should be used in detaching sequestrum, the movable portion being separated by proper forceps and most careful manipulation.

The Mercurials are not so efficient in this stage as in the earlier manifestations of syphilis, the biniod offering the best service. Iodide of Potash in 5 to 10 grs. at a dose, three times a day, Aurum, Silica and Hepar, are the remedies which will prove most serviceable, the two former having the preference.

Nourishing diet is absolutely necessary, Cod-liver oil being an important adjuvant.

DISCUSSION.

DR. SCHLEY'S PAPER.

Dr. G. M. DILLOW: Dr. Schley has purposely called attention by an interrogation mark after "new" to the fact that the disease is not new, but newly described. It is probably as old as hypertrophied tonsils. The so-called follicles at the base of the tongue are essentially the same tissue histologically as that which makes up the tonsils proper,lymph tissue. It is frequently found hypertrophied in connection with tonsilar hypertrophy. The production of cough in consequence of their enlargement depends upon another fact, the length and curvature of the epiglottis which varies in different subjects. If the epiglottis is long and curved forwards, it is liable to be caught in and irritated by these projections. Probably one reason why children with their hypertrophy do not more often have cough in consequence, is that in the young the epiglottis is more overhanging. Some seven or eight years ago I examined a unique case which shows the similarity between the follicular tissue of the tongue and the tonsils. A lady past middle life complained for a long time of a great deal of soreness at the base of the tongue, with pricking, and a dry cough which had resisted all treatment. Upon examination I found a certain degree of hypertrophy of the tonsils, and in each tonsil a number of calcareous concretions. The follicles at the base of the tongue were also enlarged, and a number, (ten to fifteen,) of calcareous concretions as large as small peas were embedded also in the lingual follicles. In her case the epiglottis was long and curved forwards. The case was seen but once, as treatment was declined because her circumstances were too good for the charity of a public institution.

Dr. L. A. BULL: The case related by Dr. Dillow is very similar to a case described by Dr. Adkins, quoted in the Albany Medical Annals,

the last number from the Brit. Med. Jour., in which the epiglottis was caught under a profuse growth of papillæ at the base of the tongue. It was cured by applications of galvano cautery.

Dr. J. L. MOFFAT: This paper emphasizes the necessity for a thorough examination of the throat and adjacent organs in cases of persistent cough, in order to see whether the cause may not be found there. We may find the epiglottis caught under the hypertrophied papillæ, or possibly some graver condition.

DR. DILLOW'S PAPER.

Dr. BULL: The doctor speaks of these concretions in the crypts of the tonsils, which should be removed, the cavities cleansed with Peroxide of Hydrogen, and the bases cauterized with Chromic acid. Now this sounds easy, but when you try it you will find it a much more difficult procedure. I have labored more to remove these concretions than in almost any other manipulation about the throat. I had a case last year where I tried to get these concretions out but they would not come, they seemed as closely adherent as though cemented in. In my anxiety to do something I touched them with Acetic acid, and the result was very satisfactory; the hardened substances were dissolved, and the subsequent removal was comparatively easy. Before that I could only pinch off the top, but got nothing from the depth of the crypt. He also spoke against the use of the cautery. It is always policy to give patients, especially adults, the choice of two methods. The fact that dangerous hemorrhages from the use of the tonsillotome have occurred, while not very many, are yet too many, to lead us to take too many chances. I have found good results from five to seven applications of the galvanic cautery. One of the points brought out at the late International Congress at Washington, was the fact that ignipuncture was a great advance in the treatment of enlarged tonsils.

Dr. G. M. DILLOW: I did not refer especially to the methods by which tonsillotomy should be performed. As regards comparison of rapid removal and the application of the galvano-cautery, I believe the latter treatment is more prolonged and painful, and as a rule patients do not like to submit. It is much better if you are going to remove the tonsils by an operation, to do so at once with the tonsillotomebistoury, or galvano-cautery wire if you are afraid of hemorrhage, but continued and repeated applications with escharotics or the galvanocautery I do not thing good practice. It gives a great deal more pain in the aggregate and is essentially as destructive.

Dr. DEWITT G. WILCOX: The best method in the removal of the tonsils is the direct one, instead of the slow mode with caustics or cautery. Children especially have a great dread of operative procedures, and in them the quicker operation is the better one. I am in the habit of accustoming them to the instrument by using it as a tongue depressor or similar manipulation, for a few days before the operation. By this means you gain their confidence, and it becomes an easy matter to slip over the tonsil and excise it without frightening them. It seems to me that the hygienic methods could be carried out better after removal, the latter being the best step in the beginning. It is my experience that you get better effects from your constitutional treatment after the removal of the tonsil than before.

