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THE INDICATIONS FOR REMOVAL OF TONSILS.
298
histology, embryology, physiology, pathology, and the practice of medicine and surgery. To sum up, the grave shortcomings in the anatomic knowledge of practitioners are widely conceded. The professional anatomist blames it on the clinician, the clinician on the professional anatomist, and latterly the pendulum throughout the world has at least started to swing toward " anatomy in its relation to practice." In conclusion, allow me to quote the final sentence of my preface : " If this volume tends in any degree, directly or indirectly, to bring the teacher and student of anatomy into closer sympathy it will have fulfilled its mission "
T
am
yours very
truly
MABSH in publishing
PITZMAN.
*** We have much pleasure Pitzman’s views and their sound reasons.-ED. L.
Dr.B
THE INDICATIONS FOR REMOVAL OF TONSILS. To the Editor of THE LANCET. SIR,-The article by Mr. M. Vlasto which appears in your issue of Jan. 22nd contains several points which
’
call for comment. The first of these is the statement that tonsillotomy secures drainage for the deeper crypts of the tonsil. Surely the scar-tissue, which is formed as the result of this or any other operation, must bring about just the reverse condition, and is the great argument against this particular operation in any case where one suspects that the " deeper crypts " are involved. Secondly, I do not consider that guillotine enucleation can be satisfactorily performed under short anæsthetics such as ethyl chloride-unless I one is satisfied with a " scramble operation." I submit than an adequate general anaesthesia is necessary in all these cases, whether child or adult, if anything like routine success is to attend the efforts of the surgeon. In order to decide if tonsils can be successfully enucleated by the guillotine method it is best to wait till the patient is anæsthetised, and then see whether the tonsil can be dislocated from the pharyngeal wall, and pushed completely through the ring of the guillotine. The instruments for both varieties of technique should be sterilised and at hand, otherwise one is bound to encounter the futile situation where the anæsthetic has been given for a rapid enucleation with guillotine and closer investigation proves that dissection is necessary. It is also vitally important, in either case, that the surgeon should have time to secure any obvious bleeding point and satisfy himself that all bleeding has been controlled before the case leaves the theatre. The writer hardly refers to this possible complication, which cannot be provided for by one of the short anaesthetics ; use of the latter, therefore, should not be considered an advantage of enucleation by guillotine. He states that " less traumatism of the tonsillar bed " is produced by the guillotine method than by dissection, and that of two tonsils, one enucleated with the guillotine and the other by dissection, the former will have a capsule " smooth and white," in comparison with the "rougher surface" and "ruddy tinge" of the latter. I maintain that in both these cases the difference is due not to the instrument used, but to (a) the tonsil itself and its past history, and (b) the skill of the surgeon; and that whereas one of the " small fibroid septic tonsils " enucleated by either method will always present in a greater or less degree "the ruddy tinge of its muscular bed," another tonsil which has not undergone those repeated attacks of inflammation can be removed, with its capsule just as " white and smooth," by means of dissection as by enucleation with the guillotine. Assuming the skill of the surgeon to be beyond question, the former type will always be attended with more " after-pain " than the latter, whatever instrument is used. Enucleation with the guillotine is, in my experience, no more "messy "than dissection; nor do I find the " shape " of the adult tonsil to present any disadvantage to the use of the guillotine where this instrument is not contra-indicated by adhesions of capsule, &c. In conclusion, I feel that throughout the article the writer has not laid sufficient stress on these facts :
first, that consideration of the tonsil itself must decide which instrument can best be employed; secondly, that a longer anaesthesia than that produced by ethyl chloride, &c., is essential to success in this operation. I
am,
Sir.
faithfullv, J. B. CAVENAGH.
