The Tonsils in Health and Disease. 
BY 
HARRISON ALLEN, M.D., 
OF PHILADELPHIA. 
FROM 
THE AMERICAN JOURNAL OF THE MEDICAL SCIENCES, 
January, 1892. Extracted from 
The American Journal of the Medical Sciences for January, 1892. 
THE TONSILS IN HEALTH AND DISEASE.1 
By Harrison Allen, M.D., 
OF PHILADELPHIA. 
The object of this paper is to harmonize the descriptions of the normal 
tonsil with the accounts of its morbid conditions. It is an axiom in 
medicine that the best basis on which the clinical study of any organ 
can rest is an exact knowledge of its structure. I will endeavor to show 
that our conceptions of the tonsil are not in conformity with this axiom. 
Some of the descriptions of'the tonsil have been drawn up from hyper- 
trophied glands, some from atrophied glands, while the terms used by 
anatomical and clinical writers are often at variance with one another, 
or may even conflict. I cannot recall any other structure in the economy 
of which this can be said. This confusion does not arise from lack of 
knowledge; for numbers of admirable papers have been written on the 
tonsil, and its plan is understood. But the description of the mass has 
become conventional, and clinicians have not seen fit to depart from 
antiquated and often quite inaccurate methods of expression. 
The tonsil is an association of diverticula developed from the epithelial 
layer of the mucous membrane (Ketterer, Comptes Rendus, 1885, vol. 1. 
p. 1284), in the walls of which are grouped muciparous glands and lymph- 
follicles. Resulting from this association the tonsil is marked by the 
mouths of the diverticula, which open in a uniform manner upon the 
surface of the mass. The various tonsil-groups differ from one another 
only in the arrangement of the diverticula. Thus in the lingual tonsils 
they are single, in the masses occupying the tonsillar space and the roof 
of thq pharynx they are compound. 
Such a tonsil as the one last named is exhibited in Fig. 1, from F. Th. 
Schmidt (Zeitschr.fur wissensch. Zool., 1863, xiii. p. 221, Tf. XV.). It will 
be observed that the small, linearly arranged openings are the mouths 
of the simple diverticula. Moreover, a disposition exists in every com- 
pound tonsil for a number of diverticula-from eight to eleven in 
number-to recede from the general surface of the group of which they 
are a part, and for the chamber in this way formed to be slightly nar- 
rowed at the mouth. Such a recess is called & pocket or crypt? 
1 Read before the American Laryngological Association at the Washington Congress, 
September 27, 1891. 
2 The terms (gland), follicle (vesicle), and crypt (pouch or pocket), have 
definite meanings. It is unfortunate that the term follicle in clinical studies is gener- 
ally applied to the diverticulum, while anatomists speak of the follicles as " closed nests 2 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
H. Asverus (Nov. Act. Leop. Carol., 1861, Bd. xxxix.) exhibits in a 
diagrammatic manner this disposition. 
Huschke (Sommering's Baue des menschl. Kdrp., ed. 1844, p. 32) de- 
scribes a pocket in the bottom of which smaller openings (Fig. 2) are 
found, and adds that this is a repetition of the type seen in apes and 
other mammals. 
Fig. 1. 
-b 
a 
Simple form of tonsil, a, tonsil showing the mouths of diverticula; b, the uvula. 
(After F. Th. Schmidt.) 
A 
Fig. 2. 
B 
A 
Schema of tonsil, a, a, groups of diverticula on either side of b, a crypt. 
(After Asverus.) 
This being the accepted plan of the tonsil, let us glance at some of the 
descriptions given by accepted authorities. 
Luschka (Der Schlundkopf des Menschen, 1868, p. 64) states that the 
body, as a rule, is coarsely foliated, and it is so figured. (Table IX., Figs. 
2 and 3.) Exceptionally only is a single large opening present, leading 
to a proportionally wide pocket. The general form of the body is oval 
and provided with numerous openings of irregularly disposed canals. 
Henle (Handbuch der Eingeweid elehr e des Menschen, 1866, p. 144) 
lays special stress upon the presence of longitudinal folia, although stating 
that at times a pocket-like form may prevail. 
L. Heisler (" Tonsillarum nova et accuratior descriptio," in Ephemer. C, 
Leop. Carol., Cent. HI., IV., 1715, p. 456, Table XI.) complains that 
of lymph-cells" (Asverus). In the minds of some writers the muciparous glands are also 
the tonsil follicles, while the term vesicle is used for the true follicle. The lacuna is 
the same as the crypt, but this term is used in so many ways in anatomy that it were 
better here discarded. ALLEN, TONSILS IN HEALTH AND DISEASE. 
