Diseases Of The Tonsils, Palate, And Pharynx

Diseases Of The Tonsils, Palate, And Pharynx
By JAMES EDWARD NEWCOMB, M. D.,
OF NEW YORK CITY.
DISEASES OF THE TONSILS.

General Considerations. A proper understanding of the relations of the various tonsils to each other is obtained by regarding them all as segments of the so called tonsillar ring that is, the circular continuity of lymphoid tissue, starting in the naso pharynx and extending on each side to the lips of the Eustachian tubes, thence to the posterior surface of the soft palate, to the space between the faucial pillars (forming in the latter region the faucial tonsils), and finally uniting in the so called fourth or lingual tonsil at the base of the tongue.

The faucial tonsils are limited above by the approximation of the faucial pillars, but extend a variable distance below. They may be said to lie in the anterior part of the pharyngo maxillary " interspace " that is, a space between the lateral wall of the pharynx, the internal pterygoid plate, and the upper cervical vertebre lying almost directly back from the pharyngo palatine arch. This “interspace " is filled with connective tissue. Behind it are both carotid arteries, the internal, 1 1/2 cm. and the external 2 cm. distant from its lateral periphery. In healthy throats at rest the tonsils do not protrude beyond the level of the pillars.

Structure. A tonsil, says Harrison Allen, is an association of diverticula developed from the epithelial layer of the mucosa, in the walls of which are grouped muciparous glands and lymph follicles. The various tonsillar deposits vary only in the arrangement of these diverticula. In the lingual tonsil they are single; but in the pharyngeal and faucial, compound. In the latter the arrangement is such as to render especially noticeable the depressions crypts or lacunae (not follicles) upon the surface. Soft in infancy, they become harder as age advances, partly from the growth of connective tissue and partly from a cortical hardening due to the constant impact of food. They begin to atrophy at middle life. Their more detailed anatomy and their physiology are elsewhere discussed. It may only be said here that a rarefaction of the epithelium is constantly going on at the surface even in health, and still more in disease; so that at times and in places this epithelial layer is only one or two cells thick. Hodenpyl has shown that the intact epithelium practically prevents any absorption whatever, but that its removal affords free access of infectious material to the lymph channels: yet this claim must be modified in view of Goodale's recent experiments. Various micro organisms may effect a breach through this thinned epithelial layer. Hence the frequency with which the tonsils serve as the channel of entrance of various disease poisons to the system.

Finally, it is to be borne in mind that the pathological processes affect all the tonsils alike, and that variations in local symptoms are mainly due to locality.

ACUTE TONSILLAR INFL AMM ATIONS.

This group includes the acute catarrhal, lacunar (wrongly called follicular), croupous, parenchymatous, and suppurative varieties. The catarrhal form rarely occurs apart from an acute catarrhal pharyngitis, under which heading it will be considered. The suppurative form, or quinsy, is really a peri rather than an intratonsillar affection.

Acute lacunar tonsillitis is often associated with the parenchymatous variety, into which it frequently runs. It consists of an inflammation chiefly manifested by a filling of the crypts with whitish plugs of inflammatory exudation, together with a general congestion of surrounding parts, associated with a constitutional febrile reaction.

Causes. Perhaps the most frequently assigned cause is exposure to cold. But at the outset it must be premised that in the light of our present views on pathology exposure to cold has very little significance as a causative factor in this class of diseases: it probably acts but indirectly and means only lessened resistance to morbific action. All sorts of micro organisms are constantly present in the throat, the harmful influence of which is nullified by a sound condition of the organism. Exposure to cold, by temporarily lowering the resisting power of the tissues, allows the pathogenic germs to exert their effect.

A disordered gastro intestinal canal is found in many instances, particularly in patients subject to the so called bilious attacks. Causative factors are also found in the rheumatic and gouty diatheses. In regard to rheumatism, its frequency as a cause has, in the opinion of the writer, been greatly exaggerated. His records of 586 cases of various forms of tonsillitis and pharyngitis show 154 presenting evidences of rheumatic tendency, or 26.2 per cent.; while 432, or 73.8 per cent., presented no such evidences. These figures differ from those of Haig Brown, out of whose 119 cases 64, or 54 per cent., had some rheumatic tendency. Fowler believes that 80 per cent., of all cases of rheumatism have had previous sore throats; but the line of argument followed by him does not seem convincing with reference to the point at issue. Hope denies that the tonsils are a selective area for the rheumatic poison which, he says, attacks sero fibrous rather than muco fibrous structures, such as the tonsils really are. He even regards it as rare to meet with examples of recurring angina in those who carry recent or unmistakable evidences of a rheumatic attack.

Chronic enlargements of the tonsils naturally invite recurring inflammations. Suppressed menstruation seems to be a factor in some cases. Entrance of foreign bodies, sudden changes in atmospheric conditions, and exposure to odors from detective drainage are also causative factors. The latter may be regarded as a type of a wide range of septic influences. Hospital attendants frequently suffer from this affection.

Frankel and Lennox Browne find intranasal operations to be a frequent excitant of this form of tonsillitis. It seems to follow the use of the galvanocautery rather than that of cutting instruments. The reason assigned is, that for a time after the cauterization the filtering function of the nares is held in abeyance, and that some of the bacteria found in the nose are stimulated into an abnormal virulence.

Pathology. Either one or both organs may be affected. They are swollen and reddened, while the surrounding tissues become more or less edematous. This edema is frequently marked in the soft palate and uvula, the latter often being deviated to one side. The months of the lacunae are filled with whitish plugs composed of dead epithelium, leukocytes, and various microorganisms. Sometimes more or less thick tenacious mucus is so evenly spread over the walls of the lacuna as to suggest a false membrane, but it can be easily brushed off, leaving no bleeding surface, and it does not contain fibrin.

As to bacteriological findings, both staphylococci and streptococci are present. Frankel believes the latter to be the pathogentic cause. Meyer found in 53 cases, 14 with staphylococci (generally staphylococcus aureus), 24 with a mixture of the two, and 15 with streptococci, in pure culture. A diplococcus resembling (and perhaps identical with) that of pneumonia has also been met with. The varying proportion of these two micro organisms causes no appreciable variation in the clinical features of the disease. Meyer's researches show that the secretion from non inflamed tonsils ordinarily contains a coccus very analogous to the streptococcus pyogenes, a small growth often arranged in pairs, staphylococci, and leptothrix growths.

Acute Parenchymatous Tonsillitis. Very frequently the foregoing condition is present without any marked enlargement of the tonsil; but often the organ becomes greatly increased in size from the exudation of inflammatory products into its substance, so that we have a combination of the lacunar and parenchymatous forms; or, again, the organ may be greatly swollen while the mouths of the crypts are clear.

Symptoms. The symptoms in both forms are essentially the same. The local manifestations may either precede or follow the general. The latter assume the type of an acute infectious disease. There is more or less chilliness, followed by fever of rapid rise (104' F.), with corresponding changes in pulse and respiration, headache, constipation, thirst, anorexia, general malaise, and bodily pains, with an amount of prostration out of all proportion to the apparent severity of the local lesion. The worst cases, show clammy sweats, restlessness, insomnia, and even delirium. The local manifestations begin with pricking or tingling sensations referable to the throat, soon changing to a continuous* pain. It becomes increasingly difficult, especially in the parenchymatous variety, to open the month; the glands of the neck become swollen and painful, the pain radiating to the ears. Partial bluntness of hearing, taste, and smell is not uncommon. A sense of suffocation (occasionally a real danger thereof) results from the glandular swelling. The throat is constantly filled with thick, tenacious mucus, attempts at swallowing which (or also talking) greatly increase the patient's distress. The tongue is coated and the breath offensive. Deglutition is often agonizingly painful, and fluids sometimes regurgitate through the nose. Persistence of the fever sometimes brings out a rash of an erythematous type.

Differential Diagnosis. Scarlatinal throats sometimes present lacunar inflammation, but here the disease is usually ushered in with vomiting; and the appearance of the rash within twenty four hours settles the question. Also, the faucial congestion is generally much more extensive, while the actual swelling of the parts is much less. The appearance of the tongue also helps us.

In primary specific, sore throat the lesion generally appears in symmetrical areas on both sides. The congestion is of a duller red hue; pain is slight and fever generally absent. In fact, it is rather from the simple catarrhal than the lacunar form of tonsillitis that this condition has to be separated.

From diphtheria the diagnosis is not always easy. We now recognize bacteriologically a lacunar diphtheria that is, a true diphtheria with the exudate confined to the walls of the lacunae. To the eye and in its clinical features it resembles precisely the lacunar form of acute tonsillitis. The culture medium alone will enable us to decide. Many instances of reported contagion in lacunar tonsillitis have doubtless been truly diphtheritic. It may be said that in diphtheria the exudate occurs in large patches, is generally of a grayish hue, and of a more ragged appearance. A bleeding surface after removal is no proof of true diphtheria, but only of a croupous inflammation that is, exudation with degeneration of tissue. Moreover, here the constitutional symptoms come on more slowly and the temperature rarely rises so high; indeed, may be even subnormal.

Course. The disease lasts from one to fourteen days, averaging four or five. It may leave the tonsils chronically enlarged, or before subsiding go on to quinsy. A few cases have resulted fatally, but the prognosis is regularly good.

Treatment. If cases are seen at the very outset, the disease can sometimes be aborted by painting the tonsils with strong solutions of cocain, with pure guaiacol, or with silver nitrate (15 per cent. solution). A mercurial purge followed by a saline should be administered, and small and frequent doses of aconite, belladonna, or opium should be given. The writer has used with success the familiar 11 tonsillitis tablet" composed of

R. Tr. aconite, M 1/5 ;
Tr. Bryoniae, M 1/10;
Tr. belladonna, M 1/10;
Red iodine of mercury, gr. 1/100.-M.

Of these, one may he taken hourly for three hours, and one every two hours thereafter. At the outset, cold compresses may be applied to the neck; while if the case goes on to full development, hot applications will afford greater relief. Frequent gargling with a hot solution of bicarbonate of soda in water will remove the clogging mucus.

Most cases, however, are well advanced when they come under medical care, and of remedies proposed in this and later stages there is no end. Guaiac given in the form of lozenges or dram doses of the ammoniated tincture has long enjoyed a reputation in curing this condition; but it is uncertain in effect and very disagreeable in taste. For some years the writer has had the best results with salol, given in hourly doses of five grains in mucilaginous suspension (not tablets) flavored with some essential oil. He has found that in a series of 81 consecutive cases, watched with reference to this fact, the pain was relieved on an average in fifteen hours. Allowing for sleep, not more than ninety grains are taken in the twenty four hours, and this daily dosage is perfectly safe unless there be definite kidney trouble. In a few cases of the above series the urine assumed a darkish color. Salicin has been credited (if continued for a week or more after the subsidence of the active symptoms) with the power of preventing subsequent persisting hypertrophy. Other drugs of value are sodium salicylate, antipyrin, and the muriated tincture of iron. The latter sometimes proves surprisingly efficacious after one has used in vain some of the newer and much praised remedies. The self limited nature of the affection must be borne in mind when estimating the value of any remedy. Scarifications, incisions, or punctures are not recommended in this form of tonsillitis. Occasionally relief follows the digging out of the crypts with a small sharp scoop. It is well to isolate every case of sore throat, although the direct contagious nature of lacunar tonsillitis is still a matter of dispute.

Acute Croupous Tonsillitis. By the term “croupous " is here meant an exudative inflammation leading to the degeneration or death of tissue. The change may involve the epithelial covering only, or may extend through the entire mucosa with swelling of the surrounding tissues. The exuded fluid, rich in fibrino plastic material, coagulates on the surface of the mucosa, forming the false membrane.

