TONSILS, DISEASES OP of a solution of Eucaine, the fine point of the cautery is thrust into the hypertrophic tissue at several spots so as to destroy small areas of the enlarged gland ; the subsequent cicatrisation may cause marked shrinking of the diseased organ. The plan of reducing the size of flabby tonsils by the application of a mild continuous current has been practised, but it usually fails.
Removal of enlarged tonsils by the knife, guillotine, snare, enucleation, or piecemeal extraction by punch forceps (morcellement) is the only satis factory and reliable procedure in the great majority of instances.
Much difference of opinion exists about the relative value of the above mentioned methods and of the various details in each operation. Some authorities recommend a partial removal and trust to the subsequent cicatrisation for effecting the reduction of the enlarged remnant of the gland. Others insist upon the continuous dangers of septic absorption from the recesses of the stump, and recommend complete enucleation. When the guillotine operation is decided upon, this may usually be carried out after cocainisation of the tonsil by a 5 per cent. solution. Burns strongly advises Quinine and Urea in 2 per cent. solution as the best local anesthetic; he injects a few minims into several parts of the tonsil 5 or 6 minutes before operating. In children a general should be administered, and all authorities agree that Ether is the safest. As hemorrhage is a danger always to be anticipated, it is advisable to administer Chloride of Calcium for a few days before operation. An injection of Pituitary Extract is, however, much more reliable.
The spade guillotine of Mackenzie may be passed into the illuminated mouth as the patient sits facing the operator with his tongue depressed by the surgeon's finger, and after the projecting part of the gland has been manipulated into the lumen or ring of the instrument the blade is pushed firmly home by the operator's thumb as he keeps the guillotine steady by a firm hold of his fingers. In slicing a very firm or tough tonsil by this method much help will be obtained by firm pressure from without at the angle of the jaw, so as to keep the tonsil from escaping from the lumen of the instrument before pushing home the blade.
By skilful manipulation of the guillotine the entire tonsil can be enucleated satisfactorily, and the faucial pillars and part of the capsule left.
I hemorrhage may be controlled by swabbing with Adrenalin solution; rarely will it be necessary to tie or twist any vessel. The galvano-cantery
may he employed to touch a bleeding spot. Ice usually stops capillary oozing.
The after-treatment consists in keeping the patient quiet in bed with his head raised,and food in the form of cold or iced milk should be adminis tered at short intervals. The i in too Carbolic spray is the most con venient and efficacious antiseptic application. Peroxide of Hydrogen is also a valuable local antiseptic.
Some surgeons prefer to seize the tonsil with volsella forceps, and remove a slice from the enlarged organ by a sharp probe-pointed bistoury. The snare or ecraseur with a hot wire is employed sometimes when there are special reasons for anticipating hemorrhage and when the enlargement is great. The piecemeal operation is seldom indicated, unless when the enlargement cannot be got into the guillotine. It is carried out by seizing the organ at several points with Rault or Tilley's punch forceps, and removing a portion of tissue with each bite till the bulk of the organ is considerably reduced.
Enucleation may be carried out by Waugh's operation, in which the capsule of the tonsil is fully exposed by a long incision made with a fine toothed forceps close to the free margin of the anterior faucial pillar while the tonsil is drawn upon by a Hartmann's conchotome. By steady traction and the use of forceps or blunt-pointed curved scissors, the enlarged organ is separated from its bed and removed.
The enucleation of an enlarged tonsil by the finger alone may be effected as in operation for adenoids, but usually it will be found more convenient to snip with a scissors the faucial mucous membrane, after which the gland may be shelled out by the use of the finger-nail. As a rule the hiemorhage is slight.
As already stated, complete enucleation can be effected by using the guillotine, as Mackenzie advises, by adjusting the ring around the tonsil from below and behind, pressing the gland strongly forwards and upwards, when the surgeon's index-finger, by pressing on the bulging soft palate, causes the tonsil to turn inside out through the ring of the instrument before cutting.
Murphy performs the operation of circumcision on the tonsil, in which he removes the plica triangularis (which is the obstacle to proper drainage of the tonsil) by means of the Hartmann tonsil punch.
Both tonsils may be removed at the same time by any of the above mentioned methods, and when adenoids are present they should be also extracted.