[Reprint from The Laryngoscope, St. Louis, March, 1897.] 
A STUDY OF THE LINGUAL TONSIL. 
BY LEWIS S. SOMERS, M.D., PHILADELPHIA, PA. 
Stoerck, in 1877, was the first to call attention to the mass of lym- 
phoid tissue at the base of the tongue as a factor in the production of 
irritation of the epiglottis. But only during the last few years has 
any definite study of the pathology of the lingual tonsil been made. 
The literature on the subject, with but few exceptions, consisted 
mostly of reports of isolated cases. That this portion of the oro-phar- 
ynx is the cause of many otherwise inexplainable pathological phenom- 
ena is not to be doubted, if its examination with the laryngoscope is 
made part of the routine study of all cases suffering from naso-phar- 
yngeal diseases, and especially if cough is a factor in the history of 
the patient. 
As is well known, the pharynx is surrounded by a ring, or zone, of lym- 
phoid tissue, hardly visible in some positions, and yet in other parts 
forming quite prominent agglutinations of lymphoid tissue as the faucial 
tonsils. This ring of lymphoid tissue is continued over the posterior 
pharyngeal wall, where, in the median line, well up in the naso-pharynx, 
it again becomes prominent, and is commonly designated as Luschka's 
tonsil. The anterior portion of this lymphoid circle, situated between 
the base of the tongue and the epiglottis or epiglottic folds, forms the 
so-called fourth or lingual tonsil. This tonsil is from one-eighth to 
one-quarter inch in thickness and is irregularly flat in shape, consisting 
of a collection of lymphadenoid tissue on either side of the median 
raphe of the tongue, and situated immediately posterior to thecircum- 
valate papillae. The base upon which the glands rest is composed of 
muscular tissue, fasicula from which penetrate into the substance of 
the gland and interlace between the crypts. It is especially promi- 
nent at the sides of the median line, but normally so small that a clear 
space exists between the tongue and the epiglottis. In the median 
line the follicles composing the tonsil are so minute as to be practi- 
cally invisible. 
The histology is the same as the tonsilar tissue in other portions of 
the pharynx, differing from the faucial tonsils only in the smaller 
number of crypts present. Harrison Allen* has defined a tonsil as 
♦Harrison Allen, American Journal of Medical January. 1892. 
I T Y Yfc 2 
essentially an association of diverticula?, developing from the epithe- 
lial layer of the mucous membrane. In the wall structure of these 
diverticulse are grouped mucous glands and lymph follicles. The 
stomata of these diverticulae open, in a more or less uniform manner, 
on the surface of the tonsilar mass. This description is applicable to 
all the tonsilar tissue. The lingual tonsil differs only inasmuch as the 
anatomic units, or in other words the individual crypts, are not bound 
together in one mass, as in the faucial tonsil; they are single, forming 
a group of aggregated lymphoid elements with a definite interspace be- 
tween the individual glands. Microscopically we find from four to 
eight small lymphoid glands, with a few mucous glands bound together 
by connective tissue. The crypts are irregularly shaped like the bowl 
of a lamp.* The blood supply of this region is very profuse, in 
some instances almost resembling erectile tissue. The lymphatic ves- 
sels are also abundant. 
Of the physiology of the gland little is known, but from its position 
and anatomy it seems to be of more or less value in three ways, (a) 
acting as a pad or cushion to fill out the space between the tongue and 
epiglottic folds, to prevent food from lodging here; (6) to secrete 
mucus to lubricate this region, and thus assist in the passage of the 
food bolus over the epiglottis; and finally (c) by its secretions con- 
stantly moistening the circumvallate papillae, thereby aiding in the 
sense of taste. That the functions here named are actual facts is not 
proven any more than we know definitely of the functions of any part 
of the tonsilar tissue. The lingual tonsil is not, in my experience, 
present in young children. Usually developing much later than the 
faucial tonsils, it seems to be rarely present before the fifth or sixth 
year. 
