Sometimes only one tonsil is so affected, but the other is likely to become inflamed also. Occasionally there may be only one spot of white on the tonsil. The swelling differs in degree; in some cases the tonsils may be so swollen as almost to meet together, but there is no danger of suffocation from obstruction of the throat, as occurs in diphtheria and very rarely in quinsy. The characteristic appearance then consists in large, red tonsils covered with white spots. The spots represent discharge which fills in the depressions in the tonsil. The fever lasts three days to a week, generally, and then subsides together with the other symptoms.
With apparent tonsilitis there must always be kept in mind the possibility of diphtheria, and, unfortunately, it is at times impossible for the most acute physician to distinguish between these two diseases by the appearances of the throat alone. In order to do so it is necessary to rub off some of the discharge from the tonsils, and examine, microscopically, the kind of germs contained therein. The general points of difference are: in diphtheria the tonsils are usually completely covered with a gray membrane. In the early stage, or in mild cases of diphtheria, there may be only a spot on one tonsil, but it is apt to be yellow in color, and is thicker than the white spots in tonsilitis. These are the difficult cases. Ordinarily, in diphtheria, not only are the tonsils covered with a grayish membrane, but this soon extends to the surrounding parts of the throat, whereas in tonsilitis the spots are always found on the tonsil alone. The white spot can be readily wiped off with a little absorbent cotton wound on a stick, in the case of tonsilitis, but in diphtheria the membrane can be removed in this way only with difficulty, and leaves underneath a rough, bleeding surface. The breath is apt to have a bad odor in diphtheria, and the temperature is lower (not much over 100° F.) than in tonsilitis, when it is frequently 101° to 103° F. Notwithstanding these points, it is never safe for a layman to undertake the diagnosis when a physician's services are obtainable. On the other hand, when this is not possible and the patient's tonsils present the white, dotted appearance described, especially if subject to similar attacks, one may be reasonably sure that the case is tonsilitis.
Treatment.—The patient should be put to bed and kept apart from children and young persons, and, if living among large numbers of people, should be strictly quarantined. For, although the disease is not dangerous, it quickly spreads in institutions, boarding schools, etc. If the tonsils are painted with a solution of silver nitrate (one drachm to the ounce of water), applied carefully with a camel's-hair brush, at the beginning of the attack, and making two applications twelve hours apart, the disease may sometimes be arrested. It is well also at the start to open the bowels with calomel, giving three grains in a single dose, or divided doses of one-half grain each until three grains have been taken. Pain is relieved by phenacetin in three- to five-grain doses as required, but not taken oftener than once in three hours, while at night five to ten grains of Dover's powder (for an adult) will secure sleep. For children one-half drop doses of the (poisonous) tincture of aconite is preferable to phenacetin. The outside of the throat should be kept covered with wet flannel wrung out in cold water and covered with oil silk, or an ice bag may be conveniently used in its place. A half teaspoonful of the following prescription is beneficial unless it disagrees with the stomach. It must not be taken within half an hour of a meal, and is not to be diluted with water, as it acts, partly through its local effect, on the tonsils when allowed to flow from a spoon on the back of the tongue.
| Rx | Glycerin | 4 ounces |
| Tincture of chloride of iron | 1/2 ounce |
Mix. Directions, half teaspoonful every half hour.
A mixture of hydrogen dioxide, equal parts, with water can also be used to advantage as a spray in an atomizer every two hours. The phenacetin and Dover's powder must be discontinued as soon as the pain and sleeplessness cease, but the iron preparation and spray should be continued until the throat regains its usual condition. A liquid diet is desirable during the first part of the attack, consisting of milk, cocoa, eggnog (made of the white of egg), soups, and gruels; orange juice may be allowed, also grapes. The bowels must be kept regular with mild remedies, as a Seidlitz powder in a glass of water in the morning, or one or two two-grain tablets of extract of cascara sagrada at night.
QUINSY.—Quinsy is a peritonsilitis; that is, it is an inflammatory disease of the tissues in which the tonsil is imbedded, an inflammation around the tonsil. The swelling of these tissues thrusts the tonsil out into the throat; but the tonsil is little affected. Quinsy involves the surrounding structures of the throat, and usually results in abscess. The disease is said to be frequently hereditary, and often occurs in those subject to rheumatism and gout. It is seen more often in spring and autumn and in those living an out-of-door existence, and having once had quinsy the victim is liable to frequent recurrences of the disease. Quinsy is characterized by much greater pain in the throat and in swallowing than is the case in tonsilitis, and the temperature is often higher—sometimes 104° to 105° F. When the throat is inspected, one or both tonsils are seen to be enlarged and crowded into its cavity from the swelling of the neighboring parts. The tonsils may almost block the entrance to the throat. The voice is thick and indistinct, the glands in the side of the neck become swollen, and the neck is sore and stiff in consequence, while the mouth can be only partially opened on account of pain. For the same reason the patient can swallow neither solid nor liquid food, and sits bent forward, with saliva running out of the mouth. The secretion of saliva is increased, but is not swallowed on account of the pain produced by the act. Sleep is also impossible, and altogether a more piteous spectacle of pain and distress is rarely seen. Having reached this stage the inflammation usually goes on to abscess (formation behind or above or below the tonsil), and, after five to ten days from the beginning of the attack, the pus finds its way to the surface of the tonsil, and breaks into the mouth to the inexpressible relief of the patient. This event is followed by quick subsidence of the symptoms. Quinsy is rarely a dangerous disease, yet, occasionally, it leads to so much obstruction in the throat that death from suffocation ensues unless a surgeon opens the throat and inserts a tube. Occasionally the pus from the ruptured abscess enters the larynx and causes suffocation.
Quinsy differs from tonsilitis in the following respects: the swelling affects the immediate surrounding area of the throat; there are no white spots to be seen on the tonsil unless the trouble begins as an ordinary tonsilitis; there is great pain on swallowing, and finally abscess near the tonsil in most cases.
Treatment.—A thorough painting of the tonsils at the onset of a threatened attack of quinsy with the silver-nitrate solution, as recommended under tonsilitis, may cut short the disorder. A single dose of calomel (three to five grains) is also useful for the same purpose. The tincture of aconite should be taken hourly in three-drop doses until five such have been swallowed, when the drug is to be no longer used. The constant use of a hot flaxseed poultice (as large as the whole hand and an inch thick, spread between thin layers of cotton and applied as hot as can be borne, and changed every half hour) gives more relief than anything else, and may possibly lead to disappearance of the trouble if employed early enough. The use of the poultices is to be kept up until recovery, although they need not be applied so frequently as at first. A surgeon's services are especially desirable in this disorder, as early puncture of the peritonsillar tissue may save days of suffering in affording exit for pus as soon as it forms.
DIPHTHERIA.—The consideration of diphtheria will be limited to emphasizing the importance of calling in expert medical advice at the earliest possible moment in suspicious cases of throat trouble. For, as we noted under tonsilitis, it is impossible in some cases to decide, from the appearance of the throat, whether the disease is diphtheria or tonsilitis. A specimen of secretion removed from the throat for microscopical examination by a bacteriologist as to the presence of diphtheria germs alone will determine the point. When such an examination is impossible, it is always best to isolate the patient, especially if a child, and treat the case as if it were diphtheria. Diphtheria may invade the nose and be discoverable in the nostrils. A chronic membranous rhinitis should be treated as a case of walking diphtheria.