In chronic hypertrophy of the tonsils, the glands are enlarged and hard. They can be felt externally behind the angle of the jaw, and, on inspection of the throat, are seen as two globular bodies projecting towards one an other, so as almost to touch in the middle of the throat. The anterior sur face is smooth and shining, but the internal face is irregular from the open ings of the glandular recesses. Their colour is usually of a pale brick red, but when at all congested, as they are apt to be on the occurrence of the slightestzchill, they become of a deeper tint, and yellow curdy masses appear at the orifices of the crypts. At these times, they often meet in the middle line, and the friction of the two bodies against one another may, as Dr. G. V. Poore has pointed out, be a cause of superficial ulceration. One of the results of this chronic enlargement of the glands is the frequent recur rence of attacks of inflammation, which, although amounting to no more than superficial pharyngitis, are yet a source of great discomfort. Usually, at least once in the twelve months, the inflammatory process is more severe, and the patient passes through a regular attack of quinsy.
A child who suffers from this chronic enlargement of the tonsils, presents many very characteristic symptoms. He has often an unhealthy appearance, being undersized, pale, and thin. The imperfect state of nutrition in such patients is well seen in cases where one member of a family is alone af fected. The frail appearance of the child then contrasts strikingly with the robust and healthy look of his more fortunate brothers and sisters. It has been supposed that this imperfect performance of the nutritive pro cesses is due to the impediment to respiration set up by the swollen bodies, and the consequent insufficient combustion of waste-products in the body. I cannot, however, think this a satisfactory explanation of the phenomenon. It appears to me to be rather the result of the striking susceptibility to chills almost invariably manifested by these patients. Their gastric mu cous membrane is therefore kept in a state of almost continual catarrh. As a consequence, digestion is laboured and imperfect, said the nutritive needs of the system are insufficiently supplied. Such children are often exces sively irritable and restless. Their complexion is sallow, with a dark dis colouration under the eyes. They sleep badly at night, dreaming and talk ing incoherently. Their bowels are often confined, and their stools light coloured and offensive. Sometimes the face turns suddenly white,, and the child complains of flatulent pains and of distention of the belly.
In all cases where the enlargement of the glands is at all considerable, the mucous membrane in the neighbourhood of the tonsils is habitually congested and relaxed. The child snores in his sleep ; speaks with a thick nasal tone of voice, and may be dull of hearing from the turgid state of his Eustachian tubes. Slight hmmorrhages often occur at night from the
surface of the glands, and blood-stained saliva may flow from the child's open mouth on to the pillow. Sometimes the posterior nares are almost completely closed to the passage of air. The nostrils then become flattened so as to narrow the nasal. apertures. In such children, the palate is often high and arched ; the upper jaw is small ; the teeth are crowded and overlap, and the front of the jaw is curiously rounded at the lips.
In extreme cases, the entrance of air through the larynx is impeded ; often sufficiently so to induce a state of permanent collapse at the bases of the lungs. The lower end of the sternum, with the cartilages connected with it, is then forced backwards so as to present a cup-shaped depression at that point. The upper portion of the sternum is made prominent, and one form of pigeon-breast is produced. This variety of the pigeon-breast may be readily distinguished from a somewhat similar condition in the rickety child. In the latter, the whole sternum protrudes, from softening of the ribs. In the former, the upper part of the breast-bone is prominent, and the depression at the lower part is the result of yielding, not in the ribs, but in the cartilages.
Pcetor of the breath is a common consequence of enlarged tonsils, for the glandular recesses become filled with a cheesy, decomposing secretion. Cough is also a frequent symptom It is often distressing and paroxysmal, and when combined with the pallid, weakly appearance above referred to, may give rise to fears of consumption. Such apprehensions are sometimes rather confirmed than allayed by the results of a physical examination of the chest. In many such cases, a peculiar hollow quality of breath-sound, probably conducted from the pharynx, is heard with the stethoscope at each supra-spinous fossa. To an inexperienced observer, this sign may sug gest consolidation of the lungs. There is, however, no dulness on percus sion, and the abnormal quality of breath-sound is heard principally in ex piration, and is greatly diminished, or even completely suppressed, when the child opens his mouth widely.
Diagnosis.—Primary inflammation of the tonsils can only be mistaken for the secondary inflammation which occurs in scarlatina and diphtheria. In the first case, the absence of the characteristic eruption at the end of twenty-four hours is quite sufficient to exclude the infectious fever. But, besides the rash, the appearance of the inflamed mucous membrane is very different in the two diseases. In scarlatina, it is more widely diffused, and of a more brilliant red, than at the beginning of quinsy ; and on the soft palate the redness is usually punctiform, which is not the case in tonsillitis.