266 THE INDIAN MEDICAL GAZETTE. [May, 1927.

SUNDRY CASES. (1) KERATOSIS

HARYNGIS AND LARYNGIS. (2) LONG SOJOURN OF A FOREIGN BODY IN (ESOPHAGUS. (3) A CASE OF

LIVER ABSCESS BURSTING INTO THE

RIGHT LUNG.

By F. H. B. NORRIE, m.b., ch.M., F.R.c.s. (E.)?

Medical Officer, The Angus Co., Ltd., Hooghly, Bengal.

Case 1.?Keratosis Pharyngis and Laryngis.

This condition would appear to be of sufficient rarity to warrant the publication of the following notes.

Miss S., aged 28, of Calcutta, consulted me about 8 months ago on account of some stuffiness in the nose, particularly on the left side, with post-nasal discharge. There was

slight enlargement of both inferior turbinates, and some clear mucus post-nasally. There did not appear to be any infection of t'he nasal sinuses. The tonsils were buried, but other- wise healthy.

The condition then cleared up after several

applications of cocaine and a menthol spray.

About two months ago, she again consulted

me on account of a pricking sensation in her throat, and some huskiness of her voice at

night. There were numerous greyish-white spots on both tonsils, varying in size from a small pin's head to twice the size of a vesta match-head. These could not be mopped off, as they were firmly adherent to the underlying tissues. A diagnosis of keratosis pharyngis was made, and specimens were taken with a

view to confirming this. The sections of the removed tissues showed collections of heaped- up epithelial cells.

The patient was given Mandl's paint to

apply locally, and advised with regard to the nature of the condition. Since then the number of the spots has increased, and there are now several on t'he lingual tonsil and ary- epiglottic folds. Apart from the pricking sensation in her throat, which has not

diminished, there are no other symptoms.

Keratosis pharyngis is not a common condi- tion, but is less uncommon than keratosis

laryngis. Logan Turner states that the condi- tion is not a serious one and that it should not be interfered with, as it tends to dis-

appear spontaneously, and treatment does not help. Our experience would tend to confirm this as now the right tonsil, from which the specimens were obtained, has 4 or 5 times the number of spots appearing on the left. This condition might be mistaken on a cursory examination for chronic lacunar ton- sillitis, but a probe or swab will quickly decide this.

Case 2.?Long Sojourn of a Foreign Body in the

Oesophagus. The patient, a Hindu female child, aged 3^

years, was brought to the dispensary on Septem- ber 3rd, 1926 with the history that she had swal- lowed a pice * two months previously. Since

then she had had difficulty in swallowing solid food and had become very thin. The child looked poor and ill-nourished, but had no fever, dysphagia, or dyspnoea.

The patient was screened antero-posteriorly and a circular foreign body was seen just above the supra-sternal notch. Laterally, it

was seen that the foreign body was flat and that its upper end was tilted forwards. The

size corresponded wit'h a pice, and the position to the oesophagus at the entrance to the thora-

cic cavity.

Under chloroform, laryngoscopy was per- formed with a Jackson's speculum. There

was no apparent oedema of the tissues, but some excess of secretion, which was removed by suction. The coin, with the upper edge tilted forwards, was seen lying below t'he crico-

pharyngeus. The lumen of the oesophagus was reduced to a small semilunar slit

anteriorly. The position was rectified, and the coin,

which was firmly embedded, removed with a

Jackson's lateral grasping forceps. An at-

tempt was made with a toothed forceps, but unfortunately this slipped. The coin was dis-

coloured and partly eroded. The site w'hich it

occupied was ulcerated, but not to a marked

extent. The child was given a mixture con- taining bismuth to take before meals.

This case is perhaps of interest owing to the length of time the pice had been in situ, and from the fact that, although only a small lumen remained with the coin sloped from before backwards and above downwards, thus

forming a pocket with the posterior oesopha- geal wiall, yet the child had survived so long with dysphagia and emaciation as the only symptoms. According to Jackson such

foreign bodies may remain in situ for a con-

siderable time without causing any marked

symptoms, but eventually they cause death unless removed. Removal or attempted removal with a coin-catcher is a most

dangerous procedure.

Jackson states that more harm is done by ill-advised and ill-directed attempts at removal than by the foreign body itself.

The following up of cases in India is almost impossible, and since this child was brought

* For the benefit of readers overseas, we may remark that a

"

pice" is a copper coin of about 24 millimetres in diameter.?Ed., I.M.G.

