DISEASES OF THE TONSILS.
BY J. SOLIS COHEN, M.D.
Tonsillitis.
DEFINITION.—An acute inflammation of the tonsil or tonsils; or inflammation of the tonsil or tonsils, with inflammation of the peritonsillar connective tissue and of the palatine folds.
VARIETIES.—When the inflammatory process is confined to the mucous membrane the disease is erythematous, superficial, or catarrhal tonsillitis; when it involves the lacunæ it constitutes lacunal or follicular tonsillitis; when it involves the gland as a whole it constitutes parenchymatous, phlegmonous, or suppurative tonsillitis. The two latter varieties may present in combination. When the superficial inflammatory process is a vesicular one, eventually sheathing the surface of the organ in whole or in part with a membranous envelope, it constitutes herpetic or membranous tonsillitis. This variety may complicate superficial tonsillitis. When the inflammation of the tonsil, usually superficial, is due to the presence of a cryptogamic growth, it is a mycotic or parasitic tonsillitis, benign or malignant (diphtheria), as may be. When the inflammation of the tonsil is due to rheumatism, it is rheumatic or constitutional tonsillitis.
SYNONYMS.—Inflammation of the tonsils, Amygdalitis, Quinsy, Angina tonsillaris, Angina phlegmonosa, Phlegmonous sore throat, Cynanche tonsillaris. Lacunal tonsillitis is more generally known as folliculous tonsillitis (tonsillitis follicularis). Common membranous or pseudo-membranous sore throat (angina membranosa communis) is used as a synonym for herpetic or membranous tonsillitis (tonsillitis herpetica seu membranosa). Mycosis tonsillaris is a synonym for mycotic tonsillitis (tonsillitis mycotica benigna or tonsillitis parasitica). The tonsillitis of diphtheria is sometimes termed tonsillitis diphtheritica, tonsillitis mycotica maligna; that of rheumatism, tonsillitis rheumatica, angina rheumatica, rheumatic sore throat.
HISTORY.—Tonsillitis was described by Hippocrates. Of recent authors, Sauvages, Cullen, Louis for researches on the effects of blood-letting; Bell on the specific value of guaiacum; Velpeau as to the use of powdered alum and nitrate of silver; Bourgeoise on the use of tartar emetic; Maingault on paralytic sequelæ; Hering on mycosis; and the authors of the various encyclopædias and dictionaries,—may be mentioned as chief among the numerous observers whose contributions have been of most value. The bibliographical references appended to the compilations last cited will guide the student in gaining access to the more important special observations of anomalous cases.
ETIOLOGY.—Predisposing and Exciting Causes.—Tonsillitis may be idiopathic, deuteropathic or symptomatic, or traumatic.
The predisposing cause of idiopathic tonsillitis is usually diathetic, and is associated with congenital or inherited vulnerability of the organ. Of diathetic causes, scrofula is undoubtedly the most provocative, but even rheumatism and gout are likewise so considered, though in a far more limited degree. Acute articular rheumatism is, in fact, sometimes preceded by rather a sharp attack of tonsillitis (rheumatic tonsillitis), which subsides spontaneously in a very few days, sometimes within one day, sometimes suddenly and synchronously with the onset of the ordinary manifestations of rheumatism, though the latter are often slight and transient, as if the force of the attack had been spent on the tonsils. Tonsillitis, non-specific in character, is apt to be prevalent during epidemics of scarlatina, diphtheria, rubeola, and variola. Membranous tonsillitis is common before and after epidemics of diphtheria. Epidemics of tonsillitis have been recorded, but in the face of their extreme rarity it becomes questionable whether they were not extensive examples of the proclivity just alluded to.
Tonsillitis is more frequent in individuals with chronically diseased tonsils than in individuals in whom these glands are healthy. Such individuals, too, are more liable to recurrences; and such recurrences often follow very slight provocations.