Causes. This variety frequently occurs as a complication of the exanthemata and various infectious diseases. It is seen occasionally in the later stages of renal trouble and of the wasting maladies. In one sense it may be said that the special form due to the Lofller bacillus is the lesion of diphtheria, but that is not what is meant by the title above used. It may also occur as a primary affection from almost any of the causes mentioned tinder the lacunar form.

Pathology. We find here the typical false membrane front the coagulation of the exuded liquor sanquinis, rich in fibrino plastic material, and from the emigration of leukocytes. Fibrin is thereby formed on the mucosa entangling the letikocytes, now appearing as pus cells in its meshes. Subsequent coagulation Decrosis leaves either superficial erosions or ulcers of varying depth. Bacteriologically the staphylococcus and streptococcus are the most common excitant organisms. Some classifications would include the pseudo bacillus of Loffler. It is not yet proven that a simple streptococcous sore throat is necessarily contagious in the popular acceptation of the word.

Symptoms. These are in a general way the same as those of lacunar tonsillitis, although generally of a greater severity. The tonsil may be but little swollen and the exudate limited to its convexity. The swelling of the cervical glands is generally noticeable, as is also the prostration.

Diagnosis the disease most nearly resembling simple croupous tonsillitis is diphtheria. Here, again, it is asserted with much emphasis that culture tests alone can decide in doubtful cases. The local appearance may, in the light of each practitioner's experience, incline him to this or that view, but bacteriology alone can settle the question. The disease generally runs from six to eight days, often leaving the patient very weak and anemic. Recovery is the regular rule.

Treatment. The measures outlined for the treatment of the lacunar form may be tried; but in the majority of cases it is better to rely on a constitutional tonic treatment and keep the mouth as thoroughly disinfected as possible. A 1 :3000 bichlorid mouth wash is as efficient as any, and when the membrane begins to come away, hydrogen dioxid solutions (equal parts freshly mixed with lime water) may be employed.

Acute Circumtonsillar Inflammation. It has been customary to speak of this disease as a suppurative tonsillitis or quinsy. The former is objectionable in that it implies that the tissue of the tonsil proper suppurates, while the truth is that this change takes place in the vast majority of cases in the connective tissue surrounding the tonsil, especially in front of and above it.

Causes. These are the same as those of the varieties of inflammation previously described. Any case beginning as lacunar or parenchymatous may go on to suppuration. The latter may follow a specific affection of the organ, as in the case reported by J. H. Bryan.

Pathology. We have here a pure phlegmon of the circumtonsillar cellular tissue. The tonsil may be pushed inward from the pressure of the inflammatory products and appear enlarged where it really is not. Occasionally the suppurative process actually invades the tonsillar substance. The abscess is more apt to point in the upper part of the anterior pillar or just above it; less frequently lower down in the posterior pillar. Occasionally the pus burrows its way to the bottom of one of the tonsillar crypts, through which it may be seen oozing to the surface.

Symptoms. These are of much the same character as before given, and are generally of a severe type. If the suppuration is secondary to, one of the other forms, the pus formation may engraft upon the preceding symptoms a distinct additional rigor, with high fever and profuse sweating. The swelling in the fauces becomes extreme. The whole side of the pharynx becomes enlarged, tense, and brawny. The soft palate is pushed forward and a tumor may be felt in the neck. It is often impossible for the patient to open the month at all, even to admit a tongue depressor. Swallowing is also often impossible. The uvula becomes edematous and obstructs free respiration. If left to itself and only one tonsil is attacked, the disease generally runs its course in a week, by which time the abscess will have burst. Recovery is prompt. The involvement of the other tonsil means another period of misery. A serious, though fortunately a rare, complication is edema of the glottis. The bursting of the abscess during sleep may cause some of the pus to be swallowed and the patient may awake choking. No fatal cases from this cause alone are personally known to the writer, but one or two are on record.

Treatment. This is at the outset the same as for the lacunar and parenchymatous forms. If pus formation is apparently brewing, hot sponges to the neck and the vapor from hops in boiling water are grateful to the patient. Alkaline washes help to keep the mouth clear from thick mucus. Early incision is advocated. It is permissible as soon as there is any fullness about or protrusion of the faucial pillar, and should be followed up by flushing the mouth out with hot water. Where we suspect pus the blade of the scalpel should be passed in at least half an inch, held horizontally, and the direction of the incision should be from without inward toward the median line. Deep seated pus is in this way frequently evacuated where more superficial puncture would be useless. In other words, our aim is the general one to get rid of the pus as soon as it is formed, and we treat the abscess on general surgical principles. Internal remedies are useless after pus has once formed. The syringing of the pus cavity with a long curved tube attached to a syringe full of antiseptic solution has in sonic cases apparently hastened convalescence.

The Lingual Tonsil. The fourth, or lingual, tonsil is situated between the circumvallate papillae and the anterior surface of the epiglottis. It resembles the faucial bodies in structure, except in that the arrangement of the diverticula’s of its epithelial layer is single, while in the faucial bodies it is compound. Concerning physiology and pathology, the same general remarks apply to both regions.

Simplicity of classification is furthered by saying that we may have here the simple catarrhal, the lacunar and parenchymatous, and the circumtonsillar varieties, as previously outlined. The list of causes and the nature of the lesions are identically the same. Ruault states that poisoned saliva from dental caries has a special effect on the lingual tonsil.

The general symptoms are those already described under the faucial tonsillar inflammations. The local symptoms vary somewhat from the faucial type, and this variation is due to the different area affected. Thus, the feeling as of a foreign body in the throat is especially prominent. Cough is frequently referred to the larynx, while the pain is especially referred to the root of the tongue.

In the lacunar type of the disease the constitutional symptoms are apt to be more severe than in the corresponding inflammation of the faucial bodies. The epiglottis may become swollen and even the structures around the glottic opening, thus causing dyspnea, which is at times alarming and sometimes demands operative relief. The initial pain is frequently referred to the hyoid region.

The circumtonsillar or suppurative form (lingual quinsy) is less common than in the fauces, owing to the scanty amount of connective tissue at the root of the tongue. The special point of importance is the recognition of the precise malady with which we have to do. The mirror and the finger should both be used as aids to diagnosis. Incision of a fluctuating area is preferably made with the galvano cautery. It is worth remembering that these cases are sometimes ushered in by an attack of edema of the glottis. Spontaneous evacuation of the abscess during sleep, especially if it discharges posteriorly, introduces an element of great danger. Cases of chronic abscess and of retention cysts in this region are on record.

The various forms are often overlooked because the physician contents himself with simply using the tongue depressor, a procedure which does not bring the area of the lingual tonsil into view. The laryngeal mirror will reveal the lacunae choked up with inflammatory plugs and show the enlargement of the tonsil as a whole, either as a median single mass or as bilateral masses separated by a furrow. Palpation with the finger will reveal the existence of fluctuation when pus has formed.

The treatment of these various forms of lingual tonsillitis is identical with that of the corresponding forms of the faucial affections. As local applications we may use tannin and morphin, glycerite of boro glycerin, weak cocain solutions, and menthol in olive oil or albolene (gr. xv , ~j). During, the acute stages the vapor of boiling water poured on hops is gratefully borne, and convalescence may be hastened by swabbing with diluted perchlorid of iron (one part to eight or ten of water). The worst cases of this variety may suggest Ludwig's angina.

Acute Ulcerative Tonsillitis. Under this heading Monte has recentl called attention to a sub variety of lacunar tonsillitis characterized by the presence of large ulcers which closely resemble syphilitic lesions. The tonsils present, more frequently on their mesial aspects, grayish patches covered with a cheesy coating of some thickness, but easily removed and leaving a mammillated surface. The borders of the ulcer are clean cut but not particularly swollen. The remainder of the organ may or may not be enlarged.

These ulcers may be single or multiple, without any tendency to coalesce. They may follow one another on the same tonsil, so that the organ may at one time exhibit different stages of the lesion. The process seems to start as an acute inflammation in the crypts. The gross appearance is compared by Moure to that of a cauterized tonsil from which the slough is about to separate (Fig. 575).

No special cause for this sub variety has as yet been proven. The disease seems to attack by preference young adults, and to be more prevalent in the spring and fall.

Symptoms. These correspond to an extremely mild form of the ordinary lacunar disease. The cervical glands are rarely affected.

Treatment. The ulcers should be thoroughly cleansed with zinc chlorid solution (1 :30) containing a little cocain, and then a bromid gargle in glycerin and water should follow. All pharyngeal irritants should be avoided. Initial curetting of the affected area has been done with success.

The writer has seen but one case which he would place under this heading. In this instance the left tonsil of an Italian, about thirty five years old, presented a crateriform ulcer corresponding to the description above given. Doubtless certain case , of this nature have been regarded as ulcerating gummata. The gumma, however, is generally near the periphery. Of the tonsil, so that the neighboring parts are rapidly invaded. Moreover, the edges of the specific ulcer are generally surrounded by an angry red zone which is wanting in the lacunar ulceration.

CHRONIC TONSILLAR INFLAMMATIONS.

Modern pathological views enable us to distinguish the same varieties of chronic as of acute tonsillar inflammations. The chronic catarrhal form is really one element of a chronic pharyngitis, under which beading it is referred to. The existence of a chronic croupous form is a matter of some doubt. A special variety attended with an exudate due to the bacillus coli communis is referred to later in this article.

Chronic Lacunar Tonsillitis.-Pathology.- In this condition the tonsils are but little if at all enlarged, but the crypts become filled from time to time with cheesy masses. This seems to result from the narrowing or bridging over of crypt-orifices, either by inflammatory processes or by a sort of villous ingrowth (Sokolowski) of the epithelium into the lacunae. Retention of the crypt-contents leads to dilatation, irritation, and inflammation. The plugs thus retained are composed of epithelial debris, leukocytes, fatty granules, cholesterin, and various mycotic elements. They frequently emit a very offensive odor.

Symptoms.-The symptoms of the consition are faucial irritability (tickling, burning, feeling as of foreign body), with pain radiating toward the ears, and increased on swallowing. The breath is fetid and the tongue frequently coated. Singing and smoking aggravate the symptoms. The expulsion of the plugs is followed by relief. The patients are frequently very much worried about themselves.

Inspection does not always reveal the condition. The probe must be used and the crypts explored. According to Gumpert, two sites must be closely scrutinized: (1) the upper extremity of the tonsil, between the pillars the so called epitonsillar fossa; and (2) the middle of the tonsil, directly behind the anterior pillar. The condition is frequently overlooked, and the faucial dysesthesia is referred to dilated lingual veins, enlarged pharyngeal follicles, hysteria, etc. Meanwhile, the patient gets no better.

Treatment. The crypts should all be cleared out by some spud like instrument or scoop and then slit tip thoroughly. The bared areas should then be vigorously rubbed with a strong solution of iodin and potassic iodid, of each 3jss to water 3j. This generally effects a permanent cure.

Chronic Tonsillitis Due to the Bacillus Coli Cominunis. Recent French writers have insisted that there exists a form of chronic tonsillitis due to the bacillus coli communis, and with a definite clinical course. Its characteristics are :

1. Its chronic course, beginning, it is true, with a brief stage of acute inflammation.

2. Its extreme persistence, since none of the therapeutic measures habittially directed against anginas are able to modify it. In one case only excision of the tonsil sufficed to remove it.

3. The slight intensity of the local subjective symptoms, no pain in the throat, no dryness or hypersecretion ; at times a slight difficulty in swallowing when the exudate becomes confluent.

