The Galvano-Cautery in the Treatment of Hypertro- phied Tonsils. BY CHARLES II. KNIGHT, M. D. REPRINTED FROM Neto York iHetiical for September 18S7. Reprinted from the New York Medical Journal for September 1887. THE GALVANO-CAUTERY IN THE TREATMENT OF HYPERTROPHIED TONSILS * CHARLES H. KNIGHT, M. D. We have been told by one authority that in the normal condition the tonsils do not exist, or at least are not visible,! while another observer has recently asserted that these or- gans perform an important function in eliminating from the saliva certain ingredients which would otherwise be wasted.J The special office of the portion of secretion thus absorbed is supposed to be to provide nutrition for the leucocytes formed in the tonsils. The old idea of the function of these bodies seems to have been that they furnished a lubricating secretion to facilitate the act of swallowing, as possibly suggested by the curious definition given in Moth- erby's "Medical Dictionary," published in 1795, which reads as follows : " They are of a reddish color, and exter- nally have many holes, which communicate with an irregu- lar cavity in their inside, and which contains a viscid fluid, which is gradually discharged from the holes into the * Read before the American Laryngological Association at its ninth annual congress. f F. H. Bosworth, " Trans, of the N. Y. Academy of Medicine," vol. iv, 1886, p. 298. | R. Kingston Fox, "Jour, of Anat. and Physiol.," July, 1886, p. 559. 2 THE GALVANO-CAUTERY IN THE throat." Whether we accept this view, or adopt the theory that they are in some way concerned in haematosis/or invest them with both these functions, the fact is evident that in many individuals the tonsils undergo enlargement to such a degree as to impair health, if not to endanger life, since in their hypertrophied condition they show a constant propen- sity to inflammation, which may assume a serious aspect. A fatal case of enlarged tonsils has been reported by Dr. C. A. Blair,* death resulting apparently from asphyxia. A case, reported by Shaw, is referred to by Lefferts,f in which tracheotomy was actually performed in order to save the life of the patient. A similar case has been reported by Puech. J The picture of a typical example of hypertrophied ton- sils is a fatniliar one. If a child, the victim of this condi- tion has the appearance of feeble health, the face is pale, the teeth are closely crowded in the narrow jaws, the mouth is small and is generally kept open, the lips are thick, the lower one often projecting and inverted, these condi- tions being due in part to defective development, and in part to the habit acquired of drawing the lower jaw forward in order to drag the tonsils away from the opening of the glottis. The nose is pinched, the nostrils are small and narrow. The voice is thick and lacks resonance. The child is apt to wear a heavy, stupid expression. Finally, the so-called " pigeon-breast " deformity results from the extraordinary labor demanded of the respiratory muscles. And yet we sometimes hear the advice given to let a child outgrow this condition. Undoubtedly, atrophy will in most cases occur after puberty, if the subject survives to that period, but meantime development is retarded, and ro- * " Med. and Surg. Reporter," Philadelphia, 1880, xlii. f " Med. Record," New York, 1879, xvi, 601. | " Moniteur des hop.," 1857. TREATMENT OF HYPERTROPHIED TONSILS. 3 bust health is utterly impossible. No doubt, too, when the hypertrophy of the tonsil is dependent upon a constitutional taint, much-relief may be obtained from general medication, hygiene, generous diet, etc. The question of the relation between hypertrophied tonsils and the constitution of the patient has been much debated. In his " System of Human Anatomy," * Dr. Harrison Allen observes that " it is rational to assume that overgrowth of the tonsils is an attempt at compen- sation on the part of an organ engaged in manufactur- ing blood-corpuscles, when other blood-making structures, such as the medulla of bone, are inactive." Treves, in his work on " Scrofula," f says that one of the most common manifestations of scrofula is the enlarged ton- sil. On the other hand, Bosworth J asserts that " it is the result of a purely local morbid process, not the outcropping of a constitutional dyscrasia. Impairment of health, if present, is a result, not a cause." Probably in many in- stances it would be more correct to say that impairment of health is both a cause and a result. In either case prompt recovery, or even marked amelioration, is not likely to ensue from any system of drug-giving or local applications. Very often improvement in the general condition is accom- panied by decrease of local tumefaction, but the true hyper- trophied tonsil never entirely disappears until maturity. From a critical review of the subject of amygdalotomy, by Felix Semon,* it appears that a process of atrophy is to be expected in not more than three fourths of the cases. In the mean time, nasal voice, defective articulation, mouth- breathing and snoring respiration, facial disfigurement and * Section vi, p. 640. f F. Treves, "Scrofula and its Gland Diseases," 1882, p. 110. f " Trans, of the N. Y. Acad, of Med.," vol. iv, 1886, p. 305. * "St. Thomas's Hosp. Rep.," vol. xiii, 129. 