or without associated ridges of lymphoid tissue, is common, while the foliate form is rare.

The variation which I have most frequently seen is a rounded or elliptical mass-of which the largest is also its vertical diameter-placed in the tonsillar space a little above the level of the tongue. The organ is slightly compressed from before backward and consists for the most part of a pocket or crypt-whose walls are greatly thickened-directed

View of the foliated type of tonsil. A, the small velar tonsil; B, the opening of the crypt, the parts below this remaining smooth; C, D, two coarsely nodulated ridges, constituting the folia; E, epiglottis. (After nature.)

downward. The palato-glossal muscle is to be accused of maintaining the compression here named, in some individuals, to a degree sufficient to serve as a complication in tonsillitis. In some persons the tonsil appears to be lodged almost entirely toward the palato-pharyngeal fold and displayed when the mouth is open. It may be composed of two lobate, cryptose masses arranged like two peas in a pod, but without any one of the crypts being larger than its neighbors or having special direction.

The anterior wall of the pocket is covered with mucous membrane (involucrum), which in every way is similar to that lining the pharynx, along the side of which it sometimes extends as far as the tip of the epiglottis. If close inspection be not made, this covering might be confounded with the palato-glossal fold. In such a disposition two surfaces of tonsil tissue must lie exposed toward each other. Above the mouth of the pocket lies a mass which constitutes the " tonsil" of common language. This alone is cryptose.

Very commonly the tonsil above the pocket also exhibits numerous communicating passages. I desire to call special attention to these. They can be demonstrated in the tonsils of children, where they are often long and lie deep in the gland; as well as in the adult, where they are

1 See in this connection Houze de la Aulnoit, "Mém. sur l'estranglement des Amygdales par les Piliers du Voile du Palais," 1864.

more superficial. They may be small yet well-defined, as in a sponge, or imperfectly limited by bridge-like bands, which cross the mouths of wide, shallow crypts. Allusion to these inter-communicating tracts are made by writers; vide Haller, Luschka, Bell, and Asverus, the lastnamed alone recognizing them as morbid. It is evident that they do not exist in the morphological plan of the gland, and, so far as I know, occur in the tonsil of none of the lower animals.

Simple form of the tonsil, showing the crypt and the almond-shaped mass above the opening. A, retractor pressing out the palato-glossal fold; B, probe in opening of the crypt. (After nature.)

It will be recognized that in hypertrophy of the tonsil the lower smooth part is enormously enlarged, and can be readily distinguished by a sulcus from the cryptose mass.

A, small velar tonsil; B, the main tonsil, showing the mouths of two diverticula and a crypt: the last-named being the largest opening on the tonsil. The parts below the mouth of the crypt are smooth and without diverticula. (From nature.)

The almond-shaped structure, therefore, which is so commonly described, is but a portion of the tonsil, and even this portion is continuous with the lining of the main pocket or crypt.

At a point still higher up, and tending to be placed slightly back

toward the palato-pharyngeal fold, lies a second, smaller, somewhat nodular body, which is quite distinct from the foregoing, since an interval exists between. This may receive the name of velar tonsil.

The velar tonsil is not to be confounded with the parts described by James Yearsley (Treatise on the Enlarged Tonsil and Elongated Uvula, and other Morbid Conditions of the Throat, London, 1843, p. 58). "In the most frequent kind of enlarged tonsils, where the glands maintain their original position, or at least extend in every direction, the Eustachian tubes are generally compressed. There is another variety of enlargement which I am not aware has ever before been noticed; it is where the diseased growth is confined to the upper margin of the tonsil, and which, from being hidden behind the veil of the palate and the anterior palatine arch, is quite out of sight when the throat is merely examined by the eye. In numerous cases I have verified this interesting observation, and effected cures by the indications of treatment which the knowledge of it afforded. We never can be certain that the tonsils have no share in producing deafness until these bodies have been examined carefully with the finger. In some instances, where nothing morbid was visible in the throat, the upper part of the tonsil has been of such magnitude as to produce, in addition to deafness, nasal speech, from encroaching on the posterior nares. These novel views have afforded me the most gratifying results, and I feel assured they will exert considerable influence on the future treatment of deafness." It is evident from the above extract that the growth named by Yearsley as being "confined to the upper margin of the tonsil" was really within the naso-pharynx, and in all probability was the mass now spoken of as "adenoid growth," or the "pharyngeal vegetations." It is interesting to know that Yearsley as early as 1843 described this growth; he was unfortunate, however, in the terms of his description, since it would appear at first sight that he alluded to the lower tonsil. The statement that the treatment of such a mass will exert considerable influence on the treatment of deafness has been abundantly substantiated.

