XV. Diseases of the Tonsils.
Definition:—An acute inflammation, involving either the mucous covering of the follicles or the parenchyma of the tonsils, characterized by swelling and pain, and occasionally resulting in chronic enlargement.
When the mucous membrane of the tonsil or tonsils only is involved, the inflammation is designated as superficial or catarrhal tonsillitis; when the inflammation extends to the follicles, resulting in a cheesy exudate from the tonsillar crypts, it is described under the name of follicular tonsillitis, which is designated also as acute lacunar tonsillitis. Parenchymatous tonsillitis comprehends an involvement of the entire structure of the tonsil, and in this form there is a marked tendency toward suppuration. It is especially designated as suppurative tonsillitis, tonsillar abscess or angina tonsillaris. It is commonly known as quinsy.
Etiology:—The disease seldom occurs in infancy, but is most common in children from five to fifteen years of age and in early adult life. The suppurative form occurs more frequently in adults. One attack seems to predispose a patient to future attacks, and those of lymphatic temperament or of a scrofulous diathesis are especially liable. Males are more frequently attacked than females. This is probably due to the fact that their habit and employment expose them to attacks and induce the conditions most favorable to the disease.
Patients suffering from rheumatism are especially liable to attacks, and, on the other hand, from twenty-five to thirty per cent of the patients who suffer from follicular tonsillitis subsequently develop rheumatism. The phenomena which seem to confirm a diagnosis of rheumatism may occasionally be due to septic arthritis or endocarditis, due to constitutional infection from the tonsils or from the products of the development of micro-organisms.
The disease occurs frequently in damp weather in the fall, is quite common in the spring, and is especially prevalent during an open winter. Abrupt changes of the weather, more or less extreme, induce it. It follows the breathing of smoky air or atmosphere charged with gases, especially with sewer gas. It occasionally follows the specific infectious fevers, especially scarlet fever, measles and erysipelas.
Symptomatology:—There are some essential distinctive features in the symptoms of the different forms of this disease. In simple catarrhal tonsillitis the patient complains of soreness in the throat with considerable difficulty in swallowing, before any constitutional symptoms are apparent. Simultaneously with some lassitude and indisposition, there is a slight chill, soon followed by fever, in which the temperature reaches 102.5° F., the secretions are suppressed, there is slight headache, anorexia, and occasionally nausea.
The throat is red, dry and glazed, and one gland usually is slightly swollen. The pain in swallowing increases, extending to the ear on the affected side, and the lymphatic glands swell and are tender on pressure. The early dryness of the throat is soon followed by an outpour of thin mucus, or a thicker muco-pus, which may become sticky, and induce, in efforts at its dislodgement, a slight irritating cough. The inflammation may extend to the pharynx, or nasopharynx, and ultimately involve the middle ear. The disease is sudden in its onset, and will terminate spontaneously in three or four days.
Follicular tonsillitis is most common in youth and early adult life. The onset of this form of the disease and the constitutional involvement are much more severe than in the simple form just described. The attack is preceded for a day or two by malaise and marked indisposition, with a tendency to muscular aching. Usually on the second day of indisposition the aching increases, there is a severe headache, and a sharp chill occurs, quickly followed by high fever. The face is flushed and the capillary circulation of the entire head and face is very full. The general distress becomes extreme in some cases, and as the disease progresses there is an acute debility or exhaustion, out of all proportion to the real seriousness of the disease, resembling that of diphtheria or of the severe infectious fevers. From this, however, the patient rapidly recovers.
The temperature increases until is reaches 104° or 105° F. within the course of three or four hours. Nausea is common at the onset of the fever, and vomiting occasionally occurs. The tongue is dirty and heavily furred and there is a general arrest of the secretions.
The soreness of the throat soon attracts the attention of both the patient and the physician to the cause of the severe constitutional manifestations, but this is not at first severe. The throat symptoms of extreme pain and of difficult swallowing, which later are due both to the muscular stiffness and to the developing tenderness in the glands, develop during the first twenty-four hours following the chill.