3 
anatomists have given no exact description of the tonsil. He enters 
upon what he understands to be such description, and begins by stating 
that the tonsil is covered with a membrane which is in common with the 
lining membrane of the mouth. When this is pushed aside the tonsil is 
disclosed, the upper part reaching as high as the velum and the lower 
part extending in varying degrees from the root of the tongue to the 
pharynx. In the excellent figure accompanying this description one 
finds on the left side of the throat the parts remaining undisturbed, 
while on the other the anterior part is dissected and discloses the 
tonsil in its receded position. Heisler further states that, as a rule, 
the tonsil contains a large cavity upon the walls of which many smaller 
orifices open. It is evident that in this account one of the varieties 
which I will speak of further on is correctly outlined. The single mis- 
take made by the writer is in insisting that this form is a constant one, 
instead of being one of the numerous variations which the tonsil may 
exhibit. 
Fig. 3. 
A tonsil section showing diverticula and a single crypt. Only the lower part of the 
figure exhibits the lymph-follicles. (After F. Th. Schmidt.) 
The account of Haller {Element. Physiol., 1736, vi. 65) is not ex- 
plicit. He indicates, however, an involucrum, and implies that this is 
a layer of mucous membrane which holds the gland in position. The 
gland in the lower animals is said to be of the same type as in man. 
Harrison {Dublin Dissector, Ara. ed., 1855, p. 61) describes the 
figure of the tonsil as irregular and somewhat oval. He states that 
"small holes are marked upon its surface, which lead to interlobular 
cells." 
Cruveilhier {Anatomy of the Human Body, 1844, American reprint, 
p. 334) states that the form pretty nearly resembles that of an almond. 4 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
No allusion is made to the existence of cavities, but a " compound 
tonsil" is said "to result from the component follicles being collected 
into several distinct masses." 
John and Charles Bell (Anatomy and Physiology of the Human Body, 
1834, American reprint, p. 350) make no reference to the interior of the 
tonsil other than to state that on the surface of the organ " a number of 
cells open like the mouths of veins; behind the lobes a gland is felt as 
if it were one solid body." 
A. Macalister (Text-book of Human Anatomy, 1889, p. 596) describes 
the surface as " depressed into one or more longitudinal slits, or else 
pitted into a series of rounded holes." 
It is noticeable in the above citations1 that the presence of ridges, de- 
pressions, and canals are implied, but without these parts being conformed 
to a plan, while Heisler, Huschke, Luschka, Henle, and Macalister de- 
scribe pocket-shaped and foliate forms. That the first of these shapes is 
of morphological significance is evident from the fact that in the lower 
animals it is always present. The account of Bell is apparently derived 
from an atrophic mass. The foliations are coarse rows of lymphoid 
masses which define the walls of closely disposed diverticula. They are 
best seen when the gland is divided vertically. Are these varieties of 
tonsils met with in clinical studies? I find that they are. But the 
morphology of the gland is disguised to a remarkable extent by the 
products of diseased action, and it is not always easy to see in the tonsil 
the details of the general plan. I am sure unprejudiced observers will 
agree with Luschka that any comparison of the tonsil with an almond- 
shaped body is misleading, and that the cryptose or pocket-form, with 
or without associated ridges of lymphoid tissue, is common, while the 
foliate form is rare. 
The variation which I have most frequently seen is a rounded or ellip- 
tical mass-of which the largest is also its vertical diameter-placed in 
the tonsillar space a little above the level of the tongue. The organ is 
slightly compressed from before backward and consists for the most part 
of a pocket or crypt - whose walls are greatly thickened - directed 
downward. The palato-glossal muscle is to be accused of maintaining 
the compression here named, in some individuals, to a degree sufficient 
to serve as a complication in tonsillitis.2 In some persons the tonsil 
appears to be lodged almost entirely toward the palato-pharyngeal fold 
and displayed when the mouth is open. It may be composed of two 
1 The account of Kolliker (Mikroscop. Anat., 1852, ii. 42) is not included in the above 
citations. His schema, which has been so often copied, exhibits the closed follicle, but 
defines no distinction between diverticulum and crypt. The dilated space in the single 
depression is called simply a "cavity" (Hbhlung des Balges). 
2 See in this connection Houze de la Aulnoit, " Mem. sur 1'estranglement des Amyg- 
dales par les Piliers du Voile du Palais," 1864. ALLEN, TONSILS IN HEALTH AND DISEASE 
5 
lobate, cryptose masses arranged like two peas in a pod, but without 
any one of the crypts being larger than its neighbors or having special 
direction. » 
Fig. 4. 
A 
-C 
D 
B 
E 
View of the foliated type of tonsil, a, the small velar tonsil; b, the opening of the 
crypt, the parts below this remaining smooth; c, o, two coarsely nodulated ridges, con- 
stituting the folia; e, epiglottis. (After nature.) 
The anterior wall of the pocket is covered with mucous membrane 
(involucrum), which in every way is similar to that lining the pharynx, 
along the side of which it sometimes extends as far as the tip of the 
epiglottis. If close inspection be not made, this covering might be con- 
founded with the palato glossal fold. In such a disposition two surfaces 
of tonsil tissue must lie exposed toward each other. Above the mouth 
of the pocket lies a mass which constitutes the " tonsil " of common lan- 
guage. This alone is cryptose. 
Fig. 5. 
