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OF THE MEDICAL SCIENCES.
THE TONSILS IN HEALTH AND DISEASE.
BY HARRISON ALLEN, M.D.,
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 hypertrophied 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 (Retterer, Comptes Rendus, 1885, vol. 1. p. 1284), in the walls of which are grouped muciparous glands and lymphfollicles. 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 the pharynx they are compound.
| Read before the American Laryngological Association at the Washington Congress, September 27, 1891.
VOL. 103, no. 1.- JANUARY, 1892,
Such a tonsil as the one last named is exhibited in Fig. 1, from F. Th. Schmidt (Zeitschr. für 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 compound tonsil for a number of diverticula—from eight to eleven in
Simple form of tonsil.
a, tonsil showing the mouths of diverticula ; b, the uvula.
(After F. Tu. SCHMIDT.)
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 narrowed at the mouth. Such a recess is called a pocket or crypt.
H. Asverus (Nov. Act. Leop. Carol., 1861, Bd. xxxix.) exhibits in a diagrammatic manner this disposition.
Huschke (Sömmering's Baue des menschl. Körp., ed. 1844, p. 32) describes 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.
i The terms diverticula (gland), follicle (vesicle), and crypt (pouch or pocket), have definite meanings. It is unfortunate that the term follicle in clinical studies is generally applied to the diverticulum, while anatomists speak of the follicles as “closed nests of lymph-cells" (Asverus). In the minds of some writers the muci parous 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.
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 Eingeweidelehre 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.
A tonsil section showing diverticula and a single crypt. Only the lower part of the
figure exhibits the lymph-follicles. (After F. TH. Schmidt.)
L. Heisler (“Tonsillarum nova et accuratior descriptio," in Ephemer. C., Leop. Carol., Cent. III., IV., 1715, p. 456, Table XI.) complains that 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.
The account of Haller (Element. Physiol., 1736, vi. 65) is not explicit. 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, Am. 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."
Cruveil hier (Anatomy of the Human Body, 1844, American reprint, p. 334) states that the form pretty nearly resembles that of an almond. 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 citations that the presence of ridges, depressions, and canals are implied, but without these parts being conformed to a plan, while Heisler, Huschke, Luschka, Henle, and Macalister describe 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 almondshaped body is misleading, and that the cryptose or pocket-form, with
1 The account of Kölliker (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” (Höhlung des Balges).