Idiopathic tonsillitis is rare in infancy. At the period of eruption of the permanent teeth it is much more liable to occur than before that period, and the liability increases progressively until the second dentition has been completed. It is most frequent during the decennium immediately following puberty—that is to say, in adolescents and young adults—or from the fifteenth to the twenty-fifth year. The disposition or predisposition to renewed attacks continues marked during the decennium immediately succeeding; after which attacks are more and more infrequent. Certain anatomical changes occurring in the tonsils, as the rule about the fortieth year, may diminish their proclivity to inflammation. Nevertheless, the disease occasionally occurs in advanced age.1
1 Solomon Solis Cohen, "Abscess of the Tonsil in an Octogenarian," Med. News, Philada., Feb. 16, 1884, p. 186.
Deuteropathic tonsillitis is quite frequent in infancy, being excited by the infection of scarlet fever, diphtheria, measles, and small-pox, as discussed under these headings respectively. Under similar circumstances it occurs in the adolescent and the adult likewise. It is also produced in carcinoma and sarcoma of the tonsil.
Rheumatic tonsillitis, a deuteropathic variety, is most prevalent during atmospheric changes.
Herpetic tonsillitis, often a deuteropathic variety, seems sometimes of nervous origin exclusively. It is sometimes traceable to defective drainage. It is sometimes prevalent during epidemics of diphtheria, when its membranous character renders it extremely liable to be mistaken for the tonsillitis of diphtheria.
Traumatic tonsillitis occurs occasionally. The causes are—inspiration of irritant gases, the deglutition of chemically acrid substances, the accumulation of calcareous concretions in the crypts or in the lacunæ, direct and indirect gunshot and other wounds, the impaction of fish-bones, fragments of toothpicks, cherry-stones, and other foreign bodies, and the like.
Mycotic tonsillitis is due to the development of a cryptogam upon tonsils probably already in a state of catarrhal inflammation in individuals with health impaired by previous disease or unfavorable hygienic influences.
SYMPTOMATOLOGY, COURSE, DURATION, TERMINATIONS, COMPLICATIONS, AND SEQUELÆ.—The onset of tonsillitis, sometimes preceded by headache and general malaise, is often accompanied by a chill, pyrexia following within twenty-four hours. The temperature may reach 105° F., being at its maximum, as a rule, about the third day. It is rarely below 101° F. The pulse is accelerated to 120 beats per minute. Simultaneously with the constitutional symptoms local distress is usually manifested, but either set of disturbances may precede the other by several hours or by an entire day. Heat and soreness of the throat are early complained of, gradually increasing in severity to actual pain. The pain may become intense, especially during deglutition. When the posterior palatine fold is put upon the stretch, additional pain is referred to the ear, for this fold encloses the staphylo-salpingeus muscle, which runs from the palate to the pharyngeal orifice of the Eustachian tube. This pain in the ear, sometimes the principal cause of complaint, is often premonitory of suppuration. Noises in the ears on the one hand, and impairment of hearing on the other, often attend extension of the inflammation in this direction, the enlarged tonsil sometimes pressing the posterior palatine fold against the pharyngeal orifice of the Eustachian tube.
On inspecting the throat early in the disease, one of the tonsils will be seen to be swollen into an irregularly tumid, much-inflamed mass, usually of a vivid red color. Occasionally both tonsils are involved simultaneously, but this is far less frequent than involvement of the second tonsil a few days later or after subsidence of the process in its fellow. In many instances the inflammation affects one tonsil only.
The inflammatory process is seldom confined to the tonsil. All the structures of the throat, even to the base of the tongue, are often involved, and it is rarely indeed that the anterior palatine fold, distended over the surface of the tumefied gland, escapes inflammation. It is this stretching of the anterior palatine fold which occasions much of the exquisite pain that forms so prominent a subjective symptom in severe cases. The soft palate, hanging forward in the cavity of the pharynx, is often inflamed or intensely congested, and the uvula tumefied, elongated, and oedematous. It may be flaccid upon the posterior part of the tongue or hang immediately over the epiglottis or upon it, and induce painful and tiresome efforts at deglutition and expectoration to relieve the consequent titillation. Sometimes it adheres by viscid secretion to the side of the swollen tonsil.
The inflamed tonsil or the tonsil and its coverings project far into the cavity of the pharynx, often as far as the middle line, touching its fellow when both are involved, so that ulceration sometimes ensues at the points of contact. The posterior surface of the anterior palatine fold sometimes becomes unfolded, as it were, in the tumefaction of the gland, and remains stretched over it in a thin continuous layer without any line of demarcation. The swollen palate projects upon the enlarged tonsil like a shelf, from which depends the uvula, the latter being often oedematous, usually anteriorly, but sometimes posteriorly.
