LIBRARY OF CONGRESS. Chap. Copyright No. Shelf ."T^E^^Yq UNITED STATES OF AMERICA. Rhinology Laryngology and Otology SIGNIFICANCE IN GENERAL MEDICINE BY E, P* FRIEDRICH, M,D. PRIVATDOCENT AT THE UNIVERSITY OF LEIPZIG Butborl3eD translation from tbe ©erman H. HOLBROOK CURTIS, M,D. CONSULTING SURGEON TO THE NEW YORK NOSE AND THROAT HOSPITAL AND TO THE DIPHTHERIA AND SCARLET FEVER HOSPITALS PHILADELPHIA AND LONDON W, B. SAUNDERS «& COMPANY 1900 47545 l-ibrkit y of Co»im»"««s SEP 15 1900 Cofyri|*« •"try SECONO COPV. ORDtR DtVISION, SEP 20 I9UU ,^ 800/ 2 Copyright, igoo, by W. B. Saunders & CoMPA^ EDITOR'S PREFACE At the present time, when it is the fashion for almost every specialist to pad his individual work and announce a book on the ear, nose, and throat, — which upon perusal is gener- ally found to cover ground already occupied, — it is certainly with pardonable enthusiasm that we greet a masterly treatise of a thoroughly original type, the intrinsic worth of which warrants its appearance in our own language. Friedrich has realized that the general practitioner must acquaint himself with the rapid advances in the modern teaching of otolaryngology, and he has constructed a book so rich in statistics and reference, so learned in its argumentative deductions, and at the same time so convincing in the man- ner of conservative presentation, that no specialist can afford to neglect the opportunity of acquainting himself with the subject-matter of his work. The results of the vast clin- ical experience of the author, the detailed reports, and the extensive bibliography make the volume valuable alike to the specialist and the general practioner. Far too little attention has been paid in the past to early symptomatic manifestations in the respiratory tract ; nor has sufficient study been given to the reflex neuroses of the ear and air-passages and their diagnostic significance. One can not read the book without admiration for a physician who is able at once to be observant of the minutest detail of constitutional disturbance, and also to possess so intimate a knowledge of the specialties whose reciprocal relations he so ably defines. The chapters treating of nervous diseases are most inter- esting and rich in new material, as are also those upon the exanthemata and their sequels. In the translation there has been no effort made to ren- der into elegant English the characteristic construction of the German text. To preserve the exact meaning of the 5 O EDITOR S PREFACE. author and his individual style of expression has been our aim, and the work is reproduced from a strictly scientific point of view. The attention which has been given to the morbid anat- omy and pathology is exceptional, and the book as a whole ranks among the most progressive works of to-day. The editor has no hesitation in indorsing the book as the best treatise upon the relationship of general diseases to those of the ear, nose, and throat that has appeared up to this time. H. HoLBROOK Curtis. iiS ]\Ia' to examine more care- fully certain regions of the body, anatomically and physi- ologically distinct, the natural result is the growth of a specialty. As experience shows that certain portions of the organism 5 PREFACE. which, owing to their position and function, can not be reached by ordinary methods of examination practised in general medicine, demand the development of special methods to enable us to examine new regions both in the healthy and in the diseased state, and as with the growth of our knowledge additional facts are discovered, the field gradually widens, and new departments spring into exist- ence, which are only too often regarded by both physicians and laymen as isolated domains of the general science. There must, of course, be a period in the development of a specialty during which those who practise it devote their entire energy to the study of the anatomy and physiology of the new regions, and to the creation of a special pathology and method of treatment adapted to the peculiarities of the parts concerned. Once this foundation is established, however, it becomes important to incorporate the new discoveries in the scheme of general medicine. A specialty should not be regarded as a thing apart and a kind of appendage ; it should take an active part in all the problems with the solution of which general medicine is concerned. To do this an active cooperation between general medicine and every one of the various specialties is indispensable. Whenever it is lacking, the specialty is in danger of becoming a mere source of revenue and of losing its scientific significance ; while, on the other hand, the general practitioner will fail to recognize special symptoms which might have been of the greatest importance to him in the recognition and treatment of his cases. In taking this standpoint and in describing the relations which manifest themselves as disturbances of the general organism in disease of special parts, or as disturbances of special parts in general disease, I lay no claim to origin- ality, for several works on our specialties have appeared with a special reference to general medicine. Moritz- Schmidt, in his excellent book on " Diseases of the Upper Air-passages," has followed the same Hues, "writing from practice for practice" ; Lori discusses "Alterations of the Pharynx, Larynx, and Trachea due to Other Diseases " ; while Moos and Haug discuss " The Diseases of the Ear in their Relation to General Diseases," one in his chapter on the Etiology of the Diseases of the Ear in Schwartze's " Handbuch der Otologic," the other in a special mono- graph. My undertaking a new work on this theme merely shows the abundance of material accumulated during the last few years, and the development of new points of view that justify the publication of another book on the subject. It has been my endeavor to confine myself to the positive, and, disregarding speculation, to present to the reader nothing but exact and well-established information. The treatment of the subject is purposely succinct, especially the description of the commoner diseases. A detailed description of special symptomatology is not within the scope of this book, which does not pretend to be a special text-book in the ordinary sense, being intended to awaken the interests of both the general practitioner and the speciaUst in certain matters which appear to me to demand special attention and further elaboration. As I have drawn freely from the entire literature, bibliographic notes seemed to me indispensable. They do not pretend to anything like completeness, but I have, I hope, cited the most important works, a reference to which will enable the reader to elucidate any doubtful questions that may present themselves. E. P. Friedrich. CONTENTS. I. DISEASES OF THE RESPIRATORY ORGANS. PAGE General Remarks on the Relations Existing between the Nose, Pharynx, and Larynx 17 Relations Existing between the Nose, Pharynx, Larynx, and Lungs . 19 Significance of the Upper Air-passages in the Physiology of Breathing 19 Diseases of the Lungs Due to Disturbances- of the Physiologic Function of the Upper Air-passages 26 Diseases of the Lungs in Morbid Conditions of the Upper Air- passages 28 Alterations in the Upper Air-passages in Diseases of the Lungs . 31 Alterations in the Upper Air-passages in Diseases of the Medi- astinum ;^^ Relations between the Upper Air-passages and the Ears 35 The Effect of Disturbances of the Normal Function of the Eu- stachian Tube 36 Disturbances of the Function of the Eustachian Tube Due to Alterations in the Upper Air-passages 40 Diseases of the Middle Ear Due to Infection from the Post-nasal Space 43 The Effect of Various Diseases of the Respiratory Organs on the Ears 47 II. DISEASES OF THE CIRCULATORY SYSTEM. 1. Diseases of the Heart and Blood-vessels in Their Relation to the Nose, Pharnyx, and Larynx 52 2. Diseases of the Heart and Blood-vessels in Their Relation to the Ear 59 III. DISEASES OF THE DIGESTIVE SYSTEM. 1. Diseases of the Digestive System in Their Relation to the Upper Air- passages 68 Diseases and Changes in Form of the Oral Cavity in Disturbances of Nasal Respiration 68 Diseases of the Digestive Organs in Relation to the Nose, Throat, and Larynx 70 2. Digestive System and Diseases of the Ear 76 CONTENTS. IV. DISEASES OF THE BLOOD. PAGE 1. Anemia 8i 2. Leukemia 83 Alterations in the Upper Air-passages in Leukemia 83 The Manifestations of Leukemia in the Ear 86 3. Hemorrhagic Diatheses 89 V. CHRONIC CONSTITUTIONAL DISEASES. 1. Rachitis 92 2. Acromegaly 95 3. Diabetes Mellitus 96 4. Gout 102 Ictus Laryngis Occurring in the Course of Obesity, Gout, and Diabetes 104 VI. ACUTE INFECTIOUS DISEASES. 1. Measles 108 2. Scarlatina 112 3. Varicella I20 4. Variola 121 5. Typhoid Fever 123 6. Iniiuenza . I32 Aural Complications in Influenza 134 7. Parotitis Epidemica (Mumps) 138 8. Acute Rheumatoid Arthritis 139 9. Diphtheria 142 10. Erysipelas I47 11. Malaria 148 VII. CHRONIC INFECTIOUS DISEASES. 1. Tuberculosis and Lupus 15 1 Tuberculosis of the Nose 158 Tuberculosis of the Pharynx 161 Tuberculosis of the Larynx 162 Tuberculosis of the Ear 169 Lupus 174 2. Leprosy 177 3. Malleus Humidus (Glanders) 183 4. Foot-and-mouth Disease 184 5. Anthrax 185 6. Actinomycosis 185 7. Rabies 186 8. Trichinosis 187 VIII. DISEASES OF THE KIDNEY. Edema of the Pharynx and Larynx ...... 188 Hemorrhages in the Pharynx and Larynx 189 Nephritic Aural Diseases 189 CONTENTS. 1 3 IX. DISEASES OF THE SKIN AND OF THE SEXUAL ORGANS. PAGE 1. Diseases of the Skin 193 2. The Influence of Normal or Pathologically Altered Sexual P'unctions on the Upper Air-passages 197 Relation of the Sexual Organs to the Upper Air-passages . . . 197 Relations between the Sexual Organs and the Ears 201 3. Gonorrhea 203 4. Syphilis 205 X. DISEASES OF THE EYE. 1. Relations between the Eye and the Nose 224 2. Relations between the Eyes and the Ears 234 XI. INTOXICATIONS. Acids and Alkalies 242 lodids . 243 Arsenic and Lead 245 Mercury . 246 Copper, Phosphorus, etc 247 Quinin, Salicylic Acid, etc 248 Chloroform, Tobacco, Alcohol 249 XII. NERVOUS DISEASES. 1. General Remarks on Diseases of the Larynx in Diseases of the Central Nervous System 251 Diseases of the Sensory and Motor Nerves of the Larynx ... 251 Localization of Centers for Movement of the Vocal Cords in the Central Nervous System, and the Effect of Diseases of the Central Nervous System 258 2. General Remarks on the Aural Disturbances Produced in Diseases of the Central Nervous System 263 The Mechanism of Functional Disturbances in the Ear and the Electric Reactions of the Auditory Nerve 263 The Localization of the Ear in the Central Nervous Organs . . 270 3. Nervous Diseases which Produce Definite Alterations in the Nose, Pharynx, and Larynx, and in the Ears 275 Diseases of the Spinal Cord 275 Tabes Dorsalis 275 Multiple Sclerosis 289 Diseases of the Medulla Oblongata 291 Syringomyelia 29I Progressive Amyotrophic Buliiar Paralysis 292 Neuroses ; 293 Paralysis Agitans 293 Epilepsy 294 Chorea Minor 295 Hysteria 295 14 CONTENTS, APPENDIX. PAGE Nasal Reflex Neuroses 306 The Significance of Some of the Cranial Nerves in Rhinology and Otology, 314 The Trifacial Nerve 314 The Chorda Tympani 320 The Facial Nerve 323 Diseases of the Meninges and of the Cerebral Sinuses 325 Their Significance in Connection with the Nose, Larynx, and Ears . . 325 Diseases of the Meninges in Nasal Affections 328 Diseases of the Meninges and of the Cerebral Sinuses in Ear Disease 330 INDEX 337 RHINOLOGY LARYNGOLOGY AND OTOLOGY AND THEIR SIGNIFICANCE IN GENERAL MEDICINE [. DISEASES OF THE RESPIRATORY ORGANS. J. GENERAL REMARKS ON THE RELATIONS EXISTING BETWEEN THE NOSE, PHARYNX, AND LARYNX. The upper air-passages, comprising the nose, pharynx, and larynx, present a canal of varying form and diameter, lined in its entire extent, except where the respiratory and alimentary tracts cross each other in the pharynx, by mucous membrane covered with ciliated columnar epithelium ; so that nose, pharynx, and larynx imperceptibly merge one into the other without the interposition of a sharp line of demarcation. It follows that pathologic changes in any portion of the upper air-passages are not sharply limited in their local effects and ultimate consequences, but invade adjacent areas quite irrespective of the anatomic boundaries of nose, pharynx, and larynx. It is well known that catarrhal affections of the upper air-passages are not limited to a circumscribed area ; they display, on the contrary, a peculiar descending character, as it is called, beginning in the nose as an acute rhinitis and invading at certain definite intervals the pharynx and the larynx. The comparative immunity enjoyed by the larynx as compared to the pharynx is not altogether accidental, although to a certain extent dependent on accidental causes, for it is generally admitted that progressive morbid processes meet with a certain resistance wherever the char- acter of the epithelium changes, which resistance may be sufficient to arrest their further advance. Now, the ciliated columnar epithelium of the nose and nasopharynx is re- placed in the oral pharynx by squamous epithelium, which extends as far as the upper border of the larynx ; but at this point the epithelium returns to the ciliated columnar type of the higher air-passages, and this type is retained 2 17 1 8 THE RESPIRATORY ORGANS. throughout the interior of the larynx — with the exception of a zone of squamous epithehum extending over the interarytenoid notch to the posterior wall and to the vocal cords. Hence we can readily understand that the boun- daries between these various kinds of epithelium oppose to the progress of an acute catarrh a barrier more or less insurmountable, according to the intensity of the process and the disposition of the individual. In the comparatively rare cases where the larynx becomes involved in a de- scending catarrh, the laryngeal symptoms develop several days after the first appearance of the nasal and pharyngeal symptoms, or even after convalescence has begun in the higher air-passages. Ascending catarrh, on the contrary, differs diametrically from the descending form in the matter of frequency, and it seldom or never happens that an acute pharyngitis or laryn- gitis spreads to the higher portions of the respiratory tract. With the infectious diseases, especially diphtheria, the case is quite different ; they may originate either in the pharynx or in the nose, although, as a matter of fact, they usually appear first in the pharynx, and spread from that region either upward into the nose or downward to the larynx. The relation between the nose and the nasopharynx is a particularly intimate one, so much so that only very few diseases are limited to one or the other of these two structures. Any chronic condition leading to obstruction and to the passage of morbid products — such as mucus and pus — into the nasopharynx exerts an injurious effect on that structure ; and, conversely, any disease of the nasopharynx, by causing chronic enlargement of the phar- yngeal tonsils, thereby obstructing the nasal passages and interfering w'ith nasal respiration, sets up a congestive catarrh ; the secretions accumulate as the expiratory blast is no longer able to remove them, and a hyperplasia of the mucous membrane eventually results. If, on account of obstruction, the nasal secretion is unable to make its escape outward and flows back into the nasor pharynx, the harm which results is not confined to this locality ; the discharges trickling down along the posterior pharyngeal wall accumulate in the oral pharynx, and the subsequent course of the disease then depends on the SIGNIFICANCE OF THE UPPER AIR- PASSAGES. 1 9 quantity and consistency of the morbid secretion. If the patient is unable to remove it by hawking and coughing, it will adhere to the posterior pharyngeal wall in the form of a thick, tenacious coating, and thence will gradually spread to the posterior wall of the larynx. This mode of spread- ing from the nose to the pharynx and larynx is especially characteristic of certain definite diseases, the most typical of which is atrophic rhinitis with fetor and crust formation. The greenish-yellow, foul-smelling crusts with which the atrophied nasal cavities are covered — as the walls of a room are covered with wall-paper — are also found clinging to the roof and posterior wall of the pharynx, while in the larynx a tenacious material accumulates on those parts which are least concerned in the movements of phonation and respiration, especially in the region below the glottis. Similar consequences attend any chronic inflammation of the nose, accompanied with copious secretion and suppura- tive processes in the tributary cavities of the nose, whenever the position of their openings permits a backward flow of pus. 2. RELATIONS EXISTING BETWEEN THE NOSE, PHARYNX, LARYNX, AND LUNGS, SIGNinCANCE OF THE UPPER AIR-PASSAGES IN THE PHYSIOLOGY OF BREATHING. Leaving the description of the interdependence of nose, pharynx, and larynx, which really belongs to the domain of special pathology, we now turn our attention to the influence exerted on the lungs by disease of the upper air-passages. The first requisite for a thorough understanding of this subject is a knowledge of the physiologic significance of the air-passages in the act of respiration. They should not be viewed merely in the light of canals for the transmission of the inspired air ; for each segment has a special function of its own and contributes to the preparation of the air for reception in the lungs, and this function can not remain in abeyance without detriment to the organism. We begin with the consideration of the upper air-passages as the respiratory pathway and with the changes experienced by the inspiratory air-current during its passage through the nose. 20 THE RESPIRATORY ORGANS, I. The Nose as the Respiratory Pathway. — The nose is the portal through which the air gains admittance to the body, and it has certain special functions to perform which lend to it a greater importance than belongs to the pharynx and larynx. It is charged with the duty of preparing the air for its entrance into the deeper air-passages, in the fol- lowing ways : 1. By removing foreign substances as much as possible. 2. By warming the air. 3. By imparting to the air the requisite degree of moisture. 4. A subordinate function consists in protection of the organism by means of the sense of smell and the nasal reflexes. In order to gain a full understanding of these various functions let us examine the path followed by the air in its transit through the nose. Even at the present day we frequently hear of the division of the nasal cavity into a respiratory and an olfactory region, the former correspond- ing with the maxillary, and the latter with the ethmoidal, portion. It should follow from this subdivision that the lower half of the nose, as far as the middle turbinated bone, is concerned exclusively in the act of breathing, while the remaining upper half subserves solely the sense of smell. Experimental researches prove, however, that such a division is not justified, either by the nature of the respira- tory air-current or by the distribution of the nerves, to which we shall return later. Experiments have been made by Paulson, Kayser,^ Franke,^ and Scheff,^ and those of Scheff have recently been repeated and confirmed by Danziger.* The perfect agreement of these experiments and the convincing care with which they were performed, justify us in rejecting the older theory, according to which the respiratory air-current passes only through the lowest segment of the meatus nasi communis : that is, the space between the inferior turbinated bone and the septum. The most important fact brought out by recent investigations is that the respiratory current passes principally through the middle and upper parts of the nose, and hardly touches the 1 "Zeitschr. f. Ohr.," vol. XX, p. 96. 2 " Arch. f. Laryng.," vol. I, p. 230. 3 *' Klin. Zeit- u. Streitfr.," Vienna, 1895, vol. IX, part U. 4 "Mon. f. Ohr.," 1896, p. 331. THE NOSE AS THE RESPIRATORY PATHWAY. 21 inferior meatus under normal conditions. As the entrance to the nose is in the horizontal plane, the current of air, on entering, rises in a line parallel to the dorsum of the nose ; it is then deflected backward in the region of the agger nasi (which in man is rudimentary), describing a curve, the concavity of which faces downward, while its apogee may project above the superior, and never falls below the middle turbinated bone, and passes out through the upper half of the posterior nares. According to Franke, the air-current also forms an eddy somewhere in the region of the inferior turbinated bone. During expiration the curve is flattened, its elevation being in direct proportion to the depth of the inspiratory movement. While we must accept this as the type of nasal respira- tion to be considered in judging of pathologic conditions, we must also take into account the shape of the external nose, the position of the anterior nares, and the width from side to side of the internal openings — which depends on the prominence of the plica alaris. The significance of these factors was shown by Kayser in his experiments to determine the manner of aspiration in variously shaped noses. In the narrow, aquiline variety of nose, in which the external opening is horizontal and the inner opening usually small, the air-current follows the direction which has been described ; on the other hand, we have the testi- mony of various authors that in the broad, turned-up, so- called pug-nose, in which the space between the septum and the plica vestibuli is large, the air-current enters in a more horizontal direction, and is directed toward the lower portion of the nose. This apparently complicated arrangement enables the nose to fulfil the three different functions which pertain to it in the preparation of the respiratory air-current, by in- suring the greatest possible extent of contact with the walls of the nasal cavities. I. Removal of Foreign Substances from the Respira= tory Air=current. — When we consider the great variety of conditions with which we are surrounded, it is self- evident that the purity of the air, which depends on the presence or absence of dust and gaseous substance, is sub- ject to considerable change. Under the head of dust we have to consider solid particles of a mineral or vegetable nature and microorcranisms. 22 THE RESPIRATORY ORGANS. The nose is provided with various means of defense against the entrance of these deleterious substances : the vibrissas which hne the inner margin of the nostrils, the moist surface of the mucous membrane, the reflex act of sneezing, and, lastly, a bactericidal property which probably resides in the mucous secretion. The vibrissae act like a coarse filter which arrests the larger particles. The moist surface of the mucous mem- brane attracts and holds fast any foreign substances in the air-current as it passes through the narrow and complicated passages of the nose. This occurs especially at certain points where the current impinges on the surface of the mucous membrane and is deflected, necessitating a certain amount of friction between the air and the walls of the cavities. In consequence of this friction, the dust particles suspended in the air-current are brought into close contact with the mucous membrane, and stick fast to its moist surface, later to be swept out by the outward current of the ciliated epithelium. One important region of this kind is found on the cartilage of the septum, at the level of the inferior turbinated bone, at the spot where the inspired current, after being deflected inward by the plica vestibularis, strikes the septum ; another corresponds to the posterior pharyngeal wall, opposite the posterior nares. The purifi- cation which the air undergoes in the nose does not, how- ever, entirely prevent the inhalation of dust into the lungs, as we know from the occurrence of anthracosis and other forms of pneumoconiosis. A similar resistance is offered by the tissues of the nose to the entrance of microorgan- isms. Considering the number of bacteria contained in the air, and the great quantity of air that passes through the nose, we would expect to find a very large number of microorganisms in the nasal chambers, as it is probable that they do not penetrate into the deeper air-passages. Opinions are divided on the fate of germs introduced into the nose, both as to the depth to which they penetrate into the nose and as to their behavior therein. While some in- vestigators state that the nose is a playground for all kinds of bacteria, others, like Thomson and Hewlett, ^ have recently advanced the theory that the germs are arrested in the vestibule, and only in exceptional cases and in 1 " Medico-Chirurgical Transactions," vol. LXXVni, 1895. THE NOSE AS THE RESPIRATORY PATHWAY. 23 small numbers penetrate into the deeper portions of the nose. The question whether the nose contains germs under normal conditions has a practical bearing. There have been found the staphylococcus pyogenes aureus, the pneu- mococcus of Friedlander, the streptococcus, the diplococ- cus of Frankel-Weichselbaum, diphtheria bacilli, and count- less other bacteria of less importance, and Straus has shown that tubercle bacilli are frequently present in the noses of healthy individuals living among phthisical patients. But it is a matter of everyday observation that injuries or operative wounds in the nose usually heal without causing any, or at any rate very little, general disturbance, in spite of the apparent danger from infection which should result from the presence of such large numbers of bacteria. The explanation of this want of virulence on the part of the germs in the nasal cavities has been sought in a bactericidal quality of the mucous secretions. This was assumed by Wurtz and Lermoyez.^ but Thomson and Hewlett found that the nasal mucus is not directly bactericidal, although it arrests the growth of germs to a certain extent. It is idle, in the absence of exact proofs, to discuss this question of the bactericidal powers of the secretion. The most that can be said is that it is not a favorable soil, and hinders the development of the microorganisms more or less. The conditions in this respect are evidently analogous to those found in the oral cavity, which contains even a greater abundance of bacteria. The mere presence of germs is not in itself injurious to the nose ; other factors must be taken into account : the number and virulence of the pathogenic germs which gain entrance ; the disposition of the individ- ual ; and the presence of other bacteria, which either assist or retard the growth of the pathogenic varieties. 2 and 3. Warming and Saturation of the Inspired Air. — It has been proved by the experiments of Aschenbrandt and of R. Kayser,^ that the temperature of the air-current during its passage through the narrow chambers of the nose is raised to from 25° to 35° C, depending on the external temperature. It would, however, be wrong to suppose that this function of the nose is indispensable for breathing ; Kayser has shown that the inspired air is 1 " Ann. des mal. de I'oreille," 1893, p. 661. 2 " Pfliiger's Arcliiv," vol. XI.I. 24 THE RESPIRATORY ORGANS. warmed only half a degree less in mouth-breathing than in nasal respiration, and that after tracheotomy the trachea and bronchi are quite capable of warming the air to 30° C. — the average temperature imparted to it in the nose — without injury to the lungs. Gaule suggests that the abundant supply of blood-vessels in the nose, and the property possessed by them of changing their volume, enable them to adapt themselves more easily to the ther- mic changes of the outside air. A far more important function of the nose is to supply the necessary moisture to the inspired air — a function which the mouth is unable to perform. The nose thus relieves the bronchi and lungs of an onerous duty, which falls on them to a much greater degree if respiration is performed through the mouth. To enable it to supply the required amount of moisture the nose is endowed with unusual secretory activity. The latter is derived in part from the abundant supply of serous and mucous glands and from an extensive system of lym- phatics ; also in part from an " irrigation-system, which keeps the epithelium constantly supplied with the necessary amount of moisture." The source of this special system is to be sought, according to Schieffendecker, not in the lymphatic vessels, but in the lymph-spaces of the tissues, the moisture making its way to the surface through the basal canaliculi, which pierce the basal membrane and emerge between the epithelial cells. 4. In addition to these functions of the nose, there are other protective contrivances of less importance in the upper air=passages, which prevent the entrance of deleteri- ous substances into the lungs. Thus, the sense of smell serves to protect the organism by testing the inspired air and guarding the lungs against the entrance of substances which can be recognized by their odor. This protection is, after all, a faulty one, as there are many odorless gases which are injurious to the lungs and can not be detected in the inspired air by the sense of smell. In the physiologic reflexes the body possesses another means of ridding itself of coarse particles of matter that have gained entrance to the nose with the inspiratory air- current, the mucous membrane bringing the sneezing reflex into action. PHARYNX AND LARYNX AS RESPIRATORY PATHWAYS. 25 It is thus seen that under normal conditions respiration is effected through the nose, the hps being closed and the oral cavity occluded anteriorly and posteriorly by means of the tongue. The latter completely fills the oral cavity during nasal respiration, its tip being pressed against the upper teeth and the dorsum and edges fitting against the palate and alveolar processes, while the base of the tongue arches upward and is closely applied to the soft palate, so that the oral cavity is hermetically closed and shut off from the pharynx. The question presents itself, whether the mouth is capa- ble of supplying the functions of the nose in preparing the air for respiration, or whether mouth-breathing is injurious to the organism ; and the answer must be that the oral cavity is not in any way adapted to replace the nose in the act of breathing. The width of the oral cavity is such that the air-current encounters no resistance, and conse- quently its progress is not retarded, as it is in the narrow passages of the nasal cavity, and no time is afforded for purification and saturation. The less abundant vascular supply and the absence of cavernous tissue (the amount of blood in which is regulated by the external temperature, and thus tends to maintain the required degree of tempera- ture in the nose) ; the absence of an abundant watery secre- tion in the oral cavity ; the nature of the epithelium in the mouth, which is of the squamous variety, and therefore in- capable, in contradistinction to the ciliated epithelium in the nose, of removing automatically any deleterious sub- stances in the air-current all these structural differences combine to make the mouth unfit to supply an air-current which would be other than injurious to the organism. II. Pharynx and Larynx as Respiratory Pathways. — When the air reaches the pharynx and larynx, after passing through the nose, it has undergone the necessary preparatory changes for its entrance into the lungs, and needs no further alteration of any moment. If any par- ticles of dust enter the larynx with the inspired air, they are promptly expelled by the ciliated columnar epithelium. But the pharynx and larynx are nevertheless supplied with a protective apparatus capable of preventing the passage of foreign bodies in either direction — into the postnasal space and the nose, or into the trachea and deeper air-passages ; and it is called into activitv whenever food is taken, to 26 THE RESPIRATORY ORGANS. guard the air-passages against the invasion of food par- ticles. The oral cavity is completely shut off from the rhinopharynx by the application of the soft palate against the posterior pharyngeal wall, but the larynx is not entirely occluded during deglutition, the bolus of food gliding easily into the esophagus over the arching dorsum of the tongue (which guards the entrance to the larynx), so that the action of the epiglottis in closing the larynx is not abso- lutely indispensable. If a foreign body, however, does get into the larynx, the glottis immediately closes,- — as it does always at the slightest touch, — and the offending particle is expelled by coughing. DISEASES OF THE LUNGS DUE TO DISTURBANCES OF THE PHYSIOLOGIC FUNCTION OF THE UPPER AIR-PASSAGES. In returning from this physiologic digression to the dis- cussion of the influence exerted on the respiratory organs by disease of the upper air-passages, I shall adopt a classi- fication in which the first place is accorded to those diseases of the lung that develop in consequence of disturbances of the function of the upper air-passages. Such disturbances may arise because the respiratory air- current can not make its way through the nose, so that mouth-breathing becomes necessary. The obstruction may be situated in the nose or in the postnasal space. Any one of the following conditions may be present, and necessitate mouth-breathing : Hyperplasias and tumors in the nose ; structural anomalies in the framework of the nose obstruct- ing the lumen, caused by deviation of the septum, by ridges on its surface, or by abnormal bulging or cystic formations in the muscles ; occlusion of the posterior nares by tumors in the postnasal space, and especially by adenoid growths on the vault of the pharynx. The evil effects of mouth-breathing first manifest themselves in the mucous lining of the pharynx and larynx, which becomes dry because the air has not been properly prepared and saturated. Dust particles are deposited first on the mucous membrane of the mouth and oral pharynx — which is cov- ered only with squamous epithelium — and later make their way into the larynx and deeper air-passages. The con- stant irritation of the dry and unpurified air coming in contact with the mucous membranes of the upper and lower DISEASES OF THE LUNGS. 2/ air-passages gives rise, as we can easily understand, to chronic catarrhal conditions. Thus it is found that mouth- breathers, as represented typically by children in the early stages of enlarged tonsils, are prone to become the subjects of catarrh of the upper air-passages, of recurring pharyn- geal and laryngeal catarrh, and of acute bronchial catarrh ; while if the condition continues, they usually develop chronic bronchitis, which can be permanently cured only by restoring nasal respiration. In this way we can frequently explain the chronic catarrh which is seen almost constantly in children of scrofulous habit, in whom the hypertrophy of the lymphatic elements in the postnasal space is followed by occlusion of the posterior nares. Mouth-breathing is, however, not the only pre- cursor of chronic catarrh in the deep air-passages ; the condition frequently develops as a sequel to pathologic alterations in the nose itself, provided they are sufficient to render it unfit to afford the necessary protection to the lungs. In atrophic conditions of the nose, coupled, as they are, with metaplasia of the epithelium, foreign bodies contained in the inspired air cling to the walls of the cavities, and eventually penetrate into the deep air-passages. In examin- ing persons afflicted in this way, whose work obliges them to breathe impure air, a mere inspection of the nose, pharynx, and larynx shows the dust-particles, whether mineral or vegetable, as, for instance, coal-dust and flour, clinging to the mucous surface, and it is easy to understand that these dust-particles may be carried down with the inspiratory blast and settle in the bronchi. Suchmorbid changes must necessarily favor the development of the various forms of pneumoconiosis, especially anthracosis and chalicosis. Disturbances of the sensibility and of the reflex activity of the pharynx and larynx have an important bearing on the lungs and bronchi, as they facilitate the development of inspiration pneumonia. If there is anesthesia of the pharynx and larynx, and the cough reflex is diminished, it is easy for particles of food to enter the larynx ; and when from anesthesia of the larynx the glottis fails to close, and there is no reflex cough, the offending body readily finds its way into the lower air-passages. Hence an inspiration pneumonia frequently complicates nervous affections, which, like diphtheria, are accompanied with disturbances of sensi- bilitv\ or, like bulbar disease, witli loss of reflexes. 28 THE RESPIRATORY ORGANS. On the other hand, it is worthy of remark that ulcera- tions and disturbances of mobihty in the epiglottis do not, as a rule, interfere with deglutition, and therefore are not followed by inspiration pneumonia. Motor disturbances of the epiglottis are usually mechanical, being due to inflam- mation and swelling of the member, while ulcerations, which may be so great as to destroy the entire organ, usu- ally result from syphilitic or tuberculous lesions. When either of these conditions is present, we should naturally expect that food particles would penetrate into the air- passages, the entrance to the larynx not being sufficiently occluded by the epiglottis. The fact that it does not hap- pen is proof that the epiglottis is of no great importance as a protection to the larynx, its place being easily filled by the base of the tongue. If, however, the muscles of the tongue are paralyzed or atrophied, as in progressive bul- bar paralysis, foreign bodies find no difficulty in entering the deeper air-passages. DISEASES OF THE LUNGS IN MORBID CONDITIONS OF THE UPPER AIR-PASSAGES. Diseases of the lungs may owe their origin to direct ex- tension of disease of the upper air-passages to the trachea and bronchi. The causes are the same as those we have referred to in discussing the relations existing between dis- eases of the upper air-passages, chronic hypertrophic and chronic atrophic catarrh, and suppurative processes in the nose, in its tributary cavities, and in the postnasal space. Chronic bronchitis is the most frequent of the various sequels, and proves very obstinate, especially in cases of chronic suppuration in the tributary cavities of the nose, where the pus trickles down from the nasal pharynx into the deep air-passages and sets up a chronic irritation. The question of the relation between chronic catarrh of the upper and of the deeper air-passages has not received the attention it deserves ; it is barely mentioned in the most general terms in connection with bronchitis, and the pos- sibility of emphysema, bronchiectasis or fetid bronchitis being due to such causes is usually ignored. A paper by Sticker, 1 in which he establishes a causal relation between atrophy, or dry catarrh of the mucous membranes of nose 1 "Arch. f. klin. Med.," vol. LVII. DISEASES OF THE LUNGS. 2g and pharynx, and similar atrophic conditions in the trachea, bronchi, lungs, and pleura, is therefore worthy of notice. Genuine ozena, or rhinitis foetida atrophica, is an atrophic process in the mucous membrane, shared to some extent by the skeleton of the nose, so that the turbinated bones are often entirely destroyed, and the nasal cavity attains enormous dimensions. The atrophy affects the glands and the erectile tissue, partly destroying both structures, but does not extend to the blood-vessels, which, on the con- trary, according to recent investigators, become dilated. At the same time the ciliated cylindric epithelium is con- verted into horny squamous epithelium, giving the mucous membrane a dry, cicatricial appearance, which in the later stages also extends to the pharynx and larynx after the atrophic process has reached these parts. The disease is regularly accompanied by the secretion of a tenacious material, which dries, forms crusts, and gives off a characteristic penetrating fetor. The discharges make their way into the pharynx and larynx, and thence into the deeper air-passages, where they may set up chronic irritative conditions. Sticker has shown that, aside from the fact that diseases of the lungs may be caused by disease of the deeper air-passages secondary to a similar process in the nose and postnasal space, there is a general condition of which the atrophy of the mucous membrane is merely the superficial expression, and this he has called xerosis of the mucous membranes. This condition event- ually leads to a wide-spread and more or less complete atrophy of all the mucous membranes in the body, and, as old age comes on, to a progressive increase in the size of the nasal and postnasal cavities, the larynx, the trachea, the bronchi, and, finally, the lungs. In cases of marked atrophy with ozena of the nose and pharynx experience teaches us to expect not only chronic bronchitis, but also emphysema and asthma-like attacks. If such a condition is met with in elderly persons who have all their lives suf- fered from chronic bronchitis due to ozena, it is readily ex- plained as senile emphysema, or as a secondary emphy- sema, such as may develop gradually in chronic bronchitis. But how are we to explain such cases of pulmonary em- physema in young persons, barely twenty years old, with all the symptoms — especially dyspnea and cyanosis — which are found only in the severest grades of emphysema? I 30 THE RESPIRATORY ORGANS. remember particularly a healthy young farmer, twenty-one years old, who suffered from severe emphysema, and the only explanation that could be found was a marked ozena, which the patient said he had had for a long time. Great as was the temptation to establish a causal relation between the two diseases, there did not seem to be sufficient justifi- cation for doing so, if the lung disease was viewed merely as secondary to the disease in the postnasal space. Such cases confirm Sticker's theory of a general xerosis. The tendency of the finer bronchioles to a dry catarrh, leading to simple increased volume (volumen pulmonum acutum) and pulmonary emphysema, is interpreted by Sticker in his previously mentioned paper, as an expression of the gen- eral xerosis which primarily affects both the upper and lower air-passages. But how does this xerosis originate? Is it a disease, brought on by external influences, by bacteria, by suppura- tions or excoriations in the nose, which is hidden under the disguise of what we call genuine ozena? Every one of the hypotheses that have been advanced to explain the occurrence of atrophic fetid rhinitis must be rejected as in- adequate. All the various causes, from alterations in the epithelium, glands, and blood-vessels to the latest bacterio- logic discoveries, to which the symptom-complex known as ozena has been attributed, while they may possess some accessory importance, are certainly not the primary etio- logic factors. The production of a fetid secretion with a tendency to crust formation is not peculiar to ozena. Ex- perience teaches that it may occur in any condition in which the capacity of the nose is increased, whether from destruc- tion of the skeleton or from too severe treatment with the galvanocautery, or any form of atrophy of the mucous mem- brane. There is nothing new about Sticker's suggestion of syphilis as the cause of his mucous membrane xerosis. Stork repeatedly emphasized the probability of a causal relation between ozena and hereditary syphilis ; but Sticker put the matter in a clearer light when he showed that the conspicuous local alterations in the nose are comparatively unimportant, and that the general xerosis is the primary condition, corresponding to a postsyphilitic destruction of the parenchyma, which may, by becoming complicated with chronic catarrh, give rise to ozena with its characteristic secretion. ALTERATIONS IN THE UPPER AIR-PASSAGES. 3 I It is at least worth while to examine this xerosis of the upper and lower air-passages, in order to determine whether chronic bronchitis and emphysema are really due to the same cause as the disease of the nose and postnasal space. Among- pathologic curiosities may be mentioned the cases in which corrosive fluids penetrate into the larynx, trachea, and bronchi. There have also been reported instances of fibrinous exudations due to vapor of ammonia being formed in the nose, pharynx, larynx, trachea, and even in the finest bronchioles (Hoffmann). Phthisical patients who had been treated for a long time with local applica- tions of lactic acid on account of tuberculosis of the larynx have been known to expectorate ribbon-like shreds of mucus from the trachea and bronchi. ^ Scleroma of the upper air-passages which, as Schrotter ^ and Baurowicz ^ had occasion to observe, extends to the bronchi and leads to stenosis, is a very rare condition, at least in this country. Schrotter's patient died of maras- mus and fetid bronchitis ; Baurowicz' s, of asphyxia brought on by stenosis of the bronchi. ALTERATIONS IN THE UPPER AIR-PASSAGES IN DISEASES OF THE LUNGS. The most important alterations in the upper air-passages occurring in the course of the various diseases of the lungs are those which are due to the irritation of the mucous membranes by the passage of the secretions. Any chronic disease of the lungs in which sputum is secreted is followed sooner or later by chronic laryngeal and pharyngeal catarrh, the intensity of which is in direct proportion to the amount and consistency of the expectorated material and to the amount of effort required to effect its expulsion. Hence, asthmatic and emphysematous patients, whose bronchi are filled with tenacious sputum which requires severe coughing and straining to remove, suffer more from inflammatory conditions of the upper air-passages than do those who have a simple bronchitis with watery secretions, which they can expel without straining the muscles of the neck and throat. ^ F. A. Hoffmann, " Die Krankh. der Bronchien," in Nothnagel's "Spec. Path. u. Therap.," p. 135. * " Mon. f. Olir. ," 1895, p. 149 et seq. ^ "Arch. f. Laryng. ," iv, p. 99. 32 THE RESPIRATORY ORGANS. A form of ascending catarrh of the air-passages has been described, beginning with bronchitis and terminating in acute larjmgitis and pharyngitis. Emphysematous in- dividuals suffer from congestive catarrh, and are prone to have hemorrhages. According to Heinze ^ and Landgraf,^ croupous pneu- monia is sometimes followed by laryngeal complications. Among fifty cases of laryngeal ulceration, Heinze found one in which the vocal cords were ulcerated in the course of croupous pneumonia, and he states that the ulcerations were not tuberculous. Landgraf analyzed eighty cases of croupous pneumonia, and found two cases of ulceration in the larynx. In both cases the primary disease was severe, — one being a bilious form and the other being accompanied by severe sensory phenomena, — and he attributes the ulcers to the dyspnea, " interpreting them as decubital ulcers analogous to t}'phoid ulcers" : "The closure of the glottis which precedes the cough — in other words, the pressure on the vocal processes and free borders of the vocal cords — led to the formation of ulcers in these situations." The most frequent complications of lung diseases in the larynx consist in paralysis, the occurrence of which after disease of the lungs and pleura is explained by the course of the recurrent larjmgeal nerve. The plications ^ which form in the pleura over the apices in chronic inflammations are very apt to include the nerve, especially on the right side, where such a complication is favored by the relation of the nerve to the subclavian artery ; and, on the other hand, indurations of the apex may during cicatrization exert traction on the nerve. Paralyses of the right or left recurrent are most frequent in chronic indurative pleuritis, and produce permanent alterations in an acute left pleuritis. Schrotter * once observed a paralysis, which disappeared after ten days, and infers that it was a case of inflamma- tory edematous infiltration of the pleura. Paralysis rarely develops in pleural exudations. Moeser ° claims to have observed that patients with pleural exudations, particu- larly when there is a copious effusion of fluid, and oftener ^ " Die Kehlkopfschwindsucht," p. 87. 2 " Charile Ann.." xil, p. 244 et seq. 3 Comp. Gerhardt, " Virch. Arch.," xxvn, p. 76. * " Die Krankheiten des Kehlkopfes," p. 414. 5 " Arch. f. klin. Med.," XXXVII, p. 570 et seq. ALTERATIONS IN THE UPPER AIR-PASSAGES. 33 on the right than on the left side, present peculiar motor disturbances of the vocal cord on the corresponding side, which almost always consisted in " diminished power of abduction "; but his observations are not sufficiently con- vincing, and do not present the typical picture of a pro- nounced paralysis of the recurrent. Nor is there more plausibility in the attempts to explain a paralysis occurring in a left pleural effusion by the downward displacement of the heart exerting direct traction on the aorta and the recurrent nerve ; or one occurring in a right effusion by the displacement of the heart to the left and the consequent traction on the vessels of the right side, especially the subclavian artery and the recurrent nerve which winds around it. Chronic conditions in the apex of the right lung — such as tuberculous consolidation or chronic induration from the inhalation of dust — may produce recurrent paralysis. Compared to the great frequency of pulmonary tubercu- losis, paralysis due to this condition is exceedingly rare, — Jurasy ^ saw only three cases, which he did not describe in detail, — and the diagnosis can not even be established with absolute certainty during life, for, as will be described later, the nerve may be pressed upon by swollen lymph-glands within the thorax. The same is true of recurrent par- alysis in anthracosis, examples of which are found in cases of Baumler ^ and Kohn,^ in which the cause of the par- alysis turned out to be an adhesion of the recurrent nerve to an indurated, deeply pigmented and contracted bron- chial gland. ALTERATIONS IN THE UPPER AIR-PASSAGES IN DISEASES OF THE MEDIASTINUM. Before closing the section on the respiratory organs, mention should be made of alterations due to disease in the mediastinum and changes in the thyroid gland. The inferior laryngeal nerves traverse the mediastinum, and are, therefore, exposed to injuiy from disease in that locality. In the case of mediastinal tumors the left nerve, on ac- 1 " Krankh. der ob. Luftwege," p. 476. 