This mass of lymphoid tissue is frequently the seat of some morbid 
process; from its position and surroundings this must be expected. 
The food passing over it may produce irritation or infection; lying in 
a hollow, as it does, particles of food may remain and act as foreign 
bodies, with the usual results. Irritation may also result from constant 
motion of the tongue; or inflammation, simple or specific, may spread 
by continuity or contiguity, and involve it, both from the faucial ton- 
sils and pharynx, or tongue. Frequently simple inflammation of the 
faucial tonsil will, in a few days from the onset, be followed by inflam- 
mation of the lingual tonsil. That diphtheria may involve this mass 
of tissue seems probable, but I have found no cases reported in the 
literature at my command, and am not prepared to say conclusively 
that I have seen it; but a case of pharyngeal diphtheria extending to 
♦Swain, New York Medical Journal, July 25th, 1896. 3 
the larynx, seen several years ago, very probably presented involve- 
ment of the lingual tonsil, as the epiglottis, in part, and a small por- 
tion of the base of the tongue, was covered with the membrane, cul- 
tures from which showed the Klebs-Loeffler bacillus. The lingual 
tonsil may be diseased, while other portions of the oro-pharyngeal 
lymphadenoid tissue are normal, or vice versa. That this occurs is 
well shown in a case seen by Schaede* in which the faucial tonsils and 
pharynx were the seat of atrophy, while the lingual tonsil was 
normal. 
Diathetic conditions frequently localize themselves in the lingual 
tonsil, as syphilis,! and rheumatism may manifest itself in this local- 
ity, as seen in one case, in which the faucial and lingual tonsils were 
violently inflamed (twice going on to suppuration) just preceding the 
rheumatic attack of the joints. The aetiology may be dismissed in a 
few lines, as it differs in no essentials from that of the faucial tonsils, 
certain factors seemingly being more potent in the production of dis- 
eased conditions of the former than in the latter. It seems to be the 
general concensus of opinion that the lingual tonsil is affected more 
often in females than in the opposite sex. Such has been the case in 
my patients, the female sex predominating. As to the influence of 
age, as before said, the lingual tonsil is not present until about the 
fifth or sixth year. After this period of life, in contradistinction to 
lymphatic glandular hypertrophy being most common in children, dis- 
eases of the lingual tonsil are seen after the age of puberty, there be- 
ing an increased tendency to its inflammation during adult life. For 
this reason, as a general rule, it may be said that it bears little or no 
relation to the production of adenoid growths in the pharyngeal vault. 
In my cases the tonsil was diseased most frequently between the ages 
of ten and twenty. 
In the simple hypertrophic form a nervous or anaemic condition of 
the patient is generally present. Lewis! has lately called attention to 
the lingual tonsil as a factor in the production of varied pressure sen- 
sations when goitre was present in the same individual, and advises an 
examination of this tonsil when the symptoms are out of proportion to 
the thyroid enlargement. The causes of syphilitic infection of the lin- 
gual tonsil are, usually : excessive smoking, abuse of alcohol, and long- 
continued speaking or use of the voice in those who have recently con- 
tracted syphilis. Before describing the various morbid processes by 
which this tonsil may become affected, it will be well to name the more 
♦Schaede, Berl. klin. Wochenschr., No. 13, 1891. 
■fJames E. Newcomb, Medical Neus, July 2nd, 1892. 
JEdwin R. Lewis, Laryngoscope, Vol. 1, No. 1. 4 
important symptoms characteristic of disease in this locality in a gen- 
eral way, leaving the symptomatology of the special morbid conditions 
under the appropriate disease in question. 
