Pharmacodynamics
If I may be pardoned for discussing things pharmacological in a text on practice, I want to urge that chemicals as such, are usually a failure in treatment. My results from various series of experimental work both laboratory and clinical, show quite conclusively that there are very few, if any, chemical substances that have actual value by virtue of their chemical properties alone. There are, however, cases in which chemical agents may be used to advantage to obtain desirable physical results and physiologic reactions.
The salt mixture mentioned above increases the solvent power of the water for mucus, pus, and other collected material and it also renders the water less irritating to the mucous membranes. Other than this, it has no value so far as I know. This solution is certainly not antiseptic or germicidal, further than that cleanliness may be considered an antiseptic procedure.
The phenol-glycerine (10% phenol and 90% glycerine) which we have recommended, is somewhat germicidal, non-irritating, except to the nasal mucosa, is a protectant to inflamed membranes in some instances and is also somewhat hygroscopic. These virtues to the limited extent that they may be of advantage, depend chiefly upon physical qualities.
Adrenalin in high dilutions (1 to 5000 to 1 to 10,000) is of value in retracting the erectile tissues of the nares for purposes of examination and for obtaining better drainage, etc. It also constricts the small blood vessels and thus reduces the chances for hemorrhage or absorption of narcotic drugs which may necessarily be used as local anesthetics. The effects of adrenalin are very temporary and it is, therefore, of little value in treatment.
Following irrigation I have used the petroleum oils (liquid petrolatum) to advantage as a protection to the mucous membrane. One-half gram each of menthol and camphor and two or three drops of cinnamon oil to the pint of this oil, is readily dissolved and produces a pleasant, soothing effect to inflamed membranes, but further than this, the added substances have no particular value. The above named chemical agents constitute, except in rare instances, my stock of “drugs” for treatment purposes.
Hyperesthetic Rhinitis—Hay Fever
There is perhaps no disease in which there has been more speculation concerning the etiology than in hay fever, and while osteopathy has accomplished a wonderful advance in the treatment of this disease, I am not sure that the cause or causes are yet thoroughly understood.
Etiology.—The theoretic causes of this disease may be expressed in the various names which have been given to it as follows: The term Hay Fever suggests that it is a febrile condition caused by hay pollen irritation. Peach cold, Rose cold, Rose fever, Rose catarrh, Rye fever and Ragweed fever suggest similar specific causes. Idiosyncratic coryza means nothing and this probably expresses what the theorists know about its cause better than any other name. Hysteric rhinitis suggests a probable psychic cause, which certainly does exist in some cases. If I may be pardoned, and I know I never will be, let me suggest just one more name—“Respiratory Reflex Inefficiency.”
Intoxications.—Auto-intoxication from focal infections or from gastro-intestinal perversions certainly have an important influence either directly or as predisposing factors and should always be carefully considered in treatment.
Osteopathic Lesions.—Osteopathic lesions, such as interosseous, muscular and ligamentous, seem to function as predisposing causes by their general effects upon the system. It seems probable that their effects upon the organs of metabolism and elimination are of greater importance than any direct or specific effect in causing the immediate symptoms. In practically all cases lesions of the upper thoracic vertebræ and ribs and of the cervical region are present. It is my opinion that such lesions are more often secondary than primary.
Respiratory Reflex Inefficiency.—Measurement of nerve force in these cases shows that none are really possessed with “an excess of nerve force,” but that practically all vary from two-thirds to four-fifths normal, showing that probably all cases are deficient in nerve force.
This instability of the nervous system can be explained, I believe, in the theory of peripheral reflex insufficiency. As evidence of this the following facts may be cited:
1. It is known that peripheral irritation of almost any nature, to the mucous membranes of the nasopharyngeal tract, will excite an attack in susceptible individuals.
2. That any treatment which tends to increase the resistance of these membranes will prevent or relieve an attack.
3. That peripheral inhibition to these surfaces will temporarily relieve an attack.
4. That complete normalization of these membranes will make the patient resistive to the so-called specific irritants, such as pollen, dust, etc.
5. That the mucous membranes of the entire respiratory and gastro-intestinal tract react to irritants to bring about “the hay fever state” and that any treatment which tends to normalize these membranes, renders the patient more resistive to hay fever attacks.
Exciting Causes.—There is no doubt that various air-borne irritants, such as pollen, dust, chemical fumes, emanations from animals, etc., act as exciting causes of acute attacks, and yet there are cases that develop acute attacks out of season or at a time when it seems that there could be no air-borne irritation. From evidence which will be offered later (see prognosis) I am led to believe that probably all susceptible cases can be made entirely resistive to the air-borne irritants.