2 Comp. Baumler, "Arch. f. klin. Med.," xxxvn, p. 231 et seq. ' " Miinch. med. Wochen.," 1895, P- ^^Z^- 3 34 THE RESPIRATORY ORGANS. count of its position in the lowest part of the mediastinum, is most apt to be included within the growth. But it also happens, as in Michael's case/ that in spite of its more superficial course the right recurrent nerve becomes em- bedded in the tumor. Paralysis of the inferior laryngeal nerves may follow dis- ease of the bronchial lymph-glands, and of the glands be- longing to the group oi ganglions tracJieo-lath-aiix (Barety),^ designated as ganglions peiitracheo-laryngiens by Gougen- heim and Leval Picquechef,^ which occupy the groove be- tween the trachea and the esophagus, and therefore come into close relation with the recurrent nerve, which emerges from the mediastinum in the same situation on each side of the body. 4 These glands often become enlarged in scrofulous chil- dren after bronchopneumonia and other forms of chronic pulmonary catarrh ; they are also found to be enlarged in tuberculosis and in melanotic degeneration. An example of the latter has recently been mentioned in Baumler's case, while the literature of tuberculosis of the bronchial glands has lately been worked up by Fronz.^ If suppuration take place in the glands, the abscess sometimes ruptures into the trachea, and the pus is evacuated into the larynx, as observed by Massei ^ in several cases. Besides pressing on the nerve-trunk, mediastinal tumors may push the larynx to one side or the other and compress the trachea. Such a stenosis from compression of the walls is sometimes seen in the trachea with the laryngoscope ; rotation of the trachea and larynx may take place, so that the glottis appears oblique in the laryngoscopic image. Struma is a more frequent cause of tracheal stenosis than mediastinal tumor, a large percentage of all stenoses being due to goiter. Rosenberg "^ found that out of fifty-four cases of tracheal stenosis, thirty-eight were caused by struma. The occurrence of vocal cord paralysis in struma de- 1 "Die med. Wochen.," 1895, No. 25. 2 Comp. F. A. Hoffmann, " Erkrankungen des Mediastinum," 1896, p. 30. 3 " Ann. des mal. de roreille," etc., 1884. * An excellent illustration of these anatomic relations is found in Gougen- heim — Glover's " Atlas of Laryngology," I, xix. 5 " Jahrb. f. Kinderheilk.," vol. XLIV. •^ ^' Rev. de lar., d'ot et de rhin.," 1897, No. 7. " Heymann, " Handb. der Laryng.," i, p. 568. THE AIR- PASSAGES AND THE EARS. 35 pends more on the position than on the bulk of the enlarge- ment ; if the lateral lobes are affected, pressure is exerted on the nerves, and paralysis frequently results. Among the structures in the mediastinum which may affect respiration unfavorably the thymus gland must also be mentioned. In recent times, cases of sudden death in children have been attributed to hyperplasia of the thymus, ^ just as the inspiratory stridor of the new-born is now gen- erally acknowledged to be referable to the same cause. Siegel 2 and Avellis ^ have contributed valuable descrip- tions of the clinical picture presented, supplemented with full histories of the cases. A signal proof of the relation between inspiratory stridor and enlarged thymus is afforded by Rehn's case, reported by Siegel, and by a case operated on by Konig, in which recovery was brought about by exposing the gland, after resection of the sternum, and fixing it to the cervical fascia in one case, and by extirpating a part of the gland in the other. In the typical case there is labored, groaning res- piration, not occurring in paroxysms but persistent ; the dyspnea sometimes amounts to violent choking fits with cyanosis, so that the affection (which is also called asthma thymicum) has often been erroneously described as laryn- gismus stridulus. Since the clinical feature is not a spasm of the vocal cords, but a compression of the trachea and bronchi, the term inspiratory stridor is the most scientific, and should be applied at least to cases in which the diag- nosis of a thymic origin for the dyspnea is not quite clear. This compression, as M. Schmidt ^ observed in a woman, twenty-five years old, who had suffered from inspiratory stridor during infancy, may be permanent. 3. RELATIONS BETWEEN THE UPPER AIR- PASSAGES AND THE EARS. The interdependence of the upper air-passages and the . ears depends, in the majority of cases, on the communica- tion established by the Eustachian tubes, which open into 1 Avellis, "Arch. f. Laryng.," vni, p. 159. 2 " Berlin klin. Wochen.," 1896, No. 40. 3 "Miinch. med. Wochen.," 1898, Nos. 30 and 31. * Cited by Avellis. 36 THE RESPIRATORY ORGANS. the lateral walls of the pharynx, and their function in con- nection with the middle ear. Hence, to understand the mechanism of secondary ear affections, when the primary disease focus is in the upper air-passages, the following points, which will later be described more in detail, must be borne in mind. The Eustachian tube ventilates the middle ear, and regulates the tension by equalizing the differences that may arise between the atmospheric pressure on the tympanic membrane in the external meatus and in the postnasal space, and the pressure of the air imprisoned in the middle ear. Whenever the equilibrium is disturbed, auditoiy disturb- ances result, which have their seat in the tympanic mem- brane and in the sound-conducting apparatus. Such disturbances may follow disease in the upper air- passages, obstructing or occluding the pharyngeal orifice, or interfering with the action of the palatal muscles which effect the opening and closing of the tube. The Eustachian tube represents the path by which disease of the pharyngeal vault spreads by continuity to the middle ear ; the mucous membrane of the tube becomes involved in any disease affecting the mucous membrane of the nose and pharynx ; or, in other words, the tube repre- sents the channel through which infection reaches the mid- dle ear from the upper air-passages. THE EFFECT OF DISTURBANCES OF THE NORMAL FUNC- TION OF THE EUSTACHIAN TUBE. For the proper comprehension of this relation a few in- troductory remarks are required to explain the mechanism by which the normal tube neutralizes the variations in pres- sure of the atmospheric air in the middle ear. The tube does not keep up a constant communication between the two air- chambers — that of the pharynx and that of the middle ear. In the state of rest its pharyngeal extremity remains closed, ^ and is opened only when the muscles of the palate and pharynx, which are devoted to its service, are brought into action. As the opening of the tube is effected by the tensor veli and levator veli muscles, the pharyngeal orifice must be opened whenever these muscles contract, which happens 1 Hammerschlag, in "Wien. med. Wochen.," 1896, Nos. 39 and 40, makes the assertion that the tube is normally open. DISTURBANCES OF THE EUSTACHIAN TUBE. 37 regularly and frequently, accompanying the act of deglu- tition. The opening of the tube is, therefore, under the control of the will power, and we can equalize any disturb- ances of the pressure equilibrium by the simple act of swallowing, which establishes a communication between the postnasal space and the middle ear, through the opened tube. We instinctively take advantage of this phenomenon whenever a change in the atmospheric pressure takes place, as in climbing high mountains, during explosions and loud detonations, and, artificially, for therapeutic purposes, by means of pneumatic chambers. What, then, is the result if the tube fails to maintain the equilibrium ? What happens when the pressure is greater in the pharynx than in the middle ear, either because the pressure of the outside air has been raised or because the pressure of the air in the middle ear has been lowered ? Valsalva's experiment, which consists in artificially rais- ing the air pressure in the postnasal space by making a forced expiration with the nose held shut, — when the pharyn- geal orifice of the tube is forcibly opened and the air escapes into the middle ear, — would appear to indicate that the orifice opens automatically whenever the pressure in the pharynx is even slightly increased. This is not the case, however. On the contrary, a rise in the atmospheric pres- sure has the efifect of closing the tube tighter than ever, for we know from practical as well as experimental observation that increased pressure in the pharynx brings the mem- branous wall of the tube into closer apposition with the cartilage, thus forming a kind of valve, which shuts the canal off from the middle ear. The closure effected in this way may be so obstinate that an ordinary act of swallowing is unable to overcome it. A rise of pressure takes place regularly in the pharynx, independently of changes in the atmospheric pressure, when- ever the tube remains closed for any length of time, and the air imprisoned in the cavities of the tympanum undergoes rarefaction. It follozvs, therefore, that a fall in the tympanic pressjire occurs in all diseases in which the pharyngeal orifice of the Eustacliian tube is occluded. In explanation of this phe- nomenon we can not do better than quote the words of Bezold :i " In the middle ear, as in all vascular, air-con- 1 "Berl. klin. Wochen.," 1883, No. 36. 38 THE RESPIRATORY ORGANS. taining cavities, the volume of air diminishes whenever free communication with the atmosphere is interrupted, because the oxygen enters into chemic combination with the blood and the amount of CO2 given up is not enough to compen- sate for the loss in volume." These pressure variations give rise to a series of clinical pictures which are included under the general term of acute or chronic middle-ear catarrh, and hav^e as their most prominent symptom retraction of the tympanic membrane — a purely mechanical result of the increased pressure in the external auditory meatus. In the otoscopic image this abnormal position and the curvature of the tympanic membrane find their expression in the absence of the cone of light from its normal situation ; in the presence of irreg- ular reflexes ; in displacement of the handle of the malleo- lus, which assumes a more horizontal position, or eventually even disappears behind the posterior fold ; and, finally, in a marked projection of the short process and handle of the malleolus from the retracted membrane. The subjective symptoms are diminished auditory acuity and tinnitus aurium ; occasionally the patient complains of pain. The question whether the occasional occurrence of exudation in conditions of diminished tympanic pressure is due solely to hypcrcEinia ex vacuo can not be answered in the affirmative in every case. Although the possibility of such an origin deserves consideration, the fact that JiypercEinia ex vacuo is not by any means a regular accompaniment of occlusion of the tube is sufficient proof that other factors must also be operative to produce an effusion, and it is safe to assume the occurrence of an irritative inflammation of the mucous membrane. The idea of hydrops ex vacuo is therefore limited in its application, and must in many cases give way to the theor}^ of an inflammatory exudate. This view is con- firmed by clinical experience, since it is found that chronic occlusion of the tube, which produces the greatest dimin- ution of density, is not, as a rule, followed by exudation. On the other hand, in almost all cases of occlusion oc- curring after acute inflammations an exudate is formed which betrays its inflammatory nature in the otoscopic image by a simultaneous swelling and congestion of the deeper layers of the membrana tympani, and can be ascribed only to inflammatory swelling of the mucous membrane of the middle ear, with secondarv extension to the mucosa of DISTURBANCES OF THE EUSTACHIAN TUBE. 39 the membrana tympani. It follows, therefore, that the exudate is as much a symptom of middle-ear inflammation, or the time-honored "otitis media catarrhalis," as of oc- clusion of the Eustachian tube. The results of bacterio- logic investigations of this condition are not uniform enough to throw much light on the subject. Kanthack i found a great variety of pathogenic organisms in exudations follow- ing occlusion of the tube, while Scheibe ^ and Brieger ^ deny the presence of these organisms, and consider the " exudate ex vacuo " sterile ; hence we are not as yet jus- tified either in adducing the finding of microorganisms as proof of the inflammatory character of the exudate, or in denying it on the strength of a negative bacteriologic result. There is also a possibility of the pressure equilibrium being disturbed by an excess of pressure in the middle ear, most frequently due to a fall in the atmospheric pressure. Its pathologic significance is slight compared to the oppo- site condition. The rise in pressure is readily equalized by the tube, because, as previously described, there is no occlu- sion of the pharyngeal orifice by the air pressure, and the equilibrium is therefore easily restored by the act of deglu- tition. Hence a gradual fall in pressure, such as is ex- perienced in balloon ascensions and in mountain climbing, is easily borne, because the excess of pressure which at first occurs in the middle ear soon accommodates itself to the surrounding conditions. On the other hand, when the external pressure is suddenly removed, the excessive pres- sure in the middle ear is very apt to produce disturbances in the auditory organs by rupture of the membrana tym- pani. This is apt to occur when men are released from a caisson without the necessary precautions. Sudden rise of pressure in the middle ear is sometimes produced by blow- ing the nose, if the pharyngeal orifice is forcibly opened by a sudden increase in pressure in the postnasal space, allow- ing the air to escape through the tube. It is particularly in cases of nasal obstruction, when the expiratory blast can not escape and becomes imprisoned in the postnasal space, that violent blowing of the nose is apt to be followed by serious consequences in the ear, by producing hemorrhages or rupture of the membrane, especially if the latter is diseased or atrophic. 1 " Zeitschr. f. Ohr.," XXI. 2 "Zeitschr. f. Ohr.," xxiii. 3 " Deitr. z. Ohrenheilk.," p. 59. 40 THE RESPIRATORY ORGANS. It is still an open question whether the tinnitus aurium which occasionally occurs in gradual changes of the external air pressure originates within the organ of hearing, or whether it is due to other causes. The subjective noises heard during balloon ascensions and mountain climbing are naturally attributed to the variations in pressure between the middle ear and the external air. But if we study the clinical picture of so-called mountain sickness, we are struck with the predominance of the circulatory phenomena, the markedly accelerated pulse, the dyspnea, and local symptoms of flashes and subjective noises in the ears ; we are irresistibly led to attribute the ocular and aural phenomena to the vascular disturbances, and not to alter- ations of the special sense organs. It may be well in this connection to call attention to the fact that similar phenomena, though somewhat milder in character, occur in the treatment of heart and lung diseases with rarefied and compressed air, when the patients are entering or leaving the pneumatic chamber. A certain degree of caution is therefore advisable in the case of in- dividuals whose hearing is not quite perfect, especially such as are troubled with tinnitus aurium. Schwartze's ^ observation that " many persons with incurable middle-ear sclerosis experience relief during a protracted stay in high Alpine health resorts, on account of their freedom from the distressing tinnitus aurium, and the marked improvement in the hearing " has not been ex- plained. But is it not permissible to assume that the aural symptoms are due to circulatory disturbances ? For if the tinnitus is really a vascular murmur within the ear, would it not be relieved by the beneficial effect of the altitude on the heart? DISTURBANCES OF THE FUNCTION OF THE EUSTACHIAN TUBE DUE TO ALTERATIONS IN THE UPPER AIR-PASSAGES. The diseases of the upper air-passages that diminish the permeability of the tubes are principally those which are accompanied by swelling of the mucous membrane. The relation existing between the nose and the postnasal space is a very intimate one, and very few diseases have their 1 " Die chirurg. Erkr. des Ohres," p. 169. DISTURBANCES OF THE EUSTACHIAN TUBE. 4 1 origin and exclusive seat in the postnasal space without in- volving the nose. The great majority of pharyngeal diseases arise, as we have already stated, by extension from the nose, so that the importance of rhinology in the study of diseases of the ear is easily explained. Any acute catmn^Ji in the upper air-passages may lead to intumescence and occlusion of the pharyngeal orifice, and thereby produce a fall in the pressure of the middle ear. As soon as the swelling subsides and the tube again becomes patulous, the morbid symptoms usually disappear without treatment. In chronic catarrh, on the other hand, as the hypertrophy of the mucous membrane does not, like the hyperemia in acute catarrh, tend to disappear sponta- neously, the changes produced in the middle ear by occlu- sion of the tube are of a more lasting character. The continued tension of the membrana tympani leads to atrophy, and the persistent retraction disturbs the normal relation of the ossicles, which then exert a constant pressure on the fenestra ovalis. It is fair to assume that, in consequence, the muscles of the ossicles — the tensor tympani and the stapedius — are thrown into a state of permanent contraction, and probably atrophy from disuse ; while, as a result of the hypercBinia ex vacuo, a chronic inflammation of the mucous membrane of the tympanum develops, giving rise to morbid conditions which can not be distinguished clinically from catarrh of the middle ear due to other causes. These conditions are in great need of anatomic and clinical investigation ; in fact, the concept of middle-ear disturbance by occlusion or obstruc- tion of the tube has never been clearly differentiated from the idea of inflammatory middle-ear catarrh, and the various views advanced in the text-books descriptive of middle-ear catarrh of inflammatory and noninflammatory origin merely add to the confusion. Any and all diseases of the nose and postnasal space which are followed by obstruction of the nasal passages lead to passive hyperemia in the mucous membranes, which in turn produces occlusion of the Eustachian canal. The recognition of this important fact is comparatively recent, and since the causal relation between these disturbances and the interference with nasal respiration by the presence of adenoid growths was definitely established the attention of clinicians has been directed to tlie significance of nasal 42 THE RESPIRATORY ORGANS. Stenoses in occlusions of the Eustachian tube. The inter- ference with nasal breathing may be due to a number of conditions within the nose, as hypertrophy of the mucous membrane, mucous polypi, tumors, syphilitic or tuberculous infiltrations, foreign bodies, etc. There may be a congeni- tal narrowing of the nasal cavity from deformity, and hy- perplasia of the septum or abnormal curvature of the tur- binated bones. The obstruction may be situated in the postnasal space, and may take the form of hypertrophied pharyngeal tonsils, tumors, syphilis, or tuberculosis occlud- ing the posterior nares. Hence the recognition and re- moval of any obstacle to nasal respiration should constitute an integral part of every examination and treatment of the ears. There can be no hope of curing the ear affection be- fore the causes which are responsible for the congestion of the mucous membrane have been removed and the permea- bility of the tube has been restored. If I have included hypertrophy of tlie pharyngeal tonsils or adenoid vegetations among the diseases which produce hy- peremia and swelling of the mucous membrane, with occlu- sion of the tube by interfering with nasal respiration, it is because I believe the occlusion is due to a general " adenoid habit" of the nose and pharynx, rather than to the direct mechanical intrusion of the pharyngeal tonsil. The "ade- noid habit" manifests itself in the rhinoscopic image as a hyperplasia of the entire lymphatic ring of Waldeyer ; the follicles in the posterior pharyngeal wall and in the longitu- dinal folds on each side of the pharynx are more numerous, and are intensely red and swollen. Hyperplasia of Rosen- miiller's crypts and of the anterior fold of the tube may develop as the manifestation of a general hyperplasia of all the lymphatic elements entering into the formation of the so-called pharyngeal lymphatic ring ; hyperplasia of these structures necessarily favors the occlusion of the tube by compressing the orifice. Two forms of adenoid enlargement are distinguished : a diffuse, cushion-like hyperplasia, and a villous variety con- sisting of finger-like projections or true vegetations. Their usual seat is the roof and upper portion of the posterior wall of the pharynx, so that they fill the upper part of the postnasal space more or less completely, and whenever they hang down below the level of the upper margin of the posterior nares, the latter are obstructed and nasal breath- DISEASES OF THE MIDDLE EAR. 43 ing is interfered with. As the vegetations usually spring from the median line, they are not, when at rest, in contact with the lateral walls of the pharynx and therefore do not occlude the orifices, as we are frequently able to demon- strate in the postrhinoscopic image ; but whenever the palatal and pharyngeal muscles contract, as in swallow- ing, retching, and similar movements, the lumen of the postnasal space is constricted and the enlarged growths are forced against the lateral walls of the pharynx, thus giving rise to periodic occlusion of the tube. The adenoid tissue is not the soft, gelatinous mass that it is sometimes com- pared to, but is comparatively firm, and returns to its normal position of rest, dependent on gravity, as soon as the constrictors of the pharynx and the tensores and leva- tores palati relax and the postnasal cavity regains its normal volume. But it is not clear to me how a momentary occlu- sion of the orifice can have the same effect as a permanent one, and I therefore consider the hyperemia of the entire mucous membrane the most important factor in the produc- tion of aural complications. Paralysis of the muscles of the soft palate, especially of the levator veli palatini and tensor veli palatini, — muscles which effect the opening of the Eustachian tube, — is fol- lowed by permanent occlusion, with the usual appearances of the membrana tympani. The action of the muscles may be similarly affected by tumors, by syphilitic, tubercular, or other kinds of ulcerations or their scars, and by cleft palate, so that these conditions are also occasionally accompanied by middle-ear disease. DISEASES OF THE MIDDLE EAR DUE TO INFECTION FROM THE POSTNASAL SPACE. The cartilaginous portion of the Eustachian tube is lined with ciliated columnar epithelium, the ciliary current being directed toward the pharynx, which is replaced at the isth- mus by cells of the same type as that of the middle ear. Since, therefore, the mucous membrane of the tube is a direct continuation of the epithelium of the postnasal space, we can readily understand that an inflammatory process beginning in the latter is not arrested at the pharyngeal orifice, but is continued into the tube itself, and may be followed by acute inflammation of the mucous membrane 44 THE RESPIRATORY ORGANS. of the middle ear. Next to acute rhinitis and pharyngitis, the most important inflammations in the etiology of otitis media are those which occur in the aaite exanthemata. These will be discussed elsewhere. In addition to the ordinary inflammations of the mucous membrane of the tube and middle ear, we observe acute suppurative otitis media in the train of acute nasal and phar- yngeal diseases. As we may have either a simple or a suppurative inflammation without any apparent external reason, we are forced to assume a different behavior of the mucous membrane of the middle ear in regard to the in- vading pathogenic germs to explain the occurrence of sup- puration in the middle ear through the channel of the Eustachian tube. It is well known, as has been mentioned, that the nose and postnasal space harbor a multitude of microorganisms. Their presence in the healthy organism appears to have no significance, perhaps because of a bactericidal property of the mucous secretion which destroys the virulence of the pathogenic germs and prevents their further development. It may also be assumed — and has, in fact, been practically demonstrated experimentally by Zaufal, Kanthack, Scheibe, and others, in spite of the differences in the individual results — that the middle ear normally contains bacteria which may, under favoring circumstances, regain their vir- ulence. The number of bacteria in the middle ear and the liability of the organ to infection depend on the condition of the epi- thelium lining the tube and the size of the lumen. If the ciliated epithelium is intact, it enables the tube to rid itself of any deleterious substances, and thus forms a protection against invasions from the pharynx. Since any inflamma- tory alterations, be they acute or chronic, which destroy the integrity of the epithelium tend to remove this natural pro- tection, they will naturally be accompanied by inflamma- tion and suppuration in the middle ear. The question whether abnormal dilatations of the tube may produce pathologic conditions in the ear by affording an easier entrance to pathogenic germs deserves passing mention. In catheterization of the tube the nature of the blowing noise, and the strength of the concussion-note afford a clue to the size of the lumen. But, in addition to this, other DISEASES OF THE MIDDLE EAR. 45 signs have been noted, depending on the respiration, which point to abnormal dilatation and permanent patulousness of the tube. Respiratory movements have been observed in the tympanic membrane by Lucae,i Schwartze,^ Wagenhauser, ^ and Ostmann ; * the membrane retracts during inspiration and bulges toward the external meatus in expiration. These observations were, however, always made on atrophic or cicatricially contracted membranes, which respond to a much slighter pressure than would a tense healthy mem- brane. According to Ostmann, it is sometimes possible, with the aid of a tube inserted into the external meatus, to hear an inspiratory and expiratory murmur, even in healthy individuals during quiet nasal respiration. Finally, Lucae's manometric experiments called attention to the occurrence o^ pressure valuations in the external auditory meatus synchro- nous with the respiratory movements. Ostmann, it is true, obtained varying results when he tried the same experiments; although he observed a constant variation of about ^ of a mm., synchronous with the pulse-beat, he could not demon- strate a constant coincidence with the respiratory move- ments. The first-mentioned phenomenon — respiratory move- ments of the tympanic membrane — is undoubtedly to be attributed to abnormal dilatation and permanent patulous- ness of the tube, while the second is of no value in the diagnosis of these conditions. Abnormal dilatation of the tube is practically a constant feature of atrophic catarrh of the nose and pharynx, rhinitis foetida atrophica, and these conditions are regularly accompanied by disease of the middle ear, either in the form of sclerosis of the middle ear or chronic suppurative otitis media. Sclerosis occurring in atrophic rhinitis is caused by a disease of the mucous membrane analogous to the dry catarrh of the upper air-passages. The histologic changes in otitis media sclerotica closely resemble those of "xero- sis " of the mucous membranes of the upper air-passages (Sticker), so that the middle-ear affection must be interpreted as a process analogous to atrophic rhinitis and pharyngitis. This was pointed out several years ago by Abel, when he 1 " Arch. f. Ohr.," vol. il. 2 << ^rch. f. Ohr.," vol. 11 3 " Arch. f. Ohr.," vol. xxi. ■* " Arch. f. Ohr.," vol. XXXIV. 46 THE RESPIRATORY ORGANS. demonstrated his bacillus mucosus ozcenae in the middle ear, although that discovery seems to me to be of little import- ance, in view of the questionable connection between this bacillus and the development of ozena. It may be said that suppuration in the middle ear is principally due to the greater ease with which pathogenic germs can gain entrance when the tube is dilated, and to metaplasia of the epithelium. Ostmann ^ has called attention to another pathologic change at the pharyngeal orifice which may produce dilata- tion of the tube. The lateral wall of the tube is provided with a pad of fat, which normally acts as a natural protec- tion by facilitating the close application of the lateral to the median wall and thereby closing the tube. In emaciated individuals this pad is so much reduced that the tube is not perfectly closed, and there is a greater tendency to infection of the middle ear from the pharynx. Ostmann believes this to be the explanation of tubercular suppuration in the middle ear, which develops in phthisical patients when the general condition is weakened, and in the fourth or fifth week of typhoid, when the nutrition of the patient is much reduced. From a practical standpoint the infection of the middle ear through the introduction of infectious material into the tubes by therapeutic measures is extremely important. It may occur — by the current of air carrying mucus and pus from the nose, postnasal space, or orifice of the tube into the ear — during the performance of Valsalva's experiment or violent blowing of the nose with the nostrils closed, which has the same effect, and in Politzer's method of in- flating the tympanum, which consists in blowing air through one side of the nose while the nasopharynx is shut off from the oral cavity and the anterior nares are closed, so as to raise the air pressure in the postnasal space and force open the pharyngeal orifice of the Eustachian tube. Another danger of infection of the middle ear from the pharynx arises from the use of nasal douches in hypertrophic conditions of the nasal mucous membrane. As the water enters the nasal cavities under considerable pressure, and can not escape through the nose on account of the swelling of the membrane, it is dammed up in the postnasal ^ "Arch. f. Ohr.," xxxiv, p. 188, etc. THE EARS. 47 space, and being under pressure, easily makes its way into the middle ear. This is, therefore, an example of the im- proper use of the nasal douche, being in violation of the principle that the use of a nasal douche with low pressure is permissible only when both sides of the nose are sufficiently open to allow free access to and egress from the nose. Even when this rule is carefully observed there is a possibility of water reaching the middle ear, if during its passage the patient swallows or chokes, or performs a similar act which opens the Eustachian tubes and facilitates the entrance of the fluid into the middle ear. ^ But as, in spite of the frequency of these harmful condi- tions and the presence of infectious mucus in the upper air-passages, infection of the middle ear takes place only occasionally and in certain cases, it is evident that the de- velopment of pathogenic germs is determined more by a favorable condition in the ear itself than by the fact of their gaining entrance through the tube. Such a condition is produced chiefly by acute inflammations of the mucous membrane, and we expect to find suppuration of the middle ear in acute coryza, in the acute exanthemata which are accompanied by rhinopharyngitis, and in the acute inflam- mation which follows the use of the galvanocautery in the nose ; and we can not emphasize too strongly that air douches, as well as the ordinary nasal douche, are to be avoided in acute disease of the nose and throat with inflam- matory changes in the Eustachian tubes. 4. THE EFFECT OF VARIOUS DISEASES OF THE RESPIRATORY ORGANS ON THE EARS. Pain in the cars or pain radiating from the neck to the ears is a symptom occurring in a great variety of diseases of the upper air-passages. It occurs with the greatest regu- larity in all inflammatory diseases of the epiglottis and upper margin of the larynx which are accompanied by swelling, and is met with also in malignant tumors of the ' The rule which obtains in our country — viz., to introduce the tip of the nasal douche only into the side of the nose most obstructed, to allow free exit of the fluid from the more open side — would seem an important sugges- tion. — Ed. 48 THE RESPIRATORY ORGANS. larynx and upper portion of the esophagus. The physi- cian sees many cases of tuberculosis with infiltration and ulceration of the mucous membrane covering the cartilages, and perichondritis of the epiglottis and arytenoid and cricoid cartilages, in which the patients complain of violent pain radiating to or localized in the ear. The pain is in- creased by any pressure or movement in the affected region, and usually attains its maximum intensity during the act of swallowing, making it very difficult to feed the patient properly. The greatest distress is usually complained of when the patient invoknitarily goes through the act of swallowing, just as in any form of angina, and especially in tonsillar abscess, while the swallowing of slimy, semisolid food is a little less painful. In carcinoma of the larynx pain radiating to the ears is practically a constant symptom ; it is usually of a paroxys- mal character, like the lancinating pain of neuralgia. In the early stages of the growth the pain is dull and localized in the larynx, but radiates to the ears when the ulcerative stage is reached. ^ Since the sensory nerves at the entrance to the larynx and in the deeper portions of the pharynx are branches of the vagus, and the external auditory meatus receives sensory fibers from the same trunk through the auricular nerve, the vagus must be the channel by w^hich these reflex pains are transmitted. The reflex arc is very well devel- oped, as is shown by the fact that irritation of the sensory filaments of the auricular nerve of the vagus in the external meatus — as, for instance, when a speculum is introduced — often brings on a fit of coughing. Our information in regard to the relation existing between croupous pneumonia and purulent otitis media is not very definite and lacks clinical confirmation ; it amounts to this : suppuration in the middle ear is rare after croupous pneu- monia, presents no distinct type, and its course is not different from that of any other form of purulent otitis media. In severe cases of pneumonia with high fever the tympanic membrane is found to be injected without exuda- tion taking place, just as in other infectious fevers, especially typhoid. Again, as in other diseases characterized by great 1 Comp. Fauvel, " Traite pratique des malad. du larynx," 1876, p. 707. THE EARS. 49 elevation of temperature, a chronic suppuration may tem- porarily subside during the fever, and the perforated membrane and mucosa of the tympanum appear dry and dark red in color ; but there is no reason to suppose that these phenomena have any specific relation with the pneu- monia. Acute suppuration in the middle ear is occasionally pro- duced by the diplococcus pneumoniae of Frankel-Weichsel- baum. Netter,! as early as 1890, called attention to the frequent occurrence of the pneumococci in the pus found in the ears of little children at autopsies, and his findings have been confirmed by Rasch,^ who found the pneumococci of Talamon-Frankel in the ear secretion of 33 out of 43 cases examined by him ; he also comments upon the remarkable fact that these exudations are practically never accom- panied by perforation of the tympanic membrane. Zaufal ^ says there are ear-diseases " which run a strictly pneumonic course ; they are ushered in with a chill, the temperature falls, and recovery takes place by crisis on the seventh or eighth day." This observation of Zaufal led Haug '^ and Brieger ^ to "assume a strictly pneumonic character and course for otitis due to diplococcus infection," or at least to point out the similarity " evidently existing in many particu- lars between genuine pneumonia and acute purulent otitis media." If they had read two lines further in Zaufal' s article they would have seen that he considers it practically certain " that otitis due to streptococcus infection may run exactly the same course." When it is remembered that the diplococcus pneumoniae is simply a pathogenic organism which does not produce pneumonia exclusively, and may give a general septic infection in no way distinguishable from that produced by other pyogenic organisms ; and when, on the other hand, it is considered that diplococci are constant inhabitants of the upper air-passages in the healthy body, and can easily reach the middle car and set up a suppuration if the condition of the mucous membrane is favorable, just like any other pathogenic organism that 1 " Comptes rendus de la soc. de biolog.," iSgo. 2 " Jahrb. f. Kinderheilk.," xxxvn, p. 32S e^ se//. ^ " Arch. f. Ohr.," xxxi, p. 184 ^/ si-i/. *" Die Kranklieiten des Olires," etc., p. 50. 5 <' Klin. ]5eitrage zur Ohrenbeilk.," p. 68. 50 THE RESPIRATORY ORGANS. may be constantly present in the air-passages, it is well- nigh incredible that the mere fact of this organism playing a certain not thoroughly understood role in croupous pneu- monia, and setting up a suppuration in the middle ear, should be utilized as a base on which to rear, with infinite art and ingenuity, the edifice of an entirely new disease, under the name of "pneumonic otitis media.'" Wreden ^ maintains that disease of the ear may be caused hy atelectasis, bronchiectasis, 2X\.(\ capillary broncliitis ; citing in explanation Lucae's observation that under normal conditions there is a regular pressure variation synchronous with the respiration. Believing, with Lucae, that the mid- dle ear is in this way ventilated with every respiration, he concludes that the ventilation is insufficiently performed whenever the respiration is impaired, and consequently any disease which is attended with reduction of the respiratory function may be followed by disease in the ear. We have already said enough on this subject to show that we consider these opinions as disposed of, but Wreden must nevertheless be given credit for having pointed out the frequency of ear anomalies observed at the autopsy in infants about a year old who died of pneumonia, presumably the catarrhal form. Later, Rasch '-^ examined the bodies of 43 children dead of bronclwpneiimonia, and in 42 in- stances found inflammatory conditions in the ears, which in 30 consisted in middle-ear suppuration ; while Ponfick,^ in 10 out of 1 1 cases of uncomplicated pneumonia, found middle-ear suppuration at the autopsy, the ages ranging from one month to four years. In the absence of more convincing information, especially of a clinical nature, the question whether catarrhal pneumonia is the real cause of the suppuration must remain undecided. In the present state of our knowledge it seems more likely that the child- ish organism is predisposed to suppuration of the middle ear by any disease which seriously interferes with its nu- trition, whether it be catarrhal pneumonia or any other affection. Later on we shall study the significance of intes- tinal affections in the production of ear diseases in young infants, and shall then learn that occasionally nutritive dis- turbance, by its weakening effect on the general resisting 1 " Mon. f. Ohr.," 1S68, p. 105 et seq. 2 Loc cit. 3 " Berl. klin. Wochen.," 1897, p. 852. THE EARS. 5 I power of the infantile organism, is the predisposing cause of the aural complication. The possibility of infection in the opposite direction de- serves passing mention. Bronchitis and bronchopneumonia occasionally develop after purulent otitis media by aspira- tion of particles of pus and the contained bacilli which have found their way into the pharynx from the middle ear. II. DISEASES OF THE CIRCULATORY SYSTEM. L DISEASES OF THE HEART AND BLOOD-VES- SELS IN THEIR RELATION TO THE NOSE, PHARYNX, AND LARYNX. Diseases of the heart and blood-vessels lead to — 1. Circulatory disturbances in the mucous membranes of the upper air-passages, producing hemorrhages, hyper- emia, and congestive catarrh. 2. Motor disturbances by direct injury to the laryngeal nerves which are situated in their immediate neighborhood. 3. Pulsation of the large arterial trunks, when they are diseased, is transmitted to various portions of the upper air-passages. 4. Aneurysm of the aorta may lead to stenosis of the trachea or rupture into that tube. Hemorrhages from the mucous membranes of the upper air-passages constitute a frequent concomitant of cardiac disease without compensation, and occur also, in conse- quence of the rise of arterial pressure, when compensation exists ; they are most common in venous stases due to failure of compensation in mitral disease and in aortic insuffici- ency. They are also observed in arteriosclerosis, and Edgren ^ reports the occurrence of epistaxis " during the presclerotic period, at a time when the only recognizable symptom is a heightened arterial pressure " ; he considers it, when occurring in elderly persons without apparent cause or after violent emotion, a symptom of incipient arterio- sclerosis. The attacks soon cease to appear, even when they have been severe at one time. During the later stages of arteriosclerosis "the attacks 6f epistaxis appear to dimin- ish in frequency, probably because of lowered blood pres- sure and lessened cardiac activity " (Edgren). 1 "Die Arteriosklerose," Leipzig, 1898. 52 THE HEART AND BLOOD-VESSELS. 53 Epistaxis is the commonest form of bleeding from the mucous membranes ; hemorrhages from the pharynx and larynx are rare. Although the usual, one might almost say the constant, seat of epistaxis is the spot known as locus Kieselbachii, on the cartilaginous portion of the sep- tum, — recognized by the greater density of the vascular plexus, — the hemorrhages which occur in general circula- tory disturbances often appear to originate in the lateral walls, and especially in the cavernous tissue. It is, unfor- tunately, impossible to locate the bleeding point while the hemorrhage continues, and even after the bleeding has stopped it is not always possible to determine its origin, on account of the hyperemic condition of the nasal mucous membrane and the presence of blood-clots. Hemorrhages have been reported from the veins at the base of the tongue, which sometimes become enormously engorged in condi- tions of passive hyperemia, and Compaired ^ mentions hemorrhage from the plexus on the glosso-epiglottidean fold in mitral insufficiency. The hyperemia in course of time gives rise to congestive catarrh, involving the entire mucous membrane of the upper air-passages, and presenting the symptoms and clin- ical appearances seen in chronic rhinitis, pharyngitis, and laryngitis. The recognition of the symptoms of these forms of chronic catarrh is important, as it materially affects the treatment. Local measures are, of course, little •adapted to effect a cure ; painting with silver nitrate solu- tion, which for some reason is such a favorite mode of treatment, is absolutely useless as long as constitutional treatment is neglected. Passive edema in the larynx is a late complication, which does not develop in heart disease until failure of compen- sation has led to general edema ; it therefore has no great value in diagnosis, as the local symptoms at this period are always overshadowed by the general phenomena.^ The paralyses which occur in the course of cardiac and vascular disease find their explanation in the proximity of the recurrentnerves to the great vessels in the mediastinum. The inferior laryngeal nerve is a branch of the pneumogas- ' " Ann. des maL de I'oreille," 1896. p. 470. ^ In "Arch. f. Laryng.,',' vol. vni, No. 3, v. Sokolowski gives a descrip- tion of the "morbid changes in the upper portion of the respiratory tract in the course of valvular disease." 54 THE CIRCULATORY SYSTEM. trie, arising in the mediastinum, and, as its name — recurrens — implies, running back and upward to the larjmx. The two nerves follow a different course^ and therefore come into relation with different structures on the two sides of the body. The left nerve winds around the aorta and ascends along the posterior margin of the lateral wall of the trachea, in the groove between it and the esophagus, to reach the larynx ; the right arises from the vagus at the level of the subclavian artery, winds around this vessel from before backward, and follows a course between the trachea and esophagus similar to that of its fellow. The commonest causes of disturbances in the upper air- passages are found in dilatations of the great vessels, due to aneurysm. The most important are the aneurysms of the aorta, the symptoms of which require a detailed description. They consist in paralysis of the recurrent by direct injury to the nerve ; transmitted pulsation of the larynx and trachea ; tracheal stenosis from displacement of the wall of the trachea ; and, lastly, rupture of the aneurysmal sac into the trachea. Since the left recurrent nerve is in contact with the entire circumference of the acch of the aorta, it is affected by any aneurysm exerting pressure or traction on that structure. Traube ^ was the first to describe a paralysis of the recur- rent due to aneurysm of the aorta, and since his day in- numerable similar cases have been reported, so that paraly- sis of the left vocal cord has become one of the most important symptoms in the diagnosis of aneurysm of the aorta. Paralysis of the recurrent nerve — a term by which, as will be more fully explained in treating of diseases of the nerves, is meant complete paralysis of all the muscles supplied by the inferior laryngeal nerve, the adductors as well as the abductors — is a typical symptom of aneurysm of the aorta, and, on account of the peculiar hoarseness it produces, rarely escapes the notice of either the doctor or the patient. It is quite different with the other form of paralysis of the recurrent, which affects only the cricoary- tcxnoideus posticus, and exerts but little influence on either phonation or respiration, so that for several reasons it is not often observed in aneurysmal disease. It represents the 1 " Deutsche Klinik," i860, No. 41. THE HEART AND BLOOD-VESSELS. 55 early stage of paralysis, and may be present when the aneurysm is beginning to develop, before any clinical symptoms have made their appearance. As this form of paralysis produces no functional disturbances, it escapes the notice of the physician, unless it is accidentally discovered in the course of a laryngoscopic examination. It is owing to these two facts — the gradual, and at first painless, development of the aneurysm and the absence of symptoms in paralysis of the posticus — that the disease does not, as a rule, come under observation until it has made considerable progress, and the change from the median to the cadaveric position, which is the outward sign of paralysis of the recurrent, has taken place. Among other motor disturbances in the larynx in aneurysms of the aorta may be mentioned laryngospastic attacks and periodic palsies of the vocal cords. Lori and Grossmann have de- scribed certain laryngeal disturbances which are rarely observed as symptoms of incipient aneurysm of the aorta. Lori 1 says that the pressure of the aneurysm on the re- current nerve in some cases provokes transient motor phenomena in the muscles of one-half of the larynx, which manifest themselves in difficult articulation ; in hoarseness, occurring at frequent intervals and without discoverable cause ; in sudden changes of the voice or of a single note ; and occasionally in spasm of the vocal cords. These phenomena, however, which are due to the irritation of very slight pressure, according to Lori, are replaced after a few days or weeks by paralysis of the entire half of the larynx from the increased pressure on the recurrent nerve. In agreement with Lori, Grossmann explains similar phenomena observed by him as the effect of irritation by the gradually increasing pressure of the aneurysm on the nerves. His case ^ is remarkable from the fact that he was able to observe it more than a year. The patient came to be treated for frequent attacks of dyspnea of short duration, before there was any suspicion of aneurysm. After one of these attacks Grossmann observed a " paraly- sis of the left vocal cord," which disappeared on the follow- ing day. A few days later there was another attack of dyspnea, also accompanied by " total left-sided paralysis '"Die diirch Allgemeinerkrankung Ijewirkten anderweitigen Veninder- ungen," etc., p. 61. 