BLOODLESS TONSIL ENUCLEATION. pl)i oii the surgeoii's memory ...

988 JUNE T, 1929] BLOODLESS TONSIL ENUCLEATION.
BLOODLESS TONSIL ENUCLEATION.
A MODIFIED TECHNIQUE AN-D A NEW GUILLOTINE.
BY
0. POPPER, F.R.C.S., M.B., CH.B.EDIN.,
rIRST ASSISTANT, ROYAL EAR HOSPITAL, UNIVERSITY COLLEGE HOSPITAL.
TWENTY years ago Whillis and Pybus publislhed their now
classical technique of guillotine enucleationi by tho reversed
method. It has been universally adopted, tlhouglh often
inicorrectly ascribed to Sluder, and its position remainis
unchallenged and is likely so to continuie.
Somei three years ago it occurred to melo that if "traction"
couild be applied to tho posterior aspect of tleo tonsil
(lurinig the dislocation manceulvre of tleo Wlhillis and Pybus
teclhnique, the deep fibroseed or so-calle(d " difficult " cases
could be more easily dealt witlh. To tllis end I lhad tlhe
distal rim of tho fenestra of my guiillotinie miiade in tlhe
formii of a series of miniatLiro slhap clhisels. The guillotinie
hiead is inserted from below upu-aids, hehinld the tonsil
and in front of tho posterior pillar. The low er polo of
the tonsil is threaded tliroulli tlie fenestrai anid the tonsil
is elevated to bulge the anterior pillar in tlic iusual way
(Fig. 1). The little chisels haxoenow dug themiselves inito
tleo postero-lateral aspect of the tonisillar capsule alid fix
FIG. L FIG. 2.
it in a lharpoon-like manner. The next step is designed to
pull the tonsil out of its bed, tlhereby stretching tilo peritonsillar
tissue; the tonsil, beinig fixed, will liot slip off
the guillotine, and tractioni is applied to it by retracting
the guillotine towards the mid-linie and- sliglhtly forwardsthat
is, away from the posterior pharynigeal wail (Fig. 2).
Slight counter-pressure is exerted w-itlh the tlhulml) over the
tonsil. With the guillotine maintained rigidly in this
position the whole tonsil is inverted through tIle fenestra
aiid the blado driven lhome bcliiiid the aniterior pillar
(Fig. 3). It will be seen that apart from tle " tracti-oni "
the whole manceuvre, whiclh takes but a few seconids, is the
ordinary Whillis and Pybus teclhniique.
IUp to this point tho operationi is bloodless if a blunit
guillotine is used. By the ordiniary miietlhod the tonsil is
fiow severed froiii its bed and, accordinig to tlie inatutre of
tihe case, the bleeding miiay be more or less severe. Whlether
the mode of severance be in theo nature of torsioni or
avulsion, tile stump is invariably torni away deep to its
crushed portion, hence tile inadequate lhaemostasis.
A single blade cainnot be expected to performni botll tile
functions of crushing and of cutting. For' this purpose a
well-designed two-bladed guillotinie is esseiltial. I lavo
made use of such ani iilstrumiient, and, as is inidicated by
tho main title of this communicationi, tile whole operationi
cani be rendered bloodless.
Where the ordinary guillotine teclniiique )plus " traction
is employed many toinsils, whicll in the ordinary way would
call for dissection, can be dealt witlh by tlle guillotine.
The surgeon, however, will prefer to dissect-especially
adult cases-unless he Pan be sure tllat, tlhe imillediate.
liaemorrhage incidental to ordinary guillotinie procedure
can be controlled.
.[The question which must be decided is not " Can o'ne
guillotinie?" but " Should one gutillotine?" I- tlinik it cai
be failrly stated that guillotininig is the cleaniest lietIlO(I,
and, if haemorrhago is slight, recovery is rapid aid(l lhealinig
perfect. The latter is only natuiral whieni one reflects that
waithi thio guillotilne there is thie miniiinuni handling andI
traumia of tisstues as compared withi eveni the most inimiiaculato
dissection.
Whleni wo examine thie peritonsill'ar tissue in a case of
chronic tonisillitis we find masses of fibrous tissiue witi
vessels run1ninig thrLough it. Obviouslv, when cuit thlrouighi,
these would gape. In tho child the peritonsillar tissue is
loose anid elastic; thie vessels here ilivoluto naturally, anid
bleeding is minimal.* The decisioni as to whether to guillotine
or dissect toilsils therefore rests very largely oln thio
questioni of tiho amiioulit of bleeding aniticipated.
