by w^hich these reflex\\npains are transmitted. The reflex arc is very well devel-\\noped, as is shown by the fact that irritation of the sensory\\nfilaments of the auricular nerve of the vagus in the external\\nmeatus as, for instance, when a speculum is introduced\\noften brings on a fit of coughing.\\nOur information in regard to the relation existing between\\ncroupous pneumonia and purulent otitis media is not very\\ndefinite and lacks clinical confirmation it amounts to this\\nsuppuration in the middle ear is rare after croupous pneu-\\nmonia, presents no distinct type, and its course is not\\ndifferent from that of any other form of purulent otitis\\nmedia. In severe cases of pneumonia with high fever the\\ntympanic membrane is found to be injected without exuda-\\ntion taking place, just as in other infectious fevers, especially\\ntyphoid. Again, as in other diseases characterized by great\\n1 Comp. Fauvel, Traite pratique des malad. du larynx, 1876, p. 707.", "height": "3496", "width": "2084", "jp2-path": "rhinologylaryng00frie_0054.jp2"}, "55": {"fulltext": "THE EARS. 49\\nelevation of temperature, a chronic suppuration may tem-\\nporarily subside during the fever, and the perforated\\nmembrane and mucosa of the tympanum appear dry and\\ndark red in color but there is no reason to suppose that\\nthese phenomena have any specific relation with the pneu-\\nmonia.\\nAcute suppuration in the middle ear is occasionally pro-\\nduced by the diplococcus pneumoniae of Frankel-Weichsel-\\nbaum. Netter,! as early as 1890, called attention to the\\nfrequent occurrence of the pneumococci in the pus found in\\nthe ears of little children at autopsies, and his findings have\\nbeen confirmed by Rasch,^ who found the pneumococci of\\nTalamon-Frankel in the ear secretion of 33 out of 43 cases\\nexamined by him he also comments upon the remarkable\\nfact that these exudations are practically never accom-\\npanied by perforation of the tympanic membrane. Zaufal\\nsays there are ear-diseases which run a strictly pneumonic\\ncourse they are ushered in with a chill, the temperature\\nfalls, and recovery takes place by crisis on the seventh or\\neighth day. This observation of Zaufal led Haug and\\nBrieger to assume a strictly pneumonic character and\\ncourse for otitis due to diplococcus infection, or at least to\\npoint out the similarity evidently existing in many particu-\\nlars between genuine pneumonia and acute purulent otitis\\nmedia. If they had read two lines further in Zaufal s\\narticle they would have seen that he considers it practically\\ncertain that otitis due to streptococcus infection may run\\nexactly the same course. When it is remembered that the\\ndiplococcus pneumoniae is simply a pathogenic organism\\nwhich does not produce pneumonia exclusively, and may\\ngive a general septic infection in no way distinguishable\\nfrom that produced by other pyogenic organisms and\\nwhen, on the other hand, it is considered that diplococci\\nare constant inhabitants of the upper air-passages in the\\nhealthy body, and can easily reach the middle car and set\\nup a suppuration if the condition of the mucous membrane\\nis favorable, just like any other pathogenic organism that\\n1 Comptes rendus de la soc. de biolog., iSgo.\\n2 Jahrb. f. Kinderheilk., xxxvn, p. 32S e^ se//.\\nArch. f. Ohr., xxxi, p. 184 si-i/.\\nDie Kranklieiten des Olires, etc., p. 50.\\n5 Klin. ]5eitrage zur Ohrenbeilk., p. 68.", "height": "3456", "width": "2084", "jp2-path": "rhinologylaryng00frie_0055.jp2"}, "56": {"fulltext": "50 THE RESPIRATORY ORGANS.\\nmay be constantly present in the air-passages, it is well-\\nnigh incredible that the mere fact of this organism playing\\na certain not thoroughly understood role in croupous pneu-\\nmonia, and setting up a suppuration in the middle ear,\\nshould be utilized as a base on which to rear, with infinite\\nart and ingenuity, the edifice of an entirely new disease,\\nunder the name of pneumonic otitis media.\\nWreden maintains that disease of the ear may be\\ncaused hy atelectasis, bronchiectasis, 2X\\\\.(\\\\ capillary broncliitis\\nciting in explanation Lucae s observation that under normal\\nconditions there is a regular pressure variation synchronous\\nwith the respiration. Believing, with Lucae, that the mid-\\ndle ear is in this way ventilated with every respiration, he\\nconcludes that the ventilation is insufficiently performed\\nwhenever the respiration is impaired, and consequently any\\ndisease which is attended with reduction of the respiratory\\nfunction may be followed by disease in the ear.\\nWe have already said enough on this subject to show\\nthat we consider these opinions as disposed of, but Wreden\\nmust nevertheless be given credit for having pointed out\\nthe frequency of ear anomalies observed at the autopsy in\\ninfants about a year old who died of pneumonia, presumably\\nthe catarrhal form. Later, Rasch examined the bodies\\nof 43 children dead of bronclwpneiimonia, and in 42 in-\\nstances found inflammatory conditions in the ears, which in\\n30 consisted in middle-ear suppuration while Ponfick,^ in\\n10 out of 1 1 cases of uncomplicated pneumonia, found\\nmiddle-ear suppuration at the autopsy, the ages ranging\\nfrom one month to four years. In the absence of more\\nconvincing information, especially of a clinical nature, the\\nquestion whether catarrhal pneumonia is the real cause of\\nthe suppuration must remain undecided. In the present\\nstate of our knowledge it seems more likely that the child-\\nish organism is predisposed to suppuration of the middle\\near by any disease which seriously interferes with its nu-\\ntrition, whether it be catarrhal pneumonia or any other\\naffection. Later on we shall study the significance of intes-\\ntinal affections in the production of ear diseases in young\\ninfants, and shall then learn that occasionally nutritive dis-\\nturbance, by its weakening effect on the general resisting\\n1 Mon. f. Ohr., 1S68, p. 105 et seq. 2 Loc cit.\\n3 Berl. klin. Wochen., 1897, p. 852.", "height": "3468", "width": "2084", "jp2-path": "rhinologylaryng00frie_0056.jp2"}, "57": {"fulltext": "THE EARS. 5 I\\npower of the infantile organism, is the predisposing cause of\\nthe aural complication.\\nThe possibility of infection in the opposite direction de-\\nserves passing mention. Bronchitis and bronchopneumonia\\noccasionally develop after purulent otitis media by aspira-\\ntion of particles of pus and the contained bacilli which have\\nfound their way into the pharynx from the middle ear.", "height": "3344", "width": "2092", "jp2-path": "rhinologylaryng00frie_0057.jp2"}, "58": {"fulltext": "II. DISEASES OF THE CIRCULATORY\\nSYSTEM.\\nL DISEASES OF THE HEART AND BLOOD-VES-\\nSELS IN THEIR RELATION TO THE NOSE,\\nPHARYNX, AND LARYNX.\\nDiseases of the heart and blood-vessels lead to\\n1. Circulatory disturbances in the mucous membranes\\nof the upper air-passages, producing hemorrhages, hyper-\\nemia, and congestive catarrh.\\n2. Motor disturbances by direct injury to the laryngeal\\nnerves which are situated in their immediate neighborhood.\\n3. Pulsation of the large arterial trunks, when they are\\ndiseased, is transmitted to various portions of the upper\\nair-passages.\\n4. Aneurysm of the aorta may lead to stenosis of the\\ntrachea or rupture into that tube.\\nHemorrhages from the mucous membranes of the upper\\nair-passages constitute a frequent concomitant of cardiac\\ndisease without compensation, and occur also, in conse-\\nquence of the rise of arterial pressure, when compensation\\nexists they are most common in venous stases due to failure\\nof compensation in mitral disease and in aortic insuffici-\\nency. They are also observed in arteriosclerosis, and\\nEdgren reports the occurrence of epistaxis during the\\npresclerotic period, at a time when the only recognizable\\nsymptom is a heightened arterial pressure he considers it,\\nwhen occurring in elderly persons without apparent cause\\nor after violent emotion, a symptom of incipient arterio-\\nsclerosis. The attacks soon cease to appear, even when\\nthey have been severe at one time. During the later stages\\nof arteriosclerosis the attacks 6f epistaxis appear to dimin-\\nish in frequency, probably because of lowered blood pres-\\nsure and lessened cardiac activity (Edgren).\\n1 Die Arteriosklerose, Leipzig, 1898.\\n52", "height": "3468", "width": "2088", "jp2-path": "rhinologylaryng00frie_0058.jp2"}, "59": {"fulltext": "THE HEART AND BLOOD-VESSELS. 53\\nEpistaxis is the commonest form of bleeding from the\\nmucous membranes hemorrhages from the pharynx and\\nlarynx are rare. Although the usual, one might almost\\nsay the constant, seat of epistaxis is the spot known as\\nlocus Kieselbachii, on the cartilaginous portion of the sep-\\ntum, recognized by the greater density of the vascular\\nplexus, the hemorrhages which occur in general circula-\\ntory disturbances often appear to originate in the lateral\\nwalls, and especially in the cavernous tissue. It is, unfor-\\ntunately, impossible to locate the bleeding point while the\\nhemorrhage continues, and even after the bleeding has\\nstopped it is not always possible to determine its origin, on\\naccount of the hyperemic condition of the nasal mucous\\nmembrane and the presence of blood-clots. Hemorrhages\\nhave been reported from the veins at the base of the tongue,\\nwhich sometimes become enormously engorged in condi-\\ntions of passive hyperemia, and Compaired mentions\\nhemorrhage from the plexus on the glosso-epiglottidean\\nfold in mitral insufficiency.\\nThe hyperemia in course of time gives rise to congestive\\ncatarrh, involving the entire mucous membrane of the\\nupper air-passages, and presenting the symptoms and clin-\\nical appearances seen in chronic rhinitis, pharyngitis, and\\nlaryngitis. The recognition of the symptoms of these\\nforms of chronic catarrh is important, as it materially affects\\nthe treatment. Local measures are, of course, little\\n\u00e2\u0080\u00a2adapted to effect a cure painting with silver nitrate solu-\\ntion, which for some reason is such a favorite mode of\\ntreatment, is absolutely useless as long as constitutional\\ntreatment is neglected.\\nPassive edema in the larynx is a late complication, which\\ndoes not develop in heart disease until failure of compen-\\nsation has led to general edema it therefore has no great\\nvalue in diagnosis, as the local symptoms at this period are\\nalways overshadowed by the general phenomena.^\\nThe paralyses which occur in the course of cardiac and\\nvascular disease find their explanation in the proximity of\\nthe recurrentnerves to the great vessels in the mediastinum.\\nThe inferior laryngeal nerve is a branch of the pneumogas-\\nAnn. des maL de I oreille, 1896. p. 470.\\nIn Arch. f. Laryng., vol. vni, No. 3, v. Sokolowski gives a descrip-\\ntion of the morbid changes in the upper portion of the respiratory tract in\\nthe course of valvular disease.", "height": "3456", "width": "2068", "jp2-path": "rhinologylaryng00frie_0059.jp2"}, "60": {"fulltext": "54 THE CIRCULATORY SYSTEM.\\ntrie, arising in the mediastinum, and, as its name recurrens\\nimplies, running back and upward to the larjmx. The\\ntwo nerves follow a different course^ and therefore come\\ninto relation with different structures on the two sides of\\nthe body. The left nerve winds around the aorta and\\nascends along the posterior margin of the lateral wall of the\\ntrachea, in the groove between it and the esophagus, to\\nreach the larynx the right arises from the vagus at the\\nlevel of the subclavian artery, winds around this vessel from\\nbefore backward, and follows a course between the trachea\\nand esophagus similar to that of its fellow.\\nThe commonest causes of disturbances in the upper air-\\npassages are found in dilatations of the great vessels, due to\\naneurysm. The most important are the aneurysms of the\\naorta, the symptoms of which require a detailed description.\\nThey consist in paralysis of the recurrent by direct injury\\nto the nerve transmitted pulsation of the larynx and\\ntrachea tracheal stenosis from displacement of the wall of\\nthe trachea and, lastly, rupture of the aneurysmal sac into\\nthe trachea.\\nSince the left recurrent nerve is in contact with the entire\\ncircumference of the acch of the aorta, it is affected by any\\naneurysm exerting pressure or traction on that structure.\\nTraube was the first to describe a paralysis of the recur-\\nrent due to aneurysm of the aorta, and since his day in-\\nnumerable similar cases have been reported, so that paraly-\\nsis of the left vocal cord has become one of the most\\nimportant symptoms in the diagnosis of aneurysm of the\\naorta.\\nParalysis of the recurrent nerve a term by which,\\nas will be more fully explained in treating of diseases of\\nthe nerves, is meant complete paralysis of all the muscles\\nsupplied by the inferior laryngeal nerve, the adductors as\\nwell as the abductors is a typical symptom of aneurysm\\nof the aorta, and, on account of the peculiar hoarseness it\\nproduces, rarely escapes the notice of either the doctor or\\nthe patient. It is quite different with the other form of\\nparalysis of the recurrent, which affects only the cricoary-\\ntcxnoideus posticus, and exerts but little influence on either\\nphonation or respiration, so that for several reasons it is not\\noften observed in aneurysmal disease. It represents the\\n1 Deutsche Klinik, i860, No. 41.", "height": "3468", "width": "2084", "jp2-path": "rhinologylaryng00frie_0060.jp2"}, "61": {"fulltext": "THE HEART AND BLOOD-VESSELS. 55\\nearly stage of paralysis, and may be present when the\\naneurysm is beginning to develop, before any clinical\\nsymptoms have made their appearance. As this form of\\nparalysis produces no functional disturbances, it escapes the\\nnotice of the physician, unless it is accidentally discovered\\nin the course of a laryngoscopic examination.\\nIt is owing to these two facts the gradual, and at first\\npainless, development of the aneurysm and the absence of\\nsymptoms in paralysis of the posticus that the disease\\ndoes not, as a rule, come under observation until it has\\nmade considerable progress, and the change from the\\nmedian to the cadaveric position, which is the outward sign\\nof paralysis of the recurrent, has taken place. Among\\nother motor disturbances in the larynx in aneurysms of the\\naorta may be mentioned laryngospastic attacks and periodic\\npalsies of the vocal cords. Lori and Grossmann have de-\\nscribed certain laryngeal disturbances which are rarely\\nobserved as symptoms of incipient aneurysm of the aorta.\\nLori 1 says that the pressure of the aneurysm on the re-\\ncurrent nerve in some cases provokes transient motor\\nphenomena in the muscles of one-half of the larynx, which\\nmanifest themselves in difficult articulation in hoarseness,\\noccurring at frequent intervals and without discoverable\\ncause in sudden changes of the voice or of a single note\\nand occasionally in spasm of the vocal cords. These\\nphenomena, however, which are due to the irritation of very\\nslight pressure, according to Lori, are replaced after a few\\ndays or weeks by paralysis of the entire half of the larynx\\nfrom the increased pressure on the recurrent nerve.\\nIn agreement with Lori, Grossmann explains similar\\nphenomena observed by him as the effect of irritation by\\nthe gradually increasing pressure of the aneurysm on the\\nnerves. His case is remarkable from the fact that he\\nwas able to observe it more than a year. The patient came\\nto be treated for frequent attacks of dyspnea of short\\nduration, before there was any suspicion of aneurysm.\\nAfter one of these attacks Grossmann observed a paraly-\\nsis of the left vocal cord, which disappeared on the follow-\\ning day. A few days later there was another attack of\\ndyspnea, also accompanied by total left-sided paralysis\\nDie diirch Allgemeinerkrankung Ijewirkten anderweitigen Veninder-\\nungen, etc., p. 61.\\n2 Arcli. f. I.aryng., vol. 11, p. 254.", "height": "3448", "width": "2052", "jp2-path": "rhinologylaryng00frie_0061.jp2"}, "62": {"fulltext": "56 THE CIRCULATORY SYSTEM.\\nof the vocal cord. It is not quite clear from the descrip-\\ntion whether we have here a paralysis of the posticus or of\\nthe recurrent. One year later unmistakable clinical symp-\\ntoms of aneurysm had developed, and, with the appearance\\nof a total left-sided paralysis of the recurrent, the laryngo-\\nspastic attacks ceased.\\nWe have so far confined ourselves to the effects of pres-\\nsure on the left inferior laryngeal nerve by an aneurysm of\\nthe aorta. The explanation of those cases, first described\\nby Gerhardt and Baumler,^ in which left-sided paralysis\\nof the recurrent is combined with a similar paralysis on the\\nright side, or in which there is right unilateral paralysis of\\nthe vocal cords, presents greater difficulties, as the course\\nof the right recurrent nerve does not make the occurrence\\nof such a condition appear probable. Among similar cases\\nmay be quoted Onodi s,^ in which the right vocal cord\\nwas fixed in the cadaveric, and the left in the median posi-\\ntion, and Cartaz s case, in which there was marked dyspnea\\nand both vocal cords were seen in the median line, two or\\nthree millimeters apart, immovable, with concave edges. It\\nis remarkable how often Lori found the right nerve in-\\nvolved he reports three cases of paralysis of the right half\\nof the larynx and two cases of bilateral paralysis. Baum-\\nler gives as an explanation of his case that the aneurysm\\nproduced overfilling, or even an aneurysmal dilatation, in\\nthe right subclavian artery, or that it pressed on the nerve\\nfrom below at its origin from the pneumogastric. Another\\nexplanation appears to me to be suggested by the fact that\\nunilateral paralysis of the pneumogastric is capable of pro-\\nducing bilateral disturbances of mobility. Semon,^ and\\nbefore him Lori,^ gives the following explanation A\\nperipheral stimulus of the pneumogastric is transmitted\\nthrough the afferoit fibers of that nerve to the center in the\\nmedulla from there it passes into the two motor nuclei of\\nthe vagus (Semon calls them the accessory nuclei), and\\nthus gives rise to a bilateral disturbance of motility (John-\\nson s theory\\nAneurysms of the aorta ultimately produce changes in\\nVirch. Arch., xxvn, p. 75. 2 Arch. f. klin. Med., Ii, p. 550.\\nSemon s Centralbl., X, p. 429.\\nSemon s Centralbl., vni, pp. 35S and 493. Loc. cif., p. 62.\\nHeymann s Handb. der Laryng., I, p. 615.\\nSemon quotes Med. Chir. Trans., vol. Lviii, 1875.", "height": "3468", "width": "2108", "jp2-path": "rhinologylaryng00frie_0062.jp2"}, "63": {"fulltext": "THE HEART AND BLOOD-VESSELS. 57\\nthe trachea pulsating movements, which may extend to the\\nlarynx tracheal stenoses by compressing the walls and,\\nfinally, pressure nlcers and perforations.\\nThe arch of the aorta curves over the left bronchus from\\nbefore backward, and lies close to the left anterior aspect of\\nthe trachea, just above the bifurcation, so that it occupies\\nthe obtuse angle formed by the trachea and left bronchus.\\nEven under normal conditions a movement can be observed\\nin the spur of the trachea in the laryngoscopic image,\\ncaused by the transmitted pulsation of the aorta. When\\nthe arch and descending limb of the aorta are dilated by an\\naneurysm and brought into closer contact with the trachea,\\nthe pulsation is communicated to the entire trachea, and can\\nbe observed even in the larynx. Oliver suggests bending\\nthe patient s head back, so as to draw the larynx upward,\\nfor the purpose of bringing out tracheal pulsation, while\\nCardarelli observes the pulsation by the movements of\\nAdam s apple with the patient s head bent back, and even\\npretends to be able to diagnose the seat of the aneurysm by\\nthe oblique direction of the pulsating movements.\\nCompression of the windpipe by an aneurysm in most\\ncases produces a so-called scabbard-like stenosis of the\\ntrachea on the left side, with stenosis of the left bronchus.\\nWhen the aneurysm is in the ascending limb, or in the arch,\\nthe pressure may in rare cases be exerted on the right side\\nof the trachea and on the right bronchus. It is important\\nto recognize these tracheal stenoses, as the respiratory em-\\nbarrassment might otherwise be attributed to paralysis of\\nthe vocal cords which is usually present at the same time.\\nTracheotomy under such circumstances is, of course, use-\\nless even the introduction of a cannula to the bifurcation,\\nbeyond the seat of the stenosis, gives only a temporary\\nrelief, because the pressure of the cannula very soon pro-\\nduces decubital ulcers in the trachea, through which rupture\\nof the aneurysm takes place.\\nThe rupture of an aneurysm into the trachea or bron-\\nchus is not a rare occurrence, but the mechanism has been\\nvariously explained by different anatomists. Eppinger\\nbelieves that the tracheal rings are forced apart by the wall\\nof the aneurysm, and that rupture takes place through\\nsecondary aneurysms which form between the separated\\n1 Centralbl. f. inn. Med., 1894, No. 42, p. 988.\\n2 Klebs, Handb. der pathol. Anatomic, VH, p. 270 ct seq.", "height": "3456", "width": "2060", "jp2-path": "rhinologylaryng00frie_0063.jp2"}, "64": {"fulltext": "58 THE CIRCULATORY SYSTEM,\\nrings. He saw no proliferation of the cartilage or ulcera-\\ntion of the mucous membrane: The edges around the\\nseat of rupture were turned toward the interior of the\\ntrachea, and regularly sharp or delicately serrated and scaly,\\njust as in true traumatic ruptures. Other authorities have\\ndescribed conversion of the cartilage into detritus in con-\\nsequence of compressing aneurysms, and atrophy of the\\ncartilage by a process of fatty degeneration. Accord-\\ning to Selter,^ who examined five cases, ulcers form in the\\nmucous membrane as a result of the pressure, and subse-\\nquently lead to rupture of the aneurysms into the trachea\\nor bronchus, so that the rupture is prepared from without.\\nIn rare cases, paralysis of the vocal cords follows disease\\nof other arterial trunks. Selter saw an aneurysm of the\\ninnominate artery with paralysis of the right recurrent\\nE. Meyer describes the same lesion in aneurysm of the\\nright subclavian artery in another case, marked pulsation\\nin the pharynx was referred to aneurysmal dilatation of the\\ncarotid.\\nA pericardial exudate sometimes gives rise to paralysis of\\nthe left recurrent. Baumler first pointed out that the\\nsame condition can also produce paralysis of the right re-\\ncurrent. If the exudate is very abundant, and distends\\nthe pericardium as far as the jugular notch, the engorge-\\nment of the veins which meet at that point may exert\\ndirect or indirect pressure on the right recurrent. The\\ncase he quotes, which seems to me entirely convincing, has\\nbeen called in question by Landgraf,^ because the autopsy\\nshowed some slight syphilitic alterations in the larynx.\\nThe paralysis attains its greatest intensity at the height of\\nthe exudative process, and subsides with the pericarditis.\\nIn this respect Landgraf s case is instructive a pericar-\\ndial effusion developed after articular rheumatism, and\\nproduced at first a paralysis of the posticus in the median\\nposition, which developed into paralysis of the recurrent in\\nthe course of the next two weeks, but the paralysis disap-\\npeared when the primary disease was removed.\\nPalpitation of the heart is one of the reflex neuroses, due\\nKlebs. Handb. der pathol. Anatomic, vii, p. 270 et seq.\\nVirch. Arch., 133 also comp. D. Gerhardt, Virch. Arch., 123,\\np. 201.\\n3 Arch, f, Laryng., II, p. 263.\\nArch. f. klin. Med., 11, p. 550 et seq.\\n5 Charite Ann., XIII,", "height": "3468", "width": "2104", "jp2-path": "rhinologylaryng00frie_0064.jp2"}, "65": {"fulltext": "THE EAR. 59\\nto irritation in the nose. It occurs in chronic rhinitis with\\nhypertrophy and polypus formation, and sometimes takes\\nthe paroxysmal form, analogous to sthenocardiac attacks\\nand cardialgia. An interesting phenomenon, which has not\\nas yet been satisfactorily explained, is sudden death from\\nheart failure, which sometimes takes place a few days after\\nextirpation of the larynx. Stork attributes the phenom-\\nenon to injury of a depressomotor branch of the superior\\nlaryngeus, which is not constantly present Grossmann\\nthmks it is caused by a central irritation of the superior\\nlaryngeal or of the vagus during the operation, while Toti^\\nreports, without explaining, a case in which acceleration of\\nthe pulse rate to from i6o to i8o occurred thirty hours\\nafter an operation for the total extirpation of the larynx\\nand after twenty-four hours more of uninterrupted tachy-\\ncardia the patient died of cardiac paralysis.\\n2. DISEASES OF THE HEART AND BLOOD-\\nVESSELS IN THEIR RELATION TO\\nTHE EAR.\\nTinnitus aurium is a frequent symptom of disease of the\\nheart and blood-vessels and of anemia or hyperemia of\\nthe vascular systems within the ear. Our knowledge of\\nthese conditions is unfortunately very scanty, and we are\\nhardly more advanced than w^as v. Troltsch twenty years\\nago, when he wrote There is no doubt that tinnitus\\naurium is much oftener due to vascular murmurs than the\\nprofession has been inclined to believe up to the present time,\\nas we are in the habit of attributing them chiefly to the in-\\nfluence of the nervous apparatus. It is often impossible to\\ndecide which of the two varieties is present, and simulta-\\nneous processes in both the circulatory and the nervous\\napparatus are probably of still more frequent occurrence.\\nBefore proceeding to the discussion of pathologic changes,\\nlet us direct our attention for a moment to the normal con-\\nditions in which we do not observe any vascular murmurs.\\nSince Weil could hear the heart-sounds communicated to\\n1 Wien. med. Wochen., i8S8 and Alpiger, Langenb. Arch., xl.\\n2 Wien. med. Presse, 1892, Nos. 44-46.\\nDeutsche med. Wochen., 1S93, p. 87.\\nDie Auscultation der Arterien u. Ventn, 1S75.", "height": "3456", "width": "1960", "jp2-path": "rhinologylaryng00frie_0065.jp2"}, "66": {"fulltext": "60 THE CIRCULATORY SYSTEM.\\nthe blood stream as vascular murmurs by auscultation of\\nthe carotid in the neck, it might be supposed that they could\\nbe equally well heard over the internal carotid where it\\npasses through the canal in the petrous portion of the\\ntemporal bone. The solid bone which lodges the labyrinth\\nis excellently adapted to conduct the sound to the internal\\near, and the position of the carotid near the anterior wall of\\nthe tympanum would appear to render its perception very\\neasy. The fact that the sound is not heard appears to be due\\nto the venous plexus which surrounds the artery within the\\ncarotid canal, and acts like a cushion to arrest the pulsations\\nand soften the sound.\\nThe sinus of the jugular vein lies beneath the cavity of\\nthe tympanum and unless there are venous murmurs, there\\ncan not be any sound transmitted to the ear.\\nThe ear itself is provided with two systems of blood-\\nvessels one in the middle ear and one in the internal ear.\\nThe former is composed of various branches derived from\\nthe external and internal carotids the latter belongs to the\\ninternal auditory artery, a branch of the basilar. To the\\ninvestigations of Eichler and Siebenmann^ we owe our\\nknowledge of the distribution of the capillaries in the\\nneighborhood of Corti s organ. It was found that the\\nmembranes of Reissner and Corti, as well as that portion of\\nthe zona pectinata contained between the external pillar and\\nthe ligamentum spirale, are quite free from blood-vessels,\\nand therefore the sensitive terminal apparatus of the\\nauditory nerve is as far as possible removed from the\\ninfluence of the vascular system.\\nIt follows, therefore, that since, in spite of the proximity\\nof the great vessels, the healthy ear does not perceive\\nvascular murmurs, one of two pathologic possibilities must\\naccount for the occurrence of vascular noises there must\\nbe disease either of the organ of hearing or of the vascular\\nsystem.\\nIn the former case the pathologic changes in the organ of\\nhearing bring about more favorable conditions for the per-\\nception of the normal blood murmurs either the sound is\\nmore readily conducted on account of alterations in the\\n1 Die Wege des Blutstroms iin menschl. Labyrinth, Abhandl. der\\nmath. phys. CI. der kgl. sachs. Gesellsch. der Wissensch. vol. xviii, No. 5,\\nP- 327-\\n2 See Handb. der Anatomie, edited by v. Bardeleben, vol. v, part 2.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0066.jp2"}, "67": {"fulltext": "THE EAR. 6 I\\nbone or the presence of an exudate, or the irritability of the\\nauditory nerve is heightened, so that noises which before\\nwere below its range of hearing are now appreciated by the\\nsensory end-organs. The quality of this kind of tinnitus\\naurium, which must be included under the general head of\\nentotic vascular murmurs, is not as yet sufficiently known\\nto make a classification into definite types possible. The\\ndifferent characters of an arterial and a venous murmur, as\\nthey have been described, and the interruption of the sound\\nby compression of the respective artery or vein are not\\nconstant symptoms and can not be utilized in making a\\ndiagnosis. We shall return to this subject in another place.\\nThe second group of subjective noises observed in dis-\\neases of the heart and blood-vessels are due to the trans-\\nmission of abnormal vascular murmurs to the healthy ear.\\nAmong these we must distinguish those which originate in\\nthe heart and those which begin in the vessels.\\nTo the former class belong the noises heard in valvular\\ndisease and in aneurysm, in which blowing, breathing, and\\nhissing sounds are often heard in the ear and described as\\npulsating, hammering, or knocking noises. These descrip-\\ntions are so common as to arouse the suspicion that the\\npatient is describing a sensory perception of the arterial\\npulse, and not a true tinnitus aurium. Such a confusion of\\nsensory perception of periodic movements with auditory\\nimpressions is much more probable than appears at first\\nsight it is often met with to an astonishing degree in test-\\ning with the tuning-fork. Just as the patient who is not\\nused to observing accurately distinguishes with difficulty\\nbetween the zdbrations imparted to the entire head by a fork\\nof low pitch and the tone of the fork transmitted to the ear\\nover the craniotympanic conducting arc, so he may be mis-\\nled by the sensation of the arterial pulse, and interpret it as\\nan auditory impression, for we observe these hammering\\nand knocking noises whenever the cardiac activity is height-\\nened. Any one can hear the beating of his heart after\\nphysical exertion or mental emotion, but he can not say\\nwith certainty whether the impression is due to cardiac or to\\nvascular murmurs. The theory that what is perceived by\\nthe patient in heart disease is not the valvular murmur, but\\nrather the heightened arterial pulsation due to increased\\ncardiac activity, finds further confirmation in the observation\\nthat these entotic vascular murmurs are complained of", "height": "3456", "width": "2068", "jp2-path": "rhinologylaryng00frie_0067.jp2"}, "68": {"fulltext": "62 THE CIRCULATORS SYSTEM.\\nparticularly in aortic regurgitation with its rapid pulse,\\nwhich produces an arterial pulsation that is perceptible even\\nin the capillaries.\\nThe murmurs which originate in the vessels themselves\\nare produced by eddies in the blood stream, not by any\\nspecial action of the vessel walls. The most important\\npredisposing causes are the size of the lumen and the elas-\\nticity of the vessels.\\nIt appears from reports of cases, some of which will be\\ngiven later, that entotic vascular murmurs, whether of\\narterial or of venous origin, are observed with great fre-\\nquency in aneurysm, in anemia and chlorosis, and in\\narteriosclerosis they occur as the result of circulatory dis-\\nturbances in general plethora, in alcoholism, and after\\nintoxications which are followed by a rise in blood pressure,\\nor vasomotor paralysis, especially after the abuse of tobacco,\\nand after full doses of quinin and salicylic acid. In this\\nclass belong the vasomotor disturbances with tinnitus\\naurium which occur in paralysis of the sympathetic, in\\nconnection with hyperemia of the skin they represent a\\nsymptom of Basedow s disease, which, according to Mobius,\\nmust now be regarded as an intoxication depending on the\\nloss of the function of the thyroid gland, and not, as was\\nformerly supposed, as a disease of the sympathetic system.\\nFinally, there are subjective noises which occur after\\nzvotmds of the head in connection with partial loss of hear-\\ning and vertigo they are usually attributed to vasomotor\\nirritation. As these symptoms are usually observed only\\nin cases of accidents, there is a natural tendency to ascribe\\nthem to traumatic hysteria and neurasthenia. This is the\\nview adopted by Schwartze some time ago but Miiller,\\nin a recent communication from Trautmann s clinic, pointed\\nout that a wound of the head may give rise to irritation of\\nthe vasomotor center, manifesting itself first in contraction\\nand later in relaxation and paralysis of the muscular walls\\nof the blood-vessels this may in turn be followed by\\nextravasations and permanent functional disturbances which\\nexplain the subjective symptoms complained of by the\\npatient. The tinnitus aurium in this case is, therefore,\\nto be regarded as the result of hyperemia manifesting\\nitself at first in hyperemia of the tympanic membrane and\\n1 Deutsche med. Wochen., 1898, No. 31.", "height": "3468", "width": "2096", "jp2-path": "rhinologylaryng00frie_0068.jp2"}, "69": {"fulltext": "THE EAR. 63\\nexternal auditory meatus, which later may be replaced by\\ncloudiness of the membrane.\\nThe investigations in arterial auscultation by Weil and\\nV. Frey show that the blood-vessels give forth a peculiar\\nnote, rarely heard in healthy individuals, but frequently in\\nfever patients, in anemia and chlorosis, and in aneurysm on\\nthe other hand, according to Weil s observations on the\\nfemoral artery, the tone was persistently absent in condi-\\ntions of high arterial tension from atheromatosis and nephri-\\ntis with hypertrophy of the heart. In the former case the\\nresults of auscultation coincide with the subjective ear\\nsymptoms, while in the latter the frequent occurrence of\\nentotic vascular murmurs in arteriosclerosis is in marked\\ncontradiction to them. But we find an explanation for the\\noccurrence of tinnitus aurium in atheromatosis in the in-\\nvestigations of Nolet,^ who found that murmurs in the\\nvessels may be caused by sudden changes in the pressure\\nand velocity of the blood wave, such as are produced by\\nchanges in the lumen of the vessel. These conditions are\\nmost marked in arteriosclerosis when there are aneurysmal\\ndilatations in the vessels. The behavior of the blood-vessels\\nof the ear in arteriosclerosis has, unfortunately, never been\\nexamined anatomically, but it is safe to say that the pro-\\nduction of entotic murmurs depends on the extent of ather-\\nomatous change and the presence of miliary aneurysmal\\ndilatations a unilateral tinnitus aurium, therefore, does not\\nnecessarily exclude an atheromatous origin, but merely\\nsuggests the existence of a local form. Stacke reports a\\ncase characterized by the perception of marked subjective\\ntones, high in pitch, combined with central deafness of the\\nright ear he explains the unilateral character of the symp-\\ntoms by the existence of a circumscribed atheromatosis of\\nthe vessels in the right side of the neck.\\nBeing convinced of the frequency of tinnitus aurium as a\\nconcomitant of arteriosclerosis, I examined for this symp-\\ntom the 124 case histories of arteriosclerotic patients\\nreported by Edgren,^ but to my astonishment I found\\nsuch complaints in only three of the histories, although\\nEdgren himself remarks further on (p. 207) that vertigo and\\nAuscultation der Arterien u. Venen, 1875.\\n2 V. Frey, Die Unteisuchung des Pulses, 1892, p. 6 et seq.\\n3 Arch. d. Heilkunde, 1S71. Arch. f. Ohr., xx, p. 286.\\n5 Arteriosklerose, Leipzig, 1S98.", "height": "3456", "width": "2052", "jp2-path": "rhinologylaryng00frie_0069.jp2"}, "70": {"fulltext": "64 THE CIRCULATORY SYSTEM.\\ntinnitus aurium are complained of early in the disease by\\nmany patients. His interpretation of these complaints\\ndiffers somewhat from my own views he finds the cause of\\nthe noises in the brain, and attributes them simply to in-\\ncreased arterial tension, without any material alterations in\\nthe brain itself.\\nI shall now proceed to quote a few cases of subjective\\nnoises in the ear. Moos reports a case in which the\\nnoises were very loud and compared by the patient to the\\nnoise of machinery and railroad trains at the autopsy the\\nsinus of the jugular vein was found abnormally dilated.\\nWagenhauser attributes a case of marked tinnitus\\naurium, aggravated by cough and demonstrable objectively\\nwith the auscultatory tube, to an aneurysmal dilatation of\\nthe internal carotid but as the patient, a girl of nineteen,\\npresented besides a marked emphysematous habit, a large\\ngoiter, and a cyanotic appearance, his explanation is open\\nto criticism. Brandeis regarded a noise which was heard\\nin a disease of the upper cervical vertebrae as a vascular\\nmurmur emanating from a dilated vertebral artery. The\\nliterature contains many cases of aneurysmal dilatation in\\nvarious vascular systems which produced subjective ear\\nnoises. Among the external vessels of the head the region\\nof the temporal, occipital, and posterior auricular arteries\\nfurnishes examples quoted by Chimani and Herzog.\\nSubjective and objective noises in the head maybe of great\\nsignificance in the diagnosis of aneurysm at the base of\\nthe brain. In the case of a woman who suddenly began to\\ncomplain of tinnitus aurium and impaired hearing and lost\\nconsciousness, Varrentrapp found at the autopsy a rup-\\ntured aneurysm of the basilar artery. Lebert, in his\\nstudies on aneurj^sm of the cerebral vessels, calls attention\\nto the frequency of tinnitus aurium as a symptom of\\naneurysm of the middle cerebral and basilar arteries in the\\ncase of the latter it may have great diagnostic value as an\\nearly symptom. Deafness has often been observed in com-\\nbination with the subjective noises sometimes it comes on\\n1 Arch. f. Augen- u. Ohrenheilk., vol. TV.\\n2 Arch. f. Ohr., xix, p. 62. u Zeitschr. f. Ohr., vol. xi.\\n\u00e2\u0080\u00a2i Arch. f. Ohr., VIII.\\n5 ]\\\\Ion. f. Ohr., 1S81, Nos. 8 and 9; with review of cases reported up to\\ndate.\\n6 Arch. d. Heilkunde, 1865.\\nBerlin, klin. Wochen., 1866, pp. 251, 2S2.", "height": "3468", "width": "2108", "jp2-path": "rhinologylaryng00frie_0070.jp2"}, "71": {"fulltext": "THE EAR, 65\\nsuddenly, and must be explained partly by the obliteration\\nof the arteries supplying the ear, and partly as the result\\nof pressure on the auditory nerves. Oppenheim was able\\nto auscult a loud pulsating murmur over the left half of the\\nskull, which, because of a coexisting ocular disturbance, he\\nreferred to aneurysm of the posterior communicating artery\\nbut there is no record in the history that the patient had\\nbeen aware of the murmur. Hyrtl contributes the obser-\\nvation that the artery of the stapes is sometimes very large,\\nand in that case is likely to give rise to vascular murmurs.\\nWhen the character of the entotic vascular niiirmurs is\\nexamined, it is found that the difference between arterial\\nand venous murmurs has been very differently described.\\nThe arterial murmurs are said to have a distinct pulsating\\ncharacter, to be synchronous with the apex-beat, and to\\nmanifest themselves as a series of buzzing or pounding\\nnoises in the ear or in the head (Kayser^), whereas the\\nvenous murmurs are breathing or blowing in quality, and\\ncontinuous. As we must depend for a description of the\\nmurmurs on the statements of the patient, for even when\\nan aneurysmal bruit can be heard objectively we have no\\nmeans of judging whether the patient hears the noise in the\\nsame way, it is easily understood why the descriptions\\nvary so widely. The patient naturally chooses a com-\\nparison from his surroundings or from among the sounds\\nhe has become familiar with in his calling, so that the\\nmurmurs have been compared to the rush of water over a\\ndam, the rustling of leaves in the forest, the noise of\\nmachinery and railroad trains, the hiss of boiling water, the\\nchirping of a cricket, etc.\\nA few examples are given to show that even the general\\ncharacter of the arterial and venous murmurs, as just\\ndescribed, does not apply in every case. Kayser lays down\\nthe rule that arterial hyperemia, like the inhalation of amyl-\\nnitrite, produces low-pitched, buzzing sounds, while anemia,\\nlike syncope, gives rise to high, resonant tones. According\\nto v. Troltsch, the predominant characteristic of the noises\\nin anemia and chlorosis is hissing and blowing. According\\nto Stacke, in arteriosclerosis the subjective noises are high in\\npitch and it is worthy of remark that although of arterial\\n1 Berlin, klin. Wochen., 1896, p. 402.\\n2 Quoted by Urbantschitsch, Schwartze s Ilandl)., vol. i, p. 413.\\n3 Bresgen s collection 11, part 6, ]i. 2 S.\\n5", "height": "3456", "width": "2008", "jp2-path": "rhinologylaryng00frie_0071.jp2"}, "72": {"fulltext": "66 THE CIRCULATORY SYSTEM.\\norigin, the sounds are not intermittent in character. Moos^\\npoints out that they are aggravated by anything which tends\\nto stimulate the circulation. In his case mentioned in\\nanother place he ascribes the subjective noises to a marked\\ndilatation of the sinus of the internal jugular vein. The\\nnoises which the patient compared to the din of machinery\\nand railroad trains were so intense that they drove him\\nto commit suicide. The interpretation of this case is\\nopen to criticism, as there evidently existed a psychosis.\\nThe noises caused by heart disease and aneurysm are\\nusually described as intermittent and buzzing or soughing\\nin character.\\nThe differential diagnosis between entotic vascular mur-\\nmurs and simple noises in the ear can be established in\\nsome cases by compressing the corresponding vascular\\ntrunks that is, the external and internal carotids, the\\nvertebral artery, and the internal jugular vein which are\\nconcerned in the blood supply of the ear. The effect pro-\\nduced by compressing the blood-vessel will vary according\\nas the vascular murmur is arterial or venous in character^\\nand emanates from the distribution of the carotids in the\\ntympanum or from the branches of the vertebral artery in\\nthe internal ear. Schwartze mentions the disappearance\\nof pulsating murmurs after compression of the carotid, and\\nsuggests ligation of the carotid for the cure of aneurysm\\nto remove the murmurs. In Wagenhauser s case, where\\naneurysm of the internal carotid was suspected, the vascu-\\nlar murmur was diminished by pressure on that vessel in\\nOppenheimer s case of aneurysm of the posterior commu-\\nnicating artery, in which the murmur was heard only\\nobjectively, compression of the carotid had no effect.\\nVon Troltsch quotes Tiirck as saying that pressure on the\\nfirst cervical vertebra alters and usually diminishes the\\nmurmur momentarily, and, similarly, Dundas Grant^ rec-\\nommends compression of the vertebral artery in cases of\\nvascular murmurs, so as to relieve the tension in the distri-\\nbution of the basilar arteiy, of which the internal auditory\\nis a branch.\\nAlthough the general impression prevails that pressure\\n1 Schwartze s Handb., vol. I, p. 535.\\n2 Die chir. Krankh. des Ohres, p. 170.\\n3 Lehrb 7th edition, p. 606.\\nQuoted by Brieger, Klin. Beitr., p. 139.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0072.jp2"}, "73": {"fulltext": "THE EAR. 67\\non the internal jugular vein as, for instance, by struma\\nor a tight collar produces tinnitus aurium, Boudet^ main-\\ntains that the noises can be suppressed by compression of\\nthe vein.\\nOn the subject oi embolic disease of the ear in endocarditis\\nwe have the investigations of Trautmann,^ which confirm the\\nextreme rarity of its occurrence and the absence of marked\\nsymptoms, at least in thrombosis of any of the smaller\\nvessels. Embolism of the basilar or of the internal audi-\\ntory artery may give rise to sudden deafness, as happened\\nin a case of Friedreich s but emboli in the smaller arte-\\nrial branches of the middle ear do not necessarily cause\\nany functional disturbance.\\nTrautmann s anatomic investigations on the cadaver con-\\nvinced him that embolic processes are more apt to occur in\\nthe tympanum than in the internal ear, because the arterial\\npath from the posterior auricular to the stylomastoid is\\nstraighter than that which leads from the tortuous verte-\\nbral artery to the basilar and internal auditory. It appears\\nfrom Trautmann s observations that of thirteen cases of\\nendocarditis four showed petechial hemorrhages in the\\ntympanic membrane and the mucous membrane of the\\nmiddle ear but his findings can not be utilized for ear dis-\\neases following simple endocarditis without a reservation, as\\nmost of his patients were cases of ulcerative endocarditis\\nand general sepsis, showing septic embolism of cutaneous\\nvessels with roseola-like macules and petechial hemorrhages.\\nThe changes in the ear may be regarded as analogous with\\nthe latter, and caused, not by endocarditis in general, but\\nby the sepsis present in these cases. Habermann^ recently\\nreported a case of rather sudden deafness of the right ear, in\\nwhich there was double mitral disease with endocarditis.\\nThe prognosis of deafness after embolism of the internal\\nauditory artery is unfavorable as to recovery of hearing,\\nwhich differentiates this form from that due to hemorrhage\\ninto the central auditory tract, which usually ends in re-\\ncovery by absorption.\\n1 Quoted by Urbantschitsch from Henle s Jahresber. 1862, p. 520.\\n2 Arch. f. Ohr., Xiv. p. 73.\\n3 Moos, Wien. med. V^ ^ocben.. 1S63, p. 661.\\n4 Verhandl. der D. otol. Gesellsch., 1898, p. 90.", "height": "3456", "width": "2036", "jp2-path": "rhinologylaryng00frie_0073.jp2"}, "74": {"fulltext": "III. DISEASES OF THE DIGESTIVE SYSTEM.\\nI. DISEASES OF THE DIGESTIVE SYSTEM IN\\nTHEIR RELATION TO THE UPPER AIR-\\nPASSAGES.\\nDISEASES AND CHANGES IN FORM OF THE ORAL CAVITY\\nIN DISTURBANCES OF NASAL RESPIRATION.\\nMorbid changes in the oral mucous membrane and\\nchanges in the shape of the oral cavity result from obstruc-\\ntion of the nasal chambers the etiology of the latter and\\nits effect on the respiratory passages has already been fully\\ndiscussed. The inspiratory air current, in passing through\\nthe mouth, exerts a cooling and desiccating influence on\\nthe mucous membrane, giving rise to a subjective feeling\\nof dryness in the mouth and throat, and, from the deposi-\\ntion of dust, to a stale, disagreeable taste and general\\nanorexia. It seems probable that mouth-breathers are\\nmore exposed to catarrhal affections of the gums and\\nof the mucous membrane covering the tongue and oral\\ncavity on account of the greater facility of direct infection^\\nbut the supposition has never been proved, any more than\\nthe statement that they are more disposed to inflammation\\nof the tonsils.\\nSince Moldenhauer and Bloch, among others, called at-\\ntention to the changes produced in the shape of the upper\\nmaxilla by obstruction of the nasal respiration, the subject\\nwas carefully investigated by Korner and by his disciple\\nWaldon,2 and their statements are confirmed by the obser-\\nvations of others. Korner divides the malformations of\\nthe jaw into those which occur before the period of second\\ndentition and those which are produced if there is nasal\\nobstruction while that process is going on.\\n1 Untersuchungen iiber Wachsthurnsstorungen und Missgestaltung des\\nOberkiefers und des Nasengeriistes in Folge von Beliinderung der Nasenath-\\nmung. Leipzig, F. C. W. Vogel, 1891.\\n2 Arch. f. Lar. u. Rhin., vol. Ill, p. 233 et seq,\\n68", "height": "3468", "width": "2108", "jp2-path": "rhinologylaryng00frie_0074.jp2"}, "75": {"fulltext": "NASAL RESPIRATION. O9\\nThe first consists in a dome-like elevation of the\\npalate, the highest point of which corresponds to the ante-\\nrior portion of the roof of the mouth, the posterior surface\\nof the median portion of the alveolar process rising almost\\nperpendicularly behind the incisors. The curve of the\\nalveolar border, which in normal impressions is usually seen\\nto correspond to a semicircle, takes the form of an ellipse.\\nWhen the deformity develops during the period of second\\ndentition, there is, in addition to these changes, a marked\\nupward growth of the superior maxilla in the sagittal axis,\\nand a corresponding diminution in the transverse diameter,\\nso that the jaw appears both high and narrow. The teeth,\\nwhich had not been affected before, also show the effect of\\nthe deformity in the position of the central incisors, which,\\nowing to the lateral approximation of the alveolar pro-\\ncesses and their meeting in an acute angle in the median\\nline, are placed with their posterior surfaces facing each\\nother. And as, in consequence of the excessive lengthen-\\ning of the jaw, the anterior alveolar border is pushed for-\\nward and loses its perpendicular position, the incisors\\nnecessarily take the same direction, and usually project\\nbeyond the lower teeth, reminding one of a rodent. In\\naddition to all these changes, there is a general hypoplasia\\nof the superior maxilla, which is regarded as a kind of\\narrested development due to the respiratory inactivity of\\nthe nose. The interior of the nose is also undeveloped,\\nand this explains the upward growth of the palate. The\\nlateral contraction of the palate is explained, after Korner,\\nby the pressure exerted on the sides of the jaw by the\\nstretching of the cheeks when the mouth is open this\\nexplanation seems plausible, since it is generally accepted\\nthat the mouth is at rest when closed, and the act of open-\\ning it, which in mouth-breathers becomes habitual, is asso-\\nciated with contraction of the muscles about the jaw.\\nAlthough the lower jaw is equally subjected to the\\nlateral pressure of the contracted muscles (which produce\\nthe approximation and protrusion of the alveolar process\\nof the upper jaw), a similar malformation can not result,\\nbecause a counterpressure is maintained from within by the\\ntongue, which fixes the rami of the jaw in their normal\\npositions. Hence the lower jaw does not, like the upper,\\nsuffer any alterations when nasal respiration is obstructed.\\nThe habit of keeping the mouth open results in atrophy", "height": "3456", "width": "1968", "jp2-path": "rhinologylaryng00frie_0075.jp2"}, "76": {"fulltext": "70 THE DIGESTIVE SYSTEM.\\nof the orbicularis oris, which shows itself in the diminished\\nwidth of the lips and shortness of the upper lip, so that the\\nlower half of the teeth are not covered.\\nDISEASES OF THE DIGESTIVE ORGANS IN RELATION TO\\nTHE NOSE, THROAT, AND LARYNX,\\nDiseases of the teeth play no inconsiderable part in the\\npathology of the antrum of Highmore and of the nose\\nthe ulceration may spread through the alveolar process to\\nthe mucous membranes of these cavities, a dental cyst\\nmay simulate an empyema, or a tooth may even develop in\\nthe antrum of Highmore or in the nose.\\nWhile it must be admitted that diseases of the teeth\\noccupy a prominent place in the etiology of suppurative\\nprocesses in the antrum, it would be a great mistake to fall\\nunder the influence of the dentists, who have claimed the\\npathology of the tributary cavities as their own province,\\nand neglect other sources of infection for the nose. It is\\ntrue that many cases of empyema of the antrum are due to\\ninfection derived from a carious tooth or to the encroach-\\nment of a dental cyst but if every suppuration of the\\nantrum is to be referred to disease of the teeth, how shall\\nwe explain the inflammations which occur in the frontal\\nsinuses quite as frequently as in any of the other accessory\\ncavities\\nThe danger to the antrum of infection from a decaying\\ntooth varies with the individual tooth, the anatomic rela-\\ntions of the alveolar process, and the size of the accessory\\ncavity concerned.\\nThe lumen of the antrum may be conveniently described\\nas representing a pyramid the base corresponds to the\\nlateral wall of the nose, the apex lies in the zygomatic or\\nmalar process, and the three sides are formed by the inner\\naspects of the facial, orbital, and pterygopalatine or zygo-\\nmatic surfaces of the superior maxilla. The junction of\\nthe facial and nasal walls of the cavity comes into close\\nrelation with the alveolar process, but nearer the median\\nline the sockets are separated from the floor of the cavity\\nby a thicker ridge of bone. The longer the alveolar proc-\\ness, as roughly determined by the elevation of the roof\\nof the mouth, the thicker the mass of bone which separates\\nthe roots of the teeth from the antrum, and the less", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0076.jp2"}, "77": {"fulltext": "NOSE, THROAT, AND LARYNX. /I\\nprominent their outlines on the inner surface of the cavity.\\nThese relations are, of course, variable, and the possibility\\nof a morbid process spreading from the teeth to the antrum\\ndepends on whether the roots of the teeth are separated\\nfrom the cavity by a thick layer of bone or only by a\\nslender lamella and the epithelial lining of the antrum.\\nIt may be laid down as a rule, independent of these\\nvarying anatomic relations, that certain teeth are always\\nnearest the cavity, and therefore most dangerous to the\\nantrum if they become diseased while, on the other hand,\\nthey also offer the readiest means of access to the antrum\\nfor therapeutic purposes. The floor of the antrum is\\ndeepest over the second bicuspid and first molar hence,\\nwhatever the thickness of the intervening bone at other\\npoints, these two teeth always lie nearest the cavity, and\\nconstitute the point of election for attacking the maxillary\\nsinus through the alveolar process.\\nOn the subject of periodontal cysts and their extension\\nto the antrum of Highmore there is a paper by Kunert^ in\\nwhich he points out the diagnostic points between such a\\ncyst and true empyema of the antrum. I am willing to\\nadmit that protrusion of the facial and orbital plates and of\\nthe hard palate is characteristic of cysts but in bulging of\\nthe outer wall of the nose, accompanied by a flow of pus\\nfrom the middle meatus, symptoms referred by Kunert to\\nthe spontaneous opening of a cyst, I believe the rhinolo-\\ngists will be inclined to exclude any cystic condition from\\nthe etiology. Kunert betrays his imperfect acquaintance\\nwith rhinology when in the diagnosis of a true empyema of\\nthe antrum he utterly ignores the significance of granula-\\ntions and polypi in the middle meatus, coupled with dis-\\nease of other adjoining cavities.\\nThe presence of a tooth in the inferior meatus on the\\nfloor of the nose or in the antrum admits of two explana-\\ntions either it is an inverted tooth or it is the product of\\na dental papilla which wandered into the nasal cavity before\\nclosure of the palatal cleft had taken place. Sometimes a\\nforeign body lying loose on the floor of the nose, and cov-\\nered or surrounded with swollen mucous membrane, is\\nremoved from the nose, and, to the surprise of the surgeon,\\nturns out to be a fully or only partly developed tooth,\\nArch. f. Laryng., vn, p. 34.", "height": "3456", "width": "2036", "jp2-path": "rhinologylaryng00frie_0077.jp2"}, "78": {"fulltext": "72 THE DIGESTIVE SYSTEM.\\nwhich must have been there lor years without causing any\\nsymptoms.\\nThe theory which formerly prevailed, that spasm of the\\nvocal cords in children is due to difficult dentition, has\\nbeen disproved. As will be shown later on, in the section\\non rachitis, the phenomenon must be regarded as a symp-\\ntom of the general impairment of nutrition, more particu-\\nlarly of the rachitic habit.\\nThe diseases of the palate and of the oral pharynx will\\nbe found fully treated in the special text-books devoted to\\nthem, and need not be discussed here.\\nDiseases of the esophagus, in the form of tumors, diver-\\nticula, and peri-esophageal abscess, have their effect on the\\nupper air-passages whenever the larynx and trachea become\\ninvolved in the morbid process, or whenever the tumor pro-\\nduces paralysis by pressure on the laryngeal nerves. Malig-\\nnant tumors originating in the highest portion of the esoph-\\nagus, at the level of the cricoid cartilage, are prone to spread\\ninto the interior of the larynx, and it is often difficult to de-\\ncide, by the laryngoscopic image, whether the primary seat of\\nthe tumor is in the larynx or in the esophagus. Whenever\\nthere are distinct signs of carcinomatous changes in the inte-\\nrior of the larynx, and a mass suddenly makes its appearance\\nin the pyriform sinus, or, as is sometimes observed, pushes\\nits way into the lumen of the larynx over the interarytenoid\\nnotch, it may be said with certainty that the tumor has in-\\nvaded the esophagus. In operating on such cases it must\\nbe remembered that the process has probably attained such\\ndimensions that there is no possibility of a radical cure\\nwithout extensive resection of the esophagus and pharynx.\\nThe possibility of tumor or dislocation of the esophagus\\nproducing paralysis of the vocal cords follows logically\\nfrom the course of the recurrent nerves in the groove be-\\ntween the trachea and esophagus, which has been suffi-\\nciently described in another place.\\nDyspepsia is often found associated with atrophic fetid\\nrhinitis and pharyngitis and with abscess in the cavities\\nadjoining the nose, obviously because the pus which enters\\nthe pharynx is often swallowed. It would be well worth\\nwhile to examine these relations more closely from a\\nclinical standpoint, for, as far as my experience goes, this\\ncause for chronic gastric catarrh has so far barely received\\na passing mention. When complaints of failing appetite", "height": "3468", "width": "2108", "jp2-path": "rhinologylaryng00frie_0078.jp2"}, "79": {"fulltext": "NOSE, PHARYNX, AND LARYNX. 73\\nand bad digestion are constantly heard in cases of ozena,\\nwhere the cavities of the nose are enormously enlarged\\nand its walls covered with crusts, where the pharynx and\\nposterior pharyngeal wall is filled with offensive discolored\\nmasses of secretion, it seems but natural to attempt to\\nestablish a causal relation between the two conditions. A\\nsecondary chronic gastritis is readily explained either by\\nthe anomalies of smell and taste which result from the\\nozena and manifest themselves in paresthesise and anesthe-\\nsise, destroying the appetite and causing a bad taste in the\\nmouth, or directly by the irritation of the decomposing secre-\\ntions in the stomach.\\nThe American literature contains a few observations on\\nthe significance of dyspepsia in the etiology of rhino-\\npharyngeal catarrh. Beverley Robinson s remarks on this\\nsubject are worth quoting Dyspepsia, this writer says,\\nincreases an already existing pharyngeal catarrh, because\\nthe eructations of gas act as an irritant, and the acid matters,\\nwhich contain large quantities of butyric acid and similar\\nsubstances, tend to aggravate the condition.\\nIn regard to spasm of the vocal cords in infants, which is\\nsaid to be caused by defective nutrition of the sensory nerve-\\nendings of the vagus in the stomach, there is a discussion\\nby Rehn,2 which will be referred to again in connection\\nwith rachitis.\\nThe theory that cough may be produced by reflex irrita-\\ntion of the pneumogastric in the stomach was formerly\\naccepted by physicians, and even now enjoys a wide recog-\\nnition among the laity, as we know by the generally ac-\\ncepted term stomach-cough.\\nThe symptom has now entirely disappeared from the\\nliterature, for the possibility of such reflex irritation has\\nbeen denied on theoretic grounds (Nothnagel, Naunyn)\\nnor does the literature furnish any cases which can be\\naccepted as proving it absolutely. Even the case reported\\nby Bull, 3 in his paper on stomach-cough, which is sup-\\nposed to be a clinical observation of stomach-cough of\\nreflex origin from irritation of the gastric walls, does not\\nconvince me, as the paroxysms, which could be brought on\\nby pressure on the epigastrium, as well as the entire course\\n1 Kef. Semon s Centralbl, vr, p. 83 x, p. 349.\\n2 Berlin, klin. Wochen., i8g6, No. 33.\\n3 Deutsclies Arch. f. klin. Med., vol. xu.", "height": "3456", "width": "2024", "jp2-path": "rhinologylaryng00frie_0079.jp2"}, "80": {"fulltext": "74 THE DIGESTIVE SYSTEM.\\nof the disease, with its repeated relapses, appear to me to\\nhave a distinctly hysteric character.\\nWhen the intestines are in a state of irritation from the\\npresence of parasites, reflex tickling sensations and a desire\\nto sneeze are often felt in the nose, especially when the irrita-\\ntion is in the rectum. These conditions are usually due\\nto excessive acidity of the urine, although it is admitted that\\nthey may be caused by the presence of seat-worms and tape-\\nworms. The statement is occasionally met with that spasm\\nof the glottis may be due to reflex irritation of worms.\\nIn cirrhosis of the liver, owing to the impaired nutrition of\\nthe vessel walls, or as the result of a primary hypertrophy\\nof the heart, hemorrhages occur in the mucous membranes,\\nsometimes severe enough to constitute epistaxis, but usually\\nmerely in the form of ecchymoses in the larynx and post-\\nnasal cavity. Cases of genuine laryngeal hemorrhage are\\nvery rare Dreyfuss lately published two cases, the\\netiology of which, however, was somewhat obscured by the\\npresence of other laryngeal disease. These hemorrhages\\nand varicose conditions are easily explained, as are hemor-\\nrhages and varicose veins in the esophagus, by the free\\nanastomosis existing between the laryngeal veins and the\\ntributaries of the inferior and superior thyroid, and, through\\nthem, with the peri -esophageal veins which belong to the\\nportal system.\\nThe icteric hue manifests itself in the mucous membranes\\nby a lemon-yellow color, just as in the epidermis. In\\nthe larynx it is most marked in the valleculae, above the\\nepiglottis, and on the vocal processes. Paresthesiae in the\\nthroat have been described, exciting cough and hawking,\\nA few cases of paralysis of the vocal cords have been\\nreported in jaundice with fever. Gerhardt and Hertel\\ndescribe a paralysis of the adductors, with gaping of the\\nglottis during phonation, and moderate injection of the vocal\\ncords the paresis diminished as the jaundice disappeared,\\nand phonation was gradually restored. In these cases\\nthere may have been an intoxication of the nerves, owing\\nto their absorbing the cholates. or it may be that paralysis\\noccurs only in the infectious form of jaundice, known as\\nWeil s disease, for the course of both Gerhardt s and Her-\\n1 Miinch. med. Wochen., 1898, No. 32.\\n2 Die med. Wochen., 1887, p. 325.\\n3 Chaiite Ann., 1891, xvi.", "height": "3496", "width": "2120", "jp2-path": "rhinologylaryng00frie_0080.jp2"}, "81": {"fulltext": "NOSE, PHARYNX, AND LARYNX. 75\\ntel s cases strongly suggest that disease. M. Schmidt calls\\nattention to the paroxysmal cough sometimes excited by\\nthe reflex irritation of gall-stones, and mentions Cahn s\\ncase of vasomotor coryza (hydrorrhea nasalis) directly\\ncaused by hepatic colic, and another in which there Avas a\\ncausal relation between vasomotor coryza and round ulcer\\nof the stomach.\\nFinally, cholera asiatica and severe cases of ordinary\\ncholera may give rise to various disturbances in the upper\\nair-passages. The most familiar of these is the aphonia,\\nor vox cholerica, which accompanies the attack of cholera it\\nis usually attributed to weakness of the muscular tissues\\nwhich are deprived of the necessary moisture. Matter-\\nstock 2 made a series of laryngoscopic examinations in the\\nWiirzburger Klinik during a cholera epidemic. It appears\\nfrom his investigations that the interior of the larynx be-\\ncomes cyanotic, and the vocal cords discolored and moder-\\nately injected. The most conspicuous change was a marked\\nprominence of the vocal processes, the vocal cords being\\nvery much hollowed out, so as to present the shape of a\\nsickle. Wide gaping of the glottis during phonation\\naccounted for the aphonia, which was not constantly pres-\\nent, the patient regaining his voice temporarily under the\\ninfluence of excitement or after the application of the faradic\\ncurrent. Matterstock rejects the foregoing interpretation,\\nwhich is the one generally accepted, and refers the paresis\\nto nervous influences the aphonia, according to him, is\\nnot dependent on the excessive loss of fluid, so that one\\nmight regard the vox cholerica as a toxic paralysis, analo-\\ngous to those which occur in the course of other infectious\\ndiseases.\\nThe croupous and diphtheric inflammations of the\\npharyngeal and laryngeal mucous membranes in cholera\\nare interpreted by Liebermeister as superficial necroses,\\ndue to the profound disturbance of nutrition and circulation,\\ncomparable to similar complications in typhoid fever,\\nvariola, and puerperal fever.\\n1 Die Kranlvh. der ob. Luftwege, 2d ed., p. 749.\\n2 Berl. klin. Wochen., 1874.\\n3 Die Cholera, in Nothnagel s Spec. Path. u. Therap., vol. iv, i,\\np. 68.", "height": "3460", "width": "2044", "jp2-path": "rhinologylaryng00frie_0081.jp2"}, "82": {"fulltext": "76 THE DIGESTIVE SYSTEM.\\n2. DIGESTIVE SYSTEM AND DISEASES OF THE\\nEAR.\\nThe influence of disease of the intestinal canal on the ear\\nis inconsiderable. Moos and Haug refer to auditory dis-\\nturbances said to have been observed by Meniere in gas-\\ntric disease, and Haug mentions one or two other unim-\\nportant cases, but both devote a great deal of attention\\nto diseases of the teeth as the cause of aural disturbances.\\nOf all the complications presently to be mentioned there\\nis only one neuralgia localized in the ear after caries of\\nthe teeth that appears to me to be definitely proved. As\\nfor the exudative otitis media in diseases of the teeth, which\\nis said to result from reflex irritation of the dental branches\\nof the trigeminus, which, as will be explained in another\\nplace, exercises a trophic influence on the mucous mem-\\nbrane of the middle ear, I do not consider that the etio-\\nlogic relationship has been clearly established.\\nIt happens every day that a patient comes to the doctor\\ncomplaining of earache, and the cause of this alleged ear-\\nache is found in a carious tooth or a patient with acute\\notitis media describes the pain as radiating to the molars.\\nIt is, no doubt, this radiation of the pain in earache that is\\nresponsible for the popular belief that toothache can be\\nrelieved by dropping warm oil into the external auditory\\nmeatus, and induces many women of the lower classes to put\\ncotton in their ears for the same purpose. It is not at all\\nsurprising that the people at large should harbor the super-\\nstition that a running ear may be caused by the process of\\nfirst or second dentition, when we remember the layman s\\ntalent for confusing cause and effect and his remarkable in-\\ngenuity in interpreting reflex conditions, before which the\\ninventiveness of the most ingenious discoverer of reflex\\nneuroses sinks into insignificance but that such views\\nshould still prevail in medical circles is simply incompre-\\nhensible. It is indeed difficult to conceive how a purulent\\notitis media could be the result of the physiologic process\\nof dentition, except on the very improbable hypothesis\\nthat the inflammatory irritation of the gums was communi-\\n1 Rev. mens, de lar., etc., 1886, No. 6.\\n2 For instance, quoted by Moos Burnett, Am. Journ. of Otol., vol. 11,\\npart IV, p. 285.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0082.jp2"}, "83": {"fulltext": "THE EAR. J J\\ncated to the middle ear by way of the postnasal space and\\nthe Eustachian tube. For similar reasons I am inclined\\nto deny any connection between purulent otitis media and\\ncaries of the teeth, and the cases published in support of\\nthe theory do not appear to me to bear the scrutiny of\\ncloser inspection. Thus, a woman has a tooth filled, and\\nduring the following night is taken with vertigo and head-\\nache, her hearing is impaired, and she has tinnitus aurium.\\nA week later, suffering with acute middle-ear catarrh in\\nprocess of regeneration, she comes under the care of an\\near specialist, who concludes that the aural inflammation is\\nthe result of filling the carious tooth. But it is much more\\nlikely that the patient originally referred the pain of an\\nacute otitis to a tooth, and as she happened to have a\\ncarious tooth at the time, she had it filled, without, of\\ncourse, arresting the course of the inflammation when, a\\nweek later, the otologist found only the remains of an\\notitis, he hastily concluded, without going into the case\\nvery critically, that the carious tooth was the primary cause.\\nA similar case was observed by Blau he, however, was\\ntoo critical to admit an etiologic connection between the\\ndental and the aural conditions without a reservation.\\nHaug,2 on the other hand, attributes a case of hemorrhagic\\nexudation into the tympanic cavity, with ecchymoses in\\nthe external auditory meatus, to pulpitis of a molar tooth.\\nThe spontaneous cure of the aural affection within sixteen\\ndays after the tooth was extracted does not confirm the\\ndiagnosis, as any uncomplicated acute hemorrhagic in-\\nflammation would have subsided just as rapidly. Nor is\\nthere any better proof in a case described by Schwartze^ as\\nacute purulent otitis media with caries of the mastoid\\nprocess resulting from caries of a second molar.\\nThe ingestion of food may be seriously interfered with if\\nthe ear disease involves the articulation of the lower jaw,\\nand mastication, or even opening the mouth, becomes pain-\\nful or impossible. Such disturbances occur most com-\\nmonly in otitis externa, with furuncle on the anterior wall\\nof the meatus, and infiltration of the parts about the joint.\\nExtensive caries of the temporal bone and malignant tumors\\n1 Arch. f. Ohr., x.xni, p. 12.\\n2 Verh^ndl. der D. otol. Gesellsch., 1S95, p. 41.\\n3 Zeitschr. f. Ohr., xxili.", "height": "3464", "width": "2044", "jp2-path": "rhinologylaryng00frie_0083.jp2"}, "84": {"fulltext": "78 THE DIGESTIVE SYSTEM,\\nin the external or middle ear may destroy some of the\\ntissues entering into the construction of the joint.\\nDisturbances of the sense of taste due to ear disease\\nwill be discussed in the section devoted to nervous dis-\\neases.\\nIn persons afflicted with chronic purulent otitis media\\nthe trickling of pus through the Eustachian tubes intO the\\npharynx (according to Itard sometimes produces nausea\\nand vomiting, with bad taste in the mouth and indigestion.\\nBut it is chiefly during infancy and early childhood that the\\nconnection between diseases of the gastro-intestinal canal\\nand inflammations and suppurations in the middle ear is\\nnoticeable. The striking coincidence of digestive disturb-\\nances and running of the ear, and the frequent presence\\nof pus and inflammatory exudate in the ears of children\\nwho have died of enteritis, leave no room for doubt that\\nwe have to deal with a deeper etiologic relationship and\\nnot merely with an accidental coincidence.\\nIt has taken a long time to arrive at a clear understand-\\ning of the nature of this connection up to a very recent\\ndate the most extrav^agant suppositions were entertained\\nregarding the normal condition of the middle ear in the\\nnew-born and during the first months of the infant s life,\\nand, in consequence, widely divergent interpretations were\\nsuggested for cases in which the autopsy revealed the\\npresence of a mucopurulent secretion, with swelling and\\ninjection of the mucous membrane of the middle ear.\\nThe process of involution which takes place in the middle\\near of the new-born, consisting in resorption of the so-\\ncalled fetal pad of mucous membrane or mucoid embry-\\nonic connective tissue which fills the cavities of the middle\\near during intra-uterine life, led certain authors to explain\\nthe presence of mucopus in the middle ear of infantile\\ncadavers as a physiologic formation due to a persistence\\nof the embryonic tissue.^ This confusion of ideas con-\\ntinued until Hartmann instituted his first systematic\\ninvestigations on the cadavers of infants. The confusion\\nwas aggravated by the current belief that the diagnosis of\\ndiseases of the ear and the interpretation of the otoscopic\\nimage in infants were based on an entirely different set of\\nQuoted by Urbantschitsch, Lehrb., 2d ed.. p. 251.\\n2 For the literature see AschofF, Zeitschr. f. Ohr., xxxi, p. 345.\\nDeutsche med. Wochen., 1894, No. 26.", "height": "3492", "width": "2120", "jp2-path": "rhinologylaryng00frie_0084.jp2"}, "85": {"fulltext": "THE EAR. 79\\nprinciples, and offered peculiar difficulties, as compared\\nwith similar conditions in adults.\\nHartmann repeatedly pointed out the significance of puru-\\nlent otitis media in the nutritive disturbances of infants\\nthen Ponfick contributed his evidence to the elucidation of\\nthe subject, and Goeppert showed that purulent otitis\\nmedia is often a sequel of intestinal diseases in infants,\\nwhich up to that time had been practically disregarded.\\nWe have already seen that the interdependence of lung and\\near diseases has been known and studied for some time, and\\nnow Goeppert finds that the percentage of ear complica-\\ntions is much higher among children suffering from intes-\\ntinal troubles than it is among those admitted for other\\ndiseases; 12^ of the former and 39^ of the latter class\\nwere found to have healthy ears. As to the mode of\\norigin of ear diseases in gastro-intestinal affections, it is just\\nas difficult to explain as it is to decide in cases of long\\nstanding whether the ear or the intestinal tract is the\\nprimary seat of disease. The question may, perhaps, best\\nbe answered by referring to what has been said in connec-\\ntion with purulent otitis occurring in the course of lung\\ndiseases the power of the organism to resist infection\\nhaving been weakened by disease, the infant is more prone\\nto suppurative processes in the tympanic cavity and in the\\nsame way marasmus must be regarded as a frequent cause of\\ndisease in the ear. Goeppert s theory, that infection during\\nan intestinal disease occurs solely through the entrance of\\nvomited matter into the middle ear by way of the tubes, can\\nhardly be accepted in all cases.\\nSecondary nutritive disturbances play an important role\\nin primary ear diseases in the case of infants. A regular\\ndigestion and a uniform increase in the body-weight afford\\nthe best criterion of an infant s health, for its digestive\\norgans are so sensitive that the slightest local or general\\ndisturbance may suffice to upset its stomach. If there is a\\npurulent focus anywhere in the body, auto-intoxication will\\nbe much more likely to result from the absorption of the\\nproducts of metabolism in the infant than in the adult, and\\nwill show itself chiefly in the organs which are functionally\\nthe most important that is, it will be followed by indiges-\\ntion and a falling-off in weight. Thus, there is danger of\\n1 Ponfick, Berlin, klin. Wochen., 1897, No. 38.\\nGoeppert, Jahrb. f. Kinderheilk., vol. XLV, p. I.", "height": "3460", "width": "1960", "jp2-path": "rhinologylaryng00frie_0085.jp2"}, "86": {"fulltext": "80 THE DIGESTIVE SYSTEM.\\nauto-infection whenever the secretions are retained in the\\nmiddle ear in purulent otitis media, because there is no per-\\nforation, or only an insufficient one, in the tympanic mem-\\nbrane for the toxins contained in the pus are distributed\\nthroughout the body, and set up an enteritis, with its train\\nof evil consequences. Hartmann investigated these con-\\nditions in the Berliner Kinderklinik, and found, as Ponfick\\nhad, that purulent otitis media and intestinal catarrh react\\non each other so directly that paracentesis and evacua-\\ntion of the secretions may be followed by return of\\nthe disturbed digestive function to the normal, and an\\nincrease in weight instead of a loss. In one case of\\nacute otitis media, when a second rise in temperature\\nclearly indicated paracentesis, the intestinal condition pre-\\nsented a perfect reflection of the state of the suppurative\\nprocess. On two other occasions retention of the pus\\nwas followed by indigestion and a loss of weight, but both\\nconditions immediately began to improve after paracentesis\\nhad been performed. Auto-infection may also result, as Pon-\\nfick has shown, from swallowing the pus that has reached\\nthe pharynx through the Eustachian tubes.\\nHartmann rightly concludes from his observations that in\\nall intestinal diseases of infants accompanied by rise in tem-\\nperature and loss of weight the ears should be examined\\nto ascertain whether any inflammation is present.\\nBrieger mentions the rare occurrence of icterus in the\\ncourse of a genuine otitis media, and explains it by the\\ndecomposition of blood-corpuscles in hemorrhagic exuda-\\ntions in the tympanic cavity. A slight icteric discoloration\\nof the skin, which may be explained in a similar way, is\\nrarely seen a few days after an operation on the mastoid\\nprocess.\\n1 Verhandl. der D. otol. Gesellsch., 1898, p. 87.\\nKlin. Beitr. zur Ohrenheilk., p. 64.", "height": "3468", "width": "2132", "jp2-path": "rhinologylaryng00frie_0086.jp2"}, "87": {"fulltext": "IV. DISEASES OF THE BLOOD.\\nU ANEMIA.\\nThe three forms of anemia simple or symptomatic ane-\\nmia, chlorosis, and pernicious anemia will be discussed\\ntogether, as the symptoms they produce in the organs\\nunder discussion are essentially the same.\\nA constant symptom noted by inspection of the upper\\nair-passages is a marked pallor of the mucous membranes,\\nwhich may be very intense even in the nose, where anemia\\ndoes not, as a rule, produce any noticeable alteration. In\\nacute anemia after hemorrhage, and in the anemia of star-\\nvation, olfactory hallucinations and exaggerated sensitive-\\nness of the olfactory nerves are observed. These are prob-\\nably analogous to the rarely mentioned auditory hallucina-\\ntions,^ and, though we are unable to explain them, cerebral\\nanemia is no doubt the cause.\\nThe mucous membrane of the pharynx and larynx, espe-\\ncially in chlorotic subjects, is often the seat of hyperesthesia\\nand paresthesiae, such as dryness and tickling in the throat,\\nexciting cough and hawking. Chlorotic young girls often\\ncomplain that the voice is weak, is easily tired by talking\\nand even more by singing, and that it becomes hoarse.\\nThe laryngoscopic image often shows nothing but a slight\\ninsufficiency of the vocal muscles and of several adductors.\\nIt seems probable that this functional aphonia is merely the\\nexpression of a weakened state of the muscles due to the\\nanemia, for laryngoscopic examination often shows that the\\ncords move perfectly with the first efforts at phonation\\nparesis developing only after a number of movements have\\nbeen made, as the muscles become fatigued very rapidly.\\nAmong aural symptoms in anemic states are tinnitus and\\nvertigo, and, more rarely, difficult hearing, which may go^\\non to total deafness. Opinions are divided on the question:\\nHoffmann, Lehrb. der Constitutionskrankh. pp. 19 nnd 36.\\n2 Haug, Krankh. des Ohres, p. 176.\\n6 81", "height": "3464", "width": "2012", "jp2-path": "rhinologylaryng00frie_0087.jp2"}, "88": {"fulltext": "82 THE BLOOD.\\nof the seat of these disturbances. The results of a func-\\ntional examination point to disease of the internal ear, but\\nno characteristic signs are elicited. The anemic distur-\\nbances of the hearing have been attributed to anemia of the\\nlabyrinth, which is assumed to give rise to the symptoms\\nof tinnitus, difficult hearing, and vertigo but no satisfactory\\nexplanation has been offered of the way in which anemia of\\nthe labyrinth could produce such phenomena.\\nAs most cases of grave anemia are, in fact, associated\\nwith tinnitus and vertigo, it is quite natural to regard these\\nsymptoms as the expression of an anemia of the labyrinth,\\nwhich has brought on a pathologic condition of irritation in\\nthe end-organs of the auditory nerve in the labyrinth.\\nThis view of the origin of tinnitus and vertigo finds some\\nsupport in a case reported by Lermoyez.^ in which the tin-\\nnitus disappeared and hearing improved after food was\\ntaken, but the symptoms reappeared in a few hours, with\\nreturning inanition. Impaired hearing from anemia may\\nperhaps be interpreted as the expression of a nutritive dis-\\nturbance in the organ of Corti, which would explain such\\ncases as Abercrombie s, in which the patient was deaf in the\\nsitting posture, but regained his hearing perfectly on lying\\ndown but there is another possible explanation for this\\ncase as well as for Litten s,^ where a chlorotic subject suf-\\nfered with deafness lasting several hours, sometimes, but not\\nalways, after a fainting fit, namely, that the deafness is\\ndue to anemia of the deep nucleus of the auditory nerve in\\ngeneral anemia of the brain. These periodic attacks of\\ndeafness which may occur without any permanent lesions\\nof the auditory apparatus, as shown by the fact that the\\ndeafness is variable and eventually ends in recovery are in\\nmarked contrast to deafness coming on suddenly after a\\nsevere hemorrhage, in which the prognosis is very unfavor-\\nable. Such sudden deafness after profuse bleeding at the\\nnose was observed by Urbantschitsch^ it also occurs in\\ngreater or less degree after difficult labors attended with\\ngreat loss of blood. It can not be explained as a result of\\nthe sudden change in blood pressure, and must be attributed\\nto a more profound lesion. Some light has been thrown on\\nits mode of origin by the discovery of hemorrhages in the\\n1 Ann. des mal. de I oreille, 1896, part II, p. 28.\\n2 Bleichsucbt, Nothnagel s Spec. Path. u. Ther., p. 97.\\n3 Arch. f. Ohr., xvi, p. 105.", "height": "3492", "width": "2120", "jp2-path": "rhinologylaryng00frie_0088.jp2"}, "89": {"fulltext": "ANEMIA. LEUKEMIA. 83\\nlabyrinth by Habermann^ in a series of autopsies on sub-\\njects who had died of simple and pernicious anemia. These\\nhemorrhages appear to be analogous to those found in\\nanemia in the spinal marrow, in the medulla, and in the\\nnerve-trunks.\\nThe theory which seeks to explain that tinnitus aurium\\nin anemia and chlorosis is the noise of the blood stream\\nperceived by the patient himself lacks confirmation, and does\\nnot seem probable, as tinnitus aurium is not a constant feat-\\nure in chlorosis with vascular murmurs. The condition\\nAvhich obtains when the vessels are diseased has been ex-\\nplained elsewhere, and we will only mention here that the\\nvariation in the perception of subjective noises in chlorosis\\nhas been attributed by Wolf to differences in the conduct-\\ning power of the bone, depending possibly on imperfect\\ndevelopment of the mastoid cells.\\nLermoyez suggests the inhalation of amyl nitrite as a\\ndiagnostic aid in determining whether tinnitus and vertigo,\\nin a given case, are due to anemia, as its administration is\\nfollowed by hyperemia and consequent disappearance of\\nthe symptoms.\\n2. LEUKEMIA.\\nALTERATIONS IN THE UPPER AIR-PASSAGES IN\\nLEUKEMIA.\\nAssociated with the waxen hue of all the mucous mem-\\nbranes in leukemia there is a peculiar yellowish pallor of\\nthe upper air-passages, more conspicuous in the pharyngeal\\ncavity and in the larynx than in the nose, where changes\\nof color are not so marked. As an expression of\\nthe hemorrhagic diathesis in leukemia we frequently have\\nepistaxis, which may occur at any stage of the disease\\nwithout appreciable macroscopic alterations in the nasal\\nmucous membrane, but appears to be most common in the\\nacute form of leukemia, which has lately become better\\nknown through the investigations of Ebstein. Microscop-\\nically, Suchanneck found lymphoid infiltrations in some of\\nthe arterioles of the nasal mucous membrane, and large\\naccumulations of pigment around the vessels. Similar\\nPrag. med. Wochen. 1890, No. 39.\\n2 Zeitschr. f. Ohr., xx, p. 42.", "height": "3464", "width": "1952", "jp2-path": "rhinologylaryng00frie_0089.jp2"}, "90": {"fulltext": "04 THE BLOOD.\\nhemorrhages are found in the external skin and in the\\nmucous membranes, as well as in the pharynx and\\nlarynx.\\nBut in addition to these minor changes, during leukemia\\nwe find in the pharynx and larynx lymphoid nodules,\\nlymphomatous infiltrations of the mucous membranes with\\nsecondary necrosis, and ulceration, making up a clinical\\npicture of genuine leukemic pharyngitis and laryngitis.\\nVirchow s description of the condition has become classic,\\nand well deserves quoting Lymphoid nodules appear on\\nthe inner surface of the epiglottis, on the aryepiglottic folds,\\nand over the entire surface of the larynx and trachea,\\nsometimes even in the bronchi, presenting usually a small,\\nwhitish, moderately raised and rounded swelling of rather\\nsoft consistency, frequently situated at the orifices of gland\\nducts, but also found in other situations. The nodules\\nare usually discrete, but occasionally they coalesce and\\nform a dense uniform infiltration, as observed by Vlrchow\\nin the upper segment of the larynx. Sometimes they\\nattain to a large size and form tumors. Such tumors,\\nhaving the consistency of marrow and a glossy surface, are\\nfound on the mucous membrane of the pharynx, at the\\nbase of the tongue, and on the tonsils. Thus, hyper-\\ntrophy of the palatal and pharyngeal tonsils is often a valu-\\nable sign of leukemic pharyngitis. Virchow remarks that\\nthe nodules show no tendency to undergo fatty or cheesy\\ndegeneration, and thereby distinguish themselves from mili-\\nary tubercles, which they resemble in external appearance.\\nWe also have superficial ulcerations (as in the intestine),\\nwhich, although they also more rarely affect the epiglottis,\\nand have been observ^ed in one instance on the vocal cords\\nin the form of flat ulcers with thickened and slightly red-\\ndened edges, show a predilection for the fauces and folli-\\ncles of the tongue. In some cases the tonsils and fauces\\ntake on a dark red, livid color, become greatly swollen,\\nand then undergo necrotic disintegration. This is often\\nassociated with a gangrenous form of stomatitis and gin-\\ngivitis, which strongly suggests grave mercurial intoxi-\\n1 Krankh. Geschwulste, vol. n, pp. 569 and 574.\\n2 Recklinghausen, Virch. Arch., vol. xxx, p. 370. Mosler, Virch.\\nArch., vol. XLII, p. 445.\\nFrankel, Deutsche med. Wochen., 1895, p. 679. Kraus, Nothnagers\\nSpec. Path. u. Ther. xvi, I. Th., I. Abth., p. 291.\\nV. Recklinghausen, Virch. Arch., xxx, p. 370.", "height": "3496", "width": "2108", "jp2-path": "rhinologylaryng00frie_0090.jp2"}, "91": {"fulltext": "LEUKEMIA. 85\\ncation or scurvy (Kraus). It is of comparatively frequent\\noccurrence in acute leukemia, and is probably due to bac-\\nterial infection of the mucous membrane which has been\\ndeprived of its superficial epithelium by some mechanical\\ntrauma and, owing to its impaired nutrition, is unable to\\noffer any resistance to the invasion of pathogenic germs.\\nLori 2 and Hoffmann have reported paralyses of the\\nrecurrent nerve from pressure or traction of the leukemic\\ntumors on the vagus or recurrent.\\nThe same alterations are found in pseudoleiikeinia as in\\nleukemia, but the literature on the subject is very scanty.\\nStieda and Kiimmel observed diffuse infiltrations, which\\nin the former s case led to a stenosis requiring tracheotomy\\nfor its relief, and in the latter s presented a peculiar mar-\\nrow-like appearance and caused a thickening of the entire\\nmucous membrane, as well as of the aryepiglottic folds and\\nthe posterior arc of the entrance to the larynx, and led\\nto a laryngeal stenosis. In a case reported by Kraus the\\nmucous and muscular tissues of the pharyngeal vault and\\nposterior nares were replaced by a hard, whitish mass,\\nslightly raised above the level of the surrounding parts.\\nNecrotic disintegration of the tonsils has occurred in pseudo-\\nleukemia, and hemorrhages from the nose, pharynx, and\\nlarynx are sometimes observed.\\nContrasted with these diffuse pseudoleukemic infiltrations\\nwe meet with circumscribed lymphatic tumors on the\\nepiglottis and on the base of the tongue, as observed by\\nBeale and Eppinger in general lymphomatosis.\\nWith symptoms such as these, which in Eppinger s case\\nled to a clinical diagnosis of multiple carcinomatosis, one\\nmay well hesitate whether to ascribe the neoplasms to\\npseudoleukemia or to consider them as idiopathic malignant\\ntumors.\\nThere is another form of morbid growth, known as\\nlymphosarcoma, to which it is even more difficult to assign\\na place among the pseudoleukemias. According to Kun-\\n1 Kraus, Nothnagel s Spec. Path. u. Ther., xvi, i.Tb., i. Abtli., p. 291.\\n2 Die Veranderungen des Rachens, etc., p. 94.\\n2 Lehrb. der Constilutionskiankh.\\nArch. f. Laryng., IV, p. 46.\\nVerhandl. der D. otol. Gesellsch., 1896.\\nLoc. cil. p. 303.\\nQuoted from Stieda, Arcli. f. Laryng. vol. iv.\\n8 In Klebs Ilandb. der path. Anat., 7th ed., 1S80, p. 209.", "height": "3456", "width": "2020", "jp2-path": "rhinologylaryng00frie_0091.jp2"}, "92": {"fulltext": "86 THE BLOOD.\\ndrat,i lymphosarcoma is more closely allied to lymph-\\noma, especially of the pseudoleukemic variety, than it is\\nto sarcoma, although it differs from the former by its\\natypical structure, its mode of growth, and its tendency\\nto invade neighboring tissues. The close relation exist-\\ning between pseudoleukemia and lymphosarcoma is shown\\nby the tendency of pseudoleukemic lymphomata to change\\ninto lymphosarcomata. Kundrat describes them as origi-\\nnating in lymph glands (which consist of follicular and\\nadenoid tissue) in certain regions, following the course of\\nthe lymph-channels in their subsequent growth. Lympho-\\nsarcomata often originate in the structures of the pharynx\\nand, according to Stork, the disease frequently begins\\nas a hyperplasia of the pharyngeal tonsil, simulating the\\npicture of adenoid vegetations. The general appearance\\nof the patients, their pallor and cachexia, and the enlarge-\\nment of the lymphatic elements in the mesentery and\\nretroperitoneal space and of the lymphatic glands generally,\\nwhich is found at the autopsy, point to leukemia, although\\nthe differential diagnosis is indicated by the absence of\\nhepatic and splenic alterations. The tonsils and the folli-\\ncles of the tongue and of the posterior pharyngeal wall\\nmay become enlarged, or an extensive infiltration distributes\\nitself over the posterior and lateral walls of the pharynx,\\nand appears in the larynx either primarily or as an exten-\\nsion from the pharynx. The infiltrated areas usually\\nbecome the seat of tumors, which differ from similar\\ngrowths in leukemia in their tendency to cicatrization. In\\nthe literature there is no record of hemorrhasres.\\nTHE MANIFESTATIONS OF LEUKEMIA IN THE EAR.\\nIt has been known for some time that the ear sometimes\\nbecomes diseased in the course of leukemia. Vidal and\\nIsambert found auditory disturbances in three out of\\nthirteen and in four out of forty-one cases, respectively, but\\nin the absence of reliable clinical observations and anatomic\\nstudies the nature of the aural disease and its connection\\nwith leukemia remained shrouded in mystery. In 1884\\nPolitzer published a paper on the subject, and since then a\\n1 Wien. klin. Wochen., 1893, Nos. 12 and 13.\\n2 Nothnagel s Spec. Path. u. Ther., Xiil, 2. Th., I. Abth.; vol. I, p. 204.", "height": "3496", "width": "2120", "jp2-path": "rhinologylaryng00frie_0092.jp2"}, "93": {"fulltext": "LEUKEMIA. J\\nfew Other cases were reported. Finally, Schwabach con-\\ntributed a decided addition to our knowledge of leukemic\\ndisease of the ear by five observations of his own, with\\nanatomic notes, and thereby brought the total number of\\ncases reported up to fifteen.\\nIt has been mentioned that, according to Vidal and Isam-\\nbert, the proportion of aural complications in leukemia is\\nlofo Schwabach puts it at ZZ%, as his five cases of ear\\ndisease represent the proportion among fourteen cases\\nof leukemia. F. A. Hoffmann also considers disturb-\\nances of the hearing fairly common in leukemia.\\nThe aural disease may appear at any time in the course\\nof the general disease, but is most frequent in chronic\\ncases during the last few weeks before death.\\nThe auditory disturbance is usually profound and points\\nto disease of the internal ear as a rule, the onset is sudden,\\nwith vertigo, tinnitus aurium, and sometimes vomiting, and\\nis immediately, or within a few days or hours, followed by\\nmarked reduction in the hearing or even by total deafness.\\nIn many cases, including the five out of the fifteen reported\\nby Schwabach, the aural phenomena made their appearance\\nsuddenly, simulating the picture of Meniere s symptom-\\ncomplex.\\nIt has not as yet been determined just how far one is\\njustified in assuming a causal relation between leukemia and\\nthese attacks of deafness which do not present any definite\\nclinical type. The assumption that there is a true leukemic\\nform of ear disease is amply justified by the investigations\\nof Schwabach, who found in fourteen of the fifteen cases\\nexamined so far anatomic alterations which were undoubt-\\nedly dependent on the leukemia.\\nThese changes, which were also observed by F. A.\\nHoffmann, consist in hemorrhages and in lymphomata\\nsituated not only in the labyriiith, but also in the auditory\\nnerve and its branches. Aggregations of leukocytes or lym-\\nphatic infiltrations with extravasations of blood were fre-\\nquently found in the trunk of the auditory nerve, in the\\ncochlea and vestibule, and in the semicircular canals some-\\ntimes pigmentation was present a consequence of former\\nhemorrhages. The marrow-spaces in the spongy tissue of\\n1 Zeitschr. f. Ohr., xxxi, p. 103.\\n2 Lehrb. der Constitutionskrankh., p. 79.\\n3 Alt und Pineles, Wien. klin. Wochen., 1896, No. 38.", "height": "3464", "width": "1984", "jp2-path": "rhinologylaryng00frie_0093.jp2"}, "94": {"fulltext": "iSb THE BLOOD.\\nthe mastoid process may be filled to bursting with mono-\\nnuclear leukocytes, interspersed with hemorrhagic extrava-\\nsations. It would appear that these masses sometimes or-\\nganize and are converted into connective or bony tissue.\\nA unique case is reported by Kast The labyrinth and\\nauditory nerve were intact, but in the medulla there was an\\narea corresponding to the olivar)^ nucleus, and to the\\nnuclei of the hypoglossus, glossophar^aigeal. vagus, audi-\\ntory, and facial nerves, in which the medullated nerve-\\nfibers were diminished. Yet here bulbar phenomena had\\nnot been observed, for the only clinical symptoms were im-\\npaired hearing and facial paralysis. Facial paralysis was\\nalso present in one of Schwabach s cases.\\nThe complications of the middle ear are less pronounced\\nand less frequent, and the external meatus and tympanic\\nmembrane scarcely ever present alterations referable to\\nleukemia. If we disregard the deviations from the normal\\nobserved in the otoscopic image, calcifications or opacities\\nw^hich had nothing to do with the leukemic process, we\\nfind few instances of hemorrhage or injection of the mem-\\nbrane and external auditory meatus. Occasional extrava-\\nsations of blood, with a variable admixture of red and\\nwhite blood-corpuscles, have been observed more fre-\\nquently the mucous membrane of the middle ear was\\nthickened, but it w^as rarely the same extensive leukemic\\ninfiltration as that which occurs in the internal ear.\\nThese findings are sufficiently characteristic to remove\\nany doubt that ear disease of leukemic origin is possible.\\nBut there is no reason for adopting the opinion of Gra-\\ndenigo,^ based on three cases, that an inflammatory pro-\\ncess in the ear must be regarded as an essential predispos-\\ning factor of ear complications in leukemia.\\nExamination with the tuning-fork is of the greatest im-\\nportance in the diagnosis of leukemic ear disease there\\nare, it is true, a few cases where the hearing was only\\nslightly impaired, even for whispered sounds, but they are\\nvery exceptional compared to those which are character-\\nized by great reduction in the hearing or even total deaf-\\nness. Without the results of the functional test, which\\nincidentally enables us to determine whether the sound-\\nconducting or the sound-perceiving apparatus is chiefly\\n1 Zeitschr. f. klin. Med., 1895.\\n2 Arch. f. Ohr., xxni, p. 261.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0094.jp2"}, "95": {"fulltext": "LEUKEMIA. 89\\naffected, the symptoms of tinnitus and vertigo are of no\\nvalue in the diagnosis of leukemic disease of the organ\\nof hearing, as both phenomena may be present in this\\nas in other morbid states of the blood-producing organs,\\nespecially in anemia, quite independent of any organic lesion\\nin the ear.\\nThe prognosis is unfavorable, though there may be tem-\\nporary improvement in the hearing.\\nOur knowledge of auditory disturbances in pseudoleu-\\nkemia is very limited. Kiimmel^ reports a case which he\\nobserved very carefully, and in which the tympanic mem-\\nbrane was dark blue, almost violet in color, the handle of\\nthe malleolus being very distinctly seen. At the autopsy\\nan extravasation of blood, mixed with leukocytes, was found\\nin the middle ear. In a case of Hodgkin s disease reported\\nby Brauneck^ it is said that the hearing, which had always\\nbeen bad, became worse toward the end, and the diagnosis\\nof disease of the labyrinth or of the central organs was\\nmade by an ear specialist.\\n3. HEMORRHAGIC DIATHESES,\\nIn the hemorrhagic diatheses hemophilia, purpura, and\\nscorbutus the same processes are found in the mucous\\nmembranes as in the skin. Ecchymoses and hemorrhages\\nmay appear in the mucous membranes of the upper air-\\npassages, just as they attack the external auditory meatus,\\nthe tympanic membrane, and the middle ear.\\nThese complications are, however, rarely observed, and\\ntheir diagnosis, when they appear in connection with the\\nprimary disease, presents no difficulties, so that nothing\\nwould be gained by giving a detailed description, and I\\nshall content myself with presenting a few examples of the\\nindividual varieties, culled from the literature.\\nEpistaxis occupies the first place among spontaneous\\nhemorrhages from mucous membranes in hemophilia\\namong 236 hemorrhages of various kinds 122, according\\nto one authority, 3 were from the nose. In the same place\\n1 Verliandl. der D. otol. Gesellsch., 1896.\\n2 Deutsches Arch. f. klin. Med., vol. XLIV, p. 297.\\n3 Quoted from Hoffmann, Lehrb. der Constitutionskrankh., p. 121,\\nNo. 43.", "height": "3456", "width": "2060", "jp2-path": "rhinologylaryng00frie_0095.jp2"}, "96": {"fulltext": "90 THE BLOOD.\\na quotation is found from Eichhorst, to the effect that the\\nhemorrhage may be preceded by perversions of the senses\\nof taste and smell one patient could smell, another taste,\\nthe approach of his hemorrhage.\\nI have seen hemorrhages from the larynx in a bleeder,\\na young woman of twenty-five, in association with periodic\\nsubcutaneous and other hemorrhages. The patient ex-\\npectorated blood, and in the laryngoscopic image the blood\\ncould be seen trickling from a point at the posterior ex-\\ntremity of the left false vocal cord and spreading over the\\nadjacent parts, while the entire mucous membrane, includ-\\ning the true vocal cords, showed marked redness. The\\nattacks usually lasted from one to two days, and during\\nthe intervals of freedom from hemorrhage the laryngeal\\nimage was entirely normal and the source of the hemor-\\nrhage could not be recognized.\\nAn excellent example of hemophilic alterations in the\\near is furnished by a case of Rohrer s.^ in which there were\\nhemorrhages in both tympanic membranes, which were\\ndark red in their entire extent. A week later there was\\nanother hemorrhage in both membranes, which were deeply\\ninjected on the left side the membrane was dark red,\\nalmost black, in color, with the handle of the malleolus\\nsharply defined in white against the dark background a\\nsign that there was a hemorrhage in the middle ear. Haug\\nreports one case of hemorrhage lasting several hours from\\nrupture of the ear-drum by a blow, and another in which\\nminute punctiform ecchymoses appeared in both mem-\\nbranes after an attack of sneezing. These alterations may,\\nhowever, occur in anybody, whether he be a bleeder or not,\\nand are not in any sense to be considered characteristic of\\nhemophilia.\\nIn purpura haemorrhagica the occurrence of epistaxis,^\\necchymoses, and subcutaneous hemorrhages in the larynx,\\nas well as of ulcerations in the pharynx and larynx, has\\nbeen reported. Krieg gives a reproduction of hemor-\\nrhage on the laryngeal surface of the epiglottis in purpura\\nSchnitzler, a picture of diffuse hemorrhages from the true\\nand false vocal cords in morbus maculosus Werlhofii.\\nReported in Arch. f. Ohr., xxxii, p. 59.\\nDie Krankh. des Ohres, p. 179.\\nE. Wagner. Deutsches Arch. f. klin. Med., xxxix, p. 475.\\nAtlas, PI. in, Fig. 7. 5 Atlas, PI. n.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0096.jp2"}, "97": {"fulltext": "HEMORRHAGIC DIATHESES. 9 1\\nMusser mentions inflammation of the throat simulating\\ndiphtheria in purpura. Kaposi saw an ulcer on the epi-\\nglottis. E. Wagner described extensive ulcerations in the\\nlarynx and pharynx and the laryngoscopic examination\\nshowed marked turgescence and intense redness of the epi-\\nglottis and aryepiglottic folds, and at the autopsy there were\\nfound ulcers varying in size from a split pea to a dime,\\nsome with a granulating and others with a smooth base,\\nsituated on the vocal cords, the aryepiglottic fold, near the\\nfree border of the epiglottis, and on the posterior and lateral\\nwalls of the pharynx and velum palati. Wagner regards\\nthese ulcers as the expression of a process analogous to a\\ncutaneous erythema.\\nMoos 4 and Haug are the only ones who have de-\\nscribed alterations in the ear. The former found a hema-\\ntotympanum with ecchymoses in the bulging tympanic\\nmembrane the latter, petechise in the cochlea and ex-\\nternal auditory meatus and on the tympanic membrane.\\nAccording to Litten,^ severe attacks of epistaxis occur\\nin scorbutus, which require tampons to control the hemor-\\nrhage and may lead to a fatal issue. The hemorrhage is\\nsaid to be more apt to occur after a slight injury to the\\nnasal mucous membrane or violent blowing of the nose\\nthan spontaneously.\\nTruckenbrodt reports the autopsy of a man who had\\ndied of scorbutus the patient had not been examined in\\nvivo, but had never complained of tinnitus or pain in the\\near. An extravasation of blood was found in the dermic\\nlayer of the right tympanic membrane the mucous mem-\\nbrane of the middle ear was puckered and contained a\\nhemorrhage, and a few petechial hemorrhages were found\\nin the mastoid antrum.\\n1 Schmidt s Jahrb., CCXL, p. 244.\\n2 Semon s Centralbl. f. Laryng., 11, p. 476.\\n3 Deutsches Arch. f. klin. Med., vol. XXXIX, p. 467.\\n4 Schwartze s Handb., I, p. 547.\\n5 Die Krankh. des Ohres, p. 178.\\n6 Nothnagel s Spec. Path. u. Thar., viu, i. Th., p. 298.\\nArch. f. Ohr., xx, p. 265.", "height": "3452", "width": "2084", "jp2-path": "rhinologylaryng00frie_0097.jp2"}, "98": {"fulltext": "V. CHRONIC CONSTITUTIONAL DISEASES.\\nJ. RACHITIS.\\nIt has always been the custom to regard laryngeal spasm\\nas a symptom of rachitis, but in recent years a literary con-\\ntroversy was provoked by the writings of Escherich and\\nLoos,i and there is now a movement in favor of treating\\nlaryngeal spasm as a symptom of tetany, denying any\\netiologic relation with rachitis.\\nAn analysis of all reported cases, however, shows\\nbeyond a doubt that rachitis exists in the great majority\\nof cases of laryngeal spasm, three-fourths of all cases\\naccording to some authorities, 90^ according to others,\\nand it is preposterous to ascribe this coincidence entirely to\\naccident. Loos himself, although he denies any causal\\nrelationship, states that the children affected with spasm of\\nthe glottis as a rule exhibit distinct signs of rachitis.\\nLaryngospasm, or spasm of the glottis, is an expiratory\\napnea occurring usually in children under two years of age.\\nThe attacks come on suddenly, without ascertainable cause,\\nlast from a few seconds to about half a minute, and end\\nabruptly, with a deep whistling or with several rapid,\\nsuperficial inspirations, after which quiet breathing is re-\\nstored. The child assumes a rigid attitude, with head\\nthrown back, eyes fixed and staring upward, arms extended,\\nand hands clenched the face becomes cyanotic and wears\\na look of extreme fright in short, we have the terrifying\\npicture of complete asphyxia. But the attack, although it\\nseems very alarming, usually subsides, and only in rare\\ninstances terminates fatally.\\nThe whole clinical picture shows that we have more\\nthan a simple spasm of the adductors of the vocal cords\\nto deal with, in which the dyspnea is due solely to occlusion\\nof the glottis. In the latter form which we observe, for\\ninstance, after endolaryngeal interference the integrity\\n1 Deutsches Arch. f. klin. Med., vol. L.\\n92", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0098.jp2"}, "99": {"fulltext": "RACHITIS. 93\\nof the respiratory muscles is retained, as we see by the dis-\\ntinct voluntary inspiratory movements but in laryngismus\\nstridulus of infants the expiratory muscles and the dia-\\nphragm are also involved in the spasm. It is, therefore, not\\na spasm of the larynx, but, to quote Rehn,i a spastic\\nsymptom-complex, for which no appropriate name has\\nas yet been discovered. The term tetanus apnoicus\\ninfantum, suggested by Elsasser,^ has the objection, in\\nthese days of controversy on the subject of tetany and\\nrachitis, of appearing to take the etiology for granted and\\nOppenheimer s 3 asthma rhachiticum, while it has the\\nsame objection, is also misleading, as the condition it is in-\\ntended to designate in no way resembles asthma.