2 " Arcli. f. I.aryng.," vol. 11, p. 254. 56 THE CIRCULATORY SYSTEM. of the vocal cord." It is not quite clear from the descrip- tion whether we have here a paralysis of the posticus or of the recurrent. One year later unmistakable clinical symp- toms of aneurysm had developed, and, with the appearance of a total left-sided paralysis of the recurrent, the laryngo- spastic attacks ceased. We have so far confined ourselves to the effects of pres- sure on the left inferior laryngeal nerve by an aneurysm of the aorta. The explanation of those cases, first described by Gerhardt ^ and Baumler,^ in which left-sided paralysis of the recurrent is combined with a similar paralysis on the right side, or in which there is right unilateral paralysis of the vocal cords, presents greater difficulties, as the course of the right recurrent nerve does not make the occurrence of such a condition appear probable. Among similar cases may be quoted Onodi's,^ in which the right vocal cord was fixed in the cadaveric, and the left in the median posi- tion, and Cartaz's case, in which there was marked dyspnea and both vocal cords were seen in the median line, two or three millimeters apart, immovable, with concave edges. It is remarkable how often Lori * found the right nerve in- volved ; he reports three cases of paralysis of the right half of the larynx and two cases of bilateral paralysis. Baum- ler gives as an explanation of his case that the aneurysm produced overfilling, or even an aneurysmal dilatation, in the right subclavian artery, or that it pressed on the nerve from below at its origin from the pneumogastric. Another explanation appears to me to be suggested by the fact that unilateral paralysis of the pneumogastric is capable of pro- ducing bilateral disturbances of mobility. Semon,^ and before him Lori,^ gives the following explanation : A peripheral stimulus of the pneumogastric is transmitted through the afferoit fibers of that nerve to the center in the medulla ; from there it passes into the two motor nuclei of the vagus (Semon calls them the accessory nuclei), and thus gives rise to a bilateral disturbance of motility (John- son's theory '^). Aneurysms of the aorta ultimately produce changes in " Virch. Arch.," xxvn, p. 75. 2 « Arch. f. klin. Med.," Ii, p. 550. " Semon's Centralbl.," X, p. 429. " Semon's Centralbl.," vni, pp. 35S and 493. ^ Loc. cif., p. 62. Heymann's " Handb. der Laryng.," I, p. 615. Semon quotes " Med. Chir. Trans.," vol. Lviii, 1875. THE HEART AND BLOOD-VESSELS. 57 the trachea ; pulsating movements, which may extend to the larynx ; tracheal stenoses by compressing the walls ; and, finally, pressure nlcers and perforations. The arch of the aorta curves over the left bronchus from before backward, and lies close to the left anterior aspect of the trachea, just above the bifurcation, so that it occupies the obtuse angle formed by the trachea and left bronchus. Even under normal conditions a movement can be observed in the spur of the trachea in the laryngoscopic image, caused by the transmitted pulsation of the aorta. When the arch and descending limb of the aorta are dilated by an aneurysm and brought into closer contact with the trachea, the pulsation is communicated to the entire trachea, and can be observed even in the larynx. Oliver suggests bending the patient's head back, so as to draw the larynx upward, for the purpose of bringing out tracheal pulsation, while Cardarelli ^ observes the pulsation by the movements of Adam's apple with the patient's head bent back, and even pretends to be able to diagnose the seat of the aneurysm by the oblique direction of the pulsating movements. Compression of the windpipe by an aneurysm in most cases produces a so-called scabbard-like stenosis of the trachea on the left side, with stenosis of the left bronchus. When the aneurysm is in the ascending limb, or in the arch, the pressure may in rare cases be exerted on the right side of the trachea and on the right bronchus. It is important to recognize these tracheal stenoses, as the respiratory em- barrassment might otherwise be attributed to paralysis of the vocal cords which is usually present at the same time. Tracheotomy under such circumstances is, of course, use- less ; even the introduction of a cannula to the bifurcation, beyond the seat of the stenosis, gives only a temporary relief, because the pressure of the cannula very soon pro- duces decubital ulcers in the trachea, through which rupture of the aneurysm takes place. The rupture of an aneurysm into the trachea or bron- chus is not a rare occurrence, but the mechanism has been variously explained by different anatomists. Eppinger ^ believes that the tracheal rings are forced apart by the wall of the aneurysm, and that rupture takes place through secondary aneurysms which form between the separated 1 "Centralbl. f. inn. Med.," 1894, No. 42, p. 988. 2 Klebs, " Handb. der pathol. Anatomic," VH, p. 270 ct seq. 58 THE CIRCULATORY SYSTEM, rings. He saw no proliferation of the cartilage or ulcera- tion of the mucous membrane: "The edges around the seat of rupture were turned toward the interior of the trachea, and regularly sharp or delicately serrated and scaly, just as in true traumatic ruptures." Other authorities have described " conversion of the cartilage into detritus in con- sequence of compressing aneurysms, and atrophy of the cartilage by a process of fatty degeneration." ^ Accord- ing to Selter,^ who examined five cases, ulcers form in the mucous membrane as a result of the pressure, and subse- quently lead to rupture of the aneurysms into the trachea or bronchus, so that the rupture is prepared from without. In rare cases, paralysis of the vocal cords follows disease of other arterial trunks. Selter ^ saw an aneurysm of the innominate artery with paralysis of the right recurrent ; E. Meyer ^ describes the same lesion in aneurysm of the right subclavian artery ; in another case, marked pulsation in the pharynx was referred to aneurysmal dilatation of the carotid. A pericardial exudate sometimes gives rise to paralysis of the left recurrent. Baumler * first pointed out that the same condition can also produce paralysis of the right re- current. " If the exudate is very abundant, and distends the pericardium as far as the jugular notch, the engorge- ment of the veins which meet at that point may exert direct or indirect pressure on the right recurrent." The case he quotes, which seems to me entirely convincing, has been called in question by Landgraf,^ because the autopsy showed some slight syphilitic alterations in the larynx. The paralysis attains its greatest intensity at the height of the exudative process, and subsides with the pericarditis. In this respect Landgraf 's case is instructive : a pericar- dial effusion developed after articular rheumatism, and produced at first a paralysis of the posticus in the median position, which developed into paralysis of the recurrent in the course of the next two weeks, but the paralysis disap- peared when the primary disease was removed. Palpitation of the heart is one of the reflex neuroses, due ^ Klebs. " Handb. der pathol. Anatomic," vii, p. 270 et seq. -"Virch. Arch.," 133 ; also comp. D. Gerhardt, " Virch. Arch.," 123, p. 201. 3 "Arch, f, Laryng.," II, p. 263. * "Arch. f. klin. Med.," 11, p. 550 et seq. 5 " Charite Ann.," XIII, THE EAR. 59 to irritation in the nose. It occurs in chronic rhinitis with hypertrophy and polypus formation, and sometimes takes the paroxysmal form, analogous to sthenocardiac attacks and cardialgia. An interesting phenomenon, which has not as yet been satisfactorily explained, is sudden death from heart failure, which sometimes takes place a few days after extirpation of the larynx. Stork ^ attributes the phenom- enon to injury of a depressomotor branch of the superior laryngeus, which is not constantly present ; Grossmann ^ thmks it is caused by a central irritation of the superior laryngeal or of the vagus during the operation, while Toti^ reports, without explaining, a case in which acceleration of the pulse rate to from i6o to i8o occurred thirty hours after an operation for the total extirpation of the larynx ; and after twenty-four hours more of uninterrupted tachy- cardia the patient died of cardiac paralysis. 2. DISEASES OF THE HEART AND BLOOD- VESSELS IN THEIR RELATION TO THE EAR. Tinnitus aurium is a frequent symptom of disease of the heart and blood-vessels and of anemia or hyperemia of the vascular systems within the ear. Our knowledge of these conditions is unfortunately very scanty, and we are hardly more advanced than w^as v. Troltsch twenty years ago, when he wrote : " There is no doubt that tinnitus aurium is much oftener due to vascular murmurs than the profession has been inclined to believe up to the present time, as we are in the habit of attributing them chiefly to the in- fluence of the nervous apparatus. It is often impossible to decide which of the two varieties is present, and simulta- neous processes in both the circulatory and the nervous apparatus are probably of still more frequent occurrence." Before proceeding to the discussion of pathologic changes, let us direct our attention for a moment to the normal con- ditions in which we do not observe any vascular murmurs. Since Weil ^ could hear the heart-sounds communicated to 1 " Wien. med. Wochen.," i8S8 ; and Alpiger, "Langenb. Arch.," xl. 2 "Wien. med. Presse," 1892, Nos. 44-46. ■'" Deutsche med. Wochen.," 1S93, p. 87. ■^ " Die Auscultation der Arterien u. Ventn," 1S75. 60 THE CIRCULATORY SYSTEM. the blood stream as vascular murmurs by auscultation of the carotid in the neck, it might be supposed that they could be equally well heard over the internal carotid where it passes through the canal in the petrous portion of the temporal bone. The solid bone which lodges the labyrinth is excellently adapted to conduct the sound to the internal ear, and the position of the carotid near the anterior wall of the tympanum would appear to render its perception very easy. The fact that the sound is not heard appears to be due to the venous plexus which surrounds the artery within the carotid canal, and acts like a cushion to arrest the pulsations and soften the sound. The sinus of the jugular vein lies beneath the cavity of the tympanum ; and unless there are venous murmurs, there can not be any sound transmitted to the ear. The ear itself is provided with two systems of blood- vessels — one in the middle ear and one in the internal ear. The former is composed of various branches derived from the external and internal carotids ; the latter belongs to the internal auditory artery, a branch of the basilar. To the investigations of Eichler ^ and Siebenmann^ we owe our knowledge of the distribution of the capillaries in the neighborhood of Corti's organ. It was found that the membranes of Reissner and Corti, as well as that portion of the zona pectinata contained between the external pillar and the ligamentum spirale, are quite free from blood-vessels, and therefore the sensitive terminal apparatus of the auditory nerve is as far as possible removed from the influence of the vascular system. It follows, therefore, that since, in spite of the proximity of the great vessels, the healthy ear does not perceive vascular murmurs, one of two pathologic possibilities must account for the occurrence of vascular noises : there must be disease either of the organ of hearing or of the vascular system. In the former case the pathologic changes in the organ of hearing bring about more favorable conditions for the per- ception of the normal blood murmurs ; either the sound is more readily conducted on account of alterations in the 1 " Die Wege des Blutstroms iin menschl. Labyrinth," " Abhandl. der math. phys. CI. der kgl. sachs. Gesellsch. der Wissensch. ," vol. xviii, No. 5, P- 327- 2 See " Handb. der Anatomie," edited by v. Bardeleben, vol. v, part 2. THE EAR. 6 I bone or the presence of an exudate, or the irritability of the auditory nerve is heightened, so that noises which before were below its range of hearing are now appreciated by the sensory end-organs. The quality of this kind of tinnitus aurium, which must be included under the general head of entotic vascular murmurs, is not as yet sufficiently known to make a classification into definite types possible. The different characters of an arterial and a venous murmur, as they have been described, and the interruption of the sound by compression of the respective artery or vein are not constant symptoms and can not be utilized in making a diagnosis. We shall return to this subject in another place. The second group of subjective noises observed in dis- eases of the heart and blood-vessels are due to the trans- mission of abnormal vascular murmurs to the healthy ear. Among these we must distinguish those which originate in the heart and those which begin in the vessels. To the former class belong the noises heard in valvular disease and in aneurysm, in which blowing, breathing, and hissing sounds are often heard in the ear and described as pulsating, hammering, or knocking noises. These descrip- tions are so common as to arouse the suspicion that the patient is describing a sensory perception of the arterial pulse, and not a true tinnitus aurium. Such a confusion of sensory perception of periodic movements with auditory impressions is much more probable than appears at first sight ; it is often met with to an astonishing degree in test- ing with the tuning-fork. Just as the patient who is not used to observing accurately distinguishes with difficulty between the zdbrations imparted to the entire head by a fork of low pitch and the tone of the fork transmitted to the ear over the craniotympanic conducting arc, so he may be mis- led by the sensation of the arterial pulse, and interpret it as an auditory impression, for we observe these hammering and knocking noises whenever the cardiac activity is height- ened. Any one can " hear " the beating of his heart after physical exertion or mental emotion, but he can not say with certainty whether the impression is due to cardiac or to vascular murmurs. The theory that what is perceived by the patient in heart disease is not the valvular murmur, but rather the heightened arterial pulsation due to increased cardiac activity, finds further confirmation in the observation that these " entotic vascular murmurs " are complained of 62 THE CIRCULATORS SYSTEM. particularly in aortic regurgitation with its rapid pulse, which produces an arterial pulsation that is perceptible even in the capillaries. The murmurs which originate in the vessels themselves are produced by eddies in the blood stream, not by any special action of the vessel walls. The most important predisposing causes are the size of the lumen and the elas- ticity of the vessels. It appears from reports of cases, some of which will be given later, that entotic vascular murmurs, whether of arterial or of venous origin, are observed with great fre- quency in aneurysm, in anemia and chlorosis, and in arteriosclerosis ; they occur as the result of circulatory dis- turbances in general plethora, in alcoholism, and after intoxications which are followed by a rise in blood pressure, or vasomotor paralysis, especially after the abuse of tobacco, and after full doses of quinin and salicylic acid. In this class belong the vasomotor disturbances with tinnitus aurium which occur in paralysis of the sympathetic, in connection with hyperemia of the skin ; they represent a symptom of Basedow's disease, which, according to Mobius, must now be regarded as an intoxication depending on the loss of the function of the thyroid gland, and not, as was formerly supposed, as a disease of the sympathetic system. Finally, there are subjective noises which occur after zvotmds of the head in connection with partial loss of hear- ing and vertigo ; they are usually attributed to vasomotor irritation. As these symptoms are usually observed only in cases of accidents, there is a natural tendency to ascribe them to traumatic hysteria and neurasthenia. This is the view adopted by Schwartze some time ago ; but Miiller, ^ in a recent communication from Trautmann's clinic, pointed out that a wound of the head may give rise to irritation of the vasomotor center, manifesting itself first in contraction and later in relaxation and paralysis of the muscular walls of the blood-vessels ; this may in turn be followed by extravasations and permanent functional disturbances which explain the subjective symptoms complained of by the patient. The tinnitus aurium in this case is, therefore, to be regarded as the result of hyperemia manifesting itself at first in hyperemia of the tympanic membrane and 1 "Deutsche med. Wochen.," 1898, No. 31. THE EAR. 63 external auditory meatus, which later may be replaced by cloudiness of the membrane. The investigations in arterial auscultation by Weil ^ and V. Frey ^ show that the blood-vessels give forth a peculiar note, rarely heard in healthy individuals, but frequently in fever patients, in anemia and chlorosis, and in aneurysm ; on the other hand, according to Weil's observations on the femoral artery, the tone was persistently absent in condi- tions of high arterial tension from atheromatosis and nephri- tis with hypertrophy of the heart. In the former case the results of auscultation coincide with the subjective ear symptoms, while in the latter the frequent occurrence of entotic vascular murmurs in arteriosclerosis is in marked contradiction to them. But we find an explanation for the occurrence of tinnitus aurium in atheromatosis in the in- vestigations of Nolet,^ who found that murmurs in the vessels may be caused by sudden changes in the pressure and velocity of the blood wave, such as are produced by changes in the lumen of the vessel. These conditions are most marked in arteriosclerosis when there are aneurysmal dilatations in the vessels. The behavior of the blood-vessels of the ear in arteriosclerosis has, unfortunately, never been examined anatomically, but it is safe to say that the pro- duction of entotic murmurs depends on the extent of ather- omatous change and the presence of miliary aneurysmal dilatations ; a unilateral tinnitus aurium, therefore, does not necessarily exclude an atheromatous origin, but merely suggests the existence of a local form. Stacke'^ reports a case characterized by the perception of marked subjective tones, high in pitch, combined with central deafness of the right ear ; he explains the unilateral character of the symp- toms by the existence of a circumscribed atheromatosis of the vessels in the right side of the neck. Being convinced of the frequency of tinnitus aurium as a concomitant of arteriosclerosis, I examined for this symp- tom the 124 case histories of arteriosclerotic patients reported by Edgren,^ but to my astonishment I found such complaints in only three of the histories, although Edgren himself remarks further on (p. 207) that vertigo and ^ " Auscultation der Arterien u. Venen," 1875. 2 V. Frey, " Die Unteisuchung des Pulses," 1892, p. 6 et seq. 3 "Arch. d. Heilkunde," 1S71. * "Arch. f. Ohr.," xx, p. 286. 5 " Arteriosklerose," Leipzig, 1S98. 64 THE CIRCULATORY SYSTEM. tinnitus aurium are complained of early in the disease by many patients. His interpretation of these complaints differs somewhat from my own views ; he finds the cause of the noises "in the brain," and attributes them simply to in- creased arterial tension, without any material alterations in the brain itself. I shall now proceed to quote a few cases of subjective noises in the ear. Moos ^ reports a case in which the noises were very loud and compared by the patient to the noise of machinery and railroad trains ; at the autopsy the sinus of the jugular vein was found abnormally dilated. Wagenhauser ^ attributes a case of marked tinnitus aurium, aggravated by cough and demonstrable objectively with the auscultatory tube, to an aneurysmal dilatation of the internal carotid ; but as the patient, a girl of nineteen, presented besides a marked emphysematous habit, a large goiter, and a cyanotic appearance, his explanation is open to criticism. Brandeis ^ regarded a noise which was heard in a disease of the upper cervical vertebrae as a vascular murmur emanating from a dilated vertebral artery. The literature contains many cases of aneurysmal dilatation in various vascular systems which produced subjective ear noises. Among the external vessels of the head the region of the temporal, occipital, and posterior auricular arteries furnishes examples quoted by Chimani * and Herzog. ^ Subjective and objective noises in the head maybe of great significance in the diagnosis of aneurysm at the base of the brain. In the case of a woman who suddenly began to complain of tinnitus aurium and impaired hearing and lost consciousness, Varrentrapp ^ found at the autopsy a rup- tured aneurysm of the basilar artery. Lebert, '^ in his studies on aneurj^sm of the cerebral vessels, calls attention to the frequency of tinnitus aurium as a symptom of aneurysm of the middle cerebral and basilar arteries ; in the case of the latter it may have great diagnostic value as an early symptom. Deafness has often been observed in com- bination with the subjective noises ; sometimes it comes on 1 "Arch. f. Augen- u. Ohrenheilk.," vol. TV. 2 "Arch. f. Ohr.," xix, p. 62. ^ u Zeitschr. f. Ohr.," vol. xi. •i " Arch. f. Ohr.," VIII. 5"]\Ion. f. Ohr.," 1S81, Nos. 8 and 9; with review of cases reported up to date. 6 "Arch. d. Heilkunde," 1865. " " Berlin, klin. Wochen.," 1866, pp. 251, 2S2. THE EAR, 65 suddenly, and must be explained partly by the obliteration of the arteries supplying the ear, and partly as the result of pressure on the auditory nerves. Oppenheim ^ was able to auscult a loud pulsating murmur over the left half of the skull, which, because of a coexisting ocular disturbance, he referred to aneurysm of the posterior communicating artery ; but there is no record in the history that the patient had been aware of the murmur. Hyrtl ^ contributes the obser- vation that the artery of the stapes is sometimes very large, and in that case is likely to give rise to vascular murmurs. When the character of the entotic vascular niiirmurs is examined, it is found that the difference between arterial and venous murmurs has been very differently described. The arterial murmurs are said to have a distinct pulsating character, to be synchronous with the apex-beat, and to manifest themselves "as a series of buzzing or pounding noises in the ear or in the head" (Kayser^), whereas the venous murmurs are breathing or blowing in quality, and continuous. As we must depend for a description of the murmurs on the statements of the patient, — for even when an aneurysmal bruit can be heard objectively we have no means of judging whether the patient hears the noise in the same way, — it is easily understood why the descriptions vary so widely. The patient naturally chooses a com- parison from his surroundings or from among the sounds he has become familiar with in his calling, so that the murmurs have been compared to the rush of water over a dam, the rustling of leaves in the forest, the noise of machinery and railroad trains, the hiss of boiling water, the chirping of a cricket, etc. A few examples are given to show that even the general character of the arterial and venous murmurs, as just described, does not apply in every case. Kayser lays down the rule that arterial hyperemia, like the inhalation of amyl- nitrite, produces low-pitched, buzzing sounds, while anemia, like syncope, gives rise to high, resonant tones. According to v. Troltsch, the predominant characteristic of the noises in anemia and chlorosis is hissing and blowing. According to Stacke, in arteriosclerosis the subjective noises are high in pitch ; and it is worthy of remark that although of arterial 1 "Berlin, klin. Wochen.," 1896, p. 402. 2 Quoted by Urbantschitsch, " Schwartze's Ilandl).," vol. i, p. 413. 3 Bresgen's collection 11, part 6, ]i. 2^ness and atrophy may be found in the larynx. In this connection it is worth mentioning that aphasia has occasionally been noted in association with diabetic hemiplegia"* ; F. A. Hoffmann ^ includes paralysis of the vocal cords among diabetic palsies, but I have not been able to find any case of it in the literature. Furunculosis and pruritus occur in the auditory meatus as they do in the external skin (Wolf,^ Haug'^). If the former recurs frequently, it is said to be a sign of diabetes ; but the diagnostic value of this statement is open to ques- tion when we contrast the frequency of furunculosis in the 1 " Zeitschr. f. klin. Med.," xxvii, p. 139. 2 " Krankh. d. ob. Luftwege," 2d ed., p. 226. 3 " Veranderungen des Rachens und Kehlkopfes," p. 97. •* Charcot, "Arch, de neurolog.," May, 1890. Blanchet, " Gaz. des hopit.," 1885. ■^ " Constitutionskrankheiten," p. 316. « "Arch. f. Ohr. ," p. l66. ' " Die Krankh. des Ohres," etc. DIABETES MELLITUS. 9/ ear with the rarity of furunculosis of the auditory meatus in diabetes. I have never observed it myself, nor seen it mentioned in any good case history. Blau^ reports a case in which attacks of furunculosis kept recurring for years without his ever being able to demonstrate any signs of diabetes. Neuralgia of the mastoid process is mentioned among the complications of diabetes by Brieger^ ; it is, however, of secondary importance. On the other hand, the middle ear and mastoid cells are sometimes attacked by a disease which presents certain characteristic appearances, and justifies the assumption that it is more or less closely related to diabetes. Toynbee de- scribes a case of suppuration of the mastoid process in which extensive carious destruction of the structure was found after death, without, however, referring it to the dia- betes which was present at the same time. How recent our knowledge of diabetic ear disease really is appears from the remarks of Senator^ and Blau, published in 1876 and 1883 respectively, to the effect that loss of hearing and implication of the organ of hearing generally must be very rare in diabetes, to judge from the lack of reported experi- ences. Naunyn,* on the contrary, in his recently published work on diabetes devotes an entire section to diabetic ear diseases, showing how much our knowledge of such com- plications has advanced in the short space of twelve years. To Kirchner,^ and even more to Kuhn^ and Korner,'^ we owe the first discussions on the subject, and to-day we have a goodly number of instructive observations at our disposal which afford certain definite conclusions. The disease is characterized by the sudden onset of violent pain, localized in the ear or, more frequently, in the mastoid. The patients are usually quite unable to give any cause for the pain. In some cases the affected ear was quite healthy before the attack ; in others, there is a history of antecedent purulent otitis media. After a longer or shorter interval of pain, usually on the third to the fifth day, perforation takes place spontaneously and pus is discharged. The secretion contains nothing that may not be present in any acute sup- " Arch. f. Ohr.," xix, p. 208. - " Klin. Beitr. f. Ohr.," p. 115. In Ziemssen's " Handbuch." Naunyn, Nothnagel's "Spec. Path. u. Ther.," vol. vii, 6. Th. "IMon. f. Ohr.," 1884, p. 221. " .\rch. f. Ohr.," xxix. '' " Arch. f. Ohr.," xxix. 7 98 CHRONIC CONSTITUTIOXAL DISEASES. puration of the middle ear. It may be a mixture of blood and serum, seropurulent, or, in a long-standing case, muco- purulent. Raynaud's 1 case began as a copious hemor- rhage from the auditory meatus, which was followed by such an abundant flow of serosanguineous, and later serous, secretion, " as is ordinarily seen only in the discharge of cerebro-spinal fluid after trephining," and finally went on to the purulent stage. In a remarkably short time the morbid process in diabetic otitis spreads to the bones. The rapidity with which the disease is followed by carious disintegration of the mastoid cells is commented upon by Toynbee and, after him, by many other observers ; it is even greater, according to Kuhn, than in the most malignant cases of diphtheria. Within the short space of two or three days the interior of the mastoid process in many cases is converted into a large cavity, filled with pus and granulations mixed with seques- tra of bone, and in a few weeks the transverse sinus and dura mater of the posterior fossa of the skull are laid bare. Raynaud found, when his case came to the autops}% the mastoid cells filled with a reddish fluid mixed with inspis- sated pus, while the mucous membrane was soft and red ; in Kuhn'scase the bony parts that had escaped destruction were inflamed and so soft that they could be molded and cut like wax. I myself operated on two cases in which the spongy tissue was much discolored and scantily streaked with pus ; the bone was very anemic and brittle from necrosis, suggesting the appearance of a preparation which has been in alcohol for a long time. In several places there were large sequestra, which could be easily removed from the surrounding tissue. Are these clinical pictures such as to justify the assump- tion of a diabetic form of middle-ear disease, since their only deviation from an ordinary case of purulent otitis media lies in the rapidity of the course and the early implication of the bone ? We can not deny that this is an important element, in spite of Brieger's ^ opinion that the intensity of the process is not sufficient warrant for assuming the existence of a special form of disease. Haug ^ tested the aural secretion for sugar, and found it " at least qualitatively " positive (by what methods ?) ; Raynaud, on 1 " Ann. des mal. de I'oreille," 1881, p. 63. 2 " Klin. Beitr. zur Ohrenheilk.," p. 112. ^ Lg^^ ^it., j). 166. DIABETES MELLITUS. 99 the Other hand, found albumin, but no sugar, in the serous secretion. As the most various secretions and excretions of the body have been found to contain sugar in diabetes, Haug's positive results can not weigh very heavily, while Raynaud's negative result is interesting from the fact that an examination of the fluid taken from the edematous scrotum in the same case showed 0.7^ sugar. The point at which perforation of the tympanic mem- brane occurs varies, and is of no value for diagnosis, as it occurs indifferently in the anterior or posterior half of the membrane (Raynaud). The course of the suppurative process is characterized, as has been stated, by rapidity of extension to the bone. Arguing from the extensive and rapid destruction of the mastoid processes, with comparatively mild disease of the middle ear, Kuhn and Korner have advanced the opinion that the process in diabetic ear disease begins as a primary osteitis of the mastoid, and extends secondarily to the tym- panum, thus bringing about perforation. It is quite natural that the original opponents of the doctrine of a primary mastoid osteitis should oppose such an assumption, but they were reinforced by others (David- son i), who based their objections on a review of the liter- ature. In favor of Kuhn's theory we have the clinical features and course of the disease, especially the circumstance (insisted on by Korner) that the changes found in the middle ear bear no proportion to the intense degree of destruction in the mastoid process, and the flow of pus subsides as soon as the diseased bone is opened, as I have myself observed in one of the patients I operated on. Another argument in favor of Korner's view is found in the necrotic, gangrenous appearance of the bone, which I have mentioned, and which was equally marked in both my cases ; a dry, gangrenous appearance of the tissues being a well-recognized feature of the diabetic diathesis. On the other hand, it may be urged against the fore- going theory that the resisting power of the tissues to bacterial invasion is diminished by the presence of sugar, which affords a favorable soil for the growth of pathogenic micro-orcranisms. so that an accidental infection of the mid- 1.^4 Berlin, klin. Wocben.," 1894, No. 51. lOO CHRONIC CONSTITUTIONAL DISEASES. die ear finds the most favorable conditions for the spread of the disease. The comparative benignity of the middle- ear affection can be explained by the drainage facilities through the perforated membrane, which are wanting in the mastoid cells, where the carious process accordingly continues its work of destruction. It should also be said, in justice to the opponents of a primary osteitis, that there are cases in which the bone disease appeared late in the course of a chronic purulent otitis media, just as there are others in which an acute suppuration terminated favor- ably without involving the mastoid cells. In this connection a case of Naunyn's ^ is peculiarly in- teresting. In a severe case of diabetes a violent otitis media developed on the fourth day ; the patient, a boy of eight, complained of severe headache, and there were marked cerebral symptoms, with vomiting, great hebetude, and " large respiration, as in diabetic coma," Paracentesis was performed on the fifth day and a large quantity of pus was evacuated ; recovery followed in a few days. I once saw a similar case in a boy of fourteen, with grave diabetes, who experienced pain in the ear and a slight otorrhea two days before the occurrence of diabetic coma. On the fol- lowing day, while the coma continued, the flow subsided, and the ear-drums, which were perforated and showed the scars of former lesions, were seen to be slightly swollen and of a uniform bluish-red color, which soon disappeared. Six months later, the same ear was attacked by acute middle-ear inflammation, necessitating paracentesis ; after the discharge had lasted about a week the patient again recovered. In reviewing the facts before us, it appears that there are unquestionably cases of simple diabetic otitis which prove the existence of a diabetic disease localized in the middle ear ; but it is equally certain that there are many cases, reported by Kuhn, Korner, and others, which as emphat- ically justify the assumption of a primary osteitis, espe- cially since we possess the description of a case of diabetic osteitis and multiple periosteitis elsewhere in the body, which confirms the possibility of such primary bone disease in diabetes. Ho\ve\'er that may be, whether we have to deal with a 1" Diabetes" in Nothnagel's " Spec. Palh. u. Then," p. 287. DIABETES MELLITUS. 1 01 primary osteitis or a primary otitis media, the occurrence of suppuration from the ear in diabetes constitutes a grave compHcation, which must be combated from the outset with all the means at our command. There was a time when operative treatment of diabetic otitis media was thought to be contraindicated, because a few deaths had been reported. If the wound is properly treated, this fatal result must be charged to postoperative diabetic coma (two out of four cases by Bucki), and not, so far as I can see, to the opera- tion itself^ (one case reported by Sheppard died of inter- current erysipelas and purulent meningitis 3). As it is well known that the morbid process in the bone spreads very rapidly in diabetes, without giving rise to any pronounced subjective symptoms, trephining of the mastoid process is indicated whenever the ominous sinking of the posterior wall of the meatus has been present for some time, or deep ab- scesses have made their appearance in the mastoid process itself. A liigli sugar percentage is, however, an absolute contraindication, as it enhances the danger of postoperative diabetic coma ; this is probably the direct result of chloro- form narcosis, which is followed by a rise in the percentage of sugar, as observed in Korner's cases and in my own that terminated favorably (from 0.2 to 1.85^ in my cases). Since, therefore, the danger lurks in the anesthesia as well as in the operation itself, one should never operate without first reducing the sugar as much as possible by a long course of dieting. Recent experience teaches that in this way we also diminish the danger of sepsis, which, according to Schwartze,^ " renders the prognosis as to life a doubtful one, even in mild grades of diabetes, because there is danger of an unfavorable postoperative course, ending in sepsis." At all events, it is not great enough to forbid operative interference, any more than the imaginary danger^ of uncontrollable hemorrhage, which appears to be founded on a case of Moos,"^ in which "the operation was inter- rupted by an uncontrollable hemorrhage, lasting three-quar- ters of an hour" — its origin is not stated, and who is to say that it was due to the diabetes ? 1 "Arch. f. Ohr.," XL, p. 138. 2 I recently saw a death during coma on the fourth day after the operation ; nt the autopsy a large abscess was found in the deep muscles of the neck. 3 " Zeitschr. f. Ohr.," xxix, p. 268. •* " Handb.," 11, p. 841. * Haug, " Krankh. des Ohres," p. 167. 6 " Deutsche med. Wochen.," 1888, No. 44. 102 CHRONIC CONSTITUTIONAL DISEASES. 4. GOUT, The most familiar examples of gouty alterations are the catarrhal phenomena in the pharynx and larynx. They occur most frequently in the form of angina uratica, with dark-red discoloration of the mucous membrane of the uvula, soft palate, the two pillars of the fauces, and the tonsils. Sometimes an acute edema is superadded, as has been observ^ed by Vaton,i M. Mackenzie, ^ and Danziger. ^ Solis-Cohen * insists on the frequency of pains and abnor- mal sensations in circumscribed areas of the mucous mem- brane which appeared to be perfectly healthy, and in which he found only dilated vessels or a dark-red discoloration. Acute attacks of angina uratica always make their appear- ance two or three days before a typical outbreak of gout, and subside as soon as the gouty joint-affection has declared itself There is also, as a rule, chronic pharyn- geal catarrh, associated sometimes with tophi (Litten^). Gouty disease of the larynx is rarely observed. It mani- fests itself in a great variety of forms, the inflammatory redness and swelling being often attended with the deposi- tion of urates in the joints and cartilages. The mucous membrane of the vocal cords is involved, as well as that of the rest of the larynx, and not infrequently there are cir- cumscribed swellings in special portions of the larynx. Thus, in a gouty patient I have seen an infiltration of the right ventricular band persist for many years following a laryngitis which had come on after an acute attack of gout. M. Mackenzie ^ observed a gouty inflammation of the left false vocal cord, with granulations, which had been diag- nosed as cancer. Virchow,' Litten, Morell, and Mac- kenzie saw gouty deposits : in one case a white body as large as the head of a pin, at the posterior extremity of the right vocal cord ; at other times, as infiltrations in the cords and articulations of the larynx. In Mackenzie's case it was the crico-arytenoid articulation that was affected, and the resulting imperfect approximation of the vocal cords gave rise to aphonia. Litten found postmortem marked infiltra- 137- ^ "Semon's Centralbl.,' VIII, p. 85. * " Journ. of Laryngol., ' 1889, p. 313. 3 " Mon. f. Ohr.," 1895, p. 14. * " Semon's Centralbl.,' XI, p. 318. 5«Virch. Arch.,' ' 66. 6 Loc. cit. ' " Virch. Arch., ' 44, P GOUT. 103 tion of the same joints and their hgaments (the cHnical appearance of the larynx is not given). The gouty process in the cartilages not infrequently goes on to ossification. Of the gouty alterations in the organ of hearing those which affect the concha have been known a long time, and every physician is familiar with them. In nearly all of Garrod's ^ case histories we find mention of small gouty nodules in the concha, sometimes on the posterior surface, more commonly on the helix and fossa navicularis. The cartilage is said to be the seat of a peculiar induration and of the formation of small softening foci. In some cases there is inflammation of the external auditory meatus (pru- ritus). The statement that exostoses in the external meatus are due to gout (Kirchner) has never been proved. Judg- ing from the frequency of complaints from arthritic patients to the effect that they suffer from difficulty in hearing, especially progressive loss of hearing and tinnitus, we must infer that other lesions occur in the organ of hearing. We are not inclined to accept angina as the explanation of the loss of hearing in gouty subjects, as suggested by Haug ; for there really is not any form of aural complication that might not occasionally be referred to a hypertrophic phar- yngeal catarrh. Ebstein's arguments in his treatise on "Aural Vertigo" seem to us more plausible. 2 The clinical picture of gouty ear disease, which, as has been said, has for its principal features a progressive dimin- ution of the hearing, with tinnitus and vertigo, may be ex- plained in as many different ways as there have been causes assigned for gout itself. It is still a question whether the gouty process is in the middle or in the internal ear ; we can not say positively that the chalky deposits seen during life on the tympanic membranes of gouty subjects consist of urates, for the manner in which the morbid process affects the organ of hearing is very imperfectly understood. A specific gouty affection of the organ of hearing may be situated in the tympanic membrane, where the resulting functional disturbance would probably be slight, or in the chain of ossicles in the form of arthritic disease. Unfortu- nately, we are without anatomic experience on this point, and even the clinical stock of observations at our command is ver}^ limited. A case history, to have any statistical 1 Deutsche Uehersetzung von Eisenmann, p. loi. ^" Arch. f. klin. Med.," 58, p. I. 104 CHRONIC CONSTITUTIONAL DISEASES. value in showing a connection between gout and diseases of the middle ear, should contain not only the results of an accurate functional examination, but also some infor- mation in regard to the movability of the chain of ossicles. Brieger ^ reports a case in which the usual prodromata of an attack of gout were followed by an acute otitis media, with marked bulging and swelling of the tympanic mem- brane, and interprets it as an arthritic process in the artic- ulation, between the malleus and incus. According to Agnano,2 persons with the gouty diathesis usually develop deafness between the ages of fifteen and twenty. Still more uncertain are we whether the labyrinth is ever attacked by the gouty process. Since the imaginary hem- orrhages which are sometimes supposed to form the basis of the phenomena in the labyrinth, mentioned previously under the name of Meniere's symptom-complex, must be rejected as being without anatomic foundation, the most natural explanation of these symptoms is suggested by the vascular changes which are a constant feature of gout, and we are therefore inclined to seek the cause of these aural phenomena in a primary arteriosclerosis. This view ap- pears to be supported not only by the observations of Ebstein, but also by de Lacharriere's statement that "aural phenomena are most common in persons who, besides being subject to attacks of genuine articular gout, show their in- herited gouty tendencies in attacks of gastralgia, dyspepsia, migraine, and neuralgia." Ebstein is right, no doubt, when he says that it must, for the present, remain an open question whether the ear disease in gouty subjects is to be referred to the primary disease, to obesity, or to car- diac changes the result of overindulgence in alcoholic beveraees. ICTUS LARYNGIS OCCURRING IN THE [COURSE OF OBESITY, GOUT, AND DIABETES. That there is a certain relationship between the three constitutional anomalies, obesity, gout, and diabetes, ap- pears from the way in which they manifest themselves in individual members of a gouty family — now under one form, now under another. They produce chronic catarrhal 1 " Klin. Beitr. zur Ohrenheilk.," p. 77. 2 " Rev. hebd, de lar.," 1896, p. 703. ICTUS LARYNGIS. IO5 changes in the mucous membranes of the upper air-pas- sages, and a peculiar form of neurosis in the larynx, which has been called " ictus laryngis." Their relation to aural vertigo, tinnitus, and progressive chronic loss of hearing has been sufficiently discussed under the head of gout, where reference was made to Ebstein's treatise on the sub- ject. We shall, however, give a short description of what is known as " laryngeal vertigo," a condition which more frequently comes under the observation of the general practitioner than that of the laryngologist. By ictus laryngis is meant a sudden attack of syncope of short duration, preceded usually by a slight paroxysm of coughing. It was first described by Charcot in 1876, then by two French writers, Garel and Collet, and by the Italian, Massei, while in Germany up to the present time only a very few observations have appeared (for in- stance, Schadewaldt's). Charcot proposed the term vcrtige larynge, and it is still found in many text-books on laryn- gology, although vertigo itself is one of the rarest features in the symptom-complex ; Kurz's suggestion of lipothymia laryngea (laryngeal syncope) ^ has not met with a very favorable reception. The term laryngeal crisis, which has also been suggested, would only cause a confusion of ideas, because it is applied to an entirely different symptom-com- plex, which, as we shall see, is peculiar to tabes dorsalis. The attack occurs without warning in the midst of per- fect health ; it may come on while the subject is working, sitting, standing, walking, or even lying dow^n. Quite fre- quently the attack comes on after a meal ; sometimes the patient is aAvakened at night by a slight cough, sits up in bed, and has an attack. The description usually given is that the patient feels a tickling sensation in the throat, has a slight attack of coughing, and loses consciousness for a few seconds ; the breathing stops and the face becomes cyanotic. If the subject is standing at the time, he falls to the ground ; if he is sitting, the head falls forward on the chest. In a few instances the attack was attended with twitching in the muscles of the upper extremity or of the face, but never with biting of the tongue. The duration is very short, — usually a few seconds ; the patient does not 1 " Deutsche med. Wochen.," 1S93. I06 CHRONIC CONSTITUTIONAL DISEASES. feel unwell after it is over, and goes on with whatever he is doing at the time as if nothing had happened. When questioned, he says he has had an attack of coughing, but does not complain of any other symptom. The cases reported nearly all refer to men in the fifth decade of life. The predisposing causes usually given are chronic catarrh of the upper air-passages, chronic phar- yngitis and laryngitis, occasionally chronic catarrh of the lungs. Schadewaldt emphasizes chronic alcoholism as a predisposing factor, while Garel and Collet attach great importance to constitutional diseases, as gout, obesity, and diabetes. Cardiac changes play an important role : Schade- waldt found the heart hypertrophied (cor adiposum) in five of his seven cases. The clinical picture aroused the suspi- cion in the minds of the observers that they had to deal with an epileptic attack, but subsequent experience has failed to establish any connection whatever with epilepsy. From the fact that an attack can be brought on by introducing a sound into the larynx, and controlled by cocainizing the mucous membrane, it was argued that it must be a kind of reflex neurosis, but the descriptions offered for the reflex arc rest on a purely hypothetic basis. It seems to be proved by the fact that the attack begins with a tickling and burning sensation in the throat, that it is due to irrita- tion of the superior laryngeal nerve. This being the case, it is supposed that the vasomotor center in the medulla is stimulated through the depressomotor fibers of the vagus, and a fall in the blood pressure takes place ; at the same time the irritation is communicated to the cardiac inhibitory center, so that the action of the heart is diminished. These two factors cooperating to produce anemia of the brain, furnish an explanation of the loss of consciousness, which is characteristic of the attack. Spastic phenomena are altogether wanting, although some observers attempt to explain the attacks as laryngeal spasm, and it is doubtful whether we are, after all, justi- fied in regarding ictus laryngis as a local neurosis of the larynx. The circulatory system unquestionably plays an important part in the etiology, for many of the cases were complicated with heart disease, and a marked predisposi- tion to the attacks was observed in plethoric persons and in those addicted to good living and alcoholic abuse. The frequent occurrence of the attacks during the digestive ICTUS LARYNGIS. lO/ pause immediately following a meal also points to the cir- culatory system. Schadewaldt reports a case which ended fatally ; the patient had had an attack of ictus laryngis on the previous day, after supper, but felt so well on the day of his death that he took his customary horseback ride. In the afternoon, however, while engaged in conversation with a companion, he had another slight attack of coughing, lost consciousness, fell to the ground, and died instantly, without exhibiting any other symptoms. No autopsy is given, but the history of cardiac hypertrophy in a robust, alcoholic individual, fifty-nine years old, justifies the diag- nosis of death from heart failure. VI. ACUTE INFECTIOUS DISEASES. J. MEASLES. Catarrhal disease of the mucous membranes in the upper air-passages constitutes an integral part of the chnical picture in measles. It takes the form of an exanthema, which always precedes the skin eruption, and is absent, ac- cording to Monti, 1 only in children who are very anemic or weakened by previous disease. Even during the prodromal stage of measles there is a dark-red discoloration of the pharynx and palate ; it is irregularly distributed, and is most marked on the lateral and posterior pharyngeal walls and on the pillars of the fauces. The discoloration is also seen on the mucous mem- branes of the cheeks and lips, where it constitutes Koplick's ^ sign. The redness is accompanied by a feeling of dryness in the throat ; on the following day the mucous membrane appears moist and the true exanthema begins to break out. This exanthematous eruption is most marked on the pillars, where it takes the form of small isolated or confluent macules or papules of varying size, elevated above the level of the mucous membrane (Monti). The skin eruption appears usually from twelve to twenty-four hours later, and with its appearance the patches begin to subside. In addi- tion to the redness and swelling, Tobeitz ^ observed a super- ficial slough, resembling that produced by a mild caustic, which he interprets as an epithelial necrosis. Similar appearances are seen in the larynx ; they also accompany other catarrhal diseases, particularly influenza. The mucous membrane of the larynx presents a bright- red color, in irregular patches, interspersed with fine granu- lar nodules (Gerhardt). This variety of laryngitis usually appears two or three days after the exanthematous erup- 1 " Jabrb. f. Kinderheilk.," vi, p. 22. 