days suppuration occurs; the tumor, which was at first hard, is now softer, and yields to the finger, or the presence of pus may be detected by placing one finger on the tonsil, another outside behind the angle of the jaw. If the case be left, the abscess bursts into the throat, the temperature falls; and recovery quickly takes place in from four to seven days, though convalescence may be protracted for some time longer. Rarely the abscess has burrowed into the neck or chest, or eroded the carotid artery; and Dr. Fagge records a case of suffocation from entrance of the pus into the larynx. Diagnosis. -Quinsy may resemble follicular tonsillitis: it is more often unilateral, the fever is more severe, the redness extends to adjacent parts, secretion does not accumulate in the follicles, and pus may be eventually detected. Sometimes the two occur together.

Treatment.—In the early stages, ice often relieves the pain; it should be sucked as well as applied to the throat externally. If suppuration has commenced, hot fomentations and poultices probably hasten it. When pus

is detected, an incision should be made into the tonsil with a bistoury, covered up to the last half inch with plaster, so as to protect the other parts of the mouth. The patient is generally confined to bed, and can take nothing but fluid food. This should consist of milk, beef-tea, and strong broths; and stimulants are usually required. Internally, quinine and iron should be given in full doses. Aconite, in doses of 3 to 5 minims of the tincture, and guaiacum in lozenges of 3 grains each every two hours, have been recommended in the early stages as likely to bring about subsidence of the inflammation without suppuration.

FOLLICULAR TONSILLITIS.

Etiology. This form of tonsillitis also recurs frequently in the same. people, and arises from cold and from impure air.

Symptoms. The tonsil is red and swollen, and presents several yellow prominent spots, which are follicles distended with secretion; and the surface is covered with more or less mucus. The swelling can be felt externally behind the angle of the jaw. In severer forms the secretion of the follicles is more abundant, and they are distended with large bright white plugs, which may present a close resemblance to the white material of diphtheria. Both tonsils are frequently affected. There is moderate constitutional disturbance, furred tongue, slight pyrexia, feeling of malaise, and the same local discomfort as in other forms of tonsillitis.

Diagnosis.-Diphtheria is closely simulated when the plugs of secretion. are large and white. Generally, their obvious formation within the follicle of the tonsil, or the existence of several on each side, serves to distinguish them; on the other hand, a single white patch of some extent, apparently only on the surface, is in favor of diphtheria, and an extension to the soft palate is conclusive. Recovery always takes place.

Treatment should be nourishing and stimulating; quinine and iron, and port wine in weakly individuals. The tonsils may be painted with astringent or antiseptic solutions, such as glycerine of tannic acid, the liquor sodæ chlorinatæ, solutions of alum, or boric acid. Lozenges of chlorate of potash or rhatany may also be sucked.

CHRONIC ENLARGEMENT OF THE TONSILS.

Etiology. This is of common occurrence in children, without any apparent cause; some, it is true, are weakly in other ways, others maintain good health. Sometimes it can be traced to previous attacks of sore throat; on the other hand, those who have chronic enlargement of the tonsils are liable to temporary attacks. It often subsides as the patient approaches middle age, if not earlier.

Symptoms.-The tonsils are large, pale pink, lobulated on the surface, and firm in consistence. When only of moderate size, they may cause no symptoms. In other cases, the tonsils obstruct the passage of air from the nose through the pharynx, and the breathing is at all times somewhat snoring. From the same cause, the child breathes with the mouth open, and the nasal passages being little used, the anterior nares are small, and the alæ compressed. A more remote effect is the production of pigeon-breast, from deficient expansion of the anterior part and bases of the lungs when the ribs are yet soft and yielding. Swallowing is laborious and clumsy, and speech is suggestive of something being in the mouth. Hearing is also deficient, from catarrh of the Eustachian tube; and taste and smell are said to be affected.

Pathology.-The change in the tonsil is one of simple hypertrophy of all the component tissues.

Treatment. The general health should be maintained by cod-liver oil, iron, and other tonics, including sea air. Local applications are of little service; but if the discomfort is considerable, the tonsils may be removed by the bistoury or guillotine.

CHRONIC PHARYNGITIS.

Etiology.-Chronic inflammation of the pharynx may arise from repeated acute attacks, but more frequently results from certain injurious influences, such as the abuse of alcohol, excessive smoking, and the con tinual use of the voice, as, for instance, in clergymen, singers, and hawkers. The condition is constantly associated with a similar change in the soft palate, tonsils, or posterior part of the nose.

Symptoms. The mucous membrane may be reddened, with dilated veins; in other cases there are numerous small gray elevations scattered over

the pharynx (granular pharyngitis); in others, again, small abrasions or ulcerations occur. The gray projections in granular pharyngitis are the enlarged follicles or mucous glands. In some cases the mucous membrane is covered with increased secretion, and the patient is constantly hawking and spitting; in others, the surface is dry, and a certain amount of discomfort and difficulty in swallowing, with pricking pain and desire to cough, is the result.

Granular pharyngitis is often spoken of as a distinct affection. It may spread beyond the fauces proper to the top of the pharynx and to the larynx; the mucous membrane is in most cases dry, but sometimes the follicles are covered with viscid mucus. It may cause little or no discomfort; but there may be stiffness and dryness of the throat, constant desire to hawk and spit, and distress and difficulty in swallowing. The effort to talk is also painful, and the patient may be obliged to stop to clear the throat. This condition of things is not uncommon in clergymen, public speakers, and others of like vocation, and has consequently been called "Clergyman's sore throat." The symptoms are aggravated by exposure to cold, and an inherited predisposition has been observed by some writers.

