specific disease like scarlet fever, erysipelas, or sunstroke.

(R. 596.)

Traumatism is the principal cause, and only a comparatively few cases are associated with the specific diseases.

In the supposed idiopathic non-tubercular form the chief differentiation to be made is from the tubercular. The leading features to be considered in the non-tubercular are suddenly developed headache in a child previously healthy, lack of tubercular family history or source of infection, lack of objective signs of tuberculosis and high fever (103° to 106° F.), extreme photophobia, early appearance of convulsions, rapid pulse (150 to 170) comparatively regular, rapid respiration comparatively regular (30 to 50), and duration two to eight days. (R. 612.)

In tubercular meningitis, the child usually shows some of the objective signs of tuberculosis before the cerebral symptoms appear. (S. 468.) Cerebral symptoms develop gradually compared with the non-tubercular.

The child becomes peevish and easily excited, dizzy, vomits usually without nausea, temperature a little above normal (99° to 101°).

Pulse and respiration are at first slightly quickened, but later become subnormal and more or less irregular.

Convulsions appear later and are less violent than in the non-tubercular. In the non-tubercular cases, the inflammation. may go on to exudation and cerebral compression to cause strabismus, ptosis, bulging at the fontanelles in infancy, and loss of special senses, but these symptoms are found more commonly in the tubercular.

And now, lastly, we must consider a disease, the real pathology of which is but little known, but of which, more than any other, convulsion is a prominent manifestation. Epilepsy is probably an organic disease of the nervous system, affecting chiefly the cortical motor cells.

In the mildest types, petit mal, convulsions do not appear, but in grande mal the convulsions are usually very severe, and affect the whole body.

In a large number of cases epilepsy probably originates in early infancy. (R. 724.)

In place of the globus of hysteria, there is an aura present in most cases of epilepsy.

Professor Hare says that in syphilitic epilepsy aura is present in five cases out of six, and more commonly in posthemiplegic than in idiopathic.

Epileptic children are liable to bursts of furor and uncontrollable violence. Convulsions may result from changes produced by cerebral hemorrhage, or a single convulsion may be associated with apoplexy, when the convulsion is usually Jacksonian. (H. 455)

One half of post-hemiplegic epilepsy occurs during the first two years (H. 456), but paralysis may occur in infancy and epilepsy be delayed till puberty.

An epileptic spasm may be the cause of cerebral hemor rhage. (H. 455.)

Osler found epilepsy to occur in twenty out of ninety-seven cases of hemiplegia in one series of cases collected, and in fifteen out of twenty-three in a second series.

Gaudard found it to follow in eleven out of eighty, and Wallenburg in sixty-six out of one hundred cases.

The shrill cry so characteristic of idiopathic epilepsy is often wanting, and the convulsions are frequently followed by paralysis in syphilitic epilepsy. Large doses of certain medicines employed, as cardiac sedatives, aconite, verat. vir., sabadilla, and hydrocyanic acid, may cause convulsions closely simulating epilepsy. The chief distinguishing feature between epilepsy and hysteria is the character of the convulsive

movements.

Hysteria is purposive, emotional, and the movements are chiefly aggravations of those of daily life, while epileptic convulsions appear at variance with accustomed movements, and are less guarded from doing bodily harm. (H. 466.)

In hysteria the convulsions may break into laughing or crying, while in epilepsy sleep usually succeeds a convulsion.

In hysterical manifestations, there is usually a little tremor of the upper eyelids, which is seldom found in the profounder disturbances presenting convulsions and unconsciousness for consideration.

Several eminent physicians a few years ago believed and asserted that idiopathic epilepsy could be demonstrated to depend upon uræmia, but more recently less has been said in this regard.

As a general rule, any case presenting convulsions for consideration should be carefully studied, the family history investigated, habits of eating and drinking determined, and a definite diagnosis made if possible, for upon this the prognosis must largely rest, and is never flattering in convulsions due to diseases in the central nervous system.

In hysteria, however, the prognosis is better for the patient than for the relatives.

(References to authorities, and pages in each: R.=“Pediatrics," by Thomas M. Rotch, 1896; S. "Diseases of Children," by J. Lewis Smith, 1886; F. "Diseases of Children," by C. E. Fisher, 1896; H.=“Practical Diagnosis," by H. A. Hare, 1896.)

SURGICAL DISEASES OF THE FAUCIAL TONSILS.