2 " Deutsche med. Wochen.," 1898. * "Arch. f. Kinderheilk.," vni, p. 326. 108 MEASLES. 109 tioii, seldom later, and gives rise to hoarseness and cough of a croupy character. The patches of epithelial necrosis mentioned by Tobeitz take the form of erosions and shallow ulcerations on the posterior pharyngeal wall, and are sup- posed by Gerhardt to be due to mechanical injury of the already loosened mucous membrane by the act of coughing. Croupous laryngitis is a rare occurrence in measles. To- beitz saw evidences of very mild forms at autopsies, not severe enough to cause stenosis, rather a shallow croupous deposit ; the mucous membrane in these cases was of a bright-red hue, but not much swollen, and the surface was deprived of its epithelium and in places necrotic. Compli- cations of measles with diphtheria and true diphtheric laryngitis are not unknown. Thanks to trustworthy anatomic investigations, our knowledge of ear diseases in the course of measles is more complete than is the case in the other infectious diseases. To Tobeitz, Rudolf, Bezold, and Habermann we are in- debted for investigations on the cadavers of children which give us uniform results concerning the nature and mode of spread of aural complications in measles. One valuable feature of these investigations — especially of Bezold's, who examined a large number of cadavers — is the fact that par- ticular attention was paid to the organs of hearing in those cases which during life had presented few, if any, symptoms of disease, so that an opportunity was afforded of studying the earliest stages of the alterations. In 16 cases examined by Rudolf (and tabulated under Bezold's direction), 17 by Bezold ^ himself, 17 others by Tobeitz, 2 6 by Siebenmann,^ and 7 by Habermann, ^ with only two exceptions there were found signs of an aaite otitis media, which must be regarded as a special localiza- tion of the disease. It was found to persist for some time after the appearance of the eruption, for Bezold's cases belong to the period from the third to the thirty-third day of the disease. According to Bezold's description of these early appear- ances in disease of the middle ear — and they can frequently be demonstrated in the first three days after the appearance 1 "Zeitschr. f. Ohr.," xxviii, p. 209. 2 "Arch. f. Kinderheilk.," in, 341. 3 Quoted from Bezold, " Zeitschr. f. Ohr.," vol. xxviil, p. 249. * " Schwartze's Handb.," vol. i, p. 261. IIO ACUTE INFECTIOUS DISEASES. of the eruption — there is a diffuse injection and turgescence of the mucous membrane, and the tympanic cavity contains more or less fluid. It is an important point that the dis- ease also extends to the lining of the mastoid antrum and cells. The secretion in the tympanic cavity was never of the purely serous type found in simple occlusion of the tubes, but was mucopurulent or seropurulent or consisted of pure pus. The injection of the blood-vessels was irregularly distributed over the mucous membrane in the form of patches and minute, punctiform extravasations. Occasion- ally, a fibrinous exudate (" pseudomembrane ") was seen. The swelling was less marked than is usual in middle-ear suppurations. Bezold never found the mucous membrane destroyed so as to expose the bone. The tympanic mem- brane in all the cases described showed a marked resistance to the attacks of the disease, being thickened, but otherwise intact, even in those cases which came to the autopsy as late as the thirty-third day after the appearance of the erup- tion. We could not expect, therefore, to have any appre- ciable changes in the otoscopic image at this stage of the disease, and as it does not give rise to any marked subjec- tive symptoms, it is probable that such low grades of inflam- mation pass off without being observed clinically. The prognosis is good ; after the inflammation subsides and the exudate is absorbed the parts are completely restored to their normal condition. It is not to be inferred, however, that all aural complica- tion in measles run this benign course. We know from practical experience that acute purulent otitis media ivith perforation is a very common sequel of measles, and, if neglected and allowed to become chronic, it may lead to any of the consequences — such as caries of the bone, ex- uberant granulations, and cholesteatomata — which we are accustomed to see after any suppurative process in the middle ear. To show how wide-spread is the belief among the laity that measles may be followed by disease of the ear, it may be mentioned that in about 3 ^ ^ of all cases of aural disease measles is given as the original cause by the patient or his friends, and that 5.1 ^ of all cases of purulent otitis media are attributed to this disease. Again, that 1 From Blau and Bihkner. the otitis of measles is not quite so benign as might be sup- posed from the shght attention it has received even in medi- cal circles, — there being a general impression that it requires no special treatment, — is shown by the fact that measles is charged with 4^ of all cases of acquired deaf-mutism. As has been previously indicated, the otitis that accompanies measles is not especially malignant, and runs much the same course as any other acute or chronic otitis media. Blau succeeded in curing 28 cases of acute purulent otitis following measles without the hearing being impaired. Bone disease with abscess formation is not more common after measles than in ordinary otitis media. Otitis usually makes its appearance during the stage of desquamation between the second and third week ; two cases have been reported in which it appeared before the eruption. The course of the disease presents nothing characteristic. Blau 1 reports a case of diphtheric disease of the external auditory meatus, without involvement of the middle ear, which appeared five days before diphtheria of the pharynx following measles. Haug ^ describes a primary caries of the mastoid process, with secondary suppuration of the middle ear, which developed during the stage of desqua- mation. We do not attach much importance to Moos's ^ observations that disease of the internal ear with sudden deafness and vertigo may follow an attack of measles, as they lack the confirmation of other observers. A review of our knowledge concerning the nature and course of the otitis of measles justifies the following con- clusions : It appears, from the results of clinical and ana- tomic investigations, that there are two varieties of otitis in measles, the second of which represents a complication of the first. The otitis media described by Bezold and others represents a true measle eruption affecting the mucous membranes, while the suppurative process with perforation of the tympanic membrane must be regarded, after Bezold, as the result of a mixed infection which finds a favorable soil in the mucous membrane weakened in its resisting power by the primary disease. Another view, which is advocated by Wagenhauser * and 1 " Berlin, klin. Wochen.," vol. XXXIII, 1SS4. 2" Arch. f. Ohr.," xxxii. p. 1S3. ^ i< Zeitschr. f. Ohr.," XVIII. * Quoted by Habermann, " Schwartze's Ilandb.," I, p. 761. 112 ACUTE INFECTIOUS DISEASES. others, regards the otitis of measles as a simple inflamma- tion derived from the postnasal space through the Eusta- chian tubes ; but in the light of recent investigations on cadavers, this view seems to us to lack general application, although it may hold in isolated cases. The early devel- opment of the acute inflammation, coincident with the appearance of the eruption, confirms the hypothesis that we have to deal with a true measle eruption precisely analo- gous to that on the mucous membrane of the respiratory tract, and worthy of a place in the general symptom-com- plex in measles. We know from the investigations of Bezold that the catarrhal process in the middle ear runs a very chronic course, and that the mucous membrane shows little tendency to regeneration and granulation ; hence, its susceptibility to secondary infection, even several weeks after the measles has run its course, is quite readily under- stood. 2. SCARLATINA, Among the complications of scarlet fever in the upper air-passages we distinguish catarrhal angina and a form of diphtheria. The catarrh of scarlet fever is distinguished from that which occurs in measles by being restricted in the main to the pharynx, faucial pillars, and tonsils, while the nose and larynx usually escape, or, at any rate, become involved much later. It manifests itself as a deep-red or violaceous discoloration, at first uniform, and after a few days dis- tributed in patches ; the mucous membrane is dry and very much swollen, causing a feeling of dryness and tickling in the throat and a desire to swallow at frequent intervals. The onset and course of the angina do not appear to follow any definite rule ; in most cases it appears before the erup- tion and lasts several days. In some cases of malignant scarlatina without eruption, which terminate fatally very soon after the onset of the dis- ease, with grave constitutional symptoms, this dark-red dis- coloration of the pharyngeal structures may form the only symptom, and its relation to scarlet fever can be determined only by the existence of an epidemic or by the subsequent outbreak of the disease in other members of the family. The regularity with which this catarrh of the mucous MEASLES. 113 membrane appears at the very outset of the infectious dis- ease, and its locahzation in the region of the pharyngeal ring, so abundantly supplied with lymphatic elements, jus- tify the assumption that the virus of the disease, the nature of which is not known, gains entrance to the system at this point, and that the angina of scarlet fever represents the earliest reaction of the organism to the scarlatinal poison. In uncomplicated cases these catarrhal symptoms subside in a few days, but in a large proportion of cases a strepto- coccal infection of the diseased mucous membranes is super- added to the scarlatinal poison and gives rise to a group of morbid phenomena which are designated by the general term " diphtheroid scarlatina." It is a necrotic inflammation of the mucous membrane, presenting the anatomic picture of diphtheria, but having etiologically nothing in common with genuine diphtheria, from which it is distinguished by the absence of Loffler's bacilli and by certain clinical differ- ences in the mode of spread and the development of sequels. Before Heubner's publications appeared to throw some light on the question, the greatest confusion prevailed in the diagnosis and description of diphtheroid scarlatina, the shadow of which overhangs even the most recent rhino- otologic literature and materially detracts from the value of reported observations. Heubner ^ divides diphtheroid scarlatina into three forms, according to the clinical course, — a mild form, a subacute form, and an epidemic form, — which together represent various grades of virulence, both in respect to the extent of mucous membrane involved and to the manner in which the neighboring glands react to the poison. ' The first form is characterized by the deposition on the first to the third day of small superficial exudates on the surface of the inflamed tonsils ; these soon run together and form a deli- cate membrane, which can be removed with a pair of for- ceps without causing hemorrhage. After persisting a few days the membrane is replaced by shallow ulcers which rapidly heal, while the swelling of the submaxillary glands subsides. Heubner observed this favorable course in about one- i"Volkmann's Vortr.," No. 322 (iSSS); and Hirschfeld, " Jahrb. f. Kinderheilk.," vol. XLiv, p. 237. 8 114 ACUTE INFECTIOUS DISEASES. fourth of all cases of scarlatinoid diphtheria. In almost all cases the mild form is followed by the so-called subacute ['' Icntcscoit" ) form of scarlatinoid diphtheria (Hirschfeld observed it in 53.6^ in a series of 211 cases); or the milder form may not be present and the subacute may be the first to appear. After a mild onset the temperature rises suddenly on the fourth or fifth day, the glands become enlarged, and a yellowish exudate appears on the tonsils, on the posterior pharyngeal wall, and on the pillars of the fauces. The diphtheric process spreads to the postnasal space, the nasal cavities, and the larynx, and gives rise to ulceration and tissue destruction varying in form and extent. This purulent form of rhinitis is always the result of exten- sion from the postnasal space, and therefore develops a few days later ; the clinical picture presents no characteristic features to distinguish it from diphtheric disease of the nose. There is, however, a characteristic discharge of a thin, yellow- ish, offensive fluid, tinged with blood, from the excoriated nares, which, in connection with the glandular enlargement, is of some value for early diagnosis. It is a sign that the nasopharynx is involved, and appears even before the nose itself is directly attacked. It is somewhat remarkable that the larynx is rarely in- volved in this form of the disease, just as in the catarrhal variety, so that a laryngeal stenosis simulating true diph- theria is a rare occurrence. If the membrane does spread to the larynx, it is found to be soft and semifluid, and much less adherent than in diphtheria. In rare cases edema of the larynx and asphyxia were observed ; Moure saw an abscess at the base of the epiglottis and about the upper part of the left ventricular band which ruptured spontaneously on the tenth day of scarlet fever. The loss of substance caused by the destruction of large tracts of mucous membrane in the postnasal space and on the pillars eventually leads to the formation of permanent scars and cicatricial contractions, which in later life may easily be mistaken for syphilitic scars, especially when they occupy the interv^al between the pillars of the fauces and the posterior pharyngeal wall. The formation of adhesions in the interior of the nose in scarlet fever should also be mentioned ; the skeleton itself is never involved. Finally, Heubner describes a vialignaiit form which pre- sents all the symptoms of an intense general septicemia, ] SCARLET FEVER. I I 5 with rapid destruction of the mucous membrane of the nose and throat, and with necrosis of the cervical and parotid glands and of the skin covering them ; the glands at first are of a stony hardness. This variety, which appeared in 16.3^ of the 211 cases in Heubner's clinic, terminated fatally about the seventh to the tenth day. Diphtheric disease due to scarlet fever presents certain important distinctions from true diphtheria, caused by Loffler's bacillus, in the nature of the sequels which are apt to follow. The peripheral palsies which constitute some of the most dreaded after-effects of diphtheria, and of which we are concerned only with paralysis of the pillars of the fauces and of the larynx, are never observed after scarlet fever. This is confirmed by Heubner and by Leich- tenstern, who refers to 600 cases, so that the isolated con- tradictory cases, cited for the most part by, older writers, must be explained in some other way. Without giving the individual case histories, Wreden 1 makes the statement that he observed paralysis of the pillars of the fauces, the vocal cords, the extremities, and the heart in eighteen cases of nasal and pharyngeal diphtheria complicated with scar- latina. But, in the first place, any ulceration in the pillars of the fauces may interfere mechanically with the move- ments of the uvula ; and, in the second place, there have been reported cases of genuine diphtheria combined with scarlet fever when the finding of Loffler's bacillus rendered the diagnosis absolutely certain (Jurgensen^). In such cases of double infection the occurrence of post diphtheric palsies is, of course, conceivable, but they must be attrib- uted to the diphtheria and not to the scarlet fever. Scarlet fever plays a more important role in the etiology of diseases of the ear than any of the other infectious dis- eases. The literature does not afford many statistics in regard to the frequency of aural disease as a complication of scarlatina, the only statistics I was able to find being those of Burckhardt-Merian, who reports middle ear dis- ease in 5 out of 15, and in another series in 8 out of 36, cases. On the other hand, the frequency of scarlatina as the original cause of aural diseases forms the subject of numerous articles based on a large amount of material. The most reliable statistics are those contributed by 1 Wreden, " jNIon. f. Ohr.," Ii, p. 151. 2 Nothnagel's "Spec. Path. u. Ther.," IV, 2, p. 133. Il6 ACUTE INFECTIOUS DISEASES. Bezold/ who collected 640 cases of aural disease second- ary to scarlet fever, covering a period of eleven years, from 1 88 1 to 1892, in which 984 organs of hearing were affected, one-half of all the cases being bilateral. The total number of cases of scarlet fever during the same period Bezold estimated from other statistical sources at 17,087, so that 3.75 ^ of all aural affections must be attributed to scarlet fever. This percentage tallies approximately with the results of other statistics, ^ in which the percentage ranges from 2.3 to 9.3, with a total average of 5.17 ^. The frequency with which the different parts of the ear are affected varies greatly, affections of the middle ear showing a heavy preponderance over those of the internal, and espe- cially of the external ear, which are extremely rare. To show how frequently the middle ear is involved, it is only necessary to state that about 1 2. i ^ ^ of all cases of pu- rulent otitis media must be regarded as secondary to scarlet fever. While these figures alone suffice to show the significance of scarlet fever in the etiology of aural diseases, it becomes even more apparent w^hen we consider the functional dis- turbances and other sequels that follow in its wake. To quote at random from Bezold's statistics, we find the appall- ing statement that in 109 out of 217 cases of chronic puru- lent otitis media with polypi, and in i 54 out of 3 1 5 cases without polypi, the disease lasted longer than eight years. When it is considered that in 48.5 ^/o of all Bezold's cases the distance at which whispered tones could be heard was less than ^ of a meter, and that in 13.5/^ a whisper could not be heard at all, and when, in addition to this, the fre- quency of acquired deafmutism after scarlet fever, which shows an average of 19%,"* is taken into account, it is easy to understand the otologist's repeated appeals to the gen- eral practitioner, adjuring him to devote more attention to aural complications in scarlet fever than appears to have been done hitherto. We will first consider the grave andfortunately rare form of otitis which is designated the diphtheric form, being anal- 1 " Uberschau iiber den gegenwartigen Stand," etc., 1S95, Wiesbaden, Bergmann, pp. 168, 169, table viii. 2 Blau, " Arch. f. Ohr.," 27, p. 140. ^ Average of Blau's figures, "Arch. f. Ohr.," 27, p. 142, table il. 4 Blau, loc. cit., p. 143, table iv. SCARLET FEVER. I I / ogous to diphtheroid scarlatina of the throat. The same confusion that prevailed in regard to the diseases of the throat before the subject was somewhat clarified by the works of Heubner and others still befogs the various de- scriptions of diphtheric inflammations of the ears in scarlet fever. The opinion is abroad, based chiefly on the writings of Wreden and Burckhardt-Merian, that otitis in the course of scarlet fever in practically every instance consists in a diphtheric inflammation of the middle ear. ~ The i8 cases reported by Wreden, which date from the year 1868, can not be regarded as authentic, as they represent suppura- tions occurring " during the decline of scarlet fever " (sub decursu febris scarlatinosae) ; the time of their appearance (late in the course of the disease), and the statement that they were frequently followed by palsies, arouse the suspicion that we have to deal with a genuine complication of scarlet fever with diphtheria, and Burckhardt-Merian 's remarks on diphtheria, found in his paper on otitis in scarlet fever, are of no value in the present discussion, for the very reason that the diphtheria of scarlet fever is a very different thing from genuine diphtheria. From the description ^ ^ by Moos and Pulitzer, who designate diseases of the ear in scarlet fever simply as diph- theric diseases or scarlatino-diphtheric suppurations of the middle ear, it might be inferred that the diphtheric form is the only possible aural complication in scarlet fever. But how, then, are we to reconcile the frequency of middle ear disease in scarlatina with the rarity of diphtheric disease of the middle ear? Gottstein's unsuccessful attempt to prove that the diphtheric aural affection forms an integral part of the morbid process in scarlet fever is followed by the in- genious explanation that the aural affections did not come under the observation of the ear specialist until after the end of the diphtheric and the beginning of the purulent stage, while Wreden had the opportunity to observe the disease in its early stages. A strange caprice of fate, in- deed, if that early diphtheric stage regularly escaped the notice of the physician ! The most authentic cases of a diphtheric form of otitis 1 " Schwartze's Handb.," vol. I, " Allgemeine Aetiologie der Ohren- krankheiten." ^ " Lehrb. der Olirenheilkunde." I I 8 ACUTE INFECTIOUS DISEASES. media in scarlet fever are those reported by Blau,^ Katz,^ and Siebenmann.3 According to these observers, the cHnical course of the disease is as follows : Coincident with the diphtheric com- plication in the throat there takes place a rapid destruction of the tympanic membrane followed by an otorrhea, in which the fluid is described as muddy and serous in char- acter, not purulent. A diphtheric membrane is formed on the mucous membrane of the tympanum and discharged into the external meatus. The diphtheric process is not limited to the middle ear, and may manifest itself in the formation of membranes in the external meatus and in the auricle, as was observed in several instances. Blau's case was not followed to the end ; the cases reported by Katz and Siebenmann terminated fatally on the fifteenth and twentieth day respectively. Siebenmann's attempts to dis- cover diphtheria bacilli in the membranes found in the middle ear after death were unsuccessful. As the disease progresses the mucous membrane under- goes necrosis ; the bones of the tympanum are laid bare, and may eventually become carious. The serous, muddy secretion is later replaced by a purulent discharge ; in other words, the diphtheric process is converted into a chronic suppuration characterized by extensive carious destruction. The coincidence of this form of otitis with the diphtheric process in the throat suggests the thought that they are both caused by the same malign influence manifesting itself in different parts of the body. The simplest explanation of the aural complication on this tlieory would be direct extension of the diphtheric process in the pharynx through the Eustachian tube, but of this we have no proof. In Siebenmann's case, which is so excellently described, the tube was unfortunately destroyed at the autopsy. A much more frequent form of aural complication in scarlet fever is unite otitis media without any special char- acteristic features. It begins during the period of desqua- mation, — that is to say, in the third or fourth week of the disease, — with a rise in temperature and pain radiating from the affected ear and increasing in severity toward evening, so that the patient is unable to sleep. There is usually 1 "Berlin, klin. Wochen.," i8Sl, Nos. 49, 50. 2 "Berlin, klin. Wochen.," 1S84, No. 13. 3 " Zeitschr. f. Ohr.," XX, p. I. SCARLET FEVER. I I 9 some glandular enlargement behind and under the angle of the jaw, on the mastoid process, or in the back of the neck. The tympanic membrane is red, swollen, and inflamed, and bulges so that immediate paracentesis is indicated ; if it is not performed, spontaneous perforation takes place, often within a few hours after the first appearance of subjective symptoms. An important variation from the ordinary clini- cal picture as just described is to be found in the description given by some observers of a remarkable absence of pain, which they arbitrarily attribute to anesthesia of the sensory nerves. Up to this point the course of the disease is essentially the same as that of simple otitis media, but after the occur- rence of perforation, which preferably takes place in the lower anterior quadrant, the membrane undergoes rapid disintegration and is often totally destroyed. According to Bezold,^ total destruction of the membrane occurs in 25.2^ of all cases of scarlet fever, and a destruction of at least two-thirds of the disc in 24.7^. The flow is very abundant and presents the usual mucopurulent appear- ance. The most characteristic features of the otitis media are an obstinate resistance to treatment and a tendency to carious destruction, which frequently involves the ossicles, as well as the bony walls of the tympanum and contigu- ous cavities. As the hearing is much impaired in scarlet fever, it is probable that the disease extends to the internal ear ; but whether we have to deal simply with a secondary carious destruction of the labyrinth, or with a special locali- zation of the disease, is not known. How are we to explain the origin of this form of otitis in scarlet fever ? Is it a disease due to the extension of the initial pharyn- gitis through the tubes, and presenting phenomena in the form of an otitis media such as we must expect after any catarrhal rhinopharyngitis ? or is it a specific disease caused by the virus of scarlet fever or by certain toxins which it produces ? Mere hypotheses add little to our knowledge, which must necessarily remain incomplete as long as the nature of the scarlatinal contagium is unknown. Certain con- clusions can, however, be drawn as to the origin of the 1 Loc. ciL, p. 172. I20 ACUTE INFECTIOUS DISEASES. disease from the time of its appearance as a complication and from its general character. It occurs regularly during the period of desquamation — at a time, therefore, when there exists a tendency to other complications as well ; for, except in the rare cases of diphtheroid scarlatina, there is no record of its occurring immediately subsequent to the scarlatinal angina which lasts only a few days. That the resisting power of the mucous membrane of the tubes and of the tympanum to the invasion of pathogenic germs — which might set up a suppurative process in the middle ear independent of the scarlatina — is especially lowered during this period of the disease is not only not proved, but is even improbable, as no such condition of affairs is observed in the mucous membranes of the upper air- passages, where secondary streptococcal infections usually follow immediately after the scarlatinal angina, in the first week of the disease. Again, if we assume that the aural complication is merely accidental, or that it is dependent on the pharyngeal condition, it is, to say the least, remarkable that simple catarrh and mild otitis media without perforation do not occur in scarlet fever, or at least are so rare that they can not be included among the list of compHcations of the disease. If, on the other hand, we consider that it is during the desquamation period that we find nephritis, — a disease which is unquestionably toxic in character and there- fore indicates a septic condition of the organism, — the assumption that the aural complication is due to the action of the same toxins seems plausible. If a parallel could be established between nephritis and purulent otitis media, — as in a case observed by Voss, where the onset, course, and subsidence of the two diseases progressed pari passu, — it would offer another argument in support of the dependence of the aural disease on a general intoxication of the system. The bacteriology of scarlatinal otitis media and the sig- nificance of a mixed infection have not as yet been dis- cov^ered. 3. VARICELLA. In varicella, vesicles appear on the mucous membrane of the mouth and pharynx at the same time as the skin erup- tion ; in rare cases a few isolated pustules were found in VARICELLA. VARIOLA. I 2 I the larynx. Cases of grave suffocative laryngitis have been described by Marfan and Halle ^ and by Harlez,^ which, it appears, occurred suddenly at the time of the eruption, with symptoms of asphyxia, attended with hoarse- ness, cough, and muffled phonation. Tracheotomy was required in every instance ; no laryngoscopic examinations are reported ; in one of the cases ulcers were found on the vocal cords at the autopsy. In a unique case reported by Biirkner, ^ two pustules were found in the external auditory meatus, with only a -scanty eruption on the scalp. 4. VARIOLA. In variola the mucous membranes contiguous to the external skin are regularly attacked. E. Wagner * found that the nasal mucous membrane was affected in every case in which it was examined. In a series of 170 cases the upper pharynx alone was affected twice ; the pharynx and larynx alone, 38 times ; the pharynx, larynx, and upper half of the trachea, 54 times ; the pharynx, larynx, trachea, and large bronchi, 52 times. The larynx was therefore involved altogether in 144 cases out of the 170. Between the third and sixth day of the smallpox eruption (Macken- zie) pustules make their appearance in the pharynx and spread to the postnasal space and larynx. They may be isolated in different parts of the larynx, or they may be multiple and coalesce to form large ulcers. At first the pustules resemble those on the external skin, but the covering of mucous membrane soon becomes macerated, is cast off, and leaves a red, excoriated patch, which is apt to bleed. In the hemorrhagic form ecchymoses appear in the mucous membranes. These superficial eruptions on the mucous membranes are complicated with deeper ulcer- ative processes, which lead to edema of the larynx and abscess formation ; by extension to the cartilages this may give rise to a perichondritis of the larynx, as illustrated by 1 " Rev. d. mal. d. 1' enf," Xiv, Jan., 1S96, rep. in " Semon's Centralb.," xn, p. 499. 2 " Indep. med.," July 14, 1S97, rep. in "Semon's Centralb. ," xn', p. 214. ^"Arcli. f. Ohr.," 18, p. 300. ^"Arcli.d. Ileilkunde," xni. 122 ACUTE INFECTIOUS DISEASES. Tiirck ^ in a number of cases. In addition to the pustular, Mackenzie mentions a papular form, and Lori reports hyperemia of the mucous membranes without pustular eruption. Ruhle,2 among others, speaks of a diphtheric croupous inflammation of the laryngeal mucous membrane, with secondar}^ invasion of the postnasal space. That this was the result of confluence of the pustules is denied by Lori on the ground that there never were any pustules on the mucous membrane ; but E. Wagner says that in the nu- merous cadavers he examined the pustules were often so closely set, especially in advanced stages of the disease, that it was difficult to demonstrate their variolous character. Finally, we have the occurrence of palsies as a very rare complication. Mackenzie saw two cases which were fol- lowed by paralysis of the adductors of one cord. The nature of these palsies is not known, but they are probably due to mechanical causes, such as ankylosis of the ary- tenoid cartilage, observed after perichondritis or after the cicatrization of a deep ulcer. Aural disease during smallpox was studied by Wendt^ in 1 68 organs taken from 84 persons of all ages who had died in various stages of the disease. As the ears were found to be intact in only 3 cases, there can be no doubt of the frequency of aural complications in variola. The nature of the lesions varies, according to Wendt's findings ; in some instances the morbid process was identical with, or closely related to, variola, in others the lesions were such as occur in connection with other constitutional or local diseases, or even without them. From the external skin the eruption spreads to the concha and auditory meatus ; from the mucous membrane of the pharynx to the pharyn- geal orifice of the tubes. Whether the epithelial thicken- ing and suppuration, and the hyperemias, hemorrhages, and exudations in the middle ear, are the product of the primary disease or the result of the tubal condition is an open question. So far as has been observed, the tympanic membrane is never the seat of a pustular eruption, but it is frequently found to be red and swollen. These anatomic findings 1 " Klinik der Kehlkopf krankheiten." 2 "Klinik der Kehlkopf krankheiten," lS6l. 3 "Arch. f. Heilkunde," xni. TYPHOID FEVER. I 23 of Wendt are directly contradicted by the clinical observa- tions ofOgston.i The latter, after examining the ears of 229 smallpox patients, reached the conviction that "the structures and tissues of the ear itself are not affected by variola." The prognosis, according to Wendt, is favorable ; he be- lieves that the healing of the smallpox lesions in the ear is not followed by any functional disturbance, nor have there ever been found cicatricial stenoses or synechise from the healing of pustules in the external auditory meatus or in the tubes. 5. TYPHOID FEVER. The laryngeal phenomena occurring in the course of typhoid fever may be divided into three main groups — catarrhal conditions, ulcerations, and palsies ; edema and perichondritis are regarded as accompaniments or com- plications of one of the three main divisions. There are plenty of data to determine the frequency of these compli- cations, but a certain reserve is necessary in drawing general conclusions, for the statistics would be quite differ- ent if a systematic laryngoscopic examination were made in every case of typhoid fever, without waiting for the patient to complain of pain in the throat or for the appearance of such obvious symptoms as dyspnea and aphonia. The results obtained vary according as they are based on ob- servations made on the living subject or on the cadaver, for complications are naturally much more frequent in severe cases of typhoid terminating fatally than in the milder forms. Another factor is the severity of the epi- demic that happens to furnish the basis for the statistics. The most comprehensive figures are those published by Luning,^ who puts the percentage, as computed from clinical statistics, at 3, and the postmortem percentage at 17. It would be interesting to know the relative frequency of the various forms of laryngeal disease ; but on this point we can not hope for any information from the results ob- tained at autopsies, as they naturally include only the gravest complications, such as perichondritis or diphtheric disease. 1 "Arch f. Ohr.," vr, p. 267. 2 " Langenheck's Arch.," vol. xxx. 124 ACUTE INFECTIOUS DISEASES. Clinically speaking, simple catarrh and superficial ulcera- tion are the complications most frequently observed, while deep ulcerations which lead to edema and perichondritis, or which, when extensive, present the so-called diphtheric form (" laryngotyphus ") are much rarer. If the latter are more frequently and more fully described it is only because of their alarming symptoms and the laryngeal stenosis which characterizes them and directly threatens the patient's life. Stenosis and edema of the larynx are sometimes induced by typhoid processes in neighboring organs ; thus, cases have been reported in which acute inflammation or abscess formation in the thyroid gland — which condition appears to be quite frequent in the course of typhoid — led to compression of the trachea and edema of the larynx. Our knowledge of post-typhoidal palsies is of very recent date. They were formerly considered a very rare com- plication, for Lublinski could collect no more than 25 cases, including 6 of his own, and Landgraf met with only 2 cases of laryngeal palsies among 166 typhoid patients. A special interest, therefore, attaches to Przedborski's^ report, accompanied by very complete case histories, of 25 laryn- geal palsies among 100 cases of abdominal typhoid, and of 7 among 25 cases of exanthematous typhoid. The pharyngeal and laryngeal mucous membrane is often attacked by catarrh in the beginning of the disease, while, on the other hand, the nasal mucous membrane not only escapes but presents an unusually dr}^ appearance. The only nasal symptom observed is epistaxis. The hemor- rhage shows a predilection for the septum, but is also ob- served in other parts of the mucous membrane. In a few cases which came under my observation the nasal mucous membrane after the hemorrhage presented the previously mentioned desiccated appearance, the septum was marked with rhagades, while the walls and interior of the nose were covered with larger and smaller masses of black, clotted blood, which moved to and fro with the respiratory movements. The epistaxis occurs in the beginning of the disease. As the patients at this time are usually in bed and more or less prostrated by the fever, the blood usu- ally flows backward into the throat, and the resulting bloody sputum may give rise to errors in diagnosis. Perforation of 1 Volkmann's " Sammlung klin. Vortr.,'" Xo. 182, 1897. TYPHOID FEVER. 125 the septum, like that produced by a perforating ulcer, has been observed after typhoid fever. Typhoid pharyngitis and laryngitis are characterized by intense redness, while the swelling of the mucovis membrane is comparatively slight. Marked swelling and edema are rare in this stage. The so-called catarrhal redness of the larynx in typhoid is not uniformly distributed. It may be due to venous stasis (Landgrafi). Ulcers appear in various forms both clinically and ana- tomically. The commonest variety consists in superficial ulcerations from necrosis of circumscribed portions of the swollen mucous membrane. They manifest a preference for certain regions of the pharnyx and larynx, being found almost regularly on the faucial pillars, the free border or laryngeal surface of the epiglottis, the aryepiglottic folds, and occasionally below the glottis ; they are rarely seen on the vocal cords. At first there is a diffuse catarrh, and the mucous membrane is darker in color and slightly swollen in the areas mentioned ; the epithelium soon breaks down, and exposes a small, shallow ulcer with a yellowish floor, resembling herpes ; similar ulcers appear in the neigh- borhood and coalesce with the original one to form larger, irregular, quite superficial ulcers, with clearly defined edges, but without redness or swelling of the adjacent parts. These ulcers occur in all stages of typhoid, and may be due to a variety of causes. They can not be re- garded as decubital ulcers,^ as there is no reason why, if we accept such an etiology, similar ulcers should not occur in any other disease attended with the same degree of prostration ; nor can they be attributed to the effect of contact and direct infection with the typhoid bacillus, as it has been possible in only a very few instances to demon- strate the presence of bacilli in the secretion, and there is no satisfactory explanation of the mode of infection. The ulcers are undoubtedly to be regarded as the result of a nutritive disturbance in the catarrhal mucous mem- brane connected with the general typhoidal infection, but their mode of origin and direct dependence on infection by the bacillus are not so clear. They are superficial, and, on the whole, may be considered benign, as they heal without leaving a scar and do not require any local treat- 1 Landgraf, "Charite Ann.." 1S89. 2 Riihle, " VerhdI. der Naturf. Vers.," 1S62. 126 ACUTE INFECTIOUS DISEASES. ment. There are cases, however, in which the ulcers extend to the deeper structures, probably as the result of a mixed infection. Eppinger^ calls them mycotic necrotic ulcers, and gives a detailed description of the way in which they invade the deeper structures and eventually destroy the perichondrium and cartilage. The cases which go on to phlegmon formation are to be explained as due to such mixed infection ; Villecourt^ describes one that was local- ized in the glottis and posterior laryngeal wall. These ulcers differ both clinically and anatomically from the altera- tions described by Eppinger under the name of diffuse typhoid infiltrations ; he considers them in every way analogous to the typhoid lesion in the intestinal follicles, and therefore assumes that they originate in circumscribed areas containing adenoid tissue in the mucous membranes of the upper air-passages. These infiltrations lead to ulceration, the ulcers being distinguished from those of the first group by the hardness and swelling of their undermined edges. Although they show no tendency to invade deeper structures, they may, as the result of a mixed infection, assume larger propor- tions and lead to diseases of the cartilaginous structure of the larynx. There is one form of diphtheria accompanying typhoid often described by older authors (Landgraf also mentions a case of typhoid which was probably complicated with true diphtheria), in w^hich the disease is said to originate in the larynx and pharynx and to extend upward to the nasal mucous membrane. As true diphtheric membrane corresponding to casts of the interior of the larynx were observed, the occurrence of such cases can not well be doubted, though they have never been seen by later ob- servers, such as Schrotter, for instance. At all events, these cases do not represent a true diphtheria, but rather the last group of typhoid ulcers, in which, as a result of mixed infection, croupous processes develop. As in all forms of ulcerations which occasion destruction in the deeper tissues, the healing of the ulcers leaves de- fects and adhesions, which often lead to stenosis of the larynx and may subsequently require local treatment. Such sequels may be of various kinds ; their diagnosis ^ Klebs, " Handb. d. pathol. Anatomic," vol. n, Abth I. 2 " Gaz. des hop.," 1893, No. 116. . TYPHOID FEVER. 12/ often presents great difficulties, and they may be con- founded Avith syphilitic, diphtheric, and other scars, for post-typhoid adhesions present no special characteristics. Thus, Halasz^ described a case of membranous adhe- sions between the lower edges of the vocal cords after typhoid. Diseases of the perichondrium and of the cartilages of the larynx after typhoid fever deserve special attention. They are always to be regarded as secondary, due to the exten- sion of the ulcerating process to the perichondrium. They present various clinical appearances, and closely correspond with diseases of the cartilage from other causes ; a large number of very instructive cases, in part illustrated with ex- cellent cuts, are found in Tiirck's text-book. The various cartilages may become diseased singly or in connection with others ; according to a statistical investigation of the frequency in the individual cartilages (by Liining, Bus- senius, and others), the cricoid cartilage is attacked far more frequently than any other. Liining found it affected in 44 out of 5 5 cases of perichondritis ; Bussenius2 in 49 out of 72 cases. This phenomenon is worthy of special attention, as Bussenius has shown that the distribution of the disease in syphilis and tuberculosis is quite different as regards the individual cartilages, the arytenoid cartilage being affected in by far the greater number of cases. A few cases of paralysis of the laryngeal muscles have been observed. They occur chiefly in the stage of con- valescence (Mendel, Boulay), but may also be met with, according to Przedborski, in the febrile stage. The latter is, in fact, said to be the rule in typhus exanthematosus (petechial typhus). The paralysis presents no character- istic type, and all the muscles may be affected, either singly or combined ; Mendel and Boulay found paralysis of the adductors in only 4 out of 17 cases. The abductors must be regarded as most frequently affected by paralysis, but Przedborski, in his 32 observations, reached a different conclusion, finding both abductors and adductors affected with about equal frequency. But as the former include a number of paralyses of the vocal cords, such as we frequently observe in anemic persons after exhaustive infec- 1 " Pest. med. chir. Presse," 1S93, No. 40 ; see " Centralb. f. klin Med.," 1893, No. 52. 2 " Charite Ann.," 1S96. 128 ACUTE INFECTIOUS DISEASES. tious diseases, and are therefore in no sense peculiar to typhoid, it is quite possible that the figures may have to be again revised. It would be interesting to investigate the fact reported by Przedborski that the muscles become affected one after the other without any definite order such as is usually observed in the dev^elopment of a recurrent paralysis. Opinions are divided as to the nature of the paralysis, but the general tendency is to regard it as anal- ogous to that which occurs in diphtheria ; in other words, as a peripheral paralysis, such as is observed in other infectious diseases, although it is still a matter of dispute whether the muscles themselves or the peripheral nerves suffer a pathologic alteration. The attempt has also been made to explain it as a central paralysis due to hemorrhage in the central organs. According to Przedborski, the prognosis as to recovery is favorable, as he found that the paralysis usually disappeared in the course of from one to three Aveeks. In a few cases a simultaneous paralysis of one-half of the uvula was observed — paralysis pharyngoglossolabialis ; as, for instance, in one case of a boy twelve years old.^ The ear frequently becomes involved in typhoid, the complications being more frequent in typhus exanthematosus (petechial typhus) than in typhus abdominalis. We possess a few statistics concerning their frequency, based on a number of examinations which were made on a series of typhoid patients without regard to the presence of any sub- jective symptoms. Bezold ^ found fifty aural complications among 1243 cases of typhoid (4.02 %); Hengst,^ 28 among 1228 (2.3 ^); Botkin * saw 19 cases of purulent otitis among 357 typhoid patients. The statistics of Zaufal, Kramer, and Schmalz, quoted by Biirkner, yield a percent- age which varies from 1.8 to 2.5. These figures do not, as Haug seems to imply, relate to the frequency of otitis in typhoid fever, but to the frequency with which typhoid fever was given as the cause of aural disease. The com- plications consist mainly in disease of the middle ear ; a few isolated cases have also been reported of involvement of the external and internal ear, but of this we know very ^ Briick, *' Sest. raed. chir. Presse," 1891, No. 30; see " Semon's Cen- tralbl.," vni, p. 510. 2 "Arch. f. Ohr ," XXI. ^ u Zeitschr. f. Ohr.," XXIX. p. 184. 4 See " Mon. f. Ohr.," 1895, p. 135. TYPHOID FEVER. 