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HALLUX VALGUS
548 with the utmost possible thoroughness, for the vague rheumatic " symptoms for which the tonsils are being removed may be caused by a disc lesion. No laryngologist could fail to agree with Sir Charles that ‘’ symptoms [of cervical spondylosis] existing before operation should certainly be an indication for caution but it would be unfortunate if the hyperextended position were to be abandoned without further careful thought. Last year, with the assistance of Dr. H. L. Thornton, we examined the tracheo-bronchial tree bronchoscopically in 100 consecutive children after removal of the tonsils by dissection and adenoids by curettage. In a first group of 50 cases the operation was performed in the hyperextended position, with a thyroid " pillow placed under the shoulders and the free portion of the Boyle-Davis gag supported manually by the anaesthetist. On completion of the operation a bronchoscope was passed before the pillow was removed. In none of these cases was any blood found in the tracheo-bronchial tree. In a second group of 25 cases the operation was performed in the same position and by an identical technique, but the bronchoscope was passed after the pillow had been removed. Macroscopic blood was found in 7 (28%) cases. The blood was on the anterior tracheal wall in 2 cases, and in the posterior commissure of the larynx in 4 cases ; in the 7th case it was present in considerable quantity throughout the trachea and in the right main bronchus. Haemorrhage had been controlled, and any residual blood removed from the mouth and pharynx by suction, in every case before bronchoscopy was performed. We believe that the blood was introduced through the open and anaesthetised glottis from the " nasopharyngeal sump " as the head was brought into the anatomical (or even flexed) position when the pillow was removed. We recommend, therefore, that the patient should be placed in the correct postoperative position before the pillow is removed ; and we have found that, with little practice, the pillow can be removed and the patient easily effected in a single movement. The third group of 25 cases is even more important to the present problem, for it relates to head-position during the operation. In this group the Boyle-Davis gag was supported throughout the operation by a Mayo table, not manually as in the other two. Bronchoscopy was performed (as in the first group) before the pillow was removed. With this method of support, satisfactory hyperextension was rarely attained ; it was consequently difficult to maintain a good airway, and macroscopic blood was found in the tracheo-bronchial tree in no fewer than 5 (20%) cases. The blood was on the anterior tracheal wall in 1 case, and in the posterior commissure of the larynx in 2 cases ; it was present in considerable quantity in the trachea and main bronchus in the other 2 cases-in 1 case in the left main bronchus, in the other *’
"
in the
right.
The blood in the tracheo-bronchial tree was aspirated by bronchoscopic suction in those cases (in the second and third groups) where it was present, and there were no
respiratory complications.
Head-position during tonsillectomy has become very important medicolegally, in view of the case (no. 5) cited by Sir Charles Svmonds.l The laryngologist is faced with two possible courses, neither of them without risk. In the first place, he can perform tonsillectomy in the hyperextended position and run the extremely small, but equally serious, risk of paralysis from protrusion of an intervertebral disc. Such a possibility can be minimised by the exclusion, of an existing disc lesion ; but a through disc lesion may be present without symptoms and accidents can also occur with a normal disc. The second course is to perform the operation in a position of less extension and to run the risk of allowing blood to be
investigation,
1. See also
Lancet, 1952, ii, 1077.
aspirated into the tracheo-bronchial tree. This hazard, though numerically much greater, is obviously less serious than the first, as the blood is effectively removed by coughing when the depth-or, more correctly, the shallowness-of an2esthesia is properly controlled. (The depth of anaesthesia in our cases was considerably greater than it would normally be on completion of the operation, to allow the passage of the bronchoscope.) Furthermore. most of the respiratory complications that may follow aspiration can be readily detected and efficiently treated. We feel that a satisfactory position could probably be attained by placing the " thyroid " pillow under the shoulders and maintaining, but not in any way exag. gerating, the extension so afforded by gentle support of the Boyle-Davis gag. This manoeuvre would aim primarily at maintaining an efficient airway ; any further tilt required to prevent aspiration of blood could then be made by lowering the head of the table. It would be of great interest to learn the views of others on the attitude to be adopted in this, the commonest of all operations.
J. CHALMERS BALLANTYNE Senior St. Mary’s
Hospital,
London, W.2.
E.N.T.