The symptom, complex, may be divided into three parts: local, con- 
stitutional and reflex. The local symptoms may again be subdivided 
into subjective and objective; the subjective symptoms being a sensa- 
tion of a foreign body in the throat, not disappearing on deglutition, 
and in many instances is located by the patient at the base of the 
tongue. Constant endeavor to clear the throat; cough, irritative in 
character, and not explained by any morbid process of the respiratory 
tract; laryngeal fatigue, as shown by the voice easily becoming tired, 
and by hoarseness. Hemorrhage may be quite severe, but practically 
consists of a staining of the expectoration. Every swallowing motion, 
if there is much enlargement, causes the tonsil to impinge either 
against the base of the tongue, faucial tonsils or epiglottis, with 
resulting discomfort. When the entire group of glands comprising 
the tonsil is enlarged or inflamed, there is a feeling of stiffness or 
actual pain on movement of the tongue. The objective symptoms will 
depend upon the character of the lesion present, as seen by the laryn- 
goscope. The tonsil may be slightly enlarged from congestion, or the 
various degrees of acute inflammation, even to abscess formation, may 
be present. 
The constitutional symptoms do not differ in any respect from those 
presented by the various simple or specific inflammations of the faucial 
tonsils. The temperature may run as high, while malaise and anorexia 
in severe cases are always present to a greater or less degree. The 
reflex symptomatology is varied, most prominent being cough ; this is 
of a peculiar dry, nervous character, differing from the form of 
cough previously mentioned as resulting from irritation of the lingual 
tonsil by friction against adjoining tissues. More or less constant is 
the sense of constriction around the throat, referred to a level of the 
upper portion of the thyroid cartilage. In nervous or hysterical cases, 
globus hystericus may be simulated, especially in young women. 
Casadesus* has reported a case of hypertrophy giving rise to attacks 
of nocturnal asthma, which was cured by the use of the galvano- 
cautery to the diseased glands. 
The diagnosis of the various conditions can be made only by the 
laryngoscope. The prognosis, as far as life is concerned, is always 
very favorable, the only danger that is liable to occur being oedema 
of the glottis in severe acute inflammations, and that is somewhat 
remote. As to cure, that will depend upon whether the affection 
*Casadesus, Atlanta Medical and Surgical Journal, October, 1894. 5 
present is local or the result of some constitutional infection, such as 
syphilis. In general terms, treatment is eminently successful, the 
acute inflammations subsiding under appropriate treatment in from 
two to six days, and in the chronic hyperplasias cure may be effected 
in a few weeks at the most. In a few cases, occasionally seen, parts 
of the lymphoid groups will be successively inflamed and relapses 
are frequent. The frequency with which the lingual tonsil is diseased 
is more common than generally supposed. Scheppegrell* saw 
hypertrophy eight times in one hundred consecutive cases of naso- 
pharyngeal disease. No doubt, if more attention was paid to this 
part of the oro-pharynx, fully twenty per cent, of all our nose and 
throat patients would present some morbid alteration of this group of 
glands. The author last named reported fifteen cases, ten of which 
were females. 
The study of the various pathological processes involving the lingual 
tonsil has caused me to construct the following classification. Until 
future studies have been made this must necessarily remain more or 
less incomplete. The various affections may be classed as follows: 
1. Acute congestion. 2. Simple acute inflammation. 3. Periton- 
silar inflammation. 4. Abscess. 5. Hypertrophy. 6. Acute follicu- 
lar inflammation. 7. Chronic follicular inflammation. 8. Cheesy 
degeneration. 9. Syphilis. 10. New growths. 
Acute congestion of the lingual tonsil is usually the result of some 
nervous excitement, and rapidly diminishes as the cause is removed. 
The patient complains only of a dry, nervous cough, due to the friction 
of the tonsil on the adjoining parts. This condition of congestion 
may also result from a "cold in the head" by reflex action. If the 
congestion is not arrested, it will, in a few hours, pass into the condi- 
tion of simple acute inflammation, with pain, referred to the base of 
the tongue, fever, and the general symptom of acute inflammation, as 
seen in the faucial tonsil. The inflammation at this time may be so 
severe as to interfere with free motion of the tongue, and similarly, 
from congestion of the adjacent parts, the voice may become more or 
less affected. Cough is a constant symptom. This form rarely passes 
on to pus formation, and under appropriate treatment usually subsides 
in a few days. If the attacks occur'frequently, usually from coryza, 
the condition gradually passes into hypertrophy of the glandular 
structure, with hyperplasia of the connective tissue elements. 
