Retrospective
A Consideration of the Tonsil Question
How the role of the tonsils was viewed in 1918. An excerpt from an article published in the first issue of Minnesota Medicine.
By Norven H. Gillespie, M.D.
Editor’s Note
The procedure that we know today as tonsillectomy was conceived and described in the first years of the 20th century.1 Its popularity peaked in the United States in the 1940s and ’50s, with 1.4 million tonsillectomies performed in 1959.2 Although the procedure is no longer the rite of passage it once was for children, it has survived many changes in thinking about infection and disease process. Tonsillectomy was a topic of discussion at the annual meeting of the Minnesota State Medical Association in St. Paul on October 11 and 12, 1917. Physicians expressed a range of opinions about what the surgery accomplished and why, and their presentations were recorded and published in the first issue of Minnesota Medicine, dated January 1918. The following is an excerpt of an article from that issue that provides insight into the beliefs about the tonsils and the accepted way of removing them at that time.
References
1. Koempel JA. On the Origin of Tonsillectomy and the Dissection Method. The Laryngoscope. 2002;112(9):1583-86. 2. The Modern Tonsillectomy. Grand Rounds Presentation, University of Texas Medical Branch, Department of Otolaryngology, Galveston. April 27, 2005
The faucial tonsils have no function, as this term is ordinarily used—one should speak of them in their relation to the process of immunity and infection. The tonsils are lymph nodes or modified lymph glands, so constituted as to be especially liable to the invasion of bacteria. All food passes between them, and impurities from the air, gases, etc., have access to them.
Bacteria and foreign substances pass through the tonsil crypts; this is definitely proven; even primary tuberculosis of the tonsil is not so rare as usually believed. This is due to the inability of the tonsil epithelium to hold the tubercle bacilli, allowing them to pass into the deeper lymph glands of the neck. The rapidity and measure of invasion is in proportion to the depth of penetration and severity of insult to the tonsil. For example, crypts that have been curetted, punctured, or interfered with surgically offer a favorable avenue for organisms to pass through the injured and less-resisting epithelium into glands beyond. Surface epithelium is tolerant and has a selective action to dust and organisms; it becomes tolerant by habitual environment. This tolerance is lost in the deep portion of the gland. The Streptococcus is commonly found in the tonsil crypts of patients, both in health and disease. In most instances, in order to induce an attack of tonsillitis, auto-infection is necessary, together with a sort of molecular disturbance of the sympathetic induced by fatigue, exposure, and some systemic disorder.
The most convincing evidence we have that the tonsils are among the most important of the primary foci of systemic infection is derived from the postoperative results of tonsillectomy. Joint, heart, kidney, goiter, and glandular conditions show such marked improvement after tonsillectomy as to leave no doubt whatever as to the source of infection. Not alone where the attention is called to tonsillar symptoms, but also when the tonsils are small and without demonstrative lesions; in these cases, the clinician is often unable to say with certainty that the fault lies in the tonsils. But if cryptic retention and chronic toxemia, associated with general malaise, anemia and loss of weight, are manifest, without other definite localized lesion, the tonsils should be condemned.
The infection may be divided into two groups: that due to a chronic condition in the tonsil itself; and that reaching the tonsil from without, through the medium of water, milk, and other articles of food.
It is my opinion that the various forms of septic sore throat looked upon as different diseases, are in reality identical—merely representing degrees of virulence of the same process. During the epidemics of this disease in Boston and Albany, Drs. Smily and Smith isolated a variety of Streptococcus common in all the cases, calling it the Streptococcus of Smith. The Streptococcus pyogenes group is usually associated with septicemia, erysipolas, etc., while the Streptococcus angiosus group is associated with endocarditis, adenitis, otitis, etc. In all the epidemics of septic sore throat occurring in Boston, Albany, Illinois, and Wisconsin in the past few years, milk was the most common carrier favoring the development of the Streptococcus and giving it added pathogenic power.
Since vicious organisms may pass from tonsils so readily into the lymph stream, it is not difficult to understand the present prominence given to focal infections in the causation of many internal maladies. Dr. Frank Billings, in a study of 70 cases of arthritis, found the center of infection was most frequently a Streptococcus focus from the faucial tonsils. A hemolytic Streptococcus was found in most of the cases. In the Toronto Hospital for Sick Children, it is reported from a large number of tonsillectomies that 4 percent of the children showed albumen in the urine, and 2 percent albumen and tube casts, which conditions cleared up after tonsillectomy.
