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TONSILLECTOMY                                    127

AFTER-TREATMENT. On the day of operation the patient is \w_; .. ; .
reactionary haemorrhage. Later in the day mouth washes are given ar.ti
patient is encouraged to drink fruit juice. Jelly or ice-cream may be given >\,
the evening. Pain may require morphine for adults or heroin for children in
doses appropriate to the age and body weight. On the following morning
breakfast should consist of scrambled egg, bread and butter, and fluids, and
from then on three meals a day should be eaten. It is not sufficient for the
patient merely to drink, he must be encouraged to chew food. Hard foods are
avoided, but mince, fish and eggs are acceptable. Raw fruit is painful until the
throat has healed.

Children are allowed home 2 or 3 days after surgery, but adults may stay in
hospital for 4 or 5 days. On going home the patient should go to bed, and be
allowed up for increasing lengths of time each day. Sloughs form in the tonsil
beds, and these harden and finally separate some 7-10 days after the operation.
When this happens swallowing becomes easier and the patient may then be
allowed out. Children will be off school for a further 10 days, and adults will
be off work for a total of 3 weeks from the operation.

COMPLICATIONS. Reactionary haemorrhage occurs within a few hours of the
operation and may be severe. It may occur after either form of operation, and is
treated by a return to the theatre when the vessel is ligated under anaesthesia.
If there has been much loss of blood a transfusion may be given, but this is
less liable to be required if the nursing staff is alert and prompt action is taken.

Secondary haemorrhage occurs some 5-8 days after the operation, and is
usually due to a refusal on the part of the patient to eat. Chewing of food keeps
the muscles of the throat active and appears to keep the tonsil beds free from
infection. If food is refused the slough becomes septic and bleeding occurs at
the time of its separation. A similar haemorrhage may occur if a patient is
incubating an upper respiratory tract infection at the time of surgery. The
patient should be readmitted to hospital and an appropriate dose of morphia
for adults or heroin for children is injected, and a course of systemic antibiotic
ordered. This is usually enough to control the bleeding, and only rarely is a
transfusion necessary. It is not common to have to anaesthetize the patient and
search for the bleeding point. The haemoglobin level of the blood should be
ascertained and if necessary a course of ferrous fumarate (Fersamal) or some
other iron preparation is prescribed. The patient can usually be discharged in
48 hours provided that he is eating well.

Infection may occur after operation. A pyrexia is not uncommon on the
morning after tonsillectomy, but this usually settles after the bowels are
opened, helped by an aperient if necessary. Prolongation of the pyrexia should
be treated by systemic antibiotics for 5 days.

Pain on swallowing is common for the first week after tonsillectomy until
the slough has separated. As a rule breakfast causes most discomfort and
swallowing becomes easier during the day. Adults may find that a gargle of
soluble aspirin before meals makes swallowing easier. The patient should be
encouraged to talk freely as this also activates the muscles of the pharynx.
Pain is often referred to the ears during swallowing, and relief may be
obtained by the expedient of holding the hands over the ears during degluti-
tion provided that there is no evidence of otitis media to cause the pain.

Nervous complications are found in children following hospitalization.
Visiting of a child on the day of operation is not encouraged because the child