1 29 little. We will first discuss the middle ear diseases in typhoid. Among the 50 cases observed by Bezold, the middle ear complication in 48 consisted of inflammation, while in only 2 cases was there a simple tubular catarrh which was not dependent on the typhoid fever. The in- flammatory phenomena usually appear in the fourth or fifth week of the disease (according to Bezold, 45 times between the twenty-fourth and twenty-fifth day, and only 5 times before the twentieth day) ; they are heralded by rises in the temperature, which can be referred to the typhoid dis- ease, although they occur in the stage of recrudescence, in which the fever shows a remittent type with occasional marked exacerbations. The patients usually complain of earache and tinnitus aurium, and the attendants note a diminution in their power of hearing. The course of the otitis media is variable, and three forms may be distinguished : a simple inflammatory form without perforation, a purulent form with perforation of the ear- drum, and a form in which involvement of the mastoid process is the prominent feature. In the first form the otoscopic picture shows moderate redness of the ear-drum, especially in the region of the handle of the malleus, without any bulging of the mem- brane. According to Bezold, the congestion evinces a marked tendency to spread to the external meatus. The ear-drum shows little or no bulging, and, as a rule, is not swollen. This form, which is the mildest, may pass into the purulent perforative variety, or the inflammation is so acute from the outset that the ear-drum, which shows a marked redness, soon bulges outward, and perforation rapidly takes place. The suppuration itself is not char- acteristic ; perforation is said to occur preferably in the posterior inferior quadrant. The size of the opening varies, and cases of multiple perforation have even been reported. I myself once observed a case in which bilateral chronic suppuration, which had existed before the onset of the typhoid disease, became arrested during the fever. In the fourth week earache made its appearance. The ear- drums on both sides were very red, and on the left side there was a defect, but no discharge, while the fever still continued high. Eight days later, after thefever had fallen, the congestion subsided, and marked suppuration again set in. These forms of otorrhea which subside during high 9 130 ACUTE INFECTIOUS DISEASES. temperatures were referred to in the discussion of croupous pneumonia, and appear to occur in all infectious fevers where the patient is a subject of chronic suppuration. One peculiarity of purulent otitis media during typhoid, which is mentioned by most authors, is the early involve- ment of the mastoid process. Inflammatory phenomena make their appearance in the mastoid process at the same time that the acute inflammation invades the middle ear, and various cases have been described in which there was marked tenderness on pressure out of all proportion to the appearance of the ear-drum. Brieger observed a case in the eighth week of typhoid in which fluctuation was made out over the mastoid process within four days after the first ap- pearance of the earache, while the corresponding ear-drum was markedly hyperemic and quite flat, and only ruptured on the next day, the perforation being very small and followed by a slight discharge. An operation was performed a week after the onset of the pain, and showed the presence of sequestrums in the mastoid process. The case ended fatally in five weeks, death being due to thrombosis of a sinus. Brieger points out that this does not correspond to the ordinary course of bone disease following typhoid, as there is usually a tendency to spontaneous cure of the inflamma- tion. There is no doubt that the bone is extensively in- volved. This is shown by Bezold's investigations ; in 19 out of 41 cases he found marked tenderness on pressure, which in 1 1 cases made its appearance at the same time as the inflammation. In 5 out of these 19 cases a periosteal abscess resulted, and required incision. It being established that the bone disease either pro- gresses pari passit with the otitis media or precedes it, the question of the etiologic relations existing between the bone disease and typhoid otitis now presents itself According to Bezold, the inflammation in the middle ear may begin in one of the three following ways : First, by direct extension of the inflammation from the nasopharynx through the tube, simple occlusion of the tube being probably insufficient to be regarded as an etio- logic factor, at least for the suppurative processes. Second, by the passage of septic material directly from the nasopharynx into the middle ear. Third, by the formation of emboli in the vessels of the mucous membrane of the middle ear, emanating either TYPHOID FEVER. I3I from an endocarditis and thrombosis of the left heart, or from purulent foci in the periphery, Bezold therefore considers the aural complication as secondary and excludes the effect of the general infection as an etiologic factor. If Bezold's exposition of the eti- ology is accepted, it is difficult to explain how the disease, which is at first localized in the middle ear, can be trans- planted to the walls of the mastoid process with such rapidity as to make the secondary, appear to precede the primary disease. Even if we admit the possibility of the middle ear becoming infected through the tubes, we can not discard the theory that we have to deal with an acute osteomyehtis of the mastoid process, which is to be re- garded as a true complication of the typhoid disease. The demonstration of typhoid bacilli would settle the matter beyond dispute ; unfortunately, we do not possess any bacteriologic data ; however, the course of the bone dis- ease, as has been previously stated, is in itself quite different from that which is usually observed in the complications of typhoid fever, and even if we assume a mixed infection to explain the sequestration of the bone and the formation of periosteal abscesses, the question why the disease in the bone should precede or even accompany the suppuration from the ear remains unsolved. Complication of the external ear (the auricle and the external meatus) is a very rare occurrence. Haug i quotes a case of gangrene of the auricles from Obre. Von Troltsch and Hoffmann ^ each observed a case of suppura- tion of the parotid gland with rupture into the external meatus. In Hoffmann's case there was a fistula at the junc- tion between the cartilaginous and bony portions of the meatus. On the other hand, Botkin ^ observed bilateral otitis externa 21 times among 26 typhoid patients, and erects the improbable hypothesis that suppurations from the middle ear in typhoid are due to an extension of otitis externa to the ear-drum and to the tympanic cavity. An apparent reduction in the power of hearing is fre- quently met with in the course of typhoid fever, although no objective changes can be found to account for it. It is quite unjustifiable to interpret such cases as nervous 1 " Die Krankh. des Ohres," etc., p. 90. 2 " Arch. f. Ohr.," IV, 6th Observation. 3 See "Mon. f. Ohr.," 1S95, p. 135. 132 ACUTE INFECTIOUS DISEASES. deafness, for clinical experience teaches that the difficult hearing is due to somnolence, and improves as soon as the mental faculties are restored. I have myself observ^ed that the hearing varies during the febrile stage, being remarkably improved during the remissions of the temperature which follow cold baths. When Haug 1 remarks "that this typhoidal deafness sometimes reaches its highest point at the crisis of the general disease, and then gradually dimin- ishes and allows the ear to return to its normal condition during the stage of convalescence," and insists particularly on the fact that "disturbances of the sphere of coordination have never been observed," we may be pardoned for express- ing a doubt of this " nervous ear affection." This must not, however, be taken to imply that we deny the possibility of the nervous hearing apparatus being in- volved in typhoid fever, and there are, in fact, a few obser- v^ations which prove that difficult hearing and tinnitus aurium, with the other phenomena of the nervous affection, undoubt- edly occur during the stage of convalescence ; in fact, the anatomic investigations of Pulitzer, Moos, Lucae, and Schwartze demonstrated an anatomic basis for this clinical picture — a hyperemia of the internal ear or ecchymoses and hemorrhages in the vestibule and in the cochlea. The clinical cases of nervous deafness which have been described as progressive after typhoid fever, must, in the absence of detailed histories, be accepted with a reservation, as they may have something to do with the exhibition of quinin or salicyHc acid during the course of the fever. 6. INFLUENZA. Although the port of entry for the carriers of the infection of influenza is probably to be sought in the mucous mem- branes of the upper air-passages, the parts themselves are directly involved in only a small percentage of the cases. Leichtenstern 2 has designated this form as catarrhal res- piratory influenza, in contradistinction to the gastro-intes- tinal form and the purely toxic form with fever and nervous phenomena. The frequency of rhinitis is variously given at from 25 ^ to 79^, that of laryngitis from 5 ^ to 16 ^ ; these figures appear remarkably low in comparison with the ^ Loc. cit., p. 95. 2 Nothnagel's spec. *' Path. u. Ther.," vol. iv, I, p. 77. INFLUENZA. 1 33 frequency with which these conditions are observed in practice. There can not be said to be a typical clinical picture for the complications of influenza in the upper air-passages, for they manifest themselves under the most various forms. Two principal groups are distinguished — one affecting principally the mucous membrane, the other the nervous system. With regard to affections of the mucous membranes, it has been pointed out by Leichtenstern that the inflammation is not uniformly distributed over all the mucous membranes, and that the deeper portions do not always become affected secondarily to the disease in the upper portions, — i. e., the nose and the nasopharynx, as is the case in most other con- ditions, — but every portion of the respiratory tract is cap- able of becoming primarily affected by the morbid process. In the nose the inflammation presents the picture of an acute rhinitis which is distinguished from an ordinary coryza only by the rapidity of its course, the inflammatory symptoms and secretion subsiding within a very few days. The rhinitis is occasionally accompanied by epistaxis, although we find very contradictory statements in regard to this symptom. Schmidt and Litten regard epistaxis as a very frequent complication, while Tissier,i Leichten- stern, and Frankel,^ on the other hand, say that it is comparatively rare. We should mention the occurrence of acute or, later, chronic suppurations in the accessory cavities as one of the complications. Thus, the maxillary sinus is frequently the seat of an acute inflammation, accompanied with nasal obstruction and facial neuralgia, which immediately disappears either spontaneously or after the swelling in the mucous membrane has subsided and the orifice of the cavity has been exposed. The best descriptions of suppurations of the accessory cavities are given by Tissier, who claims to have found all the various sinuses affected. Ewald^ reports a very malig- nant case in which a purulent basal meningitis developed after an empyema of the antrum of Highmore had been opened ; the meningeal complication at the autopsy was accounted for by the finding of a suppuration in the ethmoid cells. 1 " Ann. des mal. de I'oreille," 1S92, p. 425. '■' " Semon's Centralbl.," vii, p. 3S. 3 "Berlin, klin. Wochen.," 1S90, No. 3. 134 ACUTE INFECTIOUS DISEASES. Catarrh of the pharynx and larynx also presents the ordinary picture of an acute inflammation, except that hemorrhage appears to be a more frequent complication than in the nose ; the term laryngitis Jicviorrliagica has been ap- plied to this form of the disease. The affected mucous mem- branes are frequently the seat of whitish patches, not ele- vated above the swollen and reddened mucous membrane. They are analogous to similar patches found in acute catarrh, and are to be interpreted as a superficial necrosis. In a few instances marked edema of the laryngeal mucous membrane was observed, which even went on to abscess formation, and Rethi described a coexisting perichondritis of both plates of the thyroid cartilage. ^ As regards nervous diseases, a few cases of anosmia and parosmia have been reported, and while paralysis of the palatal muscles and of the constrictors of the pharynx may occur, by far the most important complication con- sists in paralysis of the laryngeal nerves, which must be regarded as a typical influenza neuritis such as occurs in all parts of the body. Besides rare cases of paralysis of the sensory superior laryngeal nerve we meet with paralyses of the laryngeal muscles, both of the adductors (Onodi saw an isolated paralysis of the cricoarytenoideus lateralis, and Rosenberg frequently noticed paralyses of the vocal cords) and of the abductors ; they usually make their appearance after the acute inflammation has subsided. So far as the observations have gone, the abductors appear to be more frequently involved than the adductors, and both unilateral and bilateral paralysis of the crico-arytenoideus posticus has been observed. Seifert^ reports a unique case of a right-sided total paralysis of the vagus which he re- gards as peripheral in origin. Besides the usual cardiac and circulatory symptoms there was paralysis of the right recurrent and of the superior laryngeal nerves. AURAL COMPLICATIONS IN INFLUENZA. Soon after the appearance of the influenza epidemic of 1 889-1 890 the attention of aural surgeons was directed to the frequency of purulent otitis media as a complication of influenza, and the numerous observations that have been 1 "Wien. klin. Wochen," 1894, No. 48. 2 '« Rev. hebd. de lar., d'ot. et de rhin.," 1896, p. 1537. INFLUENZA. I 3 5 made since then, and that any physician can make for him- self even now in the sporadic cases of influenza, justify the conclusion that this epidemic infectious disease occupies an important place in the etiology of aural complications. It was learned by the statistics of Ludwig and Jansen that a rapid increase in middle-ear diseases occurred during the months of November and December, 1889, and January, 1890, and this increase was attributed to the epidemic which was prevalent at that time. It is important to note that the increase did not affect middle-ear diseases in gen- eral, but Avas limited exclusively to inflammations of the middle ear. Thus, in the Halle Ear Clinic the number reached 137 during the months of the epidemic, as against 41 or 44 during the same months of the preceding years ; and, according to Gruber, there were 625 cases from No- vember, 1889, to January, 1890, as against 238 and 84 during the same period of the preceding years. Jansen's statistics are most convincing in this respect : they show that the percentage of acute inflammations of the middle ear, which in the first eleven months of the year 1889 amounted to from 10^ to ly.yfo, rose to 37^ in Decem- ber, 1889, 29^ in January, and 20.6^ in February 1890, although there was no appreciable increase in the frequency of simple catarrh of the middle ear. The discrepancy can not be explained as an ordinary increase in the frequency of the disease due to the season of the year, since the com- parison with the months of November, December, and Jan- uary of the five preceding years shows a percentage ranging from 8.1 to 21.5, and in only one winter a percentage as high as 25.5. In spite of the increase in this particular form of disease the total number of patients was not appre- ciably increased, as might have been expected from the general prevalence of disease during the epidemic. Leich- tenstern's objection, that "the statistics of specialists merely show the enormous distribution of the influenza," is quite irrelevant. On the contrary, if we examine the statistics of specialists, we find that the great frequency of certain ear diseases — such as acute inflammation and suppuration of the middle ear which are known to follow in the wake of other infectious diseases — and their abnormally rapid and malignant course during an epidemic of influenza, are not merely accidental, but directly dependent on the epidemic. With regard to the frequency of aural complications of 136 ACUTE INFECTIOUS DISEASES. influenza in general we possess only general statistics, according to which from o. 5 % to 2 ^ of all cases are com- plicated with disease of the ear ; but these figures are prob- ably below the true percentage, as the milder cases of influenza remain only a short time in the hospital, and the aural disease therefore appears only as a sequel. The otitis in influenza makes its appearance in the form of an acute suppuration of the middle ear from a few days to several weeks after the beginning of the primary disease. As influenza is an infectious disease with a special prefer- ence for the upper air-passages, it is probable that a large proportion of the aural affections are due to infection from the nasopharynx through the tubes, and, as such, appear under the form of an ordinary purulent otitis media. There is, in addition, another manifestation of influenza which possesses a distinct hemorrhagic character, and is by many regarded as a pure form of influenza otitis. These two varieties can not be accurately distinguished in prac- tice, as the typical appearance in the latter form disappears after the first k\v days and is replaced by the picture of an ordinary otitis media. The finding of the bacillus of influenza — which was first positively reported by Scheibe, and after him by several other investigators, although never with any regularity — is of very little importance, as sooner or later in any form of suppuration from the middle ear there develops a mixed infection in which other micro- organisms may supplant the primary disease germ. As regards the clinical course of influenza otitis, it was formerly universally believed that hemorrhages were to be regarded as a regular symptom of the disease in the acute form, in accordance with the first descriptions given by Patrzek, Schwabach, Dreyfuss, and Jankau ; Schwartze, however, adheres to his opinion that the hemorrhages are not observed with any greater frequency than in inflam- mations from other causes. We find ecchymoses, var^ang from the size of a pinhead to that of a split pea, either single or multiple, on the ear-drum and on the walls of the external meatus ; or we may have bluish-red extravasations of varying extent, sometimes covering the entire ear-drum. Korneri speaks of secondary circular hemorrhages which he saw through the ear-drum after hypertrophy of the 1 " Zeitschr. f. Ohr.," xxvii, p. 11. INFLUENZA. 1 3/ mucous membrane. The hemorrhages often take the form of villous or pouch-shaped diverticula in the tympanic mucous membrane, due to marked swelling of the mucous membrane of the middle ear, and, after perforation, pro- lapse through that structure into the external meatus. They show a special tendency to recurrence, and frequently reform after simple cauterization. Some observers speak of perforation taking place in a definite portion of the ear- drum, but the statements are so contradictory that it is not worth while to repeat them ; isolated involyement of the cupola (infundibulum cochleae) in influenza, mentioned by Kosegarten and Haug, must be very rare. The dis- charges are bloody on the first day, and hemorrhages may occur even later without leading to suppuration, while in other cases the bloody discharge is replaced by serosanguineous fluid, which is eventually followed by suppuration. The statement that purulent otitis media in influenza is more severe than other forms of suppuration from the mid- dle ear is based on the frequent implication of the mastoid process (according to Jansen, in 57 out of 105 cases, 25 of which necessitated trephining). The complication leads to suppurations in the bone and to periosteal abscess, which are greatly to be dreaded on account of the intensity of the process and its rapid extension. According to Komer, Eulenstein, and Lemcke, primary myelitis of the mastoid process with secondary involvement of the middle ear may occur ; but the opposite direction, from the middle ear to the mastoid process, is probably to be regarded as the regular mode of infection. The internal ear is very rarely involved, and the nature of the condition is not known. Lannois ^ and Barnick ^ described cases of labyrinthine deafness after influenza. According to the former, the prognosis as regards restora- tion of the hearing is bad ; according to the latter, favorable. Gradenigo ^ mentions difficult hearing after influenza, which he interprets as a neuritis of the auditory nerve. ^ The occurrence of otalgia tympanicais occasionally men- tioned, and although the condition can hardly be diagnosed 1 "Rev. de lar., d'ot. et de rhin.," 1890, No. 17. 2 "Arch. f. Ohr.," 38, p. 1S3. 3 See " Arch. f. Ohr.," 36, p. 141. * Comp. Leyden and Guttmann, "Die Influenzaepidemie," Wiesbaden, 1892, p. 132; and Ebstein, " D. Arch. f. klin. Med.," vol. LVili, p. 14. 138 ACUTE INFECTIOUS DISEASES. with certainty, it may be accepted as a possible complica- tion through the trifacial nerve, in view of the frequency of other neuralgic manifestations in influenza. 7. PAROTITIS EPIDEMICA (MUMPS), In this obscure epidemic disease, which belongs to the class of infectious diseases, the general infection manifests itself in various parts of the body, showing that the typical swelling of the parotid gland is only a local expression of the general disease. The commonest complication — that of orchitis and epididymitis — is as little understood as the occasional involvement of the ear. The aural complication usually takes the form of laby- rinthine deafness, appearing, as a rule, during the first days of the disease, along with other symptoms of Meniere's complex, and offering an obstinate resistance to every mode of treatment, while the accompanying symptoms of vertigo, tinnitus aurium, and disturbances of the equilibrium sub- side. Like the complications in the sexual organs, those in the ear show a predilection for the age of puberty, being most frequent between the tenth and twentieth years. 1 The total number of cases reported is very small. In 1884 Connor was able to collect 34 cases, and in 1883 Gradenigo could report only 38 positive observations of deafness due to mumps. One or both ears may be affected, and there appears to be no connection with the situation of the pri- mary disease if the latter has been unilateral. There have even been reported rudimentary cases in which orchitis and deafness were present without glandular swelling (Gra- denigo's case). As the prognosis is absolutely unfavorable, the disease may, if it be bilateral and occurs in early infancy, lead to deafmutism, the frequency of which is given as 0.3^ by Mygind, in the Saxon deaf and dumb statistics, and as 0.5^ by American statisticians. The otoscopic picture is in every respect negative, and there is absolutely no proof that inflammations of the tym- panic membrane and exudations in the middle ear have anything to do with the disease. Functional test shows deafness or marked reduction in the hearing of the internal 1 Gradenigo, " Schwartze's Handb.," Ii, p. 440, ACUTE RHEUMATOID ARTHRITIS. 1 39 ear, while, according to Moos,i the power of hearing for the lower notes and bone conduction may bfe preserved. Numerous attempts have been made to explain the deaf- ness of infectious parotitis, but they are all more or less improbable, and therefore of no interest. The subject will be found discussed at length in papers by Rossa,2 Moos,^ Haug,^ Gradenigo,^ and Alt.^ Pilatti '^ describes a case of parotitis in which tracheotomy was required on account of edema of the larynx. 8. ACUTE RHEUMATOID ARTHRITIS (POLYAR- THRITIS RHEUMATICA ACUTA). One of the first diseases in which the tonsils were recog- nized as the port of entry for a general infection was acute articular rheumatism. The importance of angina in the etiology of this disease was first pointed out by Lagranere, Boeck, Loebl, Mantle, and others, all basing their asser- tions on clinical observations. But the confusion that still prevails with regard to the cause of acute articular rheumatism was not removed by the bacteriologic examination of cases of rheumatoid angina, for the greatest variety of microorganisms — staphylococcus aureus, pyogenic streptococci, streptococ- cus citreus, and pneumococci — was found. As this is not the place for a detailed theoretic discussion of the relation between the angina and rheumatism, — which will be found, together with a complete report of all the cases in the literature, in the works of Buss,^ Suchannek,^ and Bloch,i ^ — I shall merely refer briefly to the clinical observations that have been reported. Any one of the varieties of tonsillitis, both catarrhal and follicular, may appear either as a forerunner of rheumatism before the joints are affected, or as a feature of the fully developed clinical picture. The complication can not at the present time 1 " Berlin, klin. Wochen.," 1S84, No. 3. 2 " Zeitschr. f. Ohr.," vol. xn. ^ << Schwartze's Handb.," i, p. 584. * " Die Krankh. des Ohres," etc., p. 75. 5 " Schwartze's Handb.," 11, p. 439. 6 " Mon. f. Ohr.," 1896, p. 525. ' See " Semon's Centralbl.," Vin, p. 149. 8 "D. Arch. f. klin. Med.," vol. i.iv. ^ Bresgen's Sammlung, vol. i, II. i. 10 "Munch, med. Wochen:," 1S9S, Nos. 15, 16. I40 ACUTE INFECTIOUS DISEASES. be regarded as a rare occurrence in Germany, as stated by Wagner ^ in 1878, and its frequency shows that it is not an accidental coincidence, but that it represents a symptom of the general disease. Gerhardt ^ mentions, as a strong proof of internal connection between tonsillitis and rheumatism, a case of Staffel's,^ in which an attack of articular rheumatism rapidly followed a severe inflamma- tion of the tonsils, and the articular affection was removed only after methodical treatment of the mouth. In addition to tonsillitis and pharyngitis, we also have catarrhal lar}'n- gitis ; but by far the most important diseases of the larynx, from a practical point of view, are those which must be regarded as typical rrianifestations of the rheumatic infec- tion. They may be divided into two varieties, which have been designated respectively as disease of the joints of the larynx and as laryngitis acuta rheumatica circumscripta (Nodosa). The crico-arytenoid articulation is the only one tiiat has been known to be involved in an acute articular rheuma- tism, although the fact that there is no report of the crico- thyroid joint being involved may be due to defective diag- nosis, and it seems to me that Meyer's ^ case might easily be regarded as one of this kind, since the laryngoscopic findings w^ere negative. Rheumatism of the crico-arytenoid articulation is usually bilateral, and manifests itself in the laryngeal image in redness and swelling of the arj^tenoid region and in sluggishness or arrest of the vocal cords, sim- ulating paralysis. Besides the aphonia, the subjective symp- toms consist in a sensation as of a foreign body, dyspnea, and dysphagia, all. of which, according to Meyer's descrip- tion, are worse when the patient lies down. An important diagnostic point is the tenderness over the crico-arytenoid joint or over the thyroid cartilage ; in the latter case the symptom possibly points to disease of the cricothyroid articulation. The laryngeal complication usually develops between the fourth and the twelfth day after the onset of the articular rheumatism ; the prognosis is favorable, recovery usually occurring in a short time (according to Meyer, in a week). Grijnwald ^ mentions a case of " cadaver position " ^ Wagner, " Ziemssen's Handb.," VII, p. 148. 2 " Verhdl. des Congr. f. inn. Med.," 1896, p. 180. ^" Zeitschr. f. prakt. Aerzte," 1896, No. 4. 4 " Berlin, klin. Wochen.," 1894, No. 16. 5 "Berlin, klin. Wochen.," 1892, No. 20. ACUTE RHEUMATOID ARTHRITIS. I4I on the right side after articular rheumatism which was cured in two years. The disease usually responds promptly to salicylic acid. The reported cases, which are very few in number, have been collected by Lacoarret ^ and Sendziak ^ ; Archambault's ^ thesis is also well worth reading. The second form of rheumatic disease in the larynx is described by Uchermann ^ as laryngitis acuta rheumatica circumscripta (nodosa), although Goldscheider ^ lays claim to priority, as he reported an analogous case in an earlier paper. The condition occasionally manifests itself in con- nection with erythema nodosum as a "circumscribed red- dish or bluish-red, moderately firm infiltration, very sensi- tive to the touch," which may attain a considerable size (as large as an almond), seated usually in the neighborhood of the crico-arytenoid articulation or in the aryepiglottic fold ; in the former situation pseudo-ankylosis, with immobility of the vocal cord, is likely to result. As the inflammation also invades neighboring portions of the larynx, and thus leads to edema both in the aryepi- glottic folds and on the epiglottis, the symptoms of dyspnea and dysphagia may be added. The prognosis in this form also is favorable. Wolf ^ described two cases of acute inflammation of the middle ear in acute articular rheumatism. In the first case both ears were affected one after the other ; one of the ear-drums ruptured spontaneously ; in the other, par- acentesis was required. The rheumatism was very severe, and did not appear in the joints until several days later ; the suppuration which followed the inflammation was cured in four weeks. In the second case the aural disease was followed after only nine days by diffuse swellings in the joints. From the fact that in both cases the impairment of hearing and thickening of the ear-drum were permanent. Wolf concludes that articular rheumatism may be the cause of sclerotic catarrh in the middle ear. A similar case is reported by Meniere.'^ We have no knowledge of disease in the joints of the ear ossicles ; the possibility of rheumatism in the joint between the malleus and the incus, and between the incus and the stapedius, is, however, worth considering. 1 " Rev. de lar., d'ot. et de rhin.," 1S91, No. II. 2 " Arch. f. Laryng.," iv, p. 264, and VI, p. 168. ^ TWse de Paris, 1886. * "Deutsche med. Wochen.," 1897, p. 749. ^ Ibid., p. 807. ^ " Arch. f. Ohr.," 41, p. 213. ' " Rev. mens, de lar., d'ot., et de rhin." 142 ACUTE INFECTIOUS DISEASES. The cases reported by Bloch ^ in which disease of the ear is said to have produced an acute articular rheumatism do not seem to me sufficiently convincing to justify the assumption of a new mode of infection for that disease. . 9. DIPHTHERIA. The description of diphtheria belongs to the domain of internal medicine, ^ and the manifestations of the disease in the nose, pharynx, and larynx will be found amply discussed in the text-books. I shall not, therefore, attempt to give a description, as it does not belong to the scope of this work, and would, if it made any pretensions to thoroughness, occupy too much space. Instead, I shall confine myself to a discussion of the sequels occurring after diphtheria in the nose, pharynx, and larynx, and in the ears. In the pharynx and larynx we have post-diphtheric palsies of both the sensory and motor nerves, the cause of which is now generally conceded to be a peripheral neuritis. The time of their appearance is usually given as from two to six weeks after the diphtheria. The paralysis affects most frequently the uvula. The nature of the paralysis is unmistakable, as it can be seen by direct inspection, and manifests itself, besides, in the con- spicuous symptoms of dysphagia, regurgitation of liquids through the nose, and nasal speech. Although this form of paralysis has occasionally been observed early, fol- lowing immediately upon the pharyngeal disease, it must be remembered that a paretic condition of the palatal mus- cles may be produced by the diphtheric disease of the mucous membrane invading the deeper-lying muscles. Anesthesia of the pharyngeal and laryngeal mucous membrane is much more rare. It was observed in the cases cited by v. Ziemssen ^ and elsewhere. Paralysis of the vocal cords has been observed with at least sufficient frequency to remove any doubt of its oc- currence, and it is difficult to understand what could have led Baginsky ^ to say that " he was unable to find among 1 " Miinch. med. Wochen.," 1898, Nos. 15, 16. ^ The latest description is by Baginsky, in Nothnagel's " Spec. Path. u. Then," 11. Bd., i. Th. 3 In "v. Ziemssen's Handb.," vol. iv, p. 405. * Loc. cit., p. 215, DIPHTHERIA. 1 43 all the reported cases any description of paralysis of the crico-arytenoidei postici due to lesion of the recurrent laryn- geal nerves after diphtheria ; he himself had certainly never seen it." Von Ziemssen ^ reports two cases of diphtheric paralysis of the pharynx, larynx, and extremities. In one case the left vocal cord was completely paralyzed in the cadaver position, while the right was very sluggish and limited in its excursions. I once saw a doubtful case in which a unilateral complete paralysis of the uvula and vocal cords was associated with anesthesia of the mucous membrane and abolition of all the reflexes. The paralysis occurred about six weeks after a mild case of diphtheria, and after it had lasted seven weeks the vocal cord gradually returned to the median position and finally completely regained its movabihty. ClifFord-Beacher ^ observed a case in which paralysis of the adductors followed that of the abductors, while recov- ery took place in the inverse order. According to Lublinsky, ^ postdiphtheric paralysis of the vocal cords is more frequent, and occurs earlier when the serum treatment is employed ; in one case he saw it as early as the ninth day of the disease. The prognosis of postdiphtheric paralysis is favorable. In anesthesia and impairment of the reflexes in the upper air-passages there is some danger of inspiration pneumonia. In addition to these peripheral palsies there have been observed paralyses of central origin, probably due to hem- orrhage, manifesting themselves under the form of hemi- plegia and presenting the symptoms of paralysis of the uvula and aphasia. It is not stated whether or not the vocal cords were also paralyzed. Edgren ^ gives a review of the cases reported in the literature, adding some of his own. Diseases of the ear in diphtheria may be divided into — 1. Diphtheric inflammations of the external auditory meatus. 2. Diphtheric inflammations of the tube and of the middle ear. 3. Acute catarrhal and purulent inflammations of the mid- dle ear without the formation of membranes. 1 Loc. cit., p. 215. 2 " Semon's Centralbl.," IX, p. 86. 8 "Deutsche med. Wochen.," 1S95, No. 26. *" Deutsche med. Wochen.," 1893, No. 36. 144 ACUTE INFECTIOUS DISEASES. 1. Diphtheria of the external auditory meatus is very rarely seen. The only reliable observation of its occur- rence in connection with pharyngeal diphtheria is that of Treitel, ^ while in the other published cases of croupous inflammation of the external meatus, by Wreden, Blau, and others, the diagnosis of true diphtheria is not positive, some of the cases representing the scarlatinal variety. In Trei- tel's case, diphtheric membranes were found in both ears, representing a complete cast of the external auditory mea- tus. The inflammatory symptoms were very marked, and there was extensive swelling over the mastoid process. The disease extended to the auricle, but the ear-drum re- mained intact. A bacteriologic examination was made by Kossel, and was negative, although he found rod-shaped organisms resembling the diphtheria bacillus ; Treitel attributes the negative outcome of the cultures to the sublimate solution in which he had preserved the membranes before they were examined. 2. As regards diphtheric disease in the tube and in the middle ear, we do not possess any positive investigations supported by the bacteriologic demonstration of diphtheria bacilli, but we are forced by the result of autopsies and by clinical observation to assume the occurrence of such com- plications in true diphtheria. When we attempt to analyze the reported cases, most of which belong to the prebacteriologic period, or else are so little to be relied upon as to be quite unworthy of dis- cussion, it is often difficult to separate cases of false from those of true diphtheria. Wreden ^ and Burkhardt- Merian,^ for instance, discuss scarlatinal diphtheria and true diphtheria and their complications with croupous inflammation of the middle ear without making any dis- tinction between them. On the other hand, we find in the observations of Wendt,^ Kiipper,^ Moos, and Hirsch ^ the necessary materials for a description of diphtheric disease of the ear. The middle ear may be affected alone or in combination 1 " Deutsche med. Wochen.," 1S93, p. 13S8, 2 " Mon. f. Ohr.," vol. 11, p. 148. 3 Volkmann's " Sammlung klin. Vortr.," I. Reihe, Serie vii. No. 182. * " Arch. f. Heilkunde," xi and xni. 5 "Arch. f. Ohr.," xi, p. 20. « " Zeitschr. f. Ohr.," XIX, p. loi. DIPHTHERIA. I45 with the tube. Diphtheric membranes are found adhering to the mucous membrane of the tympanic cavity or cover- ing the ossicles or Hning the cells in the bone. In a case of acute purulent otitis media after diphtheria, reported by Lommel,! beginning membrane formation was found in individual mastoid cells. The symptoms of the disease are those of any acute otitis media, rise of temperature and pain being the most prominent ; the pain is aggravated by the fact that the ear- drum shows no tendency to spontaneous perforation, so that expulsion of the membranes into the external meatus occurs only after paracentesis has been performed. The course of a croupous disease of the ear following diphtheria appears to be the same as that of one following scarlet fever ; both diseases are considered equally malig- nant as regards destruction of the walls and of the ossicles in the middle ear, the production of extensive caries in the temporal bone, and extension to the labyrinth, so that the prognosis must be regarded as unfavorable. Nothing definite is known in regard to the frequency of true diphtheria in the ear. It is certainly very rare, and does not bear any proportion to the frequency of scarlatinal diphtheria. 3. It has been demonstrated by anatomic investigations — among which those of Wendt and Lommel ^ are worthy of special mention — that even without clinical appearances, and certainly without any involvement of the drum mem- brane, certain alterations are regularly found in the middle ear of diphtheric cadavers which we must regard as due to catarrhal otitis media with or without serous exudation, catarrhal otitis media without purulent but with mucous secretion, or acute purulent otitis media. Although Lommel found pus in the middle ear in one-half of his cases, the ear-drum was never perforated nor even markedly congested, showing that a clinical diagnosis based on the appearance of the otoscopic image would have been impossible. This explains why the anatomic findings of Lommel in regard to the frequency of aural complication in diphtheria are in direct opposition to clinical observations. While, on 1 " Zeitschr. f. Olir.," xxix, cases VII and xxiv, p. 301. 2 "Zeitschr. f. Olir.," XXIX, p. 301. 10 146 ACUTE INFECTIOUS DISEASES. the one hand, Lommel found the ear intact in only i out of 25 autopsies of diphtheric cadavers, and therefore laid down the rule that otitis media forms an integral part of the clinical picture of " diphtheric disease of the respiratory organs," Baginsky,i on the other hand, reports that although he examined the ears of his diphtheria patients with the greatest care, he found only from 5^ to 6^ in which an inflammation was present. Hence we must not overestimate the significance of these findings from a clin- ical point of view, and as in my cases the reports show that the alterations in the mucous membrane of the middle ear were very slight and analogous to those which are found in other infectious diseases, — especially measles (Rudolf and Bezold), — we must assume that they undergo regeneration without giving rise to any clinical symptoms. As has been stated in connection with croupous inflam- mation of the middle ear, the tube may remain intact. Lommel found that the cartilaginous extremity was rarely attacked, while the "main central portion" was regularly free from any inflammatory process, even in one case where there was a diphtheric exudate about the orifice itself. Hence, direct extension of the inflammation from the pharynx to the middle ear is to be regarded as unusual, the middle-ear disease being rather the expression of the general infection ; and I may remark that, in harmony with this statement, consecutive ear disease after nondiphtheric tonsillitis, whether of the catarrhal, lacunar, or suppurative variety, is rare, notwithstanding the fact that those diseases are usually referred to in the text-books as frequent etio- logic factors in suppuration of the middle ear. Lastly, it appears that nerve deafness may occur after diphtheria ; it is probably due to toxic influences, and be- longs to the class of postdiphtheric palsies. The cases reported are so few ^ ^ and so incomplete that it is impos- sible to draw any conclusions from them. 1 " Diphtheric und diphtheritischer Croup," in Nothnagel's *' Spec. Path. u. Then," Bd. ii, i. Th., p. 258. 2 Kretschmann, ' 40-42, 1895. ^ " Arch. f. Laryng.," V. 154 CHRONIC INFECTIOUS DISEASES. found intact at the autopsy. We can not admit as proof of primary laryngeal disease cases in which the lungs are found to be affected at the autopsy, even when we find the assertion that the lung disease is of more recent origin than the laryngeal affection. Primary tubercular chondritis and perichondritis may possibly occur ; cases of perichon- drial tubercular abscess on the exterior surfaces of the thy- roid cartilage, unaccompanied by other laryngeal or pul- monary manifestations, are occasionally met with, and, as I have had occasion to observe, such cases, if operated on, yield a favorable prognosis. Angelot ^ and Catti ^ have described cases of acute miliary tuberculosis beginning in the pharynx and larynx. Angelot's case terminated fatally in from two to six months ; the two cases by Catti on the eighth and ninth day, respectively. The latter author emphasizes the fact that the laryngeal symptoms may be so prominent as to mask any morbid symptoms in other organs and to suggest diphtheria. The most frequent, not to say regular, form of infection met with in the upper air-passages is the secondary one ; but here again opinions diverge as to whether the infection is brought about by direct contact with the infected sputum or through the lymphatics and blood-vessels. The former opinion may be called that of the morbid anatomists, as we find among its representatives such names as Orth ^ and E. Frankel,* while the other is held chiefly by laryngologists, such as Korkunoff (v. Ziemssen's clinic),^ Schnitzler, Schrotter, and others ; but it is worthy of remark that neither of the two factions considers its own view as the only possible explanation, and admits the pos- sibility of the opposite mode of infection in isolated cases. Orth says : " When we hav^ to deal with a typical case, where, perhaps, there is only a large ulcerated cavity in one apex ; where all the bronchi through which the secre- tions from this cavity must pass during expectoration are full of tubercular ulcers ; where we find smaller ulcers only on that side of the main bronchus and lower portion of the trachea which, from the position of the body, must come into contact with the secretion, and the ulcers are found 1 Quoted by Orth, p. 323. 2 a Wien. klin. Wochen.," 1894, p. 438. 3 " Lehrb. der spec. path. Anat.," p. 320. ■i"Virch. Arch.," cxxi, p. 523. 5 " D. Arch. f. klin. Med.," XLV, p. 43, TUBERCULOSIS AND LUPUS. I 55 to increase in size and frequency as we ascend ; where, omitting a part of the trachea, the tubercular affection is seen to be more extensive wherever the walls of the air-passages are approximated, and the sputum is there- fore forced against the sides, — the conclusion seems inevi- table that the sputum constitutes the vehicle by which the tubercular toxin is conveyed from the cavity and deposited during its transit through the air-passages on favorable regions of the mucous membrane." Such "inoculation " is, of course, quite conceivable, and the formation of ulcers by the entrance of bacilli from the exterior, either through excoriations or through the intact epithelium, is possible ; but, instead of regarding it, with E. Frankel, " as the essen- tial and primary mode of infection," would it not be more logical to view it only as an occasional factor in the etiology of the disease ? The strongest argument in the hands of those who believe that the infection takes place through the vascular and lymphatic channels is found in the morbid anatomy of laryngeal tuberculosis. The first stage of the disease is characterized by the deposition of tubercles within the mucosa at a greater or less distance from the epithelium, which at first retains its integrity ; in fact, there is fre- quently a broad, wide zone of healthy tissue between the infiltration and the epithelium. In the laryngoscopic image tubercular infiltration of this kind, which may become quite extensive through the subsequent formation of a large num- ber of tubercles, manifests itself in a circumscribed swelling covered with healthy mucous membrane. These condi- tions can be studied in preparations of tubercular larynges, and thus we have a confirmation of the excellent descrip- tions given at first by Heinze,^ and more recently by Kor- kunoff 2 and others. It is only later, when the tubercle increases in size and reaches the level of the epithelium, that the latter begins to degenerate ; the membrane be- comes loosened and the epithelium breaks down into detritus. In this way a tubercular ulcer is formed, the superficial necrosis keeping pace with the progress of the tubercular infiltration. The distribution of the tubercle bacilli also corresponds with these anatomic conditions. Korkunoff found that while the outer layers of the epithe- 1 "Kehlkopfschwindsucht," Leipzig, Veit & Co., 1879. 