A 
B 
Simple form of the tonsil, showing the crypt and the almond-shaped mass above the 
opening, a, retractor pressing out the palato-glossal fold; b, probe in opening of the 
crypt. (After nature.) 
Very commonly the tonsil above the pocket also exhibits numerous 
communicating passages. I desire to call special attention to these. 
They can be demonstrated in the tonsils of children, where they are often 
long and lie deep in the gland ; as well as in the adult, where they are 6 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
more superficial. They may be small yet well-defined, as in a sponge 
or imperfectly limited by bridge-like bands, which cross the mouths of 
wide, shallow crypts. Allusion to these inter-communicating tracts are 
made by writers; vide Haller, Luschka, Bell, and Asverus, the last- 
named alone recognizing them as morbid. It is evident that they do 
not exist in the morphological plan of the gland, and, so far as I know, 
occur in the tonsil of none of the lower animals. 
It will be recognized that in hypertrophy of the tonsil the lower 
smooth part is enormously enlarged, and can be readily distinguished 
by a sulcus from the cryptose mass. 
Fig. 6. 
A 
B 
a, small velar tonsil; b, the main tonsil, showing the mouths of two diverticula and 
a crypt: the last-named being the largest opening on the tonsil. The parts below the 
mouth of the crypt are smooth and without diverticula. (From nature.) 
The almond-shaped structure, therefore, which is so commonly de- 
scribed, is but a portion of the tonsil, and even this portion is continuous 
with the lining of the main pocket or crypt. 
At a point still higher up, and tending to be placed slightly back 
toward the palato-pharyngeal fold, lies a second, smaller, somewhat 
nodular body, which is quite distinct from the foregoing, since an interval 
exists between. This may receive the name of velar tonsil. 
The velar tonsil is not to be confounded with the parts described by 
James Yearsley ( Treatise on the Enlarged Tonsil and Elongated Uvula, 
and other Morbid Conditions of the Throat, London, 1843, p. 58). " In the 
most frequent kind of enlarged tonsils, where the glands maintain their 
original position, or at least extend in every direction, the Eustachian 
tubes are generally compressed. There is another variety of enlarge- 
ment which I am not aware has ever before been noticed; it is where 
the diseased growth is confined to the upper margin of the tonsil, and 
which, from being hidden behind the veil of the palate and the anterior 
palatine arch, is quite out of sight when the throat is merely examined by 
the eye. In numerous cases I have verified this interesting observation, 
and effected cures by the indications of treatment which the knowledge 
of if afforded. We never can be certain that the tonsils have no share ALLEN, TONSILS IN HEALTH AND DISEASE. 
7 
in producing deafness until these bodies have been examined carefully 
with the finger. In some instances, where nothing morbid was visible in 
the throat, the upper part of the tonsil has been of such magnitude as 
to produce, in addition to deafness, nasal speech, from encroaching on 
the posterior nares. These novel views have afforded me the most grati- 
fying results, and I feel assured they will exert considerable influence 
on the future treatment of deafness." It is evident from the above 
extract that the growth named by Yearsley as being " confined to the 
upper margin of the tonsil " was really within the naso-pharynx, and in 
all probability was the mass now spoken of as " adenoid growth," or the 
" pharyngeal vegetations." It is interesting to know that Yearsley as 
early as 1843 described this growth ; he was unfortunate, however, in 
the terms of his description, since it would appear at first sight that he 
alluded to the lower tonsil. The statement that the treatment of such a 
mass will exert considerable influence on the treatment of deafness has 
been abundantly substantiated. 
The tonsil is in whole or in part ordinarily exposed when the mouth 
is open. But in some individuals it lies concealed between the palato- 
pharyngeal and the palato glossal folds; in such a situation it cannot be 
inspected unless the palato-glossal fold is drawn outward by a retractor 
(Heisler, loo. cit.'). A tonsil thus concealed is almost never seen in 
children or young adults. I attribute this lack of harmony between 
such a form and that of full maturity to the fact that the tonsil is best 
developed when the formative forces of the economy are unexpended. 
Until about the twenty-fifth year these exhibit their greatest activities. 
In adult life the tonsil is apt to atrophy and become exceedingly aber- 
rant in shape. When atrophic, while all semblance of the plan is lost, 
clinical study is best conducted by recalling it. In many instances it 
must be acknowledged that the gland forms irregular, hard nodular 
masses, which are apparently without diverticula. The causes producing 
this change are obscure. They can be assigned, in part, to certain 
inherent dispositions to degeneration, and in part to the results of in- 
flammation. Few individuals escape frequent attacks of tonsillitis, 
ranging in severity from the mild form of miscalled follicular inflamma- 
tion to the severe parenchymatous invasions. Again, the tonsil which 
projects from the tonsillar spaces will be disposed to rind-like thicken- 
ings from impact with food, etc. As a result most adults exhibit the 
gland more or less indurated, the free surface being especially firm in 
consistence, and occupied by minute white cicatricial bands which tend 
to occlude the crypts. Beneath this cortex-like layer the parenchyma 
may have a softer texture. According to Gustav Harff ( Ueber die anat. 
