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THE Mitchell Lecture [ABRIDGED] ON TUBERCULOSIS OF THE LARYNX :
948
SIR STCLAIR THOMSON: TUBERCULOSIS OF THE LARYNX.
early stage of the disease. These are cases with limited lesions and, at this period, might well be called " favourable." In severe cases the proportion mounts up to 18-3 per cent., while in the advanced type of disease which forms Group III. of the Turban-Gerhardt [ABRIDGED] classification the proportion of laryngeal disease is ON almost double-viz., 31-5 per cent. Both women and men are increasingly liable to a laryngeal lesion TUBERCULOSIS OF THE LARYNX : with the progress of the pulmonary disease. Only ITS SIGNIFICANCE TO THE PHYSICIAN. 1 out of every 20 poitrinaires with an early lesion is Delivered before the Royal College of Physicians, London, on liable to throat trouble ; in more serious cases-i.e., those in Group II. of the Turban-Gerhardt classificaNov. 6th, 1924, tion-the proportion may be 1 in 5 ; and in the BY SIR STCLAIR THOMSON, M.D. LOND., advanced cases of Group III. 1 patient in every 3 F.R.C.S. ENG., will have the disease in the larynx. This developCONSULTING SURGEON, DISEASES OF THE THROAT, KING’S COLLEGE ment, as will soon be shown, diminishes so markedly HOSPITAL ; LARYNGOLOGIST, KING EDWARD VII. SANATORIUM, the prospect of recovery that it emphasises the great MIDHURST. of diagnosing pulmonary tubercle in its and persuading the patient to submit to stage early TUBERCULOSIS is the most important disease with best treatment. which humanity has to cope. There is no other of Larynx Attacked.-It is quite certain that Region specific disease so common in the larynx. As the the favourite site is the neighbourhood of the posterior 106,990 cases of laryngeal tuberculosis in this country commissure-i.e., the interarytenoid area, the anterior to-day must look principally to the physician forsurface of the arytenoid body and the vocal processes. guidance and help, it is well worth while considering The vocal cords come next in frequency, while the what assistance in his task can be offered by a epiglottis and the region of the anterior commissure laryngologist who, during a period of 10 years, has are attacked more rarely and are generally late extencarefully watched the progress of 477 instances of of the disease. in 2541 patients with pulmonary laryngeal disease 1 1:’rognost’W Value of ’L’uberC1ÛOS1.S of the Larynx in tuberculosis. Regard to Mortality. Proportion of Laryngeal Cases in Pulmonary Of much importance to the general physician is an Tuberculosis. appreciation of what tuberculosis in the larynx counts In the early years of this period 1 case out of for in regard to the mortality of pulmonary cases. every 4 had trouble in the larynx, while the average Of the 2541 patients with pulmonary tuberculosis of the whole decade showed a proportion of 18-77 per who were discharged from the King Edward cent. These patients were seen in a sanatorium and Sanatorium, Midhurst, between 1911 and 1921, the were, relatively, early cases, for the records of the proportion of those alive between one and ten years post-mortem room show that the larynx is diseased later was, amongst those with a sound larynx, double in 48 to 83 per cent. of all fatal cases. that of those with tuberculous laryngitis. Of patients Suggestive Symptonts.-The two most suggestive found to have tubercle in the larynx during these symptoms are, first, slight but persistent huskiness, ten years, 2 out of every 3 were dead. Of those and secondly, discomfort referred to the throat or with a sound larynx it is the reverse-2 out of 3 even pain in swallowing. Of all the 477 cases of laryngeal were still alive. The latter is a symptom which is more frequent tuberculosis which passed through my service at with advanced cases ; therefore, for the all-important Midhurst between 1911 and 1921 no less than 70-5 per attainment of an early diagnosis, any hoarseness or cent. are now dead. This darkening of the prognosis any slight change in voice which does not clear up in occurs in all stages of the disease. two or three weeks should rouse suspicion and entail Put in another way, a Group I. patient-i.e., a an expert examination of the larynx. But we must " slight " case-with a laryngeal lesion has a worse not forget that tubercle occasionally invades the prospect than a Group II. case with a sound larynx. larynx without causing the slightest alteration of And a Group II. case-i.e., a " severe " case-with voice or any other local symptom. Of the 477 cases throat trouble has a gloomier expectation than if he of laryngeal tuberculosis I found no less than 57 had had a healthy larynx but lungs so invaded as to (34 men and 23 women) who had no complaint of their be classed in Group III.