Inflammation of the connective tissue about the lower jaw, especially when at or near the articulation, often renders it difficult or even impracticable to open the mouth sufficiently to permit direct inspection of the parts; but it is rarely that sufficient space cannot be made to allow partial protrusion of the tongue on the one hand, and the introduction of a fore finger for exploratory purposes on the other, though both of these acts are sometimes impossible. The tumefaction of the parts impairs the freedom and ease of deglutition, which may become so painful as to prevent the swallowing of the saliva, which then may dribble from the mouth.
The pain experienced in swallowing is often manifested by convulsive action of the muscles of deglutition and of the muscles of the face. The swollen tonsils prevent the soft palate from being applied to the surface of the pharynx, as usual in deglutition; and as the upper or retro-nasal portion of the pharynx thus fails to be shut off from the lower oesophageal portion, liquids are often forced up into the nasal passages posteriorly, and are regurgitated through the nostrils, thus rendering it impracticable, for the time, to slake thirst or to swallow liquid nourishment.
At first sensations of dryness and pastiness in the throat are complained of, but in a few hours these symptoms become relieved by a more copious secretion of mucus or mucus and saliva. This secretion soon becomes viscid, and so adherent to the parts as to be detached only with difficulty, thus causing harassing efforts for its dislodgment by hawking and expectoration, or equally distressing efforts to swallow it. Should the inflammatory process extend to the salivary glands, as is not infrequently the case, secondary ptyalism often results, with increased distress from this source, and the patient lies or sits with his head inclined upon the diseased or most diseased side to favor the uninterrupted flow of saliva from the mouth.
Extension of the inflammatory process to the submaxillary glands, or to the parotid, or to the connective tissue surrounding them, is indicated by tumefaction externally, which is often exquisitively sensitive to pressure.
The timbre or quality of the voice is often impaired in a peculiar manner by the tumefaction of the throat and the immobility of the soft palate. The voice is thick, throaty, or guttural, having a characteristic harsh, rasping aspiration in enunciation, while articulation is much impeded by impairment in the movements of the jaw, palate, tongue, and lips. At times it is also painful. Speech is sometimes indistinguishable or impossible, and the voice may even become suppressed, so that signs and writing remain the sole means of communication.
Impairment of respiration, at least to any considerable degree, does not occur, unless both tonsils are involved and swollen to an intense degree—conditions under which dyspnoea may become pronounced, severe, and even urgent, and suffocation become imminent. Painful respiration is not uncommon in rheumatic tonsillitis.
The fever is sthenic in type. There are often severe aching pains in the limbs. Headache, restlessness, insomnia, nausea, and even vomiting, may occur. The tongue is heavily coated, the breath is fetid, appetite is impaired, and the bowels are constipated. The urine is diminished in quantity, high-colored, and of high specific gravity. It usually shows slight increase of urea and great diminution of chlorides. Albuminuria occurs in rare instances.
The symptoms are proportionate to the severity of the attack. A first attack is usually much severer than subsequent ones, and suppurative cases more severe than those terminating by resolution. Resolution is the usual termination, and the parts are restored to a normal condition at the end of ten to fourteen days, sometimes earlier; in exceptional cases not until three or four weeks. Sometimes permanent hypertrophy of the tonsil remains.
Where the inflammatory process fails to subside, suddenly at the end of five or six days, or a little later, or not until ten days to a fortnight have passed, slight rigors supervene, announcing suppuration, and the local distress is very great, with pulsation and lancinating pains in the tonsils, until all at once the abscess bursts and its contents are discharged with immediate relief. Sometimes the pus or much of it is involuntarily swallowed; sometimes it is expectorated. In exceptional instances the pus has escaped into the larynx and suffocated the patient, usually during sleep.2 In rare instances the abscess, having burrowed beneath the pharyngeal muscles, may open at the external angle of the jaw or behind the sterno-mastoid muscle. It may discharge into the epiglotto-pharyngeal fold, and thence reach and distend the epiglottis. It has been known to descend along the planes of connective tissue into the mediastinum or into the lungs. Even ulceration into the maxillary and carotid arteries has occurred, usually with fatal result, occasionally with an opportunity to save life by ligating the carotid (Erhmann).3
2 Stokes, Med. Times and Gaz., Aug. 29, 1874, p. 251; Littlejohn, Brit. Med. Journ., Jan. 2, 1875, p. 16.
3 Gaz. méd., Paris, 1878, p. 42.
The most frequent point of spontaneous rupture externally is at the upper portion of the gland anteriorly, just beneath the anterior palatine fold. Sometimes internal rupture occurs into the lacunæ.