\\nLaryngoscopic examination during the attack is out of\\nthe question, and the assumption that the glottis is convul-\\nsively closed during the attack rests on a purely speculative\\nbasis. Schrotter, who is an adept in laryngoscopic\\ntechnic, says that spasm of the glottis is not a subject for\\nlaryngoscopic examination, from which it may be inferred\\nthat he never saw a laryngeal image in this affection, and\\nit is therefore the more surprising that Lori,^ without even\\nalluding to the difficulties attending the examination, and\\nthe possibility of failure, gives the following description\\nDuring the attack I always found the rima glottidis tightly\\nclosed, but the closure in every case was effected by the\\ntrue vocal cords alone, without the aid of the false cords.\\nThe epiglottis was always depressed, as is constantly the\\ncase in very young children, except when they are crying\\nin a very high key, or choking or drawing breath with a\\nwhooping sound but the depression was never complete,\\nso that in most cases I could see the posterior segments of\\nboth vocal cords, and in some instances the entire posterior\\nhalf. I have never seen the epiglottis wedged in between\\nthe arytenoid cartilages.\\nVarious views have been advanced on the mode of origin\\nof spasm of the glottis. Some seek the cause in rachitic\\nchanges and the rachitic diathesis others in disturbances\\n1 Berlin, klin. Wochen., 1896, No. 33.\\n2 Quoted by Flesch, Gerh. Handb. der Kinderkrankh., p. 289.\\n3 Deutsches Arch. f. klin. Med., .XXI, p. 559.\\n4 Krankh. dcs Kehlkopfes, 1st ed., p. 386.\\nVeranderungen des Rachens, des Kehlkopfes und der Luftrohre, p. 99.\\nKassowitz, Wien. med. Wochen., 1893, P- 545- Vierordt, Noth-\\nnagel s Spec. Path. u. Ther., vol. vii, i. Th.", "height": "3456", "width": "2044", "jp2-path": "rhinologylaryng00frie_0099.jp2"}, "100": {"fulltext": "94 CHRONIC CONSTITUTIONAL DISEASES.\\nof the digestion more or less closely dependent on rachi-\\ntis still others in a nervous predisposition and some,\\nfinally, reject rachitis altogether and attribute the phenom-\\nenon to tetany.^\\nRehn takes a middle view, and attributes the spasm to\\nirritation of the sensory fibers of the vagus by toxins elab-\\norated in the stomach as the result of faulty metabolism.\\nAs the origin of this symptom-complex which, although\\nits etiology is still very obscure, has been termed infantile\\ntetany has been thought by some authorities to be due\\nto the action of toxins manifesting itself in digestive dis-\\nturbances, we see in this proposition of Rehn s the possibility\\nof a uniform etiology for that hitherto antagonistic tripod\\nrachitis-laryngospasm-tetany.\\nIt is admitted by everybody that malnutrition is a pre-\\ndisposing factor, or even an exciting cause, of spasm of the\\nglottis, and it has been found by experience that the most\\nsuccessful treatment of laryngospastic attacks consists in\\nregulating the nutrition.\\nSince the spasm is not limited to the larynx, but merely\\nforms a part of the general convulsions which play so im-\\nportant a part in rachitis, it can not be regarded as the\\neffect of irritation of a definite portion of the peripheral or\\ncentral nerve paths presiding over the action of the laryngeal\\nmuscles and until the etiology is better understood, it is\\nidle to suppose a cortical irritation or a lesion in the me-\\ndulla or in the pneumogastric. There is little foundation\\neither for Kassowitz s theory that spasm of the glottis is\\ndue to irritation of the cortical centers (described by Semon-\\nHorsley, Krause, and Unverricht-Preobraschensky) by a\\nhyperemic, inflammatory condition of the rachitic cranial\\nbones, or for that of Oppenheimer, which assumes some\\nirritative action of the jugular vein on the vago-accessorius\\nnucleus due to rachitic alterations at the jugular foramen.\\nThe most we can say is that spasm of the glottis in chil-\\ndren is the expression of an abnormal excitability of all the\\nrespiratory muscles, and that it often occurs, in association\\nwith tetanic symptoms (Chvostek, facial nerve phenome-\\n1 P lesch, Spasmus glottidis, in Gerh. Handb. der. Kinderkrankh.,\\n1879. Rehn, Berlin, klin. Wochen., 1896, No. 33. Hauser, Berlin, klin.\\nWochen., 1896, No. 35.\\nFlesch, Spasmus glottidis, in Gerh. Handb. der Kinderkrankh.,\\n1879.\\n3 Loos, Deutsches Arch. f. klin. Med., L, p. 169.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0100.jp2"}, "101": {"fulltext": "RACHITIS. ACROMEGALY. 95\\nnon), in rachitic subjects as the result of digestive dis-\\nturbances.\\nOf the relations between racliitis and aural disease noth-\\ning positive is known. The attempt to establish a connec-\\ntion between the former and purulent or catarrhal disease\\nof the middle ear has been made, but there is not a shadow\\nof proof to justify it. Such superficial statements as those\\nmade by Ertelberg, and faithfully repeated by Haug, are\\nof no value whatever; for the mere fact that among 250\\nrachitic children there were 25 cases of middle-ear disease\\nand only 27 absolutely normal tympanic membranes,^\\nespecially when the histories were not altogether negative\\nin the matter of previous infectious diseases, or that among\\n180 rachitic children purulent otitis media was found 16\\ntimes, otitis externa twice, eczema 9 times, otitis media\\ncatarrhalis 19 times, and catarrh of the tubes even more\\nfrequently (Haug^), is not in the least significant, as the\\nsame conditions are found, even without rachitis, in the\\nchildren who make up ordinary polyclinic material.\\nIt is quite possible that the general nutritive disturbances\\nand frequent attacks of bronchial catarrh which characterize\\nthe course of rachitic disease tend to produce a favorable\\nsoil for the development of aural complications, but we are\\nvery far from possessing any scientific proof that such is\\nactually the case.\\n2. ACROMEGALY.\\nIn acromegaly a hyperplasia of the submucous and\\nintermuscular connective tissue takes place, which pro-\\nduces certain alterations in the bones and cartilages. These\\nchanges affect more or less the nose, pharynx, and larynx,\\nand to some extent the ears.\\nBesides the external changes in the nose, which consist\\nin an abnormal increase of the cartilaginous and bony por-\\ntions, there is hypertrophy of the nasal mucous membrane.\\nThe tongue becomes enormously enlarged, and hyperplasia\\nof the submucous tissue in the soft palate takes place. The\\n1 Jahrb. f. Kinderheilk., xxvii, p. 96.\\n2 Die Krankh. des Ohres, etc., p. 173.\\n3 Sternberg, Zeitschr. f. klin. Med., xxvii, p. 86. Sternberg, Noth-\\nnagel s Spec. Path. u. Ther. vii, 2. Th.", "height": "3456", "width": "2048", "jp2-path": "rhinologylaryng00frie_0101.jp2"}, "102": {"fulltext": "96 CHRONIC CONSTITUTIONAL DISEASES.\\nlarynx is increased in size, as we can determine by external\\npalpation, and the voice is unusually deep and rough and\\nis stronger than normal. As there is no visible alteration in\\nthe laryngoscopic image, these phenomena are probably\\ndue to the general enlargement of the larynx, to hyper-\\ntrophy of the mucous membrane, and in part to increased\\nresonance of the voice from the greater volume of air in the\\nchambers of the upper air-passages (Marie).\\nSternberg describes diminutions in the caliber of the\\nexternal auditory vieatus from exostoses, quotes similar ob-\\nservations by Osborne, and adds that the bony portion of\\nthe meatus was unusually deep on account of hyperostosis of\\nthe bony parts of the skull. As these alterations have been\\nfound in acromegalic skulls in several instances, Stem-\\nberg believes himself justified in including them among the\\nconstant objective symptoms of the disease.\\n3, DIABETES MELLITUS.\\nIn diabetes the dryness of the oral mucous membrane of\\nwhich the patients complain finds its counterpart in a dry\\npharyngitis with redness of the mucous membrane, which,\\nHke chronic pharyngitis, is regarded by M. Schmidt^ as an\\nearly symptom of the disease. Lori claims that the same\\ncondition of dr ^ness and atrophy may be found in the\\nlarynx. In this connection it is worth mentioning that\\naphasia has occasionally been noted in association with\\ndiabetic hemiplegia F. A. Hoffmann includes paralysis\\nof the vocal cords among diabetic palsies, but I have not\\nbeen able to find any case of it in the literature.\\nFurunculosis and pruritus occur in the auditory meatus\\nas they do in the external skin (Wolf,^ Haug If the\\nformer recurs frequently, it is said to be a sign of diabetes\\nbut the diagnostic value of this statement is open to ques-\\ntion when we contrast the frequency of furunculosis in the\\n1 Zeitschr. f. klin. Med., xxvii, p. 139.\\n2 Krankh. d. ob. Luftwege, 2d ed., p. 226.\\n3 Veranderungen des Rachens und Kehlkopfes, p. 97.\\nCharcot, Arch, de neurolog., May, 1890. Blanchet, Gaz. des\\nhopit., 1885.\\nConstitutionskrankheiten, p. 316.\\nArch. f. Ohr. p. l66. Die Krankh. des Ohres, etc.", "height": "3468", "width": "2180", "jp2-path": "rhinologylaryng00frie_0102.jp2"}, "103": {"fulltext": "DIABETES MELLITUS. 9/\\near with the rarity of furunculosis of the auditory meatus\\nin diabetes. I have never observed it myself, nor seen it\\nmentioned in any good case history. Blau^ reports a case\\nin which attacks of furunculosis kept recurring for years\\nwithout his ever being able to demonstrate any signs of\\ndiabetes. Neuralgia of the mastoid process is mentioned\\namong the complications of diabetes by Brieger^ it is,\\nhowever, of secondary importance.\\nOn the other hand, the middle ear and mastoid cells are\\nsometimes attacked by a disease which presents certain\\ncharacteristic appearances, and justifies the assumption that\\nit is more or less closely related to diabetes. Toynbee de-\\nscribes a case of suppuration of the mastoid process in\\nwhich extensive carious destruction of the structure was\\nfound after death, without, however, referring it to the dia-\\nbetes which was present at the same time. How recent\\nour knowledge of diabetic ear disease really is appears from\\nthe remarks of Senator^ and Blau, published in 1876 and\\n1883 respectively, to the effect that loss of hearing and\\nimplication of the organ of hearing generally must be very\\nrare in diabetes, to judge from the lack of reported experi-\\nences. Naunyn,* on the contrary, in his recently published\\nwork on diabetes devotes an entire section to diabetic ear\\ndiseases, showing how much our knowledge of such com-\\nplications has advanced in the short space of twelve years.\\nTo Kirchner,^ and even more to Kuhn^ and Korner, we\\nowe the first discussions on the subject, and to-day we have\\na goodly number of instructive observations at our disposal\\nwhich afford certain definite conclusions. The disease is\\ncharacterized by the sudden onset of violent pain, localized\\nin the ear or, more frequently, in the mastoid. The\\npatients are usually quite unable to give any cause for the\\npain. In some cases the affected ear was quite healthy\\nbefore the attack in others, there is a history of antecedent\\npurulent otitis media. After a longer or shorter interval of\\npain, usually on the third to the fifth day, perforation takes\\nplace spontaneously and pus is discharged. The secretion\\ncontains nothing that may not be present in any acute sup-\\nArch. f. Ohr., xix, p. 208. Klin. Beitr. f. Ohr., p. 115.\\nIn Ziemssen s Handbuch.\\nNaunyn, Nothnagel s Spec. Path. u. Ther., vol. vii, 6. Th.\\nIMon. f. Ohr., 1884, p. 221.\\n.\\\\rch. f. Ohr., xxix. Arch. f. Ohr., xxix.\\n7", "height": "3464", "width": "2084", "jp2-path": "rhinologylaryng00frie_0103.jp2"}, "104": {"fulltext": "98 CHRONIC CONSTITUTIOXAL DISEASES.\\npuration of the middle ear. It may be a mixture of blood\\nand serum, seropurulent, or, in a long-standing case, muco-\\npurulent. Raynaud s 1 case began as a copious hemor-\\nrhage from the auditory meatus, which was followed by\\nsuch an abundant flow of serosanguineous, and later serous,\\nsecretion, as is ordinarily seen only in the discharge of\\ncerebro-spinal fluid after trephining, and finally went on\\nto the purulent stage.\\nIn a remarkably short time the morbid process in diabetic\\notitis spreads to the bones. The rapidity with which the\\ndisease is followed by carious disintegration of the mastoid\\ncells is commented upon by Toynbee and, after him, by\\nmany other observers it is even greater, according to\\nKuhn, than in the most malignant cases of diphtheria.\\nWithin the short space of two or three days the interior of\\nthe mastoid process in many cases is converted into a large\\ncavity, filled with pus and granulations mixed with seques-\\ntra of bone, and in a few weeks the transverse sinus and\\ndura mater of the posterior fossa of the skull are laid bare.\\nRaynaud found, when his case came to the autops}% the\\nmastoid cells filled with a reddish fluid mixed with inspis-\\nsated pus, while the mucous membrane was soft and red\\nin Kuhn scase the bony parts that had escaped destruction\\nwere inflamed and so soft that they could be molded and\\ncut like wax. I myself operated on two cases in which\\nthe spongy tissue was much discolored and scantily\\nstreaked with pus the bone was very anemic and brittle\\nfrom necrosis, suggesting the appearance of a preparation\\nwhich has been in alcohol for a long time. In several\\nplaces there were large sequestra, which could be easily\\nremoved from the surrounding tissue.\\nAre these clinical pictures such as to justify the assump-\\ntion of a diabetic form of middle-ear disease, since their\\nonly deviation from an ordinary case of purulent otitis\\nmedia lies in the rapidity of the course and the early\\nimplication of the bone We can not deny that this is\\nan important element, in spite of Brieger s opinion that\\nthe intensity of the process is not sufficient warrant for\\nassuming the existence of a special form of disease. Haug\\ntested the aural secretion for sugar, and found it at least\\nqualitatively positive (by what methods Raynaud, on\\n1 Ann. des mal. de I oreille, 1881, p. 63.\\n2 Klin. Beitr. zur Ohrenheilk., p. 112. Lg^^ ^it., j). 166.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0104.jp2"}, "105": {"fulltext": "DIABETES MELLITUS. 99\\nthe Other hand, found albumin, but no sugar, in the serous\\nsecretion. As the most various secretions and excretions\\nof the body have been found to contain sugar in diabetes,\\nHaug s positive results can not weigh very heavily, while\\nRaynaud s negative result is interesting from the fact that\\nan examination of the fluid taken from the edematous\\nscrotum in the same case showed 0.7^ sugar.\\nThe point at which perforation of the tympanic mem-\\nbrane occurs varies, and is of no value for diagnosis, as it\\noccurs indifferently in the anterior or posterior half of the\\nmembrane (Raynaud).\\nThe course of the suppurative process is characterized,\\nas has been stated, by rapidity of extension to the bone.\\nArguing from the extensive and rapid destruction of the\\nmastoid processes, with comparatively mild disease of the\\nmiddle ear, Kuhn and Korner have advanced the opinion\\nthat the process in diabetic ear disease begins as a primary\\nosteitis of the mastoid, and extends secondarily to the tym-\\npanum, thus bringing about perforation.\\nIt is quite natural that the original opponents of the\\ndoctrine of a primary mastoid osteitis should oppose such\\nan assumption, but they were reinforced by others (David-\\nson i), who based their objections on a review of the liter-\\nature.\\nIn favor of Kuhn s theory we have the clinical features\\nand course of the disease, especially the circumstance\\n(insisted on by Korner) that the changes found in the\\nmiddle ear bear no proportion to the intense degree of\\ndestruction in the mastoid process, and the flow of pus\\nsubsides as soon as the diseased bone is opened, as I have\\nmyself observed in one of the patients I operated on.\\nAnother argument in favor of Korner s view is found in\\nthe necrotic, gangrenous appearance of the bone, which I\\nhave mentioned, and which was equally marked in both\\nmy cases a dry, gangrenous appearance of the tissues\\nbeing a well-recognized feature of the diabetic diathesis.\\nOn the other hand, it may be urged against the fore-\\ngoing theory that the resisting power of the tissues to\\nbacterial invasion is diminished by the presence of sugar,\\nwhich affords a favorable soil for the growth of pathogenic\\nmicro-orcranisms. so that an accidental infection of the mid-\\n1.^4\\nBerlin, klin. Wocben., 1894, No. 51.", "height": "3448", "width": "2120", "jp2-path": "rhinologylaryng00frie_0105.jp2"}, "106": {"fulltext": "lOO CHRONIC CONSTITUTIONAL DISEASES.\\ndie ear finds the most favorable conditions for the spread\\nof the disease. The comparative benignity of the middle-\\near affection can be explained by the drainage facilities\\nthrough the perforated membrane, which are wanting in\\nthe mastoid cells, where the carious process accordingly\\ncontinues its work of destruction. It should also be\\nsaid, in justice to the opponents of a primary osteitis, that\\nthere are cases in which the bone disease appeared late in\\nthe course of a chronic purulent otitis media, just as there\\nare others in which an acute suppuration terminated favor-\\nably without involving the mastoid cells.\\nIn this connection a case of Naunyn s is peculiarly in-\\nteresting. In a severe case of diabetes a violent otitis media\\ndeveloped on the fourth day the patient, a boy of eight,\\ncomplained of severe headache, and there were marked\\ncerebral symptoms, with vomiting, great hebetude, and\\nlarge respiration, as in diabetic coma, Paracentesis was\\nperformed on the fifth day and a large quantity of pus was\\nevacuated recovery followed in a few days. I once saw\\na similar case in a boy of fourteen, with grave diabetes,\\nwho experienced pain in the ear and a slight otorrhea two\\ndays before the occurrence of diabetic coma. On the fol-\\nlowing day, while the coma continued, the flow subsided,\\nand the ear-drums, which were perforated and showed the\\nscars of former lesions, were seen to be slightly swollen\\nand of a uniform bluish-red color, which soon disappeared.\\nSix months later, the same ear was attacked by acute\\nmiddle-ear inflammation, necessitating paracentesis after\\nthe discharge had lasted about a week the patient again\\nrecovered.\\nIn reviewing the facts before us, it appears that there are\\nunquestionably cases of simple diabetic otitis which prove\\nthe existence of a diabetic disease localized in the middle\\near but it is equally certain that there are many cases,\\nreported by Kuhn, Korner, and others, which as emphat-\\nically justify the assumption of a primary osteitis, espe-\\ncially since we possess the description of a case of diabetic\\nosteitis and multiple periosteitis elsewhere in the body,\\nwhich confirms the possibility of such primary bone disease\\nin diabetes.\\nHo\\\\ve\\\\ er that may be, whether we have to deal with a\\n1 Diabetes in Nothnagel s Spec. Palh. u. Then, p. 287.", "height": "3468", "width": "2180", "jp2-path": "rhinologylaryng00frie_0106.jp2"}, "107": {"fulltext": "DIABETES MELLITUS. 1 01\\nprimary osteitis or a primary otitis media, the occurrence of\\nsuppuration from the ear in diabetes constitutes a grave\\ncompHcation, which must be combated from the outset with\\nall the means at our command. There was a time when\\noperative treatment of diabetic otitis media was thought to\\nbe contraindicated, because a few deaths had been reported.\\nIf the wound is properly treated, this fatal result must be\\ncharged to postoperative diabetic coma (two out of four\\ncases by Bucki), and not, so far as I can see, to the opera-\\ntion itself^ (one case reported by Sheppard died of inter-\\ncurrent erysipelas and purulent meningitis 3). As it is well\\nknown that the morbid process in the bone spreads very\\nrapidly in diabetes, without giving rise to any pronounced\\nsubjective symptoms, trephining of the mastoid process is\\nindicated whenever the ominous sinking of the posterior wall\\nof the meatus has been present for some time, or deep ab-\\nscesses have made their appearance in the mastoid process\\nitself. A liigli sugar percentage is, however, an absolute\\ncontraindication, as it enhances the danger of postoperative\\ndiabetic coma this is probably the direct result of chloro-\\nform narcosis, which is followed by a rise in the percentage\\nof sugar, as observed in Korner s cases and in my own that\\nterminated favorably (from 0.2 to 1.85^ in my cases).\\nSince, therefore, the danger lurks in the anesthesia as well\\nas in the operation itself, one should never operate without\\nfirst reducing the sugar as much as possible by a long\\ncourse of dieting. Recent experience teaches that in this\\nway we also diminish the danger of sepsis, which, according\\nto Schwartze,^ renders the prognosis as to life a doubtful\\none, even in mild grades of diabetes, because there is\\ndanger of an unfavorable postoperative course, ending in\\nsepsis. At all events, it is not great enough to forbid\\noperative interference, any more than the imaginary danger^\\nof uncontrollable hemorrhage, which appears to be founded\\non a case of Moos, in which the operation was inter-\\nrupted by an uncontrollable hemorrhage, lasting three-quar-\\nters of an hour its origin is not stated, and who is to say\\nthat it was due to the diabetes\\n1 Arch. f. Ohr., XL, p. 138.\\n2 I recently saw a death during coma on the fourth day after the operation\\nnt the autopsy a large abscess was found in the deep muscles of the neck.\\n3 Zeitschr. f. Ohr., xxix, p. 268.\\nHandb., 11, p. 841. Haug, Krankh. des Ohres, p. 167.\\n6 Deutsche med. Wochen., 1888, No. 44.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0107.jp2"}, "108": {"fulltext": "102 CHRONIC CONSTITUTIONAL DISEASES.\\n4. GOUT,\\nThe most familiar examples of gouty alterations are the\\ncatarrhal phenomena in the pharynx and larynx. They\\noccur most frequently in the form of angina uratica, with\\ndark-red discoloration of the mucous membrane of the\\nuvula, soft palate, the two pillars of the fauces, and the\\ntonsils. Sometimes an acute edema is superadded, as has\\nbeen observ^ed by Vaton,i M. Mackenzie, and Danziger.\\nSolis-Cohen insists on the frequency of pains and abnor-\\nmal sensations in circumscribed areas of the mucous mem-\\nbrane which appeared to be perfectly healthy, and in which\\nhe found only dilated vessels or a dark-red discoloration.\\nAcute attacks of angina uratica always make their appear-\\nance two or three days before a typical outbreak of gout,\\nand subside as soon as the gouty joint-affection has\\ndeclared itself There is also, as a rule, chronic pharyn-\\ngeal catarrh, associated sometimes with tophi (Litten^).\\nGouty disease of the larynx is rarely observed. It mani-\\nfests itself in a great variety of forms, the inflammatory\\nredness and swelling being often attended with the deposi-\\ntion of urates in the joints and cartilages. The mucous\\nmembrane of the vocal cords is involved, as well as that of\\nthe rest of the larynx, and not infrequently there are cir-\\ncumscribed swellings in special portions of the larynx.\\nThus, in a gouty patient I have seen an infiltration of the\\nright ventricular band persist for many years following a\\nlaryngitis which had come on after an acute attack of gout.\\nM. Mackenzie observed a gouty inflammation of the left\\nfalse vocal cord, with granulations, which had been diag-\\nnosed as cancer. Virchow, Litten, Morell, and Mac-\\nkenzie saw gouty deposits in one case a white body as\\nlarge as the head of a pin, at the posterior extremity of the\\nright vocal cord at other times, as infiltrations in the cords\\nand articulations of the larynx. In Mackenzie s case it was\\nthe crico-arytenoid articulation that was affected, and the\\nresulting imperfect approximation of the vocal cords gave\\nrise to aphonia. Litten found postmortem marked infiltra-\\n137-\\nSemon s Centralbl.,\\nVIII, p. 85.\\nJourn. of Laryngol.,\\n1889, p. 313.\\n3 Mon. f. Ohr., 1895,\\np. 14.\\nSemon s Centralbl.,\\nXI, p. 318. 5\u00c2\u00abVirch. Arch.,\\n66.\\n6 Loc. cit.\\nVirch. Arch.,\\n44, P", "height": "3468", "width": "2188", "jp2-path": "rhinologylaryng00frie_0108.jp2"}, "109": {"fulltext": "GOUT. 103\\ntion of the same joints and their hgaments (the cHnical\\nappearance of the larynx is not given). The gouty process\\nin the cartilages not infrequently goes on to ossification.\\nOf the gouty alterations in the organ of hearing those\\nwhich affect the concha have been known a long time, and\\nevery physician is familiar with them. In nearly all of\\nGarrod s case histories we find mention of small gouty\\nnodules in the concha, sometimes on the posterior surface,\\nmore commonly on the helix and fossa navicularis. The\\ncartilage is said to be the seat of a peculiar induration and\\nof the formation of small softening foci. In some cases\\nthere is inflammation of the external auditory meatus (pru-\\nritus). The statement that exostoses in the external meatus\\nare due to gout (Kirchner) has never been proved. Judg-\\ning from the frequency of complaints from arthritic patients\\nto the effect that they suffer from difficulty in hearing,\\nespecially progressive loss of hearing and tinnitus, we must\\ninfer that other lesions occur in the organ of hearing. We\\nare not inclined to accept angina as the explanation of the\\nloss of hearing in gouty subjects, as suggested by Haug\\nfor there really is not any form of aural complication that\\nmight not occasionally be referred to a hypertrophic phar-\\nyngeal catarrh. Ebstein s arguments in his treatise on\\nAural Vertigo seem to us more plausible. 2\\nThe clinical picture of gouty ear disease, which, as has\\nbeen said, has for its principal features a progressive dimin-\\nution of the hearing, with tinnitus and vertigo, may be ex-\\nplained in as many different ways as there have been causes\\nassigned for gout itself. It is still a question whether the\\ngouty process is in the middle or in the internal ear we\\ncan not say positively that the chalky deposits seen during\\nlife on the tympanic membranes of gouty subjects consist\\nof urates, for the manner in which the morbid process\\naffects the organ of hearing is very imperfectly understood.\\nA specific gouty affection of the organ of hearing may be\\nsituated in the tympanic membrane, where the resulting\\nfunctional disturbance would probably be slight, or in the\\nchain of ossicles in the form of arthritic disease. Unfortu-\\nnately, we are without anatomic experience on this point,\\nand even the clinical stock of observations at our command\\nis ver}^ limited. A case history, to have any statistical\\n1 Deutsche Uehersetzung von Eisenmann, p. loi.\\nArch. f. klin. Med., 58, p. I.", "height": "3448", "width": "2120", "jp2-path": "rhinologylaryng00frie_0109.jp2"}, "110": {"fulltext": "104 CHRONIC CONSTITUTIONAL DISEASES.\\nvalue in showing a connection between gout and diseases\\nof the middle ear, should contain not only the results of\\nan accurate functional examination, but also some infor-\\nmation in regard to the movability of the chain of ossicles.\\nBrieger reports a case in which the usual prodromata\\nof an attack of gout were followed by an acute otitis media,\\nwith marked bulging and swelling of the tympanic mem-\\nbrane, and interprets it as an arthritic process in the artic-\\nulation, between the malleus and incus. According to\\nAgnano,2 persons with the gouty diathesis usually develop\\ndeafness between the ages of fifteen and twenty.\\nStill more uncertain are we whether the labyrinth is ever\\nattacked by the gouty process. Since the imaginary hem-\\norrhages which are sometimes supposed to form the basis\\nof the phenomena in the labyrinth, mentioned previously\\nunder the name of Meniere s symptom-complex, must be\\nrejected as being without anatomic foundation, the most\\nnatural explanation of these symptoms is suggested by the\\nvascular changes which are a constant feature of gout, and\\nwe are therefore inclined to seek the cause of these aural\\nphenomena in a primary arteriosclerosis. This view ap-\\npears to be supported not only by the observations of\\nEbstein, but also by de Lacharriere s statement that aural\\nphenomena are most common in persons who, besides being\\nsubject to attacks of genuine articular gout, show their in-\\nherited gouty tendencies in attacks of gastralgia, dyspepsia,\\nmigraine, and neuralgia. Ebstein is right, no doubt,\\nwhen he says that it must, for the present, remain an\\nopen question whether the ear disease in gouty subjects is\\nto be referred to the primary disease, to obesity, or to car-\\ndiac changes the result of overindulgence in alcoholic\\nbeveraees.\\nICTUS LARYNGIS OCCURRING IN THE [COURSE OF\\nOBESITY, GOUT, AND DIABETES.\\nThat there is a certain relationship between the three\\nconstitutional anomalies, obesity, gout, and diabetes, ap-\\npears from the way in which they manifest themselves\\nin individual members of a gouty family now under one\\nform, now under another. They produce chronic catarrhal\\n1 Klin. Beitr. zur Ohrenheilk., p. 77.\\n2 Rev. hebd, de lar., 1896, p. 703.", "height": "3468", "width": "2184", "jp2-path": "rhinologylaryng00frie_0110.jp2"}, "111": {"fulltext": "ICTUS LARYNGIS. IO5\\nchanges in the mucous membranes of the upper air-pas-\\nsages, and a peculiar form of neurosis in the larynx, which\\nhas been called ictus laryngis. Their relation to aural\\nvertigo, tinnitus, and progressive chronic loss of hearing\\nhas been sufficiently discussed under the head of gout,\\nwhere reference was made to Ebstein s treatise on the sub-\\nject.\\nWe shall, however, give a short description of what\\nis known as laryngeal vertigo, a condition which more\\nfrequently comes under the observation of the general\\npractitioner than that of the laryngologist.\\nBy ictus laryngis is meant a sudden attack of syncope of\\nshort duration, preceded usually by a slight paroxysm\\nof coughing. It was first described by Charcot in 1876,\\nthen by two French writers, Garel and Collet, and by the\\nItalian, Massei, while in Germany up to the present\\ntime only a very few observations have appeared (for in-\\nstance, Schadewaldt s). Charcot proposed the term vcrtige\\nlarynge, and it is still found in many text-books on laryn-\\ngology, although vertigo itself is one of the rarest features\\nin the symptom-complex Kurz s suggestion of lipothymia\\nlaryngea (laryngeal syncope) has not met with a very\\nfavorable reception. The term laryngeal crisis, which has\\nalso been suggested, would only cause a confusion of ideas,\\nbecause it is applied to an entirely different symptom-com-\\nplex, which, as we shall see, is peculiar to tabes dorsalis.\\nThe attack occurs without warning in the midst of per-\\nfect health it may come on while the subject is working,\\nsitting, standing, walking, or even lying dow^n. Quite fre-\\nquently the attack comes on after a meal sometimes the\\npatient is aAvakened at night by a slight cough, sits up\\nin bed, and has an attack. The description usually given\\nis that the patient feels a tickling sensation in the throat, has\\na slight attack of coughing, and loses consciousness for a\\nfew seconds the breathing stops and the face becomes\\ncyanotic. If the subject is standing at the time, he falls to\\nthe ground if he is sitting, the head falls forward on the\\nchest. In a few instances the attack was attended with\\ntwitching in the muscles of the upper extremity or of the\\nface, but never with biting of the tongue. The duration is\\nvery short, usually a few seconds the patient does not\\n1 Deutsche med. Wochen., 1S93.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0111.jp2"}, "112": {"fulltext": "I06 CHRONIC CONSTITUTIONAL DISEASES.\\nfeel unwell after it is over, and goes on with whatever\\nhe is doing at the time as if nothing had happened. When\\nquestioned, he says he has had an attack of coughing, but\\ndoes not complain of any other symptom.\\nThe cases reported nearly all refer to men in the fifth\\ndecade of life. The predisposing causes usually given are\\nchronic catarrh of the upper air-passages, chronic phar-\\nyngitis and laryngitis, occasionally chronic catarrh of the\\nlungs. Schadewaldt emphasizes chronic alcoholism as a\\npredisposing factor, while Garel and Collet attach great\\nimportance to constitutional diseases, as gout, obesity, and\\ndiabetes. Cardiac changes play an important role Schade-\\nwaldt found the heart hypertrophied (cor adiposum) in five\\nof his seven cases. The clinical picture aroused the suspi-\\ncion in the minds of the observers that they had to deal with\\nan epileptic attack, but subsequent experience has failed to\\nestablish any connection whatever with epilepsy. From\\nthe fact that an attack can be brought on by introducing a\\nsound into the larynx, and controlled by cocainizing the\\nmucous membrane, it was argued that it must be a kind of\\nreflex neurosis, but the descriptions offered for the reflex\\narc rest on a purely hypothetic basis. It seems to be\\nproved by the fact that the attack begins with a tickling\\nand burning sensation in the throat, that it is due to irrita-\\ntion of the superior laryngeal nerve. This being the case,\\nit is supposed that the vasomotor center in the medulla is\\nstimulated through the depressomotor fibers of the vagus,\\nand a fall in the blood pressure takes place at the same\\ntime the irritation is communicated to the cardiac inhibitory\\ncenter, so that the action of the heart is diminished. These\\ntwo factors cooperating to produce anemia of the brain,\\nfurnish an explanation of the loss of consciousness, which\\nis characteristic of the attack.\\nSpastic phenomena are altogether wanting, although\\nsome observers attempt to explain the attacks as laryngeal\\nspasm, and it is doubtful whether we are, after all, justi-\\nfied in regarding ictus laryngis as a local neurosis of the\\nlarynx. The circulatory system unquestionably plays an\\nimportant part in the etiology, for many of the cases were\\ncomplicated with heart disease, and a marked predisposi-\\ntion to the attacks was observed in plethoric persons and in\\nthose addicted to good living and alcoholic abuse. The\\nfrequent occurrence of the attacks during the digestive", "height": "3468", "width": "2132", "jp2-path": "rhinologylaryng00frie_0112.jp2"}, "113": {"fulltext": "ICTUS LARYNGIS. lO/\\npause immediately following a meal also points to the cir-\\nculatory system. Schadewaldt reports a case which ended\\nfatally the patient had had an attack of ictus laryngis on\\nthe previous day, after supper, but felt so well on the day\\nof his death that he took his customary horseback ride.\\nIn the afternoon, however, while engaged in conversation\\nwith a companion, he had another slight attack of coughing,\\nlost consciousness, fell to the ground, and died instantly,\\nwithout exhibiting any other symptoms. No autopsy is\\ngiven, but the history of cardiac hypertrophy in a robust,\\nalcoholic individual, fifty-nine years old, justifies the diag-\\nnosis of death from heart failure.", "height": "3432", "width": "2120", "jp2-path": "rhinologylaryng00frie_0113.jp2"}, "114": {"fulltext": "VI. ACUTE INFECTIOUS DISEASES.\\nJ. MEASLES.\\nCatarrhal disease of the mucous membranes in the\\nupper air-passages constitutes an integral part of the chnical\\npicture in measles. It takes the form of an exanthema,\\nwhich always precedes the skin eruption, and is absent, ac-\\ncording to Monti, 1 only in children who are very anemic\\nor weakened by previous disease.\\nEven during the prodromal stage of measles there is a\\ndark-red discoloration of the pharynx and palate it is\\nirregularly distributed, and is most marked on the lateral\\nand posterior pharyngeal walls and on the pillars of the\\nfauces. The discoloration is also seen on the mucous mem-\\nbranes of the cheeks and lips, where it constitutes Koplick s\\nsign. The redness is accompanied by a feeling of dryness\\nin the throat on the following day the mucous membrane\\nappears moist and the true exanthema begins to break out.\\nThis exanthematous eruption is most marked on the pillars,\\nwhere it takes the form of small isolated or confluent\\nmacules or papules of varying size, elevated above the level\\nof the mucous membrane (Monti). The skin eruption\\nappears usually from twelve to twenty-four hours later, and\\nwith its appearance the patches begin to subside. In addi-\\ntion to the redness and swelling, Tobeitz observed a super-\\nficial slough, resembling that produced by a mild caustic,\\nwhich he interprets as an epithelial necrosis. Similar\\nappearances are seen in the larynx they also accompany\\nother catarrhal diseases, particularly influenza.\\nThe mucous membrane of the larynx presents a bright-\\nred color, in irregular patches, interspersed with fine granu-\\nlar nodules (Gerhardt). This variety of laryngitis usually\\nappears two or three days after the exanthematous erup-\\n1 Jabrb. f. Kinderheilk., vi, p. 22.\\n2 Deutsche med. Wochen., 1898.\\nArch. f. Kinderheilk., vni, p. 326.\\n108", "height": "3468", "width": "2180", "jp2-path": "rhinologylaryng00frie_0114.jp2"}, "115": {"fulltext": "MEASLES. 109\\ntioii, seldom later, and gives rise to hoarseness and cough\\nof a croupy character. The patches of epithelial necrosis\\nmentioned by Tobeitz take the form of erosions and shallow\\nulcerations on the posterior pharyngeal wall, and are sup-\\nposed by Gerhardt to be due to mechanical injury of the\\nalready loosened mucous membrane by the act of coughing.\\nCroupous laryngitis is a rare occurrence in measles. To-\\nbeitz saw evidences of very mild forms at autopsies, not\\nsevere enough to cause stenosis, rather a shallow croupous\\ndeposit the mucous membrane in these cases was of a\\nbright-red hue, but not much swollen, and the surface was\\ndeprived of its epithelium and in places necrotic. Compli-\\ncations of measles with diphtheria and true diphtheric\\nlaryngitis are not unknown.\\nThanks to trustworthy anatomic investigations, our\\nknowledge of ear diseases in the course of measles is more\\ncomplete than is the case in the other infectious diseases.\\nTo Tobeitz, Rudolf, Bezold, and Habermann we are in-\\ndebted for investigations on the cadavers of children which\\ngive us uniform results concerning the nature and mode of\\nspread of aural complications in measles. One valuable\\nfeature of these investigations especially of Bezold s, who\\nexamined a large number of cadavers is the fact that par-\\nticular attention was paid to the organs of hearing in those\\ncases which during life had presented few, if any, symptoms\\nof disease, so that an opportunity was afforded of studying\\nthe earliest stages of the alterations.\\nIn 16 cases examined by Rudolf (and tabulated under\\nBezold s direction), 17 by Bezold himself, 17 others by\\nTobeitz, 2 6 by Siebenmann,^ and 7 by Habermann, with\\nonly two exceptions there were found signs of an aaite\\notitis media, which must be regarded as a special localiza-\\ntion of the disease. It was found to persist for some time\\nafter the appearance of the eruption, for Bezold s cases\\nbelong to the period from the third to the thirty-third day\\nof the disease.\\nAccording to Bezold s description of these early appear-\\nances in disease of the middle ear and they can frequently\\nbe demonstrated in the first three days after the appearance\\n1 Zeitschr. f. Ohr., xxviii, p. 209.\\n2 Arch. f. Kinderheilk., in, 341.\\n3 Quoted from Bezold, Zeitschr. f. Ohr., vol. xxviil, p. 249.\\nSchwartze s Handb., vol. i, p. 261.", "height": "3456", "width": "2132", "jp2-path": "rhinologylaryng00frie_0115.jp2"}, "116": {"fulltext": "IIO ACUTE INFECTIOUS DISEASES.\\nof the eruption there is a diffuse injection and turgescence\\nof the mucous membrane, and the tympanic cavity contains\\nmore or less fluid. It is an important point that the dis-\\nease also extends to the lining of the mastoid antrum and\\ncells.\\nThe secretion in the tympanic cavity was never of the\\npurely serous type found in simple occlusion of the tubes,\\nbut was mucopurulent or seropurulent or consisted of pure\\npus. The injection of the blood-vessels was irregularly\\ndistributed over the mucous membrane in the form of\\npatches and minute, punctiform extravasations. Occasion-\\nally, a fibrinous exudate pseudomembrane was seen.\\nThe swelling was less marked than is usual in middle-ear\\nsuppurations. Bezold never found the mucous membrane\\ndestroyed so as to expose the bone. The tympanic mem-\\nbrane in all the cases described showed a marked resistance\\nto the attacks of the disease, being thickened, but otherwise\\nintact, even in those cases which came to the autopsy as\\nlate as the thirty-third day after the appearance of the erup-\\ntion. We could not expect, therefore, to have any appre-\\nciable changes in the otoscopic image at this stage of the\\ndisease, and as it does not give rise to any marked subjec-\\ntive symptoms, it is probable that such low grades of inflam-\\nmation pass off without being observed clinically. The\\nprognosis is good after the inflammation subsides and the\\nexudate is absorbed the parts are completely restored to\\ntheir normal condition.\\nIt is not to be inferred, however, that all aural complica-\\ntion in measles run this benign course. We know from\\npractical experience that acute purulent otitis media ivith\\nperforation is a very common sequel of measles, and, if\\nneglected and allowed to become chronic, it may lead to\\nany of the consequences such as caries of the bone, ex-\\nuberant granulations, and cholesteatomata which we are\\naccustomed to see after any suppurative process in the\\nmiddle ear. To show how wide-spread is the belief among\\nthe laity that measles may be followed by disease of the\\near, it may be mentioned that in about 3 of all cases of\\naural disease measles is given as the original cause by the\\npatient or his friends, and that 5.1 of all cases of purulent\\notitis media are attributed to this disease. Again, that\\n1 From Blau and Bihkner.", "height": "3492", "width": "2120", "jp2-path": "rhinologylaryng00frie_0116.jp2"}, "117": {"fulltext": "the otitis of measles is not quite so benign as might be sup-\\nposed from the shght attention it has received even in medi-\\ncal circles, there being a general impression that it requires\\nno special treatment, is shown by the fact that measles is\\ncharged with 4^ of all cases of acquired deaf-mutism. As\\nhas been previously indicated, the otitis that accompanies\\nmeasles is not especially malignant, and runs much the\\nsame course as any other acute or chronic otitis media.\\nBlau succeeded in curing 28 cases of acute purulent otitis\\nfollowing measles without the hearing being impaired.\\nBone disease with abscess formation is not more common\\nafter measles than in ordinary otitis media.\\nOtitis usually makes its appearance during the stage of\\ndesquamation between the second and third week two\\ncases have been reported in which it appeared before the\\neruption.\\nThe course of the disease presents nothing characteristic.\\nBlau 1 reports a case of diphtheric disease of the external\\nauditory meatus, without involvement of the middle ear,\\nwhich appeared five days before diphtheria of the pharynx\\nfollowing measles. Haug describes a primary caries of\\nthe mastoid process, with secondary suppuration of the\\nmiddle ear, which developed during the stage of desqua-\\nmation. We do not attach much importance to Moos s\\nobservations that disease of the internal ear with sudden\\ndeafness and vertigo may follow an attack of measles, as\\nthey lack the confirmation of other observers.\\nA review of our knowledge concerning the nature and\\ncourse of the otitis of measles justifies the following con-\\nclusions It appears, from the results of clinical and ana-\\ntomic investigations, that there are two varieties of otitis in\\nmeasles, the second of which represents a complication of\\nthe first. The otitis media described by Bezold and others\\nrepresents a true measle eruption affecting the mucous\\nmembranes, while the suppurative process with perforation\\nof the tympanic membrane must be regarded, after Bezold,\\nas the result of a mixed infection which finds a favorable\\nsoil in the mucous membrane weakened in its resisting\\npower by the primary disease.\\nAnother view, which is advocated by Wagenhauser and\\n1 Berlin, klin. Wochen., vol. XXXIII, 1SS4.\\n2 Arch. f. Ohr., xxxii. p. 1S3. i Zeitschr. f. Ohr., XVIII.\\nQuoted by Habermann, Schwartze s Ilandb., I, p. 761.", "height": "3448", "width": "2132", "jp2-path": "rhinologylaryng00frie_0117.jp2"}, "118": {"fulltext": "112 ACUTE INFECTIOUS DISEASES.\\nothers, regards the otitis of measles as a simple inflamma-\\ntion derived from the postnasal space through the Eusta-\\nchian tubes but in the light of recent investigations on\\ncadavers, this view seems to us to lack general application,\\nalthough it may hold in isolated cases. The early devel-\\nopment of the acute inflammation, coincident with the\\nappearance of the eruption, confirms the hypothesis that we\\nhave to deal with a true measle eruption precisely analo-\\ngous to that on the mucous membrane of the respiratory\\ntract, and worthy of a place in the general symptom-com-\\nplex in measles. We know from the investigations of\\nBezold that the catarrhal process in the middle ear runs a\\nvery chronic course, and that the mucous membrane shows\\nlittle tendency to regeneration and granulation hence, its\\nsusceptibility to secondary infection, even several weeks\\nafter the measles has run its course, is quite readily under-\\nstood.\\n2. SCARLATINA,\\nAmong the complications of scarlet fever in the upper\\nair-passages we distinguish catarrhal angina and a form of\\ndiphtheria.\\nThe catarrh of scarlet fever is distinguished from that\\nwhich occurs in measles by being restricted in the main to\\nthe pharynx, faucial pillars, and tonsils, while the nose and\\nlarynx usually escape, or, at any rate, become involved\\nmuch later. It manifests itself as a deep-red or violaceous\\ndiscoloration, at first uniform, and after a few days dis-\\ntributed in patches the mucous membrane is dry and very\\nmuch swollen, causing a feeling of dryness and tickling in\\nthe throat and a desire to swallow at frequent intervals.\\nThe onset and course of the angina do not appear to follow\\nany definite rule in most cases it appears before the erup-\\ntion and lasts several days.\\nIn some cases of malignant scarlatina without eruption,\\nwhich terminate fatally very soon after the onset of the dis-\\nease, with grave constitutional symptoms, this dark-red dis-\\ncoloration of the pharyngeal structures may form the only\\nsymptom, and its relation to scarlet fever can be determined\\nonly by the existence of an epidemic or by the subsequent\\noutbreak of the disease in other members of the family.\\nThe regularity with which this catarrh of the mucous", "height": "3468", "width": "2188", "jp2-path": "rhinologylaryng00frie_0118.jp2"}, "119": {"fulltext": "MEASLES. 113\\nmembrane appears at the very outset of the infectious dis-\\nease, and its locahzation in the region of the pharyngeal\\nring, so abundantly supplied with lymphatic elements, jus-\\ntify the assumption that the virus of the disease, the nature\\nof which is not known, gains entrance to the system at\\nthis point, and that the angina of scarlet fever represents\\nthe earliest reaction of the organism to the scarlatinal\\npoison.\\nIn uncomplicated cases these catarrhal symptoms subside\\nin a few days, but in a large proportion of cases a strepto-\\ncoccal infection of the diseased mucous membranes is super-\\nadded to the scarlatinal poison and gives rise to a group of\\nmorbid phenomena which are designated by the general\\nterm diphtheroid scarlatina. It is a necrotic inflammation\\nof the mucous membrane, presenting the anatomic picture\\nof diphtheria, but having etiologically nothing in common\\nwith genuine diphtheria, from which it is distinguished by\\nthe absence of Loffler s bacilli and by certain clinical differ-\\nences in the mode of spread and the development of\\nsequels.\\nBefore Heubner s publications appeared to throw some\\nlight on the question, the greatest confusion prevailed in\\nthe diagnosis and description of diphtheroid scarlatina, the\\nshadow of which overhangs even the most recent rhino-\\notologic literature and materially detracts from the value of\\nreported observations.\\nHeubner divides diphtheroid scarlatina into three forms,\\naccording to the clinical course, a mild form, a subacute\\nform, and an epidemic form, which together represent\\nvarious grades of virulence, both in respect to the extent\\nof mucous membrane involved and to the manner in which\\nthe neighboring glands react to the poison. The first form\\nis characterized by the deposition on the first to the third\\nday of small superficial exudates on the surface of the\\ninflamed tonsils these soon run together and form a deli-\\ncate membrane, which can be removed with a pair of for-\\nceps without causing hemorrhage. After persisting a few\\ndays the membrane is replaced by shallow ulcers which\\nrapidly heal, while the swelling of the submaxillary glands\\nsubsides.\\nHeubner observed this favorable course in about one-\\ni Volkmann s Vortr., No. 322 (iSSS); and Hirschfeld, Jahrb. f.\\nKinderheilk., vol. XLiv, p. 237.\\n8", "height": "3464", "width": "2136", "jp2-path": "rhinologylaryng00frie_0119.jp2"}, "120": {"fulltext": "114 ACUTE INFECTIOUS DISEASES.\\nfourth of all cases of scarlatinoid diphtheria. In almost all\\ncases the mild form is followed by the so-called subacute\\nIcntcscoit form of scarlatinoid diphtheria (Hirschfeld\\nobserved it in 53.6^ in a series of 211 cases); or the\\nmilder form may not be present and the subacute may be\\nthe first to appear. After a mild onset the temperature rises\\nsuddenly on the fourth or fifth day, the glands become\\nenlarged, and a yellowish exudate appears on the tonsils,\\non the posterior pharyngeal wall, and on the pillars of the\\nfauces. The diphtheric process spreads to the postnasal\\nspace, the nasal cavities, and the larynx, and gives rise to\\nulceration and tissue destruction varying in form and extent.\\nThis purulent form of rhinitis is always the result of exten-\\nsion from the postnasal space, and therefore develops a few\\ndays later the clinical picture presents no characteristic\\nfeatures to distinguish it from diphtheric disease of the nose.\\nThere is, however, a characteristic discharge of a thin, yellow-\\nish, offensive fluid, tinged with blood, from the excoriated\\nnares, which, in connection with the glandular enlargement,\\nis of some value for early diagnosis. It is a sign that the\\nnasopharynx is involved, and appears even before the nose\\nitself is directly attacked.\\nIt is somewhat remarkable that the larynx is rarely in-\\nvolved in this form of the disease, just as in the catarrhal\\nvariety, so that a laryngeal stenosis simulating true diph-\\ntheria is a rare occurrence. If the membrane does spread\\nto the larynx, it is found to be soft and semifluid, and\\nmuch less adherent than in diphtheria. In rare cases\\nedema of the larynx and asphyxia were observed Moure\\nsaw an abscess at the base of the epiglottis and about the\\nupper part of the left ventricular band which ruptured\\nspontaneously on the tenth day of scarlet fever.\\nThe loss of substance caused by the destruction of large\\ntracts of mucous membrane in the postnasal space and on\\nthe pillars eventually leads to the formation of permanent\\nscars and cicatricial contractions, which in later life may\\neasily be mistaken for syphilitic scars, especially when they\\noccupy the interv^al between the pillars of the fauces and\\nthe posterior pharyngeal wall. The formation of adhesions\\nin the interior of the nose in scarlet fever should also be\\nmentioned the skeleton itself is never involved.\\nFinally, Heubner describes a vialignaiit form which pre-\\nsents all the symptoms of an intense general septicemia,", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0120.jp2"}, "121": {"fulltext": "SCARLET FEVER. I I 5\\nwith rapid destruction of the mucous membrane of the nose\\nand throat, and with necrosis of the cervical and parotid\\nglands and of the skin covering them the glands at first\\nare of a stony hardness. This variety, which appeared in\\n16.3^ of the 211 cases in Heubner s clinic, terminated\\nfatally about the seventh to the tenth day.\\nDiphtheric disease due to scarlet fever presents certain\\nimportant distinctions from true diphtheria, caused by\\nLoffler s bacillus, in the nature of the sequels which are\\napt to follow. The peripheral palsies which constitute\\nsome of the most dreaded after-effects of diphtheria, and\\nof which we are concerned only with paralysis of the pillars\\nof the fauces and of the larynx, are never observed after\\nscarlet fever. This is confirmed by Heubner and by Leich-\\ntenstern, who refers to 600 cases, so that the isolated con-\\ntradictory cases, cited for the most part by, older writers,\\nmust be explained in some other way. Without giving\\nthe individual case histories, Wreden 1 makes the statement\\nthat he observed paralysis of the pillars of the fauces, the\\nvocal cords, the extremities, and the heart in eighteen cases\\nof nasal and pharyngeal diphtheria complicated with scar-\\nlatina. But, in the first place, any ulceration in the pillars\\nof the fauces may interfere mechanically with the move-\\nments of the uvula and, in the second place, there have\\nbeen reported cases of genuine diphtheria combined with\\nscarlet fever when the finding of Loffler s bacillus rendered\\nthe diagnosis absolutely certain (Jurgensen^). In such\\ncases of double infection the occurrence of post diphtheric\\npalsies is, of course, conceivable, but they must be attrib-\\nuted to the diphtheria and not to the scarlet fever.\\nScarlet fever plays a more important role in the etiology\\nof diseases of the ear than any of the other infectious dis-\\neases. The literature does not afford many statistics in\\nregard to the frequency of aural disease as a complication\\nof scarlatina, the only statistics I was able to find being\\nthose of Burckhardt-Merian, who reports middle ear dis-\\nease in 5 out of 15, and in another series in 8 out of 36,\\ncases. On the other hand, the frequency of scarlatina as\\nthe original cause of aural diseases forms the subject of\\nnumerous articles based on a large amount of material.\\nThe most reliable statistics are those contributed by\\n1 Wreden, jNIon. f. Ohr., Ii, p. 151.\\n2 Nothnagel s Spec. Path. u. Ther., IV, 2, p. 133.", "height": "3460", "width": "2120", "jp2-path": "rhinologylaryng00frie_0121.jp2"}, "122": {"fulltext": "Il6 ACUTE INFECTIOUS DISEASES.\\nBezold/ who collected 640 cases of aural disease second-\\nary to scarlet fever, covering a period of eleven years,\\nfrom 1 88 1 to 1892, in which 984 organs of hearing were\\naffected, one-half of all the cases being bilateral. The total\\nnumber of cases of scarlet fever during the same period\\nBezold estimated from other statistical sources at 17,087,\\nso that 3.75 of all aural affections must be attributed to\\nscarlet fever. This percentage tallies approximately with\\nthe results of other statistics, in which the percentage\\nranges from 2.3 to 9.3, with a total average of 5.17\\nThe frequency with which the different parts of the ear are\\naffected varies greatly, affections of the middle ear showing\\na heavy preponderance over those of the internal, and espe-\\ncially of the external ear, which are extremely rare. To\\nshow how frequently the middle ear is involved, it is only\\nnecessary to state that about 1 2. i of all cases of pu-\\nrulent otitis media must be regarded as secondary to scarlet\\nfever.\\nWhile these figures alone suffice to show the significance\\nof scarlet fever in the etiology of aural diseases, it becomes\\neven more apparent w^hen we consider the functional dis-\\nturbances and other sequels that follow in its wake. To\\nquote at random from Bezold s statistics, we find the appall-\\ning statement that in 109 out of 217 cases of chronic puru-\\nlent otitis media with polypi, and in i 54 out of 3 1 5 cases\\nwithout polypi, the disease lasted longer than eight years.\\nWhen it is considered that in 48.5 ^/o of all Bezold s cases\\nthe distance at which whispered tones could be heard was\\nless than of a meter, and that in 13.5/^ a whisper could\\nnot be heard at all, and when, in addition to this, the fre-\\nquency of acquired deafmutism after scarlet fever, which\\nshows an average of 19%, is taken into account, it is easy\\nto understand the otologist s repeated appeals to the gen-\\neral practitioner, adjuring him to devote more attention to\\naural complications in scarlet fever than appears to have\\nbeen done hitherto.\\nWe will first consider the grave andfortunately rare form\\nof otitis which is designated the diphtheric form, being anal-\\n1 Uberschau iiber den gegenwartigen Stand, etc., 1S95, Wiesbaden,\\nBergmann, pp. 168, 169, table viii.\\n2 Blau, Arch. f. Ohr., 27, p. 140.\\nAverage of Blau s figures, Arch. f. Ohr., 27, p. 142, table il.\\n4 Blau, loc. cit., p. 143, table iv.", "height": "3468", "width": "2136", "jp2-path": "rhinologylaryng00frie_0122.jp2"}, "123": {"fulltext": "SCARLET FEVER. I I\\nogous to diphtheroid scarlatina of the throat. The same\\nconfusion that prevailed in regard to the diseases of the\\nthroat before the subject was somewhat clarified by the\\nworks of Heubner and others still befogs the various de-\\nscriptions of diphtheric inflammations of the ears in scarlet\\nfever. The opinion is abroad, based chiefly on the writings\\nof Wreden and Burckhardt-Merian, that otitis in the course\\nof scarlet fever in practically every instance consists in a\\ndiphtheric inflammation of the middle ear. The i8 cases\\nreported by Wreden, which date from the year 1868, can\\nnot be regarded as authentic, as they represent suppura-\\ntions occurring during the decline of scarlet fever (sub\\ndecursu febris scarlatinosae) the time of their appearance\\n(late in the course of the disease), and the statement that they\\nwere frequently followed by palsies, arouse the suspicion\\nthat we have to deal with a genuine complication of scarlet\\nfever with diphtheria, and Burckhardt-Merian s remarks on\\ndiphtheria, found in his paper on otitis in scarlet fever, are\\nof no value in the present discussion, for the very reason\\nthat the diphtheria of scarlet fever is a very different thing\\nfrom genuine diphtheria.\\nFrom the description by Moos and Pulitzer, who\\ndesignate diseases of the ear in scarlet fever simply as diph-\\ntheric diseases or scarlatino-diphtheric suppurations of the\\nmiddle ear, it might be inferred that the diphtheric form is\\nthe only possible aural complication in scarlet fever. But\\nhow, then, are we to reconcile the frequency of middle ear\\ndisease in scarlatina with the rarity of diphtheric disease of\\nthe middle ear? Gottstein s unsuccessful attempt to prove\\nthat the diphtheric aural affection forms an integral part of\\nthe morbid process in scarlet fever is followed by the in-\\ngenious explanation that the aural affections did not come\\nunder the observation of the ear specialist until after the\\nend of the diphtheric and the beginning of the purulent\\nstage, while Wreden had the opportunity to observe the\\ndisease in its early stages. A strange caprice of fate, in-\\ndeed, if that early diphtheric stage regularly escaped the\\nnotice of the physician\\nThe most authentic cases of a diphtheric form of otitis\\n1 Schwartze s Handb., vol. I, Allgemeine Aetiologie der Ohren-\\nkrankheiten.\\nLehrb. der Olirenheilkunde.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0123.jp2"}, "124": {"fulltext": "I I 8 ACUTE INFECTIOUS DISEASES.\\nmedia in scarlet fever are those reported by Blau,^ Katz,^\\nand Siebenmann.3\\nAccording to these observers, the cHnical course of the\\ndisease is as follows Coincident with the diphtheric com-\\nplication in the throat there takes place a rapid destruction\\nof the tympanic membrane followed by an otorrhea, in\\nwhich the fluid is described as muddy and serous in char-\\nacter, not purulent. A diphtheric membrane is formed on\\nthe mucous membrane of the tympanum and discharged\\ninto the external meatus. The diphtheric process is not\\nlimited to the middle ear, and may manifest itself in the\\nformation of membranes in the external meatus and in the\\nauricle, as was observed in several instances. Blau s case\\nwas not followed to the end the cases reported by Katz\\nand Siebenmann terminated fatally on the fifteenth and\\ntwentieth day respectively. Siebenmann s attempts to dis-\\ncover diphtheria bacilli in the membranes found in the\\nmiddle ear after death were unsuccessful.\\nAs the disease progresses the mucous membrane under-\\ngoes necrosis the bones of the tympanum are laid bare,\\nand may eventually become carious. The serous, muddy\\nsecretion is later replaced by a purulent discharge in other\\nwords, the diphtheric process is converted into a chronic\\nsuppuration characterized by extensive carious destruction.\\nThe coincidence of this form of otitis with the diphtheric\\nprocess in the throat suggests the thought that they are\\nboth caused by the same malign influence manifesting itself\\nin different parts of the body. The simplest explanation of\\nthe aural complication on this tlieory would be direct\\nextension of the diphtheric process in the pharynx through\\nthe Eustachian tube, but of this we have no proof. In\\nSiebenmann s case, which is so excellently described, the\\ntube was unfortunately destroyed at the autopsy.\\nA much more frequent form of aural complication in\\nscarlet fever is unite otitis media without any special char-\\nacteristic features. It begins during the period of desqua-\\nmation, that is to say, in the third or fourth week of the\\ndisease, with a rise in temperature and pain radiating from\\nthe affected ear and increasing in severity toward evening,\\nso that the patient is unable to sleep. There is usually\\n1 Berlin, klin. Wochen., i8Sl, Nos. 49, 50.\\n2 Berlin, klin. Wochen., 1S84, No. 13.\\n3 Zeitschr. f. Ohr., XX, p. I.", "height": "3468", "width": "2192", "jp2-path": "rhinologylaryng00frie_0124.jp2"}, "125": {"fulltext": "SCARLET FEVER. I I 9\\nsome glandular enlargement behind and under the angle of\\nthe jaw, on the mastoid process, or in the back of the neck.\\nThe tympanic membrane is red, swollen, and inflamed, and\\nbulges so that immediate paracentesis is indicated if it is\\nnot performed, spontaneous perforation takes place, often\\nwithin a few hours after the first appearance of subjective\\nsymptoms. An important variation from the ordinary clini-\\ncal picture as just described is to be found in the description\\ngiven by some observers of a remarkable absence of pain,\\nwhich they arbitrarily attribute to anesthesia of the sensory\\nnerves.\\nUp to this point the course of the disease is essentially\\nthe same as that of simple otitis media, but after the occur-\\nrence of perforation, which preferably takes place in the\\nlower anterior quadrant, the membrane undergoes rapid\\ndisintegration and is often totally destroyed. According to\\nBezold,^ total destruction of the membrane occurs in\\n25.2^ of all cases of scarlet fever, and a destruction of at\\nleast two-thirds of the disc in 24.7^. The flow is very\\nabundant and presents the usual mucopurulent appear-\\nance. The most characteristic features of the otitis media\\nare an obstinate resistance to treatment and a tendency to\\ncarious destruction, which frequently involves the ossicles,\\nas well as the bony walls of the tympanum and contigu-\\nous cavities. As the hearing is much impaired in scarlet\\nfever, it is probable that the disease extends to the internal\\near but whether we have to deal simply with a secondary\\ncarious destruction of the labyrinth, or with a special locali-\\nzation of the disease, is not known.\\nHow are we to explain the origin of this form of otitis in\\nscarlet fever\\nIs it a disease due to the extension of the initial pharyn-\\ngitis through the tubes, and presenting phenomena in the\\nform of an otitis media such as we must expect after any\\ncatarrhal rhinopharyngitis or is it a specific disease\\ncaused by the virus of scarlet fever or by certain toxins\\nwhich it produces\\nMere hypotheses add little to our knowledge, which\\nmust necessarily remain incomplete as long as the nature\\nof the scarlatinal contagium is unknown. Certain con-\\nclusions can, however, be drawn as to the origin of the\\n1 Loc. ciL, p. 172.", "height": "3452", "width": "2120", "jp2-path": "rhinologylaryng00frie_0125.jp2"}, "126": {"fulltext": "I20 ACUTE INFECTIOUS DISEASES.\\ndisease from the time of its appearance as a complication\\nand from its general character. It occurs regularly during\\nthe period of desquamation at a time, therefore, when\\nthere exists a tendency to other complications as well\\nfor, except in the rare cases of diphtheroid scarlatina, there\\nis no record of its occurring immediately subsequent to the\\nscarlatinal angina which lasts only a few days. That the\\nresisting power of the mucous membrane of the tubes and\\nof the tympanum to the invasion of pathogenic germs\\nwhich might set up a suppurative process in the middle\\near independent of the scarlatina is especially lowered\\nduring this period of the disease is not only not proved,\\nbut is even improbable, as no such condition of affairs is\\nobserved in the mucous membranes of the upper air-\\npassages, where secondary streptococcal infections usually\\nfollow immediately after the scarlatinal angina, in the first\\nweek of the disease.\\nAgain, if we assume that the aural complication is\\nmerely accidental, or that it is dependent on the pharyngeal\\ncondition, it is, to say the least, remarkable that simple\\ncatarrh and mild otitis media without perforation do not occur\\nin scarlet fever, or at least are so rare that they can not be\\nincluded among the list of compHcations of the disease.\\nIf, on the other hand, we consider that it is during the\\ndesquamation period that we find nephritis, a disease\\nwhich is unquestionably toxic in character and there-\\nfore indicates a septic condition of the organism, the\\nassumption that the aural complication is due to the action\\nof the same toxins seems plausible. If a parallel could\\nbe established between nephritis and purulent otitis media,\\nas in a case observed by Voss, where the onset, course,\\nand subsidence of the two diseases progressed pari passu,\\nit would offer another argument in support of the dependence\\nof the aural disease on a general intoxication of the system.\\nThe bacteriology of scarlatinal otitis media and the sig-\\nnificance of a mixed infection have not as yet been dis-\\ncov^ered.\\n3. VARICELLA.\\nIn varicella, vesicles appear on the mucous membrane of\\nthe mouth and pharynx at the same time as the skin erup-\\ntion in rare cases a few isolated pustules were found in", "height": "3468", "width": "2204", "jp2-path": "rhinologylaryng00frie_0126.jp2"}, "127": {"fulltext": "VARICELLA. VARIOLA. I 2 I\\nthe larynx. Cases of grave suffocative laryngitis have\\nbeen described by Marfan and Halle and by Harlez,^\\nwhich, it appears, occurred suddenly at the time of the\\neruption, with symptoms of asphyxia, attended with hoarse-\\nness, cough, and muffled phonation. Tracheotomy was\\nrequired in every instance no laryngoscopic examinations\\nare reported in one of the cases ulcers were found on the\\nvocal cords at the autopsy.\\nIn a unique case reported by Biirkner, two pustules\\nwere found in the external auditory meatus, with only a\\n-scanty eruption on the scalp.\\n4. VARIOLA.\\nIn variola the mucous membranes contiguous to the\\nexternal skin are regularly attacked. E. Wagner found\\nthat the nasal mucous membrane was affected in every case\\nin which it was examined. In a series of 170 cases the\\nupper pharynx alone was affected twice the pharynx and\\nlarynx alone, 38 times the pharynx, larynx, and upper\\nhalf of the trachea, 54 times the pharynx, larynx, trachea,\\nand large bronchi, 52 times. The larynx was therefore\\ninvolved altogether in 144 cases out of the 170. Between\\nthe third and sixth day of the smallpox eruption (Macken-\\nzie) pustules make their appearance in the pharynx and\\nspread to the postnasal space and larynx. They may\\nbe isolated in different parts of the larynx, or they may\\nbe multiple and coalesce to form large ulcers. At first\\nthe pustules resemble those on the external skin, but the\\ncovering of mucous membrane soon becomes macerated,\\nis cast off, and leaves a red, excoriated patch, which is apt\\nto bleed. In the hemorrhagic form ecchymoses appear in\\nthe mucous membranes. These superficial eruptions on\\nthe mucous membranes are complicated with deeper ulcer-\\native processes, which lead to edema of the larynx and\\nabscess formation by extension to the cartilages this may\\ngive rise to a perichondritis of the larynx, as illustrated by\\n1 Rev. d. mal. d. 1 enf, Xiv, Jan., 1S96, rep. in Semon s Centralb.,\\nxn, p. 499.\\n2 Indep. med., July 14, 1S97, rep. in Semon s Centralb. xn p.\\n214.\\nArcli. f. Ohr., 18, p. 300. Arcli.d. Ileilkunde, xni.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0127.jp2"}, "128": {"fulltext": "122 ACUTE INFECTIOUS DISEASES.\\nTiirck in a number of cases. In addition to the pustular,\\nMackenzie mentions a papular form, and Lori reports\\nhyperemia of the mucous membranes without pustular\\neruption.\\nRuhle,2 among others, speaks of a diphtheric croupous\\ninflammation of the laryngeal mucous membrane, with\\nsecondar}^ invasion of the postnasal space. That this was\\nthe result of confluence of the pustules is denied by Lori\\non the ground that there never were any pustules on the\\nmucous membrane but E. Wagner says that in the nu-\\nmerous cadavers he examined the pustules were often so\\nclosely set, especially in advanced stages of the disease,\\nthat it was difficult to demonstrate their variolous character.\\nFinally, we have the occurrence of palsies as a very rare\\ncomplication. Mackenzie saw two cases which were fol-\\nlowed by paralysis of the adductors of one cord. The\\nnature of these palsies is not known, but they are probably\\ndue to mechanical causes, such as ankylosis of the ary-\\ntenoid cartilage, observed after perichondritis or after\\nthe cicatrization of a deep ulcer.\\nAural disease during smallpox was studied by Wendt^\\nin 1 68 organs taken from 84 persons of all ages who had\\ndied in various stages of the disease. As the ears were\\nfound to be intact in only 3 cases, there can be no doubt\\nof the frequency of aural complications in variola. The\\nnature of the lesions varies, according to Wendt s findings\\nin some instances the morbid process was identical with, or\\nclosely related to, variola, in others the lesions were such\\nas occur in connection with other constitutional or local\\ndiseases, or even without them. From the external skin\\nthe eruption spreads to the concha and auditory meatus\\nfrom the mucous membrane of the pharynx to the pharyn-\\ngeal orifice of the tubes. Whether the epithelial thicken-\\ning and suppuration, and the hyperemias, hemorrhages,\\nand exudations in the middle ear, are the product of the\\nprimary disease or the result of the tubal condition is an\\nopen question.\\nSo far as has been observed, the tympanic membrane\\nis never the seat of a pustular eruption, but it is frequently\\nfound to be red and swollen. These anatomic findings\\n1 Klinik der Kehlkopf krankheiten.\\n2 Klinik der Kehlkopf krankheiten, lS6l.\\n3 Arch. f. Heilkunde, xni.", "height": "3496", "width": "2192", "jp2-path": "rhinologylaryng00frie_0128.jp2"}, "129": {"fulltext": "TYPHOID FEVER. I 23\\nof Wendt are directly contradicted by the clinical observa-\\ntions ofOgston.i The latter, after examining the ears of\\n229 smallpox patients, reached the conviction that the\\nstructures and tissues of the ear itself are not affected by\\nvariola.\\nThe prognosis, according to Wendt, is favorable he be-\\nlieves that the healing of the smallpox lesions in the ear is\\nnot followed by any functional disturbance, nor have there\\never been found cicatricial stenoses or synechise from the\\nhealing of pustules in the external auditory meatus or in\\nthe tubes.\\n5. TYPHOID FEVER.\\nThe laryngeal phenomena occurring in the course of\\ntyphoid fever may be divided into three main groups\\ncatarrhal conditions, ulcerations, and palsies edema and\\nperichondritis are regarded as accompaniments or com-\\nplications of one of the three main divisions. There are\\nplenty of data to determine the frequency of these compli-\\ncations, but a certain reserve is necessary in drawing\\ngeneral conclusions, for the statistics would be quite differ-\\nent if a systematic laryngoscopic examination were made in\\nevery case of typhoid fever, without waiting for the patient\\nto complain of pain in the throat or for the appearance of\\nsuch obvious symptoms as dyspnea and aphonia. The\\nresults obtained vary according as they are based on ob-\\nservations made on the living subject or on the cadaver,\\nfor complications are naturally much more frequent in\\nsevere cases of typhoid terminating fatally than in the\\nmilder forms. Another factor is the severity of the epi-\\ndemic that happens to furnish the basis for the statistics.\\nThe most comprehensive figures are those published by\\nLuning,^ who puts the percentage, as computed from\\nclinical statistics, at 3, and the postmortem percentage at 17.\\nIt would be interesting to know the relative frequency\\nof the various forms of laryngeal disease but on this point\\nwe can not hope for any information from the results ob-\\ntained at autopsies, as they naturally include only the\\ngravest complications, such as perichondritis or diphtheric\\ndisease.\\n1 Arch f. Ohr., vr, p. 267. 2 Langenheck s Arch., vol. xxx.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0129.jp2"}, "130": {"fulltext": "124 ACUTE INFECTIOUS DISEASES.\\nClinically speaking, simple catarrh and superficial ulcera-\\ntion are the complications most frequently observed, while\\ndeep ulcerations which lead to edema and perichondritis,\\nor which, when extensive, present the so-called diphtheric\\nform laryngotyphus are much rarer. If the latter are\\nmore frequently and more fully described it is only because\\nof their alarming symptoms and the laryngeal stenosis\\nwhich characterizes them and directly threatens the patient s\\nlife. Stenosis and edema of the larynx are sometimes\\ninduced by typhoid processes in neighboring organs thus,\\ncases have been reported in which acute inflammation or\\nabscess formation in the thyroid gland which condition\\nappears to be quite frequent in the course of typhoid led\\nto compression of the trachea and edema of the larynx.\\nOur knowledge of post-typhoidal palsies is of very recent\\ndate. They were formerly considered a very rare com-\\nplication, for Lublinski could collect no more than 25 cases,\\nincluding 6 of his own, and Landgraf met with only 2\\ncases of laryngeal palsies among 166 typhoid patients. A\\nspecial interest, therefore, attaches to Przedborski s^ report,\\naccompanied by very complete case histories, of 25 laryn-\\ngeal palsies among 100 cases of abdominal typhoid, and\\nof 7 among 25 cases of exanthematous typhoid.\\nThe pharyngeal and laryngeal mucous membrane is often\\nattacked by catarrh in the beginning of the disease, while,\\non the other hand, the nasal mucous membrane not only\\nescapes but presents an unusually dr}^ appearance. The\\nonly nasal symptom observed is epistaxis. The hemor-\\nrhage shows a predilection for the septum, but is also ob-\\nserved in other parts of the mucous membrane. In a few\\ncases which came under my observation the nasal mucous\\nmembrane after the hemorrhage presented the previously\\nmentioned desiccated appearance, the septum was marked\\nwith rhagades, while the walls and interior of the nose\\nwere covered with larger and smaller masses of black,\\nclotted blood, which moved to and fro with the respiratory\\nmovements. The epistaxis occurs in the beginning of the\\ndisease. As the patients at this time are usually in bed\\nand more or less prostrated by the fever, the blood usu-\\nally flows backward into the throat, and the resulting bloody\\nsputum may give rise to errors in diagnosis. Perforation of\\n1 Volkmann s Sammlung klin. Vortr., Xo. 182, 1897.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0130.jp2"}, "131": {"fulltext": "TYPHOID FEVER. 125\\nthe septum, like that produced by a perforating ulcer, has\\nbeen observed after typhoid fever. Typhoid pharyngitis and\\nlaryngitis are characterized by intense redness, while the\\nswelling of the mucovis membrane is comparatively slight.\\nMarked swelling and edema are rare in this stage. The\\nso-called catarrhal redness of the larynx in typhoid is\\nnot uniformly distributed. It may be due to venous stasis\\n(Landgrafi).\\nUlcers appear in various forms both clinically and ana-\\ntomically. The commonest variety consists in superficial\\nulcerations from necrosis of circumscribed portions of the\\nswollen mucous membrane. They manifest a preference\\nfor certain regions of the pharnyx and larynx, being found\\nalmost regularly on the faucial pillars, the free border or\\nlaryngeal surface of the epiglottis, the aryepiglottic folds,\\nand occasionally below the glottis they are rarely seen on\\nthe vocal cords. At first there is a diffuse catarrh, and the\\nmucous membrane is darker in color and slightly swollen in\\nthe areas mentioned the epithelium soon breaks down,\\nand exposes a small, shallow ulcer with a yellowish floor,\\nresembling herpes similar ulcers appear in the neigh-\\nborhood and coalesce with the original one to form larger,\\nirregular, quite superficial ulcers, with clearly defined\\nedges, but without redness or swelling of the adjacent\\nparts. These ulcers occur in all stages of typhoid, and\\nmay be due to a variety of causes. They can not be re-\\ngarded as decubital ulcers,^ as there is no reason why,\\nif we accept such an etiology, similar ulcers should not\\noccur in any other disease attended with the same degree\\nof prostration nor can they be attributed to the effect of\\ncontact and direct infection with the typhoid bacillus, as it\\nhas been possible in only a very few instances to demon-\\nstrate the presence of bacilli in the secretion, and there\\nis no satisfactory explanation of the mode of infection.\\nThe ulcers are undoubtedly to be regarded as the result\\nof a nutritive disturbance in the catarrhal mucous mem-\\nbrane connected with the general typhoidal infection, but\\ntheir mode of origin and direct dependence on infection\\nby the bacillus are not so clear. They are superficial, and,\\non the whole, may be considered benign, as they heal\\nwithout leaving a scar and do not require any local treat-\\n1 Landgraf, Charite Ann.. 1S89.\\n2 Riihle, VerhdI. der Naturf. Vers., 1S62.", "height": "3452", "width": "2120", "jp2-path": "rhinologylaryng00frie_0131.jp2"}, "132": {"fulltext": "126 ACUTE INFECTIOUS DISEASES.\\nment. There are cases, however, in which the ulcers\\nextend to the deeper structures, probably as the result of a\\nmixed infection. Eppinger^ calls them mycotic necrotic\\nulcers, and gives a detailed description of the way in which\\nthey invade the deeper structures and eventually destroy\\nthe perichondrium and cartilage. The cases which go on\\nto phlegmon formation are to be explained as due to such\\nmixed infection Villecourt^ describes one that was local-\\nized in the glottis and posterior laryngeal wall. These\\nulcers differ both clinically and anatomically from the altera-\\ntions described by Eppinger under the name of diffuse\\ntyphoid infiltrations he considers them in every way\\nanalogous to the typhoid lesion in the intestinal follicles,\\nand therefore assumes that they originate in circumscribed\\nareas containing adenoid tissue in the mucous membranes\\nof the upper air-passages.\\nThese infiltrations lead to ulceration, the ulcers being\\ndistinguished from those of the first group by the hardness\\nand swelling of their undermined edges. Although they\\nshow no tendency to invade deeper structures, they may,\\nas the result of a mixed infection, assume larger propor-\\ntions and lead to diseases of the cartilaginous structure of\\nthe larynx.\\nThere is one form of diphtheria accompanying typhoid\\noften described by older authors (Landgraf also mentions\\na case of typhoid which was probably complicated with\\ntrue diphtheria), in w^hich the disease is said to originate in\\nthe larynx and pharynx and to extend upward to the\\nnasal mucous membrane. As true diphtheric membrane\\ncorresponding to casts of the interior of the larynx were\\nobserved, the occurrence of such cases can not well be\\ndoubted, though they have never been seen by later ob-\\nservers, such as Schrotter, for instance. At all events,\\nthese cases do not represent a true diphtheria, but rather\\nthe last group of typhoid ulcers, in which, as a result of\\nmixed infection, croupous processes develop.\\nAs in all forms of ulcerations which occasion destruction\\nin the deeper tissues, the healing of the ulcers leaves de-\\nfects and adhesions, which often lead to stenosis of the\\nlarynx and may subsequently require local treatment.\\nSuch sequels may be of various kinds their diagnosis\\nKlebs, Handb. d. pathol. Anatomic, vol. n, Abth I.\\n2 Gaz. des hop., 1893, No. 116.", "height": "3468", "width": "2180", "jp2-path": "rhinologylaryng00frie_0132.jp2"}, "133": {"fulltext": "TYPHOID FEVER. 12/\\noften presents great difficulties, and they may be con-\\nfounded Avith syphilitic, diphtheric, and other scars, for\\npost-typhoid adhesions present no special characteristics.\\nThus, Halasz^ described a case of membranous adhe-\\nsions between the lower edges of the vocal cords after\\ntyphoid.\\nDiseases of the perichondrium and of the cartilages of the\\nlarynx after typhoid fever deserve special attention. They\\nare always to be regarded as secondary, due to the exten-\\nsion of the ulcerating process to the perichondrium. They\\npresent various clinical appearances, and closely correspond\\nwith diseases of the cartilage from other causes a large\\nnumber of very instructive cases, in part illustrated with ex-\\ncellent cuts, are found in Tiirck s text-book. The various\\ncartilages may become diseased singly or in connection\\nwith others according to a statistical investigation of the\\nfrequency in the individual cartilages (by Liining, Bus-\\nsenius, and others), the cricoid cartilage is attacked far\\nmore frequently than any other. Liining found it affected\\nin 44 out of 5 5 cases of perichondritis Bussenius2 in 49\\nout of 72 cases. This phenomenon is worthy of special\\nattention, as Bussenius has shown that the distribution\\nof the disease in syphilis and tuberculosis is quite different\\nas regards the individual cartilages, the arytenoid cartilage\\nbeing affected in by far the greater number of cases.\\nA few cases of paralysis of the laryngeal muscles have\\nbeen observed. They occur chiefly in the stage of con-\\nvalescence (Mendel, Boulay), but may also be met with,\\naccording to Przedborski, in the febrile stage. The latter\\nis, in fact, said to be the rule in typhus exanthematosus\\n(petechial typhus). The paralysis presents no character-\\nistic type, and all the muscles may be affected, either singly\\nor combined Mendel and Boulay found paralysis of\\nthe adductors in only 4 out of 17 cases. The abductors\\nmust be regarded as most frequently affected by paralysis,\\nbut Przedborski, in his 32 observations, reached a different\\nconclusion, finding both abductors and adductors affected\\nwith about equal frequency. But as the former include\\na number of paralyses of the vocal cords, such as we\\nfrequently observe in anemic persons after exhaustive infec-\\n1 Pest. med. chir. Presse, 1S93, No. 40 see Centralb. f. klin Med.,\\n1893, No. 52.\\n2 Charite Ann., 1S96.", "height": "3452", "width": "2100", "jp2-path": "rhinologylaryng00frie_0133.jp2"}, "134": {"fulltext": "128 ACUTE INFECTIOUS DISEASES.\\ntious diseases, and are therefore in no sense peculiar to\\ntyphoid, it is quite possible that the figures may have to\\nbe again revised. It would be interesting to investigate\\nthe fact reported by Przedborski that the muscles become\\naffected one after the other without any definite order such\\nas is usually observed in the dev^elopment of a recurrent\\nparalysis. Opinions are divided as to the nature of the\\nparalysis, but the general tendency is to regard it as anal-\\nogous to that which occurs in diphtheria in other words,\\nas a peripheral paralysis, such as is observed in other\\ninfectious diseases, although it is still a matter of dispute\\nwhether the muscles themselves or the peripheral nerves\\nsuffer a pathologic alteration. The attempt has also been\\nmade to explain it as a central paralysis due to hemorrhage\\nin the central organs. According to Przedborski, the\\nprognosis as to recovery is favorable, as he found that\\nthe paralysis usually disappeared in the course of from\\none to three Aveeks.\\nIn a few cases a simultaneous paralysis of one-half of the\\nuvula was observed paralysis pharyngoglossolabialis as,\\nfor instance, in one case of a boy twelve years old.^\\nThe ear frequently becomes involved in typhoid, the\\ncomplications being more frequent in typhus exanthematosus\\n(petechial typhus) than in typhus abdominalis. We possess\\na few statistics concerning their frequency, based on a\\nnumber of examinations which were made on a series of\\ntyphoid patients without regard to the presence of any sub-\\njective symptoms. Bezold found fifty aural complications\\namong 1243 cases of typhoid (4.02 Hengst,^ 28\\namong 1228 (2.3 Botkin saw 19 cases of purulent\\notitis among 357 typhoid patients. The statistics of Zaufal,\\nKramer, and Schmalz, quoted by Biirkner, yield a percent-\\nage which varies from 1.8 to 2.5. These figures do not, as\\nHaug seems to imply, relate to the frequency of otitis in\\ntyphoid fever, but to the frequency with which typhoid\\nfever was given as the cause of aural disease. The com-\\nplications consist mainly in disease of the middle ear a\\nfew isolated cases have also been reported of involvement\\nof the external and internal ear, but of this we know very\\nBriick, Sest. raed. chir. Presse, 1891, No. 30; see Semon s Cen-\\ntralbl., vni, p. 510.\\n2 Arch. f. Ohr XXI. u Zeitschr. f. Ohr., XXIX. p. 184.\\n4 See Mon. f. Ohr., 1895, p. 135.", "height": "3468", "width": "2176", "jp2-path": "rhinologylaryng00frie_0134.jp2"}, "135": {"fulltext": "TYPHOID FEVER. 1 29\\nlittle. We will first discuss the middle ear diseases in\\ntyphoid. Among the 50 cases observed by Bezold, the\\nmiddle ear complication in 48 consisted of inflammation,\\nwhile in only 2 cases was there a simple tubular catarrh\\nwhich was not dependent on the typhoid fever. The in-\\nflammatory phenomena usually appear in the fourth or fifth\\nweek of the disease (according to Bezold, 45 times between\\nthe twenty-fourth and twenty-fifth day, and only 5 times\\nbefore the twentieth day) they are heralded by rises in\\nthe temperature, which can be referred to the typhoid dis-\\nease, although they occur in the stage of recrudescence, in\\nwhich the fever shows a remittent type with occasional\\nmarked exacerbations. The patients usually complain of\\nearache and tinnitus aurium, and the attendants note a\\ndiminution in their power of hearing.\\nThe course of the otitis media is variable, and three forms\\nmay be distinguished a simple inflammatory form without\\nperforation, a purulent form with perforation of the ear-\\ndrum, and a form in which involvement of the mastoid\\nprocess is the prominent feature.\\nIn the first form the otoscopic picture shows moderate\\nredness of the ear-drum, especially in the region of the\\nhandle of the malleus, without any bulging of the mem-\\nbrane. According to Bezold, the congestion evinces a\\nmarked tendency to spread to the external meatus. The\\near-drum shows little or no bulging, and, as a rule, is not\\nswollen. This form, which is the mildest, may pass into\\nthe purulent perforative variety, or the inflammation is so\\nacute from the outset that the ear-drum, which shows a\\nmarked redness, soon bulges outward, and perforation\\nrapidly takes place. The suppuration itself is not char-\\nacteristic perforation is said to occur preferably in the\\nposterior inferior quadrant. The size of the opening\\nvaries, and cases of multiple perforation have even been\\nreported. I myself once observed a case in which bilateral\\nchronic suppuration, which had existed before the onset of\\nthe typhoid disease, became arrested during the fever. In\\nthe fourth week earache made its appearance. The ear-\\ndrums on both sides were very red, and on the left side\\nthere was a defect, but no discharge, while the fever still\\ncontinued high. Eight days later, after thefever had fallen,\\nthe congestion subsided, and marked suppuration again set\\nin. These forms of otorrhea which subside during high\\n9", "height": "3456", "width": "2056", "jp2-path": "rhinologylaryng00frie_0135.jp2"}, "136": {"fulltext": "130 ACUTE INFECTIOUS DISEASES.\\ntemperatures were referred to in the discussion of croupous\\npneumonia, and appear to occur in all infectious fevers\\nwhere the patient is a subject of chronic suppuration.\\nOne peculiarity of purulent otitis media during typhoid,\\nwhich is mentioned by most authors, is the early involve-\\nment of the mastoid process. Inflammatory phenomena\\nmake their appearance in the mastoid process at the same\\ntime that the acute inflammation invades the middle ear,\\nand various cases have been described in which there was\\nmarked tenderness on pressure out of all proportion to the\\nappearance of the ear-drum. Brieger observed a case in the\\neighth week of typhoid in which fluctuation was made out\\nover the mastoid process within four days after the first ap-\\npearance of the earache, while the corresponding ear-drum\\nwas markedly hyperemic and quite flat, and only ruptured on\\nthe next day, the perforation being very small and followed\\nby a slight discharge. An operation was performed a week\\nafter the onset of the pain, and showed the presence of\\nsequestrums in the mastoid process. The case ended\\nfatally in five weeks, death being due to thrombosis of a\\nsinus. Brieger points out that this does not correspond to the\\nordinary course of bone disease following typhoid, as there\\nis usually a tendency to spontaneous cure of the inflamma-\\ntion. There is no doubt that the bone is extensively in-\\nvolved. This is shown by Bezold s investigations in 19\\nout of 41 cases he found marked tenderness on pressure,\\nwhich in 1 1 cases made its appearance at the same time as\\nthe inflammation. In 5 out of these 19 cases a periosteal\\nabscess resulted, and required incision.\\nIt being established that the bone disease either pro-\\ngresses pari passit with the otitis media or precedes it, the\\nquestion of the etiologic relations existing between the\\nbone disease and typhoid otitis now presents itself\\nAccording to Bezold, the inflammation in the middle ear\\nmay begin in one of the three following ways\\nFirst, by direct extension of the inflammation from the\\nnasopharynx through the tube, simple occlusion of the\\ntube being probably insufficient to be regarded as an etio-\\nlogic factor, at least for the suppurative processes.\\nSecond, by the passage of septic material directly from\\nthe nasopharynx into the middle ear.\\nThird, by the formation of emboli in the vessels of the\\nmucous membrane of the middle ear, emanating either", "height": "3468", "width": "2132", "jp2-path": "rhinologylaryng00frie_0136.jp2"}, "137": {"fulltext": "TYPHOID FEVER. I3I\\nfrom an endocarditis and thrombosis of the left heart, or\\nfrom purulent foci in the periphery,\\nBezold therefore considers the aural complication as\\nsecondary and excludes the effect of the general infection\\nas an etiologic factor. If Bezold s exposition of the eti-\\nology is accepted, it is difficult to explain how the disease,\\nwhich is at first localized in the middle ear, can be trans-\\nplanted to the walls of the mastoid process with such\\nrapidity as to make the secondary, appear to precede the\\nprimary disease. Even if we admit the possibility of the\\nmiddle ear becoming infected through the tubes, we can\\nnot discard the theory that we have to deal with an acute\\nosteomyehtis of the mastoid process, which is to be re-\\ngarded as a true complication of the typhoid disease.\\nThe demonstration of typhoid bacilli would settle the\\nmatter beyond dispute unfortunately, we do not possess\\nany bacteriologic data however, the course of the bone dis-\\nease, as has been previously stated, is in itself quite different\\nfrom that which is usually observed in the complications\\nof typhoid fever, and even if we assume a mixed infection\\nto explain the sequestration of the bone and the formation\\nof periosteal abscesses, the question why the disease in the\\nbone should precede or even accompany the suppuration\\nfrom the ear remains unsolved.\\nComplication of the external ear (the auricle and the\\nexternal meatus) is a very rare occurrence. Haug i quotes\\na case of gangrene of the auricles from Obre. Von\\nTroltsch and Hoffmann each observed a case of suppura-\\ntion of the parotid gland with rupture into the external\\nmeatus. In Hoffmann s case there was a fistula at the junc-\\ntion between the cartilaginous and bony portions of the\\nmeatus. On the other hand, Botkin observed bilateral\\notitis externa 21 times among 26 typhoid patients, and\\nerects the improbable hypothesis that suppurations from\\nthe middle ear in typhoid are due to an extension of otitis\\nexterna to the ear-drum and to the tympanic cavity.\\nAn apparent reduction in the power of hearing is fre-\\nquently met with in the course of typhoid fever, although\\nno objective changes can be found to account for it. It\\nis quite unjustifiable to interpret such cases as nervous\\n1 Die Krankh. des Ohres, etc., p. 90.\\n2 Arch. f. Ohr., IV, 6th Observation.\\n3 See Mon. f. Ohr., 1S95, p. 135.", "height": "3460", "width": "2120", "jp2-path": "rhinologylaryng00frie_0137.jp2"}, "138": {"fulltext": "132 ACUTE INFECTIOUS DISEASES.\\ndeafness, for clinical experience teaches that the difficult\\nhearing is due to somnolence, and improves as soon as the\\nmental faculties are restored. I have myself observ^ed that\\nthe hearing varies during the febrile stage, being remarkably\\nimproved during the remissions of the temperature which\\nfollow cold baths. When Haug 1 remarks that this\\ntyphoidal deafness sometimes reaches its highest point at\\nthe crisis of the general disease, and then gradually dimin-\\nishes and allows the ear to return to its normal condition\\nduring the stage of convalescence, and insists particularly\\non the fact that disturbances of the sphere of coordination\\nhave never been observed, we may be pardoned for express-\\ning a doubt of this nervous ear affection.\\nThis must not, however, be taken to imply that we deny\\nthe possibility of the nervous hearing apparatus being in-\\nvolved in typhoid fever, and there are, in fact, a few obser-\\nv^ations which prove that difficult hearing and tinnitus aurium,\\nwith the other phenomena of the nervous affection, undoubt-\\nedly occur during the stage of convalescence in fact, the\\nanatomic investigations of Pulitzer, Moos, Lucae, and\\nSchwartze demonstrated an anatomic basis for this clinical\\npicture a hyperemia of the internal ear or ecchymoses and\\nhemorrhages in the vestibule and in the cochlea. The\\nclinical cases of nervous deafness which have been described\\nas progressive after typhoid fever, must, in the absence of\\ndetailed histories, be accepted with a reservation, as they\\nmay have something to do with the exhibition of quinin or\\nsalicyHc acid during the course of the fever.\\n6. INFLUENZA.\\nAlthough the port of entry for the carriers of the infection\\nof influenza is probably to be sought in the mucous mem-\\nbranes of the upper air-passages, the parts themselves are\\ndirectly involved in only a small percentage of the cases.\\nLeichtenstern 2 has designated this form as catarrhal res-\\npiratory influenza, in contradistinction to the gastro-intes-\\ntinal form and the purely toxic form with fever and nervous\\nphenomena. The frequency of rhinitis is variously given\\nat from 25 to 79^, that of laryngitis from 5 to 16\\nthese figures appear remarkably low in comparison with the\\nLoc. cit., p. 95.\\n2 Nothnagel s spec. Path. u. Ther., vol. iv, I, p. 77.", "height": "3468", "width": "2132", "jp2-path": "rhinologylaryng00frie_0138.jp2"}, "139": {"fulltext": "INFLUENZA. 1 33\\nfrequency with which these conditions are observed in\\npractice.\\nThere can not be said to be a typical clinical picture for\\nthe complications of influenza in the upper air-passages, for\\nthey manifest themselves under the most various forms. Two\\nprincipal groups are distinguished one affecting principally\\nthe mucous membrane, the other the nervous system. With\\nregard to affections of the mucous membranes, it has been\\npointed out by Leichtenstern that the inflammation is not\\nuniformly distributed over all the mucous membranes,\\nand that the deeper portions do not always become affected\\nsecondarily to the disease in the upper portions, i. e., the\\nnose and the nasopharynx, as is the case in most other con-\\nditions, but every portion of the respiratory tract is cap-\\nable of becoming primarily affected by the morbid process.\\nIn the nose the inflammation presents the picture of\\nan acute rhinitis which is distinguished from an ordinary\\ncoryza only by the rapidity of its course, the inflammatory\\nsymptoms and secretion subsiding within a very few days.\\nThe rhinitis is occasionally accompanied by epistaxis,\\nalthough we find very contradictory statements in regard\\nto this symptom. Schmidt and Litten regard epistaxis\\nas a very frequent complication, while Tissier,i Leichten-\\nstern, and Frankel,^ on the other hand, say that it is\\ncomparatively rare. We should mention the occurrence\\nof acute or, later, chronic suppurations in the accessory\\ncavities as one of the complications. Thus, the maxillary\\nsinus is frequently the seat of an acute inflammation,\\naccompanied with nasal obstruction and facial neuralgia,\\nwhich immediately disappears either spontaneously or\\nafter the swelling in the mucous membrane has subsided\\nand the orifice of the cavity has been exposed. The\\nbest descriptions of suppurations of the accessory cavities\\nare given by Tissier, who claims to have found all the\\nvarious sinuses affected. Ewald^ reports a very malig-\\nnant case in which a purulent basal meningitis developed\\nafter an empyema of the antrum of Highmore had been\\nopened the meningeal complication at the autopsy was\\naccounted for by the finding of a suppuration in the\\nethmoid cells.\\n1 Ann. des mal. de I oreille, 1S92, p. 425.\\nSemon s Centralbl., vii, p. 3S.\\n3 Berlin, klin. Wochen., 1S90, No. 3.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0139.jp2"}, "140": {"fulltext": "134 ACUTE INFECTIOUS DISEASES.\\nCatarrh of the pharynx and larynx also presents the\\nordinary picture of an acute inflammation, except that\\nhemorrhage appears to be a more frequent complication than\\nin the nose the term laryngitis Jicviorrliagica has been ap-\\nplied to this form of the disease. The affected mucous mem-\\nbranes are frequently the seat of whitish patches, not ele-\\nvated above the swollen and reddened mucous membrane.\\nThey are analogous to similar patches found in acute\\ncatarrh, and are to be interpreted as a superficial necrosis.\\nIn a few instances marked edema of the laryngeal mucous\\nmembrane was observed, which even went on to abscess\\nformation, and Rethi described a coexisting perichondritis\\nof both plates of the thyroid cartilage.\\nAs regards nervous diseases, a few cases of anosmia\\nand parosmia have been reported, and while paralysis of\\nthe palatal muscles and of the constrictors of the pharynx\\nmay occur, by far the most important complication con-\\nsists in paralysis of the laryngeal nerves, which must be\\nregarded as a typical influenza neuritis such as occurs in\\nall parts of the body. Besides rare cases of paralysis\\nof the sensory superior laryngeal nerve we meet with\\nparalyses of the laryngeal muscles, both of the adductors\\n(Onodi saw an isolated paralysis of the cricoarytenoideus\\nlateralis, and Rosenberg frequently noticed paralyses of the\\nvocal cords) and of the abductors they usually make\\ntheir appearance after the acute inflammation has subsided.\\nSo far as the observations have gone, the abductors appear\\nto be more frequently involved than the adductors, and both\\nunilateral and bilateral paralysis of the crico-arytenoideus\\nposticus has been observed. Seifert^ reports a unique case\\nof a right-sided total paralysis of the vagus which he re-\\ngards as peripheral in origin. Besides the usual cardiac\\nand circulatory symptoms there was paralysis of the right\\nrecurrent and of the superior laryngeal nerves.\\nAURAL COMPLICATIONS IN INFLUENZA.\\nSoon after the appearance of the influenza epidemic of\\n1 889-1 890 the attention of aural surgeons was directed to\\nthe frequency of purulent otitis media as a complication of\\ninfluenza, and the numerous observations that have been\\n1 Wien. klin. Wochen, 1894, No. 48.\\n2 Rev. hebd. de lar., d ot. et de rhin., 1896, p. 1537.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0140.jp2"}, "141": {"fulltext": "INFLUENZA. I 3 5\\nmade since then, and that any physician can make for him-\\nself even now in the sporadic cases of influenza, justify the\\nconclusion that this epidemic infectious disease occupies an\\nimportant place in the etiology of aural complications. It\\nwas learned by the statistics of Ludwig and Jansen that a\\nrapid increase in middle-ear diseases occurred during the\\nmonths of November and December, 1889, and January,\\n1890, and this increase was attributed to the epidemic\\nwhich was prevalent at that time. It is important to note\\nthat the increase did not affect middle-ear diseases in gen-\\neral, but Avas limited exclusively to inflammations of the\\nmiddle ear. Thus, in the Halle Ear Clinic the number\\nreached 137 during the months of the epidemic, as against\\n41 or 44 during the same months of the preceding years\\nand, according to Gruber, there were 625 cases from No-\\nvember, 1889, to January, 1890, as against 238 and 84\\nduring the same period of the preceding years. Jansen s\\nstatistics are most convincing in this respect they show\\nthat the percentage of acute inflammations of the middle\\near, which in the first eleven months of the year 1889\\namounted to from 10^ to ly.yfo, rose to 37^ in Decem-\\nber, 1889, 29^ in January, and 20.6^ in February 1890,\\nalthough there was no appreciable increase in the frequency\\nof simple catarrh of the middle ear. The discrepancy can\\nnot be explained as an ordinary increase in the frequency\\nof the disease due to the season of the year, since the com-\\nparison with the months of November, December, and Jan-\\nuary of the five preceding years shows a percentage ranging\\nfrom 8.1 to 21.5, and in only one winter a percentage as\\nhigh as 25.5. In spite of the increase in this particular\\nform of disease the total number of patients was not appre-\\nciably increased, as might have been expected from the\\ngeneral prevalence of disease during the epidemic. Leich-\\ntenstern s objection, that the statistics of specialists merely\\nshow the enormous distribution of the influenza, is quite\\nirrelevant. On the contrary, if we examine the statistics of\\nspecialists, we find that the great frequency of certain ear\\ndiseases such as acute inflammation and suppuration of\\nthe middle ear which are known to follow in the wake of\\nother infectious diseases and their abnormally rapid and\\nmalignant course during an epidemic of influenza, are not\\nmerely accidental, but directly dependent on the epidemic.\\nWith regard to the frequency of aural complications of", "height": "3460", "width": "2104", "jp2-path": "rhinologylaryng00frie_0141.jp2"}, "142": {"fulltext": "136 ACUTE INFECTIOUS DISEASES.\\ninfluenza in general we possess only general statistics,\\naccording to which from o. 5 to 2 of all cases are com-\\nplicated with disease of the ear but these figures are prob-\\nably below the true percentage, as the milder cases of\\ninfluenza remain only a short time in the hospital, and the\\naural disease therefore appears only as a sequel.\\nThe otitis in influenza makes its appearance in the form\\nof an acute suppuration of the middle ear from a few days\\nto several weeks after the beginning of the primary disease.\\nAs influenza is an infectious disease with a special prefer-\\nence for the upper air-passages, it is probable that a large\\nproportion of the aural affections are due to infection from\\nthe nasopharynx through the tubes, and, as such, appear\\nunder the form of an ordinary purulent otitis media. There\\nis, in addition, another manifestation of influenza which\\npossesses a distinct hemorrhagic character, and is by\\nmany regarded as a pure form of influenza otitis. These\\ntwo varieties can not be accurately distinguished in prac-\\ntice, as the typical appearance in the latter form disappears\\nafter the first k\\\\v days and is replaced by the picture of an\\nordinary otitis media. The finding of the bacillus of\\ninfluenza which was first positively reported by Scheibe,\\nand after him by several other investigators, although never\\nwith any regularity is of very little importance, as sooner\\nor later in any form of suppuration from the middle ear\\nthere develops a mixed infection in which other micro-\\norganisms may supplant the primary disease germ.