Pathology
Functional Pathology.—Certainly in this disease there is ample evidence of marked perversions of function or functional pathology. Kyle believes that in many cases the cause of local irritation lies in “some chemical change in the constituents of the mucus-secreting glands,” and “it is a well known fact that in many cases of hay fever the irritation is not limited to the nasal mucous membrane. The eyes and mucous membrane of the stomach and bladder, and even the intestines may be markedly irritated.”
These chemical changes in the secretion of the mucous membranes, together with the excess of uric acid would seem to point either to a general perversion of the secretory mechanism or to a deficient elimination, or to both. The periodic occurrence may be accounted for by assuming that the systemic strain is sufficient to initiate the symptoms. The fact that the attack is actually delayed or hastened in susceptible individuals by the late or early beginning of hot weather, and that these cases get relief by going to a more moderate climate is further evidence of this.
Again we are reminded of Dr. Still’s teaching, that the body maintains its own chemical laboratory which adjusts or tends to adjust its work to the needs of that body, but under abnormal strain this adjustive mechanism may fail to meet all of the demands of function. It seems here that the osteopathic concept may easily include all environmental causes as well as internal causes in the predisposition to deficient function or disease.
Structural Pathology.—During the attack there is a general catarrhal inflammation of all nasopharyngeal membranes, accompanied by a watery discharge and marked swelling of the turbinates. Sensitive areas may be found on the middle turbinate and opposite wall of the septum. Probably it is this hypersusceptibility to irritation that causes the attack from the air-borne irritants.
The pseudo-membrane which may be found covering a part or all of the mucous membranes of the nares probably results from this irritation and is formed for the purpose of protection.
Clinical Types.—Clinically, three rather indefinite types of hay fever may be recognized, viz.: Vernal, those cases which have their attack sometime during May, June or July; Autumnal, in which the attack occurs in August or September and usually lasts until the beginning of cold weather, and an indefinite or pseudo form occurring at any time of the year, with no characteristic attack, as in the other forms, but with indefinite symptoms resembling hay fever.
Symptoms and Diagnosis.—Patients usually go to the physician self diagnosed. The characteristic sneezing, the watery discharge from the nose, and the irritation of all membranes of the nasopharynx and conjunctiva will serve to make a diagnosis in most cases. Direct examination will reveal the nasal congestion and other characteristic pathology as described above.
Termination.—Most cases of the autumnal form, unless successfully treated, continue with equal or increased severity until after the first or second frost, when they usually terminate in asthma, bronchitis or sinuitis, which lasts for several weeks or months. Each year the attack lasts longer and is more severe and the asthma occurs earlier and is more severe.
Treatment
Intranasal Surgery.—Intranasal abnormalities, such as deflected septum, spurs on the septum, hypertrophied turbinates, polypi, etc., which materially reduce the breathing space, usually demand surgery. Nasal surgery, carefully and properly done, is always a great aid and often absolutely essential to the successful treatment of hay fever and asthma, but nasal surgery carelessly done frequently does more harm than good.
The correction of a deflected septum or the removal of a spur on the septum by submucous operation often aids materially in the prevention of pressure irritation, increases the breathing space and normalizes drainage from the sinuses.
Surgery is therefore very essential in many cases of hay fever, but surgery is never the all essential part of the treatment, because if the proper after treatment is not given, the surgery alone will seldom result in either temporary relief or cure.
Focal Infection.—The importance of focal infection of the sinuses, tonsils, teeth and occasionally other parts, such as the nasal cavities, epipharynx, middle ear and mastoid cavities cannot be overestimated. Such conditions may be effective in causing hay fever, by causing direct infection of the membranes of the nasopharyngeal tract or by auto-intoxication.
Digital Surgery, for the removal of adhesions in the posterior nares and pharynx, is in my opinion, very essential, and this work should be done thoroughly. Massage of the soft palate or pharyngeal walls is of no particular value. All adhesions and adenoid tissue must be removed because this removes an effective source of constant irritation and focal infection and tends to normalize the direct and reflex nerve mechanism.
The practice of the radical intranasal technique as originated by J. D. Edwards, D. O., is indicated, I believe, in some cases in which the crushing of cellular middle turbinates, or the breaking of adhesions is indicated, but I am not yet ready to accept this theory of “curetting” the mucous membrane by radical digital technique. The fracture of the turbinates is not necessarily a bad technique provided they are properly readjusted as Dr. Edwards does it, but to fracture and not readjust is a dangerous practice. The efficiency and safety of any method depends upon the operator’s definite knowledge of what needs to be accomplished and how it is to be done.