Dr. DILLOW: Enlarged tonsils are essentially an hypertrophy of normal tissue. We do not know the physiological uses of the tonsils in every particular, and they may hypertrophy for some good purpose, as in cases of hypertrophy of the heart. I think it sounder practice not to cut them off as routine practice because they are redundant tissue, but rather attempt to reach them and the other hypotrophied lymph tissue in the pharynx by remedies which remove the underlying constitutional causes. I have seen improvement follow removal, and I have seen no improvement from it. Yesterday, a young man came into my clinic at the New York Ophthalmic Hospital, whose tonsils I had excised seven years ago, but the catarrhal symptoms, mouth breathing, and enlarged follicles at the base of the tongue, enlarged lymph tissue in the submucosa of the pharynx, hypertrophied mucous membrane over the turbinatids, and the deviated septum, still remained. My rule is, first to attempt the correction of the so-called symptoms which have been ascribed an effect of enlarged tonsils, but which are often the effect of nasal obstruction, before removing the tonsil as the essential cause. Where patients have frequently recuring attacks of acute tonsilitis and the swelling of the tonsils causes distressing symptoms, I partially excise the tonsils.

DR. STRONG'S PAPER.

Dr. G. M. DILLOW: In these cases I have used lately Iodol in place of Iodoform, bcause not swelling so badly, and it seems more effective. It contains a little more Iodine than Iodoform. It is more irritative to some, but not as a rule the syphilitic, in whom it acts more speedily than Iodoform.

The physiological relation of the tonsil to the organism of which it is a part is very slightly known as yet and what little knowledge we have of its function must be drawn from its histological relations. As was stated by Dr. Geo. M. Dillow in a paper read before this society last February, the tonsil is to be grouped with the follicular glands at the base of the tongue with the pharyngeal tonsil, with the lymph follicles in the walls of the stomach, with the lymphatic glands, probably with the thymus glands, and possibly with the thyroid body, the supra-renal capsules and the spleen. These glands are aggregations of lymph tissue and are connected in some manner with the processes of nutrition. This supposition, so far as the tonsil is concerned, receives strong support from the fact that a principal cause of inflammation of this is to be found in various diathesis which profoundly influence nutrition.

organ

*Semi-Annual Meeting.

Tonsilitis is a disease quite common among young people, most commonly occurring, according to Mackenzie, between the ages of 20 and 30.

The predisposing causes may be found in enlarged tonsils which frequently sympathize with any irregularity in the mode of life or of different organs or in the various diathesis strumous-rheumatic or gouty; while the exciting causes are invariably cold and wet.

The inflammation may be deep seated or superficial; if the first, it is usually confined to one tonsil and the result is abscess if not checked by treatment. If superficial, the mucus membrane covering both tonsils and dipping down into their lacunæ is the seat of the inflammation and the tendency is toward recovery after a few days of high temperature and exceeding feeling of illness.

I think it will be acknowledged that in no disease is the feeling of intense discomfort and sickness more marked than in this; the temperature frequently rises to 105° Fahrenheit in the first 48 hours, the swelling of the muscles of the jaws prevents opening the mouth and the act of deglutition gives rise to acute pain extending to the ears.

In the superficial form the disease runs its course in four or five days but in parenchymatous form, whether going on to abscess or not, it is usually from ten days to two weeks before a healthy condition is re-established.

But it is rather to a plan of treatment which I desire to call your attention. I have been treating this disease in this manner for the past three years, and while it is routine of the straitest kind yet my success has been such as to keep me in it and to have no necessity for further remedies. I was led to its adoption by the condition of a brother physician who called in at my office to see if I could do anything for him, saying that he was in for a two weeks seige-he had been through it so often that he knew all the steps. The secretions of the mouth and fauces were extremely acid so I sprayed the parts thoroughly with a hot saturated solution of Bicarbonate of Soda under a pressure of 30 lbs. the spray was also sent through the nose. He was given Ferrum phos. 4 to take hourly in hot water and was ordered to gargle hourly with a hot solution of Sodabicarbonate. This patient was not confined to the house a day, though in his previous attacks he had been confined to bed for a week or more, having at different times the benefit of both high and low attenuation prescriptions. This result has been repeated in the same case. I have the same gratifying outcome in a family of four, of rheumatic diathesis. The mother of this family has the severest attacks, but since she has been getting this method of treatment is rarely confined to the house