ON THE SEQUELS AND PROPHYLAXIS OF SIMPLE 
TONSILLAR HYPERTROPHY IN CHILDREN. 
BY 
Dr. BEVERLEY ROBINSON, 
SURGEON TO MANHATTAN EYE AND EAR HOSPITAL (DEPARTMENT OF THE THROAT) 
Reprinted from the American Journal of Obstetrics and Diseases of 
Women and Children, Col. VIII., No. III., November, 1875. 
N E W_ YOR K: 
WILLIAM WOOD & CO., 27 QREAT JONES STREET. 
1875. ON THE SEQUELS AND PROPHYLAXIS OF TONSIL- 
LAR HYPERTROPHY IN CHILDREN. 
By De. BEVERLEY ROBINSON, 
Surgeon to Manhattan Eye and Ear Hospital (Department of the Throat). 
Chronic enlargement of the tonsils is an affection so com- 
monly met with amongst children, that the general practitioner 
is apt to overlook the importance of disturbed function of these 
glands, and to pay but little regard to their active treatment. 
So many are subjects of this disease, in a relatively slight degree, 
and so widely spread is the idea, that even in a somewhat 
aggravated form, the affection is one which will last only a few 
months, or years, and then in many instances disappear sponta- 
neously, that it is considered almost, if not entirely, useless to 
interfere, or at all events to employ topically any very active 
medicinal agents. The cost in trouble, pain and anxiety, both 
to parents and children, in ridding little sufferers of their 
malady, seems to more than balance any evil consequences 
which will probably arise from its presence. Thus it is, that 
healthy and sickly children go on from year to year, bearers 
of this tumefaction of the fauces, without serious attention 
being directed towards it. Suddenly, however, some acute 
trouble of the throat shows itself, either idiopathic in its 
nature, or allied with one of the exanthemata, and then 2 
Robinson : On the Sequelae and Prophylaxis of 
anxiety is at once excited, and this frequent condition of 
additional risk is considered with a greater or less degree of 
alarm. 
Again, a child, who in its infancy has enjoyed good, or even 
robust, vigorous health, becomes pale, emaciated, loses appetite 
and strength, and is afflicted with spasmodic disease (laryngismus 
stridulus, asthma, etc.) of frequently recurrent character, and 
soon maternal solicitude is awakened, and the origin, or cause 
of the change earnestly sought for at the hands of the medical 
adviser. 
Too often, we regret to add, the source of physical weakness 
may be found in the hyperplastic development of the tonsils ;— 
and that this is true, cannot be doubted, when we fairly esti- 
mate the pernicious effects upon the general health, which 
surely follow in the wake of their diseased state. 
What are the tonsils ? 
Histologists tell us they resemble in structure other lympha- 
tic organs of the body. At the same time they inform us 
that they are characterized by differential features, which ap- 
proach them to glandular structures. On the one hand, we 
tind in the walls surrounding the central cavity of each one of 
the masses, which conglomerated form the entire organ, a num- 
ber of closed follicles, similar to those that form a component 
part of Peyer’s patches in the small intestine ; on the other, we 
have a number of tortuous tubes not unlike in form and struc- 
ture the ducts of acinous glands, and these tubes open either 
directly upon the mucous surface of the tonsil, or else into the 
lacuna of the lobules. Now, from this structure proceed two 
distinct functions: 1, the formative function, which relates to 
the constitution of the blood; 2, the glandular, which deter- 
mines the secretion of a clear, viscid fluid. This fluid, when 
poured into the buccal cavity, by the contraction of the sur- 
rounding muscles in the effort of deglutition, serves to imbibe 
and lubricate the alimentary bolus. 
The tonsils are situated, as you are aware, between the pil- 
ars of the fauces on either side, and when of normal size, al- 
though easily seen if the mouth be opened and the throat in- 
spected, are not prominent enough to materially diminish the 
diameters of the isthmus, or interfere with essential vital 
functions. Simple Tonsillar Hypertrophy in Children. 
How changed this statement becomes whenever the tonsils are 
diseased ! First, and considered as lymphatic organs, their influ- 
ence upon the transformation of the white blood corpuscles is 
imperfect, or null. Secondly, the secretion from the glandular 
structure is altered. It rapidly becomes cloudy and fetid, is 
apt to flow less easily from the orifices of the follicles, and in 
many instances these latter become blocked up completely 
with a white, sebaceous substance of cheesy consistence, which 
is also soon rendered putrescent. As a consequence the ali- 
mentary bolus, though lubrified in its passage through the buc- 
co-pharyngeal opening, carries with it a quantity of morbid se- 
cretion, which rapidly sets up dyspeptic trouble, and absorbed 
into the circulation leads finally to unhealthy nutrition. Ow- 
ing to the position of the tonsils, we can at once perceive how 
in cases of chronic enlargement, no matter what may be their 
intimate or structural characters, several important functions 
are morbidly affected in a greater or less degree. If the ton- 
sils enlarge towards the median line, the faucial opening is 
often greatly diminished. At times, and when the hypertrophy 
is exaggerated in this direction, deglutition is fatiguing and oc- 
casionally painful. If the enlargement also takes place in the 
upward direction, partial obstruction of the posterior nares and 
Compression of the Eustachian orifices are natural sequences, 
and hence we have difficult respiration and imperfect hearing, 
and on account of the relative immo/bi/ity of the soft palate, 
the voice takes that nasal and muffled intonation so familiar to 
every medical practitioner. 