Upon examination, both tonsils, usually, in this form of the disease, are greatly swollen, one more than the other. The swelling increases until the throat may be closed, the tonsils meeting at the uvula, and are intensely congested and angry looking. As the disease progresses the mucous membrane between the crypts becomes covered with a muco-purulent exudate, and there are prominent yellowish white spots scattered over the surface of the tonsils, where the crypts give off a cheesy substance, which may be squeezed out of the follicles and wiped off. These exudates soon cause the breath to give off an offensive odor. The extreme swelling of the glands and the muscular stiffness greatly interfere with the opening of the mouth or examining the throat. The cervical lymph glands usually become enlarged and very tender. In some cases small abscesses develop within the follicles, and again, the exudate which fills the lacunae may become calcareous or chalky in character and may be thrown off as small concretions.
This disease runs its course in about ten days, reaching its height at the end of the fourth day.
Frequently it leaves the tonsils in a state of chronic enlargement. Endocarditis, pericarditis, pleuritis and nephritis have developed so soon after tonsillitis as to suggest that disease as the cause of their appearance.
In the form of the disease known as parenchymatous tonsillitis, or quinsy, the inflammation in the throat at times progresses so rapidly that free suppuration occurs on the second or third day. While this may occur without severe constitutional symptoms, the patient making great complaint, often, of the throat, but refusing to go to bed, usually the constitutional symptoms are even more severe than in the follicular variety. Quickly following the chill, which may not be a severe one, the temperature may reach 105° F. within two or three hours, and the pulse 125 or 130 beats per minute. There is extreme restlessness, and delirium is not uncommon.
Dryness in the throat and frequent swallowing, with the early premonitory symptoms, suggest the location of the disease. A patient who has had the disease will foretell an attack before the characteristic evidences appear. The pain appears early and is very severe. It will be located in the throat in the adjacent muscular structure and in the ear on the affected side.
Usually only one tonsil is involved. This becomes enormously swollen and edematous, is usually of a dull or dark red color, is smooth or shining on the surface, and is not covered with an exudate or clotted with follicular patches, as in the other varieties, unless one or both of the other varieties occur at the same time. The uvula may also become involved in the inflammation, and may be so greatly enlarged as to cause much distress. Deglutition is very painful and difficult, sometimes almost impossible, and always avoided. Respiration is impeded and a slight cyanosis may appear. In some cases there is an aggravating, hacking cough.
There is soon a complete loss of appetite, the tongue is heavily coated, the inflamed parts are bathed in a thick, ropy mucus, or muco-purulent secretion, and the breath is exceedingly offensive. The skin and mouth are dry, the bowels obstinately constipated, and the urine is scanty and highly colored, with high specific gravity, sometimes containing a small quantity of albumin. The muscles of the jaws become stiffened, and with the swelling of the submaxillary glands, which frequently occurs, it becomes almost impossible for the mouth to be opened, rendering examinations difficult or impossible.
As the suppurative stage approaches, usually about the third day, all the symptoms become aggravated. The patient becomes anxious and greatly distressed, there is constant moaning, and he is inclined to assume a partial sitting posture, because of the difficulty in breathing upon lying down. Talking is painful and well nigh impossible, and the voice is greatly altered. Spontaneous rupture gives immediate and almost complete relief.
The rupture may occur while the patient is lying down or during sleep, when strangulation may result, as the quantity of foul, bloody pus is sometimes quite considerable. With the discharge of the pus the pain is gone, the soreness and muscular stiffness subsides and the swelling disappears, but the patient is very weak.
In an occasional case the suppuration may involve the adjacent cellular tissues between the tonsils, and the pterygoid muscles, and may gravitate, downward to the clavicle. This is a rare termination, as is also edema of the larynx, which has occurred in a few cases. This inflammation is more liable to terminate by resolution in children than in adults, although prompt specific treatment from the onset should so end nearly all cases.