There are contraindications to digital, as well as any other kind of nasopharyngeal surgery, such as: (1) Acute infection of any part of the nasopharyngeal tract; (2) evidence of sinus involvement; (3) septal deflections, spurs and hypertrophied turbinates, which would not permit such work without undue trauma.
There are certain other precautions such as thorough cleanliness of the parts to be treated; aspiration of the sinuses before and afterward, and the use of a finger of sufficient size which will not produce undue trauma. In my opinion very few doctors have such fingers.
Failure in accomplishing results is due to three things, viz., (1) Insufficient knowledge of diagnosis and prognosis; (2) insufficient knowledge of what should be accomplished and the technique of doing it, and (3) the necessary additional or supportive treatment.
It is a great mistake to think that the removal of adhesions in the pharynx or nares is sufficient, because if this is not followed by the proper supportive treatment, no results or even bad results will frequently occur. This treatment is not a massage in any sense, but a definite operative procedure and requires as much care and skill as the removal of adenoids or tonsils.
Space will not permit an explanation of the digital technique and the radical treatment should not be attempted without some definite knowledge of the methods and technique.
Intranasal Treatment.—The intranasal method of treatment as explained above under hypertrophic rhinitis is very effective and if carefully and thoroughly done is in most cases just as efficient as intranasal digital surgery. This treatment followed by irrigation and oil spray and nasal packing will be found effective in most cases if the treatment is properly done.
Nasal Packing.—Thorough packing of the nasal cavities after all sources of focal infection have been removed and after thorough cleansing has been done, by means of long strips of absorbent cotton is effective in reducing the swelling and irritation.
The Radical Packing Method.—This method can be done best in a hospital. The nares are prepared as for surgical operation, by complete retraction of all erectile tissue, thorough cleansing by irrigation and the application of a local anesthetic. Anesthesia need not be complete. A careful examination is then made for any synechia, or focal infections. Packing should never be done until the doctor is sure there is no sinus involvement. The entire nasal cavity is then packed very firmly with sterile gauze. This is best done by means of a special packing instrument or long nasal packing forceps, using narrow gauze contained in tubes. In some cases the nasal cavity is lubricated before packing.
The packing should be done early in the morning and removed just before bed-time, so that the patient may sleep. This treatment is repeated daily until all signs and symptoms of nasal irritation are gone and then replaced by irrigation and oil spray.
If this treatment is properly done, there will be a complete sloughing of the pseudo-membrane followed by a restoration of normal and resistive tissue. The results of our two years’ experience (we have tried this on only a few patients each year) are very encouraging. Relief from the symptoms are very prompt and seemingly more permanent than from other methods.
Treatment of Auto-intoxication.—All sources of focal infection are thoroughly treated. Sinus infection is very common and must receive proper attention before any other treatment can be effective.
Our experience shows that many cases have auto-intoxication of gastro-intestinal origin. The hospital care of such cases makes possible the thorough cleansing of the colon by irrigation and the reestablishment of an acid producing flora which seems to prevent fermentation.
Osteopathic Corrective Work.—Thoroughness of treatment for the removal of all causes is the secret of success. To successfully remove the immediate sources of auto-intoxication by treating a sinus infection or by thoroughly freeing the colon from fermentation products means only temporary results if the underlying causes are not corrected. A thorough osteopathic examination is necessary to determine such causes and certainly such treatment should not be neglected.
Correction of all cervical and upper thoracic lesions and particularly the clavicles and ribs is important. These lesions seem to be the result rather than the cause, but normal respiratory functions seemingly cannot be maintained unless such treatment is done.
Sinuitis
Acute or chronic inflammatory disease of the nasal accessory sinuses with or without suppuration is more common, I believe, and is responsible for more complications and chronic affections of the nose and throat than is generally known.
Etiology.—The cause in most cases lies in unsuccessfully treated acute infections involving the nose and throat. Abnormalities of the nasal respiratory passages such as deflected septum, enlarged or cellular turbinates, adhesions resulting from cautery or careless surgery, causing deficient drainage, constitute the local causes. Underlying some of these direct causes, lesions of the cervical region which impair the nutrition to and drainage from the head are to be considered.
Symptoms and Diagnosis.—Acute or chronic headaches and neuralgic pains of the head are common symptoms. Acute sinuitis of the frontal sinuses is accompanied by marked and persistent frontal headache and pain in the eyes. In infections of the maxillary sinus there is usually pain over the affected part, but there is often referred pain to other parts of the head. Sphenoidal sinuitis usually causes general headache with no definite location.
By direct examination of the nasal cavities a purulent or mucopurulent discharge may be seen and the source determined. In many cases, however, the pus may be retained or insufficient in amount to detect by direct examination.
