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Mapa, platea, charts, etc.. may be filmed at different reduction ratioa. Thoae too large to be entirely included in one aiMiposL-ra are filmed beginning In the upper le/t hand comer, left to right and top to bottom, aa many framea aa required. The following diagrama illustrate the method: Laa cartaa, planchaa. tableaux, ate, pauvent dtra filmte it dee taux da rMuetion diffirants. Lorsqua la document eat trop grand pour dtra raproduit en un saul cliche, il est film^ d partir da I'angle supiriaur gaucne, da gauche d droite, et de haut en baa, an prenant le nombre d'Imagea nicassaira. Las diagrammea suivants illustrent la m^thoda 1 2 3 1 2 3 4 5 6 HYPERKERATQ- '"M YCOSI .S OT THB P HARYN X BY J^N Dr. Charles A. WILSON-PREVOST. Graduate of the University of Paris; Late Extern of the Hospitals of Paris; Membre Correspondant do la Societe Anatomique de Paris; Member of the Physicians' Mutual Aid Asso- ciation of New York; Surgeon to the French Hospital. (' H Y PER KER ATO- MIC OS IS OF Tin: PHARYNX. BT Dr. Charles A. WILSON-PRHVOST. Graduate of the Iniversity of Paris; Late Extern of tl-e Hospitals of Pans; Membre Correspondant de la Societe Anatomicme.de Pans: riembeiof the Physicians' Mutual Aid Asso- ciation of .New York; Surgeon to the l-'rench Hospital. i DAMJlliY, CUNX: DANliiriiV AIkdrai, PlUNTJNG Co.MI'ANV. I SOS / I A MmNSIEUK LK PUOFKSSKlll n. B. St. john-Roosa. :'HO.''E8SOi{ .,y LdrifcJAr^KM Ot 11. f: KVK AND EAIl IN TIIK NK\V VoltK I'O.ST- UUAOUATK VrDICAT. £711001 AN') >r0SPIT.vL; StIUOEON TO TII{: MAN- H.'.TlviN Ei'E AT n KAli'lOStMT.'.T.: *'-^UMKI{r-Y IM{OFf:SSOU OF DIS- |:A!-K^ UF rui- FYE in the i NlVKi-.SITV OF THE CrXY OF NKV VORK 'UM. TlEb.-Ti, KliSlTVOFVEUMONT; roN- mTTiN i .-UMOKON TO I 'IK BliOOII.YN EYE AND EAIt mopri'Ar.: ex-fkesident of the new york .\( .\DEMY0F>IEDK'INE:U0N0UAI{Y MEMBEIt OK THE MEDICO-CUrRUUcaCAL SOCIETY OF EDINBURGH; IIONOUAUY FEI.r.OM- MF THE ACADEMY OF MEDKINK OF HAVANA, CUBA. ETC., ETC. ]Mon cher Maitre: <^, Je vous dedie ce petit livre en temoiage de la reconnaissance, du devouement que je vous dois, et de I'amitie que vous avez fait naitre entre nous. c. A. W. P. I I INTRODUCTION. ib On June, 1897, I had the honor to submit to the appreciation of the Protessors of the Fa- culty of Medicine of Paris, a work on the " mycosis of the pharynx," suggested to me by my eminent and amiable master, Mr. A, Cas- tex. The ''pharyngo-mycosis" was discovered in 1873, by Frsenkel, of Berlin, and since then, a great number of cases were published, the authors all concluding that the mycosis was an accumulation of leptothrix buccalis, and that this microbe was the cause of all the trouble. Two years ago (1896), M. A. Brown-Kelly, of Glasgow, said that the mycosis, already des- cribed, was nothing but hyperkeratosis, this disease being characterized by an accumulation of corneous tissue, without any microbe. After I published my paper, I made long researches, consulting very carefully the bibliography, I arrive at the conclusion that in the said *'my- cosis of the pharynx" we always find all the different microbes of the pharynx and of the mouth, infiltrated in a corneous tissue. The description g-iven by A. Kelly is not very clear, and I do not agree with him when he says that hyperkeratosis is seen without mycosis. So instead of having two different diseases, as proposed by Brown-Kelly, I would suggest that these two diseases be known und^r thje name of "hyperkerato-mycosis of the pharynx." I justify plainly my proposal in the course of this book. I think it will be useful to give an entire and complete description of the hyperkerato-niy- cosis, its history, and a short recapitulation of what was said by all the other authors. r n m HISTORIC NOTES. In 1873, B. FraiKkel published for the first time in ''Medkal Gazette of Berlin,'' an article on the '-Benignant mycosis of the pharynx," and immediately, in a microscopic examin- ation, he has stated that the "lepto rix buc- calis," found in the mycosic spots, was the cause of that disease. This disease had never before been described. In 1 876, Baginski and Klebs published another case. Klebs found the "leptothrix buccalis," and confirms the distribution of the filaments in formof fasces, which, according to M. Charles Robin, is characteristic of that leptothrix. In 1880, B. Frsenkel published his second observation. In 1882, E. Frainkel, of Hamburg, published in his turn, a case of tonsillary mycosis." The professor S.^.debeck, who made an histological study of the subject, speaks of ihe filaments seen before by B. Fraenkel, Baginski and Klebs, but he thinks that these are the products of a new organism, which he named according to its shape "bacillus fasciculatus." Sadebeck considers as spores the numerous grains which are between the filaments, while E. Frsenkel considers that spores and tipcats 8 HYPERKERATO-MYCOSIS represent the different phases of development of the same micro-organism. In the same year, 1882, Bayer (of Brussels) published two observations in the '^Revuc nien- suelle de Luryrtgologie, etc." Also in 1882, Gumbiner (of Berlin) published a case. But these interesting observations forestalled somewhat the attention of the laryngologists, for in the same epoch, 1882, came out the great book on the diseases of the larynx, the pharynx and the windpipe, by Morell-McKenzie. In that work, where the diseases of the pharynx are minutely treated, the word "pharyngo- mycosis" is not once used. M. Hering, of Varsovia, published six obser- vations in 1884. He speaks, under the name of "pharyngo-mycosis," of a disease of the tonsils and of the basis of the tongue, characterized by the presence of small whitish and grayish spots, sometimes globular, more often pediculated; or of excrescences having the form of thorns. In 1886, Guinier published an observation. From that time a few specialists studied care- fully this disease, and the cases became more numerous. The year 1887 was very fruitful in publica- tions on this disease. OF THE PHARYNX. 9 Chiari and Creswell-Baber each, brought in a new case. Mendes-Bonito, of Bordeaux, published his thesis upon this subject, with twelve obser- vations taken in the service of Dr. E. J. Moure. M. Ferre made histological researches and found the "leptothri.v buccalis.'' Dr. Moure relates that there were only twenty cases pub- lished, but we must attribute this rareness to the fact, that the disease was unknown, and was very often unobserved. At the congress of Oran, in 1888, Dr. Moure says that he considers the mycosis of the pharynx ap very frequent. In the same year Lober, Oltuszewski, J acob- son. Decker and Seifert, published various communications of mycosis. The following year, 1889, Vanderpool de- scribed two forms to the mycosis; the circum- scribed and the diffuse forms. At the same time Goris found muscular fibres with the mycroscopic examination, but, as M. Collin, in his thesis, had observed it advisedly, the wrench- ing of the white spots was made too deeply, and the muscular fibres had nothing to do with the disease. In 1889, Gautier published an article on the mycosis in Journal of Laryngology. In 189T, 10 HYPERKERATO-MYCOSIS Spaaus, Piiternam, Dubler, Newcomb and Jurasz, published different articles. . The same year