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Medical Societies.MEDICAL SOCIETY OF LONDON.

A MEETING of this Society was held at 11, Chandos-street, Cavendish-square, W., on Feb. 11th, Dr.HERBERT SPENCER being in the chair, when a dis-cussion was held on the

General Symptoms and Remote lJ;I anifestations of.Commoaa Affections of the Nasopharynx, the Nasal

Accessory Simlses, and the Throat.:1B11’. HERBERT TILLEY, in opening the discussion,

said that he would limit his remarks to conditions ofinflammatory origin, and largely restricted himselfto a demonstration by lantern-slides of the chiefpoints of interest in his communication. Diseases ofthe nasopharynx, he said, were largely the patho-logical conditions which affected the lymphoid tissueof the post-nasal space. The well-defined but

Ianatomically connected deposits of lymphoid or Iadenoid tissue grouped around the nasopharyngealand faucial regions, forming what was known as

Waldeyer’s ring comprised the lymphoid tissue of thenasopharynx, the palatine or faucial tonsils, and thelingual tonsils. Lymphatic vessels passed from eachof these to well-defined groups of cervical glands inthe anterior or posterior triangles of the neck. Therewere also, in children, up to the third or fourth year,two pairs of lymphatic glands between the posteriorwall of the pharynx and the anterior surface of thesecond and third cervical vertebrae. The commonform of retropharyngeal abscess was the result ofinflammation and suppuration in these glands.Histologically these lymphoid structures were essenti-ally identical, and pathological conditions were rarelylimited to any one of them. It was well-known thatthese aggregations were normal and well-definedstructures in the earlier years of childhood, and thatthey exhibited a marked tendency to involutionabout the age of puberty and during the period ofadolescence, but it was often forgotten that such achange might not take place, and consequentlypathological conditions of these lymphoid collectionswere not uncommon in adult life. Their functionscarcely came within the title of the discussion, buthad an important bearing upon it.Amongst other contributions the work of Kenelm

Digby, Good (Chicago), and Dudley (Medical ResearchCouncil) went far to prove that the phagocytes ofthe tonsils, Peyer’s patches and other sub-epithelialsolitary lymph glands were continually ingestingthe adjacent bacteria in the nasal and alimentarychannels, and thereby constantly producing a healthilyacquired immunity against various infections. Itwould be an extremely valuable piece of informationif the medical officers of fever hospitals could showwhat sort of response to infection has been made bypatients whose tonsils and adenoids had been com-pletely removed in comparison with those who stillpossessed a normal amount of those tissues.The lymphoid tonsillar deposits were well-developed

in children. Their reaction to infection, as well asthat of their associated cervical glands, suggestedthat they acted as protective structures in the firstand second " lines of defence " respectively. Atvarying periods of time after complete removal of thefaucial tonsils their recesses were occasionally seen tobe partially occupied by lymphoid tissue which hadgrown up from the adjacent lingual tonsils. These I

were not a recurrence, but simply a pushing up oftissue into that place. In other instances prominentlongitudinal deposits of a similar nature occupiedthe lateral walls of the pharynx. Quite recently hehad seen a boy, aged 10, who four years before hadhis adenoids removed and tonsils enucleated. Onthe posterior pharyngeal wall there were the largest"

granulations " of lymphoid tissue he had ever seen,

which were probably the cause of the chronic " dry

cough" from which relief was sought. Nature,apparently, had some very definite reason for placingsub-epithelial lymphatic tissue in those situations ;thus such structures should not be sacrificed withoutmore consideration than is often given to the questionof their removal. Whether the constituents ofWaldeyer’s ring furnished an internal secretion akinto those of the endocrine glands was a view at presentbased rather upon theoretical considerations than onclinical observation and experience.