All the above phenomena may be present as well with adults 
as children. There are others, however, which relate almost 
solely to children, viz.: those which attach themselves naturally 
to arrest of development. 
A well-known physiological law is expressed in the follow- 
ing terms: whenever an organ of the body during its period 
of growth is thrown into disuse, or cut off completely from its 
normal function by some mechanical obstacle, deformation and1 
arrest of development, followed by atrophy, are natural sequelae.. 
Let us make the application of this law. Owing to the passage 
of a less quantity of air through the nasal passages, in the con- 
dition under consideration, a diminished volume also enters the 
larynx and lungs. Robinson : On the Sequelae and Prophylaxis of 
4 
What is the result? The nasal passages do not increase in 
capacity proportionately with the growth of the child, and this 
lack of growth affects in an equal degree the palatine arch ; con- 
sequently we find the olfactive and gustatory senses restricted. 
Again, the lungs do not receive a sufficient supply of oxy- 
gen, a certain number of their terminal vesicles are not 
expanded at all during ordinary inspirations, and those vesicles 
that are filled are insufficiently so, and the chemical blood 
changes which take place in the pulmonary structure are but 
very imperfectly accomplished. Besides, atmospheric pressure 
in the interior of the lungs, owing to the rarefaction of the air, 
does not fully counterbalance that from the exterior, and sink- 
ing in, with a peculiar deformation of the chest walls, is pro- 
duced. This visible alteration in the chest is sufficiently notable 
to be in the estimation of some authors as pathognomonic 
of tonsillar enlargement, as a somewhat analogous appearance 
is of rickets. The physical development and proper growth 
of children thus affected is manifestly seriously impeded. 
Their nutrition languishes and their muscular energy and ac- 
tivity are markedly diminished. 
Further, we may add, by compression of the large vessels of 
the neck cerebral circulation is at times incompletely performed, 
the brain becomes dull and apathetic, less inclined to exert it- 
self, and suffers concomitantly with the body, from a condition 
which is local in origin and may at any time, with rare excep- 
tions, be remedied by a ready and safe operatory procedure. 
In the prophylactic treatment of chronic enlargement of the 
tonsils in children we attach great importance to first, the habit 
of cold bathing. 
We all know how readily children “ catch cold,” and how 
frequently this catching cold, as it is termed, manifests itself 
upon the mucous membrane lining the faucial opening. It is 
to frequently repeated inflammations of the throat more than to 
any other single cause that is due the disease under considera- 
tion. 
To guard our little patients efficiently then against the recur- 
rence of colds, let us endeavor by bathing in water of low tem- 
perature to activate the functions of the skin, and thus to les- 
sen the likelihood of localized mucous congestion. 
Mothers, nurses, and even some of our professional brethren, Simple Tonsillar Hypertrophy in Children. 
5 
are too much disposed to underrate the value, or be fearful of 
cold ablutions. They recognize how useful a preventive 
agent against colds they have ever close at hand whenever 
adults are in question, but they do not believe this to he true of 
children, or if they acknowledge that cold baths might prove 
useful, they dread putting their knowledge into practice. They 
seem to consider that a small child is not sufficiently strong, 
that its vital forces are not energetic enough to be able to re- 
sist such an heroic method of treatment. They tremble for the 
safety of their nurslings, or children of a more advanced age, 
and cannot bear to carry out this rational therapeutic system. 
And yet is it not manifest in our ever varying climate, where 
extremes of temperature so closely approximate, that in spite 
of every precaution being exercised which is dictated by ma- 
ternal solicitude, children must of necessity be more or less 
frequently exposed to all the evils that result from draughts, or 
from cold, or excessive humidity in the atmosphere \ Our ob- 
ject then should be to protect them efficiently from the adverse 
effects of our trying climate. Now, hot, or even tepid bathing, 
is, we believe, one of the main causes of recurring congestion 
or inflammation of the throat. And, we may ask, Can it be 
otherwise ? Take a child of relatively feeble and lymphatic 
constitution and subject it to> bad hygienic influences, viz.: 
surround it with an insufficient or vitiated supply of air, give 
it improper food, or cover it with badly adapted clothing, and 
will you not And that it gradually becomes more markedly 
strumous and sickly ? Warm bathing is to be ranked in the 
same category. It is enervating, and takes away from bodily 
vigor. 
The skin, it is true, is actively congested during the period 
of the bath and its capillary circulation greatly augmented, 
but just so soon as the ambient cold air iayringes again, upon 
the cutaneous surface, either directly or through the habitual 
wearing apparel, the blood supply is driven with increased 
force (owing to the rapid contraction of the small vessels of the 
integument) towards the internal viscera and mucous linings, 
which, in their turn, become congested, and remain so more or 
less constantly, unless by a superabundance of clothing the body 
is kept in an unnatural state of heat. 