Lennox Brown published his ''Treatise of the Diseases of the Larynx," in which he devoted twenty lines to the descrip- tion of the ''pharyngo-mycosis." It is natur- ally an insufficient review of what had been said of that disease. Henr> 3ixby Hemenway, (in Journal of Laryngology, February, 1892) wrote an article of eleven pages on the history of ''pharyngo- mycosis" and its microscopical study. He found above all the "leptothrix buccalis" and the 'bacillus fasciculatus." Then he recommends as treatment, the thermo and galvano-cau- tery. Garel, in a microscopical study of the disease found the ''leptothrix buccalis" and the "cocci bacillus fasciculatus." Higguet, of Brussels, found in the white patches, small lamina of corneous epidermis origin. In TraitcdeMedecine M. Ruault writes a few lines on the different diagnosis with the chronic caseous lacunary tonsillitis. Bosworth also, in 1892, in his "Treatise of the diseases of the nose and throat," gives a few pages to the description of that disease. <; I .; I OF THE PHARYNX. II M. Albert Colin, in 1893, published his thesis on the mycosis and seven unpublished observa- tions of which a few are personals and the others belong to the service of M. Ruault. M. Colin states that "always," the leptothrix buccalis is the cause of the pharyngo-mycosis. M. Colin advised the use of smoking tobacco, as one of the ways of treatment. M. Wagnier published three cases of recovery, by touch of chromic acid. M. Eugene Krauss (in Bulletin Medical, 15 of March, 1893) considers the catarrhal state as a condition "sine qua non" of the development of the mycosis. And so, the different causes, which can irritate the pharyngeal mucous membrane, can indirectly be the cause of the mycosis. M. Labit (in Revue de Laryngologie, ist March, 1893) published a case of pharyngo-mycosis, whicn is rather curious, because the white patches reached the aryteno-epiglottis recess. In 1894, Homer M. Thomas, A. M., M. D., (in Medical Record, d January, 1894) gave a very good description of the disease, but without saying anything new. He advises the treat- ment with cautery. In 1806. Royet (in Echo Medical de Lyon, 15 August) gave a very good description of the 12 HYPERKERATO-MYCOSIS "pharyngo-mycosis" and affirms that the "lepto- thrixbuccalis" exists in the mouth of eight per- sons out of ten taken at random. In the same year, A. Brown-Kelly (in Glas- gow Medicaljournal), considers that the disease called ''pharyngo-mycosis" is in reality hyper- keratosis and in support of his thesis he gives ten personal observations. This work is long and conscientious, but is not convincing. The small lamina of corneus epidermis nature exist always in the pharyngo-mycosis, and, in the meantime, as M. Brown-Kelly says, simple gargarisms are not sufficient to destroy the ''pharyngo mycosis." Beside the cases of spon- taneous recovery, we do not know any case which was so docile under that treatment that we can call "facetious." -^ W' OF THE PHARYNX. 13 ■K mt- PATHOLOGICAL ANATOMY. Ever since 1873 when B. Fraenkel gave the first description of the "hyperkerato-mycosis," the specialists have been on the **qui vive," and every year the observations became more numerous. Although Krauss believed that the microscop- ical examination was unnecessary in making the diagnosis, most of the observers have made a bacteriological study of all their cases. As a rule, they agree to acknowledge the "lepto- thrix buccalis" in the white patches, and few of them deduct from the constant presence of the leptothrix that it is always the cause of the disease. Our opinion is different. The leptothrix buc- calis is almost constant in the saliva and the different parts of the mouth; it would be aston- ishing if we could not see it in the diseases of the mouth, and according to the bibliography that we have to consult conscientiously, and also from our own personal researches, we can say that we meet not only the 'leptothrix buc- calis, but also the oi'dium albicans, the nigri- ties linguae, the mycosis sarcine, the aspergiilus fumigatus, etc." 14 HYPERKERATO-MYCOSIS And for the present time, we can not affirm that the leptothrix is the bacillus that engen- ders the hyperkerato-mycosis of th? pharynx. Sometimes, on examination, not one microbe is seen; nothing can be seen but small lamina of corneous-epidermis nature. Our amiable master, M. A. Castex, was kind enough to make us a gift of a tuft of mycosis taken from a ton- sil of one of his patientr . (Observation No. V.) That small tuft, or in preference that small point, has a filiform aspect, having a length of about 4 millimetres, of whitish color, having a ravel extremity, sharply, in connection with the depth of the crypts; the other extremity being swollen, having a millimetre and a half of thickness, is connected with the surface of the mucous membranes of the tonsil. I had put first that small nail in a vial, containing a solu- tion ot alcohol, yl Then, two days after, I could,thanks to the extreme obligingness of my master and friend, M. G. Durante, chief of the laboratory of pathological anatomy in the "Charite's" Hospital, make a microscopical ex- amination of the small mycosic tuft. The disorganization of the ravel point, cor- responding to the depth of the crypt, was very easy. I could even crush it easily on the glass OF THE PHARYNX. 15 plate. Regarding the swallowing extremity, it was differently, and besides a work strength- ened with patience, the microscopical examina- tion was impossible. I could take off only a few particles. The other part was hard, cor- neous and shining. Then I submit all to differ- ent proceedings of coloration. I St. With a solution: Anilina water, 90 grammes. Alcoolic concentrated solutionof thi- onin, 10 grammes. 2nd. With the liquid of Loeffler. 3rd. With the solution of fuchsin (Gram). Naturally I took care to fix over a gas Bun- sen, before the coloration; then I had it washed with alcool, and I covered the whole thing with Canada's balsam. Accumulations of filaments are seen with a sometimes considerable length, so that one filament can occupy all the field of the micro- scope. They are rectilineal or a little curved one way, sometimes having the form of a para- bola, rarely sinuous. They nearly all seemed to be formed of fila- ments more or lesslong, with their length 3 or 4 times greater than their thickness. Their diameter is sensibly analogous, i milli- meter to 1.5 m. l6 HYPERKERATO-MYCOSIS These micro-organisms are nothing but lep- tothrix in tufts. These leptothrix and these tufts are often found growingonacell of flattened epithelium, which is generally granulosus and transparent. In these cells are recognized a series of other micro-organisms which are the common mi- crobes of the mouth; these microbes are either round, or in mass, or have the form of small sticks. Quite a number of cells form a mass filled with these round microbes. A few cells con- tained several of these varieties, while others contain only one variety. All the granulosus cells which seemed to be modified with a small magnifying are more or less filled with organisms. On the surface of the mucous membrane, where the leptothrix is planted, we see some- times a depression in which the corneous epi- thelium continues itself with the mucous body of the mucous membrane. Filaments of leptothrix are planted perpen- dicularly or obliquely on the first corneous coat. Goris had found fasces of leptothrii isolated, cocci associated in different ways, epithelial cells. He had also found striated muscular OF THE PHARYNX. 