I Effects of Inflammation.With regard to the evil results which may follow

when pathological conditions affect any one or moreof the constituents of the lymphatic ring, the chiefinterest centred around the effects produced byinflammation arising from infection by pathogenicor pyogenic organisms, or both. The most frequentresult, and especially after recurrent attacks ofinflammation, was that hypertrophy of the lymphoidtissue known as " adenoids and tonsils "—i.e.. theexistence of an abnormal amount of lymphoid tissuein the nasopharynx and in the recesses between thefaucial pillars. While hyperplasia was the usualresult of inflammation during childhood it was

important to bear in mind that pathological conditionsmight exist without hypertrophic changes, in whichcase the remoter manifestations were often moreprominent than the local evidences of disease. Suchconsiderations rendered it easier to answer the question." What do we mean by diseased tonsils and adenoids "The pathologist might hold that the Biere presence ofpurulent debris and micro-organisms in their cryptsand recesses was only an expression of physiologicalactivity, while epithelial abrasions and the existenceof polymorphonuclear leucocytes should be regardedas a surer sign of disease. The practical clinicianwould probably, and, he thought, rightly, maintainthat the question could be answered only by aninvestigation of the history of the symptoms and ofall the factors presented by the individual case.

Adenoids.It was a common experience to meet this affectionwithout a corresponding hypertrophy of the faucial

tonsils, but less frequent to find the latter conditionwithout some overgrowth of the nasopharyngeallymphoid tissue. The general symptoms caused byadenoids might be divided into three categoriesaccording to the most prominent type of symptomsproduced-viz. : (1) Those which indicate obstructionof the upper air passages ; (2) local or remote sym-ptoms of infection ; (1) disturbance of reflex origin.

The Throat.The commoner affections of the throat were due to

inflammation of the palatine or faucial tonsils. Thegeneral symptoms of the commoner types of acuteinflammation or tonsillitis were well known ; theirclinical manifestations were determined by the natureand virulence of the infecting organisms, their site ofentry, and the resisting power of the patient. Otherthings being equal, the local and constitutionalsymptoms would be more severe should the predomi-nating organism be a virulent type of streptococcusthan in the case of staphylococcal or pneumococcalinfection. The site of invasion had led to the recogni-tion of at least three types of acute tonsillitis : (1}lacunar tonsillitis, where the brunt of the inflammationaffects the crypts or lacunae (often spoken of as

" ulcerated sore throat ") ; (2) parenchymatoustonsillitis, in which the lymphoid follicles were acutelyinflamed ; (3) peritonsillitis or quinsy, where, whilethe tonsil was always inflamed, the characteristiclesion was inflammation and suppuration in thecellular tissues outside the capsule of the tonsilterminating in an abscess. This usually " pointed

"

in the soft palate above and to the outer side of thetonsil.

It was usual to recognise at least three types ofchronic inflammation-viz., (1) chronic lacunal’tonsillitis, where the crypts were filled with inflam-

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matory products and swarming with micro-organisms ;(2) hyperplasia of the lymphoid follicles, which

produced large, soft tonsils of varying size and shape ;(3) fibroid degeneration, in which connective tissuepreponderated at the expense of the lymphoid elements.

Tuberculosis of the Tonsils.As was the case in adenoids, tuberculosis of the

tonsils was not infrequent, being latent and exhibitingno clinical signs of its presence. Philip Mitchellstated that of 64 children with tuberculous glands inthe neck, 24 showed histological evidence of tuber-culosis of the tonsils. The remoter manifestations ofchronic tonsillitis were second only in importance toinfective conditions of the teeth. In addition toill-defined symptoms of impaired general health manydefinite and localised lesions had been proved to bedue to a focus of infection in the tonsils. Such wasthe case with respect to fibrositis, myositis, and chronicarthritis.