4. A notable deterioration out of all proportion to the local condition, and generally manifested in digestive disorders. These features are clearly of tonsillar origin, as they lessen after the clearing out of the crypts, but return upon the reappearance of the exudate.

5. The characteristic appearance of the tonsillar exudate viz., a dullwhite color, semisoft consistence, punctiform masses emerging from the crypts, but not, as a rule, encroaching upon the intercryptic surface, the mucosa covering which presents only a slight redness. Occasionally the masses coalesce, suggesting a pseudo membrane, slightly adherent but removable without leaving a bleeding surface, resistant, and not disintegrating when placed in water.

6. The integrity of the peritonsillar and pharyngeal regions.

7. The absence of glandular enlargements.

Bacteriologically, the exudate shows a pure culture of the bacterium coli commune, not only on the surface but in sections of the tonsillar tissue. The micro organism differs from that isolated from the intestine in certain minor culture reactions.

The authors, moreover, declare that this germ is frequently found in healthy human mouths, and express the belief that this form of tonsillitis is frequently overlooked. The most common condition with which it might be confounded is the ordinary leptothrix mycosis. But in the latter the exudate is generally hard and horny, is removed with difficulty, and under the microscope reveals its characteristic mycelial threads and spores.

Chronic Parenchymatous Tonsillitis. This is one of the most common affections with which we have to do. It may occur as the result of preceding acute attacks; or it may be seen so early in life that it is impossible to say just when it began: It is regularly found in strumous children and in those living under bad hygienic surroundings. It may, however, occur in grown people without any dyscrasia and in those comfortably housed and fed.

Pathology. The entire tonsil is enlarged (one or both) and of varying consistency. In the child or in very recent cases in the young adult it feels more or less pulpy, while in the older cases it is distinctly hard. Under the microscope it is seen that the lymphoid elements have undergone a true hyperplasia and that more or less connective tissue has developed. This may be seen even by the naked eye as irregular trabeculae running through the mass, and by their contractile tendency hardening the latter (Fig. 576).

Not infrequently we find that the anterior pillar of the fauces appears as a broad and thick fibrous band, which completely envelops the anterior half of the tonsil; and by a process, apparently of contraction, has pressed and rotated the latter backward, so that whatever remains of its free surface presents toward the posterior wall of the pharynx. Adhesion to the posterior faucial pillar may also occur.

This connective tissue development bears on the question of possible hemorrhage after tonsillotomy. It leads to a canalization of the blood vessels, so that after section their mouths are held open and they cannot retract within their sheaths. The organ may feel soft at the surface but be quite bard at the plane of the section. Its general state constantly invites fresh inflammatory attacks. The crypts become clogged up, and the waste products accumulating behind these plugs lead to renewed inflammation. Removal of a layer of surface tissue corresponding to the depth of these crypts will often give surprising relief to the constant series of outbreaks, although, of course, such a plan of treatment is to be condemned as not being sufficiently thorough.

Symptoms. Enlarged tonsils are in a sense foreign body and give rise to symptoms accordingly. All functions of the surrounding parts are more or less hindered. An enlarged pharyngeal tonsil (so called "adenoid vegetations ") may, coexist with enlarged faucial tonsils; and it is difficult to determine to which of the two areas of diseased tissue a given symptom is to be referred. The voice is thick, the patient speaking as if the mouth was partially full, and some of the normal nasal resonance of phonation is lacking. Breathing is somewhat interfered with, although in adults true dyspnea is rare. In children, however, the oro pharynx seems to be encroached upon, so that a slow carbonic acid accumulation in the system takes place, Snoring and mouth breathing may occur. The need of oxygen finally becomes so great that the child, if asleep, will wake up suddenly, presenting the familiar “night terrors." The senses of taste, smell, and hearing are more or less blunted, and there may be actual aural inflammation. The enlarged tonsils, moreover, interfere mechanically with the actions of the delicate muscles which govern the functions of the Eustachian tubes.

Children with enlarged tonsils are apt to suffer from defects of chest development and general physique. They will sometimes improve with marvellous rapidity after the pharynx is cleared out. Doubtless many chest deformities referred to enlarged tonsils should be referred along with the latter to some underlying diathesis. The breath is offensive, the stomach frequently disturbed, and the bowels disordered. The inspired air passing over the diseased crypts containing cheesy plugs of decayed epithelia, fermenting mucus, and particles of food, the child is constantly inhaling a vitiated atmosphere. Nocturnal enuresis is sometimes present.

Diagnosis. Even a casual inspection of the fauces will reveal the enlarged masses, which the act of gagging throws out still more prominently into view.

Treatment. The condition offers no hope of improvement if left to itself. It is true that the tonsils will atrophy in later years, but by this time irreparable damage may have been done in various directions. If the tonsils are large enough to cause any of the foregoing symptoms, they should be removed. The only question is as to preference of methods in such removal.

In children tonsillotomy with some approved instrument is preferable (for operation, see page 1205), and it is the writer's experience that a more satisfactory removal can be accomplished without anesthesia than with it.

Where the tonsils are large but flat and non projecting it is difficult, if not impossible, to engage any considerable portion of them within the ring of the guillotine. Under these circumstances we may employ ignipuncture (see below) or the method of Ruault " traitement par morcellement." He has devised a tonsil punch forceps, by which pieces of the tonsillar substance may be bitten off. This instrument will engage in the tonsillar tissue if the surface of the latter is at all uneven. If it is smooth, the crypts should first be scraped out, adhesions to the faucial pillars broken down with a palatehook, and the tonsillar surface incised with a small blade set at a right angle to the axis of its shaft. In this way bits of tissue are presented to the punch forceps for removal. After bleeding has ceased, the raw surface should be vigorously rubbed with a cotton carrier dipped in a solution of iodin 1 part, potassium iodid 1 part, water 8 parts. A smart stinging sensation ensues, which passes off in twenty minutes. Secondary retraction of the stump greatly increases the amount of reduction in size.

In older patients the use of the guillotine is somewhat hazardous, owing to the liability to hemorrhage. We may use here either the cold wire or galvano cautery snare the latter being the one more frequently employed. The cold snare can be used with a stiff wire which can be accurately adjusted. It can be tightened slowly and hemorrhage thereby avoided. It is extremely painful, and owing to the time its use requires, the latter necessitates in children a general anesthetic. In adults the cold snare can be used under cocain.

The hot snare (galvano cautery loop) has the advantage of being practically a bloodless operation. The wire should he of irido platinum, which is much stiffer than pure platinum wire, while retaining also all of the latter's, advantages. It is somewhat difficult to adjust the loop and hold it in position until the current can be turned on, unless the tonsillar mass to be removed is of considerable size. It is therefore often of service to make on the posterior aspect of the tonsil a groove either with a bent electrode or with the concavity of the loop itself. In this way the latter will hold and not slip off when it is tightened. The current should be turned on and off alternately, the snare being tightened in the meantime, the latter part of the cautery section being slowly made.

It is not necessary to remove the entire tonsil. A thick slough will eventually come away, causing a still further shrinkage of the tonsil. It has been said that entire removal of the latter leaves an annoying dryness of the mouth, but this has Dot been the personal experience of the writer.

Where the shape or disposition of the tonsillar structures is such as to necessitate removal by piecemeal or gradually, we have in addition to the method of Ruault that of ignipuncture. This can be made practically painless by injecting one or two drops of a 5 per cent., cocain solution tinder those area, , selected for operation. The cautery tip should be inserted deeply into a crypt, the current then turned on, and the tip be made to burn its way diagonally outward. Eight or ten such punctures can be made at each sitting. The throat is quite sore for a day or two, and it is better to attack only one tonsil at a time. lee water gargles and antiseptic mouth washes can be used ad interim. There is a great variation in the rapidity of shrinkage after such treatment some tonsils rapidly melting away, as it were, while others require repeated seances. Care should be taken to avoid burning the faucial pillars, for the minute cicatrices thus formed are apt to become neuralgic foci on every slight cold in the throat.

Of course, neither the cautery snare nor tip should be used without a rheostat. It must be remembered that contact with moist tissues quickly abstracts beat from the wire, and allowance must be made accordingly.

Chronic Inflammation of the Lingual Tonsil. For all practical purposes only the parenchymatous variety need be mentioned. One case (perhaps others) has been recorded of chronic encysted abscess in this situation.

The affection has been commonly regarded as more frequent in women about middle life and with a history of previous menstrual disorders than in men. Out of 17,566 cases of throat trouble, Lennox Browne found varicose veins at the base of the tongue associated with hypertrophy of the lingual tonsil in 1866, or 10.6 per cent. Again, in 1547 cases, 438, or 28.3 per cent. Of this latter group, however, only 31 per cent. were in women, while 69 per cent., were in men. Of his private cases, 99 per cent. were voice users.

In any event the affection is one belonging to the period of middle life, and this is a point worthy of note, because at this age atrophy of all the tonsillar structures is generally present. Hickman has recorded the case of a child dying of asphyxia a few hours after birth, supposedly from a congenital glottic tumor, but the autopsy revealed all enormous hypertrophy of the normal tissue on the posterior part of the tongue.

Other causes are those in general of the various forms of chronic tonsillar inflammation, including especially all forms of irritant ingesta.

Pathology. The enlarged lymphoid mass may be situated in the middle line, or there may be a mass on each side with a deep furrow between. The growths often project sufficiently to infringe upon the edges of' the epiglottis an(] even to compress the latter (the so called " incarceration of the epiglottis " ). Minutely examined, we find nodular elevations which exhibit a well marked umbilication. This latter is a central crypt due to a depression of the stratified epithelium. Such crypts are sometimes lined with ciliated epithelium. In minor cases the enlargement may consist almost entirely of an epithelial hyperplasia, which is hard and wart like rather than soft like the typical lymphoid overgrowth (Fig. 577). The lymphatic channels from this region pass directly backward, and after coursing through the deep lingual glands join the deep cervical glands in the neighborhood of the bifurcation of the common carotid artery.

Symptoms. The principal symptom is pharyngeal dysesthesia, manifested in a great variety of ways. There may be every intervening grade between a slight tickling and a sharp stinging pain. At other times there is a sensation as if the throat was grasped from the outside and forcibly compressed, or there may be the sensation as of a foreign body stuck in the tissues, with a constant desire to clear the throat.

Manifold varieties of reflex or direct neuroses are often present. The purity and vigor of the singing voice become impaired; esophageal spasm is frequently evoked, and the condition of the lingual tonsil should never be overlooked in searching for the cause of globus hystericus. Asthmatic attacks are not uncommon. The patients are, as a rule, extremely neurotic, and women especially are apt to fear that these pharyngeal disturbances are the forerunners of cancer.

Treatment. The condition is not a serious one, and the annoyance it causes is out of all proportion to its real pathological importance. But patients have a just grievance and have a right to demand relief. This does not come without interference. Outside of the cessation of any vicious practice in eating, drinking, voice use, etc., the end to be sought is the reduction in size of the offending mass.

If necessary, a previous application of cocain should be made before any manipulative measures are attempted. If the masses are large enough to engage in the ring of the tonsillotome (especially the Mackenzie instrument, curved to correspond with the curve of the tongue), the latter may be used to remove them. We may also use the cold wire snare in a curved cannula, employing transfixion needles to insure engagement of the snare in the tissue. The ordinary curved uvulotomy scissors will answer in some cases, or we have also at our disposal the hot snare.

