REMOVAL OF TONSILS AND ADENOIDS. \

By G. T. BIRDWOOD, m.a., m.d., \J Deal and Walmcr Hospital, Kent.

The operation for removal of the tonsils and adenoids is frequently called for in the large towns of India, where European and Anglo- Indian communities are met with. Indians themselves do not so frequently suffer from enlarged tonsils, though I have occasionally been called upon to operate on them. During the last 16 years at the civil stations of Agra, Mussoorie and Iyucknow, I have frequently had to do the operation, .The chief trouble in

my mind has been what is the most efficient method of removal, and also the fear of

haemorrhage. I used to ask every medical man I met (especially those out recently from England) to describe the recent methods of removal but got very little advice and help.

Some said " have the patient on the side and reverse the guillotine," others said " on the back and push the tonsil into the guillotine from the angle of the jaw from outside." I retired from practice in India last year and I am now in general practice in England, where removal of tonsils and adenoids is more common than any other operation. There are a few men who still say the operation is not necessary and that en-

largement of tonsils can be sufficiently reduced by medical means, but for the following reasons the profession as a whole strongly advocate the operation when the tonsils are enlarged :?

(1) Enlarged tonsils are a continual source of infection for .rheumatism, idiphtheria and catarrhal organisms.

(2) Recurrent colds are avoided by removal. (3) Recurrent tonsillitis is avoided. (4) Recurrent bronchitis is avoided. (5) Avoidance of enlarged glands in neck. (6) Avoidance of catarrh of middle ear. (7) Avoidance of mastoid trouble and

deafness.

(8) Avoidance of diphtheria carriers.. ..

(9) Avoidance of nose breathing and mal- formation of chest.

Throat specialists now attend the school clinics of all the large cities and do many hundred operations per week. The throat department of every big hospital does many cases a week and every G. P. does his share.

Before settling in English practice, I at- tended several throat hospitals to learn the chief points in' the technique of the operation now in vogue. This article is written to describe simply the operation and to em-

phasize one or two points with the Hope that it may help surgeons in India who are unable to get to England to see and learn the opera- tion for themselves. I myself would have \velcomed such an article four or five years ago- The operation now done is total enucleation

of the tonsil by the guillotine. Some of the specialists (Mr. Tilley, for instance, and others) advocate dissection of the tonsil on the grounds that it is a better surgical procedure and bleeding is more easily controlled. But dissection out of the tonsil is undoubtedly more difficult, takes a much longer time, and needs more skilful anaesthesia. Total enucleation by the guillotine, although the bleeding is smart, is rarely followed by severe haemorrhage, and it is both rapid and efficient.

Points in the Operation of Totai, Enucleation :.

1. The anaesthetic is generally ethyl chloride or ethyl chloride followed by ether or ether alone or chloroform alone. Chloroform is now seldom used but a few still adhere to it.

2. A Doyen's self-retaining mouth gag is essential.

94 THE INDIAN MEDICAL GAZETTE. [March, 1922.

3. Guillotines now used are of the Macken- zie pattern with various modifications. Heath's guillotine (fig. 1) has a very fat handle.

O'Malley's (fig. 2) has a scissors-action in the handle. Two sizes are needed?the medium and the large. It is difficult to squeeze a

very big tonsil into too small a guillotine. It

is essential that the guillotine should not be too sharp but have a blunt cutting edge. Mathieu's guillotine is not used at all. The steps of the operation are as follows :?

(1) The patient lies on the back, if you have a good head-light, or half on back and half on right side facing a good big window. .(2) The child is anaesthetised. The Doyen's

gag is put in the mouth and opened. (3) The operator stands on the right side

of the patient and faces the patient. (4) Next get a survey of the mouth. The

guillotine (closed) is held in the right hand and used as a tongue depressor. The tonsils are well looked at, and then examined by the left forefinger and an estimate of their size and position made.

(5) You then proceed to remove the right tonsil first. The guillotine is withdrawn from the mouth and its blade pulled back. Held in the right hand, it is passed across the mouth from the left angle of the mouth. Its

point is passed behind the right tonsil (fig. 3). The shaft lies in the left angle of the mouth. Whe-i the opening is behind the tonsil, and the tonsil rests on the opening, the handle of

guillotine is depressed and the business end with tonsil resting on it is strongly pressed upwards and forwards. The tonsil rises as a small elevation with the anterior pillar stretched over it.

(6) The left forefinger is then passed in at the right angle of the mouth and presses the tonsil well into the opening of the guillotine. The finger via the anterior pillar. The left

finger keeps the tonsil well pressed down till the blade is pushed home by the right thumb.

(7) Just as the section through the base of the tonsil is completed, the right hand hold- ing the guillotine is sharply pronated, so that the back of the right hand faces the operator, and the end of the guillotine. With the ton- sil on, it is so turned that its under surface faces the naso-pharynx. By this sharp turn the final attachments of the capsule are

severed. Removal of the Left Tonsil.?The left tonsil

is removed by taking the guillotine into the left hand and passing it across the mouth from the right angle of the mouth under the left tonsil, then pressing the tonsil into the guillotine with the right forefinger. The guillotine is not difficult to manipulate with the left hand.