Transillumination in a dark room by means of a good transilluminator will usually show a darkened area over the affected part. The average battery equipments commonly sold for this purpose are of little value. The X-ray plate when properly done, is more dependable than the transilluminator.
In some cases, all of these methods fail to locate the affected sinus and the cause can be found only by opening into the sinuses, aspirating with a catheter and making microscopic examination of the aspirated material. The microscope is indispensable for this work. Every suspicious discharge should be stained until pus is found and except in well defined cases, this is the only practical method of positive diagnosis.
Treatment.—Local treatment of the nasal cavities by retracting the turbinates and irrigation will be successful in many cases, but unless there is a large normal opening the pus will not drain sufficiently and probe treatment is required. In acute cases in which the pain is marked, osteopathic treatment of the cervical region, deep relaxation of the submaxillary structures and the application of heat over the affected part, together with the local nasal treatment should be given, but if this does not relieve the pain within twenty-four hours, the sinus should be opened and thoroughly drained. If efficient drainage is not established early the symptoms will usually increase until the pain is almost unbearable and serious complications may result.
In practically every case of acute sinuitis, I believe it is best to make a good, free opening into the affected sinus first and secure complete drainage by catheter aspiration. If this is properly done every case will recover much more quickly and without complications or danger of chronic infection.
Non-Suppurative Sinuitis
Cases of non-suppurative sinus involvement are not at all uncommon. The so-called “Vacuum sinuitis” which results from a closure of the normal opening, resulting in inflammation without pus formation, is responsible for many of the complicated cases of referred pain, which are so often improperly diagnosed. Chronic headaches and the various symptoms of fifth nerve affections, the neuralgias of the head, are frequently caused by non-suppurative sinus involvement.
Treatment.—The treatment consists of establishing good drainage and proper ventilation of the affected sinus or sinuses followed by thorough intranasal treatment as explained above. The osteopathic corrective work must not be neglected.
Syphilis of the Nose
In osteopathic practice syphilis is not a common disease. The occurrence of syphilis of the nose is still more rare but certainly should be recognized.
Diagnosis.—The local lesions of the nose are of two types, those of acquired syphilis and of congenital syphilis.
There are three characteristic manifestations of acquired syphilis as follows. The primary lesion or hard chancre is a firm, indurated ulcerated mass with only slight discharge. Chancre of the nose is exceedingly rare. In secondary syphilis there is the mucous patch, the result of mucous membrane necrosis. In tertiary syphilis the local lesion is the gumma or more commonly, the ulceration left from necrosis of the gumma. These lesions may appear from a few to many years after the initial infection, but they never follow immediately. The lesions may appear on almost any part of the intranasal structures. They resemble the lesions of atrophic rhinitis but in atrophic rhinitis there is never the extent of destruction that so frequently results from tertiary syphilis.
Treatment.—It has been my practice to refer all suspected cases to Dr. F. J. Stewart for differential diagnosis and treatment and his method of the use of salvarsan has proven efficient.
Epistaxis—Nose Bleed
The causes of nose bleed may be divided into two general groups, local and constitutional. The first group consists of trauma directly to the nose either external or internal, from nasal operations and other causes. The presence of a cluster of thin-walled veins on the anterior part of the septum which readily rupture from slight cause, constitutes perhaps the most common cause of nose bleed. The ulcers of atrophic rhinitis or syphilis occasionally cause bleeding. Malignant growths of the nose may cause frequent and profuse hemorrhage. The constitutional causes of epistaxis are, the acute fevers, cardiac and arterial diseases, which cause excessive tension; and cases of altered composition of the blood such as the anemias, malaria, purpura, chlorosis, hemophilia, etc.
Diagnosis.—Direct examination of the nose will usually reveal the cause. If there are no signs of trauma or rupture of the anterior group of vessels and the bleeding does not respond quickly to packing of the affected side, there is either a rupture of a large vessel, which requires long continued packing, or it belongs to the class of constitutional disease.
If there is evidence of some necrotic disease of the nose or if there are areas of exposed bone or cartilage from careless surgery, these may usually be seen and the point of bleeding located.
Treatment.—Cold applications, irrigation of the nares with cold normal salt solution and the application of an absorbent cotton or gauze pack is usually sufficient to stop the average case of epistaxis from any cause. The direct application of cold to the lower cervical region will cause capillary restriction.
There are many cases in which the membranes of the nose have lost their tone due to various irritants or from deficient nutrition to the parts. These are cases of a wholly different type from that of the well known necrotic diseases such as atrophic rhinitis and syphilis. Hay fever is a result of such a cause. The treatment in such cases consists of removing any local causes or osteopathic lesions and then normalizing the resistance of the membranes by the methods described under the treatment for hay fever.
