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greatly interferes with speaking and with eating. It frequently happens that while destruction is going on in one part of the nose, cicatrization is taking place in another. Occasionally the dis- eased bone, instead of becoming necrotic, becomes dense and eburnated, and acts as an obstruction. The excruciating pain that is sometimes com- plained of in syphilitic affections of the nose, is usually due to the involvement of one of the large nerves that pass through the numerous foramina in the nose. Rarely it is due to the extension of the syphilitic process to the meninges. A typical syphilitic ulcer in the nose can scarcely be mistaken. It is cup-shaped, the sur- face is covered with a thick, firmly attached crust, and its edges are elevated and undermined. In some instances the destructive process appears to be self-limited, and, after a certain amount of tissue has been destroyed, repair begins. In other cases there appears to be no limit to the destruc- tion. As soon as denudation, and consequent necro- sis, takes place, there occurs that unmistakable and disagreeable odor known as syphilitic ozena ; a smell like that of crushed bedbugs, that clings to the patient, and appears to saturate his buy topamax online without script very clothing. In this disease, as in most other forms of chronic rhinitis, migraine prescription topamax the bad smell is seldom apparent to the patient, or at least not in the same degree as to those about him. This is partly because he has insensibly grown accustomed to the odor, and partly owing to the impaired sensibility of the olfactory membrane. Decomposition and crust formation are present in all forms of intranasal ulceration, and the fetor that accompanies de- struction of bone is as constantly present in topamax mg for weight loss sim- ple forms of atrophic rhinitis, in which the de- struction is molecular, as in syphilis, in which it is cii iiiassc. The discharge of offensive crusts, mixed with blood and pus, from the nose is char- acteristic of a syphilitic ulcer. Often the dis- charge contains pieces of foul-smelling bone that have a worm-eaten appearance, the dislodgment of which may produce severe, and even dangerous hemorrhage. After the activity of the syphilitic process has abated and the lesions have healed, the formation of dense scar tissue takes place. Except a deep burn, no lesion is followed by greater cicatricial contraction than a deep syphili- tic ulcer. The scars have the same radiate appearance of syphilitic scars elsewhere, being dense, glistening, and tense. Where the destruc- tion is extensive, the resulting contraction may be so great as to lead to troublesome stenosis and marked deformity. The most noticeable sequence of syphilitic in- tranasal ulceration is the repulsive and highly disfiguring flattening known as saddle-back nose. The practically incurable nature of this deformity, and the insidious manner of its development, makes the timely treatment of all syphilitic affec- tions of the nose a matter of the greatest impor- tance. Syphilitic nasal deformities are of three kinds: Those in which the septum is destroyed and the nose is sunken ; do i need a prescription for topamax those in which some part of the external nose is destroyed, and those in which both the former and latter conditions are combined. Unusual deformities are those in which the lateral walls, as well as the septum, are destroyed, so that the nose is completely flattened and its profile is not seen above the face. In extreme destruction there is order topamax canada atrophy of the soft parts, and the tip of the nose is turned up and greatly reduced in size, giving the face an ape- like appearance. The treatment of syphilitic affections of the nose is both local and general. The constitutional treatment is that of the disease in general, and continuous rather than intermittent medication is advised until the lesions are healed. Although the lesions are usually of the tertiary variety, in which potassium iodide is indicated, they are more promptly controlled by the mixed treat- ment. In my experience most lesions can be brought under perfect control by internal non prescription topamax medi- cation, but, in exceptional cases, hypodermic in- jections of mercur}', or inunctions of the same drug, are necessary to check the progress of the disease. Inunctions are particularly applicable in children, and they may be supplemented with the administration of the syrup get prescription topamax of the iodide of iron. Adults can begin with 5 grains of potassium iodide and 1-5 grain of the protoiodide of mer- cury after each meal, with plenty of milk, gradu- ally increasing the dose until the lesions have dis- appeared. Then the dose can be reduced and given intermittently. Just how long antisyphi- iitic medication should be given in order to con- fer immunity has not yet been determined, but it is wise to continue treatment for at least two years after the ulcers have healed. Local treat- ment consists in cleanliness, the removal of ne- crotic bone, stimulation of the ulcer, and preven- tion of adhesions and deformity. Few lesions are more amenable to medication Nov. lo, 1906] MEDICAL RECORD. 