registrar
J. MACDERMOTT Late resident anæsthetist.
PRACTICAL PENICILLIN
SIR,-I should like to comment on some of Mr. Cohen’s remarks (Feb. 28). He states that no mention was made of bacteriology in his paper because general practitioners in Liverpool have neither time nor facilities to subject ’ pus to examination. I should like to point out that there is a very fine service offered by th6 City Laboratories at 126, Mount Pleasant, where a report on the nature of the organism is forthcoming in 24 hours and its sensitivity to penicillin, streptomycin, chloramphenicol, &c., is given in 48 hours. In this practice in a working-class area similar to Dr. Sytner’s, we have availed ourselves of this service and frequently found penicillin-resistant organisms which have responded to other antibiotics as shown in their sensitivity tests. I feel that giving a tremendous dose ofDistaquaine’ is rather unscientific when one has such good facilities at hand. B. DOVER. HALLUX VALGUS Sin,—In discussing the causes of hallux valgus (Feb. 14) you made no mention of the civilised habit of turning the toes outwards. The natural way to walk is with the long axis of the foot fore and aft, so that knee, ankle, and toe joints are all working in the sarqe plane. Barefooted races normally walk like this, and any normal young child, if left to its own devices, will do so too ; but we products of civilisation are taught in our nurseries to turn our toes outwards, thus imparting a pronating movement to the foot with each pace and forcing the big toe intoa valgus position. (This pronating action is also a prime cause of flat-foot.) It is true that hallux valgus occasionally occurs in barefooted people ; but, in my experience, it is found only among those who turn their toes outwards. Uliprotected big toes are liable to injury, and the foot is then externally rotated to avoid pressure on the painful toe : in some cases this becomes a habit, with the inevitable result-hallux valgus and a rigid flat-foot. Unsuitable shoes will certainlv contribute to the production of hallux valgus and other foot troubles. but I believe that external rotation of the foot R-hih walking is a primary cause of the prevalence of hallux valgus among civilised races. Royal Naval Sick Quarters, E. B. POLLARD. Shotley, Ipswich.
"
in the
right.
The blood in the tracheo-bronchial tree was aspirated by bronchoscopic suction in those cases (in the second and third groups) where it was present, and there were no
respiratory complications.
Head-position during tonsillectomy has become very important medicolegally, in view of the case (no. 5) cited by Sir Charles Svmonds.l The laryngologist is faced with two possible courses, neither of them without risk. In the first place, he can perform tonsillectomy in the hyperextended position and run the extremely small, but equally serious, risk of paralysis from protrusion of an intervertebral disc. Such a possibility can be minimised by the exclusion, of an existing disc lesion ; but a through disc lesion may be present without symptoms and accidents can also occur with a normal disc. The second course is to perform the operation in a position of less extension and to run the risk of allowing blood to be
investigation,
1. See also
Lancet, 1952, ii, 1077.
aspirated into the tracheo-bronchial tree. This hazard, though numerically much greater, is obviously less serious than the first, as the blood is effectively removed by coughing when the depth-or, more correctly, the shallowness-of an2esthesia is properly controlled. (The depth of anaesthesia in our cases was considerably greater than it would normally be on completion of the operation, to allow the passage of the bronchoscope.) Furthermore. most of the respiratory complications that may follow aspiration can be readily detected and efficiently treated. We feel that a satisfactory position could probably be attained by placing the " thyroid " pillow under the shoulders and maintaining, but not in any way exag. gerating, the extension so afforded by gentle support of the Boyle-Davis gag. This manoeuvre would aim primarily at maintaining an efficient airway ; any further tilt required to prevent aspiration of blood could then be made by lowering the head of the table. It would be of great interest to learn the views of others on the attitude to be adopted in this, the commonest of all operations.
J. CHALMERS BALLANTYNE Senior St. Mary’s
Hospital,
London, W.2.
E.N.T.
registrar
J. MACDERMOTT Late resident anæsthetist.
PRACTICAL PENICILLIN
SIR,-I should like to comment on some of Mr. Cohen’s remarks (Feb. 28). He states that no mention was made of bacteriology in his paper because general practitioners in Liverpool have neither time nor facilities to subject ’ pus to examination. I should like to point out that there is a very fine service offered by th6 City Laboratories at 126, Mount Pleasant, where a report on the nature of the organism is forthcoming in 24 hours and its sensitivity to penicillin, streptomycin, chloramphenicol, &c., is given in 48 hours. In this practice in a working-class area similar to Dr. Sytner’s, we have availed ourselves of this service and frequently found penicillin-resistant organisms which have responded to other antibiotics as shown in their sensitivity tests. I feel that giving a tremendous dose ofDistaquaine’ is rather unscientific when one has such good facilities at hand. B. DOVER. HALLUX VALGUS Sin,—In discussing the causes of hallux valgus (Feb. 14) you made no mention of the civilised habit of turning the toes outwards. The natural way to walk is with the long axis of the foot fore and aft, so that knee, ankle, and toe joints are all working in the sarqe plane. Barefooted races normally walk like this, and any normal young child, if left to its own devices, will do so too ; but we products of civilisation are taught in our nurseries to turn our toes outwards, thus imparting a pronating movement to the foot with each pace and forcing the big toe intoa valgus position. (This pronating action is also a prime cause of flat-foot.) It is true that hallux valgus occasionally occurs in barefooted people ; but, in my experience, it is found only among those who turn their toes outwards. Uliprotected big toes are liable to injury, and the foot is then externally rotated to avoid pressure on the painful toe : in some cases this becomes a habit, with the inevitable result-hallux valgus and a rigid flat-foot. Unsuitable shoes will certainlv contribute to the production of hallux valgus and other foot troubles. but I believe that external rotation of the foot R-hih walking is a primary cause of the prevalence of hallux valgus among civilised races. Royal Naval Sick Quarters, E. B. POLLARD. Shotley, Ipswich.