The treatment for those cases of epistaxis due to constitutional disease depends wholly upon the causative factors and the proper treatment of these. Any local treatment in such cases will be expected to produce only temporary results.
Diseases of the Nasopharynx
The nasopharynx may be the location of acute or chronic inflammations, neoplasms, malignant or nonmalignant, processes of atrophy or hypertrophy, adhesions, etc. It is important to remember that the nasopharynx admits the Eustachian tubes and supports four superficially located ganglia of the fifth nerve.
Acute Nasopharyngitis.—Acute inflammatory processes of this region may result from rhinitis, infections of the lower pharynx, focal infections of these parts or from direct involvement of its own structures.
The symptoms are post nasal tenderness and mucus dropping. Some patients experience the sensation of a foreign body in that location. The thick, adherent collections of mucus are difficult to dislodge and sometimes are so persistent that they cause nausea. There is usually occlusion of the Eustachian tubes, resulting in partial deafness, tinnitus and often dizziness.
The Treatment consists of thorough cleanliness by irrigation and osteopathic corrective work to the cervical region. It is also essential to keep the anterior neck structures particularly those of the submaxillary region, thoroughly relaxed to maintain efficient drainage.
Chronic Nasopharyngitis
This is one of most common diseases of the nasopharyngeal tract, causative of many complications and yet perhaps the least recognized in proportion to its significance. The frequent occurrence of adhesions of the pharyngeal fossæ, hypertrophied membranes, enlarged spongy extensions of the inferior and middle turbinates (the posterior turbinate bodies) occlusion of the orifice of the Eustachian tubes and chronic, excessive secretion of thick mucus all show that this disease has either gone unrecognized or at least has not received proper treatment.
Treatment.—Complete surgical removal of all abnormal growths, adhesions, etc. as described under the treatment of chronic non-suppurative otitis media and this followed by thorough irrigation and other methods of local treatment described above are efficient. The successful treatment of this disease requires time. There has been a partial or, in some cases, almost a complete loss of the normal functions of the nerve reflex mechanism of these parts, peripheral reflex inefficiency and this must be restored. Efficient and long continued treatment of the lesions commonly found in the cervical and upper thoracic regions will do much to restore these normal functions, but this alone without the surgical treatment will never effect a permanent cure. Neither will the surgery and local treatment alone effect a cure. The whole treatment is required.
Adenoids
Adenoids are the hypertrophied lymphoid tissue of the nasopharynx. They occur commonly in children, as a result of acute inflammations. Possibly the suckling process of the child produces a partial vacuum of the epipharynx and thus causes excessive blood supply to the part and therefore excessive growth of these soft tissues.
Adenoids, however, are not confined to children but frequently occur in adults. In all cases they are a source of much annoyance and often the cause of acute and chronic disease.
Symptoms and Diagnosis.—Mouth breathing, head colds, partial deafness, etc. are the common symptoms. The flattened nose, the high arch of the hard palate and the stupid appearance of the face are diagnostic. By direct palpation to the nasopharynx the nature and extent of the adenoid mass can be determined and this is the best method of diagnosis.
Treatment.—Many methods of non-surgical treatment have been employed, but there is nothing as satisfactory as complete surgical removal. Adenoid tissue has no known function different from that of other lymphoid tissue and there is always sufficient to perform any necessary function without excess of adenoid growth. The excessive adenoid growth is in every case a detriment to normal development, because it impairs nasal respiration and usually causes chronic nasopharyngitis and thus reduces resistance against all diseases of childhood. There is therefore, no excuse, much less a reason, why excessive adenoid growths should not be removed surgically, provided it is properly and thoroughly done.
The operation for removing adenoids requires in children, a general anesthetic. In adults, a local anesthetic is used by some operators. I have found it best to first break the adenoid mass away from the side walls of the pharynx digitally. A LaForce or Gradle adenotome is then used to remove the adenoid mass. If either of these instruments is properly used it will always remove the greater part of the adenoid mass without undue trauma or injury to any of the pharyngeal structures. Curets should never be used because they almost never remove the adenoid mass properly, but they usually do injure the pharynx. Many cases of pharyngeal adhesions, Eustachian tube occlusion and nasopharyngitis result from direct injury caused by curets.
After the adenoid mass has been removed the finger is inserted into the pharynx and any adenoid growths in the posterior nares are removed. The pharyngeal fossæ are also thoroughly freed from adenoid tissue and adhesions and the orifices of the pharyngeal portions of the tubes are gently dilated. This method insures complete removal of all excessive adenoid tissue, and normal functions of the nasopharynx. Adenoids thus removed do not return.