The following case illustrates this simple inflammation, and also 
shows the effect produced upon the epiglottis, as occasionally seen. 
The patient, a woman, age 22 years, with a general sclerotic condition 
♦Scheppegrell, Medical News, October 19,1892. 6 
of the nose and pharynx, complained of pain and irritation at the base 
of the tongue, a sense of constriction around the neck was well marked, 
and mild constitutional symptoms were present. On examination, the 
lingual tonsil was found to be inflamed, and filling up the -space 
between the papillae maximae and the epiglottic folds. Under treat- 
ment, relief was obtained in a few hours, with subsidence of the 
inflammation by the second day. On subsequent examination of the 
case a few months later, it was found that the apex of the epiglottis 
was firmly adherent to the base of the tongue, with a moderate amount 
of laryngeal irritation, due to the imperfect covering of the larynx by 
the epiglottis. 
Acute inflammation is, as a general rule, a mild condition, differing 
in many respects from the much more serious form-peri-tonsilar 
inflammation. This condition is marked by constitutional symptoms 
only slightly less than those caused by the same variety of inflamma- 
tion of the faucial tonsils. Fever may be as high as 104 or 105 
degrees, in some cases with marked general prostration. The sub- 
jective symptoms are more severe than in the preceding forms, and 
when the peri-tonsilar infiltration becomes a feature of the affection, 
the entire tongue may become swollen and inflamed, motion and 
swallowing becoming nearly impossible. The secretion of saliva is 
increased to a marked extent, and the epiglottis may become involved, 
adding to the processes already present, the additional danger of 
oedema of the glottis. The cervical glands may be swollen, usually 
on one side, but depending upon the amount of inflammation present; 
in severe cases the glandular swelling is bilateral. This form of 
involvement of the fourth tonsil is well illustrated by five cases of 
peri-amygdalar cellulitis reported by Ruaulb*. 
Abscess of the lingual tonsil may result from the simple form of 
inflammation, but is usually the sequence of a previous acute peri- 
amygdalar infiltration. The sense of suffocation is probably the most 
annoying symptom in this condition and an element of gravity is 
present in acute abscess, on account of the proximity of the pus col- 
lection to the larynx. It is hardly necessary to record the more com- 
mon symptoms here, as they are identical with the same condition as 
seen in the faucial tonsils. A form of lingual tonsil abscess has been 
noted by Mounierf in two cases reported, in which all the symptoms 
were slight, with a very small amount of inflammation present. For 
these reasons he says that the abscess may readily pass unperceived. 
Judging from reported cases and my own experience, hypertrophy 
*Ruaulb, Archiv. Internal, de Laryngol, Vol. 5, No. 1. 
tMounier, Annates des maladies de I'oreille, du larynx, du nezet du pharynx, Paris, June 1894. 7 
is the most frequent morbid condition met with in the lingual tonsil. 
The hypertrophic condition usually affects the gland, as used in a col- 
lective term, symmetrically, but cases are seen in which the enlarge- 
ment may be in the median line, or either on one of the lateral halves. 
Although not able to ascertain the exact causes producing this condi- 
tion of hypertrophy, yet it certainly seems to be due to repeated 
attacks of a moderate degree of acute congestion or inflammation, as 
is seen so frequently in the faucial tonsils. The following case will 
illustrate the general hypertrophy of the fourth tonsil: Miss L. R.; 
age 19 years. Has been treated for over one year for obstinate 
cough, worse in the morning and accompanied with profuse muco- 
purulent expectoration from the nasopharynx. Local and general 
treatment was used as directed to the cough, but were of no avail. 