May, 1927.] SUNDRY CASES: NORRIE. 267

from a village some sixteen miles away it is Irnprobable that we will be able to see her again, with a view to relieving hereof a steno- SIS which is likely to occur. Case 3.?Patient No. 119. Angus Hospital. Laksham Mia, aged 50, Mahommedan male,

an inhabitant of Alakbani, Pipra Police

Ration, Matihari District, was admitted to

hospital on the 21st June 1926 with the follow- ing symptoms:

. (?) Pain and considerable (bulging in the rig"ht hypochondriac region.

(^) Severe convulsive cough, and reddish >rown expectoration. (c) Fever.

(d) General emaciation. He is a weaver in the Hessian Department of the Angus Jute Mill. He smokes tobacco,

but does not drink alcohol. He has lived in Pucca coolie lines for the last 6 years, and takes an ordinary mixed Mahommedan diet. In his youth he drank tari (toddy) for 2 years. About 4 years ago he suffered from dysentery, which lasted for a month, and for which he was

treated by a liakim in his village. About

^ rnonths ago he suffered from remittent fever for days. After that he experienced severe pain ln the right hypochondriac region. The pain

^vas continuous for 3 weeks and he was treated with quinine with no benefit. Liater,

^

he

developed a cough with reddish expectoration, j*nd the pain was lessened to some extent. He had expectorated pus mixed with blood for 30ut a week before admission.

Present condition on admission.?The patient complains of a dull, aching pain in the right hypo- c tandrium, extending to the right shoulder, with L^derness on pressure over the hepatic aiea. 1 he right lobe of the liver is enlarged upwards, whilst its lower margin can ibe felt 3 inches below * ie costal margin. The temperature is normal in

morning, but rises in the afternoon, some- nies with a rigor, to 100? 101?F. He has

Profuse perspiration. The face is pale, com- P'exion muddy, and the conjunctivas bile- gained. The 4th, 5th, 6th and 7th right inter- costal spaces bulge outwards in the axillary lr,e. Cough with brick red expectoration continues.

Respiration is increased to 30 per minute. Hie lower two-thirds of the chest bulges out-

wards, and movement is diminished. Vocal remitus is diminished on the right side. On

Percussion the liver dulness commences on the

r,ght side from the 3rd intercostal space in the nipple

line. ? cti, mid- ? JU1

? " ... i-

axillary line. ? 7th ? ? scapular

line.

The breath sounds are diminished on the

right side. Riales and rhonchi are heard over the lower half of the right lung. No tubercule bacilli were found in the

sputum, which contained numerous pus and blood cells. The cardiac apex beat was in the normal position; the pulse 70 per minute, the rhythm irregular, volume small, and tension low. The total leucocyte count was 22,000 per c.mm. With regard to the alimentary system the appetite was diminished, the bowels irregular. The breat'h was offensive, and

gingivitis was present, whilst the tongue was thickly coated. The abdomen was sunken, but there was

bulging present in the right hypochondriac region, with diminished movement of the

diaphragm. There was dulness over the bulg- ing area, as well as in the upper part of the

right lumbar region. Examination of the stools showed cysts of

Entamoeba histolytica and vegetative and

encysted forms of Giardia intestinalis. The

urine had a specific gravity of 1022, was

alkaline, and showed albumin. Excess of

phosphates was present in the deposit, together with numerous blood cells and some pus cells.

Diagnosis.?It was obvious from the above

picture that we were dealing with a case of amoebic abscess of the liver which had ruptured into the right lung.

Treatment (a) Surgical.?Under novocaine anesthesia a needle was inserted in the 8th intercostal space in the axillary line

posteriorly on the 21st June, and pus wias

found. An opening was made along t'he course of the needle and two drainage tubes inserted in the intercostal space. Irrigation of the wound was carried out with eusol every 3rd or 4th day according to the condition of the discharge, and was continued for 3 weeks.

(b) Medical.?A course of emetine hydro- chloride, 1 grain subcutaneously every alter- nate day, was commenced from the 2nd day after operation. In the intervals between

injections stovarsol was given, 2 tablets at

night. He received in iall 8 injections of emetine and 16 tablets of stovarsol. He was

put on, cod liver oil and creasote from the date of admission. Within a few days of operation the patient's

general condition improved and the blood- stained expectoration ceiased. For a purulent discharge from the wound which persisted, he was given an autogenous vaccine of strepto- cocci and staphylococci intradermally twice a week from July 20th for 18 days. The

patient was discharged cured on the 13t'h August 1926.

I am indebted to Dr. K. M. Chakravartty for the notes on these cases.