When the growth is diffused, some sort of caustic must be employed. Nitrate of silver is useless because its action is too superficial. Chlorid of zinc solutions, caustic pyrozone, and chromic acid are at our disposal. Perhaps the cauterizing agent most frequently employed is the galvanocautery tip at a dull red heat, five or six punctures being made at each sitting Caustics should not be recklessly used in this situation, for the formation of too much cicatricial tissue at this point may eventually aggravate the very condition we hope to relieve. More important than this, however, is the fact that too much irritation might start a neoplastic formation liable to assume a malignant character.

Hemorrhage after any cutting operation here is usually slight. Swelling is for a time very painful lee pellets should be freely used. All hot drinks, spices, condiments, and coarse foods should be avoided for a day or two.

In the use of caustics special care must be taken to avoid injuring the epiglottis, which is apt to react severely to very slight trauma.

LINGUAL VARIX.

Apart from the enlargement of the lingual tonsil, the veins in this situation may become tortuous and dilated, assuming a varicose condition. To this have been given the names of lingual varix, hemorrhoids of the tongue, etc. As to the local physical condition, it is practically identical with that in rectal hemorrhoids.

Causes. The affection is rare before the twentieth year, and far more common about middle life. It most frequently occurs in patients with torpid liver and those who suffer from chronic dyspepsia associated with constipation and piles. It may be present in almost any chronic visceral affection obstructing free venous return, and occasionally seems to be one of the local manifestations of a general tendency to vaso motor neuroses.

Pathology. The veins are entangled and appear as a network of darkred or reddish blue streaks or bands, with here and there local dilatations: or there may be actual nodosities, small ampullae in which the blood current stagnates.

Symptoms. The symptoms are the same as those of simple enlargement, with the important addition that from time to time small hemorrhages may occur. These, while rare, generally give great alarm to the patient, as he is apt to regard them as the forerunner of lung trouble.

Treatment. The digestive apparatus and bowels should be regulated and any dietetic errors corrected. The vessels are best obliterated by the galvano cautery tip at a dull red heat and under the general precautions already noted.

CHRONIC ENCYSTED TONSILLAR ABSCESS.

Among the causes of tonsillar enlargement may be mentioned the occurrence of chronic encysted abscess. This condition has been carefully studied by Peyrissac, who has analyzed ten cases. Some presented a hard condition of the organ, suggesting a fibroma. They are to be regarded as similar in their mode of origin to the ordinary cold abscess, although they have no tubercular element. Bacteriologically, they have no characteristics other than those of abscesses in general, and do not seem to have any relation to a special diathesis.

An intermittent purulent discharge may suggest the nature and underlying cause of the tonsillar enlargement. The contents of the abscess cavity may be grumous or syrupy in consistency. The pus cells show marked fatty and granular degeneration, and are rich in cholesterin crystals. The lining wall is apparently of a low grade of connective tissue, organized from the surrounding tonsillar parenchyma.

The treatment is not attended with any particular difficulty.

POLYPOID HYPERTROPHY OF THE TONSIL.

Apart from hypertrophy of the tonsil as a whole, we may have a localized enlargement giving rise in a lesser degree to the same symptoms as general hypertrophy and remediable by the same measures, especially the snare. In these adjunct masses there is generally an excessive development of connective tissue, resembling at times an actual sclerosis.

Such growths arise from one of three possible sources:

1. They may be accessory tonsils.
2. There may be an elongation at the site of implantation of one or several lobules of a multilobular and hypertrophied tonsil.
3. The entire tonsil may become pedunculated.

CALCULI OF THE TONSIL

Not infrequently small stone like bodies, tonsilloliths, as they are called, are found in the tonsil or are discharged from its surface. They vary in size from a pin's head to a pea, and a few very large ones have been reported. Their composition, as determined by Langier, is: calcium phosphate, 50; calcium carbonate, 12.5; mucus, 12.5; water, 25 per cent. The constant occurrence therein of cholesterin is a disputed point. It certainly has been found in some instances, as have also magnesium salts. The starting point of formation may be a minute foreign body; but is generally a mass of retained secretion in the crypts. Various micro organisms have been found embedded in these calculi.

The symptoms are those of a foreign body, sometimes causing tonsillar enlargement. Palpation and the exploring needle will render the diagnosis certain.

Treatment consists in incising the tissue over the calculus, scooping the latter out and cauterizing its bed.

FOREIGN BODIES IN THE TONSIL.

These are generally either chicken or fish bones, pins, hairs, or bristles from a tooth brush. Occasionally the entire foreign body becomes embedded in the tissue, but generally a portion projects and can be seen or felt. In case inspection reveals nothing we must always palpate. Removal by forceps is generally easy enough.

That large class of cases must not be forgotten in which the body has been swallowed but has left a slight lesion, causing much pharyngeal discomfort. This dysesthesia can be relieved by a mild cocain spray. Even then it is difficult to persuade patients of the groundlessness of their fears.

XEROSTOMIA (DRY MOUTH).

This condition was first described in 1868 by J. Hutchinson who gave it the name it bears. Since that time some twenty five cases have been recorded. The most prominent feature in all has been a persistent and extreme dryness of the buccal mucosa. The dryness may begin in the eyes and nose, extending thence to the pharynx and trachea. The teeth are apt to crumble. All the cases thus far reported have been in women.

The nature of the disease is unknown. It shows no constant lesion. In one or two instances the parotid glands have been enlarged, but the ducts have remained pervious. Many of the cases have presented coincident trophic changes in other parts of the body, suggesting the central origin of the affection.

All local or constitutional remedies have thus far proven useless. Pilocarpin and potassium iodid seem to exert no effect on the condition.

DISEASES OF THE EPIGLOTTIS.

It is unusual for the epiglottis to be the seat of primary inflammatory affections. It is generally secondarily involved, as in lupus, tuberculosis, and syphilis, in which it presents the lesions characteristic of these respective affections. It shares, so far as its mucous covering is concerned, in the various catarrhal conditions of the pharynx and larynx. In enlargement of the lingual tonsil the latter sometimes compresses the edges of the epiglottis, giving rise to the so called “incarceration “of the latter. The epiglottis itself frequently responds to this irritation by growing larger, but this increase in size will disappear when the tonsil is properly removed.

The organ in health may be curved, angular, pendulous, or folded. Its edges may be smooth, serrated, or crenated. The under surface is always of a redder hue than the upper.

Concerning its function, we are still in considerable ignorance. It undoubtedly does help to protect the larynx from the entrance of food; but we know, both from animal experimentation and from the results of disease, that absence of the organ is not incompatible with easy deglutition. It has also been regarded as a "sounding board," reflecting the vocal sound wave to the pharynx, where it is in part articulated. If it is destroyed, the voice is less distinct, and if its edges are irregular and jagged, the voice may be rough and harsh.

The specific affections of the epiglottis are elsewhere considered. We have here to treat of simple enlargement.

Enlargement of the Epiglottis. This is a pure hyperchondrosis, with more or less thickening of the mucosa covering it.

The causes are the same in general as those which lead to the production of chronic pharyngeal catarrhs.

Symptoms. It is difficult to separate the symptoms of an enlarged epiglottis from those which may be referred to an enlarged lingual tonsil or a varicose condition of the lingual veins. We find here the same pharyngeal dysesthesia, pain in varying degree, irritative cough, empty swallowing, and sensation as of a foreign body, vocal impairment, and gastric irritability. During acute exacerbations of catarrhal states painful swallowing is perhaps the most disturbing feature.

Rice has described a form of epiglottic inflammation caused by a natural size of the organ sufficient to bring it into contact with surrounding parts. The organ is abnormally hard throughout. In such cases the least exciting cause, as talking, singing, eating, going out into the cool air, change of body posture, etc., may cause an attack of coughing, or at least render the voice temporarily incompetent for any vocal effort.

Treatment. This is in a general way that of the catarrhal condition always found in these cases, including, of course, the removal of all sources of irritation. Such measures, if faithfully carried out, will often reduce an enlarged epiglottis to its normal size. Astringent applications alone are of but little value. Cocain and oily sprays are but palliative, and their continued use is objectionable. The employment of the galvano cautery generally provokes severe inflammatory reaction. Rice advises trimming off about one eighth of an inch from the margins of the cartilage where they impinge upon the pharyngeal walls, using for this purpose long handled curved scissors. Reaction is but moderate and hemorrhage is not excessive. He specially cautions against the removal of more than a narrow ribbon of tissue Price Brown has used the galvano cautery in one case where the epiglottis was long and narrow, but with its tip turned up into a horizontal position. No evil results followed.

DISEASES OF THE UVULA.

The anatomy of the uvula is elsewhere described. Concerning its physiology we are still uncertain, for the various functions assigned to it do not seem to suffer by its removal.

Malformations. We can do no better than quote the statistics of C. Berens, who found in 3000 throats, 84 cases of abnormality in shape viz. : hypertrophy, 11 ; pendulous, 2 ; fish tailed shape, 39; attached to other parts, 2 ; deeply cleft, 14 ; worm like shreds, 8 ; completely separate, 2

supernumerary, 4 ; also absent, 2.

Acute Uvulitis. This is generally seen in connection with acute pharyngitis and tonsillitis, but may occur independently. It may arise from trauma (including excessive vocal effort), septic absorption, and occasionally after ignipuncture of the tonsils. The uvula becomes swollen and edematous. It may even bleed and one or two cases have been reported in which there was a hemorrhage into the substance of the uvula itself.

Symptoms. These are (1) general, in the form of a slight febrile reaction; and (2) local, as dysphagia, pain, a feeling that the throat is filled up, rarely dyspnea. There is generally slight dry cough, thick voice, and general pharyngeal discomfort.

Treatment. The uvula should be punctured freely with a finely pointed bistoury, especially when the edema is marked. Demuleent washes, hot alkaline gargles, etc., may then be used, followed later by an astringent preparation, as :

R. Tr. kino,
Tr. cateebu co.,
Glycerit., aside tarmici, aa 3j._M.
S. Teaspoonful in one half glass cold water for gargle.

Chronic Uvulitis. This is generally secondary to chronic catarrhal conditions of surrounding parts and cured by the treatment of the latter. It is an essential part also of elongated uvula, to be next considered.

Enlarged Uvula. This condition is present in varying degree in nearly all patients who are subject to frequent sore threats of any kind, and especially in those who indulge in forced and unregulated vocal effort.

Pathology. The enlargement may be a general thickening or merely an elongation. The latter may be merely a prolapse of the mucous membrane upon the muscular substance, or may be a true hypertrophy of the entire organ with downward extension, so that the tip rests on the dorsum of the tongue. There is always more or less paresis of the soft palate.

Symptoms. The amount of disturbance produced by this condition varies greatly in different patients. Some with very long uvulae make no, complaint whatever. Generally there is more or less tickling, coughing, retching, and even vomiting. These may be excited by the sudden change from one temperature to another, by diffused cold to the skin (as in bathing), or when fatigued. In the worse cases there may be nocturnal glottic spasm, the uvula being most relaxed during sleep. The constant coughing sometimes causes rupture of the superficial vessels of the lower pharyngeal mucosa, and the patients bring up an occasional tinge of blood in the gelatinous pellets they expel. All these symptoms sometimes lead the sufferer to believe that he has serious lung disease, but a removal of the offending tissue quickly reassures him. To vocalists an enlarged uvula is a serious menace. The voice becomes easily fatigued, loses its range, strength, and clearness, and frequently becomes tremulous.

In examining these cases the parts must be relaxed and nasal respiration maintained, else the soft palate will be drawn up and a wrong perspective of the parts be presented.

Treatment. In those cases where the mucosa is merely edematous and prolapsed on the muscle, simple astringent troches and mouthwashes may suffice. If, however, their use for a reasonable length of time does not effect the requisite shortening of the organ, or if there is a true hypertrophy with elongation of the muscle, a portion of the latter should be removed. (For Uvulotomy, see page 1208.)