2 " D. Arch. f. klin. Med.," vol. .KLV, p. 43. I 56 CHRONIC INFECTIOUS DISEASES. Hum contained few bacilli, the deeper portions, nearer the tubercles, contained large numbers. The anatomic condi- tions, therefore, would appear to show that the tubercular process spreads by way of the lymphatic or vascular chan- nels, and this is in accord with daily clinical experience, for we frequently find that apparently harmless thicken- ings, especially on the posterior wall, often undergo a bluish discoloration, become necrotic, and are converted into ulcers, so that it does not seem plausible in these cases of tubercular infiltration to suppose an infection by contact notwithstanding that Orth refuses to admit the explanation of the subepithelial appearance of the tubercles. There is no doubt that tubercles produced by contact do occur in the epithelium of the larynx, but they are of an entirely different nature, both anatomically and clinically. They were formerly described as diphtheric (Rokitansky), then as aphthous erosion and corrosion ulcers ; a difference of opinion concerning their origin existed for a long time, as it seemed doubtful whether they should be explained as simple tubercular or merely as arrosion ulcers, due either to irritation of the mucous membrane by the contents of the cavity or to a secondary infection of superficial ero- sions. These ulcers are not the result of an infiltration, as was formei-ly believed, but represent superficial miliary tubercle nodules in process of degeneration. They form flat super- ficial ulcerations with a decided tendency to spread, while the tendency to form granulations in the floor of the ulcer, which is such a marked clinical characteristic of other tubercular lesions, is absent. The floor of the ulcer is covered by a thick, yellowish exudate, which sometimes forms a true fibrinous membrane slightly raised above the level of the surrounding parts. It is probably this appear- ance that induced Rokitansky to describe them as diph- theric ulcers. These arrosion ulcers represent, therefore, another spe- cific expression of the tubercular process, ultimately due to the action of the tubercle bacilli, but their mode of infec- tion is evidently quite different from that which I have so far described. Since from the very beginning of the disease the tubercular infiltration is superficial, we can not in this case suppose a movement of the bacilli from within outward, — in other words, from the vascular or lymphatic channels, TUBERCULOSIS AND LUPUS. I 5/ — and must admit the explanation of an infection by con- tact with tubercular sputum. The significance of a mixed infection with staphylococci and streptococci has not as yet been determined, but such an infection appears probable when we consider the rapid spread of these ulcers. Certain clinical arguments have been advanced to prove the occurrence of infection from the lungs and larynx through the blood-vessels, but the observations of Friedreich, Schrotter, and Schech (which were not con- firmed by Heinze's postmortem investigations), that the disease always affects the organs on the same side, are not above criticism. If we accept direct infection of the larynx as the rule, it is at least remarkable that when the expectora- tion is very copious and contains bacilli, there is no laryn- geal disease ; whereas it is present in cases when there is little or no sputum in a beginning pulmonary tuberculosis, and there is therefore no possibility of long-continued con- tact of the sputum with the mucous membrane, favoring the entrance of the bacilli. To meet this objection, Orth assumes a certain constitutional predisposition or weakness of the mucous membranes to explain the occurrence of in- fection by contact. But if contact with the sputum plays such an important role in predisposed individuals, why does the disease become localized in the larynx ? Does not the squamous epithelium in the deeper portion of the pharynx, in the pyriform sinuses, and on the posterior and lateral pharyngeal walls present the same possibility of infection from without as the epithelium of the larynx, which shows a special preference for tubercular disease in those portions covered by squamous epithelium ? The sputum collects in much larger quantities in these regions than it does in the larynx itself, where it is constantly expelled by reflex cough, and therefore infection by contact would be quite as likely to occur as in the larynx ; but, as a matter of fact, this is not the case. We know from the observation of other laryngeal diseases, especially carcinoma, that enlargement of the lymphatic glands and extension to the surrounding structures occur only in the later stages of the disease, and it appears that the lymphatic system of the larynx occupies, in a certain sense, a unique position. Of course, we can not as yet say with any certainty that this factor in any way contributes to the tendency of the infection to localize itself in the larynx, to the exclusion of other por- 158 CHRONIC INFECTIOUS DISEASES. tions of the upper passages, but the observation is worthy of consideration. We therefore reach the conclusion that both views in re- gard to secondary infection of the larynx from the lungs have their pros and cons, and that it is impossible to draw any absolute theoretic deductions in support of either theory. In view of our clinical and anatomic experience, we recognize infection of the larynx by way of the lymph- channel, as probably more frequent, and reserve infection by contact for those cases which manifest themselves in the form of arrosion ulcers. Tuberculosis of the nose manifests itself in three different forms : {a) Tuberculoma. ib) Extensive infiltration with ulceration. ic) Bone disease with secondary extension to the mucous membrane. The typical seat of tuberculous tumors is the cartilag- inous septum, although in a few cases they are found on the bony portion. They appear as tumors w^ith a broad base, imperfectly circumscribed, and of varying size, so that they lead to a greater or less constriction of the nasal cavity. The epithelium is usually preserved and appears healthy on the surface ; the mucous covering is smooth ; the surface is either uniform or slightly bosselated ; occasionally, several distinct nodules can be made out on the tumor. They show very little tendency to ulceration and caseation of the con- tained tubercle ; it is only in very old cases that there is occasionally seen a tendency to ulceration at the apex of the tumors (Koschier). The swelling usually appears first on one side of the septum, but later a similar swelling is seen on the opposite side, so that we have two dark-red or grayish-red tumors, which can be seen without the aid of a reflector and resemble traumatic abscesses of the septum. In this stage of the disease the perichondrium becomes the seat of round-celled infiltration ; the process invades the cartilage of the septum, which undergoes necrosis ; the dividing wall between the two tumors breaks down, and they become fused. This destructive process may go on for years without any marked alteration in the clinical picture. In some cases, however, the surfaces become ulcerated and the tubercular tumor undergoes further disintegration, and TUBERCULOSIS AND LUPUS. I 59 finally becomes merged in the ulcerative process which at- tacks the deeper tissues. As the septum has already been attacked by the morbid process, the loss of tissue now becomes evident by the de- struction of the tuberculous granulation ; usually, the greater portion of the cartilage is found to have been destroyed, while the bony septum always escapes. Although now the most conspicuous symptom of the clinical picture is the perforation of the septum, the granulations and nodules found at the edge of the perforation furnish a valuable diag- nostic sign to distinguish it from perforating ulcer of the septum, in which the edges are smooth and sharply defined. This form of destruction of the septum is not followed by any alterations in the external nose. The subjective symptoms, which consist in obstructed nasal respiration, are at first insignificant, but increase with the growth of the tumor. Their appearance is occasionally preceded by epistaxis. The formation of crusts is no part of the clinical picture as long as the integrity of the epithe- Hum is preserved, but it appears as soon as ulceration has begun. It is convenient to mention the so-called scrofulous alter- ations in the nose in connection with the tuberculomata, which Koschier, from their histologic structure, describes as tuberculoscrofulous lymphomata. Scrofula, as a separate process, has ceased to enjoy the recognition it formerly had, and is now generally regarded as a manifestation of tubercu- losis peculiar to the childish organism. In addition to con- stitutional phenomena, it finds expression in chronic eczema, with infiltration of the skin at the anterior nares and the upper lip, where it produces the characteristic thickening of the scrofulous habit. The disease strongly resembles chronic dermatitis, for it is localized almost exclusively in those regions of the skin which are covered with epidermis, and it is at least doubtful whether we are justified in dis- tinguishing the eczema of " true scrofula " from the form which often occurs in children as the result of nasal obstruc- tion and consequent chronic rhinitis. Hence, scrofulous eczema does not extend beyond the plica vestibuli, which forms the boundary between epidermis and mucous membrane. Unless we can demonstrate the tubercular process in such infiltrations and erosions on the nose and upper lip, we can not consider scrofulous eczema as l6o CHRONIC INFECTIOUS DISEASES. a form of tuberculosis, and as this proof is lacking, and scrofulous eczema fails to show any peculiar characteristic, we can only designate it as a form of chronic eczema peculiar to the scrofulous habit. On the other hand, those cases in which the tuberculo- scrofulous tumor shows a distinct tubercular structure are to be regarded as genuine manifestations of tuberculosis, in no way connected with scrofula ; such cases frequently go on to granulation and ulceration, with occasional destruc- tion of the septum and of the inferior turbinated bone. Al- though in practice the conception of scrofula as a distinct morbid process may be expedient, it can not be denied that the term is often used to cover many processes in the childish organism for which as yet no satisfactory explana- tion has been found, and it is consequently advisable to re- strict its application as much as possible. The second or ulcerated form of nasal tuberculosis presents the characteristics of ordinary tuberculosis affecting mucous membranes. Infiltrations going on to degeneration, with the formation of ulcers with infiltrated edges and covered with granulations (Schech ^ stands alone in describing them as poor in granulation tissue), form the anatomic basis and lead to a more or less extensive destruction of the nasal mucous membrane, which can be demonstrated clinically. The ulcers vary in depth, and may spread to the bones and cartilages, where they lead to necrosis and deformities in the bony and cartilaginous framework. In this form of the disease the principal symptoms are at first epistaxis, the formation of crusts of dried secretions, and the discharge of mucopus, so that it was formerly described as a tubercular ozena. When the bone is involved, there might be some diffi- culty in distinguishing the condition from syphilitic disease, were it not for the fact that in every case of advanced nasal tuberculosis undoubted signs of tuberculosis are found in the lungs, for it appears from the observations published thus far that this form of tuberculosis always occurs secondary to extensive tubercular disease of the lungs. Finally, there is a third form of nasal tuberculosis, begin- ning in the bone or cartilage, which Koschier ^ described on the strength of a single observation, although it is in accord 1 " Krankh. der Mundhohle," etc., Fifth Edit., p. 317. 2 " Wien. klin. Wochen.," 1896. TUBERCULOSIS OF THE PHARYNX. l6l with earlier descriptions by v. Volkmann, who observed this form of the disease quite frequently. Nevertheless, I am inclined to consider it much less frequent than the other two, especially the tumor-like variety, which I have often observed myself, while I have yet to see my first example of the former variety. I shall therefore quote the description given by Koschier, in which three factors are emphasized as characteristic of this form of the disease. These are, in the first place, alterations in the form of the external nose, which, as has been said, do not occur in the other forms ; the wide distribution of the disease, which does not confine itself to one side of the septum, or even the entire septum, but takes in almost the entire skeleton of the nose ; and, finally, the comparatively early appear- ance of large, deep ulcers in the mucous membrane, together with extensive necrosis, and the separation of necrotic por- tions of the cartilage and bone. These are the diagnostic points which serve to distinguish it from the variety of nasal tuberculosis which originates in the bony and cartilaginous portions. Tubercular disease of the ///«;^^;/,r is infrequent. Tuber- culomata on the posterior surface of the uvula (AvelHs ^) and on the roof of the pharynx (Koschier ^) must be regarded as extremely rare. Mouret ^ described a unique case of tubercular granulations about the size of a bean appearing on the palatal tonsil of a patient twenty years of age, suffering from pulmonary and laryngeal disease. The ulcerated form, first described by Isambert,* occurs more frequently. The anemic mucous membrane is the seat of closely aggregated grayish nodules about the size of a split pea, which later coalesce and break down. The ulcers, which have been minutely described and designated as " lenticular" by B. Frankel,'^ are characterized by a ten- dency to grow toward the periphery rather than to invade the deeper tissues. The edges of the ulcer are slightly infiltrated and are irregular in outline, while the floor is covered with minute granulations and a dirty yellow secre- tion. In accordance with the superficial seat of the ulcers there is no diffuse infiltration of the mucous membrane, 1 "Deutsche med. Wochen.," 1891, Nos. 32 and 33. 2 Loc. cil. 3 "Rev. hebd. de lar.," 1896, No. 54. •* " Ann. des mal. de I'oreille," I, 1875, p. 77, and 11, p. 162. 5 " Berlin, klin. Wochen.," 1876, No. 46. II 162 CHRONIC INFECTIOUS DISEASES. such as is seen in the larynx. These ulcers are found chiefly on the soft palate and on the uvula ; sometimes on the anterior and posterior arch of the palate and on the lateral pharyngeal wall ; and in rare cases on the posterior pharyngeal wall and in the postnasal space. Although the ulcers are superficial, they nevertheless produce extensive destruction in the soft palate, but they have never been known to attack the bone. The subjective symptoms con- sist in dysphagia, and often in violent pain radiating toward the ears. In some cases partial cicatrization is said to occur, Kraus ^ reports having seen adhesions of the soft palate.; but these accidents are rare, for there is very little tendency to spontaneous cure. Hence the prognosis in this form of pharyngeal tuberculosis, characterized by the pres- ence of miliary nodules with a tendency to degenerate, is very unfavorable. The great majority of cases, as pointed out by Isambert, occur in the last stages of pulmonary phthisis, and this fact is of value in the diagnosis, which occasionally presents difficulties to the novice, who might be in danger of mistaking the tubercular for syphilitic ulcers. Another manifestation of tuberculosis in the pharynx is seen in the cold abscesses which sometimes occur in the posterior pharyngeal wall, and are due to carious disease of the vertebral column. They give rise to a fluctuating tumor about the size of a hen's egg, usually on one side of the posterior pharj-ngeal wall, at a level varying with the particular vertebra affected. The patient complains of a sensation as of a foreign body in the throat when he swallows, and the voice has the well-known palatal quality. The presence of these symptoms of primaiy vertebral dis- ease differentiates the diagnosis from tumors or other varieties of abscesses. In the larynx we distinguish three forms of tuberculosis : One characterized by infiltration followed by degeneration ; superficial ulcers (arrosion ulcers) ; and, finally, the tumor- like variety — tuberculoma. The most frequent form of the disease is the first-mentioned, and it presents such typical phenomena that the diagnosis can, as a rule, be easily made from the characteristic infiltration and ulceration. As the infiltration is due to the formation of tubercles in the mucous membrane, and has its seat in the submucosa, 1 " Nothnagel's Handbuch," xvi, I. Th., I. Abth., p. 276. TUBERCULOSIS OF THE LARYNX. 1 63 the clinical picture varies with the anatomic relations of the mucous membrane in the various portions of the larynx, the degree of swelling depending on the thickness of the submucous tissue ; and according as the mucous membrane is or is not in close relation with the other structures in the larynx, especially the cartilage, there will be a greater or less tendency for the infiltration and ulceration to spread to these deeper parts. On the plica vocalis, where there is no submucous tissue, the stage of infiltration is less conspicu- ous than it is in the interarytenoid space, where the looser structure of the submucous tissue presents a favorable medium for the development of infiltration and secondary edema. Where, as on the epiglottis and the arytenoid cartilage, the mucous membrane is closely adherent to the cartilage, or in the vocal process, where it is intimately joined to the elastic fibers in the cartilage, the infiltration is very likely to extend to the perichondrium and to set up a perichondritis followed by necrosis of the cartilage ; while, on the other hand, if the disease is situated on the ven- tricular bands or the aryepiglottic folds, there is less danger of its spreading to the adjoining cartilages. The most frequent seat of infiltration is the mucous membrane in the interarytenoid space, — /. e., the interior surface of the posterior laryngeal wall, — so much so that its appearance in this situation is almost pathognomonic. In the early stages of the disease there is in this region a slight swelling, which becomes prominent when the mucous membrane is stretched, as in deep respiration. The swell- ing is not uniformly distributed over the posterior wall, but forms a slight prominence, either in the middle or to either side of the median line. It may be distinctly isolated, like a tumor, as Tijrck ^ described it, while the covering of mucous membrane remains intact. At first there may be some difficulty in differentiating these tuberculous infiltra- tions from chronic laryngitis, in which the parts are also swollen, especially when the entire upper respiratory tract shares in the descending catarrh ; the catarrhal swelling is, however, diffuse, being due to uniform thickening of the mucous membrane. The latter arches forward toward the interior of the larynx in the respiratory position, but in the median position becomes puckered into folds. The color 1 " Atlas," I, XVII, vol. II. 164 CHRONIC INFECTIOUS DISEASES. of this catarrhal infiltration is characteristic, being a bluish- gray or whitish-gray, in consequence of the catarrhal thickening of the epithelial layers. In the tubercular variety as the disease progresses the infiltration increases in size and its surface becomes nodular. At this time functional disturbances begin to appear. The accurate apposition of the arytenoid cartilages, on which normal function depends, becomes mechanically impossible on account of the tumor-like infiltration, and more or less pronounced hoarseness develops. The laryngoscopic image simulates the appearance of a paresis, as the posterior por- tions of the vocal cords fail to approximate on account of the swelling. The epithelium itself now begins to undergo alteration. As the tubercular infiltrate approaches the surface the upper layers of the epithelium become necrotic and assume a grayish-white discoloration, the surface finally undergoes more extensive alteration, and we have the formation of ulcers and granulations. The tubercular ulcers are characterized by elevated, infil- trated margins, which in the laryngoscopic picture largely obscure the floor of the ulcer owing to the foreshortening of all plane surfaces in the reflected image, so that the true condition is sometimes difficult to recognize. The second characteristic of tubercular ulcers is a tendency to the formation of granulations in the floor of the ulcer, and as it is difficult in ordinary laryngoscopy to see all of the poste- rior laryngeal wall, it is often impossible to determine whether there are deep ulcers or granulating surfaces hid- den behind the infiltrations ; it is, however, of little practi- cal significance, as the granulations themselves rapidly undergo decomposition, and there is throughout the disease a continual alternation between granulation and ulcerative disintegration. Thus the surface presents an irregular ap- pearance, ulcerating areas alternating with papillary masses of granulations, and, when seen in profile from above, sug- gesting the picture of a chain of mountains with narrow valleys running between them. It is well to bear in mind that the disease is usually more extensive on the posterior wall than appears in the laryngoscopic image. Whether the ulcers and granulations extend from the interarytenoid space down below the vocal cords, or occupy only the upper seg- ment of the posterior wall, the laryngoscopic image will be .TUBERCULOSIS OF THE LARYNX. 1 65 the same, as the elevated infiltrated margins of the ulcers completely hide the deeper portions. In such cases it is often possible to obtain an approximately correct image of the surface by employing Killian's method of examining the posterior wall, which consists in having the patient bend his head well forward while the operator sits on a low stool, or even kneels down in front of him. Even better than this is Kirchstein's method, which permits the observer to obtain a most satisfactory view of the posterior wall. From the interarytenoid mucous membrane the morbid process extends to the posterior extremities of the vocal cords, which are eventually destroyed. Sometimes large flat ulcers extend from the posterior wall to the vocal cords, and if the granulations do not happen to be very abundant, these may easily be overlooked. ^ On the other hand, it must not be forgotten that the arytenoid cartilage is occasionally visible through the pallid mucous membrane above the vocal processes, and might in that case be mistaken for an ulcer. The epiglottis and the aryepiglottic folds are favorite seats for the tubercular process, and suffer the same destruction that we have described in the case of the posterior wall. The course of the disease can readily be traced on the epiglottis. The infiltration is the first change to appear, and lends a cushion-like shape to the epiglottis, which covers the greater part of the interior of the larynx. Later, ulceration begins accompanied by the appearance of granulations and grayish tubercles the size of a split pea in the neighborhood of the ulcer. If the aryepiglottic folds are involved there is usually marked swelling ; the lateral wall of the larynx is attacked, and after the breaking-down of the infiltrated area this may lead to the formation of deep ulcers. The infiltrated ventricular bands become so swollen that they completely hide the vocal cords ; occa- sionally ulcers and granulations are seen in the ventricle of the lar^^nx, the former breaking directly through the ven- tricular bands into the interior, the latter projecting from the entrance like papillomatous tumors. Eventually, the tis- sues in all these regions of the upper portion of the larynx suffer more or less destruction, as the ulcers show little tendency to heal spontaneously by cicatrization, and the infiltration constantly tends to spread. 1 See illustrations in Scbnitzler's " Atlas," Plate ix, Nos. I and 2. 1 66 CHRONIC INFECTIOUS DISEASES. In the vocal cords the tubercular changes in the early stages are less pronounced, the catarrhal disease being more conspicuous than the infiltrations. The vocal cord is red and swollen, and assumes what is usually described as a cylindrical form. But even in these early stages the distribution of the disease, which often does not in- clude the entire vocal cord or is confined to one-half of the larynx, points to tuberculosis rather than to catarrh, where the changes are usually symmetrical. In rare cases a series of tubercular nodules resembling a string of pearls is observed on the free border of the vocal cord. In most cases, however, the inflammation in the vocal cords is followed by destruction of the epithelium, and the forma- tion of ulcers covered with a yellowish exudate. It is worthy of remark, as pointed out by M. Schmidt, that when the vocal cord is covered by a diffuse superficial ulceration, the yellowish exudate occasionally makes it appear almost normal. No matter how small or superfi- cial an ulcer may appear in a tubercular patient, it should be regarded as tuberculous, as there can be no question of its being a catarrhal ulcer. The tissue destruction that takes place in the subsequent course of the disease first attacks the free border of the vocal cord, and later extends over larger areas. It is frequently accompanied by active granulation, forming large masses resembling a cock's comb on the vocal cords, and in some cases leading to stenosis of the glottis. Some- times the swollen and infiltrated vocal cord presents a fur- row running parallel with and underneath the free border, converting the structure into two separate folds, one above the other. A picture of this kind is seen when ulcers appear on the lower surface of the vocal cord, or when there is a series of ulcers, above described as resembling a string of pearls. The different forms of tuberculosis described thus far may vary in their extent and in the order of their appear- ance, and give rise to a great variety of clinical pictures. When, however, the infiltration extends to the cartilaginous frame of the larynx, the appearance changes, infiltration and ulceration of the perichondrium being followed by necrosis of the cartilage. The epiglottis and the arytenoid cartilages with their vocal processes, being nearest to the favorite seat of the disease, are most frequently attacked ; TUBERCULOSIS OF THE LARYNX. 1 6/ more rarely, perichondritis extends to the crico-arytenoid articulation, and from there to the arytenoid and cricoid cartilages, the thyroid cartilage being very rarely involved. Whenever the epiglottis shows signs of edema, perichon- dritis should be suspected. The peculiar structure and porosity of the epiglottis, which permit the glands and blood-vessels to pass through the cartilage from the laryn- geal to the oral surface, allow the infiltration to spread in all directions, so that we do not get necrosis of the car- tilage, but rather a complete liquefaction. This progresses pari passu with the infiltration of the mucous membrane, and may end in complete destruction of the epiglottis. In addition to the edema which characterizes the disease in the epiglottis, there is the symptom of pain, usually de- scribed as radiating toward the ears. Sometimes the dys- phagia becomes so great that the taking of food gives rise to excruciating pain. The infiltration, as has been said, is prone to spread from the posterior wall to the posterior portions of the vocal cords, where the vocal processes present a favorite seat for the disease. In this situation redness and swelling first ap- pear, sometimes without involving the ligamentous portion of the vocal cord, so that the inexperienced observer is led to suspect pachydermia. Soon, however, deeper ulcers appear in these regions, and microscopic examination shows that there is a disintegration of the reticular portion of the arytenoid cartilage. Later, the process spreads to the perichondrium of the hyaline portion of the cartilage, and thus secondary perichondritis is followed by necrosis of the cartilage and the separation of sequestra. Perichondritis of the arytenoid cartilage produces a char- acteristic swelling and edema in the aryepiglottic fold, and motion is impeded solely by the mechanical pressure of the swelling. Before long, however, the disease spreads to the capsule of the crico-arytenoid articulation, and, after destroying the joint, attacks the cricoid cartilage. This results in interference with the movement of the ary- tenoid cartilages, which finds expression in an apparent paresis of the vocal cords. Although it has been said that an edematous swelling over the affected portion of the car- tilage is an important diagnostic point, it may be well, in order to avoid a misunderstanding, to point out that it has diagnostic value only when it is preceded by the break- 1 68 CHRONIC INFECTIOUS DISEASES. ing down of infiltrations in the areas mentioned, so that if a larynx is seen to be affected in this way at the first exam- ination, there is always a possibility that one has to deal with a simple tubercular infiltration of the mucous mem- brane. Deep ulcers in the aryepiglottic folds are very often surrounded by edematous areas ; perichondritis of the cricoid and thyroid cartilages is rare and presents no typical appearances. The diagnosis of the tubercular nature of the disease is based on the appearances in the other portions of the larynx. There are rare cases in which there is a so-called external perichondritis, the morbid process appearing on the external surface of the cartilage, principally on the lateral plates of the thyroid. Lastly, we may mention three symptoms which are occasionally described as characteristic of tubercular laryn- geal disease : anemia of the laryngeal mucous membrane, catarrhal laryngitis, and paresis of the vocal cords. Anemia of the nnicoiis membranes is an expression of the general phthisical habit, and can not be regarded as a symptom of beginning laryngeal tuberculosis. The question whether or not there exists a tubercular catarrh of the larynx is difficult to decide, and there are experienced laryngologists who believe it to be possible ; but in those cases where the laryngoscope shows an un- complicated image of catarrhal laryngitis it is more scien- tific to speak of chronic catarrh of the larynx associated with tuberculosis of the lungs than to speak of tubercular catarrh, since the latter term is hardly justified by the clin- ical and anatomic appearances. Paresis of the vocal cords is a symptom that frequently occurs in the beginning of tuberculosis and occasionally forms the prelude to tubercular disease ; sometimes it appears only periodically after exces- sive use of the voice. E. Frankel^ found that it was due to atrophy of the muscular fibers, but the question whether tubercular changes occur in the muscle so early in the disease, or whether we have to deal with simple fatigue of the muscle due to anemia, such as occurs in all grave organic anemias, can not be determined at present. There is another variety of tubercular ulcers differing from those following infiltration, which we shall describe as' arrosion 7ilcers, due to local tubercular infection by the 1 " Virch. Arch.," LXXi, p. 261. TUBERCULOSIS OF THE EAR. 1 69 sputa. They are distinguished by their superficial charac- ter and their tendency to spread over the surface of the membrane. Their favorite seat is the epiglottis, especially its free border ; after that, the surface of the larynx, the aryepiglottic folds, and the lateral wall of the larynx. They begin as small ulcers the size of a split pea, with a moderately injected base, and finally become covered with necrotic epithelium, which separates and exposes a shallow depression. The ulcers run together and tend to spread toward the periphery, so that eventually large areas of the mucous membrane become involved. They occur princi- pally in the later stages of pulmonary tuberculosis, and are found usually combined with other tubercular appearances in the larynx. A rarer form of tuberculosis is found in the tuberculo- mata, which appear as circumscribed tumors. We learn from an exhaustive analysis of the cases by Avellis ^ that they grow most frequently "in the ventricle of the larynx under the angle of the glottis and on the posterior wall ; more rarely on the ventricular bands ; and least fre- quently on the vocal cords." Panzer ^ reports three cases of tubercular polyps on the vocal cords from Chiari's polyclinic. These tumors frequently do not differ from ordinary fibromata of the larynx, and, as a rule, show no tendency to ulceration. In some cases they must be regarded as a primary localization of the tubercular process, as no signs are found in the lungs or other organs of the body ; in such cases their true nature can be determined only by histologic examination, for they are absolutely with- out any clinical characteristics. The prognosis is good if the tumors are removed ; M. Schmidt ^ remarks that he often observed removal of the tumors to be followed by perma- nent cure or by a long period of health, until a new ulcer or a hemorrhage of the lungs supervened and confirmed the microscopic diagnosis. TUBERCULOSIS OF THE EAR. While the manifestations of tuberculosis in the larynx, though varying in their external appearance, are funda- 1 " Deutsche med. Wochen.," 1891, Nos. 32 and 23- 2 " Wein. med. Wochen.," 1895, Nos. 3-5. 2 " Die Krankh. der ob. Luftwege," 2d edit., p. 362. I/O CHRONIC INFECTIOUS DISEASES. mentally the same, this is not the case with the organ of hearing. In the larynx the diagnosis is readily made, even in advanced stages of the disease, by the presence of infil- tration, ulceration, and granulation ; but in tuberculosis of the ear the clinical picture varies greatly, and there is no characteristic course. This may be partly explained by the fact that the aural disease at first presents no more alarming symptoms than difificult hearing and discharges from the ear, and does not come under observation until quite late, when the process is so far advanced that it can not be distinguished from a simple chronic otitis media. Hence it is that the most prominent features of the picture are destruction of the tympanic membrane, suppuration and abscess formation in the mucous membrane of the middle ear, and carious destruction of large portions of the tem- poral bone, which separate as sequestra, while the granula- tions, which are so characteristic of the tubercular process, are comparatively insignificant. It is almost superfluous to say that nowadays we base a description of tuberculosis of the organ of hearing exclu- sively on the demonstration of tubercle bacilli or on the histologic appearance characteristic of tuberculosis. We merely mention the fact because even in recent times such authors as Bezold and Hegetschweiler depend on the macroscopic appearance of the clinical picture and neglect bacteriologic examinations. That Bezold and some other authors differ from most of the authorities in regard to the diagnostic significance of tubercle bacilli in suppurative aural disease is due to the fact that there is a want of agree- ment in the literature as to the presence of tubercle bacilli. Among forty cases of otorrhea in tuberculous subjects, Nathan found tubercle bacilli in only twelve instances, while Lucae was unable to find them once among seven- teen patients whom he had inoculated with tuberculin. On the other hand, I have rarely failed to find the bacilli, although I have examined a large number of cases. But this failure to demonstrate the bacillus in every in- stance is explained, as already pointed out by Gottstein, by the fact that the pus is derived from the tubercular carious foci in the middle ear, which, it is well known, often fail to show the presence of bacilli. When we consider that, as Krause ^ has shown, the finding of bacilli in tubercular ^ " Tuberculose der Knochen und Gelenke," Leipzig, 1891, p. 7. TUBERCULOSIS OF THE EAR. lyi bone disease is rare, and when we consider also that we often fail to find bacilli in undoubted cases of pulmonary tuberculosis, it can not surely be denied that the finding of bacilli should be a deciding proof of the existence of the disease. It is possible, by using proper methods of staining, to avoid the errors which are sometimes occasioned by the smegma bacillus. The latter is often found in old, purulent foci. Brieger supposes that the tubercle bacilli found by Bezold in cholesteatomata were really smegma bacilli, and I have myself found them in the pus derived from a sar- coma of the ear ; they were easily decolorized with alcohol or dilute hydrochloric acid. Tuberculosis of the ear may occur in any stage of the pulmonary disease, but it presents itself most characteris- tically in the later stages. It may be unilateral or bilat- eral, although some authors maintain that the left ear is more often affected than the right. A universal characteris- tic of tuberculosis of the ear is the absence of pain, which often leads the patient to neglect the disease as unimportant, so that the earlier stages do not come under observation. It would appear that tuberculosis in the ear is usually secondary. The few cases so far reported as primary are open to criticism, and for the present we have no proof of primary tubercular osteomyelitis of the mastoid process. It is difficult, if not impossible, from the clinical point of view, to decide whether one has to deal with primary tuber- culosis of the bone, with secondary involvement of the tympanic cavity, or with the opposite condition ; accord- ingly, we find that opinions are divided on the subject (Kiister and Schwartze). But it would seem plausible to assume that we have to deal with primary tuberculosis of the bones of the ear in those cases in which there is a dif- fuse tubercular bone disease with fistula formation in scrofulous children. Chronic tuberculosis, which is the most frequent form, is probably due to infection by way of the lymphatic channels. Barnick ^ supposes hematogenous infection in chronic tuberculosis of the middle ear to be quite frequent, espe- cially in scrofulous children, " in whom, after rupture of a cheesy focus containing a few bacilli, the infection car- riers are transmitted by the blood." 1 "Arch. f. Ohr.," vol. XL. 1/2 CHRONIC INFECTIOUS DISEASES. Next in order of importance as a channel of infection we have the Eustachian tube. As the mucous membrane of the tube shares in the general atrophy characteristic of the phthisical habit, the lumen is usually dilated, and readily permits the entrance of sputum from the postnasal space. If there is ulceration in the nasopharynx, the conditions are, of course, even more favorable for infection. This mode of infection is perfectly possible, since the bacilli are capable of penetrating between the epithelial cells of the tympanic mucous membrane, even when the external layer of the epithelium is intact. It is further supported by the fact that tuberculosis most frequently begins in the mid- dle ear. On the other hand, it would appear, from E. Frankel's^ observations, that the danger of infection from the postnasal space is not very great, for among fifty autop- sies of tubercular patients, he found ten cases of tuber- cular disease in the postnasal space, without implication of the ear. We have no means of judging whether it is possible for tubercular disease of the middle ear to be produced by direct immigration of the tubercle bacillus through a tuber- cular infiltration in the tympanic membrane, as there are no facts to support such a supposition. On the tympanic membrane tuberculosis attacks both the epidermis and the mucous membrane. The former variety is rare, and lacks histologic demon- stration ; it includes only those cases in which there was undoubted tubercular disease in the external layers of the tympanic membrane without involvement of the middle ear. There is so little material that it is impossible to describe any distinct form for the tuberculosis ; the descriptions by Stacke and Preysing (from Korner's clinic) differ widely, so that one is forced to assume two distinct types, a miliary, nodular form and one which appears as a granulation tumor. In Stacke's case ^ the tympanic membrane is de- scribed as presenting a bulging of its posterior half, and a yellowish discoloration, as though there were an exudate behind it. The surface was covered with split-pea-sized yellowish nodules, with small vessels radiating from their centers. The tympanic cavity contained no exudate. The redness of the tympanic membrane gradually increased, 1 " Zeitschr. f. Ohr. ," x. ^ l&£&'.mi:i ELECTRIC REACTION OF AUDITORY NERVE. 265 imperfectly described or entirely omitted in text-books on otology, — I feel impelled to present a general resume of the significance of electric reaction of the auditory nei've. The attempt has been made to utilize the electric irrita- bility of the auditory nerve for purposes of diagnosis and therapeutics ; but the results in either direction have not been such as to justify the expectations raised by the dog- matic teachings of Brenner, published thirty -five years ago in his " Elektro-otiatrik." Brenner gives a normal formula for the healthy individual as follows : Ka. CI R''''. Very loud ringing. Ka. D.* R 00 . Ringing persists during continuance of current. Ka. O Nothing. An. CI Nothing. An. D Nothing. An. O R^ >• Louder ringing, gradually dying away. (*During passage of current. ) His most important results are embodied in the propo- sitions ^ that : " The cathodal contraction produces auditory sensation when the circuit is closed, and also during con- tinuance of the current, but not when the circuit is opened. The anodal contraction gives no reaction either when the circuit is closed or during the continuance of the current, but does give a reaction when the circuit is opened. The anodal reaction ceteris paribus is weaker than the catho- dal reaction. The cathodal reaction occurs immediately, the anodal reaction only after the current has lasted a cer- tain time. After a short duration of the current, opening is not followed by a reaction at the cathode. The cathodal reaction becomes markedly increased immediately after closure, a phenomenon described by the patients as an echo, for they frequently remark that the echo is stronger than the first (or closing) sound. The reaction persists for some time, with a lessened intensity, — ' reverberating echo,' — and then completely disappears, although the strength of the current remains constant." The publication of these statements was, of course, re- ceived with equal interest by ear specialists and by neurolo- gists, and gave rise to numerous control investigations. Schwartze ^ deserves the credit of being the first to find i"Virch. Arch.," 28, p. 207. 2" Arch. f. Ohr.," i, p. 44. 266 NERVOUS DISEASES. flaws in Brenner's formulae, which materially diminished the value of the electric reactions for the diagnosis and treat- ment of aural diseases. His objections amount to the following proposition : That Brenner's normal formula for the reaction of a healthy auditory nerve is not by any means constant in persons with normal hearing ; that Bren- ner's normal formula is given in absolute deafness, which can be only due to a disease of the nervous apparatus ; and, finally, that, as far as treatment is concerned, the restoration of the normal "formula of reaction " has no effect on the power of hearing. These objections were answered by Brenner ^ and Erb. ^ At first Erb said ^ that "those who deny the existence or correctness of Brenner's discoveries are simply mistaken," but later he modified his opinion to the extent of confirming the first of Schwartze's objections. Although opinions in regard to the diagnostic value and the production of the reaction are now fairly well settled, the skeptical attitude adopted by Schwartze has in the main been justified, and the value of " Elektro-otiatrik " is not nearly so great to the ear specialist as would appear from the statements of neurologists. The electric examination is conducted in two different ways, called the internal and external methods. The former was employed by Brenner, who filled the external auditory meatus with water, and then introduced an electrode, with certain precautions, ^ so that its extremity was rigidly held at a certain distance from the ear-drum and from the walls of the meatus. The other electrode was applied to the mastoid process, the forehead, the nape of the neck, the trunk, or the extremities. The external method introduced by Erb is the one now exclusively employed. It consists in applying an ordinary flat electrode — the cathode — in front of the tragus (taking care not to press on the tragus and thereby close the auditory meatus, as this would give rise to buzzing and humming noises), while the other elec- trode — the anode — is placed on the nape of the neck or the palm of the hand. A third method, in which the elec- trode is applied to the auditory meatus, filled with water (Brenner, Erb), presents no special advantage, while the 1 " Virch. Arch.," xxxi, p. 483. 2 "Arch. f. Augen- u. Ohrenheilk.," vol. I, p. 156. ' "Arch. f. Augen- u. Ohrenheilk.," vol. i, p. 158. 4 "Virch. Arch.," xxxi, p. 493. ELECTRIC REACTION. 26/ results of the examination are no more satisfactory when one of the electrodes is replaced by a silver wire introduced through a tubular catheter into the middle ear, as proposed by Wreden.i The question has been raised whether the auditory nerve or its terminations are really excited by the electric cur- rent, or whether what is designated as the reaction of the nerve may not be due to the irritation of other structures in the ear. It was alleged that the reaction may be pro- duced by contraction of the internal muscles of the middle ear (Schwartze, Wreden), by irritation of the sympathetic (Benedikt), or by a reflex irritation of the auditory through the trifacial nerve. While it has long been known that the bony labyrinth is a bad electric conductor, the question was again discussed by Gartner and Pollak,^ who declared, after a series of investigations on pathologic organs, that the electric irritability of the auditory nerve depends on the excitability of the nerve itself to an electric current and on the resistance met with in the ear. I have not the space to discuss in detail the various arguments which have led to the adoption of the view that the condition of the auditory nerve itself determines the results of the reaction, without entirely disregarding the modification in the resistance due to hyperemic and secretory processes ; but in order to elucidate the present status of the question, I shall cite the propositions promulgated by Gradenigo,^ which most nearly correspond with the results of practical experience in the healthy and in the diseased ear. 1. The normal ear gives an electric reaction of the auditory nerve only in exceptional cases and when the electric current is unusually strong. 2. There is a heightened irritability in all inflammatory and hyperemic diseases of the external, middle, and inter- nal ear, and in the initial stages of a central cerebral disease. 3. The mode of reaction of the auditory nerve to the elec- tric current is analogous to that observed in the other sen- sory and motor nerves. In regard to the first proposition, it may be remarked that even the earliest followers of Brenner's doctrines be- came more and more reluctant to designate the acoustic ^ " Petersb. raed. Zeitschr.," 1891 ; reported in "Arch. f. Ohr.," VI, p. 147. 2"Wien. klin. Wochen.," 1888, Nos. 31, 32. 8 " Arch. f. Ohr.," XXVII and xxviii. 268 NERVOUS DISEASES. reaction as the normal formula to be aimed at in the healthy- individual. Schvvartze was not able to obtain the reaction in every case ; later, Gradenigo found it present in only from 5^ to 12^ of normal ears, and then only when a higher current strength was employed, usually from 10 to 16 m.a., certainly never under 6 m.a. This agrees with Erb's 1 more recent publication, in which he says that gal- vanic stimulation of the auditory nerve is not always pos- sible. As a very strong current is requisite to obtain the reaction in healthy individuals, the examination is usually attended with very unpleasant concomitant phenomena, such as vertigo and flashes of light. It is therefore better to assume that there is a pathologic condition of the nerve whenever there is hyperesthesia to the galvanic current and not to attempt to lay down any normal reaction for healthy individuals. Daily experience shows that electric excitability is not common in persons the sub- jects of ear disease. Gradenigo found that he could usually obtain the reaction in 66^ of cases of ear disease with a current strength of from i to 3 m.a., and always with a strength of less than 6 m.a. Although this increased ex- citability of the auditory nerve to weak currents undoubtedly points to pathologic processes in the organ of hearing, it has no special diagnostic significance, as it may occur in a great variety of diseases both of the ear and of the nervous system. It is much to be desired that ear specialists might contribute more to the investigation of electric excitability of the auditory nerve, in the hope of obtaining some definite diagnostic points ; for the prevailing theory that the audit- ory nerve reacts readily in those diseases of the middle or the internal ear that are accompanied by intense inflamma- tory processes, but fails to react after the inflammation has subsided, and that the reaction of the nerve in acute or chronic exudative or nonexudative catarrh of the middle ear and in cases of gradual extension of such disease to the internal ear does not differ from that w^hich occurs under normal conditions (Gradenigo), ^ is in urgent need of further elucidation, as it is in direct contradiction to other observa- tions, especially those published by Erb,^ which are in every way admirable. 1 Ziemssen's " Handb. der allgem. Ther.," ni, 18S2, p. 236. 2 "Arch. f. Ohr.," xxviii, p. 247. 3 Ziemssen's " Handb. der allgem. Ther.," ui, 1882. ELECTRIC REACTION. 269 The power of hearing does not appear to bear any rela- tion to the electric behavior of the auditory nerve. Accord- ing to Gradenigo, the greatest value of galvanic hyperes- thesia of the auditory nerve in diagnosis of central abscess of the nervous system is found in connection with brain- tumor ; he found the phenomenon present in all but one out of 18 cases. In tabes dorsalis, multiple sclerosis, and chronic myelitis it is absent, according to Gradenigo, but is said to have been observed by Erb. Gradenigo points out that in subnormal sensitiveness to auditory impressions in hysteria the electric reaction of the auditory nerve is never increased. ^ It is worthy of remark that ocular disturbances due to central or intracranial paralytic lesions in the domain of the organ of sight, such as ocular palsies and disturbances of the accommodation, are associated with galvanic hyperes- thesia of the auditory nerve (Brenner, Erb). In ordinary disturbances associated with facial paralysis the electric con- ditions vary. In some cases there is hyperesthesia with paradoxic reaction (Remak) ; ^ a hyperesthesia was observed occasionally in cases of aural hallucinations (Jolly). ^ Finally, it may be mentioned that certain alterations occur in the reactions of the auditory nerve which have been de- scribed as a paradoxic reaction and as a galvanic hyperes- thesia, with anomaly and inversion of the normal formula. Paradoxic reaction consists in the production of sensations, corresponding to the indifferent electrode, in the ear which is not included in the circuit ; this is regarded by Erb as the expression of so intense a heightening of the galvanic irrit- ability of the auditory nerve that even the weaker loops of the current, which reach the ear not included in the circuit, are capable of producing the auditory sensation. In a case of complete left-sided deafness, with the remains of an old suppuration, Erb found the normal formula inverted, as follows : Ka. Cl Ka. D Ka. O p>' (piping sound, gradually disappearing). An. Cl R^ An. D Pec . An. O. 1 " Haug's Vort.," p. 411. 2 " Grundriss der Elektrodiagnostik u. Elektrotherapie," 1895. 3 " Arch. f. Psych.," 1894, iv. 2/0 NERVOUS DISEASES. I have seen in sclerosis of the middle ear with involve- ment of the internal ear cases in which the ear under examination presented the normal formula, while the ear not included in the circuit presented the paradoxic formula : Right. Left (included in circuit) . . . Ka. CI . . . R (ringing). . . . Ka. D . . . Rco. R . . . Ka. R ... An. CI. ... Rco . . . . . . An. D . . . An. O . . . . R. As an instance of other anomalies, Erb gives the follow- ing reactions, which occurred in a man fifty-four years old with chronic impairment of the hearing, tinnitus aurium, and opacity and contraction of the ear-drum. Ka. Ci P^ Ka. D P 00 . Ka. O b (buzzing noise). An. CI B^ An. D , B >. An. O p >. It is impossible to determine whether torpor of the audit- ory nerve is present or not, as the reaction in the healthy individual is not constant. THE LOCALIZATION OF THE EAR IN THE CENTRAL NERVOUS ORGANS. The origin and root-fibers of the cochlear and vestibular nerves, which together make up the auditory nerve, are twofold. While our knowledge of the former is fairly complete, thanks to the investigations of Held, Flechsig, and Bechterew, any description of the latter must be largely hypothetic. The fibers of the cochlear nerve, the per- ipheral endings of which are found in the cochlea, spring from the ventral auditory nucleus, and to a slight extent from the tuberculum acusticum.