Reports of Societies.

THE LOUISVILLE MEDICO-CHIRURGICAL SOCIETY.*

Stated Meeting, February 1, 1901, the President, Louis Frank, M. D., in the Chair.

Chancre of the Tonsil. Dr. S. G. Dabney: A young man came to me in the last few weeks with an ulcer on his tonsil, in a rather unusual situation, because it lay between the right tonsil and the posterior palatine fold. I have long been of the opinion that I heard Dr. J. M. Mathews express before a recent meeting of the Louisville Surgical Society that any well-defined, sharply outlined ulceration of mucous membrane (and this is especially true about the throat) is not a simple affair, but it means either cancer, tuberculosis or syphilis; and as this young man's appearance and his age were absolutely contra-indicative of cancer, and there being absolutely no evidence or history of tuberculosis, I assumed this ulceration was syphilitic.

It did not look like an ordinary tertiary sore, and at first I was considerably at sea as to the exact nature of the trouble. He was given very little in the way of treatment. I gave him small doses of iodide of potassium, rather leaning to the opinion that it was probably an unusual form of tertiary ulceration.

Three weeks after he first came to see me he began having general glandular involvement, the glands of the neck were enlarged, and there was considerable tenderness just above the elbow on one side; I found an enlarged gland there also. He had a pretty well-defined eruption on his skin; a typical secondary eruption somewhere between three and five weeks from the time he first appeared at my office.

In view of these developments, I told the young man I was inclined to think the ulceration in his throat was a chancre, and asked him if he knew of any way by which he had acquired the disease, by drinkingvessel or any thing of that kind. He stated that his room-mate was suffering from syphilis just now, and he recalled having time and again smoked his room-mate's pipe, and it occurred to me that was the mode of transmission of the disease.

This is the first case of chancre of the tonsil that has fallen under my notice, and the young man's symptoms were not absolutely typical of chancre or of syphilis. To confirm the diagnosis I sent him to an

*Stenographically reported for this journal by C. C. Mapes, Louisville, Ky.

experienced genito-urinary specialist. He was also positive that the lesion was a chancre of the tonsil.

I think the case is worth reporting simply as a rare one of chancre of the tonsil, and also to suggest that perhaps we are not always as careful as we ought to be about warning our patients, particularly young men, in regard to accidents such as this young man had. The character of the sore was an ulceration situated between the tonsil and the posterior palatine fold, not very deep, and, as far as I could feel, I can not say that it was very hard. Perhaps the hardness of a chancre may be more difficult to detect in that situation than it would be in the structures of the penis. It was covered with a grayish surface, and was about the size of a five-cent piece.

Discussion. Dr. T. C. Evans: Three or four years ago I reported to one of the Louisville medical societies three cases of chancre of the tonsils, all of which came under my observation within twelve or eighteen months. I had never seen one before and have seen none since. I believe Dr. Ray saw two of the cases with me. One of them was in the person of a young physician, another was in a young laboring man, and the other case occurred in an old lady, aged sixty-three years. She had a rather superficial ulceration of the tonsil; at that age it will be remembered there is not much tonsil tissue left to be involved by a chancre. It was not deep, but extended over a considerable surface. I treated it for a week or ten days, rather under the impression that it might be a tertiary lesion, although she gave no history of syphilis. Secondary eruption was delayed until very late in the disease, coming on probably at the end of the third month after the initial lesion; but when it appeared it was a typical eruption; the old lady had palmar psoriasis, paronychia, etc. A grandchild of this woman contracted the disease, having a chancre of the lip, and went through the typical symptoms. Notwithstanding the fact that she was warned both by the family physician and myself in regard to the danger of kissing this child, or in fact any one else, she evidently thought we did not know what we were talking about; at any rate she paid no attention to our instructions, and the little child developed chancre and went through the typical and characteristic symptoms of the disease. In the chancres of the tonsil that I have seen bubo of the neck has been the most constant and most typical symptom, glandular enlargement of the neck being marked and painful.

I also reported at the same time one case of chancre of the tongue. My experience with extra-genital chancres has been that the syphilis which follows them is more severe than that which follows the ordinary genital chancre.

I am not very familiar with the statistics, but believe that the tonsil is one of the most frequent sites of chancre about the mouth. Next to the lips it appears to be the most common location for chancre. In the cases I saw the induration was not marked, and I do not believe it is a characteristic of chancre of the tonsil to be indurated. In none of my cases did the patient know how the disease had been contracted. The lady stated that some time before coming to see me she had in her employ a servant whom she suspected had syphilis.

In this connection the literature of the subject refutes the old idea that these chancres are contracted by bestial practices; they are in the vast majority of instances accidently contracted.

Dr. J. M. Ray: I have seen three or four cases of chancre about the tonsils. One was an unfortunate case; a young lady was engaged to be married, and, I think, contracted syphilis from her sweetheart, and came to see me with a chancre on the tonsil. A few weeks before the time set for the marriage she had a typical secondary eruption. In all the cases of chancre of the tonsil that I have seen there has been enormous gland infiltration about the neck and in front of the ear.

