To be mixed with one quart of water (or two teaspoons to the glass of water) for gargling.

It must be used at very short intervals in order to obtain any lasting effect. Chlorate of potassium in saturated solution has enjoyed much popularity as a gargle, but on doubtful grounds. The dangerously poisonous nature of the drug, which has caused many deaths, should curtail its use, especially in children. There is not much more to be gained by using any so-called antiseptic sprays. The liability to persistence of tonsillitis in a subacute form after the acute symptoms have subsided can be effectually checked by various topical applications, such as nitrate of silver (10 to 15 per cent.) or tincture of iron. The writer has seen the best effects, however, from the use of Löffler's solution (compare ¶ 25).

Much can be done to guard against the habitual recurrence of tonsillitis. Our action must depend upon the previous history of the patient. Enlarged tonsils liable to become inflamed should be abscised. Smaller, irregularly shaped, but chronically inflamed tonsils which cannot be removed satisfactorily may be rendered harmless by cauterization with the galvanic burner. A pointed burner bent like a hook should be introduced into every visible crypt, whereby the crypts become obliterated (compare ¶ 151).

135. Acute inflammation of the lingual tonsil is a rare occurrence which manifests itself by the same systemic disturbance as ordinary tonsillitis. The pain is rather more acute, especially during swallowing, and is referred to the base of the tongue. On searching with the mirror the lingual tonsil is found swollen, red, and often marked with specks of lacunar exudation. Whatever has been said of the course of treatment of faucial tonsillitis applies equally to the present form of disease.

136. Acute inflammation of the pharyngeal tonsil is a subject scarcely mentioned in literature until recently, though it forms part of most cases of severe coryza. The only additional symptoms to which it gives rise, besides those directly due to the nasal inflammation, are purulent discharge in the throat and very slight soreness on swallowing. Collateral hyperemia may extend down into the oral part of the pharynx. Postrhinoscopic inspection shows acute inflammation at the roof of the pharynx.

Acute tonsillitis of the pharyngeal tonsil may also occur in rare instances as an independent affection. The writer has seen about half a dozen instances, mostly in children. It begins like tonsillitis, but lasts usually somewhat longer, up to six or nine days. In all instances there had previously been unimpeded nasal permeability until within some hours after the fever began. The nose was more or less blocked, especially during sleep, and the voice acquired the nasal twang characteristic of enlargement of the pharyngeal tonsil. There was, however, no coryza with it, but moderate mucopurulent. secretion in the throat. Pain was not mentioned. The mirror inspection, often unsatisfactory in children, showed redness in the upper part of the pharynx, while the finger could detect a swelling and some tenderness of the pharyngeal tonsil. In all instances the pharyngeal tonsil regained its normal size, and, after recovery, perfect nasal respiration became reestablished. In some of the later instances the writer made applications of Löffler's solution during the latter part of the disease, apparently with beneficial results. The intense irritation due to Löffler's solution did not last long. No complications were observed.

ACUTE PHARYNGITIS.

137. Acute diffuse inflammation of the entire pharyngeal lining is not so common a disease as tonsillitis. It occurs mostly in children. It begins like tonsillitis and

has about the same duration, sometimes lasting a few days longer. There is rather more pain on swallowing than in tonsillitis. There is, besides, some mucopurulent secretion coming from the roof of the pharynx. The entire pharyngeal lining appears diffusely red. Occasionally a few white lacunar specks are seen in the center of follicles on the posterior wall. Such follicles, however, had existed before the disease. In many instances pharyngitis is combined with tonsillitis. Pure pharyngitis has not the liability to recurrence characteristic of inflammation of the tonsil. Its course, causes, complications, and treatment are the same as in tonsillitis.

138. A rare occurrence which the patient is apt to consider as an acute inflammation in the throat is edema of the uvula. It begins suddenly, with some soreness, usually without recognizable cause, and gives rise to a feeling of foreign body, which the patient is tempted. to swallow. The discomfort may increase to intense anguish. On inspection the uvula is seen to be swollen, sometimes enormously, but pale and evidently edematous. In the course of hours the edema subsides. Scarification is recommended. The writer has been able to relieve the few instances seen by him by long-continued massage of the sides of the neck. Suprarenal solution might deserve a trial.

CHAPTER XIX.

PERITONSILLAR ABSCESS OR QUINSY.-RETROPHARYNGEAL ABSCESS.

On

139. Peritonsillar abscess, also known as quinsy, or deep or phlegmonous tonsillitis, begins like ordinary acute tonsillitis, with or without lacunar exudation. the first day no distinction can be made between it and acute tonsillitis in many cases. In some, however, the systemic disturbances begin with less abruptness than in simple tonsillitis. The fever may decline within a day or two, but does not disappear until the abscess opens. The local discomfort increases steadily. After one or two days the patient has a constant feeling of fulness in the throat, with a sense of oppression, embarrassing the breathing subjectively. This distress interferes with sleep. There may or may not be visible dyspnea. The moderate pain becomes intense upon swallowing and prevents eating. Characteristic is an enormous secretion of clear mucus in the pharynx. The voice is peculiarly "thick" and somewhat nasal, but not so "dead" as in blockage of the nasopharynx. The tonsillar swelling shows on the outside of the neck. The cervical glands are usually palpable.

Quinsy is more often one-sided than bilateral. On inspection the reddened and enlarged tonsil is seen projecting toward the middle line or even beyond. There is distinct swelling in front of the anterior pillar and in the soft palate above the tonsil. After the lapse of five to nine days a spontaneous perforation occurs, usually through the soft palate, about 1 cm. above and inward from the tonsil. The symptoms now subside, and within half to one day complete relief is obtained. About three days later the disease is ended.

Quinsy, much less common than tonsillitis, may occur at any age, but least often in childhood. It is clearly a pyogenic infection, evidently entering through the tonsil. It is doubtful whether it ever occurs except in subjects with some tonsillar hypertrophy. Its determining conditions are unknown. Recurrences in subsequent years are not uncommon. The exact seat of the abscess has not been determined by autopsies. It is not within the tissue of the tonsil, but external to it.

Notwithstanding the severity of its symptoms quinsy is scarcely ever followed by complications, even on the part of the ear. In enfeebled, decrepit subjects the abscess may extend and perforate into the external meatus of the ear. Under such circumstances death may occur from pyemia or septicemia, especially on extension into the mediastinal space.

The rational treatment is the evacuation of the pus. No other measures give any relief, but until distinct pointing of the abscess is visible the surgeon can never be sure of striking the pus. Yet the attempt must be made even with the chances against its success. The surface can be anesthetized by the prolonged application of a pledget wet with cocain solution (20 per cent.). Sometimes a blunt probe thrust into the supratonsillar fossa will reach the abscess. If this fails, a knife may be thrust into the most prominent part of the soft palate, directed outward and backward. The anatomy of the large vessels must be remembered, but they would only be endangered by carelessness or unnecessarily deep incisions. Incisions through the tonsils generally fail to reach the pus. If the operator does not succeed, he may try again daily until the pus can escape. No further treatment is required. After recovery a painstaking abscission of the tonsil should be made, to guard against future recurrences of peritonsillitis.

140. Phlegmonous inflammation underneath the lingual tonsil has been reported by several observers, evidently a rare occurrence. In connection with the