GENERAL ARTICLES

Tonsil Trouble

HUGH GRANT ROWELL June 1 1935
GENERAL ARTICLES

Tonsil Trouble

HUGH GRANT ROWELL June 1 1935

Tonsil Trouble

HUGH GRANT ROWELL

TONSILS and trouble begin with the same letter— trouble for mankind, trouble for doctors. You do the physical suffering and your doctor gets the headache. You march courageously into your doctor’s examining room, open your mouth and pronounce the customary half-choked “Ah,” with your throat half filled with sundry gadgets. Or you tell Johnny to be a good boy and do just what the nice doctor wishes. In either case, the disciple of Aesculapius is supposed to take one swift look, assume his most convincing manner and decide all. Everybody thereafter to lead the life of Reilly.

The only trouble is that the last part of this scenario can’t be staged. For no one as yet has been able to convince us exactly what tonsils are or why they are, though many more or less scientific guesses have been made. As to what to do about tonsils—let’s leave that till you hear the rest of the tale of woe.

Five ball-like masses or lumps form the mystic circle or the tonsillar ring or, to use another alias, Waldeyer’s ring. The five always remind me of one of those Arab pyramid or “brother” acts you see in vaudeville or the circus.

In the Waldeyer tonsillar troupe we call the topmounter or highest fellow in the middle, the adenoid. The chaps along the side are the ordinary tonsils. At the bottom, as “understanders”—though least understood—come the lingual tonsils, to which, like the sturdy fellows who support the other Arabs in the pyramid, we pay least attention. There you are, five little tonsils, all in a ring.

They can be fiends, these five. Compared with the

mischief created by the tonsils and their devils’ brew, Macbeth’s troubles were nothing. No wonder we became desperate some years ago, shouted “Away with them,” and “liquidated” these double-crossing, backbiting, unfathomable denizens of our throats. The massacre, among medical men at any rate, is still popularly known as “The Slaughter of the Tonsils.” Yet even today, when time might have tempered our wrath, we are by no means sure that such universal destruction of tonsils is not the best plan. Nor will we ever be certain till we clear up the mystery of Waldeyer’s circle.

In structure the mysterious five tonsils resemble each other closely. Likewise they resemble the areas of lymphoid tissue found all along the food tract.

Examined closely, they are more full of pockets than a schoolboy’s ideal for a pair of pants. So, as you would expect, they’re excellent junk catchers. The lingual tonsils, having the shallowest pockets, are considered the least receptive by nature.

Examined under the microscope, the tonsillar five reveal hundreds of little white cells of the lymphoid type. White cells we usually associate with defense.

The tonsils have a rich blood supply and a close connection with that other distribution system, the lymphatics, as well. They .can, therefore, easily send bacteria or bacterial poisons through the body. Tonsils, being mainly of lymphoid tissue, partake of another of its characteristics—high susceptibility to various external influences. Result—

usually enlargement.

Because of their close relationship to the canal between the ear and throat, the tonsils are in a position to do immense damage to hearing through a process of direct extension up the tube. By a similar process, trouble in the tonsil family may spread to those skull caverns, the sinuses.

So much for location and a few general characteristics. Now about life history.

Good Tonsils

TF YOU look in the mouth of a baby, the regular tonsils, which are all of the mystic five that are perceived without considerable discomfort for all concerned, are quite large

in terms of the throat space. They are approximately spherical in shape. And they are so much out in the open that doctors often call them “thumbnail” tonsils, on the theory that you could pretty nearly operate on them with a sharpened thumbnail.

The child grows older. The regular tonsils become smaller and flatter and recede into pockets in the side of the throat called fossae. In the adult the tonsils ought to seem inconsequential, though most doctors can recall a few cases where they seemed positively elephantine.

Growth, then, changes the situation; the size, shape, and even somewhat the location. It’s about the same with the adenoids. As for the linguals, let’s forget them.

Analysis of the life history of the tonsillar tissue suggests some relationship to the period of growth. A reasonably comparable parallel is found in the thymus gland, which is found in pretty good size under the chestbone of the tiny tot but which degenerates to a mere string of nothing at all in the adult. The thymus, we know, is definitely concerned with growth.

