arise from the operation of local irritating causes on the tongue; such as acrid substances taken into the mouth; wounds; bruises; the sting of an insect; scalding; calculous concretions in the salivary" ducts. It may also be produced by atmospheric vicissitudes, or the influence of a cold and damp atmosphere. Dr. Hosack relates a case which was caused by sitting in a current of cold air, immediately after being much heated by exercise. Reil states that glossitis has occurred epidemically; and Stark has known it to come on periodically, in consequence of suppressed menstruation.t

Treatment.-General blood-letting, promptly and decisively practised, followed by the application of leeches along the margin of the lower jaw, and, if practicable, to the lower surface and extremity of the tongue, are indispensable remediate measures in this affection. Much advantage may also be derived from scarifying the anterior part of the tongue; and still more from making an incision into its substance along the middle. This practice was particularly recommended by de la Motte‡ many years ago; and in a late number of the Edinburgh Medical and Surgical Journal, an interesting case is related by Mr. Martin, which was successfully treated by incisions.§ Reil also, (loc. sit.) speaks strongly in favour of superficial incisions, from an inch and a half to two inches in length, along the middle of the tongue. The bleeding must be promoted by emollient gargles. Richter says, that the swelling generally subsides speedily after the incisions; and they readily heal without any disagreeable consequences, From the impossibility of swallowing, internal remedies cannot be employed. Laxative enemata, however, are very useful, and should be frequently administered until the bowels are well evacuated. Considerable benefit may also arise from a large blister laid on the back of the neck or on the throat, after proper general and local depletion has been employed.

* Fieberlehre, tom. ii. p. 411.

† Handbuch zur Kennt. und Heil. der innern Krankh. p. 140.

+ Med. de l'Acad. de Chirurg. tom. v.

§ The tongue, in this case, "increased in size until it protruded from the mouth, and separated the jaws. The organ was smooth, hard, and covered with a thick coating of viscid saliva. The patient was bled to 30 ounces, with some relief and the same quantity of blood was taken in an hour after, which enabled him to articulate distinctly. In three hours more, the swelling had increased,respiration through the mouth was impracticable, and that through the nostrils was difficult-in short, suffocation was threatened. A deep incision was made in the most prominent part of the right side of the tongue, from whence issued a quantity of blood and pus, with evident relief. Two other incisions were made when the first ceased to discharge blood. In a quarter of an hour after the first incision, the patient could articulate distinctly-respiration was free. Next day he was nearly well."-Med. Chir. Rev. October, 1827.

SECT. II.--Of Tonsilitis.—Cynanche Tonsillaris.—Quinsy.

In this variety of angina, the inflammation is seated in the tonsils, soft palate, and fauces, and is of a strictly phlegmonous character. In cold and variable climates, it is a disease of frequent occurrence, and although by no means so dangerous a malady as the anginose affections of the respiratory passages, it is much more painful, and in violent cases always alarming, and sometimes fatal.

Symptoms.-The disease usually begins with slight chills, succeeded by a high grade of febrile reaction, accompanied with an uneasy feeling in the fauces, and more or less pain in this part on swallowing. In a few hours, a fixed pain is felt about the region of the tonsils, and the act of deglutition becomes more and more painful, until at last it is attended with extreme suffering, or altogether impossible. On examining the throat, one or both tonsils are found very much swollen, and the whole surface of the fauces very red and somewhat tumefied. The tongue also is swollen, white, and covered with a thick layer of transparent vicid mucus. The face is red and tumid; the carotids beat strongly; respiration is difficult; hearing obtuse; the pulse frequent, hard, and full; and the voice is indistinct or whispering. In general, much more difficulty and pain is experienced in swallowing liquids than soft or pultaceous solids. The pain generally shoots from the fauces into the ears, particularly on attempting to speak or to swallow, and the mouth is opened with great difficulty and pain. A very thick ropy mucus commonly adheres to the inflamed parts, and contributes much to the difficulty of respiration. The uvula and soft palate, are generally very much swollen; but the principal pain and difficulty of breathing arise from the tumefied tonsils; for when both are inflamed, they sometimes become so much enlarged as to come in contact with each other, confining the tumid uvula behind them, or pressing it forwards into the mouth.* The external part of the throat, in the region of the tonsils, is always somewhat tumefied, and tender to the touch. In some instances, the tonsils are covered with flakes of coagulable lymph, of a whitish colour, resembling superficial sloughs. Occasionally small excoriations or ulcerations oecur on the inflamed tonsils. These ulcers arise from small yellowish pustules bursting and pouring out a lymph-like fluid, which concretes into a whitish pseudo-membranous layer on the surface of the tonsil. This, after some time, separates, and exposes a bright red and very sensible surface or erosion, from which a purulent matter is discharged.f