Treatment.-Local treatment is necessary in granular pharyngitis. Gargles are of little use, as they do not reach beyond the soft palate; but inhalations of alum or tannin may be employed, or the throat may be painted with astringent solutions, such as nitrate of silver or perchloride of iron (30 grains to the ounce) or tannin (a drachm to the ounce). Iodized glycerine is also recommended. If these fail, the granulations must be destroyed; and this is best done by the galvanic cautery or Paquelin's thermo-cautery, each nodule being successively touched. This may of course require several sittings; the resulting inflammation is checked by sucking ice for some hours afterward.

RETRO-PHARYNGEAL ABSCESS.

This, though chiefly a surgical complaint, requires short notice here, since it is apt to complicate the diagnosis of some throat complaints, especially laryngeal obstruction. It arises often from caries of the spine, or inflammation of the post-pharyngeal glands; and it forms a swelling in the back of the pharynx, which may press upon the larynx so as to cause dyspnoea and asphyxia. Thus it may be mistaken for croup or laryngeal diphtheria, but the cough and voice are not husky and hoarse as in the latter, but rather "gurgling." In a doubtful case, the finger should be passed to the back of the throat, when a fluctuating swelling will be felt. It should be opened by

the surgeon.

DISEASES OF THE ESOPHAGUS.

CESOPHAGITIS.

The oesophagus is much less liable than other parts of the alimentary canal to the various forms of inflammation. It may be injured by chemical substances or hot fluids, or inflammation may extend to it from neighboring parts. Chronic inflammation results from the pressure of tumors, and from valvular disease of the heart. It produces thickening and opacity of the epithelium, or actual warty growths, or in some cases dilatation of the veins and desquamation of the epithelium.

OBSTRUCTION OF THE ESOPHAGUS.

This is the most important pathological condition of this part of the alimentary tube. The causes are impaction of foreign bodies, such as false teeth; compression from outside by mediastinal growths and thoracic aneurisms; the growth of cancerous or other tumors in the walls of the tube itself; constriction by the contraction of ulcers following injury by corrosive poisons; and functional spasm of the muscular walls. The last three conditions will be separately considered.

CANCER OF THE ESOPHAGUS.

This generally occurs in advanced life, and in males more often than in females. It occupies the middle and lower thirds of the œsophagus much more often than the upper third; but it is especially frequent opposite the bifurcation of the trachea, and is rare at the cardiac extremity of the œsophagus. It is always primary, usually of the epithelial variety, and of different degrees of consistence. In course of time it forms an irregular ulcerated surface on the inside. The tumor partially or completely encircles the tube, extending vertically from one to four inches. The mediastinal lymph-glands are enlarged, and the growth often involves the trachea, or the root of the lung, or compresses the recurrent laryngeal nerves.

Symptoms. The first and prominent symptom is dysphagia. The patient finds he has difficulty in swallowing solids, when he may get fluids down with comfort. The difficulty increases gradually, and at length solid food has to be given up; liquids can alone be taken, and if too much is attempted at a time it is soon regurgitated. Pain is usually absent. After a few weeks the patient begins to emaciate, and loses strength and energy. The symptoms are generally progressive, but occasionally temporary improvement takes place from crumbling away of portions of growth from the surface, so as to enlarge again the calibre of the oesophagus. If no relief be afforded death takes place from simple exhaustion, or from complications.

Thus, in some cases a communication with the trachea is produced by the spread of the growth; and food-particles are inhaled, and set up pneumonia. In others, the lung is directly invaded by the new growth, and gangrene or broncho-pneumonia carries off the patient. In others, again, compression of the recurrent laryngeal nerves leads to paralysis of the abductors of the glottis, which may produce asphyxia. Lastly, there may be deposits in other organs, especially in the liver and lungs. Occasionally these are the cause of death, when the growth in the oesophagus has been too slight to produce any difficulty in swallowing.

Diagnosis.-Gradually increasing dysphagia in a person over fifty years of age is, in the great majority of cases, due to cancer of the oesophagus. The presence of an obstruction is confirmed by the use of the œsophageal bougie, which will also show its position, and the extent of narrowing. The beginning of the oesophagus is six inches from the teeth, and its junction with the stomach is sixteen inches. The bougie, however, does not discriminate between cancer in the walls and a tumor or aneurism; the possibility of rupturing an aneurism must always be borne in mind, and a careful examination for the symptoms of aneurism should be made before the bougie is used.

Auscultation of the esophagus may sometimes give assistance. It is effected by listening successively over each of the dorsal spines while the patient swallows a mouthful of water, previously taken into his mouth. A peculiar gurgling sound is heard down to the point of obstruction, but not below.

Prognosis. This is absolutely bad. Even if the obstruction is overcome, the malignant growth must be fatal by its further extension within a short time. The duration is generally from six to twelve months.

Treatment.—This is entirely mechanical. While a bougie, even of small size, can be still passed, some time may be gained by its use every two or three days; or the tube may be kept in permanently, and the patient fed thereby, a method that has been employed by Krishaber and Symonds. The latter uses a short tube, with a funnel-shaped upper end just projecting above the top of the stricture, and secured by a string which hangs from the patient's mouth. If these measures are inapplicable, the patient may be fed per rectum, or the stomach may be opened by the operation of gastrostomy.

CICATRICIAL STRICTURE.

In this again dysphagia is the main symptom; but it differs from cancer in this, that it may not advance beyond a certain point, and that it does not lead to any secondary effects, except dilatation of the tube above it. In consequence of this dilatation food often accumulates above the stricture, and is regurgitated after a time.

The Diagnosis is generally determined by the history, and the absence of other symptoms. Cancer would be excluded if the patient were young.