\\nAs regards the clinical course of influenza otitis, it was\\nformerly universally believed that hemorrhages were to be\\nregarded as a regular symptom of the disease in the acute\\nform, in accordance with the first descriptions given by\\nPatrzek, Schwabach, Dreyfuss, and Jankau Schwartze,\\nhowever, adheres to his opinion that the hemorrhages\\nare not observed with any greater frequency than in inflam-\\nmations from other causes. We find ecchymoses, var^ang\\nfrom the size of a pinhead to that of a split pea, either single\\nor multiple, on the ear-drum and on the walls of the\\nexternal meatus or we may have bluish-red extravasations\\nof varying extent, sometimes covering the entire ear-drum.\\nKorneri speaks of secondary circular hemorrhages which\\nhe saw through the ear-drum after hypertrophy of the\\n1 Zeitschr. f. Ohr., xxvii, p. 11.", "height": "3468", "width": "2192", "jp2-path": "rhinologylaryng00frie_0142.jp2"}, "143": {"fulltext": "INFLUENZA. 1 3/\\nmucous membrane. The hemorrhages often take the form\\nof villous or pouch-shaped diverticula in the tympanic\\nmucous membrane, due to marked swelling of the mucous\\nmembrane of the middle ear, and, after perforation, pro-\\nlapse through that structure into the external meatus.\\nThey show a special tendency to recurrence, and frequently\\nreform after simple cauterization. Some observers speak\\nof perforation taking place in a definite portion of the ear-\\ndrum, but the statements are so contradictory that it is not\\nworth while to repeat them isolated involyement of the\\ncupola (infundibulum cochleae) in influenza, mentioned\\nby Kosegarten and Haug, must be very rare. The dis-\\ncharges are bloody on the first day, and hemorrhages\\nmay occur even later without leading to suppuration,\\nwhile in other cases the bloody discharge is replaced by\\nserosanguineous fluid, which is eventually followed by\\nsuppuration.\\nThe statement that purulent otitis media in influenza is\\nmore severe than other forms of suppuration from the mid-\\ndle ear is based on the frequent implication of the mastoid\\nprocess (according to Jansen, in 57 out of 105 cases, 25 of\\nwhich necessitated trephining). The complication leads to\\nsuppurations in the bone and to periosteal abscess, which\\nare greatly to be dreaded on account of the intensity of the\\nprocess and its rapid extension. According to Komer,\\nEulenstein, and Lemcke, primary myelitis of the mastoid\\nprocess with secondary involvement of the middle ear\\nmay occur but the opposite direction, from the middle ear\\nto the mastoid process, is probably to be regarded as the\\nregular mode of infection.\\nThe internal ear is very rarely involved, and the nature\\nof the condition is not known. Lannois and Barnick\\ndescribed cases of labyrinthine deafness after influenza.\\nAccording to the former, the prognosis as regards restora-\\ntion of the hearing is bad according to the latter, favorable.\\nGradenigo mentions difficult hearing after influenza, which\\nhe interprets as a neuritis of the auditory nerve.\\nThe occurrence of otalgia tympanicais occasionally men-\\ntioned, and although the condition can hardly be diagnosed\\n1 Rev. de lar., d ot. et de rhin., 1890, No. 17.\\n2 Arch. f. Ohr., 38, p. 1S3. 3 See Arch. f. Ohr., 36, p. 141.\\nComp. Leyden and Guttmann, Die Influenzaepidemie, Wiesbaden,\\n1892, p. 132; and Ebstein, D. Arch. f. klin. Med., vol. LVili, p. 14.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0143.jp2"}, "144": {"fulltext": "138 ACUTE INFECTIOUS DISEASES.\\nwith certainty, it may be accepted as a possible complica-\\ntion through the trifacial nerve, in view of the frequency of\\nother neuralgic manifestations in influenza.\\n7. PAROTITIS EPIDEMICA (MUMPS),\\nIn this obscure epidemic disease, which belongs to the\\nclass of infectious diseases, the general infection manifests\\nitself in various parts of the body, showing that the typical\\nswelling of the parotid gland is only a local expression of\\nthe general disease. The commonest complication that\\nof orchitis and epididymitis is as little understood as the\\noccasional involvement of the ear.\\nThe aural complication usually takes the form of laby-\\nrinthine deafness, appearing, as a rule, during the first days\\nof the disease, along with other symptoms of Meniere s\\ncomplex, and offering an obstinate resistance to every mode\\nof treatment, while the accompanying symptoms of vertigo,\\ntinnitus aurium, and disturbances of the equilibrium sub-\\nside. Like the complications in the sexual organs, those\\nin the ear show a predilection for the age of puberty, being\\nmost frequent between the tenth and twentieth years. 1\\nThe total number of cases reported is very small. In 1884\\nConnor was able to collect 34 cases, and in 1883 Gradenigo\\ncould report only 38 positive observations of deafness due\\nto mumps. One or both ears may be affected, and there\\nappears to be no connection with the situation of the pri-\\nmary disease if the latter has been unilateral. There have\\neven been reported rudimentary cases in which orchitis\\nand deafness were present without glandular swelling (Gra-\\ndenigo s case). As the prognosis is absolutely unfavorable,\\nthe disease may, if it be bilateral and occurs in early infancy,\\nlead to deafmutism, the frequency of which is given as\\n0.3^ by Mygind, in the Saxon deaf and dumb statistics,\\nand as 0.5^ by American statisticians.\\nThe otoscopic picture is in every respect negative, and\\nthere is absolutely no proof that inflammations of the tym-\\npanic membrane and exudations in the middle ear have\\nanything to do with the disease. Functional test shows\\ndeafness or marked reduction in the hearing of the internal\\n1 Gradenigo, Schwartze s Handb., Ii, p. 440,", "height": "3468", "width": "2176", "jp2-path": "rhinologylaryng00frie_0144.jp2"}, "145": {"fulltext": "ACUTE RHEUMATOID ARTHRITIS. 1 39\\near, while, according to Moos,i the power of hearing for\\nthe lower notes and bone conduction may bfe preserved.\\nNumerous attempts have been made to explain the deaf-\\nness of infectious parotitis, but they are all more or less\\nimprobable, and therefore of no interest.\\nThe subject will be found discussed at length in papers\\nby Rossa,2 Moos,^ Haug,^ Gradenigo,^ and Alt.^\\nPilatti describes a case of parotitis in which tracheotomy\\nwas required on account of edema of the larynx.\\n8. ACUTE RHEUMATOID ARTHRITIS (POLYAR-\\nTHRITIS RHEUMATICA ACUTA).\\nOne of the first diseases in which the tonsils were recog-\\nnized as the port of entry for a general infection was acute\\narticular rheumatism. The importance of angina in the\\netiology of this disease was first pointed out by Lagranere,\\nBoeck, Loebl, Mantle, and others, all basing their asser-\\ntions on clinical observations.\\nBut the confusion that still prevails with regard to the\\ncause of acute articular rheumatism was not removed by\\nthe bacteriologic examination of cases of rheumatoid\\nangina, for the greatest variety of microorganisms\\nstaphylococcus aureus, pyogenic streptococci, streptococ-\\ncus citreus, and pneumococci was found. As this is not\\nthe place for a detailed theoretic discussion of the relation\\nbetween the angina and rheumatism, which will be found,\\ntogether with a complete report of all the cases in the\\nliterature, in the works of Buss,^ Suchannek,^ and Bloch,i\\nI shall merely refer briefly to the clinical observations\\nthat have been reported. Any one of the varieties of\\ntonsillitis, both catarrhal and follicular, may appear either\\nas a forerunner of rheumatism before the joints are\\naffected, or as a feature of the fully developed clinical\\npicture. The complication can not at the present time\\n1 Berlin, klin. Wochen., 1S84, No. 3.\\n2 Zeitschr. f. Ohr., vol. xn. Schwartze s Handb., i, p. 584.\\nDie Krankh. des Ohres, etc., p. 75.\\n5 Schwartze s Handb., 11, p. 439.\\n6 Mon. f. Ohr., 1896, p. 525.\\nSee Semon s Centralbl., Vin, p. 149.\\n8 D. Arch. f. klin. Med., vol. i.iv.\\nBresgen s Sammlung, vol. i, II. i.\\n10 Munch, med. Wochen:, 1S9S, Nos. 15, 16.", "height": "3456", "width": "2100", "jp2-path": "rhinologylaryng00frie_0145.jp2"}, "146": {"fulltext": "I40 ACUTE INFECTIOUS DISEASES.\\nbe regarded as a rare occurrence in Germany, as stated\\nby Wagner in 1878, and its frequency shows that it\\nis not an accidental coincidence, but that it represents a\\nsymptom of the general disease. Gerhardt mentions, as\\na strong proof of internal connection between tonsillitis\\nand rheumatism, a case of Staffel s,^ in which an attack of\\narticular rheumatism rapidly followed a severe inflamma-\\ntion of the tonsils, and the articular affection was removed\\nonly after methodical treatment of the mouth. In addition\\nto tonsillitis and pharyngitis, we also have catarrhal lar} n-\\ngitis but by far the most important diseases of the larynx,\\nfrom a practical point of view, are those which must be\\nregarded as typical rrianifestations of the rheumatic infec-\\ntion. They may be divided into two varieties, which have\\nbeen designated respectively as disease of the joints of the\\nlarynx and as laryngitis acuta rheumatica circumscripta\\n(Nodosa).\\nThe crico-arytenoid articulation is the only one tiiat has\\nbeen known to be involved in an acute articular rheuma-\\ntism, although the fact that there is no report of the crico-\\nthyroid joint being involved may be due to defective diag-\\nnosis, and it seems to me that Meyer s case might easily\\nbe regarded as one of this kind, since the laryngoscopic\\nfindings w^ere negative. Rheumatism of the crico-arytenoid\\narticulation is usually bilateral, and manifests itself in the\\nlaryngeal image in redness and swelling of the arj^tenoid\\nregion and in sluggishness or arrest of the vocal cords, sim-\\nulating paralysis. Besides the aphonia, the subjective symp-\\ntoms consist in a sensation as of a foreign body, dyspnea,\\nand dysphagia, all. of which, according to Meyer s descrip-\\ntion, are worse when the patient lies down. An important\\ndiagnostic point is the tenderness over the crico-arytenoid\\njoint or over the thyroid cartilage in the latter case the\\nsymptom possibly points to disease of the cricothyroid\\narticulation. The laryngeal complication usually develops\\nbetween the fourth and the twelfth day after the onset of the\\narticular rheumatism the prognosis is favorable, recovery\\nusually occurring in a short time (according to Meyer, in a\\nweek). Grijnwald mentions a case of cadaver position\\nWagner, Ziemssen s Handb., VII, p. 148.\\n2 Verhdl. des Congr. f. inn. Med., 1896, p. 180.\\nZeitschr. f. prakt. Aerzte, 1896, No. 4.\\n4 Berlin, klin. Wochen., 1894, No. 16.\\n5 Berlin, klin. Wochen., 1892, No. 20.", "height": "3468", "width": "2176", "jp2-path": "rhinologylaryng00frie_0146.jp2"}, "147": {"fulltext": "ACUTE RHEUMATOID ARTHRITIS. I4I\\non the right side after articular rheumatism which was cured\\nin two years. The disease usually responds promptly to\\nsalicylic acid. The reported cases, which are very few in\\nnumber, have been collected by Lacoarret and Sendziak\\nArchambault s thesis is also well worth reading.\\nThe second form of rheumatic disease in the larynx is\\ndescribed by Uchermann as laryngitis acuta rheumatica\\ncircumscripta (nodosa), although Goldscheider lays claim\\nto priority, as he reported an analogous case in an earlier\\npaper. The condition occasionally manifests itself in con-\\nnection with erythema nodosum as a circumscribed red-\\ndish or bluish-red, moderately firm infiltration, very sensi-\\ntive to the touch, which may attain a considerable size (as\\nlarge as an almond), seated usually in the neighborhood of\\nthe crico-arytenoid articulation or in the aryepiglottic fold\\nin the former situation pseudo-ankylosis, with immobility of\\nthe vocal cord, is likely to result.\\nAs the inflammation also invades neighboring portions\\nof the larynx, and thus leads to edema both in the aryepi-\\nglottic folds and on the epiglottis, the symptoms of dyspnea\\nand dysphagia may be added.\\nThe prognosis in this form also is favorable.\\nWolf described two cases of acute inflammation of the\\nmiddle ear in acute articular rheumatism. In the first\\ncase both ears were affected one after the other one\\nof the ear-drums ruptured spontaneously in the other, par-\\nacentesis was required. The rheumatism was very severe,\\nand did not appear in the joints until several days later\\nthe suppuration which followed the inflammation was cured\\nin four weeks. In the second case the aural disease was\\nfollowed after only nine days by diffuse swellings in the\\njoints. From the fact that in both cases the impairment of\\nhearing and thickening of the ear-drum were permanent.\\nWolf concludes that articular rheumatism may be the cause\\nof sclerotic catarrh in the middle ear. A similar case is\\nreported by Meniere. We have no knowledge of disease\\nin the joints of the ear ossicles the possibility of rheumatism\\nin the joint between the malleus and the incus, and between\\nthe incus and the stapedius, is, however, worth considering.\\n1 Rev. de lar., d ot. et de rhin., 1S91, No. II.\\n2 Arch. f. Laryng., iv, p. 264, and VI, p. 168. TWse de Paris, 1886.\\nDeutsche med. Wochen., 1897, p. 749. Ibid., p. 807.\\nArch. f. Ohr., 41, p. 213.\\nRev. mens, de lar., d ot., et de rhin.", "height": "3460", "width": "2120", "jp2-path": "rhinologylaryng00frie_0147.jp2"}, "148": {"fulltext": "142 ACUTE INFECTIOUS DISEASES.\\nThe cases reported by Bloch in which disease of the\\near is said to have produced an acute articular rheumatism\\ndo not seem to me sufficiently convincing to justify the\\nassumption of a new mode of infection for that disease.\\n9. DIPHTHERIA.\\nThe description of diphtheria belongs to the domain of\\ninternal medicine, and the manifestations of the disease in\\nthe nose, pharynx, and larynx will be found amply discussed\\nin the text-books.\\nI shall not, therefore, attempt to give a description, as it\\ndoes not belong to the scope of this work, and would, if it\\nmade any pretensions to thoroughness, occupy too much\\nspace. Instead, I shall confine myself to a discussion of\\nthe sequels occurring after diphtheria in the nose, pharynx,\\nand larynx, and in the ears.\\nIn the pharynx and larynx we have post-diphtheric\\npalsies of both the sensory and motor nerves, the cause\\nof which is now generally conceded to be a peripheral\\nneuritis. The time of their appearance is usually given\\nas from two to six weeks after the diphtheria. The\\nparalysis affects most frequently the uvula. The nature\\nof the paralysis is unmistakable, as it can be seen by\\ndirect inspection, and manifests itself, besides, in the con-\\nspicuous symptoms of dysphagia, regurgitation of liquids\\nthrough the nose, and nasal speech. Although this\\nform of paralysis has occasionally been observed early, fol-\\nlowing immediately upon the pharyngeal disease, it must\\nbe remembered that a paretic condition of the palatal mus-\\ncles may be produced by the diphtheric disease of the\\nmucous membrane invading the deeper-lying muscles.\\nAnesthesia of the pharyngeal and laryngeal mucous\\nmembrane is much more rare. It was observed in the\\ncases cited by v. Ziemssen and elsewhere.\\nParalysis of the vocal cords has been observed with at\\nleast sufficient frequency to remove any doubt of its oc-\\ncurrence, and it is difficult to understand what could have\\nled Baginsky to say that he was unable to find among\\n1 Miinch. med. Wochen., 1898, Nos. 15, 16.\\nThe latest description is by Baginsky, in Nothnagel s Spec. Path. u.\\nThen, 11. Bd., i. Th.\\n3 In v. Ziemssen s Handb., vol. iv, p. 405. Loc. cit., p. 215,", "height": "3468", "width": "2180", "jp2-path": "rhinologylaryng00frie_0148.jp2"}, "149": {"fulltext": "DIPHTHERIA. 1 43\\nall the reported cases any description of paralysis of the\\ncrico-arytenoidei postici due to lesion of the recurrent laryn-\\ngeal nerves after diphtheria he himself had certainly never\\nseen it. Von Ziemssen reports two cases of diphtheric\\nparalysis of the pharynx, larynx, and extremities. In one\\ncase the left vocal cord was completely paralyzed in the\\ncadaver position, while the right was very sluggish and\\nlimited in its excursions.\\nI once saw a doubtful case in which a unilateral complete\\nparalysis of the uvula and vocal cords was associated with\\nanesthesia of the mucous membrane and abolition of all\\nthe reflexes. The paralysis occurred about six weeks\\nafter a mild case of diphtheria, and after it had lasted seven\\nweeks the vocal cord gradually returned to the median\\nposition and finally completely regained its movabihty.\\nClifFord-Beacher observed a case in which paralysis of\\nthe adductors followed that of the abductors, while recov-\\nery took place in the inverse order.\\nAccording to Lublinsky, postdiphtheric paralysis of\\nthe vocal cords is more frequent, and occurs earlier when the\\nserum treatment is employed in one case he saw it as early\\nas the ninth day of the disease.\\nThe prognosis of postdiphtheric paralysis is favorable.\\nIn anesthesia and impairment of the reflexes in the upper\\nair-passages there is some danger of inspiration pneumonia.\\nIn addition to these peripheral palsies there have been\\nobserved paralyses of central origin, probably due to hem-\\norrhage, manifesting themselves under the form of hemi-\\nplegia and presenting the symptoms of paralysis of the\\nuvula and aphasia. It is not stated whether or not the\\nvocal cords were also paralyzed. Edgren gives a review\\nof the cases reported in the literature, adding some of his\\nown.\\nDiseases of the ear in diphtheria may be divided into\\n1. Diphtheric inflammations of the external auditory\\nmeatus.\\n2. Diphtheric inflammations of the tube and of the middle\\near.\\n3. Acute catarrhal and purulent inflammations of the mid-\\ndle ear without the formation of membranes.\\n1 Loc. cit., p. 215. 2 Semon s Centralbl., IX, p. 86.\\n8 Deutsche med. Wochen., 1S95, No. 26.\\nDeutsche med. Wochen., 1893, No. 36.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0149.jp2"}, "150": {"fulltext": "144 ACUTE INFECTIOUS DISEASES.\\n1. Diphtheria of the external auditory meatus is very\\nrarely seen. The only reliable observation of its occur-\\nrence in connection with pharyngeal diphtheria is that of\\nTreitel, while in the other published cases of croupous\\ninflammation of the external meatus, by Wreden, Blau, and\\nothers, the diagnosis of true diphtheria is not positive, some\\nof the cases representing the scarlatinal variety. In Trei-\\ntel s case, diphtheric membranes were found in both ears,\\nrepresenting a complete cast of the external auditory mea-\\ntus. The inflammatory symptoms were very marked, and\\nthere was extensive swelling over the mastoid process.\\nThe disease extended to the auricle, but the ear-drum re-\\nmained intact.\\nA bacteriologic examination was made by Kossel, and\\nwas negative, although he found rod-shaped organisms\\nresembling the diphtheria bacillus Treitel attributes the\\nnegative outcome of the cultures to the sublimate solution\\nin which he had preserved the membranes before they were\\nexamined.\\n2. As regards diphtheric disease in the tube and in the\\nmiddle ear, we do not possess any positive investigations\\nsupported by the bacteriologic demonstration of diphtheria\\nbacilli, but we are forced by the result of autopsies and by\\nclinical observation to assume the occurrence of such com-\\nplications in true diphtheria.\\nWhen we attempt to analyze the reported cases, most of\\nwhich belong to the prebacteriologic period, or else are so\\nlittle to be relied upon as to be quite unworthy of dis-\\ncussion, it is often difficult to separate cases of false from\\nthose of true diphtheria. Wreden and Burkhardt-\\nMerian,^ for instance, discuss scarlatinal diphtheria and\\ntrue diphtheria and their complications with croupous\\ninflammation of the middle ear without making any dis-\\ntinction between them. On the other hand, we find in the\\nobservations of Wendt,^ Kiipper,^ Moos, and Hirsch the\\nnecessary materials for a description of diphtheric disease\\nof the ear.\\nThe middle ear may be affected alone or in combination\\n1 Deutsche med. Wochen., 1S93, p. 13S8,\\n2 Mon. f. Ohr., vol. 11, p. 148.\\n3 Volkmann s Sammlung klin. Vortr., I. Reihe, Serie vii. No. 182.\\nArch. f. Heilkunde, xi and xni.\\n5 Arch. f. Ohr., xi, p. 20. Zeitschr. f. Ohr., XIX, p. loi.", "height": "3492", "width": "2132", "jp2-path": "rhinologylaryng00frie_0150.jp2"}, "151": {"fulltext": "DIPHTHERIA. I45\\nwith the tube. Diphtheric membranes are found adhering\\nto the mucous membrane of the tympanic cavity or cover-\\ning the ossicles or Hning the cells in the bone. In a case\\nof acute purulent otitis media after diphtheria, reported by\\nLommel,! beginning membrane formation was found in\\nindividual mastoid cells.\\nThe symptoms of the disease are those of any acute\\notitis media, rise of temperature and pain being the most\\nprominent the pain is aggravated by the fact that the ear-\\ndrum shows no tendency to spontaneous perforation, so\\nthat expulsion of the membranes into the external meatus\\noccurs only after paracentesis has been performed.\\nThe course of a croupous disease of the ear following\\ndiphtheria appears to be the same as that of one following\\nscarlet fever both diseases are considered equally malig-\\nnant as regards destruction of the walls and of the ossicles\\nin the middle ear, the production of extensive caries in the\\ntemporal bone, and extension to the labyrinth, so that the\\nprognosis must be regarded as unfavorable.\\nNothing definite is known in regard to the frequency of\\ntrue diphtheria in the ear. It is certainly very rare, and\\ndoes not bear any proportion to the frequency of scarlatinal\\ndiphtheria.\\n3. It has been demonstrated by anatomic investigations\\namong which those of Wendt and Lommel are worthy of\\nspecial mention that even without clinical appearances,\\nand certainly without any involvement of the drum mem-\\nbrane, certain alterations are regularly found in the middle\\near of diphtheric cadavers which we must regard as due to\\ncatarrhal otitis media with or without serous exudation,\\ncatarrhal otitis media without purulent but with mucous\\nsecretion, or acute purulent otitis media. Although\\nLommel found pus in the middle ear in one-half of his\\ncases, the ear-drum was never perforated nor even markedly\\ncongested, showing that a clinical diagnosis based on the\\nappearance of the otoscopic image would have been\\nimpossible.\\nThis explains why the anatomic findings of Lommel in\\nregard to the frequency of aural complication in diphtheria\\nare in direct opposition to clinical observations. While, on\\n1 Zeitschr. f. Olir., xxix, cases VII and xxiv, p. 301.\\n2 Zeitschr. f. Olir., XXIX, p. 301.\\n10", "height": "3460", "width": "2120", "jp2-path": "rhinologylaryng00frie_0151.jp2"}, "152": {"fulltext": "146 ACUTE INFECTIOUS DISEASES.\\nthe one hand, Lommel found the ear intact in only i out of\\n25 autopsies of diphtheric cadavers, and therefore laid down\\nthe rule that otitis media forms an integral part of the\\nclinical picture of diphtheric disease of the respiratory\\norgans, Baginsky,i on the other hand, reports that\\nalthough he examined the ears of his diphtheria patients\\nwith the greatest care, he found only from 5^ to 6^ in\\nwhich an inflammation was present. Hence we must not\\noverestimate the significance of these findings from a clin-\\nical point of view, and as in my cases the reports show that\\nthe alterations in the mucous membrane of the middle\\near were very slight and analogous to those which are\\nfound in other infectious diseases, especially measles\\n(Rudolf and Bezold), we must assume that they undergo\\nregeneration without giving rise to any clinical symptoms.\\nAs has been stated in connection with croupous inflam-\\nmation of the middle ear, the tube may remain intact.\\nLommel found that the cartilaginous extremity was rarely\\nattacked, while the main central portion was regularly\\nfree from any inflammatory process, even in one case where\\nthere was a diphtheric exudate about the orifice itself.\\nHence, direct extension of the inflammation from the\\npharynx to the middle ear is to be regarded as unusual,\\nthe middle-ear disease being rather the expression of the\\ngeneral infection and I may remark that, in harmony with\\nthis statement, consecutive ear disease after nondiphtheric\\ntonsillitis, whether of the catarrhal, lacunar, or suppurative\\nvariety, is rare, notwithstanding the fact that those diseases\\nare usually referred to in the text-books as frequent etio-\\nlogic factors in suppuration of the middle ear.\\nLastly, it appears that nerve deafness may occur after\\ndiphtheria it is probably due to toxic influences, and be-\\nlongs to the class of postdiphtheric palsies. The cases\\nreported are so few and so incomplete that it is impos-\\nsible to draw any conclusions from them.\\n1 Diphtheric und diphtheritischer Croup, in Nothnagel s Spec. Path.\\nu. Then, Bd. ii, i. Th., p. 258.\\n2 Kretschmann, Arch. f. Ohr., xxrii, p. 236.\\n3 Haug, Die Krankh. des Ohres, etc., p. 69.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0152.jp2"}, "153": {"fulltext": "ERYSIPELAS. 1 47\\nJO. ERYSIPELAS.\\nPrimary erysipelas of the mucous membrane of the upper\\nair-passages is a very rare occurrence, and its pathology\\nand clinical course can not readily be distinguished from\\nthose of other infectious diseases of the mucous membrane\\nattended with high fever, redness, swelling, edema, and lead-\\ning finally to abscess formation. Indeed, various authors\\nhave objected to applying the term erysipelas to any dis-\\nease of the pharynx or larynx. Kuttner and Semon\\nare probably quite right in advocating the adoption of the\\ngeneral term acute septic inflammations of the larynx,\\nrejecting the terms erysipelas of the pharynx and larynx,\\nphlegmon, angina (Ludovici), or acute edema of the pharynx\\nand larynx as being merely synonymous terms for the same\\nclinical picture. Cases of undoubted erysipelatous infection\\nof the mucous membranes of the throat, while rare, are none\\nthe less of the highest importance, as primary erysipelas of\\nthe mucous membrane of the nose, pharynx, larynx, and\\nmouth may, by extension to the external skin, give rise to\\nsecondary facial erysipelas. This once occurred in\\nSchwartze s ear clinic a patient who had had a pharyn-\\ngeal tonsil removed went to see an erysipelatous patient\\nand contracted erysipelas of the nasopharynx, which spread\\nthrough the tubes to the middle ear, and from there to the\\nexternal meatus, the auricle, and the face. Rendu saw a\\ncase of erysipelas, where the diagnosis was confirmed by\\nbacteriologic examination, in a man suffering with syphil-\\nitic glossitis there was a fresh rise in the temperature when\\nthe erysipelas spread to the face. Garel describes a case\\nof erysipelas which began in the tongue and reached the\\nface by way of the pharynx and nose.\\nErysipelas occasionally occurs as a remote consequence\\nof disease of the anterior nares, of the auricle, and of the ex-\\nternal auditory meatus, for excoriations and rhagades due\\nto chronic eczema may form the port of entry for the germs\\nof the disease. That this is the mode of infection is proved\\nby the subsequent extension of the erysipelas, which in\\nLarynxodem und submukose Laryngitis, Berlin, 1895, Georg Reimer.\\n2 Med. chirurg. Transactions, vol. LXXVIII, 1895.\\nArch. f. Ohr., vol. xxxviii, p. 213.\\nFrance m6d., 1892 see Semen s Centralbl., x, p. 131.\\n5 Ann. des malad. de I oreille, etc., 1891, No. 5.", "height": "3452", "width": "2148", "jp2-path": "rhinologylaryng00frie_0153.jp2"}, "154": {"fulltext": "148 ACUTE INFECTIOUS DISEASES.\\nsuch cases first appears in the neighborhood of the nose\\nand ear, and gradually extends fi-om those points to the\\nskin of the face and head. This variety often shows a ten-\\ndency to recurrence, and habitual facial erysipelas 1 is\\nusually due to chronic eczema of the nose or of the ear.\\nThis etiologic sequence is important from a therapeutic\\npoint of view, as the occurrence of erysipelas can be\\nguarded against only by combating the eczema and the\\nbasal disease which is responsible for the eczema, such as\\nchronic rhinitis or suppuration from a neighboring cavity\\nor from the ear.\\nA suppuration from the middle ear due to erysipelas,\\nlike any other suppuration, may extend to the labyrinth and\\nproduce symptoms in that locality, as shown in a case\\nreported by Schwartze. I can not imagine what Haug\\nmeans when he says that the internal ear itself probably\\nescapes, in some cases at least, in so far as the inflam-\\nmation does not extend to the labyrinth at most there\\nmay be signs of a temporary congestion, nor am I much\\nimpressed by the elegant phrase that erysipelas not\\nrarely reaches its terminal phase in the periauricular lym-\\nphatic glands.\\niU MALARIA,\\nWe find numerous statements in regard to the occur-\\nrence of vasomotor rhinitis and hydrorrhoea nasalis in\\nmalaria. Chapell has collected a series of cases in which\\nthe hydrorrhea occurred periodically, corresponding to the\\nmalarial attacks.\\nWhether epistaxis is to be regarded as a characteristic\\nsymptom of the disease or not, is still a matter of doubt.\\nAccording to Lori, we rarely have in malaria the\\ntypical occurrence of aphonia. On various occasions he\\nobserved hoarseness or aphonia, synchronous with the\\nattack, occurring as early as the algid stage and disap-\\npearing as the temperature fell. In these intermittent\\naphonias he always found, on laryngoscopic examina-\\ntion, paralysis of all the muscles supplied by the recur-\\nComp. Friedrich, Pachydermie im Anschluss an habituelles Gesichts-\\nerysipel, Miinch. med. Wochen., 1897, No. 2.\\n2 Die Krankh. des Ohres, etc., 1893, p. 107.\\n3 See Semon s Centralbl., xi, pp. 395 and 508.\\nDie Veranderungen des Rachens, etc., p. 156.", "height": "3468", "width": "2144", "jp2-path": "rhinologylaryng00frie_0154.jp2"}, "155": {"fulltext": "MALARIA. 149\\nrens sometimes only on one side, sometimes on both.\\nEdema of the larynx, according to him, is an occasional\\nsymptom of the malarial cachexia.\\nHaug 1 has given us a comprehensive presentation of\\nmalarial diseases of the ear in which the literature is fully\\nquoted. Protozoic origin has been assumed for certain\\ndiseases of the ear which occur in periodic attacks, corre-\\nsponding to the type of malaria, at intervals of from one to\\nthree days, and present the picture of an acute inflammation\\nof the middle ear or of nervous deafness without being neces-\\nsarily accompanied by other malarial symptoms. Even the\\nolder physicians were well aware of the fact that intermittent\\notalgia sometimes occurred in the course of intermittent\\nfever, and Schoenlein states that the neuralgia may be\\nlocalized in the posterior auricular nerve and in the chorda\\ntympani, which, as Voltolini adds in explanation, shows\\nthat the pain is felt in the interior of the ear, as the chorda\\ntympani itself is not capable of giving rise to neuralgia.\\nAs Weber- Liel was the first to point out the connection\\nbetween otitis intermittens with malaria, and gave clinical\\nhistories in support of his assertion, I shall quote his de-\\nscription of the form of malaria which is attended with acute\\nirritation of the ear After an attack of tonsillitis and\\ncatarrh of the nasopharynx, at least in most cases, the aural\\naffection usually appears toward evening or during the\\nnight, accompanied by chills, which may be more or less\\nmarked or only barely perceptible. At first there is only\\nan uncomfortable sense of fullness and buzzing in the ears,\\nwhile not rarely a feeling of pressure in the head and vertigo\\nare among the first symptoms. The patient passes a\\nrestless night, perspires profusely, but feels quite well on the\\nfollowing day. These phenomena recurred after the man-\\nner of malaria for two or three days the ear-drum and the\\nexternal meatus were very hyperemic the middle ear was\\nthe seat of a serous or serosanguineous exudate cor-\\nresponding in quantity to the frequency of the attacks, and\\nin some cases perforation of the ear-drum occurred,\\nfollowed by serosanguineous or purulent discharge, as was\\nalso observed by Haug.^ For an explanation of this symp-\\nDie Krankh. desOhres, etc., p. 145.\\n2 Quoted by Voltolini, Men. f. Ohr., 1S78, p. 57.\\n3 Mon. f. Ohr., i87i,p. 125. Mon. f. Ohr., 1S78, p. 59.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0155.jp2"}, "156": {"fulltext": "150 ACUTE INFECTIOUS DISEASES.\\ntom-complex we are driven to assume a trophoneurosis of\\nthe trifacial nerve.\\nOf the second form of malarial disease Garzia gives the\\nfollowing description, based on the observation of 24 cases\\nAfter a rise of temperature, pain and deafness appear in both\\nears, the pain disappearing as the fever subsides, while the\\ndeafness remains. According to Haug, all kinds of subjective\\nnoises may make their appearance periodically.\\nThe diagnosis for both forms of the aural disease is based\\non the intermittent type, the exposure of the patient to\\nmalarial infection, and the beneficial effects of quinin, which\\nare said to be very striking and even capable of curing the\\ndeafness of the second form.\\n1 Verhandl. des internal. Congresses in Rom, reported in Arch, f.\\nOhr., XXXVII, p. 258.", "height": "3448", "width": "2200", "jp2-path": "rhinologylaryng00frie_0156.jp2"}, "157": {"fulltext": "VII. CHRONIC INFECTIOUS DISEASES.\\nU TUBERCULOSIS AND LUPUS.\\nTuberculosis manifests itself in all its various forms in\\nthe upper air-passages. The anatomic process is analogous\\nto that seen in all mucous membranes, presenting as its\\nchief type that of tuberculous infiltration, with tubercle\\nformation in the submucosa and mucosa, followed by ulcer-\\nation and granulation. It will be shown in a later chapter\\nhow these fundamental types can readily be classified by\\ntheir clinical appearances into separate subdivisions, which\\ntend to make the picture of tuberculosis appear somewhat\\nmore complicated than it really is when its mode of origin\\nis thoroughly understood. But before going into that\\nquestion we must adopt some theory as to how tuber-\\nculosis originates in the upper air- passages. The\\nmode of infection has given rise to much discussion, and\\nvarious opinions have been advanced in regard to the path\\nby which the tubercle bacillus, the causative agent in all\\nthe various forms, effects an entrance into the tissues.\\nThe mode of origin depends largely on whether the\\ntuberculosis is considered as a primary or as a secondary\\ndisease, since if the pathogenic germs first become localized\\nin the upper air-passages, the infection maybe derived from\\nthe inspired air and the food ingested while if we assume\\na primary tubercular focus in other organs, as, for instance,\\nthe lungs, secondary infection of the upper air-passages\\nmay take place either from within, by way of the lymphatic\\nand vascular channels, or from without, by direct infection\\nof the mucosa through the agency of tubercular sputa.\\nThe first of these two groups that of primary tuberculosis\\nof the throat, nose, and larynx is comparatively rare. It\\nis only recently that it has achieved general recognition,\\nand in the case of the larynx, its existence is still a matter\\nof dispute. The most recent studies in the mode of tuber-\\ncular infection have led to the careful investigation of the\\nvarious lymphatic elements in their relation to tuberculosis,\\n151", "height": "3460", "width": "2120", "jp2-path": "rhinologylaryng00frie_0157.jp2"}, "158": {"fulltext": "152 CHRONIC INFECTIOUS DISEASES.\\nThough formerly primary tuberculosis of the palatal, lin-\\ngual, and pharjaigeal tonsils was not believed to occur, the\\npresent tendency, since Strassmann s investigations, in\\nthe course of which he found tonsillar tuberculosis in 13\\nout of 21 tuberculous cadavers, is to regard not only\\ntuberculosis in general, but also primary infection of the\\npharyngeal lymphatic ring as of comparatively frequent\\noccurrence. Clinical observation has not been able to keep\\npace with anatomic investigation on account of the difficulty\\nof diagnosing latent tonsillar tuberculosis with any degree\\nof certainty. The palatal and pharjmgeal tonsils show no\\nmacroscopic alterations in cases in which they appear mani-\\nfestly tuberculous under the microscope as a rule, they\\nwere found to be only slightly hypertrophied, while in a\\nsomewhat larger proportion of cases small atrophic and\\nbrawny nodules were observed. As far as I know, Ruge s\\ncase, in which the clinical diagnosis of latent tonsillar tuber-\\nculosis was confirmed by subsequent examination of the\\nextirpated tonsils, is the only one of its kind, and even in\\nthis case the symptoms were very vague. The patient, a\\ngirl eighteen years old, had had enlarged tonsils since\\nchildhood, and for some time had complained of a vague\\nfeeling of discomfort in the throat later. Pott s disease of\\nthe cervical vertebrae developed. A few cases have been\\nreported in which extirpation of the pharyngeal or palatal\\ntonsils was followed by a fatal pulmonary tuberculosis\\nwithin a period of from one to two years, probably as the\\nresult of a recrudescence of a latent tonsillar tuberculosis\\nand the effect of surgical interference. Tuberculosis of\\nthe lymphatic structures of the pharynx is usually at-\\ntributed to direct bacillary infection by the respiratory air\\ncurrent or the food and it is not necessary in either of these\\nmodes of infection to suppose an abrasion of theepithehum\\nwhich should afford a port of entry to the pathogenic germs,\\nfor Stohr, Suchaneck, and Lexer have been able to\\ndemonstrate the possibility of the germs gaining entrance\\nthrough sound mucous membrane of the pharyngeal struc-\\ntures. This affords a strong argument for the possibility\\nof a latent tonsillar tuberculosis giving rise to a descending\\n1 Virch. Arch., xcvi, p. 319. Virch. Arch., cxLiv.\\n3 Kafemann, Bresgen s Samml., U, H. 4-5.\\nVirch. Arch., XCVH.\\n5 Ziegler s Beitrage, l888. Arch. f. klin. Chir., Bd. Liv.", "height": "3468", "width": "2212", "jp2-path": "rhinologylaryng00frie_0158.jp2"}, "159": {"fulltext": "TUBERCULOSIS AND LUPUS. I 53\\ntuberculous infection of the cervical lymphatic glands.\\nThe relation of such cases to those in which there is a co-\\nexistent tuberculosis of the lungs and larynx that is to\\nsay, whether they represent a primary infection which has\\nbecome latent, or one secondary to the pulmonary and laryn-\\ngeal affection can not at present be determined with cer-\\ntainty. A few authors maintain the possibility of primary\\ntuberculosis of the pharynx, but its occurrence is at least\\ndoubtful.\\nThe study of tuberculosis of the nose has established the\\npossibility of primary tuberculosis in this organ. This\\nstatement is based not only on clinical investigations, in\\nmany cases all the other organs were found to be free from\\ntuberculosis, but also on the favorable effect of removing\\nthe tubercular tumors which are often found on the\\ncartilaginous septum of the nose. It is evident that in\\nthis form of nasal tuberculosis we have to deal with a pri-\\nmary infection. This region of the septum plays an impor-\\ntant part in the pathology of the nose, as it is the point\\nwhere the inspiratory air current first impinges on the sep-\\ntum after passing through the vestibule, and deposits any\\nforeign body which it may contain. In this way erosions\\non the septum occur which lead to the sequel known as\\nxanthosis, and it is at this point, where the nutrition is nor-\\nmally low, that the tubercle bacillus is apt to establish\\nitself in favorable subjects and to lead to tubercular ulcera-\\ntion or tumor formation.\\nPrimary tuberculosis of the larynx must be regarded as\\nexceptional indeed, we should be inclined to deny its\\noccurrence altogether were it not for the positive postmor-\\ntem proof afforded by the two examples of Orth and\\nDemme and the statement of M. Schmidt, based on a large\\nexperience, that it is particularly apt to occur in the form of\\ntumors on the vocal cords and ventricular bands, although\\nM. Schmidt himself points out the lack of postmortem evi-\\ndence. The theory of primary tuberculosis of the larynx,\\nwhich is doubted even by Stork and Schrotter, finds little,\\nif any, confirmation in Aronsohn s paper, as his cases are\\nnot above criticism, and an analysis of cases published else-\\nwhere yields only three instances where the lungs were\\n1 Chiari, Arch. f. Laryng., I. Koschier, Wien. klin. Wochen.,\\n36, 37, 39 40-42, 1895.\\nArch. f. Laryng., V.", "height": "3440", "width": "2056", "jp2-path": "rhinologylaryng00frie_0159.jp2"}, "160": {"fulltext": "154 CHRONIC INFECTIOUS DISEASES.\\nfound intact at the autopsy. We can not admit as proof\\nof primary laryngeal disease cases in which the lungs\\nare found to be affected at the autopsy, even when we find\\nthe assertion that the lung disease is of more recent origin\\nthan the laryngeal affection. Primary tubercular chondritis\\nand perichondritis may possibly occur cases of perichon-\\ndrial tubercular abscess on the exterior surfaces of the thy-\\nroid cartilage, unaccompanied by other laryngeal or pul-\\nmonary manifestations, are occasionally met with, and, as I\\nhave had occasion to observe, such cases, if operated on,\\nyield a favorable prognosis. Angelot and Catti have\\ndescribed cases of acute miliary tuberculosis beginning in\\nthe pharynx and larynx. Angelot s case terminated fatally\\nin from two to six months the two cases by Catti on the\\neighth and ninth day, respectively. The latter author\\nemphasizes the fact that the laryngeal symptoms may be so\\nprominent as to mask any morbid symptoms in other\\norgans and to suggest diphtheria.\\nThe most frequent, not to say regular, form of infection\\nmet with in the upper air-passages is the secondary one\\nbut here again opinions diverge as to whether the infection\\nis brought about by direct contact with the infected\\nsputum or through the lymphatics and blood-vessels.\\nThe former opinion may be called that of the morbid\\nanatomists, as we find among its representatives such names\\nas Orth and E. Frankel,* while the other is held chiefly\\nby laryngologists, such as Korkunoff (v. Ziemssen s\\nclinic),^ Schnitzler, Schrotter, and others but it is worthy\\nof remark that neither of the two factions considers its own\\nview as the only possible explanation, and admits the pos-\\nsibility of the opposite mode of infection in isolated cases.\\nOrth says When we hav^ to deal with a typical case,\\nwhere, perhaps, there is only a large ulcerated cavity in\\none apex where all the bronchi through which the secre-\\ntions from this cavity must pass during expectoration are\\nfull of tubercular ulcers where we find smaller ulcers only\\non that side of the main bronchus and lower portion of the\\ntrachea which, from the position of the body, must come\\ninto contact with the secretion, and the ulcers are found\\n1 Quoted by Orth, p. 323. 2 a Wien. klin. Wochen., 1894, p. 438.\\n3 Lehrb. der spec. path. Anat., p. 320.\\n\u00e2\u0096\u00a0i Virch. Arch., cxxi, p. 523.\\n5 D. Arch. f. klin. Med., XLV, p. 43,", "height": "3468", "width": "2184", "jp2-path": "rhinologylaryng00frie_0160.jp2"}, "161": {"fulltext": "TUBERCULOSIS AND LUPUS. I 55\\nto increase in size and frequency as we ascend where,\\nomitting a part of the trachea, the tubercular affection\\nis seen to be more extensive wherever the walls of\\nthe air-passages are approximated, and the sputum is there-\\nfore forced against the sides, the conclusion seems inevi-\\ntable that the sputum constitutes the vehicle by which the\\ntubercular toxin is conveyed from the cavity and deposited\\nduring its transit through the air-passages on favorable\\nregions of the mucous membrane. Such inoculation\\nis, of course, quite conceivable, and the formation of ulcers\\nby the entrance of bacilli from the exterior, either through\\nexcoriations or through the intact epithelium, is possible\\nbut, instead of regarding it, with E. Frankel, as the essen-\\ntial and primary mode of infection, would it not be more\\nlogical to view it only as an occasional factor in the etiology\\nof the disease\\nThe strongest argument in the hands of those who\\nbelieve that the infection takes place through the vascular\\nand lymphatic channels is found in the morbid anatomy of\\nlaryngeal tuberculosis. The first stage of the disease is\\ncharacterized by the deposition of tubercles within the\\nmucosa at a greater or less distance from the epithelium,\\nwhich at first retains its integrity in fact, there is fre-\\nquently a broad, wide zone of healthy tissue between the\\ninfiltration and the epithelium. In the laryngoscopic image\\ntubercular infiltration of this kind, which may become quite\\nextensive through the subsequent formation of a large num-\\nber of tubercles, manifests itself in a circumscribed swelling\\ncovered with healthy mucous membrane. These condi-\\ntions can be studied in preparations of tubercular larynges,\\nand thus we have a confirmation of the excellent descrip-\\ntions given at first by Heinze,^ and more recently by Kor-\\nkunoff 2 and others. It is only later, when the tubercle\\nincreases in size and reaches the level of the epithelium,\\nthat the latter begins to degenerate the membrane be-\\ncomes loosened and the epithelium breaks down into\\ndetritus. In this way a tubercular ulcer is formed, the\\nsuperficial necrosis keeping pace with the progress of the\\ntubercular infiltration. The distribution of the tubercle\\nbacilli also corresponds with these anatomic conditions.\\nKorkunoff found that while the outer layers of the epithe-\\n1 Kehlkopfschwindsucht, Leipzig, Veit Co., 1879.\\n2 D. Arch. f. klin. Med., vol. .KLV, p. 43.", "height": "3456", "width": "2056", "jp2-path": "rhinologylaryng00frie_0161.jp2"}, "162": {"fulltext": "I 56 CHRONIC INFECTIOUS DISEASES.\\nHum contained few bacilli, the deeper portions, nearer the\\ntubercles, contained large numbers. The anatomic condi-\\ntions, therefore, would appear to show that the tubercular\\nprocess spreads by way of the lymphatic or vascular chan-\\nnels, and this is in accord with daily clinical experience,\\nfor we frequently find that apparently harmless thicken-\\nings, especially on the posterior wall, often undergo a\\nbluish discoloration, become necrotic, and are converted\\ninto ulcers, so that it does not seem plausible in these cases\\nof tubercular infiltration to suppose an infection by contact\\nnotwithstanding that Orth refuses to admit the explanation\\nof the subepithelial appearance of the tubercles. There\\nis no doubt that tubercles produced by contact do occur\\nin the epithelium of the larynx, but they are of an entirely\\ndifferent nature, both anatomically and clinically. They\\nwere formerly described as diphtheric (Rokitansky), then\\nas aphthous erosion and corrosion ulcers a difference of\\nopinion concerning their origin existed for a long time, as\\nit seemed doubtful whether they should be explained as\\nsimple tubercular or merely as arrosion ulcers, due either\\nto irritation of the mucous membrane by the contents of\\nthe cavity or to a secondary infection of superficial ero-\\nsions.\\nThese ulcers are not the result of an infiltration, as was\\nformei-ly believed, but represent superficial miliary tubercle\\nnodules in process of degeneration. They form flat super-\\nficial ulcerations with a decided tendency to spread, while\\nthe tendency to form granulations in the floor of the ulcer,\\nwhich is such a marked clinical characteristic of other\\ntubercular lesions, is absent. The floor of the ulcer is\\ncovered by a thick, yellowish exudate, which sometimes\\nforms a true fibrinous membrane slightly raised above the\\nlevel of the surrounding parts. It is probably this appear-\\nance that induced Rokitansky to describe them as diph-\\ntheric ulcers.\\nThese arrosion ulcers represent, therefore, another spe-\\ncific expression of the tubercular process, ultimately due to\\nthe action of the tubercle bacilli, but their mode of infec-\\ntion is evidently quite different from that which I have so\\nfar described. Since from the very beginning of the disease\\nthe tubercular infiltration is superficial, we can not in this\\ncase suppose a movement of the bacilli from within outward,\\nin other words, from the vascular or lymphatic channels,", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0162.jp2"}, "163": {"fulltext": "TUBERCULOSIS AND LUPUS. I 5/\\nand must admit the explanation of an infection by con-\\ntact with tubercular sputum. The significance of a mixed\\ninfection with staphylococci and streptococci has not as yet\\nbeen determined, but such an infection appears probable\\nwhen we consider the rapid spread of these ulcers.\\nCertain clinical arguments have been advanced to\\nprove the occurrence of infection from the lungs and\\nlarynx through the blood-vessels, but the observations of\\nFriedreich, Schrotter, and Schech (which were not con-\\nfirmed by Heinze s postmortem investigations), that the\\ndisease always affects the organs on the same side, are not\\nabove criticism. If we accept direct infection of the larynx\\nas the rule, it is at least remarkable that when the expectora-\\ntion is very copious and contains bacilli, there is no laryn-\\ngeal disease whereas it is present in cases when there is\\nlittle or no sputum in a beginning pulmonary tuberculosis,\\nand there is therefore no possibility of long-continued con-\\ntact of the sputum with the mucous membrane, favoring\\nthe entrance of the bacilli. To meet this objection, Orth\\nassumes a certain constitutional predisposition or weakness\\nof the mucous membranes to explain the occurrence of in-\\nfection by contact. But if contact with the sputum plays\\nsuch an important role in predisposed individuals, why does\\nthe disease become localized in the larynx Does not the\\nsquamous epithelium in the deeper portion of the pharynx,\\nin the pyriform sinuses, and on the posterior and lateral\\npharyngeal walls present the same possibility of infection\\nfrom without as the epithelium of the larynx, which shows\\na special preference for tubercular disease in those portions\\ncovered by squamous epithelium The sputum collects in\\nmuch larger quantities in these regions than it does in the\\nlarynx itself, where it is constantly expelled by reflex cough,\\nand therefore infection by contact would be quite as likely\\nto occur as in the larynx but, as a matter of fact, this is\\nnot the case. We know from the observation of other\\nlaryngeal diseases, especially carcinoma, that enlargement\\nof the lymphatic glands and extension to the surrounding\\nstructures occur only in the later stages of the disease,\\nand it appears that the lymphatic system of the larynx\\noccupies, in a certain sense, a unique position. Of course,\\nwe can not as yet say with any certainty that this factor in\\nany way contributes to the tendency of the infection to\\nlocalize itself in the larynx, to the exclusion of other por-", "height": "3456", "width": "2028", "jp2-path": "rhinologylaryng00frie_0163.jp2"}, "164": {"fulltext": "158 CHRONIC INFECTIOUS DISEASES.\\ntions of the upper passages, but the observation is worthy\\nof consideration.\\nWe therefore reach the conclusion that both views in re-\\ngard to secondary infection of the larynx from the lungs\\nhave their pros and cons, and that it is impossible to draw\\nany absolute theoretic deductions in support of either\\ntheory. In view of our clinical and anatomic experience,\\nwe recognize infection of the larynx by way of the lymph-\\nchannel, as probably more frequent, and reserve infection\\nby contact for those cases which manifest themselves in the\\nform of arrosion ulcers.\\nTuberculosis of the nose manifests itself in three different\\nforms\\n{a) Tuberculoma.\\nib) Extensive infiltration with ulceration.\\nic) Bone disease with secondary extension to the mucous\\nmembrane.\\nThe typical seat of tuberculous tumors is the cartilag-\\ninous septum, although in a few cases they are found on\\nthe bony portion. They appear as tumors w^ith a broad\\nbase, imperfectly circumscribed, and of varying size, so that\\nthey lead to a greater or less constriction of the nasal cavity.\\nThe epithelium is usually preserved and appears healthy on\\nthe surface the mucous covering is smooth the surface is\\neither uniform or slightly bosselated occasionally, several\\ndistinct nodules can be made out on the tumor. They show\\nvery little tendency to ulceration and caseation of the con-\\ntained tubercle it is only in very old cases that there is\\noccasionally seen a tendency to ulceration at the apex of\\nthe tumors (Koschier). The swelling usually appears first\\non one side of the septum, but later a similar swelling is\\nseen on the opposite side, so that we have two dark-red or\\ngrayish-red tumors, which can be seen without the aid of\\na reflector and resemble traumatic abscesses of the septum.\\nIn this stage of the disease the perichondrium becomes\\nthe seat of round-celled infiltration the process invades\\nthe cartilage of the septum, which undergoes necrosis the\\ndividing wall between the two tumors breaks down, and\\nthey become fused. This destructive process may go on for\\nyears without any marked alteration in the clinical picture.\\nIn some cases, however, the surfaces become ulcerated and\\nthe tubercular tumor undergoes further disintegration, and", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0164.jp2"}, "165": {"fulltext": "TUBERCULOSIS AND LUPUS. I 59\\nfinally becomes merged in the ulcerative process which at-\\ntacks the deeper tissues.\\nAs the septum has already been attacked by the morbid\\nprocess, the loss of tissue now becomes evident by the de-\\nstruction of the tuberculous granulation usually, the greater\\nportion of the cartilage is found to have been destroyed,\\nwhile the bony septum always escapes. Although now\\nthe most conspicuous symptom of the clinical picture is the\\nperforation of the septum, the granulations and nodules\\nfound at the edge of the perforation furnish a valuable diag-\\nnostic sign to distinguish it from perforating ulcer of the\\nseptum, in which the edges are smooth and sharply defined.\\nThis form of destruction of the septum is not followed by\\nany alterations in the external nose.\\nThe subjective symptoms, which consist in obstructed\\nnasal respiration, are at first insignificant, but increase with\\nthe growth of the tumor. Their appearance is occasionally\\npreceded by epistaxis. The formation of crusts is no part\\nof the clinical picture as long as the integrity of the epithe-\\nHum is preserved, but it appears as soon as ulceration has\\nbegun.\\nIt is convenient to mention the so-called scrofulous alter-\\nations in the nose in connection with the tuberculomata,\\nwhich Koschier, from their histologic structure, describes\\nas tuberculoscrofulous lymphomata. Scrofula, as a separate\\nprocess, has ceased to enjoy the recognition it formerly had,\\nand is now generally regarded as a manifestation of tubercu-\\nlosis peculiar to the childish organism. In addition to con-\\nstitutional phenomena, it finds expression in chronic eczema,\\nwith infiltration of the skin at the anterior nares and the\\nupper lip, where it produces the characteristic thickening of\\nthe scrofulous habit. The disease strongly resembles\\nchronic dermatitis, for it is localized almost exclusively in\\nthose regions of the skin which are covered with epidermis,\\nand it is at least doubtful whether we are justified in dis-\\ntinguishing the eczema of true scrofula from the form\\nwhich often occurs in children as the result of nasal obstruc-\\ntion and consequent chronic rhinitis. Hence, scrofulous\\neczema does not extend beyond the plica vestibuli, which\\nforms the boundary between epidermis and mucous\\nmembrane. Unless we can demonstrate the tubercular\\nprocess in such infiltrations and erosions on the nose and\\nupper lip, we can not consider scrofulous eczema as", "height": "3468", "width": "2056", "jp2-path": "rhinologylaryng00frie_0165.jp2"}, "166": {"fulltext": "l6o CHRONIC INFECTIOUS DISEASES.\\na form of tuberculosis, and as this proof is lacking, and\\nscrofulous eczema fails to show any peculiar characteristic,\\nwe can only designate it as a form of chronic eczema peculiar\\nto the scrofulous habit.\\nOn the other hand, those cases in which the tuberculo-\\nscrofulous tumor shows a distinct tubercular structure are\\nto be regarded as genuine manifestations of tuberculosis, in\\nno way connected with scrofula such cases frequently go\\non to granulation and ulceration, with occasional destruc-\\ntion of the septum and of the inferior turbinated bone. Al-\\nthough in practice the conception of scrofula as a distinct\\nmorbid process may be expedient, it can not be denied\\nthat the term is often used to cover many processes in the\\nchildish organism for which as yet no satisfactory explana-\\ntion has been found, and it is consequently advisable to re-\\nstrict its application as much as possible.\\nThe second or ulcerated form of nasal tuberculosis presents\\nthe characteristics of ordinary tuberculosis affecting mucous\\nmembranes. Infiltrations going on to degeneration, with the\\nformation of ulcers with infiltrated edges and covered with\\ngranulations (Schech stands alone in describing them as\\npoor in granulation tissue), form the anatomic basis and\\nlead to a more or less extensive destruction of the nasal\\nmucous membrane, which can be demonstrated clinically.\\nThe ulcers vary in depth, and may spread to the bones and\\ncartilages, where they lead to necrosis and deformities in the\\nbony and cartilaginous framework.\\nIn this form of the disease the principal symptoms are at\\nfirst epistaxis, the formation of crusts of dried secretions,\\nand the discharge of mucopus, so that it was formerly\\ndescribed as a tubercular ozena.\\nWhen the bone is involved, there might be some diffi-\\nculty in distinguishing the condition from syphilitic disease,\\nwere it not for the fact that in every case of advanced nasal\\ntuberculosis undoubted signs of tuberculosis are found in\\nthe lungs, for it appears from the observations published\\nthus far that this form of tuberculosis always occurs\\nsecondary to extensive tubercular disease of the lungs.\\nFinally, there is a third form of nasal tuberculosis, begin-\\nning in the bone or cartilage, which Koschier described on\\nthe strength of a single observation, although it is in accord\\n1 Krankh. der Mundhohle, etc., Fifth Edit., p. 317.\\n2 Wien. klin. Wochen., 1896.", "height": "3496", "width": "2208", "jp2-path": "rhinologylaryng00frie_0166.jp2"}, "167": {"fulltext": "TUBERCULOSIS OF THE PHARYNX. l6l\\nwith earlier descriptions by v. Volkmann, who observed\\nthis form of the disease quite frequently. Nevertheless,\\nI am inclined to consider it much less frequent than the\\nother two, especially the tumor-like variety, which I have\\noften observed myself, while I have yet to see my first\\nexample of the former variety. I shall therefore quote\\nthe description given by Koschier, in which three factors\\nare emphasized as characteristic of this form of the disease.\\nThese are, in the first place, alterations in the form of the\\nexternal nose, which, as has been said, do not occur in the\\nother forms the wide distribution of the disease, which\\ndoes not confine itself to one side of the septum, or even\\nthe entire septum, but takes in almost the entire skeleton\\nof the nose and, finally, the comparatively early appear-\\nance of large, deep ulcers in the mucous membrane, together\\nwith extensive necrosis, and the separation of necrotic por-\\ntions of the cartilage and bone. These are the diagnostic\\npoints which serve to distinguish it from the variety of nasal\\ntuberculosis which originates in the bony and cartilaginous\\nportions.\\nTubercular disease of the ///\u00c2\u00ab;^^;/,r is infrequent. Tuber-\\nculomata on the posterior surface of the uvula (AvelHs\\nand on the roof of the pharynx (Koschier must be\\nregarded as extremely rare. Mouret described a unique\\ncase of tubercular granulations about the size of a bean\\nappearing on the palatal tonsil of a patient twenty years of\\nage, suffering from pulmonary and laryngeal disease.\\nThe ulcerated form, first described by Isambert,* occurs\\nmore frequently. The anemic mucous membrane is the\\nseat of closely aggregated grayish nodules about the size of\\na split pea, which later coalesce and break down. The\\nulcers, which have been minutely described and designated\\nas lenticular by B. Frankel, are characterized by a ten-\\ndency to grow toward the periphery rather than to invade\\nthe deeper tissues. The edges of the ulcer are slightly\\ninfiltrated and are irregular in outline, while the floor is\\ncovered with minute granulations and a dirty yellow secre-\\ntion. In accordance with the superficial seat of the ulcers\\nthere is no diffuse infiltration of the mucous membrane,\\n1 Deutsche med. Wochen., 1891, Nos. 32 and 33.\\n2 Loc. cil. 3 Rev. hebd. de lar., 1896, No. 54.\\nAnn. des mal. de I oreille, I, 1875, p. 77, and 11, p. 162.\\n5 Berlin, klin. Wochen., 1876, No. 46.\\nII", "height": "3468", "width": "2036", "jp2-path": "rhinologylaryng00frie_0167.jp2"}, "168": {"fulltext": "162 CHRONIC INFECTIOUS DISEASES.\\nsuch as is seen in the larynx. These ulcers are found\\nchiefly on the soft palate and on the uvula sometimes on\\nthe anterior and posterior arch of the palate and on the\\nlateral pharyngeal wall and in rare cases on the posterior\\npharyngeal wall and in the postnasal space. Although the\\nulcers are superficial, they nevertheless produce extensive\\ndestruction in the soft palate, but they have never been\\nknown to attack the bone. The subjective symptoms con-\\nsist in dysphagia, and often in violent pain radiating toward\\nthe ears. In some cases partial cicatrization is said to\\noccur, Kraus reports having seen adhesions of the soft\\npalate.; but these accidents are rare, for there is very little\\ntendency to spontaneous cure. Hence the prognosis in this\\nform of pharyngeal tuberculosis, characterized by the pres-\\nence of miliary nodules with a tendency to degenerate, is\\nvery unfavorable. The great majority of cases, as pointed\\nout by Isambert, occur in the last stages of pulmonary\\nphthisis, and this fact is of value in the diagnosis, which\\noccasionally presents difficulties to the novice, who might\\nbe in danger of mistaking the tubercular for syphilitic ulcers.\\nAnother manifestation of tuberculosis in the pharynx is\\nseen in the cold abscesses which sometimes occur in the\\nposterior pharyngeal wall, and are due to carious disease\\nof the vertebral column. They give rise to a fluctuating\\ntumor about the size of a hen s egg, usually on one side\\nof the posterior pharj-ngeal wall, at a level varying with\\nthe particular vertebra affected. The patient complains of\\na sensation as of a foreign body in the throat when he\\nswallows, and the voice has the well-known palatal quality.\\nThe presence of these symptoms of primaiy vertebral dis-\\nease differentiates the diagnosis from tumors or other\\nvarieties of abscesses.\\nIn the larynx we distinguish three forms of tuberculosis\\nOne characterized by infiltration followed by degeneration\\nsuperficial ulcers (arrosion ulcers) and, finally, the tumor-\\nlike variety tuberculoma. The most frequent form of the\\ndisease is the first-mentioned, and it presents such typical\\nphenomena that the diagnosis can, as a rule, be easily\\nmade from the characteristic infiltration and ulceration.\\nAs the infiltration is due to the formation of tubercles in\\nthe mucous membrane, and has its seat in the submucosa,\\n1 Nothnagel s Handbuch, xvi, I. Th., I. Abth., p. 276.", "height": "3468", "width": "2156", "jp2-path": "rhinologylaryng00frie_0168.jp2"}, "169": {"fulltext": "TUBERCULOSIS OF THE LARYNX. 1 63\\nthe clinical picture varies with the anatomic relations of the\\nmucous membrane in the various portions of the larynx,\\nthe degree of swelling depending on the thickness of the\\nsubmucous tissue and according as the mucous membrane\\nis or is not in close relation with the other structures in the\\nlarynx, especially the cartilage, there will be a greater or\\nless tendency for the infiltration and ulceration to spread to\\nthese deeper parts. On the plica vocalis, where there is no\\nsubmucous tissue, the stage of infiltration is less conspicu-\\nous than it is in the interarytenoid space, where the looser\\nstructure of the submucous tissue presents a favorable\\nmedium for the development of infiltration and secondary\\nedema. Where, as on the epiglottis and the arytenoid\\ncartilage, the mucous membrane is closely adherent to the\\ncartilage, or in the vocal process, where it is intimately\\njoined to the elastic fibers in the cartilage, the infiltration is\\nvery likely to extend to the perichondrium and to set up a\\nperichondritis followed by necrosis of the cartilage while,\\non the other hand, if the disease is situated on the ven-\\ntricular bands or the aryepiglottic folds, there is less danger\\nof its spreading to the adjoining cartilages.\\nThe most frequent seat of infiltration is the mucous\\nmembrane in the interarytenoid space, e., the interior\\nsurface of the posterior laryngeal wall, so much so that its\\nappearance in this situation is almost pathognomonic. In\\nthe early stages of the disease there is in this region a\\nslight swelling, which becomes prominent when the mucous\\nmembrane is stretched, as in deep respiration. The swell-\\ning is not uniformly distributed over the posterior wall, but\\nforms a slight prominence, either in the middle or to either\\nside of the median line. It may be distinctly isolated, like\\na tumor, as Tijrck described it, while the covering of\\nmucous membrane remains intact. At first there may be\\nsome difficulty in differentiating these tuberculous infiltra-\\ntions from chronic laryngitis, in which the parts are also\\nswollen, especially when the entire upper respiratory tract\\nshares in the descending catarrh the catarrhal swelling is,\\nhowever, diffuse, being due to uniform thickening of the\\nmucous membrane. The latter arches forward toward the\\ninterior of the larynx in the respiratory position, but in the\\nmedian position becomes puckered into folds. The color\\n1 Atlas, I, XVII, vol. II.", "height": "3464", "width": "2104", "jp2-path": "rhinologylaryng00frie_0169.jp2"}, "170": {"fulltext": "164 CHRONIC INFECTIOUS DISEASES.\\nof this catarrhal infiltration is characteristic, being a bluish-\\ngray or whitish-gray, in consequence of the catarrhal\\nthickening of the epithelial layers.\\nIn the tubercular variety as the disease progresses the\\ninfiltration increases in size and its surface becomes nodular.\\nAt this time functional disturbances begin to appear. The\\naccurate apposition of the arytenoid cartilages, on which\\nnormal function depends, becomes mechanically impossible\\non account of the tumor-like infiltration, and more or less\\npronounced hoarseness develops. The laryngoscopic image\\nsimulates the appearance of a paresis, as the posterior por-\\ntions of the vocal cords fail to approximate on account of\\nthe swelling.\\nThe epithelium itself now begins to undergo alteration.\\nAs the tubercular infiltrate approaches the surface the upper\\nlayers of the epithelium become necrotic and assume a\\ngrayish-white discoloration, the surface finally undergoes\\nmore extensive alteration, and we have the formation of\\nulcers and granulations.\\nThe tubercular ulcers are characterized by elevated, infil-\\ntrated margins, which in the laryngoscopic picture largely\\nobscure the floor of the ulcer owing to the foreshortening\\nof all plane surfaces in the reflected image, so that the true\\ncondition is sometimes difficult to recognize. The second\\ncharacteristic of tubercular ulcers is a tendency to the\\nformation of granulations in the floor of the ulcer, and as it\\nis difficult in ordinary laryngoscopy to see all of the poste-\\nrior laryngeal wall, it is often impossible to determine\\nwhether there are deep ulcers or granulating surfaces hid-\\nden behind the infiltrations it is, however, of little practi-\\ncal significance, as the granulations themselves rapidly\\nundergo decomposition, and there is throughout the disease\\na continual alternation between granulation and ulcerative\\ndisintegration. Thus the surface presents an irregular ap-\\npearance, ulcerating areas alternating with papillary masses\\nof granulations, and, when seen in profile from above, sug-\\ngesting the picture of a chain of mountains with narrow\\nvalleys running between them. It is well to bear in mind\\nthat the disease is usually more extensive on the posterior\\nwall than appears in the laryngoscopic image. Whether the\\nulcers and granulations extend from the interarytenoid space\\ndown below the vocal cords, or occupy only the upper seg-\\nment of the posterior wall, the laryngoscopic image will be", "height": "3468", "width": "2208", "jp2-path": "rhinologylaryng00frie_0170.jp2"}, "171": {"fulltext": ".TUBERCULOSIS OF THE LARYNX. 1 65\\nthe same, as the elevated infiltrated margins of the ulcers\\ncompletely hide the deeper portions. In such cases it is\\noften possible to obtain an approximately correct image of\\nthe surface by employing Killian s method of examining\\nthe posterior wall, which consists in having the patient bend\\nhis head well forward while the operator sits on a low stool,\\nor even kneels down in front of him. Even better than\\nthis is Kirchstein s method, which permits the observer to\\nobtain a most satisfactory view of the posterior wall.\\nFrom the interarytenoid mucous membrane the morbid\\nprocess extends to the posterior extremities of the vocal\\ncords, which are eventually destroyed. Sometimes large\\nflat ulcers extend from the posterior wall to the vocal cords,\\nand if the granulations do not happen to be very abundant,\\nthese may easily be overlooked. On the other hand,\\nit must not be forgotten that the arytenoid cartilage is\\noccasionally visible through the pallid mucous membrane\\nabove the vocal processes, and might in that case be mistaken\\nfor an ulcer. The epiglottis and the aryepiglottic folds\\nare favorite seats for the tubercular process, and suffer the\\nsame destruction that we have described in the case of the\\nposterior wall. The course of the disease can readily be\\ntraced on the epiglottis. The infiltration is the first change\\nto appear, and lends a cushion-like shape to the epiglottis,\\nwhich covers the greater part of the interior of the larynx.\\nLater, ulceration begins accompanied by the appearance of\\ngranulations and grayish tubercles the size of a split pea in\\nthe neighborhood of the ulcer. If the aryepiglottic folds\\nare involved there is usually marked swelling the lateral\\nwall of the larynx is attacked, and after the breaking-down\\nof the infiltrated area this may lead to the formation of\\ndeep ulcers. The infiltrated ventricular bands become so\\nswollen that they completely hide the vocal cords occa-\\nsionally ulcers and granulations are seen in the ventricle of\\nthe lar^^nx, the former breaking directly through the ven-\\ntricular bands into the interior, the latter projecting from the\\nentrance like papillomatous tumors. Eventually, the tis-\\nsues in all these regions of the upper portion of the larynx\\nsuffer more or less destruction, as the ulcers show little\\ntendency to heal spontaneously by cicatrization, and the\\ninfiltration constantly tends to spread.\\n1 See illustrations in Scbnitzler s Atlas, Plate ix, Nos. I and 2.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0171.jp2"}, "172": {"fulltext": "1 66 CHRONIC INFECTIOUS DISEASES.\\nIn the vocal cords the tubercular changes in the early\\nstages are less pronounced, the catarrhal disease being\\nmore conspicuous than the infiltrations. The vocal cord\\nis red and swollen, and assumes what is usually described\\nas a cylindrical form. But even in these early stages\\nthe distribution of the disease, which often does not in-\\nclude the entire vocal cord or is confined to one-half of\\nthe larynx, points to tuberculosis rather than to catarrh,\\nwhere the changes are usually symmetrical. In rare cases\\na series of tubercular nodules resembling a string of pearls\\nis observed on the free border of the vocal cord. In most\\ncases, however, the inflammation in the vocal cords is\\nfollowed by destruction of the epithelium, and the forma-\\ntion of ulcers covered with a yellowish exudate. It is\\nworthy of remark, as pointed out by M. Schmidt, that\\nwhen the vocal cord is covered by a diffuse superficial\\nulceration, the yellowish exudate occasionally makes it\\nappear almost normal. No matter how small or superfi-\\ncial an ulcer may appear in a tubercular patient, it should\\nbe regarded as tuberculous, as there can be no question of\\nits being a catarrhal ulcer.\\nThe tissue destruction that takes place in the subsequent\\ncourse of the disease first attacks the free border of the\\nvocal cord, and later extends over larger areas. It is\\nfrequently accompanied by active granulation, forming large\\nmasses resembling a cock s comb on the vocal cords, and\\nin some cases leading to stenosis of the glottis. Some-\\ntimes the swollen and infiltrated vocal cord presents a fur-\\nrow running parallel with and underneath the free border,\\nconverting the structure into two separate folds, one above\\nthe other. A picture of this kind is seen when ulcers\\nappear on the lower surface of the vocal cord, or when\\nthere is a series of ulcers, above described as resembling a\\nstring of pearls.\\nThe different forms of tuberculosis described thus far\\nmay vary in their extent and in the order of their appear-\\nance, and give rise to a great variety of clinical pictures.\\nWhen, however, the infiltration extends to the cartilaginous\\nframe of the larynx, the appearance changes, infiltration\\nand ulceration of the perichondrium being followed by\\nnecrosis of the cartilage. The epiglottis and the arytenoid\\ncartilages with their vocal processes, being nearest to the\\nfavorite seat of the disease, are most frequently attacked", "height": "3468", "width": "2160", "jp2-path": "rhinologylaryng00frie_0172.jp2"}, "173": {"fulltext": "TUBERCULOSIS OF THE LARYNX. 1 6/\\nmore rarely, perichondritis extends to the crico-arytenoid\\narticulation, and from there to the arytenoid and cricoid\\ncartilages, the thyroid cartilage being very rarely involved.\\nWhenever the epiglottis shows signs of edema, perichon-\\ndritis should be suspected. The peculiar structure and\\nporosity of the epiglottis, which permit the glands and\\nblood-vessels to pass through the cartilage from the laryn-\\ngeal to the oral surface, allow the infiltration to spread in\\nall directions, so that we do not get necrosis of the car-\\ntilage, but rather a complete liquefaction. This progresses\\npari passu with the infiltration of the mucous membrane,\\nand may end in complete destruction of the epiglottis. In\\naddition to the edema which characterizes the disease in\\nthe epiglottis, there is the symptom of pain, usually de-\\nscribed as radiating toward the ears. Sometimes the dys-\\nphagia becomes so great that the taking of food gives rise\\nto excruciating pain.\\nThe infiltration, as has been said, is prone to spread from\\nthe posterior wall to the posterior portions of the vocal\\ncords, where the vocal processes present a favorite seat for\\nthe disease. In this situation redness and swelling first ap-\\npear, sometimes without involving the ligamentous portion\\nof the vocal cord, so that the inexperienced observer is led\\nto suspect pachydermia. Soon, however, deeper ulcers\\nappear in these regions, and microscopic examination shows\\nthat there is a disintegration of the reticular portion of the\\narytenoid cartilage. Later, the process spreads to the\\nperichondrium of the hyaline portion of the cartilage, and\\nthus secondary perichondritis is followed by necrosis of the\\ncartilage and the separation of sequestra.\\nPerichondritis of the arytenoid cartilage produces a char-\\nacteristic swelling and edema in the aryepiglottic fold, and\\nmotion is impeded solely by the mechanical pressure of\\nthe swelling. Before long, however, the disease spreads\\nto the capsule of the crico-arytenoid articulation, and,\\nafter destroying the joint, attacks the cricoid cartilage.\\nThis results in interference with the movement of the ary-\\ntenoid cartilages, which finds expression in an apparent\\nparesis of the vocal cords. Although it has been said that\\nan edematous swelling over the affected portion of the car-\\ntilage is an important diagnostic point, it may be well, in\\norder to avoid a misunderstanding, to point out that it\\nhas diagnostic value only when it is preceded by the break-", "height": "3448", "width": "2108", "jp2-path": "rhinologylaryng00frie_0173.jp2"}, "174": {"fulltext": "1 68 CHRONIC INFECTIOUS DISEASES.\\ning down of infiltrations in the areas mentioned, so that if a\\nlarynx is seen to be affected in this way at the first exam-\\nination, there is always a possibility that one has to deal\\nwith a simple tubercular infiltration of the mucous mem-\\nbrane. Deep ulcers in the aryepiglottic folds are very\\noften surrounded by edematous areas perichondritis of\\nthe cricoid and thyroid cartilages is rare and presents no\\ntypical appearances. The diagnosis of the tubercular\\nnature of the disease is based on the appearances in the\\nother portions of the larynx. There are rare cases in\\nwhich there is a so-called external perichondritis, the\\nmorbid process appearing on the external surface of the\\ncartilage, principally on the lateral plates of the thyroid.\\nLastly, we may mention three symptoms which are\\noccasionally described as characteristic of tubercular laryn-\\ngeal disease anemia of the laryngeal mucous membrane,\\ncatarrhal laryngitis, and paresis of the vocal cords. Anemia\\nof the nnicoiis membranes is an expression of the general\\nphthisical habit, and can not be regarded as a symptom\\nof beginning laryngeal tuberculosis.\\nThe question whether or not there exists a tubercular\\ncatarrh of the larynx is difficult to decide, and there are\\nexperienced laryngologists who believe it to be possible\\nbut in those cases where the laryngoscope shows an un-\\ncomplicated image of catarrhal laryngitis it is more scien-\\ntific to speak of chronic catarrh of the larynx associated\\nwith tuberculosis of the lungs than to speak of tubercular\\ncatarrh, since the latter term is hardly justified by the clin-\\nical and anatomic appearances. Paresis of the vocal cords\\nis a symptom that frequently occurs in the beginning of\\ntuberculosis and occasionally forms the prelude to tubercular\\ndisease sometimes it appears only periodically after exces-\\nsive use of the voice. E. Frankel^ found that it was due to\\natrophy of the muscular fibers, but the question whether\\ntubercular changes occur in the muscle so early in the\\ndisease, or whether we have to deal with simple fatigue of\\nthe muscle due to anemia, such as occurs in all grave\\norganic anemias, can not be determined at present.\\nThere is another variety of tubercular ulcers differing\\nfrom those following infiltration, which we shall describe as\\narrosion 7ilcers, due to local tubercular infection by the\\n1 Virch. Arch., LXXi, p. 261.", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0174.jp2"}, "175": {"fulltext": "TUBERCULOSIS OF THE EAR. 1 69\\nsputa. They are distinguished by their superficial charac-\\nter and their tendency to spread over the surface of the\\nmembrane. Their favorite seat is the epiglottis, especially\\nits free border after that, the surface of the larynx, the\\naryepiglottic folds, and the lateral wall of the larynx.\\nThey begin as small ulcers the size of a split pea, with a\\nmoderately injected base, and finally become covered with\\nnecrotic epithelium, which separates and exposes a shallow\\ndepression. The ulcers run together and tend to spread\\ntoward the periphery, so that eventually large areas of the\\nmucous membrane become involved. They occur princi-\\npally in the later stages of pulmonary tuberculosis, and are\\nfound usually combined with other tubercular appearances\\nin the larynx.\\nA rarer form of tuberculosis is found in the tuberculo-\\nmata, which appear as circumscribed tumors. We learn\\nfrom an exhaustive analysis of the cases by Avellis that\\nthey grow most frequently in the ventricle of the larynx\\nunder the angle of the glottis and on the posterior wall\\nmore rarely on the ventricular bands and least fre-\\nquently on the vocal cords. Panzer reports three\\ncases of tubercular polyps on the vocal cords from Chiari s\\npolyclinic. These tumors frequently do not differ from\\nordinary fibromata of the larynx, and, as a rule, show no\\ntendency to ulceration. In some cases they must be\\nregarded as a primary localization of the tubercular process,\\nas no signs are found in the lungs or other organs of the\\nbody in such cases their true nature can be determined\\nonly by histologic examination, for they are absolutely with-\\nout any clinical characteristics. The prognosis is good if the\\ntumors are removed M. Schmidt remarks that he often\\nobserved removal of the tumors to be followed by perma-\\nnent cure or by a long period of health, until a new ulcer\\nor a hemorrhage of the lungs supervened and confirmed\\nthe microscopic diagnosis.\\nTUBERCULOSIS OF THE EAR.\\nWhile the manifestations of tuberculosis in the larynx,\\nthough varying in their external appearance, are funda-\\n1 Deutsche med. Wochen., 1891, Nos. 32 and 23-\\n2 Wein. med. Wochen., 1895, Nos. 3-5.\\n2 Die Krankh. der ob. Luftwege, 2d edit., p. 362.", "height": "3456", "width": "2108", "jp2-path": "rhinologylaryng00frie_0175.jp2"}, "176": {"fulltext": "I/O CHRONIC INFECTIOUS DISEASES.\\nmentally the same, this is not the case with the organ of\\nhearing. In the larynx the diagnosis is readily made, even\\nin advanced stages of the disease, by the presence of infil-\\ntration, ulceration, and granulation but in tuberculosis of\\nthe ear the clinical picture varies greatly, and there is no\\ncharacteristic course. This may be partly explained by\\nthe fact that the aural disease at first presents no more\\nalarming symptoms than difificult hearing and discharges\\nfrom the ear, and does not come under observation until\\nquite late, when the process is so far advanced that it can\\nnot be distinguished from a simple chronic otitis media.\\nHence it is that the most prominent features of the picture\\nare destruction of the tympanic membrane, suppuration and\\nabscess formation in the mucous membrane of the middle\\near, and carious destruction of large portions of the tem-\\nporal bone, which separate as sequestra, while the granula-\\ntions, which are so characteristic of the tubercular process,\\nare comparatively insignificant.\\nIt is almost superfluous to say that nowadays we base a\\ndescription of tuberculosis of the organ of hearing exclu-\\nsively on the demonstration of tubercle bacilli or on the\\nhistologic appearance characteristic of tuberculosis. We\\nmerely mention the fact because even in recent times such\\nauthors as Bezold and Hegetschweiler depend on the\\nmacroscopic appearance of the clinical picture and neglect\\nbacteriologic examinations. That Bezold and some other\\nauthors differ from most of the authorities in regard to the\\ndiagnostic significance of tubercle bacilli in suppurative\\naural disease is due to the fact that there is a want of agree-\\nment in the literature as to the presence of tubercle bacilli.\\nAmong forty cases of otorrhea in tuberculous subjects,\\nNathan found tubercle bacilli in only twelve instances,\\nwhile Lucae was unable to find them once among seven-\\nteen patients whom he had inoculated with tuberculin. On\\nthe other hand, I have rarely failed to find the bacilli,\\nalthough I have examined a large number of cases.\\nBut this failure to demonstrate the bacillus in every in-\\nstance is explained, as already pointed out by Gottstein, by\\nthe fact that the pus is derived from the tubercular carious\\nfoci in the middle ear, which, it is well known, often fail to\\nshow the presence of bacilli. When we consider that, as\\nKrause has shown, the finding of bacilli in tubercular\\nTuberculose der Knochen und Gelenke, Leipzig, 1891, p. 7.", "height": "3468", "width": "2156", "jp2-path": "rhinologylaryng00frie_0176.jp2"}, "177": {"fulltext": "TUBERCULOSIS OF THE EAR. lyi\\nbone disease is rare, and when we consider also that we\\noften fail to find bacilli in undoubted cases of pulmonary\\ntuberculosis, it can not surely be denied that the finding of\\nbacilli should be a deciding proof of the existence of the\\ndisease. It is possible, by using proper methods of staining,\\nto avoid the errors which are sometimes occasioned by the\\nsmegma bacillus. The latter is often found in old, purulent\\nfoci. Brieger supposes that the tubercle bacilli found by\\nBezold in cholesteatomata were really smegma bacilli, and\\nI have myself found them in the pus derived from a sar-\\ncoma of the ear they were easily decolorized with alcohol\\nor dilute hydrochloric acid.\\nTuberculosis of the ear may occur in any stage of the\\npulmonary disease, but it presents itself most characteris-\\ntically in the later stages. It may be unilateral or bilat-\\neral, although some authors maintain that the left ear is\\nmore often affected than the right. A universal characteris-\\ntic of tuberculosis of the ear is the absence of pain, which\\noften leads the patient to neglect the disease as unimportant,\\nso that the earlier stages do not come under observation.\\nIt would appear that tuberculosis in the ear is usually\\nsecondary. The few cases so far reported as primary are\\nopen to criticism, and for the present we have no proof of\\nprimary tubercular osteomyelitis of the mastoid process.\\nIt is difficult, if not impossible, from the clinical point of\\nview, to decide whether one has to deal with primary tuber-\\nculosis of the bone, with secondary involvement of the\\ntympanic cavity, or with the opposite condition accord-\\ningly, we find that opinions are divided on the subject\\n(Kiister and Schwartze). But it would seem plausible to\\nassume that we have to deal with primary tuberculosis of\\nthe bones of the ear in those cases in which there is a dif-\\nfuse tubercular bone disease with fistula formation in\\nscrofulous children.\\nChronic tuberculosis, which is the most frequent form, is\\nprobably due to infection by way of the lymphatic channels.\\nBarnick supposes hematogenous infection in chronic\\ntuberculosis of the middle ear to be quite frequent, espe-\\ncially in scrofulous children, in whom, after rupture of\\na cheesy focus containing a few bacilli, the infection car-\\nriers are transmitted by the blood.\\n1 Arch. f. Ohr., vol. XL.", "height": "3448", "width": "2108", "jp2-path": "rhinologylaryng00frie_0177.jp2"}, "178": {"fulltext": "1/2 CHRONIC INFECTIOUS DISEASES.\\nNext in order of importance as a channel of infection we\\nhave the Eustachian tube. As the mucous membrane of\\nthe tube shares in the general atrophy characteristic of the\\nphthisical habit, the lumen is usually dilated, and readily\\npermits the entrance of sputum from the postnasal space.\\nIf there is ulceration in the nasopharynx, the conditions\\nare, of course, even more favorable for infection. This\\nmode of infection is perfectly possible, since the bacilli are\\ncapable of penetrating between the epithelial cells of the\\ntympanic mucous membrane, even when the external layer\\nof the epithelium is intact. It is further supported by the\\nfact that tuberculosis most frequently begins in the mid-\\ndle ear. On the other hand, it would appear, from E.\\nFrankel s^ observations, that the danger of infection from\\nthe postnasal space is not very great, for among fifty autop-\\nsies of tubercular patients, he found ten cases of tuber-\\ncular disease in the postnasal space, without implication of\\nthe ear.\\nWe have no means of judging whether it is possible for\\ntubercular disease of the middle ear to be produced by\\ndirect immigration of the tubercle bacillus through a tuber-\\ncular infiltration in the tympanic membrane, as there are\\nno facts to support such a supposition.\\nOn the tympanic membrane tuberculosis attacks both\\nthe epidermis and the mucous membrane.\\nThe former variety is rare, and lacks histologic demon-\\nstration it includes only those cases in which there was\\nundoubted tubercular disease in the external layers of the\\ntympanic membrane without involvement of the middle ear.\\nThere is so little material that it is impossible to describe\\nany distinct form for the tuberculosis the descriptions by\\nStacke and Preysing (from Korner s clinic) differ widely, so\\nthat one is forced to assume two distinct types, a miliary,\\nnodular form and one which appears as a granulation\\ntumor. In Stacke s case the tympanic membrane is de-\\nscribed as presenting a bulging of its posterior half, and a\\nyellowish discoloration, as though there were an exudate\\nbehind it. The surface was covered with split-pea-sized\\nyellowish nodules, with small vessels radiating from their\\ncenters. The tympanic cavity contained no exudate. The\\nredness of the tympanic membrane gradually increased,\\n1 Zeitschr. f. Ohr. x. i Arch. f. Ohr., vol. xx, p. 270.", "height": "3464", "width": "2196", "jp2-path": "rhinologylaryng00frie_0178.jp2"}, "179": {"fulltext": "TUBERCULOSIS OF THE EAR. 1 73\\nand a yellowish ulcer formed in the inferior posterior seg-\\nment and led to a gradually increasing perforation. The\\nexamination failed to show the usual tubercular appear-\\nances.\\nPreysing/ on the other hand, described a case of multi-\\nple tubercular tumors on the skull, in which the tympanic\\nmembrane was perforated in its inferior anterior segment\\nand presented a flesh-colored, uniform mass, which eventu-\\nally proved to be tubercular granulation tissue. The author\\ngot the impression that the tympanic membranes became\\ninfiltrated and broke up into tumor-like masses, but the\\nexternal layer of the epidermis was always found to be\\nintact. The typical form of the disease in the tympanic\\nmembrane is that which begins in the mucosa and ends in\\nthe destruction of the membrane.\\nAccording to Habermann s histologic investigations, the\\ndisease begins with the formation of tubercular nodules ap-\\npearing on the tympanic membrane as small, yellowish ele-\\nvations, which rapidly break down and lead to liquefaction\\nnecrosis of the entire membrane, although some cases are\\nfound in which the mucosa alone is involved, while in a\\nfew others the substantia propria also shares in the process.\\nAs the nodules break down, the integrity of the membrane is\\ndestroyed, so that we often see several distinct perforations\\nat the same time, before the coalescence of the ulcers has\\nresulted in the entire destruction of the membrane. Hence,\\nthe statement of various authors that tubercular perfora-\\ntions preferably affect the inferior posterior segment of the\\ntympanic membrane can not be accepted.\\nA significant diagnostic point is the painless course of\\nthe disease while other inflammatory processes in the\\ntympanic membrane are always associated with great pain,\\nthe symptom is almost always absent in tuberculosis in\\nspite of the wide-spread inflammation and tissue destruc-\\ntion.\\nThe nodule formation followed by disintegration is also\\ncharacteristic of the disease in the other portions of the\\nmiddle ear, but it is evident from the paucity of the reported\\ncases that it is rarely possible to demonstrate it clinically.\\nUsually, tuberculous disease of the middle ear presents\\nitself in the guise of chronic otitis media. There is an\\n1 Zeitschr. f. Olir., xxxii, p. 369.", "height": "3456", "width": "2100", "jp2-path": "rhinologylaryng00frie_0179.jp2"}, "180": {"fulltext": "174 CHRONIC INFECTIOUS DISEASES.\\nabundant discharge of a seropurulent secretion, which may-\\nbe more or less offensive. As the result of the breaking-\\ndown of the caseous nodules, the mucous membrane pre-\\nsents an ulcerated appearance. Granulations and polypi\\nare not present, as a rule.\\nAs we have said in connection with the perforation of\\nthe tympanic membrane, the course of the disease is usu-\\nally painless, but, on the other hand, it is characterized by\\nrapid impairment of the hearing. This is due to the\\nextensive infiltration, which spares neither the walls of the\\nmiddle ear nor the immediate adjacent parts. One of the\\nchief characteristics of the disease is the rapid development\\nof caries, which soon destroys the ossicles and bony walls\\nof the middle ear. Later, it involves the labyrinth and the\\nmastoid process and leads to extensive tissue destruction,\\nfollowed by grave functional disturbances. Eventually,\\nthe walls of the carotid artery and jugular vein may be\\neroded and fatal hemorrhage result, or the facial nerve is\\ndestroyed and paralysis ensues, or there may be total deaf-\\nness as the result of the destruction of the labyrinth.\\nThere is a constant danger of the process spreading to the\\ninterior of the skull, and thus producing fatal results.\\nEither the carious bones undergo cheesy degeneration and\\nare cast off as sequestra, or they merely show a gray or\\nblack discoloration. Marked granulation is usually absent.\\nThe entire bone crumbles, and it is often possible to remove\\nlarge sequestra with the forceps. The operator is often\\nsurprised to see how deep the destruction has gone, espe-\\ncially in children, often without any external signs not\\nrarely it is possible to remove the entire bony wall as far as\\nthe middle or posterior fossa, so that a large portion of the\\ninterior of the skull is laid bare. Necrotic portions of\\nbone from the labyrinth or the posterior wall of the audi-\\ntory meatus are occasionally discharged through the ear.\\nIn neglected cases we often find behind the ear a bone\\nfistula that continues to discharge for many years.\\nLUPUS.\\nLupus of the mucous membranes of the upper air-\\npassages may be primary or secondary to lupus of the ex-\\nternal skin. The primary form appears most frequently in\\nthe nose, although in recent years cases of primary disease", "height": "3468", "width": "2152", "jp2-path": "rhinologylaryng00frie_0180.jp2"}, "181": {"fulltext": "LUPUS. 175\\nin the pillars of the fauces, base of the tongue, and larynx\\nhave also been reported. But the secondary form is far\\nmore frequent it coexists with lupus of the external skin,\\nbeing communicated to the interior of the nose, the upper\\nlip, or the external lip, especially the alse or, from the\\nskin surrounding the mouth, to the mucous membrane of\\nthe cheeks, the palate, the pharynx, and the larynx.\\nThe chief characteristic of the disease is its painless\\ncourse, which explains why the primary lupus eruptions\\non the mucous membranes usually escape observation,\\nand the patient does not present himself for treatment\\nuntil he is made aware of his malady by functional disturb-\\nances or by beginning deformity. This is abundantly\\nproved by the systematic rhinoscopic and laryngoscopic\\nexamination of all cases of lupus of the external skin, for,\\naccording to Chiari and Riehl s statistics, the larynx was\\ninvolved in 6 out of 68 cases of lupus of the skin i. e., in\\n8.8^ while in former years, when an examination was\\nmade only Avhen demanded by the subjective symptoms of\\nthe patient, only 6 out of 725 cases, or o.^fc, were found\\nto present this complication.\\nLupus of the mucous membrane presents the character-\\nistic reddish-brown nodules, as large as the head of a pin,\\nslightly excoriated or covered with silvery epithelial scales\\nwhich run together and form extensive, slightly elevated\\ninfiltrations, or even grow into larger masses of a distinct\\npapillomatous appearance. As in the external skin, the\\nlesions show a marked tendency to break down, and the\\nresulting scars lend to the diseased areas their well-known\\nappearance. Occasionally, the disintegration of contigu-\\nous infiltrated areas leads to the production of deep ulcers,\\nwhich, owing to successive granulations, fail to heal, and\\nare followed by the formation of irregular, glandular masses\\nof hypertrophic and disintegrated granulations, traversed\\nby bands of cicatricial tissue (Chiari and Riehl). In\\nspite of the active ulceration there is little tendency on the\\npart of the ulcers to attack the deeper structures, and the\\nbony skeleton of the nose and the cartilaginous structure\\nof the larynx, excepting the epiglottis, are not as a rule\\ninvolved on the other hand, the destruction of the cartil-\\naginous septum is a frequent, not to say regular, phenom-\\nVierteljahrsschr. f. Dermat. u. Sj ph., 1882.", "height": "3456", "width": "2096", "jp2-path": "rhinologylaryng00frie_0181.jp2"}, "182": {"fulltext": "1/6 CHRONIC INFECTIOUS DISEASES.\\nenon. The scars show a tendency to contract, and this\\nproduces stenosis at certain points on the entrance to the\\nnose, on the isthmus of the fauces, on the entrance of the\\nlarynx, and on the vocal cords.\\nAs regards lupus of the nose, it is found most frequently\\nin the vestibule, and spreads from there to the septum, to\\nthe floor and lateral walls, and to the turbinated bodies.\\nThe external nose appears swollen at the tip and about the\\nalse, and shows deformities corresponding to the cutaneous\\ndestruction, for the cartilaginous and fibrous portion of the\\nseptum may be destroyed without the exterior of the nose\\nbeing attacked by the disease. The nose becomes swollen\\nand drops forward, the tip coming nearer the upper lip. The\\nmost striking deformity is seen in the septum at first,\\nwhile any tissue remains of the dividing wall, it appears\\non inspection to surround a huge perforation but later,\\nwhen this slender remnant of tissue disappears and the\\nnose loses its support, it is converted into a mere pendu-\\nlous mass finally the ulceration attacks the remaining tis-\\nsues of the nose, or the formation of cicatrices leads to\\nfurther distortions and deformities.\\nThe cartilaginous septum occasionally presents a form\\nof lupus described by the French as lupus pseudo-\\npolypeux. It often appears isolated, without any coex-\\nistent lesion in the external skin, but without a reservation\\nwe can not accept this as a special form of the disease, as\\nthere appears to be good reason to include it among the\\ntuberculomata.\\nLupus of the mucous membrane preferably attacks the\\nuvula, the pillars of the fauces, the posterior and lateral\\npharyngeal walls, and especially the base of the tongue,\\nwhence the disease may spread to the epiglottis and to the\\nlarynx. In fact, the epiglottis is the point of election, and,\\naccording to Chiari and Riehl, escaped in only 3 out of\\n38 cases. Next in order of frequency follow the epiglottic\\nfolds, and last the vocal cords. It has been stated that\\nthe ulcers show no tendency to involve the cartilage\\n(Kaposi, 2 however, as against this generally accepted view,\\nmentions a case of complicated laryngeal perichondritis\\nand chondritis), with the sole exception of the epiglottis,\\nCotnp. Simon in Rev. de lar., d ot. etc., 1895, No. 17.\\n2 Lehrb., 4th edit., p. 776.", "height": "3468", "width": "2208", "jp2-path": "rhinologylaryng00frie_0182.jp2"}, "183": {"fulltext": "LEPROSY. 177\\nthe cartilaginous matrix of which falls an easy prey to the\\nulcerative process.\\nThe papillomatous granulations or cicatricial adhesions\\noccasionally lead to laryngeal stenosis which may demand\\ntracheotomy. Lupus of the vocal cords produces disturb-\\nances in the voice. On the whole, however, the course of\\nthe disease, especially in the initial stages, presents no\\nsymptoms, and the patients are remarkably free from pain.\\nLupus of the external ear differs in nowise from that of\\nthe external skin, and needs no special description.\\n2. LEPROSY.\\nAlthough leprosy is not endemic in our part of the\\nworld, an accurate knowledge of its nature is nevertheless\\nnecessary, as we not rarely meet with sporadic cases, espe-\\ncially in the large cities where there are many foreigners.\\nWe find it stated in the latest descriptions of the malady\\nthat the mucous membranes of the upper air-passages, as\\nwell as the external skin, are a favorite seat of the disease,\\nso much so, in fact, that the peculiar raucous voice pro-\\nduced by laryngeal involvement has been regarded as\\nabsolutely typical of leprosy. Even at the present day\\nthere are so many more reports of leprosy of the larynx\\nand pharynx than of nasal leprosy that after reading the\\nusual text-books of the special literature one might get the\\nimpression that there is no typical clinical picture of nasal\\nleprosy. The alterations that take place in the external\\ntissues of the nose are well known, but the various descrip-\\ntions of leprosy of the interior of the nose differ widely.\\nIt was customary to speak of epistaxis, obstructive\\ncatarrh, perforation of the septum, and the development\\nof ozena as characteristic of the disease and some\\nauthors describe a diffuse swelling of the entire mucous\\nmembrane, with the formation of nodes, which later became\\nulcerated on the surface. Until recent years opinions\\ndiverged in regard to whether the disease extended to the\\ncartilaginous and bony skeleton. Virchow s proposition\\n1 Jeanselur et Laurens, Soc. med. des Hopit. u. Lepra-Confer. Berlin,\\n1897. Joseph, Berlin, klin. Wochen., 1896, No. 25. Zwillinger und\\nLaufer, Wien. med. Wochen., 1888, Nos. 26 and 27. Journal of\\nLaryng., 1888, No. i (M. Mackenzie).\\n2 Geschwulste 11, p. 520.\\n12", "height": "3452", "width": "2104", "jp2-path": "rhinologylaryng00frie_0183.jp2"}, "184": {"fulltext": "1/8 CHRONIC INFECTIOUS DISEASES.\\nwas that true perforation of the septum and depression\\nof the bridge of the nose do not occur. This statement\\nis not borne out by chnical experience. Although it is\\nprobably true that these destructions are not due directly\\nto leprous disease of the cartilage and bones, yet necrosis,\\nsuch as follows all ulcerative or inflammatory diseases of\\nthe nasal mucous membrane, undoubtedly does occur, as\\nthe mucosa plays a very important part in the nutrition of\\nthe skeleton of the nose, and even to some extent replaces\\nthe periosteum.\\nIn recent years the study of the pathogenesis of leprosy\\nhas produced a number of new theories in which the nasal\\nalterations play an important role. The question was dis-\\ncussed at some length in the Leprosy Convention held in\\nBerlin in 1887, and since that time opinions in regard to\\nthe significance, frequency, and time of appearance of the\\nnasal disease have undergone a marked change.\\nIn the older literature we frequently see it stated that the\\nnose becomes involved later than the larynx and pharynx,\\nand it was believed that the nasal disease was secondary to\\nthe pharyngeal process, although this theory is in direct\\nopposition with the assumption that leprosy is an infectious\\ndisease which does not spread by continuity, but by the\\nextension through the lymph-channels of the leprous infil-\\ntrate to all parts of the skin and mucous membrane.\\nWe now know that the nose is frequently attacked before\\nthe deeper portions of the air-passages, or may even be the\\nonly seat of the disease. Indeed, according to Gliick s\\nstatistics, the percentage of nasal leprosy is greater than that\\nof leprosy of the larynx and pharynx. Again, opinions\\ndiffer as to whether the process in the mucous membrane\\nis secondary to the cutaneous eruption or is to be consid-\\nered as going hand in hand with it, as it was believed that\\nthe mucous membrane was not involved in the leprous\\nprocess until a later stage of the disease had been reached.\\nAt the present time, however, there is a general conviction\\nthat the process in the mucous membrane is a concomitant\\nof the cutaneous disease, or even precedes it. After Gliick\\nhad published his percentage of 89.19 in a series of 33\\ncases, Lima and de Mello found the frequency of early\\nappearance of leprosy in the nose to be 95.83^, and\\n1 Berl. Lepraconfer., 1897, i, i. Abth., pp. 19, 20.", "height": "3468", "width": "2148", "jp2-path": "rhinologylaryng00frie_0184.jp2"}, "185": {"fulltext": "LEPROSY. 1 79\\nthereby placed leprosy of the nose in its proper light. The\\nquestion was finally solved when it was pointed out that in\\nmost cases the first effects of the infection were to be found in\\nthe nose, and that the nasal secretions of lepers constituted\\nthe most important factor in the spread of the disease.\\nSticker 1 in a careful examination of 153 lepers failed\\nto find distinct anatomic changes in the nose in only 13\\ncases, and of these 13 there were 9 whose nasal secretions\\ncontained numerous bacilli of leprosy, thus affording an-\\nother strong argument in favor of the view we have just\\nstated, which is that of Sticker and of some others. We find\\na similar difference of opinion in regard to tuberculosis 01\\nthe nasal mucous membrane, which has been found very\\nmuch more frequently since its appearance was demon-\\nstrated clinically it now plays a considerable part in the\\npathology of the nose, and is universally regarded as the\\nresult of direct infection. In both cases the divergence is\\nexplained by our advance in the knowledge of nasal dis-\\neases, as, owing to the polymorphous nature of the interior\\nof the nose, early alterations are not very characteristic,\\nand are merely classed under the head of chronic catarrh.\\nWhen the disease has progressed so far that the changes\\nare clearly visible in the skeleton and outer covering of the\\nnose, the diagnosis becomes extremely easy, but the analy-\\nsis of the changes becomes more and more difficult as the\\ndisease progresses, and the clinical picture becomes more\\nand more complicated.\\nAs an example of the clinical picture seen in the early\\nstages of leprosy I may mention a case which I had occa-\\nsion to examine in the medical clinic of Professor Cursch-\\nmann. It agrees so perfectly with the descriptions given\\nby Gliick, Zwillinger, and Laufer of the earliest appear-\\nances in nasal leprosy that I will give it in lieu of a general\\ndescription\\nA man, thirty-six years old, who had lived in Brazil\\nsince his sixth year, developed signs of anesthetic leprosy\\nduring the last three years, and during the last six months\\npatches and diffuse infiltrations appeared on the skin, evi-\\ndently the beginnings of a tubercular leprosy. The patient\\ndid not complain of subjective symptoms in the upper\\npassages there was neither epistaxis nor nasal obstruc-\\n1 Berl. Lej^raconfer., 1897, i, I. Abth., p. 99, and 11, p. 55.", "height": "3460", "width": "2052", "jp2-path": "rhinologylaryng00frie_0185.jp2"}, "186": {"fulltext": "l80 CHRONIC INFECTIOUS DISEASES.