* We may be sceptical, however, with regard to the assertion of Marcellus Donatus, who affirms that he has seen the uvula thus pressed forwards by the swollen tonsils, ad anteriores usque dentes.-De Medica Historia Mirabili, p. 84.

† Dr. W. Sachse, Encyclopädisches Wörderbuch der Medicinishen Wissenschaften. Band, ii. p. 464.

In

The inflammation in this affection terminates either in resolution or suppuration, gangrene being an extremely rare occurrence. no structure is inflammation more apt to terminate in abscess, than in the tonsils. Internal suppuration often occurs in a few days, notwithstanding the most active local and general antiphlogistic, measures. The quantity of matter discharged from a suppurated tonsil is seldom so abundant as to become very perceptible in the sputa, a portion of it, no doubt, being commonly swallowed with the saliva. Cases occur, in which the abscess, instead of breaking internally, is gradually enlarged; and extending outwards, points externally under the angle of the jaw. Dodonæus relates a case, in which the patient appeared near dying, where speedy relief was obtained by an external incision into the abscess, and the consequent discharge of a large quantity of pus.* Frequent attacks of the disease are apt to produce permanent enlargement and induration of the tonsils. In some instances the inflammation passes down into the larynx, an occurrence which always greatly increases the dangerousness of the affection.

Causes. Some individuals are peculiarly predisposed to this variety of angina. This is especially observed in persons who have already once or twice suffered an attack of the disease. The constitutional influence of mercury, or salivation, appears to create an increased aptitude to this affection; a strumous habit, also appears to, constitute a state of predisposition to the disease.

The ordinary exciting cause of this complaint is cold and damp air, or cold applied in any manner so as to give a sudden check to the perspiration. Standing long on cold and wet ground, is particularly apt to give rise to the disease in those who are predisposed to it. It may also arise from local causes, such as irritation from the cutting of one of the posterior teeth; (Sachse, loc. cit. p. 475;) the fumes of arsenic; (Sheffler, von. d. Gesundh. der Bergleute,) acrid substances, swallowed or applied to the fauces. (Fabricius, cent. iv. obs. 15.) Treatment. The treatment must be vigorously antiphlogistic; and although Cullen asserts that a copious abstraction of blood is seldom necessary, general experience is decidedly in favour of prompt and efficient bleeding in this affection. In slight cases we may sometimes subdue the inflammation without blood-letting, but as we cannot be sure, at first, whether the disease will continue a mild course, or acquire much severity, it is always best at once, to moderate the momentum of the circulation by depletion. Local bleeding, by scarifying the tonsils, generally produces excellent effects, and may be accounted much more efficacious than the application of leeches to the throat or under the ears. Cupping on the back of the neck and under the ears may also be resorted to with

* Obs. Med. p. 192, as quoted by Van Swieten.

† Kopp, an eminent German physician, says, that blood drawn from the tonsils by scarification, is the best, most certain, and promptest remedy we possess in this affection.

VOL. I.-27

benefit. Baglivi asserts, that he has known the abstraction of blood by cupping between the shoulders, afford great advantage in this affection. Internally, purgatives and the usual antiphlogistic diaphoretic remedies must be actively employed. An active purge should be one of the first remediate measures adopted; the bowels must afterwards be kept freely moved, either by the daily repetition of purgatives, or frequent laxative enemata. A bolus of calomel and jalap, or of from fifteen to twenty grains of the compound extract of colocynth, with ten grains of calomel, or a full dose of one of the neutral purgative salts, may be used for this purpose.