Termination by gangrene is exceptional, and is confined to individuals with debilitated constitutions. It is much less frequent than formerly—as a result, perhaps, of better methods of treatment.
Metastasis is one of the methods of termination as to joints or muscles in rheumatic tonsillitis—to lungs, brain, or gastro-intestinal tract—as formerly occurred with much more frequency under direct depletory treatment.
In rare cases extension of the inflammation occurs to the epiglottis, even to the larynx, and the laryngitis may be so severe as to threaten life from the occurrence of oedema. Diffuse inflammation of the retro-pharyngeal connective tissue or of the connective tissue of the neck may constitute an unpleasant complication of the disease.
In a few instances paralysis of the palate occurs as a sequel of tonsillitis, and in exceptional cases the paralysis may also affect the arytenoid muscles of the larynx, and even the accommodator muscles of the eyes.
PATHOLOGY AND MORBID ANATOMY.—Tonsillitis is almost always associated with inflammation of the tissues surrounding the tonsil and those contiguous to it, even in the mildest and most frequent manifestations of the affection. Thus, inflammation of the palate (staphyllitis) and uvula, and even of the pharynx (pharyngitis), are anatomically included with tonsillitis in angina or sore throat.
The mildest form of the malady is a catarrhal inflammation of the mucous membrane covering the gland, and does not extend along the lacunæ which dip inward from the surface and divaricate toward the interior of the organ. It is termed catarrhal tonsillitis, and, as has been intimated, is almost always associated with catarrhal sore throat. It is attributed to hyperæmia, with passive engorgement of the vessels, following retrocession of blood from the cutaneous surface after undue exposure to cold and moisture. A severer form of the malady involves the lacunæ in addition—several or all of them. This should be termed lacunar tonsillitis, as suggested by Wagner. Primarily, at least, it does not involve the follicles of the tonsils which open into the lacunæ, and is therefore incorrectly denominated follicular tonsillitis, although it is most generally so described. The lacunæ are involutions of the mucous membrane, and in health furnish a slightly turbid mucoid secretion which serves to lubricate the parts and, as is generally believed, to facilitate deglutition. When the lacunæ are inflamed these products become pent up in them to a certain extent, accumulate, and project in part at their orifices in turbid creamy or curdy masses, plastered over the parts when thin in consistence, or tightly imbedded when thick or desiccated. These masses are usually white, but sometimes, owing to various admixtures, they are more or less yellowish or gray or brown. They consist of epithelium chiefly, with more or less pus and accumulation of cells similar to those of which the follicles are composed—whether from follicles which have become distended by proliferation of their constituents, and have then burst, is not known. This epithelium has often undergone fatty degeneration in part. Cholesterin is an occasional constituent, and swarms of micrococci and bacteria abound when the masses are not recent, especially if the inflammation is occurring in a tonsil long the seat of chronic disease of the lacunæ.
The tonsil itself is moderately swollen and its mucous membrane hyperæmic. If the parenchyma of the tonsil be involved likewise, as often occurs, the swelling will be much greater, so that the gland will project a considerable distance beyond the margins of the palatine folds. When a hypertrophied tonsil is the seat of the inflammation the tumefaction will be much greater than when the inflamed tonsil has been normal.
Acute inflammation of the palatine folds often coexists, especially of the anterior fold. The soft palate may also be engaged in the morbid process, which may involve the uvula likewise. Pharyngitis is an occasional accompaniment, and stomatitis quite a rare one.