After the surgical work has been completed the nasopharyngeal tract should be thoroughly irrigated with hot salt mixture solution. This thoroughly cleanses the membranes, hastens healing, prevents hemorrhage and avoids post-operative infection. Irrigation of the nasopharynx should be continued for some days or until all evidences of inflammation have ceased. The pharynx should then be examined to be sure that no adhesions have developed from inflammation, but if the operation is carefully done, complications will never result.
Diseases of the Oropharynx
Acute Pharyngitis
Acute inflammations of the pharynx alone or in common with inflammations of other parts of the nasopharyngeal tract are common. This disease is most common as a result of the acute infections affecting the nose and throat.
Etiology.—The predisposing causes are focal infections of the nasopharynx, such as tonsillitis, sinuitis, etc. Deficient nutrition or anemia of the pharynx or systemic anemia are common causes. Lesions of the cervical, upper thoracic and hyoid are common predisposing causes. Undue exposure of the neck in susceptible persons or too much or too tight clothing about the neck may also predispose to inflammations of the pharynx.
The exciting causes are the acute infections, colds and focal infections. Perhaps the most common exciting cause is tonsillitis, acute or chronic.
Symptoms and Diagnosis.—The characteristic dryness of the pharynx, pain and persistent coughing are diagnostic. Upon direct examination, the reddened, swollen appearance of the pharynx and posterior pillars can be seen.
Treatment.—The treatment should be general and local and should be determined by the causes and conditions present. This disease is usually an acute infection and like other acute infections, the usual systemic treatment should be applied.
The local treatment consists of thorough cleansing of the nasopharynx (by irrigation if the patient can permit) and the frequent (or occasional as required) use of some gargle until the inflammation has subsided. Any cleansing nonirritative solution may be used for a gargle. Equal parts of peroxide, alcohol and glycerine, a tablespoonful to a half glass of very warm water or ten to fifteen drops of phenol-glycerine to a half glass of warm water will make a good cleansing gargle.
The osteopathic treatment consists of corrective work to the cervical, upper thoracic and hyoid and thorough relaxation of the submaxillary musculature to obtain good venous and lymphatic drainage. If sufficient care be taken to avoid trauma, digital stretching of the soft palate and pharyngeal muscles by the use of the finger internally, is very efficacious.
Chronic Pharyngitis
Chronic pharyngitis may be hypertrophic, atrophic or granular. In hypertrophic pharyngitis the pathologic changes have passed beyond the stage of hyperemia and there is always hypertrophy or hyperplasia, usually the latter, of the pharyngeal membranes. These changes in most cases, have extended to and involved all of the nasopharyngeal membranes.
Chronic granular pharyngitis, or so-called clergyman’s sore throat, has a similar pathology to that described above, but with swollen and inflamed lymph follicles. This condition seems to be a result of excessive use of the voice.
Chronic atrophic pharyngitis has a similar etiology and the diagnostic signs are also similar to atrophic nasopharyngitis with which it is usually associated.
Etiology.—The causative factors are similar or the same as those of nasopharyngitis. Lesions of the cervical and upper thoracic and chronic focal infections such as tonsillitis, sinuitis, etc. are the common causes.
Treatment.—The nature of the treatment should be determined by the causes found. The nature of the pathology requires long continued treatment and careful attention to all causes. Thorough osteopathic corrective work, the removal of all sources of focal infection, proper attention to any gastro-intestinal perversions which may be causing auto-intoxication and thorough cleanliness of the parts by gargling with some cleansing, non-irritating solution and by irrigation.
In most cases there is a considerable collection of adhesions in the nasopharynx or posterior nares or in both. Enlarged “posterior turbinate bodies” and the extension of the inferior turbinates into the pharynx are also common results of the hypertrophic process. Complete surgical removal of this excess tissue and the after treatment as described above under chronic nasopharyngitis are frequently required to obtain complete and permanent results.
These cases can be successfully treated if the proper attention is given to all possible causes in each individual case. It is the individualization, the specific and detailed attention to the cause or causes, and such treatment continued for sufficient time, that will obtain results.
In atrophic pharyngitis, normal nutrition to the parts and usually to the entire system must be restored. Many such cases are secondary to systemic anemia or to rheumatic intoxication. A careful examination should be made for evidence of systemic causes. In many cases, I believe that thorough osteopathic corrective work applied to the mid and lower spine is the most essential part of the treatment. Other than this the local treatment as described under atrophic rhinitis applies here.
Tonsillitis
There is perhaps no other organ of the body, diseases of which have caused a greater variance of opinion relative to treatment than the tonsils. There are those who believe that every hypertrophied, atrophied, or infected tonsil together with its fellow of the opposite side should be removed. There are also those who believe that no tonsils, regardless of their pathology, should ever be removed. These are the radicals and their views are not at all in keeping with present day facts.