4 THE GALVANO-CAUTERY IN THE thoracic deformity, impaired audition, not from encroach- ment of the enlarged gland upon the Eustachian orifice, but from thickening of the mucous membrane of the tube, imperfect mastication, dyspepsia, and declining general health-comprise a train of symptoms which render the ex- istence of the patient a burden to himself and to others. The extraordinary statement occurs in Billroth's " Surgical Pathology "* that hypertrophied tonsils are commonly a sequel rather than a cause of pharyngeal inflammation, and hence relief of the latter can not be expected to follow their extirpation. Quite the contrary opinion is generally held. Disturbed cerebral circulation as a result of pressure from the enlarged glands has been suggested by Chas- saignac, f and the same observer has called attention to dis- orders of digestion due not only to impeded deglutition, but also to the conveyance of putrid secretions from the tonsils to the stomach. Mackenzie J notices that the senses of smell and taste become defective if the condition of hypertrophy be allowed to persist for a long time. In view of all these possible evils, the question of surgical in- terference must be considered. The surgical treatment of enlarged tonsils has been a subject of no little discussion. The large number of amyg- dalotomes devised by various operators bears witness to the favor with which a cutting operation is regarded, while the supposed danger of haemorrhage altogether deters not a few surgeons from the use of the knife. The question of haemorrhage after amygdalotomy was the subject of an able paper presented to this association in 1881 by Dr. Lefferts.* The conclusions then reached were that fatal haemorrhage * Transl. of 4th German ed., N. Y., 1872, p. 611. f " Lemons sur 1'hypertrophie des amygdales," Paris, 1857, p. 7. j " Diseases of the Nose and Throat," vol. i, p. 65. * "Trans, of the Am. Laryngol. Assoc," 1881, p. 136. TREATMENT OF HYPERTROPHIED TONSILS. 5 was rare, that dangerous haemorrhage occasionally occurred, that serious haemorrhage, immediate or remote, was not un- usual, while moderate bleeding, to a degree requiring press- ure or the use of strong astringents, was common. In the course of the discussion following, Dr. Allen stated that he had discarded the bistoury and amygdalotome for fear of haemorrhage, and was inclined to prefer the galvano-cautery. On the other hand, Elsberg announced that he had operated more than eleven thousand times, generally by cutting, and had met with but two cases of alarming haemorrhage. In my own experience only two cases of serious bleeding have oc- curred-one in a child, which came on on the fifth day after a very radical amygdalotomy, and ceased spontaneously; the other in an adult, the haemorrhage being finally checked by continuous pressure. A somewhat careful review of the literature of the subject shows that a large majority of cases in which this accident has happened were those of adults, and that in most of them it followed the use of the bistoury. According to Mackenzie, four cases have been reported by Velpeau in which the internal carotid artery was laid open during removal of a tonsil with the bistoury. Billroth * seems to have wounded the ascending pharyngeal artery while operating with a bistoury. Other cases are on record of haemorrhage from a large tonsilar artery, from injury to one of the faucial pillars, and from wounding the venous plexus at the lower border of the tonsil. It seems to me, however, that this risk of the operation in children has been overestimated. Yet it must be admitted that the dan- ger of haemorrhage is the chief objection to excision of the tonsils. Probably few of us use the amygdalotome without the suggestion of its possibility. Among arguments in opposi- tion to removal of the tonsils in general, which are sometimes * J. Walker Downie, "Edinb. Med, Jour,," August, 1886, p. 116, 6 THE GALVANO-CAUTERY IN THE urged, may be mentioned the statement that the voice is thereby weakened and the sexual function impaired. Obser- vations to the contrary are now too numerous to leave any room for question on these points. There has been a super- stition that enlarged tonsils are a protection against infec- tive disease, but it is now pretty generally agreed that they are a direct encouragement to infection, especially diph- theritic, while the subject of this hypertrophy is constantly liable to attacks of amygdalitis and peri-amygdalitis, ex- tremely painful and often disabling. It is hardly probable that "suicidal mania," as a result of amygdalotomy, will be used as an objection to the operation by those who present an adverse plea, but it may be of interest to notice incidentally that four cases of suicide after amygdalotomy have been re- ported by Rubio.* In addition to haemorrhage, which, if not serious, may be very troublesome and a source of agita- tion to the patient, it is not uncommon to meet with other obstacles to a cutting operation. We frequently see broad, flat tonsils, deeply seated between the pillars, the anterior pillar often overlapping the gland and being firmly adherent to it. The use of the guillotine here is difficult, if not im- possible. Finally, in some cases the patient's aversion to the knife can not be overcome. Under such circumstances the galvano-cautery, said to have been introduced into surgery by Middeldorpf, offers a satisfactory alternative. Two methods of its application to the treatment of enlarged tonsils have been found useful-by cautery-puncture, as practiced by Voltolini, and by the gal- vano-caustic snare. In the former method a fine cautery- point is passed deeply into a crypt of the enlarged gland, if we have to deal with a condition of simple hypertrophy, or in the case of a hyperplastic tonsil, where the crypts are * R. B, Taylor, " On Amygdalotomy and Suicide," " Med. Times and Gaz.," ii, 1881, p. 758. TREATMENT OF HYPERTROPHIED TONSILS. 