-i.e., an " advanced " case. throat and whose voices, both to their own ear and Therefore laryngeal tuberculosis cannot be listed in to mine, sounded quite clear and normal. any group which might be termed " slightor Proportion of Laryngeal Cases in Relation to Sex.- " favourable." Its discovery at once labels a case as It used to be thought that the female sex was less " severe," and authorises a physician -to warn Ms subject than the male to contract pulmonary tuber- client that treatment will necessarily, even in the culosis. But it has been shown that any difference most hopeful cases, be long and arduous. In only between the sexes in this respect is not, as regards too many instances-in 70-5 per cent. of my fairly tubercle, due to any sexual predisposition but simply favourable selection-it will be his duty to advise the to the fact that, until recent times, women have led friends that the prospect of a recovery is so slight that a more sheltered life and have been less exposed both it may be unjustifiable to submit the sufferer to any to fatigue and to infection than men who work in trying, dangerous, or expensive treatment. office or factory. When both sexes are exposed to l £ esictts of 1’reatment. the same conditions, woman is just as subject to Let us now turn to the record of 119 cures. To in or as tuberculosis (in lungs man ; perhaps larynx) The conclusion is that, amongst bread- appraise them at a fair value I may be permitted to more so. winners, we must be prepared to find tubercle just as say that such a large total of well-authenticated cases healing in a larynx with tuberculosis has never frequently in the larynx of the female as of the male. of Another is that man’s greater indulgence in alcohol before been published in this country. The satisand tobacco does not seem to render his larynx faction of quoting this record is enhanced when I recall that in 1880 Morell Mackenzie wrote : " The more vulnerable to tuberculosis. of laryngeal phthisis is always extremely in Relation to Cases prognosis Stage Proportion of Laryngeal of Pulmonary Disease.---It has long been established unfavourable, and it is not certain that any cases that the frequency with which the larynx is invaded ever recover." A complete repair of the larynx has increases with the progress of the pulmonary disease. been obtained in no less than 25 per cent. of patients with tuberculous laryngitis. This may occur even in 4-8 per cent. of cases CurvesHow Obtained.-I have no doubt that the StClair Thomson ; Tuberculosis of the Larynx. Ten Years’ Experience in a Sanatorium. Medical Research Council. H.M. principal factor in obtaining these arrests has been sanatorium regirrae and the prompt prescription of one Stationery Office. 1924. 2s. 6d. THE
Mitchell Lecture
importance
: Ithe
sions
’
in an
1
DR. W. T. BENSON: or more
DIPHTHERIA PREVENTION.
949
surgical methods of cure have all been abandoned useless and frequently harmful. The galvano-cautery is the best local treatment we have at present. In suitable cases it has replaced all
of the three chief methods of local treatment-
Local
viz., whispers, silence, and the galvano-cautery. Fifty patients were cured, so far as local measures are concerned, by the simple reduction of voice use entailed by whispers." Complete silence resulted in a cure in 23 instances, or in 34’3 per cent. of the Women give a slightly cases in which it was ordered. higher percentage of cures, both with whispers and silence, their greater patience and endurance-or
by
"
me as
other methods. It effected a cure in 46 out of 74 cases in which it was tried(= 62’1 per cent.). Of these 46 cures, 29 are alive and well; 12 of them have now maintained their cure for 10 years.
Conclusions. The majority of cases of tuberculosis of the larynx do not recover. It is necessary for the physician to recognise this ; to try and determine which cases come within this category, and to act accordingly. But these 119 cures are witnesses of the more hopeful outlook we now have for a fair proportion of patients of whom an authority has said that, 45 years ago, " all were doomed to die : the appearance of the disease The in the larynx was the warrant of death."22 pessimistic past has now a more optimistic outlook.
recovery power ?-being most neiteworthy in the ordeal The galvano-cautery yielded of the silence cure. 46 cures. Lasting Laryngeal Cures.-Of the 119 cases in which complete healing took place in the larynx, 69 are alive at periods varying from 2 to 10 years afterwards. Fifty are dead, and they have died, as a rule, with a still cicatrised larynx. Their deaths, usually, were due to the extent or virulence of their pulmonary disease.