Those physicians and surgeons who have tried to arrive at some safe conclusion on this subject, believe that there are certain methods of non-surgical treatment which are effective in many cases and they also believe that in other cases, tonsillectomy is imperative.
Functions of the Tonsils.—Many and varied functions for the tonsils have been held by various theorists such as: the absorption of the products of salivary digestion; the secretion of an amylolytic ferment; that they are atavistic structures and therefore have no function; that they eliminate systemic toxins; that they serve as culture tubes for the production of vaccines; that they protect the deeper cervical tissues from bacterial invasion; the theory of internal secretion and a score of other theories which so far, have never been substantiated by either clinical or experimental evidence.
The hematopoietic theory or the theory of blood formation has a rather definite basis because such a function would be possible from the histologic structure. The formation of small lymphocytes has been attributed to tonsil tissue (Flemming) and this view has been generally accepted. Some of the lymphocytes however, find their way through the epithelial walls into the crypts and are discharged as “mucous plugs”, while others are carried by the efferent lymphatics into the circulatory system. In this respect, the tonsils, like other lymphoid tissue, produce lymphocytes which are essential constituents of the blood. This function is particularly marked during the growing period, but this function is also highly developed in all lymph nodules during this period, and in the growing child there is an abundance of such tissue and thus it seems that the tonsils, while important to the growing child, would not be at all indispensable structures.
Some physicians claim to have observed deficiencies in growth and development of children whose tonsils had been removed during the first ten or fifteen years of life, but this is not commonly accepted. The tonsils have their greatest cellular activity during the growing period and unless chronically hypertrophied they atrophy during adult life.
Tonsillectomy
We may safely conclude from this evidence, that in the growing child, it may be well to retain the tonsils providing they are not directly affected in such a way as to endanger the general health of the child, but that there is little, if any, danger in their early removal. In adults, there seems to be no reason why they should not be removed in cases in which there is evidence of involvement beyond restoration by treatment or those cases in which there is evidence of toxic absorption.
When surgical removal of the tonsils is indicated, the complete removal or tonsillectomy should always be done. A careful and complete enucleation of the tonsils when properly done will never be followed by any untoward results other than the temporary surgical sore throat. There is never any excuse, much less a reason, for partial removal of the tonsils or tonsillotomy, because such operations never accomplish the desired result and they nearly always require tonsillectomy later.
In association with a reputable vocal teacher I have studied the results of tonsillectomy on the voice. In none of the twenty cases studied was there any impairment following the operation, but on the other hand sixty per cent were improved either in range of pitch, quality or endurance, in addition to their being more free from laryngitis, pharyngitis, etc. for which the operation was done. Doctors Ruddy, Edwards and Reid of our profession have told me of similar experiences, so I am certain that tonsillectomy properly done will in selected cases, improve the voice.
Acute Tonsillitis
Acute tonsillitis is an acute infectious and often a contagious disease characterized pathologically by inflammation of the tonsils. Some authors differentiate between follicular tonsillitis in which the crypts or lacunæ are involved, and parenchymatous tonsillitis in which the parenchyma is involved.
Etiology.—The predisposing and exciting causes are the same as in other acute infections of the upper air passages except that there is usually a chronic tonsillitis as a result of some previous attack.
Symptoms and Diagnosis.—The symptoms also are similar to other acute infections of the nasopharyngeal tract, with sore throat, variable temperature, headache, etc. By direct examination of the pharynx, the protruding masses with white or yellow patches are readily seen.
Treatment.—Infection, drainage and elimination are three words inseparable in the therapeutics. The local treatment (I doubt if many will agree) in either acute or chronic tonsillitis is essentially the same—radical aspiration drainage. In all cases, except young children who will not permit it, I place a vacuum cup directly over the tonsil and apply as much vacuum as can be obtained. This treatment will, when properly done, empty the crypts of all pus. This accomplished, each crypt is probed with a cotton applicator dipped into phenol-glycerine.
Cervical and upper thoracic treatment and deep relaxation of the sub-tonsil tissues to increase the normal blood supply and to decrease congestion by drainage elimination are essential. The lower thoracic and lumbar should receive due attention for the purpose of increasing general elimination. The diet and other treatment are no different from that in other infectious fevers.
Peritonsillar Abscess
(Quinsy Sore Throat.)
Peritonsillar abscess results from the collection of pyogenic bacteria and pus formation between the tonsil and the pillars of the fauces. It is perhaps a result of the closing of an infected crypt causing deep penetration of the pus.
Diagnosis.—The symptoms are those of acute tonsillitis but usually more marked and with one tonsil decidedly more protruding than the other. In some cases the location of the abscess can be seen and it is comparatively easy to open with a knife or probe, but in many cases the abscess is so situated that it cannot be located except by exploratory probing.
