Morbid Anatomy.—In acute tonsillitis, the inflamed tonsil becomes swol len with inflammatory exudation. An increased production of epithelial cells takes place in the recesses of the gland. The crypts are distended with them, and the cells appear as creamy-looking masses at the orifices. Almost at the same time the lymphatic follicles swell and soften, and form abscesses which run together so as to give rise to a considerable collection of pus. This is eventually expelled by one or more openings. The inflam mation then subsides, and the swelling more or less completely disappears. It seldom happens that both tonsils are attacked at exactly the same time. Usually, the inflammation begins first on one side, and partly runs its course before the tonsil on the other side begins to suffer. There is also more or less inflammation of the soft palate and pillars of the fauces, and the salivary glands may participate in the inflammation and get hard and swollen.
In tonsils permanently enlarged from chronic inflammation, the increase in size is due to an inflammatory the sub-mucous connec tive tissue. The glands are enlarged and hard, and their surface is often uneven.
Symptoms.—The inflammation begins with a chill, or even a distinct rigor, and the child complains of a feeling of dryness and aching in the region of the fauces. His temperature rises to between 102° and 103°, and he looks and feels ill. Often there is general aching and soreness of the body, such as is experienced at the beginning of attacks of severe catarrh ; the pulse is rapid and full, and the tongue is thickly-coated with fur. On inspection of the throat, the tonsils are seen to be swollen and vividly red, and there is also redness of the soft palate, uvula, and pillars of the fauces. The uvula is not however, swollen at the first, although later it is apt to become oedematous.
As the inflammatory process increases, the pain and aching at the back of the throat grow more distressing, and the discomfort is increased by a secretion of thick mucus from the inflamed mucous membrane. Degluti tion is accompanied by a sharp pain, which often shoots up into the ears and side of the head, and all movement of the jaws is painful. The child is afraid or unable to swalloW, and often an attempt to do so produces a choking sensation, and a return of the fluid through the nose. Singing in the ears and deafness are often present, and the voice of the sufferer has a peculiar nasal quality which is very characteristic. At the height of the disease, the temperature is often as high as 104° ; the skin is moist and clammy ; the pulse is rapid and compressible ; there is a feeling of great prostration, and the face is pale, haggard, and distressed.
If one tonsil only be affected, at the end of five or six days a yellowish spot can be detected on the reddened and glossy surface of the gland. In a few hours, or on the following day, the abscess bursts at this point, and discharges a large quantity of thick pus, to the great and almost immediate relief of the patient. Often, however, at this time, or shortly before, the
opposite tonsil begins to swell, and the discomfort, if it had partially abated, returns.
The swollen gland may reach a large size. It can be felt externally behind the angle of the jaw, and often seems to block up the whole pas sage of the throat. When the inflammation runs its course on both sides at the same time, there may be difficulty of breathing, and the face assumes an agonized expression of distress. Fortunately, any but a favourable ter mination to the complaint is excessively rare ; and the child's friends may be comforted by the assurance that the severity of the symptoms is out of all proportion to the actual danger of the illness, and that recovery may be expected with confidence. When the abscess Musts, its purulent contents are almost invariably swallowed by the child ; but the cessation of much of his distress, the relief shown in his face, the rapid fall of temperature, and the improvement in his general symptoms, allow us to infer, even with out examination of the throat, that evacuation of the matter has occurred.
After discharge of its contents the gland begins to diminish in size ; deglutition, although still painful, is accomplished with greater ease ; the haggard expression of the face disappears, and the desire for food begins to return. Often, at this time, a discharge of blood takes place from the abscess. The appearance of blood from the mouth may be a cause of great alarm to the child's relatives, and it is well to warn them of the possibility of its occurrence.
The duration of the disease is from one to two weeks, according to whether both tonsils or only one becomes inflamed. Convalescence is short, and after the cessation of the attack, the child quickly recovers his strength.
In a considerable proportion of cases, especially if judicious treatment is early adopted, the inflammatory process stops short of suppuration. The redness then begins to diminish, and the swelling to subside, at the end of forty-eight hours, or in the course of the fourth day. In many of these instances, the red and swollen tonsils are speckled over with gray patches from the secretion at the mouths of the follicles, and sometimes shallow ulcers are seen on the inside of the cheeks and lips, or on the tongue, but rarely on the tonsils themselves. In this form of the disease, the febrile action is less high than in the suppurative variety, but the depression and feeling of illness are fully as severe. When occurring in this form, tonsil litis is probably always a consequence of insanitary conditions. The cases are often met with in groups, several inmates of the same house or row of houses being attacked almost at the same time. Although included under the name of quinsy, the disease is probably distinct in its nature from the suppurative variety, and, if suitable treatment be adopted early, it can be readily arrested.