The normal organ averages in the adult about three eighths of an inch in length, and when the mouth is closed should bang free in the fauces without touching the tongue. It must not be forgotten that the frequent hawking caused by enlarged uvula tends mechanically to aggravate still further the condition.

DISEASES OF THE PHARYNX.

The pharynx is a fibro muscular funnel shaped tube, extending from the under surface of the basilar process of the occipital to a point about opposite to the sixth cervical vertebra and on a level with the cricoid cartilage below. The upper part of the tube is expanded into a dome, imperfect in front, and likened to a “carriage hood with the front window half way down." At its sides are the common and internal carotid arteries.

Above, it communicates anteriorly with the posterior nares, laterally with the Eustachian tubes, in the middle with the mouth, and below with the larynx and esophagus. It has a strong fibrous investment, with a series of muscular constrictors and a mucous lining continuous with that of the surrounding cavities.

The epithelial lining is Of the columnar ciliated variety in the dome and as low down as the floor of the nose ; below it assumes the squamous type. It has a rich glandular supply, the acinous variety being generally distributed, less abundantly, however, in the vault; while the lymphoid deposits (not true glands) are massed about the orifices of the Eustachian tubes and in the dome, forming in the latter the third, pharyngeal, or Luschka's, tonsil.

In any consideration of pharyngeal maladies, two facts should be borne in mind. One is inherent in its structure and the other in its function. Being a combination of mucous membrane, muscle, and fibrous aponeurosis, it is naturally subject to the general run of acute inflammatory conditions; but it also bears the brunt of many outbreaks due to the gouty and rheumatic diatheses.

Moreover, the pharynx is a food as well as an air conduit. It has thus a relation to the digestive as well as to the respiratory tract; and disturbances of either may be caused by pharyngeal disturbances, or may even cause them. The existence of a scrofulous taint acts in the same direction.

Acute Catarrhal Pharyngitis. This is an acute exudative inflammation of the mucous lining of the pharynx. This cavity is a veritable breeding place for all sorts of micro organisms, and yet in a condition of health they are harmless. Exposure to cold really means lessened resistance of the tissues to germ vitality and germ entrance into the substance of the membrane. The excessive use of alcohol and tobacco, the ingestion of irritant food, the presence Of foreign bodies, etc., are accountable for many attacks. Gouty and rheumatic poisons frequently expend themselves upon this area. Another frequent exciting cause is a disordered state of the, stomach and a torpid liver, especially that group of symptoms collectively known as a “bilious attack."

As predisposing causes we may have a bad general environment, poor ventilation, improper clothing, the breathing of noxious gases, and occupations of a sedentary character. The disease is more prevalent during the damp seasons of spring and fall, affecting especially those exposed to sudden temperature changes. All agoes suffer from it.

Pathology. The affection is the simple type of acute exudative inflammation occurring in a mucous membrane, with its stages of congestion,, swelling, dryness, and later increased secretion. It may be confined to, various areas, as the post pharyngeal wall, the palatal folds, the fauces, or may affect the entire cavity. Pretty generally the covering of the tonsils is involved, and we really have an acute catarrhal tonsillitis as well as pharyngitis. The mucosa may be shining and smooth or of a granular appearance.

Symptoms. In a simple case there is generally a very mild constitutional febrile reaction. Locally, we have pain of various degrees of intensity, painful swallowing, irritative cough, with a constant desire to clear the throat. Viscid mucus is expectorated, sometimes in pellets and occasionally blood streaked. Smell, taste, and even hearing may be impaired the latter especially when the attack is engrafted upon an old tonsillar enlargement. The attack may pass off into "a cold in the bead."

The prognosis is always good, the inflammation rarely extending to the deeper structures.

Treatment. At the outset a mercurial and saline should be given, followed by aconite and belladonna in small but frequent and alternating doses. Pellets of ice are grateful, and in the milder cases relief may come from the free use of some astringent lozenge, such as the krameria or redgum troches. Weak cocain solutions may be sparingly sprayed on to relieve pain, but a graduated atomizer should always be employed, so as to register the amount of the drug used. Menthol in albolene (gr. xv 3j) is often just as efficacious. For this and similar purposes the " pyrozone atomizer " may be employed.

In the diathetic cases, guaiac, salicylates, colchicum, and syrup of iodid of iron find their proper application. Iced compresses may be used externally. An edematous uvula or palate should be freely punctured. Food should be soft and non irritating.

A simple tonic is often advisable after the subsidence of the acute symptoms. For the excessive secretion some form of astringent gargle is generally employed. A good formula is that given on page 938.

It has become fashionable in certain circles to decry the use of gargles on the ground that the fluid comes in contact with only a very small part of the affected area, never passing, as ordinarily used, beyond the anterior faucial pillars. The ideal method of gargling is that known as the “Von Troltsch “plan. The patient sits, or better lies down, with the head thrown back. He takes a mouthful of the gargle and begins the movement of swallowing without letting the liquid go down his throat. He next throws the bead suddenly forward, when part of the fluid will go up into the naso pharynx and find its exit through the nostrils, while the rest escapes through the mouth.

It is obvious that but few patients can thus juggle with their swallowing: apparatus. Moreover, the method is painful at any time and therefore practically inadmissible in many acute inflammatory states. As a matter of fact, however, Swain has demonstrated that by this method fluid may be brought in contact with the outer or extra laryngeal surface of the epiglottis, the aryepiglottic ligament, the arytenoid cartilages, and the posterior commissure of the larynx, as well as with the upper surfaces. In the later stages of acute, catarrhal pharyngitis mild antiseptic troches or mouth washes may be of service. To avoid a repetition of the attacks proper foot wear and woolen underclothing should be worn. The neck and upper chest should be douched night and morning with cold water and briskly rubbed with a coarse towel.

Chronic Catarrhal Pharyngitis. Under this heading is to be considered the chronic catarrhal condition of the membrane as a whole, and also that distinct affection of its lymphoid elements known as "follicular pharyngitis." A localized variety of the latter is known as pharyngitis lateralis.

Simple Chronic Catarrhal Pharyngitis. In this form the lesion is generally confined to the pharyngeal mucosa proper. The uvula, palate, and faucial pillars usually escape. The tonsils, however, are frequently enlarged.

Quite a difference of opinion exists as to the cause of this affection. The majority of writers would seem to regard it either as a result of repeated acute catarrhal processes, as in the case of mucous membranes generally, or as a disease set up by some of the long acting causes named below. Bosworth emphatically states his conviction that “chronic pharyngitis is in no instance the result of repeated attacks of acute inflammation; but, on the contrary, the chronic process sets in first, whereupon its clinical history is marked by repeated attacks of acute catarrhal sore throat " According to his view, the condition is generally secondary to a chronic gastritis, especially that form due to alcohol.

A frequent cause is the inhalation of all sorts of irritants, including tobacco smoke. Here again we tread on disputed ground, some claiming that the nicotine and irritating salts of the smoke will set up a pharyngitis ab initio, and others that they merely aggravate a pre existing condition. Some cases seem to arise from the extension of a naso pharyngeal process or to be aggravated by the constant hawking and straining of the pharyngeal muscles.

Finally it all the air inspired through the nose. Hence, if this air is not (owing to intranasal abnormalities) properly strained, moistened, and warmed it will act as an irritant. Particularly is this the case if nasal obstruction is sufficient to cause mouth breathing.

Pathology. We have here to deal with a proliferative inflammation occurring in a mucous membrane. The blood vessels take no share in the process, which consists in the formation of a low grade of connective tissue in the deeper layers. The mucous gland , which are here scanty, are not much affected. The secretion is apparently increased and abnormally viscid. The lymphoid elements are not involved. In some of the older cases enlarged veins may course over the surface.

Symptoms. As the affection is so frequently associated with gastric disorders, the symptoms of the latter are very much in evidence in the form of flatulency, gagging, nausea, and even vomiting. Combined with these is a continuous smarting feeling in the pharynx, with special discomfort in swallowing spiced foods or hot drinks. A coexisting naso pharyngitis aggravates all symptoms. The whole mucous lining of the pharynx is excessively irritable. It is often impossible at the first sitting to make a satisfactory examination. Particularly is this the case in institution patients, with their usual excesses in malt liquors and inferior tobacco. The mucosa is of a dark red, beefy color, which rarely extends forward beyond the posterior faucial pillars. The breath is sour and offensive, while the tongue is more or less coated.

Treatment. In man ' v cases the pharynx itself is best left alone for awhile and attention directed toward the removal of vicious practices in eating and drinking. If irritability of the mucosa prevents proper examina¬tion, weak cocain applications may be made, or the patient may be put under the influence of the bromids, using also a strong solution of the latter for a gargle. Alcohol and tobacco must be cut off entirely, and tea and coffee during treatment. The bowels should be regulated with Salinas and cholagogues. An alkali with a bitter may be given after meals. Greasy foods, pastries, etc., fall under the ban. But little fluid should be taken at meals, so as to ensure the proper mastication of the food.

These procedures will alone cure many cases of chronic catarrhal pharyngitis. If, however, local discomfort persists after the stomach is regulated, we may make local applications to the pharyngeal mucosa. Silver nitrate (gr. xv 3j) or the zinc salts (except the chlorid) in the same strength may be used. These remedies are exactly as good as the host of new ones recently placed on the market. Nothing is gained in the care of these common maladies by running after strange therapeutic gods.

A valuable Menstruum for many topical agents is the new oleo stearate must not be forgotten that the pharyngeal mucosa is bathed by of zinc, a union of stearate of zinc with benzoinated albolene. It forms a viscid whitish mixture, not disagreeable to the taste. It can be used as a vehicle for the ordinary run of topical agents.

Chronic Follicular Pharyngitis. In this affection the brunt of the pathological process falls upon the lymphoid structures which lie in the deeper layers of the mucosa. This change is of the greater clinical importance in that the process seems to involve in some way not entirely clear the sensory nerve filaments of the area, giving rise to symptoms causing great discomfort.

Causes. Over and above all there lies a diathesis to which has been given the name of “lymphatism." It is a tendency of all Iymphoid structures at an early period of life to take on an overgrowth. With the earlier writers this tendency figures under the category of scrofula. At the present time we are disposed to admit the affinity, though not the identity, of the two.

The lymphatic overgrowth beginning in childhood affects more or less all the lymphoid deposits in the naso pharynx and pharynx. The evidences of disease in the former of these two regions greatly predominate, so that not until later years do the troubles referable to the follicular ailment in the pharynx distinctly show themselves. Bad hygienic general environment pre disposes to this form of catarrh; but there is no reason to believe that it has any relation to rheumatism or gout.

Pathology. The follicular enlargement is a distinct process from the beginning, and probably is never a passing over from the simple catarrhal process described in the previous section. It may be accompanied by a simple surface catarrh. It may be diffused over the surface of the pharynx, which assumes a granular appearance (granular pharyngitis), or may localize itself at the sides, just behind the posterior faucial pillars. To these ridges or bead chain like deposits Schmidt has given the name of ' pharyngitis lateralis." These ridges occasionally become adherent to the pillars, so that their union appears as large cords on either side.

The affection of the follicles seems to be most pronounced near the mouths of the muciparous glands. The process is really one of hyperplasia, a true increase in the number of lymphoid elements, especially about the efferent channels of the lymph nodes. This hyperplasia may be diffused throughout the deeper as well as the superficial lymphatic structure of the mucosa, causing a thickening thereof, or it may be localized as blunt masses projecting a little from the surface. At first these masses are soft, but in later years they grow smaller and harder and may even disappear, leaving no symptom; but their persistence in later years is the legacy of the changes during the time of “lymphatism " (Fig. 579).