Proportionate Progress o Pulmonary and Laryngeal Lesions. The above references to the durability of healing in the larynx, while the disease in the lungs progresses, are sufficient to show that tubercle does not necessarily advance pari passu in both situations. This latter view is still maintained and, as it is not correct, it may occasionally mislead the physician. Improvement very commonly does proceed along parallel lines and, in the same way, a retrogression in one is often followed by progress of the disease in the other. Spontaneous cure has taken place in the larynx in many cases and has been maintained till the patient died of his pulmonary disease years afterwards. But the reverse has never occurred-i.e., I have never seen a larynx getting worse while the pulmonary disease has improved. It has occasionally, in such instances, been reported to me that the lung trouble was in statu quo ; but, if the larynx did not mend, the pulmonary disease inevitably, within a definite period, took on
DIPHTHERIA PREVENTION. THE
SCHICK TEST AND ACTIVE IMMUNISATION VARIOUS SCHOOLS AND INSTITUTIONS IN THE CITY OF EDINBURGH.
BY W. T. BENSON, B.SC. ST. AND., M.D. D.P.H. CAMB., D.T.M. & H. LOND., ASSISTANT
MEDICAL
OFFICER
OF
IN
EDIN.,
HEALTH.
Introduction by WM. ROBERTSON, M.D. Glasg., D.P.H., F.R.C.P. Edin., MEDICAL OFFICER OF HEALTH.
AT the recent Conference of the Royal Sanitary Institute, held at Liverpool, the fear was expressed, or implied, that the introduction of the Schick test and the consequent immunisation of susceptible activity. This is useful knowledge for the physician. A subjects by means of toxin-antitoxin would not larynx may improve or get well, while the lung disease meet with much success in this country. The reason remains quiescent or gets worse ; but if the disease in offered was that our people had not been educated the larynx advances the pulmonary disease cannot to the need for the procedure. If we had adopted possibly become arrested and soon makes progress. such a non possumus attitude in Edinburgh we This again shows the value to the physician, from the should possibly have shared the pessimism expressed point of prognosis, of periodic examination of the during the discussion of Dr. R. A. O’Brien’s excellent contribution. It is a mistake to underrate the intellilarynx. Tuberculosis in the larynx is always a serious gence and interest of the citizens of our respective complication of pulmonary disease. Physicians would administrative areas. They are keenly alive to the be well advised, therefore, to assure themselves of its importance of prevention of disease. It was with presence or absence in any case of tuberculosis. If that knowledge in my mind that a campaign of present, it adds considerably to the seriousness of the diphtheria prevention was begun in the Leith district. prognosis and to the prolongation of the case and The response to our appeal for cooperation was most time required for successful treatment, even in cases encouraging. Dr. Benson, my assistant, at once set otherwise early and promising. When the laryngeal to work and the results detailed in his valuable lesion is extensive and active, the outlook is particularly contribution should act as an incentive to others to serious. If the lesion is limited and becomes inactive, go and do likewise. It is not work that can be lightly it may be arrested, although the prospect of life may undertaken. Careful readings must be made by those not be great. who have studied a considerable number of reactions. From prolonged observations on nearly 500 sana- Objections will naturally be offered to the procedure. torium patients, a cure of the laryngeal lesion may be We have experienced them. secured in 1 out of every 4 patients. These were, Every effort was made by the " antis " to cast comparatively speaking, early cases. But a much doubt on the value and safety of the various applicahigher proportion of cures could certainly be obtained tions that were required. The most was made of if more cases of pulmonary tuberculosis were diagnosed accidents that had occurred in America and that while they are still Group 1. patients-i.e., with only had been duly explained. The members of the school 4’8 per cent. showing laryngeal lesions-instead of authority were circularised, the press was tried, and Group III.-i.e., with 31’5 per cent. with the larynx the members of the public health committee were involved. More cures could be effected if every case of tempted, but no difficulties confronted us as a result persistent huskiness or throat discomfort were earlier of the attempted obstruction. I feel confident the submitted to a skilled examination. results will convince hesitating parents that the is not only safe but also wise. During the procedure Principles of Success in Treatment. winter months the campaign will be conensuing It is manifest that a patient has a more sure hope tinued, and when more facts are available they will of a quicker cure inside a well-conducted sanatorium be published. The figures given by Dr. W. H. Park, of than he can expect otherwise. The chief local New York, together with Dr. A. Zingher’s interesting requirement is voice rest, which can be so easily carried data, were so convincing that no doubt was left in out in a sanatorium, but is elsewhere so difficult. mind as to the need for doing more to reduce Out of 119 cases which were cured, the healing wasI my the incidence of diphtheria than the swabbing of obtained without other local treatment than voice rest (whispers or silence) in no less than 73 instances. 2 J. Nolan Mackenzie : Jour. of Laryn., 1916, xxxi., 411.