\\ntion. There was a diffuse infiltration in the mucous mem-\\nbrane of the septum the surface was smooth. As the\\nresult of the swelling in the middle of the right lateral\\nwall of the nose there was a horizontal furrow, which at first\\nsight looked like a deviation, while on the left side the\\nhypertrophy was uniform. The mucous membrane over the\\nturbinates was slightly hyperemic. The spongy tissue of the\\ninferior turbinate was tense and swollen, returning to nor-\\nmal on the application of cocain, showing that these parts\\nwere not as yet involved in the leprous infiltration. The\\nvibrissas were preserved, the epithelium intact except in a\\nsmall spot about the size of a split pea, situated in the pre-\\nviously mentioned furrow in the septum, at the boundary\\nbetween the cartilaginous and bony portions. This area\\npresented the appearance of a superficial ulcer, with smooth\\nedges, not raised above the level of the surrounding mucous\\nmembrane. The secretion of the nose was mucopurulent\\nand moderately abundant in both halves of the nose the\\nright side showed a greater tendency to the formation of\\ncrusts than the left, but the secretions did not possess any\\nother characteristics of ozena. Thus, while the appearances\\nof the interior of the nose were comparatively unimportant\\nand not at all characteristic, the postrhinoscopic image pre-\\nsented very conspicuous signs of the disease. Here there\\nwas also a diffuse infiltration of the mucous membrane of\\nthe septum and of the upper margin of the choanae, but,\\nin addition, there were elevations about the size of a pea,\\nwith broad bases. These elevations were spotted, of a\\nshiny yellowish color, corresponding to the whitish colora-\\ntion of the nasal mucous membrane described by Lima and\\nde Mello. The process did not extend beyond the poste-\\nrior nares.\\nThe leprous nature of these alterations was abundantly\\nproved by the finding of innumerable leprosy bacilli, partly\\nin clumps, partly in chains, or in the form of leprosy cells\\nand even in sections taken from the extirpated mucous\\nmembrane of the septum bacilli were found in large numbers.\\nFalling of the vibrissae, which usually occurs late, was\\nnot observed in my case. There were no disturbances of\\nsensibility in the nose. The sense of smell was somewhat\\nimpaired, although the patient himself did not observe it,\\nand the examination with strongly odoriferous substances\\nwas difficult, as the man had lived in the primeval forests", "height": "3468", "width": "2144", "jp2-path": "rhinologylaryng00frie_0186.jp2"}, "187": {"fulltext": "since his sixth year, and was, therefore, unacquainted with\\nthe odors of any of them. In a series of 13 cases, Gliick\\ndid not find much alteration in the sense of smell the\\nsensibility of the mucous membrane was reduced in 3 cases\\nout of 6. Epistaxis is an almost constant early symptom\\nof nasal leprosy, but in my case it had not occurred. As\\na rule, the mucous membranes are dry, and there is a ten-\\ndency to crust formation, so that the picture of ozena is\\nsimulated. If the infiltration extends more deeply, and\\nespecially if it attacks the turbinated bones, obstruction\\nof the nose and consequent interference with respiration\\nresult. The tendency of the nodes to break down is espe-\\ncially characteristic of the disease in the nasal mucous\\nmembrane, and in a short time ulcers develop in every part\\nof the nasal cavity. As in the case of tuberculomata,\\nseptum perforations may be produced in the cartilage by\\nthe leprous infiltration. Lima and de Mello,i who give an\\nexcellent description of nasal leprosy, emphasize the pre-\\ndilection of the nodes and ulcers for the turbinated bodies,\\nwhich may be atrophied and porous, or partly or totally\\ndestroyed, so that scarcely a trace of them remains\\n(Gluck). Defects have also been found in the other bones\\nof the nasal skeleton, the vomer, the nasal bones, and the\\nnasal spine however, they are not to be regarded as due to\\nleprosy, but rather as the expression of a disturbance in the\\nnutrition of the mucous membrane leading to atrophy and\\ncaries of the bones.\\nIn the pharynx leprosy affects principally the pillars of\\nthe fauces, the uvula, and to some extent the tonsils and\\nthe hard palate. Ulceration is said to be particularly apt\\nto occur in the postnasal space. The fauces and the uvula\\nbecome the seat of slightly elevated infiltrations, grayish-\\nwhite or bluish in appearance, which undergo ulceration\\nand cicatrization and lead to the formation of adhesions,\\nparticularly of the uvula. Perforations of the hard\\npalate are mentioned by Zwillinger and Laufer, although\\nGliick finds no confirmation of the statement in the litera-\\nture or in his own cases. It is somewhat remarkable that\\nBergmann frequently found the posterior laryngeal wall\\nintact when the other parts were affected with leprosy, and\\nthis is confirmed by Gliick, although the latter adds that he\\n1 Monatsch. f. prakt. Dermat., vol. vr, 1887, No. 13 and I4.", "height": "3456", "width": "2100", "jp2-path": "rhinologylaryng00frie_0187.jp2"}, "188": {"fulltext": "1 82 CHRONIC INFECTIOUS DISEASES.\\noften found characteristic changes in this structure when\\nthe alterations in the mouth and nose were quite incon-\\nsiderable.\\nIn the larynx the epiglottis is the commonest and earliest\\nseat of leprosy. It becomes uniformly hypertrophied\\nand studded with nodules, and presents a characteristic\\nform and position, being markedly displaced backward and\\nmore or less compressed from side to side (Bergengrun).^\\nIn severe grades of the disease the cartilage has a plump\\nappearance the lateral margins of the glottis are uniformly\\nthickened where they merge into the aryepiglottic folds.\\nIn severer grades, where the uniform hypertrophy extends\\nbelow the ventricular bands and involves the posterior laryn-\\ngeal wall, the lumen becomes circular in outline and,\\nfinally, in the severest grades the nodules on the thickened\\nventricular bands and the enormously hypertrophied pos-\\nterior laryngeal wall reduce the lumen of the larynx to an\\norifice no larger than a lead-pencil, and completely obstruct\\nthe view of the deeper portions. Both the ventricular\\nbands and the vocal cords participate in the nodule forma-\\ntion and in the general hypertrophy, and even the subglot-\\ntic mucous membrane is often markedly thickened. As\\nthe result of these changes, the voice becomes rough and\\nhoarse in the later stages laryngeal stenosis makes its\\nappearance, and sometimes during the night produces at-\\ntacks of suffocation, so that the leprous wards are con-\\nstantly filled with the blowing, gurgling, and whistling\\nnoises of the occupants (Bergengriin). The flat and\\ncomparatively extensive ulcers which form in the infiltrated\\nand nodular portions of the larynx show a marked ten-\\ndency to undergo cicatrization, and, as a result, not only\\nis the mucous membrane sometimes shrunken and de-\\nformed, but even the cartilages maybe reduced in size\\n(Gliick). The cartilages of the larynx are never attacked\\nalone, but the perichondrium almost regularly shows\\nmarked infiltration, and the bacilli may invade the cartilage\\nfrom above (Neisser and Gliick). Little is known as to the\\nsensibility of the diseased mucous membrane in the larynx\\nand pharynx. A few observers refer to the ease with\\nwhich a laryngeal examination can be made, and attribute\\nit to anesthesia of the parts.\\nArch. f. Laryng., vol. TI.\\n2 Schrotter, Vorles. iiber Kehlkopf krankh., 1892, p. 170.", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0188.jp2"}, "189": {"fulltext": "GLANDERS. 1 83\\nIn the external ear, characteristic changes, consisting in\\ninfiltration and nodule formation on the lobe, appear almost\\nregularly in leprosy, but there is little mention in the litera-\\nture of involvement of the organ of hearing. Extension of\\nthe leprous infiltration to the tubes may lead to tubular\\ncatarrh. Lima and de Mello examined the ears of 48\\nlepers. They never found any alterations in the auditory\\nmeatus. In some cases the tympanic membrane was\\nthickened, of a dull whitish color resembling a fibrous\\nplate, and immovable during Valsalva s experiment.\\nThere are adhesions in the wall of the tympanic cavity or\\nbetween the ossicles. Other changes, consisting in anom-\\nahes of position and in convexity, are not leprous in char-\\nacter. In one case perforation of the tympanic membrane\\noccurred it was due to purulent otitis media.\\n3. MALLEUS HUMIDUS. GLANDERS.\\nGlanders is a disease of domestic animals, usually trans-\\nmitted to man by the horse. The infection is carried by the\\nmalleus bacillus, which is contained in the secretion of the\\nulcers, especially in the nose, and gains entrance to the\\nhuman organism through the skin or mucous membranes.\\nThe mucous membranes of the upper air-passages always\\nshare in the morbid process and present the characteristic\\nmiliary nodules, which later undergo ulceration. The\\nbreaking-down of neighboring nodules results in the for-\\nmation of large ulcers, the floors of which are covered\\nwith a foul, sanguineous secretion. The ulcers show a\\nmarked tendency to invade deeper structures and occasion\\ngreat tissue destruction.\\nClinically we distinguish a chronic and an acute form.\\nChronic nasal glanders, according to Koranyi,^ is ushered\\nin by a feeling of fullness in the nose, a dry cold in the\\nhead, a feeling of heat in the throat, rough voice, cough,\\nand, finally, by a mucous secretion, sparingly streaked with\\nblood. Dry, blackish crusts are later expelled from the\\nnose, and the mucous membrane underneath is seen to be\\nswollen and ulcerated. Although the destructiv^e process\\nis slower than in the acute form, in the end the amount of\\n1 Mon. f. prakt. Derm., 1887, p. 650.\\nNothnagel, vol. v. Part 5, p. 73.", "height": "3448", "width": "2096", "jp2-path": "rhinologylaryng00frie_0189.jp2"}, "190": {"fulltext": "1 84 CHRONIC INFECTIOUS DISEASES.\\ntissue destroyed is quite as great. The acute form may-\\noccur either immediately after an infection or during the\\ncourse of a chronic attack. It is accompanied by a cutaneous\\neruption, which spreads to the mucous membrane often it\\nreminds one of variola, appearing first in the form of red\\npatches, which later are replaced by pustules (Koranyi).\\nBy extension of the ulcers which result from the breaking-\\ndown of the infiltrate large areas are destroyed in the\\nnose the septum becomes perforated, in the larynx the car-\\ntilaginous structure is destroyed. The voice is rough or\\nhoarse as the result of erosion of the vocal cords in the\\nlarynx the edema accompanying the ulceration sometimes\\nleads to stenosis.\\nThe disease attacks the nasal bones, and these, as well\\nas the skin covering them, are destroyed. The accessory\\ncavities of the nose are also involv^ed. In Weichselbaum s\\ncase masses of pus were found at the autopsy in the antrum\\nof Highmore and in the frontal sinuses, and the mucous\\nmembrane was covered with numerous confluent yellow\\ninfiltrations. Occasionally, the disease attacks the cartil-\\naginous orifices of the tubes. The prognosis of nasal glan-\\nders is fatal, both in the chronic and in the acute form,\\nwhile in chronic glanders of the skin cicatrization of the\\nulcers and arrest of the malady have occasionally been\\nobserved.\\n4. FOOT-AND-MOUTH DISEASE. (THRUSH;\\nSTOMATITIS APHTHOSA EPIDEMICAj\\nThe mode of transmission of foot-and-mouth disease\\nfrom animal to man has been extensively investigated in\\nrecent years. Although the disease almost exclusively\\nconcerns the digestive tract, if we disregard the constitu-\\ntional phenomena to which it gives rise, it deserves to be\\nmentioned in this connection, as it has also occasionally\\nbeen observed on the mucous membrane of the nose, of the\\npharynx, and of the larynx. Koranyi has given us a de-\\ntailed description of the disease Siegel, in various papers,\\nhas reported an epidemic and the bacteriologic examina-\\ntions which it occasioned, and his results, while attacked\\n1 Wien. med. Wochen., 1885, No. 22.\\n2 Nothnagel s, Spec. Path. u. Therap., v. Part 5.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0190.jp2"}, "191": {"fulltext": "ANTHRAX ACTINOMYCOSIS. I 8 5\\nby some, are confirmed by Bussenius,i who agrees with\\nSiegel in regarding a smooth, ovoid bacillus as the common\\ncause of stomatitis in man and of foot-and-mouth disease\\nin cattle. The typical lesions consist of blebs, which rap-\\nidly collapse and leave an ulcer, the floor of which is\\ncovered with a milky white exudate, while the edges are\\nraised, dark red, and irregular in outline. The lesions are\\nfound on the tongue, gums, and palate, and occasionally\\nalso on the pharynx, and especially on the/r^^ border of the\\nepiglottis. In the case reported by Bussenius large ulcers\\nwere found at the autopsy over the right arytenoid cartilage\\nand on the epiglottis. According to Siegel, the disease is\\noften followed by catarrh of the tubes, which in chil-\\ndren is usually purulent. Further details concerning this\\ncomplication are wanting, but it is probably to be regarded\\nas a suppuration from the middle ear.\\n5. ANTHRAX.\\nIn the form of anthrax known as ragpickers disease, or\\npulmonary anthrax, which is produced by the inhalation\\nof dust containing the spores of anthrax, and which is usu-\\nally ushered in by a chill, we find, according to Koranyi,\\nwho quotes H. Eppinger in support of his statement, the\\nnasal mucous membrane swollen, suffused with blood,\\nand the seat of small carbuncle-like formations the\\nmucous membrane of the pharynx red and swollen, the\\ntonsils covered with a diphtheroid membrane, the epiglottis\\nred in color and hypertrophied.\\n6. ACTINOMYCOSIS.\\nInfection with actinomyces occurs usually in the mouth\\nand oral pharynx by the wounding of the mucous mem-\\nbrane with spicules of grain, and is then followed by the\\nwell-known infection of the jaw and the submaxillary region.\\nIn rare cases actinomycosis extends to the larynx (Mund-\\nler^ and Berard^). There is in all cases a board-like infil-\\n1 Arch. f. Laryng., VI, 1897. 2 Arch. f. Laniyg., Ill, p. j8i.\\n3 Beitr. zurklin. Chir., 1892.\\nLyon m6d., 1895, April 21 see in Semon s Centralb., X[i,p. 320.", "height": "3448", "width": "2104", "jp2-path": "rhinologylaryng00frie_0191.jp2"}, "192": {"fulltext": "1 86 CHRONIC INFECTIOUS DISEASES.\\ntration of the outer tissues of the neck, which in Berard s\\ncases formed a rigid collar embracing the entire middle por-\\ntion of the neck and rendering mov^ement of the head im-\\npossible. The larynx, the pharynx, the thyroid gland, and\\nthe large vessels and nerves were found embedded in a\\nmass of infiltrated tissue. Later, as a result of softening of\\nthe infiltration, pustules are formed, through which the\\ncharacteristic yellow nodules are discharged.\\nIn other cases the disease manifests itself in the forma-\\ntion of tumors on the thyroid cartilage and interior of the\\nlarynx Stork saw a tumor which involved the aryepi-\\nglottic fold, the arytenoid fold, and the epiglottic pharyn-\\ngeal region of one-half of the larynx, and cites a similar\\ncase observed by Illich.\\n7. RABIES (LYSSA).\\nThe clinical picture of rabies in man is characterized by\\nsymptoms of irritation in the sensory and motor nerves,\\ntheir intensity depending on the course of the disease. The\\nhyperesthesia of the olfactory nerve finds expression in hal-\\nlucinations of smell, that of the trigeminus in attacks of\\nsneezing, both of which phenomena are observed in the pro-\\ndromal stage of the disease. The full development of the\\ndisease is characterized by respiratory cramp, erroneously\\ndesignated spasm of the glottis, which involves all the mus-\\ncles of respiration. It is not even definitely known whether\\na so-called spasm of the glottis that is to say, a closure of\\nthe glottis occurs in Pitt s case,^ where a laryngoscopic\\nexamination was made during the attack, the glottis was\\nfound to be gaping, as a result (according to Semon) of\\nviolent irritation of the respiratory center causing contrac-\\ntion of the crico-arytenoideus posticus, the respiratory mus-\\ncle of the larynx, and thereby effecting abduction of the vocal\\ncords. Lori also examined a patient during an inspiratory\\nspasm, and was unable to demonstrate any participation of\\nthe laryngeal muscles.\\nThe implication of the auditory sphere manifests itself in\\na hyperesthesia of the auditory nerve.\\n1 Nothnagel s Spec. Path. u. Therap., vol. xiii, Th. ii, Abth., I, 2d\\nvol., p. 169.\\n2 Compare Semon s Centralb. i, p. 251.", "height": "3468", "width": "2140", "jp2-path": "rhinologylaryng00frie_0192.jp2"}, "193": {"fulltext": "TRICHINOSIS. 187\\n8. TRICHINOSIS.\\nNavratil and Friedreich each reported a case of laryn-\\ngeal paralysis, the result of trichinosis. The left vocal\\ncord was immovable midway between phonation and respi-\\nration, and there was, in addition, a paralysis of the con-\\nstrictors of the pharynx.\\n1 Berlin, klin. Wochen., 1876, p. 292.\\n2 Quoted by Lori, Die Veranderungen des Rachens, etc., p. 237.", "height": "3448", "width": "2120", "jp2-path": "rhinologylaryng00frie_0193.jp2"}, "194": {"fulltext": "VIII. DISEASES OF THE KIDNEY.\\nThe complications which may appear in the course of\\nnephritis in the upper air-passages consist in edema, hem-\\norrhage, and general nutritive disturbance in the mucous\\nmembranes.\\nEdema occurs in the pharynx and larynx, especially in\\nportions where the submucosa is well developed. Edema-\\ntous swellings are, therefore, found chiefly in the uvula,\\nthe posterior faucial pillars, and on the lateral pharyngeal\\nwall in the larynx they are constantly found on the ary-\\nepiglottic folds, either on one or on both sides, and in their\\nextension to other portions of the organ obey the general\\nprinciples governing the spread of edema in the larynx.\\nAccording to Fauvel and Schr6tter,i edema of the larynx\\nis often the first sign of nephritis, and therefore enjoys a\\ncertain distinction from a diagnostic point of view. It must,\\nhowever, be a very rare occurrence at least, Morell Mac-\\nkenzie 2 failed to find a single case, although he made a\\nlaryngoscopic examination of 200 nephritic patients with\\nthis end in view. Lori reports two cases observed by\\nhimself The edema is passive, being entirely due to ven-\\nous stasis, and is occasionally observed on the posterior\\ntracheal wall. Appearances simulating laryngeal stenosis\\nare seen in uremic conditions, for uremic asthma may\\nresemble bronchial asthma if expiration is prolonged, or\\nmay simulate laryngeal stenosis if inspiration is prolonged\\n(E. Wagner But the fact that it always appears period-\\nically in individuals with normal respiration establishes the\\ndifferential diagnosis. I once had occasion to make a laryn-\\ngoscopic examination of this kind two days before the out-\\nbreak of a fatal uremia in spite of the negative appearance\\nof the laryngeal image, the apparent laryngeal stenosis had\\nled the attending physician to perform tracheotomy.\\nVorlesungen, p. 92, 1st edit.\\n2 Lehrb. libers, von Semon, I, p. 374. Loc. ciU, p. 80.\\nZiemssen s Handbuch, ix, 3d edit., p. 70.\\n188", "height": "3468", "width": "2140", "jp2-path": "rhinologylaryng00frie_0194.jp2"}, "195": {"fulltext": "It may be mentioned that uremic apliasia has been\\nobserved in combination with unilateral palsies, due solely\\nto serous infiltration of the brain-substance.\\nA more familiar and more frequent occurrence than edema\\nis hemorrhage, due partly to the increase in blood pressure\\nand partly to the changes in the blood-vessels which are so\\nfrequent in chronic interstitial nephritis. In addition to the\\nepistaxis, which is often severe, there may be lesser hemor-\\nrhages in the pharynx and larynx they occur a short time\\nbefore the appearance of the uremia. As in all diseases of\\nthe circulatory apparatus, we find nutritive disturbances in\\nthe mucous membrane, manifesting themselves as atrophic\\ncatarrh and if at the same time there are similar hemor-\\nrhages, there usually results the form of nephritis and\\nlaryngitis which is sometimes described as the chronic\\nhemorrhagic variety. In the case of uremia which I have\\njust mentioned I found a remarkable appearance of the mu-\\ncous membrane there was a marked dryness throughout\\nthe upper air-passages, although there could not be said to\\nbe any atrophic alterations in the nose or in any other part.\\nThe nose, as well as the larynx, was covered with minute\\ndark-colored coagula, the remains of hemorrhages in the\\nnose and throat. These coagula were so completely dried\\nout that they were expelled in the form of dust with the\\nrespiratory air-current, which, on account of the dyspnea,\\nwas very violent. Tiirck describes a case of sudden\\nhoarseness and pain in the larynx, in which the organ was\\nmuch inflamed at the autopsy the mucous membrane of\\nthe interior of the larynx was found to be red in color and\\ncovered here and there with patches of delicate croupous\\nmembrane. Lori also observed a case, which he described\\nas diphtheritic, in the course of a chronic parencJiyinatous\\nnephritis The lesions consisted in grayish-white crusts\\nthe size of a pea, embedded in the mucous membrane of the\\ntonsils and of the left arytenoid cartilage, and in a similar\\nmore extensive alteration on the upper surface of the epi-\\nglottis, which disappeared in a few days. This clinical\\npicture hardly justifies the diagnosis of diphtheritis.\\nTo Dieulafoye and his followers we owe a detailed descrip-\\ntion of nephritic aural diseases, a few cases of which are also\\nSenator, Nothnagel s Handbuch Nierenkrankh., p. 69 and Jaeckel,\\nBerliner Dissert., 1884.\\n2 Klinik, pp. 177 and 178, Case 20. x^^. cit., p. 82.", "height": "3452", "width": "2104", "jp2-path": "rhinologylaryng00frie_0195.jp2"}, "196": {"fulltext": "190 THE KIDNEY.\\nfound in the older literature. Morf^ has contributed a\\ncomprehensive treatise, in which, in addition to three of\\nhis own cases, he discusses twenty-two others collected\\nfrom the literature. He admits, however, that his explana-\\ntion of the clinical appearances and the nature of the dis-\\nease is somewhat faulty, as he classes into one group\\nnephritic disturbances due to pathologic processes in the\\near, demonstrable microscopically or by functional exami-\\nnation, and into another group cases in which it was not\\npossible to account for the functional disturbances by any\\npathologic changes in the tissues.\\nIt must be admitted that aural disturbances are rare in\\nnephritis. The statistics reported are small as regards the\\nnumber of cases, and not very reliable on account of the\\nlimited amount of material on which they are based. It\\ncan not be determined whether any one form of nephritis\\npossesses any special power of producing disease in the ear,\\nbut it would appear that chronic diffuse nephritis is more\\napt to do so than any other in a few cases aural disease\\nwas observed in chronic nephritis after intermittent fever\\nand in scarlatinal nephritis. Clinical and anatomic investi-\\ngations have shown that aural disturbances may occur in\\nthe course of nephritis as the result of the general edema,\\nand in uremia after hemorrhages. Tinnitus aurium and\\nloss of hearing also occur as the result of secondary dis-\\nease of the blood-vessels and, lastly, it may be mentioned\\nthat a certain influence on the development and course of\\npurulent otitis media has been ascribed to nephritis.\\nHemorrhages in the middle ear have been described by\\nSchwartze,^ Buck,* and Trautmann.^ They manifest\\nthemselves either as suffusions in the middle ear or as\\nhemorrhages in the mucous membrane the latter are ex-\\nplained by Trautmann as the result of diapedesis. The\\ndiagnosis can be made by the bluish-red coloration of the\\ntympanic membrane seen in the otoscopic image, while the\\nsubjective symptoms vary according as the hemorrhage\\nwas sudden or gradual, the tinnitus aurium being accord-\\ningly rapid or more gradual in its onset.\\nAs examples of the other form of impaired hearing due\\n1 Zeitschr. f. Ohr., xxx., H. 4.\\n2 Die Krankh. des Ohres, pp. 185-188.\\n2 Arch. f. Ohr., iv, p. 12. Arch. f. Ohr., vii, p. 301.\\nArch. f. Ohr., xiv, pp. 91, 92.", "height": "3468", "width": "2132", "jp2-path": "rhinologylaryng00frie_0196.jp2"}, "197": {"fulltext": "EAR. 191\\nto general edema we may mention one case of Rosenstein^\\nand two cases of Morf,^ in which, in the course of a chronic\\nnephritis after intermittent fever (twice), and in acute\\nnephritis (once), a gradually increasing loss of hearing\\nwas observed culminating in total deafness. Here the\\ntuning-fork test for air- or bone-conduction was almost\\nor quite negative (Morf). In both cases the hearing was\\noccasionally completely restored during the course of the\\nnephritis, and such temporary improvement was always\\naccompanied by improvement in the general condition and\\nsubsidence of the edema. Rosenstein s case is the only\\none in which an autopsy was held it was entirely negative.\\nThe fact that the loss of hearing progresses pari passu\\nwith the development of the edema, the periodic complete\\nreturn of the power of hearing, and its final disappearance,\\nin the case of acute nephritis without any local treatment\\nof the ear, suggests the explanation advanced by Rosen-\\nstein for his own case that we have to deal with edema of\\nthe roots and trunk of the auditory nerve, and that the\\nvariations in the power of hearing are directly dependent\\non the increase or decrease of the edematous infiltration.\\nA similar explanation applies to the disturbance observed\\nin chronic uremia due to serous infiltration of the brain-\\nsubstance. It is impossible to find any anatomic changes\\nto account for the tinnitus and loss of hearing, nor can the\\nexact location of the lesion be determined by means of the\\nfunctional test.\\nMany cases of tinnitus aurium and defective hearing\\noccurring in the course of nephritis are undoubtedly refer-\\nable to secondary disease of the blood-vessels, and belong\\nin the same category with the phenomena observed in\\narteriosclerosis and valvular lesions.\\nFinally, we have to consider suppurations in the middle\\near, which are considered by some authors among them\\nMorf, Voss,^ and Haug as caused, or at least influenced,\\nby nephritis.\\nThere have been observed in the course of nephritis\\nacute and chronic catarrhal, acute and chronic purulent,\\nand hemorrhagic inflammations of the middle ear, but the\\nnephritic character of the aural disease has not been defi-\\nNierenkrankheiten, 4th edit., 1S94, p. 260.\\n2 Zeitschr. f. Ohr., pp. 324 and 32S.\\n2 Arch. f. Ohr., xxvi, p. 233.", "height": "3452", "width": "2120", "jp2-path": "rhinologylaryng00frie_0197.jp2"}, "198": {"fulltext": "192 THE KIDNEY.\\nnitely established. In proof of its dependence on nephritis\\ncertain postmortem appearances have been cited, consist-\\ning chiefly in hyperplasia of the submucous tissue in the\\nmiddle ear, interpreted as an edema but such a finding\\nis not in the least remarkable in view of the long duration\\nof the cases under discussion (Gurovitsch and Moos 2),\\nand is often found quite independent of nephritis. Morf\\nclaims that purulent processes in the middle ear have a\\nremarkable tendency to produce necrotic osteitis and a\\ncarious liquefaction of the bony walls of the air spaces in\\nthe temporal bone, but his claim finds little support in the\\nliterature, and the autopsy in one case of purulent otitis\\nmedia after nephritis, which suggests the possibility of a\\ncasual relation between nephritis and otitis (I mean that of\\nGurovitsch), did not show any marked disease of the bones.\\nAlthough the suppuration had existed for three months,\\nthere was no more than a seropurulent fluid in the mastoid\\ncells. Thus it is seen that there is not sufficient proof to\\nwarrant the assumption of a special nephritic purulent otitis.\\nIt would appear, however, from certain reliable observa-\\ntions, that the course of chronic otitis media may be influ-\\nenced by a coexistent nephritis, any exacerbation of the\\nrenal trouble being accompanied by increase in the purulent\\nflow, and vice versa. This interdependence is clearly shown\\nin Gurovitsch s case, and it also appears, from observations\\nby Voss, that the dyscrasia which accompanies nephritis is\\ncapable of aggravating an existing aural trouble in diabetes.\\nThe value of Voss observations is somewhat impaired by\\nthe fact that they refer to a case of scarlatinal nephritis,\\nsince the development of both diseases the nephritis and\\nthe otitis depends on an intoxication, and therefore a\\ncoincident increase in both sets of symptoms may be ex-\\nplained by an increase in the common virus. Haug^ men-\\ntions a case of scarlatinal nephritis and otitis in which open-\\ning of the mastoid process was followed by improvement in\\nthe nephritic symptoms, while a subsequent exacerbation\\noccurred in consequence of retention of pus due to granu-\\nlations this observation should at least incite us to more\\ncritical investigation of the Hterature in this respect.\\n1 Berlin, klin. Wochen, 1880, No. 42.\\n2 Schwartze s Handb., i, 538. Loc. cit., p. 188.", "height": "3468", "width": "2144", "jp2-path": "rhinologylaryng00frie_0198.jp2"}, "199": {"fulltext": "IX. DISEASES OF THE SKIN AND OF THE\\nSEXUAL ORGANS.\\nU DISEASES OF THE SKIN,\\nThe vestibule of the nose, as far as the ph ca vestibuli,\\nis lined with epidermis, and is therefore attacked by the\\nsame diseases that affect the external integument. The\\nmost frequent disease affecting the vestibule, and with it\\nthe upper lips, is eczema, which leads to the same appear-\\nances in these regions as on the external skin. The nose\\nmay be either the primary or the secondary seat of eczema,\\nfor in scrofulous children, the subjects of chronic rhinitis,\\nwe frequently observe the development of eczema, which,\\nas a result of the continual irritation of the nasal secretions,\\ntends to spread more and more and to invade the face,\\nwhile, conversely, general eczema of the external skin\\nsometimes spreads to the vestibule of the nose.\\nWe could mention a large number of skin diseases\\nwhich extend into the vestibule of the nose but as their\\ndiagnosis and treatment are the same here as on the exter-\\nnal skin, with the exception of infectious processes such as\\nlupus and syphilis, which are treated of elsewhere, they\\nneed not be discussed in detail in this place. There are\\ncertain diseases of the skin which in rare cases also lead to\\nalterations in t/ie miicons membranes of the upper air-passages\\nanalogous to the general process, although presenting cer-\\ntain differences in their appearance. Thus, there is a\\ngreater tendency to loss of epithelium and ulceration, due\\nno doubt to the maceration which occurs in the mucous\\nmembrane as the result of the secretion, the moisture, and\\nthe warmth of the air-passages, so that, speaking generally,\\nthe mucous membrane shows defects and ulcerated surfaces,\\nwhereas the diseased epidermis of the skin remains as a\\nprotective covering in the form of scales and crusts.\\nFor this reason a disease in the mucous membrane will\\nin a few hours undergo certain peculiar changes and lose\\nn 193", "height": "3460", "width": "2120", "jp2-path": "rhinologylaryng00frie_0199.jp2"}, "200": {"fulltext": "194 THE SKIN AND THE SEXUAL ORGANS.\\nthe characteristic appearance of the same disease in the\\nskin. The vesicle-formation of herpes and the formation\\nof larger blebs characteristic of pemphigus are rarely seen,\\nas the loosened epithelial cells are rapidly cast off, and thus\\nthe typical appearance of the disease is destroyed in im-\\npetigo and erythema the superficial infiltration rapidly\\nundergoes necrotic changes and is replaced by ulcers, so\\nthat all these diseases present the uniform picture of an\\nexudative process followed by ulceration, and Seifert\\nand Schech accordingly include them under one clinical\\npicture, which, when it occurs in the larynx, is designated\\nby the latter as exudative laryngitis.\\nOwing to the scarcity of complications in the mucous\\nmembranes of the upper air-passages, we are reduced to a\\nfew reports from other countries,^ which would be even\\nscantier were it not for the fact that affections of the oral\\ncavity, particularly of the hard and soft palates, are often\\nincluded among diseases of the pharynx. Among the\\nskin diseases observed in the nose, the pharynx, and the\\nlarynx are herpes, urticaria, lichen, impetigo, and erythema.\\nI decline to include miliaria (Lori and eczema of the\\nthroat (M. Schmidt because I do not regard either of\\nthese affections as anything more than an acute inflamma-\\ntion of the mucous membrane accompanied with unusual\\nredness and swelling of the gland ducts, in no sense to be\\ncompared with eczema or miliaria of the external skin. In\\na general way, the seats of predilection of these diseases\\nmay be said to be the uvula, the posterior and lateral\\nlaryngeal walls, the base of the tongue, the epiglottis, and\\nthe upper margin of the larynx it is quite possible that a\\npredisposing factor for this particular localization is to be\\nsought in the mechanical irritation to which these parts are\\nparticularly exposed during the ingestion of food. Herpetic\\neruptions, like those illustrated in Krieg s Atlas, occur\\nin the pharynx and larynx, usually in combination with\\nherpes labialis occasionally, the eruption in these parts is\\nHeym. Handb. der Laryng. u. Rhin., I, p. 448.\\n2 Miinch. med. Wochen., 1898, No. 26.\\n3 I shall not quote the reported cases they have been given by Schech,\\nMiinch. med. Wochen., 1898, No. 26; by Seifert, Heym. Handb. der\\nLaryng., i, p. 448, and by Klemperer, Heym. Handb., I, p. 1286.\\nDie durch anderweitige Erkrankung bedingten Veranderungen, etc.,\\np. 86. 5 Krankh. der ob. Luftwege, 2d edit., p. 531.\\n6 Atlas. Plate XXXV.", "height": "3504", "width": "2216", "jp2-path": "rhinologylaryng00frie_0200.jp2"}, "201": {"fulltext": "DISEASES OF THE SKIN. 1 95\\nsecondary to that on the lips. As the vesicles are deprived\\nof their covering they frequently coalesce and lead to the\\nulceration of larger areas, as pointed out by Stepanow,i thus\\ncomplicating the differential diagnosis from syphilis and\\ndiphtheria. Schrotter says he has never seen herpetic vesi-\\ncles converted into ulcers. According to him, the membrane\\nwhich in a short time replaces the vesicle separates without\\nleaving any alterations behind. The literature is particularly\\nrich in cases of pemphigus in the upper air-passage, where\\npemphigus vulgaris, pemphigus foliaceus, and pemphigus\\nvegetans have been observed. As an example of pemphigus\\nvulgaris we may mention Schrotter s case,^ in which there\\nwere periodic eruptions in the larynx, varying in extent\\nand analogous to those on the rest of the body Thus\\nthe clear, transparent vesicle would appear on the epiglottis,\\nand after a few hours the contents would become turbid,\\nand finally yellow. The vesicle itself gradually con-\\ntracted and collapsed more and more, and finally lay in\\nfolds on the surface, like a croupous membrane. The sur-\\nrounding area was not specially inflamed. Thost gives\\nthe following description of chronic pemphigus foliaceus\\nwith implication of the nasal, laryngeal, and pharyngeal\\nmucous membrane. The diseased portions of the mucous\\nmembrane became the seat of isolated whitish patches,\\nirregular in shape, and varying in size from a split pea to a\\nquarter of a dollar. These patches consisted of loosened\\nepidermis, which appeared like a crumpled piece of paper\\nor hung in shreds, and in the nose and postnasal space\\nbecame dry and scaly, while the snow-white color changed\\nto a dirty grayish-brown, or even reddish tint, if any blood\\nwas present. The surrounding portion of the mucous mem-\\nbrane showed marked reddening. The white epithelial\\ncovering was easily torn, and could be removed from the\\nrete Malpighii without difficulty, exposing the red papillary\\nlayer, which bled when touched with a probe. Accord-\\ning to Thost, the process heals without cicatrization in\\na short time, often within twenty-four hours, although\\nKrieg, in his case of recurring pemphigus foliaceus, of\\nwhich he gives several very good illustrations, speaks of\\nthe cicatricial appearance of the palatal mucous membrane.\\n1 Mon. f. Ohr., 1885, p. 237.\\n2 Vorlesungen iiber die Krankh. des Kehlkopfes, 1st edit., p. 62.\\n3 Mon. f. Ohr., 1896, p. 165. Atlas, Plate XXXVI.", "height": "3460", "width": "2084", "jp2-path": "rhinologylaryng00frie_0201.jp2"}, "202": {"fulltext": "196 THE SKIN AND THE SEXUAL ORGANS.\\nNeumann,^ in describing pemphigus vegetans, points out\\nthat in an analysis of 41 cases the primary seat of the dis-\\nease was frequently found in the pharynx and larynx, and\\nonce in the nose.^ In regard to diseases of the mucous\\nmembranes in erythema exudativum multiforme, we have\\ncases reported by Lanz and Schoetz.^ Du Mesnil and\\nMarx give an example of impetigo herpetiformis\\n(Uffinger and one of lichen ruber acuminatus, while\\nhchen ruber planus is described by Marx. Occasionally,\\nthe mucous membrane of the upper air-passages partici-\\npates in urticarial eruptions, especially in the chronic\\nrelapsing form, where, as described by Cala,^ the mucous\\nmembrane of the larynx may gradually become swollen\\nand lead to asphyxia.\\nDiseases of the skin frequently spread from the external\\nskin to the external ear and auditory meatus. Eczema is\\nthe most important, although herpes, impetigo, pityriasis,\\npsoriasis, and pruritus also occur. It is, of course, of the\\ngreatest importance in the treatment to decide what form of\\notitis externa eczematosa is present, and whether there is\\nsuppuration of the middle ear w^th perforation of the mem-\\nbrane. As the diagnosis is often rendered difficult by the\\npresence of a marked purulent secretion due to the eczema,\\nand by the impossibility of inspecting the drum membrane\\non account of the great swelling of the walls of the meatus,\\nit is well to bear in mind the symptoms which establish a\\ndiagnosis of purulent otitis media, without the macroscopic\\ndemonstration of perforation of the tympanic membrane. If\\nthe pus contains mucus, it is a sign that the middle ear is\\nthe source of the discharge while pulsation of the pus in\\nthe external meatus and the presence of bubbles in the dis-\\ncharge are positive proofs of the existence of a perforation.\\nExcept in cases of moist eczema or of other processes asso-\\nciated with transudation, when the epidermic layer of the\\ntympanic membrane becomes thickened and the membrane\\nitself chronically inflamed, these skin diseases do not invade\\nthe ear-drum or the middle ear.\\n1 Wien. klin. Wochen., 1898, No. 8.\\n2 Riegel, Wien. med. Wochen., 1882, p. 274.\\n3 Berlin, klin. Wochen., 1886, No. 41. Ibid., 1889, No. 27.\\n5 Arch. f. Derm. u. Syph., 1889, xxi.\\nSemen s Centralbl., XI, p. 3S6. Lukasiewicz, Arch. f. Derm. u.\\nSyph., 1896, vol. XXXIV.\\nWiirzburger Dissertation. La Semaine Med., 1889, S. 346.", "height": "3496", "width": "2208", "jp2-path": "rhinologylaryng00frie_0202.jp2"}, "203": {"fulltext": "SEXUAL ORGANS AND UPPER AIR-PASSAGES. 1 97\\n2. THE INFLUENCE OF NORMAL OR PATHO-\\nLOGICALLY ALTERED SEXUAL FUNCTIONS\\nON THE UPPER AIR-PASSAGES.\\nRELATION OF THE SEXUAL ORGANS TO THE UPPER AIR-\\nPASSAGES.\\nOur knowledge of the relations existing between the\\nmale, and especially the female, sexual functions and the\\nupper air-passages has recently been enriched by a number\\nof important additions.\\nEven the earlier literature contains a few contributions on\\nthe subject of vicarious menstruation through the nose,\\nswelling of the nose and coryza during the menses or during\\nthe sexual act, and epistaxis as a consequence of masturba-\\ntion. It has, however, been reserved to the most recent times\\n(Hack) to reduce these relations to a system, although it\\nseems to me that Fliess occasionally exaggerates, in his\\notherwise noteworthy and on the whole scientific work on\\nthe relations between the nose and the female sexual organs.\\nSuch relations exist even under physiologic conditions at\\nthe time of puberty and during coJiabitation, and in the\\nfemale during nienstmation, the menopmise, and pregnancy.\\nThe most important pathologic condition is found in\\nmasturbation, although some influence is to be ascribed to\\ngynecologic diseases, especially chronic endometritis and\\ndisplacement of the uterus. In the last category of cases,\\nhowever, it is difficult to tell to what extent the primary\\ndisease, or rather the hysteric condition of the patient\\nwhich frequently accompanies it, can be held responsible\\nfor the sequels, which usually manifest themselves in the\\nform of a nasal reflex neurosis. Examining the symptoms\\nobserved in the upper air-passages under the influence of\\nsexual disease, we find that they consist in the main of\\nphenomena referable to the vascular system, such as Jiyper-\\neniia, siuelling, exudations, and hemorrhages in the mucous\\nmembrane.\\nThe vasomotor system of the entire body is intimately\\nconnected with the sexual functions. Hence it is easy to\\nunderstand that in any universal determination affecting the\\nentire body the specialized vascular system of the nose\\nJohn Mackenzie, Johns Hopkins IIosp. Bull., Baltimore, Jan., 1S98.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0203.jp2"}, "204": {"fulltext": "igiS THE SKIN AND THE SEXUAL ORGANS.\\nshould be more extensively implicated than other systems\\nin the body. We must bear in mind the abundant blood\\nsupply of the nasal fossae, and especially the erectile tissue\\nembedded in the mucous membrane of certain portions\\nof the turbinate bodies and of the septum. The pres-\\nence of this tissue, which in its structure is analogous to\\nthe erectile tissue in the sexual organs, suggests the idea\\nthat it bears a certain relation to the sexual processes in the\\nbody, and it has been stated that the swelling in the nose\\nis analogous to that which takes place in the clitoris and\\nin the penis. There are, however, two considerations which\\ntend to disprove the existence of such a relation In the\\nfirst place, the nasal phenomena must be regarded as ex-\\nceptional and, in the second place, while the anatomic\\nstructure of the erectile tissue in the nose in a general\\nway resembles that found in the genitalia in the arrange-\\nment of smaller cavities on the surface and larger ones\\nin the deeper tissues, it presents one important difference\\nin the fact that the individual cavities possess muscular\\nwalls, which, under the influence of the sphenopalatine\\nganglion, may cause its contraction or dilatation. As we\\nhave previously explained, the position of the tissue in the\\nnose shows that it is concerned solely with respiration if\\nit had any connection with the sexual function, it would\\nbe hard to understand why it is found in the respiratory\\nportion of the nose and not in the olfactory.\\nWe therefore consider the congestion which takes place in\\nthe nose as a mere local expression of a universal determi-\\nnation in a region particularly rich in blood-vessels. The\\nmildest grades correspond to the hyperemia that accompa-\\nnies any simple swelling and usually leads to periodic ob-\\nstruction of one or both nares the secretion of the swollen\\nmucous membrane is increased, and in the end may even go\\non to hemorrhage. These hemorrhages appear to be usually\\ndiffuse, like carious hemorrhages in other parts of the body\\nthey do not lead to tissue-destruction, and are usually de-\\nrived from the turbinate bodies, although the septum may\\nalso be the source of a habitual epistaxis. In the sexual\\nlife of the woman such conditions, which, in consequence\\nof the congestion, are generally associated with headache,\\nare observed in the beginning, or even as prodromal symp-\\ntoms, of menstruation but they may also have a compensa-\\ntory function when the menstruation is abnormal, and finally", "height": "3468", "width": "2208", "jp2-path": "rhinologylaryng00frie_0204.jp2"}, "205": {"fulltext": "SEXUAL ORGANS AND UPPER AIR-PASSAGES. 1 99\\nmay appear after the establishment of the menopause at the\\nregular menstrual intervals.\\nWe should call attention also to the observation of\\nvarious authors that these phenomena may also appear in\\na diseased nasal mucous membrane, for Mackenzie states\\nthat in ozena the odor becomes more intense and the secre-\\ntion more abundant during the menstrual period.\\nThe so-called erysipele catameniale may also be in-\\ncluded among the vasomotor reflex neuroses referable to\\nthe genital organs. It manifests itself in redness and swell-\\ning of the tissues about the external nose and of the organ\\nitself.\\nThere are certain reflex relations between definite regions\\nof the nasal mucous membrane and the female genitalia.\\nAlthough they may appear very obscure, and in Fliess\\ndescription baffle comprehension, their existence, proved by\\na series of well-known facts, can not be disregarded. As\\nlong ago as 1884 we find in Kupper s paper a warning\\nagainst the use of the galvanocautery on the erectile tissue\\nof the nose in pregnant women, on the ground that he twice\\nsaw it followed by abortion, and Schech goes so far as to\\nsay that pregnancy is an absolute contraindication to the\\nuse of the galvanocautery. Fliess has shown by an exten-\\nsive series of investigations in the gynecologic clinic of the\\nUniversity of Berlin that there are certain points on the\\nanterior extremity of the middle and inferior turbinate\\nbodies and on the tubercle of the septum designated by\\nhim genital areas through which some influence can be\\nexercised on pathologic conditions in the female sexual\\napparatus. By cocainizing the genital areas the pains\\nwhich accompany or follow the menstrual flow can be re-\\nlieved and labor pains can be reduced to a minimum, while\\nby cauterizing these areas permanent cure of dysmenor-\\nrhea may be achieved.\\nThe pharynx, and especially the larynx, as well as the\\nnose, may be the seat of congestions which can only be\\ninterpreted as derived from the genitalia. As during\\npuberty, at the time of the so-called change of voice,\\nthe mucous membranes of the upper air-passages are sub-\\nject to congestions, which are often the cause of the voice\\nbecoming easily tired, similar hyperemic conditions occur\\n1 Loc. cit. 2. Deutsclie med. Woclien., 1884, No. 51.\\n3 Schech, 5th ed., p. 289.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0205.jp2"}, "206": {"fulltext": "200 THE SKIN AND THE SEXUAL ORGANS.\\nduring menstruation, during pregnancy, and in certain\\nuterine affections, which from their effect on the singing\\nvoice are generally much better appreciated by singers\\nthan by physicians. Ruault observed hemorrhages from\\nthe vocal cords accompanying the menstrual flow.\\nSensory disturbances in the form of paresthesia and\\nhyperesthesia, depending on sexual influences, have been\\ndescribed in all the mucous membranes of the upper air-\\npassages they manifest themselves in dryness of the\\nthroat, a feeling as of a foreign body, and desire to cough.\\nThey may be due partly to the hyperemia of these parts,\\nbut more particularly to the irritable condition which char-\\nacterizes the entire nervous system at these periods. Irrita-\\ntion of the olfactory nerves, in the form of hyperosmia and\\nparosmia, is sometimes observed. In speaking of asthmatic\\nattacks as produced by disturbances in the genital region\\nwe approach perilously near the boundary-line between\\nconditions due to sexual disturbances and coexistent hys-\\nteric phenomena, a boundary which is difficult to define in\\npractice.\\nFinally, we must mention those phenomena which mani-\\nfest themselves during the sexual development of the biody\\nin functional disturbances of the voice. The most famliar\\nof these is the change which occurs at puberty. It is\\na purely physiologic process, due to the increased develop-\\nment of the larynx, which occurs at this time and neces-\\nsitates the adaptation of the muscles to the increased\\nsize of the organ. In most cases the change from the\\nchildish treble to the adult register takes place during the\\ntime of puberty without any marked disturbances, provid-\\ning the voice, which at this time becomes easily hoarse and\\nfatigued, is not unduly strained. Occasionally a slight\\nhyperemia is observed in the vocal cords, but there is no\\nabnormality in the movements of the larynx. The change\\nof voice may be considered pathologic only when it lasts\\nfor some time and when the voice after puberty retains a\\nchildish or uncertain tone, without the character of a defi-\\nnite register. In the male this consists in a high, piping\\nvoice, which often changes suddenly to a deeper tone for a\\nfew words under the influence of emotion or, if it changes\\nto a higher register, gives out altogether while in the\\nSee Semon s Centralbl., vi, p. 323.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0206.jp2"}, "207": {"fulltext": "SEXUAL ORGANS AND THE EARS. 20I\\nyoung- girl, as pointed out by Storck, it becomes abnor-\\nmally deep and rough.\\nIn the male this falsetto voice, which must be regarded\\nas the effect of an abnormal prolongation of the voice-\\nchanging period, is designated as the eunuch s voice (Four-\\nnier) it may last for only a short time after puberty, or\\nmay, as shown by numerous cases, persist a greater length\\nof time as a more or less ridiculous vocal anomaly. Al-\\nthough the condition causes the patient a good deal of\\nannoyance, it, as a rule, readily yields to treatment.\\nThere is no alteration of the laryngeal image, either in\\nthe form of redness or anomalies of motion of the vocal\\ncords, notwithstanding Fournier s attempt to construct a\\nseries of clinical pictures. This is what we should expect\\nif we remember that the eunuch s voice is the expression\\nof a disturbance in the coordination of the laryngeal mus-\\ncles, consisting in a failure of the mechanism to adapt itself\\nto the dimensions of the fully developed larynx, and the per-\\nsistence of a false register. By a judicious series of exer-\\ncises, consisting mainly in training the voice to adhere to a\\nlower key, a cure can usually be effected in a few sittings.\\nThe vocal changes which accompany old age, and con-\\nsist in roughness or shrillness, may be due to ossification\\nof the laryngeal skeleton and to consequent changes in the\\nvibrations.\\nRELATIONS BETWEEN THE SEXUAL ORGANS AND THE\\nEARS.\\nStepanow,! Eitelberg, and Gradenigo have observed\\ncases in which hemorrhages from the ears occurred either\\nvicariously or coincidently with menstruation. In most of\\nthe cases the organ of hearing had been affected with\\nchronic catarrh or chronic suppuration, and the power of\\nhearing was more or less reduced during the intervals be-\\ntween the attacks. The hemorrhages from the ear usually\\noccurred on the day before the appearance of menstruation,\\nand, in the cases of menstrual anomalies, on the days on\\nw^hich the menses should have appeared. They were usu-\\nally confined to one side, the same ear being affected in\\nevery attack. The amount of blood varied from two drops\\n1 Mon. f. Ohr., 1885, No. Ii.\\n2 Arch. f. Ohr., vol. xxviii, p. 82.", "height": "3452", "width": "2120", "jp2-path": "rhinologylaryng00frie_0207.jp2"}, "208": {"fulltext": "202 THE SKIN AND THE SEXUAL ORGANS.\\nto quantities greater than that of a normal menstrual flow.\\nThe hemorrhage is usually heralded by a kind of aura, con-\\nsisting in headache, slight vertigo, and tinnitus aurium.\\nThe region of the hemorrhage appears to be the tympanic\\nmembrane and the external meatus, especially the mouths\\nof the cerumen glands on the posterior and upper walls.\\nAfter the hemorrhage has subsided, nothing abnormal is\\nusually found except a slight hyperemia of the gland ducts\\nreferred to, though in Eitelberg s case the tympanic mem-\\nbrane was the seat of petechiae.\\nWe may mention that certain observers have reported the\\noccurrence of hemorrhages at the time of menstruation in\\ncases of perforating chronic otitis media, associated with\\ngranulations. These cases are too obscure to be regarded\\nas vicarious hemorrhages. The same statement applies to a\\nfew doubtful cases in which hemorrhage is said to have\\noccurred in the labyrinth at the appearance of the menses.\\n(Jacobson,^ Koll-.)\\nThe changes in the auditory function during these vicari-\\nous hemorrhages from the ear are interesting. During the\\nhemorrhage there is a uniform hyperesthesia of the auditory\\nnerve for all registers, and a diminution in the electric reac-\\ntion. The sensibility is reported in some cases as increased\\nin others, as aboHshed. At the time of menstruation tinni-\\ntus aurium is often observed it is probably due to the\\nhyperemia accompanying the flow.\\nMasturbation is said to aggravate an existing aural affec-\\ntion and to exaggerate a chronic catarrh or suppuration. It\\nis sometimes given as the cause of subjective noises, which\\nare probably an expression of abnormal irritability of the\\nvasomotor centers.\\nThe connection between pregnancy and the pucrpcruun\\nand chronic catarrh of the middle ear is so generally recog-\\nnized among the laity that it is given as the cause of deaf-\\nness -in an abnormally large number of the cases, but the\\nvalue of the patient s statement in this respect is much\\nreduced when we find that in most cases it is possible to\\ndemonstrate objective alterations in the ear which can not\\npossibly be referred to that physiologic condition of the\\nfemale organism. If, as I believe we are justified in doing,\\nwe exclude all cases of obstinate catarrh of the middle ear,\\n1 Arch. f. Ohr. xxi, p. 2S0. 2 Arch. f. Ohr., xxv, p. 88.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0208.jp2"}, "209": {"fulltext": "GONORRHEA. 203\\nthe cause of which can be demonstrated in diseases of the\\nnose and pharynx, and cases of former purulent otitis media\\nwith remaining alterations in the middle ear and on the drum\\nmembrane, there remain only the forms of so-called chronic\\ncatarrhal otitis media without alteration of any kind in the\\ntympanic membrane, and cases attended with tinnitus\\naurium. Bezold has found that among 190 women suffer-\\ning from this form of middle ear catarrh, ly.gfo referred\\nthe beginning, or at least a subsequent aggravation of\\ntheir deafness, to pregnancy or the puerperium. In some\\ncases there was a successive deterioration in the auditory\\npower at each pregnancy.\\nThese auditory disturbances are no doubt closely related\\nto the disturbances in the circulation to which the female\\norganism is subject during the time of menstruation and\\npregnancy, and to the anemic conditions which follow the\\npuerperal period. Thus we find that, analogous to the in-\\nfluence exerted by diseases of the circulatory system on the\\near, anemia and hyperemia constitute important etiologic\\nfactors in the production of functional disturbances of the\\nauditory organ. As the deafness and tinnitus aurium which\\noccur during menstruation may be regarded as the result of\\nthe general determination, and as representing hyperemic\\nconditions in the deeper portions of the organ of hearing, it\\nis equally plausible that the chronic venous stasis and in-\\ncreased irritability of the entire nervous apparatus which\\ncharacterize pregnancy should be capable of producing dis-\\nturbances in the auditory function. Concerning emboli in\\nthe ear during the puerperium, and pyemic disease of the\\near after puerperal fever, we have very few contributions.\\n3. GONORRHEA.\\nThe occurrence of gonorrhea in the nose and in the\\npharyngeal cavity is now beyond dispute, and the many\\nassertions made to the contrary in former times are\\nwholly without foundation. These depended partly on\\ntheoretic speculation in regard to the mode of infection\\nof mucous membrane covered with squamous and cylin-\\ndric epithelium in gonorrhea. The rarity of nasal infection\\nin comparison to the frequency of gonorrhea is to be\\ni Arch. f. Olir., vol. XXV, p. 225.", "height": "3460", "width": "2120", "jp2-path": "rhinologylaryng00frie_0209.jp2"}, "210": {"fulltext": "204 THE SKIN AND THE SEXUAL ORGANS.\\nattributed to the fact that the vestibule of the nose is hned\\nwith epidermis. Infection is usually due to uncleanliness\\nin the use of handkerchiefs the skin, however, opposes a\\nnatural barrier to the invasion of the virus. We find not\\nonly in the new-born, in connection with gonorrheal con-\\njunctivitis, where infection takes place during birth, but\\nalso in adults, as the result of direct transmission to the\\nnasal mucous membrane from other sources, a purulent\\nrhinitis as the result of this mode of infection, the nature of\\nwhich is proved by the bacteriologic demonstration of the\\ngonococci (Miller i). I once had occasion to observe two\\ncases of purulent rhinitis in the secretions of which typical\\ngonococci were found within the pus-cells, occurring in\\ntwo children of the same family, aged four and six respec-\\ntively, who lived amid poverty-stricken and uncleanly sur-\\nroundings and shared the bed of their gonorrheal mother.\\nIn this connection it is interesting to note the possibility\\nof gonorrhea being conveyed to the oral mucous mem-\\nbrane of infants (Rosinski 2), where it manifests itself in\\nthe form of a whitish exudate Cuttler and Salzmann\\neach report a case of gonorrheal ulcerative stomatitis, the\\nresult of an infection contracted by coitus per os.\\nOccasionally arthritis may be localized in the articulations\\nof the larynx and produce symptoms similar to those\\nwhich occur in acute articular rheumatism. Liebermann\\nand Simpson describe a disease of the crico-arytenoid\\narticulation which appeared in connection with swellings in\\nother joints after an acute gonorrhea. In one of these\\ncases the left arytenoid cartilage was the seat of redness\\nand swelling, most marked over the articulation, and\\nthis on sounding was found to be fluctuating. The left\\nvocal cord failed in adduction. At the same time there\\nwere aphonia and violent pain in the region of the larynx,\\nincreased by pressure on the thyroid cartilage. Gradu-\\nally the voice improved, and after six weeks the swell-\\ning disappeared, although the vocal cord continued slug-\\n1 Stork, Nothnagel s Handb., xni, 1st half, p. 86.\\n2 Zeitschr. f. Gynak, 1891.\\nSee Semon s Centralbl., vi, p. 166.\\nKraus, Nothnagel s Handb., XVI, I Th., I Abth. p. 244.\\ns From Soc. med. des Hopit., 1S73, p. 388, reprinted by Archam-\\nbault, Th6se de Paris, 1886.\\nFrom Med. Rec, July, 1S89, reprinted by Lacoarret, Rev. d.\\nLaryng., 1891, p. 398.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0210.jp2"}, "211": {"fulltext": "SYPHILIS. 205\\ngish in its movements after the voice had almost re-\\ngained its usual quality. In Simpson s case the swelling\\nsubsided more rapidly, but there also remained a sluggish-\\nness in the movements of the vocal cord on the affected\\nside and in the region of the joint when the patient was\\ndischarged after eleven days. Lazarus^ has described a new\\nvariety of gonorrheal disease of the larynx on the strength\\nof a case of bilateral paralysis of the crico-arytenoidei\\npostici in gonorrheal arthritis. As no alterations could be\\ndemonstrated with the laryngoscope in the arytenoid car-\\ntilages or in the mucous membrane of the interarytenoid\\nspace, and as there was neither tenderness nor pain in the\\ncartilages of the larynx, the clinical picture of this form is\\nclearly distinguished from that seen in the articular affec-\\ntions just described, and we must agree with Lazarus\\nalthough he does not dwell on these points in the differ-\\nential diagnosis in explaining his case as one oi gonorrheal\\nneuritis, the occurrence of which finds ample confirmation\\nin the investigations carried out by Leyden.^\\nThe localization of gonorrheal disease in the ear has\\nnever been reported Flesch believes that he once found\\ngonococci in the pus derived from the middle ear of an\\ninfant. One of Fischel s histories contains a note to the\\neffect that, in a case of gonorrhea, tinnitus aurium was fol-\\nlowed within twenty-four hours by complete bilateral deaf-\\nness, but it is of little value.\\n.4. SYPHILIS,\\nWe are unable to devote to syphilis of the upper air-pas-\\nsages the space which its importance and frequency demand.\\nThe subject is fully discussed in all text-books on syphilis\\nand in many special essays,^ so that I shall refer only\\nbriefly to the most important points.\\nPrimary sores are found in the nose in the region of the\\nvestibule, which is accessible to infection by the finger.\\n1 Arch. f. Laryng., V, p. 232. 2 Zeitschr. f. klin. Med., 1S92.\\n3 Berlin, klin. Wochen., 1892, No. 48.\\nFischel, Prag. med. Wochen., 1891, No. 11.\\n5 Neumann, Syphilis, Nothnagel s Spec. Path. u. Therap., 1897, vol.\\nXXIII. Lang, Vorlesungen, 2d ed., 1895. Gerber, Syphilis der Nase u.\\ndes Halses, Berlin, bei Karger, 1895. Seifert, Deutsche med.\\nWochen., 1893, 42, 44, 45.", "height": "3452", "width": "2120", "jp2-path": "rhinologylaryng00frie_0211.jp2"}, "212": {"fulltext": "206 THE SKIN AND THE SEXUAL ORGANS.\\nThey have been observed on the alse and on the septum,\\nand deserve mention because they may obscure a diagnosis\\nin two different ways. When the sore is situated on the\\ninner surface of the alae and leads to marked swelling and\\nredness of that region, there is at first, before the glands of\\nthe face and neck become enlarged and the induration sur-\\nrounding the ulcer becomes apparent, a possibility of mis-\\ntaking it for furuncle and when the symptoms are fully\\ndeveloped, the lesion may be mistaken for a gumma. The\\nsecondary stage appears on the mucous membrane of the\\nnose at the same time as on the external skin, but it occurs\\nless frequently and presents fewer morphologic varieties.\\nErythema and papules are probably very rare on the mu-\\ncous membrane, for opinions differ as to the possibility of\\ntheir occurrence there they are somewhat more frequent\\nin the vestibule and, according to some, on the floor of\\nthe nose and septum. Lang depicts a vegetating papule\\nsituated on the boundary between the epidermis and car-\\ntilaginous septum. One form of early syphilis in the nose\\nis a peculiar catarrh, differing from acute catarrh by its\\ninsidious onset and by the character of the secretion, which\\nis thick, though scanty. It may possibly be regarded as a\\nspecific erythema. The mild character of the symptoms\\nand the fact that complete recovery takes place for super-\\nficial ulcerations in the mucous membranes are very rare\\n(Lang) probably explain the scarcity of the reports about\\nthis form of catarrh.\\nThe most important manifestations of syphilis in the nose\\nbelong to the tertiary stage. Both the lesions themselves\\nand the defects and cicatricial contractions which result\\nafter they heal often require local treatment. The heredi-\\ntary forms resemble the tertiary in their course.\\nIt is well known that gummatous disease may appear\\nunder various forms and run a very different course in dif-\\nferent cases. The circumscribed tumor-like variety is rare\\nin the nose when it does occur, it is most frequently local-\\nized on the epidermic and cartilaginous septum and on the\\nalae. According to Koon, Manasse,^ and Kuttner,^ one\\nought to distinguish as a special form syphilitic granulo-\\nmata, which, however, can not be differentiated from tuber-\\nculomata either clinically or histologically, at least in those\\n1 Loc. cit.. Fig. 56. 2 Virch. Arch., Bd, CXLVn, p. 32.\\n3 Arch. f. Lar. u. Rhin., vn, 1898.", "height": "3492", "width": "2208", "jp2-path": "rhinologylaryng00frie_0212.jp2"}, "213": {"fulltext": "SYPHILIS. 207\\ncases in which it is impossible to find either tubercle bacilli\\nor cheesy detritus in the tubercle. They differ from the\\nordinary gummatous tumors by the presence of a pedicle\\nor a broad base and by their greater vitality, as they\\nshow no tendency to central necrosis, and only a slight\\ntendency to superficial ulceration. Manasse regards them\\nas simple connective-tissue tumors, originating in the sub-\\nmucous connective tissue, and either pushing the epithe-\\nlium before them or breaking through it.\\nGummatous infiltration with chronic inflammation lead-\\ning to hyperplasia of the mucous membrane is very com-\\nmon, and manifests itself in the form of a hypertrophic\\nrhinitis the coryza neonatorum of hereditary syphilis.\\nSooner or later the process goes on to tumor formation, but\\nbefore that event occurs the disease may attack the peri-\\nchondrium and periosteum of the cartilages and bones\\nof the nasal skeleton, and lay the foundation for necrosis of\\nthe cartilage and sequestration of the bone. Referring to\\nsuch cases, in which sequestra were found under the hyper-\\ntrophic, intact mucous membrane, Sanger and E. Frankel\\nmake the statement that the bony framework of the nose\\nmay become diseased independently of the mucous mem-\\nbrane. Sanger distinguishes three forms of bone disease,\\nwhich he calls exfoliated necrosis following suppurating\\nprocesses, rarefying luetic osteitis, or caries sicca, and rare-\\nfying and plastic osteitis. We also recognize a syphilitic\\nchondritis in addition to perichondritis. As a result of all\\nthese processes we find the familiar defects in the soft parts\\nand in the bones, producing the characteristic cicatricial\\ncontractions and distortions, and often leading to adhesions\\nand stenosis.\\nWhile any part of the bony skeleton may be attacked by\\nthe disease, the median and lateral walls manifest a peculiar\\npredisposition. In the septum the bony portion is chiefly\\ninvolved, and the vomer, as well as the perpendicular plate\\nof the ethmoid bone, may be more or less completely\\ndestroyed by the necrosis. The situation of these defects\\nis of significance in the differential diagnosis from tubercu-\\nlosis, which produces its ravages especially in the cartil-\\naginous septum although it not rarely happens that the\\nsyphilitic process involves the cartilaginous as well as the\\nVierteljahrschr. f. Derm. u. Syph., 1S77, pp. 89 and 90.\\n2 Virch. Arch., 75.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0213.jp2"}, "214": {"fulltext": "208 THE SKIN AND THE SEXUAL ORGANS.\\nbony septum. We must take exception to the statement\\nmade by Schech^ that syphilis preferably attacks the ante-\\nrior cartilaginous portion of the septum. The detection of\\na perforation of the septum is sometimes difficult when the\\nmucous membrane is still in the hypertrophic stage, or if\\nthe sequestrum, as often happens, separates from the poste-\\nrior extremity of the vomer. Next to the septum the\\nturbinate bodies are the commonest seats of the disease,\\nand are sometimes partly or completely destroyed. The\\nfloor of the nose becomes involved, and large perforations,\\nheralded by swelling of the floor, occur in the hard palate\\nand sometimes afford a view into the nose from the mouth,\\nLang mentions extension of the disease to the lamina crib-\\nrosa, with following meningitis. Syphilitic caries of the\\nethmoid cells has been reported by Gerber, Lange, and\\nHellmann^.\\nAfter a hypertrophic syphilitic rhinitis has passed through\\nthe stage of ulceration, the cicatricial contraction or the\\natrophy of the mucous membrane leads to a condition that\\nis clinically known as atrophic rhinitis. Owing to its con-\\nversion into scar tissue, the loss of the ciliated columnar\\nepithelium, the degeneration of the blood-vessels, and the\\ndisappearance of the glands and erectile tissue, the mucous\\nmembrane loses the power of performing its normal\\nfunction the dried secretions accumulate in the widened\\ncavities of the atrophic organ, undergo decomposition, and\\nlead to the formation of crusts. The offensive odor with\\nwhich the condition is associated has given rise to the\\nunscientific and misleading term ozena syphilitica. It\\nappears from the investigations of Zukerkandl^ that the\\nmucous membrane of the accessor}^ cavities may also par-\\nticipate both in the hypertrophy and in the subsequent cica-\\ntricial process.\\nWhile crust formation and fetor are rarely absent in old\\ncases of nasal syphilis, they may also be found in the\\nearlier stages of a variety of diseases. Crust formation is\\nobserved in any form of ulceration, while fetor always\\naccompanies necrosis of the bone and is constantly present\\nin atrophic rhinitis. The tissue destruction that takes\\nplace in the course of syphilis in the skin and in the car-\\ntilaginous and bony framework of the nose produces the\\n1 Die Krankh. der Mundhohle, etc., p. 311.\\n2 Arch. f. Lar. u. Rhin., ni, p. 210. Anat. der Xase, vol. n.", "height": "3496", "width": "2208", "jp2-path": "rhinologylaryng00frie_0214.jp2"}, "215": {"fulltext": "SYPHILIS. 209\\nmost extensive alterations, which only are not visible with\\nthe rhinoscope, but also leave an indelible mark of the\\ndisease on the external appearance of the patient. The\\nwell-known syphilitic nose is the terror of patients, and,\\nwith the exception of lupus, there is no other disease\\ncapable of producing such frightful disfigurement. The\\ncommonest deformity consists in the so-called ^saddle-nose,\\ncharacterized by the sinking of the bridge of the nose and\\nelevation of the tip, while* the flattening that accompanies\\nit appears to increase the transverse diameter. The nose\\nas a whole is reduced in size, which is explained by Neu-\\nmann as a molecular atrOphy of the bone. Besides the ab-\\nsence of the nasal septum, this deformity may be produced\\nby various causes. Defects in the cartilaginous portion of\\nthe septum do not alter the shape of the nose, even when\\nthe vomer is destroyed. When, however, the upper ante-\\nrior portion of the perpendicular plate of the ethmoid bone,\\nthe posterior support of the two nasal bones, is destroyed,\\nthe sinking of these bones, which is further increased by\\nthe cicatricial contraction, produces a marked change in\\nthe shape of the nose. There are, however, cases of\\nsaddle-nose in which no such coarse destructions of tis-\\nsue are found, and several theories have been offered to\\nexplain their formation. According to Moldenhauer, 1 it is\\nproduced by a cicatricial contraction of the connective tis-\\nsue that unites the cartilaginous and bony portions of the\\nexternal nose, while Neumann mentions two novel phys-\\nical factors, the first of which consists in the loosening\\nand partial destruction of the connections between the\\nbony and cartilaginous structures, and the second in a\\ndifference of atmospheric pressure between the external air\\nand that of the interior of the nose which accompanies\\nevery inspiration. As long as the framework of the\\nnose is intact and the musculature of the cartilaginous\\nportion performs its functions, these two factors suffice to\\nmaintain the equilibrium during the decreased pressure\\nwhich accompanies the inspiration. But as soon as these\\nstructures suffer a loss of integrity they are no longer\\ncapable of resisting the external pressure, and a sinking of\\nthe nose results in the direction of the increased external\\npressure.\\n1 Lehrb. der Nasenkrankh., Leipzig, 1886.\\n2 Nothnagel s Spec. Path. u. Therap., xxiii, p. 344.\\n14", "height": "3460", "width": "2060", "jp2-path": "rhinologylaryng00frie_0215.jp2"}, "216": {"fulltext": "2IO THE SKIN AND THE SEXUAL ORGANS.\\nThe destruction of the bony, cartilaginous, and epidermic\\nportions of the septum produces a characteristic deformity\\nof the profile, consisting in a depression of the nose, which,\\ndeprived of its posterior support, becomes a mere mass of\\nflesh overhanging the nasal cavity, and, in obedience to the\\nlaws of gravity, approaches the upper lip. Various other\\ndeformities may be seen as the result of destruction of\\nother parts of the bony or cartilaginous framework of the\\nexternal nose, among which we may mention one that is\\nparticularly common in the hereditary forms of syphilis, and\\nin which, in addition to the saddle-shape, there is a com-\\nplete flattening of the nose by destruction of the alae and\\ncartilages of the lateral walls, so that in profile the nose is\\nnot raised above the level of the face, and in the front view\\npresents the appearance of two irregular, distorted open-\\nings, corresponding to the anterior nares, covered by a\\nperforated plate of tissue.\\nThe pharynx is a favorite seat of syphilis in all its forms.\\nThe primary chancre is found on the palatal tonsils, which\\nare much swollen, dark blue in color, and frequently the\\nseat of superficial ulceration, while the submaxillary and\\nsubmental glands are at the same time greatly enlarged.\\nInfection may take place in a variety of ways by direct\\ninoculation during improper practices, by eating with\\ninfected forks or spoons, and sometimes even by surgical\\ninstruments. It is important to mention that a chancre on\\nthe tonsil may be mistaken for diphtheric tonsillitis, tonsil-\\nlary abscess, carcinoma or sarcoma of the tonsils, or for a\\ngumma. The erythematous and papular eruptions which\\noccur on the faucial pillars, on the tonsils, and on the soft\\npalate are so well known that their description may here be\\nomitted.\\nThey are never observed on the posterior laryngeal wall,\\nbut are occasionally seen in the postrhinoscopic image on\\nthe posterior surface of the uvula.\\nCondylomata resembling papillomata are sometimes seen\\non the hard and soft palate, on the pillars of the fauces,\\nand on the tonsils, in the form of pale gray nodular excres-\\ncences.\\nThe tertiary forms of acquired syphilis and the various\\nhereditary types produce marked alterations in the pharynx.\\nSome instructive illustrations are found in Rang, loc. cit., Figs. 62-68.", "height": "3468", "width": "2152", "jp2-path": "rhinologylaryng00frie_0216.jp2"}, "217": {"fulltext": "To begin with the tonsillar space, we may mention the\\ngumma infiltrations, tumors, and ulcerations that are\\nusually found associated with diseases in the nose and in\\nthe oral pharynx. The diagnosis in such cases presents no\\ndifificulties. It is more difficult when the nasopharynx\\nalone is diseased. The symptoms complained of by the\\npatient are very vague headache, depression, lassitude,\\nloss of appetite, and occasionally earache nothing that\\nmight point to an exact diagnosis and the diseased focus\\nmay remain undiscovered until for some reason a postrhi-\\nnoscopic examination is made. We then find ulcerations\\nin the roof of the pharynx, in the neighborhood of the\\nchoanae, and sometimes on the lateral pharyngeal wall,\\nwhich are readily recognized as syphilitic ulcers by their\\nirregular outline, sharp edges, and excavated floors cov-\\nered with yellowish secretions. The disease may invade\\nthe periosteum and the bone, or there may be from the\\nbeginning a syphilitic osteitis, ending in necrosis and ex-\\ntensive destruction of the surrounding bony walls. If the\\ndisease is situated in the roof of the pharynx, part of the\\nsphenoid bone, if on the posterior wall, parts of the cervi-\\ncal vertebrae, especially the atlas and axis, may give way\\nand cause large openings into the vertebral canal, or ulcer-\\nation and severe hemorrhage from the vertebral artery may\\noccur.\\nA gumma on the posterior surface of the soft palate\\ngenerally results in perforation of that structure, usually\\njust below its attachment to the palatal bone, and leads to\\nvarious deformities, according to the size of the perfora-\\ntion. If the tissue destruction is great, the soft palate is\\nloosened from its attachment and drops down, so that if\\nthe perforation is situated in the middle line above the\\nuvula, the latter may come in contact with the base of the\\ntongue. In extensive ulcerations the entire uvula and large\\nportions of the soft palate and faucial pillars may be de-\\nstroyed and as the disease is not limited to the soft parts,\\nthe palatal bone itself is often perforated, so that it is pos-\\nsible to obtain a view of the nose from below.\\nThe syphilitic alterations in the posterior and lateral\\nwalls of the pharynx deserve special attention, as they may\\nbe mistaken for follicular catarrh or for a chronic hypertro-\\nphic catarrh of the plica salpingopharyngea (Neumann), if\\nthey appear in the nodular form or in the form of diffuse", "height": "3460", "width": "2040", "jp2-path": "rhinologylaryng00frie_0217.jp2"}, "218": {"fulltext": "212 THE SKIN AND THE SEXUAL ORGANS.\\ninfiltrations. The true nature of the disease is easily recog-\\nnized by its tendency to cause rapid destruction of tissue.\\nKrecke^ once saw two hard, spherical granulation tumors,\\nthe size of a pigeon s egg, on the posterior wall of the\\npharynx, which showed no tendency to break down, and\\ndisappeared on the administration of potassium iodid.\\nThey probably belonged to the same category as the gran-\\nulation tumors described by Kuhn-Manasse.\\nAs has been stated, the tissue destructions that occur in\\nthe course of tertiary or hereditary syphilis are of the\\ngreatest importance, and their practical significance is\\naccentuated by the subsequent cicatricial contractions and\\nadhesions, which may lead to marked functional disturb-\\nances. While, on the one hand, destruction of the hard\\nand soft palates produces changes in the voice and difficulty\\nin swallowing by making it impossible to effect a closure\\nof the posterior nares, the cicatricial contractions, on the\\nother hand, frequently lead to stenoses in the nasal\\npharynx, which embarrass nasal respiration, and rarely to\\na stenosis in the deeper portions of the pharynx, which\\ninterferes with the ingestion of food.\\nTl;ie scar that follows the healing of a specific ulcer on the\\nmucous membrane has the same radiate appearance char-\\nacteristically seen in the external skin after the healing of\\nsyphilitic lesions. Where there is a solid foundation, as on\\nthe posterior pharyngeal wall, the mucous membrane has a\\ntense, glistening appearance, resembling tendon, while in the\\nneighborhood of the isthmus the scars lead to distortions of\\nthe soft tissues. The symmetry of the posterior nares is\\ndestroyed, the uvula is drawn to one side or rolled on itself,\\nand the palatal ridges are distorted almost beyond recogni-\\ntion.\\nNeighboring areas in the mucous membranes are fre-\\nquently the seat of cicatricial adhesions, which are due to\\nthe tendency of the lesions to produce contact ulcers on op-\\nposed surfaces. Thus, we frequently see bands of adhesion\\nuniting the posterior pharyngeal wall to the soft palate.\\nThe adhesion may be so extensive as to shut off the oral\\ncavity completely from the postnasal space, or the adhesion\\nmay be only partial, leaving a chimney-like opening into the\\npostnasal space, through which the secretions from the\\n1 Miinch. med. Wochen. 1894, No. 47.", "height": "3492", "width": "2224", "jp2-path": "rhinologylaryng00frie_0218.jp2"}, "219": {"fulltext": "SYPHILIS. 213\\nnose trickle down into the pharynx, as there is usually a\\ncoexistent chronic fetid rhinitis. These adhesions may be\\nvisible at the first glance on ordinary inspection, but some\\nof them are more obscure, and require a postrhinoscopic or\\nlaryngoscopic examination for their detection. Among\\nthese we include the adhesions which are seen when the soft\\npalate is only partly destroyed, and which take the form of\\na horizontal diaphragm-like membrane between the pos-\\nterior surface of the soft palate, near its attachment to the\\npalatal bone, and the posterior pharyngeal wall, or those\\nwhich lead to the formation of adhesive bands in the post-\\nnasal space between the roof of the pharynx and the swollen\\norifices of the Eustachian tubes, or between the latter and\\nthe margins of the choana; or the posterior pharyngeal wall.\\nBoth these forms of postsyphilitic alterations occasion great\\ndiscomfort, the destructive variety interfering with nasal res-\\npiration and lending a peculiar dead quaUty to the voice,\\nwhile the cicatricial form, by involving the tubes, leads to\\ncertain disturbances in the hearing, to be discussed later. A\\nrare form of adhesion is one which forms between the base\\nof the tongue and the posterior pharyngeal wall.\\nSynechia; between the soft palate and the posterior wall\\nare of such frequent occurrence and give rise to such dis-\\ntressing symptoms that they often require operative treat-\\nment. In view of the tendency of the two divided portions\\nof an adhesion to reunite, and thus oppose a serious\\nobstacle to the success of the operation, it may be well to\\ndiscuss briefly the conditions which explain not only the\\noriginal formation of the synechia, but also its tendency to\\nrecurrence. When the soft palate performs its normal\\nfunctions, and when, in obedience to the laws of gravity, it\\nretains its perpendicular position and moves with every act\\nof deglutition and phonation, there is small danger of\\nthe opposing surfaces becoming adherent, even when they\\nare the seat of ulcers, as the constant movement of the soft\\npalate would loosen any adhesive bands as fast as they\\nformed but when, on the contrary, the soft palate, as the\\nresult of deformity or the distortion of syphilitic scars, is\\nbrought nearer the posterior wall of the pharynx and loses\\nits normal mobility, the conditions for the formation of an\\nadhesion are proportionately more favorable. Neumann\\nNothnagel s Spec. Patli. u. Therap., xxni, p. 320.", "height": "3464", "width": "2060", "jp2-path": "rhinologylaryng00frie_0219.jp2"}, "220": {"fulltext": "214 THE SKIN AND THE SEXUAL ORGANS.\\nhas pointed out that adhesions are especially liable to form\\nwhen the faucial pillars are totally or partially destroyed, and\\nwhen, owing to an antecedent syphilitic myositis, the palato-\\nglossus, the palatopharyngeal, and the pterygo-, mylo-,\\nglosso-, and buccolaryngeal muscles, as well as the middle\\nconstrictor of the pharynx, fail to act.\\nThe hoarseness of syphilis, under the name of raiicego\\nsyphilitica, was formerly deemed of some importance by\\nphysicians, is still regarded among the laity as a frequent\\nsign of an old infection. It is, therefore, surprising to\\nlearn from the statistics that syphilitic disease of the\\nlarynx is comparatively rare. Statistics based on dispen-\\nsary work in diseases of the throat show a rather low per-\\ncentage of laryngeal syphilis. According to Schrotter,!\\n8.7^ among 35,826 patients; according to Rosenberg,^\\n3.6^ (there were 58 cases of specific laryngeal disease\\namong 16,000 patients in B. Frankel s polyclinic) while\\nother authors give somewhat larger percentages, based on\\nshorter series of cases. It might be thought that this\\nconspicuous infrequency of the disease is due to the noto-\\nrious indifference of the patients, and to the fact that many\\nphysicians do not feel called upon to devote any special\\nattention to it, as it disappears under general antisyphilitic\\ntreatment, were it not for the fact that the investigations\\nby syphilographers, made with a view to determining the\\nlaryngeal complications, have yielded similar results. The\\nmost reliable analysis is that made by Lewin,^ who,\\namong 20,000 syphilitic subjects in his clinic, found 575\\ncases, or 2.9^, of laryngeal diseases, 13^ of which were\\ngrave and ^y ^o comparatively mild.\\nSecondary syphilis appears in the larynx in the form of\\nerythematous and papular eruptions, going on to ulcera-\\ntion while the tertiary stage, which often appears as early\\nas one year after infection (Semond is represented by\\ngummatous disease, which may manifest itself as a small\\nnodular syphilid, as a diffuse infiltration, or as a circum-\\nscribed gumma. The symptom-complex of laryngeal\\nsyphilis further includes the ulcers due to the breaking-\\ndown of the gummatous tumors and to the perichondritis\\nSee Gerber s statistics, loc. cit., p. 44.\\nKrankh. der Mundhohle, etc., 1893 Karger, p. 306.\\nCharite Ann., vol. vi, p. 538.\\nCentralbl. f. Laryng., X, 203.", "height": "3492", "width": "2232", "jp2-path": "rhinologylaryng00frie_0220.jp2"}, "221": {"fulltext": "SYPHILIS. 215\\nwhich follows as the result of extension to the cartilages.\\nFinally, we may regard as sequels the scar formations and\\nthe chronic infiltrations and contractions which remain and\\nlead to permanent functional disturbances in the voice or\\nto marked stenosis.\\nThe question whether we are justified in considering\\ncatarrhal disease of the laryngeal mucous membrane as an\\nerythematous eruption is still undecided, in spite of\\nLewin s paper advocating the recognition of such an\\nerythema. For my part, I agree with that author, and\\nbelieve that the condition usually designated as syphilitic\\ncatarrh is not a catarrh in the ordinary sense of the word\\nand differs clinically from an ordinary catarrhal laryn-\\ngitis. _\\nIt is characterized by a peculiar, dark, bluish-red or\\nbrownish-red (Lewin) discoloration, which makes it appear\\nin the laryngeal image like a peculiar, one might almost\\nsay specific, hyperemia, especially as it lacks swelling and\\nincreased secretion, the ordinary symptoms of catarrh of\\nthe mucous membrane. Although it has been so described\\nby certain French authors, the red discoloration is not such\\nas to justify the designation of roseola or macular syphilid,\\nbeing diffuse rather than circumscribed.\\nIn some cases the erythema as we have just described it\\nbecomes covered with gray patches or rings elevated above\\nthe hyperemic mucous membrane (as illustrated by Schnitz-\\nler),2 resembling the mucous patches of the soft palate.\\nAlthough they are also observed on the epiglottis and on\\nthe aryepiglottic folds, their favorite seat is on the vocal\\ncords. The superficial layers of the epithelium very soon\\nseparate and the patches are converted into superficial\\nulcers. The occurrence of flat and of acuminate condy-\\nlomata on the laryngeal mucous membrane has been de-\\nscribed. The former are due to hyperplasia of the papillae,\\nand appear as pale gray prominences with broad bases,\\nslightly elevated above the mucous membrane, preferably\\nsituated on the free border of the vocal cords, on the epi-\\nglottis, and on the aryepiglottic folds. They rather resem-\\nble papules or opalescent patches, and the old name of\\ncondylomata would perhaps best be discarded, especially in\\ndiseases of the mucous membrane. This applies still more\\n1 Charite Ann., vol. VI. Atlas, PI. xil, I.", "height": "3460", "width": "2032", "jp2-path": "rhinologylaryng00frie_0221.jp2"}, "222": {"fulltext": "2l6 THE SKIN AND THE SEXUAL ORGANS.\\nto the so-called acuminate condylomata that have been\\ndescribed in the larynx, the existence of which, however,\\nis denied by the majority of authors Lewin, for instance,\\nnever saw a case of this kind. They can not be positively\\ndistinguished from the granulating edges of an ulcer, or\\neven from connective-tissue tumors, such as fibromata,\\npapillomata, and so on, as they do not yield to antisyphilitic\\ntreatment.\\nAmong tertiary lesions, as has been stated, we distin-\\nguish the three forms of nodular syphilids, diffuse gumma-\\ntous infiltration, and gummy tumor.\\nThe first of these manifests itself in the form of small\\nnodules, varying from the size of a pinhead to that of a\\nsplit pea, closely aggregated or even confluent. Lewin\\nremarks that their covering of mucous membrane, which is\\nat first normal, gradually assumes a yellowish discoloration\\nas the process passes into ulceration. This form, which is\\nalso found on the palate and in the pharynx, maybe diffi-\\ncult to diagnose from lupus or tuberculosis in the absence\\nof evident signs of syphilis in other parts of the body. It\\nis true that the nodules show less tendency to the scar for-\\nmation which in lupus appears coincident with the forma-\\ntion of ulcers, and the reaction in the surrounding areas is\\nless marked, but these phenomena are all so variable that\\nwe are often driven to the test of antisyphilitic treatment.\\nThe subjective symptoms are of some diagnostic value,\\nsince syphilitic disease, as in the other mucous membranes\\nof the upper air-passages, runs a painless course, while\\nlupus, and especially tuberculosis, is associated with severe\\npain in the throat and with dysphagia.\\nThe diffuse infiltrations and the gummy tumors represent\\ndifferent expressions of the same gummatous disease. The\\nformer are the more frequent the latter, until recent times,\\nwere considered as very rare forms, although a hasty sur-\\nvey of the last volume of Semon s Centralblatt fiir Laryn-\\ngologie reveals a goodly number of cases. While the\\ndiffuse infiltrations preferably affect the epiglottis and the\\naryepiglottic folds, where they lead to a diffuse swelling,\\ncovered with healthy, smooth mucous membrane, the\\ngummy tumors may be found in any part of the larynx in\\nthe form of circumscribed spherical bulgings. They also\\noccur on the ventricular bands and below the vocal cords,\\nare frequently isolated, and may, as long as the mucous", "height": "3468", "width": "2224", "jp2-path": "rhinologylaryng00frie_0222.jp2"}, "223": {"fulltext": "SYPHILIS. 217\\nmembrane remains intact, be confounded with incipient\\nmalignant tumors, such as carcinoma or sarcoma.\\nWith the exception of certain nodular varieties, which\\nmay perhaps be compared to the syphilitic granulation tu-\\nmors (Kuhn-Manasse), these forms are rarely demonstrated\\nby laryngoscopic examination, as they possess a marked ten-\\ndency to undergo ulceration.\\nThe ulcers vary in size and depth. Those which develop\\nfrom infiltrations are wide-spread and flat, while those which\\nfollow gummata are deeper, and correspond in size with the\\ngumma which they replace. Their boundaries are sharply\\ndefined, the edges are undermined, elevated above the sur-\\nface, and thickened, while the surrounding area is the\\nseat of a dusky red discoloration, more or less distrib-\\nuted over the entire larynx. The floor of the ulcer is\\ncovered with a thin, grayish, creamy exudate, the removal\\nof which reveals the whitish speckled appearance of the\\nfirm infiltration (Orth). The differential diagnosis from\\ntubercular ulcers is based on the sharp edges, the speckled\\nfloor, the absence of nodules in the surrounding area,\\nand the absence of any tendency to the formation of granu-\\nlations, although there are cases in which the diagno-\\nsis can be decided only by a bacteriologic or a general\\nexamination. It must also be borne in mind that syphilis\\nand tuberculosis are not rarely associated, as was pointed\\nout in various papers by Schnitzler. Moreover, we learn\\nfrom daily experience that even when the external appear-\\nance of the ulcer fails to afford any diagnostic points, the\\ndiagnosis may be inferred from its situation in the larynx.\\nWhile tuberculous ulcers are preferably found on the pos-\\nterior laryngeal wall, and on the posterior extremities of the\\nvocal cords, syphilis affects chiefly the ligamentous portion\\nof the vocal cords. While tuberculosis is frequently uni-\\nlateral, especially when it appears in the vocal cords, the\\nsyphilitic ulcers are always bilateral, and very often dis-\\ntributed symmetrically on the free borders, being evidently\\nproduced by contact of opposed portions of the cords.\\nTubercular ulcers usually occupy the surface of the vocal\\ncords, while syphilitic ulcers are situated on the free border,\\nand give to it a dentated appearance. The ulcers event-\\nually break down and lead to tissue destructions which\\ndiffer greatly in extent. The appearance of the laryngeal\\nimage varies widely, as any one can convince himself by", "height": "3468", "width": "2040", "jp2-path": "rhinologylaryng00frie_0223.jp2"}, "224": {"fulltext": "2l8 THE SKIN AND THE SEXUAL ORGANS,\\nglancing through Schnitzler s or Krieg s Atlas. Edema\\nis not characteristic of syphilis, as some authors maintain\\nit always depends on ulceration or on perichondritis. The\\nlatter may be primary or secondary, more frequently\\nsecondary, and develops in any case of deep ulceration of\\nthe cartilage it is, of course, followed by necrosis and\\nexfoliation of the diseased portions, and the resulting defects\\nin the framework of the larynx may give rise to great de-\\nformities and malpositions. Syphilitic is much less frequent\\nthan tubercular disease of the cartilage.\\nAs syphilis readily yields to specific remedies, unas-\\nsisted by local treatment, it often leaves conspicuous alter-\\nations, due to cicatricial contraction or to connective-tissue\\nneoplasms, while tuberculosis of the larynx, owing to its\\nunfavorable prognosis, rarely comes under observation in\\nthe stage of regeneration. The scars, which vary in depth\\nand size according to the ulcers that they replace, are stel-\\nlate in form, and by their contractions often produce dis-\\ntortions in isolated portions of the larynx, so that not only\\nthe vocal cords and ventricular bands, but also the aryepi-\\nglottic folds and the epiglottis, may be so displaced by the\\ncontraction of the scar that the relations in the laryngeal\\nimage are much disturbed. Subjective symptoms are\\nusually wanting. On the other hand, adhesions between\\nneighboring parts are common, especially between the\\nvocal cords, which are usually both ulcerated along their\\nfree borders, and therefore present a favorable seat for the\\nformation of synechiae. The cords in such cases are\\nunited by cicatricial membranes, which always begin at\\nthe anterior extremity and extend for a variable distance\\nbackward, interfering with the mobility and function of the\\ncords, very frequently giving rise to severe dyspnea. The\\nulceration in the epiglottis is sometimes so great as to\\ndestroy one-half of the structure or one entire free margin,\\nand if, as frequently happens, it is bent backward and an\\nadhesion forms between it and the aryepiglottic fold, the\\nlumen of the larynx becomes obstructed and serious em-\\nbarrassment of respiration may result.\\nHausemann i recently described a certain cicatricial\\nlesion on the epiglottis that he often had occasion to\\nobserve at autopsy, having found it in 25 out of 42 cases\\n1 Berlin, klin. Wochen., 1896, No. II.", "height": "3468", "width": "2196", "jp2-path": "rhinologylaryng00frie_0224.jp2"}, "225": {"fulltext": "SYPHILIS. 219\\nof syphilitic subjects. The epiglottis, from the frenulum to\\nthe upper border, was the seat of a process resembling the\\nso-called smooth atrophy of the base of the tongue, first\\nseen by Virchow and minutely described by Lewin.^\\nWe omitted this because it is of no value in clinical diag-\\nnosis. The effect of the lesion was to draw the cartilage\\nforward so as to effect an anteflexion of the epiglottis.\\nAmong permanent postsyphilitic alterations we must\\nmention a diffuse hyperplasia of the mucous membrane,\\nwhich may lead to extensive stenosis of the larynx and\\ndyspnea, if it occurs below the vocal cords. We find it\\nmentioned by Neumann^ and Eppinger^ describes it as\\na fibroid degeneration accompanied by ulceration or cica-\\ntrization and producing a diffuse puckering of the mucous\\nmembrane, such as Tiirck described after his so-called\\nparenchymatous inflammation of the mucous mem-\\nbrane. Whether the hyperplastic condition of the squa-\\nmous epithelium which has been called, after Virchow,\\npachyderma laryngis is due to syphilis is not definitely\\nknown, but it seems probable.\\nI once saw paralysis of the vocal cords (paralysis of the\\nright posticus) in secondary syphilis, which yielded to anti-\\nsyphilitic treatment. A few other cases are found in the\\nliterature. The most natural explanation for this occur-\\nrence is enlargement of the mediastinal or peritracheal\\nlymph-glands exerting pressure on the nerves, as syphilitic\\nneuritis of the nerve-trunk is unknown.\\nSyphilis of the ear is definitely known to occur only in\\nthose parts which can be directly inspected that is, on the\\nexternal ear, in the external auditory meatus, on the drum-\\nhead, in the region overlying the mastoid process, and, with\\nthe aid of posterior rhinoscopy, on the pharyngeal orifices\\nof the tubes. The external ear presents all the alterations\\nthat are seen as the expression of secondary or tertiary\\nsyphilis on the external skin, and in the much-quoted case\\nof Zucker* even a primary affection of the external ear was\\ndemonstrated. The manifestations on the skin of the ex-\\nternal ear correspond in time of appearance and morphology\\nwith syphilis of the external skin. Thus, we find roseola,\\npapules, and condylomata in the secondary nodular syphil-\\n1 Virch. Arch., vol. CXXXVIII. ^^^_ ^^y^ p ^q.\\n3 Handb. der pathol. Anatomie, Klebs, 7th ed., p. 123.\\nZeitschr. f. Ohr. IX.", "height": "3448", "width": "2052", "jp2-path": "rhinologylaryng00frie_0225.jp2"}, "226": {"fulltext": "220 THE SKIN AND THE SEXUAL ORGANS.\\nids, and gummata in the tertiary stage. The cases re-\\ncorded in the Hterature are comparatively few, and confirm\\nwhat we learn from statistical sources of the infrequency of\\nthese complications. The course of the papular form in\\nthe external meatus is remarkable it was first carefully\\ndescribed b}^ Stohr^. The wall of the meatus at first shows\\na muddy, bluish-red discoloration this is followed by\\nswelling and diffuse redness embracing the tympanic mem-\\nbrane, in which Stohr also observed similar muddy, bluish-\\nred patches. A few authors (Kretschmann, Lang) observed\\npapules on the tympanic membrane, described by Lang as\\npale, glistening patches, the size of a millet seed, over the\\nprocessus brevis. In the auditory meatus the papules lead\\nto excoriations the walls become very much swollen, and\\nthere is a copious flow of bloody, purulent fluid. Later,\\nthese excoriated patches become the seat of excrescences\\nwhich eventually lead to the formation of condylomata pre-\\nsenting themselves as villi or polypoid structures with\\nsmall bases, either within the external meatus or protrud-\\ning from the canal. According to Christinneck, there is a\\ntendency to the formation of circular ulcers at the entrance\\nof the external auditory meatus.\\nThe diagnosis of these affections is based on the pres-\\nence of constitutional syphilis, as they are very easily con-\\nfounded with otitis externa eczematosa or with granulations\\ndue to some other cause.\\nGummata have been described on the external ear\\n(Hessler on the bony wall of the external auditory\\nmeatus (Brieger,^ Habermann on the tympanic mem-\\nbrane (Baratoux in the mastoid process, both central\\n(Schede,^ Haug and in the periosteum (Pollak,^\\nBrieger they present no special characteristics. These\\naffections all yield to antisyphilitic treatment, but they\\nleave scars which may produce marked stenosis of the\\nexternal auditory meatus, or periosteal deposits and exos-\\ntoses on the bony portions of the external meatus and on\\nthe mastoid process.\\nThe pharyngeal orifices of the Eustachian tubes may\\n1 Arch. f. Ohr., V, p. 130. 2 Arch. f. Ohr., xx, p. 242.\\nBeitr. z. Ohrenheilk., p 161. Schwartze s Handb., I, p. 277.\\n5 Rev. mens, de lar., 1885, No. 7.\\nQuoted from Kloos, Schwartze s Handb., I, p. 486, 29, No. 14.\\nArch. f. Ohr., XXXVI, pp. 201, 202.\\nSee Arch. f. Ohr., xvin, p. 204.", "height": "3468", "width": "2188", "jp2-path": "rhinologylaryng00frie_0226.jp2"}, "227": {"fulltext": "SYPHILIS. 22 1\\nshare in the syphihtic process in a variety of ways they\\nmay be the seat of primary syphihs in consequence of in-\\nfection by a polluted catheter, or they may be attacked\\nduring the secondary and tertiary stages in connection\\nwith the postnasal space and become involved in the re-\\nsulting cicatricial contractions and adhesions. The seat\\nand the nature of the disease are easily demonstrated by\\na rhinoscopic examination after symptoms in the middle\\near, retraction, opacities, difficult hearing, and tinnitus\\naurium have aroused the suspicion of tubular occlu-\\nsion. Suppuration from the middle ear is common in\\nsyphilitic subjects. So far, our clinical and anatomic\\nobservations do not justify us in regarding it as a specific\\nsuppuration, since it has not been possible to demonstrate\\nthe occurrence of irritative syphilitic processes in the mid-\\ndle ear, although theoretically the existence of syphilitic\\ndisease of the middle ear seems plausible. Authorities\\nin the main agree that in acute and subacute simple, as\\nwell as in acute and chronic purulent, affections of the\\nmiddle ear occurring in the course of syphilis, the nasal\\nand pharyngeal disease plays an important role (Be-\\nzold 1). The same etiology may be assumed for suppu-\\nration from the middle ear in hereditary syphilis. Fournier,^\\nit is true, says that these suppurations may constitute the\\nprimary manifestations of hereditary syphilis, and mentions\\nthe absence of pain as a characteristic symptom in such\\ncases, but his observations are not satisfactory from an\\notologic standpoint, and do not carry much weight.\\nExudative inflammation of the middle ear is mentioned\\nby Schwartze and Kirchner subsequently observed\\nsuch a case, which was, however, complicated by the ex-\\nistence of ulcers in the nasopharynx. At the autopsy\\nKirchner found in the middle ear, besides a serosanguin-\\neous exudate, round-celled infiltrations, split-pea-shaped\\nneoplasms in the bone, and a constriction of the blood-\\nvessels, which he interpreted as a syphilitic endarteritis.\\nKirchner s case is, however, not very convincing, and it\\nseems remarkable that in his microscopic investigations he\\ndid not take any account of the fact that the cadaver had\\n1 Arch. f. Ohr., xxi, p. 260.\\n2 Lectures on Late Hereditary Syphilis, translated by Korbl and Zeissel,\\n1894, p. 150.\\n3 Arch. f. Ohr, VI, 267. Arch. f. Ohr. xxviii, p. 172.", "height": "3456", "width": "2052", "jp2-path": "rhinologylaryng00frie_0227.jp2"}, "228": {"fulltext": "222 THE SKIN AND THE SEXUAL ORGANS.\\nbeen in water several days, and that he found no post-\\nmortem changes. Finally, a form of sclerotic middle-ear\\ncatarrh has been described as a consequence of syphilis.\\nGradinego and Chambellan assume a sclerosis of the\\nmiddle ear, which the former explains as a parasyphilitic\\naffection in hereditary lues.\\nThere is a form of syphilis affecting the nervous appara-\\ntus of the organ of hearing the existence of which is based\\nsolely on clinical observation. During the tertiary, and\\neven more frequently during the secondary, stage, a few\\nweeks after the appearance of the skin eruption, the patient\\nsuddenly complains of severe headache and loss of hearing,\\nwhich may go on to complete deafness within a few days\\nthe condition is always accompanied by tinnitus aurium or\\nother subjective noises or harmonic tones, sometimes with\\nvertigo and vomiting, and Schwartze adds to these symp-\\ntoms a reeling gait in the dark. The disease is usually\\nunilateral, occasionally bilateral. Otoscopic examination\\nreveals no alterations, but the functional test shows that the\\nlesion is in the nervous path Rinne s test is positive, and\\nwhen the tuning-fork is placed on the head the tone may\\nsuddenly change to the healthy side frequently there is\\ninability to hear high-pitched notes. Gradenigo de-\\nscribes three different varieties, according to the course of\\nthe inflammation a slowly progressing, a rapidly progress-\\ning, and one with apoplectiform onset. Fourniervery cor-\\nrectly points out a similarity between the latter form and\\nthe loss of hearing in tabes, without, however, recognizing\\nan etiologic connection for all cases.\\nIn the hereditary form there is a disease of the inner ear\\nanalogous to that which occurs in tertiary syphilis. It\\noccurs principally between the ages of ten and twenty (six\\nto eighteen), and is frequently associated with interstitial\\nkeratitis and Hutchinson s teeth, although it is much rarer\\nthan the ocular disease Fournier met with it in only 40\\nout of 212 cases. Gradenigo says that the power of\\nhearing often varies from one day to the next, but except\\nfor this, and the fact that the disease is always painless and\\nbilateral, it does not differ from the form seen in acquired\\n1 Arch. f. Ohr., xxxviii, p. 310.\\n2 Ann. des mal. de I oreille, 1895, p. 267.\\nChirurg. Erkrank. des Ohres, p. 376.\\nSchwartze s Handb., II, p. 424.", "height": "3468", "width": "2180", "jp2-path": "rhinologylaryng00frie_0228.jp2"}, "229": {"fulltext": "SYPHILIS. 223\\nsyphilis. There is, however, a marked difference in the\\nmatter of prognosis; for, whereas secondary and tertiary ner-\\nvous diseases of the ear may be favorably influenced or even\\ncured by antisyphilitic treatment if they are taken in hand\\nearly, the prognosis in the hereditary form is unfavorable.\\nThe term nervous disease of the ear in syphilis has\\nbeen used designedly, as the seat of the lesion is unknown.\\nThe value of the investigations in regard to histologic\\nchanges in the labyrinths of syphilitic subjects is impaired\\nby the fact that the etiology in these cases of alleged heredi-\\ntary syphilis is doubtful (see Gradenigo and, in the\\nsecond place, the changes found in secondary and tertiary\\nsyphilis described as round-celled infiltration, calcifica-\\ntions, and hyperemia are so general that nothing is gained\\nfor the pathology by the recording of such doubtful cases,\\nwhich can only by much ingenuity be brought into har-\\nmony with the classic description of syphilis. There is a\\ngeneral tendency to ascribe syphilitic deafness to disease of\\nthe vestibule and of the first turn of the cochlea, but there\\nis nothing to justify such an assumption, and the seat of the\\ndisease might just as well be placed in the nerve-endings or\\nin the nerve -trunk itself.