tion. There was a diffuse infiltration in the mucous membrane of the septum; the surface was smooth. As the result of the swelling in the middle of the right lateral wall of the nose there was a horizontal furrow, which at first sight looked like a deviation, while on the left side the hypertrophy was uniform. The mucous membrane over the turbinates was slightly hyperemic. The spongy tissue of the inferior turbinate was tense and swollen, returning to normal on the application of cocain, showing that these parts were not as yet involved in the leprous infiltration. The vibrissæ were preserved, the epithelium intact except in a small spot about the size of a split pea, situated in the previously mentioned furrow in the septum, at the boundary between the cartilaginous and bony portions. This area presented the appearance of a superficial ulcer, with smooth edges, not raised above the level of the surrounding mucous membrane. The secretion of the nose was mucopurulent and moderately abundant in both halves of the nose; the right side showed a greater tendency to the formation of crusts than the left, but the secretions did not possess any other characteristics of ozena. Thus, while the appearances of the interior of the nose were comparatively unimportant and not at all characteristic, the postrhinoscopic image presented very conspicuous signs of the disease. Here there was also a diffuse infiltration of the mucous membrane of the septum and of the upper margin of the choanæ, but, in addition, there were elevations about the size of a pea, with broad bases. These elevations were spotted, of a shiny yellowish color, corresponding to the whitish coloration of the nasal mucous membrane described by Lima and de Mello. The process did not extend beyond the posterior nares.

The leprous nature of these alterations was abundantly proved by the finding of innumerable leprosy bacilli, partly in clumps, partly in chains, or in the form of leprosy cells; and even in sections taken from the extirpated mucous membrane of the septum bacilli were found in large numbers. Falling of the vibrissæ, which usually occurs late, was not observed in my case. There were no disturbances of sensibility in the nose. The sense of smell was somewhat impaired, although the patient himself did not observe it, and the examination with strongly odoriferous substances was difficult, as the man had lived in the primeval forests

since his sixth year, and was, therefore, unacquainted with the odors of any of them. In a series of 13 cases, Glück did not find much alteration in the sense of smell; the sensibility of the mucous membrane was reduced in 3 cases out of 6. Epistaxis is an almost constant early symptom of nasal leprosy, but in my case it had not occurred. As a rule, the mucous membranes are dry, and there is a tendency to crust formation, so that the picture of ozena is simulated. If the infiltration extends more deeply, and especially if it attacks the turbinated bones, obstruction of the nose and consequent interference with respiration result. The tendency of the nodes to break down is especially characteristic of the disease in the nasal mucous membrane, and in a short time ulcers develop in every part of the nasal cavity. As in the case of tuberculomata, septum perforations may be produced in the cartilage by the leprous infiltration. Lima and de Mello,1 who give an excellent description of nasal leprosy, emphasize the predilection of the nodes and ulcers for the turbinated bodies, "which may be atrophied and porous, or partly or totally destroyed, so that scarcely a trace of them remains (Glück). Defects have also been found in the other bones of the nasal skeleton, the vomer, the nasal bones, and the nasal spine; however, they are not to be regarded as due to leprosy, but rather as the expression of a disturbance in the nutrition of the mucous membrane leading to atrophy and caries of the bones.

In the pharynx leprosy affects principally the pillars of the fauces, the uvula, and to some extent the tonsils and the hard palate. Ulceration is said to be particularly apt to occur in the postnasal space. The fauces and the uvula become the seat of slightly elevated infiltrations, grayishwhite or bluish in appearance, which undergo ulceration and cicatrization and lead to the formation of adhesions, particularly of the uvula. Perforations of the hard palate are mentioned by Zwillinger and Läufer, although Glück finds no confirmation of the statement in the literature or in his own cases. It is somewhat remarkable that Bergmann frequently found the posterior laryngeal wall intact when the other parts were affected with leprosy, and this is confirmed by Glück, although the latter adds that he

1 Monatsch. f. prakt. Dermat.," vol. VI, 1887, No. 13 and 14.

often found characteristic changes in this structure when the alterations in the mouth and nose were quite inconsiderable.