u. path. Struktur des Tonsillengewebe, Bonn, 1875), the closed lymph- 
follicles have a disposition in the adult to be less well defined than in 
the young, and the connective tissue of the entire organ to be increased 8 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
in volume. These conditions certainly tend to indurations, and indi- 
rectly to atrophy. In some states of health in such a tonsil, probably 
owing to long-continued pharyngeal irritation, the folds, especially the 
palato-pharyngeal, become greatly exaggerated in volume, and in an indi- 
vidual having a large tongue, the motion of this organ backward and 
downward aids the fold in exerting a certain amount of tension on the 
gland. However the situation may be explained, the result in the 
shape of the gland being moulded by resisting forces is evident; thus, 
it may appear to be greatly compressed from before backward, and so 
project into the pharynx as to exert pressure against the posterior wall 
and excite irritation. In most instances the mass has a disposition to 
retroversion. A tonsil of apparently medium size may, in the act of 
gagging, assume larger proportions, a circumstance due to the fact that 
an actual turning of the gland from before backward and from with- 
out inward takes place. 
The small velar mass is probably the same as the supernumerary 
tonsil, upon which the late Dr. E. Carroll Morgan (Trans. Amer. Laryng. 
Assoc., 1889, p. 4) has written. It varies greatly in size, and, as a rule, is 
smaller than the main tonsil. In some instances it becomes pediculated, 
and may even suddenly slip away from its usual position and hang into 
the throat so as to interfere with speech and deglutition. Such a mass 
was removed by me in a patient who reported in a speechless condition, 
and showed the pharynx in part occupied by a pediculated mass the size 
of a walnut. A somewhat similar case is given by Jurasz (Monatsschr. f. 
Ohrenheilk., 1885, p. 361). Heisler (inst Chir., 1747) describes methods 
of removal of what he terms an indurated tonsil, when the mass hangs 
by a slender stalk, and it is probably true that this writer clearly recog- 
nized the above clinical condition. 
I believe many morbid processes may be restricted to the upper tonsil, 
the main mass not of necessity participating. 
Figs. 4 and 6 exhibit the proportions usually noted as existing 
between the velar and the main tonsil. 
But what of the foliate type of tonsil which has been noted in the early 
part of this paper? I may briefly say that while it is occasionally met 
with in practice, it is so rare that it scarcely enters into clinical study. 
I subjoin a sketch of this form of tonsil taken from a subject eleven 
years of age. It will be seen that the upper and main masses are present 
as in the simplest forms, but that the foliate formations appear at the 
side lying between the main tonsil and the palato-glossal fold. The 
folia are not true laminae, but are rather of the nature of bridge-like 
(annectant) masses of tonsil tissue imperfectly limiting large crypt-like 
openings into the main tonsil and extending from the level of this mass 
to some of the lymphoid tissue at the side, and most likely are measurably 
the results of diseased action (see p. 4). ALLEN, TONSILS IN HEALTH AND DISEASE. 
9 
I will now glance at some additional clinical conditions of the tonsil. 
In the first place it must be remembered that the influence which the 
tonsil exerts in the economy is not known. The knowledge, therefore, 
of a disturbance of functions being sought for as a clue to the nature of 
diseased action is in this instance futile. The mucoid secretion of the 
tonsillar surface aids in lubricating the food and prepares it for swallow- 
ing, but no reason other than the fact that adenoid tissue is everywhere 
developed in childhood can be given to explain why the tonsil should be 
larger at one time of life than another. As already mentioned, the 
organ is larger in childhood and early maturity than in adult life. It 
appears to be compensatory with the thymus body. In proportion as 
the thymus body disappears the tonsil increases in size. At the time 
when the narrow chambers of the long bones are assuming actively the 
function of manufacturing blood corpuscles, the tonsil is also large, and 
it is probable that both structures are allied in function. R. Kingston 
Fox (Journ. Anat. and Phys., 1886, xx. 559) attributes the large size of 
the faucial tonsil to the law of marginal overgrowths. " New growths," 
says he, " are apt to arise at such junctions (viz., of the hypoblast and 
the epiblast). Now, it is curious that the fauces (if it be such junction) 
should be the spot selected by so many diseases for the production of 
inflammatory lesions." 
Fig. 7. 
Hypertrophied tonsils showing constriction between the cryptose and the smooth non- 
eryptose portion. The last named is alone covered with veins. The velar tonsil is not 
seen. (After nature.) 
The structure of the tonsil does not prevent analogies being drawn 
between them and the true lymphatic glands. From the typical lymph- 
atic glands some writers distinguish the lymph bodies appended to the 
alimentary canal under the name of peripheral lymph-glands. They 
are apparently independent of those clinical indications which exist 
between lymphatic glands and the region in their immediate neighbor- 
hood. I have noticed that the tonsils are very generally small in pul- 
monary phthisis. It is probable that a connection exists between the 10 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
size of the tonsil, the rate of dental development, and the small size of 
the jaws. The tonsil is largest at the time when the greater number of 
permanent teeth are in the jaws ready to be erupted. It is an interesting 
fact that they are larger in the human subject than in the lower animals. 