\\nIn an interesting variety of cases the loss of hearing is\\ndue to direct lesion of the auditory nerve or of its centers\\nby a gumma in the brain, or gummatous basal meningitis,\\nor cerebrospinal meningitis for the auditory nerve may\\nbe implicated in this disease as well as any of the other\\ncranial nerves. Such a case is described by Oppenheim,^\\nwho in another place (p. 16) remarks that it may event-\\nually be possible to demonstrate the same symptoms in the\\nauditory nerve which, up to the present time, has been\\nrather neglected (treated like a stepchild) that have been\\naccurately observed in the ocular, motor, and facial nerves.\\nSchwartze^ mentions a case of intracranial syphilitic paral-\\nysis of the left auditory nerve, associated with paresis of\\nthe left arm and paralysis of the tongue, but without facial\\nparalysis Gradenigo quotes a case from Helmet of sud-\\ndenly developing deafness in a young syphilitic woman, in\\nwhich, at the autopsy, scattered foci of encephalitis were\\nfound, one of them at the exit of the auditory nerve-trunk.\\nSchwartze s Handb., il, p. 431.\\nSyphil. Erkrank. des centr. Nervensystems, 1890, p. 30.\\n3 Arch. f. Ohr., IV, p. 267 (1869). Schwartze s Handb., II, p. 529.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0229.jp2"}, "230": {"fulltext": "X. DISEASES OF THE EYE.\\nJ, RELATIONS BETWEEN THE EYE AND\\nTHE NOSE.\\nDuring the past few years particular attention has been\\ndirected to the relations existing between the eye and the\\nnose, and it is being recognized more and more that patho-\\nlogic conditions of the nose play an important part in the\\ngenesis of ocular diseases. Although the cases that tend\\nto throw light on this etiologic connection are not numer-\\nous, they are all the more convincing. Seifert, in a series\\nof investigations in v. Michel s eye clinic, found nasal dis-\\nease in all but 2 among 38 cases of dacryocystoblennorrhea.\\nIn another series of 48 cases the nose was regularly in-\\nvolved. Winckler,^ among all the children which he\\nexamined in the course of three years in the Children s\\nHospital at Bremen, found the nose diseased in 50^ of\\nthose suffering with scrofulous eye disease, and Ziem^ gives\\nit as his belief that two-thirds of all cases of ocular disease\\nare due to disease of the nose.\\nIt is often difficult to determine after a single examina-\\ntion whether or not there is any connection between the\\nnose and the eye, as the conditions in the nose are much\\ninfluenced by the presence of swelling, and the amount of\\nmucus is variable, especially in scrofulous patients, who\\nfurnish the bulk of the material. Hence, the question\\nwhether or not the nose is diseased depends more or less\\non the judgment of the examiner and on his standard of\\nregularity in structure and degree of moisture for the nor-\\nmal nose. Ziem appears to have the highest standard in\\nthis respect, and this may explain his large percentage of\\nnasal disease accompanying disease of the eye, and, as will\\n1 Miinch. med. Wochen., 1898, No. 29.\\n2 Semon s Centralbl., xii, p. 92, and Bresgen s Sammlung, Bd.\\nin., H. I.\\n3 Mon. f. Ohr., 1893, Nos. 8 and 9.\\n224", "height": "3468", "width": "2180", "jp2-path": "rhinologylaryng00frie_0230.jp2"}, "231": {"fulltext": "RELATIONS BETWEEN THE EYE AND THE NOSE. 2 25\\nbe mentioned later, his radical views in regard to interde-\\npendence between eye and nose. Thus, before admitting\\nthe integrity of the nose he subjects it to a test irrigation,\\nas, he says, this procedure often reveals the presence of\\npus which escaped the detection of anterior and posterior\\nrhinoscopy. For my part, the finding of mucus or pus\\nin the irrigating fluid after a nasal douche would not con-\\nvince me of the existence of nasal disease unless I was\\nable at the same time by inspection to determine the origin\\nof the pus if the nose is really diseased to such an extent\\nas to be capable of affecting the eye, the diagnosis can\\nalways be made with the aid of rhinoscopy, without using\\na nasal douche. It is this divergence of opinion in regard\\nto what constitutes the difference between a healthy and a\\ndiseased nose that is responsible for the different views held\\nas to the frequency of a relationship between the nose and\\nthe eye, and for the fact that many physicians (Ziem and\\nothers) consider it a proof of etiologic connection between\\na nasal and an ocular disease if the ocular disease is favor-\\nably influenced by local treatment of the nose. Thus, we\\nmeet with cases of disease of the uveal tract and of visual\\ndisturbances that are ascribed to a pathologic condition of\\nthe nose, because galvanocautery or some other local inter-\\nference is followed by improvement in the ocular symptoms,\\nalthough no good internal evidence can be adduced to\\nprove the connection between the two diseases.\\nThere are three possible ways in which disease may be\\ntransmitted from the nose to the eye through the lacrimo-\\nnasal duct, through the blood and lymph streams, and\\nby way of the nerves.\\nThe most important role in the production of consecutive\\neye disease belongs to the lacrimonasal duct, on account\\nof its anatomic relations to the nose. The location of its\\nmouth in the inferior nasal meatus, below the inferior\\nturbinate bone, close behind its anterior expanded extremity,,\\nreadily explains the occurrence of disease of the tear-ducts\\nwhenever the normal drainage of the lacrimal fluid becomes\\nobstructed, or when disease of the nose spreads to the\\nlacrimonasal duct and to the lacrimal sac. In addition,,\\nthe latter may be the means of causing disease of the con-\\njunctiva and of the cornea by direct transmigration of\\npathogenic organisms from the nose to the eye.\\nEpiphora and blennorrhea of the lacrimal sac regularly\\n15", "height": "3456", "width": "2108", "jp2-path": "rhinologylaryng00frie_0231.jp2"}, "232": {"fulltext": "226 THE EVE.\\nfollow obstruction of the nasolacrimal canal. The obstruc-\\ntion may be due to various conditions in the nose, such as\\nacute and chronic hypertrophies, tumors, ulcerations, and\\ncicatricial contractions whenever they are seated in the\\ninferior nasal meatus. Of course, the influence of a tem-\\nporary disease, such as acute rhinitis, is not very great, and\\nit is only after chronic conditions that we have lasting\\naffections of the lacrimal sac. Among these must be\\nmentioned particularly the hypertrophic conditions found\\nin scrofulous children, and the polypoid hypertrophies of\\nthe lower turbinate body reaching down to the nasal floor\\nand completely obstructing the inferior nasal meatus. Even\\nmilder grades of hypertrophy may exert a very injurious\\ninfluence if the septum is deformed and its covering puck-\\nered in folds. Here belong also hypertrophic conditions\\nof the nose due to obstruction of the nasopharynx, and\\nwe therefore find in adenoid vegetations of the pharnygeal\\nvault one of the most fruitful sources of ocular disease.\\nEven an atrophic rhinitis may under certain conditions lead\\nto disease of the lacrimal sac, although the opening of the\\nlacrimonasal duct necessarily shares in the general dilatation,\\nfor the walls of the nose, including the orifice of the\\nlacrimonasal duct, may be entirely covered over by the\\nclosely adhering crusts of dried secretion. In this connec-\\ntion special mention must be made of those forms of ozena\\nin which the lower turbinate bodies have been destroyed in\\nconsequence of caries of the bone due to the rhinitis foetida\\natrophica, or genuine ozena, or to syphilitic ozena. In\\nsuch cases the orifice of the lacrimonasal duct, which may\\nbe abnormally expanded as a result of atrophy of the\\nmucous membrane or of cicatricial changes, opens directly\\ninto the nasal cavity, so that the crusts which cover the\\nnasal walls may completely occlude it, an event which can\\nnot take place as long as the inferior turbinate bone is\\npresent and affords a certain protection. Thus, we see some\\nof the most obstinate cases of blennorrhea of the lacrimal sac\\nin hereditary syphilitic ozena, in which, particularly in\\nthe case of young children, the turbinate bones and the\\nseptum are destroyed and the entire nasal cavity is com-\\npletely filled with hard, stinking crusts, which can be removed\\nonly with great difficulty by means of the douche and a\\ncotton-carrier. Their rapid recurrence can, at best, only\\nbe delayed by the most conscientious regularity in treat-", "height": "3468", "width": "2188", "jp2-path": "rhinologylaryng00frie_0232.jp2"}, "233": {"fulltext": "RELATIONS BETWEEN THE EYE AND THE NOSE. 22/\\nment, so that we can readily understand the frequent re-\\nlapses and the chronic course of the ocular complication.\\nTumors rarely lead to obstruction of the inferior nasal\\nmeatus in their early stages, as they usually spring from the\\nregion of the ethmoid bone. The same is true of nasal\\npolypi, as they rarely occur in the anterior half of the lower\\nturlDinate body, and can not, therefore, affect the tear-ducts\\nby direct obstruction of the orifice they do not become\\nimportant until they have grown so large and so numerous\\nas to fill every part of the nasal cavity.\\nLastly, we have ulcerative processes and granulations,\\nsuch as occur in tuberculosis, lupus, syphilis, rhinoscleroma,\\nleprosy, glanders, etc. These may lead to stenosis or occlu-\\nsion of the canal, even after they have healed, by reason\\nof the cicatricial contractions and adhesions which remain.\\nThe effects of the nasal disease are not always limited to\\nocclusion of the lacrimonasal duct the infection may spread\\nthrough the canal of the eye itself and lead to inflammations of\\nthe lacrimal sac, to conj unctivitis, and to keratitis. It is in this\\nway that we explain the occurrence of eczematous keratitis\\nand conjunctivitis in connection with eczema of the vestibule\\nand chronic hypertrophic rhinitis in scrofulous individuals,\\nas demonstrated by Knies in 90 of cases occurring in\\nchildren. 1 It is interesting to note that Seifert^ found\\nrhinitis foetida atrophica in the great majority of all cases\\nof spreading ulcer of the cornea, so that he was led to infer\\nthe extension of an infection of the cornea from the nose.\\nBuck 3 mentions corneal ulcers following ozena. According\\nto Fuchs,^ ozena is a frequent complication of trachoma;\\nand Klunzinger, Ziem, Gerber, and Kuhnt assume a con-\\nnection between trachoma and disease of the nose, on the\\nground that the granulosis of the nose may set up a\\nsecondary granulation in the lacrimal apparatus and on the\\npalpebral conjunctiva a view which is not confirmed by\\nother authors. Although Lowenberg s ozena bacillus has\\nbeen found in the conjunctival sac by Terson and Gabriel-\\nides, and although Abel also found his bacillus mucosus\\n1 Knies, Die Beziehungen des .Sehorgans und seiner Erkrankung,\\np. 285.\\nMiinch. med. Wochen., 1898, No. 29.\\n3 Ref. Semon s Centralbl., XI, p. 217.\\n4 Lehrb. der Augenheilk., p. 570.\\n5 Arch, d ophthalm., XIV, p. 488, quoted from Schmidt- Rimpler.\\nNolhnagel s Ifandb., XXI, p. 430.\\nZeitschr. f. Hygiene, Bd. xxi, II. I.", "height": "3448", "width": "2100", "jp2-path": "rhinologylaryng00frie_0233.jp2"}, "234": {"fulltext": "228 THE EYE.\\nozceii(2, no local lesion directly due to the micro-organisms\\ncould be demonstrated in the eye in either case.\\nDespite the fact that it is generally assumed that diseases\\nare transmitted through the lacrimal duct only from the\\nnose to the eye, and that transmission in the other direc-\\ntion is not considered important, this method does, never-\\ntheless, appear to play some part in gonorrheal infection\\nof the eyes, as Miller repeatedly found the nasal mucous\\nmembrane diseased in blennorrhea neonatorum, and was\\nable to demonstrate the presence of gonococci.\\nTransmission of tuberculosis of the nose to the lacrimal\\nsac has been observed (Wagonmann-Fuchs and lupus\\nalso may spread to the eye.\\nBatut 3 reports two cases of diphtheric disease of the\\nnose and eye without bacteriologic findings.\\nIt is well known that there is an intimate relationship\\nexisting between the vascular system of the nose and that\\nof the eye. Arterial anastomosis between the nose and the\\neye is effected by means of the ethmoid arteries, by\\nbranches of the ophthalmic, and b}^ a collateral trunk along\\nthe lacrimonasal duct, which joins the angular, the ophthal-\\nmic, and a branch of the infra-orbital arteiy (Zuckerkandl).\\nIn the same way a communication is established by means\\nof a network of veins between the lacrimal plexus and the\\nveins of the nose, the orbit, and the face besides, there are\\nlarger venous trunks running from the nose to the cranial\\nand orbital cavities the ethmoid veins. Ziem lays the\\ngreatest stress on the connections between both the arterial\\nand the venous systems in the etiology of ocular disease\\naccompanying disturbances of the nasal circulation, which\\noccur in acute and chronic inflammations and in the passive\\nhyperemias that are so common in the nose. But as these\\ndisturbances are followed by disease of the eye only in com-\\nparatively rare instances, Winckler believes that the cause\\nis to be sought in individual anomalies in the anastomoses.\\nConjunctivitis as well as blepharitis and epiphora are fre-\\nquently observed to follow circulatory disturbances of this\\nkind occuring in acute and chronic hypertrophic conditions,\\nand in almost every variety of nasal stenosis, but the doc-\\n1 Stork, Nothnagel s Handb., xni, i. Th., i. Abth., p. 86 (note).\\n2 Lehrb. der Augenheilk., p. 570.\\nAnn. des mal. de I oreille, 1S93, p. II4.\\nE. Winckler, Bresgen s Sammlung, ni, H. i.", "height": "3468", "width": "2188", "jp2-path": "rhinologylaryng00frie_0234.jp2"}, "235": {"fulltext": "RELATIONS BETWEEN THE EYE AND THE NOSE. 229\\ntrine of Ziem that diseases of the uveal tract often origi-\\nnate in this way has not found many adherents.\\nThe following cases are probably to be ascribed to circu-\\nlatory disturbances Straub reports a case in which there\\nwere attacks of pain and congestion in both eyes, lasting\\nfrom two to six days, accompanied by epiphora and proto-\\nphobia he assumes a vasomotor neurosis originating in\\nthe nose, as removal of a crista septi and cauterization of\\nthe hypertrophic turbinate bodies was followed by almost\\ncomplete cure. Dunn saw a case of recurring edema of\\nthe upper eyelid which disappeared after removal of the\\nanterior extremities of both middle turbinate bones, which\\nwere the seat of polypi.\\nThe fifth nerve supplies a part of the nose through a\\nbranch of its first division the innervation of the septum,\\nthe vestibule, and the external skin of the nose being\\neffected by the external and internal branches of the nasal\\nnerve.\\nThis nervous connection explains the reflex sensations in\\nthe nose tickling and sneezing which follow irritation of\\nthe ciliary nerve when the eye is suddenly subjected to a\\nstrong light, as, for instance, when we look into the sun, or\\nin inflammatory disease of the. eye. On the other hand,\\nirritation of the ocular nerves by way of the branches of the\\nfifth which we have just described in disease of the nose is\\nmuch more common. Its simplest expression is seen in\\nthe redness of the conjunctiva and the lids and in the in-\\ncreased flow of tears which follow the slightest local inter-\\nference in the nose, even the mere touching of the corre-\\nsponding side of the nose with a probe. In this category we\\nmay include a ciliary neurosis described by Seifert,* due to\\nsynechiae, after extensive cauterizations in the interior of\\nthe nose.\\nQuite a number of other ocular affections have been\\nascribed to primary nasal disease, without, however, suffi-\\ncient proof of the etiology and the manner of the reflex\\ninfluence being forthcoming. Thus, for instance, Laurens\\ndivides reflex disturbances of the eye into those which\\nCompare Mon. f. Ohr., 1893, p. 262.\\n2 Nederl. Tijdschr. v. Geneesk., 1S96; see Semon s Centralbl., XII,\\np. 425.\\n3 See Semon s Centralbl., ix, p. 371. Loc. at.\\n5 Ann. d ocul., April, 1896; see Semon s Centralbl., xii, p. 426.", "height": "3456", "width": "2108", "jp2-path": "rhinologylaryng00frie_0235.jp2"}, "236": {"fulltext": "230 THE EYE.\\naffect the general or special sensibility of the eye (neu-\\nralgias, photophobia, amblyopia) reflex disturbances of\\nthe motility (blepharospasm, mydriasis, strabismus, asthe-\\nnopia) and, finally, nutritive and vasomotor disturbances\\nin the coverings of the e}^e (conjunctivitis, iritis, glaucoma,\\nexophthalmos). The danger of exaggeration in artifi-\\ncially constructing such relations can not well be empha-\\nsized too strongly. The reflex connection between the eye\\nand the nose, through the agency of the trigeminus, is\\nmuch less extensive than might be supposed from the\\nstatements of many authors (Fortunati, for instance), who\\nwould ascribe to the second division of the trigeminus the\\npower of producing reflex disturbances in the eye through\\nits nasal ramifications, although Ziem goes to the opposite\\nextreme and attributes the origin of secondary diseases of\\nthe eye principally to the agency of the vascular system.\\nIn proof of the reflex influence of nasal diseases cases are\\nreported by Knies,i Schmidt- Rimpler,^ Lieven,^ and E.\\nWinckler,* but I shall not repeat them here, as they neither\\nprove nor explain anything.^ I may, however, mention a\\nfew rather spurious examples taken from the latest litera-\\nture, Laurens observed a case of blepharospasm which\\ndisappeared after obstruction of the nose due to hyper-\\ntrophy of the mucous membrane and synechias had been\\ncorrected. He also reports seeing a six-year-old girl with\\nleft converging strabismus, which disappeared after an\\noperation for adenoid growths. On the other hand,\\nBaumgarten considers strabismus, which he observed\\ntwice in hypertrophy of the pharyngeal tonsils, an acci-\\ndental complication, as it was not influenced by operation.\\nSchloss and Myles report several cases of asthenopia\\nwhich subsided after removal of hypertrophied turbinate\\nbodies, the removal of a spine on the septum, and, in some\\ncases, of tumors. Myles believes that hypertrophies of\\nthe tissues, by pressure on the nerves, provoke ocular\\nsymptoms, but this supposed connection with the nose was\\nnot proved to exist in all the cases in which a nasal opera-\\n1 Loc. cit. 2 i^Qi-_ i-jf_ 3 \u00c2\u00a3u^_ ^//_ 4 i^Q^^ ^//_\\nSee reports in Semon s Centralbl.\\ns Presse med., iSq6, Jan. 22 see Semon s Centralbl., xn, p. 425.\\nNeurosen und Reflexneurosen des Nasenrachenraumes, Volkmann s\\nklin. Vortr., N. F., No. 44.\\nPacific Med. Jour., 1894, and N. Y. Med. Record, 1894; see\\nSemon s Centralbl., xi, pp. 280 and 281.", "height": "3468", "width": "2196", "jp2-path": "rhinologylaryng00frie_0236.jp2"}, "237": {"fulltext": "RELATIONS BETWEEN THE EYE AND THE NOSE. 23 1\\ntion was performed. Bernstein speaks of improvement\\nin errors of refraction after removal of nasal hypertrophies.\\nAccording to Knies,^ operative interference on the nasal\\nmembrane is rarely followed by visual disturbances con-\\nsisting in concentric narrowing of the visual field with or\\nwithout disturbance of the central sight and of the color-\\nsense. Fortunati assumes a nasal origin for two cases of\\nneurokeratitis in which ulceration and perforation of the\\ncornea, with prolapse of the iris, occurred after a long-\\ncontinued obstruction of the nose. Winckler reports a\\ncase of retrobulbar optic neuritis with serous tenonitis\\nwhich was treated for six weeks without benefit, and was\\nfinally cured within a month after removal of papillomata\\non the turbinate bodies. Pupillary changes mydriasis\\nand myosis have also been described as due to nasal irri-\\ntation, as the snuffing-up of cold water into the nose\\n(Ostmann\\nInflammatory disease of the accessory cavities is always\\naccompanied by hypertrophic and polypoid alterations in\\nthe interior of the nose, which may in turn lead to the dis-\\nturbances we have just described. After Ziem, the pioneer\\nin this field, Kuhnt deserves the credit of describing in a\\ncomprehensive work the dependence of ocular complica-\\ntions on diseases of the accessory cavities, thereby awaken-\\ning the interest of other investigators in many questions\\nhitherto much neglected. The lines he laid down were\\nfollowed among others by Schmidt-Rimpler, who has pro-\\nduced the latest work on this subject, while the same ques-\\ntions have also been extensively dealt with by Griinwald.\\nThe latter has collected a large number of cases.\\nThe anatomic position of the accessory nasal cavities is\\nsuch that a morbid process originating within them is easily\\ntransmitted to the orbits. The lateral wall of the ethmoid\\ncells, consisting principally of the os planum (lamina\\npapyracea), and completed at the anterior and posterior\\nethmoid walls by the juxtaposition of the lacrimal bone and\\nthe orbital processes of the palatal bone, also forms the\\n1 Med. News, July 22, 1893 see Senion s Centralbl., x, p. 386.\\n2 Loc. cit., p. 288.\\n3 Arch, d otol., 1896, No. 2 see Semon s Centralbl., xiii, p. 330.\\nSemon s Centralbl., xn, p. 92. a ^rch f. Ophthalm., 43.\\nUeber die entziindlichen Erkrankungen der StirnhShle und ihre Folge-\\nzustande, 1895.\\nDie Lehre von den Naseneiterungen, 2d ed. 1896, p. 122.", "height": "3456", "width": "2108", "jp2-path": "rhinologylaryng00frie_0237.jp2"}, "238": {"fulltext": "232 THE EYE.\\nmedian wall of the orbits immediately above it lies the\\nfrontal sinus, and beneath its floor the antrum of Highmore,\\nso that all these cavities have at least one wall in common\\nwith the orbit. On the other hand, the sphenoid sinus, the\\nlast of the series of cavities which make up the accessory-\\npneumatic system of the nose, does not possess a very\\nintimate relation with the eye, except that the robust layer\\nof bone which forms its roof lies in apposition with the\\ninterior of the cranium, and in rare cases endocranial per-\\nforations may be produced and lead to direct injury of the\\noptic nerve, but accompanied, usually, by other anatomic\\ncomplications. Berger^ remarks that even a simple in-\\nflammation of the sphenoid sinus may lead to retrobulbar\\noptic neuritis when the opticosphenoid wall is unusually\\nthin or is traversed by fissures.\\nAlthough from an anatomic point of view a pathologic\\nrelation may exist between these accessory cavities and the\\neye, clinical experience teaches that only certain diseases\\nappear to possess a tendency to spread to the orbital cavity,\\ndepending on the seat and the nature of the particular dis-\\nease. The commonest way in which sequels occur in the\\neye is when in acute or chronic inflammation of the acces-\\nsory cavities a serous or purulent exudate is retained, and\\nthus produces bulging of the cavity walls. The likelihood\\nof pus being retained in an accessory cavity depends on its\\nrelative position and on the size of the openings by which\\nit normally communicates with the interior of the nose\\nthat is to say, the more imperfect the drainage, the\\ngreater the danger of retention. Thus, in the antrum of\\nHighmore and frontal sinus the nasal openings are so un-\\nfavorably situated that even a slight alteration in the neigh-\\nborhood of the opening is capable of producing reten-\\ntion. While in the antrum the median wall, which lies\\ntoward the nasal cavity, the exterior wall (canine fossa), or\\nthe palatal bone is more likely to bulge than the roof of\\nthe cavity, directed toward the orbit, yet in the frontal\\nsinus it is the orbital wall, which corresponds to the floor\\nof the cavity, that is more liable, on account of its extreme\\ntenuity, to break down under the weight of the accumulated\\nsecretion than is the more robust anterior wall. Bulging\\nof the lateral nasal wall due to empyema of the antrum may\\n1 Soc. franQ. ophth., May, 1894; see Semon s Centralbl., XI, p.\\n573-", "height": "3468", "width": "2196", "jp2-path": "rhinologylaryng00frie_0238.jp2"}, "239": {"fulltext": "RELATIONS BETWEEN THE EYE AND THE NOSE. 233\\nin rare cases produce compression of the lacrimal duct.\\nSuch an event is much less frequent, however, than dis-\\nplacement of the globe outward and downward by bulging\\nof the orbital wall of the frontal fossa and the resulting dis-\\nturbances in the mobility, function, and drainage of the\\neyeball. The protrusion of the eyeball is usually preceded\\nby edema at the upper inner angle of the orbit, at which\\npoint empyema of the sinus sometimes ruptures into the\\norbit and leads to orbital phlegmon. From the tenuity of\\nthe OS planum, which separates the ethmoid cells from the\\norbit, we should expect to see empyema of these cells fol-\\nlowed by disturbances in the eye. This is not the case,\\nhowever, as there is little tendency to retention of the pus,\\nbecause the outlets of the cells toward the nose are short\\nand spacious, and the walls of the cells are so thin on either\\nside that perforation into the nose easily takes place.\\nThese remarks do not by any means exhaust the subject\\nof the relations existing between the eye and disease of the\\naccessory cavities there is a host of inflammatory and\\nfunctional disturbances which are said to accompany and\\nto be dependent on inflammatory conditions of these cavi-\\nties. Hyperemic and catarrhal conditions of the conjunc-\\ntiva and cornea, and diseases of the uveal tract, by sub-\\nsiding after the recognition and treatment of suppuration\\nin the accessory cavities, appear to indicate a mutual rela-\\ntionship, although Kuhnt^ justly observes that the removal\\nof inflammatory conditions in the accessory cavities plays\\nonly a secondary part in the treatment of ocular diseases,\\nand merely assists and reinforces the general treatment he\\ndoes not believe that the ocular disease can be cured in\\nthis way without careful local treatment of the eye.\\nWhen we come to functional disturbances, we have\\nhyperemia and venous stasis of the papilla, and peripapillary\\nopacity of the retina in suppuration of the frontal sinus of\\nthe same side, which, according to Kuhnt,^ always disap-\\npears after removal of pus, thus indicating a connec-\\ntion with the disease of the accessory cavity. When\\nrestrictions in the field of vision occur, they are usually\\nbilateral, although more marked on the affected side.\\nThey are usually accompanied with weakness of the inter-\\nnal muscles (Kuhnt). For the sake of completeness we\\nI.oc. cit., p. 112. 2 i-K^^ p 121.", "height": "3448", "width": "2108", "jp2-path": "rhinologylaryng00frie_0239.jp2"}, "240": {"fulltext": "2 34 THE EYE.\\nmay mention that Kuhnt does not absolutely deny\\nZiem s statement that cataract may be produced by sup-\\npuration in an accessory cavity. Careful investigation is\\nurgently needed before the dependence of all these condi-\\ntions on suppurations in the accessory cavities can be\\naccepted as proved. But meanwhile the meager clinical\\nmaterial that has been contributed by reliable investigators\\nis not to be disregarded, even if the explanation offered is\\nnot always quite satisfactory. Kuhnt s theory that absorp-\\ntion of purulent or fetid masses from the diseased cavities\\nplays the principal part in the etiology of functional dis-\\nturbances of the eye, and not the vascular system, as Ziem\\ncontends, deserves attention. The effect on the nervous\\nsystem of this absorption varies with the individual, and may\\nbe responsible for a rapid tiring or even a kind of obtuse-\\nness in the optic tract and in the nerve-endings of the\\nretina.\\nNoninflammatory diseases in the accessory cavities, such\\nas malignant tumors, carcinomata, and sarcomata, may\\nspread to the orbits and lead to appearances identical\\nwith those of orbital tumors. Photiades^ reports a reflex\\nmydriasis due to endolaryngeal interference for the removal\\nof laryngeal polyps.\\n2. RELATIONS BETWEEN THE EYES AND THE\\nEARS.-\\nThe eye may be influenced by the ear in various ways,\\nand may furnish valuable diagnostic points to the otologist\\nwhile, on the other hand, diseases of the eye do not involve\\nthe ear, if we except a few scattered observations relating\\nto the impairment of the power of hearing or to the pro-\\nduction of tinnitus aurium by sudden flashes of light, or\\nsuch cases as Stevens in which division of a slightly in-\\nsufficient internal rectus was followed by the disappearance\\nof tinnitus aurium, or where, after iridectomy for glaucoma\\nand optic iridectomy in leukoma of the cornea an improve-\\n1 Semon s Centralbl., pp. 277, 278.\\n2 For extensive report of cases see Ostmann, Arch. f. Ophthal, 43, p.\\n22; Schmidt-Rimpler, Nothnagel s Spec. Path. u. Therap. vol. xxr, p.\\n435; Knies, Beziehungen des Sehorgans und seiner Erkrankung, etc.,\\n1893, p. 289.\\n2 Stevens, Arch. f. Ohr., xix, p. 75.", "height": "3468", "width": "2184", "jp2-path": "rhinologylaryng00frie_0240.jp2"}, "241": {"fulltext": "RELATIONS BETWEEN THE EYES AND THE EARS. 235\\nment in hearing was noted/ or where, as reported by\\nWolf, 2 subjective aural sensations occurred during attacks\\nof glaucoma.\\nReflex irritation of the eye originating in the ear plays an\\nimportant part in these relations, while direct injury of the\\noptic nerves depends rather on endocranial sequels of optic\\ndisease than on disease of the ear itself Reflex irritation\\nmay give rise to disturbances in the function of the eye\\nmuscles, as the vestibular and cochlear branches of the\\nauditory nerve are in close relation with the optic pathway.\\nThere is no doubt that the vestibular nerve may exert an\\ninfluence on the coordinating center that presides over the\\naction of the ocular muscles, and that irritation of the nerve\\nitself or of its endings in the ampulla and in the membra-\\nnous semicircular canals may produce motor disturbances\\nin the domain of the oculomotor, the abducens, and the\\ntrochlear nerves, manifesting themselves in nystagmus,\\nocular palsy, and disturbances in the pupillary reaction.\\nThis has been proved by numerous physiologic experiments\\non disturbances of equilibrium following injury of the laby-\\nrinth, and particularly by Stein, who was perhaps some-\\nwhat hasty in applying unfinished theories to practical\\ndiagnosis. This reflex connection has been utilized in the\\ndiagnosis of aural vertigo. For the transmission of re-\\nflex irritation from the ear to the eye by means of the\\nvestibular nerve we possess some anatomic basis, but for\\nthe connection between the cochlear nerve and the ocular\\nnerve the anatomic basis is not equally clear, and rests\\nsolely on the occurrence of aural hallucinations, as described\\nby Bleuler, Lehmann,^ and Urbantschitsch.\\nWe have, however, in Held s investigations an important\\ncontribution to the physiology and pathology of the nervous\\nsystem, which may eventually lead to the overthrow of the\\nvague theories at present prevailing concerning the reflex\\nconnection between the ear and the eye, and furnish a posi-\\ntive proof that auditory stimuli are capable of affecting the\\nmovements of the muscles. Held s investigations re-\\nsulted in the demonstration of a reflex arc by which audi-\\n1 Knies, loc. ciL, p. 291. Arch. f. Augen u. Ohr., IV.\\n3 Arb. a. d. Bazanow scben KHnik i, i, Moscow, 1897; Zeitschr. f.\\nOhr., vol. XXVII.\\nZwangsmassige Licbtempfindiint^durcli Scball und verwandte Erschein-\\nungen auf dem Gebiete der Sinnesnerven.\\n5 Arch. f. Anat. und Entwickelungsgesch., 1S93, p. 201.", "height": "3452", "width": "2104", "jp2-path": "rhinologylaryng00frie_0241.jp2"}, "242": {"fulltext": "236 THE EYE.\\ntory stimuli may be transmitted to the motor apparatus of\\nthe eye, for he proved that auditory stimuH can be commu-\\nnicated to the oculomotor, trochlear, and abducens nerves\\nby way of the reflex arc common to the optic and auditory\\nnerves, having its origin in the anterior corpora quadri-\\ngemina. This same reflex arc also includes other paths by\\nwhich auditory stimuli may reach the nucleus of the facial\\nnerve and the formatio reticularis, and can probably be\\ntransmitted from these to the respiratory, vasomotor, and\\nother centers.\\nThe reflex movements which follow auditory stimuli, and\\nconsist in turning the eyes or the head toward the side\\nfrom which the sound proceeds, may be explained in the\\nsame way; they suggest the possibility of pathologic pro-\\ncesses in the ocular muscles manifesting themselves as\\natactic movements, being produced by improper or irregu-\\nlar irritation of the cochlear nerve.\\nIf auditory stimuli are capable of producing coordinated\\nmovements of the eyes by means of this reflex arc when the\\nhearing is normal, it is conceivable that when in disease of\\nthe ear the sound is not heard with equal intensity on both\\nsides, the sound waves, being perceived in a different way\\non the two sides, may possibly produce a different reflex\\nirritation on the two optic tracts.\\nIf the coordinating center for a properly regulated move-\\nment of the eye receives an impulse of normal strength from\\none cochlear nerve and a weaker impulse, or none at all,\\nfrom the other, the equilibrium in the coordinated muscular\\nmovement may be disturbed, and atactic movements of the\\noptic muscles are produced. In this way we may perhaps\\nexplain cases like Biirkner s,^ in which the effort of the\\nright ear, which was the seat of a suppuration, to catch the\\nsound during the functional test was followed by nystagmus.\\nThe effect is always bilateral, because of the decussation of\\nthe deep roots of the ocular nerves unilateral reflex dis-\\nturbance of the eye through the ear is impossible.\\nThe ocular phenomena that follow increased pressure\\nin the middle ear are due to the pressure changes commu-\\nnicated to the labyrinthine fluid by the simultaneous pres-\\nsure on the fenestrse, and it is probable that the reflex\\nirritation follows the same paths of the vestibular and coch-\\n1 Arch f. Ohr., xvii, p. 1S5.", "height": "3468", "width": "2184", "jp2-path": "rhinologylaryng00frie_0242.jp2"}, "243": {"fulltext": "RELATIONS BETWEEN THE EYES AND THE EARS. 237\\nlear nerves that we have just described. Lucae was able,\\nby raising the pressure in the middle ear through the ex-\\nternal meatus in a case of perforated ear-drums, to produce\\nvertigo, which was proved to be optic in character by the\\nfact that it immediately disappeared when the eyes were\\nclosed. As in Lucae s cases crossed double images were\\nproduced, he argues that the increased pressure led to\\nirritation of the abducens nerve.\\nI have given this short description of the physiologic\\npossibility of reflex ocular movements being produced by\\nirritation in the ear so as to throw some light on the clinical\\ncases which have been described as belonging to this cate-\\ngory.\\nNystagmus has been said to follow irrigation of the\\nexternal meatus, and to occur in cerumen concretions, in\\npurulent otitis media, and after extraction of polyps from\\nthe middle ear. In those cases where the reflex is pro-\\nduced by local influences in the external meatus and on the\\ndrum membrane, in irritation and in accumulations of\\ncerumen, reflex irritation must be explained by pressure\\nchanges in the labyrinthine fluid, as in the case described\\nby Lucae. To what extent the trigeminus may be con-\\ncerned in reflex connections between the ears and the eyes\\nis not definitely known, although reflex irritation of the\\nocular muscles through this nerve seems possible in view\\nof the connections which are known to exist anatomically.\\nThat the trigeminus may be concerned in the reflex irrita-\\ntion appears to be indicated by the fact that the temperature\\nof the fluid used in irrigation has some effect on the pro-\\nduction of reflex ocular movements, as very cold or very\\nhot water appears to favor their occurrence. Lucae s\\nobservation that the reflex irritation which occurred when\\nthe ear-drum was perforated was absent when that mem-\\nbrane was intact, can not be utilized to determine whether\\nthe irritation affects the mucous membrane of the middle\\near directly or not, as individual peculiarities appear to\\ncome into play that can not be overlooked.\\nIt appears to be proved by experience that disturbances\\nof coordination may be produced in the movements of the\\neye muscles by pressure changes in the middle ear, such\\nas are frequently observed in catheterization. For similar\\n1 Arch. f. Ohr., xvii, p. 237.", "height": "3448", "width": "2020", "jp2-path": "rhinologylaryng00frie_0243.jp2"}, "244": {"fulltext": "238 THE EVE.\\ndisturbances in the course of an acute or chronic purulent\\notitis media, however, the proof is not so clear, as there is\\nno anatomic basis for a direct reflex irritation on the ocular\\nnerves by inflammatory conditions in the middle ear, unless it\\nbe by means of the tympanic plexus, and this is exceedingly\\ndoubtful. The occurrence of nystagmus or other motor\\ndisturbances in the eye in cases of purulent otitis media\\nprobably depends on labyrinthine or intracranial complica-\\ntions of the ear affection. Ostmann says that ocular\\nsymptoms occurring in the course of acute purulent otitis\\nmedia must be regarded as due to tonic spasm within the\\nlabyrinth or to an intracranial sequela. Jansen 2 considers\\nnystagmus a somewhat vague symptom, most probably\\nto be referred to an affection of the labyrinth, and, in the\\nabsence of such an affection and of leptomeningitis, he\\nattributes to it a certain significance for the diagnosis of\\nsinus phlebitis or periphlebitis in the neighborhood of the\\ntemporal bone. It may occur in extradural abscesses as\\nthe result of pressure on the occipital lobe and on the cor-\\ntical centers for the ocular movements which it contains.\\nHe describes nystagmus as bilateral and synchronous, as a\\nhorizontal or a rotatory and vibratory movement, usually\\nshort and sharp, sometimes slow and more extensive,\\noccurring during fixation of the eyeball. It appears prin-\\ncipally when the glance is directed away from the affected\\near, sometimes as soon as the median line is passed, and\\nincreases as the eye is moved farther away, whereas when\\nthe eyeball is rotated toward the affected ear it remains in\\na state of complete rest, or at most indulges in a few inter-\\nrupted movements.\\nOur knowledge of pupillary anomalies during purulent\\notitis media is very meager. The phenomenon has been\\nreported by Schwartze and by Moos.\\nWhile reflex irritation of the trochlear and abducens\\nnerves by way of the trochlear nerve is well known to\\noccur physiologically after an auditory impression, and\\nprobably occurs also under pathologic conditions, paralysis\\nof these nerves in diseases of the middle ear and of the\\nlabyrinth must always be referred (as pointed out by\\nHabermann 4) to intracranial complications, and in the\\n1 Arch. f. Ophthal., p. 13. 2.. Arch. f. Ohr., xxxvi.\\n3 Arch. f. Ohr., xvi, p. 263.\\n4 Verhandl. der D. otol. Gesellsch., 1898, p. 98.", "height": "3468", "width": "2196", "jp2-path": "rhinologylaryng00frie_0244.jp2"}, "245": {"fulltext": "RELATIONS BETWEEN THE EYES AND THE EARS. 239\\nabsence of any conspicuous alterations at the autopsy it is\\nto be explained by the existence of a serous meningitis or\\nan inflammation of the pia too slight to attract attention.\\nSuch palsies of the ocular muscles have frequently been\\nobserved after intracranial complications of an ear affec-\\ntion, and in the latest literature on the sequels of diseases\\nof the ear we find them described as depending on the\\nmode of extension of the disease to the sinuses, the\\nserous membranes, and the brain-substance itself\\nAnother important symptom that accompanies these\\nconditions is papillitis of the optic nerve. When it occurs\\nin a purulent otitis media, if there is a suspicion of intra-\\ncranial complication it is of vital significance, in spite of\\nJansen s 2 statement that it appears to occur in rare\\ncases, even in uncomplicated empyema of the mastoid pro-\\ncess or in otitis media, through the agency of the carotid\\nplexus, and should always be regarded as a proof that\\nthe inflammation has spread to the interior of the cranium.\\nWhen chronic purulent otitis media is associated with con-\\ngestive papillitis and cranial symptoms, it becomes very\\nimportant to determine whether the two diseases have any-\\nthing to do with each other or not. In tuberculous patients\\nwith chronic middle-ear disease it must always be borne in\\nmind that the ocular and cranial symptoms, which may\\nappear to simulate otitic meningitis or an extradural or\\ncerebral abscess, may have their origin in a tubercular\\nmeningitis or in cerebral tuberculosis and be in no way\\ndependent on the aural affection.\\nSensory disturbances in the eye may be secondary to\\nearache transmitted from the tympanic plexus by way of\\nthe trifacial nerve they manifest themselves in the eye as\\npain, increased lacrimation, and injection of the conjunc-\\ntival vessels.\\nUrbantschitsch s statement that visual acuity may be\\naffected by aural disease is not borne out by the results of\\nOstmann s investigations. The mutual influence of audi-\\ntory and ocular impressions, which are described by Bleu-\\nler and Hoffman under the names of Gehorsphotismen\\n1 Jansen, Arch. f. Ohr., xxx\\\\ i Hessler, Otogene Pyamie\\nKorner, Die otitischen Erkrankungen, etc.\\n2 Arch. f. Ohr., XXXVI. i pflUger s Arch., XXX, p. 129.\\nArch, f Ophthal., p, 43.\\n5 Quoted from Urbantschitscli, -Schwartze s Ilandb., i, p. 451.", "height": "3456", "width": "2108", "jp2-path": "rhinologylaryng00frie_0245.jp2"}, "246": {"fulltext": "240 THE EYE,\\nand Lichtphotismen (aural and ocular hallucinations)\\nare as yet of no clinical value.\\nThe occurrence of blepharospasm with spasm of the sta-\\npedius muscle is to be explained as a reflex irritation due\\nto the fact that both the stapedius muscle and the orbic-\\nularis palpebrarum derive their innervation from the facial\\nnerve.\\n1 Gottstein, Arch, f, Ohr., xvi, p. 6i.\\nI", "height": "3408", "width": "2192", "jp2-path": "rhinologylaryng00frie_0246.jp2"}, "247": {"fulltext": "XI. INTOXICATIONS.\\nThe upper air-passages are very much exposed to local\\ninjury during intoxications, both when the poison is con-\\ntained in the air and thus comes into immediate contact\\nwith the mucous membrane of the nose, the pharnyx, and\\nlarynx, and when it is ingested in the form of a fluid or\\nsolid, and during its passage through the pharynx inflicts\\ndirect injury on that structure and on the upper margin\\nof the larynx. From this point the poison may make its\\nway into the interior of the larynx and set up an extensive\\nmorbid process. The ear escapes, as a rule, unless the\\ntubes are involved in hypertrophic conditions of the post-\\nnasal space hence, the number of substances capable of\\nexerting any influence on the ear when taken by the mouth\\nis very limited.\\nThe most frequent symptoms produced by the great\\nmajority of organic and inorganic chemic bodies by direct\\nirritation of the mucous membrane of the upper air-pas-\\nsages are hyperemia and sensory irritative phenomena,\\nsuch as sneezing and coughing.\\nTheir recognition presents no difficulty, as the cause of\\nthe intoxication can usually be ascertained, and the clinical\\npicture presents no special characteristics for the individual\\nkinds of intoxications, so that it is not worth while to\\nenumerate all the various acids, alkalies, ethereal oils, etc.,\\nin this place.\\nAnother group of symptoms which it is customary to\\nrefer to the action of various poisons can not be accepted\\nas toxic phenomena without a reservation. Among these\\nwe have aphonia, hoarseness, and tinnitus aurium. The\\nformer is due to adynamia, when the constitutional effect\\nof the poison has so debilitated the entire organism that the\\nphonetic function shares in the impairment of all the other\\nfunctions, especially those of the central nervous system\\n(Stuffer 1 on Toxic Aphonia In the literature of al-\\nkaloid poisoning we find in particular nervous disturbances\\nArch. f. Laryng., vol. VI.\\ni6 241", "height": "3448", "width": "2068", "jp2-path": "rhinologylaryng00frie_0247.jp2"}, "248": {"fulltext": "242 INTOXICATIONS.\\nof speech mentioned along with these adynamic phenom-\\nena, so that mistakes are very apt to be made in interpreting\\nthe findings.\\nThe same apphes to the auditory disturbances, which are\\nusually given as tinnitus aurium. When we consider the\\nmanifold causes that may give rise to this phenomenon\\nhow frequently it is due to circulatory disturbances, which\\nplay so important a role among the toxic effects of many\\npoisons-; and that tinnitus aurium, and even hallucinations,\\noften occur after the exhibition of stimulant remedies, we\\nrealize how easy it is to refer symptoms which really orig-\\ninate outside of the ear to a direct toxic effect of the poison\\non the ear itself\\nWe shall, therefore, mention only those substances which\\nproduce marked clinical disturbances clearly due to the\\nconstitutional effect of the poison, leaving out all the symp-\\ntoms of a vague and indefinite character.\\nAcids and alkalies exert a direct caustic effect on the\\nmucous membranes that manifests itself in various ways.\\nThe effect of acids is chiefly that of a cauterizing agent,\\ncausing constriction of the tissues and the formation of\\ncrusts, that is to say, the effect is more superficial and is\\nlocalized in the region where it is applied, whereas alka-\\nlies tend to dissolve the tissues and to produce deep\\ndestruction involving the entire surface of the mucous\\nmembrane and not confined to the area of contact. In\\nboth cases the affected part becomes surrounded by an\\narea of marked inflammation and swelling. As the inges-\\ntion of liquid poisons is always accompanied with the cau-\\nterization of the pharynx and of the entrance to the larynx,\\nthat is, of the epiglottis and the aryepiglottic folds, the\\nedema which follows may be very extensive, and the\\npatient s life is endangered more by stenosis of the larynx\\nthan by the toxic effect of the substance itself\\nThe manner of healing and cicatrization similarly varies\\nin accordance with this difference in the effects of acids and\\nalkalies in the former the resulting scars are smooth and\\nsuperficial, while in the latter we have deep cicatricial con-\\ntractions, and particularly the formation of cicatricial adhe-\\nsions uniting the upper margin of the larynx with the deeper\\nportions of the pharyngeal wall.\\nThe commonest examples of these two kinds of intoxi-\\ncation are poisoning with sulphuric, hydrochloric, and nitric", "height": "3492", "width": "2208", "jp2-path": "rhinologylaryng00frie_0248.jp2"}, "249": {"fulltext": "ACIDS AND ALKALIES. IODIDES. 243\\nacids on the one hand, and poisoning with potassium or\\nsodium hydrate and ammonia on the other hand. That\\nchlorid of zinc is capable of producing the same kind of de-\\nstruction of the mucous membranes as an acid is shown by\\na case of v. Jaksch s 1, in which, after the drinking of a\\nsolution of chlorid of zinc and hydrochloric acid, such as is\\nused in soldering (68 gm. of zinc chlorid and 3.5 gm. of\\nhydrochloric acid to lOO c.c), laryngeal stenosis occurred\\nwhich necessitated tracheotomy. Among the intoxications\\nby inorganic acids we must mention particularly chromic\\nacid poisoning, as this substance is a favorite cauterizing\\nagent in rhinologic practice. Acute chromic acid poisoning\\nmay follow the use of only a few centigrams, as in cauter-\\nization of the pharynx, and leads to a general intoxication\\nin addition to the local symptoms while, on the other\\nhand, the chronic form of poisoning, which occasionally\\noccurs in employees in chromic acid factories, produces\\ndeep-seated alterations of the mucous membranes. The\\ninhalation of chromic acid in the form of dust at first leads\\nto an inflammation of the nasal mucous membrane, which\\nis soon followed by arrosions on the septum and on the\\nanterior extremities of the turbinate bones, constantly\\naccompanied by epistaxis. Ulceration also takes place in\\nregions to which the particles of dust may be carried by the\\ninspiratory air that is, the tonsils, the uvula, and the pos-\\nterior pharyngeal wall. According to Seifert,^ purulent\\ninflammation of the tympanic cavity may also occur by\\nextension through the Eustachian tubes.\\nThe internal administration of the iodids, especially potas-\\nsium iodid, is sometimes followed by alarming symptoms\\nin the upper air-passages. It is well known that the exhi-\\nbition of iodin is always accompanied by a slight swelling,\\nredness, and desquamation of the mucous membranes,\\nmanifesting themselves in more or less marked coryza, lac-\\nrimation, pharyngitis, and laryngitis. But, in addition,\\nthe literature contains a number of intoxications following\\nthe use of potassium iodid which led to alarming symptoms,\\nand in a few cases even necessitated tracheotomy. The\\nsymptom referred to is edema of the larynx. It has been\\nobserved in every part of the larynx on the lateral wall,\\nabout the entrance, on one side of the larynx only, or on\\n1 Nothnagel s Spec. Path. u. Therap., vol. I.\\n2 Die Gewerbekrankheiten der Nase, etc., Fischer, Jena, 1895.", "height": "3464", "width": "2068", "jp2-path": "rhinologylaryng00frie_0249.jp2"}, "250": {"fulltext": "244 INTOXICATIONS.\\nboth sides in the subglottic region. Our knowledge of its\\ncause and of its mode of origin is very meager. The in-\\ntoxication does not appear necessarily to follow large doses\\nof the drug, as cases have been reported in which a short\\ncourse of treatment with small doses produced an intoxica-\\ntion (Rosenberg). In two cases reported by Schmiegelow\\nin which tracheotomy had to be performed, edema\\noccurred after the administration of three teaspoonfuls of a\\n5^ solution taken morning and evening in one case, and\\nin the other case after only three tablespoonfuls of the same\\nsolution had been taken three times a day for several\\ndays. The cases in which the intoxication occurred after\\nwithdrawal of the drug (Heymann), or after it had been\\nused for several weeks, must be considered exceptional, for\\nwe know that, as a rule, the mucous membrane becomes\\naccustomed to the drug after a few days of catarrh and,\\neven in those cases in which edema of the larynx had\\noccurred after a few days use, the drug was subsequently\\nvery well borne when it was given in more conservative\\ndoses. The manner in which the intoxication occurs is as\\nlittle known as its cause it is remarkable how seldom grave\\ntoxic appearances are seen when we consider the enormous\\nnumber of cases which are constantly treated with potassium\\niodid. Rosenberg believes that the occurrence of intoxica-\\ntion depends on the presence of glands Avellis, arguing\\nfrom an interesting case of unilateral paralysis of the recur-\\nrent nerve in which the administration of potassium iodid\\nwas followed by edema of the larynx on the unaffected half\\nof the larynx only, suggests that iodid poisoning takes\\nplace by way of the nerves, like the angioneuritic edema of\\nStriibing while G. Lewin, in the face of antagonistic\\nobservations reported by Rosenberg and others, assumes\\nthat iodid edema depends on syphilitic disease, on the\\nground that a syphilitic ulcer reacts more intensely to\\niodin.\\nThe aural symptoms observ^ed after the use of potassium\\niodid consist in tinnitus aurium associated with difficult and\\ndouble hearing. The first two phenomena occur in asso-\\nciation with catarrh of the pharyngeal mucous membrane,\\nwhich has led to acute catarrh of the tubes and its conse-\\nquences but it seems to me we may also assume that the\\nArch. f. Laryng., vol. I.", "height": "3492", "width": "2192", "jp2-path": "rhinologylaryng00frie_0250.jp2"}, "251": {"fulltext": "ARSENIC AND LEAD. 245\\niodin may exert a direct influence on the mucous membrane\\nof the middle ear in the form of swelling and exudation.\\nWith regard to the remarkable phenomenon of double\\nhearing, Moos reports a case in which, after the potassium\\niodid had been taken for six weeks, there followed, in addi-\\ntion to the iodin eruption and coryza, a peculiar affection\\nof the left ear, so that the notes from d to g were heard\\ndouble, each perception being separated by a short interval.\\nI myself once observed, after the use of potassium iodid\\n{S%), a case of double hearing for all the sounds of ordi-\\nnary conversation which only subsided several weeks after\\nthe withdrawal of the drug. In the treatment of iodin\\nintoxication the preparations of belladonna and sodium\\ncarbonate have been recommended.\\nArsenic is used in many of the arts, and leads to diseases\\nin the nose, in the postnasal space, and in the larynx,\\nwhile the ear is not affected, if we except ulcers in the\\nexternal auditory meatus. When arsenic is taken inter-\\nnally, especially in the case of arsenic eaters, aphonia and,\\naccording to SeHgmiiller,^ paralysis of the vocal cords are\\nobserved. Unfortunately, these statements lack the sup-\\nport of actual observation. The only well-reported case of\\nparalysis of the left recurrent nerve said to be due to arsenic\\nis contributed by P. Heymann,^ but unfortunately it admits\\nof more than one interpretation, as the patient was exposed\\nto the fumes of cyanid gas as well as to arsenic, and the\\nparalysis may therefore have been due to the effect of that\\nsubstance.\\nThe catarrh of the nose and of the post-nasal space,\\nwhich, according to Seifert, has been observed by many\\nauthors, is to be referred to the inhalation of dust particles\\ncontaining arsenic, especially the color known as Schwein-\\nfurt green. The excoriations and ulcers which result\\naffect particularly the septum, and often lead to perforation\\nof the cartilaginous portion. Toeplitz found perforations\\nof this kind in 19 out of 31 employees in a chemic factory\\nwhere Schweinfurt green was made in other words, in\\n6i.3fo.\\nParalysis of the laryngeal muscles occurs in chronic\\nlead-poisoning, the substances being usually hydroxid of\\nlead, lead oxid, and red peroxid of lead (Mennige). To\\nCompare Seifert, Die Gewerbekrankheiten, etc.\\n2 Die Krankheiten der Nerven. Arch. f. Laryng., vol. iv.", "height": "3464", "width": "2036", "jp2-path": "rhinologylaryng00frie_0251.jp2"}, "252": {"fulltext": "246 INTOXICATIONS.\\njudge by the numerous descriptions, the clinical picture\\nvaries a good deal, and there is no typical form for the\\nparalysis. Seifert, Schech, Krause, and P. Heymann have\\ndescribed paralysis of various muscles, including the ad-\\nductors and abductors. We have individual palsies of the\\ncricoarytenoideus lateralis, and of the interarytenoideus\\nunilateral and bilateral paralysis of the posticus and of the\\nrecurrent laryngeal nerve and we can not agree with M.\\nMackenzie when he says that the adductors only are\\nimplicated, just as in cases of systemic lead-poisoning the\\nextensors are exclusively affected. Krause mentions a\\npeculiar form of phonatory disturbance, an intention tremor,\\nas a result of lead-poisoning. The prognosis is favorable.\\nThe three cases observed by Heymann all ended in recovery\\nafter the customary treatment for lead-poisoning.\\nIn the ear the effects of lead-poisoning have been described\\nas tinnitus aurium and a gradual deterioration in the power\\nof hearing. Wolf reports several cases in which the degree\\nand kind of deafness were variable, so that the functional\\ntest sometimes appeared to locate the seat of the disease in\\nthe middle ear, at others in the internal ear. In one of\\nWolf s cases, in which the onset was acute, he assumes an\\nacute exudation into the cochlea which underwent absorp-\\ntion after treatment, and thus allowed the function to be\\nrestored. We may assume a neuritis of the auditory nerve\\nanalogous to that which occurs in other cranial nerves, such\\nas the vagus and the optic nerve, without, however, neglect-\\ning theetiologic importance of the arteriosclerotic condition\\nof the vessels which accompanies the intoxication.\\nMercurial poisoning is well known under the name of\\nptyalism, and affects the mucous membrane of the mouth\\nand pharynx, while, as far as we know, the nose and larynx\\nescape. Von Jaksch describes a case of acute sublimate\\npoisoning following the ingestion of a teaspoonful of the\\ndrug. The mucous membrane of the uvula, the pharynx,\\nthe epiglottis, and the aryepiglottic folds were greatly swollen\\nand covered with a whitish exudate, while the vocal cords\\nwere only slightly inflamed. On the fourteenth day after\\nthe accident ulcers were found in these regions, the swell-\\ning had subsided, and at the autopsy, which was held on\\n1 Verhandl. der D. otol. Gesellsch., 1S95.\\n2 Compare Ebstein, D. Arch. f. klin. Med., LVIII, p. i.\\n3 Nothnagel s Handb., vol. I, p. 220.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0252.jp2"}, "253": {"fulltext": "COPPER, PHOSPHORUS, ETC. 247\\nthe twenty-fifth day, deep ulcers were found, some of them\\npartly healed.\\nMercury is said to have the same effect as lead on the\\nsound-perceiving apparatus of the ear.\\nCopper, antimony, and phosphorus are said to produce\\nhoarseness, but the manner of its production is nowhere\\nindicated. Hemorrhages into the pharyngeal structures,\\nespecially the tonsils, have been observed in phosphorus-\\npoisoning.\\nCopper and phosphorus, as they are used in the arts, may\\nset up acute rhinitis and effect alterations in the septum\\nanalogous to those produced by chromic acid (Seifert).\\nIn a case of poisoning by silver nitrate in a man who\\nworked with the substance in a glass pearl factory, v.\\nJakscli found patches of bluish-black pigmentation on the\\nexternal skin, on the mucous membrane of the mouth and\\ntongue, on the drum membrane, and on the laryngeal\\nmucous membrane.\\nThe medicinal use of compounds belonging to the aro-\\nmatic series is often followed by disturbances in the auditory\\nsphere, even when the maximum dose is not exceeded. The\\nupper air-passages usually escape. In a very few cases\\nerythema (quinin, antipyrin, and saHcylic acid), pemphigoid\\neruptions (antipyrin 2), or hemorrhages were found on the\\nmucous membrane of the pharynx as on the ejcternal skin.\\n(We find no mention of the larynx in this connection.)\\nWe may mention a few very unusual observations, such as\\na case, reported by Ebstein,^ of intoxication in an employee\\nof a salicylic acid factory, in which, in addition to marked\\npharyngitis, there was edematous swelling about the vocal\\nprocesses and in the trachea Hilbert remarks that after\\nthe use of antipyrin and antifebrin he has observed the\\noccurrence of parosmia consisting in the smelling of aro-\\nmatic flavors, such as cinnamon and, finally, the occurrence\\nof an acute edematous angina after the use of salol a\\nstatement for which Lavallee is responsible.\\nIn strychnin-poisoning there is marked hyperesthesia of\\nthe auditory nerve, which may, under the influence of an\\nauditory impression, lead to general convulsions.\\nNothnagel s Spec. Path. u. Therap., vol. I, p. 240.\\n2 Veil, Arch. f. Derm. u. Syph. 189I, p. 33.\\n3 Wien. klin. Wochen., 1896, No. 11.\\n\u00e2\u0096\u00a01 See Semon s Centralbl., viir, p. 558.\\n5 See Semon s Centralbl., viii, p. 3S0.", "height": "3452", "width": "2052", "jp2-path": "rhinologylaryng00frie_0253.jp2"}, "254": {"fulltext": "248 INTOXICATIONS.\\nQuinin, salicylic acid, and antipyrin give rise to tinnitus\\naurium and difficult hearing. The toxic effect of the two\\nfirst-named substances is generally recognized, and has\\nbeen studied experimentally we possess investigations by\\nWeber- Lie 1 and his followers as well as by Kirchner which\\nestablish beyond a doubt the occurrence of clinical and\\nanatomic disturbances in the organ of hearing. According\\nto these investigations, the effect of quinin and salicylic\\nacid are very much the same, except that the disturbances\\nafter excessive use of salicylic acid are more violent and\\nsomewhat more persistent. The administration of i gm.\\nof muriate of quinin and from 4.5 to 5 gm. of sodium\\nsalicylate was followed after from one to one and one-\\nhalf, and from two and one-half to four hours respec-\\ntively, by various subjective noises in the ear, which had\\ncompletely disappeared twelve hours later while after the\\nuse of salicylic acid the subjective symptoms lasted several\\ndays. The effect on the hearing occurred somewhat later\\nthan the tinnitus aurium, and always lasted longer, but after\\nsalicylic acid it persisted for several months. We learn\\nsomething of the way in which the auditory disturbance is\\nproduced by Kirchner s experiments on animals after\\ngiving quinin (i.o) and sodium salicylate (2.0), he found\\necchymoses in the mucous membrane of the tympanic\\ncavity and of the vestibule, showing that the phenomenon\\nis due to a disturbance of blood pressure, and not to a\\ndirect toxic effect on the organ of hearing. In view of the\\npossibility of extravasations occurring in the labyrinth,\\nwhere absorption is imperfect and the functional disturb-\\nances which result are therefore lasting, the greatest caution\\nis indicated in prescribing this remedy for persons who\\nhave ever been subject to ear disease; Weber- Liel found\\nthat the impairment of hearing which follows the use of\\nthese remedies lasts much longer, and may even become\\npermanent, in persons subject to ear disease.\\nPoisoning with sausage and fish, due to the presence of\\nptomains containing a number of alkaloid bodies, produces\\ndryness of the mucous membrane and hoarseness similar\\nto that observed in atropin-poisoning. According to v.\\nJaksch, there may be symptoms of bulbar paralysis and\\npharyngeal and laryngeal palsies, but unfortunately we\\n1 Weber- Liel, Mon. f. Olir., 1SS2, p. 7.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0254.jp2"}, "255": {"fulltext": "CHLOROFORM, TOBACCO, ALCOHOL. 249\\nhave no laryngoscopic findings, and Stuffer remarks on the\\ndifference of opinion as to the occurrence of hoarseness in\\nfish-poisoning.\\nIt has been said by Moos and Hackley that chloroform\\nnarcosis may be accompanied by deafness, tinnitus aurium,\\nand double hearing, and Haug reports having seen such\\ndisturbances very frequently. But as the tinnitus aurium,\\nparacousis, and auditory hallucinations can be attributed to\\nthe narcosis, Haug s statement especially with regard to\\nauditory hyperesthesia, which may persist for several\\nhours or even several days after the narcosis, and with\\nregard to double hearing can not be accepted unreservedly\\nin the absence of positive case histories. It appears to be\\ntrue that a progressive diminution in the power of hearing\\noccasionally follows narcosis, particularly after the patient\\nhas been repeatedly subjected to an anesthetic, but the etio-\\nlogic factor concerned is very difficult of interpretation. I\\nhave often seen patients, particularly women, gradually\\ndevelop a slowly increasing deafness, which is usually\\nattributed to chronic middle-ear catarrh, several decads\\nafter they have undergone chloroform narcosis but we\\nshould accord to the imagination of our patients a fatal in-\\nfluence on our science if we allowed such statements to pass\\nas current.\\nFinally, we may mention the intoxications that follow the\\nabuse of tobacco and alcohol. Here we have to deal both\\nwith a local irritant effect on the mucous membranes of the\\nupper air-passages and with the general toxic effect on the\\nsystem. The catarrh of the smoker and the alcoholic has\\nbecome proverbial. We have all had ample opportunity\\nto convince ourselves of its occurrence, and there can be\\nno doubt on the subject. The question Avhether the com-\\nbustion products which are mixed with the smoke or a spe-\\ncific quality inherent in the vegetable poison of Avhich\\nnicotin is usually considered the prototype is responsible\\nfor this irritation of the mucous membrane may perhaps\\nfind its answer in the results of investigations conducted on\\nchewers and snuff takers, in whom, except for the mechan-\\nical irritation, the effect on the mucous membrane bears no\\nproportion as to intensity and extension of the process to\\nthat observed in smokers, in spite of the fact that the\\ntobacco is much more thoroughly and completely absorbed.\\nAnalocrous to the extensive lar\\\\ nc[-eal catarrh, we have", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0255.jp2"}, "256": {"fulltext": "250 INTOXICATIONS.\\ncatarrh of the tubes, with its consequences to the middle\\near in the form of catarrhal otitis media, which offers the\\nbest explanation for the chronic hardness of hearing so fre-\\nquently observed in smokers, and which usually presents\\nthe character of a simple middle-ear catarrh. The possi-\\nbility of a chronic neuritis of the auditory nerve analogous\\nto tobacco amblyopia, which Moss assumes to be the cause\\nof the difficult hearing and tinnitus aurium, can not be\\ndenied but, so far, we have no proof of its occurrence.\\nThe effect of alcohol on the organ of hearing is well\\nknown. It leads to tinnitus aurium and difficult hearing\\nof a progressive character. The chief etiologic factor\\ngiven is chronic middle -ear catarrh secondary to chronic\\npharyngitis in addition to which the effect of the alcohol\\non the vascular system and its stimulating psychic effect\\nno doubt play an important part in the production of tin-\\nnitus aurium and hallucinations.\\nHoarseness has been mentioned as a symptom of acute\\nalcoholic poisoning, but since alcoholic paralysis of the re-\\ncurrent nerve has never been described, it must be regarded\\nas the result of a disturbance of coordination due to the\\nintoxication.\\nAlt 1 had occasion to observe alcoholic neuritis of the\\nauditory nerve in a case of alcoholic multiple neuritis.\\nIn conclusion, I wish to add a caution in regard to the\\nuse of irritating and astringent remedies in the treatment\\nof the nose, as such substances, especially when used in the\\nform of a douche or a powder, are very likely to pro-\\nduce disturbance of the sense of smell. In this respect\\nthe zinc salts, alum, tannin, and carbolic acid are particu-\\nlarly dangerous, and should be absolutely avoided in the\\ntreatment of the nose.\\n1 Mon. f. Ohr., 1897, p. 171.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0256.jp2"}, "257": {"fulltext": "XII. NERVOUS DISEASES.\\nU GENERAL REMARKS ON DISEASES OF THE\\nLARYNX IN DISEASES OF THE CENTRAL\\nNERVOUS SYSTEM.\\nDISEASES OF THE SENSORY AND MOTOR NERVES OF\\nTHE LARYNX.\\nThe disturbances which may occur in the larynx as a\\nresult of disease of the central nervous system are both\\nsensory and motor. The pneumogastric nerve supplies\\nthe larynx with sensory fibers through the superior laryn-\\ngeal nerve and its internal branch, which is distributed to\\nthe mucous membrane of the base of the tongue, the epi-\\nglottis, the pyriform sinuses, and the entire interior of the\\nlarynx hence, disease of the sensory nuclei and roots of\\nthe pneumogastric may produce sensory disturbances in\\nthe form of anesthesia, paresthesia, and hyperesthesia.\\nThese are most frequent in bulbar disease and in diseases\\naffecting the trunk of the vagus, and are therefore of great\\nimportance for the diagnosis of these conditions. They\\nhave also been occasionally observed in hemiplegia, in\\ncerebral focal diseases, and in progressive paralysis, but\\nhave only a historic interest in this connection.\\nThe motor disturbances in the larynx manifest them-\\nselves as irritative motor phenomena, as disturbances of\\ncoordination, and as palsies. The irritative phenomena\\noccur in the form of tonic spasms, which are designated\\nspasm of the glottis, laryngeal crises, and ictus laryngis\\nor in the form of clonic spasms, as rhythmic twitchings\\nand tremors or atactic movements of the vocal cords, such\\nas are sometimes observed in cases of brain tumor, cerebral\\nabscess, and meningitis, and particularly in multiple scle-\\nrosis, in bulbar paralysis, and in a great number of neu-\\nroses.\\nParalysis may occur either in the groups of muscles sup-\\n251", "height": "3444", "width": "2052", "jp2-path": "rhinologylaryng00frie_0257.jp2"}, "258": {"fulltext": "252 NERVOUS DISEASES.\\nplied by the superior laryngeal or in those supplied by the\\ninferior laryngeal or recurrent nerve. The superior laryn-\\ngeal nerve, through its external motor branch, supplies the\\ncricothyroideus muscles, whose function it is to make tense\\nthe vocal cords. Paralysis of this muscle, which manifests\\nitself in roughness of the voice and sagging of the vocal\\ncord on the paralyzed side during phonation, and by a\\nslight waviness of the free border of the vocal cord, occurs\\nvery rarely as the result of an isolated paralysis of the ex-\\nternal branch of the superior laryngeal nerve, and is never\\nthe result of a central lesion. When a paralysis of the\\ncricothyroid muscles occurs in connection with a general\\nparalysis of the motor fibers of the pneumogastric, either\\nof central or peripheral origin, involving both the inferior\\nand superior laryngeal nerves, it becomes merged in the\\ngeneral picture of complete paralysis of the vocal cords,\\nand can not be distinguished clinically from that of par-\\nalysis of the recurrent nerve alone.\\nParalysis of the recurrent nerve is by far the most im-\\nportant from a diagnostic point of view, for it is the typical\\nsymptom of a lesion of the motor paths in the central ner-\\nvous system, whenever peripheral disease of the nerves or\\ninjury to the nerve-trunk can be excluded. As the ques-\\ntion of paralysis of the recurrent nerve, its origin, and the\\ninterpretation of the laryngoscopic image which it pro-\\nduces has been and still is the subject of numerous contro-\\nversies, it may not be out of place to present the present\\nstate of the question of paralysis of the recurrent nerve.\\nThe muscles of the larynx that exert any influence on\\nthe movements of the vocal cords are divided into three\\ngroups, named, respectively, the openers, closers, and ten-\\nsors of the rima glottidis. Opening of the glottis is\\neffected by the crico-arytenoideus posticus drawing the\\nmuscular process of the arytenoid cartilage to which it is\\nattached inward and at the same time rotating the vocal\\nprocess outward. Closure of the glottis is accomplished\\nby the combined action of various muscles which together\\nmake up a muscular ring embracing the entire glottis.\\nEach one of these small muscles has its peculiar action,\\nand the cooperation of all is required to effect exact ap-\\nproximation of the vocal cords. Finally, there is a third\\ngroup of muscles, which connects the cricoid with the thy-\\nroid cartilage, and whose function it is to stretch the vocal", "height": "3468", "width": "2160", "jp2-path": "rhinologylaryng00frie_0258.jp2"}, "259": {"fulltext": "PARALYSIS OF THE RECURRENT NERVE. 253\\ncord by increasing the distance between the vocal process\\nand the anterior angle of the thyroid cartilage. As the\\nresulting posterior displacement of the plate of the cricoid\\ncartilage is accompanied by depression, the vocal cord,\\nwhen stretched in this way, occupies a deeper position.\\nThese three groups of muscles are supplied by the infe-\\nrior, or recurrent, and the superior laryngeal nerve. Now,\\nit is a remarkable fact that the openers and closers of the\\nglottis, although mutually antagonistic, are both supplied\\nby the inferior laryngeal nerve, while the motor branch of\\nthe superior nerve exclusively supplies the tensor mus-\\ncles. It follows that any sudden injury to the inferior\\nlaryngeal nerve affects the openers and closers equally, so\\nthat the vocal cord, in the absence of antagonistic muscular\\ntraction, assumes a position of equihbrium a position, in\\nshort, which is designated the pathologic cadaveric posi-\\ntion. The term cadaveric position was first used by\\nv. Ziemssen, because it was found that the position of the\\nvocal cords postmortem was the same as that seen in\\nparalysis of the recurrent nerves. In both cases the vocal\\ncords assume a position midway between inspiration and\\nexpiration. In recent times it has been repeatedly pointed\\nout that the width of the glottis is not exactly the same in\\nboth cases, and that in the pathologic cadaveric position\\ndue to paralysis of the recurrent the vocal cords are slightly\\nmore adducted than in the so-called genuine cadaveric\\nposition, as seen in the dead body. This variation is to be\\nattributed to the action of the crico-thyroid muscles, which\\nare not affected by paralysis of the recurrent nerves, as\\nthey receive their innervation from the superior laryngeal,\\nand can therefore continue to act in a peripheral palsy of\\nthe recurrent nerves. We know that the action of these\\nmuscles consists in stretching the vocal cords and at the\\nsame time in slightly approximating the edges of the vocal\\ncords to the median line. This phenomenon is found to\\nbe retained in the pathologic cadaveric position, and ex-\\nplains the difference between the two kinds of cadaveric\\nposition. How the function of the cricothyroid muscle is\\naffected in central palsies is not known, but it is probable\\nthat its motor nerve has the same origin as the other nerves,\\nso that it must be held to be involved in any central par-\\nalysis of the vocal cords.\\nIn addition to this complete paral\\\\-sis of the recurrent", "height": "3456", "width": "2064", "jp2-path": "rhinologylaryng00frie_0259.jp2"}, "260": {"fulltext": "2 54 NERVOUS DISEASES.\\nnerve, which affects the adductors and abductors equally,\\nthere is another important form of paralysis affecting this\\nnerve, which is dQS\\\\gr\\\\?Lt 6. posticus paralysis. In the laryn-\\ngoscopic image the vocal cord is seen to be immovably\\nfixed in the median line, while the free border is taut,\\ninstead of concave, as in paralysis of the recurrent, so that\\nphonation remains normal. This median position is ex-\\nplained by the failure of the abductors, and the condition is\\ntherefore designated posticus paralysis. It is this posticus\\nparalysis that has given rise to so many controversies, which\\nhave again been revived in recent times, and are still very\\nactive. In order to understand the question thoroughly we\\nmust premise Semon s proposition, which says In organic\\nprogressive diseases of the roots and trunks of the spinal\\naccessory, pneumogastric, and recurrent nerves the dilator\\nfibers are affected earlier than the constrictor fibers, or may\\neven be attacked exclusively. Applied to actual practice,\\nthis means that in such progressive diseases of the recur-\\nrent nerve we have first a paralysis of the posticus, and later\\nparalysis of the adductors of the vocal cord, such as have\\njust been described as total paralysis of the recurrent nerve.\\nThe correctness of this law, which is known as Semon s\\nlaw, has been subjected to a rigorous test by Semon him-\\nself. He first formulated it on the basis of a series of\\nchnical cases, and has since confirmed it in various publica-\\ntions by adducing physiologic and etiologic facts in its sup-\\nport. But in spite of these positive proofs the law has not\\nbeen accepted, and many animated controversies have taken\\nplace between Semon and his followers on the one hand,\\nand his opponents on the other, I am forced to go into\\nthis matter in some detail, as an exact understanding of the\\nentire question is necessary in the criticism of the volumi-\\nnous literature which has appeared on the subject. The\\nquestion of this primary posticus paralysis of Semon s is\\nimportant, because it enables us approximately to judge of\\nthe duration of a paralysis by observing whether the affected\\nvocal cord is in the median or in the cadaveric position, and\\nbecause it is a sign that the primary disease is progressing\\nif the posticus paralysis, in spite of treatment, goes on to\\ncomplete paralysis of the recurrent nerve.\\nI shall divide this discussion of the median position of\\nthe paralyzed vocal cord which has been designated as\\nposticus paralysis into two sections for, in the first place,", "height": "3492", "width": "2200", "jp2-path": "rhinologylaryng00frie_0260.jp2"}, "261": {"fulltext": "PARALYSIS OF THE RECURRENT NERVE. 255\\nthe question must be settled whether a median position of\\nthe vocal cord necessarily means that there is an isolated\\nparalysis of the crico-arytenoideus posticus, and, in the\\nsecond place, we must attempt to explain how, when the\\nfibers that supply the antagonistic muscles are contained in\\nthe same nerve-trunk, those which innervate the crico-ary-\\ntenoideus posticus can be for years the only ones affected\\nby the paralysis.\\nAccording to Krause, who bases his opinion on experi-\\nmental investigation, a median position of the vocal cord\\nmay, under certain conditions, not as yet very well ex-\\nplained, be due to reflex contraction of the laryngeal\\nmuscles. Krause experimented on animals by slowly con-\\nstricting the recurrent nerve under proper precautions, and\\nobserved that a median position very soon appeared, which\\nafter about twenty-four hours changed to the cadaveric\\nposition. He accordingly adopts the theory, which he\\nexplains with much ingenuity, that the gradually increasing\\nirritation of the nerve first gives rise to a reflex contraction,\\nwhich first manifests itself in a median position of the vocal\\ncord, because the adductors surpass all the other muscles\\nin bulk, but which finally goes on to the cadaveric position\\nwhen the nerve is completely paralyzed.\\nThe promulgation of this theory, which is accepted by\\nvarious authors, was followed by another, recently advanced\\nby Grossman, to the effect that total paralysis of the recur-\\nrent is not a. cadaveric position, as is generally supposed, but\\nrather a position of adduction near the middle line, which\\npractically (Grossman is not very clear on this point) cor-\\nresponds to the median position. The final cadaveric posi-\\ntion is, according to him, the expression of an additional\\nparalysis of the cricothyroid muscle, the occurrence of\\nwhich he explains as the result of secondary atrophy of\\nthe antagonistic adductor muscles, due to disuse in conse-\\nquence of the paralysis.\\nAlthough at first sight both Krause s and Grossman s\\nhypotheses may appear plausible, they will not bear the\\ntest of careful examination, and are in direct contradiction\\nto a great number of clinical and experimental facts. To\\ngive all my reasons for this difference of opinion would lead\\nme too far astray, but I will mention a few facts of pathologic\\nanatomy which are insisted on by various authors As\\nagainst Krause s hypothesis we ha\\\\ e many cases in which", "height": "3456", "width": "2024", "jp2-path": "rhinologylaryng00frie_0261.jp2"}, "262": {"fulltext": "256 NERVOUS DISEASES.\\nthe picture of a posticus paralysis was seen in vivo, and\\nwhere, after death, only the crico-arytenoideus posticus\\npresented an atrophy which was too pronounced to be\\nreconciled with the theory of muscular contraction, in\\nview of the long duration of the posticus paralysis and\\nthe integrity of the adductor muscles.\\nIn refutation of Grossman s hypothesis we have, in ad-\\ndition to many other considerations, the anatomic fact that\\nit has so far been impossible to demonstrate positively the\\noccurrence of atrophy of the cricothyroids in a simple par-\\nalysis of the recurrent nerve, where the superior laryngeal\\nwas positively excluded a condition which is absolutely\\nnecessary to demonstrate atrophy due to disuse, as claimed\\nby Grossman.\\nI therefore assume that I have disposed of these objec-\\ntions, and that in the form known as posticus paralysis we\\nhave actually to deal with an isolated paralysis of the crico-\\narytenoideus posticus muscle. As, therefore, paralysis of\\nthe abductors is the first sign of a slowly progressing injury\\nto the recurrent nerve, we are confronted with the most in-\\nexplicable phenomenon when we consider that this nerve\\ninnervates not only the paralyzed muscle, but also its\\nantagonists, the adductors. Hence, the discussion is prac-\\ntically narrowed down to the question as to why the dilators\\nbecome paralyzed before the closers, in spite of the fact that\\nboth are supplied by the same nerve.\\nThe explanation that the fibers destined for the posticus\\nmuscle are more superficial than those which supply the\\nadductors can not be taken seriously, but I may mention\\nthe attempted explanation, whicl? is based on Exner s ex-\\nperiments on animals. Exner and his disciples have de-\\nvoted much study to the innervation of the larynx, and have\\nfound certain individual variations most muscles appear to\\nhave a double innervation, either the corresponding nerves\\non both sides or several nerves of the same side being con-\\ncerned in the innervation of one muscle. If this condition\\noccurred regularly in man, we should naturally be led to\\nconclude that in cases of isolated paralysis of the posticus,\\nalthough there is a total paralysis of the recurrent fibers,\\nthe paralysis affects only the dilators, because in such a case\\nthe adductors derive an additional supply from another\\nnerve. Unfortunately, this hypothesis is contradicted by a\\ngreat number of clinical observations, as we have absolutely", "height": "3468", "width": "2192", "jp2-path": "rhinologylaryng00frie_0262.jp2"}, "263": {"fulltext": "PARALYSIS OF THE RECURRENT NERVE. 25/\\nno proof of individual variation in the form of a double in-\\nnervation besides, many of Exner s experiments are\\nwanting in clearness, and other experimenters have not been\\nable to confirm his results.\\nI recently, for a different purpose, practised extirpation\\nof the various laryngeal nerves in rabbits, and in every case\\nI observed atrophy of the abductors and adductors after\\ndivision of the recurrent nerve, so that I am forced to ex-\\nclude the existence of a double innervation for these cases.\\nOn the other hand, in a series of experiments which go to\\nprove that there is a physiologic difference in the biologic\\nrelations of the two groups of muscles, we have exact and\\nincontestible proofs of the greater vulnerability of the dila-\\ntors, which might be responsible for a primary paralysis of\\nthe postici. It is proved by one series of experiments that\\nthe electric irritability of the posticus muscle disappears long\\nbefore that of the adductors, and this condition is found not\\nonly postmortem, but also in ether anesthesia and when the\\nnerve is gradually allowed to freeze. In this connection it\\nis important to remember Grabower s discovery that the\\nnerve-endings in the abductors differ morphologically from\\nthose in the adductors. From this we may conclude that\\nthe adductors and abductors are not ordinary antagonists,\\nlike the extensors and flexors of the extremities, and we\\nmust try to find some cause for their physiologic difference.\\nThis difference is found in their function, since the adduct-\\nors of the vocal cords are concerned in phonation, while the\\nabductors merely represent respiratory muscles. Corre-\\nsponding to these different functions there must be different\\nkinds of fibers in the recurrent nerve, some of which are in-\\ntended for phonation while others transmit reflex impulses\\nconnected with respiration.\\nThe question whether the action of the crico-arytenoideus\\nposticus is exclusively a reflex action has been carefully\\nstudied by Semon and Horsley. These authors found that\\nthe ordinary respiratory position in which the glottis gapes\\nwider than in the cadaveric position must be regarded as a\\nreflex tonic spasm, which is constantly present in the posti-\\ncus muscle under the influence of the respiratory center, its\\nobject being to keep the glottis sufficiently dilated for the\\nact of respiration. The existence of such a reflex tonic\\nspasm in the nerve-fibers destined for the posticus would\\nserve to explain the physiologic fact previously mentioned,\\n17", "height": "3464", "width": "2020", "jp2-path": "rhinologylaryng00frie_0263.jp2"}, "264": {"fulltext": "258 NERVOUS DISEASES.\\nthat the abductors of the vocal cords become fatigued\\nearlier than the adductors, since on this supposition we have\\nto deal with two kinds of nerves in the recurrent afferent\\nand efferent nerves. The afferent nerves produce reflex\\ntonic spasm in the posticus muscle, while the efferent nerves\\nact as simple motor nerves to the adductors. Thus, the\\nearly and isolated appearance of paralysis of the posticus is\\nbest explained by the physiologic law that the irritability\\nof afferent nerves is exhausted earlier than that of efferent\\nnerves.\\nTo sum up, we have learned that there are two kinds of\\nparalysis of the recurrent nerve the first stage of a lesion\\nto the recurrent nerve gives rise to posticus paralysis, while\\na fully developed recurrent paralysis finds expression in the\\nso-called pathologic cadaveric position. We have left to\\nconsider only the mode of transition from one form to the\\nother, and we learn from clinical observation that this\\ntakes place in a typical manner. The first step in the\\nprogress of the paralysis consists in a relaxation of the free\\nborder of the vocal cord, which was tightly stretched in\\nthe simple posticus paralysis. The border becomes con-\\ncave toward the median line, then gradually bows outward,\\nand finally goes on to recurrent paralysis. If recovery\\ntakes place in a recurrent paralysis, as I saw lately in a\\ncapital case of postdiphtheric paralysis, the vocal cord first\\nmoves into the median position, and for a short time pre-\\nsents the picture of a posticus paralysis, before it regains its\\nnormal movability.\\nTHE LOCALIZATION OF CENTERS FOR THE MOVEMENT\\nOF THE VOCAL CORDS IN THE CENTRAL NERVOUS\\nSYSTEM, AND THE EFFECT OF DISEASES OF THE CEN-\\nTRAL NERVOUS SYSTEM.\\nHemorrhages, foci of softening, pseudobulbar paralysis,\\nsclerotic foci, tumors, tubercular and syphilitic tumors, and\\ncerebral abscesses may produce paralysis of the vocal cords\\nwhen the lesion is situated in the central motor paths for voice\\nproduction and for the movements of the vocal cords. The\\nlocalization of movements of the vocal cords in the cere-\\nbrum is still a matter of dispute, so that the diagnostic\\nvalue of paralysis of the vocal cords for the localization of\\nsuch diseases is limited.\\nThe number of cases of which we possess a clinical and", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0264.jp2"}, "265": {"fulltext": "LOCALIZATION OF LARYNGEAL MOVEMENTS. 259\\nanatomic description is too small to afford a basis for a\\ndefinite symptomatology of laryngeal disturbances in dis-\\neases of the central nervous system, and if I were to take\\nup the various brain diseases individually, my description\\nwould be nothing more than an incoherent series of facts re-\\npeated from the literature. I shall therefore content myself\\nwith a short presentation of the views which prevail at the\\npresent time in regard to the localization of laryngeal\\nmovements in the central nervous system. This will form\\na basis in any given case for deducting the site of the\\nmorbid focus from the existing disturbances in the larynx.\\nThe motor paths for the larynx in the medulla oblongata\\nare better known than those in the cerebrum. The nuclei\\nbecome typically involved in certain systemic diseases, and\\nsensory as well as motor disturbances of the larynx result.\\nBut even in this region, although the question in the main\\nis fairly well settled, there are certain points which are still\\nunder dispute, the most important one of which is whether\\nthe nucleus of the motor nerves of the larynx is to be\\nfound in the vagus or in the spinal accessory. After we\\nhave given a general description of the localization of the\\nlarynx in the cerebrum and its relation to the medulla\\noblongata, it will be necessary to discuss a few diseases of\\nthe spinal cord which give rise to typical disturbances in the\\nlarynx as a part of their general symptom-complex.\\nThe motor nerves of the larynx are the superior and\\ninferior (or recurrent) laryngeal nerves branches of the\\nvagus. The trunk of the vagus, therefore, contains the\\nperipheral paths which transmit nerve impulses to the vocal\\ncords and cause them to open or to close the rima glottidis\\nin the service of the phonatory and respiratory function of\\nthe larynx. As the larynx has a double function that of\\nphonation, which is purely motor and is dependent on the\\nwill, and that of respiration, which consists in the reflex\\nopening of the glottis under the influence of the respiratory\\ncenter there must be two different centers for adduction\\nand abduction in the central nervous system. For the\\nvoluntary movements performed during speech we must\\nassume, in addition to the center in the medulla oblongata,\\na second center in the cortex, while the reflex opening of\\nthe glottis during respiration, which takes place independ-\\nently of the will, is probably but little, if at all, under the\\ninfluence of the cortical center.", "height": "3456", "width": "2012", "jp2-path": "rhinologylaryng00frie_0265.jp2"}, "266": {"fulltext": "26o NERVOUS DISEASES.\\nWe emphasize this point because an impression has\\nlately gone abroad that the vocal cords can be voluntarily\\nadducted or abducted on one side. This view accords\\nwith the conception of a bilateral symmetric movement\\nonly so far as respiration is not altogether reflex, but partly\\nsubject to the will, since we are able to make deep volun-\\ntary inspirations and thereby effect a wide gaping of the\\nrima glottidis. We learn from experimental investigations\\nand from pathology that the assumption of two separate\\ncenters for the two kinds of movement is necessary to\\nexplain the occurrence of the different kinds of paralysis.\\nIt must be admitted at the outset, however, that the\\ndiscussion is only in its infancy, and that, owing to the\\ncontradictory statements and findings of careful observers\\nand experimenters, it is impossible to give a clear objective\\npresentation of the state of affairs, so that in attempting to\\nexplain the various phenomena which present themselves\\nwe are often forced to resort to hypotheses to bridge the\\ngaps in our argument.\\nEven the question of the origin of the motor nerves of\\nthe larynx is not definitely settled. The controversy as to\\nwhether the nucleus of the vagus or that of the spinal\\naccessory, or both together, represents their origin has\\nbeen going on for several decads, and has been lately\\nrekindled by Grabower s investigation, just as the authori-\\nties were beginning to incline to the opinion that the motor\\nfibers for the larynx were derived from the nucleus of the\\nspinal accessory.\\nGrabower has proved by a series of sections through the\\nmedulla oblongata and the spinal cord that the spinal acces-\\nsory is a purely spinal nerve its nucleus and deep roots\\nhave no relation to the nucleus of the vagus. According\\nto him, the ventral nucleus of the vagus (the nucleus\\nambiguus) represents the origin of the motor nerves of the\\nlarynx. In a detailed discussion of this question Semon\\nsays that his clinical experiences have been such that he can\\nnot agree with Grabower s opinions, because he is unable\\nto reconcile them with certain observed cases of simulta-\\nneous paralysis of the vocal cords and of the trapezius and\\nsternocleidomastoid muscles, which are supplied by the\\nspinal accessory nerve. But Grabower himself denies\\nHeymann s Handb. d. Laryng., vol. I, p. 606.\\n2 Arch. f. Laryng., vol. v.", "height": "3468", "width": "2204", "jp2-path": "rhinologylaryng00frie_0266.jp2"}, "267": {"fulltext": "BULBAR AND CORTICAL PARALYSES. 26 1\\nthat those cases in which there is a simultaneous paralysis\\nof the larynx and of the spinal accessory are any proof that\\nthese various groups of muscles are under the control of a\\ncommon nucleus. Hence, we have to regard the question\\nas still undecided for the present. We may mention that\\nClaude Bernard has advanced the opinion that the spinal\\naccessory represents the nerve of phonation, and the vagus\\nthe nerve of respiration.\\nWhile the occurrence of bulbar paralysis in the larynx,\\nin diseases which affect the bulbar nuclei, is definitely estab-\\nlished, the question whether cortical paralysis of the larynx\\never occurs is still undecided. It is known that Krause\\nfound a spot on the anterior lower extremity of the anterior\\ncentral convolution, immediately behind the precentral\\nfissure, called after him, Krause s center, irritation of\\nwhich on one side of the brain produces a bilateral adduc-\\ntion of the vocal cords. It follows, therefore, that each of\\nthese two cortical centers for adduction is capable of influ-\\nencing the movements of both vocal cords but, on the\\nother hand, unilateral lesion of this cortical region is not\\ncapable of suspending movement in the larynx, as has been\\nshown by extirpation of these parts. In view of the great\\nfrequency of apoplexy and of other lesions in this region of\\nthe cortex, the literature ought to contain a great number\\nof cortical palsies, but, as a matter of fact, we possess only\\na very small number of observations, which can not even\\nbe definitely referred to a unilateral cerebral injury, because\\nno autopsies are given and the clinical history is not quite\\nclear. On the other hand, when the centers on both sides\\nof the cerebrum are diseased, cortical palsy undoubtedly\\nresults, as was proved by Semon,^ both by experiments on\\nanimals and by two cases where the diagnosis was con-\\nfirmed by an autopsy.\\nIn syphilis, tuberculosis, multiple sclerosis, and menin-\\ngitis, and in tumors and hemorrhages, we should therefore\\nexpect a cortical palsy, affecting both vocal cords, due to\\ninjury of both Krause s centers.\\nA great number of theories, more or less well supported\\nby experiments on animals, have been presented on this\\nsubject, while clinical observations, on the other hand, are\\nCases bearing on this question will be found quoted by Onodi, Rev.\\nhebd. de laryng., etc., 1898, No. 4.\\n2 Heymann s Handb. der Laryng., i, pp. 692 and 701.", "height": "3448", "width": "2056", "jp2-path": "rhinologylaryng00frie_0267.jp2"}, "268": {"fulltext": "262 NERVOUS DISEASES.\\nvery meager. If all these observations were perfectly\\nclear there would be no controversy, but as some authors\\nclaim to have seen a crossed unilateral cortical paralysis of\\nthe vocal cords, while others absolutely deny that any but a\\nbilateral cortical lesion is capable of producing a double\\nparalysis of the vocal cords, there is evidently room for a\\ngreat deal of discussion, and any contributions, such as\\nthose which have lately been added by Uchermann,^ are\\nwell worthy of attention. In connection with a case of\\nright-sided hemiplegia, motor aphasia, and paralysis of the\\nadductors in the larynx, he raises the question whether a\\none-sided that is to say, left-sided injury of the phona-\\ntion center is capable of producing a double palsy of the\\nadductors, and suggests the possibility that the center of\\nphonation, like that of speech, is usually located on one\\nside. Injury of the fibers which pass through the internal\\ncapsule from the cortex to the medulla oblongata neces-\\nsarily produces the same effect as a cortical lesion.\\nThe existence of a center of phonation in the posterior\\ncorpora quadrigemina, and the corresponding area in the\\nfloor of the fourth ventricle, capable of producing approxi-\\nmation of the vocal cords, even after communication with\\nthe cortex has been interrupted, is maintained by Onodi, and\\ndenied by Klemperer and Grabower.\\nAccording to Semon and Horsley, abduction of the vocal\\ncords or opening of the rima glottidis is under the control\\nof two different regions in the medulla oblongata One\\nof these is situated in the ala cinerea the other, in the\\nregion of the origin of the auditory nerve, extending to the\\nmouth of the aqueduct of Sylvius. Irritation of these\\nregions was always followed by bilateral abduction of the\\nvocal cords.\\n1 Arch. f. Laryng. u. Rhinol., p. 332.", "height": "3468", "width": "2188", "jp2-path": "rhinologylaryng00frie_0268.jp2"}, "269": {"fulltext": "FUNCTIONAL DISTURBANCES IN THE EAR. 263\\n2, GENERAL REMARKS ON THE AURAL DIS-\\nTURBANCES PRODUCED IN DISEASES OF THE\\nCENTRAL NERVOUS SYSTEM,\\nTHE MECHANISM OF FUNCTIONAL DISTURBANCES IN\\nTHE EAR AND THE ELECTRIC REACTIONS OF THE\\nAUDITORY NERVE.\\nThe functional disturbances produced in the organ of\\nhearing by disease in the central nervous system consist in\\ndisturbances of the hearing or in the equilibrium, according\\nas the paths of the cochlear or those of the vestibular\\nnerves are involved. When the trunk of the auditory nerve\\nis diseased, both hearing and equilibrium are affected.\\nNervous disturbances of the hearing in central disease mani-\\nfest themselves either in abnormal excitability of the audi-\\ntory nerve, which may be so intense that the perception of\\ncertain tones becomes positively painful, or in torpor of the\\nnerve, which, again, may go on to complete insensibility to\\nauditory impressions. This form of deafness is accompanied\\nby certain characteristic pathologic alterations in the ear\\nwhich enable us to distinguish it from those disturbances\\nhaving their seat in the sound-conducting apparatus. The\\nhearing in such cases is lost for certain tones, so that in\\ntesting the field of hearing one is forced to use a long series\\nof graduated tuning-forks. The tuning-fork test is intended\\nto determine the power of the auditory nerves to perceive\\ntones which reach the internal ear through the air or\\nthrough the craniotympanic conducting path. If cranio-\\ntympanic conduction is very much weakened or entirely\\nabsent, it is a sign of nervous disease.\\nTinnitus aurium is the first symptom observed in disease\\nof the auditory nerve paths. In the first stage of a disease\\nin the central nervous system it may be the expression of\\nirritability of the auditory nerve, but it may also occur in\\nthe later periods, in which the irritability of the nervous\\npaths is entirely lost. These subjective noises present cer-\\ntain characteristic qualities, which serve to distinguish them\\nfrom those produced in the middle ear they may be con-\\ntinuous and low in pitch, and so intense as to be compared\\nwith the thunder of cannon or the din of a railroad train\\nthey may be high-pitched and musical the tinnitus aurium\\nmay have a register or pitch of C to C^ or it may be a", "height": "3456", "width": "2052", "jp2-path": "rhinologylaryng00frie_0269.jp2"}, "270": {"fulltext": "264 NERVOUS DISEASES.\\nmusical or harmonious sound described as a melody, the\\nringing of bells, or the twittering of birds.\\nFinally, we have the disturbances of equilibrium which\\nare regarded as the expression of disease of the vestibular\\nnerve, and which are often associated with nausea and\\nvomiting.\\nThese three symptoms are described together under the\\nname of Meniere s symptom-complex. Before the purely\\nsymptomatic nature of these phenomena which are com-\\nmon to all diseases of the auditory nerve paths was appre-\\nciated, it was customary to speak of a Meniere s disease,\\nbecause Meniere had first observed these symptoms in a\\ncase of sudden hemorrhage from the labyrinth. Since the\\nappearance of v. Frankel Hockwart s publication, in which\\nhe presents this Meniere s symptom-complex in its true\\nlight for the benefit of the nonspecialist, it is to be hoped\\nthat the term Meniere s disease, as applied to the most\\nvarious diseases of the nervous hearing apparatus, will be\\ndiscarded altogether.\\nThe functional disturbances just described do not enable\\nus to determine the exact location of the disease in the\\nauditory paths. They are simply diagnostic of a nervous\\ndisturbance of the hearing, and, so far as our present\\nknowledge of these disturbances goes, we are unable to\\ndetermine whether the peripheral terminations of the audi-\\ntory nerve in the labyrinth, the nerve-trunk, or the central\\nnervous paths are diseased.\\nTo discuss these symptoms in detail would lead us too\\nfar into the domain of physiologic research concerning the\\nspecial functions of the individual portions of the ear we\\nmust, however, devote some attention to the electric exami-\\nnation of the auditory nerve, which has reached a high\\ndegree of perfection in the hands of nerve specialists, and is\\nnow universally used by them as a method of examination,\\nwhile ear specialists even now stand skeptically aloof, just\\nas they did thirty years ago, and continue to doubt the\\nimportance of a method which is insisted on by a great\\nnumber of writers on neurology.\\nAs the results of electric examination of the auditory\\nnerve have been applied in various ways to diseases of the\\ncentral auditory paths, although it is, as a rule, very\\nNothnagel s Spec. Path. u. Therap., xi.", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0270.jp2"}, "271": {"fulltext": "THE CARE OF THE BABY. By\\nP. Ctozct Griffith, M.D., Clinical\\nProfessor of Diseases of\\nChildren, University of\\nPennsylvania Physi-\\ncian to the Children s\\nHospital, Philadelphia, etc. Octavo.\\n404 pa^es. Illustrated. Cloth, $1.50.\\nGRIFTITH\\nON THE\\nBABY\\nSECOND EDITION, REVISED.\\nThe author has endeavored to furnish a reliable\\nguide for mothers anxious to inform themselves\\nwith regard to the best way of caring for their\\nThe best book for the use of the 5 oung\\nmother with which we are acquainted. There\\nare very few general practitioners who could not\\nread the work through with advantage.\\nAfckives of Pediatrics.\\nchildren in sickness and in health. He has\\nmade his statements plain and easily understood,\\nin the hope that the volume may be of service\\nThe whole book is characterized by rare\\ngood sense, and is evidently written by a master\\nhand. It can be read with benefit not only by\\nmothers but by medical students and by any\\npractitioners who have not had large opportuni-\\nties for observitig children. American Journal\\nof Obstetrics.\\nnot only to mothers and nurses but also to med-\\nical students and to practitioners whose oppor-\\ntunities for observing children have been limited.\\nFor sale by all Booksellers, or sent post-paid on\\nreceipt of price.\\nW. B. SAUNDERS CO., Publishers,\\n925 Walnut St., Philadelphia.", "height": "3456", "width": "2048", "jp2-path": "rhinologylaryng00frie_0271.jp2"}, "272": {"fulltext": "NERVOUS AND MENTAL DIS-\\nEASES. By Archibald Church, M.D.,\\nProfessor of\\nClinical Neu-\\nrology, Mental\\nDiseases, and\\nMedical Juris-\\nCHURCH AND\\nPETERSON S\\nNERVOUS AND\\nMENTAL DISEASES\\nprudence, Northwestern University\\nand Frederick Peterson, M.D., Chief of\\nClinic, Nervous Department, CoUegfe\\nof Physicians and Surg^eons, New York.\\nHandsome octavo, 843 pages, with over\\n300 illustrations. Cloth, $5.00 net;\\nHalf Morocco, $6.00 net.\\nSECOND EDITION.\\nThis book is intended to furnish students and\\npractitioners with a practical, working knowl-\\nedge of nervous and mental diseases. Written\\nby men of wide experience and authority, it\\nwill present the many recent additions to the\\nsubject. The book is not filled with an ex-\\ntended dissertation on anatomy and pathology,\\nbut, treating these points in connection with\\nspecial conditions, it lays particular stress on\\nmethods of examination, diagnosis, and treat-\\nment. In this respect the work is unusually\\ncomplete and valuable, laying down the defi-\\nnite courses of procedure which the authors\\nhave found the most generally satisfactory.\\nFor sale by all Booksellers, or sent post-paid on\\nreceipt of price.\\nW. B. SAUNDERS CO., Publishers,\\n925 Walnut St., Philadelphia.\\ntMs4^: l .mi:i", "height": "3468", "width": "2208", "jp2-path": "rhinologylaryng00frie_0272.jp2"}, "273": {"fulltext": "ELECTRIC REACTION OF AUDITORY NERVE. 265\\nimperfectly described or entirely omitted in text-books on\\notology, I feel impelled to present a general resume of\\nthe significance of electric reaction of the auditory nei ve.\\nThe attempt has been made to utilize the electric irrita-\\nbility of the auditory nerve for purposes of diagnosis and\\ntherapeutics but the results in either direction have not\\nbeen such as to justify the expectations raised by the dog-\\nmatic teachings of Brenner, published thirty -five years ago\\nin his Elektro-otiatrik. Brenner gives a normal formula\\nfor the healthy individual as follows\\nKa. CI R Very loud ringing.\\nKa. D.* R 00 Ringing persists during continuance of\\ncurrent.\\nKa. O Nothing.\\nAn. CI Nothing.\\nAn. D Nothing.\\nAn. O R^ Louder ringing, gradually dying away.\\n(*During passage of current.\\nHis most important results are embodied in the propo-\\nsitions that The cathodal contraction produces auditory\\nsensation when the circuit is closed, and also during con-\\ntinuance of the current, but not when the circuit is opened.\\nThe anodal contraction gives no reaction either when the\\ncircuit is closed or during the continuance of the current,\\nbut does give a reaction when the circuit is opened. The\\nanodal reaction ceteris paribus is weaker than the catho-\\ndal reaction. The cathodal reaction occurs immediately,\\nthe anodal reaction only after the current has lasted a cer-\\ntain time. After a short duration of the current, opening\\nis not followed by a reaction at the cathode. The cathodal\\nreaction becomes markedly increased immediately after\\nclosure, a phenomenon described by the patients as an\\necho, for they frequently remark that the echo is stronger\\nthan the first (or closing) sound. The reaction persists for\\nsome time, with a lessened intensity, reverberating\\necho, and then completely disappears, although the\\nstrength of the current remains constant.\\nThe publication of these statements was, of course, re-\\nceived with equal interest by ear specialists and by neurolo-\\ngists, and gave rise to numerous control investigations.