Symptoms. As the most prominent we note pharyngeal dysesthesia, due' first to the unusually rich nerve supply of the pharyngeal mucosa, and second to the fact already noted that the nerve filaments are involved in the nodal changes. We may have all grades of sensation, from a mere discomfort to an actual pain. On account of this neurotic element it has been claimed that the disease is more common among women, but we have not so found it.

Overuse of the voice aggravates the discomfort. Painful swallowing is often felt. It has been suggested that the circulation through the follicles is increased and that attendant pressure changes cause a true neuralgia.

The secretion is not, as a rule, increased in amount. Sometimes the follicles seem to lie on a bed of whitish connective tissue and the whole area looks very dry (pharyngitis sicca). The voice is husky, probably from a reflex influence upon the phonatory muscles. A dry nervous cough is often present.

The uvula may be elongated, especially when an accompanying naso pharyngitis produces much hawking. So, also, the faucial and lingual tonsils may be enlarged. Frequently the enlarged veins are seen coursing over the pharyngeal wall, but they are Dot distinctive of this condition. The disease may continue indefinitely, although without any extension to neighboring parts. There is no conclusive evidence that it predisposes to phthisis.

Treatment. As to general measures, we may refer to the treatment of the simple catarrhal form. The local treatment consists in the removal or destruction of the diseased follicles.

Of destructive agents we have chromic and trichloracetic acids, and the galvano cautery at a bright cherry red beat. Six or eight follicles may be treated at each sitting. A drop of 5 per cent., cocain solution injected at their bases through a curved needle will render the cauterization painless. E. Mayer curettes these diseased surfaces, and has devised a special instrument for this purpose and obtains excellent results. An antiseptic mouthwash should be used after cauterization.

In pharyngitis lateralis the same plan may be followed. Several sittings are required, and the reaction after the cauterly is more severe in this situation than on the post pharyngeal wall.

Hemorrhage from the Pharynx. A brief note should be made concerning hemorrhages from the pharynx. These may be due to two different classes of causes: (1) Changes in the blood, and possibly in some cases in the blood vessels, which permit the escape of the blood in various parts of the body e. g., purpura, hemophilia, leukemia, pernicious anemia, etc. (2) Ulcerations of various kinds, suppuration, trauma, the so called 11 hemorrhagic laryngitis," and perhaps varicose veins. The latter source has been alluded to tinder " lingual varix."

Pharyngeal hemorrhages from the causes enumerated under the first of the foregoing divisions are rare. Under the second we may include cancerous ulcerations and also laryngitis sicca where the formation of crusts and their subsequent dislodgement may cause erosion of superficial vessels.

Tubercular ulceration of the larynx rarely, if ever, causes local bleeding, although the larynx may retain blood coming from the lungs or bronchi.

Where patients come to the physician with the history of having raised a little blood, the lungs are naturally first examined, and if there are neither signs nor symptoms of pulmonary trouble, the bleeding is referred to the throat and apt to be regarded as of slight moment. Such reasoning is fallacious. True pharyngeal hemorrhages are extremely rare, and their existence should never be predicated unless a clot or a bleeding point can actually be seen upon the mucous membrane of the pharynx. In the greater majority of all these cases the blood comes from some part of the respiratory tract below the glottis i. e., signifies lung trouble, whether there are any other signs or symptoms to correspond with it or not.

Of course, the mouth and gums must be carefully searched in this class of cases. So, also, allowance must be made for the existence of valvular cardiac trouble and pulmonary hyperemia. In some cases the blood escapes by diapedesis rather than by actual rupture of vessels.

It must be borne in mind that the intimate anatomical and physiological relations of the pharynx with the larynx and parts below permit blood effused in one situation to quickly deposit itself in another. Hence we must be cautious in our deductions as io the actual source of the bleeding. Moreover, blood effused high up in the tract may get into the lungs and so predispose to tubercular invasion.

Finally, we must be on our guard against malingerers who, for their own various purposes, can produce pharyngeal hemorrhage with the greatest readiness.

Pharyngo mycosis. Under this title is properly included all mycotic growths occurring in this situation. Among the parasites most frequently found here are the oidium albicans, actinomyces, aspergillus fumigatus, bacillus fasciculatus, and the growth causing that rare affection nigrities lingua or black tongue. By common clinical consent, however, the term, unless qualified, is restricted to cases of leptothrix growth. This form was first described by Frankel in 1873.

Causes. As predisposing causes we have preceding inflammations, especially of the tonsils, and carious teeth. It frequently follows acute tonsillitis, and has doubtless been often mistaken for chronic lacunar affection. The exciting cause, or rather the essence of the disease, is the growth of the leptothrix threads.

Pathology. The deposits occur most frequently on the faucial and lingual tonsils, but they are occasionally seen on the pharyngeal tonsil, less frequently on the soft palate, post pharyngeal wall, glosso epiglottic folds, and larynx. J. Wright found them in one instance upon the inferior turbinal body. They appear as patches apparently embedded in the tonsillar crypts and projecting above the surface. They are generally hard and horny, being removed with great difficulty. They may exist as isolated areas of varying size or they may be connected by threads extending from one to~ another and interlacing like the tendrils of running vines.

If a bit of deposit is removed, teased in glycerin, and examined with a, low power objective, we note a mass of epithelia (an accidental feature) surrounded by irregular granules, in which are embedded the rod like cells of various species of the leptothrix fungus (belonging to the group of schizomycetes). These rods or mycelial threads generally occur in links, and some times curl up at heir ends into fine hair like filaments. Other rods appear colorless, but with sharp, dark borders, the centers seeming to be full of granular matter. The loose granules are in some instances the spores of the growth. Methyl blue staining will bring out alternating colored and uncolored segments on the threads; while Lugol's solution gives with them the characteristic starch reaction.

This fungus has never been cultivated outside of living bodies. Leptothrix threads of various species inhabit ever healthy mouth. The presence, of tartar on the teeth, an altered reaction of buccal secretion, and a disordered digestion all seem to promote their growth. There is no proof that the gouty or rheumatic states predispose to them. They are found in rhinoliths, tonsillar concretions, and vesical calculi; in the secretion of tracheal ozena, fetid bronchitis, and pulmonary gangrene; on the coating of the tongue in low fevers, in the lachrymal duct, intestine, vagina, and feces. Most of the cases of mycosis reported have been in young women. In any situation the growth may precipitate lime salts from fluids holding them in solution.

A somewhat novel view of the nature of this affection is that advanced by Sichenmann, who contends that Frankel's benign tonsillar mycosis, with its formation of solid horny matter, should be taken from the category of mycoses and put in that of hyperkeratosis of the mucosa As a product of a less complete keratosis should be regarded the less complete epithelial keratosis which is found in all tonsils, and which is an excellent medium for the development of the organisms of decomposition. The collection of incompletely keratosed epithelium is therefore a constant menace to the surrounding tissues, analogous to cholesteatoma of the middle ear. Sichenmann would drop the name “pharyngo mycosis “and substitute therefore “lacunar hyperkeratosis."

Symptoms. These consist of constant irritation in the fauces and a pricking or a pasty feeling, with mild cough and difficulty in swallowing. In one case sub maxillary glandular enlargement was noted. Schech has found fever with general malaise, weakness, and anorexia preceding the local deposits. The tonsils themselves may be a little red and swollen. Semon has seen the soft palate and uvula Congested, the latter being also very edematous.

Course. The deposits come and go sometimes regardless of treatment. There is no danger in the affection. It is of more pathological interest than of clinical importance.

Treatment. All functional disorders should be corrected; the teeth must be put in good condition. In one of the writer's cases the deposits permanently disappeared as soon as this was done. Sweets must be cut off from the diet. A change of climate will alone cure some cases.

As to topical measures, nearly every caustic and antiseptic in the pharmacopeia has been recommended e. g., solutions of zinc chlorid, balsam of Peru in alcohol, iodin and carbolic acid in glycerin, salicylic acid in alcohol, borax, bichlorid, chromic acid, silver nitrate, and pyrozone. Smoking is reported to have cured one case, and an instance in the writer's experience lends some color to this view. Nicotin solutions, however, should not be applied. Some of the larger deposits may be torn away with forceps. The favorite measure is the galvano cautery tip carried to the base of each deposit. Tonsillotomy may be done if the organ is large enough to engage in the guillotine. Internally, salol and the alkalies have been used.

Herpes of the Fauces. This is one of the rare diseases. Obviously, different clinicians have had different conditions in mind in their use of this term. Else how can we account for the fact that of two prominent writers, one has seen only 12 cases in a lifetime, while the other reports over 100 cases in six years?

The disease consists in the occurrence on the uvula, soft palate, tongue, and inside of the cheeks of small blisters, resembling somewhat the customary herpetic patches seen on the skin. The tonsils and epiglottis may also be invaded, while the posterior pharyngeal wall regularly escapes. The affection may be unilateral or bilateral. It occurs more frequently in children, in those constitutionally delicate, and in neurotic young women. It is especially prevalent during diphtheritic outbreaks, in damp climates, and during the colder months. Many of the patients are distinctly anemic.

Pathology. In the initial stages small distended vesicles are seen with a surrounding zone of inflamed mucosa. These occur singly or in patches. They may disappear by absorption, leaving no trace; or may burst, leaving shallow circular ulcers. The vesicular stage is a brief one, for the epithelial covering of the patch is so delicate that it cannot bold the fluid which collects beneath it except for a very short time. Still, again, the patches may coalesce, forming a large bulla, which after discharging its contents becomes covered with a membranous deposit, suggesting diphtheria. Bosworth records three cases where the eruption assumed the form of herpes iris i. e., " small rings of minute papules enclosing a patch of healthy membrane." He regards the process as a localized inflammation of the papillae of the subepithelial layer of the mucosa originating principally in the terminal filaments of the nerves.

Symptoms. These consist of a moderate febrile reaction and a burning feeling in the fauces, increased by deglutition. Occasionally there is a severe itching about the parts. The pain may radiate to the ears, nose, and even to the larynx. A similar rash may appear coincidently on the lips, thus assisting in the diagnosis. The fauces show a circular arrangement of the eruption, at times popular, or vesicular, or even pustular, with the later history above described.

Cause. The duration is about a week, and patients always recover; but the mucous membrane may be left predisposed to infection. Successive crops of eruption occasionally prolong the disease.

Treatment. All neurotic and anemic states must be corrected, for these cases frequently relapse. At the outset sedative and demulcent mouthwashes are indicated. Morphin and carbolic acid in glycerin may be applied to the painful areas. Potassium chromate is useless, and may even increase the local discomfort. Mild caustics may prevent the spreading of the patches.

Under this heading are considered acute and chronic post nasal catarrh and enlargement of the pharyngeal tonsil, including lymphoid hypertrophy in the vault of the pharynx, the so called “adenoids." Other naso pharyngeal affections are dealt with elsewhere in this work.

Acute Naso pharyngitis: Acute Post nasal Catarrh. This affection is essentially an acute exudative inflammation of the mucosa lining the naso pharyngeal space. It is frequently associated with an acute rhinitis, or rather both lesions occur in that condition known as a 11 cold in the bead;" but it is possible for either to occur separately.

Causes. Exposure to cold and damp plays the chief exciting role. Here also should be borne in mind what has already been said regarding such exposure as related to temporary impairment of tissue vitality. As occurring in very young patients, we generally find acute naso pharyngitis associated with more or less enlargement of the pharyngeal tonsil, which in turn may have resulted from repeated attacks of acute rhinitis. The abuse of alcohol and tobacco, exposure to dust laden air, noxious vapors, and various septic influences are all contributing causes. The relation of any particular diathesis to the acute form of the disease cannot be regarded as proven. Disease of the nasal mucosa is regularly present, and is regarded by some. as the most frequent excitant cause.