Treatment.—Drainage by direct incision of the abscess pocket is indicated as early as a definite diagnosis can be made. There is no definite technic to be followed except to observe certain general principles. If the “pointing” of the abscess can be located, it is comparatively easy to make a good, free, direct incision and accomplish complete drainage. In many cases the only way to locate the pocket is to employ a probe or small, long, scalpel and explore between the pillar and tonsil until the pus pocket is found. As soon as this is located the pus pours out around the probe and this gives the location. Free drainage by means of a liberal incision should then be made. Aspiration of the pus pocket and filling with phenol-glycerine is effective after drainage has been obtained, but a liberal drainage must be maintained.
The non-surgical treatment as described under acute tonsillitis is to be applied here.
Chronic Tonsillitis
Chronic tonsillitis usually is the result of one or many attacks of acute infections of the tonsils. Occasionally cases of marked chronic tonsillitis occur in which the patient denies ever having had an acute attack.
The pathology consists of hypertrophy of the lymphoid tissue and connective tissue.
Diagnosis.—The purpose in diagnosis is not to determine whether the tonsil is hypertrophied but to determine whether the tonsil is causing any local or general physiological perversions and if so, whether local treatment or surgery should be applied.
The direct examination should be made very carefully, because otherwise a bad tonsil may be readily overlooked. The mere fact that a tonsil is large or has open crypts from which a whitish mass may be expressed does not mean that such a tonsil is directly responsible for local or systemic physiologic perversions.
The examination should be made by means of a tongue depressor, tonsil retractor and a good head mirror and reflecting lamp. Every part of the tonsil and surrounding pillars should be carefully examined. Firm pressure applied against the tonsil from in front and behind will often force material from the crypts or out around the capsular margin. Any such material thus expressed should be examined microscopically. By probing the crypts with a small pointed cotton-wound probe and staining the material obtained, the condition of the deep parts of the tonsil can be determined.
The symptoms in every case, are to be considered with the microscopic findings, but there are cases in which either of these, together with appearance on direct examination, is sufficient to determine the advisability of tonsillectomy.
In general, we may say that the following factors would indicate tonsillectomy.
1. Chronic, recurrent tonsillitis with or without complications, which does not respond to non-surgical treatment.
2. Positive evidence of arthritis of any form with microscopic evidence of some virulent organism, such as staphylococcus, streptococcus or long-chain pneumococcus, present deep in the tonsillar tissue.
3. Any persistent discharge of pus from the tonsil in which the microscope shows the presence of virulent bacteria and which will not be relieved by treatment.
4. Markedly hypertrophied tonsils which directly interfere with the voice, deglutition or respiration and which do not respond to treatment.
5. Persistent focal infections of the middle ears, or sinuses or root abscesses which do not respond to treatment and in which case there is a virulent infection of the deep parts of the tonsil, shown by microscopic examination.
The above are only general conditions and there are probably many other indications or groups of symptoms that would indicate tonsillectomy. In most cases, unless the findings show positively that tonsillectomy should not be delayed, we advise treatment. If treatment does not restore to normal, it will probably reduce the time of the surgical sore throat following the operation.
Non-surgical treatment.—The local direct treatment, as we practice it, consists of: 1. Direct aspiration by means of the tonsil cup, applying from fifteen to twenty inches of vacuum. 2. Application of phenol-glycerine by means of cotton applicator to the full depth of each crypt. 3. Irrigation of the crypts by means of a catheter and hot salt mixture solution. 4. Syringing of the crypts by means of the catheter and phenol 10%, alcohol 20% and glycerine 70%.
The digital treatment of the tonsil consists of: 1. Applying pressure against the anterior pillar thus forcing the contents out of the tonsil, the Ruddy method. 2. By the bidigital technic, the front finger of one hand inside, posterior and inferior to the tonsil and the fingers of the other hand outside exerting deep pressure and opposing the finger inside. In this way the tonsil can be lifted forward and upward and its contents expressed. The digital treatment is not as effective as that described above.
The osteopathic corrective treatment consists of adjustment of the atlas and axis and the mandibular articulation and the obtaining of free movement of the hyoid and the relaxation of the submaxillary musculature and other deep structures.
This treatment, if followed persistently, will relieve the local symptoms of a very high percentage of cases of chronic tonsillitis, and in many cases even the systemic complications will be relieved. Whether in cases of systemic absorption this is the preferable treatment I am not sure, because, once the local condition is improved the patient will usually refuse operation and even if the physician finds definite evidence of toxic absorption he cannot convince the patient that his tonsils require surgery.