Ph. Stohr {Virchow's Archiv, 1884, xcvii. H. 2, p. 211) demonstrates that 
the follicles while closed permit their contained leucocytes to wander 
freely through the epithelium into the diverticula. He finds this migra- 
tion to be constant in all ages and in all quadrupeds. Its significance 
as a factor in the peculiarities of the tonsil is therefore not apparent. 
Unlike Peyer's patches and the solitary glands in the small intestine 
(bodies which measurably recall the nature of the tonsil), no inclination 
to specific diseased action is here exhibited. It is true that the diph- 
theritic membrane frequently appears upon the tonsil, but this is appa- 
rently due to the ease with which the microbe of this disease is mechani- 
cally held within the recesses of the organ. Nevertheless a property is 
possessed by the tonsil which I believe is constant in adult life (I 
have never noted it in young children or in the aged), namely, the 
formation and ejection of solid pellets. They appear to be of the nature 
of epithelial desquamations and as such are of importance in the clini- 
cal study of the gland. When the pellets escape into the mouth, as is 
normally the case, the tonsil may be said to be normal, but when they 
escape into the interspaces of the gland and are caught between the 
tonsil and the adjacent folds, or are imbedded in the gland itself, they 
are fertile sources of mischief. How is the removal of these masses 
best secured? I have answered this question in my own practice by 
assuming that all operative procedures upon an organ should be in har- 
mony with the plan on which it is framed. Hence in the exploration 
of the tonsil for retained pellets I first attempt to define the main 
pocket or crypt. If I fail to detect this, I assume that its orifice has 
been obliterated by inflammation and that it should be opened. Even 
if it is found open and a number of the pellets be detected and removed, 
it is well to divide the pocket its entire length and sear the divided 
surfaces. Should the pellets, however, lie in the spaces between the 
tonsil and its adjacent folds, or in the spaces between the lobules, if 
these be present, they can be best removed by carefully exposing the 
entire tonsillar space. When this is thoroughly done the pellets will 
often fall out of themselves or can be washed away. In order to carry 
out the detail in the process last mentioned the following method of 
examination is recommended: A tongue-depressor is placed upon the 
tongue and given to the patient to hold. The mouth is opened to its 
widest extent, and an aneurism-needle (the adjustable end of which has 
been firmly soldered on to the shank or handle) is inserted behind the 
palato-glossal fold, and gentle traction made forward and slightly out- 
ward. To a patient who is untrained, it is quite likely that gagging will ALLEN, TONSILS IN HEALTH AND DISEASE. 
11 
«nsue upon this manipulation. With the exercise of a little care, however, 
the irritability may be so far overcome as to enable the tonsil to be 
freely seen. Very often no trace of a tonsil is discerned until such a 
manipulation is resorted to. It is an interesting fact that the act of gag- 
ging itself rather assists than otherwise in the examination, since a dis- 
position exists for the tonsil to be turned slightly upon itself. If the 
patient remains composed and does not move the shoulders backward, 
both he and the physician can remain indifferent to the gagging as long 
as it does not excite vomiting. 
Hypertrophy of the Tonsil.-As has been stated, the tonsil is 
largest in childhood, yet a point arises as to whether this is simply a 
physiological state of the organ or an overgrowth. In this connection 
I may be permitted to make the following statement: No matter how 
large the tonsil may become, it need not constitute a clinical state unless 
respiration is impeded. If the child has nasal respiration, a natural form 
of chest and roof of mouth, and if the teeth are regular, the tonsils are in 
a physiological condition ; but if there is snoring respiration, irregular 
teeth, the habit of mouth-breathing established, a high, narrow palatal 
arch being present, and the child be pigeon-breasted, then the enlarged 
tonsil may be said to constitute a clinical condition. A. Macalister (7oc. 
tit., p. 596) asserts that the normal tonsil should not project beyond the 
glosso-palatine fold. According to this statement the tonsil is almost 
always abnormal in childhood. 
An error is often made in maintaining that difficulties in respiration 
are due to enlarged tonsils, when the cause lies in disease of the naso- 
pharynx. I have seen cases where the tonsils have been needlessly 
removed to correct the habit of mouth-breathing, when in each instance 
the naso-pharynx was stuffed with a neglected adenoid growth. Hyper- 
trophy of the tonsil being diagnosticated and attempts at reduction being 
demanded, the question arises as to what method is the best to accom- 
plish this. In my judgment tonsils should never be removed as a 
whole; this operation leaves a large, open, and often irritable surface. 
As is well known, after amputation of the tonsil, the patient in going 
out into the open air, or travelling in heated steam-cars, may have 
attacks of bronchitis, or even of pneumonia. It may be said that these 
are very infrequent cases, and that many physicians having extended 
experience have not encountered such accidents; but that such are 
likely to occur cannot be denied. 
From what has been seen in the above sketch, a transverse incision of 
the gland is not in the line of any of its directions of growth. Why 
should these several parts be treated as though they were masses of fun- 
goid tissue? 
