when there is a diffuse deep redness of the soft palate and uvula, and when vomiting occurs. Syphilis, too, produces occasionally a typical picture of follicular tonsillitis, but the clinical course is different in this case. The disease is not of sudden onset, does not produce the intense systemic involvement, and lasts many days unchanged, but accompanied by a low fever.

134. Under the head of treatment text-books present a formidable and suspiciously long array of drugs for both internal and local use in acute tonsillitis, and each author lauds his own method. An unbiased discoverer can draw one inference only from the comparison of different text-books. We possess at present no method of treatment which can shorten the typical course of any infectious disease, except the so-called specific medication -viz., the artificial employment in an intensified form of those means by which the organism rids itself of the disease during natural recovery. Such, for instance, is the treatment of diphtheria by antitoxic serum. There is neither any logical reason nor any definite experience to warrant the belief that we can abort an attack of tonsillitis. All claims to this effect are based either on the want of recognition of the self-limitation of the disease, or on the confusion of acute tonsillitis with subacute aggravations of chronic pharyngeal trouble. We can minister only to the comfort of the patient, and by combating the liability to complications, obtain the shortest possible course of tonsillitis. The febrile discomfort may be lessened by the use of alcoholic drinks. Headache and bone-ache can be allayed by antipyrin. Sleep may be enforced by chloral or even morphin if the patient's condition demands it. Any gargle which tends to check secondary decomposition in the mouth is agreeable and apparently useful, even though it does.not reach the tonsillar surface to any extent. The writer has been pleased with the clinical effects of a combination which certainly lessens the odor of the breath and adds to the patient's local comfort. It is:

.

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.

139. Peritonsillar abscess, also known as quinsy, or deep or phlegmonous tonsillitis, begins like ordinary acute tonsillitis, with or without lacunar exudation. On 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.