Strictly speaking, we cannot go quite that far with the tonsils. But it does seem as if they perform some function —apparently their most useful function—during the growth period. And we know that defenses are badly needed at that time. For a tiny tot of six months age has practically no immunity to anything under the sun. Immunity develops as he grows older, though not necessarily to a full degree.

In this early time of need we know that all the lymphoid structures in the body are actively functioning. They continue so to function till they involute, which is best defined as giving up the ghost physically and actively.

Tonsils, then, in infancy and childhood, would seem to have something to do with the defense mechanisms of the body. And they seem to protect against whatever invaders would cause them to be swollen.

If this early function exists, it is only common sense to feel that the tonsillar tissue should not be removed earlier than puberty unless the damage being done may offset reputed advantages. There are other parallel cases in point. Such a policy seems sane. But let us seek farther.

Bad Tonsils

T HAVE hinted at T dangers from the tonsillar tissue. What is to be feared from tonsils turned gangsters? Plenty.

Standing, as they do, in positions of influence at the major gateway of the body, tonsils have ample opportunity for participating in dire plots against the welfare of We, Us & Co. Yet, in fairness, they lead apparently honest lives till overwhelmed by evil invaders. Whereupon, like the good boy gone wrong through evil associates, they turn against erstwhile friends and allies and rend them.

Invaded, two things may result. The bacteria may break through to the next line of defense, and so on till stopped. Or some or all may remain in the tonsils, generate their witches’ brew and send it through the body as toxin. Which happens depends on the type of bacterial invader. During the process the tonsils become chronically inflamed. Their usefulness is diminished or gone. They have become a menace. And so have their sisters and their cousins and their aunts, the adenoids and linguals—perhaps.

The damage may be broad in scope, and include:

Impaired hearing, through extension of the common cold into tonsillar tissue and thence through the tunnel into the middle ear, following which the fireworks begin. Or the sinuses may be similarly invaded and the bacteria lurk and work there as part of the plot. Which doesn’t extenuate the guilt of the tonsils, but merely adds accomplices.

Enlarged “glands” of the neck, secondary to infected tonsillar tissue. Rarely tuberculous glands of the neck—the old-time scrofula or king’s evil—may be associated with lurking tuberculosis germs in the tonsils, though, thanks to our Christmas seals as good bankers, it has been possible to do much toward controlling this bacillus.

Obstructed breathing in children. Enlarged lymphoid tissue may be the cause. For some curious reason, along with obstructed breathing when associated with enlarged adenoids, may come decaying teeth. Heredity is somewhere in this picture. Here, strangely enough, we can find no signs of infection in the tonsillar type of tissue.

Frequent sore throats. It was shown in comparative studies of overworked hospital personnel exposed to throat infection, that routine removal of the tonsils meant better health. Of course we cannot claim this must be applied to ordinary situations where it is not all work and no outdoor play.

Rheumatic fever, with its tortured swollen joints. Heart

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disease. St. Vitus’s dance. Kidney infections. All these frequently may be credited to infection of tonsillar tissue. But you may have to go farther in a proved case than removing tonsils and adenoids to stop the process. You are really dealing with causes in the whole upper respira tory tract. Serious? Well, rheumatic heart disease is the commonest kind in younger people and children, and represents one of the biggest health problems of the moment.

Malnutrition. Interference with growth. Oh, that’s no new idea. But it still holds good as one of the major sins of tonsillar tissue. Get rid of the offending organs and weight picks up, height increases and health improves—provided we follow the operation with proper food, fresh air, sunshine and the other classic health goodies.

Guilty, then, is the verdict in the case of the People against the Waldever family. Guilty of what? First, of leading a mysterious and often a Dr. Jekyll-Mr. Hyde life. Second, of leading a fairly useful early life, but soon becoming parasites and troublemakers. Third, of the numerous and specified sins as per indictment above.

What About Operations?

SENTENCE? Shall it be routine removal, removal for cause, or watchful waiting? Certainly there is no excuse for placing much trust in any known scions of the tonsil family.

Routine removal, as soon as a tiny tot can stand operation, seems pretty drastic, though it is the safe thing to do in terms of tonsillar offense. But don’t forget that even the simplest, safest operation carries a small hazard. And don’t forget that defense service which lymphoid tissue seems to render in our tenderest days.