17 fibres, but as I said before, the extirpation was probably made too deeply, beyond the sick re- gion, in the muscular plan. Garel says that the lymphoid tissue has dis- appeared, and that a fibro-conjunctivitis stroma, in which the vessels are atrophied, has taken its place; in this stroma, the crypts are repre- sented like cavities, real cysts by retention, covered by an accumulation of corneous la- mella. Between these lamellas exist spores and leptothrix. It seemed as if the crypt was first injured, and then the parasite found a fav- orable ground for its culture. Garel adds that a number of particles of my- cosis, taken off with the forceps, offer a yellow- ish extremity, ravel, like a hard cone, corres- ponding with the depth of the crypt. This consistence of the point must, according to Garel, proceed from incrusted calcareous salt; it explains beyond the difficulty shown often in the extraction of some islets of mycosis. Krauss pretends that when the parasite has; succeeded in its development it keeps and exaggerates the irritation of the mucous mem- brane, because it penetrates in the depth of the conjunctive tissue, in the interior of Ihe glands,, and in the follicles. l8 HYI'ERKERATO MYCOSIS Krauss, after a microscopical examination,has found the leptothrix, that took a blue color, with a solution of iodine and of iodide of potas- sium. Krauss could take off Ihe mycosis mass with a very great difficulty, and each time he was obliged to use violent and sudden manoeu- vres which had produced hemorrhage. This difficulty is the fact that the parasite had pene- trated and ramified itself in the depth of the tissues. The author adds that it is hard to disorganize the extirpated mass for the micro- scopical examination. Moure (of Bordeaux) says that the white tufts are composed of the elements of the lep- tothrix buccalis. Hemenway also believes that the pharyngo- Tnycosis is due to a parasite. As the tonsils are the most frequent seat of the parasites, he ad- vivsesto call if'tonsillo-mycosis." Higguet (of Brussels) after a microscopical examination of the white spots states that the iilaments were small lamella of corneous epi- dermis nature, without any other element. This seems much like Observation V. Vanderpool says that the oidium albicans is the most frequent vegetal parasite in the pharynx. The others, as nigrities linguse, mycosis sarcine, aspergillus, are more rare. fif^ k OF THE PHARYNX, 19 The nigrities linguae is seen in the pharynx only by extension in the neighborhood of the basis of the tongue, and it develops itself mostly on that organ. The aspergillnsis more frequent in the ear than in the pharynx. Gautier says that the caseous masses, seen in the crypts, are especially composed with "lep- tothrix buccalis." The disease, according to him, attacks in preference the isthmus of the throat, the palatine tonsils, rarely does it attack the pharynx and the trachea. According to Royet, the leptothrix develops itself mostly on the part of the tongue situated before the lingual V. From this it extends in the neighborhood. He adds that the tufts of leptothrix are placed on the lingual tonsil, be- tween the lobules of the gland; we can sec them also on the tonsils of the palate, on the mucous membrane of the pharynx, and on the pharyn- geal tonsil. 20 HYPKRKERATO MYCOSIS ETIOLOGY. Many things have been said about the etiology of the hyperkerato-mycosis, but nearly every one agrees that this is obscure. Our re- searches were not more fruitful than those of our predecessors. And naturally, knowing nothing exact, many causes, more or less plaurWe, were incrimin- ^ However, it seems that in the majority of the cases, the patients seized with hyperkerato- mycosis were in bad health and presented an alteration of the pharyngeal mucous mem- brane. Upon that question Krauss is very energetic; he considers that a catarrhal state of the pharynx is a condition "sine qua non" of the development of the mycosis, and in the Bulletin Medical, 15 March, i?.>:'„ he ex- pressed himself to that effect. "There is only one fact certain, according to other observerc- and to myself, which is, that the mycosis never grow upon an undamaged mucous membrane, but that it must be modeled in a certain way, before the appearance of the mycosis. The characteristic of that modiBcation is not known yet, but it is very probable that the least i OF THF. PHARYNX. 2 1 alteration of the mucous membrane, or a slight catarrh is sufficient to make it the seat of the colonies of parasites." It is at that point of distance that all the causes which can irritate the mucous mem- brane of the pharynx, can indirectly cause the hyperkerato-mycosir,. Garel, in 1893, after a study of twenty -nine cases, says that the disease seems to develop itself on patients seized with naso-pharyngeal catairh. Brown Kelly, in 1896, affirmed that the my- cosis develops itself by means of a bad general or local state, that ha^. modified the vitality of the mucous membrane. The dyspepsia would also be a oause of that disease. The dental caries, the acidity of the saliva, the inflammation, are favorable conditions; also the chronic tonsillitis, the pharyngeal catarrh. Hemenway also has seen the disease upon persons having a catarrhal inflammation or large tonsils. M. Johnson, of BaltLxiore, has observed these cases especially on weaken scholars or older people. In the thesis of Dr. Colin, 1893, it is repDrted that a pregnant woman, attacked with hyper- ; 22 HYPERKERATO MYCOSIS kerato-mycosis, was absolutely cured after her confinement. We think it will be useful to reproduce that observation. OBSERVATION I. (Thesis of Dr. .A Colin, 1895.) Mrs. X., 21 years old, door-keeper. One day, her daughter was seized with angina; then she thought to look in her own throat, although she did not feel any trouble, and saw several white spots on each of her tonsils. She came, a month af^er, the nth of March, 1891, to the clinic of laryngology, at the "Institution des Sourds-Muets," and then, the tonsils were cov- ered in numerous places with small excres- censes of a white yellowish. Analogous excrescences were seen also on the back wall of the pharynx and on the basis of the tongue These productions were of a hard consis- tence and were taken away with difficulty^ with the dull forceps. Diagnosis. — Leptothrix-mycosis, recognized with the microscope. Treatment. — Ablation of the tufts of mycosis and washing with a solution of iodine with I K. We met that door-keeper again on the 15th of March, 1892; she declared that one month ^ <1> ^ ^ II OF THE PHARYNX. after her first visit she saw new white spots on the right tonsil, which were treated for a little time with lemon juice. She was confmed on April last. At that mo- ment, she still had mycosic productions that had come back in greater number, since she had stopped the treatment. The first time she got up, two weeks after her confinement, she looked at her throat and saw that there were no more white spots there. We examined her, and saw in fact that all the parts