If the temperature of the water used in bathing is as low or 6 
Robinson : On the Sequelae and Prophylaxis of 
lower than that of the surrounding atmospheric medium, what a 
different physiological action takes place ! 
A temporary shock follows immersion or the use of the 
sponge filled with water, after which there is a short period 
when the surface temperature of the body is lowered, and then 
a natural warmth or glow takes place, the skin is reddened, its 
capillary circulation is heightened, and not merely in a tempo- 
rary maimer, but shortly becomes so permanently, and the in- 
terior organs are relieved of an overload of blood and greatly 
activated in their several functions. In the event of the natural 
warmth, which almost invariably succeeds the use of cold water 
for bathing purposes (unless it be continued too great a length 
of time on each occasion), not manifesting itself, we ought to 
have recourse to friction. And rubbing, gently at first and 
soon with a firmer pressure, the entire trunk and limbs, will 
greatly stimulate the action of the skin. The rubbing should 
always proceed from the extremities towards the heart, or in 
the direction of the venous blood-flow. The use of some fatty, 
or oleaginous substance of bland, unirritating nature is an 
excellent adjunct in carrying out the above treatment, and is 
especially of service where the skin is dry, offers a slightly 
scaly or furfuraceous aspect, and so gives evidence of imper- 
fect nutrition, or lack of healthy power. Of course, in the above 
indications of prophylaxis, we would naturally include careful 
attention to the periodical, but not too frequent use of ‘pure 
soap. The selection of this article has its importance, and we 
shall therefore particularly recommend Pears’ transparent gly- 
cerine soap, which is manufactured in London, and is one of 
the best soaps of which wre have cognizance. 
Another subject to which we claim attention is care of the 
feet. They should be kept warm and dry. Cold, moist feet 
are an habitual and most efficient cause in producing hyper- 
trophy of tonsils. Nowadays our people have finally been 
awakened to the necessity of warm and appropriate clothing for 
small children, if they hold to their continuance in good health. 
Happily, therefore, naked arms, legs, shoulders, and chests are 
not so frequently encountered as formerly. 
Mothers are willing for the sake of permanent good to their 
offspring to abandon in this regard foolish notions of dress or 
fashion. Simple Tonsillar Hypertrophy in Children. 
7 
While, however, wise solicitude and care have been directed 
to clothing, properly speaking, how has it been with respect to 
the covering of the feet ? How many little ones do we see 
walking the sidewalks of a cold, wintry day with light, paper- 
like soles to their shoes ? And in wet weather, do we always 
find them better protected ? True it is, that over-shoes, arctics, 
etc., are usually put on over the ordinary walking shoe, but is 
this the best way of securing warmth and dryness ? Decidedly 
not. Excepting those times when there is much slush or snow 
upon the ground, we consider the cork-sole shoe far superior to 
the gutta-percha, or other style of impermeable over-shoe, be- 
cause, 1st, it keeps the feet quite as dry, 2d, warmth is secured 
without that constant moisture of the feet almost inevitable 
with over-shoes on account of arrest of insensible evaporation. 
Another way of preventing the soles of shoes or boots from 
absorbing water is to cover them with a coating of oil (castor- 
oil is the best), which will render them impermeable and may 
be used without risk of injurious effects to the wearer. 
Thick-sole shoes will of course lessen the facility with which 
the feet become cold or wet. Allowing, however, that the feet 
are prevented from getting really wet, it must still be admitted 
that the soles of shoes are frequently made, cold and humid. 
Kow this circumstance alone will promote rapid and direct ab- 
sorption of heat from the feet, and the effect will be consider- 
ably increased by the evaporation due to atmospheric action, 
which is constantly continued. 
Colds may also be rendered somewhat less frequent in young 
children, and attacks of acute tonsillitis may, we are told, be 
occasionally aborted by putting a plug of cotton wool in eithei 
ear whenever they go into the open air during a period of ex 
cessive cold or high winds. This habit is recommended in a late 
number of the London Practitioner (and the physiological ex- 
planation given), and lauded far above the custom of surround- 
ing the neck with mufflers of any description. 
One other point is worthy of consideration, viz.: Cold is 
taken just as easily by the rapid passage from a very cold, or 
damp atmosphere, to one where the temperature is excessively 
dry or elevated, as by the sudden change from the latter con- 
ditions to those first mentioned. We should be careful there- 
fore to counsel nurses— Robinson : Simple Tonsillar Hypertrophy. 
1st. Not to keep the nursery at a too high temperature, and 
always to have a basin, pitcher, or bucket full of fresh, pure 
water, with the surface exposed to the air contained in the 
room. 
2d. Not to allow children to approach a fire-place or register 
immediately upon entering or leaving the house. 
3d. Not to keep extra wraps on their little charges, when at 
home, a moment longer than is absolutely essential. 
Practical attention to the preceding rules, and also to what 
we have written with respect to cold bathing, care of the feet, 
etc., as prophylactic measures of hypertonsillar growth, will 
be found, we are firmly convinced, of unquestionable utility.