\\nSchwartze deserves the credit of being the first to find\\ni Virch. Arch., 28, p. 207.\\n2 Arch. f. Ohr., i, p. 44.", "height": "3456", "width": "2024", "jp2-path": "rhinologylaryng00frie_0273.jp2"}, "274": {"fulltext": "266 NERVOUS DISEASES.\\nflaws in Brenner s formulae, which materially diminished the\\nvalue of the electric reactions for the diagnosis and treat-\\nment of aural diseases. His objections amount to the\\nfollowing proposition That Brenner s normal formula for\\nthe reaction of a healthy auditory nerve is not by any\\nmeans constant in persons with normal hearing that Bren-\\nner s normal formula is given in absolute deafness, which can\\nbe only due to a disease of the nervous apparatus and,\\nfinally, that, as far as treatment is concerned, the restoration\\nof the normal formula of reaction has no effect on the\\npower of hearing. These objections were answered by\\nBrenner and Erb. At first Erb said that those who\\ndeny the existence or correctness of Brenner s discoveries\\nare simply mistaken, but later he modified his opinion to\\nthe extent of confirming the first of Schwartze s objections.\\nAlthough opinions in regard to the diagnostic value and\\nthe production of the reaction are now fairly well settled,\\nthe skeptical attitude adopted by Schwartze has in the main\\nbeen justified, and the value of Elektro-otiatrik is not\\nnearly so great to the ear specialist as would appear from\\nthe statements of neurologists.\\nThe electric examination is conducted in two different\\nways, called the internal and external methods. The former\\nwas employed by Brenner, who filled the external auditory\\nmeatus with water, and then introduced an electrode, with\\ncertain precautions, so that its extremity was rigidly held\\nat a certain distance from the ear-drum and from the walls\\nof the meatus. The other electrode was applied to the\\nmastoid process, the forehead, the nape of the neck, the\\ntrunk, or the extremities. The external method introduced\\nby Erb is the one now exclusively employed. It consists\\nin applying an ordinary flat electrode the cathode in\\nfront of the tragus (taking care not to press on the tragus\\nand thereby close the auditory meatus, as this would give\\nrise to buzzing and humming noises), while the other elec-\\ntrode the anode is placed on the nape of the neck or the\\npalm of the hand. A third method, in which the elec-\\ntrode is applied to the auditory meatus, filled with water\\n(Brenner, Erb), presents no special advantage, while the\\n1 Virch. Arch., xxxi, p. 483.\\n2 Arch. f. Augen- u. Ohrenheilk., vol. I, p. 156.\\nArch. f. Augen- u. Ohrenheilk., vol. i, p. 158.\\n4 Virch. Arch., xxxi, p. 493.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0274.jp2"}, "275": {"fulltext": "ELECTRIC REACTION. 26/\\nresults of the examination are no more satisfactory when\\none of the electrodes is replaced by a silver wire introduced\\nthrough a tubular catheter into the middle ear, as proposed\\nby Wreden.i\\nThe question has been raised whether the auditory nerve\\nor its terminations are really excited by the electric cur-\\nrent, or whether what is designated as the reaction of the\\nnerve may not be due to the irritation of other structures\\nin the ear. It was alleged that the reaction may be pro-\\nduced by contraction of the internal muscles of the middle\\near (Schwartze, Wreden), by irritation of the sympathetic\\n(Benedikt), or by a reflex irritation of the auditory through\\nthe trifacial nerve. While it has long been known that the\\nbony labyrinth is a bad electric conductor, the question was\\nagain discussed by Gartner and Pollak,^ who declared,\\nafter a series of investigations on pathologic organs, that\\nthe electric irritability of the auditory nerve depends on\\nthe excitability of the nerve itself to an electric current and\\non the resistance met with in the ear.\\nI have not the space to discuss in detail the various\\narguments which have led to the adoption of the view that\\nthe condition of the auditory nerve itself determines the\\nresults of the reaction, without entirely disregarding the\\nmodification in the resistance due to hyperemic and secretory\\nprocesses but in order to elucidate the present status of\\nthe question, I shall cite the propositions promulgated by\\nGradenigo,^ which most nearly correspond with the results\\nof practical experience in the healthy and in the diseased ear.\\n1. The normal ear gives an electric reaction of the\\nauditory nerve only in exceptional cases and when the\\nelectric current is unusually strong.\\n2. There is a heightened irritability in all inflammatory\\nand hyperemic diseases of the external, middle, and inter-\\nnal ear, and in the initial stages of a central cerebral disease.\\n3. The mode of reaction of the auditory nerve to the elec-\\ntric current is analogous to that observed in the other sen-\\nsory and motor nerves.\\nIn regard to the first proposition, it may be remarked\\nthat even the earliest followers of Brenner s doctrines be-\\ncame more and more reluctant to designate the acoustic\\nPetersb. raed. Zeitschr., 1891 reported in Arch. f. Ohr., VI, p. 147.\\n2 Wien. klin. Wochen., 1888, Nos. 31, 32.\\n8 Arch. f. Ohr., XXVII and xxviii.", "height": "3456", "width": "2108", "jp2-path": "rhinologylaryng00frie_0275.jp2"}, "276": {"fulltext": "268 NERVOUS DISEASES.\\nreaction as the normal formula to be aimed at in the healthy-\\nindividual. Schvvartze was not able to obtain the reaction\\nin every case later, Gradenigo found it present in only\\nfrom 5^ to 12^ of normal ears, and then only when a\\nhigher current strength was employed, usually from 10 to\\n16 m.a., certainly never under 6 m.a. This agrees with\\nErb s 1 more recent publication, in which he says that gal-\\nvanic stimulation of the auditory nerve is not always pos-\\nsible. As a very strong current is requisite to obtain the\\nreaction in healthy individuals, the examination is usually\\nattended with very unpleasant concomitant phenomena,\\nsuch as vertigo and flashes of light.\\nIt is therefore better to assume that there is a pathologic\\ncondition of the nerve whenever there is hyperesthesia to the\\ngalvanic current and not to attempt to lay down any normal\\nreaction for healthy individuals. Daily experience shows\\nthat electric excitability is not common in persons the sub-\\njects of ear disease. Gradenigo found that he could usually\\nobtain the reaction in 66^ of cases of ear disease with a\\ncurrent strength of from i to 3 m.a., and always with a\\nstrength of less than 6 m.a. Although this increased ex-\\ncitability of the auditory nerve to weak currents undoubtedly\\npoints to pathologic processes in the organ of hearing, it\\nhas no special diagnostic significance, as it may occur in a\\ngreat variety of diseases both of the ear and of the nervous\\nsystem. It is much to be desired that ear specialists might\\ncontribute more to the investigation of electric excitability\\nof the auditory nerve, in the hope of obtaining some definite\\ndiagnostic points for the prevailing theory that the audit-\\nory nerve reacts readily in those diseases of the middle or\\nthe internal ear that are accompanied by intense inflamma-\\ntory processes, but fails to react after the inflammation has\\nsubsided, and that the reaction of the nerve in acute or\\nchronic exudative or nonexudative catarrh of the middle\\near and in cases of gradual extension of such disease to the\\ninternal ear does not differ from that w^hich occurs under\\nnormal conditions (Gradenigo), is in urgent need of further\\nelucidation, as it is in direct contradiction to other observa-\\ntions, especially those published by Erb,^ which are in every\\nway admirable.\\n1 Ziemssen s Handb. der allgem. Ther., ni, 18S2, p. 236.\\n2 Arch. f. Ohr., xxviii, p. 247.\\n3 Ziemssen s Handb. der allgem. Ther., ui, 1882.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0276.jp2"}, "277": {"fulltext": "ELECTRIC REACTION. 269\\nThe power of hearing does not appear to bear any rela-\\ntion to the electric behavior of the auditory nerve. Accord-\\ning to Gradenigo, the greatest value of galvanic hyperes-\\nthesia of the auditory nerve in diagnosis of central abscess\\nof the nervous system is found in connection with brain-\\ntumor he found the phenomenon present in all but one\\nout of 18 cases. In tabes dorsalis, multiple sclerosis, and\\nchronic myelitis it is absent, according to Gradenigo, but is\\nsaid to have been observed by Erb. Gradenigo points out\\nthat in subnormal sensitiveness to auditory impressions in\\nhysteria the electric reaction of the auditory nerve is never\\nincreased.\\nIt is worthy of remark that ocular disturbances due to\\ncentral or intracranial paralytic lesions in the domain of the\\norgan of sight, such as ocular palsies and disturbances of\\nthe accommodation, are associated with galvanic hyperes-\\nthesia of the auditory nerve (Brenner, Erb). In ordinary\\ndisturbances associated with facial paralysis the electric con-\\nditions vary. In some cases there is hyperesthesia with\\nparadoxic reaction (Remak) a hyperesthesia was observed\\noccasionally in cases of aural hallucinations (Jolly).\\nFinally, it may be mentioned that certain alterations occur\\nin the reactions of the auditory nerve which have been de-\\nscribed as a paradoxic reaction and as a galvanic hyperes-\\nthesia, with anomaly and inversion of the normal formula.\\nParadoxic reaction consists in the production of sensations,\\ncorresponding to the indifferent electrode, in the ear which\\nis not included in the circuit this is regarded by Erb as the\\nexpression of so intense a heightening of the galvanic irrit-\\nability of the auditory nerve that even the weaker loops of\\nthe current, which reach the ear not included in the circuit,\\nare capable of producing the auditory sensation. In a case\\nof complete left-sided deafness, with the remains of an old\\nsuppuration, Erb found the normal formula inverted, as\\nfollows\\nKa. Cl\\nKa. D\\nKa. O p (piping sound, gradually disappearing).\\nAn. Cl R^\\nAn. D Pec\\nAn. O.\\n1 Haug s Vort., p. 411.\\n2 Grundriss der Elektrodiagnostik u. Elektrotherapie, 1895.\\n3 Arch. f. Psych., 1894, iv.", "height": "3456", "width": "2108", "jp2-path": "rhinologylaryng00frie_0277.jp2"}, "278": {"fulltext": "2/0 NERVOUS DISEASES.\\nI have seen in sclerosis of the middle ear with involve-\\nment of the internal ear cases in which the ear under\\nexamination presented the normal formula, while the ear\\nnot included in the circuit presented the paradoxic formula\\nRight.\\nLeft (included in circuit)\\nKa. CI\\nR (ringing).\\nKa. D\\nRco.\\nR\\nKa.\\nR\\nAn. CI.\\nRco\\nAn. D\\nAn. O\\nR.\\nAs an instance of other anomalies, Erb gives the follow-\\ning reactions, which occurred in a man fifty-four years old\\nwith chronic impairment of the hearing, tinnitus aurium,\\nand opacity and contraction of the ear-drum.\\nKa. Ci P^\\nKa. D P 00\\nKa. O b (buzzing noise).\\nAn. CI B^\\nAn. D B\\nAn. O p\\nIt is impossible to determine whether torpor of the audit-\\nory nerve is present or not, as the reaction in the healthy\\nindividual is not constant.\\nTHE LOCALIZATION OF THE EAR IN THE CENTRAL\\nNERVOUS ORGANS.\\nThe origin and root-fibers of the cochlear and vestibular\\nnerves, which together make up the auditory nerve, are\\ntwofold. While our knowledge of the former is fairly\\ncomplete, thanks to the investigations of Held, Flechsig,\\nand Bechterew, any description of the latter must be largely\\nhypothetic. The fibers of the cochlear nerve, the per-\\nipheral endings of which are found in the cochlea, spring\\nfrom the ventral auditory nucleus, and to a slight extent\\nfrom the tuberculum acusticum.^ A second system of\\nfibers originates in the ventral auditory nucleus (accessory\\nnucleus), and, after passing through the corpus trapezoides,\\nextends to the superior olive of the same and of the oppo-\\nsite side. The lateral root represents the continuation of\\nthe cochlear tract to the posterior corpora quadrigemina.\\nIt is joined, however, by the fibers from the auditory\\nAfter Edinger s description, p. 359, Fifth Edit.", "height": "3464", "width": "2132", "jp2-path": "rhinologylaryng00frie_0278.jp2"}, "279": {"fulltext": "LOCALIZATION, 2/1\\ntubercle, which run directly through the striae acustica to\\nthe lateral root. The lateral loop ends in the posterior\\nquadrigemina. Each of the posterior corpora quadrige-\\nmina sends out fibers through the inferior brachia, both of\\nthe same and of the opposite side, to the internal genicu-\\nlate body, where some of these fibers end. The remainder\\npass under the pulvinar into the internal capsule, where\\nthey divide into two bundles and are distributed to the\\ntransverse convolutions of the temporal lobe (superior\\ntemporal convolution). One of these bundles ascends\\nin the neighborhood of the external capsule and reaches\\nthe auditory sphere, while the other accompanies the optic\\nradiation for some distance and, after passing around the\\ninferior posterior portion of the fossa Sylvii, ascends to the\\ntransverse convolutions in the temporal lobe close to the\\nsecond and third convolutions.\\nThe course of the vestibular nerve is very obscure. It\\nappears to originate in the dorsal auditory nucleus or\\nDeiter s nucleus, which lies to the mesial side of the resti-\\nform body. Its connections with the vermiform process of\\nthe cerebellum are not known.\\nFrom this description it follows that auditory disturb-\\nances may be expected in disease of the auditory nucleus\\nin the medulla oblongata, of the superior olivary nucleus\\nin the pons, of the posterior quadrigemina, and, finally, of\\nthe first (superior) temporal convolution, and in disturb-\\nances of the nervous paths which connect these nuclei.\\nTumors and abscesses, foci of softening in the brain-sub-\\nstance, tubercular and syphilitic disease, cerebral hemor-\\nrhage, and many other diseases of the central nervous\\nsystem may produce a focal lesion by destroying the cen-\\ntral pathways. The only symptom of such a lesion in the\\ncochlear tract is difficult hearing, while vertigo and the\\nsigns of Meniere s symptom-complex generally are absent.\\nImpaired hearing from a central cause is recognized by the\\npresence of other phenomena of cerebral disease, and its\\ngradual increase in a subject whose hearing had always\\nbeen perfectly good corresponds to the gradual growth of\\nthe tumor. Unfortunately, we have no accurate knowl-\\nedge concerning the nature of a central deafness localized\\nin the cortex, but when the cause is found in a lesion of\\n1 See illustration No. 247, Edinger.\\nFlechsig, Gehirn u. Seele, 1896, p. 75.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0279.jp2"}, "280": {"fulltext": "2/2 NERVOUS DISEASES.\\nthe tegmentum or mesencephalon, the resulting auditory\\ndisturbance presents certain characteristics, which have been\\ndescribed by Siebenmann. Bone conduction is very much\\nimpaired or entirely abolished. Weber s experiment is\\nnot regularly successful, and may be lateralized either to\\nthe healthy or to the affected side. In the beginning of\\nthe developing deafness perception is lost for the lower\\nnotes only, while later in the course of the disease all the\\nnotes of the scale become uniformly inaudible, so that\\nfinally the patient retains only the power of hearing a cer-\\ntain number of notes in the lower middle register, as in\\ndiseases of the labyrinth and of the auditory nerve.\\nSubjective ear noises are rarely observed. Hyperes-\\nthesia of the auditory nerve appears to be possible in the\\nearly stages of a lesion of the auditory centers; at least,\\nthis would seem to explain the increased electric irritability\\nof the auditory nerve described by Gradenigo.\\nOppenheim quotes the statement that in tumor of the\\nsuperior temporal convolution the epileptic attacks were\\npreceded by an auditory aura. The important question\\nas to which side is affected in unilateral lesion of the\\ncerebral roots of the cochlear nerve has not yet been\\ndecided. The pathways cross each other at various\\npoints in their course through the pons, in the tegmentum,\\nand in the corpora quadrigemina, but the decussation\\nappears to be only partial, so that the cortical centers for\\nhearing on both sides of the brain appear to be connected\\nwith both auditory nerves. The result of this arrangement\\nis that unilateral disease in the region of the temporal lobe,\\nwhere the cortical center for hearing is found, does not\\nproduce unilateral deafness of the opposite side (crossed\\ndeafness), as some authors have claimed. Permanent cen-\\ntral deafness can be produced only by the destruction of\\nthe cortical centers for hearing in both hemispheres.\\nThe significance of the posterior corpora quadrigemina in\\nauditory disturbances has lately been carefully investigated\\nby Weinland and Siebenmann. Weinland maintains that\\ndisease of one of the posterior corpora quadrigemina pro-\\nduces auditory disturbance on the opposite side while\\nSiebenmann, on the contrary, claims that a lesion of only\\none of the posterior corpora quadrigemina does not produce\\nLehrb. der Nervenkrankh., p. 94.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0280.jp2"}, "281": {"fulltext": "LOCALIZATION. 2/3\\ndeafness a statement which is in direct opposition to the\\ngenerally accepted opinion that the corpora quadrigemina\\ncontain one of the auditory centers. By a careful review of\\nthe literature Siebenmann shows that in all cases of deaf-\\nness due to injury of the mesencephalon there is either\\ncompression or destruction of the tegmentum (or of the in-\\nternal capsule), whereas in simple cases of tumor of the\\ncorpora quadrigemina the hearing remains intact. From\\nthis he argues that the auditory disturbance is not directly\\ndue to the situation of the tumor in the posterior corpora\\nquadrigemina, but rather to its interference with the sur-\\nrounding parts and to the compression of the adjacent por-\\ntions of the mesencephalon, which contain the auditory\\npathways.\\nAs we have just remarked, Weinland says that the loss\\nof hearing occurs on the side opposite to that of the dis-\\neased corpora quadrigemina Oppenheim believes that\\neither the ear on the same side as the tumor or that on the\\nopposite side, or even both ears, may be affected while,\\naccording to Siebenmann, any lesion of the tegmentum\\nproduces bilateral deafness.\\nThe auditory disturbances that have been observed in\\ndiseases of the cerebellum must be attributed to extension\\nof the diseased focus to the medulla oblongata and pons, or\\ndirectly to the trunk of the auditory nerve. Such a disease\\nnecessarily interferes with the roots and centers of the ves-\\ntibular nerve contained in the cerebellum, but as we have\\nno definite knowledge of the relation existing between this\\ncerebellar ataxia and the static functions of the organ of\\nhearing, the question will not be included in the present\\ndiscussion.\\nIt is often very difficult to distinguish an auditory dis-\\nturbance due to central lesion from intracranial lesion of\\nthe trunk of the auditory nerve. A great number of cases\\nare known in which the auditory nerve was included in\\ntumors originating at the base of the brain, in the cere-\\nbellum, or in the pineal body. Such tumors even penetrate\\nthrough the porus acusticus internus into the labyrinth.\\nA differential diagnosis in such cases is impossible.\\nIn the etiology of the auditory disturbances which we\\nhave just described we have so far considered only those\\n1 Zeitschr. f. Obr., vol. xxix.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0281.jp2"}, "282": {"fulltext": "2/4 NERVOUS DISEASES.\\ndiseases which produce a direct lesion of the auditory path-\\nway and its cerebral centers. In other words, we regarded\\nthe auditory disturbance as a direct result of such a lesion.\\nWe must now mention another pathologic condition, which\\nis recognized by various authors, and to which Gradenigo,\\nin Schwartze s Handbuch der Ohrenheilkunde, assigns\\na very important place, although its occurrence is now\\ngenerally discredited namely, the question of the hiflitence\\noil licaring of a rise in the intracrajiial pressure.\\nReasoning by analogy from papillary congestion, it was\\nnatural to assume that increased intracranial pressure might\\nexert some influence on the auditory nerve, as the condi-\\ntions are in certain respects similar. Moos considered it\\ndoubtful that auditory disturbances could be due to increased\\npressure from cerebral tumors Steinbriigge interpreted a\\ndepression of Reissner s membrane as dependent on increased\\nintracranial pressure (an explanation which caused some\\ndiscussion in the Naturf. Vers, in Heidelberg, the sense of\\nthe meeting being that the depression was simply an arti-\\nfact) and Gradenigo assumes that in cases of brain-tumor\\nwith increased intracranial pressure, a lymphatic infiltration\\noccurs at the peripheral ending of the auditory nerve anal-\\nogous to the papillary congestion of the optic nerve.\\nThis interpretation is very artificial and anything but unas-\\nsailable, for most pathologists deny that papillary conges-\\ntion of the eye is due to intracranial pressure alone, attrib-\\nuting it rather to toxic influences. Although histologists\\npossess perfect methods and abundant material for the\\nanatomic investigation of the eye, their results are not by\\nany means uniform how, then, can we expect to draw any\\nreliable conclusion from the superficial descriptions of only\\ntwo histologic examinations of the labyrinth, in the exami-\\nnation of which it has so far been impossible to exclude\\nwith certainty the fallacies of artifacts? It is therefore not\\nto the credit of otology, and does not in the least add to\\nour understanding of the question, to erect a hypothetic\\npapillary congestion of the auditory nerve merely for\\nthe purpose of substantiating a preconceived opinion. In\\naddition we may mention the conclusion reached by Asher\\nin a very careful work on the subject that rise in the\\nintracranial pressure does not produce any constant dis-\\n1 Vol. II, p. 530.\\n2 D. Zeitschr. f. klin. INIed., 27, p. 513.", "height": "3468", "width": "2144", "jp2-path": "rhinologylaryng00frie_0282.jp2"}, "283": {"fulltext": "SAUNDERS^\\nMF.DICAL HAND-ATLASES,\\n:n view of the extraordinary success attending\\nthe publication of Saunders Medical Hand\\nAtlases, Mr. Saunders has contracted with the\\npublisher of the original German edition foi\\nONE HUNDRED THOUSAND\\nCOPIES\\nof these books. In consideration of this enor-\\nmous undertaking, the publisher has been en-\\nibled to prepare and furnish special addiliotia\\n:oIored plates, making these books even hand-\\nsomer and more complete than was originally\\nntended. ^^^^^^^ji^jX\\nAs an indication of the great practical value\\nDf these Atlases, and of the immense favot\\nsvith which they have been received by the\\nmedical profession, it should be noted that\\nThe Medical Department of the\\nTJ. S. Army\\nI\\n1\\naas adopted the Atlas of Operative Surgery\\nIS its standard, and has ordered the book in\\narge quantities for distribution to the various\\negiments and army posts, ji jt ji\\n4^.:p", "height": "3456", "width": "2112", "jp2-path": "rhinologylaryng00frie_0283.jp2"}, "284": {"fulltext": "Mr. Saunders points with a teeiing\\nof pardonable pride to the success that has\\nattended the publications issued from his house\\n\u00e2\u0080\u0094a record that is without parallel in the his-\\ntory of medical publication.\\nSince the appearance of the first of the\\nSAUNDERS QUESTION-COMPENDS\\nover 175,000 copies of these invaluable self-\\nhelps have been sold to physicians and students.\\nTHE AMERICAN TEXT-BOOKS\\nhave also met with a success that is nothing\\nless than phenomenal, as is attested by the fact\\nthat in the short period since the publication of\\nthe first volume of the series over 100,000 copies\\nof these popular text-books have been sold in\\nthis country and abroad.\\nOnly books of rare merit could have\\nattained such extraordinary sales, which fur-\\nnish indisputable evidence of the high standing\\nacquired by these books among physicians and\\nstudents throughout the civilized world.\\njT ai? jT jf", "height": "3464", "width": "2152", "jp2-path": "rhinologylaryng00frie_0284.jp2"}, "285": {"fulltext": "TABES DORSALIS. 2/5\\nturbances in the organ of hearing, as the pressure conditions\\nin the endolymphatic and perilymphatic spaces, which\\ndepend on the hydrostatic pressure of the lymphatic fluid,\\ntend to regulate each other mutually, and thus to prevent\\nthe occurrence of excessive pressure.\\n3. NERVOUS DISEASES WHICH PRODUCE DEFI-\\nNITE ALTERATIONS IN THE NOSE, PHAR-\\nYNX, AND LARYNX, AND IN THE EARS,\\nDISEASES OF THE SPINAL CORD.\\nTabes Dorsalis.\\nThe occurrence of laryngeal disturbances in tabes was\\nformerly regarded as very rare, and until very recently\\nopinions diverged as to the existence of any relation\\nbetween tabes and difficult hearing. But now we have a\\nlong series of statistics and reported cases which prove that\\nthe vagus and auditory nerve are comparatively often in-\\nvolved in tabes dorsalis, if not quite as frequently as the\\noptic nerve. According to Klippel,^ the olfactory nerve\\nalso becomes involved in tabes, and there result disturb-\\nances of the sense of smell, manifesting themselves in uni-\\nlateral anosmia, parosmia, and hallucinations of scent.\\nStatistics differ very widely as to the frequency of laryn-\\ngeal symptoms in tabes dorsalis Krause found motor dis-\\nturbances in 13 out of 38 cases, but does not give any\\ndetailed description of their nature Marina, on the strength\\nof Fano s investigation, gives 19 cases of motor disturbances\\nin 36 patients suffering from tabes, in all of which the con-\\nditions were found to be abnormal. Dreyfus found two cases\\nof double posticus paralysis among 22 tabes patients\\nBurger in 6 out of 20 cases found that motor disturbance\\ncould be demonstrated with the laryngoscope. I may add\\nthat among 27 tabetic patients in the Medicinische Uni-\\nversitats-Poliklinikin Leipzig I found no disturbances in the\\nlarynx while, on the other hand, in the case of one tabetic\\npatient who had sought medical advice on account of dysp-\\nnea I found a double posticus paralysis associated with\\nparesis of the vocal cords. Statistics based on such small\\n1 Arch, de Nenrol., 1897 see .Schm. Jahrb. vol. CCLVii, p. 82.\\n2 Die laryngealen Storungen bei Tabes dorsalis, Leiden, 1891.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0285.jp2"}, "286": {"fulltext": "2/6 NERVOUS DISEASES.\\nmaterial are, however, of very little value, as were shown by\\nSemon, who found among the 12 first cases of tabes which\\nhe examined unilateral or bilateral posticus paralysis five\\ntimes, whereas the next 30 cases did not yield a single\\nlaryngeal disturbance. Of more recent contributions we\\nmay mention that of Gerhardt,^ who found 17 paralyses\\nin 122 tabetic patients, 11 of the posticus (5 bilateral,\\n4 the right posticus, 2 the left posticus), and 3 of the\\nrecurrent laryngeal nerve (i bilateral, 2 unilateral on the\\nright side). The 3 remaining cases consisted of paral-\\nysis of the posticus and thyroid muscles once, paralysis of\\nthe recurrent nerve of one side and of the posticus nerve of\\nthe other side once, and 2 paralyses of the thyroid aryte-\\nnoid muscle. In 2 cases there were ataxic movements of\\nthe vocal cords in 4 cases there were laryngeal crises.\\nAmong 100 cases of tabes Semon found 8 unilateral\\nposticus paralyses, 3 bilateral posticus paralyses, and 3\\nunilateral paralyses of the recurrent nerve.\\nThe most frequent laryngeal complications consist in\\nmotor palsies of the laryngeal muscles. The typical tabetic\\npalsy is that of the crico-arytenoideus posticus, either of one\\nor of both sides. In Berger s table of 71 cases of tabetic\\nlaryngeal paralysis published up to 1891, there are 33 cases\\nof unilateral paralysis of the posticus, in a few of which\\nthere was a coexistent paralysis of the intemus the\\nremaining 38 cases consisted of unilateral paralysis of the\\nposticus, while a few cases showed paralysis of the posticus\\non one side and paralysis of the recurrent nerve on the\\nother.\\nFrom this it would appear that bilateral paralysis of the\\nposticus is almost as frequent as the unilateral form. It\\nmust, however, be remembered that the symptoms due to\\nthe various forms of paralysis may either be so marked as\\nto produce a very noticeable alteration in the voice or res-\\npiration, and thus arouse a suspicion of laryngeal disturb-\\nance, or they may be so mild as to escape the examiner s\\nnotice altogether, unless every tabetic patient is systematic-\\nally subjected to a laryngoscopic examination. Hence,\\nunilateral paralysis of the posticus, which does not affect\\nphonation and respiration, is frequenth- overlooked, while\\nbilateral paralysis of the abductors of the glottis never\\n1 Nothnagel s Spec. Path. u. Ther., vol. xiii, p. 55.\\n2 Heymann s Handb., vol. i, p. 705.", "height": "3468", "width": "2140", "jp2-path": "rhinologylaryng00frie_0286.jp2"}, "287": {"fulltext": "TABES DORSALIS. 2 J J\\nescapes detection, because it is always associated with\\nhoarseness and dyspnea.\\nComplete paralysis of the recurrent nerve is extremely\\nrare in tabes dorsalis. As we have previously stated, a\\nsubacute disease affecting the nuclei of the vagus and of\\nthe recurrent nerve first produces paralysis of the posticus,\\nwhich only becomes converted into paralysis of the recur-\\nrent later in the disease. The question naturally suggests\\nitself. Why do we not observe this transition from the\\nmedian to the cadaveric position in those cases of tabes\\ndorsalis which persist for many years, and which, as\\nwe know from the reports of autopsies, attack the nuclei in\\nthe medulla oblongata The only clinical fact which\\npoints to a progressive nature of posticus paralysis is the\\noccurrence of paresis of the internus, which manifests itself\\nin the laryngeal image in relaxation of the vocal cord,\\nand clinically in the hoarseness and a diminution of the\\ndyspnea due to the bilateral paralysis the rare cases\\nof recurrent paralysis in tabes, being imperfectly described,\\nare open to question, and can not be regarded as secondary\\nto posticus paralysis. One thing is absolutely certain the\\nadductors or closers of the glottis are never affected\\nalone in tabes dorsalis. The cricothyroid muscles are also\\npractically never attacked Gerhardt s case of paralysis of\\nthe cricothyroid associated with that of the posticus is the\\nonly one that we have met with.\\nThe laryngeal palsies are usually observed in the earlier\\nstages of tabes dorsalis and sometimes precede all other\\nsymptoms.\\nIt has been occasionally stated that intermittent paral-\\nysis of the vocal cords may be observed in tabetic patients,\\nand that a posticus paralysis may disappear after a few days\\nand return after the lapse of weeks but the statement has\\nnot been satisfactorily proven, and until we have more\\naccurate observations we must assume that once the tabetic\\nparalysis has developed in the larynx there is no hope of\\ncure. The paralysis may, however, develop very gradually,\\nand several cases have been reported which remained con-\\nstantly under observation and in which a complete posticus\\nparalysis developed in the course of weeks or months at\\nfirst there was some power of abducting the vocal cords\\n1 Ann. des mal. de I oreille, iSgi, p. 4S0.", "height": "3456", "width": "2052", "jp2-path": "rhinologylaryng00frie_0287.jp2"}, "288": {"fulltext": "278 NERVOUS DISEASES.\\nthis gradually diminished, and finally the vocal cords\\nremained immovable in the median position.\\nThe subjective symptoms are the same as those which\\noccur in paralysis of the vocal cords from other causes.\\nWhen there is hoarseness, a posticus paralysis produces no\\nsymptoms unless the vocal cords are implicated any marked\\ndisturbances always tend to posticus paralysis. The symp-\\ntoms consist in dyspnea, the voice being only slightly,\\nif at all, affected. As the paralysis develops very gradually,\\nthe patient becomes accustomed to the stenotic condition of\\nthe rima glottidis, and the interference with respiration is\\ncomparatively slight, except during bodily exertion and\\nphonation during sleep, however, the stenosis becomes\\nvery marked. There is a good deal of inspiratory dyspnea,\\nshowing itself in loud, sighing inspirations, while the\\nexpiration is quite free. There is, of course, a constant\\ndanger of asphyxia whenever a greater demand is made on\\nthe respiration during any form of bodily activity, so that\\nsooner or later tracheotomy becomes necessary in cases of\\nposticus paralysis.\\nAn experiment performed by Ruault deserves mention\\nin this place. He excised 1.5 cm. from the recurrent nerve\\nin a tabetic patient who was suffering from intense dyspnea\\ndue to posticus paralysis, in the hope of bringing the vocal\\ncords into the cadaveric position, but the operation was not\\nfollowed by any change either in the laryngeal image or in\\nthe subjective symptoms of the patient. This is the only\\ncase of its kind, and has no particular value.\\nAtaxia of the vocal cords is a name given to a condition\\nin which the vocal cords execute irregular movements dur-\\ning phonation and deep respiration. Krause was the first\\nto remark that the vocal cords tended to move in jerks and\\nto stop midway between complete adduction and the inspi-\\nratory position, producing interrupted or scanning speech.\\nIt has been elaborately proved by Burger that this motor\\nanomaly, which occurs exclusively in tabes, is a true ataxia,\\nor disturbance in the coordination of all the antagonistic\\ngroups of muscles the cooperation of which is necessary to\\nproduce all the movements of the vocal cords.\\nLaryngeal crises consist in convulsive attacks of cough\\nand dyspnea, and occur in the beginning of, or during the\\ncourse of tabes, like gastric crises. They differ from attacks\\nof simple laryngeal spasm in that all the other respiratory", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0288.jp2"}, "289": {"fulltext": "TABES DORSALIS. 2/9\\nmuscles are involved. The attacks either occur without\\nany ascertainable cause or after slight external, mechanical,\\nor psychic irritation, particularly swallowing and the intro-\\nduction of a probe into the throat. According to Oppen-\\nheim, pressure on the throat at a point near the anterior\\nborder of the sternomastoid muscle at the level of the cri-\\ncoid cartilage produced attacks of coughing. The attacks\\noccur with variable frequency they may be repeated\\nseveral times within a few hours, or a single attack may be\\nfollowed by a period of freedom lasting for months or years,\\nor may never be repeated. They are usually preceded by\\na feeling of tickling or burning in the throat this is followed\\nby a choking attack, with loud, strident inspirations and\\nshort, puffing expirations, accompanied by a violent, bark-\\ning cough which has been compared to whooping-cough.\\nThe patient becomes intensely excited and greatly terrified\\nat the idea of impending suffocation, until, after a short\\ntime the attacks rarely last longer than a minute the\\nrespiration is suddenly or gradually restored, sometimes\\nafter the expectoration of a little mucus (Burger). They\\nusually end in recovery in spite of their intensity, although\\nBurger was able to collect five cases which terminated\\nfatally during the attack.\\nPharyngeal crises are described by Oppenheim as attacks\\nof convulsive gulping movements, which, however, are for-\\neign to our subject. Sensory disturbances of the larynx\\nduring tabes are rare. A few cases of anesthesia and\\nhyperesthesia of the pharyngeal and laryngeal mucous\\nmembrane have been observed. With regard to the appear-\\nances produced by tabes dorsalis in the organ of hearing, I\\nshall here reprint a paper which I read before the Deutsche\\nOtologische Gesellschaft in Dresden, in 1897, and which\\nappeared in a rather inaccessible portion of the reports of\\nthat meeting\\nIn spite of the fact that several papers have appeared\\non the subject of aural disturbances in tabes dorsalis,\\nopinions are still divided as to their nature, and there are\\nthose who deny the occurrence of deafness as a result of\\ntabes.\\nI shall omit the list of reported cases and shall not\\nrepeat the various opinions which have been expressed on\\nthis subject, contenting myself with referring to Burger,", "height": "3444", "width": "2048", "jp2-path": "rhinologylaryng00frie_0289.jp2"}, "290": {"fulltext": "280 NERVOUS DISEASES.\\nTreitel,! and Haug,^ who have given a complete bibli-\\nography of the subject. I shall make it my task to attempt\\nto explain the probable nature of ear disease in tabes dor-\\nsalis by means of our anatomic and clinical knowledge of\\nthe conditions. Although there are no anatomic investiga-\\ntions at my disposal, I shall utilize the results of examina-\\ntions made on the ears of 27 tabetic patients by a Doctor-\\nand in the Medicinischen Universitats-Poliklinik at Leip-\\nzig. Among these patients there were two cases of im-\\npaired hearing which could with certainty be referred to\\ntabes at least, with as much certainty as the present state\\nof aural examination will permit. I give the percentage as\\n7.3, although I am reluctant to compute a rate on such a\\nlimited number of cases. At least, these investigations\\nshow that tabetic ear disease is extremely rare, and tally\\nalmost perfectly with the statistics published by Voigt and\\nTreitel, who found auditory disturbances in 2 cases out\\nof 100, and in 2 cases out of 20, or 2^ and 10 fo, respec-\\ntively. I was unable to obtain the statistics by Marie and\\nWalton in the original, but I have nothing to criticize in\\nthe finding of Meniere s symptom -complex in 17 out of 24\\ncases on the other hand, I object strongly to Morpurgo s\\nstatement that he found in 43 cases out of 53 auditory dis-\\nturbances which could be traced to tabes dorsalis a per-\\ncentage of 81.13. As the diagnosis was based purely on\\na positive Rinne test, at reduced hearing-distance, and on a\\nnormal condition of the ear-drum, while the air douche was\\nnot followed by improvement in the hearing, these statistics\\nare manifestly defective, and after examining the cases I\\nclaim that the list does not contain a single case of authen-\\ntic tabetic deafness.\\nThe infrequency of auditory disturbances in tabes is\\nconfirmed by the observation of clinicians with a large\\namount of material at their command. If we compare the\\nmeager reports of deafness with the great number of case\\nhistories of tabes dorsalis contained in the literature (we\\nneed only mention Erb s statistics of more than 700 cases),\\nour faith in an author who gives a percentage of 81.13 s\\nvery much shaken.\\nThe clinical picture of the ear affection is variously de-\\n1 Zeitschr. f. Ohr., xx.\\n2 Die Krankheiten des Ohres in ihren Beziehungen zu den Allgemeiner-\\nkrankungen. Vienna and Leipzig, 1893.", "height": "3468", "width": "2112", "jp2-path": "rhinologylaryng00frie_0290.jp2"}, "291": {"fulltext": "TABES DORSALIS. 28 1\\nscribed. According to some, the disease presents the\\ncharacteristics of a lesion in the sound-perceiving apparatus,\\nand is distinguished by otitis interna and by the fact that\\nperception for the higher notes is relatively good, while the\\nhearing is impaired for the deeper and middle notes of the\\nregister. Others distinguish two clinical forms, one of which\\nmust be regarded as a simple tabetic atrophy of the audit-\\nory nerve, the other as syphilitic disease of the labyrinth.\\nThe former is gradual in its onset and goes on slowly to\\ncomplete deafness, being accompanied with tinnitus aurium,\\nbut never with vertigo the latter makes its appearance\\nsuddenly, like a stroke of apoplexy, wdth the phenomena\\nof Meniere s symptom-complex, and in many cases rapidly\\nleads to total deafness.\\nIt follows from this divergence in the conception of\\nthe clinical course of the auditory disturbance in tabes that\\nthe most various attempts were made to explain the nature\\nof the disease. Some incline to regard the process as an\\natrophy of the auditory nerve, others attribute the disease\\nto trophic disturbances in the middle ear due to tabetic dis-\\nease of the trifacial nerve, while a third faction describes\\nthe disease as syphilitic. As I shall presently show, all\\nthese theories lack the support of anatomic or clinical find-\\nings, which alone afford a reliable basis for the description\\nof the disease.\\nMost authors interpret tabetic disease of the ears as an\\natrophy of the auditory nerve with the symptoms of a lesion\\nof the sound-perceiving apparatus. It is a proof of our\\npresent inability to make a clinical diagnosis of atrophy of\\nthe auditory nerve that attempts are constantly being made\\nto discover some minute changes which should be charac-\\nteristic of tabetic disease of the auditory nerve.\\nGradenigo considers it characteristic of tabes when the\\nperception of high notes is relatively good and the loss of\\nhearing applies chiefly to the lower and middle notes but\\nthis phenomenon is not constant, to say the least, for in\\nHabermann s case perception of the lower notes remained\\ngood after the patient was unable to hear higher ones.\\nAgain, many authors have emphasized the great electric\\nirritability of the auditory nerve, but this phenomenon has\\nnot met with universal recognition, and is, moreover, of\\nlittle value, in view of our imperfect knowledge of the\\nphysiology of the electric reaction of the auditory nerve.", "height": "3448", "width": "2100", "jp2-path": "rhinologylaryng00frie_0291.jp2"}, "292": {"fulltext": "^82 NERVOUS DISEASES.\\nThe conception of a progressive atrophy of the auditory-\\nnerve fails to find pathologic support, because those cases\\n\u00e2\u0080\u00a2in which disease of the nerve-endings in the labyrinth and\\nin the nuclei was found associated with atrophy of the\\nauditory nerve can not be regarded as cases of primary\\natrophy of the auditory nerve.\\nAlthough on theoretic grounds there may be no objec-\\ntion to this interpretation, since disease of the trunks of the\\n-cranial nerves is said to occur in tabes, there is, as I have\\nsaid, a complete absence of anatomic or clinical proof of its\\nrepresenting the type of a tabetic auditory disturbance\\nconsequently, other explanations were sought. When\\nLucae was able to refer the impairment of hearing in two\\ntabetic patients to simple disease of the middle ear, furnish-\\ning anatomic proof in one case, it gave rise to the opinion\\nthat the middle-ear affection was due to tabetic disease of\\nthe trifacial nerve, in support of which was cited the fact,\\ndetermined by the experiments of Baratoux, Gelle, and\\nBerthold, that trophic disturbances may appear in the\\nmiddle ear after the destruction of the roots of the trifacial\\nnerve. But there is no proof whatever that such an effect\\non the middle ear through the trifacial nerve takes place in\\ntabes, for in Lucae s case there were no other disturbances,\\nsuch as would necessarily be present in any disease of the\\ntrunk or nucleus of the trifacial, nor was there any anatomic\\nproof of such disease. On the other hand, this explanation\\nis untenable from the fact that Oppenheim found the\\nhearing to be quite normal in a case of marked alteration\\nof the trifacial where the diagnosis rested on an anatomic\\niDasis nor is there any mention of auditory disturbances in\\nanother similar case of Oppenheim s. If the opinion that\\nthe fifth nerve plays an important part in tabetic deafness\\nwere correct, the symptom would certainly have been\\npresent in these two cases its absence, however, makes\\nthe hypothesis very improbable.\\nThe syphilitic form of aural disease remains to be dis-\\ncussed. This is particularly insisted upon by Haug,^ who\\nappears to believe that these cases possess very character-\\nistic clinical features, consisting principally of Meniere s\\nsymptoms, with abrupt onset, marked vertigo, vomiting,\\n\u00e2\u0096\u00a0and sudden deafness, sometimes associated with violent\\nArch, fiir Psychistrie und Nervenheilk., xx, p. 147.\\n2 Loc. cit.", "height": "3468", "width": "2132", "jp2-path": "rhinologylaryng00frie_0292.jp2"}, "293": {"fulltext": "TABES DORSALIS. 283\\npains. The objective signs, he says, differ from those in a\\nsimple case of tabes by the fact that bone conduction is\\ncompletely abohshed. I can not see how these symptoms\\njustify Haug in believing that he has in all probability to\\ndeal with syphilis, since other nervous affections of the\\near are accompanied by the same symptoms. Haug also\\ncites the report of an autopsy which he says confirms his\\nopinion, but it is left to the reader to pick out what he con-\\nsiders characteristic of syphilis. It appears that Haug s\\ndiagnosis was determined by a little round-celled infiltration\\nwhich was found surrounding some of the smaller vessels,\\nand the proliferation in the intima of the same. Haug is\\nwelcome to consider the ear affection in his case as syph-\\nilitic but, if so, it is not tabetic, and has developed inde-\\npendently of tabes. The explanation that a primary\\nsyphilitic infection may give rise to the combination of lues\\nand tabes which occasionally appears in the organ of hear-\\ning in the form of a labyrinth affection seems rather\\nobscure, and even if we admit a connection between tabes\\nand syphilis, it is, in my opinion, a mistake to look for ter-\\ntiary syphilitic changes, as such are never found in the\\nparasyphilitic affections, to which the tabetic deafness in\\nthis case would belong.\\nThe latest investigations hardly admit of any other\\nexplanation of tabes than that it is a disease of the neurons,\\nconsisting principally in a lesion of the systems that take\\ntheir origin in the spinal ganglia. I would apply the same\\nexplanation to the auditory disturbances which occur in\\ntabes, and shall, therefore, continue the discussion of this\\nquestion by referring to the reports of autopsies and clinical\\nobservations which have hitherto been published.\\nFor the morbid anatomy, I begin by citing a case of\\nHabermann s.i in which the disease was limited to the trunk\\nof the auditory nerve and its terminal endings in the laby-\\nrinth, while the nuclei remained intact. It is Avorth men-\\ntioning that the atrophy of the fibers of the cochlear nerve\\nwas not so great on the right as on the left side. A bundle\\nof nerve-fibers at the apex of the cochlea and several\\nganglion cells in the terminal portion of the basilar convolu-\\ntion were preserved a condition which manifested itself\\nclinically in ability on the part of the patient to perceive\\ndeeper tones.\\n1 Arch. f. Ohr., xxxiii, p. iii.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0293.jp2"}, "294": {"fulltext": "284 NERVOUS DISEASES.\\nNext, I will mention Gelle s case, which is always quoted\\nin support of the doctrine of middle-ear disease in tabes. In\\na woman forty-two years of age, the subject of tabes, there\\nwas a sclerosis of the mucous membrane of the middle ear,\\nimmobility of the ear-drum and of the chain of ossicles,\\nankylosis of the stapes, and, as a result of these changes,\\nto quote the common explanation, a slight atrophy of\\npart of the various portions of the cochlea, including a dis-\\nturbance of the nerve -endings on the basilar membrane.\\nThe nerves in the lamina spiralis, in the vestibules, and in\\nthe semicircular canals were not attacked. In view of the\\natrophy of the nerve-endings on the basilar membrane I\\nquestion the propriety of regarding this case as one ot\\nsimple middle -ear disease, and am inclined to look upon\\nit as a primary peripheral disease of the cochlear nerve.\\nStriimpell has described one case of tabes in which there\\nhad been complete bilateral deafness for four years. Micro-\\nscopic examinations revealed an evident atrophy of the au-\\nditory nerves. Nothing is said about the nuclei or the\\ninternal ear, although the statement that the degenerative\\nprocess, strange to say, disappears in the restiform body\\njustifies the assumption that if there had been any disease\\nof the auditory nuclei, which are in such close proximity to\\nthe restiform body, it would not have escaped the author s\\nnotice.\\nThere remain to be mentioned three cases by Haug in\\ntwo of which the cochlear and vestibular nerves appeared\\nto be completely destroyed the trunk and nuclei of the\\nauditory nerve, however, were not examined. In the third\\ncase the fibers of the cochlear nerve. had disappeared and\\nbeen replaced by connective tissue, the cells of Corti s\\norgans were opaque, the basilar membrane was preserved,\\nwhile Corti s membrane and the reticular membrane were\\nthe seat of membranous adhesions. Unfortunately, the\\nauthor does not give a detailed description of this very in-\\nteresting aural condition, because it would lead him too\\nfar afield, so that there is nothing left to discuss but the\\nmedulla oblongata, as the trunk of the auditory nerve was\\nnot examined. One of the chief nuclei showed only a\\nslight degeneration of the nerve-fibers, while the other was\\nquite normal. The accessory nuclei could not be made\\nout, as they appeared to be replaced by round-celled infil-\\ntration. There was a diminution in the number of fibers in", "height": "3468", "width": "2228", "jp2-path": "rhinologylaryng00frie_0294.jp2"}, "295": {"fulltext": "OGDEN ON\\nTHE URINE\\nCLINICAL EXAMINATION OF\\nTHE URINE AND URINARY\\nDIAGNOSIS. A\\nClinical Gtiide for the\\nUse of Practitioners\\nand Students of Med-\\nicine and Surgery. By J. Berg;en\\nOgden, M.D., Instructor in Chemistry,\\nHarvard University Medical School;\\nAssistant in Clinical Patholog;y, Boston\\nCity Hospital. Handsome octavo,\\n425 pages, with 54 illustrations, and a\\nnumber of colored plates. Cloth, $3.00\\nnet.\\nJUST ISSUED,\\nThe design of this work is to present in as con-\\ncise a manner as possible the chemistry of the\\nurine and its relation to physiologic processes?\\nthe most approved working methods, both quali-\\ntative and quantitative j the diagnosis of diseases\\nand disturbances of the kidneys and urinary\\npassages. i*t^t|tt^t^ ^i^v?*t^\\nIn addition to chemic and microscopic methods,\\nwhich have been described in detail, special\\nattention has been paid to diagnosis, including\\nour present knowledge of the character of the\\nurine, the diagnosis and differentiation of dis-\\neases of the kidneys and urinary passages an\\nenumeration of the prominent clinical symptoms\\nof each disease and, finally, the peculiarities of\\nthe urine in certain general diseases of the body.\\nFor sale by all Booksellers, or sent post-paid on\\nreceipt of price.\\nW. B. SAUNDERS CO., Publishers,\\n925 Walnut St., Philadelphia.", "height": "3452", "width": "2088", "jp2-path": "rhinologylaryng00frie_0295.jp2"}, "296": {"fulltext": "THE TREATMENT OF FRACT-\\nURES. By Charles L. Scudder, M, D.,\\nAssistant in Clinical\\nand Operative Sur-\\ngery, Harvard Med-\\nical School. Hand-\\nsome Octavo volume, with nearly\\n600 beautiful original illustrations.\\nCrushed buckram, $4.50 net. J-\\nSCUDDER S\\nFRACTURES\\nJUST ISSUED.\\nThis book is intended to serve as a guide to the\\npractitioner and student in the treatment of fract-\\nures of bones, being a practical statement of the\\ngenerally recognized methods of dealing with\\nfractures. The attention of the student is di-\\nverted from theories to the actual conditions that\\nexist in fractured bones, and he is encouraged to\\ndetermine for himself how^ to meet the conditions\\nfound in each individual case. Methods of\\ntreatment are described in minute detail, and\\nthe reader is not only told, but is shown, how\\nto apply apparatus, for, as far as possible, all the\\ndetails are illustrated. This elaborate and\\ncomplete series of illustrations constitutes a feat-\\nure of the book. There are nearly 600 of them,\\nall from new and original drawings and repro-\\nduced in the highest style of art.\\nFor sale by all Booksellers, or sent post-paid on\\nreceipt of price.\\nW. B. SAUNDERS CO., Publishers,\\n925 Walnut St., Philadelphia.", "height": "3468", "width": "2140", "jp2-path": "rhinologylaryng00frie_0296.jp2"}, "297": {"fulltext": "TABES DORSALIS. 285\\nthe ascending limb and in the mesial root of the auditory\\nnerve, but none in the lateral root.\\nThis is the case that Haug described as syphilitic, and,\\ninteresting as it is in certain details, its value is very limited,\\nas the anatomic examination of the medulla oblongata is so\\nimperfectly described that it is impossible to obtain a clear\\nmental picture. The same may be said of Oppenheim s\\ncase, in which it is said that nothing definite could be made\\nout in the nuclei of the auditory nerve, although it was\\nquite evident that a large proportion of the root-fibers,\\nwhich leave the acoustic nucleus at the point where it dis-\\nappears beneath the nucleus of the vagus and pass up over\\nthe ascending root of the fifth nerve, were atrophied. The\\nauthor also says that the root-fibers of the auditory nerve\\nare deep red in color, and under a high power appear to\\nhave lost the characteristic appearance of nerve-fibers and\\nto be converted into a wavy mass of connective tissue very\\nrich in cells. The trunk of the auditory nerve and the\\ninternal ear were not examined.\\nIf we review these cases, we find an evident involvement\\nof the terminations of the cochlear and vestibular nerves in\\nHabermann s and in two of Haug s cases. Gelle s case\\npresents atrophy of the peripheral endings of the cochlear\\nnerve in Striimpell s case, where the internal ear was not\\nexamined, there was atrophy of the auditory nerve, while\\nthe nuclei were probably intact, and the condition in the\\nlabyrinth and cochlea is not known finally, in Haug s\\nthird case there was evidently deep-seated disease of the\\nauditory nerve and its terminations, associated possibly\\nwith disease of the acoustic nuclei. It thus appears that,\\nof all the parts which make up the auditory pathway, the\\nterminations of the cochlear nerve and its ganglion spirale,\\nthe vestibular nerve, and the trunk of the auditory nerve\\nare those most constantly affected, while in regard to dis-\\nease of the nuclei there are no reliable observations. This\\nneed not surprise us, if we consider the difficulties which\\nare encountered, even in the normal condition, in the\\ndescription of the higher auditory pathways.\\nTo make the matter a little clearer, I shall review once\\nmore the course of the auditory pathway, and for this pur-\\npose shall use the description given by Edinger. The\\ncochlear nerve represents the central process of the cells of\\nthe ganglion spirale. P rom this ganglion, which is situated", "height": "3448", "width": "2028", "jp2-path": "rhinologylaryng00frie_0297.jp2"}, "298": {"fulltext": "286 NERVOUS DISEASES.\\nin the cochlea, are derived the minute peripheral branches\\nwhich ramify among the auditory cells. The fibers of the\\ncochlear nerve, which were formerly designated as the pos-\\nterior roots, enter the ventral nucleus of the auditory nerve^\\nexcept a small portion which go to the tuberculum acus-\\nticum. These structures together represent the primary\\nneuron of the auditory pathway, the ganglion spirale repre-\\nsenting the ganglion cells the cochlear nerve, the axis-\\ncylinder; and the crista acustica, the peripheral terminations.\\nIn the vestibular nerve the conditions are not quite so clear\\nit appears, however, that the ganglia of the primary neuron\\nare situated in the labyrinth, and from that point send out\\nthe peripheral terminations to the specialized epithelium in\\nthe ampulla, while the axis-cylinder is represented by the\\nvestibular nerve which ends in the dorsal auditory nucleus.\\nThe course of the higher pathways, which are regarded as\\nsecondary and tertiary neurons, does not interest us in this\\nconnection but we may refer to the developmental rela-\\ntionship probably existing between the ganglion spirale\\nand the spinal ganglia, according to which it is assumed\\nthat the ganglion cells of the cochlear nerve in the develop-\\nment of the organism have moved out toward the periphery\\nin a manner analogous to the formation of a spinal ganglion.\\nThis relationship appears to me to furnish the explanation\\nfor tabetic auditory affections, as I agree with v. Leyden\\nand others in regarding tabes as a disease of the spino-\\ncutaneous sensory neurons. The theory is not so far\\nfetched as would appear at first sight, if we consider the\\nbehavior of the peripheral sensory nerves as studied by\\nv. Leyden and his followers and by Oppenheim. Atrophic\\nprocesses in the peripheral endings of the sensory nerves\\nhave been demonstrated in tabes, and, quite recently, Moxter\\nsuggested that disease of the optic nerve represents an\\naffection of the neurons beginning in the peripheral endings\\nin the layer of ganglion cells of the retina. As I have\\nalready pointed out, the most frequent anatomic alterations\\nin tabetic ear disease are found in the peripheral endings of\\nthe auditory nerve, and I accordingly venture to express\\nthe opinion that the tabetic ear disease represents a morbid\\nprocess localized in the peripheral endings in the primary\\nneuron of the auditory nerve that is to say, in the endings\\nof the cochlear nerve, the ganglion spirale and its axis-\\ncylinder, and the trunk of the auditory nerve.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0298.jp2"}, "299": {"fulltext": "TABES DORSALIS. 28/\\nThis conception of the seat of the disease would seem to\\nagree with the clinical picture described by Haug in a pure\\ntabetic form of disease of the auditory nerve, for he described\\nit as a very gradual impairment of the hearing, depending\\non atrophy, and associated with subjective noises.\\nAs an illustration of the clinical picture, I shall describe\\none of the two cases of tabetic ear disease which I had the\\nopportunity to observe. A woman fifty years of age had\\nbeen suffering from symptoms of tabes for a number of\\nyears the patellar reflexes were entirely abolished, the\\ngait was ataxic, the pupils were almost rigid, and Rom-\\nberg s phenomenon could be easily demonstrated. Within\\nthe last three years the hearing, which had never been\\ngood, gradually deteriorated. The optic nerve was intact.\\nThe patient complained of humming and buzzing noises in\\nthe ears, at times so marked as to give the impression of\\nthe ringing of bells, the twittering of birds, etc. On exam-\\nining the ears, an old perforation was found in the right ear-\\ndrum in the anterior inferior quadrant, together with\\nmarked calcification, while on the left side the membrane\\nshowed opacities.\\nThere had evidently existed an old purulent otitis media,\\nwhich not improbably bore some relation to an atrophic\\nrhinitis still present.\\nWhen the functional test was applied, it was found that\\nthe internal as well as the middle ear was involved. Bone\\nconduction was entirely abohshed. On the other hand, the\\ndeeper and middle notes were very faintly heard on the\\nright side (C only in strong vibrations of the fork, C2\\n60 ),i and somewhat better on the left side (C 35,\\nC 5 whereas the highest notes (C- and Galton s-\\nwhistle) were quite inaudible on the right side on the\\nleft, however, C. could just be heard when it was lightly\\ntouched, while Galton s whistle was also inaudible. On\\nboth sides speech could be heard only when it was very\\nloud. The occurrence within the last three years of a very\\nnoticeable and rapidly increasing deafness justifies the\\nassumption that two different processes are present, one of\\nwhich ran its course years ago in the middle ear while,\\n1 Normal period of tone-perception is as follows\\nC 1 10^^.\\nC5 15^^", "height": "3456", "width": "2104", "jp2-path": "rhinologylaryng00frie_0299.jp2"}, "300": {"fulltext": "288 NERVOUS DISEASES.\\nthe nervous deafness of the last few years bears a causal\\nrelationship to the tabes.\\nIt remains to speak of the other form of tabetic ear dis-\\nease which is characterized by abrupt onset and the pres-\\nence of Meniere s symptoms. Instead of giving a detailed\\ndescription of its symptomatology, I shall illustrate it by\\nthe following history that of my second case The patient,\\nforty-eight years old, was suddenly seized during the night\\nwith violent vertigo and tinnitus aurium. This was in\\n1887. He described the subjective noises as the thun-\\ndering of a hundred cannons, the ringing of bells, and the\\nrumbling of railroad trains. At the same time he was\\nseized with violent vomiting, repeated from twenty to thirty\\ntimes before the next morning, when the physician was\\n-called and administered a remedy. Immediately after the\\nattack the patient noticed that he was deaf on the right side.\\nVertigo appeared repeatedly during the next two years,\\nespecially after exertion. Tinnitus aurium did not occur\\nagain, but for several years he complained of frequent ring-\\ning of bells. This now, however, has ceased.\\nThe tabes seems to have appeared at the same time as\\nthe aural affection at least, the patient dates the first\\noccurrence of violent tearing and dragging pains in the legs\\nfrom that time. Three years ago a visual disturbance was\\nadded, consisting, on the left in a complete, and on the\\nright side in a fairly well advanced, gray atrophy of the\\noptic nerve (examination by Professor Schroter). Both\\near-drums were normal.\\nThe result of the functional test was as follows Bone\\nconduction is very much abridged, but the tuning-fork is\\nheard at the point where it is applied, except that when\\nplaced on the right mastoid process the sound is heard on\\nthe left side. Rinne on the left side, the right side\\ncould not be tested.\\nThe right ear is entirely deaf for all the notes and also\\nfor loud speech, while in the left ear the hearing is normal,\\nexcept that there is a slight shortening of the period of tone-\\nperception for C.\\nSimilar histories are reported by Althaus and Haug,\\nand it is quite evident that in this form of tabetic ear disease\\nwe must look for another situation than the one we have\\n1 Arch. f. klin. Med., xxiii, p. 601.", "height": "3468", "width": "2140", "jp2-path": "rhinologylaryng00frie_0300.jp2"}, "301": {"fulltext": "MULTIPLE SCLEROSIS. 289\\nbeen able to demonstrate for the atrophy which begins\\ngradually at the periphery. I shall not attempt to attribute\\nthis form to syphilis, as there is not the shadow of a proof\\nthat it is of a syphilitic nature. But I do venture the sug-\\ngestion that this form of tabetic disease of the auditory\\nnerve is localized in the nuclei of the medulla an assump-\\ntion which finds some justification in Haug s third case, in\\nwhich these nuclei were evidently the seat of pathologic\\nchanges, while the clinical picture during life had been such\\nas we have just described.\\nSince it has been found, according to v. Leyden, that\\nthe nuclei of most of the cranial nerves are diseased in\\ntabes, either with or without a coexistent degeneration of\\nthe corresponding peripheral trunks, I see no reason why\\nwe should not assume the occurrence of a similar disease\\nin the auditory nerve. Thus, without being obliged to\\nresort to some other unknown factor, we have a most\\nnatural explanation for this form of aural disease. I should\\nlike to add another feature, which irresistibly forces itself\\non the observer s notice in the clinical picture of this last-\\nnamed variety. Jt is the abrupt onset of the auditory dis-\\nturbance which so strongly suggests laryngeal and gastric\\ncrises. As these conditions are occasionally found asso-\\nciated with atrophy of the nuclei and roots of the vagus, it\\nseems permissible to assume disease of the acoustic nucleus\\nas the cause of these auditory crises. Finally, the imme-\\ndiate occurrence of paralysis of the vocal cords after lar-\\nyngeal crises also suggests the probability that an auditory\\ncrisis is followed by deafness.\\nBut this leads us into the realm of hypothesis. It must,\\nhowever, be admitted that such apoplectic forms of deaf-\\nness not rarely occur in other diseases, so that the question\\nwhether they represent an intercurrent affection or a true\\ncomplication of the primary disease is an extremely diffi-\\ncult one to decide.\\nMultiple Sclerosis.\\nIn multiple cerebrospinal sclerosis various motor dis-\\nturbances occur in the larynx which are accompanied with\\nintention tremors and differ from the tremulous movements\\nof the vocal cords due to other causes by the fact that they\\nare observed only during phonation, instead of both in\\nphonation and in respiration.\\n19", "height": "3464", "width": "2108", "jp2-path": "rhinologylaryng00frie_0301.jp2"}, "302": {"fulltext": "290 NERVOUS DISEASES.\\nThe most important disturbances are\\n1. A retardation of the muscular movements, so that the\\nintended movements of the vocal cords are delayed and\\naccompanied with tremulous movements.\\n2. Abnormal tendency to fatigue in the muscles. The\\nvoice is quickly fatigued by speaking, and it becomes impos-\\nsible to sustain a tone for any length of time the speech\\nis scanning and frequently interrupted by high-pitched,\\nexplosive sounds, due to the twitching movements of the\\nvocal cords.\\n3. The tension and adduction of the vocal cords are\\nincomplete, so that the voice is often rough, deep, and\\nhoarse.\\n4. Muscular palsies. These are rare, and occur more\\nfrequently in the adductors than in the abductors of the\\nvocal cords.\\nTo illustrate these phenomena I may mention Lori s\\nobservations, in which there was a marked interval be-\\ntween the muscular act of bringing the vocal cords into\\nthe phonatory position and the production of the tone.\\nWhenever the patient was asked to imitate a sound,\\na slight vibratory motion was immediately observed\\nin the vocal cords, resembling fibrillar twitchings, but\\nadduction and tone-production were delayed longer than in\\na healthy subject. Von Krzywicki gives this description\\nof the process During phonation there is a slight twitch-\\ning in the neighborhood of the vocal processes in the\\ndirection of the median line this soon passes into a general\\ntremor of both cords, which are finally brought together\\nby an abrupt movement at the end of phonation the return\\nto the respiratory position is accompanied by two or three\\npendulum-like vibrations toward the median Hne.\\nThe adductor palsies reported by Lori and Krause,*\\nconsisting in gaping of the rima glottidis during phonation,\\nare probably to be attributed exclusively to muscular weak-\\nness. Riegel s case of paralysis of the recurrent on the right\\nside, with posticus paralysis on the left, is the only one of\\nits kind it may possibly be due to paralysis of the medul-\\nlary nucleus.\\n1 Die durch andervveitige Erkrankungen bedingten, etc., p. 12.\\n2 Berlin, laryng. Gesellsch. in Semon s Centralbl., vill, p. 506.\\n3 Deutsche med. Wochen., 1893, p. 678.\\nKrause, Berlin, klin. Wochen., 1886, p. 557.", "height": "3468", "width": "2144", "jp2-path": "rhinologylaryng00frie_0302.jp2"}, "303": {"fulltext": "I\\nSYklNGOMYELIA. 29 1\\nOur knowledge of disturbances in the organ of hearing\\nin multiple sclerosis is very imperfect. Moos quotes\\ncases of tinnitus aurium and deafness from the literature,\\nand adds one of his own, in which there was difficult hear-\\ning with loss of bone-conduction, associated with anesthesia\\nof both trifacial nerves and ataxia a condition which led\\nhim to seek the seat of the disease in the medulla oblongata.\\nIn a case reported by Hess deafness suddenly developed\\nin both ears two weeks after the appearance of palsies in\\nthe extremities the hearing subsequently improved on the\\nleft side, but was permanently aboHshed on the right.\\nMicroscopic examination later revealed a sclerotic focus,\\nwhich had completely destroyed the nucleus acusticus\\nmedius sinister, while on the right side only a moderate\\nnumber of diseased ganglion cells were found.\\nMoos is therefore lea to believe that the auditory dis-\\nturbances in multiple sclerosis depend on sclerotic degen-\\neration of the auditory nuclei and of the trunk of the\\nauditory nerve.\\nWe may also have auditory disturbances due to paralysis\\nof the nucleus in epileptiform attacks during the course of\\na disseminated sclerosis. Oppenheim observed a sudden\\nonset of paralysis of the facial, auditory, and trifacial nerves\\nof the same side, with symptoms of vertigo the paralysis\\nsubsided in a few weeks and was followed after several\\nmonths by a sudden hemiataxia, which disappeared in its\\nturn,\\nDISEASES OF THE MEDULLA OBLONGATA.\\nSyringomyelia.\\nIn this disease we have, either late or in the initial stages,\\nthe appearance of bulbar phenomena, manifesting themselves\\nin motor disturbances in the larynx and in reduced reflex\\nirritability of the posterior pharyngeal wall and of the lar-\\nynx there is no record of sensory disturbances in these\\nstructures having been observed. Motor disturbances of\\nthe uvula do not appear to occur. Schlesinger collected\\n12 cases of syringomyelia with laryngeal complications,\\nSchwartze s Handb. der Ohrenh., I, p. 507.\\n2 Dissert., 1888 quoted by Moos.\\nQuoted by Leyden-Goldscheider, Nothnagel s Spec. Path. u. Ther.,\\nX, 2. Th., I. Abth., p. 474.\\nNeurolog. Centralblatt, 1894, p. 684.", "height": "3456", "width": "2052", "jp2-path": "rhinologylaryng00frie_0303.jp2"}, "304": {"fulltext": "292 NERVOUS DISEASES.\\nwhich had been pubhshed up to that time, adding five obser-\\nvations of his own. Since then two other cases have been\\npubhshed by Weintraud.\\nFrom these 19 observations it appears that the palsy\\nconsists usually in unilateral paralysis of the vocal cord,\\ndue to paralysis of the recurrent or, rarely, of the posticus\\nbilateral paralysis of the recurrent was observed in only\\nfour cases.\\nAs sometimes occurs in bulbar palsies, the paralysis of\\nthe vocal cords is often combined with palsy and atrophy\\nof the trapezius, a fact which, as we have mentioned\\nbefore, has been used as an argument for the spinal acces-\\nsory being the motor nucleus of the larynx. Two cases\\nof this kind, in which paralysis of the spinal accessory\\nwas combined with posticus paralysis, are reported by Wein-\\ntraud.^\\nProgressive Amyotrophic Bulbar Paralysis.\\nDiseases of the bulbar motor vago-accessory nucleus\\nlead to paralyses which may be unilateral or bilateral and\\nmay affect either the posticus or the recurrent nerve. They\\nare found in progressive bulbar paralysis more frequently\\nthan in any other bulbar disease, but they can not be said\\nto occur with such regularity as to justify the designation\\nof the disease as paralysie glosso-labio-laryngee.\\nAnesthesia of the pharyngeal and laryngeal membrane is\\nnot present, as a rule, but the pharyngeal, uvular, and lar-\\nyngeal reflexes are abolished. Schrotter mentions the\\noccurrence of paresthesia in the throat, variously described\\nas a feeling of dryness or as a sense of pressure.\\nAccording to v. Leyden,^ the auditory and Deiter s\\nnuclei undergo atrophy in bulbar paralysis, forming in this\\nrespect an exception to the other sensory nuclei, and per-\\nhaps explaining the occasional impairment of hearing, going\\non to deafness, and the tinnitus aurium which is sometimes\\nobserved.\\nThe phenomena produced by progressive amyotrophic\\nbulbar paralysis may also be observed in acute bulbar pal-\\n1 Deutsche Zeitschr. f. Nervenheilk., v, 1894, p. 383.\\n2 Loc. cit.\\n3 Vorles. iiber die Krankh. des Kehlkopfs, p. 382.\\n*Von Leyden and Goldscheider, Nothnagel s Spec. Path. u. Ther.,\\nX, 2, pp. 686 and 701.", "height": "3468", "width": "2136", "jp2-path": "rhinologylaryng00frie_0304.jp2"}, "305": {"fulltext": "PARALYSIS AGITANS, 293\\nsies, such, for instance, as follow embolism or compression\\nof the medulla by tumors. The latter form, which should\\nbe designated compression bulbar paralysis, since it is\\ncaused by irritation of the medulla from the pressure of the\\ntumor, manifests itself in ataxic movements of the vocal\\ncords. 1 Lastly, we must mention progressive spinal mus-\\ncular atrophy and amyotrophic lateral sclerosis, which, by\\ncombining with bulbar paralysis, may produce bulbar palsies\\nin the larynx.\\nIn pseudobulbar paralysis, which has its principal seat in\\nthe cerebrum, Lannois,^ Cartaz,^ and Krause^ observed ad-\\nductor palsies. The latter might be regarded as cerebral\\npalsies, did we not know that there are always some diseased\\nfoci in the medulla and in the pons, besides the principal\\nfocus in the cerebrum. As it is uncertain whether vocal-\\ncord paralyses ever occur in cerebral disease, one should\\nnever forget that they may possibly be explained by a\\nsimultaneous involvement of the medulla oblongata.\\nNEUROSES.\\nParalysis Agitans.\\nParalysis agitans gives rise to motor disturbances in the\\nvocal cords affecting the quality of voice and speech. In\\nthe laryngeal image we see twitching movements of the\\nvocal cords, which occur regularly in phonation and usually\\nalso in respiration, thereby distinguishing themselves from\\nsimilar movements observed in multiple sclerosis thus, Fr.\\nMiiller observed the phenomenon constantly when the\\npatient exerted himself during the examination, but found\\nthat at other times the vocal cords remained perfectly quiet.\\nThe tremors may also affect the epiglottis (Rosenberg) and\\nthe uvula.\\nAccording to Rosenberg,*^ similar disturbances of the\\nspeech occur as in multiple sclerosis. We have the scan-\\nning speech, described by Charcot as tremulous and inter-\\nrupted, like the speech of an inexperienced rider on a\\n1 Compare v. Leyden and Goldscheider, loc. cit., p. 711 and Semon-\\nHeymann s Handb. der Lar., I, p. 761.\\nRev. de medece, 1885.\\n3 France medicale, Nov. 17, 18S5.\\nThe Jour, of Larj ng. and Rhinol., 1S8S, p. 255.\\nCharite Ann., 1887, xn, p. 267.\\nBerlin, klin. Wochen., 1892, p. 771.\\nQuoted by Fr. Miiller.", "height": "3456", "width": "2028", "jp2-path": "rhinologylaryng00frie_0305.jp2"}, "306": {"fulltext": "294 NERVOUS DISEASES.\\nhigh-Stepping horse, and, as a very conspicuous feature, a\\nsudden change from a high to a low register during speak-\\ning, due to the inabiHty to sustain a tone for any length of\\ntime as the vocal cords gradually relax their tension and\\nclosure of the glottis becomes imperfect, the voice becomes\\ndeeper and rougher.\\nAlthough only a few cases of laryngeal involvement in\\nparalysis agitans have been reported, it does not seem to\\nbe a very rare occurrence, judging from Schultz s report\\nof five observations of tremors in the vocal cords out of\\ntwelve cases in Gerhardt s clinic. As the head tremors\\nthemselves lead to disturbances of speech, it is very prob-\\nable that they often mask the symptoms of motor dis-\\nturbances in the vocal cords, and are thus the cause of\\nthe latter s escaping detection.\\nEpilepsy.\\nAccording to Gottstein,^ anesthesia of the laryngeal\\nmucous membrane is a constant accompaniment of the epi-\\nleptic attack, and may occasionally persist for some time\\nafterward. The epileptic cry, which frequently heralds\\nthe attack, is accompanied by convulsive movements of\\nthe laryngeal muscles, consisting either in twitching of the\\nvocal cords or in spasm of the glottis. Semon^ attributes\\nthese phenomena to a cortical irritation.\\nIt is a well-known fact that an epileptic aura often con-\\nsists in disagreeable olfactory sensations.\\nWe also hear of auditory aurse, consisting either in im-\\npaired hearing and deafness, or in the hearing of subjective\\nnoises, which may be so marked as to deserve the name of\\nhallucinations. A few cases have been reported in which\\nepileptic attacks were followed by deafness, shown by the\\nfunctional test to be of central origin.\\nIn one case the deafness Avas permanent in another,\\nrecovery occurred after employment of the galvanic\\ncurrent.\\n1 Charite Ann., 18S7, p. 267. Berlin, klin. Wocben., i!\\n771. Schultzen, Charite Ann., 1894, XIX.\\n2 Lehrbuch der Kehlkopfkrankheiten.\\nIn Heymann s Handb. der Laryngol., vol. I, p. 632.\\nArcb. f. Ohr. xxii, p. 205.\\n5 Arcb. f. Obr., xiv, p. 134.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0306.jp2"}, "307": {"fulltext": "CHOREA MINOR, HYSTERIA. 295\\nChorea Minor.\\nThe use of the term chorea laryngis for disturbances\\nof coordination in the movements of the vocal cords in\\nvarious diseases is unfortunate, as it confuses the question\\nwhether laryngeal disturbances may occur in chorea minor.\\nIt seems probable that the vocal cords rarely participate in\\ntrue choreic movements. Schrotter says that temporary\\nconvulsive contractions occur in the larynx simultaneously\\nwith similar movements in the respiratory muscles, and\\nrepresent the cause of the sighing or gasping inspirations,\\nwhich are frequently audible at some distance.\\nThe disturbances of speech, which in severe cases man-\\nifest themselves as sudden interruptions by shrill whistling\\nsounds, are also to be attributed to choreic movements of\\nthe muscles concerned in deglutition and respiration.\\nAccording to Haug,^ the tensor veli palati and tensor\\ntympani sometimes share in the contractions, and lead to\\nthe production of subjective or objective noises in the ear,\\ndescribed as the cracking of nuts or the crackling of\\npaper.\\nHysteria.\\nHysteria is to be regarded as a neurosis without anatomic\\nbasis in which an alteration in the psychic condition of the\\npatient is the most important factor. The clinical pic-\\nture may assume an infinite variety of forms, but all the\\nsymptoms have this in common that they affect those func-\\ntions of the body which are, to a certain extent, subject to\\nthe will of the patient. Striimpell insists that hysteria\\nshows so marked a preference for the voluntary functions\\nthat it does not occur at all in the domain of the involuntary\\nmuscles and of the automatic reflexes. This law appears\\nto hold good for the regions with which we are now con-\\ncerned, for we shall see that hysteric phenomena, although\\nthey may at first sight appear to be quite irregular, never-\\ntheless seem to follow a certain system in the upper air-\\npassages and in the ear, inasmuch as they do not affect\\nthose functions of the larynx and of the ear which are con-\\nsidered purely automatic, such as the respiratory dilatation\\nof the glottis and the static function of the ear. It is con-\\n1 Die Krankh. des Kehlkopfes, First Edit., p. 3SS.\\n2 Die Krankh. des Ohres, etc., p. 204.", "height": "3444", "width": "2060", "jp2-path": "rhinologylaryng00frie_0307.jp2"}, "308": {"fulltext": "296 NERVOUS DISEASES.\\nvenient to divide hysteric disturbances into those which\\naffect the sensory region, those which affect the motor\\nregion, and those which affect the regions of special sense.\\nIn the sensory disturbances in the region of the upper\\nair-passages we have to deal with mucous membrane in the\\nnose, with the exception of the vestibule and in the organ\\nof hearing, both with epidermis (which covers the internal\\nauditory meatus and the external surface of the ear-drum),\\nand with mucous membrane, which forms the lining of the\\nmiddle ear and of the tubes.\\nThe disturbances of special sense include alterations of\\nthe senses of smell and hearing these are usually asso-\\nciated with sensory disturbances.\\nThe motor disturbances embrace those which occur in\\nthe regions of the pharyngeal and laryngeal musculature\\nand in the muscles of the tubes and of the middle ear.\\nI In the first group we have anesthesia and hyperes-\\nthesia, analgesia and hyperalgesia.\\nAlthough in general the law holds good that mucous\\nmembranes adjoining the external skin, as in the vestibule\\nof the nose, present the same sensory disturbances as the\\nadjoining external skin, this, as pointed out by Lichtwitz,^\\nis not the case when large areas of the surface are dis-\\neased. This applies particularly to hemianesthesia of\\nthe body-surface. We learn from the accurate studies of\\nLichtwitz, which harmonize with the results obtained by\\nThompson and Oppenheim,^ that in a purely cutaneous\\nhemianesthesia the hemianesthesia of the mucous membrane\\nis never complete, but usually extends over both halves of\\nthe body and, just as there may be cutaneous hemianes-\\nthesia without involvement of the mucous membranes, so\\nthe latter may be affected while the skin remains intact.\\nA characteristic feature of hysteric disturbances of sensa-\\ntion, which is also observed when other portions of the\\nbody are attacked, is that the distribution of the anesthesia,\\ninstead of corresponding to the distribution of certain\\nnerves, is a diffuse one, without any reference to the in-\\nnervation so much so that it furnishes an important point\\nin the differential diagnosis from anesthesias due to an\\norganic, anatomic lesion in which the sensory disturbances\\nare strictly limited to the domain of the affected nerves.\\n1 Les anesthesies hysteriques des muqueuses, etc., Paris, 1S87.\\n2 \u00c2\u00abArch. f. Psych, u. Nervenheilk., xv.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0308.jp2"}, "309": {"fulltext": "HYSTERIA. 297\\nThe nasal mucous membrane is less apt to be included in\\nthe anesthesia than are the other mucous membranes of the\\nupper air-passages the anesthesia never affects its entire\\nsurface, and there are always islands of intact mucous mem-\\nbrane between the anesthetic areas. According to Licht-\\nwitz, the septum always escapes, except in the lower\\nanterior portion, which lies within the domain of the\\nvestibule.\\nThe pharyngeal mucous membrane is very frequently\\naffected, perhaps more frequently than any other part of\\nthe upper air-passages, including the larynx. The occur-\\nrence of anesthesia of the epiglottis, which was regarded\\nby Chairon as pathognomonic of hysteria, is not con-\\nfirmed by other authors. It is difficult to determine the\\nfrequency of anesthesia in the upper air-passages, for it\\nnecessarily escapes the notice of the patient and does not\\nbetray itself to the physician by any visible alterations it\\ncan, therefore, be detected only by a special examination.\\nSometimes we are led to suspect it by the ease with which\\na laryngoscopic examination is performed, for the absence\\nof subjective complaints is often a very marked feature. The\\nfact that particles of food do not find their way into the\\nair-passages and lead to inspiration pneumonia, as in\\nall organic palsies, especially in postdiphtheric anesthesias\\nand in bulbar palsies, leads us to conclude that reflex\\nswallowing and reflex cough are not affected in anesthesias\\nof the pharynx and larynx. The choking reflex, on the\\nother hand, is frequently abolished.\\nDiminished sensibility of the mucous membrane fre-\\nquently occurs in hysteria, but it can not be separated from\\nanesthesia.\\nAnalgesias have been observed in connection with anal-\\ngesia of the .general body surface they may or may not be\\nassociated with anesthesia.\\nThere is another important group of hyperesthesiae and\\nparesthesias, which differ from the sensory disturbances\\njust described in the fact that they occasion marked sub-\\njective symptoms and may lead to demonstrable altera-\\ntions in the mucous membrane in the form of hyperemias\\nand consecutive chronic catarrh, as a result of the vio-\\nlent efforts at swallowing and the constant coughing\\nand hawking. In such cases the paresthesia is usually\\ncaused by the conversion of the temporary irritation in the", "height": "3456", "width": "2028", "jp2-path": "rhinologylaryng00frie_0309.jp2"}, "310": {"fulltext": "298 NERVOUS DISEASES.\\nlarynx or pharynx a passing inflammation or slight ca-\\ntarrh into a permanent neurosis, as a result of the hysteric\\ndisposition. The patients complain of a persistent tickling\\nsensation, which they usually attribute to a foreign body,\\nlike a particle of food, on a particular spot in the throat.\\nIn either case a coryza or simple sore-throat is followed by\\nhyperesthesia of the pharynx. Sometimes a nauseating bit\\nof food or a mouthful of foul water, during bathing, for\\ninstance, may lead to hysteric disturbances.\\nHyperesthesia and paresthesia manifest themselves in the\\nnasal mucous membrane in sneezing, and in the pharynx\\nand larynx in coughing, hawking, and straining, or even in\\nvomiting, or sometimes in a constant desire to swallow.\\nTo this category belongs the globus hystericus, which\\ngives the sensation of a spherical body moving up and down\\nbetween the region of the epigastrium and the throat.\\nUnder the name of anaesthesia dolorosa Schnitzler has\\ndescribed a peculiar variety of sensory disturbance in the\\npharynx, in which subjective pain in the throat is associated\\nwith anesthesia of the soft palate, of the posterior laryngeal\\nwall, and of the larynx.\\nWhen the diseased structures were examined, the finding\\nin the nose and throat was negative, while in the pharynx\\nand larynx certain alterations were seen, which were in-\\nterpreted as a mild congestive or hypertrophic condition.\\nThe mucous membrane in the pharynx, and occasionally\\nat the entrance to the larynx, may be abnormally pale, and\\nin that case represents part of a general anemia, such as\\nwe expect to see in hysteric women. On the other hand,\\nthe opposite condition may be present, in which case the\\ncongestion of the mucous membrane must be regarded as a\\nresult of the irritative cough, and as an expression of the\\nplethora such as we not infrequently observe in elderly\\nwomen with excitable sexual feelings that have never been\\ngratified.\\nThe auricle, the skin of the external auditory meatus, and\\nthe epidermis of the ear-drum are all subject to the sensory\\ndisturbances which have just been mentioned, and which\\nmay be either unilateral or bilateral. The anesthesia is\\nnot accompanied by any subjective symptoms, for Gelle s\\nopinion that the ability to locate the source of the sound\\nis disturbed in unilateral anesthesia of the ear-drum has not\\nbeen confirmed. In hyperesthesia both of the external ear", "height": "3468", "width": "2208", "jp2-path": "rhinologylaryng00frie_0310.jp2"}, "311": {"fulltext": "HYSTERIA. 299\\nand of the Eustachian tube there are marked subjective\\nsymptoms in the form of paresthesia in the external audit-\\nory meatus or an aggravation of an already existing trifling\\naffection of the organ of hearing. The presence of very\\nsmall masses of cerumen on the walls of the external meatus\\noften produces a distressing sense of a foreign body in\\nhysteric persons, while the scratching induced by the irri-\\ntation of the paresthesia may set up a mild dermatitis,\\nwhich gives the patients great distress, so that they often\\ncomplain of a feeling as if there were a movable foreign\\nbody or an insect in the ear. The hyperesthesia in the\\nmucous membrane of the tubes is said to manifest itself in\\nunusual sensitiveness to catheterization and to the passing\\nof a bougie. Hyperesthesia and hyperalgesia of the ear\\noccur, being usually localized in the middle ear (otalgia\\ntympanica) or in the mastoid process. The phenomenon\\nknown as transfert, to which we shall refer again later,\\nhas been observed in the ear during these disturbances of\\nsensibility.\\nIn this connection we must mention the so-called hyster-\\nogenic zones, irritation of which is said by Lichtwitz to bring\\non a hysteric attack, unless the parts have been previously\\ncocainized. They have been located in the mucous mem-\\nbrane of the nose, in the larynx, on the posterior wall of\\nthe nasopharynx, on the posterior surface of the uvula, on\\nthe mucous membrane of the tubes, in the external auditory\\nmeatus, and on the ear-drum sensation was preserved in\\nthe parts affected. These hysterogenic zones possess no\\ngreat practical value, and are no more significant than any\\nother sensitive portions of the body, the irritation of which,\\nas is well known, may produce hysteric attacks. The fact\\nthat a hystero-epileptic attack or any other motor reflex\\nphenomenon may be induced by probing a hypertrophied\\nregion in the pharyngeal mucous membrane, by introducing\\na catheter into the tube, or by syringing the ear for the\\npurpose of removing a plug of cerumen, is of no more sig-\\nnificance than the production of similar phenomena by irri-\\ntation of any given region on the external skin. Thus,\\ntouching a small wart on the hand has produced general\\nhysteric convulsions which disappeared after the w^art was\\nremoved with a galvanic cautery. But this would liardly\\njustify us in speaking of a hysterogenic zone, any more than\\nthe phenomenon of a woman being seized with hysteric", "height": "3452", "width": "2120", "jp2-path": "rhinologylaryng00frie_0311.jp2"}, "312": {"fulltext": "300 NERVOUS DISEASES.\\nrespiratory convulsions when a catheter was introduced\\ninto the Eustachian tube.\\nHysteric disturbances in the nerves of special sense mani-\\nfest themselv^es in the olfactory nerve as hyperosmia, hypos-\\nmia, and parosmia. The effect on the function of hearing in\\nhysteria shows itself either in deafness (hypassthesia acus-\\ntica) or in abnormal sensitiveness of the auditory nerve\\n(hyperaesthesia acustica). These disturbances may occur\\nsuddenly after fright or any violent emotion, or they may\\ndevelop gradually. It is very rarely that they constitute\\nthe only hysteric symptom, as other nerves of special sense,\\nparticularly the optic nerve, are nearly always involved.\\nNatier claims to have observed a remarkable combination\\nof hysteric deafness with inability to speak, or with func-\\ntional disturbances of the voice, such as stammering and\\nhoarseness. Diminished or increased sensibility of the\\nauditory nerve are, as a rule, unilateral. In a relatively\\nlarge number of cases the power of hearing is found to be\\nabnormally increased on one side and diminished on the\\nother. This condition is very conspicuous in a case\\nreported by Urbantschitsch.^ in which the phenomenon\\nknown as trajtsfert was typically present. As Haber-\\nmann and others have been able to perform this experi-\\nment, which is specially dwelt on by French writers on\\nhysteric deafness, it may be worth while to devote a few\\nwords to it in this place.\\nBy means of a small magnet or a piece of metal (gold)\\nplaced on the sound ear it is possible to transfer the hys-\\nteric deafness or any existing anesthesia of the ear to the\\nsound side. Urbantschitsch observed that the higher notes\\nare the first to be transferred, and, conversely, as the\\ntransfa-t returns to the side originally affected, the\\nhearing is lost for the higher notes sooner than for the\\nlower ones. A somewhat frequent phenomenon is the\\nalternation between diminished and increased sensibility at\\ncertain hours of the day.\\nThe auditory disturbance in hysteria is characterized by\\na uniform loss of perceptive power for all the notes in the\\nscale. It does not exactly correspond either to a nervous\\naffection or to disease of the sound-perceiving apparatus,\\nfor Rinne s test is usually positive, while in Weber s experi-\\n1 Arch. f. Ohr., vol. xvi, p. 176.\\nPrag. med. Wochen., 18S0, No. 22.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0312.jp2"}, "313": {"fulltext": "MATERIA MEDICA for NURSES,\\nBy Emily A, M, Stoney, Gr adttate of\\nthe Training--\\nSchool for\\nNurses, Law-\\nrence, Mass,\\nSTONEY S\\nMATERIA MEDICA\\nFOR NURSES\\nlate Superintendent of the Training-\\nSchool for Nurses, Carney Hospital,\\nSouth Boston, Mass. Octavo volume\\nof nearly 300 pages. Cloth, $J.50 net,\\nJUST ISSUED\\nThe present book differs from other similar\\nworks in several features, all of which are in-\\ntended to render it more practical and generally\\nuseful. The subject-matter is arranged in alpha-\\nbetical order, which not only renders it more\\nconvenient for study as a text-book, but also\\nadds materially to its value as a work of refer-\\nence for ready consultation. Besides this, the\\nSo far as\\nwe ca\\nn see it contains\\nabout\\ne\\n/erything\\nthat H nurse\\noueht\\nto know\\nn regard to c\\nru\\n?s. Asa\\nreference-book for\\nnurses it\\nwill w\\nthout\\nquestion be 1\\nvery useful.\\n-/Ol\\nof\\nike A\\nncrican\\nMedical\\n1\\nbook contains much useful matter not usually\\nincluded in works of this character. The Ap-\\npendix contains much practical matter, besides\\na Glossary, defining all the terms used in Materia\\nMedica, and describing the very latest drugs.\\nFor sale by all Booksellers, or sent post-paid on\\nreceipt of price.\\nW. B. SAUNDERS CO., Publishers,\\n925 Walnut St., Philadelphia.", "height": "3444", "width": "2136", "jp2-path": "rhinologylaryng00frie_0313.jp2"}, "314": {"fulltext": "THE INTERNATIONAL TEXT-\\nBOOK OF SURGERY. In two vol-\\nBy\\nINTERNATIONAL\\nTEXT-BOOK OF\\nSURGERY\\ntimes.\\nAmerican and\\nBritish au-\\nthors. Edited\\nby J. Collins Warren, M.D., LL.D.,\\nProfessor of Surgery, Harvard Medical\\nSchool, Boston, Mass. and A. Pearce\\nGould, M.S., F.R.CS., of London,\\nEngland.\\nOne of the most timely features of the work is the\\nconsideration given to JNlilitary, Naval, and Tropical\\nSurgery. The treatment of these topics is based on\\nthe latest experience of Military and Naval warfare,\\nincluding that gained during the Spanish-American\\nwar and the present wars in the Philippines and in\\nSouth Atrica, and bringing the subject absolutely\\ndown to d.ite.\\nBOTH VOLUMES NOW READY.\\nVol. I. General and Operative Surgery\\nHandsome royal octavo, 947 pages,\\n458 illustrations, 9 lithographic plates.\\nVol. II. Special or Regional Surgery\\nHandsome royal octavo, 1072 pages,\\n471 illustrations, and 8 lithographic\\nplates. Prices per volume Cloth, $5.00\\nnet Half Morocco, $6.00 net. J* J-\\nSent post-paid on receipt of price.\\nW. B. SAUNDERS CO.. Ptiblishers,\\n925 Walnut St., Philadelphia.", "height": "3468", "width": "2144", "jp2-path": "rhinologylaryng00frie_0314.jp2"}, "315": {"fulltext": "HYSTERIA. 301\\nment the tuning-fork is heard equally as often on the sound\\nas on the diseased side, or may even not be lateralized to\\neither side.\\nSubjective noises are not constantly present. Hyper-\\naesthesia acustica manifests itself either in morbidly sensitive\\nhearing or in the appearance of hysteric convulsive phe-\\nnomena, when certain tones are heard. Steinbriigge\\ndescribes a very interesting case of this kind, in which the\\nhearing of musical tones was followed by hysteric respira-\\ntory convulsions. It is worthy of remark that disturbances\\nof the hearing in hysteria are not accompanied by disturb-\\nances of the equilibrium, such as occur in organic disease\\nof the auditory nerve as a part of Meniere s symptom-\\ncomplex.\\nThe symptoms which we have just described make it\\nappear very improbable that the seat of the lesion is in the\\nauditory pathway. The phenomena of transfert and\\nthe variation in the degree of deafness appear to show that\\nthe perceptive faculty of the nervous auditory apparatus is\\nnot impaired, and that the disease is to be sought in an\\ninterruption of the nervous pathway which conveys the\\nauditory impression to the seat of consciousness and trans-\\nforms it into a sound hence, we probably have to deal\\nwith a simple disturbance of coordination in the central\\npathways,\\n3. Hysteric motor disturbances are purely disturbances\\nof coordination there is no paralysis, for the motor power\\nis not lost, but there is inability to perform the muscular\\nmovement in such a way as to produce the desired effect.\\nThis disturbance between the will and the act may consist\\neither in an excessive amount of muscular activity, or in a\\ntotal want of the necessary movements, so that either the\\npicture of a convulsion or that of a paralysis may be pro-\\nduced. When we speak of a relation between the will and\\nthe deed, it is implied that the disturbance can concern only\\nmovements which are subject to the will and under the\\ncontrol of cortical centers of coordination, while reflex\\nmovements, such as are originated below the region of the\\nwill, like the respiratory gaping of the glottis, are not\\nsubject to these hysteric disturbances.\\nWe must, however, discuss at somewhat greater length\\n1 Zeitschr. f. Ohr., xix, p. 32S.", "height": "3456", "width": "2104", "jp2-path": "rhinologylaryng00frie_0315.jp2"}, "316": {"fulltext": "302 NERVOUS DISEASES.\\ncertain hysteric posticus paralyses, as Penzoldt, West,^\\nand Dufour have described bilateral hysteric posticus\\nparalyses, and Treupel observed a unilateral paralysis\\nwhich was associated with paresis of the internus. But as\\nWest remarks that the vocal cords were in close contact\\nduring inspiration and changed to the cadaveric position\\nduring expiration, and as Penzoldt speaks of intense\\ndyspneic attacks, which imply that there were intervals of\\nfreedom in which the paresis subsided, it does not\\nappear to me that these isolated cases the rarity of which\\nis in such strong contrast to the frequency of hysteric\\nmotor disturbances in general furnish sufficient proof for\\na diagnosis of hysteric posticus paralysis. I rather incline\\nto believe that we have to deal in these cases with a so-\\ncalled perverse action of the vocal cords, a phenomenon\\nwhich depends on a disturbance of coordination and con-\\nsists in the approximation of the vocal cords toward the\\nmedian line in deep inspiration, followed by separation\\nduring expiration, such as we very often observe in excitable\\npersons at their first laryngoscopic examination.\\nMotor disturbances rarely occur in the muscles of the\\npharynx the abnormal mov^ements are synchronous with\\nthe respiration, and manifest themselves as rhythmic inspira-\\ntory contractions of the two posterior pillars of the fauces,\\nusually accompanied by simultaneous contractions of the\\nadductor muscles of the vocal cords. Hysteric motor dis-\\nturbances in the larynx chiefly affect the muscles concerned\\nin phonation. As we have previously stated, the participa-\\ntion of the abductors in the loss of phonation or a convul-\\nsion, as assumed by Przedborski,^ has not been proved.\\nThe most important symptom of these affections is the\\nhysteric aphonia, a simple disturbance of coordination in\\nwhich there is imperfect coaptation of the adductor mus-\\ncles and inability to maintain the tension necessary for\\nthe voice production. The laryngoscopic image is sub-\\nject to enormous variations, and we find in hysteria every\\nalteration in the shape of the glottis that can possibly\\nbe conceived as produced by the failure in action of indi-\\n1 D. Arch. f. klin. Med., xni, p. Il8.\\n2 See Semon s Centralbl., x, p. 39.\\n3 Th^se de Montpellier, Jan. 9, 1891 Semon s Centralbl., ix,\\np. 96.\\nDie Bewegungsstorungen im Kehlkopfe bei Hysterischen, Jena, 1895.\\n5 Mon. f. Ohr., 1885, No. 11.", "height": "3468", "width": "2144", "jp2-path": "rhinologylaryng00frie_0316.jp2"}, "317": {"fulltext": "HYSTERIA. 303\\nvidual groups of muscles. Thus, we get the picture of\\nparalysis of the internus, of isolated paralysis of the inter-\\narytenoideus, of the lateral crico-arytenoid, or of the thyro-\\narytenoid muscles, or various forms of paralysis combined,\\nso that, for instance, the action of the interarytenoid and\\nof the lateral crico-arytenoid muscles may be in abeyance.\\nThese associated palsies of the adductors are particularly\\ncharacteristic of hysteria and are rarely found in other\\ndiseases. That these hysteric disturbances do not corre-\\nspond to palsies in the ordinary sense of the term is shown\\nby the fact that during the examination the vocal cords\\noften approximate almost to the point of contact at the first\\nattempt at phonation, and then immediately separate and\\nassume a position simulating one of the forms of paralysis\\nmentioned that is to say, the muscles do not lack the\\nfaculty to perform the movements, but there is a psychic in-\\nability to perform the desired act. This finds further con-\\nfirmation in the remarkable phenomenon that hysteric sub-\\njects, although incapable of uttering a single word in a loud\\nvoice, often phonate or cough during the laryngoscopic\\nexamination, or regain their power to speak in their dreams\\nor during hypnosis while even a greater paradox is pre-\\nsented by those cases in which the singing voice is perfectly\\npreserved while there is complete aphonia. 1 Spasm of the\\nglottis and so-called laryngeal cough are occasionally ob-\\nserved, and are to be regarded as spastic phenomena or\\nhyperkinetic motor neuroses. This hysteric cough and\\nother laryngeal noises (bruits larynges), which may have\\nthe sound of bleating, howling, or grunting, are described\\nby Charcot. 2 Characteristic features are their recurrence\\nat definite hours and their complete cessation during sleep.\\nThe cough or other noises may occur only once or be\\nrepeated several times in rhythmic order dyspnea or\\napnea never occur, no matter how often the attacks may\\nbe repeated. There are no objective signs in the larynx or\\nin the lungs, and it is noteworthy that the condition is not\\naccompanied by any other hysteric symptoms, unless there\\nbe certain disturbances of sensation and of special sense,\\nsuch as anesthesia and diminution in the field of vision.\\n1 Griffen, see Semon s Centralbl., x, p. 312. Gerliardt, Kehlkopf-\\ngeschwiilste, etc., Nothnagel s Spec. Path. u. Ther., vol. xiil, 2. Th.,\\n2 Abth., p. 50.\\n2 Med. du syst. nerv., 11, p. 443.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0317.jp2"}, "318": {"fulltext": "304 NERVOUS DISEASES.\\nAll these forms of hysteria occur, either suddenly, under\\nthe influence of fright, traumatism, etc., or develop gradu-\\nally. The nature of hysteria is such that any peculiar\\nmovement that has once been executed under the influence\\nof some momentary external agency persists as the effect\\nof a morbid imagination (Treupel). As the disease does\\nnot depend on any material alterations, the line of treat-\\nment is clearly indicated an attempt should be made to\\nfree the patient from the morbid impression that he is un-\\nable to use his voice, and the normal power of the muscles\\nshould be restored by systematic exercise of the voice and\\n\u00e2\u0096\u00a0of the respiration. Moritz-Schmidt^ divides hysteric palsies\\ninto three grades, on a purely external practical basis, as\\nfollows\\nFirst, cases in which the voice may have been lost for\\nsome time, immediately reappears on laryngoscopic exam-\\nination, but is lost immediately afterward.\\nSecond, cases in which the voice does not appear during\\nexamination and the patient whispers.\\nThird, cases in which the patient can not even whisper\\na condition which has been designated apsithyria.\\nA single case of motor disturbance in the muscles of the\\near, consisting in contractions of the tensor tympani, and\\ngiving rise to subjectiv^e cracking noises, has been reported.^\\nAmong other manifestations of hysteria hemorrhages from\\nthe ear have been mentioned. As the cases referred chiefly\\nto females, or persons suffering from neurasthenia as the\\nresult of masturbation, we refer to the chapter on the sexual\\norgans for these affections.\\nCertain neurasthenic and hysteric conditions which are\\nproduced by traumatism and very frequently give rise to\\ndisturbances in the ear are closely allied to hysteria. Ob-\\nservations have been reported in regard to ear disease in\\nrailway spine, 3 and in regard to traumatic hysteria of\\nthe ear 5 after a stroke of lightning, while innumerable\\nhysteric and neurasthenic symptoms following injuries of\\nthe head have been reported. The diagnosis often pre-\\nsents the greatest difficulty to the physician on account of\\n1 Second Edit., p. 706.\\n2 Freund u. Kayser, Deutsche med. Wochen. 1891, No. 31.\\nBaginsky, Berlin, klin. Wochen., lS88, No. 3.\\n5 Freund u. Kayser, Deutsche med. Wochen., 1891, No. 31.\\nArch. f. Ohr., vol. xxix, p. 327, and vol. xxxviii, p. 102.", "height": "3468", "width": "2136", "jp2-path": "rhinologylaryng00frie_0318.jp2"}, "319": {"fulltext": "HYSTERIA. 305\\nthe want of any definite objective findings. Where no ex-\\nternal injury is visible, the patients usually complain of\\nincreasing difficulty of hearing and tinnitus aurium. Ver-\\ntigo, which is usually absent in hysteria, is conspicuous in\\nthese cases, but it is not at all clear that the symptom is\\ndue to a lesion in the ear itself The results of the func-\\ntional test are often the same as in hysteria. It is often\\nextremely difficult to interpret them correctly, both because\\nthe patient is in a state of mental excitement and gives\\ncontradictory and unreliable answers, and because the deaf-\\nness can not, as a rule, be ascribed with absolute certainty\\nto the traumatism, as it is a well-known fact that the hear-\\ning is very apt to be affected in traumatic neurasthenia\\nwith the remains of an old aural disease.", "height": "3400", "width": "2148", "jp2-path": "rhinologylaryng00frie_0319.jp2"}, "320": {"fulltext": "APPENDIX.\\nNASAL REFLEX NEUROSES.\\nSince the ground was broken by the works of Hack\\nthe doctrine of nasal reflex neuroses has received general\\nrecognition, and thus it may be said that another morbid\\nprocess has been added to the domain of pathology. As,\\nhowever, Hack in his first publications gave such a liberal\\ninterpretation to the concept of nasal reflex neurosis that\\nexperienced observers were led to warn the profession\\nagainst a too general application of his propositions, and\\nother authors after Hack in their uncritical laxity extended\\nthe range of reflex neuroses almost indefinitely, it seems\\nwell to define what is meant by reflex neuroses and their\\nv^arious forms as determined by the results of accurate ex-\\nperimentation.