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The Common Cold
The Common Head Cold:
 Principles And Practice Of Hardening

 Home Care And Treatment

 Nasal Obstruction And Mouth Breathing

 Adenoid Problem

 Tonsil Troubles

 Sinus Situation

 Voice And Speech

 Summary And Conclusions

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Tonsil Troubles

( Originally Published Early 1900's )

Not less injurious to the health of the individual than adenoids is the presence of diseased faucial tonsils.

Being practically of the same structural formation they are naturally influenced by the same causes, and as a matter of fact we nearly always find an associated enlargement and disease of both the nasopharyngeal (adenoids) and faucial ton-sils. Furthermore, as the adenoids block nasal respiration and make of the subject a mouth-breather, and as mouth-breathing tends to irritate and inflame all the structures within the oral cavity, the natural tendency to hypertrophy of the faucial tonsils is materially exaggerated.

But as the adenoids precede the arrival of enlarged tonsils, they also precede in the tendency toward atrophy, and now, after they have done their harm to the organism, they begin to dis-appear. The tonsils, however, with added instigation to inflammation and disease, go merrily on for years to come. As the adenoids, then, are the special problems of early life and childhood, the tonsils are a problem not only of those ages but also of adolescence and maturity. Fortunately they in turn tend to atrophy in the later years of life and therefore are of comparatively little trouble in old age.

Now, the tonsils have a set of troubles all their own. Outside of the tendency to repeated attacks of inflammation, generally in the form of follicular tonsillitis marked by filling up of the crypts with diseased exudate, and giving rise to the little white spots with which the surface is seen to be dotted, they are liable to the formation of abscesses.

"Quinsy" is the term used to describe that form of tonsil inflammation marked by abscess formation. If the abscess were confined to the tonsil itself, it would not be so bad, but the infection is apt to extend to the connective tissue lying outside the tonsil capsule, and then we have in-deed the devil to pay. (Fig. 13.)

Peritonsillar abscesses, as they are called, are usually marked by intense agony, painful or impossible swallowing and systemic disturbance as well as local distress.*

Any one who has ever had a peritonsillar abscess need not quibble over the question of tonsillectomy. It is a positive indication for the necessity of the operation. Outside of the likelihood of a return of the attack it is a per se evidence of a chronic diseased state of the tonsillar tissue.

From frequent attacks of inflammation, the tonsils are likely to develop adhesions to the sur-rounding parts, and sometimes the outer surface becomes overgrown with adherent membrane. If, at the same time, they become more or less deeply sunken within the tissue, we have the most intractable form of tonsil disease, the so-called imbedded or submerged tonsil.

Such a tonsil, appearing to be small, is often passed over by the casual observer as harmless, but it is in fact the worst kind, for, so shut in and imprisoned, it may become a veritable cesspool for blood-stream infection.

Tonsils give rise to more serious systemic disturbance than do adenoids, due to the more frequent occurrence of pus pockets, and the consequent toxic infection of various parts and organs of the body. The most common ailment directly traceable to diseased tonsils is rheumatism, and by far the most frequent cause of rheumatism is diseased tonsils. Any one who has had an attack of acute tonsillitis will recall vividly the rheumatic pains in all parts of the body, and especially the extreme joint soreness by which it is usually accompanied. The kind of toxin manufactured in the tonsils has an especial affinity for the serous linings of the joints, so that the so-called arthritic pains in any part of the body, (it may be in the finger joints or it may be so distant as the joints of the ankle or big toe) give good reason to hold the tonsil under suspicion. The kind of rheumatic pain particularly characteristic of tonsil infection is that affecting the muscles of the neck and shoulders producing a soreness and stiffness of the muscles in this region that is quite typical.

Yet more serious than any of these affections are the heart lesions which are liable to result from the tonsil infection. Sometimes the serous surface of the sac enveloping the heart becomes infected (pericarditis), and sometimes the inner lining of the heart (endocarditis), either one of which may place the patient in jeopardy of his life.

Kidney inflammation, high blood pressure, and general ill-health are frequently noted as coming from the same cause, when they are greatly benefited by prompt removal of the tonsils.

The general public is much given to being governed by fads in the cure of bodily ailments, and it must be admitted that the medical profession is not altogether immune from the same failing. Since it has been discovered that many diseases, formerly obscure, are traceable to a focus of infection lurking in some organ, doctors have been too prone to recommend the removal of tonsils, teeth or other organs, and the patients, very readily influenced, undergo operations that are the prevalent fashion.

We are disposed therefore to emphasise certain points that should be kept in mind in coming to a decision whether or not one's tonsils should be removed. Firstly, it must be determined by some one especially qualified whether the tonsils are diseased, and secondly, whether a given malady is a result of the disease. If one has been subject to very frequent attacks of tonsillitis the inference is in favor of chronic tonsillar trouble, and this inference becomes a certainty if the tonsil inflammation was of a type known as quinsy —that is attended with the formation of an abscess.

It must be understood, however, that in many cases the tonsils are not infrequently found to be badly diseased and septic, and so, likely to give rise to general focal infection in patients who are not conscious of any focal trouble, and who have seldom had sore throats. The expert specialist should be able easily to detect in such cases evidence of disease.

Whether or not certain ailments are the direct result of the tonsils is also a question for expert opinion, which will be governed in the first place by a general knowledge of what kind of maladies arise from tonsil disease, and a special knowledge of the particular kind of germ disease in the case, and also perhaps by the observation that the general malady in question will show exacerbation coincident with the increased local inflammation.

