/ Oct. 13, 1906. / THE HOSPITAL. 29

Hospital Clinics.

CLINICAL LECTURE ON DISEASES OF THE . Andrew By Wylie, M.D.(Glas.), Assistant Surgeon Central London and Hospital. The following interesting lecture was specially dition is called ' sicca, and is usually reported for The Hospital, and illustrates the associated with nasal disease. practical character of the teaching given to In treating this condition, if gout, anaemia, dys- graduates seeking instruction at this special centre pepsia, hepatic disease are present, these should be of graduate teaching in London. attended to. A course of saline water is usually re- The most common diseases the general practi- commended at some natural spring. In this country tioner has to treat are those belonging to the there are many good mineral springs, as at Buxton, pharynx. Many troubles and affections, including Bath, and Strathpeffer. The wonderful success of colds, , , rheumatism, scarlet- the fashionable continental springs is not due to fever, diphtheria, typhoid fever, and begin any great virtue in the waters, but to the thorough with an amount of discomfort to the pharynx way in which the treatment is carried out by On the other hand, severe maladies like tubercu- patients and doctors at these places. Besides the losis, lupus, syphilis, epithelioma, and the simpler mineral springs at Aix-les-Bains or Homburg, a growths?papilloma, fibroma, and polypi?are very thorough system of local treatment is recom- common in the pharyngeal region. mended. Mild astringents like potassium chlorate Pharyngeal disease is frequently a sequence of or sodium bicarbonate, or, in more severe or granu- occupation, and is found among miners, masons, lar cases, painting the pharynx with sulphate of motorists, vocalists, and public speakers. zinc (20 grains to the ounce), perchloride of iron, or Mandl's solution 10 to 1 Local Diseases. (iodine grains glycerine oz.) must be resorted to. If large granular fol- Acute catarrhal is a common 'pharyngitis very licles are present they can be treated the disease. The are soreness on quickly by symptoms galvano-cautery. Vocalists, and other and the membrane of clergymen, general malaise; lining the public speakers should be taught how to rest the pharynx, the , and also the nares, becomes red voice and use it properly. and inflamed. in forms. It manifests itself various A fourth condition is acute , usually caused a when (?) Idiopathic, by chill; (b) diathetic, caused by changeable weather. It appears most due to or from gout rheumatism; (c) toxic, drugs, commonly in the hot season of the year, when there as and or infectious a mercury potassium iodide, is sudden change of temperature. In many cases fevers like measles and scarlet-fever; (cl) traumatic, of this disease the Klebs-Loeffler bacillus is present, from or hot fluids irritating vapours. and such cases at first should be treated as diph- Acute inflammation of the or theria until the is In " septic pharynx, contrary diagnosis proved. hospital sore throat," is another manifestation lacunar tonsillitis the of the of local mischief. The symptoms are general becomes inflamed, with patches of yellowish malaise, rigor, rise of temperature, pain and diffi- exudation from the crypts. Soon the deeper tissues culty in swallowing. The mucous membrane be- are involved and the swelling of the tonsil becomes comes hypersemic, swollen, and oedematous, and very severe. This condition is termed parenchy- these conditions, extending to the submucous matous tonsillitis. When the connective tissue in tissues, give rise to suppuration. Some cases may front and above the tonsil becomes inflamed the spread rapidly until suppurative cellulitis ensues, term peritonsillitis is applied, and when suppura- extending to the and and ending tion takes place a is the result. fatally. The symptoms depend on the degree of inflam- In order to treat this condition effectively the mation. It commences with pain in the throat, patients must be fed as well as possible, iron and aching of the limbs, and a feeling of malaise, a strychnine administered internally, and local anti- slight rigor, rise of temperature, constipation, and septic soothing solutions employed as a -wash. a coated . Often a slight erythematous rash the A third local disease is chronic pharyngitis, appears on the surface of the body, resembling a few which may be the result of (a) simple catarrh; scarlet-fever rash. This is fairly common (?) nasal obstruction; (c) fevers; (d) gouty dia- days after the operation of tonsillotomy, and if not such a condition thesis; (e) exposure to dust or irritating fumes; the surgeon is familiar with (/) excessive use of tobacco or alcohol; (g) dyspepsia, considerable anxiety often ensues. I have known the constipation, portal congestion; (li) anaemia; (?) neu- several cases of children with a slight rash after rotic temperament in females. removal of tonsils being diagnosed as having con- In this condition the complains of weak- tracted scarlet-fever, and I remember one such case patient When ness and discomfort and a dragging sensation in the which was removed to an isolation hospital. " there is con- , with the continual up of the inflammation of the tonsil extends hawking" in . The voice gets tired and an irritable cough siderable pain in the and great difficulty become in- ensues. The mucous membrane is in some cases swallowing. The sub-maxillary glands and and the follicles fected, and the saliva is profusely secreted congested lymph hypertrophied; inflamma- in other cases it is and and there is allowed to flow from the mouth. This dry pale-looking forms a latter con- to the tissue, a diminution of lymph follicles. This tion, extending peritonsillar 30 THE HOSPITAL. Oct. 13, 1906.