I
SIR STCLAIR THOMSON: TUBERCULOSIS OF THE LARYNX.
early stage of the disease. These are cases with limited lesions and, at this period, might well be called " favourable." In severe cases the proportion mounts up to 18-3 per cent., while in the advanced type of disease which forms Group III. of the Turban-Gerhardt [ABRIDGED] classification the proportion of laryngeal disease is ON almost double-viz., 31-5 per cent. Both women and men are increasingly liable to a laryngeal lesion TUBERCULOSIS OF THE LARYNX : with the progress of the pulmonary disease. Only ITS SIGNIFICANCE TO THE PHYSICIAN. 1 out of every 20 poitrinaires with an early lesion is Delivered before the Royal College of Physicians, London, on liable to throat trouble ; in more serious cases-i.e., those in Group II. of the Turban-Gerhardt classificaNov. 6th, 1924, tion-the proportion may be 1 in 5 ; and in the BY SIR STCLAIR THOMSON, M.D. LOND., advanced cases of Group III. 1 patient in every 3 F.R.C.S. ENG., will have the disease in the larynx. This developCONSULTING SURGEON, DISEASES OF THE THROAT, KING’S COLLEGE ment, as will soon be shown, diminishes so markedly HOSPITAL ; LARYNGOLOGIST, KING EDWARD VII. SANATORIUM, the prospect of recovery that it emphasises the great MIDHURST. of diagnosing pulmonary tubercle in its and persuading the patient to submit to stage early TUBERCULOSIS is the most important disease with best treatment. which humanity has to cope. There is no other of Larynx Attacked.-It is quite certain that Region specific disease so common in the larynx. As the the favourite site is the neighbourhood of the posterior 106,990 cases of laryngeal tuberculosis in this country commissure-i.e., the interarytenoid area, the anterior to-day must look principally to the physician forsurface of the arytenoid body and the vocal processes. guidance and help, it is well worth while considering The vocal cords come next in frequency, while the what assistance in his task can be offered by a epiglottis and the region of the anterior commissure laryngologist who, during a period of 10 years, has are attacked more rarely and are generally late extencarefully watched the progress of 477 instances of of the disease. in 2541 patients with pulmonary laryngeal disease 1 1:’rognost’W Value of ’L’uberC1ÛOS1.S of the Larynx in tuberculosis. Regard to Mortality. Proportion of Laryngeal Cases in Pulmonary Of much importance to the general physician is an Tuberculosis. appreciation of what tuberculosis in the larynx counts In the early years of this period 1 case out of for in regard to the mortality of pulmonary cases. every 4 had trouble in the larynx, while the average Of the 2541 patients with pulmonary tuberculosis of the whole decade showed a proportion of 18-77 per who were discharged from the King Edward cent. These patients were seen in a sanatorium and Sanatorium, Midhurst, between 1911 and 1921, the were, relatively, early cases, for the records of the proportion of those alive between one and ten years post-mortem room show that the larynx is diseased later was, amongst those with a sound larynx, double in 48 to 83 per cent. of all fatal cases. that of those with tuberculous laryngitis. Of patients Suggestive Symptonts.-The two most suggestive found to have tubercle in the larynx during these symptoms are, first, slight but persistent huskiness, ten years, 2 out of every 3 were dead. Of those and secondly, discomfort referred to the throat or with a sound larynx it is the reverse-2 out of 3 even pain in swallowing. Of all the 477 cases of laryngeal were still alive. The latter is a symptom which is more frequent tuberculosis which passed through my service at with advanced cases ; therefore, for the all-important Midhurst between 1911 and 1921 no less than 70-5 per attainment of an early diagnosis, any hoarseness or cent. are now dead. This darkening of the prognosis any slight change in voice which does not clear up in occurs in all stages of the disease. two or three weeks should rouse suspicion and entail Put in another way, a Group I. patient-i.e., a an expert examination of the larynx. But we must " slight " case-with a laryngeal lesion has a worse not forget that tubercle occasionally invades the prospect than a Group II. case with a sound larynx. larynx without causing the slightest alteration of And a Group II. case-i.e., a " severe " case-with voice or any other local symptom. Of the 477 cases throat trouble has a gloomier expectation than if he of laryngeal tuberculosis I found no less than 57 had had a healthy larynx but lungs so invaded as to (34 men and 23 women) who had no complaint of their be classed in Group III.