On examination the following conditions were presented; a general 
hypertrophy of the pharyngeal ring of lymphoid tissue with consider- 
able enlargement of the lingual tonsil. This hypertrophy was to such 
an extent, that the epiglottis was forced back over the upper portion 
of the larynx and its movements much restricted, the mass project- 
ing above the level of the tongue. Under treatment, directed to this 
condition, the symptoms ameliorated, with a successful issue of the 
case on the subsidence of the mass of hypertrophied tissue. 
Chronic enlargement is most frequent in women, and especially in 
singers.* This interference with phonation, especially the singing 
voice, depends upon the grade of hyperplasia, and to some extent 
upon the location, i.e., laterally or in the median line. When the en- 
largement is most marked in the median line the foreign body sensa- 
tion is most prominent, and in some cases this hypertrophy may be 
such that the epiglottis will be imbedded in the mass of new-formed 
tissue. With general hypertrophy, one spot of the tonsil is usually 
more irritated than another, as friction of this portion, with a produc- 
tion of cough and a keeping-up of the low grade of inflammation is 
constant, the seat of the largest amount of hyperplasia constantly im- 
pinging against the surface of the tongue, epiglottis or faucial tonsils. 
Haemorrhage may occur, usually slight, but enough blood mixes with 
the saliva to attract the attention of the patient. This seems to oc- 
cur mostly during the night, as recently seen in a young girl with sim- 
ple hypertrophy, in which attention was called to the condition by the 
stain on her pillow when she arose in the morning. The hmmorrhage 
is small in amount, and can be readily explained by the number of 
vessels present in this region, as previously stated. Joalf has recently 
♦Dunbar Roy, Medical Neu'n, October 26th, 1895. 
+Joal, Revue de Laryng., etc., Paris, June 1st., 1894. 8 
reported three interesting cases of haemorrhage from the lingual 
tonsil, and Foster* also reported a case with bleeding, and called at- 
tention to the importance of examining the lingual tonsil when there 
is a history of bleeding from the throat. 
If the hypertrophy be situated laterally there will be more or less 
pain on swallowing, and sometimes the pain will radiate to the ears. 
I now have a case of adductor vocal paralysis in which the left half of 
the lingual tonsil is as large as a hazel nut, pale in color, and not pro- 
ductive of any special symptoms, although if present they may be 
masked by the other conditions. This patient is a female, and also a 
singer by profession. McBridef has reported cases of hypertrophy, 
and gives an excellent colored plate of the condition in his book. Re- 
flex symptoms produced by the enlargement are numerous; I have 
mentioned the most prominent in another part of this paper. Ville- 
courtl has reported a peculiar case of hypertrophy in a woman aged 
thirty years, in which intense respiratory dyspnoea suddenly appeared, 
followed by cyanosis on the following day. The right arm appeared 
heavy, motion was difficult, cutaneous sensitiveness was obtunded, and 
the electrical contractility of the muscles diminished. Treatment of 
the lingual tonsil caused the local manifestations to improve on the 
third day, the other disorders disappearing on the eighth day. This 
was evidently a case of hypertrophy with an intercurrent acute inflam- 
mation, as in addition to the symptoms present of an acute disorder of 
the tonsil there were found, on inspection, two symmetrical growths at 
the base of the tongue, each the size of a bean, surrounded by dissem- 
inated granulations. 
Acute follicular inflammation is characterized by the marked consti- 
tutional symptoms: the temperature is higher, the local symptoms more 
marked; andon the discharge of the mucus plugs filling the crypts the 
quicker decline of the symptoms than in the other forms of inflamma- 
tory involvement of these glands. The tonsil presents the ordinary 
appearances of inflammation, with the mouths of the follicles dilated, 
each follicle involved being filled with a mass of semi-solid mucus. 