If the guillotine is to be used with the right hand, on the left tonsil, the operator must change his position. He now faces the feet of the patient. He passes the guillotine across the mouth from the right angle of the mouth, to under the left tonsil. Then he

rapidly passes his left hand across the face of the patient and with his left forefinger or

Fig. 1.?Modified Heath by Contevey York. Fig. 1.?Modified Heath by Contevey York.

*ig. 2?Modified O'Malley's Guillotine. 1<ig. 2?Modified O'Malley's Guillotine.

..." doyens gag

c ?

GUILLOTINE SHAFT

Fig. 3.?Guillotine being passed across mouth to under the Tonsil.

Fig. 3.?Guillotine being passed across mouth to under the Tonsil.

Fig. 4.?Tonsil being pressed into guillotine with left forefinger.

Fig. 4.?Tonsil being pressed into guillotine with left forefinger.

March, 1922.] POST-OPERATIVE PHENOMENON rLAUDDIE. 95-

thumb presses the tonsil into the guillotine, and the blade is thrust home by the right thumb. The same sharp movement of pro- nation of the hand is done to finally sever the capsule. By this method both tonsils are entirely

enucleated in their capsules. The chief points in the operation are :?

(1) The Doyen's gag. (2) The blunt guil- lotine. (3) The guillotine being placed under the tonsil and pressing it strongly up.

(4) The finger of the other hand pressing the tonsil well home into the instrument.

(5) The sharp turn of the wrist at the final separation. Removal of adenoids.?There are one or

two points in this little operation which well deserve attention.

(1) The position of the patient. After re-

moval of the second tonsil the patient is turned at once on his right side and faces the operator, the Doyen's gag is still in the mouth.

(2) Look and see that you place the curette behind the palate for certain. This is ibest

done by looking in the mouth and placing the left

forefinger behind the palate. Pulling the soft palate slightly forward with your finger, you see that you pass the curette behind it. The best currette is the middle-sized St. Clair

Thompson's. (3) See that the head is steady while you

curette. Having passed the curette into position, put the left hand on the occiput of the child and steady the head while you curette with the right hand.

(4) One good scrape slightly downwards and then out, should be enough to remove an

adenoid. (5) The patient's head is then held over the

side of the table over a basin, and the face well sponged with cold water. What about Hemorrhage.?In bigger children

smart haemorrhage does occur, but it generally stops in a minute or two. One golden rule is not to operate within a month of an acute attack of tonsillitis. If you do, haemorrhage will be free. Severe haemorrhage, both primary and secondary, is held up as a bugbear and many are frightened of it. As a matter of fact it is very rare. Mr. Irwin Moore has done many thousands ?f operations and only had one alarming haemor- rhage. Brown Kelly says the operation in vogue when carried out completely in suitable subjects is very rarely followed by severe haemorrhage. If haemorrhage does occur, what are you to do ? As it might be possible, it is well to have a plan in your head. After discussing the sub- ject at several throat clinics, I have the follow- ing plans :?

(1) The patient is on the right side. Take out the gag and sponge the nose and face with cold water over the basin. If the blood coming from the corner of the mouth comes away in clots you need have no fear.

(2) If a continuous stream and the blood does not stop, put the gag back. Take a swab on a forceps and press it well down on the right tonsil bed. If bleeding stops, keep it there. If bleeding continues, then put a fresh swab on the left tonsil bed. That is, find out which side is bleeding and apply pressure.

(3) Give an injection of haemoplastine 1 c.c.

(Parke Davis ampoules). This i& a powerful hemostatic.

(4) If after removal of the pad from the ton- sillar bed, haelmorrhage does not stop, sit the

patient up and take out the gag. This sometimes

stops the haemorrhage at once. (5) If bleeding still continues, put in the gag

and look at the tonsillar beds ; if there is a clot on either bed, remove it with your finger, as haemorrhage often is going on under it.

(6) If bleeding still continues, take a small swab on a forceps, moisten with oil of turpen- tine and gently press on the tonsillar bed.

(7) If bleeding still continues, you must

either stitch the pillars of the fauces over the

bleeding area or else apply a Watson Williams clamp. Stitching the pillars is a difficult opera- tion?a cleft palate needle is some help. An anaesthetic is again necessary. Some authori- ties say a clamp is not much good, that it is difficult to apply and is only placed over a small part of the bleeding surface. Others say it is most valuable and indispensable and gives a great sense of security. I hope some such plan as detailed above may be of help in emer- gent haemorrhage.

After treatment of tonsils and adenoids re-

moval? 1. Nothing to eat for four hours after the

operation. 2. Then give a little warm milk or weak tea. 3. In the evening a small basin of bread and

milk. 4. On next day after operation any soft

food. 5. If there is bleeding from the mouth with-

out vomiting, give a teaspoonful of iced water every three minutes for an hour.

6. Keep in bed for two days, and for a week keep away from smells and colds in the head and school.