Diagnosis:—The diagnosis of tonsillitis is first suggested by the enlargement of one or both of the tonsils, with the characteristic appearance of the enlarged gland or glands. The other evidences which have been named are confirmatory, except in follicular tonsillitis, when it is sometimes difficult to exclude diphtheria. The pultaceous yellowish white spots or patches of the follicular form should be readily distinguished from the continuous membranous deposit of diphtheria, which is tough and resistant on a red, sunk base and is ashen-gray in color. The presence of the specific bacillus under the microscope is confirmatory of diphtheria.
Prognosis:—The ultimate recovery of all cases may be assured if no accidents or extreme complications arise. The disease is very amenable to treatment.
Treatment:—The different forms of acute tonsillitis are treated similarly, except when severe or unusual indications suggest special treatment. In my earlier practice I used three remedies with great success in the various forms of this disease. The intense local congestion and capillary engorgement suggested belladonna. The hot, dry membranes and sharp fever, with hard, sharp, quick pulse, pointed to aconite, and the glandular involvement suggested phytolacca. My subsequent experience has proved the positive value of these three remedies, and of the latter remedy more especially where the lymphatic glands are involved or where suppuration threatens early, in quinsy. If belladonna and aconite be given early in prompt, efficient doses, the disease terminates quickly by resolution, with speedy abatement of all symptoms.
At the onset, to facilitate the action of internal medication, the patient should have a thorough, hot mustard foot bath, which should be continued and the water kept pungently hot until the patient perspires freely. A compress wrung out of equal parts of vinegar and water, cold, should be applied to the throat and covered and retained with a few layers of dry flannel, during the active stage. This should be renewed once or twice.
In the severe forms of the disease, when the muscular aching is extreme, twenty drops of specific macrotys may be added to a four-ounce mixture which contains, for an adult, from ten to fifteen drops of the tincture of aconite, with twenty drops of the tincture of belladonna. When the exudate is pronounced in the follicular form, I at once administer a mixture composed of sulphurous acid one and one-half drams, sulphur one dram, in two ounces of syrup of acacia, in dram doses, every two hours. This speedily removes all exudates and destroys the fetor. In mild cases no gargles are needed. Usually it is desirable to keep the throat and mouth clean with a saturated solution of boric acid.
When there is nervous irritation, or when the muscles of the neck are very stiff and sore, I give gelsemium in full doses, from one to three minims, every two hours. It can be combined with macrotys, in one drop doses, with excellent advantage. Many of our physicians believe that veratrum has a specific influence in abating the local inflammation. I have not needed it except with which to paint the tonsils, in those cases where they were greatly swollen, dark, smooth and shiny. It is very useful in such cases.
In the parenchymatous or suppurative form of the disease, the treatment should be begun promptly with the tincture of aconite ten drops, tincture of belladonna twenty drops, specific echinacea three drams, in four ounces of water, a teaspoonful every hour for the first day. The throat should be gargled with a decoction of white oak bark, one ounce to the pint of water, to which is added a dram of boric acid and six drams of echcinacea. This course will usually prevent suppuration and cause the disease to run a mild course. If measures for the prevention of suppuration are unavailing, fluctuation should be discovered early, the abscess opened and the throat thoroughly washed and kept clean with an active antiseptic gargle.
There is no doubt that guaiac will exercise a favorable influence upon this disease, but I have not needed it, and have seldom used it, because of its ready precipitation and bad taste. Its use is objectionable to most patients, and I have found the other measures superior.
I make it a point to build my patients up as rapidly as possible after a severe attack of this disease with stimulating tonics. I have excellent results from hydrastin, nux vomica and quinin bisulphate. If it seems necessary to use measures to prevent chronic enlargement, I put the patient on the tincture of iron, or on this remedy alternated with phytolacca, and continue these remedies for a number of weeks.