adenoid enlargement. On the other hand, it cannot be said conversely that enlargement of the pharyngeal tonsil is necessarily indicative of scrofula. But some of the symptoms formerly referred to scrofula are largely dependent upon the hypertrophy of the tonsil. The frequent attacks of nasal catarrh, the thick lips, the liability to purulent otitis, all formerly considered manifestations of scrofula, are the direct results of the pharyngeal hypertrophy.

LEPROSY.

221. Although this disease is but a rare curiosity in our part of the country, it invades the upper air-passages so often that a few diagnostic comments seem proper. It has been claimed recently by Sticker that lepra begins, as a rule, in the nose in the form of septum ulceration, and that this is one of its most persistent manifestations, all the more important because the nasal discharge contains the specific germs in abundance. The lesions in the nose and pharynx consist of follicles which coalesce and ulcerate. In the course of time a spontaneous healing takes place, resulting in smooth but extensive scars, sometimes with a good deal of shrinkage. The diagnosis is said to be fairly definite from local appearances, but depends mainly on the detection of the systemic disease.

222. Rhinoscleroma, or scleroma of the upper airpassages, is a disease which requires description in connection with the diagnosis of syphilitic and tubercular lesions. It is very rarely seen in this country, and only in emigrants, but is quite common among the poor in Poland and the eastern and southern provinces of Austria. It is a chronic, slowly progressive, incurable disease, which may not destroy life until at a very late period. The lesion consists of nodular infiltration, sometimes diffuse, sometimes circumscribed, often multiple. The nodule, of hard and variable size, sometimes as large as a bean, begins often in the skin of the external nose, and may extend through the upper lip. In other instances it commences in the pharynx. Gradually the process ex

tends throughout the entire air-passages, including the larynx and trachea. There is not much ulceration, but rather a superficial erosion, with very profuse purulent discharge, drying in the form of crusts. The disease is identical with the blennorrhea of the air-passages described by Stoerck. In the course of time the infiltrated mucous membrane shrinks, and the resulting extensive scars often lead to narrowing of the pharynx or larynx. Tracheotomy may become necessary in order to prolong life.

When the diagnosis cannot be made from the appearance, an excised fragment can be examined microscopically. It shows granulation tissue, with some typical large oval cells. In the tissues short bacilli are found in great abundance, which resemble closely the pneumobacillus of Friedländer or the bacillus mucosus of ozena. They are justly regarded as the cause of the disease. Scleroma cannot be influenced by any treatment.

CHAPTER XXVI.

AFFECTIONS OF THE UPPER AIR-PASSAGES IN THE COURSE OF OTHER DISEASES.

223. Measles.-This disease is characterized by congestion and irritation of the conjunctiva and the mucous membrane of the entire upper air-passages from the start before the cutaneous eruption appears. With good illumination miliary red spots can often be seen on the first or second day on the nasal mucous membrane, and still more distinctly on the soft palate and tonsils, as well as on the inside of the cheek. The diagnosis can thereby be made before the rash appears on the skin. In the milder cases the nasal and the throat lesions pass over without further complication. In cases of moderate severity a secondary coryza sets in, sometimes quite persistent. Tonsillitis is a relatively rare complication, but any exposure to diphtheria is very likely to lead to infection as a sequel to measles. Nasal hemorrhages are not uncommon before the rash appears. The nasal sinuses are probably involved often, but it is very rare that their affection is clinically evident.

224. Scarlet Fever.-It is very rare and seems to occur only in the mildest cases that scarlet fever is not ushered in by an eruption in the throat, especially on the soft palate. This is usually the first localized symptom of the disease. It consists of dusky red, more or less coalescing spots, the injection usually spreading over the tonsils, and to some extent over the posterior wall of the pharynx. Occasionally scarlatina begins with a distinct tonsillitis. In cases of moderate severity the eruption fades as the cutaneous rash disappears. In a large proportion of average and severe cases, how

ever, there is a secondary throat affection varying from superficial inflammation to formation of diphtheritic false membranes or even gangrenous sloughing. The corresponding lymph-glands are always swollen and tender. These throat lesions are mostly due to infection by streptococci. Scarlatinous diphtheria, however, is in some cases the result of secondary infection by the diphtheria bacillus. The diphtheritic affection, due to the streptococcus, does not show the tendency to extension found in true diphtheria. Extension to the larynx is not frequent. But from the start the more severe forms of throat affection, even those without false membranes, show a septic character and septic and pyemic sequels are not uncommon. Purulent involvement of the ear is likewise a very frequent sequel. The throat affection, if of any severity, may last two to three weeks. Treatment has but a moderate influence. Antiseptic gargles and sprays (thymol or the essential oil solution (see ¶ 25 and 134)) are of some service. The most active but disagreeable local application is Löffler's solution (¶ 25).

The nose is not involved as often in scarlet fever as the throat. The initial rash is said to be visible on the nasal mucous membrane in many instances. In a small proportion of the more severe cases a purulent, sometimes a membranous, rhinitis occurs as a sequel. Autopsies show that in fatal cases disease of the nasal accessory cavities is quite common, but clinically this is usually not recognizable.

225. Small-pox is sometimes ushered in by nasal hemorrhages. They are said to be of more serious prognostic significance in adults than in children. It is stated that, as a rule, characteristic papules appear on the palate and tonsils even earlier than on the skin, and that these follow the usual course and change into pustules.

226. Typhoid fever is attended by hemorrhage from the nose in nearly one-half the cases, especially in young people. Occasionally the bleeding is alarming. During the later stage pharyngitis is not uncommon and some

times small oval ulcers of some persistence are seen, but with little liability to extend.

227. In leukocythemia nasal hemorrhages occur in perhaps half the cases at different times.

228. Influenza.-This disease has changed its character considerably in different years since its extension throughout the world in the form of an epidemic in 1889. In some years nasal affections seem quite uncommon; in others they are frequent. Autopsies have shown the frequent involvement of one or more nasal sinuses. Probably many of these instances escape clinical detection. In others the usual symptoms of sinuitis, especially of the ethmoid cells and of the sphenoid sinus, are present. The sinus affections are more often due to secondary infection by streptococci and other germs than to the influenza bacillus itself. Some of the influenza epidemics are complicated in many instances by severe purulent rhinitis, very liable to become subacute or chronic and often leading to early, sometimes to late, involvement of the ears. The throat suffers only exceptionally in this disease.

229. Herpes.-Herpes febrilis, the familiar "cold sore," occasionally involves the pharynx. This occurrence is very uncommon in this part of the country. The pharyngeal affection may occur in connection with herpes of the lips or sometimes without the latter. It begins with a sharp fever lasting not over a day. The herpes vesicles in the pharynx may be few in number or very numerous. The amount of congestion corresponds to their number. Sometimes they heal within a few days; more often each vesicle changes to a superficial ulcer with yellowish deposit. Occasionally several coalesce and form a diphtheritic-looking membrane. This may protract the disease and confuse the diagnostician. Herpes is said to attack some persons in frequent relapses during the whole life. If the vesicles do not heal spontaneously within a few days, the ulcers may be touched with nitrate of silver with advantage.