that have been touched formerly, were cured, and that there was nowhere any productions of m} cosis. According to C. Robin, the acidity of the saliva is a condition of life for the "leptothrix- buccalis." Mendes-Bonito thinks that the irritations of the pharynx, favoring this acidity of the saliva, would be the cai.se of the mycosis. But Decker and Seiferthaveinoculated some leptothrix upon sound and sick tonsils, and in. each case, have reproduced the disease. Our master, M. A. Castex, has seen that dis- ease upon a young English girl of thirteen years, who used to have tonsillitis frequently. (Observation VI.) 24 HYPERKERATO-MYCOSIS Thomas says that the women and ^he chil- dren who are seized with hypertrophy of the tonsils or of chronical pharyngitis are more predisposed to that di. ease. W. C. Glasgow says that the hyperkerato- mycosis develops itself only when the mucous membrane of the pharynx offers a favorable ground. But very often, the cause is unknown, so that persons have the disease for a long time before it is discovered b)^ chance; there are cases of singers who feel nothing at all when their voice is at rest, but after they sing for a while, they are forced to discontinue. (Observation V.) The development of the disease is by no means influenced by the age, the sex, or the profession of the individuals. However, ac- cording to several authors, it would be more frequent with women attacked then between ten and forty years ot age. In 132 cases, Brown-Kelly has calculated 5:! men and 78 women; being between 15 and 35 years of age. It was seen by Garel more frequently during childhood; upon young girls between 10 and 20 years of age. OF THE PHARYNX. 25 tn 29 cases, 14 men, 15 women. Vanderpool says that the disease is more frequent in wo- men than in men, and especially at about 30 years of age. In the thesis of M. A. Colin, there are six women and only one man, their age being from II to 30 years. Colin gives the following proportion: Three women for two men. Hering saw it in an old man. Dubler saw it in a child of 8 months. M. A. Castex, on a total of 6 persons, num- bers 2 women, 3 young girls and one man. Hemenway believes that the disease is more frequent in women than men, because the wo- men live in an impure air and he adds that the hypertrophy of the tonsils is a favorable ground for the parasite. The hygienic conditions, (food, temperature, dampness, ventilation, etc.), to which Gorishad given an etiological value, have nothing but an indirect importance in favoring a catarrhal condition of the mucous membrane. It is not proved yet that a predisposition to the syphilis, tuberculosis, etc., might be a cause. Most or the patients observed, were free of previous diseases. 26 HYFKRKERATO MYCOSIS There is no hereditary predisposition, al- though the disease may be seen on different members of the same family. Nevertheless, Guinier thinks that the lym- phatism is an excellent ground to the develop- ment of the leptothrix. On the contrary, it was stated that the ma- jority of the patients were healthy. M. A. Castex has seen it six times in his pri^ vate office: never at his clinic. (Observations V and VI.) Garel has seen it twice at the hospital and 27 times at his office. Goris says that a cold is cause o the disease. . Without exact proofs, the damp climate, the quality of swamp water, because it contains ba- cillus that resembles 1;he "leptothrix-bacillus," were incriminated. (Thomas and Hemenway.) The disease is not directly transmissable and is not contagious. Hemenway had experi- mented on himself the transplantation of ex- crescences, but without success. After all, the etiology of the **hyperkerato- mycosis" is uncertain; but if we make the n^^' croscopical examination of the white spots found on the tonsils and on the basis, of the ton- gue, we see different microbes, which could^ alone, explain the disease. . OF THE PHARYNX. * 2/ Of all those microbes, which one is to be in- criminat' ^5 especially as the etiology of the mycosis? Or, in preference, are these different microbes associated, the cause of the disease ? Our opinion upon that question is not quite firm. After a light examination, nearly all the observers had seen the "leptothrix-buccalis." But this microbe is always in the mouth nor- mally and a "fortiori," v. hen the mouth is sick. The following microbes have been seen also: oidium albicans, nigrities linguae, sarcinica, actinomyces, aspergillus fumigatus and ba- cillus f asciculatus. So these different microbes seem to be the cause of the mycosis, but some other unknown special conditions are necessary. 28 HYPERKERATO-MYCOSIS DESCRIPTION. Definition.— The "hyperkerato-mycosis of the pharynx" is a benignant and chronic dis- ease, characterized by the presence on the different tonsils, on the basis of the tongue and sometimes on the whole pharynx, of small white spots having a diameter of i to 2 milli- meters, containing the different microbes which are found in the mouth, and a certain quantity of corneous tissue. For its description, we must study first the subjective symptoms and afterwards the ob- jective signs. I OF THE PHARYNX. 29 " f - SUBJECTIVE SYMPTOMS. We must first say that these are sometimes null and that often, the disease is discovered by a mere chance, as in the case of a lady who came to consult M. Krauss, because she had seen for many months some white spots on her tonsils, which were not at all annoying, but did not disappear. Royet says that it is hard to suspect the pres- ence of the parasite, if there is no pharyngitis. The singers can have the disease without apparent symptoms, only after having sung for a little while, they have a feeling of dryness and of irritation in the isthmus of the throat. The voice is diminished in regard to the tone, and becomes hoarse. Nykamp cites the case of a patient who "com- plained of nothing," although there were gray- ish spots of hyperkerato-mycosis between the papilla of the back of the tongue and upon the epiglottis. The pharynx and the tonsils were indemnified. Garel says that the symptomology is entirely objective; and that rarely, there is uneasiness and pain with deglutition. We believe that it will be interesting to publish the observation of a young woman who was seized with hyper- 30 HYPERKERATO-MYCOSIS kerato-mycosis without any subjective symp- toms. OBSERVATION II. (Dr. Eugene Krauss.) Chambermaid, 28 years old, living in the best hygienic conditions. When I saw her for the first time, she had seen for eight months some white stains on the tonsils. No acute phenom- ena (fever, dysphagia, etc). On examining the pharyngeal cavity, the mucous membrane of the palate, of the pillars, was seen to be slightly congested. On each of the hypertrophied tonsils having the length of a hazel-nut, covered with a thick mucous membrane, of red grayish color, we see a dozen white spots, regularly disseminated, and seeming to be very distinct of the mucous membrane. All these points have about the dimensions of a millet-grass; of a white nacreous color; some of them are covered with a yellowish coat of mucus. When examined more closely wt see that they are small pointed elevations, of which the surface seemed villous, having then the appear- ance of small tufts. Nowhere are these stains confluent, and they are very isolated by the mucous membrane that surrounds them. OF THE PHARYNX. 