The severity of the local and general symptoms being directly depend- 
ent on the amount of follicular involvement. Chronic follicular 
changes, as a general rule, are a result of previous acute inflammations. 
The glands are enlarged, hyperplasia of gland cells being the most 
prominent feature, with little involvement of the inter-cellular con- 
nective tissue. The tonsil is lobulated, usually on one side of the 
*Hal Foster. Laryngoscope, Vol. 1, No. 4. 
•(•McBride, Diseases of Nose, Throat and Ear. 
JVillecourt, Gazette des hopitaux, Paris, January 9th, 1894. 9 
median line, but it may be seen as a bilateral condition. The symp- 
toms are those of simple hypertrophy, with an increased mucous se- 
cretion and a greater liability to constant acute inflammations. Con- 
gestion as in simple hypertrophy may be present, but bleeding rarely 
occurs. 
When the epithelial elements are especially involved we have the 
condition of cheesy degeneration-usually the result of previous in- 
flammation of the pharyngeal lymphoid ring and generally present in 
women or young girls, in connection with cheesy degeneration of the 
faucial tonsils. The following case will illustrate the condition: 
C. Q. ; female, age 16 years. Was seen November 3d, 1896, com- 
plaining of a sensation of a foreign body in the position of the lingual 
tonsil, and with the general symptom complex of naso-pharyngeal 
catarrh. The turbinals were hypertrophied. Cough irregular, dry 
and without result as far as the raising of mucus was concerned. The 
pharynx was sclerotic, the faucial tonsils studded with cheesy masses, 
and the seat of chronic folliculitis. The lingual tonsil was symmetri- 
cally enlarged, and the glandular crypts on each of its lateral halves 
were filled with necrosed, cheesy material, projecting from the surface 
of the already enlarged tissues. The entire mass of tonsilar tissue at 
the base of the tongue was surrounded by a moderate degree of inflam- 
mation, and was enlarged to about one-fourth its usual size. 
Syphilis in its various manifestations may involve the lingual tonsil 
alone, or, as is usually the case, the tonsil becomes affected with the 
disease along with other parts of the economy. I have been unable to 
find a case reported of hereditary syphilis in this locality, although 
Allen* has observed hypertrophy of the lingual tonsil in this form of 
the disease, and remarks that it is more common in women than in 
men. As the lingual tonsil occupies, to some extent, a sheltered posi- 
tion in the oro-pharynx, being protected by the tongue and epi- 
glottis, primary syphilitic infection is rarely seen, although the origi- 
nal lesion has been observed in this locality. Schiffersf saw a case in 
which the primary lesion was situated on the left half of the lingual 
tonsil, with swelling of the cervical glands on the same side. The 
pathology and symptomatology of the primary sore are similar to that 
when located on the faucial tonsils. 
As usually seen in its later stages, syphilis presents its manifesta- 
tions in two forms in this locality. There may be small protuberances 
separated from one another by the intervening connective tissue of the 
♦Chas. W. Allen, Morrow's System Syphilology. 
+F. Schiffers, Archives Internationales de laryngologie, de rhinologie et d'otologie, Paris 
November 30th, 1894. 10 
glands, and are grayish-red in color. On the summit of these promi- 
nences is seen the typical mucous plaque, clean cut and well defined 
from the surrounding surface, each enlargement corresponding to a 
tonsilar crypt or group of crypts, which are inflamed and their walls 
adherent. This process is localized without involvement of the ad- 
joining tissues. The other form is characterized by involvement of 
one-half or the entire tonsilar mass, showing itself as a single tume- 
faction, slight adjacent swelling, and capped with a mucous plaque. 