Pathology. As already suggested the process here is the typical one of acute exudative inflammation, with its successive stages of congestion, dryness, swelling, and hyper secretion. The follicles are reddened and enlarged and bathed first in mucus and later in muco pus.

Symptoms. Cases are ushered in with a very mild febrile reaction, general malaise, and anorexia. The fever rarely rises to 101' F., and yet the patient is miserable out of all proportion to this temperature. There is a dry, smarting feeling in the back part of the throat, with painful swallowing. Owing to the close anatomical relation between the mucosa and the bony vault, this stage of dryness from arrested secretion is apt to be prolonged. The gastro enteric tract is often in a torpid, sluggish condition, and we have coated tongue, nausea, or even vomiting and constipation.

From this stage the condition passes into that of hyper secretion, which generally affords some relief to the local discomfort. The discharge is at first whitish and mucous in character; but later becomes yellowish and of a mucopurulent consistency. It trickles down from behind the soft palate and is expectorated, or in very young patients swallowed; some of it may be blown out through the anterior nares. Such a muco purulent flow increases the tendency to gagging and nausea. This secretion is viscid, tenacious, and glairy. After a varying period of these symptoms from two to ten days there ensues a third stage characterized by progressive improvement in all symptoms.

During the course of the attack the dry sensation in the naso pharynx may amount to an actual pain, and suggests by its radiation a facial neuralgia. There may be a stiffness of the cervical muscles, as in muscular rheumatism. The voice may be of a nasal character, and a short irritative cough is not uncommon. During the stage of hypersecretion the lining of the Eustachian tube may swell, causing occlusion and more or less deafness.

Although the affection is quite distressing to patients, it is essentially mild, and if the nares are free does not extend to parts below. If, however, they are obstructed and the air is not properly warmed, moistened, and filtered, the pharynx proper may suffer in consequence.

Treatment. This should first be directed toward the gastro intestinal tract, for a restoration of the latter to activity may abort an attack. A mercurial followed by a saline should be given immediately. An initial full dose of quinin and Dover's powder with a hot bath and other diaphoretic measures are often of greatest service. For the headache and general malaise the coal tar products phenacetin, ammonol, lactophenin, etc. in five grain doses every hour, are valuable. Bosworth advocates aconitia in 1/ 500 grain doses every hour or two until the pharyngeal pain abates.

For local relief cocain may first be used to deplete the vessels and allay pain. The amount of the drug employed must be carefully restricted. After free secretion is established, the naso pharynx should be irrigated three or four times daily by any of the methods in common use. The writer prefers a small rubber catheter with a large number of very fine perforations at the distal end, while its proximal end is attached to a rubber bulb. This is filled by suction in the usual manner and then passed along the floor of each nostril until the perforated end is in the naso pharynx. Gentle pressure on the bulb will discharge a series of fine currents, which will bathe the entire cavity without injury to the Eustachian cushions, but effectually removing all secretion. The solutions to be used should be rather more than lukewarm. They may be made up of glyco thymoline, boro lyptol, listerine, etc., one teaspoonful to three ounces of water. A cheaper and yet efficient solution is one teaspoonful. to the pint of water of a powder composed of equal parts of chlorid, biborate, and bicarbonate of sodium.

After the second stage is passed, applications may be made on the postnasal cotton carrier of silver nitrate (gr. xx 3J), or Mandl's solution: iodin, gr. v; potassium iodid, gr. xv; acid carbolic, M ij ; glycerin, 3j. If much tissue hypertrophy remains in the vault, the galvano cautery or cauterizing acids are indicated. The use of a palate hook greatly facilitates the necessary manipulations.

Chronic Naso pharyngitis: Chronic Post nasal Catarrh. By this term is signified a condition characterized by the excessive discharge from the naso pharynx of a secretion altered in quality as well as quantity. It may cling to the site of production or diffuse itself more or less over the surrounding structures. Its discharge is generally effected by a characteristic nasal screatus or hawking.

This disease is common in all lands, and affects especially dwellers near large bodies of water and in damp climates. It is especially common in America, and is sometimes spoken of by English and Continental writers as “American catarrhs." It appears in every grade of severity, from a mere annoyance, scarcely noticeable, to a condition which renders the patient himself thoroughly miserable and disgusting to others.

Causes. Many cases in adults are doubtless referable to neglected disease of the pharyngeal tonsil occurring in earlier years. In childhood all inflammations are prone to invade lymphoid structures. Such a tendency is often aggravated by some intercurrent infantile disease, especially the exanthemata. The various diatheses act through this intermediate lymphatic involvement. The use of tobacco and alcohol are to be considered as exciting causes, the former perhaps only aggravating a pre existing disease; while the latter primarily affects the stomach, between which and the pharynx there exists, as we have seen, an intimate relation.

In regard to the effect of cold alone, as an excitant of the acute form which later subsides into the chronic, Bosworth strenuously insists that the chronic form precedes, and that cold produces exacerbations into an acute or subacute stage. Modern rhinology, however, assigns the most important role among the. causative factors to the condition of the nasal chambers. The recognition of their true function has been the great advance in this field of medicine. They should be examined in every case of post nasal catarrh. If they are diseased, some naso pharyngeal lesion can be safely predicated. The normal secretion from the glands of the latter region is thin, clear, and bland. If, however, owing to intranasal disease, it is constantly fanned by a current of air which is cool, dry, and dusty, its proper elaboration will be interfered with. Cell desquamation in the naso pharynx is unduly stimulated. A thick, stringy, dust laden mucus appears, very tenacious and removed with difficulty. If the disease progresses, crust formation finally results.

Pathology. In addition to the excessive cell desquamation and abnormal secretion there is more or less diffuse hyperplasia of the lymphoid elements of this region. A noteworthy impulse was given in 1885 to the discussion of this question by the publication of Tornwaldt's monograph on the "Significance of the Pharyngeal Bursa." He assigned as a frequent cause of chronic post nasal catarrh a diseased condition of this bursa. It may be the seat of chronic catarrhal inflammation or may be cystic with a closure of the outlet. To such a condition, also, Tornwaldt referred a host of reflex symptoms in various parts of the upper air tract. His views gained some adherents, but are now regarded as too extreme. He considers the bursa as a normal anatomical structure, but Schwabach, after examining over thirty different specimens, denied the statement that the bursa was a special anatomical formation. It should rather be regarded as an integral portion of the pharyngeal tonsil, sharing in common with the latter all pathological changes (Figs. 580, 581).

The beads examined by Schwabach showed in the vault of the pharynx a series of irregular clefts of varying depth forming intervening ridges of variable breadth. The older the child the less distinct was this cleft formation. The median cleft was the most persistent. The bursa, he asserts, is nothing but a remnant of this median cleft. Partial or complete agglutination of its edges forms a blind pocket or pouch, extremely favorable to the retention of mucus, which, under such circumstances, tends to become purulent, and a cyst results. Such inclusion cysts are uncommon. Their epithelial lining is the same as that of the surrounding area. The columnar type here predominates, shading off into the squamous as we pass down the pharyngeal wall; but at times even in the vault the latter type prevails, owing to irritating secretions or the attrition of inflamed surfaces.

Examination of tissue removed from such cases shows first of all an epithelial layer with a range in structure from columnar ciliated to squamous cells. Underneath are lymph nodes embedded in a mass of lymphoid tissue, which in turn presents trabeculae of scanty connective tissue. The usual cryptic depressions appear on the surface (Figs. 582, 583).

Bosworth has pointed out the difficulty of recognizing the relation between the local pathological change and its most annoying symptom viz. increased secretion. There is no increase of the ordinary muciparous follicles, and the increased secretion must therefore come from the surfaces of the clefts and ridges, which take on a functional activity not unlike that of a mucous gland. The mucus being itself abnormal further irritation is caused, and thus the vicious circle is perpetuated.

Symptoms. The most prominent symptom is the discharge of a profuse, viscid, yellowish secretion. It may adhere to the surface of the mucous membrane or flow down the posterior wall and be removed by frequent hawking. There is often the sensation of a pendant drop just behind the soft palate. We must suppose that this secretion is perfectly fluid as it appears at the mouths of the glandular ducts, and that its inspissations results from the abnormal environment it there meets. Its consistency varies from time to time. In those cases where there is an inclusion of the median cleft the discharge is more apt to be fluid. The cavity apparently fills slowly and then becomes a source of sufficient irritation to provoke hawking and lead to an evacuation of the bursal contents. During the day the natural activity of the pharyngeal muscles keeps the discharge from clogging up; but on waking in the morning the accumulation of the night hours begins to be dislodged, causing gagging, nausea, and even vomiting. During the damp weather and at the sea level the severity of the foregoing conditions is generally increased.

Does this form of catarrh predispose to affections of the lower air tract the larynx, trachea, and bronchi? This question has often been discussed. Probably none of the detached mucus ever goes down the windpipe. It glides along the post pharyngeal wall into the esophagus. It is not, therefore, the carrier of contagion to the laryngeal mucosa. Patients who suffer synchronously from naso pharyngeal and laryngeal catarrh are probably the victims of abnormal intranasal conditions. The correction of the latter is the only rational treatment of the twofold catarrhal malady.

Of reflex symptoms, we may cite asthma and headache. The middle ear catarrh sometimes seen in naso pharyngeal cases is probably due to intranasal trouble, causing improper ventilation of the pharyngeal vault and middle ear. It may at times be due to direct propagation of disease of the vault along the lining of the Eustachian tubes.

Diagnosis. In the examination of a given case we must first ascertain whether we have to do with a post nasal catarrh pure and simple or with one complicated by other morbid states.

In an uncomplicated case the small mirror will enable us to recognize either the broad diffuse hypertrophy of the mucosa or the enlarged “bursa." The latter appears as a cleft of varying depth with lateral rounded lips, making a picture which a French writer calls with greater realism than modesty the 11 vulva of the naso pharynx." An accumulation of discharge here may result from syphilitic changes; but other evidences of the latter trouble will make the diagnosis easy.

It is difficult at times to eliminate as factors of the discharge the inflammation of the sphenoidal or post ethmoidal sinuses. When the patient reclines the discharge from these cavities may trickle back into the naso pharynx, and its appearance there simulates bursal disease. A careful examination made during the day, after previously cleansing the region, will generally determine whether or Dot serious trouble exists.

Course. Patients have generally suffered, in a mild degree at least, for many years before coming under professional care. As a rule, the longer they have complained the more quickly they seem to think they can be cured. Most of them can be cured if they will follow up treatment long enough, but at the outset a full statement of the continued care necessary should be laid before them.

Treatment. Any underlying diathesis which may be found will suggest its own appropriate remedy. Special attention must be paid to bathing, clothing, foot wear, and general hygiene. Alcohol must be cut off in all its forms. At the outset tobacco must be given up, but later a mild cigar may be taken after dinner.

In regard to diet, no special rule can be laid down. More often the stomach condition, if annoying, is the effect and not the cause of the naso pharyngeal trouble. A cure of the latter will often remove the former.