large smooth swelling in front of the tonsil. If adult, wliere the haemorrhage is often troublesome fluctuation is elicited, pus is present, and should after using a tonsillotome, I use a wire ecraseur foe removed at once. The usual way is to anaesthe- or take the tonsil out piecemeal by means of punch- tise the swelling with a 10-per-cent. solution of forceps. Severe haemoiTliage after tonsillotomy is cocaine. Use a guarded knife?that is, a knife rare, but slight haemorrhage is common. It with no long blade which might injure the tongue usually comes on several hours after the operation, ?or if the patient moved, but one with a point and is due to: (a) An abnormality of the blood- only. The point of incision is well above the tonsil, vessels, (b) haemophilia, (c) a small piece half cut and should be made in the lateral direction, nearly through and left, (d) excessive retching and vomit- at the level of the base of the uvula. One free in- ing. If severe, the bleeding point must be caught cision should be made, and the wound subsequently by -forceps or touched with the galvano- opened up with a pair of sinus forceps, this ensuring cautery; but as a general rule ice to suck and com- free exit of the pus and subsequent drainage. plete rest curtails it. Various knives and instruments may be employed Hccmorrhages occur from the pharynx from a is for this operation; very ingenious appliance several causes, upon which the treatment depends. ?composed of a spring which, when pressed, reveals The causes are (a) general debility from albumi- a concealed knife for the incision and dilatation nuria, diabetes, and fevers; (b) acute inflamma- of the wound. The drawback is it cannot readily tions; (c) ulcerations, as tubercular, malignant, foe taken to pieces for sterilising purposes. and specific; (d) after excessive mercurial treat- acute tonsillitis is not The treatment of very ment ; (e) enlarged varicose or hepatic is in complicated. Sodium salicylate given fairly disease; (/) traumatic, from a needle, pin, gun- three with to iv. large doses every hours, gr. ij. gr. shot wound, or, as in a case I saw lately, where a be with The fauces should painted guaiacum and man fell on the point of his umbrella and it entered gargled with potassium chlorate or with a carbolic his pharynx. acid solution. Small pieces of ice are given to suck, Retro-pharyngeal abscess is another local disease and the strength maintained by beef-tea, milk, and of the pharynx, although it is usually associated soon as the brandy. As acute symptoms begin to with a general strumous condition, chiefly seen in of iron in doses is re- disappear perchloride large young children. It may simply be a swelling and commended. suppuration of the cellular tissue on the posterior I do not advise removal of or inflamed tonsils, for pharyngeal wall, it may be due to caries, generally the general health being lowered and the tonsil tubercular, of the upper . The is probably suppurating, it inadvisable to form any symptoms are difficulty in respiration, causing a extensive raw surface. croupy sound and slight dyspnoea. The be- Chronic enlargement of the tonsil is often the comes fixed, there is swelling of the glands at the result of acute repeated attacks, occurring in angle of the , and pain when pressing on the strumous children or amongst people inhabiting head. On examination a bulging is seen on the -damp houses or moist districts. posterior surface, and often fluctuation will be felt in the The patient trouble is subject to acute or with the finger. The treatment is to evacuate the ?sub-acute attacks of tonsillitis. Enlargement of pus. An incision is made into the most prominent the tonsils causes in difficulty . part with a guarded knife. Immediately the knife " growths are usually present in the naso-pharynx. is withdrawn the child should be turned upside The tonsil be and the lingual may enlarged, patient down," with the head low, to keep the pus from breathes the mouth generally through and snores running into the larynx or oesophagus. I had a case at The becomes night. hearing affected, the voice lately, in a young girl aged twenty-one, which I "becomes altered, and the difficulty in breathing from the posterior border of the sterno- in opened interferes?especially children?with the de- mastoid and with made an " muscle, forceps opening of the chest, and what is called into the wall of the velopment" pigeon posterior pharynx. (Lancet, a common result. The is patient grows April 14, 1906.) as well as up weak mentally bodily. The tonsil Simple and malignant growths are common in the but before that time as may atrophy, comes, I have pharynx and on the tonsils. The usual ones are the child's health has explained, become impaired. papilloma, adenoma, fibroma, and polypi hanging The simple operation of removing the tonsils from the naso-pharynx. obviates all these consequences. The treatment indicates the removal of the tonsils General Diseases. and adenoid whenever are growths they present. General diseases of the pharynx include diph- The at the Central London plan adopted Hospital theria, syphilis, tuberculosis, malignant disease, is admirable. The anaesthetic adminis- generally mycosis, lupus, sensory and motor neuroses. tered is chloride of ethyl, which gives the surgeon more time than nitrous oxide gas: it gives a Diphtheria. anaesthesia for a few but ether thorough minutes; Diphtheria as a disease was described by or nitrous oxide and ether are excellent in this posi- physicians in the second century, but it was and on several occasions I have had chloro- tion, not until 1821 that any definite written state- form with no bad effect. Different given surgeons ment it was found. The disease pre- different tonsillotomies. I concerning prefer prefer Heath's, vails in every and town, but more so in taken to to be cleaned. In country which is easily pieces country districts and in dry weather. It attacks some where the tonsil is or in an cases, very large, children, chiefly from one to five years old, but may Oct. 13, 1906, THE HOSP17AL. 31