31 With the laryngoscope, we discover twenty other spots on the basis of ^he tongue, which are grouped around the large follicles. There is nothing, abnormal in the other regions of the pharynx or of the nose. But it is not always l>o, and the subjective symptoms exist often. The disease, in six patients of my master, M. A. Castex, was always characterized by an un- easiness or sensation of stitching in the pharynx, which symptoms are the most frequent. In an observation in the thesis of M. A. Co) in, the patient complains of an uneasiness, a tick- ling, a sensation of foreign body that made her cough and so ape constantly. Sometimes there is also a sensation of dryness; there is the sen- sation of a band around the neck, which would suffocate the patient, if pressed slightly. Also it is painful for the deglutition. Thomas has seen all those symptoms, greatly exaggerated, with weakness, fever and loss of appetite. The breathing was rarely offensive, but was reported. (Gautier.) Moure says that when the subjective symp- toms exist, they «- e like granulosus pharyngitis. Hemenway says that the symptoms vary from a sensation of pricking, until there is a 32 HYPERKERATO-MYCOSIS sensation of obstruction. The local inflam- mation, painful with fever, cough and vomiting, is seen sometimes. Also asthma. As a rule, the whole system is in good con- dition. OF THE PHARYNX. 3S OBJECTIVE SYMPTOMS. As it is said of our definitior of the "hyper- kerato-mycosis of the pharynx," the objective symptoms of that disease are the presence of small whitish spots on the tonsils and on the basis of the tongue, but it is not always so. Sometimes the hyperkerato-mycosic spots are seen on the epiglottis and not on the ton- sils. The points have the form of tufts pro- jecting a few millimeters over the mucous membrane. ' ■ They resemble sometimes a small nail's head. Their surface is plain or irregular, fimbriate, of a yellowish white color; these spots are taken off with great difficulty, according to the penetration of the microbes in the th^'' ""vness of the mucous membrane; the plucking t,ume- times gives an oozing of blood. These hyper- kerato-mycosic points have often the form of millet grass or tufts of mushrooms, resembling the appearance of capuchin's bearb, or the yellowish stains like in diphtheria. The touch gives the sensation of protuberance. Thomas gives two forms in the description of these points; the diffused form and the cir- cumscribed form. In the diffused form, the 34 HVPKRKEKATO-MVCOSIS tongue is entirely covered with a brilliant mass like milk, that is frequently very dense. The movements of the tongue, and the sen- sation of the taste are not lost, and the whole condition of the patient is good. In the circumscribed form, some white spots appeared, and the mucous membrane has a pini. color. The following description belongs to Brown- Kelly. "The patches are m jre or less numerous, small, isolated, slightly projecting, having their seat on a sound mucous membrane, are taken off easily, with a superficial erosion. They are seen generally on the uvula, and on the veil of the palate." The principal characteristic of these hyper- kerato-mycosic nails is their adhesion; and after being taken off with the forceps, they re- appear rapidly in the same place, sometimes .after twenty-four hours. Sometimes, ^hcse filaments gather together and form a membraiie. Atothertimes,theyare corneous and pointed, having the form of clusters, or having the form of muscular stains. The lesion seats, by order of frequency, at the tonsils, the basis of the tongue, in the OF THE PHARYNX. 35 glosso-epiglottical dimples, the posterior and lateral walls of the pharynx, in the middle of the pillars of the naso-pharyn^eal vault of the nares. OHiiszewski observes a case of a sick person of 16 years of age, on whom the disease was suddenly seen on the tonsils, the palatal arches and the tongue with intense fever. Vanderpool says that the seat of predilection is the left tonsil. The progress of the disease is slow; at times it disappears spontaneously. We reproduce here an observation of hyperkerato-mycosis, which is generalized,diffuse, rare, consequently interestinp", the place of which is indicated in this book. OBSE^clVATION III. (Dr. Lsihit, in Revue i/e Larj/n£v, iSg^-) Mary G., 28 years old. This person, of a sickly aspect, thin and very nervous, says she is incommodated moic bv her general state than that of her throat, although she is per- suaded that the throat is the cause of all her trouble. In the examination of her throat, we perceive numerous white spots, coverin^j the right ton- sils, especially towards the center and forming there a nest of about one centimetre in width. " HYPERKERATO-MYCOSIS On the left tonsil the white spots are more disseminated. A ft,v\ wrrite spots are seen on the left lateral wall c' 'he local pharynx and on the most ex- treme part of the anterior pillars on both sides. With the mirror, we see that tissue of the basis of the tongue is covered by small white spots, separated, and as large as pin heads, lo to 12 in number. At the right side of the basis of the tongue, near the epiglottis and on the anterior part of the ary-epiglottical fold of the same side, we see two white spots of about 3 millimetres long and 4 millimetres wide; nothing is seen on the pharynx. We perceive spots, similar to the preceding ones on the lateral walls of the naso-pharynx,, especially at the left, at the entrance of the Eustachian tube on both sides, lastly on the posterior wall. All those white spots have the aspect of small projecting tufts of " to 5 millimetres long, with denticulated and fimbriate ends. The mucous membrane surrounding these small points is sound. The touching, also, gives the sensation of projecture. L * ^ n '■ * & OF THE PHARYNX. 37 The extirpation of some of these tufts is attempted, and shows that they adhere strongly to the mucous membrane. The microscopical examination shows the presence of the leptothrix Luccalis. 38 HYPEKKEKATO-MVCOSIS DIAGNOSIS. The diagnosis of the ^'hyperkerato-mycosis" is generally an easy matter, when the disease is characterized by small white points, about the size of a millet-grass disposed around the tonsils and the basis of the tongue, on a sound mucous membrane, of long duration a! d pulled out with difficulty with the forceps. All doubts are taken away when in the mi- croscopical examination the points contain the micro-organisms of the mouth, or epithelial cells, or lamina of epidermic corneous nature. If the subjective symptoms are not very marked, it is in favor of the ''hyperkerato-my- cosis." Generally, the diagnosis is easily made, but in some rare cases, the observer must have a thorough knowledge of the different diseases of the pharynx. The foUicularis angina evolutes in an acute manner; it is accompanied with fever and in- tense dysphagia. The white spots that it pro- duces are irregular in form and size: they have a pronounced tendency to confluence and seat on the congested tonsil.. ■• " OF THE PHARYNX. 