The tonsil is in whole or in part ordinarily exposed when the mouth is open. But in some individuals it lies concealed between the palatopharyngeal and the palato-glossal folds; in such a situation it cannot be inspected unless the palato-glossal fold is drawn outward by a retractor (Heisler, loc. cit.). A tonsil thus concealed is almost never seen in children or young adults. I attribute this lack of harmony between such a form and that of full maturity to the fact that the tonsil is best developed when the formative forces of the economy are unexpended. Until about the twenty-fifth year these exhibit their greatest activities. In adult life the tonsil is apt to atrophy and become exceedingly aberrant in shape. When atrophic, while all semblance of the plan is lost, clinical study is best conducted by recalling it. In many instances it

must be acknowledged that the gland forms irregular, hard nodular masses, which are apparently without diverticula. The causes producing this change are obscure. They can be assigned, in part, to certain inherent dispositions to degeneration, and in part to the results of inflammation. Few individuals escape frequent attacks of tonsillitis, ranging in severity from the mild form of miscalled follicular inflammation to the severe parenchymatous invasions. Again, the tonsil which projects from the tonsillar spaces will be disposed to rind-like thickenings from impact with food, etc. As a result most adults exhibit the gland more or less indurated, the free surface being especially firm in consistence, and occupied by minute white cicatricial bands which tend to occlude the crypts. Beneath this cortex-like layer the parenchyma may have a softer texture. According to Gustav Harff (Ueber die anat. u. path. Struktur des Tonsillengewebe, Bonn, 1875), the closed lymphfollicles have a disposition in the adult to be less well defined than in the young, and the connective tissue of the entire organ to be increased in volume. These conditions certainly tend to indurations, and indirectly to atrophy. In some states of health in such a tonsil, probably owing to long-continued pharyngeal irritation, the folds, especially the palato-pharyngeal, become greatly exaggerated in volume, and in an individual having a large tongue, the motion of this organ backward and downward aids the fold in exerting a certain amount of tension on the gland. However the situation may be explained, the result in the shape of the gland being moulded by resisting forces is evident; thus, it may appear to be greatly compressed from before backward, and so project into the pharynx as to exert pressure against the posterior wall and excite irritation. In most instances the mass has a disposition to retroversion. A tonsil of apparently medium size may, in the act of gagging, assume larger proportions, a circumstance due to the fact that an actual turning of the gland from before backward and from without inward takes place.

The small velar mass is probably the same as the supernumerary tonsil, upon which the late Dr. E. Carroll Morgan (Trans. Amer. Laryng. Assoc., 1889, p. 4) has written. It varies greatly in size, and, as a rule, is smaller than the main tonsil. In some instances it becomes pediculated, and may even suddenly slip away from its usual position and hang into the throat so as to interfere with speech and deglutition. Such a mass was removed by me in a patient who reported in a speechless condition, and showed the pharynx in part occupied by a pediculated mass the size of a walnut. A somewhat similar case is given by Jurasz (Monatsschr. f. Ohrenheilk., 1885, p. 361). Heisler (Inst. Chir., 1747) describes methods of removal of what he terms an indurated tonsil, when the mass hangs by a slender stalk, and it is probably true that this writer clearly recognized the above clinical condition.

I believe many morbid processes may be restricted to the upper tonsil, the main mass not of necessity participating.

Figs. 4 and 6 exhibit the proportions usually noted as existing between the velar and the main tonsil.

But what of the foliate type of tonsil which has been noted in the early part of this paper? I may briefly say that while it is occasionally met. with in practice, it is so rare that it scarcely enters into clinical study. I subjoin a sketch of this form of tonsil taken from a subject eleven years of age. It will be seen that the upper and main masses are present as in the simplest forms, but that the foliate formations appear at the side lying between the main tonsil and the palato-glossal fold. The folia are not true laminæ, but are rather of the nature of bridge-like (annectant) masses of tonsil tissue imperfectly limiting large crypt-like openings into the main tonsil and extending from the level of this mass to some of the lymphoid tissue at the side, and most likely are measurably the results of diseased action (see p. 4).

Hypertrophied tonsils showing constriction between the cryptose and the smooth noncryptose portion. The last named is alone covered with veins. The velar tonsil is not seen. (After nature.)

I will now glance at some additional clinical conditions of the tonsil. In the first place it must be remembered that the influence which the tonsil exerts in the economy is not known. The knowledge, therefore, of a disturbance of functions being sought for as a clue to the nature of diseased action is in this instance futile. The mucoid secretion of the tonsillar surface aids in lubricating the food and prepares it for swallowing, but no reason other than the fact that adenoid tissue is everywhere developed in childhood can be given to explain why the tonsil should be larger at one time of life than another. As already mentioned, the organ is larger in childhood and early maturity than in adult life. It appears to be compensatory with the thymus body. In proportion as the thymus body disappears the tonsil increases in size. At the time