It i.s obvious that where there3 lias beeni peritonisillar
fibrosis considerable force is required to crush theo vessels
adequatelv. In the inistrument presently to be described
suclh cr uslinig force cani bo exerte(l. There are a certain
number of cases where the tonisil is so firimily bounlid dowin
that it is imiipossible to invert it co'mpletely tlhrouglh tlle
fenestra of the guillotine. Here, of course, diskection is
the only metlho(d.
Wlheni tlho blade of tlhe guillotine is dr iven hlome the tonsil
lies isolated, separated from its bed by thle blade, tlhe
cruslhed stump intervening (Fig. 4). This stumpil, in tlho
%
prop1erly per'formed operation, con1sists of tilO circuilmforenitial
reflectioni of nmucous membrane surrouliding tile
equatorial airea of the tonsil at the jUlnctioni of its
eilibedded and iloni-emibedded portioils, togetler witlh some
areolar aiid fibrous tissue, anid vessels of the tonsillar be(d.
Thlere are several types of two-bladed guillotinies incorporlating
ciushliiig aiid cutting blades. I have fouild tlieiii
most satisfactory, particularly that of La Force. Iii this
guillotinie a very power fuil crushing foreo cani be applied,
to wilie;i I ascribe tlhe perfect lhaemostasis tilat is obtainied'.
Tleo nlode of briniging its cruslling and lockinig ectioni i]ito
play is clumiisy; fur thereniore, the fact tilat the cuttilig
blade requires to be carefully reset after eacll tonsil lhas
been remove(d is a gr ave fault, aiid no doubt tlhese tw-o
disadvanitages account in a large measure for its lack of
popular'ity in. this country.
I lhave developed the two-bladed guillotinio illustrated,
tle crus}1ing power of wlhich1 is ver-y great ail(l iiistanltaiieouis.
It locks automatically; moreover, no strain is
pl)i oii the surgeoii's memory. Tile cuttiilg blado sets
itself back automatically wlhen thlo c'rushing blade is
released, tlho recoil being utilized as in tlle Maxiiii guni.
This is ani extreiiiely iniportait featuire-as tho cutting
blade is imierely a conivenience ail(l must at no stage of
the operationi olbtlude itself or add to tlhe complexity of
liaildliiig thio inistrunlent-if onie is to elaim that this twobladed
guillotine is almost as simple to use as tile
ordiinary siiigle-bladled tvpe. The cutting blade in. this
instrument cannot be sent hlome first-a procedure that
would nQgative the bloodless object of tho operation.
Tile principlo of the guillotine is similar to that of the
guiillotinie- devised by, Ballenger, ElIphiek, ,Howarth, aund
* See autjxor's article in the JournaJ et Laryngology. and(1 Otelogy,
September,
FIG. & FIG. 4.
[ THE IBRITISH
I MEDICAL JOUSNA.
w~~

JUNE I, 19291 TTONS8ILLECTOMIY.' r MEDICAL MlTDHEC BR1ITISH JOUAL 989
La Force. There are two blades, one the crushing blade
(A), and the other the cutting blade, which lies betweenthe
bed plate -and the crusher and works close up to it.
The crusher, which grasps the stump of the tonsil, is
primarily actuated by the handles with such pressure as
may be brought to bear by the strength of the grip of the
hand. This action automatically engages the mechanism
(BCD) for the final crush-i a usefutl time-saving feature.
Th-iis mechanismn is in the form of a pair of double
cylinidrical circumvolutes, the internal or fenmale (B) being
attached to the bed of the guillotine, anid the external oIr
male (C), which has a lever (D) attached, is fitted and
rotates freely on the crushing blade and is kept in position
bv meanis of a spring (E). A quarter turn of the lever
(D) tends to drive the crusher furthler forward and exerts
extra pressure and automnaticallv locks it and completes
the crushing operation. The mechanical advantage being
about 1 to 14, the crushing effort is very great. The
cutting blade is attached to the crusher, and the final
cuvtting is performed by the depression of a lever (F) which
drives the cutting blade forward. The releasing of the
guillotine brings the lever (F) of cutting blade in contact
with the stop on (B) and automatically throws it out of
action and sets the cutting blade ready for the next
operation.
Tt will readily be seen that it is not possible for the
cutting blade to be brough:t to action until the crushing
..)is poito in order. ,
blade has done its work. Miniature sharp chisels are on
the distal rim of the fenestra (H). The purpose of screw
(Gisto set *the blades at anyi desired psto no-e
to vary the size of the feniestra. Thu-Ls one guillotinie wiill
do for all eases except' for' children under 2 years. The
iruillotinie is shown set for a small tonsil.
The actuial handling of the guillotinie is simplicity itself.