rare at a serum must at once be There is no excuse affect any age. Diphtheria is fortunately injected. tliroat hospital clinic. General practitioners en- for delay; 2,000 units should be injected at once. If case this counter most cases of diphtheria. It is a general the turns out not to be true diphtheria, disease with distinct local manifestations in any injection will have done no harm. On the other mucous membrane, but usually manifest in the hand, the injection has, in many cases, done good even in a follicular but fauces, sometimes in the or larynx. Diph- simple tonsillitis, especially theria is due to a distinct bacillus called the Klebs- in the sore throat of scarlet fever. Within the first Loeffler. An inflammation of the throat where the twenty-four hours of the disease 2,000 to 3,000 bacillus is found is diphtheria, but, on the other units repeated may be enough, but if the disease is not at once the antitoxin treatment hand, the bacillus may be found in many diagnosed mem- must be to units where there are no signs of inflammation or pushed?8,000 10,000 repeated. It is better to an overdose than too small a dose. brane, and thesfe are not described as diphtheria. give The syringe should be made so that all parts can Symptoms. be sterilised. There should be no tubing between better fixed The disease often resembles acute lacunar ton- the syringe and the needle; the latter is direct to the which should hold units sillitis, and, if the membrane is in patches, it re- syringe, 8,000 at the sembles acute follicular tonsillitis. The diagnosis least. The abdominal is most convenient for the over depends on the bacteriological examination and place injection; the to be should be well washed several prominent symptoms of diphtheria, say point punctured and causes prostration and drowsiness?a symptom which is rendered aseptic. The injection prac- not often referred to in text-books. tically no pain, and there should be no abscess or irritation afterwards if details are attended The disease is ushered in by a slight chill and sore aseptic to. Vernot and state that the sooner the throat; the temperature is never very high, and may Behring antitoxin is even be normal; the pulse weak, and the ensuing administered the less paralysis super- prostration severe. These general symptoms ad- venes, though other writers state that serum vance quickly, and the prognosis depends greatly on treatment has increased the amount of post-diph- theritic the degree of prostration. The local symptoms are, paralysis. first, a soreness in swallowing and symptoms of acute The explanation really is that those cases which pharyngitis; the glands at the angle of the lower live to develop the lesions after being cured the antitoxin would have and jaw swell, and in a few days patches appear on the by probably died been lost to or tonsils and uvula. These are thin and translucent sight statistics if antitoxin had not been at first, but become united to form the character- administered. istic false membrane The point to be is the adminis- covering emphasised early" " tough, greyish-white tration of the uvula, soft , tonsils, and pharyngeal antitoxin. Do not wait for swabs to be sent to a and on. walls. This is a true diphtheritic membrane, firmly taken, pathologist reported units of antitoxin in fixed to the fauces. If it is scraped off, a bleeding Inject 3,000 every suspected surface results. case. If it is only a tonsillitis or scarlet-fever sore Diagnosis. throat it will do no harm; in fact, several clinical observers have declared it has done and I throats be confused with fol- good, Diphtheritic may (1) know of several medical men who a small dose licular scarlet fever before the rash inject tonsillitis; (2) into scarlet fever case. enteric every appears; (3) erysipelas of the fauces; (4) The the which is often ushered in early injection prevents diphtheritic fever, by tonsillitis; toxin from with the cells. When sore throats. In doubt combining body (5) ; (6) septic any once combination with the tissues has occurred, fcbe treatment remains identical in case. every large doses of antitoxin do not have the same power. and are the chief to Complications sequelae things The dose of antitoxin will keep more of the poison These are stated as follows: fight against. briefly from absorbed, but the amount of poison both the disease and after- being (1) Prostration, during absorbed must run its course and do its due to of already wards, absorption septic poison. amount of mischief. Early administration, there- Cardiac failure is one of the most fatal (2) complica- fore, will act as an antidote; later administration tions. occur or and (3) Paralysis may early later, only as a remedy. is a common result. The muscles of the soft In nasal and laryngeal diphtheria the injection are most it loses its palate commonly affected; should be administered even earlier. power of sensation and movement, and liquids Diphtheria, therefore, if suspected, should have the nose. The often regurgitate through paralysis 2,000 units at once; next day, if still sus- affects the the injected legs, the arms, the ocular muscles, picious, 4,000 units; the third day 6,000 units, and abductor and even the dia- laryngeal muscles, even a second dose; on the fourth day, 8,000 to phragm. (4) Inflammation of the (otitis 10,000 units, and repeated in six hours. If there is a common and Albu- media) occurrence, (5) is no result after this then the diphtheritic poison minuria and are pneumonia well-known complica- has well absorbed; and in that case I would tions. got advise intravenous injection of antitoxin. The Treatment. As regards local treatment, douching the nose The treatment is definite on the first real sus- and throat with a solution of boracic acid or very picion of diphtheria. The1 suspicion is increased weak carbolic lotion is most soothing to the patient. by the occurrence of sore throat in places where A little powdered orthoform and resorcin blown on diphtheria has been known to exist. Antitoxin to the pharynx alleviates the acute symptoms. The

L 32 THE HOSPITAL. Oct. 13, 1906.