^ A second system of fibers originates in the ventral auditory nucleus (accessory nucleus), and, after passing through the corpus trapezoides, extends to the superior olive of the same and of the oppo- site side. The lateral root represents the continuation of the cochlear tract to the posterior corpora quadrigemina. It is joined, however, by the fibers from the auditory ^ After Edinger's description, p. 359, Fifth Edit. LOCALIZATION, 2/1 tubercle, which run directly through the striae acustica to the lateral root. ^ The lateral loop ends in the posterior quadrigemina. Each of the posterior corpora quadrige- mina sends out fibers through the inferior brachia, both of the same and of the opposite side, to the internal genicu- late body, where some of these fibers end. The remainder pass under the pulvinar into the internal capsule, where they divide into two bundles and are distributed to the transverse convolutions of the temporal lobe (superior temporal convolution). " One of these bundles ascends in the neighborhood of the external capsule and reaches the auditory sphere, while the other accompanies the optic radiation for some distance and, after passing around the inferior posterior portion of the fossa Sylvii, ascends to the transverse convolutions in the temporal lobe close to the second and third convolutions." ^ The course of the vestibular nerve is very obscure. It appears to originate in the dorsal auditory nucleus or Deiter's nucleus, which lies to the mesial side of the resti- form body. Its connections with the vermiform process of the cerebellum are not known. From this description it follows that auditory disturb- ances may be expected in disease of the auditory nucleus in the medulla oblongata, of the superior olivary nucleus in the pons, of the posterior quadrigemina, and, finally, of the first (superior) temporal convolution, and in disturb- ances of the nervous paths which connect these nuclei. Tumors and abscesses, foci of softening in the brain-sub- stance, tubercular and syphilitic disease, cerebral hemor- rhage, and many other diseases of the central nervous system may produce a focal lesion by destroying the cen- tral pathways. The only symptom of such a lesion in the cochlear tract is difficult hearing, while vertigo and the signs of Meniere's symptom-complex generally are absent. Impaired hearing from a central cause is recognized by the presence of other phenomena of cerebral disease, and its gradual increase in a subject whose hearing had always been perfectly good corresponds to the gradual growth of the tumor. Unfortunately, we have no accurate knowl- edge concerning the nature of a central deafness localized in the cortex, but when the cause is found in a lesion of 1 See illustration No. 247, Edinger. > Flechsig, " Gehirn u. Seele," 1896, p. 75. 2/2 NERVOUS DISEASES. the tegmentum or mesencephalon, the resulting auditory disturbance presents certain characteristics, which have been described by Siebenmann. Bone conduction is very much impaired or entirely abolished. Weber's experiment is not regularly successful, and may be lateralized either to the healthy or to the affected side. In the beginning of the developing deafness perception is lost for the lower notes only, while later in the course of the disease all the notes of the scale become uniformly inaudible, so that finally the patient retains only the power of hearing a cer- tain number of notes in the lower middle register, as in diseases of the labyrinth and of the auditory nerve. Subjective ear noises are rarely observed. Hyperes- thesia of the auditory nerve appears to be possible in the early stages of a lesion of the auditory centers; at least, this would seem to explain the increased electric irritability of the auditory nerve described by Gradenigo. Oppenheim ^ quotes the statement that in tumor of the superior temporal convolution the epileptic attacks were preceded by an auditory aura. The important question as to which side is affected in unilateral lesion of the cerebral roots of the cochlear nerve has not yet been decided. The pathways cross each other at various points in their course through the pons, in the tegmentum, and in the corpora quadrigemina, but the decussation appears to be only partial, so that the cortical centers for hearing on both sides of the brain appear to be connected with both auditory nerves. The result of this arrangement is that unilateral disease in the region of the temporal lobe, where the cortical center for hearing is found, does not produce unilateral deafness of the opposite side (crossed deafness), as some authors have claimed. Permanent cen- tral deafness can be produced only by the destruction of the cortical centers for hearing in both hemispheres. The significance of the posterior corpora quadrigemina in auditory disturbances has lately been carefully investigated by Weinland and Siebenmann. Weinland maintains that disease of one of the posterior corpora quadrigemina pro- duces auditory disturbance on the opposite side ; while Siebenmann, on the contrary, claims that a lesion of only one of the posterior corpora quadrigemina does not produce ^ " Lehrb. der Nervenkrankh.," p. 94. LOCALIZATION. 2/3 deafness — a statement which is in direct opposition to the generally accepted opinion that the corpora quadrigemina contain one of the auditory centers. By a careful review of the literature Siebenmann ^ shows that in all cases of deaf- ness due to injury of the mesencephalon there is either compression or destruction of the tegmentum (or of the in- ternal capsule), whereas in simple cases of tumor of the corpora quadrigemina the hearing remains intact. From this he argues that the auditory disturbance is not directly due to the situation of the tumor in the posterior corpora quadrigemina, but rather to its interference with the sur- rounding parts and to the compression of the adjacent por- tions of the mesencephalon, which contain the auditory pathways. As we have just remarked, Weinland says that the loss of hearing occurs on the side opposite to that of the dis- eased corpora quadrigemina ; Oppenheim believes that either the ear on the same side as the tumor or that on the opposite side, or even both ears, may be affected ; while, according to Siebenmann, any lesion of the tegmentum produces bilateral deafness. The auditory disturbances that have been observed in diseases of the cerebellum must be attributed to extension of the diseased focus to the medulla oblongata and pons, or directly to the trunk of the auditory nerve. Such a disease necessarily interferes with the roots and centers of the ves- tibular nerve contained in the cerebellum, but as we have no definite knowledge of the relation existing between this cerebellar ataxia and the static functions of the organ of hearing, the question will not be included in the present discussion. It is often very difficult to distinguish an auditory dis- turbance due to central lesion from intracranial lesion of the trunk of the auditory nerve. A great number of cases are known in which the auditory nerve was included in tumors originating at the base of the brain, in the cere- bellum, or in the pineal body. Such tumors even penetrate through the porus acusticus internus into the labyrinth. A differential diagnosis in such cases is impossible. In the etiology of the auditory disturbances which we have just described we have so far considered only those 1 " Zeitschr. f. Obr.," vol. xxix. 2/4 NERVOUS DISEASES. diseases which produce a direct lesion of the auditory path- way and its cerebral centers. In other words, we regarded the auditory disturbance as a direct result of such a lesion. We must now mention another pathologic condition, which is recognized by various authors, and to which Gradenigo, in Schwartze's " Handbuch der Ohrenheilkunde," ^ assigns a very important place, although its occurrence is now generally discredited : namely, the question of the hiflitence oil licaring of a rise in the intracrajiial pressure. Reasoning by analogy from papillary congestion, it was natural to assume that increased intracranial pressure might exert some influence on the auditory nerve, as the condi- tions are in certain respects similar. Moos considered it doubtful that auditory disturbances could be due to increased pressure from cerebral tumors ; Steinbriigge interpreted a depression of Reissner's membrane as dependent on increased intracranial pressure (an explanation which caused some discussion in the Naturf. Vers, in Heidelberg, the sense of the meeting being that the depression was simply an arti- fact) ; and Gradenigo assumes that " in cases of brain-tumor with increased intracranial pressure, a lymphatic infiltration occurs at the peripheral ending of the auditory nerve anal- ogous to the papillary congestion of the optic nerve." This interpretation is very artificial and anything but unas- sailable, for most pathologists deny that papillary conges- tion of the eye is due to intracranial pressure alone, attrib- uting it rather to toxic influences. Although histologists possess perfect methods and abundant material for the anatomic investigation of the eye, their results are not by any means uniform ; how, then, can we expect to draw any reliable conclusion from the superficial descriptions of only two histologic examinations of the labyrinth, in the exami- nation of which it has so far been impossible to exclude with certainty the fallacies of artifacts? It is therefore not to the credit of otology, and does not in the least add to our understanding of the question, to erect a hypothetic "papillary congestion of the auditory nerve" merely for the purpose of substantiating a preconceived opinion. In addition we may mention the conclusion reached by Asher ^ in a very careful work on the subject — that rise in the intracranial pressure does not produce any constant dis- 1 Vol. II, p. 530. 2 "D. Zeitschr. f. klin. INIed.," 27, p. 513. SAUNDERS^ MF.DICAL HAND-ATLASES, :n view of the extraordinary success attending the publication of Saunders' Medical Hand Atlases, Mr. Saunders has contracted with the publisher of the original German edition foi ONE HUNDRED THOUSAND COPIES of these books. In consideration of this enor- mous undertaking, the publisher has been en- ibled to prepare and furnish special addiliotia :oIored plates, making these books even hand- somer and more complete than was originally ntended. ^^^^^^^ji^jX As an indication of the great practical value Df these Atlases, and of the immense favot svith which they have been received by the medical profession, it should be noted that The Medical Department of the TJ. S. Army I 1 aas adopted the "Atlas of Operative Surgery" IS its standard, and has ordered the book in arge quantities for distribution to the various egiments and army posts, ji jt ^ ^ ji ■'''4^.:p over 175,000 copies of these invaluable self- helps have been sold to physicians and students. THE AMERICAN TEXT-BOOKS have also met with a success that is nothing less than phenomenal, as is attested by the fact that in the short period since the publication of the first volume of the series over 100,000 copies of these popular text-books have been sold in this country and abroad. Only books of rare merit could have attained such extraordinary sales, which fur- nish indisputable evidence of the high standing acquired by these books among physicians and students throughout the civilized world. }^ jT ai? jT jf TABES DORSALIS. 2/5 turbances in the organ of hearing, as the pressure conditions in the endolymphatic and perilymphatic spaces, which depend on the hydrostatic pressure of the lymphatic fluid, tend to regulate each other mutually, and thus to prevent the occurrence of excessive pressure. 3. NERVOUS DISEASES WHICH PRODUCE DEFI- NITE ALTERATIONS IN THE NOSE, PHAR- YNX, AND LARYNX, AND IN THE EARS, DISEASES OF THE SPINAL CORD. Tabes Dorsalis. The occurrence of laryngeal disturbances in tabes was formerly regarded as very rare, and until very recently opinions diverged as to the existence of any relation between tabes and difficult hearing. But now we have a long series of statistics and reported cases which prove that the vagus and auditory nerve are comparatively often in- volved in tabes dorsalis, if not quite as frequently as the optic nerve. According to Klippel,^ the olfactory nerve also becomes involved in tabes, and there result disturb- ances of the sense of smell, manifesting themselves in uni- lateral anosmia, parosmia, and hallucinations of scent. Statistics differ very widely as to the frequency of laryn- geal symptoms in tabes dorsalis ; Krause found motor dis- turbances in 13 out of 38 cases, but does not give any detailed description of their nature ; Marina, on the strength of Fano's investigation, gives 19 cases of motor disturbances in 36 patients suffering from tabes, in all of which the con- ditions were found to be abnormal. Dreyfus found two cases of double posticus paralysis among 22 tabes patients ; Burger ^ in 6 out of 20 cases found that motor disturbance could be demonstrated with the laryngoscope. I may add that among 27 tabetic patients in the Medicinische Uni- versitats-Poliklinikin Leipzig I found no disturbances in the larynx ; while, on the other hand, in the case of one tabetic patient who had sought medical advice on account of dysp- nea I found a double posticus paralysis associated with paresis of the vocal cords. Statistics based on such small 1 " Arch, de Nenrol.," 1897 ; see " .Schm. Jahrb. ," vol. CCLVii, p. 82. 2 " Die laryngealen Storungen bei Tabes dorsalis," Leiden, 1891. 2/6 NERVOUS DISEASES. material are, however, of very little value, as were shown by Semon, who found among the 12 first cases of tabes which he examined unilateral or bilateral posticus paralysis five times, whereas the next 30 cases did not yield a single laryngeal disturbance. Of more recent contributions we may mention that of Gerhardt,^ who found 17 paralyses in 122 tabetic patients, 11 of the posticus (5 bilateral, 4 the right posticus, 2 the left posticus), and 3 of the recurrent laryngeal nerve (i bilateral, 2 unilateral on the right side). The 3 remaining cases consisted of paral- ysis of the posticus and thyroid muscles once, paralysis of the recurrent nerve of one side and of the posticus nerve of the other side once, and 2 paralyses of the thyroid aryte- noid muscle. In 2 cases there were ataxic movements of the vocal cords ; in 4 cases there were laryngeal crises. ^ Among 100 cases of tabes Semon found 8 unilateral posticus paralyses, 3 bilateral posticus paralyses, and 3 unilateral paralyses of the recurrent nerve. The most frequent laryngeal complications consist in motor palsies of the laryngeal muscles. The typical tabetic palsy is that of the crico-arytenoideus posticus, either of one or of both sides. In Berger's table of 71 cases of tabetic laryngeal paralysis published up to 1891, there are 33 cases of unilateral paralysis of the posticus, in a few of which there was a coexistent paralysis of the intemus ; the remaining 38 cases consisted of unilateral paralysis of the posticus, while a few cases showed paralysis of the posticus on one side and paralysis of the recurrent nerve on the other. From this it would appear that bilateral paralysis of the posticus is almost as frequent as the unilateral form. It must, however, be remembered that the symptoms due to the various forms of paralysis may either be so marked as to produce a very noticeable alteration in the voice or res- piration, and thus arouse a suspicion of laryngeal disturb- ance, or they may be so mild as to escape the examiner's notice altogether, unless every tabetic patient is systematic- ally subjected to a laryngoscopic examination. Hence, unilateral paralysis of the posticus, which does not affect phonation and respiration, is frequenth- overlooked, while bilateral paralysis of the abductors of the glottis never 1 Nothnagel's " Spec. Path. u. Ther.," vol. xiii, p. 55. 2 " Heymann's Handb.," vol. i, p. 705. TABES DORSALIS. 2'J'J escapes detection, because it is always associated with hoarseness and dyspnea. Complete paralysis of the recurrent nerve is extremely rare in tabes dorsalis. As we have previously stated, a subacute disease affecting the nuclei of the vagus and of the recurrent nerve first produces paralysis of the posticus, which only becomes converted into paralysis of the recur- rent later in the disease. The question naturally suggests itself. Why do we not observe this transition from the median to the cadaveric position in those cases of tabes dorsalis which persist for many years, and which, as we know from the reports of autopsies, attack the nuclei in the medulla oblongata ? The only clinical fact which points to a progressive nature of posticus paralysis is the occurrence of paresis of the internus, which manifests itself in the laryngeal image in relaxation of the vocal cord, and clinically in the hoarseness and a diminution of the dyspnea due to the bilateral paralysis ; the rare cases of recurrent paralysis in tabes, being imperfectly described, are open to question, and can not be regarded as secondary to posticus paralysis. One thing is absolutely certain — the adductors or closers of the glottis are never affected alone in tabes dorsalis. The cricothyroid muscles are also practically never attacked ; Gerhardt's case of paralysis of the cricothyroid associated with that of the posticus is the only one that we have met with. ^ The laryngeal palsies are usually observed in the earlier stages of tabes dorsalis and sometimes precede all other symptoms. It has been occasionally stated that intermittent paral- ysis of the vocal cords may be observed in tabetic patients, and that a posticus paralysis may disappear after a few days and return after the lapse of weeks ; but the statement has not been satisfactorily proven, and until we have more accurate observations we must assume that once the tabetic paralysis has developed in the larynx there is no hope of cure. The paralysis may, however, develop very gradually, and several cases have been reported which remained con- stantly under observation and in which a complete posticus paralysis developed in the course of weeks or months : at first there was some power of abducting the vocal cords ; 1 " Ann. des mal. de I'oreille," iSgi, p. 4S0. 278 NERVOUS DISEASES. this gradually diminished, and finally the vocal cords remained immovable in the median position. The subjective symptoms are the same as those which occur in paralysis of the vocal cords from other causes. When there is hoarseness, a posticus paralysis produces no symptoms unless the vocal cords are implicated ; any marked disturbances always tend to posticus paralysis. The symp- toms consist in dyspnea, the voice being only slightly, if at all, affected. As the paralysis develops very gradually, the patient becomes accustomed to the stenotic condition of the rima glottidis, and the interference with respiration is comparatively slight, except during bodily exertion and phonation ; during sleep, however, the stenosis becomes very marked. There is a good deal of inspiratory dyspnea, showing itself in loud, sighing inspirations, while the expiration is quite free. There is, of course, a constant danger of asphyxia whenever a greater demand is made on the respiration during any form of bodily activity, so that sooner or later tracheotomy becomes necessary in cases of posticus paralysis. An experiment performed by Ruault deserves mention in this place. He excised 1.5 cm. from the recurrent nerve in a tabetic patient who was suffering from intense dyspnea due to posticus paralysis, in the hope of bringing the vocal cords into the cadaveric position, but the operation was not followed by any change either in the laryngeal image or in the subjective symptoms of the patient. This is the only case of its kind, and has no particular value. Ataxia of the vocal cords is a name given to a condition in which the vocal cords execute irregular movements dur- ing phonation and deep respiration. Krause was the first to remark that the vocal cords tended to move in jerks and to stop midway between complete adduction and the inspi- ratory position, producing interrupted or scanning speech. It has been elaborately proved by Burger that this motor anomaly, which occurs exclusively in tabes, is a true ataxia, or disturbance in the coordination of all the antagonistic groups of muscles the cooperation of which is necessary to produce all the movements of the vocal cords. Laryngeal crises consist in convulsive attacks of cough and dyspnea, and occur in the beginning of, or during the course of tabes, like gastric crises. They differ from attacks of simple laryngeal spasm in that all the other respiratory TABES DORSALIS. 2/9 muscles are involved. The attacks either occur without any ascertainable cause or after slight external, mechanical, or psychic irritation, particularly swallowing and the intro- duction of a probe into the throat. According to Oppen- heim, pressure on the throat at a point near the anterior border of the sternomastoid muscle at the level of the cri- coid cartilage produced attacks of coughing. The attacks occur with variable frequency ; they may be repeated several times within a few hours, or a single attack may be followed by a period of freedom lasting for months or years, or may never be repeated. They are usually preceded by a feeling of tickling or burning in the throat ; this is followed by a choking attack, with loud, strident inspirations and short, puffing expirations, accompanied by a violent, bark- ing cough which has been compared to whooping-cough. The patient becomes intensely excited and greatly terrified at the idea of impending suffocation, until, after a short time — the attacks rarely last longer than a minute — the respiration is suddenly or gradually restored, sometimes after the expectoration of a little mucus (Burger). They usually end in recovery in spite of their intensity, although Burger was able to collect five cases which terminated fatally during the attack. Pharyngeal crises are described by Oppenheim as attacks of convulsive gulping movements, which, however, are for- eign to our subject. Sensory disturbances of the larynx during tabes are rare. A few cases of anesthesia and hyperesthesia of the pharyngeal and laryngeal mucous membrane have been observed. With regard to the appear- ances produced by tabes dorsalis in the organ of hearing, I shall here reprint a paper which I read before the Deutsche Otologische Gesellschaft in Dresden, in 1897, and which appeared in a rather inaccessible portion of the reports of that meeting : In spite of the fact that several papers have appeared on the subject of aural disturbances in tabes dorsalis, opinions are still divided as to their nature, and there are those who deny the occurrence of deafness as a result of tabes. I shall omit the list of reported cases and shall not repeat the various opinions which have been expressed on this subject, contenting myself with referring to Burger, 280 NERVOUS DISEASES. Treitel,! and Haug,^ who have given a complete bibli- ography of the subject. I shall make it my task to attempt to explain the probable nature of ear disease in tabes dor- salis by means of our anatomic and clinical knowledge of the conditions. Although there are no anatomic investiga- tions at my disposal, I shall utilize the results of examina- tions made on the ears of 27 tabetic patients by a ' Doctor- and ' in the Medicinischen Universitats-Poliklinik at Leip- zig. Among these patients there were two cases of im- paired hearing which could with certainty be referred to tabes — at least, with as much certainty as the present state of aural examination will permit. I give the percentage as 7.3, although I am reluctant to compute a rate on such a limited number of cases. At least, these investigations show that tabetic ear disease is extremely rare, and tally almost perfectly with the statistics published by Voigt and Treitel, who found auditory disturbances in 2 cases out of 100, and in 2 cases out of 20, or 2^ and 10 fo, respec- tively. I was unable to obtain the statistics by Marie and Walton in the original, but I have nothing to criticize in the finding of Meniere's symptom -complex in 17 out of 24 cases ; on the other hand, I object strongly to Morpurgo's statement that he found in 43 cases out of 53 auditory dis- turbances which could be traced to tabes dorsalis — a per- centage of 81.13. As the diagnosis was based purely on a positive Rinne test, at reduced hearing-distance, and on a normal condition of the ear-drum, while the air douche was not followed by improvement in the hearing, these statistics are manifestly defective, and after examining the cases I claim that the list does not contain a single case of authen- tic tabetic deafness. The infrequency of auditory disturbances in tabes is confirmed by the observation of clinicians with a large amount of material at their command. If we compare the meager reports of deafness with the great number of case histories of tabes dorsalis contained in the literature (we need only mention Erb's statistics of more than 700 cases), our faith in an author who gives a percentage of 81.13 's very much shaken. The clinical picture of the ear affection is variously de- 1 "Zeitschr. f. Ohr.," xx. 2 " Die Krankheiten des Ohres in ihren Beziehungen zu den Allgemeiner- krankungen." Vienna and Leipzig, 1893. TABES DORSALIS. 28 1 scribed. According to some, the disease presents the characteristics of a lesion in the sound-perceiving apparatus, and is distinguished by otitis interna and by the fact that perception for the higher notes is relatively good, while the hearing is impaired for the deeper and middle notes of the register. Others distinguish two clinical forms, one of which must be regarded as a simple tabetic atrophy of the audit- ory nerve, the other as syphilitic disease of the labyrinth. The former is gradual in its onset and goes on slowly to complete deafness, being accompanied with tinnitus aurium, but never with vertigo ; the latter makes its appearance suddenly, like a stroke of apoplexy, wdth the phenomena of Meniere's symptom-complex, and in many cases rapidly leads to total deafness. It follows from this divergence in the conception of the clinical course of the auditory disturbance in tabes that the most various attempts were made to explain the nature of the disease. Some incline to regard the process as an atrophy of the auditory nerve, others attribute the disease to trophic disturbances in the middle ear due to tabetic dis- ease of the trifacial nerve, while a third faction describes the disease as syphilitic. As I shall presently show, all these theories lack the support of anatomic or clinical find- ings, which alone afford a reliable basis for the description of the disease. Most authors interpret tabetic disease of the ears as an atrophy of the auditory nerve with the symptoms of a lesion of the sound-perceiving apparatus. It is a proof of our present inability to make a clinical diagnosis of atrophy of the auditory nerve that attempts are constantly being made to discover some minute changes which should be charac- teristic of tabetic disease of the auditory nerve. Gradenigo considers it characteristic of tabes when the perception of high notes is relatively good and the loss of hearing applies chiefly to the lower and middle notes ; but this phenomenon is not constant, to say the least, for in Habermann's case perception of the lower notes remained good after the patient was unable to hear higher ones. Again, many authors have emphasized the great electric irritability of the auditory nerve, but this phenomenon has not met with universal recognition, and is, moreover, of little value, in view of our imperfect knowledge of the physiology of the electric reaction of the auditory nerve. ^82 NERVOUS DISEASES. The conception of a progressive atrophy of the auditory- nerve fails to find pathologic support, because those cases •in which disease of the nerve-endings in the labyrinth and in the nuclei was found associated with atrophy of the auditory nerve can not be regarded as cases of primary atrophy of the auditory nerve. Although on theoretic grounds there may be no objec- tion to this interpretation, since disease of the trunks of the -cranial nerves is said to occur in tabes, there is, as I have said, a complete absence of anatomic or clinical proof of its representing the type of a tabetic auditory disturbance ; consequently, other explanations were sought. When Lucae was able to refer the impairment of hearing in two tabetic patients to simple disease of the middle ear, furnish- ing anatomic proof in one case, it gave rise to the opinion that the middle-ear affection was due to tabetic disease of the trifacial nerve, in support of which was cited the fact, determined by the experiments of Baratoux, Gelle, and Berthold, that trophic disturbances may appear in the middle ear after the destruction of the roots of the trifacial nerve. But there is no proof whatever that such an effect on the middle ear through the trifacial nerve takes place in tabes, for in Lucae's case there were no other disturbances, such as would necessarily be present in any disease of the trunk or nucleus of the trifacial, nor was there any anatomic proof of such disease. On the other hand, this explanation is untenable from the fact that Oppenheim ^ found the hearing to be quite normal in a case of marked alteration of the trifacial where the diagnosis rested on an anatomic iDasis ; nor is there any mention of auditory disturbances in another similar case of Oppenheim's. If the opinion that the fifth nerve plays an important part in tabetic deafness were correct, the symptom would certainly have been present in these two cases ; its absence, however, makes the hypothesis very improbable. The syphilitic form of aural disease remains to be dis- cussed. This is particularly insisted upon by Haug,^ who appears to believe that these cases possess very character- istic clinical features, consisting principally of Meniere's symptoms, with abrupt onset, marked vertigo, vomiting, ■and sudden deafness, sometimes associated with violent ^ "Arch, fiir Psychistrie und Nervenheilk.," xx, p. 147. 2 Loc. cit. TABES DORSALIS. 283 pains. The objective signs, he says, differ from those in a simple case of tabes by the fact that bone conduction is completely abohshed. I can not see how these symptoms justify Haug in believing "that he has in all probability to deal with syphilis," since other nervous affections of the ear are accompanied by the same symptoms. Haug also cites the report of an autopsy which he says confirms his opinion, but it is left to the reader to pick out what he con- siders characteristic of syphilis. It appears that Haug's diagnosis was determined by a little round-celled infiltration which was found surrounding some of the smaller vessels, and the proliferation in the intima of the same. Haug is welcome to consider the ear affection in his case as syph- ilitic ; but, if so, it is not tabetic, and has developed inde- pendently of tabes. The explanation that " a primary syphilitic infection may give rise to the combination of lues and tabes which occasionally appears in the organ of hear- ing in the form of a labyrinth affection" seems rather obscure, and even if we admit a connection between tabes and syphilis, it is, in my opinion, a mistake to look for ter- tiary syphilitic changes, as such are never found in the parasyphilitic affections, to which the tabetic deafness in this case would belong. The latest investigations hardly admit of any other explanation of tabes than that it is a disease of the neurons, consisting principally in a lesion of the systems that take their origin in the spinal ganglia. I would apply the same explanation to the auditory disturbances which occur in tabes, and shall, therefore, continue the discussion of this question by referring to the reports of autopsies and clinical observations which have hitherto been published. For the morbid anatomy, I begin by citing a case of Habermann's.i in which the disease was limited to the trunk of the auditory nerve and its terminal endings in the laby- rinth, while the nuclei remained intact. It is Avorth men- tioning that the atrophy of the fibers of the cochlear nerve was not so great on the right as on the left side. . A bundle of nerve-fibers at the apex of the cochlea and several ganglion cells in the terminal portion of the basilar convolu- tion were preserved — a condition which manifested itself clinically in ability on the part of the patient to perceive deeper tones. 1 "Arch. f. Ohr.," xxxiii, p. iii. 284 NERVOUS DISEASES. Next, I will mention Gelle's case, which is always quoted in support of the doctrine of middle-ear disease in tabes. In a woman forty-two years of age, the subject of tabes, there was a sclerosis of the mucous membrane of the middle ear, immobility of the ear-drum and of the chain of ossicles, ankylosis of the stapes, and, as a result of these changes, — to quote the common explanation, — a slight atrophy of part of the various portions of the cochlea, including a dis- turbance of the nerve -endings on the basilar membrane. The nerves in the lamina spiralis, in the vestibules, and in the semicircular canals were not attacked. In view of the atrophy of the nerve-endings on the basilar membrane I question the propriety of regarding this case as one ot simple middle -ear disease, and am inclined to look upon it as a primary peripheral disease of the cochlear nerve. Striimpell has described one case of tabes in which there had been complete bilateral deafness for four years. Micro- scopic examinations revealed an evident atrophy of the au- ditory nerves. Nothing is said about the nuclei or the internal ear, although the statement that the " degenerative process, strange to say, disappears in the restiform body" justifies the assumption that if there had been any disease of the auditory nuclei, which are in such close proximity to the restiform body, it would not have escaped the author's notice. There remain to be mentioned three cases by Haug in two of which the cochlear and vestibular nerves appeared to be completely destroyed ; the trunk and nuclei of the auditory nerve, however, were not examined. In the third case the fibers of the cochlear nerve. had disappeared and been replaced by connective tissue, the cells of Corti's organs were opaque, the basilar membrane was preserved, while Corti's membrane and the reticular membrane were the seat of membranous adhesions. Unfortunately, the author does not give a detailed description of this very in- teresting aural condition, "because it would lead him too far afield," so that there is nothing left to discuss but the medulla oblongata, as the trunk of the auditory nerve was not examined. One of the chief nuclei showed only a slight degeneration of the nerve-fibers, while the other was quite normal. The accessory nuclei could not be made out, as they appeared to be replaced by round-celled infil- tration. There was a diminution in the number of fibers in OGDEN ON THE URINE CLINICAL EXAMINATION OF THE URINE AND URINARY DIAGNOSIS. A Clinical Gtiide for the Use of Practitioners and Students of Med- icine and Surgery. By J. Berg;en Ogden, M.D., Instructor in Chemistry, Harvard University Medical School; Assistant in Clinical Patholog;y, Boston City Hospital. Handsome octavo, 425 pages, with 54 illustrations, and a number of colored plates. Cloth, $3.00 net. JUST ISSUED, The design of this work is to present in as con- cise a manner as possible the chemistry of the urine and its relation to physiologic processes? the most approved working methods, both quali- tative and quantitative j the diagnosis of diseases and disturbances of the kidneys and urinary passages. 31.45 CATALOGUE OF THE MEDICAL PUBLICATIONS OF W. B. SAUNDERS & CO., No. 925 WALNUT STREET, PHILADELPHIAc Arranged Alphabetically and Classified under Subjects. THE books advertised in this Catalogue as being sold by subscription are usually to be obtained from travelling solicitors, but they will be sent direct from the office of pub- lication (charges of shipment prepaid) upon receipt of the prices given. All the other books advertised are commonly for sale by booksellers in all parts of the United States ; but books will be sent to any address, carriage prepaid, on receipt of the published price. Money may be sent at the risk of the publisher in either of the following vi^ays : A post- office money order, an express money order, a bank check, and in a registered letter. Money sent in any other way is at the risk of the sender. See pages 32, 33 for a List of Contents classified according to subjects. LATEST PUBLICATIONS. American Students* Medical Dictionary. See page 34. American Text-Book of Physiology — Second (Revised) Ed. Page 7. Friedrich and Curtis on Nose, Throat, and Ear. See page 34. Le Roy^s Histology. See page 34. Ogden on the Urine. See page 34. Pyle's Personal Hygiene. See page 34. Salinger and Kalteye/s Modern Medicine. See page 34. Stoney^s Surgical Technic for Nurses. See page 34. Hyde and Montgomery's Syphilis and Venereal Diseases — Revised and Enlarged Edition. See page 15. International Text-Book of Surgery. See page 15. Garrigues' Diseases of "Women— Third (Revised) Edition. Page 13. American Text-Book of Dis. of Eye, Ear, Nose, and Throat. Page 5. Saunders' American Year-Book for 1900. See page 8. Levy and Klemperer's Clinical Bacteriology. See page 17. Scudder's Treatment of Fractures. See page 26. Senn's Tumors — Second Edition. See page 27. Beck on Fractures. See page 9. Watson's Handbook for Nurses. See page 31. Heisler's Embryology. See page t5. Nancrede's Principles of Surgery. See page 20. Jackson's Diseases of the Eye. See page 16. Kyle on the Nose and Throat. See page 17. Penrose's Diseases of "Women — Third (Revised ) Edition. Page 20. "Warren's Surgical Pathology — Second (Revised) Edition. Page 31. Saunder's Medical Hand-Atlases. See pages 2, 3, 4. American Pocket Medical Dictionary — Third (Revised) Ed. Page 12. SAUNDERS' MEDICAL HAND-ATLASES. The series of books included under this title consists of authorized translations into English of the world-famous Lehmann Medicinische Handatlanten, which for scientific accuracy, pictorial beauty, com- pactness, and cheapness surpass any similar volumes ever published. Each volume contains from 50 to 100 colored plates, executed by the most skilful German lithographers, besides numerous illustrations in the text. There is a full and appropriate description of each plate, and each book contains a condensed but adequate outline of the subject to which it is devoted. One of the most valuable features of these atlases is that they offer a ready and satisfactory substitute for clinical observation. To those unable to attend important clinics these books will be absolutely indis- pensable. In planning this series of books arrangements were made with the rep- resentative publishers in the chief medical centers of the world for the publication of translations of the atlases into different languages, the litho- graphic plates for all these editions being made in Germany, where work of this kind has been brought to the greatest perfection. The expense of making the plates being shared by the various publishers, the cost to each one was materially reduced. Thus by reason of their universal transla- tion and reproduction, the publishers have been enabled to secure for these atlases the best artistic and professional talent, to produce them in the most elegant style, and yet to offer them at a price heretofore unap- proached in cheapness. The success of the undertaking is demonstrated by the fact that the volumes have already appeared in thirteen different lang-uages — German, English, French, Italian, Russian, Spanish, Japanese, Dutch, Danish, Swedish, Roumanian, Bohemian, and Hungarian. In view of the striking success of these works, Mr. Saunders has con- tracted with the publisher of the original German edition for one hun- dred thousand copies of the atlases. In consideration of this enormous undertaking, the publisher has been enabled to prepare and furnish special additional colored plates, making the series even handsomer and more complete than was originally intended. 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Chapman, M.D., Professor of Institutes of JSIedicine and Medical Jurisprudence in the Jefferson Medical College of Philadelphia. 254 pages, with 55 illustrations and 3 full-page plates in colors. Cloth, §1.50 net. "The best book of its class for the undergraduate that we know of." — Neiv York Medical Tivies. CHURCH AND PETERSON'S NERVOUS AND MENTAL DISEASES. Second Edition. Nervous and Mental Diseases. By Archibald Church, M. D., Professor of Clinical Neurology, Mental Diseases, and Medical Juris- prudence in the Northwestern University Medical School, Chicago ; and Frederick Peterson, M. D., Clinical Professor of Mental Dis- eases, Woman's Medical College, N. Y. ; Chief of Clinic, Nervous Dept., College of Physicians and Surgeons, N. Y. Handsome octavo volume of 843 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, §6. 00 net. Medical Publications of W. B. Saunders & Co. 11 CLARKSON'S HISTOLOGY. A Text=Book of Histology, Descriptive and Practical. By Arthur Clarkson, M.B., CM. Edin., formerly Demonstrator of Physiology in the Owen's College, Manchester; late Demonstrator of Physiology in Yorkshire College, Leeds. Large octavo, 554 pages; 22 engravings in the text, and 174 beautifully colored original illustra- tions. Cloth, strongly bound, ^4.00 net. " The work must be considered a valuable addition to the list of available text books, and is to be highly recommended." — New York Medical Journal. "This is one of the best works for students we have ever noticed. We predict that the book will attain a well-deserved popularity among our students." — Chicago Medical Recorder. CLIMATOLOGY. Transactions of the Eighth Annual Meeting of the American Climatological Association, held in Washington, September 22-25, 1891. Forming a handsome octavo volume of 276 pages, uniform with remainder of series. (A limited quantity only.) Cloth, $1.50. COHEN AND ESHNER'S DIAGNOSIS. Second Edition, Revised. Essentials of Diagnosis. By Solomon Solis-Cohen, M.D., Pro- fessor of Clinical Medicine and Applied Therapeutics in the Philadel- phia Polyclinic ; and Augustus A. Eshner, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. Post-octavo, 417 pages; 55 illustrations. Cloth, ^i.oo net. [See Saimders^ Question- Compends, page 23.] "We can heartily commend the book to all those who contemplate purchasing a 'com- pend.' It is modern and complete, and will give more satisfaction than many other works which are perhaps too prolix as well as behind the times." — Medical Review, St. Louis. CORWiN'S PHYSICAL DIAGNOSIS. Third Edition, Revised. Essentials of Physical Diagnosis of the Thorax. By Arthur M, CoRWiN, A.M., M.D., Demonstrator of Physical Diagnosis in Rush Medical College, Chicago ; Attending Physician to Central Free Dis- pensary, Department of Rhinology, Laryngology, and Diseases of the Chest, Chicago. 219 pages, illustrated. Cloth, flexible covers, ^1.25 net. " It is excellent. The student who shall use it as his guide to the careful study of physical exploration upon normal and abnormal subjects can scarcely fail to acquire a good working knowledge of the subject." — Philadelphia Folyclitiic. "A most excellent little work. It brightens the memory of the differential diagnostic signs, and it arranges orderly and in sequence the various objective phenomena to logical solution of a careful diagnosis." — Journal of A^ervoiis aiid Mental Diseases. CRAQIN'S GYN/ECOLOGY. Fourth Edition, Revised. Essentials of Gynaecology. By Edwin B. Cr.-^gin, M. D., Lecturer in Obstetrics, College of Physicians and Surgeons, New York. Crown octavo, 200 pages; 62 illii^irations. Cloth, $1.00 net; interleaved for notes, $1.25 net. \?)ee SaunihW Question- Compends, page 23.] " A handy volume, and a distinct improvement on students' compends in general. No author v\ho was not himself a practical gynecologist could have consulted the student's needs so thoroughly as Dr. Cragin has dont."— Medical Record, New York. 12 Meaical Publications of W. B. Saunders & Co. CROOKSHANK'S BACTERIOLOGY. Fourth Edition, Revised. A Text=Book of Bacteriology. By Edgar M. Crookshank, M.B., Professor of Comparative Pathology and Bacteriology, King's College, London. Octavo volume of 700 pages, with 273 engravings and 22 original colored plates. Cloth, $6.50 net; Half Morocco, $7.50 net. " To the student who wishes to obtain a good resume of what has been done in bacteri- ology, or who wishes an accurate account of the various methods of research, the book may be recommended with confidence that he will find there what he requires." — Lotidon Lancet. Da COSTA'S SURGERY. Second Ed., Revised and Greatly Enlarged. Modern Surgery, General and Operative. By John Chalmers DaCosta, M. D., Professor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadelphia : Surgeon to the Philadelphia "Hospital, etc. Handsome octavo volume of 911 pages, profusely illus- trated. Cloth, $4.00 net; Half Morocco, $5.00 net. "We know of no small work on surgery in the EngHsh language which so well fulfils the requirements of the modern student." — Mcdico-Chirurgical Journal, Bristol, England. DE SCHWEINITZ ON DISEASES OF THE EYE. Third Edition, Revised. Diseases of the Eye, A Handbook of Ophthalmic Practice. By G. E. DE ScHWEiNiTZ, M.D., Professor of Ophthalmology in the Jefferson IMedical College, Philadelphia, etc. Handsome royal octavo volume of 696 pages, with 256 fine illustrations and 2 chromo-litho- graphic plates. Cloth, ^4.00 net ; Sheep or Half Morocco, $5.00 net. " A clearly written, comprehensive manual. One which we can commend to students as a reliable text-book, written with an evident knowledge of the wants of those entering upon the study of this special branch of medical science." — British I^Iedical Journal. " A work that will meet the requirements not only of the specialist, but of the general practitioner in a rare degree. I am satisfied that unusual success awaits it." — William Pepper, M.D.. Professor of the Theory and Practice of Medicitte and Clinical Medicine, University of Pennsylvania. DORLAND'S DICTIONARY. Third Edition, Revised. The American Pocket Medical Dictionary. Containing the Pro- nunciation and Definition of all the principal words and phrases, and a large number of useful tables. Edited by W. A. Newman Borland, ALL). , Assistant Demonstrator of Obstetrics, University of Pennsylvania ; Fellow of the American Academy of Medicine. 518 pages ; handsomely bound in full leather, limp, with gilt edges and patent index. Price, $1.00 net; with thumb index, $1.25 net. DORLAND'S OBSTETRICS. A Manual of Obstetrics. By W. A. Newman Borland, ALB., Assistant Bemonstrator of Obstetrics, L'niversity of Pennsylvania; Instructor in Gynecology in the Philadelphia Polyclinic. 760 pages; 163 illustrations in the text, and 6 full-page plates. Cloth, $2.50 net, " By far the best book on this subject that has ever come to our notice." — American Medical Review. " It has rarely been our duty to review a book which has given us more pleasure in its perusal and more satisfaction in its criticism. It is a veritable encyclopedia of knowledge, a gold mine of practical, concise thoughts." — Af/terican Medico- Sui-gical Bulletin. Medical Publications of W. B. Saunders & Co. 13 PROTHINQHAM'S GUIDE FOR THE BACTERIOLOGIST. Laboratory Guide for the Bacteriologist. By Langdon Froth- iNGHAM, M.D.V., Assistant in Bacteriology and Veterinary Science, Sheffield Scientific School, Yale University. Illustrated. Cloth, 75 cts. " It is a convenient and useful little work, and will more than repay the outlay neces- sary for its purchase in the saving of time which would otherwise be consumed in looking up the various points of technique so clearly and concisely laid down in its pages. " — ^;«f?'2- can Medico- Surgical Bulletin. QARRIGUES' DISEASES OF WOMEN. Third Edition, Revised. Diseases of Women. By Henry J. Garrigues, A.M., M.D., Pro- fessor of Gynecology in the New York School of Clinical Medicine ; Gynecologist to St. Mark's Hospital and to the German Dispensary, New York City, etc. Handsome octavo volume of 783 pages, illus- trated by 367 engravings and colored plates. Cloth, $4.00 net; Sheep or Half Morocco, $5.00 net. " One of the best text-books for students and practitioners which has been published in the English language ; it is condensed, clear, and comprehensive. The profound learning and great clinical experience of the distinguished author find expression in this book in a most attractive and instructive form. Young practitioners to whom experienced consultants may not be available will find in this book invaluable counsel and help." — Thad. A. Reamy, M.D., LL.D., Professor of Clinical Gynecology, Medical College of Ohio. GLEASON'S DISEASES OF THE EAR. Second Edition, Revised. Essentials of Diseases of the Ear. By E. B. Gleason, S.B., M.D., Clinical Professor of Otology, Medico-Chirurgical College, Philadelphia ; Surgeon-in-Charge of the Nose, Throat, and Ear Depart- ment of the Northern Dispensary, Philadelphia. 20S pages, with 114 illustrations. Cloth, $1.00 net; interleaved for notes, $1.25 net. [See Saunders'' Question- Compe7ids, page 23.] " It is just the book to put into the hands of a student, and cannot fail to give him a useful introduction to ear-affections ; while the style of question and answer which is adopted throughout the book is, we believe, the best method of impressing facts permanently on the mind." — Liverpool Medico-Chirurgical Jotcntal. GOULD AND PYLE'S CURIOSITIES OF MEDICINE. Anomalies and Curiosities of Medicine. By George M. Gould, M.D., and Walter L. Pyle, M.D. An encyclopedic collection of rare and e.xtraordinary cases and of the most striking instances of abnormality in all branches of Medicine and Surgery, derived from an exhaustive research of medical literature from its origin to the present day, abstracted, classified, annotated, and indexed. Handsome im- perial octavo volume of 968 pages, with 295 engravings in the te.xt, and 12 full-page plates. POPULAR EDITION: Cloth, $3.00 net .