-i.e., an " advanced " case. throat and whose voices, both to their own ear and Therefore laryngeal tuberculosis cannot be listed in to mine, sounded quite clear and normal. any group which might be termed " slightor Proportion of Laryngeal Cases in Relation to Sex.- " favourable." Its discovery at once labels a case as It used to be thought that the female sex was less " severe," and authorises a physician -to warn Ms subject than the male to contract pulmonary tuber- client that treatment will necessarily, even in the culosis. But it has been shown that any difference most hopeful cases, be long and arduous. In only between the sexes in this respect is not, as regards too many instances-in 70-5 per cent. of my fairly tubercle, due to any sexual predisposition but simply favourable selection-it will be his duty to advise the to the fact that, until recent times, women have led friends that the prospect of a recovery is so slight that a more sheltered life and have been less exposed both it may be unjustifiable to submit the sufferer to any to fatigue and to infection than men who work in trying, dangerous, or expensive treatment. office or factory. When both sexes are exposed to l £ esictts of 1’reatment. the same conditions, woman is just as subject to Let us now turn to the record of 119 cures. To in or as tuberculosis (in lungs man ; perhaps larynx) The conclusion is that, amongst bread- appraise them at a fair value I may be permitted to more so. winners, we must be prepared to find tubercle just as say that such a large total of well-authenticated cases healing in a larynx with tuberculosis has never frequently in the larynx of the female as of the male. of Another is that man’s greater indulgence in alcohol before been published in this country. The satisand tobacco does not seem to render his larynx faction of quoting this record is enhanced when I recall that in 1880 Morell Mackenzie wrote : " The more vulnerable to tuberculosis. of laryngeal phthisis is always extremely in Relation to Cases prognosis Stage Proportion of Laryngeal of Pulmonary Disease.---It has long been established unfavourable, and it is not certain that any cases that the frequency with which the larynx is invaded ever recover." A complete repair of the larynx has increases with the progress of the pulmonary disease. been obtained in no less than 25 per cent. of patients with tuberculous laryngitis. This may occur even in 4-8 per cent. of cases CurvesHow Obtained.-I have no doubt that the StClair Thomson ; Tuberculosis of the Larynx. Ten Years’ Experience in a Sanatorium. Medical Research Council. H.M. principal factor in obtaining these arrests has been sanatorium regirrae and the prompt prescription of one Stationery Office. 1924. 2s. 6d. THE
Mitchell Lecture
importance
: Ithe
sions
’
in an
1
DR. W. T. BENSON: or more
DIPHTHERIA PREVENTION.
949
surgical methods of cure have all been abandoned useless and frequently harmful. The galvano-cautery is the best local treatment we have at present. In suitable cases it has replaced all
of the three chief methods of local treatment-
Local
viz., whispers, silence, and the galvano-cautery. Fifty patients were cured, so far as local measures are concerned, by the simple reduction of voice use entailed by whispers." Complete silence resulted in a cure in 23 instances, or in 34’3 per cent. of the Women give a slightly cases in which it was ordered. higher percentage of cures, both with whispers and silence, their greater patience and endurance-or
by
"
me as
other methods. It effected a cure in 46 out of 74 cases in which it was tried(= 62’1 per cent.). Of these 46 cures, 29 are alive and well; 12 of them have now maintained their cure for 10 years.
Conclusions. The majority of cases of tuberculosis of the larynx do not recover. It is necessary for the physician to recognise this ; to try and determine which cases come within this category, and to act accordingly. But these 119 cures are witnesses of the more hopeful outlook we now have for a fair proportion of patients of whom an authority has said that, 45 years ago, " all were doomed to die : the appearance of the disease The in the larynx was the warrant of death."22 pessimistic past has now a more optimistic outlook.
recovery power ?-being most neiteworthy in the ordeal The galvano-cautery yielded of the silence cure. 46 cures. Lasting Laryngeal Cures.-Of the 119 cases in which complete healing took place in the larynx, 69 are alive at periods varying from 2 to 10 years afterwards. Fifty are dead, and they have died, as a rule, with a still cicatrised larynx. Their deaths, usually, were due to the extent or virulence of their pulmonary disease.