39 All the points in a lacunaris tonsillitis are soft and friable, halt liquid andjnot; adherent; they are easily pulled out with the;'stylet. The fact that the authors, Labit, L. Brown- Kelly, Garel, Vanderpool, Hemenway, Krauss, gave to the diagnostical study of the foUicu- laris pharyngitis with the hyperkerato-mycosis, a particular interest, would make us hesitate sometimes in our diagnosis. Diphtheriahardly resembles the hyperkerato- mycosis. Here the disease is chronic, without fever and general symptoms, except in the case of concomitant tonsillitis, without^cliphtherical smell, or any pain; the objective examination of the throat is also entirely different. If the white tufts have the form of a mem- brane, it is taken off only in fragments, it leaves bleeding stains, but the mucous mem- brane is much less denuded than'in diphtheria. Although Vanderpool considers that the hy- perkerato-mycosis has often been confused with diphtheria. The microscope can, however, always decide the question, the Klebs and Loeftier's; bacillus being always easily distinguished. I do not insist on the gravity of the fault that we would commit in making a mistake in the diagnosis. 40 HYPERKERATO-MYCOSIS The appearance of mucous stains in the throat is alwj^ys accompanied by other symp- toms of the syphilis (angina, glands, etc.); the stains themselves do not have the pointed form of the mycosic colonies and are larger. Tuberculosis resembles in a very vague way the hyperkerato-mycosis and only, under the form ot miliary phthisis of the pharynx, which is declared in the last stage of tuberculosis. The general appearance of the patient, the anemia of the mucous membrane, the yellowish color and the transparence of the small nodules that are produced ia the throat of the patient, makes the diagnosis easy. Sometimes there are some wisps of mucosities and of epithelial cells in the chasms of the ton- sils. They are of a yellowish color, above the size of a millet-grass and are found isolated and in small number and are characterized by the extreme facility with which they are taken •off. Alight pression, a fit of coughing are suf- ficient to take them out of their cells. We also observe small cysts in the chasms of the tonsils; they form flat, transparent, yellow- ish elevations; they are always isolated and generally occupy the summit of the tonsils. The "thrush," a pre-eminently children's dis- ease, may sometimes attain adults. The thrush * ?) OF THE PHARYNX. 4I forms white membranes, of various sizes, that may be seated on every part of the mucous membrane of the mouth and of the pharynx, but are principally seen on the sides of the ton- gue and on its basis. They have a tendency to confluence and are easily detached by rubbings. Underneath, the mucous membrane is not ulcerated, but only congested and of a dark red. The patient is generally in a cachectic state; there is also dysphagia. In the case of "calcareous concretions'' of the tonsils, they are larger than the white spots of the hyperkerato-mycosis and give, under the stylet a stony sound, which does not exist in the preceding disease. They are isolated and do not reappear after their removal. The "caseous" concretions of thegranulosus- pharynx, may be similar to the hyperkerato- mycosis, but are still distinguished from it, by their being softer and much less adherent. There cannot be any confusion with the herpes of the pharynx, because of the fever and general discomfort, i-hat does not exist in the hyperkerato-mycosis. Although certain light herpetic anginas can cause no general reaction, the distinction will be easy because the vesicles of herpes are 42 HYPERKl!.i^ATO-MYCOSlS iated )f palate principally never on the basis of the tongue, which is gen- erally reverse in the hyperkerato-mycosis. Krauss reporis the case of an "infectious an- gina" (caused by stuffed birds) which was seen under the form of an intense follicularis an- gina, accompanied by fever and by grave pros- tration. After a few days these symptoms ceased and reappeared only at intervals of two or three weeks. The patient did not suffer during those in- tervals, but had small white spots on the ton- sils, that resembled those produced by the leptothrix. The acute characteristics distinguished also this affection from the hyperkerato-mycosis. According to Brown-Kelly, there is a perfect clinical difference between the so-called dis- eases, mycosis and hyperkeratosis. He says that the only resemblance is the presence of the leptothrix in their productions. The excrescences of the hyperkeratosis are rough, very adherent and of characteristic form. The stains of the mycosis are smooth to the touch, easy to take off and slightly prominent " ' t OF THE PHARYNX. 43 " ' and the surrounding mucous membrane is swollen. The hyperkeratosis, he says, is limited to a certain region, while the mycosis has been ob- served on every point, between the mouth and the stomach. The diagnosis of the disease is easy, when it has developed; at the beginning, the difficulty consists in discovering the colonies which are not yet numerous and which occupy the secrete places of the mucous membrane, such as the posterior part of the tonsils, the folds of the tongue, etc., and besides, the precise diagnosis is always desirable, but it is not essential, to apply to a convenient treatment. It is nevertheless important not to confound the hyperkerato-mycosis with the follicularis pharyngitis. "■i"i!^%'r:. "'iv:-,/ k-Mi^Iftiyl'v: 44 HYPERKER A TO- MYCOSIS PROGNOSIS. The prognosis is favorable, in spite of a des- pairing resistance of the parasite to the treat- ment. The recovery is sometimes spontaneous, but more often, the disease is chronic and has sev- eral returns. Hemenway thinks that the parasite can run away in the pituary or in the lungs. Being in the lungs, they can produce a very obstinate bronchitis. OF THE PHARYNX, 45 TREATMENT. It is very important to recogixize the hyper-^ kerato-mycosis at its beginning, for then the parasite has its seat on the superficial mucous membrane, and may be destroyed easily. Later, th^ treatment is longer and more diffi- cult. The different antiseptic medicaments, astrin- gent or caustic, the carbolic acid, chromic, boracic or salicylic acid, the bichloride of mer- cury, the nitrate of silver, the alcool, etc., even in concentrated solutions, have no effect on the disease. (Observation lY.) Our master, M. A. H^stex, extols the hot gargles with a i^ solution of resorcin, accom- panied with the extirpation several times of the mycosic spots, with the nasal forceps of Duplay. (Observation V.) Sometimes the galvano-cautery is successful. (Observations VI and VII.) The cautery, galvano or thermo is also in favpr with Hemenway. Moure affirms that the only treatment is the picking or the scraping off of the tufts, accom- panied with cauterization of their points of im- 4^ HPPERKERATO-MYCOSIS plantation with a solution of chloride of zinc (A to -jjJjj-) of lactic acid (>^ or pure). He employs also the thermo-cautery for the tonsils and the g-alvano-cautery for the basis of the tongue. Garel recommends the picking off with the forceps, and cauterizations with galvano- cautery. M. Natier had cured a young girl with gal- vano-cautery and chloride of zinc. M. Webster, in a case of hyperkerato-mycosis, had employed successfully the galvano-cautery and the hyposulphite of sodium. M. Frederick Knight (of Boston), when using the galvano-caustic needle, has succeeded only when it penetrated deeply in each follicle. The disappearance of all the spots came after gargles of a solution of chinolin (io%) and gal- vano-cautery, in the hands of Nykamp. Goris prefers the touching of the points with bichloride of mercury and extirpation with the forceps. When the parasite has not penetrated deeply he prefers the galvano-caustic. M. Hower-Thonias affirms that the using of galvano-cautery is the only good treatment. M. Krauss has several times employed the galvano-cautery in a very energetic way, but he never could make a complete cure. To have ; . . OF IHF, PHARYNX. 