As to local treatment, the number of remedies is legion. One is probably as good as another if thoroughly applied. Naso pharyngeal cleanliness is the foundation stone of all successful care of these cases. From two to four times daily the vault should be cleansed with some one of the solutions named in a preceding section (boro lyptol, glyco tbvmoline, pyrozone, listerine, etc.), all in the proportion of one to two teaspoonfuls in four ounce,,, of water. Available also are the old fashioned Dobell's solution or the alkaline powder (equal parts of salt, borax, and baking soda of the mixture, one teaspoonful to the pint of lukewarm water)

These washes may be snuffed up from the hand or used in the nasal douche cup or familiar 11 feeding cup " of the sick room. Ordinary atomizers spraying through the anterior nares are useless. The diseased surface must be laved with a certain volume of alkaline or antiseptic solution at body temperature, so that 311 the adherent secretion may be floated up. Of course, too forcible manipulation of any kind should be avoided.

After the parts are thoroughly cleansed, some alterative application may be made on the cotton carrier, such as the glycerite of tannic acid, or of boro glycerin or a solution of iodin gr. v, potassium iodid gr. xv, carbolic acid M ij and glycerin 3j ; silver nitrate gr. xxx ,3j; glacial acetic and lactic acids in varying strengths. All have their advocates. Such applications; should be made three times weekly.

The nasal douche with the usual reservoir and long tube has not been advocated, as the writer is convinced that but few patients are sufficiently skilful in its management to render its use entirely safe. The douche cup will suffice for every case if it is faithfully and persistently used. It can do no harm if of a proper shape and size. in office practice, the long, bard rubber syringe with curved tip will answer every purpose. An elaborate air spray apparatus is in DO wise necessary.

If the disease be more pronounced it will be necessary to actually destroy or remove the diseased tissue. For this purpose we have chromic acid and the galvano cautery. With the latter the bursa can be thoroughly eradicated. Small curettes and some of the varieties of post nasal forceps are also available. The use of the palate retractor and post nasal mirror is necessary for accurate manipulation of these instruments, use of which should be preceded by cocain on the cotton carrier in 20 per cent., solution.

Lymphoid Hypertrophy in the Pharyngeal Vault. This is the familiar condition variously known as hypertrophy of the third, pharyngeal or Luschka's tonsil, adenoid vegetations, etc. It was first described by Czermak in 1860, but be did not appreciate its clinical importance as we understand it to day. It remained for the late Wilhelm Meyer of Copenhagen to accurately portray the affection. So thorough and complete was his exposition of the subject, that no one has been able to add anything essentially new to his now classical paper , which appeared in 1870.

It is unfortunate that the term “adenoids “has come into such common use. It is in this connection anatomically incorrect. It was formerly supposed that the hypertrophy was made up of true glandular tissue, hence adenoid in structure; but this tissue contains no true secreting glands. Its folds and fissures may at times take on, so far as the elaboration Of MUCUS is concerned, a secreting function.

Causes. The condition may be congenital. Scrofula, syphilis, and tuberculosis all predispose to it. It seems hereditary in some families, but the existence of several cases in the same family may easily be referable to the same diathesis or to exposure to the same unsanitary surroundings. No race or climate is exempt from the disease. The majority of cases are seen in children from four to ten, although no age is exempt. Both sexes are equally affected. An underlying factor exists in the tendency of children to “lymphatism," which has been described in a previous section. The ebb of the lymphatic tide comes about the time of puberty, when there is a tendency of the lymphoid structures to atrophy.

Associated lesions of the malady are hypertrophic rhinitis and especially enlarged faucial tonsils. In a few cases the nasal mucosa may be distinctly atrophic.

Pathology. The lymphoid masses are variously arranged in the naso pharynx. Occasionally they are pendant from the vault; but more frequently they are irregularly distributed, running forward to the edges of or even into the choanae, filling the fossae of Rosenmuller, encroaching upon the

Eustachian orifices and extending a variable distance downward upon the posterior and lateral pharyngeal walls (Fig. 582).

Under the microscope, the tissue is seen to be covered with stratified columnar epithelium, more or less deprived of' its ciliae The surface is deeply furrowed, giving the mass a lobulated appearance. The bulk is made up of lymphoid cells with a scanty blood supply. These cells are arranged in the usual “node” form, with internodal areas sparsely supplied with a low grade of connective tissue which, however, has a fairly abundant blood supply (see Fig. 583).

These lymph nodes resemble in every respect the solitary follicles of the intestine, and have the same relation to the lymphatic system. The lymph vessels run near the bottom of the folds into which the surface is thrown. The blood vessels are for the most part atypical in structure. Those which are at the bases of the masses i. e. nearest to normal tissue may, however, show a more typical structure. The amount of connective tissue present does not bears any necessary relation to the age of the patient. As a rule, the masses are softer in young children and harder in adults.

It must be remembered that this lymphatic formation is merely an over growth of a normal histological element of the mucosa in this situation. It is not an adventitious deposit. Therefore, those who speak of complete removal use a term which, strictly speaking, is not correct, for absolutely complete removal would mean a removal of the mucosa itself.

The relative preponderance of the cellular elements gives to the growths their soft jelly like consistency, and the furrowed surface likens the feel to the examining finger to that (to use the customary simile) of "a bag full of earth worms."

It must not be forgotten that in adults also the lymphoid hypertrophy is found; but, as previously noted, the consistency of the deposits is firmer and they are aggregated in the middle of the vault, at the site of the so called third or pharyngeal tonsil. The condition is really a hypertrophy of the latter structure (see Fig. 562).

Small cysts are occasionally found in the masses.

As compared with enlargements of other segments of the tonsillar ring, the principal difference here is the small amount of connective tissue. The growths are largely protected from those irritative influences which predispose to connective tissue formation.

Symptoms. Patients are brought to the physician with the statement that the nose is more or less stuffed up and at times discharges muco pus. The children breathe through their mouths and snore at night. The voice has a peculiar “dead” quality or lack of resonance. The expression is stupid and the mental condition seemingly often below par. Deafness is not uncommon, and in marked cases an offensive aural discharge exists. Cough may occur and occasionally spasmodic breathing. Other possible features are nose bleed, night terrors, nocturnal enuresis, aprosexia, and a broadening of the bridge of the nose.

Night sweats, chest deformities, abnormal formation of the facial and palatal bones, defective development, and many other allied conditions have been directly attributed to lymphoid vegetations in the vault. Many of them are doubtless more properly referable to the underlying dyscrasia of which the vegetations are but a single expression.

Let us analyze the foregoing symptoms somewhat in detail.

The profuse nasal discharge is the result (as previously stated) Dot of an inflammation of the true acinous glands, but of the surfaces of the folds and clefts of the growths. The tissue is so soft and pulpy that it breaks down under the examining finger, which upon its withdrawal is covered with blood, and this latter fact alone evidences all abnormal naso pharynx the mouth breathing comes from the greater or less obstruction to the passage of air through the posterior nares, through the pharynx, and thence to the lungs. The snoring ensues upon the relaxation of the soft palate, always present and naturally accentuated during sleep.

The voice tone arises from the interference of the growths with the excursions of the sound waves transmitted upward from the larynx. The “sounding board “function of the pharynx is impaired. “spring," “ninety-nine," etc. are pronounced "sprig," " nidy nid." Deafness and aural discharges are sequences of rarefaction of air in the naso pharynx, hyperemia of the lining of the Eustachian tubes and middle ear, and retracted drumheads. There may be eventual ankylosis of the ossicles with atrophy of the tympanic membrane. Sometimes a true catarrhal inflammation is set up, changing to a purulent form.

Cough is referable to pharyngeal irritation, either from mouth breathing or from the impact of secretion detached from the vault. Night terrors, sense of choking, enuresis, etc., are all due to the overloading of the blood with carbonic acid gas and the resulting nervous explosion. Gronbech found enuresis in 13 per cent., of 192 cases, with a large proportion of cures of this, special symptom after removal of the vegetations. He admits a general predisposition to enuresis. Otherwise, he says, we would find it more frequently in hypertrophy than we do.

The term “aprosexia " (from a Greek derivation meaning literally "not to hold toward or to") was suggested by Guye of Amsterdam as a proper designation for the inability which many of these children manifest to concentrate their attention upon any one thing. It probably arises from a sluggish lymph circulation at the base of the brain, which in turn affects the functional integrity of the higher centers. Retzius and Axel Key have demonstrated the close anatomical relations between the lymph channels of the naso pharynx and those at the base of the brain.

Harrison Allen has called attention to a condition which he calls "adenoid disease." The obstruction is here due to a congenitally narrowed naso pharynx. It does not excite mischief by reason of its influence on either respiration or acute catarrh, but affects directly general nutrition, and in the opinion of the author quoted is allied to acromegaly and myxedema.

Several authors report cases of torticollis coexisting with but cured by the removal of the lymphoid vegetations, and the same is true as regards, epileptic seizures.

Diagnosis. Many of these cases can be recognized at sight, the peculiar facies and open mouth at once suggesting the nature of the trouble. In tractable children the small mirror enables us to actually see the deposits. In intractable ones the forefinger of the right band can easily be slipped up behind the soft palate and the situation of the masses accurately located. Another test (not diagnostic of this particular condition, however) is the throwing of a warm antiseptic or oily spray through one anterior naris. If the nose and naso pharynx are clear, the fluid will escape from the other nostril with practically undiminished force.

It is, of course, possible for these vegetations to be of a sarcomatous, syphilitic, or tubercular nature, so far as their pathological structure is concerned; but unless other and visible evidences of these respective diseases are present, our diagnosis will probably fall short of this degree of refinement Such cases have come to light mainly from the microscopic examination of the tissue removed.

Prognosis. Parents always inquire if vegetations will do any permanent injury if left alone. Most emphatically they will. The worst cases with their train of symptoms, called in general “catarrh," will have attracted the parents' attention, and they will consent to operative removal of the offending tissue. In the less marked cases they may regard an operation as unnecessary; but it must be pointed out to them that even if there seems to be no immediate danger, there is great danger of permanent damage to the organs of hearing and of the perpetuation of an intractable post nasal catarrh after puberty. Immediate dangers are the increased liability to any contagion which may surround the child, diseases from impaired vitality of the upper air tract, defective mental and physical development, deformities in the jaws, and defective dental development.

On the other hand, there is no operative procedure in the whole domain of this branch of medicine attended by happier results than is that for the removal of lymphoid hypertrophy from the vault of the pharynx. The child is physically almost born again. Dull intellects brighten, deaf ears are unstopped, phonation becomes clear and distinct, and mouth breathing disappears. In short, the child is a new creature.

Does such tissue recur after removal? The general answer has been in the negative, provided that the operation has been thorough. F. E. Hopkins, who has investigated this question, believes that recurrence may happen even after the most thorough removal. This possibility of recurrence is not surprising when we remember that the lymphoid elements in this situation are not mere surface deposits. They normally infiltrate all the layers of the mucosa down to the periosteum. Literally, complete removal of all lymphoid elements would therefore leave bare bone.

Treatment. The existence of any underlying diathesis must be sought out and remedied. For general tonics cod liver oil and syrup of the iodid of iron have no superiors. The latter should supplement every operative procedure. Customary directions should be given in regard to bathing, clothing, foot wear, diet, etc. Especially should it be insisted upon that the child shall sleep in a room directly open to outside air.

Little value resides in topical sprays and applications. They may afford temporary relief, but it is only temporary. Caustic acids and the galvanocautery have their advocates as destructive agents, but such measures are difficult to follow out in children. By exclusion, therefore, the question of treatment practically narrows itself down to the 'removal of the vegetations by some cutting or scraping method.

In children over twelve and in adults, cocain anesthesia will suffice. In younger patients we have the choice between ether, chloroform, nitrous oxide, and ethyl bromid. If ether is used, only the primary degree of anesthesia need be induced.

Of instruments we have the finger nail or the steel nail to be worn over the forefinger, various curettes and forceps almost without number. These are figured and all operative details described under Operations.

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