The various forms of angina, i. e., sore throat, have to do largely with expressions of these infections in varying degrees of severity. The adjoining mucosa and other tissues frequently participate, and it is possible to produce a painful degree of chemosis of the membranes involved in a short time. Adjoining lymph involvement, with discomfort or even distress in the region of the throat, and sometimes pronounced general malaise, are extremely common accompaniments.
The “cynanche tonsillaris” of the older writers implied an acute expression of this kind, often with more or less exudation, which, accumulating upon the exposed surfaces, produces there a membrane, the condition being most noticeable in the pronounced types of diphtheria. At other times activity is manifested rather in the peritonsillar structures, and acute and suppurative types of cellulitis, leading either to abscess in the tonsil or deep in the neck, are the result. A surprising degree of toxemia accompanies these lesions and sometimes severe and fatal general septic infection, perhaps with endocarditis. Abscess of the tonsil may produce so much occlusion of the pharynx as to make breathing difficult and even almost impossible, perhaps even to a point requiring tracheotomy. Tonsillar abscesses usually evacuate themselves in time; if they are opened by the surgeon relief comes promptly, with evacuation of pus, no matter how brought about.
Many such abscesses could be easily recognized and incised were it not for the surrounding inflammation, which prevents the patient from opening the mouth sufficiently wide to expose the pharynx. Suffering in these cases is acute.
A swollen and fluctuating tonsil, if it can reached, is easily perforated by a sharp, straight knife. Erasion and fatal perforation of the carotid artery has been known to be a sequel of such a case unrelieved. Again, pus having its source within the tonsil may burrow in such a direction as to produce a retropharyngeal abscess.
The tonsil is rarely the site of primary syphilitic lesions, more often of the secondary, and occasionally of tuberculous lesions.
The most common chronic affections of the tonsils result from failure of absorption of inflammatory products after acute inflammations, which leaves a permanent enlargement, and which is constantly irritated and provoked into further growth by the retained contents of the tonsillar crypts. It is in this way that chronic hypertrophy, or the so-called enlarged tonsils, result. These conditions are especially common in children, presenting the milder forms of the status lymphaticus. (See [Chapter XIV].) These enlargements are seldom seen alone in the tonsils. Similar involvement of the lymphoid or adenoid tissue in the vault of the pharynx, and even at the base of the tongue, is quite common, the entire original lymphoid ring being more or less involved.
The consequences of chronic enlargement of the tonsils have much to do with the subsequent welfare of patients. Not only is speech interfered with and made peculiarly “throaty,” but, owing to encroachment upon the natural breathing space, children suffering in this way contract a habit of carrying the head forward and stooping the shoulders, in order thereby to increase the dimensions of the nasopharynx; thus they become “mouth-breathers” and hard of hearing, which is deleterious to their intelligence as well as to their physical well-being. Such children, in time, become stupid, unintelligent, and defective in many ways. There is, then, every reason for removing these obstructions to respiration and for doing it early.
Children thus suffering will present such peculiarity of voice as to suggest immediate examination of the oropharynx, while the posture above described and the existence of the mouth-breathing habit should also prompt investigation. An instant inspection through the widely open mouth should permit the detection of this condition. Should it be desired to estimate it more thoroughly it may be done with the finger, although it will provoke the act of coughing or vomiting and be resisted by most children. Frequently the enlargements can be felt from the outside. There is but one suitable treatment for such a case, i. e., tonsillotomy.
Tonsillotomy may be effected with any one of several different patterns of tonsillotomes on sale in the instrument stores, most of which are neat and speedy in their work, but the surgeon need not refrain from the purpose of removal because of the lack of such an instrument, as it may be easily accomplished without one. Young and timid children are probably best anesthetized, although if one can establish perfect confidence it may be possible to do it by the aid of local anesthesia. In adults the latter will always be sufficient.
An anesthetized patient should be placed in a chair or semi-upright, and the mouth widely opened. The circular loop of the instrument should be fitted over the tonsil, this, if necessary, being drawn into its grasp by a small hook or forceps, after which by a quick motion of the cutting blade the projecting mass is removed. All instruments are made to be used with either hand and to cut on either side. The practised operator will, therefore, use his left hand when operating on the right tonsil of the patient, and vice versa, it being best to adopt this order, for should he be a little clumsy with his left hand and the patient be thereby somewhat disturbed, the right hand may more dexterously perform the excision on the other side. The surgeon should be thoroughly familiar with his tonsillotome before using it. It is not, however, necessary to employ such an instrument, and it will often be more satisfactory to grasp the projecting tonsil in the bite of a suitably constructed tenaculum forceps, or even hold it with a common tenaculum, while with blunt scissors, long handled and curved upon the flat, the tonsil itself is cut away.