Proportionate Progress o Pulmonary and Laryngeal Lesions. The above references to the durability of healing in the larynx, while the disease in the lungs progresses, are sufficient to show that tubercle does not necessarily advance pari passu in both situations. This latter view is still maintained and, as it is not correct, it may occasionally mislead the physician. Improvement very commonly does proceed along parallel lines and, in the same way, a retrogression in one is often followed by progress of the disease in the other. Spontaneous cure has taken place in the larynx in many cases and has been maintained till the patient died of his pulmonary disease years afterwards. But the reverse has never occurred-i.e., I have never seen a larynx getting worse while the pulmonary disease has improved. It has occasionally, in such instances, been reported to me that the lung trouble was in statu quo ; but, if the larynx did not mend, the pulmonary disease inevitably, within a definite period, took on
DIPHTHERIA PREVENTION. THE
SCHICK TEST AND ACTIVE IMMUNISATION VARIOUS SCHOOLS AND INSTITUTIONS IN THE CITY OF EDINBURGH.
BY W. T. BENSON, B.SC. ST. AND., M.D. D.P.H. CAMB., D.T.M. & H. LOND., ASSISTANT
MEDICAL
OFFICER
OF
IN
EDIN.,
HEALTH.
Introduction by WM. ROBERTSON, M.D. Glasg., D.P.H., F.R.C.P. Edin., MEDICAL OFFICER OF HEALTH.
AT the recent Conference of the Royal Sanitary Institute, held at Liverpool, the fear was expressed, or implied, that the introduction of the Schick test and the consequent immunisation of susceptible activity. This is useful knowledge for the physician. A subjects by means of toxin-antitoxin would not larynx may improve or get well, while the lung disease meet with much success in this country. The reason remains quiescent or gets worse ; but if the disease in offered was that our people had not been educated the larynx advances the pulmonary disease cannot to the need for the procedure. If we had adopted possibly become arrested and soon makes progress. such a non possumus attitude in Edinburgh we This again shows the value to the physician, from the should possibly have shared the pessimism expressed point of prognosis, of periodic examination of the during the discussion of Dr. R. A. O’Brien’s excellent contribution. It is a mistake to underrate the intellilarynx. Tuberculosis in the larynx is always a serious gence and interest of the citizens of our respective complication of pulmonary disease. Physicians would administrative areas. They are keenly alive to the be well advised, therefore, to assure themselves of its importance of prevention of disease. It was with presence or absence in any case of tuberculosis. If that knowledge in my mind that a campaign of present, it adds considerably to the seriousness of the diphtheria prevention was begun in the Leith district. prognosis and to the prolongation of the case and The response to our appeal for cooperation was most time required for successful treatment, even in cases encouraging. Dr. Benson, my assistant, at once set otherwise early and promising. When the laryngeal to work and the results detailed in his valuable lesion is extensive and active, the outlook is particularly contribution should act as an incentive to others to serious. If the lesion is limited and becomes inactive, go and do likewise. It is not work that can be lightly it may be arrested, although the prospect of life may undertaken. Careful readings must be made by those not be great. who have studied a considerable number of reactions. From prolonged observations on nearly 500 sana- Objections will naturally be offered to the procedure. torium patients, a cure of the laryngeal lesion may be We have experienced them. secured in 1 out of every 4 patients. These were, Every effort was made by the " antis " to cast comparatively speaking, early cases. But a much doubt on the value and safety of the various applicahigher proportion of cures could certainly be obtained tions that were required. The most was made of if more cases of pulmonary tuberculosis were diagnosed accidents that had occurred in America and that while they are still Group 1. patients-i.e., with only had been duly explained. The members of the school 4’8 per cent. showing laryngeal lesions-instead of authority were circularised, the press was tried, and Group III.-i.e., with 31’5 per cent. with the larynx the members of the public health committee were involved. More cures could be effected if every case of tempted, but no difficulties confronted us as a result persistent huskiness or throat discomfort were earlier of the attempted obstruction. I feel confident the submitted to a skilled examination. results will convince hesitating parents that the is not only safe but also wise. During the procedure Principles of Success in Treatment. winter months the campaign will be conensuing It is manifest that a patient has a more sure hope tinued, and when more facts are available they will of a quicker cure inside a well-conducted sanatorium be published. The figures given by Dr. W. H. Park, of than he can expect otherwise. The chief local New York, together with Dr. A. Zingher’s interesting requirement is voice rest, which can be so easily carried data, were so convincing that no doubt was left in out in a sanatorium, but is elsewhere so difficult. mind as to the need for doing more to reduce Out of 119 cases which were cured, the healing wasI my the incidence of diphtheria than the swabbing of obtained without other local treatment than voice rest (whispers or silence) in no less than 73 instances. 2 J. Nolan Mackenzie : Jour. of Laryn., 1916, xxxi., 411.
I