Nevertheless, it has been shown that removal of the tonsil decreases markedly the possibility of scarlet fever, the common colds and ear troubles. To a less extent, it seems to decrease the number of cases of rheumatic fever, St. Vitus’s dance and heart trouble in children. And we would have less trouble with swollen glands of the neck.

Even so, in order to advocate routine removal of an organ, I would want to feel that the evil done by the organ overbalanced the good. And I would prefer it to be in the vestigial class like the appendix, third eye, etc.—present but not voting, except unconstructively. And I would want to be sure, too, that it was impossible, in time of need or at any time, to distinguish between the good little tonsil that stays at home and attends to its tonsilling and the big bad tonsils that are already headed for a habitually criminal life.

It so happens that this last point is painfully true. The story seems to be that the guilty are more likely to escape than that the innocent should suffer. Many apparently normal tonsils have been removed in cases of systemic disease. The microscope has revealed such tonsils as positively wicked. Nor may I forget an experience of my own.

Five of us, imbued with that ever present medical spirit of “I want to know,” arranged to go to a hospital, examine quite a number of tonsils just before operation, record our findings as accurately as possible independently, and then check up against the operative and laboratory evidence.

The result, we had the colossal nerve to hope, might eventually be a long-desired method of examining and recording the tonsils which would make it possible for Dr. Smith in Vancouver to look at his case and compare it thoroughly with that of Dr. Jones in Halifax or Dr. Wye in Montreal. We sought an objective or duplicatable

test, as compared with a subjective observa-1 tion based on personal experience and measuring standards.

Did we get it? No.

And were we downhearted? Quite con-1 siderably. We drew pictures of the tonsils. ; We described them in terms of nuts and other familiar objects. We tried to measure ! them by squinting along celluloid rulers. We even thought of photography, but learned ! that it had been tried and found unprofitj able. Our pre-operation data resembled, in I agreement, the familiar accord found in disarmament conferences and discussions of how to control Old Man Alcohol.

Seeing the tonsils later, ex corpore as you ; might say, added nothing to our pleasure, for we seemed to disagree most of all with the facts—more so than among ourselves. Yet we were pretty well qualified and experienced examiners. Any doctor will tell you we tackled one of the toughest jobs in descriptive fact finding. Let me add -none of us questioned the desirability of removal, either before or after the operation, in these cases.

Look ’em Over

HERE’S HOW the whole matter looks to me: There seems more likelihood of

retaining evil tonsillar tissue than removing good. But routine removal cannot be advised only because of some indefinite influence which the tissue bears on the growth period.

It gets down to the question of determining whether the presence of the tonsillar tissue is more damaging than its absence. We don’t tty to decide the issue in one examination. And we consider the whole individual, not just five mystic masses in his throat. In all but pressing cases, we favor a period of thoughtful, careful observation before making the final decision. I find people very often seeking the opinion of two doctors and then having to get a third to break the tie. One doctor, in border-line cases, leans toward operation: the other toward watchful waiting. In spite of all the evidence I’ve shown for routine removal. I belong to the more conservative school.

As to the method of removal if necessary, even an efficiency expert will tell you any good workman has his own best ways. You'd better let the doctor decide, in terms of you. your strong points and phobias, and his own special skill. All you want is a good job. You want also a longer period of rest afterward than you usually believe. No use sending a child back to school nor an adult back to work for a week anyway. Two, I like better. Then you feel like something. And remember, operation or no operation, you can’t reform tonsils easily. Even the beginning sinners require a lot of effort to get them back on the straight and narrow path. Better still is to keep them from sinning, if you can.

There you are. The mysterious five still puzzle us. They still indulge in treacheries and other activities of public enemies. Control lies, first of all, in less self-medication and more seeking of skilled medical treatment early in colds and sore throats. Second, there’s nothing like an annual personal audit, including not only tonsils but whatever lies between the topmost hair on the top of your head and the flattest spot on your feet.

Finally, be willing, without too serious debate, to follow the advice of your physician as to whether any given set of tonsils shall be given a clean bill of health—probably a genuine rarity—or placed on probation. Or whether the tonsils shall be subjected to what is known popularly in the sly phrases of the Soviets as “the highest social protection”—here, a pretty good term.