BY T. M. STRONG, A.M., M.D.

[Read before the Massachusetts Surgical and Gynecological Society, June, 1899.] We shall in this paper confine ourselves to those conditions which arise in the faucial tonsils, where surgical measures are essential to give the needed relief, leaving the anatomy and physiology of the tonsils to be discussed in some other place. We admit willingly that there are many subacute and chronic conditions of the tonsils which can be, and are, relieved safely, if not speedily, by internal medication; and we assume therefore in this paper that all medical treatment has been tried without result, and the question is what to do next.

The conditions which meet all of us very frequently are those known as phlegmonous, interstitial, peritonsillar inflammation, or quinsy, which, as a rule, tend to suppuration. When the pointing of the abscess is unmistakable, prompt incision should follow as a matter of course, as in

other parts of the body. But you are puzzled very fre quently to know whether suppuration exists or not, and where, for there is no local sign of the condition. The persistency of the inflammation and the marked distress of the patient alone point to some complication. Here the result of extensive clinical experience alone will help us, and that not infallibly. There is no question that a free puncture will often give relief, even if no pus follows immediately on the incision. The free incision is a relief in itself, and oftentimes within a few hours pus will be noted working its way through the opening, which has become the easiest point of exit. As a rule, the point of puncture will be on the arch, in the centre of a line from the uvula to a little below the upper portion of the tonsillar area, and about three quarters of an inch back from the edge. Recurring attacks of conditions similar to the above leave the tonsils in a chronic hypertrophied condition, to which we will refer later.

The upper angle of the tonsil, often hidden by the palatine folds, may contain one or more crypts, and to this "supratonsillar" fossa much attention has been given by recent writers on this subject. On account of its position, the discharge of normal secretion may be easily interfered with, and adhesion to the surrounding parts may make it a closed cavity and a centre of irritation or even suppuration. It is often the source of unsuspected trouble in many a case where there is complaint of distress in and about the tonsil, and for which the objective symptoms do not furnish a sufficient cause. Dr. D. R. Patterson (Laryngoscope, Vol. V, p. 15), after giving a very complete description of the parts, says: "On account of the position and formation of the crypts and lacunæ, the secretion from the upper follicles tends rather to discharge into the fossa than on the surface of the tonsil. We have consequently very frequent collections of plugs, which in turn become caseous, readily undergo decomposition, become evil smelling, and set up serious irritation." From this brief description we see that serious sequences of pathological changes may be established by the plugging up of this natural outlet, thus giving

rise to lacunar and peritonsillitis, septic pharyngitis, or hospital sore throat, and possibly phlegmonous inflammation of the deep cervical tissues. It has been suggested that through this channel the tubercle bacilli find their way into the glands of the neck. Some authors, however, believe that the entrance is rather through the lingual and pharyngeal tonsils, which are more directly connected with the lymphatics.

The chronic enlarged tonsils of children are of daily occurrence and need not detain us, as their prompt removal is usually advised by the family physician. But the enlarged tonsils of adult life may be the seat of chronic abscesses, and a source of grave danger, in as much as they may lead to general pyemia or to direct infection through the cervical tissues as far down as the pleural and mediastinal cavities. Several cases are on record which point out this danger. As the abscesses are small and cause no enlargement of the tonsils, the diagnosis is difficult (Journal of Laryngoscopy, Rhinology, and Otology, August, 1898, and February, 1899).

At the last meeting of the Association of American Physicians, Dr. F. A. Packard, of Philadelphia, read a paper entitled "Endocarditis of Tonsillar Origin," to show the infectious nature of acute rheumatism; and it was stated that such tonsillitis and endocarditis are not rheumatic, but that the endocarditis is rather due to an infection by bacteria gaining access to the body through the tonsils, or to the toxins of such bacteria. In the discussion attention was called to the following facts: the frequency of nephritis originating in an attack of tonsillitis; that the tonsils may serve as the port of entry for severe general infections, as illustrated by a case of acute fatal streptococcus; a case of tonsillitis followed, the day after the rupture of the abscess, by pleuritis, ulcerative endocarditis, ecchymotic spots, and death on the seventh day; a case of so-called rheumatic iritis and pleuritis was cited, developing after an attack of tonsillitis (Philadelphia Medical Journal, May, 1899).

Cases like the following are not unfamiliar: A married woman, about thirty years of age, had suffered from child