Synonyms:—Chronic hypertrophic tonsillitis; hypertrophy of the tonsils.
Definition:—A chronic enlargement of the tonsils, affecting either one or both of these glands, and involving usually the pharyngeal tonsil as well.
It is a condition of hyperplasia, or actual overgrowth of both the fibrous and the lymphoid structures of the gland, and is most common in children.
Etiology:—This disease is common in children from five to twelve years of age, occurring more frequently in boys than in girls, and less often in boys with dark eyes and hair than in blondes—the light-haired and blue-eyed boys, especially those of somewhat relaxed muscles, less hardened and compact, or those who inherit a tendency to scrofulous, syphilitic or other diatheses, and whose environment has been unhygienic or who have been somewhat neglected. I have seen, however, some most stubborn cases among boys who were most carefully reared, really pampered, often the only boy, who received too much attention and was too fully protected from hardening and toughening influences.
The disease is usually the result of a previous attack or of repeated attacks of tonsillitis in the acute form. It also occurs as the result of diphtheria, scarlet fever, measles and la grippe, and in those who have a tendency to rheumatism. It is complicated frequently with chronic disease of the pharynx or nasal passages, and may be either the result or the cause of chronic nasal catarrh, or catarrh of the middle ear. Adenoids may serve as a cause, and when the cause has been long present, these patients, largely from the habit of mouth breathing, are apt to have a vacant expression to the countenance, an expression of stupidity or lack of intelligence.
Symptomatology:—While the disease has just been described as resulting from other previous disorders, it may come on insidiously with but few symptoms which will attract attention, until the physician is consulted for labored breathing through the widely opened mouth when the child is asleep, noisy snoring, irregular and greatly disturbed breathing, causing restlessness and sudden awakening, choking, screaming or crying out without cause for alarm. The sleep is broken and disturbed, and there is nightmare or night terrors. This group of symptoms may be present in all cases, whatever the cause.
The condition persisting, changes gradually take place in the appearance of the patient and in his growth and physical and mental development out of all proportion to any danger to life. In extreme and greatly prolonged cases the child is dull, listless and apathetic, takes but little interest in study or play, becomes morose or irritable, and quarrelsome, and presents a foolish or silly expression. The eyes are heavy, the mouth always open, and the nose "pugged" or stunted. The body is apt to be somewhat dwarfed and the chest imperfectly developed, the breast is barrel or funnel shaped, or the child is pigeon breasted, the breast being narrow and the sternum prominent at the top, or depressed below.
At first only one tonsil may be involved, but ultimately both are enlarged, dusky and sometimes hard and tough to the knife. They are sometimes dry from the mouth breathing, but often covered with thick, tenacious mucus, which is expectorated with constant effort in the older patients. The uvula is displaced, relaxed and irritating, and a constant, hacking cough, or even an asthmatic cough, may be present. The tonsillar crypts are filled with yellowish white, cheesy deposits, which give off a fetid and often disgusting odor, causing the breath of these patients, especially of the adults, to be notoriously bad.
Ultimately the roof of the mouth becomes arched, the upper teeth project, and there is in an occasional case a distinct angle in the center of the prominent superior maxillary bone. From occlusion of the eustachian tubes, or from catarrhal thickening of the mucous lining of these tubes, disease of the middle ear and tinnitus aurium and chronic deafness may result, as well as impairment of the taste and smell.
Patients in whom the disease is intractable or becomes aggravated and prolonged, may develop chronic headaches, or may become anemic, may suffer from defective vision, or palpitation, enuresis or obstinate constipation. The development both of the body and mind is slow, imperfect or perverted, and there is a peculiar susceptibility to attacks of the common infectious or contagious diseases of childhood, which are apt to be more severe with these patients.
Diagnosis:—The diagnosis is readily made by the appearance of the enlarged tonsils, which are not readily influenced by any course of treatment. The absence of acute pain will distinguish the disease from malignancy.
Prognosis:—The disease is not fatal, but it is not readily amenable to medical treatment, and its persistence can be anticipated. When the changes are distinctly fibrous in character, a cure is much more difficult than when they are lymphoid.
Treatment:—The benefit to be derived from medicinal treatment in this disease is principally prophylactic. It is possible to anticipate the occurrence of chronic hypertrophy when there have been repeated attacks of acute tonsillar inflammation. The physician should undertake to reduce an enlarged tonsil immediately following an acute attack, by the application of mild astringents, and by specifics internally. I have succeeded admirably with the persistent use of phytolacca in from two to five drop doses, four times daily, accompanied with a gargle of the tincture of iron. Occasionally it is a good plan to apply a diluted solution of ferric chlorid in glycerin. Occasionally the external use of the tincture of iodin is of some benefit. Other stimulating astringent solutions will be found serviceable in the early stage of the disease, when there is great relaxation of tissue. The tincture of capsicum or the tincture of myrrh, in a mixture of equal parts of the distilled extract of witch-hazel, and a decoction of white oak bark, will be useful in this condition, if persisted in. Occasionally the application of thuja, full strength, or a few drops of a mixture of equal parts of thuja and glycerin, injected into the structure of the tonsil every second or third day, will be of much benefit.
When the condition has become established, and especially when the structural change is of fibroid character and the enlargement is hard and unresisting, medical treatment is of but little if any benefit. Amputation of the tonsils in these cases is demanded. This course is sometimes of immediate benefit in every way, resulting in a complete metamorphosis of the patient, both in regard to the condition of his general health and in his mental condition. Immediate improvement of a long train of symptoms follows, and in children of imperfect development rapid and healthful growth supervenes.
In the more intractable incipient cases, and in those where the changes are lymphoid in character, the application of the galvanic current will be found of much value, and occasionally in the severer cases the use of the galvano-cautery will result in a permanent cure.
In an occasional case the tissue of the gland will become renewed after removal, and secondary chronic enlargement must be anticipated. While most of the symptoms will show relief from the removal of the glands, constitutional treatment is often of the utmost importance to promote a speedy restoration to health. The use of iron tonics and general restoratives is important. Other tonics should be selected with reference to the necessity of the exercise of a direct influence upon the stomach, nervous system, or in the restoration of the blood, or upon the functional action of the large glandular organs. Change of scene, careful bathing, regular habits and the use of nutritious, easily appropriated food will materially conduce to the desired results.