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The personal claims of a manufacturer may be regarded as partisan, but when a manufacturer makes no claim for his product, contenting himself with presenting the consensus of opinion of thousands of physicians, his statements merit consideration and his product deserves investigation from those members of the profession who have not used it.

Clinical Results Prove Therapeutics

and clinical results, reported by thousands of successful practitioners, demonstrate that

Papers read at the Twentieth Annual Meeting held in Council Bluffs, la., September 5, 6, 1907.

TONSILLECTOMY VS. TONSILLOTOMY; AND A SIMPLE TECHNIQUE.

David C. Hilton, A. M., M. D., Lincoln, Nebraska.

EMOVAL of the faucial tonsils by bistoury and finger nail exsection is known to have been commonly practiced two thousand years ago. It is unfortunate for tonsillar surgery that operative procedures have so far antedated the inductive study of the gland and of its relations to contiguous and to remote tissues, Questions of choice in surgical methods are burdened with a legacy of notions, prejudices, and criticisms born of antiquated and empirical misconceptions. These tend to befog judgment in adapting operative treatment of the tonsils, to our best knowledge of their pathology. Hemorrhage is the one accident that has been a disturbing element in the removal of the gland, and the fear of it has at times caused this surgical procedure to become obsolete.

Operations for the removal of a tonsil may be undertaken to excise a segment of the gland-tonsillotomy; or to enucleate it as completely as possible-tonsillectomy. To appreciate the radical differences between these two operations and to choose the one or the other wisely, the surgical anatomy of the parts and their pathology as relates to the gland, and to contiguous and remote tissues, must be understood.

The surgical anatomy is essentially a study of the pterygopharyngeal space (Fig. 1, P.p.s.). This space is bounded externally by the internal pterygoid muscle contiguous to the inner surface of the lower jaw (Fig. 1, M. p.i.). Internally it is bounded by the pharyngeal surface on which the pillars of the fauces and the intervening sinus containing the tonsil present (Fig. 1, A.g. p.,A.p.p). Posteriorly it communicates with the pharyngeal maxillary space adjacent to the posterolateral angle of the pharynx in which lie the great vessels of the neck.

The surgical anatomy of this space may be conveniently divided into that of the pharyngeal surface and that of the deep or subtonsillar tissues. In the former, we have to consider the contents of the sinus tonsillaris, and the anterior and posterior pillars of the fauces-glossopalatine and pharyngopalatine arches, respectively.

The sinus tonsillaris is a pocket between the anterior and posterior pillars of the fauces (Fig. 2, a.b.c.). Embryologically, it represents part of the second branchial cleft intervening between the second and third branchial arches form which the anterior and posterior pillars respectively develop. Each sinus is ordinarily occupied by a tonsil, the plica triangularis, and two fossae.

It is

The tonsil is a compound follicular gland, ordinarily not larger than an almond, and arises from hypoblast and subjacent mesenchyme in the sinus tonsillaris during the middle third of gestation (Fig. 2, a.). essentially composed of an epithelial and subepithelial increment. The epithelial portion makes up the mucous membrane lining the pharyngeal surface of the gland and the crypts opening thereon. The crypts are tubular invaginations of the mucosa extending into the subtsance of the gland. They often subdivide and anastomose with each other so as to make an intricate network of tubular channels. The subepithelial portion of the gland develops from the mesoblast and is essentially made up of lymphoid cell masses lying in a meshwork of connective tissue trabeoulae. These trabeculae carry the vessels and the nerve supply from the peritonsillar tissues.

The plica triangularis is a triangular fold of mucous membrane ex. tending from the free margin of the anterior pillar posteriad over a portion of the posterior surface of this pillar and a part of the pharyngeal surface of the tonsil (Fig. 2, e.). The plica subdivides the sinus tonsillaris diagonally from above downward and backward into two compartments. The space posterior to the fold contains the tonsil, and that anterior is unoccupied. The latter is a fossa between a portion of the posterior surface of the anterior pillar and the gland. It seems not to have been accurately described or named as an anatomic entity heretofore, and the author has denominated it the fossa plicae triangularis (Fig. 2, e.).

The fossa plicae triangularis may occupy the greater part of the sinus, or be reduced to scarcely demonstrable portions. In the consecutive observation of one hundred patients, it was demonstrable in ninety-six, and well marked in sixty-five. If the tonsillar border springs from the anterior pillar at a point opposite or above the upper extremity of the tonsil, the gland may not be united to the anterior pillar at any point; the fossa intervening between them. When the tonsillar border of the plica is well developed and the fossa is deep it may have the appearance of a third pillar.

The fossa may be obliterated by an hypertrophic tonsil behind the plica crowding forward, by an atrophic tonsil retracting the fold so that the space merges with the general cavity of the sinus, or by instrumentation. The fossa may take the form of a slit between the pillar and the gland. It is most persistent opposite the lower end of the anterior pillar. The crypts of the tonsil do not ordinarily open into this fossa. They open upon that surface of the gland presenting inward between the tonsillar border of the plica and the posterior pillar, and also upon that surface presenting upward into the fossa supratonsillaris.

The fossa supratonsillaris is that subdivision of the sinus lying above the tonsil (Fig. 2, d.). Three or more of the crypts open into it. It is occasionally obliterated by shrinking of the tonsil, or by operation. In a series of one hundred consecutive patients examined, it was not demonstrable from the general sinus cavity in three instances in which the gland had never been operated on.

Fig. 2

D.C.H.

a

d

a, tonsil; b, posterior pillar; c, anterior pillar; d, fossa supratonsillaris; e, fossa plicae triangularis, and plica triangularis.

The anterior pillar is a fold of mucous membrane containing the glossopalatine muscle, and branches from the lingual artery (Fig.2, c.). It extends from the soft palate above to the side of the tongue below. It is completely or partially separated from the tonsil by the fossa plicae triangularis. The length of that portion opposite the tonsil varies greatly and depends on the position of the tongue where the pillar joins it Even when the tongue is well depressed, this junction is usually above the level of the lower pole of the gland.

The posterior pillar is a similar fold containing the pharyngopalatine muscle and branches from the lingual artery (Fig.2, b.). It extends downward from the point in the soft palate where the pillars bifurcate, into the side of the pharynx. Its pharyngeal extremity is often consider. ably lower than the glossal extremity of the anterior pillar. The tonsil from pole to pole is adherent to this pillar, and occasionally extends past its lower extremity, to disappear in the mucosa of the pharynx as a tapering band of lymphoid tissue.