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for we Buy Imipramine cannot afford to be ignorant of a single fact that may explain our cases. So also we must pos- sess hundreds of remedial agents, although nine- tenths of our work may be done with a score. But it is in the remaining tenth that we find the greatest pleasures of the practice of medicine, when by the exhibition of some definite active principle that has not been needed for years we meet an indication that has not presented in that Tofranil Uses period, but for which we have had the remedy waiting. I beg my readers to pardon me for the impor- tunity with which I beseech them to consider these truths. I cannot help it ; I do so want them to know of these exquisitely differentiated remedies that I cannot Generic Tofranil help being urgent. And, knowing these things so well, how important they are for the profession and for suffering humanity, when I find that one does not really know there is a difference between hyoscine and atropine I am ready to lie down and die. Habitual Constipation and Latent Inflammations of the Peritoneum. — R. Roniiiic declares tliat an individual who suffers from habitual constipation may have a latent and unrecognized lesion of the appendix, of the adnexa, of the gall-bladder, or of some other abdominal organ. The etiological role of habitual constipation in appendicitis is well known. Villard to a certain extent reverses the terms of this problem, and in place of considering constipation as an efficient cause of appendicitis he thinks rather that obstinate constipation is often the result of Tofranil Mg a latent appen- dicitis more or less unrecognized. — La Presse Medicale. Nov. 10, 1906] MEDICAL RECORD. 737 SYPHILIS OF THE NASAL Buy Imipramine Online FOSS^. By albert BARDES, M.D., NBW YORK. Tofranil Online LBCTURBR Tofranil 50 Mg ON DISEASES OF THE NOSE AMD THROAT AT THE NSW YORK POLYCLINIC MEDICAL SCHOOL; SURQEON AT THE NEW AUSTERDAU EYE AND BAR HOSPITAL. It is apparent to every physician who labors in the clinics of New York that syphilitic affections are becoming increasingly common, and in the opinion of many Buy Tofranil Online legislation will have to be re- sorted to in order to check the progress of this loathsome disease, the ravages of which are more pronounced in the nose than in any other organ. The tertiary lesions are those that the rhinolo- gist is usually called upon to treat, these pro- ducing the characteristic ulceration and necrosis that is so injurious to the functions of the nose, and so disfiguring to its shape. The primary le- sion—the chancre — is seldom seen in the nose, and when it does occur it is usually in the Tofranil Pm vesti- bule, which is accessible to infection by the finger nail. Secondary lesions are frequently seen in the nose, in the form of mucous and erythematous patches. They appear from two to twelve months after infection, in groups, being separated from the healthy surface by a distinct outline. These lesions are the most contagious in syphilis, more virulent even than the chancre itself. Physicians should bear this in mind, and patients should be apprised of it, so that the chances of infection may be minimized. Secretion obtained from sec- ondary lesions is capable of producing syphilis by inoculation, and the blood of an individual with secondary lesions is fatal to monkeys. The true tertiary lesions, the gumma and the ulcer, are neither contagious nor inoculable. What is re- garded Buy Cheap Tofranil as the specific organism of syphilis, the spirochete of Hoffmann, is constantly present in all secondary lesions, in primary sores, and in syphilitic new-born infants. It should be ob- served that in the tertiary stage there often occurs what appears to be a mucous patch. Closer exam- ination will show that it is in reality an ulcer. In the nose, secondary lesions are frequently overlooked on account of the mildness of the symptoms — merely those of a cold in the head — and it is not until patches are also seen in the throat that the true Tofranil Price condition is brought to light. Whenever a patient complains of symptoms of rhinitis, accompanied by loss of hair, nocturnal headaches, swelling of the glands of the neck, and other signs of syphilis, it is evident that the rhinitis is of syphilitic origin, .\mong young children syphilitic rhinitis occurs oftener Tofranil Cost than is generally believed, but in many instances the condition is not recognized until the destructive changes arc well under way and are irreparable. It differs from a simple rhinitis in that the symp- toms are severe and persistent, and show no signs of being self-limited. A child with this condition has that peculiar obstructed nasal respiration known as snuffles, which greatly interferes with its nursing, and the nose constantly secretes a watery mucus, which causes excoriations and sores about the orifices of the nose and mouth. The harsh, brassy cry of many of these infants is Order Tofranil an evidence that the larynx, too, has been in- vaded. The general appearance of a syphilitic infant is quite characteristic. The shrunken body, the pale, colorless, and mummified face, and other evidences of malnutrition, stand out glaringly. Inherited syphilis resembles the acquired form in its course and general manifestations, and fre- quently it remains quiescent until the patient has reached adolescence. In most instances syphilis in infants runs its course rapidly, destructive changes