47 a good result he was obliged to extirpate first the mycosic points with the forceps. He adds that it is important not to lose sight of the patient and have to begin again the t^^atment when the parasite reappeared, as is the rule at the beginning of the treatment. The parasite wastes after a certain time, and then the obstinate disease can be cured radically. Most of the authors agree that the sole treat- ment of the hyperkerato-mycosisis ''extirpation of the mycosic spots with a forceps, cauterizing with galvano-cautery and simultaneous anti- septic gargles." Other treatments seemed to have given good results, how^ever. M. Wagnier is said to have cured two patients by touching the white spots with chromic acid, having failed with the other treatment. According to Moure, this treatment is not without danger, chromic acid being poison even in small quantity. M. Delavan had the best -esults with borax and bichloride of mercury, and especially with the suppression of dyspepsia. M. Kitchen recommends the hyposulphite of sodium. The Hydrogen Dioxide (H2 O2) was also ex- toled. and for that purpose I recommend the 48 HVPERKKRATO-MVCOSIS Marchand's Hydrozone as the best preparation of Hydrogen Dioxide. M. vSemon had cured a patient with chlorate of potassium gargles, and touches with tannic acid. Alum and the nitrate of silver have not given good results. M. Jacobson recommends the bichloride of mercury (2-1000). M. Toeplitz had tried the iron salts without success. M. M. deNabias and Sabrazes and M. Labit have obtained good results with the following treatment: Ij^ Zinc chloride melted in plates, 45 gms. Water, 25 gms. Potassium iodide, 70 gms. Iodine, 4.25 gms. The chloride of zinc is dissolved in warm distillated water. Then IK is added by de- grees. A yellow precipitation is formed^ ''vhich is dissolved again by ebullition. We take the vessel away from the fire and then the iodine is added in agitating until complete dis- solution. M. Moure has obtained good results with that solution. M. A. Colin obtained last year a complete cure with ferric chloride. OF THE PHARYNX. 49 In \.\iQ Archives de Laryngologie, 1896, page 451, the author relates the case as follows: "I had used the officinal solution that con- tains 26 parts of ferric chloride and 74 parts of water. With a plug of cotton soaked with that solu- tion I had colored the at^ icked part of the pharynx. I saw almost instantaneously all the mycosic points, impregnated with the liquid, and take hrst its yellcw tint, then become a dark-mar- oon, the mucous membrane keeping its normal tint. Two days after, when I saw the patient, the tufts were of a pure black. With the stylet I found them of a hard consistence, and with the nasal forct^ps, I extirpated them, one by one, without any difficulty. I state that the ferric chloride had deeply- penetrated, in those vegetations, only the ex- tremity of the root remaining yellow, was vir- gate, and seen through the wen. I could not see any breaking. It seemed that it had been entirely pulled out. During three weeks I made the dressing every other day, and the mycosic points dis- appeared. 5° HYPERKERATO-MYCOSIS On the basis of the tongue, on the posterior wall of the pharynx, that is to say, everywhere where the leptothrix is on the smooth mucous membrane, the vegetations had disappeared after 3 or 4 dressings, without extirpation It was more difficult to destroy the tufts that were in the crypts. For a month and a half I saw the patient only once a week. She had Ipcunaris tonsillitis but the crypts did not contain any more my' cosic spots." OBSERVATION IV. (Hemenway,) Miss K., 32 years old, came on the 13th of April, 1 89 1, complaining of a white stain on the left tonsil. The two tonsils are swollen and lightly congested, especially the left tonsil having a surrounding form. On this one there are two white spots, the larger having a diam- eter of two millimetres and a height of one millimetre over the thick surface of the mucous membrane. There were small stains on the Tight tonsil. The author made a diagnosis of tonsillary pharyngitis, prescribed a purgation and gargles with potassium permanganate. OF THE PHARYNX. 5 I Few days after the spots were larger instead of having diminished. The largest looked like a mass of fly's eggs, of a whitish color. it was examined with the microscope by the author who found a few little epithelial cells and fasces of small sticks. It was not the diphtheria, or a follicularis pharyngitis. A local treatment was applied. Boracicacid, carbolic acid, thymol, eucalyptol, menthol, iodine, were successively tried without suc- cess. Then the author proposed the electro-cautery. The patient refused and went away. The author, being convinced that the disease was a case of hyperkerato-mycosis, had the pa- tient back and took off a part of the white spots with a forceps. In July, Miss K. had an acute tonsillitis, ac- companied with augment of the hyperkerato- mycosis, for which she employed "listerin." On the 30th of August inflammation and swelling had disappeared, everything but one white tuft. M. Hemenway advises the glycerine and hy- drochloric acid without success. C2 HYPERKERATO-MYCOSIS On the 17th of September the tonsils were much smaller, each one having a white stain, different in appearance to the others. The 1 8th of September the patient consulted a specialist of Chicago, who treated her with electro-cautery. OBSERVATION V. (Unpublished, Dr. A. Castex.) Miss X., young girl 25 years of age, born in America, singer, was always in good health; no antecedent diseases. For a few months she felt a sensation of stitching in the pharynx, but it is not painful. No trouble for the degluti- tion. She states also that her voice is poor in sing- ing and tires more quickly than usually. With these subjective symptoms tonsillitis follow each other. With an objective examination we saw white spots, surrounded, having the form of tufts, on the liiternal surface of the two tonsils, a little on the back wall of the pharynx and a good deal on the tonsil of Luschka. I prescribed hot gargles, with aqueous solu- tion of resorcin (1%), and with the nasal for- ceps of Duplay I extirpated each time 5 or 6 of " QF THE PHARYNX, 53 those small blocks which were hard and whit- ish and came of the crypts of the tonsils. For the lingual tonsil I used a forceps with a particular curve, shorter than the forceps for the polypus of the larynx. After ten operations the parasite disap- peared. A few of the white spots seemed to reproduce themselves, but only in the beginning of the treatment. The way that I make the extirpation is easy and without pain. When the young girl was cured the sensation •of stitching had disappeared