A young man from Central Kentucky came to me with a large sloughing ulcer of the tonsil; the whole tonsil seemed to be involved in the ulceration, with an enormous gland infiltration starting in front of the ear and running down the side of the neck. This was during the life of the late Dr. Palmer, and I sent the young man to him. The gland in front of the ear became so enormously enlarged that his family doctor thought there was pus in it, and made an incision; but there was no pus, simply a gelatinous mass. It made a very ugly sore, which was a long time getting well.

Another case I saw in the University Dispensary; a young woman from the "red light district," who was pregnant at the time, had a typical chancre of the tonsil; she went through the stage of eruption, etc., and was delivered afterward of a healthy child.

Dr. J. A. Ouchterlony: The reporter did not state whether there. was any elevation of temperature in the case to which he refers. Usually when glandular enlargement has occurred the syphilitic fever is considerable. The most excessive glandular enlargement I have

ever seen in a case of syphilis occurred in a patient at the city hospital not many years ago. It was almost like a case of adenia, and syphilitic fever lasted for a long time. It was so marked (103° to 104° F.) that I reported the case at the time.

Dr. William Cheatham: Some years ago a gentleman came to me with mydriasis. He had been taking trips to Europe a year or two before, and came to me complaining of mydriasis, and later he developed some symptoms of locomotor ataxia. I accused him of having had syphilis, which he denied. Some months after that his wife had a sore on her tongue, and a surgeon in the city had all arrangements made to amputate the tongue, thinking it was an epithelioma; she fell into the hands of one of our syphilographers, who diagnosed chancre of the tongue, and put her on anti-syphilitic treatment, followed by complete recovery. The doctor was doubtful about where the woman contracted the chancre until I told him about having seen her husband some time before with mydriasis, etc. The husband afterward said that the only sore he ever had was on his tonsil.

I saw not long ago a case of chancre of the tonsil in an actress who was playing with a company which passed through here. My experience has been the same as that of Dr. Evans in regard to glandular enlargement associated with chancre of the tonsil; it is very great.

Dr. S. G. Dabney: In the case I have reported the glandular enlargement was not very great; it was very painful, because there seemed to be enlarged lymphatics just under the muscles at the back of the neck, and every time the patient turned his head intense pain would be caused. But the case was not nearly so well defined as those that have been described here to-night, and, as I said, I was sufficiently in doubt to have the opinion of a syphilographer to confirm my diagnosis, because neither the local evidence in the throat nor the glandular involvement was exactly typical, and but for the eruption which developed in due course I would have been inclined to think it was a tertiary lesion.

I did not take the young man's temperature. He remarked a few days ago that he felt very much better than he had a week or two previously. I think probably he had some rise of temperature in the beginning of the glandular involvement.

Fixation of the Kidney through an Abdominal Incision. Dr. A. M. Cartledge: I would like to call attention to a recent experience I have

had with fixing the kidney through an abdominal incision. At the recent meeting of the Southern Surgical and Gynecological Association Dr. McRae reported a case he had operated upon for appendicitis, and found that the patient was also the subject of a displaced and movable right kidney. By extending his incision for the appendicitis operation to the loin he was able to fix the kidney through the same incision without making an additional incision in the usual site for a nephorrhaphy.

In the early part of December I operated upon a young woman who had an undoubted history of several attacks of appendicitis, and she was also the subject of a movable right kidney. The last attack of appendicitis was quite severe, and she was convalescent at the time from that attack. The appendix was removed through the ordinary incision, and I found by extending the incision a little further I was able to strip off the parietal peritoneum from the wall and get in a nice situation for stitching the kidney. I also found that it was much easier to anchor the kidney in this way than through an incision in the loin, which we are in the habit of making. I used chromacized gut, placing in three stitches in the usual way, incising the capsule just as I would had I performed the ordinary operation in the back. I have every reason to believe this procedure will do just as well. The wound was closed without drainage, as I am in the habit of doing when I perform the posterior operation. The patient did uninterruptedly well, and I believe we should adopt this procedure more frequently than we do. We often find movable kidney associated with other troubles about the pelvis and about the appendix. It is entirely feasible. At the time Dr. McRae reported his case I thought the incision would be very long, but such is not the case. By extending the ordinary incision for appendicitis about one inch, using retractors and long forceps, with the hand you can hold the kidney where you want to; you can readily strip up the peritoneum, and suture this way easier than you can by making an incision and getting the kidney in place posteriorly. We may frequently operate upon cases of appendicitis in the female and find that there is a movable kidney by searching for it. In the case I have reported the movable kidney was giving considerable trouble in the intervals. For several years I have been noticing in certain cases of slight irritation about the appendix several layers of thin adhesions about the cecum. In some cases these adhesions are caused by a movable kidney. The constant irritation gives rise to a deposit of