Lacunar tonsillitis sometimes subsides by spontaneous evacuation of the pent-up contents of secretion and desquamation, the parts returning to their normal condition. More frequently a desiccation of some of these products ensues, with permanent chronic inflammation. Decomposition then often takes place, fouling the breath by the escape of the gases. Butyric acid has been recognized as one of the most prominent of these fetid gases. Calcareous change occurs in these contents of the lacunæ in some instances. Lacunar or follicular tonsillitis is often associated with severe inflammation of the peritonsillar connective tissue and the contiguous palatine fold, with serous or cellular infiltration into these structures almost always terminating in suppuration. This form of tonsillitis is very frequent, and is often confounded with parenchymatous tonsillitis or with tonsillar abscess. In these cases the abscess is in the peritonsillar tissue or in the posterior leaflet of the anterior palatine fold. It bursts above the tonsil at the angle between the two folds in the greater number of cases. In some instances the suppurative inflammation affects the anterior surface of the posterior palatine fold, sometimes contiguously to the antero-tonsillar abscess, sometimes independently, constituting a retro-tonsillar abscess. The follicles in the posterior palatine fold are sometimes involved, the thickened anterior surface of this structure becoming studded with small projections the size of ordinary pinheads or larger, distended with whitish-yellow contents.
In another class of cases of tonsillitis the inflammatory process may be chiefly parenchymatous, for rarely is it wholly so. That is to say, it may involve the glandular structure of the organ wholly or in main part. The disease is then an adenitis, an inflammation of gland-tissue—tonsillitis per se. It is associated with superficial inflammation of the surrounding mucous membrane, secondarily if not primarily, and often with inflammation of the lacunæ. In many instances the parenchymatous inflammation is a direct extension of the lacunar inflammation.
Parenchymatous tonsillitis may subside by resolution, or, as is quite frequent, terminate by suppuration. A number of small abscesses may be formed, which usually become confluent and rarely remain discrete. Sometimes a single large abscess is formed. The confluent abscess may discharge by several points. It is always associated with a severe inflammation of the palatine folds and palate, especially the anterior fold; sometimes of the adjoining half of the soft palate and the uvula; sometimes of the entire velum and uvula. Sometimes these parts become oedematous; sometimes suppuration ensues. Severe pharyngitis is not uncommon. Glossitis, involving the posterior portion of the tongue especially or exclusively, is an occasional accompaniment of parenchymatous tonsillitis. (See [GLOSSITIS].) Occasionally oedema takes place in the epiglottis and upper margin of the larynx.
The character of the secretions varies. Sometimes these are semifluid; sometimes soft, caseous, or pultaceous; sometimes fibrinous and arranged in pseudo-membranes; sometimes hemorrhagic; sometimes moist and viscid, sometimes very dry; often adherent, and always containing cryptogams (leptothrix, Oïdium albicans, bacteria, and micrococci). Collections of caseous products accumulate not only in the crypts of the tonsils and in their overlying mucous membrane, but likewise in the follicles of the palatine folds below the tonsil, and thence toward the base of the tongue.
The submaxillary glands often undergo engorgement, and become so tender that external manipulation is painful, and sometimes they undergo suppuration. The tumefaction due to the swollen glands and infiltrated connective tissue around it is frequently incorrectly referred to the tonsil itself, rather than to the accompanying inflamed palate, with the lymphatics of which these glands are in more direct anatomical connection. The tonsil is at a considerable distance from the inflamed glands, and cannot be felt from the exterior except under unusual circumstances.
Herpetic tonsillitis is a rare form of inflammation of the tonsil, or rather of its investing mucous membrane, characterized by the eruption of herpetic vesicles on its surface. The vesicles soon undergo rupture, and the resulting ulcers coalesce and become covered with a fibrinous exudation. The disease is usually associated with similar vesicles upon the palatine folds and upon the soft palate, and exceptionally with vesicles on the pharynx. (See Herpetic Pharyngitis.) It is by some fortuitous circumstance only that it is observed in the vesicular stage. It is confined to one side of the throat in most instances, but may be bilateral also.