I believe that abscission should be restricted to the removal of hardened 
cortex ; and that, in preference to the treatment by amputation of the 12 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
whole mass, after the removal of such cortex, should the crypt be closed, 
remembering that the tonsil is often perforated by canals which are not 
represented in the plan of the organ, I would carefully search for these, 
and when found pass a probe or director through them after the manner 
of exploring a region which is traversed by fistules or sinuses, the over- 
lying tissues being freely divided. Following this rule, I would incise the 
tonsil in any direction and to any required depth. After this is done 
the separate coarse lobules can be severally taken up by a tenaculum or 
forceps and removed, care being taken to avoid touching the opercular 
or involucral folds. Occasionally a patient presents an enormously en- 
larged involucral mass enclosing a degenerate tonsil. The latter should 
be ablated or otherwise destroyed, but the former left absolutely un- 
touched. As a rule, the lower portion of the gland should not be thus 
cut, since it does not contain the canals, and incisions into the membra- 
nous covering (involucrum) are not well borne. The submucous con- 
nective tissue is here loose, and diffuse traumatic inflammation is readily 
excited. Outlying tags of tissue may be removed with the knife or scis- 
sors when necessary. I have in many instances found the gland recede 
to normal proportions and reflex phenomena due to the hypertrophy 
disappear. 
One of the most notable features in the clinical study of the tonsil is 
he ease with which ex posed surfaces lose their epithelial covering, and 
the raw, or rather denuded, patches which arise therefrom cause the 
tonsil to be glued to one or both the adjacent folds. The velar tonsil 
moves easily with the palato-pharyngeal fold. If the gland-masses are 
united, the normal play of the folds is interfered with and irritation is 
the result. Under these conditions the bodies must be separated. If this 
be done only by the knife the surfaces at once reunite and the irritation 
persists. It is necessary to effect a permanent separation by searing the 
edges of the incision by the electro-cautery. The slow process of throw- 
ing off of the eschar prevents the recurrence of the false union. The 
same method of procedure is to be recommended in either of the anterior 
or posterior unions. If the pocket-like recess in the tonsil be the sub- 
ject of chronic inflammation it should, in all instances, be opened its 
entire length and allowed to heal after the application of the galvano- 
cautery, precisely as in the removal of secretion pellets. The employ- 
ment of the galvano-cautery, without the knife, is often made compulsory 
when the irritability of the parts or the intractableness of the patient is 
very great. When this agent is employed the electrodes should be of 
small size, and inserted in the pockets or canals, small portions only 
being destroyed at a time. 
The palato-glossal fold is really well defined only from the tonsil to 
the velum. Along the sides of the tonsil it is apt to be united to the 
main gland, except at the upper part, when a large irregular interspace ALLEN, TONSILS IN HEALTH AND DISEASE. 
13 
can be demonstrated. This interspace serves to lodge tonsil pellets and 
foreign bodies. The fold will be seen in many examples spreading over 
the front of the main tonsil and partially concealing it. I. have ventured 
to name this the opercular fold. A number of veins are often seen lying 
upon it. I am inclined to the opinion that, in operating on the tonsil 
most of the troubles due to hemorrhage are caused by interference with 
this fold; for within it often lies a branch of the facial artery. Under 
all circumstances the fold is sensitive, and the slightest wound is followed 
by pain and irritation. 
Cyst of the Tonsil.-Rokitanski, in his Pathological Anatomy, and 
Virchow, in his work on Tamora, describe tonsillar cyst as being detected 
in the dead subject. A number of years ago I observed one of these cysts 
in dissection. The specimen was exhibited before the Pathological So- 
ciety of Philadelphia {Trans. Path. Soc. Philada., 1871, iv. 68). The 
committee to whom was referred the specimen made the following report: 
" The tonsil showed the marks of chronic inflammation, the interfollicular 
connective tissue being slightly increased and indurated. The follicles 
of both tonsils, instead- of presenting the usual round or oval shape, 
were distended into large, irregular, star-shaped crypts. In these crypts, 
where the contents had not been previously evacuated, were found 
retained masses of disintegrated epithelium, fat-granules, and crystals of 
cholesterin. The occlusion of the orifice of the glands and the reten- 
tion of their secretion had given rise to the formation of cysts." 
A short time ago I had an opportunity of recognizing'a tonsillar cyst 
in the living subject. The case did not present any unusual appear- 
ances, but excessive pharyngeal irritation of long standing was com- 
plained of, and the left tonsil being larger than the other I determined 
to excise the cortex and explore the interior, since I was of the opinion 
that a number of the diverticula had been closed by inflammation. 
Greatly to my surprise, following the excision a large quantity of glairy 
fluid escaped, as though the tonsil had been converted into a cyst. Ex- 
ploration revealed the presence of a rounded chamber the size of a small 
chestnut. The irritation immediately disappeared. 