739 than those of syphilis, providing it is begun before the destructive changes are well under way. It is a good plan to give antisyphilitic remedies for all suspicious intranasal lesions, for buying topamax online not infre- quently a tumor or an ulcer, supposedly malig- nant or tuberculous, disappears entirely upon topamax generic price the administration of mixed treatment. No attempt should be made to correct a de- formity due to syphilis until the patient has been subjected to a course of medication covering a period of two years, otherwise the surgical pro- cedure may excite irritation and ulceration. A nasal deformity can be greatly improved by subcutaneous injections of paraffine. It is better to inject topamax generic availability a small amount at different sittings than to inject too much at one time, thus avoiding sloughing and other mishaps. Artificial bridges and supports have been tried and found wanting. For a perforated palate, a dental plate of hard rubber gives the most satisfaction. 304 Second Avenue. OBLITERATIVE ENDARTERITIS OF FE- MORAL DISTRIBUTION WITH GAN- topamax generic vs brand GRENE OF THE FEET. By EUGENE H. EISING, M.D.. NEW YORK. ADJUNCT SURGEON SYDENHAM HOSPITAL; SURGEON GOOD SAMARITAN DISPENSARY. Although Jaesche in 1865, and Burrow in 1867, had described cases of proliferative changes in the intima of arteries with subsequent oblitera- tion, it remained for Friedlander in 1876 to de- scribe the lesion and to recognize it as a patho- logical entity. Winiwater three years later added to the scanty literature upon this topic a 100 mg topamax detailed description of obliterative endarteritis with gan- grene of the feet. Since then there have been from time to time contributions in German, French, Russian, and English. I have failed to find any word in x\merican literature upon this_ subject. If the last had been said, and this par- ticular chapter of disease had thereby been closed, any attempt to add a word would be futile. The conditions, however, are not such ; nowhere in the topamax 50mg and weight loss realm of medical science are the etiological factors more obscure. The condition is not recognized as a clinical entity; the textbooks barely give it recognition, and much confusion reigns in cases thus far reported. Obliterative endarterial changes in the femoral distribution present a symptom complex and clin- ical picture truly distinctive, and quite as charac- teristic as similar changes occurring in the brain. The disease is slow in topamax generic weight loss progress, terminating in gangrene of distal parts, and is usually confused with Raynaud's Disease and erythronielagia. The importance of the intima in physiological and pathological need prescription topamax processes must be distinctly recog- nized. The prime function of an artery is to maintain a patent channel for the blood stream, and this depends upon the integrity of the intima. Physiological obliteration of blood-vessels as oc- curs in obsolete channels, such as the ductus ar- teriosus and the umbilical vessels, is accomplished almost entirely by a proliferation of the endothe- lium of the intima. .A similar process occurs in the pro.ximal ends of arteries following amputa- tions. Under pathological conditions we recog- nize primary changes in arteries occurring in the intima. The only primary change in the middle coat is simple degeneration — calcification. Pri- mary change does not occur in the adventitia. The intima is, in fact, the essential part of an artery; the middle and adventitious coats are mechanical necessities enabling it to fulfill its function. The endothelium of the intima re- sponds to irritation similarly to endothelium else-* where, resulting in proliferation topamax order of new cells. Owing to the resistant elastic lamina of the mid- dle and outer coats, proliferation is directed cen- tripetally, and, in consequence, the lumen of the vessel is encroached upon. According to Foster, the blood flowing through the blood-vessels is in a state of unstable equilibrium, which may at any moment be upset with clotting as a result. It would seem that the altered relationship between diseased intima and blood, or rather between dis- eased intima and fibrin ferment, maintains the fluidity of the blood in a less topamax generic brand stable state. Endo- thelial proliferation may be only fairly advanced in an artery of the dimensions of the femoral or popliteal, the lumen of which may be entirely topamax order online choked by a canalized fibrin thrombus. The thrombus can be dragged out for some inches through the cut end of the vessel. The canaliza- tion may not be sufficiently large to admit the passage of a straw. This variety of thrombus is the result of a concentric lamellation of fibrin upon the inner coat of an artery. The thrombus is long and tubular, and topamax 100 mg weight loss is not firmly adherent to the vessel wall. It receives no nutrient vessels from the wall of the artery. Endarterial oblitera- tion, as described, is therefore the result of the combined action of a slow neoplastic agency oc- curring in the intima, together with thrombus for- mation by fibrin deposit. The disease under dis- cussion is characterized by the slow lamellar thrombotic process, and corresponds to the slow advances of the clinical phenomena. During the course of the disease, however, thrombosis by clot may supervene and invite a more acute gangre- nous process. I have the good fortune of retaining under ob- servation one instance of this disease for a period covering five years, and of a second for a much shorter time. Case I. — I. G., large florid male, Russian Jew, age forty-two years. Peddler by occupation. De- nies any acquired or inherited specific taint. Uses alcohol and tobacco moderately. Attributes pres- ent condition to no known cause, other than to climatic exposure. Seven years ago began to have pain in left foot and toes. Pain was of burning character, and was nearly constant. There were occasional anginal attacks in the muscles of the leg. Pain was not aggravated by moderate pres-

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