ON 
THE •• I.ACUN.-K TONSILLARUM " 
UY 
D. BRYSON DELAVAN, M.D. 
NEW YORK 
SECRETARY, AMERICAN LARYNGOLOGICAL ASSOCIATION ; SURGEON TO DEMILT 
DISPENSARY, DEPARTMENT DISEASES OK THE THROAT J ATTENDING 
SURGEON, WORKHOUSE AND ETC. 
[Reprinted from the Transactions of the American Laryngological 
Association, 1883] THE “ LACUNAE TONSILLARUM^ 
By D. BRYSON DELAVAN, M.D. 
TO the casual observer the surface of the normal tonsil 
presents a number of depressions, so slight in extent 
and so unobtrusive in appearance that they hardly seem to 
call for more than a passing glance. That most writers 
consider them as unimportant is evident from the hasty 
manner in which, in articles upon the subject, they are 
generally dismissed. Believing, as we all doubtless do, that 
the cavities of which these indentations are the orifices, 
constitute a prominent element in the anatomical structure 
of the tonsil, and play an important role in its general 
economy, it has seemed desirable to call especial attention 
to them, to the end that certain points in their gross and 
minute anatomy might be prominently brought forward, 
and that the facts thus suggested might be utilized in the 
practical treatment of diseased conditions of the part. 
These depressions, the lacunae tonsillarum, as is well 
known, are a series of follices formed by the reduplications 
of the oral mucous membrane and their contained adenoid 
tissue, which constitute the organ known as the tonsil. 
Their number is variously estimated at from eight to 
eighteen. Many of them are spacious in extent, and they 
commonly penetrate deeply into the substance of the 
gland, sometimes almost reaching to its hilum. There are, 
also, in the interior of the tonsil, single larger cavities, each 
one of which includes several follicular folds, and procures 
their common discharge at the periphery. By this ingen- 
ious arrangement the actual superficial extent of the tonsil 
is greatly increased. 
To this fact attention is particularly directed. 
In examining under the microscope a section of human 
tonsil, we find that, in common with the rest of the buccal 
cavity, its surface is invested with a thick covering of pave- 
ment epithelium, which rests upon a delicate endothelioid 
basement membrane. Following this is a tolerably compact 
Reprinted from the Transactions of the American Laryngological 
Association, 1883. 2 
D. Bryson Delavan. 
mucosa, formed of interlacing bands of connective tissue, 
and containing many connective-tissue corpuscles. Occa- 
sionally, the adenoid tissue extends so near to the surface 
of the organ that it penetrates the mucosa, and, here and 
there, actually encroaches upon the epithelial layers. In 
the walls of the crypts this encroachment is especially 
marked, the more plainly so as the bottom of the lacuna is 
approached. In other words, the epithelial and sub- 
epithelial layers, thick at the periphery, become rapidly 
more delicate the deeper we trace them down the crypt 
wall, until, toward the lowest depth of the lacuna, they 
generally disappear, by reason probably of the attenuation 
of the mucous membrane in this locality, and its conse- 
quent liability to rapid post-mortem decomposition and to 
mechanical injury in the preparation of the microscopical 
section. 
This unusual destructibility is another point worthy of 
attention, for it, together with the point before men- 
tioned, namely, the increase in the superficial extent 
of the tonsil caused by the crypts, constitutes a factor 
of the greatest importance in the pathology and the treat- 
ment of diseased conditions of the gland. 
First, in its pathology, it is evident that any morbid 
condition which may affect the surface of the tonsil will 
also, in all probability, extend into the crypts, and thus add 
greatly to the amount of irritation apparently present in a 
given case. Moreover, the delicate nature of the lining of 
the crypt wall would facilitate the absorption of matters 
retained in the crypt, and this, together with the intimate 
connection of the tonsil with the lymphatic system would, 
manifestly, expose the patient to the danger of general 
infection in conditions attended with the presence of local 
sepsis, as, for instance, in diphtheria, and in inflammatory 
affections giving rise to purulent discharge. 
The effect of irritation of the lacuna upon the whole 
tonsil is a matter of common observation in cases where it 
has been distended by cheesy accumulations, by tonsillar 
calculi, or by retained pus. 
The writer has recently seen a case in which the latter The “ Lacuna Tonsillarum." 
3 
condition was unquestionably accountable for a well-marked 
swelling and tenderness of the cervical lymphatics, and a 
similar case has been reported to him by Dr. Albert H. 
Buck; while in diphtheria the same symptom is so common 
as almost to be pathognomonic. 
Turning now to the consideration of the matter of treat- 
ment, however, these very anatomical conditions before men- 
tioned offer possibilities for the relief of disease which have, 
by the majority of practitioners, but rarely been appreciated 
or utilized. Instead of merely painting the medicament 
over the well-protected surface of the tonsil, let it be applied 
thoroughly to the delicate wall of the interior of the crypt. 
Then, not only will a far greater extent of surface be 
reached, but, also, the effect upon the gland will be much 
more profound, from the greater ease with which the appli- 
cation will be absorbed. 
The objection may be urged, that to make such an ap- 
plication to the tonsil of a child, or even to an adult tonsil 
of normal size, would be impracticable. It should be re- 
membered, however, that morbid conditions of the tonsil 
are almost invariably accompanied by hypertrophy, and 
that the larger the tonsil the larger will be the crypts ; and 
this, together with the insensitiveness of the organ, which 
exists in many instances, will render the operation easier 
than might be supposed. By this plan three general varie- 
ties of treatment may be employed, namely: the disinfect- 
ant, the astringent, and the cauterant. The lacuna should 
first be cleansed by means of a bit of absorbent cotton upon 
a fine probe, or by a stream of water from a curved syringe, 
and the application then made by an appliance similar to 
the one used for cleansing. 
My friend, Dr. Lincoln, has for a long while advocated 
the use, in this manner, of a strong solution of iodine and 
chloride of zinc, and he and others have also used nitrate of 
silver, fused upon the end of a probe. For this purpose the 
writer has found it exceedingly convenient to apply the 
fused nitrate to the end of a small splinter of wood. This 
can readily be grasped in any good forceps, and when once 
used it can be thrown away. D. Bryson Delavan. 
4 
The measures here suggested can probably nowhere be so 
well utilized as in those troublesome cases of hypertrophy of 
the tonsil in which excision is for any reason impracticable. 
No stronger argument could be brought forward, however, 
in favor of excision of an hypertrophied tonsil than the 
anatomical points referred to in this article. The condi- 
tions in which the general measures referred to will be ap- 
plicable, will suggest themselves so 'readily, that to enter 
into details concerning them seems unnecessary. g. p. putnam’s sons, printers 
NEW YORK