• Half Morocco, $4.00 net. " One of the most valuable contributions ever made to medical literature. It is, so far as we know, absolutely unique, and every page is as fascinating as a novel. Not alone for the medical profession has this volume value: it will serve as a book of reference for all who are -interested in general scientific, sociologic, or medico-legal topics." — Brooklyn Medical Journal. "This is certainly a most remarkable and interesting volume. It stands alone among medical literature, an anomaly on anomalies, in that there is nothing like it elsewhere in medical literature. It is a book full of revelations from its first to its last page, and cannot but interest and sometimes almost horrify its readers." — American Medico- Surgical Bulletin. 14 Medical Publications of W. B. Saunders & Co. GRAFSTROM'S MECHANO=THERAPY. A Text=Book of Mechano=Therapy (Massage and Medical Qym= nasties j. By Axel V. Grafstrom, B. Sc, M. D., late Lieutenant in the Royal Swedish Army ; late House Physician City Hospital, Black- well's Island, New York. i2mo, 139 pages, illustrated. Cloth, $1.00 net. GRIFFITH ON THE BABY. Second Edition, Revised. The Care of the Baby. By J. P. Crozer Griffith, M.D., Clini- cal Professor of Diseases of Children, University of Pennsylvania; Physician to the Children's Hospital, Philadelphia, etc. i2mo, 404 pages, with 67 illustrations in the text, and 5 plates. Cloth, $1.50 net. " The best book for the use of the young mother with which we are acquainted. . . . There are very few general practitioners who could not read the book through with advan- tage." — Archives of Pediatrics. "The whole book is characterized by rare good sense, and is evidently written by a master hand. It can be read witli benefit not only by mothers but by medical students and by any practitioners who have not had large opportunities for observing children." — Ameri- can Journal of Obstetrics. GRIFFITH'S WEIGHT CHART. Infant's Weight Chart. Designed by J. P. Crozer Griffith, M.D., Clinical Professor of Diseases of Children in the University of Penn- sylvania, etc. 25 charts in each pad. Per pad, 50 cents net. GROSS, SAMUEL D., AUTOBIOGRAPHY OF. Autobiography of Samuel D. Gross, M. D., Emeritus Professor of Surgery in the Jefferson Medical College, Philadelphia, with Remi- niscences of His Times and Contemporaries. Edited by his Sons, Samuel W. Gross, M.D., LL.D., and A. Haller Gross, A.M. Pre- ceded by a Memoir of Dr. Gross, by the late Austin Flint, M.D. Two handsome volumes, over 400 pages each, demy octavo, gilt tops, with Frontispiece on steel. Price per volume, $2.50 net. HAMPTON'S NURSING. Second Edition, Revised and Enlarged. Nursing: Its Principles and Practice. By Isabel Adams Hamp- ton, Graduate of the New York Training School for Nurses attached to Bellevue Hospital ; late Superintendent of Nurses and Principal of the Training School for Nurses, Johns Hopkins Hospital, Baltimore, Md. 12 mo, 512 pages, illustrated. Cloth, ^2.00 net. " Seldom have we perused a book upon the subject that has given us so much pleasure as the one before us. We would strongly urge upon the members of our own profession the need of a book like this, for it will enable each of us to become a training school in him- self." — Ontario Aledical Journal. HARE'S PHYSIOLOGY. Fourth Edition, Revised. Essentials of Physiology. By H. A. Hare, M.D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. Crown octavo, 239 pages. Cloth, $1.00 net; inter- leaved for notes, $1.25 net. [See Sauiiders" Question- Compends, page 23.] "The best condensation of physiological knowledge we have yet seen." — Medical Record, New York. Medical Publications of W. B. Saunders & Co. 15 HART'S DIET IN SICKNESS AND IN HEALTH. Diet in Sickness and in Health. By Mrs. Ernest Hart, formerly Student of the Faculty of Medicine of Paris and of the London School of Medicine for Women ; with an Introduction by Sir Henry Thompson, F.R.C.S., M.D., London. 220 pages. Cloth, ^1.50 net. " We recommend it cordially to the attention of all practitioners ; both to them and to their patients it may be of the greatest service." — New Yo7-k Medical Journal. HAYNES' ANATOMY. A Manual of Anatomy. By Irving S. Haynes, M.D., Adjunct Professor of Anatomy and Demonstrator of Anatomy, Medical Depart- ment of the New York University, etc. 680 pages, illustrated with 42 diagrams in the text, and 134 full-page half-tone illustrations from original photographs of the author's dissections. Cloth, ^2.50 net. " This book is the work of a practical instructor — one who knows by experience the requirements of the average student, and is able to meet these i-equirements in a very satis- factory way. The book is one that can be commended." — Medical Record, New York. HEISLER'S EMBRYOLOGY. A Text=Book of Embryology. By John C. Heisler, M.D., Pro- fessor of Anatomy in the Medico-Chirurgical College, Philadelphia. Oc- tavo volume of 405 pages, handsomely illustrated. Cloth, ^2.50 net. HIRST'S OBSTETRICS. Second Edition. A Text=Book of Obstetrics. By Barton Cooke Hirst, M. D., Professor of Obstetrics in the University of Pennsylvania. Handsome octavo volume of 848 pages, with 618 illustrations, and 7 colored plates. Cloth, $5.00 net; Sheep or Half Morocco, ^6.00 net. " The illustrations are numerous and are works of art, many of them appearing for the first time. The arrangement of the subject-matter, the foot-notes, and index are beyond criticism. As a true model of what a modern text-book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a rival." — Neiu York Medical Record. HYDE AND MONTGOMERY ON SYPHILIS AND THE VENEREAL DISEASES. Second Edition, Revised and Enlarged. Syphilis and the Venereal Diseases. By James Nevins Hyde, M. D., Professor of Skin and Venereal Diseases, and Frank H. Mont- gomery, M. D., Lecturer on Dermatology and Genito-Urinary Diseases in Rush Medical College, Chicago, 111. Octavo, nearly 600 pages, with 14 beautiful lithographic plates and numerous illustrations. " We can commend this manual to the student as a help to him in his study of venereal diseases. ' ' — Liverpool Medico- Chirurgical Journal. "The best student's manual which has appeared on the subject." — St. Louis Medical and Surgical Journal. INTERNATIONAL TEXT=BOOK OF SURGERY. In two volumes. By American and British authors. Edited by J. Collins Warren, M.D., LL.D., Professor of Surgery, Harvard Medical School, Boston; and A. Pearce Gould, M.S., F.R.C.S., Lecturer on Practical Sur- gery and Teacher of Operative Surgery, Middlesex Hospital Medical School, London, Eng. Vol. I. General Siirs^ery. — Handsome octavo, 947 pages, with 458 beautiful illustrations and 9 lithographic plates. Vol. II. Special 07- Re,^ioiiaI Suri:;cry. — Handsome octavo, 1072 pages, with 471 beautiful illustrations and 8 lithographic plates. Prices per volume: Cloth, $5.00 net; Half Morocco, $6.00 net. 16 Medical Publications of W. B. Saunders & Co. JACKSON'S DISEASES OF THE EYE. A Manual of Diseases of the Eye. By Edward Jackson, A.M., M.D., sometime Professor of Diseases of the Eye in the Philadelphia Polyclinic and College for Graduates in Medicine. i2mo volume of 535 P^g^^j with 17S beautiful illustrations, mostly from drawings by the author. Cloth, 5^-50 net. JACKSON AND GLEASON'S DISEASES OF THE EYE, NOSE, AND THROAT. Second Edition, Revised. Essentials of Refraction and Diseases of the Eye. By Edward Jackson, A.M., M.D., Professor of Diseases of the Eye in the Phila- delphia Polyclinic and College for Graduates in Medicine; and — Essentials of Diseases of the Nose and Throat. By E. Bald- win Gleason, M.D., Surgeon-in-Charge of the Nose, Throat, and Ear Department of the Northern Dispensary of Philadelphia. Two volumes in one. Crown octavo, 290 pages; 124 illustrations. Cloth, §1.00 net; interleaved for notes, $1.25 net. [See Saunders' Question-Cojnpends, page 22.] " Of great value to the beginner in these branches. The authors are both capable men, and know what a student most needs." — Medical Record, New York. KEATINQ'S DICTIONARY. Second Edition, Revised. A New Pronouncing Dictionary of Medicine, with Phonetic Pronunciation, Accentuation, Etymology, etc. By John M. Keating, M.D., LL.D., Fellow of the College of Physicians of Phila- delphia, and Henry Hamilton ; with the collaboration of J. Chal- mers DaCosta, M.D., and Frederick A. Packard, M.D. With an Appendix contain! g Tables of Bacilli, Micrococci, Leucomaines, Ptomaines, etc. One volume of over 800 pages. Prices, with Ready- Reference Index: Cloth, $5.00 net; Sheep or Half Morocco, $6.00 net. Without Patent Index : Cloth, $4.00 net ; Sheep or Half Morocco, $5.00 net. "I am much pleased with Keating's Dictionary, and shall take pleasure in recommend- ing it to my classes." — Henry M. Lyman, M. D., Professor of the Principles and Practice if Medicine, Rush Medical College, Chicago, III. KEATING'S LIFE INSURANCE. How to Examine for Life Insurance. By John M. Keating, M. D., Fellow of the College of Physicians of Philadelphia; Vice- President of the American Paediatric Society; Ex- President of the Association of Life Insurance Medical Directors. Royal octavo, 211 pages ; with two large half-tone illustrations, and a plate prepared by Dr. McClellan from special dissections ; also, numerous other illustra- tions. Cloth, $2.00 net. KEEN'S OPERATION BLANK. Second Edition, Revised Form. An Operation Bl^nk, with Lists of Instruments, etc., Required in Various Operations. Prepared by W. W. Keen, M.D., LL.D., Professor of the Principles of Surgery in Jefferson Medical College, Philadelphia. Price per pad, blanks for fifty operations, 50 cents net. Medical Publications of W. B. Saunders d^ Co. 17 KEEN ON THE SURGERY OF TYPHOID FEVER. The Surgical Complications and Sequels of Typhoid Fever. By Wm. W. Keen, M.D., LL.D., Professor of the Principles of Sur- gery and of Clinical Surgery, Jefferson Medical College, Philadelphia; Corresponding Member of the Soci^te de Chirurgie, Paris ; Honorary Member of the Societe Beige de Chirurgie, etc. Octavo volume of 386 pages, illustrated. Cloth, $3.00 net. " This is probably the first and only work in the English language that gives the reader a clear view of what typhoid fever really is, and what it does and can do to the human organism. This book should be in the possession of every medical man in America." — American Medico- Surgical Bulletin. KYLE ON THE NOSE AND THROAT. Diseases of the Nose and Throat. By D. Braden Kyle, M.D., Clinical Professor of Laryngology and Rhinology, Jefferson Medical College, Philadelphia; Consulting Laryngologist, Rhinologist, and Otologist, St. Agnes' Hospital. Handsome octavo volume of about 630 pages, with over 150 illustrations and 6 lithographic plates. Price, Cloth, ^4.00 net; Half Morocco, ^5.00 net. LAINE'S TEMPERATURE CHART. Temperature Chart. Prepared by D. T. Laine, M.D. Size 8 x 131^ inches. A conveniently arranged Chart for recording Temperature, with columns for daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the back of each chart is given in full the method of Brand in the treatment of Typhoid Fever. Price, per pad of 25 charts, 50 cents net. " To the busy practitioner this chart will be found of great value in fever cases, and especially for cases of typhoid." — Itidian Lancet, Calcutta. LEVY AND KLEMPERER'S CLINICAL BACTERIOLOGY. The Elements of Clinical Bacteriology. By Dr. Ernst Levy, Profes- sor in the University of Strassburg, and Ff.lix Klemperer, Privat docent in the University of Strassburg. Translated and edited by Augustus A. EsHNER, M.D., Professor of Clinical Medicine in the Philadelphia Polyclinic. Octavo, 440 pages, fully illustrated. Cloth, $2,50 net. LOCKWOOD'S PRACTICE OF MEDICINE. A Manual of the Practice of Medicine. By George Roe Lock- WOOD, M.D., Professor of Practice in the Woman's Medical College of the New York Infirmary, etc. 935 pages, with 75 illustrations in the text, and 22 full-page plates. Cloth, ^2.50 net. " Gives in a most concise manner the points essential to treatment usually enumeratec in the most elaborate works." — Massachusetts Medical Journal. LONG'S SYLLABUS OF GYNECOLOGY. A Syllabus of Gynecology, arranged in Conformity with "An American Text=Book of Gynecology." l!y J. \\. Long, M.D., Professor of Diseases of Women and Children, Medical College of Virginia, etc. Cloth, interleaved, $1.00 net. " The book is certainly an admirable resume of what every gynecological student and practitioner should know, and will prove of value not only to those who have the ' Americar Text-Book of Gynecology,' but to others as well." — Brooklyn Medical Journal. 18 Medical Publications of W. B. Saunders & Co, MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT. Surgical Diagnosis and Treatment. By J. W, Macdonald, M.D. Edin., F.R.C.S., Edin., Professor of the Practice of Surgery and of Clinical Surgery in Hamline University ; Visiting Surgeon to St. Barnabas' Hos])ital, Minneapolis, etc. Handsome octavo volume of 800 pages, profusely illustrated. Cloth, $5.00 net; Half Morocco, $6. CO net. " A thorough and complete work on surgical diagnosis and treatment, free from pad- ding, full of valuable material, and in accord with the surgical teaching of the day. ' — The Medical JVezvs, N'ew York. " The work is brimful of just the kind of practical information that is useful alike to students and practitioners. It is a pleasure to commend the bock because of its intrinsic valuo to the medical practitioner." — Cincinttati Lancet-Clinic MALLORY AND WRIGHT'S PATHOLOGICAL TECHNIQUE. Pathological Technique. A Practical Manual for Laboratory Work in Pathology, Bacteriology, and Morbid Anatomy, wich chapters on Post-Mortem Technique and the Performance of Autopsies. By Frank B. Mallory, A.M., M.D., Assistant Professor of PatholoC'y, Harvard University Medical School, Boston; and James K. Wrujht, A.M., M.D., Instructor in Pathology, Harvard University Medical School, Boston. Octavo volume of 396 pages, handsomely illustrated. Cloth, $2.50 net. " I have been looking forward to the publication of this book, and I am gi.Td to say that I find it to be a most useful laboratory and post-mortem guide, full of practical information, and w^ell up to date." — William H. Welch, Professor of Pathology, fohns jlopkins Uni- versity, Baltimore, Aid. MARTIN'S MINOR SURGERY, BANDAGING, AND VEiiNEREAL DISEASES. Second Edition, Revised. Essentials of Minor Surgery, Bandaging, and Venvireal Diseases. By Edward Martin, A.M., M.D., Clinical Professcof Genito-Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 166 pages, with 78 illustrations. Cloth, $1.00 net; interleaved for notes, ^1.25 net. [See Saunders' Question- Compends, page 23.] "A very practical and systematic study of the subjects, and shows the author's famil- iarity with the needs of students." — Therapeutic Gazette. MARTIN'S SURGERY. Seventh Edition, Revised. Essentials of Surgery. Containing also Venereal Diseases, Surgi- cal Landmarks, Minor and Operative Surgery, and a complete de- scription, with illustrations, of the Handkerchief and Roller Bandages. By Edward Martin, A.M., ALD., Clinical Professor of Genito- Urinary Diseases, University of Pennsylvania, etc. Crown octavo, 342 pages, illustrated. With an Appendix on the preparation of the materials used in Antiseptic Surgery, etc., and a chapter on Appendicitis. Cloth, $1.00 net; interleaved for notes, $1.25 net \?)Qe Saundefs' Question- Compends, page 23.] " Contains all necessary essentials of modern surgery in a comparatively small space. Its style is interesting, and its illustrations are admirable." — Medical and Surgical Reporter, Medical Publications of W. B. Saunders & Co. 19 McFARLAND'S PATHOGENIC BACTERIA. Second Edition, Re- vised and Greatly Enlarged. Text=Book upon the Pathogenic Bacteria. By Joseph McFar- LAND, M. D. , Professor of Pathology and Bacteriology in the Medico- Chirurgical College of Philadelphia, etc. Octavo volume of 497 pages, finely illustrated. Cloth, ^2.50 net. " Dr. McFarland has treated the subject in a systematic manner, and has succeeded in presenting in a concise and readable form the essentials of bacteriology up to date. Alto- gether, the book is a satisfactory one, and I shall take pleasure in recommending it to the students of Trinity College."— H. B. Anderson, M.D. , Professor of Pathology and Bac- teriology, Trinity Medical College, Toronto. MEIGS ON FEEDING IN INFANCY. Feeding in Early Infancy. By Arthur V. Meigs, M.D. Bound in limp cloth, flush edges, 25 cents net. "This pamphlet is worth many times over its price to the physician. The author's experiments and conclusions are original, and have been the means of doing much good." — ' Medical Btdletin. MOORE'S ORTHOPEDIC SURGERY. A Manual of Orthopedic Surgery. By James E. Moore, M.D., Professor of Orthopedics and Adjunct Professor of Clinical Surgery, University of Minnesota, College of Medicine and Surgery. Octavo volume of 356 pages, handsomely illustrated. Cloth, ^2.50 net. " A most attractive work. The illustrations and the care with which the book is adapted to the wants of the general practitioner and the student are worthy of great praise." — Chicago Medical Recorder. "A very demonstrative work, every illustration of which conveys a lesson. The work is a most excellent and commendable one, which we can certainly endorse with pleasure." — ■ St. Louis Medical and Surgical Journal. MORRIS'S MATERIA MEDICA AND THERAPEUTICS. Fifth Edition, Revised. Essentials of Materia Medica, Therapeutics, and Prescription- Writing. By Henry Morris, M.D., late Demonstrator of Thera- peutics, Jefferson Medical College, Philadelphia; Fellow of the College of Physicians, Philadelphia, etc. Crown octavo, 288 pages. Cloth, ^i.oo net; interleaved for notes, $1.25 net. [See Saunders'' Question- Conpends, page 22.] "This work, already excellent in the old edition, has been largely improved by revi- sion." — American Practitioner and News. MORRIS, WOLFF, AND POWELL'S PRACTICE OF MEDICINE. Third Edition, Revised. Essentials of the Practice of Medicine. By PIenry Morris, M.D., late Demonstrator of Thera|)eutics, Jefferson Medical College, Phila- delphia; with an Apt)endix on the Clinical and Microscopic Examina- .tion of Urine, by Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia. Enlarged by some 300 essen- tial formulae collected and arranged by Wii>liam M. Powell, M.D. Post-octavo, 488 pages. Cloth, $1.50 net. [See Saunders^ Question- Compends, page 22.] " The teaching is sound, the presentntion graphic ; matter full as can be desired, '^nd s'.yle attractive." — American Practitiontr and News. 20 Medical Publications of W. B. Saunders & Co. MORTEN'S NURSE'S DICTIONARY. 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Saunders^ Question-Compend Series* Price, Cloth, $1.00 net per copy, except when otherwise ordered. "Where the work of preparing students' manuals is to end we cannot say, but the Saunders Series, in our opinion, bears off the palm at present."— yVfiw York Medical Record. 1. ESSENTIALS OF PHYSIOLOGY. By H. A. Hare, M.D. Fourth edition, revised and enlarged. 2. ESSENTIALS OF SURGERY. By Edward Martin, xM- D. Seventh edition, revised, with an Appendix and a chapter on Appendicitis. 3. ESSENTIALS OF ANATOMY. By Chari.es B. Nancrede, M.D. Sixth edition, thoroughly revised and enlarged. 4. ESSENTIALS OF MEDICAL CHEMISTRY, ORGANIC AND INORGANIC. By Lawrence Wolff, M.D. Fifth edition, revised. 5. ESSENTIALS OF OBSTETRICS. By W. Easterly Ashton, M.D. Fourth edition, revised and enlarged. 6. ESSENTIALS OF PATHOLOGY AND MORBID ANATOMY. By C. E. Armand Semple, M.D. 7. ESSENTIALS OF MATERIA MEDICA, THERAPEUTICS, AND PRE- SCRIPTION=WRITING. By Henry Morris, M.D. Fifth edition, revised. 8. 9. ESSENTIALS OF PRACTICE OF MEDICINE. By Henry Morris, M.D. An Appendix on Urine Examination. By Lawrence Wolff, M.D. Third edition, enlarged by some 300 Essential Formulse, selected from eminent authorities, by Wm. M. Powell, M.D. (Double number, ^1.50 net.) 10. ESSENTIALS OF QYN/ECOLOGY. By Edwin B. Cragin, M.D. Fourth edition, revised. 11. ESSENTIALS OF DISEASES OF THE SKIN. By Henry W. Stelwagon, M.D. Fourth edition, revised and enlarged. 12. ESSENTIALS OF MINOR SURGERY, BANDAGJNG, AND VENEREAL DISEASES. By Edward Martin, M.D. Second ed., revised and enlarged. 13. ESSENTIALS OF LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. By C. E. Armand Semple, M.D. 14. ESSENTIALS OF DISEASES OF THE EYE, NOSE, AND THROAT. By Edward Jackson, M.D., and E. B. Gleason, M.D. Second ed., revised. 15. ESSENTIALS OF DISEASES OF CHILDREN. By William M. Powell, M.D. Second edition. 16. ESSENTIALS OF EXAMINATION OF URINE. By Lawrence Wolff, M.D. Colored " Vogel Scale." (75 cents net.) 17. ESSENTIALS OF DIAGNOSIS. 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By Joseph Howard Raymond, A.M., M.D., Professor of Physiology and Hygiene and Lecturer on Gynecology in the Long Island College Hospital ; Director of Physiology in the Hoagland Laboratory, etc. Illustrated. Cloth, ^i. 25 neu SURGERY, General and Operative.— By John Chalmers DaCosta, M. D., Pro- fessor of Practice of Surgery and Clinical Surgery, Jefferson Medical College, Philadel- phia; Surgeon to the Philadelphia Hospital, etc. Second edition, thoroughly revised and greatly enlarged. Octavo, 911 pages, profusely illustrated. Cloth, ^4.00 net; Half Morocco, I5.00 net. DOSE=BOOK AND MANUAL OF PRESCR1PTI0N=WR1TINQ. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Phila- delphia. Illustrated. Cloth, §1.25 net. SURGICAL ASEPSIS. By Carl Beck, M.D., Surgeon to St. Mark's Hospital and to the New York German Poliklinik, etc. Illustrated. Cloth, ^1.25 net. MEDICAL JURISPRUDENCE. By Henry C. 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Saunders iSr Co. SAUNDBY'S RENAL AND URINARY DISEASES. Lectures on Renal and Urinary Diseases. By Robert Saundby, M.D. Edin., Fellow of the Royal College of Physicians, London, and of the Royal Medico-Chirurgical Society ; Physician to the General Hospital ; Consulting Physician to the Eye Hospitax and to the Hos- pital for Diseases of Women; Professor of Medicine in Mason College, Birmingham, etc. Octavo volume of 434 pages, with numerous illus- trations and 4 colored plates. Cloth, $2.50 net. " The volume makes a favorable impression at once. The style is clear and succinct. We cannot find any part of the subject in which the views expressed are not carefully thought out and fortified by evidence drawn from the most recent sources. The book may be cordially recommended." — British ^ledical Journal, 5AUNDERS' MEDICAL HAND=ATLA5ES. For full description of this series, with list of volumes and prices, see page 2. " Lehmann Medicinische Handatlanten belong lo that class of books that are too good to be appropriated by any one nation." — yournal of Eye, Ear, and Throat Diseases. '• The appearance of these works marks a new era in illustrated English medical works." — The CaJiadian Practitioner. SAUNDERS' POCKET MEDICAL FORMULARY. Sixtli Edition, Revised. By William M. Powell, M.D., Attending Physician to the Mercer House for Invalid Women at Atlantic City, N. J. Containing 1800 formulae selected from the best-known authorities. With an Appen- dix containing Posological Table, Formulae and Doses for Hypo- dermic Medication, Poisons and their Antidotes, Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet List for Various Diseases, Materials and Drugs used in Antiseptic Surgery, Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Hand- somely bound in flexible morocco, with side index, wallet, and flap. ^1.75 net. " This little book, that can be conveniently carried in the pocket, contains an immense amount of material. It is ver\- useful, and, as the name of the author of each prescription is given, is unusually reliable." — Medical Record, New York. SAYRE'S PHARMACY. Second Edition, Revised. Essentials of the Practice of Pharmacy. By Lucius E. Sayre, M.D., Professor of Pharmacy and Materia Medica in the University of Kansas. Crown octavo, 200 pages. Cloth, $1.00 net; interleavef for notes, ^1.25 net. [See Saunders' Question- CoJiipends, page 21.] " The topics are treated in a simple, practical manner, and the work forms a very usefuj Student's manual." — Boston Medical and Surgical Journal. SCUDDER'S FRACTURES. The Treatment of Fractures. By Chas. L. Scudder, M.D., As- sistant in Clinical and Operative Surgery, Harvard Medical School. Octavo, 433 pages, with nearly 600 original illustrations. Cloth, §4.50 Medical Publications of W. B. Saunders & Co. 11 SEMPLE'S LEGAL MEDICINE, TOXICOLOGY, AND HYGIENE. Essentials of Legal Medicine, Toxicology, and Hygiene. By C. E. Armand Semple, B. A., M. B. Cantab., M. R. C. P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 212 pages; 130 illustrations. Cloth, $1.00 net; inter- leaved for notes, $1.25 net. [See Saimders Question- Compends, page 21.] " No general practitioner or student can afford to be without this valuable work. The subjects are dealt with by a masterly hand." — London Hospital Gazette. SEMPLE'S PATHOLOGY AND MORBID ANATOMY. Essentials of Pathology and Morbid Anatomy. By C. E. Armand Semple, B.A., M.B. Cantab., M.R.C.P. Lond., Physician to the Northeastern Hospital for Children, Hackney, etc. Crown octavo, 174 pages; illustrated. Cloth, $1.00 net; interleaved for notes, $1.25 n-t. [See Saunders'' Question- Cojnpends, page 21.] " Should take its place among the standard volumes on the bookshelf of both student and practitioner." — Lotidon Hospital Gazette. SENN'S GENITO=URINARY TUBERCULOSIS. Tuberculosis of the Genito=Urinary Organs, Male and Femaleo By Nicholas Senn, M.D., Ph.D., LL.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Handsome octavo volume of 320 pages, illustrated. Cloth, ^3.00 net. " An important book upon an important subject, and written by a man of mature judg- ment and wide experience. The author has given us an instructive book upon one of the most important subjects of the day." — Clinical Reporter. " A work which adds another to the many obligations the profession owes the talented author." — Chicago Medical Recorder. SENN'S SYLLABUS OF SURGERY. A Syllabus of Lectures on the Practice of Surgery, arranged in conformity with " An American Text=Book of Surgery." By Nicholas Seen, M. D., Ph.D., Professor of the Practice of Surgery and of Clinical Surgery, Rush Medical College, Chicago. Cloth, ^1.50 net. " This syllabus will be found of service by the teacher as well as the student, the work being superbly done. There is no praise too high for it. No surgeon should be without it." — New York Medical Times. SENN'S TUMORS. Second Edition, Revised. Pathology and Surgical Treatment of Tumors. By N. Senn, M.D, Ph.D., LL.D., Professor of Surgery and of Clinical Surgery, Rush Medical College ; Professor of Surgery, Chicago Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief, St. Joseph's Hospital, Chicago. Second Edition, T]ioroui:;hly Revised. Oc- tavo volume of 718 pages, with 478 illustrations, including 12 full-page plates in colors. Prices: Cloth, ^5.00 net; Half Morocco, ;$6.oo net. " The most exhaustive of any recent book in Engiish on this subject. It is well illus- trated, and will doubtless remain as the principal monograph on the subject in our language for some years. The book is handsomely illustrated and printed, and the author has given a notable and lasting contribution to surgery." — Jourtial of the At)(erica7i Medical Association. 28 Medical Publications of W. B. Saunders & Co. SHAW'S NERVOUS DISEASES AND INSANITY. Third Edition, Revised. Essentials of Nervous Diseases and Insanity. By John C. Shaw. M.D., Clinical Professor of Diseases of the Mind and Nervous System, Long Island College Hospital Medical School ; Consulting Neurologist to St. Catherine's Hospital and to the Long Island College Hospital. Crown octavo, i86 pages; 48 original illustrations. Cloth, $1.00 net; interleaved for notes, $1.25 net. [See Saunders' Questioii-Coinpends, page 21.] "Clearly and intelligently written." — Boston Medical and Surgical Journal. "There is a mass of valuable material crowded into this small compass.' — American Medico-Surgical Bulletin. STARR'S DIETS FOR INFANTS AND CHILDREN. Diets for Infants and Children in Health and in Disease. By Louis Starr, M.D., Editor of "An American Text-Book of the Diseases of Children." 230 blanks (pocket-book size), perforated and neatly bound in flexible morocco. §1.25 net. The first series of blanks are prepared for the first seven months of infant life ; each Mank indicates the ingredients, but not the quantities, of the food, the latter directions being left for the physician. After the seventh month, modifications being less necessary, the diet lists are printed in full. Formulae for the preparation of diluents and foods are appended. STELWAGON'S DISEASES OF THE SKIN. Fourth Ed., Revised. Essentials of Diseases of the Skin. By Henry W. Stelwagon, M.D., Clinical Professor of Dermatology in the Jefferson Medical College, Philadelphia ; Dermatologist to the Philadelphia Hospital ; Physician to the Skin Department of the Howard Hospital, etc. Crown octavo, 276 pages; 88 illustrations. Cloth, $1.00 net; inter- leaved for notes, $1.25 net. [See Saunders' Question- Compends, page 21.] " The best student's manual on skin diseases we have yet seen." — Times and Register. STENGEL'S PATHOLOGY. Second Edition. A Text=Book of Pathology. By Alfred Stengel, M.D., Professor of Clinical Medicine in the University of Pennsylvania ; Physician to the Philadelphia Hospital ; Physician to the Children's Hospital, etc. Handsome octavo volume of 848 pages, with nearly 400 illustrations, many of them in colors. Cloth, $4.00 net; Half Morocco, $5.00 net. STEVENS' MATERIA MEDICA AND THERAPEUTICS. Second Edition, Revised. A Manual of Materia Medica and Therapeutics. By A. A. Stevens, A.M., IM.D., Lecturer on Terminology and Instructor in Physical Diagnosis in the LTniversity of Pennsylvania ; Professor of Pathology in the Woman's Medical College of Pennsylvania. Post- octavo, 445 pages. Flexible leather, §2.00 net. '•The author has faithfully presented modern therapeutics in a comprehensive work, and, while intended particularly for the use of students, it will be found a reliable guide and sufficiently comprehensive for the physician in practice." — University Medical Magazine. Medical Publications of W. B. Saunders & Co. 29 5TEVEN5' PRACTICE OF MEDICINE. Fifth Edition, Revised. A Manual of the Practice of Medicine. By A. A. Stevens, A. M., M. D., Lecturer on Terminology and Instructor in Physical Diagnosis in the University of Pennsylvania ; Professor of Pathology in the Woman's Medical College of Pennsylvania. Specially intended for students preparing for graduation and hospital examinations. Post- octavo, 519 pages; illustrated. Flexible leather, ^2.00 net. " The frequency with which new editions of this manual are demanded bespeaks its popularity. It is an excellent condensation of the essentials of medical practice for the student, and maybe found also an excellent reminder for the busy physician." — Buffalo Medical Journal. STEWART'S PHYSIOLOGY. Third Edition, Revised. A Manual of Physiology, with Practical Exercises. For Students and Practitioners. By G. N. Stewart, M.A., M.D., D.Sc, lately Examiner in Physiology, University of Aberdeen, and of the New Museums, Cambridge University ; Professor of Physiology in the Western Reserve University, Cleveland, Ohio. Octavo volume of 848 pages ; 300 illustrations in the text, and 5 colored plates. Cloth, ^3.75 net. " It will mate its way by sheer force of merit, and amply deserves to do so. It is one of the very best English tesct-books on the subject." — London Lancet. ' ' Of the many text-books of physiology published, we do not know of one that so nearly comes up to the ideal as does Prof Stewart's volume." — British Medical Journal. STEWART AND LAWRANCE'S MEDICAL ELECTRICITY. Essentials of Medical Electricity. By D. D. Stewart, M.D., Demonstrator of Diseases of the Nervous System and Chief of the Neurological Clinic in the Jefferson Medical College; and E. S. Lawrance, M.D., Chief of the Electrical Clinic and Assistant Demon- strator of Diseases of the Nervous System in the Jefferson Medical College, etc. Crown octavo, 158 pages; 65 illustrations. Cloth, ^i.oo net; interleaved for notes, $1.25 net. [See Saunders' Question- Compends, page 21.] " Throughout the whole brief space at their command the authors show a discriminating knowledge of their subject." — Medical News. STONEY'S NURSING. Second Edition, Revised. Practical Points in Nursing. For Nurses in Private Practice. By Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass.; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. 456 pages, illustrated with 73 engravings in the text, and 8 colored and half-tone plates. Cloth, $1.75 net. " There are few books intended for non-professional readers which can be so cordially endorsed by a medical journal as can this one." — Therapeutic Gazette. " This is a well-written, eminently practical volume, which covers the entire range of private nursing as distinguished from hospital nursing, and instructs the nurse how best to meet the various emergencies which may arise, and how to prepare everything ordinarily needed in the illness of her patient." — .4!>ierican Journal of Obstetrics and Diseases of IVowen and Childreti. " It is a work that the physician can place in the hands of his private nurses with the assurance of benefit." — Ohio Medical Journal. 30 Medical Publications of W. B. Saunders & Co. STONEY'S MATERIA MEDICA FOR NURSES. Materia Medica for Nurses. Ey Emily A. M. Stoney, Graduate of the Training-School for Nurses, Lawrence, Mass. ; late Superintendent of the Training-School for Nurses, Carney Hospital, South Boston, Mass. Handsome octavo volume of 306 pages. Cloth, $1.50 net. The present book differs from other similar works in several features, all of which are intended to render it more practical and generally useful. The general plan of the contents jollows the lines laid down in training-schools for nurses, but the book contains much use- ful matter not usually included in works of this character, such as Poison-emergencies, Ready Dose-list, Weights and Measures, etc., as well as a Glossary, defining all the terms used in Materia Medica, and describing all the latest drugs and remedies, which have been generally neglected by other books of the kind. SUTTON AND GILES' DISEASES OF WOMEN. Diseases of Women. By J. Bland Sutton, F.R.C.S., Assistant Surgeon to Middlesex- Hospital, and Surgeon to Chelsea Hospital, London; and Arthur E. Giles, M.D., B.Sc. Lond., F.R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London. 436 pages, hand- somely illustrated. Cloth, $2.50 net. "The text has been carefully prepared. Nothing essential has been omitted, and its teachings are those recommended by the leading authorities of the day." — Journal of the American Medical Association. THOMAS'S DIET LISTS. Second Edition, Revised. Diet Lists and Sick=Room Dietary. By Jerome B. Thomas, M.D., Visiting Physician to the Home for Friendless Women and Children and to the Newsboys' Home ; Assistant Visiting Physician to the Kings County Hospital. Cloth, $1.25 net. Send for sample sheet. THORNTON'S DOSE=BOOK AND PRESCRIPTION=WRITINQ. Dose=Book and Manual of Prescription=Writing. By E. Q. Thornton, M.D., Demonstrator of Therapeutics, Jefferson Medical College, Philadelphia. 334 pages, illustrated. Cloth, $1.25 net. "Full of practical suggestions; will take its place in the front rank of works of this sort." — Medical Record, New \'ork. VAN VALZAH AND NISBET'S DISEASES OF THE STOMACH. Diseases of the Stomach. By William W. Van Valzah, M.D.,. Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic; and J. Douglas Nisbet, M.D., Adjunct Professor of General Medicine and Diseases of the Digestive System and the Blood, New York Polyclinic. Octavo volume of 674 pages, illustrated. Cloth, $3.50 net. " Its chief claim lies in its clearness and general adaptability to the practical needs of the general practitioner or student. In these relations it is probably the best of the recent special works on diseases of the stomach." — Chicago Clinical Review. VECKi'S SEXUAL UMPOTENCE. The Pathology and Treatment of Sexual Impotence. By Victor G. Vecki, M D. From the second German edition, revised and en- larged. Demi-octavo, 291 pages. Cloth, $2.00 net. The subject of impotence has seldom been treated in this country in the truly scientific sr-'Ht that it deserves. Dr. Vecki's work has long been favorably known, and the German tx)ok has received the highest consideration. This edition is more than a mere translation, k)r, although based on the German edition, it has been entirely rewritten in English. 3Iedical Piihlications of W. B. Saunders & Co. 31 V^IERORDT'S MEDICAL DIAGNOSIS. Fourth Edition, Revised. Medical Diagnosis. By Dr. Oswald Vierordt, Professor of Medi- cine at the University of Heidelberg. Translated, with additions, from the fifth enlarged German edition, with the author's permission, by Francis H. Stuart, A. M., M. D. Handsome royal octavo volume of 603 pages; 194 fine wood-cuts in text, many of them in colors. Cloth, ^4.00 net; Sheep or Half Morocco, $5.00 net. " Rarely is a book published with which a reviewer can find so little fault as with the volume before us. Each particular item in the consideration of an organ or apparatus, which is necessary to determine a diagnosis of any disease of that organ, is mentioned ; nothing seems forgotten. The chapters on diseases of the circulatory and digestive apparatus and nervous system are especially full and valuable. The reviewer would repeat that the book is one of the best — probably tAe best — which has fallen into his hands." — University Medicai WATSON'S HANDBOOK FOR NURSES. A Handbook for Nurses. By J. K. Watson, M.D., Edin. Ameri- can Edition, under supervision of A. A. Stevens, A.M., M.D., Lecturer on Physical Diagnosis, University of Pennsylvania. i2mo, 413 pages, 73 illustrations. Cloth, ^1.50 net. WARREN'S SURGICAL PATHOLOGY. Second Edition. Surgical Pathology and Therapeutics. By John Collins Warren, M.D., LL.D., Professor of Surgery, Harvard Medical School. Hand- some octavo, 832 pages ; 136 relief and lithographic illustrations, 2)Z i^"^ colors ; with an Appendix on Scientific Aids to Surgical Diagnosis, and a series of articles on Regional Bacteriology. Cloth, $5.00 net; Half Morocco, ^6.00 net. "A most striking and very excellent feature of this book is its illustrations. Without exception, from the point of accuracy and artistic merit, they are the best ever seen in a work of this kind. Many of those representing microscopic pictures are so perfect in their coloring and detail as almost to give the beholder the impression that he is looking down the barrel of a microscope at a well-mounted section." — Annals of Surgery. WOLFF ON EXAMINATION OF URINE. Essentials of Examination of Urine. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia' etc. Colored (Vogel) urine scale and numerous illustrations. Crown octavo. Cloth, 75 cents net. [See Saunders' Question- Compends, page 21.] " A very good work of its kind— very well suited to its purpose."— 7z'w« and Register. WOLFF'S MEDICAL CHEMISTRY. Fifth Edition, Revised. Essentials of Medical Chemistry, Organic and Inorganic. Containing also Questions on Medical Physics, Chemical Physiology, Analytical Processes, Urinalysis, and Toxicology. By Lawrence Wolff, M.D., Demonstrator of Chemistry, Jefferson Medical College, Philadelphia, etc. Crown octavo, 222 pages. Cloth, ^i.oo net; inter- leaved for notes, gi.25 net. [See Saunders' Question- Co7npcnds, page 21.] •'The scope of this work is certainly equal to that of the best course of lectures on Medical Chemistiy. " — Fhannaceutical Era. CLASSIFIED LIST OF THE Medical Publications OF W. B. SAUNDERS & COMPANY, 925 Walnut Street, Philadelphia. ANATOMY, EMBRYOLOGY, HISTOLOGY. Clarkson — A Text-Book of Histology, 1 1 Haynes — A Manual of Anatomy, . . . 15 Heisler — A Text- Book of Embryology, 15 Nancrede — Essentials of Anatomy, . . 20 Nancrede — Essentials of Anatomy and Manual of Practical Dissection, ... 20 Sample — Essentials of Pathology, . . 27 BACTERIOLOGY. Ball — Essentials of Bacteriology, ... 8 Crookshank — A Text-Book of Bacteri- ology, 12 Frothingham — Laboratory Guide, . . 13 Levy and Klemperer's Clinical Bacte- ric^l'^gy. 17 Mallory and Wright — Pathological Technique, 18 McFarland — Pathogenic Bacteria, . . ig CHARTS, DIET-LISTS, ETC. Griffith— Infant's Weight Chart, ... 14 Hart — Diet in Sickness and in Health, . 15 Keen — Operation Blank, 17 Laine — Temperature Chart. . . -17 Meigs — Feeding in Early Infancy, . . 19 Starr — Diets for Infants and Children, . 28 Thomas — Diet-Lists 30 CHEMISTRY AND PHYSICS. Brockway — Essentials of Medical Phys- ics, 9 Wolff — Essentials of Medical Chemistry, 31 CHILDREN. An American Text-Book of Diseases of Children, . . 5 Griffith — Care of the Baby 14 Griffith — Infant's Weight Chart, ... 14 Meigs — Feeding in Early Infancy, . . 19 Powell — Essentials of Dis. of Children, 21 Starr — Diets for Infants and Children, . 26 ' DIAGNOSIS. I Cohen and Eshner —Essentials of Di- I agnosis, 11 Corwin — Physical Diagnosis, .... 11 Macdonald — Surgical Diagnosis and j Treatment, 18 j Vierordt— Medical Diagnosis, .... 31 1 DICTIONARIES. Borland— Pocket Dictionary, .... 12 j Keating — Pronouncing Dictionary, . . 16 Morten — Nurse's Dictionary, . . . . 20 1 EYE, EAR, NOSE, AND THROAT. An American Text- Book of Diseases of the Eye, Ear, Nose, and Throat, . 5 De Schweinitz — Diseases of the Eye, . 12 Gleason — Essentials of Dis. of the Ear, 13 Jackson — Manual of Diseases of Eye, . 16 Jackson and Gleason — Essentials of Diseases of the Eye, Nose, and Throat, 16 Kyle — Diseases of the Nose and Throat, 1 7 GENITO=URINARY. An American Text-Book of Genito- urinary and Skin Diseases, 6 Hyde and Montgomery — Syphilis and the Venereal Diseases, 15 Martin — Essentials of Mmor Surgery, Bandaging, and Venereal Diseases, . 18 Saundby — Renal and Urinary Diseases, 26 Senn — Genito-Urinary Tuberculosis, . 27 Vecki — Sexual Impotence, 30 GYNECOLOGY. American Text- Book of Gynecology, 6 Cragin — Essentials of Gynecology, . . II Garrigues — Diseases of Women, ... 13 Long — Syllabus of Gynecology, ... 17 Penrose— Diseases of Women, .... 20 Pryor — Pelvic Inflammations, • • • ■ 34 Sutton and Giles — Diseases of Women, 30 MATERIA MEDICA, PHARMACOL- OGY, AND THERAPEUTICS. An American Text-Book of Applied Therapeutics 5 Butler — Text-Book of Materia Medica, Therapeutics and Pharmacology, ... 10 Cerna — Notes on the Newer Remedies, 10 Griffin — Materia Med. and Therapeutics, 14 Morris— Essentials of Materia Medica and Therapeutics, . . 19 Saunders' Pocket Medical Formulary, 26 Sayre— Essentials of Pharmacy, ... 26 Stevens — Essentials of Materia Medica and Therapeutics, 28 Stoney — Materia Medica for Nurses, . . 30 Thornton — Dose- Book and Manual of Prescription-Writing, 30 MEDICAL JURISPRUDENCE AND TOXICOLOGY. Chapman — Medical Jurisprudence and Toxicology, ... .... 10 Sample — Essentials of Legal Medicine, Toxicology, and Hygiene, 27 Medical Publications of W. B. Saunders & Co. 33 NERVOUS AND MENTAL DISEASES, ETC. Burr — Nervous Diseases, Chapin — Compendium of Insanity, . . Church and Peterson — Nervous and Mental Diseases, Shaw — Essentials of Nervous Diseases and Insanity, NURSING. Griffith — The Care of the Baby, . . . Hampton — Nursing, . Hart — Diet in Sickness and in Health, Meigs — Feeding in Early Infancy, . . Morten — Nurse's Dictionary Stoney — Materia Medica for Nurses, . . Stoney — Practical Points in Nursing, . Watson — Handbook for Nurses, . . . OBSTETRICS. An American Text-Book of Obstetrics, Ashton — Essentials of Obstetrics, Boisliniere — Obstetric Accidents Dorland — Manual of Obstetrics, Hirst — Text-Book of Obstetrics, Norris — Syllabus of Obstetrics, . PATHOLOGY. An American Text-Book of Pathology, Mallory and Wright — Pathological Technique, Semple — Essentials of Pathology and Morbid Anatomy, Senn — Pathology and Surgical Treat- ment of Tumors, Stengel— Text-Book of Pathology, . . M^arren — Surgical Pathology and Thera- peutics, PHYSIOLOGY. An American Text-Book of Physi- ology, Hare — Essentials of Physiology, . . . Raymond — Manual of Physiology, . . Stewart — Manual of Physiology, . . . PRACTICE OF MEDICINE. An American Text-Book of the The- ory and Practice of Medicine, .... An American Year-Book of Medicine and Surgery, Anders — Text-Book of the Practice of Medicine, Lockwood — Manual of the Practice of Medicine, Morris — Essentials of the Practice of Medicine, Stevens — Manual of the Practice of Medicine, SKIN AND VENEREAL. An American Text-Book of Genito- urinary and Skin Diseases, Hyde and Montgomery — Syphilis and the Venereal Diseases, Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . Pringle— Pictorial Atlas of Skin Dis- eases and Syphilitic Affections, . . Stelwagon— Essentials of Diseases of the Skin, SURGERY. An American Text-Book of Surgery, 7 An American Year-Book of Medicine and Surgery, 8 Beck — Fractures, g Beck — Manual of Surgical Asepsis, . . 9 DaCosta — Manual of Surgery, . ... 12 International Text-Book of Surgery, . 15 Keen — Operation Blank, 17 Keen — The Surgical Complications and Sequels of Typhoid Fever, 17 Macdonald — Surgical Diagnosis and Treatment, 18 Martin — Essentials of Minor Surgery, Bandaging, and Venereal Diseases, . 18 Martin — Essentials of Surgery, .... 18 Moore — Orthopedic Surgery, ig Nancrede — Principles of Surgery, . . 20 Pye — Bandaging and Surgical Dressing, 21 Scudder — Treatment of Fractures, . . 26 Senn — Genito-Urinary Tuberculosis, . 27 Senn — Syllabus of Surgery, 27 Senn — Pathology and Surgical Treat- ment of Tumors, 27 Warren — Surgical Pathology and Ther- apeutics, 2 1 URINE AND URINARY DISEASES. Saundby — Renal and Urinary Diseases, 26 Wolffs Essentials of Examination of Urine, 31 MISCELLANEOUS. Abbott — Hygiene of Transmissible Dis- eases, 8 Bastin — Laboratory Exercises in Bot- any, 9 Gould and Pyle — Anomalies and Curi- osities of Medicine, 13 Grafstrom — Massage, 14 Keating — How to Examine for Lite Insurance, - • o 16 Rowland and Hedley — Archives of the Roentgen Ray, 21 Saunders' Medical Hand- Atlases, .2, 3, 4 Saunders' New Series of Manuals, 24, 25 Saunders' Pocket Medical Formulary, 26 Saunders' Question-Compends, . . 22, 23 Senn — Pathology and Surgical Treat- ment of Tumors, 27 Stewart and Lawrance — Essentials of Medical Electricity, 29 Thornton — Dose-Book and Manual of Prescription-Writing, . 30 Van Valzah and Nisbet— Diseases of the Stomach, 3° BOOKS JUST ISSUED. THE AMERICAN ILLUSTRATED MEDICAL DICTIONARY. For Students and Practitioners. A Complete Dictionary of the Terms used in Medi- cine and tlie Allied Sciences, with a large number of Valuable Tables and Numerous Handsome Illustrations. Edited by W. A. Newman Borland, M. D., Editor of the American Pocket Medical Dictionary. Handsome large octavo, 8oo pages, bound in full limp leather, and printed on thin paper of the finest quality, forming a handy volume, only I '4.' inches thick. This is an entirely new and unique work, intended to meet the need of practitioners and students for a complete, up-to-date dictionary of moderate price. The book is designed to furnish a maximum amount of matter in a minimum space and at the lowest possible cost. It contains double the material in the ordinary students' dictionary, and yet, by the use of a clear, condensed type and thin paper of the finest quality, is only i'/{ inches in thickness. It is bound in full flexible leather, and is just the kind of a book that a man will want to keep on his desk for constant reference. The book makes a special feature of the newer words, and defines hundreds of important terms not to be found in any other dictionary. It is especially full in the matter of tables, containing more than a hundred of great practical value. A new feature is the inclusion of numerous handsome illustrations, many of them in colors, drawn and engraved specially for this book. These have been chosen with great care and add infinitely to the value of the work. The book will appeal to both practitioners and students, since, besides a complete vocabulary, it gives to the more important subjects extended consideration of an encyclopedic character. BOHM, DAVIDOFF, AND HUBER'S HISTOLOGY. A Text=Book of Human Histology. Including Microscopic Technic. By Dr. A. A. BiiHM and Dr. M. von Davidoff, of Munich, and G. C. Huber, M. D., Junior Professor of Anatomy and Histology, University of Michigan. FRIEDRICH AND CURTIS ON THE NOSE, THROAT, AND EAR. Rhinology, Laryngology, and Otology in their Relations to General Medicine. By Dr. E. P. Friedrich, of the University of Leipsig. Edited by H. HoLisROOK CuR'iis, M. D., Consulting Surgeon to the New York Nose and Throat Hospital. LEROY'S HISTOLOGY. The Essentials of Histology. By l.ouis Lerov, M.D., Professor of Histology and Pathology, Vanderbilt University, Nashville, Tennessee. OQDEN ON THE URINE. Clinical Examination of the Urine. By J. Bergen Ogden, M. D., Assistant in Chemistry, Harvard Medical School. Handsome octavo volume of over 408 pages, with 54 illustrations and 1 1 full-page plates, many in colors. PYLE'S PERSONAL HYGIENE. A Manual of Personal Hygiene. Edited by Walter L. Pyle, M. D., Assist- ant Surgeon to Wills Eye Hospital, Philadelphia. Octavo volume of 344 pages, fully illustrated. SALINGER AND KALTEYER'S MODERN MEDICINE. Modern Medicine. By Julius L. SAT.ixr.ER, M. D., Demonstrator of Clinical Medicine, Jefferson Medical College, and F. J. Kaltkyer, M. D., Assistant Demon- strator of Clinical Medicine, Jefferson Medical College. Handsome octavo volume of over 800 pages, fully illustrated. STONEY'S SURGICAL TECHNIC FOR NURSES. Surgical Technic for Nurses. By Emily A. M. Stoney, late Superintendent of tlie Training-School for Nurses, Carney Hospital, South Boston, Massachusetts. I