Acute Abscess.-Opening an acute abscess of the tonsil, whether it 
be directly in the substance of the gland or in the tissue about it, is 
occasionally a procedure requiring judgment and patience. As a rule 
no difficulty is experienced, but in exceptional cases the attempts are 
annoying to the physician, painful and depressing to the patient, and 
not free from danger. Fortunately, the usual incision with a straight 
knife thrust into the centre of the mass and drawn toward the median 
line of the throat is generally successful. But pus is never to be sought 
for in a single locality. The incisions are frequently made too high and 
the palatal structures needlessly wounded. If the abscess occurs in the 
velar portion of the tonsil it cannot be reached at all by any prudently 14 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
devised incision. The pus, when in the main gland, may not point 
toward the surface, which is visible, but backward. I have seen cases 
where three deep incisions had been made without success, when a fourth 
showed that the pus lay in the posterior part of the gland as above 
indicated. In another instance the pus lay well down on the side of the 
pharynx below the curve of the tongue and was reached only by an 
incision with a laryngeal knife. All these 'peculiarities are easily ex- 
plained when the anatomical variations in the form of the tonsil are 
borne in mind. The abscess is sometimes lodged well to the outer and 
upper side of the main tonsil, above the position in which the pocket is 
usually found. If an opening to a crypt is demonstrated, a curved 
probe or director should be passed along it. Not infrequently the col- 
lection of pus can be thus emptied into the throat and the patient saved 
the pain of an incision. I have seen several cases months after an ordi- 
nary attack of quinsy in which these pus-tracks could be easily traced. 
The fact that they may lie in free communication with normal openings 
is noteworthy from several points of view. They demonstrate that in 
suppurative tonsillitis the pus is not always peri tonsillar (since it 
may be retained in the crypts and diverticula of the mass), and that 
spontaneous openings of the collection may not end in recovery if the 
shape of the parts do not favor drainage. 
Respecting the danger of opening a tonsil abscess, it must not be 
forgotten that fatal hemorrhage has followed the use of the knife in 
skilful hands. * The risks of not opening the abscess are greater than 
those attending the incision, and nothing remains for the physician 
but to operate. The bleeding may arise from a normal artery which 
has assumed extraordinary proportions under the inflammatory excite- 
ment, or from a large ascending pharyngeal artery. Never, I believe, 
does the blood spring from the internal carotid if the incision be pru- 
dently devised. Before making an incision I have been in the habit of 
placing the index finger of the disengaged hand in the throat and en- 
deavoring to introduce the tip between the tonsil and the posterior wall 
of the pharynx. The knife should be thrust toward the finger-tip. This 
manipulation protects the ascending pharyngeal artery and gives free- 
dom to the operator, who, in any event, may dread wounding the pha- 
ryngeal wall. That this is no timid precaution is evident. I have 
notes of peculiarities in three persons, and have knowledge of a fourth, 
in whom a vessel as large as the radial artery is seen pulsating on the 
posterior wall of the pharynx. I have advised these persons that in 
the event of tonsillar incision being proposed that they should inform 
the physician in attendance that an abnormally large artery lies just 
beneath the surface of the throat-passage directly back of the tonsil. 
Chronic Abscess.-Retention of pus for an indefinite period is 
unusual, and I invite attention to a few remarks on the subject. ALLEN, TONSILS IN HEALTH AND DISEASE. 
15 
A gentleman, aged fifty-six years, had had for ten years an exces- 
sively irritable pharynx. In this period, two acute attacks of inflam- 
mation were reported, the first of which was severe. The patient was 
rheumatic, although there was no history of acute rheumatic fever. 
Distress was referred to the left side of the throat; the membranes here 
were more injected than on the right side. A mild form of pharyngeal 
catarrh was present with laryngitis. The tonsils were small. After 
the patient had been under treatment for a month without relief, I 
determined to remove a portion of the left upper tonsil ; with this object 
in view, I cut away a portion about the size of a split pea. Pus to the 
amount of four or five drops escaped; at the next visit, two or three 
days after, the parts were greatly improved, and in a short time all 
signs of the trouble ceased. 
A second case illustrating chronic pus retention was that of a medical 
student, nineteen years of age. He was suffering from laryngitis, and 
had always had irritable tonsils. He had suffered from repeated attacks 
of diphtheria when a child. The present distress ensued upon a rather 
severe form of tonsillitis. Believing .that much of the condition of the 
larynx was due to irritation excited by the tonsils, I removed a portion 
of the main mass on the right side with the knife, when there escaped 
fully a half-drachm of pus. The tonsils were of great thickness, and the 
pus lay fully three lines from the surface. The patient made a satis- 
factory recovery. The laryngitis spontaneously disappeared, showing 
that it had been caused by the irritative effects of pus in the tonsil. 
J. Garel (Annales des Maladies de I' Oreille et du Larynx, 1889, p. 1) 
narrates three cases of chronic abscess of the tonsils. The first of these 
was a man forty-six years of age, who reported January, 1885 ; he devel- 
oped an acute tonsillitis on December 7, 1884, which was opened on the 
10th, and again on January 31st, so it will be observed that the duration 
of the case, including the date at which pus was supposed to have 
formed, was but seven weeks. 
