The principles and practice of modern surgery

by Roswell Park

None of these methods gives promise of complete extirpation of the tissue, which is often chronically diseased, and it is often well, therefore, to complete the extirpation with the sharp spoon or even to use the finger-nail as a curette. Hemorrhage will be active for a few moments, but is nearly always controlled with either iced water or water as hot as can be borne. Only rarely does it give rise to serious trouble. In such cases adrenalin may be used. Cases are on record where it has been necessary even to tie the carotid, but such instances are mostly bugbears which need not deter one of good judgment from a properly devised operation. Antiseptic gargles, and avoidance of speech and swallowing of hard food, will be all that are needed in the after-management.

The young and the timid will need complete anesthesia, which should be complete in order to abolish reflexes, and cocaine locally to ensure this condition. Many of these subjects are, however, those presenting minor degrees of the status lymphaticus, to whom anesthetics should be administered with caution. In such children tonsillotomy should be combined with the erasion and removal of other involved adenoid tissue in the nasopharynx. Inquiry should be made as to whether the patient bleeds unduly freely after minor injuries. In a bleeder it would be well to proceed with caution or abstain from operating.

Foreign bodies in the tonsil are as often fish-bones as any kind; they all give rise to serious irritation. True calculous formation in the tonsil is known. Every foreign body which can be detected and exposed should be removed.

Tumors of the tonsil are usually of the malignant type, either epitheliomatous or sarcomatous. A cancer of the tonsil should be recognized as such very early if operative or other relief is to be effectually afforded, and if operation is made it should be done more thoroughly than can be done through the mouth.

External pharyngotomy is the measure usually required for this purpose. This is usually performed by making a long incision along the anterior border of the sternomastoid muscle, and, after retracting it, making careful and blunt dissection down in the direction of the tonsil, separating tissues which are evidently not involved, but excising everything in which infiltration can be recognized. An extensive operation of this kind would justify preliminary or provisional ligation of the common or at least the external carotid artery. Care should be taken to avoid wounding the nerve trunks, especially the hypoglossal.

Subhyoid pharyngotomy is performed by a transverse incision just below the hyoid bone, with division of the platysma, the omohyoid, the sternohyoid, and the thyrohyoid muscles, leaving enough of their insertion into the bone to permit of subsequent reunion by suture. The thyrohyoid membrane is then divided in such a way as to also permit of its reunion by sutures. Then the mucous membrane, which will probably now protrude into the wound, is caught and divided, retraction sutures being inserted in the edges of the wound. The epiglottis may be retracted or a suture may be passed through it, to be used as a retractor. The lower portion of the pharynx is now exposed and through this opening the tonsil may be removed. After completion of the deeper work the different layers of the tissues are reunited with chromic gut and the deep wound is drained.

Transhyoid pharyngotomy. Vallas has suggested a central method of approach to the pharynx by a median incision, through which the mylohyoid muscles are separated, the body of the hyoid exposed, and its division effected with stout scissors or with cutting forceps. When its two halves are retracted a space over an inch long is made, through which the mucous membrane of the pharynx may be opened, this being done by making it protrude with the finger passed into the throat, which shall thus serve as a guide. In closing the wound it is not necessary to make suture of the hyoid bone.

THE TEETH, THE ALVEOLAR PROCESS, AND THE GUMS.

The alveolar process, which furnishes the actual sockets for the teeth, and which carries that peculiar fibrous texture with its mucous covering known as the gum, is a frequent site of ulcerative disease and fertile source of infection. While the toilet of the mouth is much more generally attended to at present than in times past, the majority of people are extremely inattentive and indifferent to the condition of the teeth and the gingival borders. As elsewhere stated the mouth is the habitat of an extensive flora and fauna, and deposits of tartar along the gingival border afford excellent hot-beds for their development and growth. This accounts for the marginal ulceration of the gum, or ulcerative gingivitis, seen in so many mouths, and it may be regarded as the beginning of a disease process, pyorrhea alveolaris (Rigg’s disease), that will eventually cause the loss of the teeth and extensive infection of the lymphatics in the neck. In almost every mouth where such accumulations of tartar have taken place the expressions of local infection may be traced by a bluish or purplish line along the gingival border, with some degree of sponginess and mild ulceration.

The enamel covering the teeth is extremely resistant, but when the dentine is exposed below the enamel line, as happens in such instances as those just described, bacteria may easily enter the dental tubules, and dental caries or alveolar suppuration is the result. In order to prevent such disease the services of the dentist should be secured at least as often as every six months, in order that all tartar may be removed and the gums placed in a healthy and resistant condition.