occurring, perhaps, from six to twelve months after infection. Fortunately, the repara- tive process in infants is such that the nose seldom becomes deformed through the ravages of the disease. In adults, the nose is the place of predilection for the destructive lesions, which appear from two to ten years after the chancre. Some ob- servers maintain that tertiary lesions are but relapses or recrudescences of secondary lesions, but their noncontagiousness and noninoculabil- ity oppose this view. In certain forms of syphilis, such as the malignant and the Asiatic, the disease passes through the cycle of changes with great rapidity, and destructive lesions may appear as early as six months after infection. Not infrequently the exciting cause of an intranasal lesion is traumatism, which stirs into activity a latent syphilitic process. Whether destruction of tissue takes place slowly or rapidly, syphilitic le- sions in the nose present certain distinguishing features that to the experienced eye are unmis- takable evidences of the disease. The gumma is the lesion that precedes all destructive changes in the nose, although it may assume a different form and run a different course in different individuals. The round tumor-like variety, so common in other parts of the body, is seldom seen in the nose, and when it does appear it is usually upon the septunt, resembling a deflection. A gumma in the nose is so well protected and free from irritating influences that it usually develops insidiously, and may not break down until the lapse of months and even years. Pathologically considered, a gumma consists of an Buy Tofranil infiltration of small, round cells or inflamma- tory corpuscles, involving soft as well as dense structure. A progressive gumma undergoes a number of changes before it disappears. First it becomes infiltrated, then it softens and degener- ates, then it ulcerates, and, lastly, it becomes firmly cicatrized. The points of predilection in the nose are the septum, the turbinates, and the nasal floor, in the order named. The gumma may start from the Tofranil Tablets surface, and secondarily invade the deeper parts, or else it may begin in the interior of the bone or cartilage, and break through the overlying structures. In the Purchase Tofranil Online nose more frequently than elsewhere a gumma breaks down, and de- struction occurs without the patient's knowledge, and often it is not until breathing is interfered with, or the odor becomes offensive, that the patient becomes aware of its Order Tofranil Online presence. A gumma in the nose resembles a carbuncle, being elevated, purple in color, and separated from the surround- ing surface by a distinct outline. Touched with the probe, it is firm and insensitive, later on be- coming soft and taking on a high color, like a maturing abscess. At this stage it pits upon pressure, is sensitive and vascular, and secretes a watery mucus. As soon as it has undergone complete degeneration, it disintegrates and be- comes an ulcer, and this ulcer enlarges until the entire infiltrated area is uncovered. Intranasal lesions, like the deep syphilodermata, are re- stricted and localized, adjacent parts not becom- ing involved until the already diseased area has first been destroyed. As said before, the most common site of an intranasal gumma is on the septum, and a lesion 738 MEDICAL RECORD. [Nov. lo, 1906 here is usually of a larger size than when it occurs elsewhere in the nose. The lesion usually starts in the bony septum and creeps forward until the cartilage is implicated and destroyed, eventually leaving a clean, round hole in the septum that looks as if it were punched out. A perforation in the lower part of the septum, involving either a part of the bone or cartilage, produces no de- formity. It is only when the entire cartilage, or else the supporting plate of bone is destroyed that the nasal arch loses its support and causes the nose to sink in. It is fortunate that the nasal arch resists destruction as well as it does, other- wise nasal deformity would occur more often. A lesion in the upper part of the nasal fossa is far more injurious than one in the lower, owin^' to the fact that an ulcer above is soon covered with a dense scab, which seals the surface and prevents the escape of the morbid secretion. This, in turn, attacks the deeper Purchase Tofranil parts and undermines the nasal skeleton. This does not occur in the lower part of the nose, owing to the facility with which foreign substances are washed away by the abundant supply of nasal mucus. Another favorite place for a gumma is upon the inferior turbinate bone. Such a lesion is difficult to detect, because it is usually situated well back in the nasal chamber, and resembles a turbinal hypertrophy. A lesion upon the turbinate is often accompanied by distressing symptoms. There is a severe nocturnal headache' and a 'dull, aching pain in the Cheap Tofranil side of the face that may last for months. As soon as the gumma breaks down, the pain and headache subside, and a purulent 'dis- charge makes its appearance. A syphilitic deposit upon the floor of the nose may exist for a long time without being detected. Frequently the first intimation that we have of a deposit in this region is a hard swelling upon the roof of the mouth, which soon breaks down and exposes to view a sequestrum of dead bone. This is soon detached and cast off, leaving a hole in the palate which

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