In the case of an operation that is so universally practised, by so many operators of varying skill and judgment, and upon patients of varying degree of bodily resistance, it is inevitable that a fatality may now and then occur, but it is an accident of very rare occurrence in the practice of those engaged exclusively in the specialty of laryngology. The author has removed thousands of tonsils, both in military and civil practice, operating on all conditions of life, in all ages from infants to old age, using all methods of operation, and yet he has not had a single fatal case to report.

The question which most often comes into the mind of every one, in connection with the subject of tonsillectomy, is as to the danger of bleeding. There is a wide-spread belief among laymen generally that the normal operation is a very bloody one, and that there is a possibility that one may bleed to death. Unfortunately, there has been some ground for the generation of this belief. It is to be found in the all too common practice of this operation by incompetent persons. In the great majority of instances, the removal of tonsils is indeed a simple procedure, but not always, because many variations occur in anatomical relations, and unusual difficulties may sometimes present them-selves.

The general physician or general surgeon will "get away" with the successful performance of most of these cases, but is liable to have trouble with the exceptional one. The operation ought therefore, to be entrusted only to those who by reason of special knowledge and skill are prepared for every possible situation.

There is even a danger that the specialist may now and then become a little lax and less watchful than he should be, simply because in a succession of cases no accident has happened. It is important to stem all the bleeding at the time of the operation, and especially is it important that every precaution be taken to prevent a hemorrhage occurring later on. Nothing can be more distressing for a patient or embarrassing for a surgeon than a bleeding that comes on a few hours or a few days after a tonsil operation. It is exceedingly painful, with throat raw and sensitive from the recent operation, to have to submit to the manipulation necessary to stop the bleeding. Yet this must be done, or else in some cases the subject is compelled to take a general anesthetic, which was purposely avoided in the original operation.

There is only one way which surgeons recognise as offering a satisfactory guarantee against hemorrhage connected with tonsillectomy, and that is by a thorough tying or ligation applied at every bleeding point. If this be true, it is naturally a question why this is not generally practised. The answer is that the application of ligation in the tonsil is not always an easy procedure.

There are surgeons who confess to an inability to perform the feat, which is especially difficult for individuals with short, stubby, unflexible fingers. One of the most satisfactory ways that has been found to secure a vessel, is by passing under it a needle with a thread which is then tied around it—the suture ligature. But there is danger that the needle may snap under the pressure of the needle holder, which may prove a very serious accident.

To obviate these difficulties, the author has devised a special instrument, which makes it possible to place a suture readily in any desired place in the tonsil fossa. As soon as the thread is in place, it may be tied by a special knot without the necessity of, at any time, placing the finger within the oral cavity.

In a published article, "A method which insures the practical control of hemorrhage in connection with the operation of Tonsillectomy,'' we de-scribed in detail our method of the procedure of tonsil operation, which if conscientiously and intelligently followed, practically guarantees against the danger of tonsil hemorrhage. It consists in the placing of sutures as a routine practice at certain designated points, which anatomical studies and experience show to be the usual sites of bleeding.

In order to be able to employ this method with facility, it may be necessary to devote a little time to acquire a thorough knowledge of its technique: But is it not time well spent, if it proves the means of preventing a great part of the serious post-operation hemorrhage, not to mention the possibility of sometimes, perhaps, actually saving life

The operation of tonsillectomy may be done either with a patient in a state of unconsciousness from a general anesthetic or with the sensation to pain deadened in the region to be operated upon, by a local anesthetic. It is proper, instead of making general rules, to individualise for each separate case. There are some individuals who are not good risks for a general anesthetic and who had better have the local; there are others for whom the operation by local anesthetic would be totally unsuited.

The question is frequently asked whether or not diseased tonsils may not be brought back to healthy, normal condition by some kind of treat-ment, thus altogether avoiding the much dreaded operation. Any one who understands the pathology and physiology of these organs knows very well that it is impossible to accomplish this by the use of any medicaments locally applied. Gargles, sprays, swabbing are useful in combating superficial acute inflammation but powerless against the deep lying infection of chronically diseased organs.

The crypts of the tonsil penetrate deeply and, in diseased tonsils, they contain a pathologic exudate or pus, which explains the reason why the for-mer method of clipping the tonsil proves a failure. The use of caustics or the electric cautery was even worse than insufficient, in that it often seared over the mouths of the crypts and imprisoned the diseased secretions. The same can be said of a method more recently brought forward under the name of electro-coagulation. For this purpose a high-frequency machine is used, generating a D'Arsonval current which can bring about a limited destruction of tissue.

A few years ago, much hope was raised by the claims of x-ray specialists, that by exposure to the rays we had a substitute for tonsillectomy. This expectation, however, has not been fulfilled, chiefly for the reason that it is not possible to concentrate enough of the rays upon the tonsil to produce a satisfactory atrophy without injury to the overlying skin and surrounding parts, especially the parotid gland. The objection, however, is largely overcome in the use of radium, which by a method originally described by the author can be inserted in the form of needles directly into the substance of the tonsil.

We demonstrated to our satisfaction that it is practicable to bring about complete atrophy of the tonsils if the procedure is properly carried out and repeated when necessary. The tonsils in fact consist chiefly of a mass of lymphoid tissues, very susceptible to radiation, and when they have been treated in this way and later subjected to microscopical examination it was found that the spongy diseased tissue had undergone actual atrophic changes and converted into fibrous tissue imitating Nature's own method of normally bringing about recovery.*

In some instances there was considerable re-action, though slight as compared to tonsillectomy, and this can be made still less by giving smaller doses more often repeated. We have had a number of cases in which the atrophy was so complete that it was impossible not to believe that the tonsils had been removed by tonsillectomy.

It must be clearly understood that there is no method of removing the tonsil that is quite as satisfactory as the cutting operation. There are, however, certain cases when such operation can-not be undertaken, or where a general anesthetic is contra-indicated. In this event radium may be advisable.

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