\\nAmong the reflex conditions which can with certainty be\\nattributed to irritation of the nasal mucous membrane we\\ninclude sneezing, trifacial cough, spasm of the glottis, and\\nasthma. In addition, there may be some effect on the ac-\\ntion of the heart, but here we must take into account the\\npossibility of vasomotor disturbances, such as the so-called\\nvasomotor coryza and hay fever. Our physiologic in-\\nvestigations of these reflexes are based on the inves-\\ntigations of Francois Franck which have been utilized\\nmore than any others in the following description. The\\nsensory nerves of the nasal cavity are derived from the tri-\\nfacial. The anterior ethmoidal nerve, a branch of the nasal\\nnerve of the first division, supplies the anterior portion of\\nthe nasal cavity corresponding to the external nose, while\\nthe remaining portion of the interior of the nose is supplied\\nby the posterior nasal branches of the second division, and\\nby a branch of the dental nerve of the third division.\\nThese nerves transmit the nasal reflexes which are known\\nas sneezing, nasal cough, and reflex spasm of the glottis.\\nThe sneezing reflex may be produced in any part of the\\n306", "height": "3468", "width": "2148", "jp2-path": "rhinologylaryng00frie_0320.jp2"}, "321": {"fulltext": "SNEEZING REFLEX. ASTHMA. 307\\nnasal mucous membrane, as any one can convince himself.\\nThe anterior and posterior extremities of the middle and\\ninferior turbinals, and the corresponding parts on the septum,\\nare said to constitute a special irritative zone, as the reflex\\nis most easily produced in these regions. The sneezing\\nreflex may also be produced by irritation at some distance,\\nwhich is transmitted to the nasal cavity through the chan-\\nnels of the trifacial nerve. Everybody is familiar with the\\nproduction of the nasal reflex by sudden illumination of the\\neye, such as occurs when we look into the sun, the re-\\nflex in this case being carried from the ciliary to the an-\\nterior ethmoidal nerve by way of the nasal nerve. The\\nsneezing can usually be prevented by exerting pressure on\\nthe trunk of the ethmoidal nerve at a point where it is\\nsuperficial, as on the inner upper wall of the orbit and at the\\nlower border of the nasal bone, where the external branch\\nleaves the inner surface of the nasal cavity, between the\\nbone and the cartilage. The reflex act of sneezing itself is\\neffected by the respiratory muscles, and consists in a deep\\ninspiration followed by a sudden explosive expiration with\\nthe glottis widely gaping and the soft palate shutting off\\nthe oral cavity from the nasopharynx, so that the entire\\nrespiratory blast escapes through the nose under high\\npressure.\\nThe nasal cough, and the reflex convulsions of the\\nglottis and of the bronchi in the form of spasm of the\\nglottis and asthma, represent various grades of a reflex\\naction transmitted through the same channels. The im-\\npulse travels toward the center along the channels of the\\ntrigeminus, and returns toward the periphery in those of\\nthe vagus. Franqois Franck and Lazarus have furnished\\nexact experimental proof of this reflex. By irritating the\\nnasal mucous membranes it is possible to constrict the\\nlumina of the bronchi, but as soon as the vagus is excluded\\nthe experiment becomes impossible. The marked contrac-\\ntion of the bronchial muscles may even give rise to visible\\nretraction of the intercostal spaces (Franqois Franck). The\\nspasmodic nature of this reflex from the nasal mucous\\nmembrane may manifest itself in spasm of the glottis as\\nwell as in asthmatic S} mptoms. The latter is to be regarded\\nas a combination of all the forms now under discussion,\\nand was observed in animals, A\\\\ liic] i, after irritation of the\\nnasal mucous membrane with the gal\\\\-anocautery, fell to", "height": "3448", "width": "2184", "jp2-path": "rhinologylaryng00frie_0321.jp2"}, "322": {"fulltext": "308 APPENDIX.\\nthe ground in a condition of asphyxia, with respiration\\narrested either in inspiration or in expiration, and recovered\\nvery slowly. Milder grades of the attack showed them-\\nselves more in a change of the respiratory rhythm and\\ngeneral restlessness of the animal.\\nThe nasal reflex neuroses manifesting themselv^es in car-\\ndiac affections in the form of retardation of the pulse and\\ncardiac arhythmia have also been proven by direct experi-\\nmentation. Another group of reflex neuroses, revealing\\nthemselves clinically in swelling and redness about the nose\\nand eyelids and in headache and vertigo find their physio-\\nlogic explanation in the vasomotor disturbances produced\\nin the nose. To this class belong the vasomotor secretory\\nneuroses which are described as vasomotor coryza, hydror-\\nrhea of the nose, and hay fever. Their etiology is usually\\nnot ascertainable most likely they represent a reflex neu-\\nrosis which any accidental external factor may induce in\\nhysteric and neurasthenic subjects. It is not as yet gen-\\nerally admitted that hay fever belongs to this group. It is\\npossible that paralysis of the sympathetic may also produce\\nhydrorrhea of the nose, although the hypothesis is not\\nconfirmed by experience. In one case of unilateral paraly-\\nsis of the cervical sympathetic I observed that the erectile\\ntissue in the turbinals was more swollen on the diseased,\\nthan on the sound side, but there was no nasal secretion,\\nand the swelling yielded promptly to cocain. Finally, we\\nmust include in this group the reflexes transmitted to the\\nsexual apparatus from the nose, since they are to be\\nregarded in the main as the effect of vasomotor irritation.\\nWe distinguish two kinds of vasomotor disturbances of\\nnasal origin, one of which manifests itself in the erectile\\ntissue and mucous membrane of the nose itself, while the\\nother finds expression in the vessels of other organs when\\nthe sensory nerves of the nose are irritated. The reflexes\\nof the first variety are chiefly vasodilator in character, such\\nas we see after probing a normal nasal mucous membrane.\\nThe reflexes of the second group, on the other hand,\\npresent various characters. Thus, Franqois Franck found\\nthat irritation of the nasal mucous membrane produced a\\ndilatation in the vessels of the head and a constriction in\\nthe superficial and deep vessels of the extremities.\\nWe often see the statement that reflex neuroses may be\\nproduced by the sense of smell, and the literature co ntains", "height": "3468", "width": "2148", "jp2-path": "rhinologylaryng00frie_0322.jp2"}, "323": {"fulltext": "OLFACTORY REFLEXES. 3O9\\na large number of cases in which the perception of certain\\nodors was followed by reflex conditions. One woman was\\nattacked with sneezing fits whenever she smelled roses\\nanother whenever she was exposed to the foul smells of\\nmanure from a horse or cow stable epileptic and asthmatic\\nattacks, and even reflex irritation of the genitalia through\\nthe olfactory nerve, have been described, and the sexual\\nexcitement induced by smelling the opposite sex has even\\nbeen interpreted as a reflex. For the first group effected\\nthrough the sense of smell we must assume an idiosyncrasy\\ndepending on hysteric predisposition, while the second form\\ncan be explained on psychologic grounds only. The scent-\\ning of the opposite sex evokes not a reflex, but a sensuous\\nexcitation analogous to that conveyed through the eye or\\nthe ear; instance the call of the male to the female among\\nanimals.\\nWhen we attempt to explain the production of a change\\nin the respiratory rhythm, which appears to be the effect of\\nreflex irritation through the olfactory nerve, we meet with\\na greater difficulty. Gaule,^ however, suggests that the\\nchange in the respiratory rhythm is not so much a reflex\\nact of the organism to protect the body against the invasion\\nof deleterious substances, as it is an effort to adapt the res-\\npiration to the act of smelling.\\nIt follows from these considerations that the existence of\\nnasal reflex neuroses now rests on a firm theoretical basis,\\ninstead of, as formerly, on mere clinical observation consist-\\ning chiefly in post hoc propter hoc arguments, such as im-\\nprovement after local treatment of the nose. But to be\\nquite exact, we should in addition demand an absolute\\nclinical proof for all nasal reflexes, viz., that they can only\\nbe produced from the nasal mucous membrane, that they\\nmay be completely arrested by anesthetizing the mem-\\nbranes, and that they can only be finally cured by direct\\ntreatment of the offending spot in the nasal mucous mem-\\nbrane. These points should be particularly insisted upon\\nin the diagnosis of all doubtful cases.\\nHack uttered the opinion in his first publication that the\\nreflexes can only be produced from certain definite regions\\nin the nasal mucous membrane corresponding to the posi-\\ntion of the erectile tissue. He set up the hypothesis that\\n1 Heymann s Ilandb. der Laryng., vol. ni.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0323.jp2"}, "324": {"fulltext": "3IO APPENDIX.\\nthe irritation of the sensory nerve endings of the nasal\\nmucous membrane is secondary to the sweUing and en-\\ngorgement of the erectile tissue, so that the reflex is not due\\nto the primary cause but to the irritation of the nerve end-\\nings by the swollen erectile tissue. This theory was an-\\ntagonized by Frankel and others, and it has now practically\\npassed into oblivion. Yet it appears to throw some light\\non certain doubtful points, for, as pointed out by Hack, it is\\na well-known fact that the reflexes are less likely to be pro-\\nduced by chronic catarrhal conditions associated with great\\nhyperplastic swelling than they are by the milder hyper-\\nemic processes, inducing an intermittent swelling of the\\nnasal mucous membranes which would be more likely to\\nirritate the nerve endings.\\nBut we can dispense with this artificial theory of Hack s\\nby laying down the maxim that reflex neuroses are most\\napt to occur when opposing regions of the mucous mem-\\nbrane periodically come into contact with one another,\\nnasal respiration, being still intact.\\nThis intermittent contact is lost when the adjoining\\nregions are brought into constant apposition by conditions\\nof hyperplasia or by the formation of large polypi. Such\\nan irritation is possible in any part of the nasal mucous\\nmembrane where the lateral wall is capable of touching the\\nmedian wall, and it is not necessary to limit its predilection\\nto the region of the erectile tissue. It is true that contact\\nwill occur most frequently between the inferior and middle\\nturbinate bones, where the embedded erectile tissue on one\\nside impinges on the other, on the tubercle of the septum,\\na condition favorable for the development of such hyper-\\nemia.\\nThe individual shape of the interior of the nose also\\nplays an important role. Thus a marked deviation, or a\\nspine or crest on the septum approaching the lateral nasal\\nwall favors a periodic contact between the opposed mucous\\nmembranes even when the swelling is very slight.\\nIn the etiology of nasal reflex neuroses we must not\\nneglect those conditions in which slight hyperplastic pro-\\ncesses are found at the anterior extremity of the middle\\nturbinate bones without any other pathologic conditions\\nin the nose, or the presence of small nasal polypi just\\nbeginning to grow from the middle turbinate in the\\nmiddle meatus. In this case the reflex neuroses appear", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0324.jp2"}, "325": {"fulltext": "SUPPURATION. PERTUSSIS. 3 I I\\nto be produced by contact of the hyperplastic mucous\\nmembrane with the free border of the inferior turbinated\\nbone.\\nAnother etiologic factor in the production of nasal reflex\\nneuroses is said to be found in adhesions between adjoining\\nportions of the nasal mucous membrane and in distortions\\nand overstretching of the membrane by the contraction of\\ncicatricial tissue. It is also quite conceivable that the con-\\ntinued presence of a foreign body in the nose might lead to\\nreflex neuroses by irritation of the sensory nerves.\\nAn important role in the production of the clinical picture\\nwhich we are considering must be conceded to suppura-\\ntions within the nose originating in adjacent cavities. We\\nmust mention in particular suppuration in the antrum,\\nespecially in those cases where, owing to a marked alteration\\nin the region of the middle meatus, there is only a slender\\nstream of pus in the middle meatus to indicate the disease.\\nIn these cases the nerve endings in the mucous membrane\\nare irritated by the pus which enters through the nasal\\norifice of the respective cavity and, by moistening the sur-\\nrounding mucous membrane, materially affects its nutritive\\nconditions, as is shown by the polypoid hypertrophies pro-\\nduced in the later stages of the disease.\\nFinally, we must emphasize that a nervous disposition is\\nnecessary for the production of the nasal reflex. The nasal\\nmucous membrane is in a condition of abnormal excitability\\nin which a mild irritation, such as in the healthy subject\\nwould produce only a slight swelling of the nose, is capable\\nof evoking a whole complex of reflex phenomena. While\\nthe pungent odor of certain substances, such as flowers or\\nagricultural products or the inhalation of smoke and dust-\\nladen air, produces in a healthy man only the normal\\nreflexes, consisting in swelling of the mucous membrane,\\nincreased secretion, and the act of sneezing, the same in-\\nfluences in the hypersensitive mucous membrane of hysteric\\nand neurasthenic persons suffice for the development of\\npathologic reflexes manifesting themselves in cough, asthma,\\nor even in the symptom-complex of hay fever.\\nIt is worth mentioning that pertussis has also been re-\\ngarded as a reflex neurosis derived from the nasal mucous\\nmembrane, and it is said that the attacks can be consider-\\nably mitigated by cocainizing that structure.\\nIn connection with the nasal reflex neuroses we must", "height": "3448", "width": "2040", "jp2-path": "rhinologylaryng00frie_0325.jp2"}, "326": {"fulltext": "312 APPENDIX.\\nrefer to certain conditions which are usually included among\\nthem, but really only represent the sequelae of interference\\nwith nasal respiration they are not the effect of reflex\\nirritation, but are produced mechanically by interference\\nwith nasal respiration and the secondary changes in the\\norganism. In these conditions we do not have to deal\\nwith a neurosis which can be shown to follow irritation of\\ncertain regions of the nasal mucous membrane, nor with a\\nneurosis which can be suppressed by cocainizing the re-\\nspective regions in the nasal mucous membrane. They\\nrepresent rather the expression of insufficient respiration\\nand defective oxidation of the blood, and may present\\nthemselves under a great variety of forms.\\nIt is hardly necessary to say that we must carefully\\nguard against too liberal a construction of the significance\\nof nasal stenosis. The most frequent manifestation is that\\nknown as aprosexia, which can be seen characteristically in\\nchildren suffering from adenoid vegetations. Enuresis\\nnocturna, chorea, and epilepsy have also been included\\namong the ultimate effects of nasal stenosis, but great care\\nshould be enjoined in interpreting such cases, remembering\\nthat very often a few accurate observations are obscured and\\nvitiated by subsequent carelessly reported cases, and thus\\nthe whole doctrine discredited.\\nUnder the name of aprosexia {a-poniyziv zw vcDv) Guye\\nhas described a clinical picture consisting of inability to fix\\nthe attention on one subject, of unusual forgetfulness mani-\\nfesting itself in the rapid disappearance of mental impres-\\nsions which originally were acquired only at the expense of\\ngreat effort, and finally of headache, which in some cases\\nwas limited to a feeling of constant or intermittent pres-\\nsure in the head, while in others it produced all the phe-\\nnomena of violent hemicrania, especially during the morn-\\ning hours.\\nAccording to Guye, we should distinguish three varieties\\nof aprosexia, the first of which is physiologic and the effect\\nof overexerting the brain the second, neurasthenic, as a\\nconsequence of pathologic brain fatigue while the third\\nrepresents the nasal aprosexia, now under discussion.\\nIt arises in consequence of nasal stenosis associated with\\nswelling and stasis in the venous and lymphatic channels of\\n1 Deutsche med. Wocben., 1S87, No. 43, and 18SS, No. 40.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0326.jp2"}, "327": {"fulltext": "APROSEXIA. ENURESIS. 313\\nthe nasal mucous membranes. The pathogenesis of. apro-\\nsexia is readily understood when we consider the intimate\\nrelation existing between the lymphatic spaces and blood-\\nvessels of the nasal mucous membrane and the subarach-\\nnoid space. Schwalbe and Retzius were able to inject the\\nlymphatic vessels of the nasal mucous membranes through\\nthe arachnoid space. An equally intimate relation exists\\nbetween certain venous regions of the nose and the interior\\nof the skull, although in this case the blood stream which,\\naccording to Zuckerkandl, is directed brainward, does not\\nsuggest stasis in the intercranial venous channels so much\\nas an engorgement of the nasal veins with stagnant venous\\nblood containing a large percentage of CO 2-\\nEnuresis nocturna occurs with comparative frequency in\\nchildren suffering from obstruction of the nose due to\\nadenoid vegetation or other causes. Gr6nbech,i how-\\never, believes that the cases are probably due to a certain\\ndisposition to enuresis, since adenoid vegetations are very\\ncommon, and the combination of enuresis with nasal ob-\\nstruction ought therefore to be observed much more fre-\\nquently.\\nThe most familiar, and at the same time most plausible\\nhypothesis, is that the relation between the two diseases\\ndepends on an excessive amount of CO 2 in the blood due\\nto defective respiration, as a result of which there is a mild\\ndegree of carbonic acid poisoning, which in turn leads to\\nrelaxation of the vesicle sphincters.\\nA simpler explanation is that the enuresis is due to the\\nfact that the children are restless and only half asleep in\\nconsequence of the defective respiration. It is often found\\nin connection with pavor nocturnus (terror infantium) in\\nmouth-breathers, and is explained by the fact that sleep is\\nfrequently interrupted by cessation of the breathing due to\\nreflex closure of the mouth.\\nIn rare cases, choreic movements, especially of the face,\\nas, for instance, wrinkling of the brow or twitching of\\nthe corners of the mouth, are described. Tic convulsif\\nand epileptiform conditions have been attributed to nasal\\nobstruction. Although we usually find the note that\\nremoval of the cause of the nasal stenosis, such as\\nadenoid vegetation or hypertrophies of the mucous mem-\\n1 Arch. f. Laryng., Ii, p. 224.", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0327.jp2"}, "328": {"fulltext": "314 APPENDIX.\\nbrane, was followed by cessation or diminution of these\\nreflex conditions, the cases can not be accepted without\\na reservation, as the causal relationship between nasal\\nstenosis and such convulsions is still very obscure.\\nOccasionally examination of the nose or other minor\\nnasal operation is followed by a partial epileptic attack of\\nsyncope similar to its epileptic equivalent, by sudden ex-\\ncitement, or by temporary unconsciousness such con-\\nvulsive attacks are not to be regarded as reflex phe-\\nnomena, they are the product of a violent psychic irri-\\ntation in subjects of a neurasthenic or hysteric disposition.\\nI have, however, seen a true epileptic attack produced in\\nan epileptic subject by endonasal interference.\\nTHE SIGNIFICANCE OF SOME OF THE CRANIAL NERVES\\nIN RHINOLOGY AND OTOLOGY.\\nThe Trifacial Nerve.\\nThe trifacial nerve is the sensory nerve of the mucous\\nmembrane of the nose and of its accessory cavities, and is\\ntherefore involved in any diseases affecting these structures.\\nHence nasal diseases are frequently accompanied by neu-\\nralgia and reflex phenomena conveyed through the\\nbranches of this nerve. The nasal reflexes have been\\nmentioned, and in speaking of diseases of the eye it has\\nbeen said that irritation of the anterior ethmoidal nerve and\\nof the nasal branches of the second division of the trifacial\\nin the interior of the nose may give rise to reflex epiphora.\\nWe will now consider exclusively the sequelae which take\\nthe form of neuralgia.\\nSupra-orbital neuralgia is a frequent symptom of disease\\nof the frontal sinuses. Both acute rhinitis with inflamma-\\ntion of the mucous membrane in the accessory cavity, and\\nacute or chronic suppuration of the frontal sinuses may\\nlead to a typical neuralgia of the first division of the fifth\\nnerve. The implication of the nerve finds a general expla-\\nnation in the fact that branches of the supra-orbital extend\\nto the anterior and lower wall of the frontal sinus, and may\\nthus transmit the pain of an inflammation to the trunk of\\nthe nerve but, in addition, certain individual anatomic\\nconditions play an important role, since the distance of the\\nsupra-orbital nerve from the walls of the cavity varies with\\nthe dimensions of the frontal sinus.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0328.jp2"}, "329": {"fulltext": "TRIFACIAL NEURALGIA. 3 I 5\\nThe symptoms of a neuralgia secondary to disease of\\nthe frontal sinus are the same as those of simple neuralgia.\\nPoints of tenderness are found at the supra-orbital foramen\\nand at the inner upper angle of the orbit where the\\nethmoidal nerve leaves that cavity. There is tenderness\\nof variable degree at the anterior lower wall of the frontal\\nsinus, while epiphora and slight edema of the upper eyelid\\noccur, with lancinating, often periodic pains radiating\\ntoward the forehead and occiput. These symptoms may be\\neither unilateral or bilateral, depending on the nature of\\nthe primary disease.\\nWhen the neuralgic symptoms predominate in the clinical\\npicture, a diagnosis is usually impossible without a nasal\\nexamination until circumscribed edema and bulging of the\\norbital or anterior wall of the frontal sinus make their\\nappearance, when even the general practitioner who is not\\nversed in rhinology can no longer entertain a doubt of the ex-\\nistence of suppuration in the frontal sinus. It can not be\\ndenied, however, that even the rhinologic examination is not\\nalways absolutely clear, as simple catarrhal changes of the\\nnasal mucous membrane may occur in primary trifacial\\nneuralgia as the effect of a reflex vasomotor and trophic\\ndisturbance. The nasal condition establishes the diagnosis\\nwhen the neuralgic pains are associated with discharge of\\npus from the middle meatus or with hypertrophic or\\npolypoid changes in the neighborhood of the hiatus semi-\\nlunaris and on the middle turbinated bone.\\nNeuralgia of the infra-orbital nerve may occur in connec-\\ntion with disease of the antrum of Highmore. The canal\\nfor the transmission of the nerve fills the upper (orbital)\\nwall of the cavity and projects sharply into the lumen,\\nwhile its numerous dental branches course along the inner\\nsurface of the lateral wall in minute grooves covered only\\nby the mucous membrane of the sinus. Although the\\ninfra-orbital nerve is nearer to the antrum of Highmore\\nthan is the supra-orbital nerve to the frontal sinus, neuralgia\\nof the inferior orbital nerve is rarer than supra-orbital\\nneuralgia. This is perhaps explained by the drainage con-\\nditions of the cavity and the location of the nerve at the\\nroof, while in the frontal sinus the retention of pus frequently\\nleads to such an increase of the pressure as to cause bulg-\\ning of the walls of the cavity. This increase of pressure\\nrarely occurs in empyema of the antrum disregarding", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0329.jp2"}, "330": {"fulltext": "3i6 APPENDIX.\\ncysts ;and, tumors which give rise to different appearances,\\nas the communication between the cavity and the nose,\\nalthough situated somewhat high and affording incomplete\\ndrainage, is still much more free than that of the frontal\\nsinus, which is situated in the narrow infundibulum of the\\nhiatus semilunaris. Hence pressure on the nerve canal or\\non the nerve itself, if the canal is gaping, is not likely to\\noccur. But if there is marked retention, the pressure\\nmanifests itself chiefly on the floor rather than against the\\norbital wall, and a bulging of the lateral wall of the cavity\\nis much more likely to ociur as it is in part membranous\\nand corresponds to the lateral wall of the nose.\\nAs the dental branches from their superficial position\\nare more exposed to disease, the inflammation may spread\\nfrom them to the nerve-trunk and give rise to typical neural-\\ngia, or at least to tenderness at the point of exit of the\\ninfra-orbital nerve.\\nGriinwald^ states that the sphenopalatine ganglion, on\\naccount of its close proximity to the anterior and inferior\\nwalls of the sphenoidal sinus and the ethmoidal cell, is\\nliable to become involved in caries of these bony cavities.\\nIn neuralgia of the first division there is a point of ten-\\nderness on the external nose where the external branch of\\nthe anterior ethmoidal nerve passes out between the nasal\\nbone and the lateral cartilage to the skin covering the tip\\nof the nose.\\nDuring operations on the septum and on the nasal floor,\\nthe pain often radiates to the upper incisors and to the\\nanterior part of the hard palate, owing to the distribution\\nof the terminal branches of the nasopalatine nerve of Scarpi\\nwhich leaves the nasal cavity through the incisor foramen\\nto reach the oral cavity.\\nThe relations between the trigeminal nerve and the organ\\nof hearing consist in\\n(i) Disturbances in the ear in disease of the trigeminus\\nand its branches and,\\n(2) Disturbances of the trigeminus in diseases of the\\near.\\nThe organ of hearing receives sensory nerves from the\\ntrifacial, the auricle and external auditory meatus being\\nsupplied by the auriculotemporal nerve, a branch of the\\n1 Die Eiterungen der Nase, 2d ed., p. 125.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0330.jp2"}, "331": {"fulltext": "TRIFACIAL NEURALGIA. OTALGIA. 317\\nthird division, while another branch running from the small\\nsuperficial petrosal to the tympanic plexus along the med-\\nian wall of the tympanum effects a connection between the\\ntrifacial and the tympanic plexus by means of the otic gan-\\nglion.\\nOtalgia is a favorite but very misleading term for all kinds\\nof earache. It is, of course, convenient, and as it is a very\\ngeneral expression, it does not commit one to anything, so\\nthat it is often used to describe any obscure symptom. It\\nw^ould be well, however, to use the expression otalgia as a\\ndiagnostic term only when it is synonymous with neuralgia\\notitica or neuralgia tympanica, affections which point to\\nimplication of the trifacial and of its aural branches.\\nThese neuralgias occur most frequently in caries of the\\nupper or lower molars. Korner gives as a symptom of\\nthis form of otalgia which is often difficult to distinguish\\nfrom toothache an increase of the pain in the ear when the\\ngland between the lower jaw and the hyoid bone is pressed\\nupon.\\nSimilar pains are complained of in diseases of the articu-\\nlation of the jaw which are variously described as rheuma-\\ntism (Schwartze^), or neuralgia (Bruck^). From my own\\nobservation of a similar case I know how difficult it is to\\ninterpret the earache correctly, and it may often be impos-\\nsible to determine whether there is an otalgia due to radia-\\ntion of the pain through the branches of the trifacial, or\\nwhether the pain in the joint is erroneously referred to the\\near.\\nThe distribution of the trifacial is also responsible for the\\nradiation to the ear of pains which have their origin in the\\nnasopharynx, the pillars of the fauces, the lateral wall of\\nthe pharynx, and the base of the tongue. Neuralgic\\npains in the ear occurring in connection with disease of the\\nepiglottis and of the larynx are probably transmitted by the\\npneumogastric through its auricular branch, which is one\\nof the sensory nerves of the external ear.\\nIt would take too long to enumerate all the diseases\\ncapable of producing neuralgia of the ear in this way. The\\ncommonest of them are ulcerations, acute inflammations,\\nangina (especially tonsillar abscess), and inflammation and\\n1 Zeitschr. f. Ohr., XXX, p. 133.\\n2 Die chir. Krankh. des Olires.\\nDeutsche nied. Wochen., 1895, No. ;i2-", "height": "3444", "width": "2120", "jp2-path": "rhinologylaryng00frie_0331.jp2"}, "332": {"fulltext": "3l8 APPENDIX.\\nswelling of the base of the tongue and of the epiglottis.\\nFinally, otalgia has long been known as a characteristic\\nsign of carcinoma of the larynx.\\nIn trifacial neuralgia the pain frequently radiates to the\\nears, or may even be especially marked in the auriculotem-\\nporal nerve. Krepuska met with a case of primary sar-\\ncoma of the Gasserian ganglion which began with obstinate\\nneuralgia. Lesions of the nucleus or trunk of the trifacial\\nnerve produce anesthesia of the external auditory meatus\\nand of the auricle. The eruptions of herpes zoster which\\noccasionally become localized in the auricle may perhaps\\nalso be referred to this innervation.\\nAs the tensor tympani muscle is innervated by a motor\\nbranch of the trifacial which is given off from the otic\\nganglion, we should expect to find interference with this\\nmuscle in disease of the trifacial nerve. It is, however,\\nvery difficult to prove that such is actually the case, as we\\npossess no reliable means of distinguishing the functions of\\nthe internal muscles of the ear. The functional disturb-\\nances which result are very slight, for paralysis of the\\nmuscle does not affect the general power of hearing it\\nonly induces hyperesthesia to very high tones, while a\\ncontraction of the muscle diminishes the vibrations of the\\nossicles and increases the pressure in the labyrinth. Clonic\\nspasms of the tensor tympani, in which the tensor veli\\npalati usually participates, manifest themselves as cracking\\nnoises in the ear they were first described by Schwartze.-\\nExtirpation of the Gasserian ganglion or of the second\\nor third divisions of the trifacial nerve, now quite fre-\\nquently done for therapeutic purposes, should afford us\\na means of studying the function of the muscle, but the\\nobservations in this respect have so far been ver)^ disap-\\npointing. In the case published by Krause, the hearing\\nwas not affected unfavorably by extirpation of the Gasserian\\nganglion, and in the case reported by Aster from Czerny s\\nclinic, of resection of the second and third division of the\\nfifth nerve, the hearing remained intact for three weeks\\nafter the operation, when another complication occurred\\nwhich will be referred to later. The only phenomenon\\n1 Krepuska, ZeitscVir. f. Ohr., xxx, p. 189.\\n2 Arch. f. Ohr., II, 4.\\nMiinch. med. Wochen., 1S95, Xos. 26 and 27.\\nI .eitr. z. klin. Chir., XI, 3 Heft.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0332.jp2"}, "333": {"fulltext": "EXTIRPATION OF GASSERIAN GANGLION. 319\\nthat may perhaps be regarded as the result of paralysis\\nof the tensor tympani is that described in one of Krause s\\ncases. The patient complained of a peculiar sensation\\nin the temporal region which she compared to the tick-\\ning of a watch, and which, she said, she had never ob-\\nserved before the operation. But as this phenomenon is\\nrather a symptom of clonic muscular cramp or irritation of\\nthe trifacial than of a paralysis, it is difficult to establish\\nany causal relationship between it and the extirpation of\\nthe nerve. Moos believes that the hyperesthesia of the\\ntrifacial nerve may, without the motor branches being\\ninvolved, lead to auditory disturbances in the form of\\nabnormal sensitiveness to certain kinds of tones and noises,\\nand explains the phenomenon as due to an increased tactile\\nsensibility of the external auditory meatus to the unusual\\nsound waves Whether the tinnitis aurium which accom-\\npanies toothache is due to reflex muscular irritation or to\\nvasomotor influences has not as yet been determined.\\nSchwartze explains it as a reflex irritation of the auditory\\nnerve through the trifacial, but the explanation does not\\nseem very clear to me.\\nUrbantschitsch^ reports a series of observations which\\nhave been interpreted as the effect of reflex irritation of the\\nsense of hearing from various regions supplied by the tri-\\nfacial nerve.\\nThe conditions found after extirpation of the Gasserian\\nganglion fail to confirm the observation of various authors,\\nbased on experimentation, that lesion or division of the\\ntrunk of the trifacial nerve sets up an inflammatory process\\nin the mucous membrane of the tympanum, designated by\\nBerthold as otitis media neuroparalytica. The latter\\nauthority claims that lesions of the trifacial, either in its\\ncontinuity or in the roots, may produce all stages of inflam-\\nmation in the middle ear from simple vascularization to\\nsuppuration, and Baratoux found that this was confirmed\\nby his experiments while Kirchner, after dividing the\\ninferior dental nerve in a cat, and subjecting it to\\n1 Virch. Arch., vol. Lxviii.\\n2 Berlin, klin. Woclien., 1S66, Nos. 12 and 13.\\nLehrb., p. 349.\\nSchwartze s Handb., p. 315.\\n5 Zeitschr. f. Ohr, x.\\n6 Arch. f. Ohr., XIX, p. 199, 200.\\nMon, f. Ohr., 1SS2, No. 4, and comp. Arch. f. Ohr., xx, p. 58.", "height": "3448", "width": "2108", "jp2-path": "rhinologylaryng00frie_0333.jp2"}, "334": {"fulltext": "320 APPENDIX.\\nelectrical irritation, observ^ed a more marked dilatation\\nof the vessels in the tympanic cavity and increased\\nsecretory activity of the mucous membrane. We may dis-\\nregard those cases in which toothache was followed by\\nacute exudative middle-ear catarrh (Walb), or those in\\nwhich paralysis of the trifacial was followed by more or\\nless complete deafness, as the connection between the two\\ndiseases is not clearly shown. In fact, the opposite appears\\nto be proved by Krause s cases, in which extirpation of the\\ntrifacial had no effect on the power of hearing. Asher s\\ncase can not, I think, be used in the evidence a serous\\nexudation in the middle ear associated with chronic catarrh\\nof the nasopharnyx developed three weeks after resection\\nof the second and third divisions of the trifacial nerve.\\nAs neuralgia of the ear may be due to diseases of the\\ntrigeminal nerve, conversely this nerve may become impli-\\ncated in diseases of the ear. The trunk of the trigeminal\\nnerve may suffer in endocranial complications of middle-ear\\ndisease, in pachymeningitis, in extradural abscess, and in\\nserous and purulent meningitis. Phlebitis of the cavernous\\nsinus gives rise to neuralgia of the first division of the fifth\\nnerve (Korner\\nAs the Gasserian ganglion is situated in Meckel s recess,\\non the upper surface of the petrosal portion of the temporal\\nbone, a purulent otitis media may, by extension toward the\\napex of the petrous portion, lead to marked nutritive dis-\\nturbances, involve the Gasserian ganglion and produce\\ntrifacial neuralgia, as was first described by v. Troltsch\\nand Schwartze,^ and later by Habermann.\\nChorda Tympani.\\nLesion of the chorda tympani gives rise to disturbances\\nin the sense of taste in the anterior two-thirds of the tongue,\\nand as the nerve passes through the tympanum and is\\nexposed to injury by any pathologic process present in that\\ncavity, it deserves special mention.\\nThe chorda tympani is given off from the facial nerve a\\n1 Otit. Hirnerkrankungen, 2d edit., 1896, p. 67.\\n2 Arch. f. Olir., iv, p. 126.\\n3 Arch. f. Ohr., xui, p. iio.\\nComp. V. Frankl-Hochwart, Nothnagel s Spec. Path. u. Therap., vol.\\nXI, II, Th. 4. Abth. Die nervosen Erkrankungen des Geschmacks, etc.,\\nthe literature will be found best in Urbantschitsch, Lehrb. der Ohrenheilk.\\nand in Schwartze s Handb., i, p. 468.", "height": "3468", "width": "2212", "jp2-path": "rhinologylaryng00frie_0334.jp2"}, "335": {"fulltext": "CHORDA TYMPANI. 321\\nlittle above the point where the latter leaves the tympanum.\\nIt reaches this cavity through a special opening in its bony\\nwall, and after sweeping from behind forward and upward\\nbetween the long process of the incus and the handle of\\nthe malleus, partially covered by the posterior ventricular\\nfold, passes through the Glaserian fissure to reach the base\\nof the brain, and is continued from that point to the lingual\\nnerve of the third branch of the trifacial, with which it\\nbecomes united.\\nAlthough a branch of the facial, it really belongs to the\\ntrigeminus, from which it is originally given off, and only\\naccompanies the facial for a short distance. As it is proven\\nthat injury of the facial above the geniculate ganglion has\\nno effect on the sense of taste, the fibers of the chorda\\ntympani may leave the facial either by way of the great, or\\nby way of the small superficial petrosal nerve. But as this\\npoint is still in dispute, opinions are divided as to whether\\nthe chorda tympani belongs to the second or to the third\\ndivision of the trifacial if to the former, the nerve runs from\\nthe great superficial petrosal nerve through the Vidian to the\\nsphenopalatine ganghon if to the latter, from the small\\nsuperficial petrosal nerve to the otic ganglion.\\nThe innervation is even more complicated, and the symp-\\ntom of loss of taste at the tip of the tongue becomes more\\nobscure, when we remember that the path of the fibers of\\ntaste is a variable one they may pass directly from the\\nchorda tympani to the otic ganglion without passing through\\nthe facial nerve, or they may join the facial after its exit\\nfrom the stylomastoid foramen without utilizing the chorda\\ntympani. The first mode of distribution may be inferred\\nwhen a lesion of the facial in the temporal bone between\\nthe geniculate ganglion and the region of the chorda tym-\\npani does not affect the sense of taste the latter, if a lesion\\nof the facial, external to the stylomastoid foramen, is followed\\nby loss of the sense of taste.\\nThe conditions being thus inconstant, we can not wonder\\nthat the functional disturbances which occur after destruc-\\ntion of the chorda tympani during its course through the\\nmiddle ear do not tally with our expectations. The state-\\nments of a patient are of no value in the determination of\\nthe frequency with which disturbances of the sense of taste\\noccur in middle-ear disease when the chorda tympani is\\ndestroyed, for we know by experience that such disturbances\\n21", "height": "3448", "width": "2044", "jp2-path": "rhinologylaryng00frie_0335.jp2"}, "336": {"fulltext": "322 APPENDIX.\\nmay often escape detection even in those who are given to\\nobserving themselves most carefully. Thus Carl, who\\nhad suffered from purulent otitis media for many years, was\\nvery much astonished when he one day discovered that he\\nhad entirely lost the sense of taste in the anterior portion\\nof the tongue and the investigations of Urbantschitsch,^\\nwho made a careful examination of 50 patients suffering\\nfrom middle-ear diseases mostly chronic suppurations,\\nand found that 46 were suffering from a gustatory disturb-\\nance, go to show that, unless a special examination has been\\nmade with a view to determine the presence of such a dis-\\nturbance, case histories are of no value in determining\\nthe frequency of its occurrence. Carl observed sharp\\nstinging sensations on the left margin of the tongue, begin-\\nning at about the middle and shooting to the tip with\\nlightning rapidity, thus corresponding to the distribution of\\nthe chorda tympani the pain occurred whenever he cleaned\\nhis ear with cotton pledgets or irrigated it with astringents\\nand salicylic acid.\\nWhile we are on the subject of gustatory disturbances due\\nto diseases in the middle ear, we must not omit to mention\\nthose which occur after injury of the tympanic plexus in\\nthe distribution of the glossopharyngeal nerve.\\nThe tympanic plexus is formed by the terminal branches\\nof Jacobson s nerve, a branch of the glossopharyngeal, and\\nconnects with the trifacial and facial nerves and with the\\nsympathetic caroticotympanic plexus. Owing to the con-\\nnection of Jacobson s nerve, which is given off from\\nthe petrosal ganglion, with the small superficial petrosal\\nnerve, this plexus contains both gustatory fibers from the\\npetrosal ganglion through the glossopharyngeal nerve, and\\ngustatory fibers from the otic ganglion through the trifacial,\\nso that one would expect disturbances of the sense of taste\\nafter lesions of the tympanic plexus, and they have in fact\\nbeen lately reported by Schlichtling from Korner s clinic.\\nAccording to Urbantschitsch and others, the secretion\\nof saliva may be affected by chemic or mechanical irritation\\nof the tympanic plexus and of the chorda tympani either\\n1 Arch. f. Ohr., X, p. 163.\\n2 Anoraalien des Geschmack, Stuttgart, 1876 (from quotations in Urbant-\\nschitsch s Lehrb. der Ohrenheilk. and elsewhere).\\n3 Zeitschr. f. Ohr., xxxii, p. 3S8.\\nSchwartze s Handb. i, p. 471.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0336.jp2"}, "337": {"fulltext": "FACIAL NERVE. 323\\nduring medication (alum, salicylic acid, etc.), or during\\ninstrumental treatment (probing), or by inflammations of\\nthe nerves in purulent otitis media, as the nerves which\\nsupply the parotid gland are derived from the sympathetic\\nand glossopharyngeal, while those which supply the other\\nsalivary glands are found in the chorda tympani.\\nFacial Kerve.\\nAs the facial and auditory nerves are united in their\\ncourse as far as the internal auditory meatus, they are often\\nattacked by the same disease. Hence the combination of\\ncentral facial paralysis with nervous auditory disturbance\\nmay afford a valuable hint for the localization of an endo-\\ncranial lesion.\\nThe facial nerve has other important relations with the\\norgan of hearing, inasmuch as it is the motor nerve for the\\nmuscles of the ear.\\nThe muscles of the auricle and the stapedius muscle are\\nsupplied by the facial nerve, and their function is therefore\\nimpaired in any paralysis of the facial situated centrally, or\\noriginating in the respective muscular branches.\\nParalysis of the posterior auricular nerve, which supplies\\nthe occipital muscle and the retrahens, attrahens, and attpl-\\nlens aurem muscles, manifests itself in immobility of the\\nauricle, and according to Erb may indicate whether the\\nseat of the paralysis is above or below the region of this\\nnerve, which leaves the facial after its exit from the stylo-\\nmastoid foramen. Patients suffering with facial paralysis\\nfrequently complain of tinnitus aurium and difficult hear-\\ning. As the stapedius muscle is supplied by the facial\\nnerve, the symptom is usually referred to paralysis of the\\nnerve, and Asher saw this confirmed anatomically in a\\ncase of facial paralysis due to direct pressure of a cerebral\\ntumor in the occurrence of atrophy of the stapedius muscle.\\nAccording to Gottstein,^ Hitzig was the first to point\\nout that patients suffering from peripheral facial paralysis\\nexperience a loud buzzing noise in the ear whenever they\\nattempt to move the paralyzed half of the face, because the\\nvoluntary impulse, being unable to innervate the muscles\\nof the face, expends all its force on the branch to the sta-\\n1 Arch. f. klin. Med., xv, p. 22.\\n2 Zeitschr. f. klin. Med., vol. XXVII.\\n3 Arch. f. Ohr., xvi, p. 61.", "height": "3448", "width": "2056", "jp2-path": "rhinologylaryng00frie_0337.jp2"}, "338": {"fulltext": "324 APPENDIX.\\npedius muscle which is still intact. In a number of Erb s\\ncases, and occasionally in the latest literature, these patients\\ncomplain of certain auditory disturbances which they de-\\nscribe as hyperacousis (oxyocoia), tinnitus aurium, and\\nheightened electrical irritability of the auditory nerve.\\nIt is, however, more than doubtful whether all these\\nphenomena can be referred to the stapedius muscle, and we\\ncan not lose sight of the possibility that the auditory nerve\\nitself may be involved on account of its proximity to the\\nfacial.\\nBuzzing noises in the ear on the paralyzed side in per-\\nipheral facial paralyses are probably always to be referred to\\nabnormal activity of the stapedius muscle.\\nHyperacousis or oxyocoia can be referred to the loss of\\nfunction of the stapedius muscle which, according to\\nLucae,! accommodates the ear to the highest known\\nmusical tones, and paralysis of which is followed by ab-\\nnormal perceptive power for deep notes and increased\\nsensitiveness to all musical tones and similar sounds, par-\\nticularly for deep tones, so that if the noises are at all loud\\nthey may produce a sensation of pain.\\nIn regard to increase in the electrical irritability of the\\nauditory nerve, there is an observation by Seterblad which\\nis often quoted, but has never been confirmed by anybody\\nelse.\\nWe may also mention another aural symptom in facial\\nparalysis it is the prodromal pain in or behind the auricle\\nwhich, according to Oppenheim,^ may appear even when\\nthe paralysis does not originate in the ear.\\nThe facial nerve, from its close proximity to the auditory\\nand its passage through the temporal bone, comes into\\nvery close relations with the organ of hearing. It ac-\\ncompanies the auditory nerve from its exit at the medulla\\noblongata as far as the internal auditory meatus hence\\nfacial paralyses due to lesion of this portion of the\\nnerve-trunk are frequently accompanied by auditory nerve\\ndeafness. Among the causes which may produce such\\nlesions, tumors and aneurysms at the base of the brain,\\nbasal meningitis, syphilitic pachymeningitis, and gummata\\nare the most frequent.\\n1 Berlin, klin. Wochen., 1874.\\nZeitschr. f. Ohr., xvi, 292.\\n3 Lehrb. der Nervenkrankh.", "height": "3468", "width": "2168", "jp2-path": "rhinologylaryng00frie_0338.jp2"}, "339": {"fulltext": "FACIAL NERVE. 325\\nAfter leaving the auditory nerve in the inner meatus, the\\nfacial continues its course in the Fallopian canal, and at the\\ngeniculate ganglion turns backward and downward, cross-\\ning the posterior portion of the median wall of the tympanic\\ncavity, and finally, after passing downward along the floor\\nof the posterior wall of the external auditory meatus, leaves\\nthe skull through the stylomastoid foramen.\\nDuring its course through the petrous portion of the\\ntemporal bone the nerve is well protected, and is therefore\\nlittle exposed to diseases other than tumors and traumatic\\nfractures of the bone. Hence such a paralysis is an im-\\nportant sign of disease in the internal ear. The nerve is\\nmost exposed to disease during its passage through the\\nmiddle ear.\\nFacial nerve palsies are often observed in acute inflamma-\\ntions of the middle ear, and are explained by extension\\nof the inflammation either through the openings which\\nexist in the canal of the facial nerve for the passage of the\\nnerve to the stapedius and the chorda tympani, or through\\ncongenital clefts which not infrequently expose the nerve at\\ndifferent points in the middle ear. It has also been stated 1\\nthat a facial paralysis may be caused by inflammatory\\nhyperemia in the domain of the stylomastoid artery, which\\nsupplies both the tympanic cavity and the auditory nerve.\\nThe danger to the nerve is of course enormously increased\\nif the suppuration in the middle ear is associated with\\ncarious disease of the bone, as such a complication leads to\\nsequestration of the bony wall of the facial canal. Injury\\nof the facial during operations can be avoided if the surgeon\\npossesses any knowledge of the anatomic relations of the\\nnerve and even a moderate experience in operative technic.\\nNevertheless, they are seen only too frequently after extir-\\npation of the petrous portion of the temporal bone and\\nradical operations.\\nDISEASES OF THE MENINGES AND OF THE CEREBRAL\\nSINUSES.\\nTheir Significance in Connection with the Nose, Lar-\\nynx, and Ears.\\nDiseases of the meninges may involve the cranial nerves\\nand thereby produce pathologic conditions in the organs\\nunder discussion.\\nSchwartze, Die chirurg. Krankli. desObres, p. 174.", "height": "3456", "width": "2048", "jp2-path": "rhinologylaryng00frie_0339.jp2"}, "340": {"fulltext": "326 APPENDIX.\\nSuch changes have been observed in pachy- and lepto-\\nmeningitis and in tubercular and syphilitic meningitis, and\\nrecently the opinion is becoming more and more prevalent\\nthat serous meningitis is often responsible for palsies of the\\ncranial nerves. Thus, paralysis of the vocal cords has been\\nobserved in various diseases in epidemic cerebrospinal\\nmeningitis irritative conditions in the muscles of the larynx\\nmay occur, as observ-ed by Oppenheim (quoted by Kraus),\\nalong with irregular twitchings in the lower distribution\\nof the facial nerve, in the uvula, and in the vocal cords,\\ntaking the form of continuous rhythmic and isochronous\\ncontractions in the vocal cords. Occasionally olfactory\\ndisturbances are reported as signs of involvement of the\\nolfactory nerve, but the most frequent sequelse of diseases\\nof the meninges are found in lesions of the auditory nerve\\nor of the labyrinth. Hence, in any case of greatly dimin-\\nished hearing or deafness acquired in early youth, we\\nshould always take into account the possibility of an ante-\\ncedent inflammation of the meninges if there is no history\\nof an infectious disease.\\nThe aural disturbance may originate in disease either of\\nthe auditor)^ nerve or of the labyrinth, since it is well known\\nthat the sheath of the auditory nerve and the aqueducts of\\nthe vestibule and of the cochlea present a natural pathway\\nfor the spread of the disease from the interior of the\\ncranium to the internal ear.\\nIn cases where it is doubtful whether the seat of the\\naural disturbance is to be sought in the trunk of the auditory\\nnerve or in the labyrinth, a coexistent facial paralysis may\\npoint to the localization of the lesion in that part of the\\ntrunk of the acusticus which lies in close proximity to the\\nseventh nerve.\\nAmong the diseases of the meninges acute cerebrospinal\\nmeningitis plays a very important role, and I take up the\\nconsideration of this disease now rather than among the\\ninfectious diseases, because it gives rise for the most part\\nto the same varieties of secondary disease of the cranial\\nnerves as a meningitis due to other causes.\\nWe learn from studies on the etiology of epidemic cere-\\nbrospinal meningitis that the nose plays an important part\\nin the genesis of the disease, the meningococcus intercel-\\nlularis (Weichselbaum) being constantly found in the nose\\nand its accessory cavities. Although the significance of", "height": "3468", "width": "2168", "jp2-path": "rhinologylaryng00frie_0340.jp2"}, "341": {"fulltext": "EPIDEMIC CEREBROSPINAL MENINGITIS. 327\\nthis bacteriologic finding is somewhat weakened by the fact\\nthat Schiff 1 found virulent cocci in 4 out of 28 cases of\\npersons who were not suffering with epidemic cerebrospinal\\nmeningitis, it is nevertheless probable that infection very\\nfrequently takes place through the nose, because the disease\\noften begins with coryza (Striimpell) and we have\\nWeigert s authority for the statement that catarrhal in-\\nflammations are frequently found in the accessory cavities\\nof the nose at the autopsy.\\nIt is quite possible that the ear as well as the nose may\\nin some cases afford entrance to the pathogenic micro-\\norganisms of acute cerebrospinal meningitis. The menin-\\ngococcus intercellularis has, indeed, been found in isolated\\ncases in the aural secretion, but not with sufficient\\nfrequency to warrant a general conclusion as to its primary\\nsignificance in the production of a secondary meningitis.\\nAs pointed out by Leyden and Schwabach, purulent\\notitis media occasionally coexists with the general disease,\\nso that the thought naturally suggests itself that both\\naffections are produced by the same pathogenic micro-\\norganism. Schwabach was able to prove in one case, in\\nwhich the internal auditory meatus and dura mater were\\nfound to be entirely free from pus at the autopsy, that the\\nsuppuration of the middle ear was not a secondary inflam-\\nmation due to extension from the cerebrum.\\nPurulent otitis media is, however, comparatively rare as\\na complication of acute cerebrospinal meningitis, and far\\nless frequent than the other form of the disease which is\\ndue to direct extension of the purulent process from the\\nmeninges to the internal ear.\\nIt has been proved by numerous anatomic investigations\\nthat the inflammation extends either along the sheath of\\nthe acusticus or through the aqueducts of the labyrinth\\nwhere the purulent or hemorrhagic inflammatory process\\nis followed by extensive tissue-destruction. As we have\\njust stated, the suppurative process in the middle ear often\\nbegins in the first stage of the systemic disease the deaf-\\nness which must be attributed either to suppuration within\\n1 Centralbl. f. inn. Med., 1898, No. 22.\\n2 Deutsche Arch. f. khn. Med., xxx.\\n3 Froniann, Congr. f. inn. Med., 1897.\\nNothnagel s .Spec. Path. u. Therap. vol. X.\\n5 Zeitschr. f. klin. Med., xvni.\\nComp. Moos, Schwartze s Handb., I, p. 575.", "height": "3452", "width": "2076", "jp2-path": "rhinologylaryng00frie_0341.jp2"}, "342": {"fulltext": "328 APPENDIX.\\nthe labyrinth or to disease of the nerv^e-trunk occurs either\\nin the course of the disease or as a sequel.\\nThe impairment of hearing, which is often accompanied\\nwith vertigo and vomiting, symptoms due probably to im-\\nplication of the vestibular segment of the labyrinth, pre-\\nsents no definite characteristic, but usually goes on pari\\npassu with the rapid extension of the alterations in the\\nmiddle ear and labyrinth, and attains a very high grade in\\na few days. Often it goes on to total deafness, affecting one\\nor both ears, and may even render the patient deaf and\\ndumb, because the rav^ages of the disease are usually so\\ngreat that the power of hearing can not be restored. The\\nstatistics in deaf and dumb asylums present convincing\\nproof of the prominent part taken by acute cerebrospinal\\nmeningitis in the medical history of their inmates.\\nDiseases of the Meninges in Nasal Affections.\\nThere have been reported in the literature a small number\\nof cases in which disease of the meninges followed disease\\nof the nose and of its accessoiy cavities. The cases have\\nbeen collected by Griinwald and Dreyfuss,^ the most fre-\\nquent diseases being purulent meningitis, cerebral abscess,\\nand thrombosis in a sinus, especially in the cavernous sinus.\\nThe number is, however, very small, and the cases lack\\nuniformity. Hence it will be impossible to show the ex-\\nistence of a definite relationship, as will be seen to be the\\ncase in otitic cerebral diseases. Therefore it is not alto-\\ngether Dreyfuss fault that he failed in his attempt to give\\na systematic presentation of diseases of the cerebrum and\\nits adnexa following suppurations in the nose, in spite of\\nhis perseverance and industry in looking up all the literature\\nbearing on the subject.\\nThe interior of the cranium ma} become infected either\\nfrom the nose or from its adjacent cavities. In the former\\ncase, infection is transmitted by the lymphatic and vascular\\nchannels, which, as we have repeatedly stated heretofore,\\nestablish an intimate relationship between the upper seg-\\nment of the nasal cavity and the anterior fossa of the cere-\\nbrum. Thus all kinds of inflammations, including the\\nreactive form due to the use of the galvanic cautery,\\nand infectious diseases of the upper portion of the nose,\\nDie Lehre von den Naseneiterungen, Munich, 1896, p. 125.\\n2 Jena. Fischer, 1896.", "height": "3468", "width": "2168", "jp2-path": "rhinologylaryng00frie_0342.jp2"}, "343": {"fulltext": "INFECTION FROM THE NOSE. 329\\nwhich approximately corresponds to the ethmoid bone,\\nfrequently set up an irritative process in the meninges and\\nlead to grave constitutional phenomena. Considering the\\nfrequency of galvanocaustic interference, the cases that go\\non to a purulent meningitis are, however, comparatively\\nrare. The latter complication is particularly to be dreaded\\nafter tamponade of the upper portion of the nose on account\\nof the resulting retention of secretion, which is always of\\nan infectious nature. The fissures which are said to be\\noccasionally present in the cribriform plate of the ethmoid\\nbone are, according to Dreyfuss,i of some significance in\\nthe genesis of rhinitic cerebral complications, but the cases\\nof Chiari and Kaiser, on which he bases iiis theory, did not\\nappear to furnish a satisfactory proof, and it is difficult to\\nbelieve that the unfortunate subjects of this anomaly are\\nin danger of contracting meningitis after any ordinary\\ncoryza, and that even a violent blowing of the nose is\\nfraught with great danger in such individuals (Dreyfuss).\\nThe second mode of infection of the cerebrum, from\\nthe accessory cavities of the nose, follows caries of the\\nwalls of the cavities, a frequent sequel of chronic sup-\\npuration. The danger of infection to the brain from\\nthe diseased cavities necessarily depends on their anat-\\nomic relations with respect to the interior of the cranium\\nand the thickness of their walls, as in some cases of\\nchronic suppuration with caries several cavities are affected\\nat the same time, so that it is often impossible to\\ndetermine the exact spot from which the suppuration has\\nextended to the cerebrum. The possibility of such an\\netiologic connection must be considered in all diseases of\\nthe meninges in patients who are the subjects of chronic\\nsuppuration from the nose. The frontal sinus, the ethmoidal\\ncells, and the sphenoidal sinus represent the cavities which\\nare in direct relation with the base of the skull, and which\\ntherefore constitute a more or less serious menace to the\\ncerebrum according to the thickness of their walls.\\nWhen, as a consequence of caries, there are evident\\ndefects in these walls through which the pus can find\\nentrance into the interior of the skull, the mode of infection\\nis manifest, but there are other cases of purulent menin-\\ngitis in which, as I have myself seen, the path followed by\\n1 Jena. Fischer, 1896, p. 47.", "height": "3456", "width": "2040", "jp2-path": "rhinologylaryng00frie_0343.jp2"}, "344": {"fulltext": "330 APPENDIX.\\nthe pus in traveling from the accessory cavities to the\\nserous membranes can not be demonstrated postmortem,\\nthe bony wall being apparently intact, so that an osteo-\\nphlebitis must be assumed to explain the infection of\\nthe meninges. It would appear from the reported cases,\\nincluding my own, that the sphenoid sinus is most apt to\\ntransmit the infection, in spite of the thickness of its roof,\\nwhich corresponds with the sella turcica.\\nDiseases of the Meninges and of the Cerebral Sinuses\\nin Ear Disease.\\nThe importance of aural disease in the production of\\nsecondary diseases of the meninges and of the cerebral\\nsinuses can not be overestimated, and the doctrine of otitic\\ncerebral disease now forms one of the most important\\nchapters of otology.\\nSince Schwartze introduced operative measures in the\\ntreatment of ear diseases, since the progress of brain sur-\\ngery removed all obstacles in the way of opening the skull,\\nsince cerebral localization became more and more perfected,\\nso that after exposing a morbid focus in the temporal bone\\nthe extension of the process to the interior of the cranium\\ncould be observed clinically, the great significance of acute\\nand especially of chronic suppurations from the middle ear,\\nwith accompanying caries of the bone and cholesteatoma\\nformation in the production of secondary cerebral disease,\\nhas won general appreciation. A large proportion of all\\nbrain abscesses estimated at one-third are secondary\\nto disease of the middle ear, the infection having been\\ncarried by means of the diseased meninges. Most cases\\nof convex meningitis, of extradural abscess, and of diseases\\nof the cerebral sinuses are to be referred to aural disease,\\nand the most practical proof of the frequency of otitic\\ncerebral complications is found in the great activity of the\\naural surgeons, who, with untiring energy, publish all their\\noperative cases. The great number of analogous cases has\\nmade it possible to determine the pathogenesis and symp-\\ntoms of these complications. Korner in Otitic Diseases\\nof the Brain, the Meninges, and the Blood-vessels,\\nhas reduced this doctrine to a system, and this has recently\\nbeen added to very largely by the important contributions\\nof Jansen.\\nWeisbaden, Eergmann, 2d edit., 1S96.", "height": "3468", "width": "2168", "jp2-path": "rhinologylaryng00frie_0344.jp2"}, "345": {"fulltext": "INFECTION FROM THE EAR. 33 1\\nThe scope of the present volume does not permit an\\nadequate description of the significance of these important\\nrelations. That belongs to the domain of special text-\\nbooks on otology, and I shall content myself with pointing\\nout the channels by which suppurations in the middle ear\\nmay reach the interior of the cranium, and by describing\\nthe most important clinical pictures.\\nI already touched upon the question of the causal disease\\nin cerebral complications when I said that they may be pro-\\nduced either by acute or by chronic disease of the ear.\\nAmong the acute suppurations from the middle ear, the\\nmost dangerous are those which follow acute infectious\\ndiseases, such as scarlatina, diphtheria, typhoid, and influ-\\nenza, and to these we must add the diseases of the bone\\nwhich often follow acute inflammation in the course of\\ndiabetes mellitus and tuberculosis, and which from the\\nrapidity of their course may reach the interior of the\\ncranium in a few weeks. As a chronic otitis media is in\\ndanger of spreading to the cerebrum, the caution can not\\nbe too often repeated that removal of a chronic suppura-\\ntion, whose destructive effect on the bone can not be\\ncontrolled, is the first law in the treatment of ear diseases.\\nIf all ordinary means fail, an operation is indicated even\\nwhen its magnitude appears to be out of all proportion to\\nthe purulent focus in the ear. In many cases the only\\ncertain means of preventing a threatened cerebral compli-\\ncation is to expose freely all the cavities of the tympanum,\\nan operation which is quite devoid of danger if the operator\\nis faultless in his technic and master of the anatomic\\nrelations.\\nOf all chronic diseases, cholesteatomata are the most dan-\\ngerous. Though their progress is slow, they exert a con-\\nstant, progressive, destructive influence, and nearly always\\nlead to extensive destruction of the temporal bone and\\nultimate exposure of the interior of the cranium.\\nThe meninges and sinuses are exposed to infection both\\nby virtue of their direct contact with the diseased portions\\nof the temporal bone and by the possibility of extension of\\na purulent otitis media to the dura through the fissures\\nwhich exist in the bony plates separating the tympanum\\nfrom the interior of the skull, especially in the roof of the\\ntympanum. Or the infection may be carried through the\\nlab\\\\ rinth after the fenestra; have been destroyed by the sup-", "height": "3448", "width": "2064", "jp2-path": "rhinologylaryng00frie_0345.jp2"}, "346": {"fulltext": "332 APPENDIX.\\npurative process or the external wall of the labyrinth has\\nbecome carious and pierced by fistula;.\\nThe mode of infection in all those cases in which the\\nbone is found diseased up to the point where it comes in\\ncontact with the dura needs no explanation, but there are\\nother cases of cerebral complications in which the bone was\\nnot found to be diseased up to that point. In explanation\\nof such cases Korner has erected an osteophlebitis which,\\nas will again be referred to, appears to be of special signifi-\\ncance in the production of otitic pyemia. From this point\\nof view the fistulas which are often found in the bone run-\\nning to an extradural abscess or to the diseased sinus rep-\\nresent periphlebitic blood-vessels.\\nThe short review which we are about to give of the\\nvarious forms of otitic cerebral disease is based on the\\nassumption that the cerebral complication depends on the\\nseat and variety of the aural disease, according to which\\nthe middle ear, the posterior cerebral fossa, the dura mater\\nor pia mater will be affected. It also plays an impor-\\ntant part in the localization of the secondary cerebral\\nabscesses.\\nDiseases of the meninges in the middle fossa of the\\ncerebrum corresponding to the temporal lobe are undoubt-\\nedly due to the passage of pus through the roof of a\\ncarious tympanum, but the importance of preformed open-\\nings in this plate of bone, which is naturally quite thin,\\nhas been greatly overestimated.\\nThe transverse sinus becomes secondarily involved during\\nits course within the sigmoid sinus as a consequence of the\\nextension of caries of the mastoid antrum and cells to the\\nposterior wall of the mastoid process. The danger of this\\ncomplication depends on individual anatomic relations, for\\nthe course of the sinus varies with the general formation\\nof the cranium, as was pointed out by Korner, it being\\nmore or less superficial and therefore nearer to, or\\nfarther removed from, the cells in the mastoid process.\\nThrombosis of a sinus is to be attributed to osteophlebitis\\neven in those cases in which the caries has not reached the\\nsinus (Korner), as the infectious thrombi in the smaller\\nblood-vessels in the bone grow into the sinus. Leutert\\nhas introduced a new pathologic factor in isolated thrombus\\ni Aich. f. Ohr.. vol. XLi.", "height": "3468", "width": "2168", "jp2-path": "rhinologylaryng00frie_0346.jp2"}, "347": {"fulltext": "INFECTION FROM MASTOID AND LABYRINTH. 333\\nformation, which he found in the bulb of the jugular vein\\nand from which he deduced a retrograde thrombosis in the\\nsinus. In thrombosis of a sinus there may be extension\\nof the thrombus in the opposite direction of the blood\\ncurrent in the horizontal portion of the transverse sinus as\\nfar as the torcular Herophili, and as this leads to occlusion\\nof the mastoid artery, there is a swelling over its point of\\nexit behind the mastoid process which may be of great\\ndiagnostic value. The thrombosis spreads to the superior\\nand inferior petrosal sinuses, and from them to the cavernous\\nsinus, or it may extend downward into the jugular vein,\\nbut in that case it rarely extends beyond the mouth of the\\nfacial vein.\\nThe dura of the posterior fossa of the cranium becomes\\ndiseased either after caries of the mastoid process or after\\nsuppuration in the labyrinth. The extension of mastoid\\ndisease to the dura of the posterior fossa depends on the\\narrangement of the system of cavities and the extent of the\\nmastoid cells. As the cells are lined with epithelium, they\\npermit the suppurative process to go on rapidly, and if they\\nextend as far as the vitreous table, the process spreads more\\nrapidly to the interior of the brain than when they are sepa-\\nrated from the interior of the skull by a thicker layer of\\ncompact bone. It is to be remembered that there is a dif-\\nference between adults and young children in this respect,\\nas pointed out by Toynbee and later by Jansen.^ As a\\nresult of the anatomic structure of the mastoid process,\\nwhich in early infancy possesses but few cells arranged in a\\nhorizontal layer while the posterior wall which separates it\\nfrom the petrous portion of the temporal bone is strongly\\ndeveloped, diseases in children up to the age of two years\\ntend to invade the cerebrum and the middle, rath er than the\\nposterior, fossa.\\nOperations are frequently interrupted by the finding of an\\nextradural abscess between the bone and the dura, the\\nquantity of pus varying from a few drops to 15 c.c. From\\nthe expansive pulsation it is easy to recognize the endo-\\ncranial origin of the discharge. The dura recedes before\\nthe pressure of the pus, and an abscess cavity is formed be-\\ntween the bone and the dura which leads to compression\\nof the cerebral substance, and sometimes attains such\\n1 Arch. f. Ohr., XXXV, p. 261.", "height": "3444", "width": "2036", "jp2-path": "rhinologylaryng00frie_0347.jp2"}, "348": {"fulltext": "334 APPENDIX.\\nenormous dimensions that the pus makes its way through\\nthe foramen magnum or the anterior jugular foramen into\\nthe deep muscles of the neck, or it may burrow along the\\nlateral wall and base of the brain and make its way out\\ndirectly through the bone, to form a deep abscess in the\\nneck.\\nExtradural abscess is usually associated with an accumu-\\nlation of pus in the external wall of the sinus, which ex-\\nposes the latter to the danger of thrombosis. Although\\nboth the dura and the wall of the sinus may successfully\\nresist this disintegration for a long time, the condition must\\neventually lead to infiltration and the formation of granu-\\nlations, which sooner or later bring about the destruction\\nof both structures. As, however, the course of the disease\\nis very slow, adhesions frequently foi;m between the dura\\nand the pia mater and brain substance, thus preventing a\\npurulent leptomeningitis.\\nNext to thrombosis of a sinus, cerebral abscess is the\\nmost frequent sequel of extradural abscess but after the\\npus has been discharged through the diseased temporal\\nbone and the extradural abscess has healed, the path of the\\notogenic infection is withdrawn from clinical observation\\nand the interpretation of the abscess becomes, difficult.\\nSuppurations in the labyrinth often lead to diseases of\\nthe dura of the cerebellum, because all preformed openings\\nin that situation lead to the posterior fossa. Since the\\nrecent additions to our knowledge of the involvement of\\nthe labyrinth in purulent otitis media the significance of\\nsuppurative processes in the labyrinth in the production of\\notitic cerebral diseases is now better understood (compare\\nJansen and others i).\\nOnce the pus has reached the labyrinth, it finds many\\nchannels through which it can enter the interior of the\\ncranium, and we can readily understand that it is more\\nlikely to make its way in this direction than toward the\\nmiddle ear, from which it is separated by the robust wall\\nof the labyrinthine capsule. The channels referred to in-\\nclude the porus acusticus internus, the aqueduct of the\\nvestibule and cochlea, which all have this in common, that\\nthey open on that surface of the petrous portion of the\\ntemporal bone which is directed toward the posterior fossa,\\n1 Arch. f. Ohr., xxxv.", "height": "3468", "width": "2168", "jp2-path": "rhinologylaryng00frie_0348.jp2"}, "349": {"fulltext": "OTITIC PYEMIA. 335\\nSO that, as we have said above, they convey the pus to the\\nmeninges of the cerebellum.\\nClosely connected with the conception of otitic cerebral\\ndisease is that of otitic pyemia, which occurs in a great\\nvariety of forms, a distinction being drawn between otitic\\npyemia due to disease of a sinus and otitic pyemia of\\nosteophlebitic origin without phlebitis of a sinus, and\\nbetween these and an otitic septicemia.\\nIf the above-mentioned theory of Leutert, that all cases\\nof pyemia are due to the presence of thrombi, however\\nminute, within the sinus or the bulb of the jugular vein is\\naccepted, the matter is somewhat simplified, as the two first-\\nmentioned forms of pyemia that produced by thrombosis\\nof a sinus and that produced by osteophlebitis are united\\nunder one head. To reject the existence of an osteo-\\nphlebitic pyemia for the sake of justifying this theory, which\\nhas never been perfectly proven, would be simply to ignore\\nthe observations of accurate observers.\\nIt would lead me too far afield to go into the details of\\nthe similarity of these various forms of pyemia following\\ndiseases of the ear. In general, it may be said that in a\\nsinus pyemia the most conspicuous feature of the clinical\\npicture, next to the chills and abrupt rises in temperature,\\nare the pulmonary metastases due to emboli from the disin-\\ntegrating thrombus while in osteophlebitic pyemia the\\nfever is high, and shows neither typical chills nor constant\\nremissions, emboli are less frequent, and when they do\\noccur usually affect the joints and muscles, as the micro-\\norganisms which get into the circulation in osteophlebitis\\nare not incased in large portions of thrombic tissue, and\\nare therefore easily able to pass through the lungs, until\\nthey are arrested somewhere in the capillary system of\\nthe systemic circulation (Korner). Otogenic septicemia,\\nfinally, presents all the appearance of general sepsis such as\\nwe are accustomed to see in grave infections of the entire\\norganism. If the habit of making a routine examination\\nof the ear in all cases of septicemia could be formed, the\\npractice would unquestionably result in a marked limitation\\nof our present vague conception of cryptogenetic septi-\\ncemia (septicopyemia).", "height": "3448", "width": "2120", "jp2-path": "rhinologylaryng00frie_0349.jp2"}, "350": {"fulltext": "", "height": "3384", "width": "2120", "jp2-path": "rhinologylaryng00frie_0350.jp2"}, "351": {"fulltext": "INDEX.\\nAbscess, 333\\ncold, of the posterior pharyngeal\\nwall in caries of the vertebrae,\\n162\\nextradural, in aural diseases, 334\\ntuberculous, of the thyroid carti-\\nlage, 154\\nAcid, salicylic, effects of, on the ears,\\n248\\non the pharynx and larynx,\\n247\\nAcids, toxic effect of, on mucous\\nmembrane of pharynx and larynx,\\n242, 243\\nAcromegaly, manifestations of, in the\\nnose, larynx, and pharynx, 95\\nActinomycosis, laryngeal complica-\\ntions of, 186\\nof the mouth and pharynx, 185\\nAdenoid habit, 42\\nvegetations, 41\\nmouth-breathing in, 18\\nocclusion of the tubes and au-\\nral affections in, 36\\nreflex neuroses from, 313\\nAdhesions in the larynx from syphil-\\nitic ulcers, 218\\nin the pharynx, 213\\nAir-passages, upper, alterations of, in\\ndiseases of the lungs, 31\\nin diseases of the mediastinum,\\n33\\nin erysipelas, 147\\nin influenza, 132\\nin leukemia, 83\\nhemorrhages from, in arterio-\\nsclerosis, 52\\nin cardiac disease, 52\\nrelation of, to ears, 35\\nscleroma of, 31\\nsignificance in respiration, I9\\nAlcohol, abuse of, eflect on the or-\\ngan of hearing, 250\\non the structure of the pharynx,\\n249\\nAlkalies, destruction of the pharyn-\\n22\\ngeal and laryngeal mucous mem-\\nbrane in poisoning by, 242\\nAnalgesia of the mucous membranes\\nof the upper air-passages in hys-\\nteria, 297\\nAnemia, general, appearances in the\\nears, 82\\nin the nose, pharynx, and lar-\\nynx, 81\\nof the laryngeal mucous mem\\nbrane in tuberculosis, 168\\nAnesthesia dolorosa, 298\\nin hysteria, 297\\nof the nose, throat, and larynx after\\ndiphtheria, 142\\nin epilepsy, 294\\nin progressive amyotrophic\\nbulbar paralysis, 292\\nsignificance of, in inspiration pneu-\\nmonia, 22\\nAneurysm of the aorta, motor dis-\\nturbances of the larynx, 55\\npressure-symptoms in the trachea,\\n54\\nof the large blood-vessels, subjec-\\ntive noises in, 54\\nAngina, catarrhal, in acute rheuma-\\ntoid arthritis, 140\\nin measles, 108\\nin scarlatina, 1 12\\nedematous, after the use of salol,\\n247\\nuratica, 102\\nAnthrax, infection of the nose and\\npharynx in, 1S5\\nAntimony poisoning, hoarseness in,\\n247\\nAntipyrin and antifebrin, olfactory\\ndisturbances after use of, 247\\ntinnitus aurium and difficult hear-\\ning after use of, 248\\nAphasia in diabetic hemiplegia, 96\\nuremic, 189\\nAphonia in arsenic eaters, 245\\nin Asiatic cholera, 75\\nin chlorosis, 81\\n337", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0351.jp2"}, "352": {"fulltext": "338\\nINDEX.\\nAphonia in hysteria, 304\\nin malaria, 148\\nAprosexia in mouth-breathers, 312\\nvarieties and pathogenesis, 312\\nArsenic-poisoning, acute and chronic\\nulcers in the external auditory\\nmeatus in, 245\\nnasal and pharyngeal catarrh in,\\n245\\nArteriosclerosis, hemorrhages in the\\nupper air-passages, 52\\ntinnitus aurium, 53\\nArthritis, gonorrheal, of the articula-\\ntions of the larynx, 204\\nAsthenopia in hypertrophy of the\\nturbinates, 230\\nAsthma in relation to the nose, 306,\\n307\\nto the sexual functions, 199\\nuremic, differential diagnosis from\\nbronchial asthma and laryngeal\\nstenosis, 1 88\\nAstringents, injurious effect of, on the\\nsense of smell, 250\\nAtelectasis as a cause of middle-ear\\ndisease, 50\\nAuditory disturbances during men-\\nstruation and pregnancy, 202\\nfrom increased intracranial pres-\\nsure, 268\\nin anemia. Si\\nin aural tuberculosis, 1 74\\nin cerebellar disease, 273\\nin disease of the central nervous\\nsystem, 263, 271, 272\\nin disease of the meninges, 326\\nin epilepsy, 294\\nin facial paralysis, 323\\nin hysteria, 300\\nin intoxications, 242\\nin leukemia, 86\\nin multiple sclerosis, 290, 291\\nin nephritis, 189\\nin parotitis epidemica, 138\\nin pseudoleukemia, 89\\nin syphilis, 220\\nin tabes dorsalis,278\\nin typhoid fever, 132\\nnerve, atrophy of, in amyo-\\ntrophic bulbar paralysis, 292\\nin tabes, 283. 286, 288\\nhemorrhage and lymphatic infil-\\ntration in leukemia, 84\\nneuritis of, from abuse of to-\\nbacco, 250\\nparalysis of, in hereditary syph-\\nilis, 223\\npathways in the central nervous\\nsystem, 271\\nAuditory nerve, reactions of, electric,\\ndiagnostic significance of, 265\\nincreased irritability of, 269\\nin hysteria, 301\\nin rabies, 186\\nin strychnin-poisoning, 247\\nmethods of examination of, 266\\nnormal formula, 265\\ninversion of, 270\\nparadoxic, 269, 270\\nreflex effect on the movements of\\nthe eye, 237, 238\\nBacillus mucosus ozoence of Abel,\\n46\\nBlennorrhea neonatorum as a compli-\\ncation in diseases of the nasal mu-\\ncous membrane, 226\\nBlepharospasm from spasm of the\\nstapedius muscle, 240\\nin atrophy of the nasal mucous\\nmembrane and adhesions within\\nthe nose, 230\\nBlood, diseases of, pathologic appear-\\nances in the upper air-passages, 81\\nBronchial glands, diseases of, and\\neffect on respiration, 34\\nBronchiectasis as a cause of middle-\\near disease, 50\\nin disease of the upper air-passages,\\n28\\nBronchitis after purulent otitis me-\\ndia, 51\\ncapillary, as a cause of aural dis-\\neases, 50\\nchronic, in scrofulous children, 29\\nfetid, as a sequel of suppuration in\\nthe accessory cavities of the nose,\\n28\\nlaryngitis and pharyngitis after,\\n31\\nsignificance of mouth-breathing in\\nproduction of, 29\\nBronchopneumonia in connection with\\npurulent otitis media, 50, 5 1\\nBruits larynges in hysteria, 303\\nBulbar palsy, progressive amyotro-\\nphic, laryngeal and aural symp-\\ntoms in, 293\\nCaries of the accessory cavities of\\nthe nose, etiologic significance in\\ndiseases of the meninges, 330\\nof the temporal bone in tubercu-\\nlosis, 173\\nsicca of the nose in syphilis, 208", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0352.jp2"}, "353": {"fulltext": "339\\nCentral nervous system, diseases of,\\nas the cause of auditory-\\ndisturbances, 263\\nof laryngeal affections,\\n251\\nCerebral disease, otitic, 334\\nsinuses, disease of, 325, 328, 330,\\nCerebrospinal meningitis, acute, sig-\\nnificance of the nose in,\\n326\\nof the ear, 327\\ndeafness in, 327, 328\\nin combination with purulent\\notitis media, 327\\nChlorid of zinc poisoning, appear-\\nance of the pharyngeal and laryn-\\ngeal mucous membrane in, 243\\nChloroform narcosis, effect of, on the\\norgan of hearing, 249\\nChlorosis, aphonia in, 81\\nChoked disc in chronic middle-ear\\ndisease, 238, 239\\nCholera Asiatica, effect of, on upper\\nair-passages, 75\\nCholesteatoma as cause of cerebral\\ndisease, 330, 331\\nChondritis laryngea in typhoid fever,\\n127\\nprimary tuberculous, 153\\nChorda tympani, lesions of, in rela-\\ntion to sense of touch, 320\\norigin and course of, 321\\nChorea minor, motor disturbances of\\nthe aural and laryngeal muscles in,\\n295\\nChoreic movements in nasal obstruc-\\ntion, 313\\nChronic acid-poisoning, chronic dis-\\nease of the upper air-passages from,\\n.243\\nCirculatory system, diseases of, in re-\\nlation to the upper air-passages, 50\\nCirrhosis of liver, hemorrhages in, 74\\nCohabitation in relation to the nose,\\n197\\nCondylomata in the auditory meatus\\nin syphilis, 219\\nConjunctivitis in scrofulous rhinitis,\\n228\\nConstitutional diseases, chronic, path-\\nologic alterations of the upper air-\\npassages in, 92\\nCoordination, disturbances of, in hys-\\nteria, 301\\nof the laryngeal muscles, disturb-\\nances of, in chorea minor, 295\\nCoryza neonatorum in hereditary\\nsyphilis, 210\\nCoryza, vasomotor, 306, 308. (See\\nalso Hydrorrhea 7iasalis.)\\nin malaria, 148\\nCough due to gall-stones, 75\\nin nasal affections, 307\\nnasal, 306\\ntrifacial, 307\\nCroup, pharyngeal and laryngeal, in\\ncholera, 75\\nDacryocystoblennorrhea after\\ndisease of the nose, 226\\nDeafness after embolism of the inter-\\nnal auditory artery, prognosis of,\\nduring menstruation, 203\\nin alcohol and tobacco intoxication,\\n249_\\nin brain-lesions, 271\\nin cerebrospinal meningitis, 328\\nin chloroform narcosis, 249\\nin combination with subjective\\nnoises, 64\\nin diseases of the meninges, 326\\nin epilepsy, 294\\nin facial paralysis, 323\\nin hysteria, 300\\nin lead-poisoning, 246\\nin leukemia, 87\\nin multiple sclerosis, 203\\nin nephritis, 189\\nin potassium iodid poisoning, 244\\nin quinin and salicylic acid poison-\\ning, 248\\nin syphilis, 221\\nin tabes dorsalis, 280\\nin typhus and typhoid, 131\\npostdiphtheric, 146\\nDeformities, nasal, in syphilis, 209\\nDiabetes mellitus, aural complications\\nin, 97\\ndryness and atrophy of the oral\\nmucous membrane in, 96\\nictus laryngis in, 105\\nmastoid disease in, 98\\nDigestive organs, diseases of, in re-\\nlation to nose, throat, and larynx, 70\\nDiphtheria, deafness in, 146\\ndiseases of the ear in, 143\\nin cholera Asiatica, 75\\nin measles, 109\\nin scarlatina, 1 13\\nin typhoid, 126\\npostdiphtheric palsies in pharynx\\nand larynx in, 142\\nDiplococcus pneumonia: in purulent\\notitis media, 49", "height": "3456", "width": "2028", "jp2-path": "rhinologylaryng00frie_0353.jp2"}, "354": {"fulltext": "340\\nINDEX.\\nDyspepsia as a cause of rhinopharyn-\\ngeal disease, 73\\ndue to disease of the nose and\\npharynx, 72\\nDyspnea in laryngitis acutica rheu-\\nmatica, 14I\\nEar, disease of, in connection with\\nmastication and deglutition,\\n77\\nin diphtheria, 143-145\\nin infants, 78, 79\\nin influenza, 134\\nin leukemia, 86\\nin malaria, 149\\ntubercular, 1 69\\neffect of various diseases of the\\nrespiratory organs on, 47\\nembolic disease of, in endocardi-\\ntis, 67\\ninnervation of, 316\\nin relation to diseases of the heart\\nand blood-vessels, 59\\nrelation of, to upper air-passages,\\n35\\nvascular systems of, 60\\nEarache, 47. (See also Otalgia.)\\nin diseases of the respiratory or-\\ngans, 47,48\\nEczema of the nose, 159\\netiologic significance of, in ery-\\nsipelas, 147\\nin scrofulous children, 160, 193\\nEdema of the upper air-passages in\\nnephritis, 188\\naural disturbances in, I90\\nEmboli in the ear during the puerpe-\\nrium, 203\\nEmphysema, relation of, to chronic\\ncatarrh of the upper air-passages,\\n28-30\\nEmpyema of antrum of Highmore,\\n70\\nEndocarditis, embolic disease of the\\norgan of hearing in, 67\\nEnteritis in children in connection\\nwith inflammation and suppuration\\nof the middle ear, 78\\nEntotic vascular murmurs, character\\nof, 61, 62, 65\\ndifferential diagnosis from\\nsimple noises in the ear, 66\\nEnuresis nocturna, etiology of, 313\\nEpiglottis, cicatricial changes in\\nsyphilis, 219\\nfunction and importance of, 28\\nin acute rheumatic laryngitis, 140\\nin lupus, 175\\nEpiglottis in typhoid, 127\\nleprosy of, 182\\notalgia in inflammatory swelling of,\\n47\\nulcerations of, in foot-and-mouth\\ndisease, 184\\nEpilepsy, symptoms of, in the larynx\\nand in the organs of hearing and\\ntaste, 294\\nEpileptic equivalent in nasal obstruc-\\ntion, 314\\nEpiphora from aural irritation, 240\\nfrom nasal irritation, 240\\nin obstruction of the lacrimonasal\\nduct, 226\\nEpistaxis in arteriosclerosis, 52\\nin cardiac disease, 52\\nin cirrhosis of liver, 74\\nin hemophilia, 89\\nin leukemia, ^i\\nin malaria, 148\\nin purpura hcemorrhagica, 90\\nin scorbutus, 91\\nin typhoid fever, 124\\nseat of, 53\\nErysipelas of the upper air-passages,\\n147\\nsecondary to eczema of nose and\\nears, 148\\nErysipele catameniale, phenomena\\nand reflex character of, 199\\nErythema exsudativum multiforme,\\n196\\nof the larynx, 215\\nof the nose, 205, 206\\nof the upper air-passages, I93\\nsyphilitic, of the gums and tonsils,\\n210\\nEsophagus, diseases of, effect on up-\\nper air-passages, 72\\nEunuch voice, etiology and cure of,\\n201\\nEustachian tube, dilatation of, in atro-\\nphic rhinitis, 45\\nfunctions of, disturbances of, 36\\ndue to alterations in upper\\nair-passages, 40\\nocclusion of, 38\\nas cause of middle-ear dis-\\nease, 42\\nby atrophy of pad of fat, 46\\ndue to paralysis of muscles of\\nsoft palate, 43\\nin acute and chronic catarrh of\\nupper air-passages, 41\\nin relation to nasal stenosis,\\n42\\nsignificance of, in middle ear,\\n37", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0354.jp2"}, "355": {"fulltext": "INDEX.\\n341\\nExanthemata, acute otitis media in,\\n44, 109, 116, 119\\nmanifestations of, in upper air-pas-\\nsages in measles, 108\\nin scarlet fever, 112, 113\\nin varicella and variola, 121\\nExostoses in the external auditory\\nmeatus in acromegaly, 96\\nExternal auditory meatus, diphtheria\\nof, 143\\nexostosis and hyperostosis of,\\nin acromegaly, 96\\nfurunculosis of, in diabetes, 96\\nhyperesthesia and hyperalge-\\nsia of, in hysteria, 298\\nin gout, 103\\nin syphilis, 220\\npressure variations in, 45\\nrespiratory murmurs in, 45\\nscarlatinal diphtheria of, 118\\nskin diseases of, 196\\nstenosis of, from syphilitic\\nscars, 220\\nsyphilitic affections of, 219\\nEyes, diseases of, in pathologic condi-\\ntions of the nose and its ac-\\ncessory cavities, 225\\nin alterations in the ear, 235\\nreflex disturbances of, movements\\nof, from the ear, 237\\nin acute and chronic otitis\\nmedia, 239\\nGasserian ganglion, effects of extir-\\npation of, 318\\nGastro-intestinal disease as cause of\\nmiddle-ear disease, 78\\nGingivitis in leukemia, 84\\nGlanders, infection through mucous\\nmembranes of upper air-passages,\\n183\\nGlottis, spasm of, 306\\nhysteric, 307\\nGonorrhea, infection of the nose by\\nsecretions of, 203\\nlaryngeal disease in, 204\\nGout, angina uratica in, 102\\naural manifestations in, 103\\nchanges in the ear in, 102, 104\\nin the larynx in, 102, 104\\nin the pharynx in, 10 1\\nictus laryngis in, 105\\nGumma in the external ear and mas-\\ntoid process, 220\\nin the larynx, 215, 217\\nin the nose, 206\\nin the pharynx, 21 1, 212\\nGums, affections of, in leprosy, 181\\nin leukemia, 85\\nin lupus, 176\\nin measles, 108\\nin middle-ear disease, 43\\nin typhoid fever, 124\\nsyphilitic, 210, 211\\nulcerative, in foot-and-mouth dis-\\nease, 184\\nFacial paralysis, 324\\ncauses of, 324\\ncourse of, 325\\nin middle-ear disease, 325\\nlocalization of lesion in, 323\\nFish-poisoning, appearance of upper\\nair-passages in, 248\\nFoot-and-mouth disease, catarrh of\\nthe tubes in, 185\\ninfection through mucous mem-\\nbranes of upper air-passages,\\n184\\nFrontal sinus, neuralgia in, 314\\nsuppuration of, hyperemia and\\nvenous stasis of tlie optic pa-\\npilla of the same side in, 233\\nGanglion, Gasserian, in purulent\\notitis media, 320\\nsphenopalatine, disease of, in caries\\nof the sphenoid and ethmoid\\nbones, 316\\nHallucinations, auditory, in abuse\\nof alcohol and tobacco, 250\\nin chloroform narcosis, 249\\nin epilepsy, 294\\nHay-fever, 306, 308\\nHeart and blood-vessels, diseases of,\\nin relation to the nose,\\npharynx, and laiynx, 52\\nto the ear, 59\\nlesion, hemorrhages in mucous\\nmembranes in, 37\\ntinnitus aurium in, 60\\nHemophilia, hemorrhages in upper\\nair-passages and ears in, 88, 89\\nHemorrhages from the ears in hys-\\nteria, 304\\nin vicarious menstruation, 201\\nin affections of the genitalia, 197\\nin cirrhosis of liver, 74\\nin hemorrhagic diathesis, 89\\nin leukemia, 83, 84, 87, 88\\nin pseudoleukemia, 85\\nin the middle ear in nephritis, 189", "height": "3456", "width": "2040", "jp2-path": "rhinologylaryng00frie_0355.jp2"}, "356": {"fulltext": "342\\nHemorrhages in the mucous mem-\\nbranes of the upper air-passages,\\n53\\nHemorrhagic diathesis, 89\\nHerpes in ear and external meatus,\\n196\\non mucous membranes, 1 94\\nHoarseness from aliuse of alcohol and\\ntobacco, 249\\nin poisoning with antimony, cop-\\nper, and phosphorus, 247\\nin syphilis, 213\\nHydrorrhea nasalis in hepatic colic,\\n75\\nin malaria, 148\\nHyperacousis, 324\\nHysteria, disturbances in the nerves\\nof special sense in, 300\\nin the ear in, 298\\nmuscles of, 304\\nmotor, in larynx, 301\\nsensory, in the nose and pharynx,\\n297\\nHysterogenetic zones in the mucous\\nmembranes of the upper air-pas-\\nsages, 298\\nIcterus in otitis media, 80\\nIctus laryngis in obesity, gout, and\\ndiabetes, 104\\nInfluenza, 132\\naural complications in, 134\\nlaryngitis hemorrhagica, 134\\nnasal complications in, 133\\npalsies in, 134\\npurulent otitis media in, 137\\nInspiration pneumonia, causes of, 27\\nInternal ear in influenza, 137\\nIntoxications, appearances of, in the\\nupper air-passages, 241\\nauditory disturbances in, 242\\nJaundice in mucous membranes, 74\\nKeratitis, eczematous, in eczema of\\nthe nose in scrofulous children, 227\\nKidneys, diseases of, 188. (See also\\nNephritis.\\nLabyrinth, diseases of, 333\\nLacrimonasal duct as a carrier of in-\\nfection from the nose to the eye,\\n225\\nLaryngeal crises in tabes dorsalis,\\n278 _\\nLaryngismus stridulus, 93\\nLaryngitis acuta rheumatica circum-\\nscripta, 141\\nhasmorrhagica, 134\\nleukemic, 84\\nLaryngospasm. Larynx\\nLarynx as respiratory pathway, 25\\nedema of, after use of potassium\\niodid, 244\\nin influenza, 133\\nin malarial cachexia, 148\\nin nephritis, 188\\nin typhoid, 124\\nextirpation of, followed by death\\nfrom heart failure, 45\\nin relation to diseases of heart and\\nblood-vessels, 52\\nto nose and pharynx, 18\\nparalysis after disease of the lungs,\\n32\\nfrom struma, 35\\nin cardiac and vascular disease,\\n53\\nin tumors of mediastinum, 34\\nrelation of, to diseases of digestive\\norgans, 70\\nspasm of, 92\\ntuberculosis of, 153-158\\nulcers of, anatomic and clinical\\nvarieties of, 125\\nin croupous pneumonia, 31\\nin leprosy, 182\\nin lupus, 176\\nin typhus and typhoid, 1 23\\npathogenesis of, 1 26\\ntuberculous, 156\\nLateral sclerosis, amyotrophic laryn-\\ngeal paralysis in, 293\\nLead poisoning, chronic, manifesta-\\ntions of, in the ear, 246\\nparalysis of the laryngeal muscles\\nin, 246\\nLeprosy, early appearances in, 179\\nof the ear, 1 83\\nof the nasal cavities, 177\\nclinical picture, 1 80\\nlocalization of nodes and ulcers\\nin, 181\\npathogenesis, 178\\nof the pharynx, 181\\ntransmission of, by nasal secretion,\\n179\\nLeukemia, 83\\nalterations in upper air-passages in,\\nhemorrhages in, 83\\nmanifestations of. in the ear, 86", "height": "3464", "width": "2216", "jp2-path": "rhinologylaryng00frie_0356.jp2"}, "357": {"fulltext": "INDEX.\\n343\\nLocalization of aural disturbances,\\n326\\nof the ear in the brain, 270\\nof the movements of the vocal\\ncords, 258\\nLocus Kieselbachii, 53\\nLungs, diseases of, due to disturbances\\nin the upper air-passages, 26\\nin morbid conditions of upper\\nair-passages, 28\\nin relation to nose, 19\\nLupus in the upper air-passages, 175\\nlocalization of, 176\\nmorbid anatomy of, 175\\nof the external ear, 177\\nof the eye, 228\\nof the pharynx, 176\\nsequels of, 176\\nLymphomata in pseudoleukemia, 85,\\n86\\nleukemic, of the internal ear, 87\\nof the pharyngeal structures, 84\\nLymphosarcoma, 85\\nof the pharyngeal structures, 86\\nMalaria, 148\\naphonia in, 149\\nepistaxis in, 148\\nhydrorrhea nasalis in, 148\\nvasomotor rhinitis in, 148\\nMalarial disease of the ears, 149\\nMastoid disease as cause of cerebral\\ndiseases, ^2;^\\nextension of, to dura,\\nin diabetes, 97-99\\nsyphilitic, 219\\ntuberculous, 17 1, 174\\nMasturbation, effect of, on existing\\naural disease, 202\\nepistaxis in, 197\\ntinnitus aurium in, 202\\nMeasles, 109\\naural complications in, 109-III\\ncroupous laryngitis in, 109\\nKoplick s sign in, 109\\nMediastinum, diseases of, effect on\\nrespiration,\\nMedulla oblongata, diseases of, motor\\nand sensory disturbances in the\\nlarynx, ear in, 291\\nMeniere s symptom-complex in tabes,\\n280, 2S3\\npathogenesis of, 263\\nrelation of, to gout, 104\\nto mumps, 137\\nMeninges, diseases of, in connection\\nwith cranial nerves, 325\\nin nasal affections, 328\\nMeninges in relation to aural affec-\\ntions, 330\\nMeningitis, purulent, as cause of\\nparalysis of cranial nerve, 326\\nin relation to nose, 329\\nparalysis of olfactory disturb-\\nances in, 326\\nof vocal cords in, 326\\nMenstruation, relation of, to nasal\\naffections, 197\\nMercurial poisoning, appearances of,\\nin mouth and pharynx, 246\\nin sound-perception apparatus,\\n246\\nMiddle ear, bacteria in, 44\\ncatarrh of, acute and chronic, 38\\nchanges in pressure in, 37\\ndisease after atelectasis, 50\\nafter bronchiectasis, 50\\nafter capillary bronchitis, 50\\ndiabetic otitis, 99, loo\\nin leukemia, 88\\nin measles, IIO\\nin scarlatina, I18\\nin typhoid fever, 129\\ndiseases of, due to infection from\\npostnasal space, 43\\ndue to obstruction of Eusta-\\nchian tube, 41\\nhj drops ex vacuo in, 38\\nhyperoemia ex vacuo in, 38\\nicterus in otitis media, 80\\ninflammatory and noninflamma-\\ntory catarrh of, 41\\notitis media sclerotica, 45\\npurulent otitis media as cause of\\nbronchitis and broncho-\\npneumonia, 51\\nas sequel of gastro-intes-\\ntinal disease, 79\\nin cerebrospinal menin-\\ngitis, 327\\nin connection with caries\\nof the teeth, 77\\nwith dentition, 77\\nin influenza, 137\\nin pneumonia, 48\\ntherapeutic infection of, through\\nEustachian tube, 46\\nvariations of pressure in, 39\\nMiliary tuberculosis, acute, beginning\\nin the larynx and pharynx, 154\\nMountain sickness, 40\\nMouth, affections of, gonorrheal, 204\\nin actinomycosis, 185\\nin foot-and-mouth disease, 184\\nin leukemia, 85\\nin mercurial poisoning, 291\\nin mouth-breathers, 68", "height": "3448", "width": "2104", "jp2-path": "rhinologylaryng00frie_0357.jp2"}, "358": {"fulltext": "344\\nMouth affections in varicella, 121\\nMouth-breathing as a cause of chronic\\nbronchitis, 29\\ncauses of, 26\\neffects of, 26\\nMuscular atrophy, progressive spinal,\\nlaryngeal palsy in, 293\\nNasal douches, dangers of, 46\\nproper use of, 47\\nNasalis luetica, 208\\nNephritis, complications of, aural,\\n190\\nin the upper air-passages. 1S8\\nNervous diseases of the larynx, 251\\nof the organ of hearing, 263\\nwith changes in the nose, throat,\\nand larynx, 275\\nNeuralgia, infra-orbital, 315\\notitica, 317\\nsupra-orbital, 314\\ntrifacial, 314, 315\\nin relation to ear, 318\\nin sarcoma of the ear, 318\\nof Gasserian ganglion, 318\\ntympanica, 317\\nNeuritis, gonorrheal, of the larynx,\\n205\\noptica in papillomata of the turbi-\\nnates, 231\\nNeuroses, involvement of the nose,\\nthroat, larynx, and ears in, 293\\nNose as respiratory pathway, 20\\nbacteria in, 22, 44\\nbactericidal power of secretion, 23,\\n44\\nhydrorrhea of, 308\\ninnervation of, 306\\nin relation to diseases of digestive\\norgans, 70\\nof the heart and blood-vessels,\\n52\\nto lungs, 19\\nlupus of, 176\\nreflex irritation of, from intestines,\\n74\\nneuroses of, 306\\nsneezing reflex, cough, etc., 306\\nstenosis of, in relation to occlusion\\nof Eustachian tube, 42\\ntuberculosis of, 153, 158-161\\neczema in, 159\\nObesity, ictus laryngis in, 104\\nOlfactory nerve, hyperesthesia of, in\\nepilepsy, 294\\nOlfactory nerve, in hysteria, 297\\nin rabies, 186\\nreflex eftects of, 308\\nsense, disturbances of, in anemia,\\n81\\nfunction of, in respiration, 24\\nOral cavity, diseases and changes in\\nform of, in disturbances of nasal\\nrespiration, 68\\nOssicles of the ear, caries of, in tuber-\\nculosis, 174\\nrheumatic disease of, 141\\nOsteitis luetica of the nose, 207\\nOsteophlebitis as cause of otitic\\npyemia, 332\\nOtalgia, 317\\nin caries of the teeth, 76\\nin diseases of the respiratory organs,\\n47\\nof the trifacial, 317\\nin hysteria, 299\\ntympanica in influenza, 137\\nOtitis media catarrhalis, 39\\nneuroparaiytica, 319\\nOxyocoia, 324\\nOzena, 29\\npathogenesis of, 30\\nrelation of, to leprosy, 177\\nto menstruation, 199\\nOzoena syphilitica, 208\\nPalate, paralysis of, in influenza,\\n133, 134\\nin progressive amyotrophic bul-\\nbar paralysis, 292\\nocclusion of tube in, 43\\npostdiphtheric, 142, 143\\nunilateral, in typhoid, 128\\nPapillitis nervi optici in purulent otitis\\nmedia, 239\\nPapules, syphilitic, in the auditory\\nmeatus, 219\\nin the larynx, 215\\non the gums, 210\\non the nasal mucous membrane,\\n206\\non the tonsils, 210\\non the tympanic membrane, 219\\nParalysie glosso-labio-laryngee, 292\\nParalysis agitans, motor disturbances\\nof the vocal cords in, 293\\nof the recurrent, definition, 54\\nfrom pericardial exudate, 58\\nin aneurysm of aorta, 55, 56\\npostdiphtheric, I42\\nParasites, intestinal, reflex symptoms\\nof, in the nasal raucous membrane,\\n74", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0358.jp2"}, "359": {"fulltext": "345\\nParesis of the vocal cords in laryn-\\ngeal tuberculosis, i68\\nParesthesia of the upper air-passages\\nfrom sexual excitement, 200\\nin amyotrophic bulbar paraly-\\nsis, 292\\nin chlorosis, 81\\nin hysteria, 298\\nParosmia from sexual excitement, 200\\nin hysteria, 300\\nin influenza, 134\\nParotitis epidemica, 138\\nPericardial exudate, paralysis of re-\\ncurrent form, 58\\nPerichondritis in typhoid, 134\\nlaryngeal, in influenza, 134\\nnasalis luetica, 207\\nsyphilitica, 215\\ntuberculous, primary, 154\\nsecondary, 1 66-1 68\\nulcerative, 125\\nPertussis, 311\\nPharyngeal crises in tabes dorsalis,\\n279\\nPharyngitis, leukemic, 84\\nPharynx as respiratory pathway, 25\\nedema of, in nephritis, 188\\nin relation to diseases of the diges-\\ntive organs, 70\\nof the heart and blood-ves-\\nsels, 52\\nto larynx, 19\\nto nose, 18\\nlupus of, 176\\nretropharyngeal abscess of, 162\\nPhenomena, irritative, in diseases of\\nthe meninges, 325\\nmotor, of the laryngeal muscles,\\n251\\nsensory, in the eyes from irrita-\\ntion in the ears, 239\\nPhonation, disturbances of, in hys-\\nteria, 302\\nPneumonia, laryngeal complications\\nin, 32\\npurulent otitis media in, 48\\nPolitzer s method of inflating tym-\\npanum, 46\\nPosticus paralysis, 256\\nin gonorrheal arthritis, 205\\nin hysteria, 302\\nin syphilis, 219\\nin tabes dorsalis, 275\\nmedian position of vocal cord in,\\n254, 255\\nPregnancy, aural affections in, 202\\nnasal affections in, 197\\nPseudobulbar paralysis, laryngeal\\nj^aralysis in, 293\\nPseudoleukemia, 85\\nauditory disturbances in, 89\\nPuerperium, aural affections in, 202\\nPupil, changes of, from nasal irrita-\\ntion, 231\\nin purulent otitis media, 239\\nPurpura, 89\\nPyemia, otitic, 332-335\\nQuiNiN, toxic effect of, on the or-\\ngan of hearing, 248\\nRabies, implication of the auditory\\nsphere in, 186\\nnervous symptoms in, 186\\nRachitis, aural disease in, 95\\nlaryngeal spasm in, 93\\nRaucego syphilitica, 213\\nRecurrent paralysis, 252\\ncadaveric position of vocal cords\\nin, 253, 254.258\\ndiagnostic significance of, 252\\nfrom pericardial exudate, 58\\nin aneurysm of aorta, 54\\nin arsenic-poisoning, 245\\nin influenza, 135\\nin leukemia (tumors), 85\\nin mediastinal tumors, 33\\nin pulmonary tuberculosis, 33\\nin swelling of bronchial glands,\\n34\\nin tabes dorsalis, 276\\nlaryngoscopic image in, 253\\nstage of posticus paralysis in, 254\\nReflex neuroses, laiyngeal, 106\\nnasal, 59, 305\\npalpitation of the heart due to irri-\\ntation in the nose, 59\\npathogenesis of, 309\\nReflexes of sexual apparatus, 308\\nolfactory, 309\\nRefraction, errors of, due to nasal\\nhypertrophies, 231\\nRespiration, changes of pressure in\\nthe external auditory meatus in,\\n37\\nnasal, effect of disturbances of, on\\noral cavity, 68\\nphysiologic pathway of, 20\\npreparation of the inspired air, 20\\nreflex influence of the olfactory\\n_ on, 309\\nsignificance of upper air-passages\\nin, 19\\nRespiratoiy air current, removal of\\nforeign substances and microorgan-\\nisms from, 21", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0359.jp2"}, "360": {"fulltext": "346\\nINDEX.\\nRespiratory air current, warming and\\nsaturation of, 23\\nmurmur, inspiratory and expiratory,\\nin the ear, 37\\nRetina, peripapillary opacity of, in\\nsuppuration of the frontal sinuses,\\n233\\nRhinitis, acute, in influenza, 132\\natrophic syphilitic, 208\\ndiseases of the eye in, 226\\nfcetida atrophica, 29\\nhypertrophic syphilitic, 207\\npurulent, from infection with gono-\\ncocci, 203\\nSaddle-nose, characteristics and\\nmode of production of, 209\\nSaliva, secretion of, in disease of\\nchorda tympani, 323\\nSalivation, eftect of irritation of the\\ntympanic plexus and chorda tym-\\npani on, 322\\nSalol, edematous angina after the use\\nof, 247\\nSausage poisoning, dryness of the\\nthroat and hoarseness in, 248\\nScarlatina, 1 12\\nacute otitis media in, 1 18\\naural complications in, 115\\ndiphtheroid, 113\\nScleroma of upper air-passages, 31\\nScorbutus, 89\\nSensory disturbances of the eyes from\\nirritation in the ear, 239\\nhysterical, 296\\nSepticemia, otogenic, 335\\nSeptum, nasal perforation of, in\\nglanders, 184\\nin leprosy, 177\\nin lupus, 176\\nin tuberculosis, 159\\nSexual functions, reflex effect of, on\\nupper air-passages and ears, 197\\nSilver-nitrate poisoning, pigmentation\\nof the mucous membrane of the\\nmouth, tongue, larynx, and tym-\\npanic membrane in, 247\\nSkin, diseases of, complications of, in\\nthe external ear and meatus,\\n196\\nin the upper air-passages, I93\\nSneezing reflex in respiration, 24,\\n306, 307\\nSpeech disturbances in chorea minor,\\n.295\\nin paralysis agitans, 293\\nSpinal cord, diseases of, pathologic\\nchanges in the nose, throat, larynx,\\nand ears in, 275\\nStapedius muscle, eftect of paralysis\\nof, 323, 324\\nStomatitis. See Month, Affections of.)\\naphthosa epidemica, 1 84\\nin leukemia, 85\\nStrabismus as a complication of\\nhypertrophied tonsils, 230\\nStridor, inspiratory, from enlarged\\nthymus, 35\\nStruma as cause of tracheal stenosis,\\n34\\nSympathetic nerve, paralysis of, etio-\\nlogic significance in hydrorrhoea\\nnasalis, 306\\nSyphilis, nervous deafness in, 221,\\n222\\nof the organ of hearing, 219\\nin hereditary lues, 222\\nof the upper air-passages, 205\\nprimary lesion of, in the nose, 206\\nin the pharynx, 210\\nsecondary manifestations, of in the\\nlarynx, 215, 216\\nin the nasal mucous mem-\\nbrane, 206\\nin the pharynx, 210\\ntertiary manifestations of, in the\\nlarynx, 215, 216\\nin the nose, 206\\nin the pharynx, 211\\nSyringomyelia, motor and reflex dis-\\nturbances in the larynx and posterior\\nwall of pharynx in, 291\\nTabes dorsalis, involvement of audi-\\ntory nerve in, 279\\nof the laryngeal nerves in,\\n275\\nof the olfactory nerve in, 275\\nTaste, disturbances of, in middle-ear\\ndisease, 321\\nTeeth, diseases of, in relation to\\nantrum of Highmore, 70\\nto nasal cavities, 71\\nTensor tympani, disturbances of, 318\\nThrombosis of cerebral sinus, 332,\\nThymus gland, alterations of, effect\\non respiration, t^ 35\\nas cause of inspiratory stridor,\\n35\\nas cause of sudden death in\\nchildren, 35\\nTic convulsif due to nasal obstruc-\\ntion, 313", "height": "3468", "width": "2208", "jp2-path": "rhinologylaryng00frie_0360.jp2"}, "361": {"fulltext": "347\\nTinnitus aurium after wounds of the\\nhead, 62\\ncaused by pressure on internal\\njugular vein, 67\\nin anemia, 62, 81\\nand hyperemia within the ear,\\n59\\nin aneurysm, 62\\nin arteriosclerosis, 62, 63\\nin disease of heart and blood-\\nvessels, 59\\nin facial paralysis, 324\\nin leukemia, 87\\nin sclerosis, 62\\nin treatment of heart and lung\\ndiseases by rarefied and com-\\npressed air, 40\\nin variations of atmospheric\\npressure, 40\\nTobacco, abuse of, auditory disturb-\\nances from, 250\\npharyngeal catarrh from, 249\\nTonsils, syphilitic disease of, 210, 21 1\\nToothache distinguished from otal-\\ngia, 3^7\\nTrachea, changes in, produced by\\naneurysm of the aorta, 57\\npressure ulcers and perforations of,\\n57\\npulsating movements of, 57\\nrupture into, in aneurysms of aorta,\\n52\\nstenosis of, 57\\nfrom mediastinal tumors, 34\\nfrom struma, 34\\nin aneurysm of aorta, 52\\nTransfert of sensory disturbances in\\nthe ear in hysteria, 299\\nTrichinosis, paralysis of laryngeal\\nand pharyngeal muscles in, 187\\npharyngeal and laryngeal palsies\\nin, 187\\nTrifacial, disease of, in relation to the\\near, 316, 320\\nsignificance of, in rhinology and\\notology, 314\\nTuberculosis, 15 1\\nof the ear, 169\\nchronic, 171, 172\\ndiagnostic significance of bacilli\\nin, 170\\nof the larynx, 153-158, 162-169\\nof the nose, 153, 158-161\\nof the pharynx, 153, 161\\nof the upper air-passages, 151\\nmode of infection in primary,\\n151\\nin secondary, 154\\nmorbid anatomy of, 151\\nTuberculosis, tonsillar, 152\\nTympanic membrane, respiratory\\nmovements in, 45\\nretraction of, 38\\nsigns and symptoms of, 38\\nrupture of, 39\\nsensory disturbances of, in hys-\\nteria, 298\\nsyphilitic papules on, 219\\nTyphoid fever, 123\\nauditory disturbances in, 132\\naural complications in, 128\\nchanges in the cartilages of the\\nlarynx in, 127\\ncomplicated with diphtheria in,\\n126\\nepistaxis in, 124\\nmastoid disease in, 130\\nmiddle-ear diseases in, 129\\npalsies in, 127, 128\\npharyngeal and laryngeal catarrh\\nin, 124\\nulcers in, 125\\nUlcers, arrosion, tuberculous, of the\\nlarynx, 156\\nlocalization and pathology\\nof, 164\\ntubercular, in the larynx, 164\\nin the nose, 160\\nin the pharynx, 15 1\\nUremia, chronic deafness in, 191\\nValsalva s experiment, 37, 46\\nVaricella, 120\\nVariola, 121\\naural complications in, 122\\npalsies in, 122\\nVasomotor disturbances of nasal ori-\\ngin, 307\\nvarieties of, 308\\nVertigo in anemia, 81\\nin leukemia, 87\\nlaryngeal, 105\\nVisual disturbances after operative\\ninterference in the nose, 231\\nVocal cords, laryngospastic attacks\\nof, 55\\nmovements of, choreic, 295\\nlocalization of, 258\\nparalysis of, in disease of the\\nliver, 74\\nparesis of, in tuberculosis of, 168\\nperiodic palsies of, 55", "height": "3456", "width": "2064", "jp2-path": "rhinologylaryng00frie_0361.jp2"}, "362": {"fulltext": "348\\nVocal cords, spasm of, due to seat-\\nworms, 74\\ntuberculous polyps of, 169\\ntumors of, in multiple sclerosis,\\n290\\nin paralysis agitans, 294\\nulcerations of. in croupous pneu-\\nmonia, 31\\nin leprosy, 182\\nin tuberculosis, 1 64, 1 65\\nVoice, change of, hyperemia of vocal\\ncord in, 200\\npathologic varieties of, 200\\nrelation of, to puberty, 199\\nVox cho erica, 75\\nXerosis of the mucous membranes,\\n29 31.45", "height": "3392", "width": "2120", "jp2-path": "rhinologylaryng00frie_0362.jp2"}, "363": {"fulltext": "CATALOGUE\\nOF THE\\nMEDICAL PUBLICATIONS\\nOF\\nW. B. SAUNDERS CO.,\\nNo. 925 WALNUT STREET, PHILADELPHIAc\\nArranged Alphabetically and Classified under Subjects.