The Nasal Accessory Sinuses.These comprised the maxillary, ethmoid, frontal,

and sphenoidal sinuses. The most common affectionsof these air-cells resulted from invasion by infectiveorganisms, and the consequent inflammation assumedan acute, subacute, or chronic form. If the nasalaccessory sinuses were methodically investigatedduring the post-mortem examinations of all cases ofacute meningitis it would be found that a large numberwere the result of unsuspected infection from thesphenoidal and ethmoidal air-cells. Concerning theremoter manifestations of accessory sinus disease inadults it was his experience that gastric, pulmonary,and ocular symptoms are more frequent than cardiac,muscular, or arthritic complications. The constantswallowing or inhalation of septic matter is probablyresponsible for the first two. The pulmonary affec-tions referred to are chronic bronchial catarrh,bronchitis, and not infrequently asthma. In con-

sulting his physician for these complaints the patientoften made no mention of a previous " chronic nasalcatarrh," which only caused an inconvenience, becauseto him the pulmonary trouble is the real grievance.The great majority of chronic nasal catarrhs werereally muco-purulent discharges from the nasal sinuses,and the infective micro-organisms which caused themwould often be found.in the patient’s expectoration.Still more important was the fact that if the source ofinfection be removed its complications in the lowerair-passages would often disappear without anyspecial treatment.

Discussion.

The PRESIDENT expressed his appreciation of thecaution advised by Mr. Tilley ; in view of the tortuouscavities which had been so well illustrated upon thescreen, operation in these cases was very difficult, andtreatment of the conditions referred to should be leftto specialists..

Sir HUMPHRY RoLLESTON said that the problemsraised were on much the same lines as those in con-nexion with oral sepsis and formed part of the widerconception of focal infections. The common affectionsof the throat and naso-pharynx were especially proneto lead, by a process of direct spread, to disorders ofthe respiratory tract-laryngitis and bronchitis ; a

special form of this sequence of events was seen inpost-operative lung complications, which in the pastwere often explained as pulmonary embolism ; butaccording to Whipple. who called the conditionpneumonitis, were commonly due to pneumococcustype IV. As with the teeth, so with the infectionsin the naso-pharynx and adjacent parts, a distinctionbetween discharge into the alimentary canal on theone hand and into the lymphatic or blood-stream onthe other hand, seemed important ; the distinctionmust not, however, be pressed too far, for haemato-genous infection, especially of the gall-bladder,might occur in the abdominal viscera. Much inflam-matory disturbance of the tonsils, sinuses, &c.,might exist, for a time at any rate, without anyobvious general or remote manifestations. As in the

more acute fevers, there was an incubation period,sometimes lasting for years, during which the processof sensitisation of parts of the body apparently tookplace. But as a cause of the sudden outburst ofgeneral or remote manifestations in a previouslylatent case of such a kind, the occurrence of a secondaryinfection must be admitted ; and further, the chronicabsorption of toxic products might have sapped thepatient’s powers of resistance and prepared the wayfor the new infection. The conception of localsensitisation of tissues, for example, of the articularstructures, to toxins absorbed from the tonsils andsinuses was also of interest in connexion withRosenow’s view that bacteria have very specialaffinities for certain tissues, for example, strepto-cocci from the tonsils are prone to select the joints,muscles, and the gall-bladder. A female patient,who was having a streptococcic vaccine, had attacksof biliary colic which seemed to be definitely relatedto the vaccines ; the latter were stopped on the hypo-thesis that they set up cholecystitis in a sensitisedgall-bladder. This stoppage was followed by cessationof the biliary attacks, and for six months all seemedwell, but then the biliary attacks recurred andoperation revealed numerous small calculi in thegall-bladder. The vaccine might have set upcholecystic reaction and extrusion of the calculi, butthese alone might as a series of coincidences havecaused the colic. A difficult point concerned withsecondary or mixed infections of the throat was todistinguish between those which give rise torheumatism-namely, manifestations held in check,if not abolished, by efficient salicylate treatment-and those which, not being thus restrained, were morevirulent. Probably these conditions might occur

together, and then at the best only a temporaryimprovement followed salicylate.