general health must be attended to. Wine, may occur without the patient's knowledge. brandy, beef-tea, milk, and stimulating foods must It is, therefore, highly important to diagnose a case be literally poured into the patient to overcome the of gumma of the pharynx early. The is acute prostration and to ward off paralysis. usually the part affected, and the first sign may be merely a want of movement. Careful examination Syphilis. with the post-pharyngeal mirror shows an injected as if would soon break Inherited Syphilis in the pharynx appears boggy mass, which, undetected, secondary and tertiary lesions. Usually Hutchin- down and lead to a perforation difficult to heal and son's teeth and keratitis are present, singly or to- causing great discomfort on speaking. gether. A primary sore is rare in the pharynx, In tertiary syphilis the treatment is potassium but has been found on the tonsil. As a rule iodide, beginning with small doses of gr. 10 and in- it is not diagnosed as syphilis until the secondaries creasing the dose to gr. 20, 30, 40, and even 50., unless result. appear. A case came to this hospital a few great depression and prostration can take doses of years ago with secondary syphilis due to in- Many patients large potassium fected instruments (Lancet, 1902). Secondary iodide without any bad results when small doses syphilis of the pharynx is as a rule easily diagnosed. would cause severe coryza, eruptions, and depres- There is a bright reddish symmetrical hyperemia, sion. It is a good plan to add liquor liydrargyri per- well confined to the soft palate. Bluish-white patches chloridi in one-drachm doses to the potassium iodide appear on the tonsils, faucial pillars, pharynx, , and aromatic spirits of ammonia. A good prescrip- and These patches are nearly always bilateral tion is: lips. " and called Hutchinson The Dutch symmetrical, by Potass, iodid gr. xv. garden symmetry." Other symptoms of syphilis Liq. hydrarg. perchlor dr. i. arom. are such as the rose-coloured spots on the Spir. amm. dr. i. present, Infus. dr. chest and abdomen. It is differentiated from quass ? diph- Aqua ad Jj. theria and septic sore throat by the pain being absent or else very slight. In using potassium iodide or mercury it is most In treating it, push mercury until salivation important to wash the mouth with potassium threatens, then diminish it or stop it for a few days chlorate and thoroughly clean the teeth. every fortnight, and continue it again. The best Other forms of treatment are: (a) The Inunction form is a pill made of hydrarg. cum creta gr. ij. three of unguent, hydrarg., about ^ to 1 drachm, times a day, and to obviate any intestinal trouble rubbed into the axilla or groin every night. (b) Hy- a small quantity of Dover's powder should be added. podermic injections of mercury. I have found the If the case has not been under treatment for some hydrarge benzol most efficacious, no abscess forming time it is often best to give the liquor hydrargyri per- at the seat of injection. The treatment of syphilis chloridi in one-drachm combined doses, with potas- must be continued long after the patient is ap- sium iodide gr. x. The throat should be gargled parently well, or else sooner or later other manifes- borax and with potass, chlorate, the teeth and gums tations of the disease will appear, not perhaps in washed few carefully every hours, and the general the pharynx, but in other organs of the body. health attended to. Tertiary lesions are often found A rule is set down in text-books that after two in the in the pharynx, especially soft palate. They years' treatment a patient is cured, may marry, and come on without or pain discomfort, and continue have healthy children. A discussion is going on until deep ulceration and loss of tissue result. at present proving, I think correctly, that syphilis lesions are Tertiary very rapid, and extensive de- is transmitted to the offspring even after two years' struction of the soft structures and necrosis of the treatment.