The mass is ovoid in shape, and a much greater area is involved than 
in the first form described. Besides the infiltration of the closed fol- 
licles there is an interstitial infiltration; in other words a sub-acute 
peri-folliculitis. The first variety rarely becomes transformed into 
that of the last. Other portions of the throat are usually involved 
when these lesions are present. And if the pharyngeal lesions are at 
all severe the lingual tonsil is generally involved in the morbid pro- 
cess.* According to Natierf the syphilitic tertiary lesions are very 
rare, as he, in 1890, had only succeeded in finding fifteen cases in the 
French literature. The diagnosis of the tertiary lesions is very diffi- 
cult, and yet it is of the utmost importance that specific treatment be 
promptly instituted, as deep ulceration is liable to occur, and import- 
ant vessels may become involved in the process. 
New growths are very rare, the most common being retention cysts, 
due to the closing of the stomata of the crypts from inflammatory 
changes. Reudat reported a case of a retention cyst in a woman 25 
years old, the prominent symptom being the sensation of a foreign 
body in the throat. Onodi § saw a case of fibro-sarcoma, the diagno- 
sis being confirmed by the microscope; the case was that of a girl aged 
1 7 years. He found but two other cases reported in literature. 
The treatment of affections of the lingual tonsil is essentially local, 
except in a few cases in which the local process may be the result of 
some general disease, or where there is a marked nervous element; in 
these cases removal of the cause and appropriate general remedies are 
indicated. In acute congestion or inflammation an astringent gargle, 
thus glabra being most efficient in my hands, with local applications of 
tr. ferri chloridi, to glycerin gj. If the inflammation be of the 
peritonsilar form, more active remedies are indicated, such as iron in 
stronger solution, nitrate of silver, gr. C to aqua gj., tannic acid, or 
any of the remedies used in the severe acute inflammations of the fau- 
♦Seifert, Munchener medicinische Wochenschrift, MUnich, February, 1894. 
•fNatier, Annals de Polycl. de Paris, 1890, page 109. 
JRueda, Arch. Internationales de laringologia, otologia et rinologia, Barcelona, Novem- 
ber, 1893. 
§Onodi, Revue de laryng., etc., October 15th, 1893. 11 
cial tonsils. Hot inhalations are of value, especially if there is any 
local oedema; the mere inhalation of steam usually gives great comfort 
to the patient. Frequently cold will be found grateful to the patient, 
when ice cracked in small pieces may be allowed to melt in the mouth. 
Temporary relief and the reduction of any excessive swelling may be 
relieved by local application of a four per cent, cocaine or eucaine so- 
lution; but these drugs are used with difficulty, as they are so rapidly 
washed away by the excessive flow of saliva. 
If the case go on to pus formation, the abscess must be opened, the 
galvano-cautery being preferred to the bistoury on account of the 
abundant blood supply of this region. Complications, such as the ex- 
tension of the inflammation to the tongue or larynx, must be treated 
promptly. When a small hypertrophy is present with severe symp- 
toms, especially cough, a four per cent, cocaine solution will reduce 
the enlargement, and greatly aid in localizing the cause of the irrita- 
tive symptoms, by causing their temporary absence. For the cure of 
the hyperplasia, iodine, or a saturated solution of nitrate of silver, 
especially the latter, are of value. The galvano-cautery or snare may 
be used when there is a large amount of hypertrophied tissue, but 
caution must be exercised in their use to avoid interference with the 
adjacent tissues. 
The follicular inflammations are treated by the usual methods appli- 
cable to the faucial tonsils. When cheesy masses are present in the 
crypts, they must be removed with the spoon or dull curette, and the 
interior of the crypt cauterized with a delicate cautery point, or the 
solid stick of silver. Syphilis should be treated with the usual specific 
remedies, iodide of potash, and mercury in some form; when ulcera- 
tions are present, local dusting with calomel, in conjunction with con- 
stitutional treatment, will probably give the best results. New 
growths require operative interference, cysts being evacuated, and 
their walls cauterized or dissected out. Merely an outline of treat- 
ment has been here suggested, as the treatment of this portion of the 
lymphoid zone differs little from that applicable to the faucial tonsils. 
3554 North Broad Street.