Dr. JOHN POYNTON dwelt on the connexion betweentonsillitis and acute rheumatism. In 1900 he andDr. Paine had isolated a diplococcus from the mitraland aortic valves, of a case of heart disease, and hadby means of this organism produced experimentalrheumatic lesions. He looked upon the tonsils as afirst line of defence, which might, if damaged, becomea source of danger, in which case they must beremoved. Removal, however, could not be reliedupon to prevent further attacks of any particularcondition. There was difficulty in defining a healthytonsil, although much was known concerning infection.With regard to appendicitis, he had used a micro-coccus from a boy with rheumatoid arthritis toproduce experimental appendicitis, from which hehad recovered the organism used. He showed slidesillustrative of experimental appendicitis, pointing outhow the infective organisms were taken up by thelymph cells, which were there shown to be exercising adefensive function. He also referred to the frequencyof acute tonsillitis in leukaemia. He believed thatsome day the so-called blood diseases would berecognised as examples of abnormal reactions toforms of blood infection.

Sir STCLAIR THOMSON spoke of the extent of thesubject, remarking that one evening could easily bespent in discussing the remote manifestations ofinfections of tonsils and another to those of infections

, of adenoids. Nasal obstruction, catarrh, and inter-ference with breathing and swallowing were the chief

, symptoms handled by the specialist, and were there-, fore not included in the discussion. The specialist, could, however, suggest two points to assist the family; physician to recognise disease of the accessory sinuses :; (1) a bad smell from the nose, observed by the patientL (2) the presence of pus, whether appearing in the nasal discharge or in the post-nasal space. He uttered al warning against too active surgery in the cases underdiscussion ; it was advisable to operate " a froid,"- not " a chaud." He showed several slides of charts, illustrating the prolonged fever sometimes caused by- the presence of pus in the nose., Mr. W. M. 10LLISON said that there was scarcely7a disease for which the surgeon was not sometimes" asked to remove the tonsils ; he proposed to deal

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only with nephritis as a result of tonsillitis. Thesurgeon was usually called in after the first attack ofnephritis ; albuminuria and haematuria generallyincreased immediately after operation for removal oftonsils, but later they disappeared. A. A. Osmanhad found that at Guy’s Hospital, of a series of over60 cases of nephritis, 55 per cent. had begun withtonsillitis. He (Mr. Mollison) recalled a case of a girl,aged 26, who had had two attacks of acute nephritisfollowing acute tonsillitis. He had removed thetonsils, and heard two or three years after from thephysician in charge of the case that the patient hadhad no further attack of acute nephritis, and showeda very slight degree of albuminuria. In other caseshe had found albuminuria persist after removal oftonsils.

Dr. E. M. CALLENDER spoke of the pitfalls of thesubject from the general practitioner’s point of view.He agreed that Waldeyer’s ring constituted a firstline of defence against infection. He could rememberno child in his own practice who had had the naso-pharynx cleared and had thereafter shown moreliability to disease; if anything, he sometimesthought, these children were less liable to be infectedthan others. The general practitioner saw thebeginnings of disease, but those beginnings were

sometimes very difficult to recognise ; he instanced acase where he had been called to a girl who wasstated to be suffering from " a touch of sun," whopresented only an ordinary febrile condition, onlycomplained of a sore throat 24 hours later, anddeveloped a tonsillitis 24 hours later still. During thewar, in both England and France, he had been struckby the numbers of men with chronic otorrhoea ; thelatter seemed to go on all right with free drainage,but there was no free drainage in infections of theaccessory sinuses. The most frequent form of suchinfections was the common cold-preventable, hethought, if taken before the bacilli were buried in theinflamed mucous membrane. He divided colds intothose caused by B. catarrhal1.s and those caused by the

I

pneumococcus.Mr. E. D. D. DAVIS named many conditions for

which he had been asked to remove tonsils. Thetonsils, being specialised lymphatic glands, mustalways be examined before other less likely causes ofillness were considered. Experience had not con-

vinced him that colds were any less frequent aftertonsillar operations.

Dr. WILLIAM HILL recalled that in his student days,before the discovery of the Klebs-Lomer bacillus, hewas taught that albuminuria should be searched forin acute tonsillitis, and that if albuminuria was

present the case was probably diphtheria rather thanacute tonsillitis. He had found in his own experiencethat this idea would not fit in with facts.

Mr. TtLLBY briefly replied.

BRIGHTON AND SUSSEX MEDICO-CHIRURGICAL SOCIETY.

