The twelve-hour tonsillectomy

19th century tonsillectomyUntil fairly recently, tonsillectomy was quite a common procedure – and for many children their first experience of surgery.  Because it’s a straightforward operation, doctors would often recommend that children had their tonsils out even if they had had only a few minor bouts of tonsillitis.  It was even used as a precautionary measure: many of the child migrants to Australia were given tonsillectomies even if they had never been ill.   In recent years, surgeons have become far more conservative, preferring to operate only on patients who have had debilitating recurrent problems, or those whose airways are obstructed by the infected glands.

Tonsillectomy is a surprisingly venerable procedure, described by the ancient medical authorities Celsus and Galen among others.  In the days before anaesthesia – that is, before about 1850 – it can’t have been much fun for the patient.  This description of a new method of carrying out the procedure invented by a professor of surgery from New York, printed in the New York Medical and Physical Journal in 1827, gives some idea of what it involved:

In cases of acute inflammation as soon as considerable tumefaction has taken place, I have found nothing so effectual in affording relief as free puncture or scarification, and even in a state of chronic enlargement, unattended with hardness, repeated scarifications are often sufficient to reduce them to their natural size.

Scarification involved scratching the surface of the tonsil; in some cases a leech was even applied directly applied to the swollen gland.  The author, Alexander Stevens, explains that if an operation is necessary he prefers not to perform it on young children; better, he thinks, to wait until they are a bit older.  But he notes that the most eminent French surgeon disagrees:

M. Dupuytren, however, with some plausibility, advises the operation to be performed early, because, as he alleges, the difficulty of respiration causes the children, in such cases, by calling the muscles of respiration into powerful action, to grow up with round shoulders, and a depression of the sides and front of the chest.  He advises the children to be put into a pillow-case, and held on the lap of an assistant during the operation.

Alexander then outlines the horrifying options open to the contemporary surgeon:

The range of cases in which scarification is proper and applicable, as an effectual means of removing chronic enlargement, is, I apprehend, very limited: cauterization with caustic is still more uncertain and tedious in its results; while cauterization with the hot iron is justly banished from modern surgery.  Of the remaining operations the French surgeons very generally employ the knife or scissors, in disregard of the danger of suffocation, witnessed by Moscati and Wiseman, from a partially separated tonsil, during an operation interrupted by efforts to vomit, falling into the rima glottides.

Another method involved drawing a ligature tight around the tonsil and leaving it there until the tissue of the gland died from lack of blood – a process which sometimes took several days.  Alexander comments that patients prefer this procedure, since it avoids the use of the scalpel:

I must refer to the paper of Dr. Physick as containing a mode of practice by which the tedious and disagreeable presence of the cannula in the mouth for five or six days is avoided.

“It has hitherto been my custom,” says the Doctor, “to allow the instrument to remain thus applied…for twenty-four hours, with a view of destroying, completely, the life of the enlarged gland.”

The separation of the dead tonsil he leaves to nature, and generally it does not take place until a lapse of several days, during which time the patient is annoyed by the excessive foetor of his breath, with consequent disgust for food, and when taken off, some of the tonsil is occasionally found to have maintained its vitality.

 Dr Alexander felt – with some justification – that this was not an entirely satisfactory state of affairs.  So he set about devising a better and quicker operation.

It occurred to him that if he could draw a loop of wire sufficiently tightly around the tonsil and leave it there for a few hours, the blood vessels would quickly die and it might be possible to sever the gland without significant bleeding taking place.  Doing so involved inventing a new type of surgical instrument, the design of which he reproduces in his article:

Instrument for tonsillectomy
Tonsil executioner

It was easy to see how such an instrument might be applied so as to act with certainty, ease, and regularity.  Such was my plan for effecting a perfect strangulation.  The first case to which I applied the instrument was that of the daughter of a medical gentleman of this city, now deceased, in whom the left tonsil was so much enlarged as entirely to hide the uvula.  The operation was done in the presence of Dr. Thomas Cock and several of his and my pupils.  The gland was drawn out by a small double hook passed through the wire, previously inserted under the lower edge of the tonsil. The hook was now given to an assistant, while with the forefinger, I depressed the tongue and adjusted the wire to the base of the tonsil, and drew the screw to which the wire was attached directly out from the canula, until the wire was buried in the gland… The usual salivation, but not vomiting as frequently happens, followed.

The operation took place at 10.30 am.  Four and a half hours later, the patient was still sitting in the surgical chair:

At three P.M., Dr. Cock was kind enough to see the patient, and gave the thumb screw three turns, by which the length of the wire around the tonsil was reduced to five-sixths of an inch in diameter.  At six, I gave three turns more; at eight, three turns more — the wire was now reduced to half an inch.  At ten o’clock, as the wire did not break, I began to reflect upon the best mode of detaching it, as the tonsil now hung by a peduncle only one-sixth of an inch in diameter, which I was determined to divide. 

By this point the little girl – who, let’s remember, had not received an anaesthetic – had been sitting with a surgical instrument in her throat for the best part of twelve hours.

I purposely turned the thumb screw, therefore, until the wire broke—separated it, and with a small hook formed by bending the point of a probe, I seized the tonsil and snipped it off with a pair of scissors.  Scarcely a drop of blood flowed, and the patient began immediately to satisfy the cravings of hunger, having been prevented from swallowing by the presence of the canula.  Thus the extirpation of the tonsil was effected in less than twelve hours.

Goodness!  What a breakthrough.

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