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.