A MEETING of this Society was held on Feb. 7th,Dr. EL]IOT CunwEr, the President, being in thechair.

Prof. HUGH MAcLEAN read a paper on the

Prese7zt Positiori of Renal Disease and Albuminuria.He considered many of the older methods for testingthe efficiency of the kidneys were of very little value,and at the present date unnecessary. The urea-con-centration test-which is of a simple character, notepen5ive, and capable of being carried out by anygeneral practitioner in a few minutes-was the mostefficient and satisfactory. Albumin in the urine liedid not consider so serious a symptom as was formerlythought. A small portion of the kidney might bedisorganised, permitting the transudation of albumin,whilst the remainder was in a healthy condition andcapable of carrying on the full functions. Rest and

warmth are the chief lines of treatment. Washing outthe kidney with large draughts of water he did notconsider of much use as the kidney in the diseasedstate was incapable of excreting the water. Greatreduction of protein food was not only consideredunnecessary but in some cases harmful.—A vote ofthanks was proposed by Dr. E. F. MAYNARD, secondedby Dr. R. SANDERSON, and carried unanimously.

Dr. H. M. GALT showed microscopical slides of (1)injected kidney, (2) normal human kidney (stained),(3) kidney in advanced interstitial nephritis, (4) kidneyshowing early amyloid change.

ROYAL MEDICO-CHIRURGICAL SOCIETY OFGLASGOW.

A MEETijsre of this Society was held on Feb. 1st,with Dr. A. MAITLAND RAMSAY, the President, in thechair.

Dr. A. E. MILNER gave a communication on the

Treatmerzt of Lupus Vulgaris by the DiathermyCurrent.

After a brief description of the current and theform of apparatus used, Dr. Milner explained indetail the method he employed in the treatment oflupus vulgaris. The patient is placed on the con-denser couch and the diathermy current turned on.The operator approximates a well-earthed electrodeabout the thickness of a darning needle to a distanceof one-sixteenth of an inch from the part to betreated, when a succession of sparks passes from thepatient to the electrode. A general anaesthetic isessential, and, of course, the danger of ether in thepresence of sparks must be remembered. The areato be treated is first circumscribed by a ring ofsparks, leaving about one-eighth inch of healthy

i tissue around it, and is then systematically cauterisedover the entire surface. A dressing of calamine andbismuth cream is employed thereafter. A few casesare cured by one treatment, but usually two or threeare necessary. The resulting scar is surprisinglygood and scarcely noticeable. Should the scar beat all thick owing to previous treatment of the lupuswith other methods, the application of X rays iseffective. Dr. Milner had found that the mostfavourable case to treat was lupus vulgaiis simplex,and emphasised the necessity of ensuring that everydiseased part was accessible to the spark. He hadfound the results unsatisfactory in the cases wherethere was, in addition to the lupus, tuberculousdisease of the mucous membrane of the nose, mouth,or lacrymal apparatus, as reinfection of the woundalmost invariably took place.The analysis of cases treated, excluding all cases

in which the nasal or other mucous membranes wereaffected with lupus, was as follows : Total numberof cases treated, 60 ; cases cured, 42 ; total numberof operations performed on cases cured, 145 ; curedby one operation, 5 ; cured by two operations, 5 ;average number of operations on cases cured, 3-6 :average t’_me occupied in treatment of each case,3-4 months. Time since cure was effected : Over4 years, 1 case ; over 3 years, 13 cases ; over 2 years.6 cases ; under 2 years, 22 cases.

Dr. A. BRUCE MACLEAN described the results of thetreatment of a variety of cases by

ltledzcal Diathermy.He had found the best results in the following typesof case : (1) Fibrositis ; where definite nodules can befelt. These nodes were usually rendered painlessafter a few applications, and often disappeared in afew weeks. (2) Neuritic pains and neuralgias ;sciatica responded well to four to six treatments ofabout 40 minutes each. (3) Arthritis. Althoughlittle influence could be exerted on the disease, reliefof pain could nearly always be obtained. (4) Circu-latory disturbances ; particularly those in which a