The second case was that of a woman, aged twenty-eight years, who 
had had her tonsils removed by tonsillotomy in infancy; she had subse- 
quently repeated attacks of quinsy with attendant suppuration on the 
left side. In January, 1885, quinsy, resulting in suppuration on the 
right side; after the escape of pus, however, the pain did not subside, 
and the patient could not report. The neck was found to be tumefied; 
dysphagia intense. The case passed from observation, but it was ascer- 
tained that a month afterward, namely, at the end of February, an 
abscess opened spontaneously, and the inflammatory condition rapidly 
subsided. The entire duration of this case appears to have been about 
one month. 
In the third observation, that of the young man, aged thirty-six 
years, who reported September 21, 1888, the patient was subject to 
repeated attacks of tonsillitis, and at the twelfth year had an attack in 
which both tonsils suppurated. In 1883 acute abscess developed in the 
right tonsil, which demanded surgical interference. In August, 1888, 
tonsillitis developed on the left side ; the physician opened the collection 
of pus on the seventh day, but the cure was not completed ; three weeks 
afterward pus could be still detected oozing from the tonsil. The open- 
ing in it was enlarged by Dr. Garel by the galvano-cautery, As a result 
of treatment by this agent, the case was cured by the 20th of October ; 
this case, therefore, had a duration of two months. 16 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
M. Noquet {Revue de Laryngologie, d' Otologie, et de Rhinologie, 1888, 
No. 7, p. 393) reports a case of a person, twenty years old, who suffered for 
six months with acute pain in swallowing at the level of the left tonsil. 
Many times a day the patient would raise pus which could be traced to 
the tonsil. This patient had had the right tonsil removed at the sixth 
year, and the left six months subsequently to the time at which the case 
came under notice. Dr. Noquet detected in the left tonsil a fistulous 
track which led to a pocket which contained pus, which, being opened, 
led to complete recovery. In the discussion which followed, M. Moure 
cited an analogous case, namely, one with abscess of the tonsil, lasting 
several years, finally cured with the galvano-cautery. Heryng names 
two cases in which abscess was detected during operation by tonsil- 
lotomy. 
Grynfellt (Gaz. hebd. des. Sei. Med. de Montpellier, No. 34, 23 Abut, 
1884) reports a case of chronic abscess of the tonsil which occurred in 
a man seventeen years of age, the result of acute tonsillitis. 
Foreign Bodies.-The practitioner is frequently called upon to 
remove foreign bodies from the pharynx. When these are large the 
most casual inspection reveals their presence. Frequently, however, 
examinations carefully conducted fail to detect them. The conclusion 
is arrived at that the objects have been either swallowed or ejected, and 
the symptoms complained of are referred to the effects of congestion 
or to the anxiety of the patient. It must not be forgotten that small 
fish-bones may be lodged within the tonsil and be out of sight when the 
throat is inspected, but may protrude during the acts of swallowing and 
speech. 
A gentleman once reported to me with the complaint that a fish-bone 
was fixed in his throat. The history was consistent, and a careful but 
futile examination had been made by the family physician. I was 
equally unfortunate in not finding thp offending bone. I ventured to 
say that it had disappeared, and that the distress could be controlled by 
the use of a soothing gargle. But in this I was mistaken. The patient 
reported after an absence of several hours and persisted in his belief that 
the bone remained in the throat. Finding the right tonsil rather large, 
I grasped it with a pair of forceps and drew it forward, thinking that 
the bone might be found between the gland and the palato-pharyngeal 
fold. Directly, I saw (as a result of compression) projecting from the 
gland the end of an exceedingly slender needle-like fish-bone, which was 
readily lifted from its bed by a pair of forceps held in the disengaged 
hand. The bone was fully an inch in length, and would have remained 
undiscovered had I not fortunately by the seizure of the gland forced 
it slightly out of its bed. On another occasion I removed a thin scale 
of an oyster-shell, which had been in the throat-forty-eight hours, from 
the interval between the upper and the main tonsil. The object was 
readily seen by drawing the palato-glossal fold forward. 
Remarks.-In conclusion it may be said: That the existence of a 
large pocket or crypt at the lower part of the tonsil is common; that a 
mass lies above the thickened cryptose tissue above the opening of the 17 
ALLEN, TONSILS IN HEALTH AND DISEASE. 
main pocket, and forms the velar tonsil; that the varieties of tonsil-form, 
as above expressed, constitute the best guide to clinical study of the 
region; that the treatment of the affections of the tonsil should be 
based upon structure ; that, this structure being of the character of 
recessions of mucous membrane from the general pharyngeal surface, 
attempts to restore such parts to their normal condition should be 
always borne in mind, and all canals or fistulous passages in the tonsil 
that are abnormal should be slit up; that closed tonsils should be 
opened ; that incisions for the reduction of enlarged tonsils should be in 
directions which harmonize with the plan of the region; and that, when 
such hints for the treatment of the tonsil are acted upon, the majority 
of the diseases of these glands are remediable. Jolirijal 
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