Dr. Charles Mayo reports, in reviewing several thousand operations on the thyroid gland, that the beginning of thyroid hypertrophy may be a defensive effort of the organism to resist toxic invasion.
In experiments conducted by Roseneau, the Streptococcus viridans was found in the tonsils of a large percentage of his cases of endocarditis. In Roseneau’s reports on poliomyelitis cases, the tonsils and nasopharynx supposedly contain the active-producing organism for a long time after convalescence; and in cases where temperature was high and paralysis progressive, improvement was noted after tonsils were removed.
In rheumatic conditions, especially of longstanding, where the joints have been sensitized by a primary focus, a very slight additional infection is necessary to produce a recurrence of the joint symptoms; and when results are not satisfactory following removal of the tonsils, it may be explained by the infection having passed to the deeper lymphatics, or to the presence of some overlooked focus elsewhere.
In the majority of cases in adults where removal of tonsils is indicated, the question is usually not one of local annoyance to the patient but of systemic poisoning.
Apart from the active varieties of bacteria, many nonpathogenic ones are found; they as a rule are not active, but their toxines are positive in their production of blood changes. It is the slow, constant absorption of these toxines that is injurous. We are indebted to Billings, Roseneau, Pynchun, Ballenger, and Slueder for brilliant contributions to the store of knowledge on the tonsil question. As to the indications for the operation of tonsillectomy, whether children or adults, with but few exceptions every tonsil is better out than in, and I have no knowledge of a single instance where a patient was made worse by a properly performed tonsillectomy.
An exquisite tonsillectomy is not beneath the dignity of the most highly gifted surgeon; in fact, with so much respect does he hold the operation that he refers the work to a laryngologist to do. Following the example or inherited instinct of a few of his older confrères, the young operator of today feels perfectly confident to perform an enucleation of the tonsils as one of his first surgical triumphs. Consequently, much poor work is being done. Many cases come up for re-operation two and three times. Appalling postoperative conditions are found, and as a result tonsil surgery does not occupy the rank it deserves. Those familiar with after-results will agree with me that the operator requires a special skill and training to perform it acceptably. This is not to be wondered at, as although we have what might be called a standard operation in instrumental dissection, we are by no means agreed how it should be done. When we can agree upon a technique which completely removes the tonsil in its capsule, does not open or wound fibers or the aponeurosis of the superior constrictor muscle, does not injure the palatoglossus or palatopharyngeus muscles, which conserves every bit of membrane over the tonsil, prevents fusion of the muscles named, and leaves a linear scar in a rudimentary fossa, with the movements of the tongue and the voice unimpaired, we will have achieved the ideal, in the light of present knowledge.
I will give you briefly the technic of a simple dissection operation….
Besides a mouth gag, two other instruments only are used: a long dressing forceps as a dissector and a blunt tonsil punch as a tractor or a volcellum. If the operation is done with general anesthesia the patient should have the usual surgical preparation with a liberal hypodermic of morphine and atropine. The anesthetist should be one constantly familiar with every detail of the work. The anesthesia should be deep, beyond any murmurs and resistance of the patient.
The operative technic is as follows: The protruding portion of the tonsil is grasped by the tractor at the supratonsillar fossa and pulled forward. At this point, the anterior pillar is picked up by the forceps and stripped outward, exposing the white, smooth surface of the capsule. The point of the forceps is inserted along the outer margin, and with a firm stroke downward, the anterior pillar is separated off. Starting at the point of insertion again, the forceps is worked around the upper lobe and down the inside, separating off the posterior pillar.
The tonsils, now being free, are grasped high up and as far back as possible on the upper lobe, and pulled and stripped down to the base of the tongue. The body of the tonsil is then grasped firmly in the tractor and, with the aid of the dissecting forceps, is forcibly pulled and stripped off the side of the tongue, taking with it a portion of the capsular attachment know as the lingual tag. When this operation is carefully done, every portion of the tonsil is removed, with slight disturbance to the muscles; and as the dissector follows the line of the capsule, the vessels are broken up in their small divisions, with minimum loss of blood. MM
Norven Gillespie practiced medicine in Duluth.