H. Gradle
1883 Journal of the American Medical Association (JAMA)  
why he preferred scissors to the tonsillotome, but presume it was on account of the large size of the tonsils. He snipped off a portion of one of the growths, but the profuse haemorrhage which followed prevented immediate removal of more of the mass. The first attempt, it seems, discouraged both phy¬ sician and patient, and her request to leave met with but slight remonstrance. The patient put up with the discomfort caused by the growth, until her suffering compelled her to consult a physician,
more » ... onsult a physician, who suggested the removal of both tonsils. Using a tonsillotome, he skillfully ringed and re¬ moved a small portion of one tonsil, when, according to the doctor, blood gushed from the patient's mouth, the profuse and continuous haemorrhage being only checked by the expenditure of much time and labor. The case was then referred to me. I found the pa¬ tient's throat occupied by a remarkably enlarged ton¬ sil. Although the fauces were roomy, but little space remained for respiration or food. The growths were paler in hue than the surrounding mucous membrane. The surface of each tonsil was roughened by numer¬ ous fine indentations. They seemed to indicate that the tonsil had undergone an irregular increase, being retarded at certain points by the fine strands of firm fibro-cellular tissue forming part of its substance. In this respect, its appearance was quite different from the familiar smooth, glandular, hypertrophied tonsil. It had the consistency of cartilage, giving a harsh, gritty sensation when pressed upon. I was reminded by these peculiarities, of my disagreeable experiences with the case already described. Her unfortunate history demonstrated the correctness of my observa¬ tion. 1 hesitated to operate upon the patient by the usual method. Mindful of the efficiency of my écraseur in operating upon vascular tumors of the nares, I selected it as for removing the tonsils without. The right tonsil was snared with No. 5 piano wire, and severed in a line with the pillars of the fauces. More than three hours were occupied in its removal, and when the divided mass was drawn from the throat, not a drop of blood escaped from the wound, nor was the saliva even tinged with blood subsequent to the operation. The patient declared she suffered no pain, and only complained of the operation being tedious. She was away from the city for three months. On her return, I was unable, by looking directly into the throat, to discover a trace of tonsillar tissue on the side from which the growth was re¬ moved. Absorption had left a sulcus between the right faucial pillars. The patient was exhibited to the students at the University Medical College, and the left tonsil eradicated in the same manner. I do not desire to play the part of an alarmist in discussing hcemorrhage after tonsillotomy. Neverthe¬ less, I believe the subject demands serious attention, in view of the number of deaths recorded as result¬ ing from the use of the knife, taken into considera¬ tion, with the natural hesitancy shown by some phy¬ sicians to publish unfortunate results, which is not a mere surmise, but an inference based upon the experi¬ ence of surgeons, communicated in a spirit of confi¬ dence, the question of the possibility of distinguish¬ ing between the hcemorrhagic and non-hcemorrhagic tonsil naturally suggests itself. I believe such a dis¬ tinction can be made in many cases by carefully comparing the appearance of enlarged tonsils, giving diverse results when operated upon. The hard or scirrhous tonsil just described, differs in many respects from the soft or malachotic gland. The malachotic, hypertrophied tonsil has a smooth surface, is often lobulated, being soft to the touch, and is usually of a light-pink color. The scirrhous hypertrophied tonsil has a rough, irregular surface, is exceedingly compact, gives a harsh, cartilaginous sensation when touched, and has a somber hue. For the removal of the firstmentioned variety, I would give preference to the tonsillotome. Any haemorrhage occuring while these tonsils are excised by the guillotine soon ceases. In this respect, they resemble the adenoid hypertrophies found in the vault of the pharynx. The scirrhous tonsil, on the contrary, bleeds profusely when incised. The analogy it bears in this respect to firm fibroid tumors is quite striking. My écraseur offers a safe, simple and reliable means for the removal of these dangerous tumors. I would discourage the use of all sharp instruments in operating upon scirrhous tonsils, believing the histories of serious or fatal hoemorrhages occur as a result of the indiscriminate use of the knife. I would recommend the knife for excising the smooth and somewhat compact, enlarged gland known as the hyperplastic tonsil. Indeed, a knife when it can be safely used, is to be preferred to the écraseur since it expedites the operation and only causes momentary pain. The scirrhous tonsil is often associated with a syphilitic history. The objection raised that the operation is inconvenient on account of the large expenditure of time, has been overcome by a very simple modification of my écraseur. I pre¬ sent to your notice this simple method of removing enlarged tonsils, as its safenessand efficiency have been tested upon a number of cases with unvarying success. You will find my distinction useful, if carefully studied. The discrimination is easily made, and must prove valuable as giving confidence to the operator.
doi:10.1001/jama.1883.02390010028001c fatcat:cfhxznkaynawpah66czsub7gf4