Mycosis tonsillaris has been described by a few observers. B. Fraenkel4 has recorded three cases, E. Fraenkel5 one, and Bayer6 two. In these cases the disease was not confined to the tonsils, but implicated the calciform papillæ of the tongue also, and one of Bayer's cases some pharyngeal follicles in addition. E. Fraenkel's case was in a male, and occupied but the right tonsil and base of tongue. The white masses in this case were formed of spores and filaments (Bacillus fasciculatus, Sadebeck), which are described as penetrating some millimeters into the gland-tissue. These masses were tenacious, and were reproduced rapidly after removal. In Bayer's cases, both females, the same microphyte was recognized. In a female patient observed at the Philadelphia Polyclinic7 this affection followed rheumatic tonsillitis, diphtheria being prevalent near her residence, which was in a very unsalubrious locality. The deposit, confined to the left tonsil, was so firmly adherent to the mucous membrane that the implicated portion had to be torn away to get rid of the growth, which was twice reproduced. The fungus was in its mycelial state, a few spores and conidiferous filaments being recognized microscopically.
4 Berlin. klin. Woch., 1873, S. 94; ibid., 1880, No. 18.
5 Zeitschrift für klin. Med., iv., 1882.
6 Rev. mens. de Laryngologie, etc., Nov., 1882, p. 329.
7 S. Solis-Cohen, The Polyclinic, March, 1884, p. 133.
Quite recently, and since the above was written, the results of an elaborate study of this affection by Theodor Hering of Warsaw have been published in a paper entitled "Pharynxmycosis leptothricia,"8 read before the Society of German Naturalists and Physicians. The author collates fourteen cases, six of which were observed by himself. He claims that the microphyte is simply the Leptothrix buccalis.
8 Zeitschrift für klinische Medicin, Bd. vii. H. 4, 1884.
The local subjective symptoms as collated by Hering vary from the merest sense of discomfort in chronic cases to intense pain, difficulty in speech and in deglutition, and various grades of cough in acute ones. In some cases they are altogether wanting. Constitutional disturbance may be entirely absent or may be presented in various febrile or sub-febrile manifestations.
DIAGNOSIS.—The history of the attack, the appearances described, and the symptoms narrated should ordinarily suffice for a correct diagnosis. Still, mistakes do occur. An unsuspected tumor of the tonsil observed for the first time during an ordinary sore throat might be taken for an inflamed tonsil, but the progress of the case would soon lead to its due recognition. While tonsillitis is infrequent after the fourth decennium, it occasionally occurs late in life, and has been observed even in the ninth decennium; and reserve is proper as to the cause of enlarged tonsils in the sore throats of those advanced in life.
The deposit in follicular or lacunar tonsillitis or angina is pulpy and not membraniform. It can be wiped from the surface with a fragment of sponge, and does not tear from the surface in strips, as is the case with the pseudo-membrane of diphtheria or of common membranous sore throat. There is no abrasion of the mucous membrane beneath the deposit. The patches are more prominent, usually more circumscribed, and dip down into the lacunæ, or rather project from the crypts upon the surface of the tonsil. In its physical aspect the deposit more closely resembles that observed in the sore throats accompanying cachectic conditions, as in chronic tuberculosis, advanced syphilis, some forms of scarlatina, typhus and typhoid fever, extreme old age (agine pultacée, Fr.; cachectic angina); but the existence of previous constitutional disease and actual debility should prevent the mistake in diagnosis. In susceptible subjects the oncoming of an attack of rheumatic tonsillitis may often be inferred, previous to the manifestation of local symptoms, from the existence of otherwise inexplicable odynphagia, the pain being especially intense upon attempts to swallow saliva. Sometimes laryngoscopic inspection at this early stage of the disease will reveal vivid redness of the mucous membrane in the neighborhood of the crico-arytenoid articulations.9 The value of this early diagnosis lies in the opportunity it affords to try abortive treatment.
9 S. Solis Cohen, The Medical News, Aug. 11, 1883, p. 146.
PROGNOSIS.—The prognosis of catarrhal tonsillitis is almost invariably favorable, except under very obviously unfavorable conditions, the inflammatory process subsiding spontaneously within a few days. It is favorable, as a rule, in phlegmonous tonsillitis subsiding within ten or twelve days in most instances, even though all the stages be completed to suppuration and discharge of the abscess. Sometimes two or three weeks are consumed in the process. A certain amount of reserve is requisite, nevertheless, in severe cases, in view of the possible complications which may prevent recovery. If both tonsils are affected to such an extent as to interfere seriously with respiration, death by suffocation may ensue should the obstruction be not relieved by excision of portions of the swollen glands or an artificial opening be not made into the air-passage. Suppuration may perforate the internal carotid or the external maxillary artery and produce sudden fatal hemorrhage. The remembrance of such occurrences should screen a surgeon from the imputation of carelessness should he be unfortunate enough to incise an abscess under similar conditions. Some cases are on record of fatal hemorrhage but a short period before a proposed operation could have been performed.