In the larynx the epiglottis is the commonest and earliest seat of leprosy. "It becomes uniformly hypertrophied and studded with nodules, and presents a characteristic form and position, being markedly displaced backward and more or less compressed from side to side" (Bergengrün).1 "In severe grades of the disease the cartilage has a plump appearance; the lateral margins of the glottis are uniformly thickened where they merge into the aryepiglottic folds. In severer grades, where the uniform hypertrophy extends below the ventricular bands and involves the posterior laryngeal wall, the lumen becomes circular in outline; and, finally, in the severest grades the nodules on the thickened ventricular bands and the enormously hypertrophied posterior laryngeal wall reduce the lumen of the larynx to an orifice no larger than a lead-pencil, and completely obstruct the view of the deeper portions."2 Both the ventricular bands and the vocal cords participate in the nodule formation and in the general hypertrophy, and even the subglottic mucous membrane is often markedly thickened. As the result of these changes, the voice becomes rough and hoarse; in the later stages laryngeal stenosis makes its appearance, and sometimes during the night produces attacks of suffocation, so that the leprous wards are constantly filled with the blowing, gurgling, and whistling noises of the occupants (Bergengrün). "The flat and comparatively extensive ulcers which form in the infiltrated and nodular portions of the larynx show a marked tendency to undergo cicatrization, and, as a result, not only is the mucous membrane sometimes shrunken and deformed, but even the cartilages may be reduced in size" (Glück). The cartilages of the larynx are never attacked alone, but the perichondrium almost regularly shows marked infiltration, and the bacilli may invade the cartilage from above (Neisser and Glück). Little is known as to the sensibility of the diseased mucous membrane in the larynx and pharynx. A few observers refer to the ease with which a laryngeal examination can be made, and attribute it to anesthesia of the parts.

1 "Arch. f. Laryng.," vol. II.

2 Schrötter," Vorles. über Kehlkopf krankh.," 1892, p. 170.

In the external ear, characteristic changes, consisting in infiltration and nodule formation on the lobe, appear almost regularly in leprosy, but there is little mention in the literature of involvement of the organ of hearing. Extension of the leprous infiltration to the tubes may lead to tubular catarrh. Lima and de Mello 1 examined the ears of 48 lepers. They never found any alterations in the auditory meatus. In some cases the tympanic membrane was thickened, of a dull whitish color resembling “a fibrous plate," and "immovable during Valsalva's experiment." "There are adhesions in the wall of the tympanic cavity or between the ossicles." Other changes, consisting in anomalies of position and in convexity, are not leprous in charIn one case perforation of the tympanic membrane occurred; it was due to purulent otitis media.

acter.

3. MALLEUS HUMIDUS.

GLANDERS.

Glanders is a disease of domestic animals, usually transmitted to man by the horse. The infection is carried by the malleus bacillus, which is contained in the secretion of the ulcers, especially in the nose, and gains entrance to the human organism through the skin or mucous membranes. The mucous membranes of the upper air-passages always share in the morbid process and present the characteristic miliary nodules, which later undergo ulceration. The breaking-down of neighboring nodules results in the formation of large ulcers, the floors of which are covered with a foul, sanguineous secretion. The ulcers show a marked tendency to invade deeper structures and occasion great tissue destruction.

Clinically we distinguish a chronic and an acute form. Chronic nasal glanders, according to Koranyi,2 is ushered in by a feeling of fullness in the nose, a dry cold in the head, a feeling of heat in the throat, rough voice, cough, and, finally, by a mucous secretion, sparingly streaked with blood. Dry, blackish crusts are later expelled from the nose, and the mucous membrane underneath is seen to be swollen and ulcerated. Although the destructive process is slower than in the acute form, in the end the amount of

1 "Mon. f. prakt. Derm.," 1887, p. 650.

2 Nothnagel, vol. V. Part 5, p. 73.

tissue destroyed is quite as great. The acute form may occur either immediately after an infection or during the course of a chronic attack. It is accompanied by a cutaneous eruption, which spreads to the mucous membrane; often it reminds one of variola, appearing first in the form of red patches, which later are replaced by pustules (Koranyi). By extension of the ulcers which result from the breakingdown of the infiltrate large areas are destroyed; in the nose the septum becomes perforated, in the larynx the cartilaginous structure is destroyed. The voice is rough or hoarse as the result of erosion of the vocal cords; in the larynx the edema accompanying the ulceration sometimes leads to stenosis.

The disease attacks the nasal bones, and these, as well as the skin covering them, are destroyed. The accessory cavities of the nose are also involved. In Weichselbaum's 1 case masses of pus were found at the autopsy in the antrum of Highmore and in the frontal sinuses, and the mucous membrane was covered with numerous confluent yellow infiltrations. Occasionally, the disease attacks the cartilaginous orifices of the tubes. The prognosis of nasal glanders is fatal, both in the chronic and in the acute form, while in chronic glanders of the skin cicatrization of the ulcers and arrest of the malady have occasionally been observed.

4. FOOT-AND-MOUTH DISEASE. (THRUSH; STOMATITIS APHTHOSA EPIDEMICA.)

The mode of transmission of foot-and-mouth disease. from animal to man has been extensively investigated in recent years. Although the disease almost exclusively concerns the digestive tract, if we disregard the constitutional phenomena to which it gives rise, it deserves to be mentioned in this connection, as it has also occasionally been observed on the mucous membrane of the nose, of the pharynx, and of the larynx. Koranyi 2 has given us a detailed description of the disease; Siegel, in various papers, has reported an epidemic and the bacteriologic examinations which it occasioned, and his results, while attacked

1 Wien. med. Wochen.," 1885, No. 22.

2 Nothnagel's, "Spec. Path. u. Therap.," v, Part 5.