and the voice was as before. OBSERVATION VI. (Unpublished, Dr. A. Castex.) Miss E. v., young English girl, 13 years old. No antecedent diseases, but is very often seized with tonsillitis. The young girl feels also a sensation of stitching in the throat and some trouble for the deglutition, but there are no other subjective symptoms. On examining the mouth and the pharynx the tonsils are seen bristled up with small white mycosic points. Nothing on the basis of the tongue nor on the back wall of the pharynx. .il«l 54 HYPERKERATO-MYCOSIS I prescribe hot antiseptic gargles with resor- cin (ifo), and with the forceps I extirpate at each time some.mycosic points. These small white tufts, being extirpated, have the form of tipcats, of nails. After the extirpation with the forceps I had cauterized with the gal vano -cautery all the points of implantation. The tufts had not com- pletely disappeared at the eighth time. M. A. Castex has seen lately four other cases, six in all (two children, a young man, a woman of 40 years old, and two young girls). The dis- ease was always characterized by a trouble or a sensation of stitching in the pharynx. The recovery is difficult. OBSERVATION VII. (Homer M. Thomas, in Med. Rec, N. K, 6th Jan., 1894, and Dr. Fraenkel, of Berlin.) The history of the case as given by the pa- tient, Mrs. C. B., is that during August, 1892, she suffered from a slight irritation of the pharynx. There were white spots on the tonsils which disappearedaftera few days but returned within a couple of weeks. . » OF THE PHARYNX. 55 The physicians consulted called the trouble a mushroom growth, and said it would require two or three treatments a week for some three months to effect a cure. The trea^ nent consisted of a forcible remov- al of the exudate by means of forceps. This method of treatment was attended with severe pain and proved unsatisfactory. The patient, becoming discouraged, consulted Dr. Fraenkel of the Berlin University in No- vember. At that time he found spots covering the tonsils and extending to the root of the tongue. His treatment consisted of swabbing the throat two or three times a week with a five per cent, solution of carbolic acid, and he recom- mended that the throat be gargled two or three times a day with pure brandy. Under this treatment the throat seemed to grow somew^hat better, but stil. le disease was not wholly eradicated. Having been called to this city (Chicago), Mrs. B. came under my care, January 4, 1893, at which time pharyngo-mycosic deposit was very extensive upon the posterior pillars of the fauces and invaded the root of the tongue, al- most completely coveting it, and there were 5^ HYPERKERATO-MYCOSIS extensive deposits upon the tonsillar sub- stance. After having confirmed the diagnosis as made by Dr. Fraenkel through microscopic ex- amination of the deposit, I advised treatment, to consist of the rough application of the gal- vano-cautery. The electrode selected was one made for me in Vienna, and consisted of a very fine elon- gated platinum point which enabled me to introduce it directly into each one of the crypts of the tonsil affected by the disease, and also to eradicate the punctated growths at the base of the tongue. At first only three or four punctures were made at each treatment, the treatments occur- ring three times a week. As the patient grew more tolerant of the irritations following the use of the galvano-cautery, the number of punctures per treatment were increased until I frequently applied the cautery to eight or ten of the mycotic masses at each treatment. The effect secured has been satisfactory to the extent that the disease has not reappeared in any of the foci cauterized. ^' OF THE PH/ RYNX. 57 CONCLUSIONS. ^^ Hyper kerato-mycosis of the pharynx^' was observed and studied for the first time in 1873, by B. Fraenkel, of Berlin. Very few observations were mr^e until 1888, when the disease being better known was noted more often. This disease is characterized by the appear- ance of small white points, looking like mush- rooms, or "Capuchin's bearb," or the heads of nails, which come on the tonsils, the base of the tongue, and sometimes on the back wall of the pharynx, and the epiglottis, etc. Generally these small white points contain various microbes, such as leptothrix buccalis, nigrities linguae, o'ldium albicans, bacillus fas- ciculatus, aspergillus, fumigatus, etc., in a corneous tissue. These white hyperkerato-mycosic points are very difficult to remove; often reappearing after twenty-four hours. The subjective symptoms are not always pres- ent; but when they are present, they are mani- fested by a tickling and sometimes a pricking gS HVPERKERATO-MYCOSIS sensation, accompanied with uneasiness and a pain when swallowing. The etiology is very obscure. The disease is more prevalent to invalids, and particularly to those having already had inflammations of the throat. This disease is most often found in women, between the ages of 15 and 30 years. The diagnosis is simple; the symptoms being both chronic and benignant, in which this dis^ ease differs from the other diseases of the throat. Prognosis is benignant. The treatment consists of picking off the hyperkerato-mycosic points, followed by cau- tery; at the same time, gargling with hot solu- tion of resorcin (i %.) t f ► \ OF THE PHARYNX. 59 f » 4 BIBLIOGRAPHY. A. Colin: Archives de Laryngologie^ 1896, p. 451. Brown-Kelly (A.) : Glasgow Medical Journal , 1896. C apart: Revue de Laryngologie, Rhinologie et Otologic, p. 502. Colin (Albert): De la mycose leptothrixique pharyng^e^ J. Steinhell, 1893. Creswell-Baber: British Medical Journal, August 22, 1887,. p. 88. Downie (Walker) : Glasgow Medical Journal ^ 1897, XLiii, pp. 370-372. Forestier ( H . ) : A re hives de Laryngologie, e tc, 1896, p. 770. Frederick-Knight: Revue de Laryng., 1892, p. 676. Garel: Annates de Laryng,^ Rhi. and Oto., 1893, p. 621. Gautier: Journal of Laryngology, etc., No. i^ 1889. Goris: Revue de Laryng., Rhi. et Oto.^ No. 10, 1889. Hamilton, (T. K.): Austral. Medical Gaz., 1894, p. 197. 6o HYPERKF.RATO-MYCOSIS H e men way : Ch icago Medical Recorder, J an . , 1892. Hemenway: Revue de Laryng.^ Rhi., etc., p. 4S5. Higguet, (of Brussels): Revue de Laryngo. Rhin. et Oto., 1892, p. 415. Homer, (Thomas): N. V. Medical Record, January 6, 1894. Journal of Laryngology, etc., No. 2, 1887, p. 61. Journal of Laryngology, etc., No. 4, 1888. Journal of Laryngology, etc., No. 5, 1888. Krauss, (Eugene): Bulletin Mddical, March, 1893. Labit: Revue de Laryngologie, Rhinologie et Otologic, 1893, p. 168. Lennox- Brown: Trait e des Maladies du Larynx^ p. 244. Lober: Bulletin Medical du Nord., No. 6, 1888. Debove et Archard: Manuel de Mcdecine, tome V, p. 163. Mendes-Bonito: Thesis of Bordeaux, 1887-88. Moure, (J.): Congress of Oran, March 30, 1888. Nykamp: Annates des maladies de Voreille-, etc., 'S88, p. 324. Range: Annates de laryngologie, Rhinologie et Otologic, 1893. Royet: Echo medical de I^yon, August 15, 1896. ! I OF THE I'HARYNX. 6l Ruault: Annates de Laryngologie, Rhinologie et Otologic, {My cose amygdaticnne), 1893. Sokolowski: Journal of Laryng., February, 1892. Vanderpool: New York If d. Journ., Febru- ary 9, 1889. Webster: Journal of Laryngo., etc., Feb- ruary, 1892. ' "^fJY^iaMfs " Cr % ^-'^.X^^'' :^^!$ff;X.g^P''i;