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101
and partly in order that the hospitals may be given the opportunity
to profit by the experience of the clinics and thus improve
their own results.
"The first possible reason for the difference is that the cases
dealt with by the hospitals may be an accidentally unfavourable
selection. As regards the degree of tonsillar or ancillary disease,
this possibility is negligible. It seemed possible, however, that
the hospitals might be drawing their patients from a lower social
stratum than the clinic, with a less favourable home environment,
which hampered recovery.
"About one -half of the children under consideration were,
therefore, investigated from this point of view. The two facts
which emerged were first, that the hospital patients averaged
rather more favourable home circumstances than the rest and
second, that within the groups, home circumstances did not differ
significantly between the improved and the unimproved.
"Operative technique is not to blame. The tonsils had been
as efficiently removed by outside and hospital practitioners as by
our own surgeon with a very few exceptions, in which, incidentally,
the results were not notably unsatisfactory.
"It follows, therefore, that after-treatment is the deciding
factor. The hospital patient, though kept in the ward over-night,
is only seen later in order that gross operative failures may be
discovered. The clinic patient, though sent home by ambulance
the same afternoon, is visited on the second and fourth days,
and subsequently if necessary, by the school nurse who advises
the mother about nasal and oral hygiene for the child and gives her
a leaflet setting out a scheme of breathing exercises, not leaving the
house till she is satisfied that both mother and child understand
the need for and the practice of the exercises.
"It would appear that here lies the key to success. Further
corroboration is seen in the fact that half the clinic's failures in
children susceptible to respiratory affections and one-third of those
in mouth breathers occurred in children whose parents confessed
that they had not carried out the exercises.
"I would suggest, therefore, that particular attention should
be paid to this point by School Medical Officers whose local authorities
carry out tonsillectomy. Moreover, parents who wish to have