7 more or less obliterated, it may be forced directly into the substance of the tonsil. Not more than three independent lacunae should be cauterized at one sitting. The pain of the operation is usually not severe, and inflammatory reac tion is seldom excessive. By the fourth or fifth day all local disturbance will have subsided, the eschar may be par- tially detached, and the operation may be repeated. In this way the largest tonsils may be destroyed in from five to ten sittings, according to the tolerance of the patient. At the International Laryngological Congress, held in Milan in 1880, Krishaber stated that he had been obliged to use the thermo-cautery of Paquelin in one case no less than fourteen times.* Such an experience with the galvano-cautery would be very exceptional. Still he maintained that patients sub- mitted to burning more readily than to cutting. In one of my cases, that of a boy not ten years old and of highly nerv- ous temperament, the use of the galvano-cautery had to be abandoned after the second operation, not, as the patient admitted, on account of pain, but because he could not over- come his repugnance to the idea of being burned. In this case treatment has been continued by means of applications of London paste, and the patient himself states that it causes greater and more lasting pain than the galvano-cautery did. Many patients complain of the disagreeable odor of the burn- ing tissues more than of pain. The discomforts of the op- eration and of the succeeding days may be reduced to a minimum by preliminary applications of cocaine in ten- per-cent. solution, and the subsequent use of carbolized alkaline gargles and, if necessary, further applications of cocaine. Galvano-caustic ecrasement is much more rapid and naturally more painful than cautery-puncture. A single operation by the former accomplishes the results of many * " Trans, of the Int. Laryngol. Congr.," Milan, 1880. 8 THE GALVANO-CAUTERY IN THE weeks by the latter. Moreover, the amount of tissue actual- ly removed by the snare does not represent the total effect of the operation, since the parts left behind are cauterized to a considerable depth. The galvano-caustic snare is op- posed by some writers, among them Schech,* who maintains that its use involves too much trouble, that it is difficult to secure an even cut surface, and that it does not exclude the danger of haemorrhage. The first objection may perhaps be admitted; the second and third are groundless. A single case of haemorrhage after the use of the galvano-caustic snare has been reported by Capart.f The bleeding, which was rather alarming, occurred in a child, eight years of age, five days after the operation, and was undoubtedly provoked by immoderate use of the voice. Two precautions are essential. The current should be employed intermittingly, and traction should be made upon the loop only during the passage of the current. Tn this way haemorrhage may be entirely avoided, and the danger of damaging the pillars of the fauces and neighboring parts by diffusion of heat may be prevented. Should any unevenness of surface remain, it is a very simple matter to remove it by subsequent cauterizations. Inclusion of the greater part of the tonsil within the loop may sometimes be effected by dragging it from its bed by means of a volsella or a mouse-toothed forceps, or by the use of a transfixion needle. In several cases pain has been almost wholly abolished by injecting into the paren- chyma of the tonsil, before applying the snare, six or eight minims of a ten-per-cent, solution of cocaine. At best this method is rather disagreeable, and is apt to be followed by * " Diseases of the Mouth, Throat, and Nose." Transl. by R. II. Blaikie, 1886, p. 130, f " Trans, du congres internal, de laryngologie," Milan, Sept., 1881, p. 96. TREATMENT OF HYPERTROPHIED TONSILS. 9 considerable local disturbance. Its only advantage over galvano-puncture is that of being less tedious. The choice of a battery is of some importance. What is known as the " C & C " Electric Motor Battery has given me excellent satisfaction. For the snare, No. 30 platinum wire has been found to be more readily heated, more easily manipulated, and to cut the tissues with greater facility. The use of the galvano-cautery in very young children will probably often be found impracticable, except under general anaesthesia. Only two of my own subjects were under the age of ten years, and one of these was unmanage- able. It is not my intention, therefore, to recommend the galvano-cautery as a universal substitute for excision of the tonsils. In the vast majority of cases a cutting operation is both possible and preferable. Galvano-cautery should be reserved for a comparatively small proportion of cases, in- cluding those in which the haemorrhagic diathesis is present or suspected, those in which vascular anomalies may be rec- ognized, those in which anatomical conditions prevent a suf- ficiently complete excision of the organ, and those in which the use of a knife is positively declined. I am strongly disposed to add that this method should be chosen for all adult patients. At any rate, as Semon has suggested, a pa- tient above the age of twenty should be allowed his option after a fair presentation of the risks and advantages of the two methods. 20 West Thirty-first Street. REASON'S WHY / "(/■-v * ** ■» Wteii JWT Physicians should Subscribe '■ ■ -for- The NewYork Medical Journal, Edited by FRANK P. FOSTER, M.D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. 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