vours
To the Editor of THE LANCET. SIR,-The perusal of the interesting and helpful papers by Mr. W. Morris and Mr. M. Vlasto in THE LANCET of Jan. 22nd on the removal of tonsils induces me to suggest to your readers the combination of methods for extraction by means of the guillotine which I have, after trying, found most effective in my hands. Standing on the left side of the patient if he is recumbent, or sitting in front of him if he is in a chair, I commence on the left tonsil (before it has been made slippery by blood) and use a Morell Mackenzie guillotine in my right hand. While steadying counter-pressure is exercised on the left cheek by the anaesthetist I slip the ring over the tonsil and draw this forward on to the tuberosity of the lower jaw ; then I exercise pressure outwards, against the jaw, so that the tonsil is made to "squash" through the ring, becoming everted in the process. Lastly, the blade is pushed home and is almost invariably found to have cut out the tonsil completely with the capsule on its deeper surface, and a narrow ring of mucous membrane, like a circumcised I then take up Ballenger’s prepuce, round its margin. guillotine in my right hand, push the extremity of the ring behind the right tonsil, which I force from before backwards through the ring, by means of my left forefinger, press the tip of the guillotine forwards by levering the handle of the instrument on to the left cheek (which is pressed still more to the right by the anaesthetist) and cut out the tonsil quite as completely as on the left side, but with rather more mucous membrane. (Instead of Ballenger’s,
Mackenzie’s guillotine, reversed, can be used.) With my left forefinger I clear the adenoids from the lateral walls of the naso-pharynx so as to press them towards the middle line. Then with Laforce’s adenoid boxcurette I remove the mass, any remnants being scraped away with Golding-Bird’s curette. Lastly, I palpate the posterior extremities of the inferior turbinals, and if I find them enlarged I remove the excess by means of Prince’s forceps. These may seem trumpery details, but it has taken me some time to decide on this mode of removing both tonsils with my right hand, being a combination of Sluder’s and Whillis’s methods. I am, Sir, yours faithfully, JAMES DUNDAS-GRANT.
THE DIET OF WELL-TO-DO CHILDREN.
of THE LANCET. SiR,-If you bend the sapling and keep it bent you To the Editor
cannot avoid an angular oak tree. If you overload the juvenile intestine you must expect to find kinks and bands in the adult colon. That we should overload those poor little intestines at all is bad enough, but that we should overload them with the wrong material is
infinitely
worse.
Intestinal -stasis is a deficiency disease. The complete absence of vitamines from children’s food, which is secured by boiling milk against the bacillus, is the beginning as well as the head and front of the offending. If vitamines were supplied instead of being suppressed there would be no overloading, for surfeit would then The be followed by a wholly beneficent diarrhoea. surfeit of boiled milk and other devitalised foods gives rise to intestinal fatigue and stagnation; hence the stasis with its multiple and incalculable consequences. It is surely time that the broad human common-sense irradiated by Dr. Des Voeux’s letter in your issue of last week replaced the bacillophobia and pseudoscientific shibboleths of drug therapeutics which still pervade and degrade the teachings of the schools. We have attained to the point of admitting that the milk of the human mother is better than that of the
histology, embryology, physiology, pathology, and the practice of medicine and surgery. To sum up, the grave shortcomings in the anatomic knowledge of practitioners are widely conceded. The professional anatomist blames it on the clinician, the clinician on the professional anatomist, and latterly the pendulum throughout the world has at least started to swing toward " anatomy in its relation to practice." In conclusion, allow me to quote the final sentence of my preface : " If this volume tends in any degree, directly or indirectly, to bring the teacher and student of anatomy into closer sympathy it will have fulfilled its mission "
T
am
yours very
truly
MABSH in publishing
PITZMAN.
*** We have much pleasure Pitzman’s views and their sound reasons.-ED. L.
Dr.B
THE INDICATIONS FOR REMOVAL OF TONSILS. To the Editor of THE LANCET. SIR,-The article by Mr. M. Vlasto which appears in your issue of Jan. 22nd contains several points which
’
call for comment. The first of these is the statement that tonsillotomy secures drainage for the deeper crypts of the tonsil. Surely the scar-tissue, which is formed as the result of this or any other operation, must bring about just the reverse condition, and is the great argument against this particular operation in any case where one suspects that the " deeper crypts " are involved. Secondly, I do not consider that guillotine enucleation can be satisfactorily performed under short anæsthetics such as ethyl chloride-unless I one is satisfied with a " scramble operation." I submit than an adequate general anaesthesia is necessary in all these cases, whether child or adult, if anything like routine success is to attend the efforts of the surgeon. In order to decide if tonsils can be successfully enucleated by the guillotine method it is best to wait till the patient is anæsthetised, and then see whether the tonsil can be dislocated from the pharyngeal wall, and pushed completely through the ring of the guillotine. The instruments for both varieties of technique should be sterilised and at hand, otherwise one is bound to encounter the futile situation where the anæsthetic has been given for a rapid enucleation with guillotine and closer investigation proves that dissection is necessary. It is also vitally important, in either case, that the surgeon should have time to secure any obvious bleeding point and satisfy himself that all bleeding has been controlled before the case leaves the theatre. The writer hardly refers to this possible complication, which cannot be provided for by one of the short anaesthetics ; use of the latter, therefore, should not be considered an advantage of enucleation by guillotine. He states that " less traumatism of the tonsillar bed " is produced by the guillotine method than by dissection, and that of two tonsils, one enucleated with the guillotine and the other by dissection, the former will have a capsule " smooth and white," in comparison with the "rougher surface" and "ruddy tinge" of the latter. I maintain that in both these cases the difference is due not to the instrument used, but to (a) the tonsil itself and its past history, and (b) the skill of the surgeon; and that whereas one of the " small fibroid septic tonsils " enucleated by either method will always present in a greater or less degree "the ruddy tinge of its muscular bed," another tonsil which has not undergone those repeated attacks of inflammation can be removed, with its capsule just as " white and smooth," by means of dissection as by enucleation with the guillotine. Assuming the skill of the surgeon to be beyond question, the former type will always be attended with more " after-pain " than the latter, whatever instrument is used. Enucleation with the guillotine is, in my experience, no more "messy "than dissection; nor do I find the " shape " of the adult tonsil to present any disadvantage to the use of the guillotine where this instrument is not contra-indicated by adhesions of capsule, &c. In conclusion, I feel that throughout the article the writer has not laid sufficient stress on these facts :
first, that consideration of the tonsil itself must decide which instrument can best be employed; secondly, that a longer anaesthesia than that produced by ethyl chloride, &c., is essential to success in this operation. I
am,
Sir.