\\nTHE books advertised in this Catalogue as being sold by subscription are usually to be\\nobtained from travelling solicitors, but they will be sent direct from the office of pub-\\nlication (charges of shipment prepaid) upon receipt of the prices given. All the other\\nbooks advertised are commonly for sale by booksellers in all parts of the United States but\\nbooks will be sent to any address, carriage prepaid, on receipt of the published price.\\nMoney may be sent at the risk of the publisher in either of the following vi^ays A post-\\noffice money order, an express money order, a bank check, and in a registered letter. Money\\nsent in any other way is at the risk of the sender.\\nSee pages 32, 33 for a List of Contents classified according to subjects.\\nLATEST PUBLICATIONS.\\nAmerican Students* Medical Dictionary. See page 34.\\nAmerican Text-Book of Physiology Second (Revised) Ed. Page 7.\\nFriedrich and Curtis on Nose, Throat, and Ear. See page 34.\\nLe Roy^s Histology. See page 34.\\nOgden on the Urine. See page 34.\\nPyle s Personal Hygiene. See page 34.\\nSalinger and Kalteye/s Modern Medicine. See page 34.\\nStoney^s Surgical Technic for Nurses. See page 34.\\nHyde and Montgomery s Syphilis and Venereal Diseases Revised\\nand Enlarged Edition. See page 15.\\nInternational Text-Book of Surgery. See page 15.\\nGarrigues Diseases of Women\u00e2\u0080\u0094 Third (Revised) Edition. Page 13.\\nAmerican Text-Book of Dis. of Eye, Ear, Nose, and Throat. Page 5.\\nSaunders American Year-Book for 1900. See page 8.\\nLevy and Klemperer s Clinical Bacteriology. See page 17.\\nScudder s Treatment of Fractures. See page 26.\\nSenn s Tumors Second Edition. See page 27.\\nBeck on Fractures. See page 9.\\nWatson s Handbook for Nurses. See page 31.\\nHeisler s Embryology. See page t5.\\nNancrede s Principles of Surgery. See page 20.\\nJackson s Diseases of the Eye. See page 16.\\nKyle on the Nose and Throat. See page 17.\\nPenrose s Diseases of Women Third (Revised Edition. Page 20.\\nWarren s Surgical Pathology Second (Revised) Edition. Page 31.\\nSaunder s Medical Hand-Atlases. See pages 2, 3, 4.\\nAmerican Pocket Medical Dictionary Third (Revised) Ed. Page 12.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0363.jp2"}, "364": {"fulltext": "SAUNDERS\\nMEDICAL HAND-ATLASES.\\nThe series of books included under this title consists of authorized\\ntranslations into English of the world-famous Lehmann Medicinische\\nHandatlanten, which for scientific accuracy, pictorial beauty, com-\\npactness, and cheapness surpass any similar volumes ever published.\\nEach volume contains from 50 to 100 colored plates, executed by the\\nmost skilful German lithographers, besides numerous illustrations in the\\ntext. There is a full and appropriate description of each plate, and\\neach book contains a condensed but adequate outline of the subject to\\nwhich it is devoted.\\nOne of the most valuable features of these atlases is that they offer a\\nready and satisfactory substitute for clinical observation. To those\\nunable to attend important clinics these books will be absolutely indis-\\npensable.\\nIn planning this series of books arrangements were made with the rep-\\nresentative publishers in the chief medical centers of the world for the\\npublication of translations of the atlases into different languages, the litho-\\ngraphic plates for all these editions being made in Germany, where work of\\nthis kind has been brought to the greatest perfection. The expense of\\nmaking the plates being shared by the various publishers, the cost to each\\none was materially reduced. Thus by reason of their universal transla-\\ntion and reproduction, the publishers have been enabled to secure for these\\natlases the best artistic and professional talent, to produce them in the\\nmost elegant style, and yet to offer them at a price heretofore unap-\\nproached in cheapness. The success of the undertaking is demonstrated\\nby the fact that the volumes have already appeared in thirteen different\\nlang-uages German, English, French, Italian, Russian, Spanish, Japanese,\\nDutch, Danish, Swedish, Roumanian, Bohemian, and Hungarian.\\nIn view of the striking success of these works, Mr. Saunders has con-\\ntracted with the publisher of the original German edition for one hun-\\ndred thousand copies of the atlases. In consideration of this enormous\\nundertaking, the publisher has been enabled to prepare and furnish special\\nadditional colored plates, making the series even handsomer and more\\ncomplete than was originally intended.\\nAs an indication of the practical value of the atlases and of the favor\\nwith which they have been received, it should be noted that the Medical\\nDepartment of the U.S. Army has adopted the Atlas of Operative\\nSurgery as its standard, and has ordered the book in large quantities for\\ndistribution to the various regiments and army posts.\\nThe same careful and competent editorial supervision has been\\nsecured in the English edition as in the originals, the translations being\\nedited by the leading American specialists in the different subjects.", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0364.jp2"}, "365": {"fulltext": "SAUNDERS^ MEDICAL HAND-ATLASES\u00c2\u00bb\\nVOLUMES NOW READY.\\nAtlas and Epitome of Internal Medicine and Clinical Diagnosis.\\nBy Dr. Chr. Jakob, ofErlangen. Edited by Augustus A. Eshner, M.D.,\\nProfessor of Clinical Medicine, Philadelphia Polyclinic. With 68 colored\\nplates, 64 text-illustrations, and 259 pages of text. Cloth, ^3.00 net.\\nThe charm of the book is its clearness, conciseness, and the accuracy and beauty of its\\nillustrations. It deals with facts. It vividly illustrates those facts. It is a scientific work\\nput together for ready reference. Brooklyn Medical Journal.\\nAtlas of Legal Medicine. By Dr. E. R. von Hofmann, of Vienna. Edited\\nby Frederick Peterson, M.D., Chief of Clinic, Nervous Dept., College\\nof Physicians and Surgeons, New York. With 120 colored figures on 56\\nplates, and 193 beautiful half-tone illustrations. Cloth, $3.50 net.\\nHofmann s Atlas of Legal Medicine is a unique work. This immense field finds in this\\nbook a pictorial presentation that far excels anything with which we are familiar in any other\\nwork. Philadelphia Medical Journal.\\nAtlas and Epitome of Diseases of the Larynx. By Dr. L. Grunwald,\\nof Munich. Edited by Charles P. Grayson, M.D., Physician-in-Charge,\\nThroat and Nose Department, Hospital of the University of Pennsylvania.\\nWith 107 colored figures on 44 plates, 25 text- illustrations, and 103 pages\\nof text. Cloth, $2.50 net.\\nAided as it is by magnificently executed illustrations in color, it cannot fail of being of\\nthe greatest advantage to students, general practitioners, and expert laryngologists. St.\\nLotas Medical and Surgical Journal.\\nAtlas and Epitome of Operative Surgery. By Dr. O. Zuckerkandl,\\nof Vienna. Edited by J. Chalmers DaCosta, M. D., Professor of\\nPractice of Surgery and Clinical Surgery, Jefferson Medical College,\\nPhiladelphia. With 24 colored plates, 217 text-illustrations, and 395\\npages of text. Cloth, ^3.00 net.\\nWe know of no other work that combines such a wealth of beautiful illustrations with\\nclearness and conciseness of language, that is so entirely abreast of the latest achievements,\\nand so useful both for the beginner and for one who wishes to increase his knowledge of\\noperative surgery. Muiichener medicinische Wochenschrijt.\\nAtlas and Epitome of Syphilis and the Venereal Diseases. By Prof.\\nDr. Franz Mracek, of Vienna. Edited by L. Bolton Bangs, M.D.,\\nProfessor of Genito-Urinary Surgery, University and Bellevue Hospital\\nMedical College, New York. With 71 colored plates, 16 black-and-\\nwhite illustrations, and 122 pages of text. Cloth, $3.50 net.\\nA glance through the book is almost like actual attendance upon a famous clinic.\\nJournal of the American Aledical Association.\\nAtlas and Epitome of External Diseases of the Eye. By Dr. O.\\nHaak, of Zurich. Edited by G. E. de Schweinitz, M.D., Professor of\\nOphthalmology, Jefferson Medical College, Philadelphia. With 76\\ncolored illustrations on 40 plates, and 228 pages of text. Cloth, $3.00 net.\\nIt is always difficult to represent pathological appearances in colored plates, but this\\nwork seems to have overcome these difficulties, and the plates, with one or two exceptions,\\nare absolutely satisfactory. Boston Aledical and Surgical Journal.\\nAtlas and Epitome of Skin Diseases. By Prof. Dr. Franz Mracek,\\nof Vienna. Edited by Henrv W. Stelwagox, M.D., Clinical Professor\\nof Dermatology, Jefferson Medical College, Philadelphia. With 63 colored\\nplates, 39 half-tone illustrations, and 200 pages of text. Cloth, ^3.50 net.\\nThe importance of personal inspection of cases in the study of cutaneous diseases is\\nreadily appreciated, and next to the living subjects are pictures which will show the appear-\\nance of the disease under consideration. Altogether the work will be found of very great\\nvalue to the general practitioner. Journal of the American Medical Association.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0365.jp2"}, "366": {"fulltext": "SAUNDERS^ MEDICAL HAND-ATLASES.\\nVOLUMES JUST ISSUED.\\nAtlas and Epitome of Special Pathological Histology. By Dr. H.\\nDuRCK, of Munich. Edited by Ludvig Hektoen, M. D., Professor of\\nPathology, Rush Medical College, Chicago. In Two Parts. Part I.\\nJust Ready, including the Circulatory, Respirator}-, and Gastro-\\nintestinal Tract, with 120 colored figures on 62 plates and 158 pages\\nof text. Price, $3.00 net. Parts sold separately.\\nAtlas and Epitome of Diseases Caused by Accidents. By Dr. Ed.\\nGoLEBiEWSKi, of Berlin. Translated and edited with additions by\\nPearce B.\\\\ilev, M. D., Attending Physician to the Department of Cor-\\nrections and to the Almshouse and Incurable Hospitals, New York.\\nWith 40 colored plates, 143 text-illustrations, and 600 pages of text.\\nAtlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel-\\nberg. Edited by Richard C. Norris, A. M., M. D., Gynecologist to\\nthe Methodist Episcopal and the Philadelphia Hospitals Surgeon-in-\\nCharge of Preston Retreat, Philadelphia. With 90 colored plates, 65\\ntext-illustrations, and 308 pages of text.\\nIN PRESS FOR EARLY PUBLICATION.\\nAtlas and Epitome of Obstetrical Diagnosis and Treatment. By\\nDr. O. Schaffer, of Heidelberg. Edited by J. Clifton Edgar,\\nM. D., Professor of Obstretics and Clinical Midwifery, Cornell Univer-\\nsity Medical School. 72 colored plates, numerous text-illustrations,\\nand copious text.\\nAtlas and Epitome of the Nervous System and its Diseases. By\\nPr()F. Dr. A. VON Strumpell, of Erlangen. Edited by Edward D.\\nFisher, M. D., Professor of Diseases of the Nervous System, Univer-\\nsity and Bellevue Hospital Medical College, New York. 83 plates and\\na copious text.\\nAtlas and Epitome of General Pathological Histology. With an\\nAppendix on Pathohistological Technic. By Dr. H. Durck, of\\nMunich. Edited by Ludvig Hektoen, M. D., Professor of Path-\\nology, Rush Medical College, Chicago. With So colored plates,\\nnumerous text-illustrations, and copious text.\\nIN PREPARATION.\\nAtlas and Epitome of Orthopedic Surgery.\\nAtlas and Epitome of Operative Gynecology.\\nAtlas and Epitome of Diseases of the Ear.\\nAtlas and Epitome of General Surgery.\\nAtlas and Epitome of Psychiatry.\\nAtlas and Epitome of Normal Histology.\\nAtlas and Epitome of Topographical Anatomy.", "height": "3468", "width": "2220", "jp2-path": "rhinologylaryng00frie_0366.jp2"}, "367": {"fulltext": "THE AMERICAN TEXT-BOOK SERIES.\\nAN AMERICAN TEXT=BOOK OF APPLIED THERAPEUTICS.\\nBy 43 Distinguished Practitioners and Teachers. Edited by James C.\\nWilson, M.D., Professor of the Practice of Medicine and of Clinical\\nMedicine in the Jefferson Medical College, Philadelphia. One hand-\\nsome imperial octavo volume of 1326 pages. Illustrated. Cloth,,\\n^7.00 net; Sheep or Half Morocco, $8.00 net. Sold by Subscription.\\nAs a work either for study or reference it will be of great value to the practitioner, a^\\nit is virtually an exposition of such clinical therapeutics as experience has taught to be ol\\nthe most value. Taking it all in all, no recent publication on therapeutics can be compared\\nwith this one in practical value to the working physician. Chicago Clinical Review.\\nThe whole field of medicine has been well covered. The work is thoroughly prac-\\ntical, and while it is intended for practitioners and students, it is a better book for the genera)\\npractitioner than for the student. The young practitioner especially will find it extremely\\nsuggestive and helpful. The Indian Lancet.\\nAN AMERICAN TEXT=BOOK OF THE DISEASES OF CHILDREN.\\nSecond Edition, Revised.\\nBy 65 Eminent Contributors. Edited by Louis Starr, M. D., Con-\\nsulting Pediatrist to the Maternity Hospital, etc. assisted by Thomp-\\nson S. Westcott, M. D., Attending Physician to the Dispensary\\nfor Diseases of Children, Hospital of the University of Pennsyl-\\nvania. In one handsome imperial octavo volume of 1244 pages,\\nprofusely illustrated. Cloth, $7.00 net; Sheep or Half Morocco,\\nJ58.00 net. Sold by Subscription.\\nThis is far and away the best text-book on children s diseases ever published in the\\nEnglish language, and is certainly the one which is best adapted to American readers.\\nWe congratulate the editor upon the result of his work, and heartily commend it to the\\nattention of every student and practitioner. American Joiu-7ial of tJie Medical Sciences.\\nAN AMERICAN TEXT=BOOK OF DISEASES OF THE EYE, EAR,\\nNOSE, AND THROAT.\\nBy 58 Prominent Specialists. Edited by G. E. de Schweinitz, M.D\\nProfessor of 0])hthalmology in the Jefferson Medical College, Phila-\\ndelphia and B. Alexander Randall, M.D., Professor of Diseases\\nof the Ear in the University of Pennsylvania. Imperial octavo, 1251\\npages; 766 illustrations, 59 of them in colors. Cloth, ;7.oo net; She ^p\\nor Half Morocco, $8.00 net. Sold by Subscription.\\nIlltistrated Catalogue of the American Text-Books sent free upon application.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0367.jp2"}, "368": {"fulltext": "6 Medical Publications of W. B. Saunders Co.\\nAN AMERICAN TEXT=BOOK OF GENIT0=UR1NARY AND SKIN\\nDISEASES.\\nBy 47 Eminent Specialists and Teachers. Edited by L. BoltoN\\nBangs, M. D., Professor of Genito- Urinary Surgery, University and\\nBellevue Hospital Medical College, New York and W. A. Hard-\\nAWAY, M. D., Professor of Diseases of the Skin, Missouri Medical\\nCollege. Imperial octavo volume of 1229 pages, with 300 engravings\\nand 20 full-page colored plates. Cloth, ^7.00 net; Sheep or Half\\nMorocco, ^8.00 net. Sold by Subscription.\\nThis volume is one of the best yet issued of the publisher s series of American Text-\\nBooks. The list of contributors represents an extraordinary array of talent and extended\\nexperience. The book will easily take the place in compreliensiveness and value of the\\nhalf dozen or more costly works on these subjects which have heretofore been necessary to\\na well-equipped library. A^rc/ York Polyclinic.\\nAN AMERICAN TEXT=BOOK OF GYNECOLOGY, MEDICAL AND\\nSURGICAL. Second Edition, Revised.\\nBy 10 of the Leading Gynecologists of America. Edited by J- M.\\nBaldy, M. D., Professor of Gynecology in the Philadelphia Polyclinic,\\netc. Handsome imperial octavo volume of 718 pages, with 341 illus-\\ntrations in the text, and 38 colored and half-tone plates. Cloth, ^6.00\\nnet; Sheep or Half Morocco, $7.00 net. Sold by Subscription.\\nIt is practical from beginning to end. Its descriptions of conditions, its recommen-\\ndations for treatment, and above all the necessary technique of different operations, are\\nclearly and admirably presented. It is well up to the most advanced views of the\\nday, and embodies all the essential points of advanced American gynecology. It is destined\\nto make and hold a place in gynecological literature which will be peculiarly its own.\\nMedical Record, New York.\\nAN AMERICAN TEXT^BOOK OF LEGAL MEDICINE AND TOXI-\\nCOLOGY.\\nEdited by Frederick Peterson, M.D., Clinical Professor of Mental\\nDiseases in the Woman s Medical College, New York Chief of Clinic,\\nNervous Department, College of Physicians and Surgeons, New York\\nand Walter S. Haines, M.D., Professor of Chemistry, Pharmacy,\\nand Toxicology in Rush Medical College, Chicago. In Preparation.\\nAN AMERICAN TEXT=BOOK OF OBSTETRICS.\\nBy 15 Eminent American Obstetricians. Edited by Richard C. Nor-\\nRis, M.D.; Art Editor, Robert L. Dickinson, M.D. One handsome\\nimperial octavo volume of 1014 pages, with nearly 900 beautiful colored\\nand half-tone illustrations. Cloth, ^7.00 net; Slieep or Half Morocco,\\n^8.00 net. Sold by Subscription.\\nPermit me to say that your American Text-Book of Obstetrics is the most magnificent\\nmedical work that I have ever seen. I congratulate you and thank you for this superb work,\\nwhich alone is sufficient to place you first in the ranks of medical publishers. Alkxander\\nJ. C. Skene, Professor of Gynecology in the Long Island College Hospital, Brooklyn, N. Y.\\nThis is the most sumptuously illustrated work on midwifery that has yet appeared. In\\nthe number, the excellence, and the beauty of production of the illustrations it far surpasses\\nevery other book upon the subject. This feature alone makes it a work which no medical\\nlibrary should omit to purchase. British Medical Journal.\\nAs an authority, as a book of reference, as a working book for the student or prac-\\ntitioner, we commend it because we believe there is no better. American Journal of the\\nM dical Sciences.\\nIllustrated Catalogue of the American Text-Books sent free upon application*", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0368.jp2"}, "369": {"fulltext": "Medical Publications of W. B. Saunders Co. 7\\nAN AMERICAN TEXT=BOOK OF PATHOLOGY.\\nEdited by Ludvig Hektoen, M. D.. Professor of General Pathology\\nand of Morbid Anatomy in the University of Pennsylvania and\\nDavid Riesman, M. D., Demonstrator of Pathological Histology in\\nthe University of Pennsylvania. In preparation.\\nAN AMERICAN TEXT=BOOK OF PHYSIOLOGY.\\nBy I o of the Leading Physiologists of America. Edited by William\\nH. Howell, Ph.D., M.D., Professor of Physiology in the Johns Hop-\\nkins University, Baltimore, Md. Second edition, revised and enlarged,\\nin two volumes.\\nWe can commend it most heartily, not only to all students of physiology, but to ever}\\nphysician and pathologist, as a valuable and comprehensive work of reference, written by\\nmen who are of eminent authority in their own special subjects. London Lancet.\\nTo the practitioner of medicine and to the advanced student this volume constitutes,\\nwe believe, the best exposition of the present status of the science of physiology in the\\nEnglish language. Atnerican Jourtial of the Medical Sciences.\\nAN AMERICAN TEXT=BOOK OF SURGERY. Third Edition.\\nBy 1 1 Eminent Professors of Surgery. Edited by William W. Keen,\\nM.D., LL.D., and J. William White, M.D., Ph.D. Handsome im-\\nperial octavo volume of 1230 pages, with 496 wood- cuts in the text,\\nand 37 colored and half-tone plates. Thoroughly revised and enlarged,\\nwith a section devoted to The Use of the Rontgen Rays in Surgery.\\nCloth, $7.00 net; Sheep or Half Morocco, $8. 00 net.\\nPersonally, I should not mind it being called THE Text-Book (instead of A Text-\\nBook), for I know of no single volume which contains so readable and complete an account\\nof the science and art of Surgery as this does. EDMUND Owen, F.R.C.S., Member of\\nthe Board of Examiners of the Royal College of Siirgeons, England.\\nIf this text-book is a fair reflex of the present position of American surgery, we must\\nadmit it is of a very high order of merit, and that English surgeons will have to look very\\ncarefully to their laurels if they are to preserve a position in the van of surgical practice.\\nLondon Lancet.\\nAN AMERICAN TEXT=BOOK OF THE THEORY AND PRACTICE\\nOF MEDICINE.\\nBy 12 Distinguished American Practitioners. Edited by William\\nPepper, M.D., LL.D., Professor of the Theory and Practice of Medi-\\ncine and of Clinical Medicine in the University of Pennsylvania. Two\\nhandsome imperial octavo volumes of about 1000 pages each. Illus-\\ntrated. Prices per volume Cloth, ^5.00 net Sheep or Half Morocco,\\n^6.00 net. Sold by Subscription.\\nI am quite sure it will commend itself both to practitioners and students of medicine,\\nand become one of our most popular text-books. Alfred Loomis, M.D., LL.D., Lro-\\nfessor of Pathology and Practice of Medicine, University of the City of Neru York.\\nWe reviewed the first volume of this work, and said It is undoubtedly one of the\\nbest text-books on the practice of medicine which we possess. A consideration of the\\nsecond and last volume leads us to modify that verdict and to say that the completed work\\nis in our opinion tlic best of its kind it has ever been our fortune to see. New York Medical\\nJournal.\\nIflttstrated Catalogue of the American Text-Books* sent free upon application.", "height": "3460", "width": "2108", "jp2-path": "rhinologylaryng00frie_0369.jp2"}, "370": {"fulltext": "8 Medical Publications of W. B. Saunders Co.\\nAN AMERICAN YEAR-BOOK OF MEDICINE AND SURGERY.\\nA Yearly Digest of Scientific Progress and Authoritative Opinion in all\\nbranches of Medicine and Surgery, drawn from journals, monographs,\\nand text-books of the leading American and Foreign authors and\\ninvestigators. Arranged with critical editorial comments, by eminent\\nAmerican specialists, under the general editorial charge of George M.\\nGould, M.D. Volumes for 1896, 97, 98, and 99. One imperial\\noctavo volume of about 1200 pages. Cloth, $6.50 net; Half Morocco,\\n$7.50 net. Year -Book of 1900 in two volumes Vol. I., including\\nGeneral Medicine; Vol. II., General Surgery. Prices per volume:\\nCloth, $3.00 net; Half Morocco, ^3.75 net. Sold by Subscription.\\nIt is difficult to know which to admire most the research and industry of the distin-\\nguished band of experts whom Dr. Gould has enlisted in the service of the Year- Book, oi- the\\nwealth and abundance of the contributions to every department of science that have been\\ndeemed worthy of analysis. It is much more than a mere compilation of abstracts, for,\\nas each section is entrusted to experienced and able contributors, the reader has the advant-\\nage of certain critical commentaries and expositions proceeding from writers fully\\nqualified to perform these tasks. It is emphatically a book which should find a place in\\nevery medical library, and is in several respects more nseful than the famous Jahrbiicher\\nof Germany. London Lamet.\\nABBOTT ON TRANSMISSIBLE DISEASES.\\nThe Hygiene of Transmissible Diseases their Causation,\\nModes of Dissemination, and Methods of Prevention. By A.\\nC. Abbott, M.D., Professor of Hygiene and Bacteriology, University\\nof Pennsylvania Director of the Laboratory of Hygiene. Octavo\\nvolume of 311 pages, containing a number of charts and maps, and\\nnumerous illustrations. Cloth, $2.00 net.\\nTHE AMERICAN POCKET MEDICAL DICTIONARY.\\n[See Dorlaud s Pocket Dictionary, page 12.]\\nANDERS PRACTICE OF MEDICINE. Third Revised Edition.\\nAText=Book of the Practice of Medicine. By James M. Anders,\\nM.D., Ph.D., LL.D., Professor of the Practice of Medicine and of\\nClinical Medicine, Medico-Chirurgical College, Philadelphia. In one\\nhandsome octavo volume of 1292 pages, fully illustrated. Cloth,\\n^5.50 net; Sheep or Half Morocco, $6.50 net.\\nIt is an excellent book, concise, comprehensive, thorough, and up to date. It is a\\ncredit to you but, more than that, it is a credit to the profession of Philadelphia to us.\\n1 A.MES C. Wilson, Professor of the Practice of Medicine and Clinical Medicine, Jefferson\\nMedical College, Philadelphia.\\nASHTON S OBSTETRICS. Fourth Edition, Revised.\\nEssentials of Obstetrics. By W. Easterly Ashton, M.D., Pro-\\nfessor of Gynecology in the Medico-Chirurgical College, Philadelphia.\\nCrown octavo, 252 pages; 75 illustrations. Cloth, $1.00 net; inter-\\nleaved for notes, 51.25 net.\\n[See Saunders^ Questioii-Compends, page 23.]\\nEmbodies the whole subject in a nut-shell. We cordially recommend it to our read\\ners. Chicago Medical Times.", "height": "3468", "width": "2220", "jp2-path": "rhinologylaryng00frie_0370.jp2"}, "371": {"fulltext": "Medical Publications of W. B. Saunders Co.\\nBALL S BACTERIOLOGY. Third Edition, Revised.\\nEssentials of Bacteriology a Concise and Systematic Introduction\\nto the Study of Micro-organisms. By M. V. Ball, M.D., Bacteriol-\\nogist to St. Agnes Hospital, Philadelphia, etc. Crown octavo, 218\\npages; 82 illustrations, some in colors, and 5 plates. Cloth, $1.00;\\ninterleaved for notes, $1.25.\\n[See Saunders Question- Conipends, page 23.]\\nThe student or practitioner can readily obtain a knowledge of the subject from a perusal\\nof this book. The illustrations are clear and satisfactory. Medical Record, New York.\\nBASTIN S BOTANY.\\nLaboratory Exercises in Botany. Bv Edson S. Bastin, M.A.,\\nlate Prof, of Materia Medica and Botany, Philadelphia College of Phar-\\nmacy. Octavo volume of 536 pages, with 87 plates. Cloth, $2.00 net.\\n**It is unquestionably the best text-book on the subject that has yet appeared. The\\nwork is eminently a practical one. We regard the issuance of this book as an important\\nevent in the history of pharmaceutical teaching in this country, and predict for it an unquali-\\nfied success. Alumni Report to the Philadelphia College of Pharmacy.\\nBECK ON FRACTURES.\\nFractures. By Carl Beck, M.D., Surgeon to St. Mark s Hospital\\nand the New York German Poliklinik, etc. 225 pages, 170 illustratione.\\nCloth, $3.50 net.\\nBECK S SURGICAL ASEPSIS.\\nA Manual of Surgical Asepsis. By Carl Beck, M.D,, Surgeon to\\nSt. Mark s Hospital and the New York German Poliklinik, etc. 306\\npages; 65 text-illustrations, and 12 full-page plates. Cloth, |i. 25 net.\\nAn excellent exposition of the very latest in the treatment of wounds as practised\\nby leading German and American surgeons. Birmingham (Eng.) Medical Review.\\nThis little volume can be recommended to any who are desirous of learning the details\\nof asepsis in surgery, for it will serve as a trustworthy guide. London Lancet.\\nBOISLINIERE S OBSTETRIC ACCIDENTS, EMERGENCIES, AND\\nOPERATIONS.\\nObstetric Accidents, Emergencies, and Operations. By L. Ch.\\nBoisLiNiERE, M.D., late Emeritus Professor of Obstetrics, St. Louis\\nMedical College. 381 pages, handsomely illustrated. Cloth, ^2.00 net.\\nA manual so useful to the student or the general practitioner has not been brought to\\nour notice in a long time. The field embraced in the title is covered in a terse, interesting\\nway. Yale Aledical Journal.\\nBROCKWAY S MEDICAL PHYSICS. Second Edition, Revised.\\nEssentials of Medical Physics. By Fred J. Brockway, M.D.,\\nAssistant Demonstrator of Anatomy in the College of Physicians and\\nSurgeons, New York. Crown octavo, 330 pages; 155 fine illustrations.\\nCloth, 5 1- 00 net interleaved for notes, $1.25 net.\\n[See Saunders Question- Comp ends, page 23.]\\nWe know of no manual that affords the medical student a better or more Concise\\nexposition of physics, and the book may be commended as a most satisfactory presentation\\nof those essentials that are requisite in a course in medicine. New York Medical Journal.", "height": "3460", "width": "2144", "jp2-path": "rhinologylaryng00frie_0371.jp2"}, "372": {"fulltext": "10 Medical Publications of W. B. Saunders Co.\\nBUTLER S MATERIA MEDICA, THERAPEUTICS, AND PHAR-\\nMACOLOGY. Third Edition, Revised.\\nA Text=Book of Materia Medica, Therapeutics, and Pharma-\\ncology. By George F. Butler, Ph.G., M.D., Professor of Materia\\nMedica and of Clinical Medicine in the College of Physicians and\\nSurgeons, Chicago Professor of Materia Medica and Therapeutics,\\nNorthwestern University, Woman s Medical School, etc. Octavo, 874\\npages, illustrated. Cloth, $4.00 net Sheep, $5.00 net.\\nTaken as a whole, the book may fairly be considered as one of the most satisfactory*\\nof any single-volume works on materia medica in the market. Journal of the American\\nMedical Association.\\nCERNA ON THE NEWER REMEDIES. Second Edition, Revised.\\nNotes on the Newer Remedies, their Therapeutic Applications\\nand Modes of Administration. By David Cerna, M.D., Ph.D.,\\nformerly Demonstrator of and Lecturer on Experimental Therapeutics\\nin the University of Pennsylvania Demonstrator of Physiology in the\\nMedical Department of the University of Texas. Rewritten and\\ngreatly enlarged. Post-octavo, 253 pages. Cloth, ^i. 00 net.\\nThe appearance of this new edition of Dr. Cerna s very valuable work shows that it\\nis properly appreciated. The book ought to be in the possession of every practising physi-\\ncian. Nezv York Medical Journal.\\nCHAPIN ON INSANITY.\\nA Compendium of Insanity. By John B. Chapin, M.D., LL.D.,\\nPhysician-in-Chief, Pennsylvania Hospital for the Insane late Physi-\\ncian-Superintendent of the Willard State Hospital, New York Hon-\\norary Member of the Medico-Psychological Society of Great Britain,\\nof the Society of Mental Medicine of Belgium. i2mo, 234 pages,\\nillustrated. Cloth, $1.25 net.\\nThe practical parts of Dr. Chapin s hook are what constitute its distinctive merit. We\\ndesire especially to call attention to the fact that on the subject of therapeutics of insanity\\nthe work is exceedingly valuable. It is not a made book, but a genuine condensed thesis,\\nwhich has all the value of ripe opinion and all the charm of a vigorous and natural style.\\nPhiladelphia Medical Journal.\\nCHAPMAN S MEDICAL JURISPRUDENCE AND TOXICOLOGY.\\nSecond Edition, Revised.\\nMedical Jurisprudence and Toxicology, By Henry C. Chapman,\\nM.D., Professor of Institutes of JSIedicine and Medical Jurisprudence\\nin the Jefferson Medical College of Philadelphia. 254 pages, with 55\\nillustrations and 3 full-page plates in colors. Cloth, \u00c2\u00a71.50 net.\\nThe best book of its class for the undergraduate that we know of. Neiv York\\nMedical Tivies.\\nCHURCH AND PETERSON S NERVOUS AND MENTAL DISEASES.\\nSecond Edition.\\nNervous and Mental Diseases. By Archibald Church, M. D.,\\nProfessor of Clinical Neurology, Mental Diseases, and Medical Juris-\\nprudence in the Northwestern University Medical School, Chicago\\nand Frederick Peterson, M. D., Clinical Professor of Mental Dis-\\neases, Woman s Medical College, N. Y. Chief of Clinic, Nervous\\nDept., College of Physicians and Surgeons, N. Y. Handsome octavo\\nvolume of 843 pages, profusely illustrated. Cloth, $5.00 net; Half\\nMorocco, \u00c2\u00a76. 00 net.", "height": "3468", "width": "2208", "jp2-path": "rhinologylaryng00frie_0372.jp2"}, "373": {"fulltext": "Medical Publications of W. B. Saunders Co. 11\\nCLARKSON S HISTOLOGY.\\nA Text=Book of Histology, Descriptive and Practical. By\\nArthur Clarkson, M.B., CM. Edin., formerly Demonstrator of\\nPhysiology in the Owen s College, Manchester; late Demonstrator of\\nPhysiology in Yorkshire College, Leeds. Large octavo, 554 pages;\\n22 engravings in the text, and 174 beautifully colored original illustra-\\ntions. Cloth, strongly bound, ^4.00 net.\\nThe work must be considered a valuable addition to the list of available text books,\\nand is to be highly recommended. New York Medical Journal.\\nThis is one of the best works for students we have ever noticed. We predict that the\\nbook will attain a well-deserved popularity among our students. Chicago Medical Recorder.\\nCLIMATOLOGY.\\nTransactions of the Eighth Annual Meeting of the American\\nClimatological Association, held in Washington, September 22-25,\\n1891. Forming a handsome octavo volume of 276 pages, uniform with\\nremainder of series. (A limited quantity only.) Cloth, $1.50.\\nCOHEN AND ESHNER S DIAGNOSIS. Second Edition, Revised.\\nEssentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro-\\nfessor of Clinical Medicine and Applied Therapeutics in the Philadel-\\nphia Polyclinic and Augustus A. Eshner, M.D., Professor of Clinical\\nMedicine in the Philadelphia Polyclinic. Post-octavo, 417 pages; 55\\nillustrations. Cloth, ^i.oo net.\\n[See Saimders^ Question- Compends, page 23.]\\nWe can heartily commend the book to all those who contemplate purchasing a com-\\npend. It is modern and complete, and will give more satisfaction than many other works\\nwhich are perhaps too prolix as well as behind the times. Medical Review, St. Louis.\\nCORWiN S PHYSICAL DIAGNOSIS. Third Edition, Revised.\\nEssentials of Physical Diagnosis of the Thorax. By Arthur\\nM, CoRWiN, A.M., M.D., Demonstrator of Physical Diagnosis in Rush\\nMedical College, Chicago Attending Physician to Central Free Dis-\\npensary, Department of Rhinology, Laryngology, and Diseases of the\\nChest, Chicago. 219 pages, illustrated. Cloth, flexible covers, ^1.25 net.\\nIt is excellent. The student who shall use it as his guide to the careful study of\\nphysical exploration upon normal and abnormal subjects can scarcely fail to acquire a good\\nworking knowledge of the subject. Philadelphia Folyclitiic.\\nA most excellent little work. It brightens the memory of the differential diagnostic\\nsigns, and it arranges orderly and in sequence the various objective phenomena to logical\\nsolution of a careful diagnosis. Journal of A^ervoiis aiid Mental Diseases.\\nCRAQIN S GYN/ECOLOGY. Fourth Edition, Revised.\\nEssentials of Gynaecology. By Edwin B. Cr.-^gin, M. D., Lecturer\\nin Obstetrics, College of Physicians and Surgeons, New York. Crown\\noctavo, 200 pages; 62 illii^irations. Cloth, $1.00 net; interleaved for\\nnotes, $1.25 net.\\n\\\\?)ee SaunihW Question- Compends, page 23.]\\nA handy volume, and a distinct improvement on students compends in general. No\\nauthor v\\\\ho was not himself a practical gynecologist could have consulted the student s needs\\nso thoroughly as Dr. Cragin has dont. Medical Record, New York.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0373.jp2"}, "374": {"fulltext": "12 Meaical Publications of W. B. Saunders Co.\\nCROOKSHANK S BACTERIOLOGY. Fourth Edition, Revised.\\nA Text=Book of Bacteriology. By Edgar M. Crookshank, M.B.,\\nProfessor of Comparative Pathology and Bacteriology, King s College,\\nLondon. Octavo volume of 700 pages, with 273 engravings and 22\\noriginal colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net.\\nTo the student who wishes to obtain a good resume of what has been done in bacteri-\\nology, or who wishes an accurate account of the various methods of research, the book may\\nbe recommended with confidence that he will find there what he requires. Lotidon Lancet.\\nDa COSTA S SURGERY. Second Ed., Revised and Greatly Enlarged.\\nModern Surgery, General and Operative. By John Chalmers\\nDaCosta, M. D., Professor of Practice of Surgery and Clinical Surgery,\\nJefferson Medical College, Philadelphia Surgeon to the Philadelphia\\nHospital, etc. Handsome octavo volume of 911 pages, profusely illus-\\ntrated. Cloth, $4.00 net; Half Morocco, $5.00 net.\\nWe know of no small work on surgery in the EngHsh language which so well fulfils\\nthe requirements of the modern student. Mcdico-Chirurgical Journal, Bristol, England.\\nDE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition,\\nRevised.\\nDiseases of the Eye, A Handbook of Ophthalmic Practice.\\nBy G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the\\nJefferson IMedical College, Philadelphia, etc. Handsome royal octavo\\nvolume of 696 pages, with 256 fine illustrations and 2 chromo-litho-\\ngraphic plates. Cloth, ^4.00 net Sheep or Half Morocco, $5.00 net.\\nA clearly written, comprehensive manual. One which we can commend to students\\nas a reliable text-book, written with an evident knowledge of the wants of those entering\\nupon the study of this special branch of medical science. British I^Iedical Journal.\\nA work that will meet the requirements not only of the specialist, but of the general\\npractitioner in a rare degree. I am satisfied that unusual success awaits it. William\\nPepper, M.D.. Professor of the Theory and Practice of Medicitte and Clinical Medicine,\\nUniversity of Pennsylvania.\\nDORLAND S DICTIONARY. Third Edition, Revised.\\nThe American Pocket Medical Dictionary. Containing the Pro-\\nnunciation and Definition of all the principal words and phrases, and a\\nlarge number of useful tables. Edited by W. A. Newman Borland,\\nALL). Assistant Demonstrator of Obstetrics, University of Pennsylvania\\nFellow of the American Academy of Medicine. 518 pages handsomely\\nbound in full leather, limp, with gilt edges and patent index. Price,\\n$1.00 net; with thumb index, $1.25 net.\\nDORLAND S OBSTETRICS.\\nA Manual of Obstetrics. By W. A. Newman Borland, ALB.,\\nAssistant Bemonstrator of Obstetrics, L niversity of Pennsylvania;\\nInstructor in Gynecology in the Philadelphia Polyclinic. 760 pages;\\n163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net,\\nBy far the best book on this subject that has ever come to our notice. American\\nMedical Review.\\nIt has rarely been our duty to review a book which has given us more pleasure in its\\nperusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge,\\na gold mine of practical, concise thoughts. Af/terican Medico- Sui-gical Bulletin.", "height": "3492", "width": "2220", "jp2-path": "rhinologylaryng00frie_0374.jp2"}, "375": {"fulltext": "Medical Publications of W. B. Saunders Co. 13\\nPROTHINQHAM S GUIDE FOR THE BACTERIOLOGIST.\\nLaboratory Guide for the Bacteriologist. By Langdon Froth-\\niNGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science,\\nSheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts.\\nIt is a convenient and useful little work, and will more than repay the outlay neces-\\nsary for its purchase in the saving of time which would otherwise be consumed in looking\\nup the various points of technique so clearly and concisely laid down in its pages. ^;\u00c2\u00abf? 2-\\ncan Medico- Surgical Bulletin.\\nQARRIGUES DISEASES OF WOMEN. Third Edition, Revised.\\nDiseases of Women. By Henry J. Garrigues, A.M., M.D., Pro-\\nfessor of Gynecology in the New York School of Clinical Medicine\\nGynecologist to St. Mark s Hospital and to the German Dispensary,\\nNew York City, etc. Handsome octavo volume of 783 pages, illus-\\ntrated by 367 engravings and colored plates. Cloth, $4.00 net;\\nSheep or Half Morocco, $5.00 net.\\nOne of the best text-books for students and practitioners which has been published in\\nthe English language it is condensed, clear, and comprehensive. The profound learning\\nand great clinical experience of the distinguished author find expression in this book in a\\nmost attractive and instructive form. Young practitioners to whom experienced consultants\\nmay not be available will find in this book invaluable counsel and help. Thad. A.\\nReamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio.\\nGLEASON S DISEASES OF THE EAR. Second Edition, Revised.\\nEssentials of Diseases of the Ear. By E. B. Gleason, S.B.,\\nM.D., Clinical Professor of Otology, Medico-Chirurgical College,\\nPhiladelphia Surgeon-in-Charge of the Nose, Throat, and Ear Depart-\\nment of the Northern Dispensary, Philadelphia. 20S pages, with 114\\nillustrations. Cloth, $1.00 net; interleaved for notes, $1.25 net.\\n[See Saunders Question- Compe7ids, page 23.]\\nIt is just the book to put into the hands of a student, and cannot fail to give him a\\nuseful introduction to ear-affections while the style of question and answer which is adopted\\nthroughout the book is, we believe, the best method of impressing facts permanently on the\\nmind. Liverpool Medico-Chirurgical Jotcntal.\\nGOULD AND PYLE S CURIOSITIES OF MEDICINE.\\nAnomalies and Curiosities of Medicine. By George M. Gould,\\nM.D., and Walter L. Pyle, M.D. An encyclopedic collection of\\nrare and e.xtraordinary cases and of the most striking instances of\\nabnormality in all branches of Medicine and Surgery, derived from an\\nexhaustive research of medical literature from its origin to the present\\nday, abstracted, classified, annotated, and indexed. Handsome im-\\nperial octavo volume of 968 pages, with 295 engravings in the te.xt,\\nand 12 full-page plates.\\nPOPULAR EDITION: Cloth, $3.00 net Half Morocco, $4.00 net.\\nOne of the most valuable contributions ever made to medical literature. It is, so far\\nas we know, absolutely unique, and every page is as fascinating as a novel. Not alone for\\nthe medical profession has this volume value: it will serve as a book of reference for all who\\nare -interested in general scientific, sociologic, or medico-legal topics. Brooklyn Medical\\nJournal.\\nThis is certainly a most remarkable and interesting volume. It stands alone among\\nmedical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in\\nmedical literature. It is a book full of revelations from its first to its last page, and cannot\\nbut interest and sometimes almost horrify its readers. American Medico- Surgical Bulletin.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0375.jp2"}, "376": {"fulltext": "14 Medical Publications of W. B. Saunders Co.\\nGRAFSTROM S MECHANO=THERAPY.\\nA Text=Book of Mechano=Therapy (Massage and Medical Qym=\\nnasties j. By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in\\nthe Royal Swedish Army late House Physician City Hospital, Black-\\nwell s Island, New York. i2mo, 139 pages, illustrated. Cloth, $1.00 net.\\nGRIFFITH ON THE BABY. Second Edition, Revised.\\nThe Care of the Baby. By J. P. Crozer Griffith, M.D., Clini-\\ncal Professor of Diseases of Children, University of Pennsylvania;\\nPhysician to the Children s Hospital, Philadelphia, etc. i2mo, 404\\npages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50 net.\\nThe best book for the use of the young mother with which we are acquainted.\\nThere are very few general practitioners who could not read the book through with advan-\\ntage. Archives of Pediatrics.\\nThe whole book is characterized by rare good sense, and is evidently written by a\\nmaster hand. It can be read witli benefit not only by mothers but by medical students and\\nby any practitioners who have not had large opportunities for observing children. Ameri-\\ncan Journal of Obstetrics.\\nGRIFFITH S WEIGHT CHART.\\nInfant s Weight Chart. Designed by J. P. Crozer Griffith, M.D.,\\nClinical Professor of Diseases of Children in the University of Penn-\\nsylvania, etc. 25 charts in each pad. Per pad, 50 cents net.\\nGROSS, SAMUEL D., AUTOBIOGRAPHY OF.\\nAutobiography of Samuel D. Gross, M. D., Emeritus Professor of\\nSurgery in the Jefferson Medical College, Philadelphia, with Remi-\\nniscences of His Times and Contemporaries. Edited by his Sons,\\nSamuel W. Gross, M.D., LL.D., and A. Haller Gross, A.M. Pre-\\nceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D.\\nTwo handsome volumes, over 400 pages each, demy octavo, gilt tops,\\nwith Frontispiece on steel. Price per volume, $2.50 net.\\nHAMPTON S NURSING. Second Edition, Revised and Enlarged.\\nNursing: Its Principles and Practice. By Isabel Adams Hamp-\\nton, Graduate of the New York Training School for Nurses attached\\nto Bellevue Hospital late Superintendent of Nurses and Principal of\\nthe Training School for Nurses, Johns Hopkins Hospital, Baltimore,\\nMd. 12 mo, 512 pages, illustrated. Cloth, ^2.00 net.\\nSeldom have we perused a book upon the subject that has given us so much pleasure\\nas the one before us. We would strongly urge upon the members of our own profession the\\nneed of a book like this, for it will enable each of us to become a training school in him-\\nself. Ontario Aledical Journal.\\nHARE S PHYSIOLOGY. Fourth Edition, Revised.\\nEssentials of Physiology. By H. A. Hare, M.D., Professor of\\nTherapeutics and Materia Medica in the Jefferson Medical College of\\nPhiladelphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter-\\nleaved for notes, $1.25 net.\\n[See Sauiiders Question- Compends, page 23.]\\nThe best condensation of physiological knowledge we have yet seen. Medical\\nRecord, New York.", "height": "3492", "width": "2216", "jp2-path": "rhinologylaryng00frie_0376.jp2"}, "377": {"fulltext": "Medical Publications of W. B. Saunders Co. 15\\nHART S DIET IN SICKNESS AND IN HEALTH.\\nDiet in Sickness and in Health. By Mrs. Ernest Hart, formerly\\nStudent of the Faculty of Medicine of Paris and of the London School\\nof Medicine for Women with an Introduction by Sir Henry\\nThompson, F.R.C.S., M.D., London. 220 pages. Cloth, ^1.50 net.\\nWe recommend it cordially to the attention of all practitioners both to them and to\\ntheir patients it may be of the greatest service. New Yo7-k Medical Journal.\\nHAYNES ANATOMY.\\nA Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct\\nProfessor of Anatomy and Demonstrator of Anatomy, Medical Depart-\\nment of the New York University, etc. 680 pages, illustrated with 42\\ndiagrams in the text, and 134 full-page half-tone illustrations from\\noriginal photographs of the author s dissections. Cloth, ^2.50 net.\\nThis book is the work of a practical instructor one who knows by experience the\\nrequirements of the average student, and is able to meet these i-equirements in a very satis-\\nfactory way. The book is one that can be commended. Medical Record, New York.\\nHEISLER S EMBRYOLOGY.\\nA Text=Book of Embryology. By John C. Heisler, M.D., Pro-\\nfessor of Anatomy in the Medico-Chirurgical College, Philadelphia. Oc-\\ntavo volume of 405 pages, handsomely illustrated. Cloth, ^2.50 net.\\nHIRST S OBSTETRICS. Second Edition.\\nA Text=Book of Obstetrics. By Barton Cooke Hirst, M. D.,\\nProfessor of Obstetrics in the University of Pennsylvania. Handsome\\noctavo volume of 848 pages, with 618 illustrations, and 7 colored\\nplates. Cloth, $5.00 net; Sheep or Half Morocco, ^6.00 net.\\nThe illustrations are numerous and are works of art, many of them appearing for the\\nfirst time. The arrangement of the subject-matter, the foot-notes, and index are beyond\\ncriticism. As a true model of what a modern text-book on obstetrics should be, we feel\\njustified in affirming that Dr. Hirst s book is without a rival. Neiu York Medical Record.\\nHYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL\\nDISEASES. Second Edition, Revised and Enlarged.\\nSyphilis and the Venereal Diseases. By James Nevins Hyde,\\nM. D., Professor of Skin and Venereal Diseases, and Frank H. Mont-\\ngomery, M. D., Lecturer on Dermatology and Genito-Urinary Diseases\\nin Rush Medical College, Chicago, 111. Octavo, nearly 600 pages, with\\n14 beautiful lithographic plates and numerous illustrations.\\nWe can commend this manual to the student as a help to him in his study of venereal\\ndiseases. Liverpool Medico- Chirurgical Journal.\\nThe best student s manual which has appeared on the subject. St. Louis Medical\\nand Surgical Journal.\\nINTERNATIONAL TEXT=BOOK OF SURGERY. In two volumes.\\nBy American and British authors. Edited by J. Collins Warren,\\nM.D., LL.D., Professor of Surgery, Harvard Medical School, Boston;\\nand A. Pearce Gould, M.S., F.R.C.S., Lecturer on Practical Sur-\\ngery and Teacher of Operative Surgery, Middlesex Hospital Medical\\nSchool, London, Eng. Vol. I. General Siirs^ery. Handsome octavo,\\n947 pages, with 458 beautiful illustrations and 9 lithographic plates.\\nVol. II. Special 07- Re,^ioiiaI Suri:;cry. Handsome octavo, 1072 pages,\\nwith 471 beautiful illustrations and 8 lithographic plates. Prices per\\nvolume: Cloth, $5.00 net; Half Morocco, $6.00 net.", "height": "3464", "width": "2140", "jp2-path": "rhinologylaryng00frie_0377.jp2"}, "378": {"fulltext": "16 Medical Publications of W. B. Saunders Co.\\nJACKSON S DISEASES OF THE EYE.\\nA Manual of Diseases of the Eye. By Edward Jackson, A.M.,\\nM.D., sometime Professor of Diseases of the Eye in the Philadelphia\\nPolyclinic and College for Graduates in Medicine. i2mo volume of\\n535 P^g^^j with 17S beautiful illustrations, mostly from drawings by the\\nauthor. Cloth, 5^-50 net.\\nJACKSON AND GLEASON S DISEASES OF THE EYE, NOSE, AND\\nTHROAT. Second Edition, Revised.\\nEssentials of Refraction and Diseases of the Eye. By Edward\\nJackson, A.M., M.D., Professor of Diseases of the Eye in the Phila-\\ndelphia Polyclinic and College for Graduates in Medicine; and\\nEssentials of Diseases of the Nose and Throat. By E. Bald-\\nwin Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and\\nEar Department of the Northern Dispensary of Philadelphia. Two\\nvolumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth,\\n\u00c2\u00a71.00 net; interleaved for notes, $1.25 net.\\n[See Saunders Question-Cojnpends, page 22.]\\nOf great value to the beginner in these branches. The authors are both capable men,\\nand know what a student most needs. Medical Record, New York.\\nKEATINQ S DICTIONARY. Second Edition, Revised.\\nA New Pronouncing Dictionary of Medicine, with Phonetic\\nPronunciation, Accentuation, Etymology, etc. By John M.\\nKeating, M.D., LL.D., Fellow of the College of Physicians of Phila-\\ndelphia, and Henry Hamilton with the collaboration of J. Chal-\\nmers DaCosta, M.D., and Frederick A. Packard, M.D. With an\\nAppendix contain! g Tables of Bacilli, Micrococci, Leucomaines,\\nPtomaines, etc. One volume of over 800 pages. Prices, with Ready-\\nReference Index: Cloth, $5.00 net; Sheep or Half Morocco, $6.00\\nnet. Without Patent Index Cloth, $4.00 net Sheep or Half Morocco,\\n$5.00 net.\\nI am much pleased with Keating s Dictionary, and shall take pleasure in recommend-\\ning it to my classes. Henry M. Lyman, M. D., Professor of the Principles and Practice\\nif Medicine, Rush Medical College, Chicago, III.\\nKEATING S LIFE INSURANCE.\\nHow to Examine for Life Insurance. By John M. Keating,\\nM. D., Fellow of the College of Physicians of Philadelphia; Vice-\\nPresident of the American Paediatric Society; Ex- President of the\\nAssociation of Life Insurance Medical Directors. Royal octavo, 211\\npages with two large half-tone illustrations, and a plate prepared by\\nDr. McClellan from special dissections also, numerous other illustra-\\ntions. Cloth, $2.00 net.\\nKEEN S OPERATION BLANK. Second Edition, Revised Form.\\nAn Operation Bl^nk, with Lists of Instruments, etc., Required\\nin Various Operations. Prepared by W. W. Keen, M.D., LL.D.,\\nProfessor of the Principles of Surgery in Jefferson Medical College,\\nPhiladelphia. Price per pad, blanks for fifty operations, 50 cents net.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0378.jp2"}, "379": {"fulltext": "Medical Publications of W. B. Saunders d^ Co. 17\\nKEEN ON THE SURGERY OF TYPHOID FEVER.\\nThe Surgical Complications and Sequels of Typhoid Fever.\\nBy Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur-\\ngery and of Clinical Surgery, Jefferson Medical College, Philadelphia;\\nCorresponding Member of the Soci^te de Chirurgie, Paris Honorary\\nMember of the Societe Beige de Chirurgie, etc. Octavo volume of\\n386 pages, illustrated. Cloth, $3.00 net.\\nThis is probably the first and only work in the English language that gives the reader\\na clear view of what typhoid fever really is, and what it does and can do to the human\\norganism. This book should be in the possession of every medical man in America.\\nAmerican Medico- Surgical Bulletin.\\nKYLE ON THE NOSE AND THROAT.\\nDiseases of the Nose and Throat. By D. Braden Kyle, M.D.,\\nClinical Professor of Laryngology and Rhinology, Jefferson Medical\\nCollege, Philadelphia; Consulting Laryngologist, Rhinologist, and\\nOtologist, St. Agnes Hospital. Handsome octavo volume of about\\n630 pages, with over 150 illustrations and 6 lithographic plates. Price,\\nCloth, ^4.00 net; Half Morocco, ^5.00 net.\\nLAINE S TEMPERATURE CHART.\\nTemperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 131^\\ninches. A conveniently arranged Chart for recording Temperature,\\nwith columns for daily amounts of Urinary and Fecal Excretions,\\nFood, Remarks, etc. On the back of each chart is given in full the\\nmethod of Brand in the treatment of Typhoid Fever. Price, per pad\\nof 25 charts, 50 cents net.\\nTo the busy practitioner this chart will be found of great value in fever cases, and\\nespecially for cases of typhoid. Itidian Lancet, Calcutta.\\nLEVY AND KLEMPERER S CLINICAL BACTERIOLOGY.\\nThe Elements of Clinical Bacteriology. By Dr. Ernst Levy, Profes-\\nsor in the University of Strassburg, and Ff.lix Klemperer, Privat docent\\nin the University of Strassburg. Translated and edited by Augustus\\nA. EsHNER, M.D., Professor of Clinical Medicine in the Philadelphia\\nPolyclinic. Octavo, 440 pages, fully illustrated. Cloth, $2,50 net.\\nLOCKWOOD S PRACTICE OF MEDICINE.\\nA Manual of the Practice of Medicine. By George Roe Lock-\\nWOOD, M.D., Professor of Practice in the Woman s Medical College\\nof the New York Infirmary, etc. 935 pages, with 75 illustrations in\\nthe text, and 22 full-page plates. Cloth, ^2.50 net.\\nGives in a most concise manner the points essential to treatment usually enumeratec\\nin the most elaborate works. Massachusetts Medical Journal.\\nLONG S SYLLABUS OF GYNECOLOGY.\\nA Syllabus of Gynecology, arranged in Conformity with An\\nAmerican Text=Book of Gynecology. l!y J. Long, M.D.,\\nProfessor of Diseases of Women and Children, Medical College of\\nVirginia, etc. Cloth, interleaved, $1.00 net.\\nThe book is certainly an admirable resume of what every gynecological student and\\npractitioner should know, and will prove of value not only to those who have the Americar\\nText-Book of Gynecology, but to others as well. Brooklyn Medical Journal.", "height": "3468", "width": "2036", "jp2-path": "rhinologylaryng00frie_0379.jp2"}, "380": {"fulltext": "18 Medical Publications of W. B. Saunders Co,\\nMACDONALD S SURGICAL DIAGNOSIS AND TREATMENT.\\nSurgical Diagnosis and Treatment. By J. W, Macdonald, M.D.\\nEdin., F.R.C.S., Edin., Professor of the Practice of Surgery and of\\nClinical Surgery in Hamline University Visiting Surgeon to St.\\nBarnabas Hos])ital, Minneapolis, etc. Handsome octavo volume of\\n800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco,\\n$6. CO net.\\nA thorough and complete work on surgical diagnosis and treatment, free from pad-\\nding, full of valuable material, and in accord with the surgical teaching of the day. The\\nMedical JVezvs, N ew York.\\nThe work is brimful of just the kind of practical information that is useful alike to\\nstudents and practitioners. It is a pleasure to commend the bock because of its intrinsic\\nvaluo to the medical practitioner. Cincinttati Lancet-Clinic\\nMALLORY AND WRIGHT S PATHOLOGICAL TECHNIQUE.\\nPathological Technique. A Practical Manual for Laboratory Work\\nin Pathology, Bacteriology, and Morbid Anatomy, wich chapters on\\nPost-Mortem Technique and the Performance of Autopsies. By Frank\\nB. Mallory, A.M., M.D., Assistant Professor of PatholoC y, Harvard\\nUniversity Medical School, Boston; and James K. Wrujht, A.M.,\\nM.D., Instructor in Pathology, Harvard University Medical School,\\nBoston. Octavo volume of 396 pages, handsomely illustrated. Cloth,\\n$2.50 net.\\nI have been looking forward to the publication of this book, and I am gi.Td to say that\\nI find it to be a most useful laboratory and post-mortem guide, full of practical information,\\nand w^ell up to date. William H. Welch, Professor of Pathology, fohns jlopkins Uni-\\nversity, Baltimore, Aid.\\nMARTIN S MINOR SURGERY, BANDAGING, AND VEiiNEREAL\\nDISEASES. Second Edition, Revised.\\nEssentials of Minor Surgery, Bandaging, and Venvireal\\nDiseases. By Edward Martin, A.M., M.D., Clinical Professcof\\nGenito-Urinary Diseases, University of Pennsylvania, etc. Crown\\noctavo, 166 pages, with 78 illustrations. Cloth, $1.00 net; interleaved\\nfor notes, ^1.25 net.\\n[See Saunders Question- Compends, page 23.]\\nA very practical and systematic study of the subjects, and shows the author s famil-\\niarity with the needs of students. Therapeutic Gazette.\\nMARTIN S SURGERY. Seventh Edition, Revised.\\nEssentials of Surgery. Containing also Venereal Diseases, Surgi-\\ncal Landmarks, Minor and Operative Surgery, and a complete de-\\nscription, with illustrations, of the Handkerchief and Roller Bandages.\\nBy Edward Martin, A.M., ALD., Clinical Professor of Genito-\\nUrinary Diseases, University of Pennsylvania, etc. Crown octavo, 342\\npages, illustrated. With an Appendix on the preparation of the materials\\nused in Antiseptic Surgery, etc., and a chapter on Appendicitis. Cloth,\\n$1.00 net; interleaved for notes, $1.25 net\\n\\\\?)Qe Saundefs Question- Compends, page 23.]\\nContains all necessary essentials of modern surgery in a comparatively small space.\\nIts style is interesting, and its illustrations are admirable. Medical and Surgical Reporter,", "height": "3468", "width": "2208", "jp2-path": "rhinologylaryng00frie_0380.jp2"}, "381": {"fulltext": "Medical Publications of W. B. Saunders Co. 19\\nMcFARLAND S PATHOGENIC BACTERIA. Second Edition, Re-\\nvised and Greatly Enlarged.\\nText=Book upon the Pathogenic Bacteria. By Joseph McFar-\\nLAND, M. D. Professor of Pathology and Bacteriology in the Medico-\\nChirurgical College of Philadelphia, etc. Octavo volume of 497 pages,\\nfinely illustrated. Cloth, ^2.50 net.\\nDr. McFarland has treated the subject in a systematic manner, and has succeeded in\\npresenting in a concise and readable form the essentials of bacteriology up to date. Alto-\\ngether, the book is a satisfactory one, and I shall take pleasure in recommending it to the\\nstudents of Trinity College. H. B. Anderson, M.D. Professor of Pathology and Bac-\\nteriology, Trinity Medical College, Toronto.\\nMEIGS ON FEEDING IN INFANCY.\\nFeeding in Early Infancy. By Arthur V. Meigs, M.D. Bound\\nin limp cloth, flush edges, 25 cents net.\\nThis pamphlet is worth many times over its price to the physician. The author s\\nexperiments and conclusions are original, and have been the means of doing much good.\\nMedical Btdletin.\\nMOORE S ORTHOPEDIC SURGERY.\\nA Manual of Orthopedic Surgery. By James E. Moore, M.D.,\\nProfessor of Orthopedics and Adjunct Professor of Clinical Surgery,\\nUniversity of Minnesota, College of Medicine and Surgery. Octavo\\nvolume of 356 pages, handsomely illustrated. Cloth, ^2.50 net.\\nA most attractive work. The illustrations and the care with which the book is adapted\\nto the wants of the general practitioner and the student are worthy of great praise. Chicago\\nMedical Recorder.\\nA very demonstrative work, every illustration of which conveys a lesson. The work is\\na most excellent and commendable one, which we can certainly endorse with pleasure.\\nSt. Louis Medical and Surgical Journal.\\nMORRIS S MATERIA MEDICA AND THERAPEUTICS. Fifth\\nEdition, Revised.\\nEssentials of Materia Medica, Therapeutics, and Prescription-\\nWriting. By Henry Morris, M.D., late Demonstrator of Thera-\\npeutics, Jefferson Medical College, Philadelphia; Fellow of the College\\nof Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth,\\n^i.oo net; interleaved for notes, $1.25 net.\\n[See Saunders Question- Conpends, page 22.]\\nThis work, already excellent in the old edition, has been largely improved by revi-\\nsion. American Practitioner and News.\\nMORRIS, WOLFF, AND POWELL S PRACTICE OF MEDICINE.\\nThird Edition, Revised.\\nEssentials of the Practice of Medicine. By PIenry Morris, M.D.,\\nlate Demonstrator of Thera|)eutics, Jefferson Medical College, Phila-\\ndelphia; with an Apt)endix on the Clinical and Microscopic Examina-\\n.tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry,\\nJefferson Medical College, Philadelphia. Enlarged by some 300 essen-\\ntial formulae collected and arranged by Wii liam M. Powell, M.D.\\nPost-octavo, 488 pages. Cloth, $1.50 net.\\n[See Saunders^ Question- Compends, page 22.]\\nThe teaching is sound, the presentntion graphic matter full as can be desired, ^nd\\ns .yle attractive. American Practitiontr and News.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0381.jp2"}, "382": {"fulltext": "20 Medical Publications of W. B. Saunders Co.\\nMORTEN S NURSE S DICTIONARY.\\nNurse s Dictionary of Medical Terms and Nursing Treat-\\nment. Containing Definitions of the Principal Medical and Nursing\\nTerms and Abbreviations of tlie Instruments, Drugs, Diseases, Acci-\\ndents, Treatments, Operations, Foods, Appliances, etc. encountered\\nin the ward or in the sick-room. By Honnor Morten, author of\\nHow to Become a Nurse, etc. i6mo, 140 pages. Cloth, $1.00 net.\\nA handy, compact little volume, containing a large amount of general information, all\\nof which is arranged in dictionary or encyclopedic form, thus facilitating quick reference.\\nIt is certainly of value to those for whose use it is published. Chicago Clinical Review.\\nNANCREDE S ANATOMY. Sixth Edition, Thoroughly Revised.\\nEssentials of Anatomy, including the Anatomy of the Vi.scera.\\nBy Charles B. Naxcrede, M.D., LL.D., Professor of Surgery and\\nof Clinical Surgery in the University of Michigan, Ann Arbor. Crown\\noctavo, 420 pages; 151 illustrations. Based upon Grafs Anatomy.\\nCloth, $1.00 net; interleaved for notes, $1.25 net.\\n[See Saiaiders Question- Coiipends, page 23.]\\nFor self-quizzing and keeping fresh in mind the knowledge of anatomy gained at\\nschool, it would not be easy to speak of it in terms too favorable. American Practitioner.\\nNANCREDE S ANATOMY AND DISSECTION. Fourth Edition.\\nEssentials of Anatomy and Manual of Practical Dissection.\\nBy Charles B. Nancrede, M.D., LL.D., Professor of Surgery and of\\nClinical Surgery, University of Michigan, Ann Arbor. Post-octavo\\n500 pages, with full-page lithographic plates in colors, and nearly 200\\nillustrations. Extra Cloth (or Oilcloth for dissection-room), $2.00 net.\\nIt may in many respects be considered an epitome of Gray s popular work on general\\nanatomy, at the same time having some distinguishing characteristics ot its own to commend\\nu The plates are of more than ordinary excellence, and are of especial value to students\\nin their work in the dissecting room. Joti) nnt of the American Medical Asiociation.\\nNANCREDE S PRINCIPLES OF SURGERY.\\nLectures on the Principles of Surgery. V Chas. B. Nancrede,\\nALD LL.D., Professor of Surgerv and of Clinical Surgery, Univer-\\nsity of Michigan. Ann Arbor. Octavo volume of 398 pages, illustrated.\\nCloth, $2.50 net.\\nNORRIS S SYLLABUS OF OBSTETRICS. Third Edition, Revised.\\nSyllabus of Obstetrical Lectures in the Medical Department\\nof the University of Pennsylvania. By Richard C. Norkis,\\nA.M., ]\\\\LD., Demonstrator of Obstetiics, University of Penns}lvania.\\nCrown octavo, 222 pages. Cloth, interleaved for notes, $2.00 net.\\nPENROSE S DISEASES OF WOMEN. Third Edition, Revised.\\nA Text=Book of Diseases of Women. By Charles B. Penrose,\\ni\\\\LD., Ph.D., Formerly Professor of Gynecology in the University\\nof Pennsylvania; Surgeon to the Gynecean Hospital, Philadelphia.\\nOctavo volume of 531 pages, handsomely illustrated. Cloth, $3.75 net.\\nT shall value very highly the copy of Penrose s Diseases of Women received.\\nI have already recommended it to my class as THE BEST book. Howard A. Kelly.\\nProfessor of Gynecology and Obstetrics, Johns Hopkins University, Baltimore, Md.", "height": "3468", "width": "2200", "jp2-path": "rhinologylaryng00frie_0382.jp2"}, "383": {"fulltext": "Medical Publications of W. B. Saunders Co. 21\\nPOWELL S DISEASES OF CHILDREN. Second Edition.\\nEssentials of Diseases of Children. By William M. Powell,\\nM.D., Attending Physician to the Mercer House for Invalid Women\\nat Atlantic City, N. J. late Physician to the Clinic for the Diseases of\\nChildren in the Hospital of the University of Pennsylvania. Crown\\noctavo, 222 pages. Cloth, |i.oonet; interleaved for notes, ^1.25 net.\\n[See Saunders Question- Coinpends, page 21.]\\nContains the gist of all the best works in the department to which it relates.\\nAmet-icajt Practitioner and Ah-ws.\\nPRINQLE S SKIN DISEASES AND SYPHILITIC AFFECTIONS.\\nPictorial Atlas of Skin Diseases and Syphilitic Affections\\n(American Edition). Translation from the French. Edited by\\nJ. J. Pringle, M.B., F.R.C.P., Assistant Physician to the Middlesex\\nHospital, London. Photo-lithochromes from the famous models in\\nthe Museum of the Saint-Louis Hospital, Paris, with explanatory wood-\\ncuts and text. In 12 Parts. Price per Part, $3.00. Complete in\\none volume, Half Morocco binding, ^40.00 net.\\nI strongly recommend this Atlas. The plates are exceedingly well executed, and\\ntvill be of great value to all studying dermatology. Stephen Mackenzie, M.D.\\nThe introduction of explanatory wood-cuts in the text is a novel and most important\\nfeature which greatly furthers the easier understanding of the excellent plates, than which\\nnothing, we venture to say, has been seen better in point of correctness, beauty, and general\\nmerit. New York Medical Journal.\\nPRYOR\u00e2\u0080\u0094 PELVIC INFLAMMATIONS.\\nThe Treatment of Pelvic Inflammations through the Vagina.\\nBy W. R. Pryor, M.D., Professor of Gynecology in New York Poly-\\nclinic. i2mo, 248 pages, handsomely illustrated. Cloth, ^2.00 net.\\nThis subject, which has recently been so thoroughly canvassed in high gynecological\\ncircles, is made available in this volume to the general practitioner and student. Nothing is\\ntoo minute for mention and nothing is taken for granted consequently the book is of the utmost\\nvalue. The illustrations and the technique are beyond criticism. \u00e2\u0096\u00a0Chicago Alcdical Recorder.\\nPYE S BANDAGING.\\nElementary Bandaging and Surgical Dressing. With Direc-\\ntions concerning the Immediate Treatment of Cases of Emergency.\\nFor the use of Dressers and Nurses. By Walter Pye, F.R.C.S., late\\nSurgeon to St. Mary s Hospital, London. Small 121110, with over 80\\nillustrations. Cloth, flexible covers, 75 cents net.\\nThe directions are clear and the illustrations are good. London Lancet.\\nThe author writes well, the diagrams are clear, and the book itself is small and port-\\nable, although the paper and type are good. British Medical Journal.\\nRAYMOND S PHYSIOLOGY.\\nA Manual of Physiology. By Joseph H. Raymond, A.M., M.D.,\\nProfessor of Physiology and Hygiene and Lecturer on Gynecology in\\nthe Long Island College Plospital Director of Physiology in the\\nHoagland Laboratory, etc. 382 pages, with 102 illustrations in the\\ntext, and 4 full-page colored plates. Cloth, $1.25 net.\\nExtremely well gotten up, and the illustrations have been selected with care. The\\ntext is fully abreast with modern physiology. British Medical Journal.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0383.jp2"}, "384": {"fulltext": "Saunders^ Question and\\nAnswer Form,\\nV^ U liO 1 IVjiN ^\u00e2\u0084\u00a2g jy[Q3 j. COMPLETE AND BEST\\n(^/^TiTT-r^T^-KTriQ ILLUSTRATED SERIES OF\\nV-^V^lVii liiNiJO COMPENDS EVER ISSUED.\\nNow the Standard Authorities in Medical Literature\\nwith Students and Practitioners in every City of the United States and Canada.\\nOVER 175,000 COPIES SOLD.\\nTHE REASON WHY.\\nThey are the advance guard of Student s Helps that do help. They are the\\nleaders in their special line, well and authoritatively written by able men, who, as teachers in\\nthe large colleges, know exactly what is wanted by a student preparing for his examinations.\\nThe judgment exercised in the selection of authors is fully demonstrated by their professional\\nstanding. Chosen from the ranks of Demonstrators, Quiz-masters, and Assistants, most of\\nthem have become Professors and Lecturers in their respective colleges.\\nEach book is of convenient size (5x7 inches) containing on an average 250 pages,\\nprofusely illustrated, and elegantly printed in clear, readable type, on fine paper.\\nThe entire series, numbering twenty-three volumes, has been kept thoroughly revised\\nand enlarged when necessary, many of the books being in their fifth and sixth editions.\\nTO SUM UP.\\nAlthough there are numerous other Quizzes, Manuals, Aids, etc. in the market, none of\\nthem approach the Blue Series of Question Compends; and the claim is made for the\\nfollowing points of excellence\\n1. Professional distinction and reputation of authors.\\n2. Conciseness, clearness, and soundness of treatment.\\n3. Quality of illustrations, paper, printing, and binding.\\nAny of these Compends will be mailed on receipt of price (see next page for List).", "height": "3492", "width": "2296", "jp2-path": "rhinologylaryng00frie_0384.jp2"}, "385": {"fulltext": "Saunders^ Question-Compend Series*\\nPrice, Cloth, $1.00 net per copy, except when otherwise ordered.\\nWhere the work of preparing students manuals is to end we cannot say, but the\\nSaunders Series, in our opinion, bears off the palm at present. yVfiw York Medical Record.\\n1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition,\\nrevised and enlarged.\\n2. ESSENTIALS OF SURGERY. By Edward Martin, xM- D. Seventh edition,\\nrevised, with an Appendix and a chapter on Appendicitis.\\n3. ESSENTIALS OF ANATOMY. By Chari.es B. Nancrede, M.D. Sixth\\nedition, thoroughly revised and enlarged.\\n4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC.\\nBy Lawrence Wolff, M.D. Fifth edition, revised.\\n5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth\\nedition, revised and enlarged.\\n6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E.\\nArmand Semple, M.D.\\n7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE-\\nSCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised.\\n8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris,\\nM.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D.\\nThird edition, enlarged by some 300 Essential Formulse, selected from eminent\\nauthorities, by Wm. M. Powell, M.D. (Double number, ^1.50 net.)\\n10. ESSENTIALS OF QYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth\\nedition, revised.\\n11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon,\\nM.D. Fourth edition, revised and enlarged.\\n12. ESSENTIALS OF MINOR SURGERY, BANDAGJNG, AND VENEREAL\\nDISEASES. By Edward Martin, M.D. Second ed., revised and enlarged.\\n13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.\\nBy C. E. Armand Semple, M.D.\\n14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT.\\nBy Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised.\\n15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell,\\nM.D. Second edition.\\n16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff,\\nM.D. Colored Vogel Scale. (75 cents net.)\\n17. ESSENTIALS OF DIAGNOSIS. By S. Solis Cohen, M.D., and A. A. Eshner,\\nM.D. Second editiijn, thoroughly revised.\\n18. ESSENTIALS OF PRACTICE OF PHARMACY. By Lucius E. Sayre.\\nSecond edition, revised and enlarged.\\n20. ESSENTIALS OF BACTERIOLOGY. By M. V. Ball, M.D. Third edition,\\nrevised.\\n21. ESSENTIALS OF NERVOUS DISEASES AND INSANITY. By John C.\\nShaw, M.D. Third edition, revised.\\n22. ESSENTIALS OF MEDICAL PHYSICS. By Fred J. Brockway, M.D.\\nSecond edition, revised.\\n23. ESSENTIALS OF MEDICAL ELECTRICITY. By David D. Stewart, M.D.,\\nand LlAVARD S. LAWRANf:K, M.D.\\n24. ESSENTIALS OF DISEASES OF THE EAR. By E. B. Gleason, M.D.\\nSecond edition, revised and greatly enlarged.\\nPamphlet containing specimen pages, etc. sent free upon application.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0385.jp2"}, "386": {"fulltext": "s\\naunders re...\\ntor otudents\\nNew Series and\\nof Manuals Practitioners.\\nI ^HAT there exists a need for thoroughly reliable hand-books on the leading branches\\nof Medicine and Surgery is a fact amply demonstrated by the favor with which\\nthe SAUNDERS NEW SERIES OF MANUALS have been received by medical\\nstudents and practitioners and by the Medical Press, These manuals are not merely\\ncondensations from present literature, but are ably w^ritten by w^ell-fcnown authors\\nand practitioners, most of them being teachers in representative American colleges.\\nEach volume is concisely and authoritatively written and exhaustive in detail, without\\nbeing encumbered with the introduction of cases, which so largely expand the\\nordinary text-book. These manuals will therefore form an admirable collection of\\nadvanced lectures, useful alike to the medical student and the practitioner: to the\\nlatter, too busy to search through page after page of elaborate treatises for what he\\nwants to know^, they will prove of inestimable value to the former they will afford\\nsafe guides to the essential points of study.\\nThe SAUNDERS NEW SERIES OF MANUALS are conceded to be superior\\nto any similar books now on the market. No other manuals afford so much infor-\\nmation in such a concise and available form. A liberal expenditure has enabled the\\npublisher to render the mechanical portion of the w^ork worthy of the high literary\\nstandard attained by these books.\\nAny of these Manuals will be mailed on receipt of price (see next page for List).", "height": "3468", "width": "2280", "jp2-path": "rhinologylaryng00frie_0386.jp2"}, "387": {"fulltext": "Saunders^ New Series of JVlanuals.\\nVOLUMES PUBLISHED.\\nPHYSIOLOGY. By Joseph Howard Raymond, A.M., M.D., Professor of Physiology\\nand Hygiene and Lecturer on Gynecology in the Long Island College Hospital\\nDirector of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, ^i. 25 neu\\nSURGERY, General and Operative.\u00e2\u0080\u0094 By John Chalmers DaCosta, M. D., Pro-\\nfessor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel-\\nphia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised\\nand greatly enlarged. Octavo, 911 pages, profusely illustrated. Cloth, ^4.00 net;\\nHalf Morocco, I5.00 net.\\nDOSE=BOOK AND MANUAL OF PRESCR1PTI0N=WR1TINQ. By E. Q.\\nThornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila-\\ndelphia. Illustrated. Cloth, \u00c2\u00a71.25 net.\\nSURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark s Hospital and\\nto the New York German Poliklinik, etc. Illustrated. Cloth, ^1.25 net.\\nMEDICAL JURISPRUDENCE. By Henry C. Chapman, M.D. Professor of Insti-\\ntutes of Medicine and Medical Jurisprudence in the Jefferson Medical College of Phila-\\ndelphia. Illustrated. Cloth, ^1.50 net.\\nSYPHILIS AND THE VENEREAL DISEASES. By James Nevins Hyde, M.D.,\\nProfessor of Skin and Venereal Diseases, and Frank H. Montgomery, M.D.,\\nLecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College,,\\nChicago. Second edition, thoroughly revised and greatly enlarged.\\nPRACTICE OF MEDICINE. By George Roe Lockwood, M.D., Professor of\\nPractice in the Woman s Medical College of the New York Infirmary; Instructor in\\nPhysical Diagnosis in the Medical Department of Columbia College, etc. Illustrated.\\nCloth, ^2.50 net.\\nMANUAL OF ANATOMY. By Irving S. Haynes, M.D., Adjunct Professor of\\nAnatomy and Demonstrator of Anatomy, Medical Department of the Ne v YorK\\nUniversity, etc. Beautifully illustrated. Cloth, ^2.50 net.\\nMANUAL OF OBSTETRICS. By W. A. Newman Dorland, M.D., Assistant\\nDemonstrator of Obstetrics, University of Pennsylvania Chief of Gynecological Dis-\\npensary, Pennsylvania Hospital, etc. Profusely illustrated. Cloth, ^2.50 net.\\nDISEASES OF WOMEN. By J. Bland Sutton, F. R. C. S., Assistant Surgeon to\\nMiddlesex Hospital and Surgeon to Chelsea Hospital, London; and Arthur E.\\nGiles, M.D., B. Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital,\\nLondon. Flandsomely illustrated. Cloth, ;^2.50 net.\\nVOLUMES IN PREPARATION.\\nNERVOUS DISEASES. By Charles W. Burr, M.D., Clinical Professor of Nervous\\nDiseases, Medico-Chirurgical College, Philadelphia Pathologist to the Orthopredic\\nHospital and Infirmary for Nervous Diseases; Visiting Physician to the St. Joseph\\nHospital, etc.\\nThere will be published in the same series, at short intervals, carefully-prepared workf\\non various subjects by prominent specialists.\\nPamphlet containing specimen pages, etc. sent free upon application.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0387.jp2"}, "388": {"fulltext": "2S Medical Publications of W. B. Saunders iSr Co.\\nSAUNDBY S RENAL AND URINARY DISEASES.\\nLectures on Renal and Urinary Diseases. By Robert Saundby,\\nM.D. Edin., Fellow of the Royal College of Physicians, London, and\\nof the Royal Medico-Chirurgical Society Physician to the General\\nHospital Consulting Physician to the Eye Hospitax and to the Hos-\\npital for Diseases of Women; Professor of Medicine in Mason College,\\nBirmingham, etc. Octavo volume of 434 pages, with numerous illus-\\ntrations and 4 colored plates. Cloth, $2.50 net.\\nThe volume makes a favorable impression at once. The style is clear and succinct.\\nWe cannot find any part of the subject in which the views expressed are not carefully thought\\nout and fortified by evidence drawn from the most recent sources. The book may be cordially\\nrecommended. British ^ledical Journal,\\n5AUNDERS MEDICAL HAND=ATLA5ES.\\nFor full description of this series, with list of volumes and prices, see\\npage 2.\\nLehmann Medicinische Handatlanten belong lo that class of books that are too good\\nto be appropriated by any one nation. yournal of Eye, Ear, and Throat Diseases.\\nThe appearance of these works marks a new era in illustrated English medical\\nworks. The CaJiadian Practitioner.\\nSAUNDERS POCKET MEDICAL FORMULARY. Sixtli Edition,\\nRevised.\\nBy William M. Powell, M.D., Attending Physician to the Mercer\\nHouse for Invalid Women at Atlantic City, N. J. Containing 1800\\nformulae selected from the best-known authorities. With an Appen-\\ndix containing Posological Table, Formulae and Doses for Hypo-\\ndermic Medication, Poisons and their Antidotes, Diameters of the\\nFemale Pelvis and Foetal Head, Obstetrical Table, Diet List for Various\\nDiseases, Materials and Drugs used in Antiseptic Surgery, Treatment\\nof Asphyxia from Drowning, Surgical Remembrancer, Tables of\\nIncompatibles, Eruptive Fevers, Weights and Measures, etc. Hand-\\nsomely bound in flexible morocco, with side index, wallet, and flap.\\n^1.75 net.\\nThis little book, that can be conveniently carried in the pocket, contains an immense\\namount of material. It is ver\\\\- useful, and, as the name of the author of each prescription\\nis given, is unusually reliable. Medical Record, New York.\\nSAYRE S PHARMACY. Second Edition, Revised.\\nEssentials of the Practice of Pharmacy. By Lucius E. Sayre,\\nM.D., Professor of Pharmacy and Materia Medica in the University of\\nKansas. Crown octavo, 200 pages. Cloth, $1.00 net; interleavef for\\nnotes, ^1.25 net.\\n[See Saunders Question- CoJiipends, page 21.]\\nThe topics are treated in a simple, practical manner, and the work forms a very usefuj\\nStudent s manual. Boston Medical and Surgical Journal.\\nSCUDDER S FRACTURES.\\nThe Treatment of Fractures. By Chas. L. Scudder, M.D., As-\\nsistant in Clinical and Operative Surgery, Harvard Medical School.\\nOctavo, 433 pages, with nearly 600 original illustrations. Cloth, \u00c2\u00a74.50", "height": "3468", "width": "2216", "jp2-path": "rhinologylaryng00frie_0388.jp2"}, "389": {"fulltext": "Medical Publications of W. B. Saunders Co. 11\\nSEMPLE S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE.\\nEssentials of Legal Medicine, Toxicology, and Hygiene. By\\nC. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond.,\\nPhysician to the Northeastern Hospital for Children, Hackney, etc.\\nCrown octavo, 212 pages; 130 illustrations. Cloth, $1.00 net; inter-\\nleaved for notes, $1.25 net.\\n[See Saimders Question- Compends, page 21.]\\nNo general practitioner or student can afford to be without this valuable work. The\\nsubjects are dealt with by a masterly hand. London Hospital Gazette.\\nSEMPLE S PATHOLOGY AND MORBID ANATOMY.\\nEssentials of Pathology and Morbid Anatomy. By C. E.\\nArmand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to\\nthe Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174\\npages; illustrated. Cloth, $1.00 net; interleaved for notes, $1.25 n-t.\\n[See Saunders Question- Cojnpends, page 21.]\\nShould take its place among the standard volumes on the bookshelf of both student\\nand practitioner. Lotidon Hospital Gazette.\\nSENN S GENITO=URINARY TUBERCULOSIS.\\nTuberculosis of the Genito=Urinary Organs, Male and Femaleo\\nBy Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of\\nSurgery and of Clinical Surgery, Rush Medical College, Chicago.\\nHandsome octavo volume of 320 pages, illustrated. Cloth, ^3.00 net.\\nAn important book upon an important subject, and written by a man of mature judg-\\nment and wide experience. The author has given us an instructive book upon one of the\\nmost important subjects of the day. Clinical Reporter.\\nA work which adds another to the many obligations the profession owes the talented\\nauthor. Chicago Medical Recorder.\\nSENN S SYLLABUS OF SURGERY.\\nA Syllabus of Lectures on the Practice of Surgery, arranged\\nin conformity with An American Text=Book of Surgery. By\\nNicholas Seen, M. D., Ph.D., Professor of the Practice of Surgery and\\nof Clinical Surgery, Rush Medical College, Chicago. Cloth, ^1.50 net.\\nThis syllabus will be found of service by the teacher as well as the student, the work\\nbeing superbly done. There is no praise too high for it. No surgeon should be without\\nit. New York Medical Times.\\nSENN S TUMORS. Second Edition, Revised.\\nPathology and Surgical Treatment of Tumors. By N. Senn,\\nM.D, Ph.D., LL.D., Professor of Surgery and of Clinical Surgery,\\nRush Medical College Professor of Surgery, Chicago Polyclinic\\nAttending Surgeon to Presbyterian Hospital Surgeon-in-Chief, St.\\nJoseph s Hospital, Chicago. Second Edition, T]ioroui:;hly Revised. Oc-\\ntavo volume of 718 pages, with 478 illustrations, including 12 full-page\\nplates in colors. Prices: Cloth, ^5.00 net; Half Morocco, ;$6.oo net.\\nThe most exhaustive of any recent book in Engiish on this subject. It is well illus-\\ntrated, and will doubtless remain as the principal monograph on the subject in our language\\nfor some years. The book is handsomely illustrated and printed, and the author has given a\\nnotable and lasting contribution to surgery. Jourtial of the At)(erica7i Medical Association.", "height": "3468", "width": "2120", "jp2-path": "rhinologylaryng00frie_0389.jp2"}, "390": {"fulltext": "28 Medical Publications of W. B. Saunders Co.\\nSHAW S NERVOUS DISEASES AND INSANITY. Third Edition,\\nRevised.\\nEssentials of Nervous Diseases and Insanity. By John C.\\nShaw. M.D., Clinical Professor of Diseases of the Mind and Nervous\\nSystem, Long Island College Hospital Medical School Consulting\\nNeurologist to St. Catherine s Hospital and to the Long Island College\\nHospital. Crown octavo, i86 pages; 48 original illustrations. Cloth,\\n$1.00 net; interleaved for notes, $1.25 net.\\n[See Saunders Questioii-Coinpends, page 21.]\\nClearly and intelligently written. Boston Medical and Surgical Journal.\\nThere is a mass of valuable material crowded into this small compass. American\\nMedico-Surgical Bulletin.\\nSTARR S DIETS FOR INFANTS AND CHILDREN.\\nDiets for Infants and Children in Health and in Disease. By\\nLouis Starr, M.D., Editor of An American Text-Book of the\\nDiseases of Children. 230 blanks (pocket-book size), perforated\\nand neatly bound in flexible morocco. \u00c2\u00a71.25 net.\\nThe first series of blanks are prepared for the first seven months of infant life each\\nMank indicates the ingredients, but not the quantities, of the food, the latter directions being\\nleft for the physician. After the seventh month, modifications being less necessary, the diet\\nlists are printed in full. Formulae for the preparation of diluents and foods are appended.\\nSTELWAGON S DISEASES OF THE SKIN. Fourth Ed., Revised.\\nEssentials of Diseases of the Skin. By Henry W. Stelwagon,\\nM.D., Clinical Professor of Dermatology in the Jefferson Medical\\nCollege, Philadelphia Dermatologist to the Philadelphia Hospital\\nPhysician to the Skin Department of the Howard Hospital, etc.\\nCrown octavo, 276 pages; 88 illustrations. Cloth, $1.00 net; inter-\\nleaved for notes, $1.25 net.\\n[See Saunders Question- Compends, page 21.]\\nThe best student s manual on skin diseases we have yet seen. Times and Register.\\nSTENGEL S PATHOLOGY. Second Edition.\\nA Text=Book of Pathology. By Alfred Stengel, M.D., Professor\\nof Clinical Medicine in the University of Pennsylvania Physician to\\nthe Philadelphia Hospital Physician to the Children s Hospital, etc.\\nHandsome octavo volume of 848 pages, with nearly 400 illustrations,\\nmany of them in colors. Cloth, $4.00 net; Half Morocco, $5.00\\nnet.\\nSTEVENS MATERIA MEDICA AND THERAPEUTICS. Second\\nEdition, Revised.\\nA Manual of Materia Medica and Therapeutics. By A. A.\\nStevens, A.M., IM.D., Lecturer on Terminology and Instructor in\\nPhysical Diagnosis in the LTniversity of Pennsylvania Professor of\\nPathology in the Woman s Medical College of Pennsylvania. Post-\\noctavo, 445 pages. Flexible leather, \u00c2\u00a72.00 net.\\n\u00e2\u0080\u00a2The author has faithfully presented modern therapeutics in a comprehensive work,\\nand, while intended particularly for the use of students, it will be found a reliable guide and\\nsufficiently comprehensive for the physician in practice. University Medical Magazine.", "height": "3468", "width": "2184", "jp2-path": "rhinologylaryng00frie_0390.jp2"}, "391": {"fulltext": "Medical Publications of W. B. Saunders Co. 29\\n5TEVEN5 PRACTICE OF MEDICINE. Fifth Edition, Revised.\\nA Manual of the Practice of Medicine. By A. A. Stevens, A. M.,\\nM. D., Lecturer on Terminology and Instructor in Physical Diagnosis\\nin the University of Pennsylvania Professor of Pathology in the\\nWoman s Medical College of Pennsylvania. Specially intended for\\nstudents preparing for graduation and hospital examinations. Post-\\noctavo, 519 pages; illustrated. Flexible leather, ^2.00 net.\\nThe frequency with which new editions of this manual are demanded bespeaks its\\npopularity. It is an excellent condensation of the essentials of medical practice for the\\nstudent, and maybe found also an excellent reminder for the busy physician. Buffalo\\nMedical Journal.\\nSTEWART S PHYSIOLOGY. Third Edition, Revised.\\nA Manual of Physiology, with Practical Exercises. For\\nStudents and Practitioners. By G. N. Stewart, M.A., M.D.,\\nD.Sc, lately Examiner in Physiology, University of Aberdeen, and\\nof the New Museums, Cambridge University Professor of Physiology\\nin the Western Reserve University, Cleveland, Ohio. Octavo volume\\nof 848 pages 300 illustrations in the text, and 5 colored plates.\\nCloth, ^3.75 net.\\nIt will mate its way by sheer force of merit, and amply deserves to do so. It is one\\nof the very best English tesct-books on the subject. London Lancet.\\nOf the many text-books of physiology published, we do not know of one that so\\nnearly comes up to the ideal as does Prof Stewart s volume. British Medical Journal.\\nSTEWART AND LAWRANCE S MEDICAL ELECTRICITY.\\nEssentials of Medical Electricity. By D. D. Stewart, M.D.,\\nDemonstrator of Diseases of the Nervous System and Chief of the\\nNeurological Clinic in the Jefferson Medical College; and E. S.\\nLawrance, M.D., Chief of the Electrical Clinic and Assistant Demon-\\nstrator of Diseases of the Nervous System in the Jefferson Medical\\nCollege, etc. Crown octavo, 158 pages; 65 illustrations. Cloth,\\n^i.oo net; interleaved for notes, $1.25 net.\\n[See Saunders Question- Compends, page 21.]\\nThroughout the whole brief space at their command the authors show a discriminating\\nknowledge of their subject. Medical News.\\nSTONEY S NURSING. Second Edition, Revised.\\nPractical Points in Nursing. For Nurses in Private Practice.\\nBy Emily A. M. Stoney, Graduate of the Training-School for Nurses,\\nLawrence, Mass.; late Superintendent of the Training-School for\\nNurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated\\nwith 73 engravings in the text, and 8 colored and half-tone plates.\\nCloth, $1.75 net.\\nThere are few books intended for non-professional readers which can be so cordially\\nendorsed by a medical journal as can this one. Therapeutic Gazette.\\nThis is a well-written, eminently practical volume, which covers the entire range of\\nprivate nursing as distinguished from hospital nursing, and instructs the nurse how best to\\nmeet the various emergencies which may arise, and how to prepare everything ordinarily\\nneeded in the illness of her patient. .4! ierican Journal of Obstetrics and Diseases of\\nIVowen and Childreti.\\nIt is a work that the physician can place in the hands of his private nurses with the\\nassurance of benefit. Ohio Medical Journal.", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0391.jp2"}, "392": {"fulltext": "30 Medical Publications of W. B. Saunders Co.\\nSTONEY S MATERIA MEDICA FOR NURSES.\\nMateria Medica for Nurses. Ey Emily A. M. Stoney, Graduate of\\nthe Training-School for Nurses, Lawrence, Mass. late Superintendent\\nof the Training-School for Nurses, Carney Hospital, South Boston, Mass.\\nHandsome octavo volume of 306 pages. Cloth, $1.50 net.\\nThe present book differs from other similar works in several features, all of which are\\nintended to render it more practical and generally useful. The general plan of the contents\\njollows the lines laid down in training-schools for nurses, but the book contains much use-\\nful matter not usually included in works of this character, such as Poison-emergencies,\\nReady Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms\\nused in Materia Medica, and describing all the latest drugs and remedies, which have been\\ngenerally neglected by other books of the kind.\\nSUTTON AND GILES DISEASES OF WOMEN.\\nDiseases of Women. By J. Bland Sutton, F.R.C.S., Assistant\\nSurgeon to Middlesex- Hospital, and Surgeon to Chelsea Hospital,\\nLondon; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin.,\\nAssistant Surgeon to Chelsea Hospital, London. 436 pages, hand-\\nsomely illustrated. Cloth, $2.50 net.\\nThe text has been carefully prepared. Nothing essential has been omitted, and its\\nteachings are those recommended by the leading authorities of the day. Journal of the\\nAmerican Medical Association.\\nTHOMAS S DIET LISTS. Second Edition, Revised.\\nDiet Lists and Sick=Room Dietary. By Jerome B. Thomas,\\nM.D., Visiting Physician to the Home for Friendless Women and\\nChildren and to the Newsboys Home Assistant Visiting Physician to\\nthe Kings County Hospital. Cloth, $1.25 net. Send for sample sheet.\\nTHORNTON S DOSE=BOOK AND PRESCRIPTION=WRITINQ.\\nDose=Book and Manual of Prescription=Writing. By E. Q.\\nThornton, M.D., Demonstrator of Therapeutics, Jefferson Medical\\nCollege, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net.\\nFull of practical suggestions; will take its place in the front rank of works of this\\nsort. Medical Record, New ork.\\nVAN VALZAH AND NISBET S DISEASES OF THE STOMACH.\\nDiseases of the Stomach. By William W. Van Valzah, M.D.,.\\nProfessor of General Medicine and Diseases of the Digestive System\\nand the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D.,\\nAdjunct Professor of General Medicine and Diseases of the Digestive\\nSystem and the Blood, New York Polyclinic. Octavo volume of 674\\npages, illustrated. Cloth, $3.50 net.\\nIts chief claim lies in its clearness and general adaptability to the practical needs of\\nthe general practitioner or student. In these relations it is probably the best of the recent\\nspecial works on diseases of the stomach. Chicago Clinical Review.\\nVECKi S SEXUAL UMPOTENCE.\\nThe Pathology and Treatment of Sexual Impotence. By Victor\\nG. Vecki, M D. From the second German edition, revised and en-\\nlarged. Demi-octavo, 291 pages. Cloth, $2.00 net.\\nThe subject of impotence has seldom been treated in this country in the truly scientific\\nsr- Ht that it deserves. Dr. Vecki s work has long been favorably known, and the German\\ntx)ok has received the highest consideration. This edition is more than a mere translation,\\nk)r, although based on the German edition, it has been entirely rewritten in English.", "height": "3492", "width": "2216", "jp2-path": "rhinologylaryng00frie_0392.jp2"}, "393": {"fulltext": "3Iedical Piihlications of W. B. Saunders Co. 31\\nV^IERORDT S MEDICAL DIAGNOSIS. Fourth Edition, Revised.\\nMedical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi-\\ncine at the University of Heidelberg. Translated, with additions,\\nfrom the fifth enlarged German edition, with the author s permission,\\nby Francis H. Stuart, A. M., M. D. Handsome royal octavo volume\\nof 603 pages; 194 fine wood-cuts in text, many of them in colors.\\nCloth, ^4.00 net; Sheep or Half Morocco, $5.00 net.\\nRarely is a book published with which a reviewer can find so little fault as with the\\nvolume before us. Each particular item in the consideration of an organ or apparatus, which\\nis necessary to determine a diagnosis of any disease of that organ, is mentioned nothing\\nseems forgotten. The chapters on diseases of the circulatory and digestive apparatus and\\nnervous system are especially full and valuable. The reviewer would repeat that the book is\\none of the best probably tAe best which has fallen into his hands. University Medicai\\nWATSON S HANDBOOK FOR NURSES.\\nA Handbook for Nurses. By J. K. Watson, M.D., Edin. Ameri-\\ncan Edition, under supervision of A. A. Stevens, A.M., M.D., Lecturer\\non Physical Diagnosis, University of Pennsylvania. i2mo, 413 pages,\\n73 illustrations. Cloth, ^1.50 net.\\nWARREN S SURGICAL PATHOLOGY. Second Edition.\\nSurgical Pathology and Therapeutics. By John Collins Warren,\\nM.D., LL.D., Professor of Surgery, Harvard Medical School. Hand-\\nsome octavo, 832 pages 136 relief and lithographic illustrations, 2)Z i^\\ncolors with an Appendix on Scientific Aids to Surgical Diagnosis, and\\na series of articles on Regional Bacteriology. Cloth, $5.00 net; Half\\nMorocco, ^6.00 net.\\nA most striking and very excellent feature of this book is its illustrations. Without\\nexception, from the point of accuracy and artistic merit, they are the best ever seen in a work\\nof this kind. Many of those representing microscopic pictures are so perfect in their coloring\\nand detail as almost to give the beholder the impression that he is looking down the barrel\\nof a microscope at a well-mounted section. Annals of Surgery.\\nWOLFF ON EXAMINATION OF URINE.\\nEssentials of Examination of Urine. By Lawrence Wolff, M.D.,\\nDemonstrator of Chemistry, Jefferson Medical College, Philadelphia\\netc. Colored (Vogel) urine scale and numerous illustrations. Crown\\noctavo. Cloth, 75 cents net.\\n[See Saunders Question- Compends, page 21.]\\nA very good work of its kind\u00e2\u0080\u0094 very well suited to its purpose. 7z w\u00c2\u00ab and Register.\\nWOLFF S MEDICAL CHEMISTRY. Fifth Edition, Revised.\\nEssentials of Medical Chemistry, Organic and Inorganic.\\nContaining also Questions on Medical Physics, Chemical Physiology,\\nAnalytical Processes, Urinalysis, and Toxicology. By Lawrence\\nWolff, M.D., Demonstrator of Chemistry, Jefferson Medical College,\\nPhiladelphia, etc. Crown octavo, 222 pages. Cloth, ^i.oo net; inter-\\nleaved for notes, gi.25 net.\\n[See Saunders Question- Co7npcnds, page 21.]\\nThe scope of this work is certainly equal to that of the best course of lectures on\\nMedical Chemistiy. Fhannaceutical Era.", "height": "3456", "width": "2192", "jp2-path": "rhinologylaryng00frie_0393.jp2"}, "394": {"fulltext": "CLASSIFIED LIST\\nOF THE\\nMedical Publications\\nOF\\nW. B. SAUNDERS COMPANY,\\n925 Walnut Street, Philadelphia.\\nANATOMY, EMBRYOLOGY,\\nHISTOLOGY.\\nClarkson A Text-Book of Histology, 1 1\\nHaynes A Manual of Anatomy, 15\\nHeisler A Text- Book of Embryology, 15\\nNancrede Essentials of Anatomy, 20\\nNancrede Essentials of Anatomy and\\nManual of Practical Dissection, 20\\nSample Essentials of Pathology, 27\\nBACTERIOLOGY.\\nBall Essentials of Bacteriology, 8\\nCrookshank A Text-Book of Bacteri-\\nology, 12\\nFrothingham Laboratory Guide, 13\\nLevy and Klemperer s Clinical Bacte-\\nric^l ^gy. 17\\nMallory and Wright Pathological\\nTechnique, 18\\nMcFarland Pathogenic Bacteria, ig\\nCHARTS, DIET-LISTS, ETC.\\nGriffith\u00e2\u0080\u0094 Infant s Weight Chart, 14\\nHart Diet in Sickness and in Health, 15\\nKeen Operation Blank, 17\\nLaine Temperature Chart. -17\\nMeigs Feeding in Early Infancy, 19\\nStarr Diets for Infants and Children, 28\\nThomas Diet-Lists 30\\nCHEMISTRY AND PHYSICS.\\nBrockway Essentials of Medical Phys-\\nics, 9\\nWolff Essentials of Medical Chemistry, 31\\nCHILDREN.\\nAn American Text-Book of Diseases\\nof Children, 5\\nGriffith Care of the Baby 14\\nGriffith Infant s Weight Chart, 14\\nMeigs Feeding in Early Infancy, 19\\nPowell Essentials of Dis. of Children, 21\\nStarr Diets for Infants and Children, 26\\nDIAGNOSIS. I\\nCohen and Eshner \u00e2\u0080\u0094Essentials of Di- I\\nagnosis, 11\\nCorwin Physical Diagnosis, 11\\nMacdonald Surgical Diagnosis and j\\nTreatment, 18 j\\nVierordt\u00e2\u0080\u0094 Medical Diagnosis, 31 1\\nDICTIONARIES.\\nBorland\u00e2\u0080\u0094 Pocket Dictionary, 12 j\\nKeating Pronouncing Dictionary, 16\\nMorten Nurse s Dictionary, 20 1\\nEYE, EAR, NOSE, AND THROAT.\\nAn American Text- Book of Diseases\\nof the Eye, Ear, Nose, and Throat, 5\\nDe Schweinitz Diseases of the Eye, 12\\nGleason Essentials of Dis. of the Ear, 13\\nJackson Manual of Diseases of Eye, 16\\nJackson and Gleason Essentials of\\nDiseases of the Eye, Nose, and Throat, 16\\nKyle Diseases of the Nose and Throat, 1 7\\nGENITO=URINARY.\\nAn American Text-Book of Genito-\\nurinary and Skin Diseases, 6\\nHyde and Montgomery Syphilis and\\nthe Venereal Diseases, 15\\nMartin Essentials of Mmor Surgery,\\nBandaging, and Venereal Diseases, 18\\nSaundby Renal and Urinary Diseases, 26\\nSenn Genito-Urinary Tuberculosis, 27\\nVecki Sexual Impotence, 30\\nGYNECOLOGY.\\nAmerican Text- Book of Gynecology, 6\\nCragin Essentials of Gynecology, II\\nGarrigues Diseases of Women, 13\\nLong Syllabus of Gynecology, 17\\nPenrose\u00e2\u0080\u0094 Diseases of Women, 20\\nPryor Pelvic Inflammations, 34\\nSutton and Giles Diseases of Women, 30\\nMATERIA MEDICA, PHARMACOL-\\nOGY, AND THERAPEUTICS.\\nAn American Text-Book of Applied\\nTherapeutics 5\\nButler Text-Book of Materia Medica,\\nTherapeutics and Pharmacology, 10\\nCerna Notes on the Newer Remedies, 10\\nGriffin Materia Med. and Therapeutics, 14\\nMorris\u00e2\u0080\u0094 Essentials of Materia Medica\\nand Therapeutics, 19\\nSaunders Pocket Medical Formulary, 26\\nSayre\u00e2\u0080\u0094 Essentials of Pharmacy, 26\\nStevens Essentials of Materia Medica\\nand Therapeutics, 28\\nStoney Materia Medica for Nurses, 30\\nThornton Dose- Book and Manual of\\nPrescription-Writing, 30\\nMEDICAL JURISPRUDENCE AND\\nTOXICOLOGY.\\nChapman Medical Jurisprudence and\\nToxicology, 10\\nSample Essentials of Legal Medicine,\\nToxicology, and Hygiene, 27", "height": "3468", "width": "2232", "jp2-path": "rhinologylaryng00frie_0394.jp2"}, "395": {"fulltext": "Medical Publications of W. B. Saunders Co. 33\\nNERVOUS AND MENTAL\\nDISEASES, ETC.\\nBurr Nervous Diseases,\\nChapin Compendium of Insanity,\\nChurch and Peterson Nervous and\\nMental Diseases,\\nShaw Essentials of Nervous Diseases\\nand Insanity,\\nNURSING.\\nGriffith The Care of the Baby,\\nHampton Nursing,\\nHart Diet in Sickness and in Health,\\nMeigs Feeding in Early Infancy,\\nMorten Nurse s Dictionary\\nStoney Materia Medica for Nurses,\\nStoney Practical Points in Nursing,\\nWatson Handbook for Nurses,\\nOBSTETRICS.\\nAn American Text-Book of Obstetrics,\\nAshton Essentials of Obstetrics,\\nBoisliniere Obstetric Accidents\\nDorland Manual of Obstetrics,\\nHirst Text-Book of Obstetrics,\\nNorris Syllabus of Obstetrics,\\nPATHOLOGY.\\nAn American Text-Book of Pathology,\\nMallory and Wright Pathological\\nTechnique,\\nSemple Essentials of Pathology and\\nMorbid Anatomy,\\nSenn Pathology and Surgical Treat-\\nment of Tumors,\\nStengel\u00e2\u0080\u0094 Text-Book of Pathology,\\nM^arren Surgical Pathology and Thera-\\npeutics,\\nPHYSIOLOGY.\\nAn American Text-Book of Physi-\\nology,\\nHare Essentials of Physiology,\\nRaymond Manual of Physiology,\\nStewart Manual of Physiology,\\nPRACTICE OF MEDICINE.\\nAn American Text-Book of the The-\\nory and Practice of Medicine,\\nAn American Year-Book of Medicine\\nand Surgery,\\nAnders Text-Book of the Practice of\\nMedicine,\\nLockwood Manual of the Practice of\\nMedicine,\\nMorris Essentials of the Practice of\\nMedicine,\\nStevens Manual of the Practice of\\nMedicine,\\nSKIN AND VENEREAL.\\nAn American Text-Book of Genito-\\nurinary and Skin Diseases,\\nHyde and Montgomery Syphilis and\\nthe Venereal Diseases,\\nMartin Essentials of Minor Surgery,\\nBandaging, and Venereal Diseases,\\nPringle\u00e2\u0080\u0094 Pictorial Atlas of Skin Dis-\\neases and Syphilitic Affections,\\nStelwagon\u00e2\u0080\u0094 Essentials of Diseases of\\nthe Skin,\\nSURGERY.\\nAn American Text-Book of Surgery, 7\\nAn American Year-Book of Medicine\\nand Surgery, 8\\nBeck Fractures, g\\nBeck Manual of Surgical Asepsis, 9\\nDaCosta Manual of Surgery, 12\\nInternational Text-Book of Surgery, 15\\nKeen Operation Blank, 17\\nKeen The Surgical Complications and\\nSequels of Typhoid Fever, 17\\nMacdonald Surgical Diagnosis and\\nTreatment, 18\\nMartin Essentials of Minor Surgery,\\nBandaging, and Venereal Diseases, 18\\nMartin Essentials of Surgery, 18\\nMoore Orthopedic Surgery, ig\\nNancrede Principles of Surgery, 20\\nPye Bandaging and Surgical Dressing, 21\\nScudder Treatment of Fractures, 26\\nSenn Genito-Urinary Tuberculosis, 27\\nSenn Syllabus of Surgery, 27\\nSenn Pathology and Surgical Treat-\\nment of Tumors, 27\\nWarren Surgical Pathology and Ther-\\napeutics, 2 1\\nURINE AND URINARY DISEASES.\\nSaundby Renal and Urinary Diseases, 26\\nWolffs Essentials of Examination of\\nUrine, 31\\nMISCELLANEOUS.\\nAbbott Hygiene of Transmissible Dis-\\neases, 8\\nBastin Laboratory Exercises in Bot-\\nany, 9\\nGould and Pyle Anomalies and Curi-\\nosities of Medicine, 13\\nGrafstrom Massage, 14\\nKeating How to Examine for Lite\\nInsurance, o 16\\nRowland and Hedley Archives of\\nthe Roentgen Ray, 21\\nSaunders Medical Hand- Atlases, .2, 3, 4\\nSaunders New Series of Manuals, 24, 25\\nSaunders Pocket Medical Formulary, 26\\nSaunders Question-Compends, 22, 23\\nSenn Pathology and Surgical Treat-\\nment of Tumors, 27\\nStewart and Lawrance Essentials of\\nMedical Electricity, 29\\nThornton Dose-Book and Manual of\\nPrescription-Writing, 30\\nVan Valzah and Nisbet\u00e2\u0080\u0094 Diseases of\\nthe Stomach, 3\u00c2\u00b0", "height": "3464", "width": "2120", "jp2-path": "rhinologylaryng00frie_0395.jp2"}, "396": {"fulltext": "BOOKS JUST ISSUED.\\nTHE AMERICAN ILLUSTRATED MEDICAL DICTIONARY.\\nFor Students and Practitioners. A Complete Dictionary of the Terms used in Medi-\\ncine and tlie Allied Sciences, with a large number of Valuable Tables and Numerous\\nHandsome Illustrations. Edited by W. A. Newman Borland, M. D., Editor of the\\nAmerican Pocket Medical Dictionary. Handsome large octavo, 8oo pages, bound in\\nfull limp leather, and printed on thin paper of the finest quality, forming a handy\\nvolume, only I 4. inches thick.\\nThis is an entirely new and unique work, intended to meet the need of practitioners and students for a\\ncomplete, up-to-date dictionary of moderate price. The book is designed to furnish a maximum amount of\\nmatter in a minimum space and at the lowest possible cost. It contains double the material in the ordinary\\nstudents dictionary, and yet, by the use of a clear, condensed type and thin paper of the finest quality, is only\\ni inches in thickness. It is bound in full flexible leather, and is just the kind of a book that a man will want\\nto keep on his desk for constant reference. The book makes a special feature of the newer words, and\\ndefines hundreds of important terms not to be found in any other dictionary. It is especially full in the\\nmatter of tables, containing more than a hundred of great practical value. A new feature is the inclusion\\nof numerous handsome illustrations, many of them in colors, drawn and engraved specially for this book.\\nThese have been chosen with great care and add infinitely to the value of the work. The book will appeal\\nto both practitioners and students, since, besides a complete vocabulary, it gives to the more important\\nsubjects extended consideration of an encyclopedic character.\\nBOHM, DAVIDOFF, AND HUBER S HISTOLOGY.\\nA Text=Book of Human Histology. Including Microscopic Technic. By Dr.\\nA. A. BiiHM and Dr. M. von Davidoff, of Munich, and G. C. Huber, M. D.,\\nJunior Professor of Anatomy and Histology, University of Michigan.\\nFRIEDRICH AND CURTIS ON THE NOSE, THROAT, AND EAR.\\nRhinology, Laryngology, and Otology in their Relations to General\\nMedicine. By Dr. E. P. Friedrich, of the University of Leipsig. Edited by\\nH. HoLisROOK CuR iis, M. D., Consulting Surgeon to the New York Nose and Throat\\nHospital.\\nLEROY S HISTOLOGY.\\nThe Essentials of Histology. By l.ouis Lerov, M.D., Professor of Histology\\nand Pathology, Vanderbilt University, Nashville, Tennessee.\\nOQDEN ON THE URINE.\\nClinical Examination of the Urine. By J. Bergen Ogden, M. D., Assistant\\nin Chemistry, Harvard Medical School. Handsome octavo volume of over 408 pages,\\nwith 54 illustrations and 1 1 full-page plates, many in colors.\\nPYLE S PERSONAL HYGIENE.\\nA Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., Assist-\\nant Surgeon to Wills Eye Hospital, Philadelphia. Octavo volume of 344 pages,\\nfully illustrated.\\nSALINGER AND KALTEYER S MODERN MEDICINE.\\nModern Medicine. By Julius L. SAT.ixr.ER, M. D., Demonstrator of Clinical\\nMedicine, Jefferson Medical College, and F. J. Kaltkyer, M. D., Assistant Demon-\\nstrator of Clinical Medicine, Jefferson Medical College. Handsome octavo volume of\\nover 800 pages, fully illustrated.\\nSTONEY S SURGICAL TECHNIC FOR NURSES.\\nSurgical Technic for Nurses. By Emily A. M. Stoney, late Superintendent\\nof tlie Training-School for Nurses, Carney Hospital, South Boston, Massachusetts.", "height": "3496", "width": "2236", "jp2-path": "rhinologylaryng00frie_0396.jp2"}, "397": {"fulltext": "", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0397.jp2"}, "398": {"fulltext": "", "height": "3464", "width": "2216", "jp2-path": "rhinologylaryng00frie_0398.jp2"}, "399": {"fulltext": "", "height": "3456", "width": "2120", "jp2-path": "rhinologylaryng00frie_0399.jp2"}, "400": {"fulltext": "", "height": "3468", "width": "2160", "jp2-path": "rhinologylaryng00frie_0400.jp2"}, "401": {"fulltext": "", "height": "3456", "width": "2096", "jp2-path": "rhinologylaryng00frie_0401.jp2"}, "402": {"fulltext": "", "height": "3448", "width": "2272", "jp2-path": "rhinologylaryng00frie_0402.jp2"}, "403": {"fulltext": "I", "height": "3452", "width": "2048", "jp2-path": "rhinologylaryng00frie_0403.jp2"}, "404": {"fulltext": "", "height": "3460", "width": "2216", "jp2-path": "rhinologylaryng00frie_0404.jp2"}}