126 THE PHARYNX AND NASOPHARYNX may be no further recurrences, the virus infection having 'burned itself out'. It is generally accepted that the role of focal sepsis in tonsils was exaggerated in the past and tonsillectomy for rheumatic or renal disorders is now less commonly recommended unless the tonsils require removal on their own account. Some children who are due for cardiac surgery may be recommended for tonsillectomy, if the criteria of sepsis are found, because of the danger of subacute bacterial endocarditis with subsequent acute streptococcal tonsillitis. In a few cases tonsils are removed because of size alone. Such children have tonsils which, although not inflamed, meet in the midline and cause gross difficulty with speech, swallowing and breathing. There is loud snoring and often choking attacks at night, and there have been reports of cor pulmonale on this account. During the day the child is constantly blocked and mouth breathes loudly. ^ CONTRA-INDICATIONS. These include severe diabetes and gross hypertension although neither is an absolute contra-indication and the patient may be prepared medically for the operation if it is imperative. Blood dyscrasias, such as leukaemia and haemophilia, are contra-indications although tonsillec- tomy has been performed with success in haemophiliacs following transfusions of plasma enriched with antihaemolytic globulin. Tonsillectomy is not performed during epidemics of poliomyelitis although these are now uncommon in the Western countries as a result of inoculation. There is evidence to suggest that the virus may gain access to the exposed nerve sheaths and so give rise to the more fatal bulbar form of the disease. Tonsillectomy is an elective operation and should not be undertaken in the presence of respiratory tract infections, or during the period of incubation after contact with one of the infectious diseases, or if there is tonsillar in- flammation. It is much safer to wait some 3 weeks after an acute inflammatory illness before operating because of the greatly increased risk of postoperative haemorrhage. The operation should not be performed without overriding reasons in the very young. Nor should it be recommended in those past middle age unless there are urgent indications. While there is no centra-indication to the operation in professional voice users, such as singers, care should be taken that they have a prolonged period of retraining of the voice following surgery. CHOICE OF OPERATION. There are two methods of removing tonsilsóby the guillotine or by the dissection method. The guillotine method is shorter. In it the tonsil is manoeuvred through the ring of the guillotine and the blunt blade is closed to constrict the areolar tissue between the tonsillar capsule and the pharyngeal aponeurosis. Stripping with the forefinger enucleates the tonsil. In the dissection method the mucosa is incised behind the palatoglossal fold, over the upper pole of the tonsil and down the palatopharyngeal fold. The tonsil is grasped and the areolar tissue is dissected along the plane of cleavage. Bleeding vessels are then caught and either tied or sealed with diathermy, whereas in the guillotine method they are allowed to seal themselves by contraction. The guillotine method has the further disadvantage that if there has been peritonsillar fibrosis, such as after a quinsy, the tonsil may tear during removal and some lymphoid tissue may be left near the upper pole. During a dissection this should not occur. For these reasons the dissection method is supplanting the guillotine in many centres.