faithfullv, J. B. CAVENAGH.
vours
To the Editor of THE LANCET. SIR,-The perusal of the interesting and helpful papers by Mr. W. Morris and Mr. M. Vlasto in THE LANCET of Jan. 22nd on the removal of tonsils induces me to suggest to your readers the combination of methods for extraction by means of the guillotine which I have, after trying, found most effective in my hands. Standing on the left side of the patient if he is recumbent, or sitting in front of him if he is in a chair, I commence on the left tonsil (before it has been made slippery by blood) and use a Morell Mackenzie guillotine in my right hand. While steadying counter-pressure is exercised on the left cheek by the anaesthetist I slip the ring over the tonsil and draw this forward on to the tuberosity of the lower jaw ; then I exercise pressure outwards, against the jaw, so that the tonsil is made to "squash" through the ring, becoming everted in the process. Lastly, the blade is pushed home and is almost invariably found to have cut out the tonsil completely with the capsule on its deeper surface, and a narrow ring of mucous membrane, like a circumcised I then take up Ballenger’s prepuce, round its margin. guillotine in my right hand, push the extremity of the ring behind the right tonsil, which I force from before backwards through the ring, by means of my left forefinger, press the tip of the guillotine forwards by levering the handle of the instrument on to the left cheek (which is pressed still more to the right by the anaesthetist) and cut out the tonsil quite as completely as on the left side, but with rather more mucous membrane. (Instead of Ballenger’s,
Mackenzie’s guillotine, reversed, can be used.) With my left forefinger I clear the adenoids from the lateral walls of the naso-pharynx so as to press them towards the middle line. Then with Laforce’s adenoid boxcurette I remove the mass, any remnants being scraped away with Golding-Bird’s curette. Lastly, I palpate the posterior extremities of the inferior turbinals, and if I find them enlarged I remove the excess by means of Prince’s forceps. These may seem trumpery details, but it has taken me some time to decide on this mode of removing both tonsils with my right hand, being a combination of Sluder’s and Whillis’s methods. I am, Sir, yours faithfully, JAMES DUNDAS-GRANT.
THE DIET OF WELL-TO-DO CHILDREN.
of THE LANCET. SiR,-If you bend the sapling and keep it bent you To the Editor
cannot avoid an angular oak tree. If you overload the juvenile intestine you must expect to find kinks and bands in the adult colon. That we should overload those poor little intestines at all is bad enough, but that we should overload them with the wrong material is
infinitely
worse.
Intestinal -stasis is a deficiency disease. The complete absence of vitamines from children’s food, which is secured by boiling milk against the bacillus, is the beginning as well as the head and front of the offending. If vitamines were supplied instead of being suppressed there would be no overloading, for surfeit would then The be followed by a wholly beneficent diarrhoea. surfeit of boiled milk and other devitalised foods gives rise to intestinal fatigue and stagnation; hence the stasis with its multiple and incalculable consequences. It is surely time that the broad human common-sense irradiated by Dr. Des Voeux’s letter in your issue of last week replaced the bacillophobia and pseudoscientific shibboleths of drug therapeutics which still pervade and degrade the teachings of the schools. We have attained to the point of admitting that the milk of the human mother is better than that of the