Nitre with antimony, in the usual proportion of the nitrous powders, constitutes the best refrigerant diaphoretic in this complaint. Some advantage may be gained by placing the nitre on the tongue, and swallowing it as it is gradually dissolved in the mouth. The muriate of ammonia, dissolved in water with the extract of liquorice, has also been particularly recommended.* Much benefit may in general be derived from nauseating doses of tart. emetic. I have frequently prescribed this remedy with the happiest effect. A grain of tart. antim. may be dissolved in two ounces of water, of which a tea-spoonful is to be taken every half hour, so as to keep up a considerable degree of nausea for several hours.

Emetics were formerly a good deal employed in this variety of angina, but their effects are much less beneficial in this, than in any of the other anginose affections.

As soon as the momentum of the circulation has been moderated by venesection, a blister should be applied to the throat, or on the back of the neck. In slight cases of the disease, rubefacients, particularly the spirits of turpentine, or a liniment composed of two parts of ac. ammonia to one of sweet oil, will in general suffice for this purpose.

Emollient poultices also, are very useful applications in simple cases of the disease. When employed as soon as the disease commences, together with warm pediluvium, and a purgative, the further progress of the inflammation will sometimes be speedily and effectually checked. In such instances three or four folds of thick flannel round the neck, with the auxiliaries just mentioned, are sufficient frequently to prevent the development of the malady. In all instances, however, where the inflammation is considerable, vesication is decidedly the most proper.

Various gargles and other applications to the seat of the inflammation have been recommended in this affection. Cullen advises a decoction of oak-bark, with alum dissolved in it, as a gargle in this disease. I have generally preferred using simply warm water, slightly acidulated with vinegar, for this purpose. Little or no advantage results from the use of gargles in this complaint, beyond that of dissolving and removing the viscid mucus which is apt to adhere

* Loeffler. Beiträgen zur. Arzn. Wissensch. 1 Th. Leips. 1791, p. 142.

to the tonsils and palate, and this is best effected by warm water, either alone, or with a portion of some vegetable acid, and perhaps honey.. Pringle states that he never derived any benefit from astringent gargles; and Storch asserts, that he has known them to do very evident harm, by checking the exhalation and secretion from the mucous surface of the inflamed parts. The inhalation of different vapours, is one of the oldest remedies in this disease. Hippocrates used the vapour of vinegar and water for this purpose.

M. Toriac asserts that the application of lunar caustic to the tonsils in the early stage of this complaint, almost always speedily arrests the inflammation and swelling. He has related several cases, which were completely subdued, by this application, in less than two hours. In the case of a lady, whose tonsils were inflamed and so much enlarged as to threaten suffocation, every disagreeable sensation was removed in one hour by the application of the nitrat. argent.*

When the inflammation has terminated in the formation of a tonsillar abscess, it should be pierced with a lancet, to give exit to the matter, an operation which always gives immediate relief from the pain and difficulty of respiration. After the pus is discharged, the patient should continue the use of some mild and slightly acidulated or astringent gargle.

SECT. III.-Of Parotitis.
Mumps.

Parotitis is a specific inflammatory affection, capable of being propagated by a peculiar contagion, and occurring sometimes epidemically. The disease usually commences with slight febrile symptoms, with a feeling of stiffness of the jaws, and a little swelling and pain either in one or both parotid glands. The swelling gradually increases until about the fourth day from the beginning of the disease, at which time the affected gland is greatly swollen and very firm and tender to the touch. The skin on the tumour is generally of a natural colour, or but slightly inflamed; although, in some instances, a pale redness is diffused over the swelling. Mastication and deglutition are always attended with considerable pain. The fever is nerally mild, and is often attended with considerable nervous irritability and restlessness. From about the fourth day the swelling gradually subsides until the detumescence is complete, which is generally about the seventh day. Soon after the inflammation of the parotids begins to decline, the breasts in females, and the testicles in males, are apt to become much swollen and hard. The subsidence of the disease is usually attended with more or less general diaphoresis, and a red sediment in the urine.

ge

* The Amer. Jour. of the Med. Sciences, vol. v. p. 212; quoted from La Clinique, &c.