Suffocation has ensued from discharge of the abscess into the air-passage, usually during sleep; but it has occurred even during the moment of speaking (Stokes).10 Such results are accidental and exceptional.
10 Med. Times and Gaz., Aug. 29, 1874, p. 251.
Recurrences are frequent, especially in scrofulous subjects, and such recurrences are apt to result in permanent hypertrophy and induration.
TREATMENT.—Mild cases of tonsillitis require no treatment except to keep the patient protected from exposure to abrupt changes of temperature. The course of the affection both in mild cases and in severe ones may often be materially shortened by prompt resort to the use of guaiacum, both internally and topically. A gargle containing an ounce each of ammoniated tincture of guaiacum and compound tincture of cinchona to the pint, with the addition of three ounces of clarified honey, and saturated with potassium chlorate (twenty grains to the ounce), may be used, a drachm at a time, every two hours, hour, or half hour, according to the urgency of the symptoms, and may likewise be administered internally in drachm doses for an adult every two or more hours. The beneficial effects will often be manifested within less than twelve hours. Pellets of ice held in the mouth from time to time often relieve pain and repress inflammation. Sodium bicarbonate locally, in powder, affords great relief in some instances. In the presence of marked pyrexia tincture of aconite may be given in drop doses every hour until an impression has been made upon the heart, when its continuance at intervals of four or more hours will be a matter for consideration.
Guaiacum and aconite may be given with equal benefit in any form preferred by the prescriber. At the same time saline laxatives may be required from time to time. Regulation of the diet is often necessary.
When the tonsils are very much swollen, gargling of all kinds becomes too painful, and therefore sprays of sedative and emollient mixtures are to be substituted, or steam from water impregnated with volatile substances, as benzoin, paregoric, hops, chamomile, and sage. When the cervical glands are swollen, continuous hot and moist applications externally afford great relief. If the suffering from the inflamed tonsil be intense, scarification should be practised and the bleeding be encouraged by warm water. When suppuration exists, the abscess should be promptly evacuated by incision at the most prominent accessible point.
Special symptoms require appropriate management on general principles. The pain in swallowing can often be diminished by pulling on the lobe of the ear at the moment of deglutition (Grewcock).11 In debilitated subjects, or during epidemics of diphtheria, quinia, iron, and supporting measures are indicated.
11 Lancet, Nov., 1882, N.Y. reprint, p. 399.
The rheumatic cases are best treated with sodium salicylate, ten to fifteen grains every hour or two until relieved. Instituted in the formative stage above alluded to, this treatment frequently seems to be veritably abortive, especially when preceded by a full dose of an alkaline purgative—say one ounce of Rochelle salts. Oil of gaultheria may be used in small doses as an agreeable flavor to the mixture, or in doses of ten to twenty minims, well diluted, as an adjuvant to the salicylate, or even as a substitute for it. After subsidence of the acute symptoms cinchonidine salicylate may be continued for a few days in appropriate doses.
Herpetic tonsillitis requires the ordinary treatment for erythematous tonsillitis, with additional topical treatment by sprays of alkaline solutions, such as sodium borate or bicarbonate, five grains to the ounce, or lime-water. Internally, small doses of mercuric chloride will be of service, the dose varying, according to the age and size of the patient, from one-forty-eighth to one-sixteenth of a grain every two hours, until the stomach shows signs of irritation therefrom. In cases of doubt as to diagnosis from diphtheria the treatment for diphtheria will be indicated as the safer measure. Here, again, the mercuric chloride is sometimes equally valuable.
Mycosis of the tonsil does not seem amenable to medicinal treatment. Thorough removal of the fungus with forceps or sharp spoons is required, even though mucous membrane be detached with it. When this is impracticable, ablation of the tonsil may be necessary. Raw or cut surfaces left by any of these manipulations should be subjected to thorough cauterization, electric cauterization being the most feasible method.