Whien the ton-sil hias been comipletely iniver-ted (Fig. 3) the
crushing blade is scent home by compressing the handle, aind
lever- (D)- 'already partly engaged-.is pushed over to its
liiit with tie free hand in a clockwise direction. After a
sui'table period the tonsil is secured with a vulsellum an-d
is cut off the guillotine by depressing. lever (F) (,ig. 4).
Lev-er (D) is then returned to its original position- anid thie
giuillotiaie Ear Hospita, will spring Unvrst open and Colg be already Hsia. set for In the no othier a...,...
ton'isil.
It is obvious that if thle crushinig pressure is m--aintained
single casetha unitil coagulation
therbIaeena has
any
takeni
primar reacostionary
place an added safe-,
ore
teondarythaemsz3ofrrhae.fleta
guard is
hsoe
incorporated. Accordingly I crush
ulo
the
ewl
stump
for
dofraleae
three to five minutes xetfrchlrnudr2Vels before removing the tonsil.
h
If
the miouth is largo eniough and a second guillotine av-ailabl-e
the other tonsil can be dealt withi whiile the first still
cruishes its stump. There will be nio bleeding-merely a
moistness of the tonsillar bed.
If desired, the stulp can be ligatured in a drv fieldan
easy matter. the whole operation in adults takes ten
iminutes at the. outside. In children, where the pentonsillar
tis'sue is soft and elastic, momentary crushing
Irwin Moore, quoting MeNab, and referring to twobladed
guillotines, complains that the anterior pillar is
frequently removed. The type of guillotine used is not
stated. I can only say that witli the technique indicated
I have niot been able to emulate this. The anterior pillar
comes through the ordeal uninjured-provided the fenestra
of the guillotine is not too large for the tonsil. Eveni in
that case the expert will manage n-ot to invert it completely
through the fenestra. It is, however, definitely an
advantage to adjust the fenestra slightly on the small side,
which caln be done in-stantly in the instrument illustrate(l.
The criticism has been made that reactionary- haemorrhage
occurs a few hours after the operationi with two-bla(ied
guillotines. I have not encountered this, anid canl only
assume that the instrumen-t used di(d lnot allow sufficicnt
crushing force to be applied to the stump.
Children whose tonsils have been removed by this moth3d
show no, or only very slight, rise of temperature. This I
attribute to the obliteration (by crushing) of -the lympliaties
and subsequent minimal toxic absorption from the open
tonsillar wound.
I wish particularly to acknowledge my ilndebtedness to my
friend Mr. Phelps, of Messrs. Mayer and Phelps, and to their
technical staff, for the great assistance and the facilities extenided
to me.
TONSILLECTOMY.
BY
H. NORMAN BARNETT, 1F.R.C.S.,
SURGEON TO THE BATH, EAR, NOSE, AND THROAT HOSPITAL.
IT is not desirable that one method, and one method only,
of perfqrrning the operation of tonsillectomy should be
adopted Jfoi -atielits, whether adults or children. Each
case is a lawi to: itself and shouild be judged on its merits.
If this menital attitude is adopted it will save the unwary
..,
anld the comparatively inexperienced, operator from maniy
pitfalls.
To at4empt tQ renmoxe the deeply embedded adherent tonsil
which has beein the site of many ittacks of tonsillitis, and
perlhaps the subject of abortive attempts at removal, by the
guillotine only, or e.ee. with a flilger on the pillar, or
traction by tonsil forceps, will only leaid to disappointmient
for the patient and the operiator. For the tonsil will not
move by finger pressure., and the forceps will take away
a super ficial piece of tissue, butit will not remove the main
mass of the glancl from, its stronig anchorage.
Anotlher subdiv-ision- -of this sort of tonsil, met with in
even young children, is that in which the plillars lhave met
in th.e median line in front, anid are indistinguislhable
from the underlyintg 'tonsil.. This type is also the product
of long-continued, chronic inflammation with interludes of
acute tonsillitis. The tissunes are usually very septic, anid
the tonsil when reaclied is generally fotind to be lying in a
pool of pus. For such tonsils dissection or partial dissection
should be employed.
It is of advantage to ermploy a tonsil forceps, such as
that made for me by Messrs. Mayer and Phelps. The
FiG. 1.-Thie Authlor's tonsil, forceps.
adv-antage of this instrument is that it need-iiot be removed
during the operation, since, by means of the ratchet, it
retainis its hold, thus freeing a hand. Moreover, the
hlandles will pass through the ring of the guillotine, if it is
desired to use this instrument. (Fig. 1)
The dissector best suited for this type of tonsil is one
with a short curve and a cu-tting edge, the other end being