intermissions in the course of this form of suppurative pharyngitis during mild weather. When the enlarged pharyngeal tonsil persists after puberty, it undergoes a sclerotic change, and is then much less likely to form pus. Hence in adults suppurative pharyngitis is more commonly observed without enlargement of the pharyngeal tonsil. In the class of cases mentioned the secretion is that of thick, yellowish green, but fluid pus. In another variety of the disease the secretion is more scant and dries in the form of adherent crusts dislodged with some difficulty. The surface underneath is found reddened and often slightly excoriated; rarely, thickened. This variety of disease, not very common in general, is extremely rare in childhood. It resembles ozena in the character of the secretion. The comparison is also borne out by the spaciousness of the pharynx often observed. The mucous membrane may even present an atrophic appearance, as judged by the naked eye. But the specific odor of ozena is lacking except when this form of pharyngitis is combined with true nasal ozena. The complaints refer, in the first place, to the secretion. It is especially when dry crusts form that patients are irritated by their presence and make forcible efforts to dislodge them, sometimes finishing by retching. The crusts seem to form only once in from one to three days. Their presence may cause reflex symptoms, such as coughing and headache referred to the occipital region. 154. Pharyngeal suppuration is usually due to a diffuse inflammation of the mucous membrane in the area of the pharyngeal tonsil. When the tonsil is enlarged enough to be prominent, there is no method of permanently arresting the process, except by the operative removal of the adenoid tissue. But as seen in adults without thickening of the pharyngeal lymphatic tissue, the suppuration may be stopped by other means. Quite often the persistent removal of the secretion by the postnasal douche will lead to a cure in the course of some weeks. An atomizer with curved pharyngeal tip may prove equally efficient if properly used. When these means do not suffice, the writer has succeeded at times, but not invariably, by brushing the pharyngeal vault with nitrate of silver solutions (20 to 30 per cent.) or Löffler's solution. Due care must be used not to spread these irritant fluids over the adjacent surface, for which purpose the palate may be held by means of a broad retractor. When the pharyngeal disease accompanies purulent rhinitis or suppuration of a sinus, the nasal lesion must be cured before the pharyngitis will yield to treat ment. 155. A peculiar pathologic basis has been claimed by Tornwaldt for many cases of suppurative pharyngitis, especially those in which crusts are observed. He attributes the disease to an inflammation localized in the pharyngeal bursa, which, he claims, is a deep persisting recess of embryologic significance. Neither his anatomic. notions nor his clinical data have received full confirmation by other observers. The bursa is not a constant, and rarely a deep, sinus, and others who have sought for this localized inflammation have not found it so typical a disease as Tornwaldt asserted. It must be admitted, however, that the clefts, and especially the central cleft between the ridges of the pharyngeal tonsil, may be the seat of a persistent suppuration, and that occasionally types of pharyngeal disease are found which correspond to Tornwaldt's description. Tornwaldt claims to have cured his patients by cauterization of the diseased recess with a bead of nitrate of silver or by the insertion of the galvanocaustic burner. In those cases where pus can be seen to issue from clefts in the pharyngeal tonsil, I have occasionally found this mode of treatment successful. 156. A lesion not rarely found in the pharyngeal tonsil are cysts with purulent contents, the result of suppuration confined to a lymph-follicle. They may be of the size of a pea or larger, and produce symptoms of pharyngeal irritation. They are removed by abscission of the tonsil (174). 157. A form of pharyngeal disturbance formerly described as "pharyngitis sicca," or "atrophic pharyngitis," must be mentioned, although it is not a real pharyngitis. The mucous membrane looks pale, dry, apparently atrophic, and is covered with a varnish-like clear secretion dried on the surface. The appearance results from purulent rhinitis or sinuitis, and with the cure of the nasal suppuration the pharyngeal lining recovers its normal condition. CHAPTER XXI. HYPERTROPHY OF THE PHARYNGEAL TONSIL OR ADENOID VEGETATIONS. 158. The frequent occurrence of hypertrophic lymphatic tissue at the vault of the pharynx had been entirely overlooked until W. Meyer described this important condition in 1869. Yet it is a very frequent and very noticeable disturbance. In various school examinations it has been found to exist in from 5 to 9 per cent. of all children. No race and no country seem to be exempt. Its existence since historic times has been made probable by Meyer by finding the characteristic facial expression indicative of it in various portraits from the middle ages and even in some statues of antiquity. The direct consequence of enlargement of the pharyngeal tonsil is obstruction of nasal breathing to an extent proportionate to the space occupied by the new growth— and hence inversely proportionate to the dimensions of the pharynx. On account of the vascularity of the lymphatic tissue its size is subject to fluctuations. While a moderate enlargement may be inappreciable during erect posture, the increased blood supply during the reclining posture may entirely prevent nasal breathing. The obstruction is also increased during sleep by the accompanying turgescence of the posterior ends of the turbinals. Still more noticeable is the obstruction when an acute coryza increases the congestion. The patient. hence sleeps with the mouth open, and snores whenever he lies on his back, although while awake he may be able to breathe through his nose (except in high degrees of hypertrophy). When there is secretion, which often occurs in this trouble, the child cannot blow his nose, resonance. but draws the pus back into the pharynx. Enlargement of the pharyngeal tonsil also betrays itself by its influence on the voice, which becoines "dead" and loses its The nasal sounds "in" and "n" are especially interfered with; the former ("m") sounding like "b," the latter ("n") like "d." An excellent description of the speech in high degrees of adenoid vegetation is given by Dickens in his character Barney, in Oliver Twist. It is only in complete obstruction of the nose by a severe coryza or polypi that the same mode of speech is heard. 159. The interference with nasal breathing results in the course of time in thickening of the lips and sinking in of the sides of the nostrils. These peculiarities, together with the open mouth, give these children a very characteristic "stupid" expression, accentuated by a "dreamy" look due to vascular fulness of the lower eyelid, whereby the lid-space is reduced in aperture. In well-marked instances the expression, as well as the voice, suggests a positive diagnosis. The characteristic appearance has been termed the "adenoid habitus." In many cases the obstruction of the nasopharyngeal space is accompanied by changes in the shape of the hard palate, which at first becomes merely arched to an abnormal degree. After the second dentition, however, its form often changes to a V-shaped or Gothic arch, while the lateral teeth, especially cuspids and bicuspids, may incline inward instead of pointing straight downward. The changes in the palate and alveolar process are, however, not absolutely characteristic of enlarged pharyngeal tonsil. Children with enlarged pharyngeal tonsils are very prone to "take cold." They get fresh nasal catarrh from slight exposure, and it often remains chronic during the inclement season or even longer. Purulent secretion, however, when present, is always due to a complicating inflammation of the nose or of the pharyngeal tonsil itself-often very persistent, but it is not a symptom resulting from mere |