What should you do about tonsils?

Tonsils were once snipped “just in case,” but many specialists now think these organs have a definite and vital job. Here’s impartial advice for parents who are worrying about this universal problem

VICTOR MAXWELL September 1 1953

What should you do about tonsils?

Tonsils were once snipped “just in case,” but many specialists now think these organs have a definite and vital job. Here’s impartial advice for parents who are worrying about this universal problem

VICTOR MAXWELL September 1 1953

What should you do about tonsils?

Tonsils were once snipped “just in case,” but many specialists now think these organs have a definite and vital job. Here’s impartial advice for parents who are worrying about this universal problem

VICTOR MAXWELL

SHOULD YOU have your child’s tonsils removed if they seem too big? Should you wait until after his fifth birthday? Should tonsils come out in the winter when it’s cold and damp or in the summer when there might be a risk of polio? Might the operation change his voice or scare him so much that deep damage may be done to his nervous system? And what about those tonsillectomy deaths you see reported in the paper every so often?

When you argue with yourself like that you are right in the middle of a medical controversy that has been going on since at least 1000 B.C. (when, according to ancient records, crude tonsillectomies were performed). Today, with doctors investigating the possibility of a connection between tonsils and polio, it is hotter than ever.

In spite of numerous surveys the medical profession still can’t make up its mind about tonsils. The two extreme views are: (a) tonsils are useless, toxin-producing germ traps that should be taken out as soon as possible; and (b) tonsils are an important part of the body’s defense against infection and disease. In between are so many shades of opinion varying from region to region and from year to year that whether your child keeps or loses his tonsils depends largely upon the views of your doctor.

From the turn of the century, when the technique of tonsillectomy was perfected, up until about twenty-five years ago, tonsil-snipping was considered as routine and necessary as vaccination is today. Whole families of ten or a dozen children lined up at the public clinics or doctors’ offices for what has been called “the massacre of the tonsil.” Occasionally a child died under the anaesthetic or bled to death, but that was considered one of the risks that had to be taken. The view of the more cynical doctors was expressed in this little verse:

T stands for tonsil Some have them still.

If you don’t take ’em out,

The other fellow will.

Then, as children-per-family became fewer and doctors became more inquiring, tonsillectomies became less frequent. In 1938 the Medical Research Council of Great Britain reported a survey of thirty thousand children in public schools which found that the incidence of coughs, colds, sore throats and other ailments among children with or without tonsils did not differ. The council doubted whether a great majority of tonsil operations were any more than “a routine prophylactic ritual for no particular reason and with no particular result.”

In October 1938, Dr. Albert Kaiser, of Rochester, N.Y., published the results of a ten-year study of forty-four hundred children, all of whom by “conventional standards” should have had their tonsils

out. Half of them did; half didn’t. He found that the removal of tonsils had no apparent effect on the incidence of colds, bronchitis, pneumonia or tuberculosis.

In spite of these findings the tonsil controversy is far from settled. Dr. Alan Brown, Canada’s senior pediatrician, stated recently that “diseased tonsils cause more trouble than all other children’s ailments put together . . . except traffic accidents.” And Brown, as physician-in-chief of Toronto’s Hospital for Sick Children, as consultant to the federal and Ontario governments and as a private practitioner, has been dealing with two hundred and fifteen thousand children a year by his own estimate.

Dr. R. W. Davis, a general practitioner with forty years’ experience in Ontario, represents the view of a small hut vocal group of doctors. In his recent hook, Health Saboteurs, he blames tonsils for just about everything that is wrong with human beings —including allergies, buck teeth and crimeand advocates their wholesale removal as soon after birth as possible.

Dr. P. E. Ireland, professor of otolaryngology (ear, nose and throat disease specialization) at the University of Toronto, says this idea is “ridiculous” and that he would no more think of removing a healthy tonsil than extracting a healthy molar.

In the summer of 1941 the tonsil-snipping business took its biggest jolt as a result of a tragedy in Akron, Ohio. Five of the six children in one family contracted polio and three died. The only

and vital job. Here’s impartial advice for parents who are worrying about this universal problem

child to escape, although polio germs were found in his system, was the one who still had his tonsils.

The panic was on. Doctors couldn’t get parents to take their children near an operating table during the summer months, up to then considered the best time for tonsillectomies. Once again medical opinion was divided and each side found plenty of statistics to prove its point.

T 1949, for instance, Dr. D. S. Cunning, of New York, published the results of a four-year, nationwide survey conducted by the American Laryngological, Rhinological and Otological Society with 36,678 cases of polio and 93,379 cases of tonsillectomy. The committee concluded that “it fails to see any causal relationship existing between poliomyelitis and tonsillectomy.”

Others don’t agree. A survey by Drs. C. W. Anderson, G. Anderson, A. E. Skaar and F. Sandler of 2,709 cases during a polio epidemic in Minnesota led to the conclusion that the risk of developing polio was at least three times as great among those undergoing tonsillectomy within one month before exposure to polio germs as among a comparable group not undergoing this operation.

These two findings are typical. Some surveys show a relationship between polio and tonsillectomy; others don’t. There seems at present to be more evidence in support of the relationship but most medical men are far from convinced one way or the other.

One thing the majority agree on: No routine surgery, even tooth extraction or vaccination,

should be performed during a polio epidemic.

What are the facts about tonsils? If you want to look at a pair of these controversial appendages, get your child to “open wide” and look inside. On either side of the throat right at the base of the tongue are two bumpy, almond-shaped growths located between what looks like two ridges of muscle. These are the palatine tonsils to laymen simply “the tonsils.” There are other tonsils down there that you can’t see. There is a ring of tonsil tissue called the tonsillar ring. Just above the soft palate at the back of the nasal cavity is a tonsillar growth called adenoids which if not removed often disappear at puberty.

The tonsillar ring surrounds the vital port of entry to the body. Past it go all the air we breathe and food we eat. Much of this food and air is too hot or too cold, loaded with dust, dirt, bacteria, viruses, smoke, tobacco tar and smog. The tonsillar ring is made up of lymphoid tissue, one of the functions of which is to localize and destroy infection.

Many doctors believe that, as part of the tonsillar ring, the tonsils in some way help fight infection. What they don’t agree on is how essential a bulwark they are. Dr. Alan Brown says we can get along without them at any age because other organs quickly take over their work. On the other hand, Dr. Francis L. Lederer, of the University of Illinois, recently stated in the Eye, Ear, Nose and Throat Monthly that tonsils play an important part in the development of what he called “auto immuniza-

tion,” that by producing toxins they do a sort of self-vaccinating job. He said this immunization is far from complete at the age of six and if tonsils are removed the child “will remain unprotected and may be endangered later in lifetime.”

It is widely accepted that the tonsils are fertile breeding-grounds for streptococcus, pneumococcus, staphylococcus, diphtheria bacteria and other germs. The tonsils contain ten to twenty crypts, little blind alleys running down into the interior, warm and moist and filled with debris, which can reproduce bacteria faster than a laboratory test tube. One theory in favor of leaving the tonsils in place holds that the toxins produced by the germs harbored by the tonsils serve as a sort of immunization mechanism to help the body fight off the attack of those germs. The doctors who recommend tonsil removal believe that the presence of germs and toxins can only be harmful.

More and more throat specialists, including Dr. J. B. Whaley, head of the ear, nose and throat service at Toronto’s Hospital for Sick Children, believe healthy tonsils should be left alone. With diseased tonsils, says Alan Brown, the important thing is to get them out before there is any “systematic involvement of the vital organs.”

When he sees a child with a history of repeated sore throats, fatigue, listlessness, lack of appetite, bad breath and swollen neck glands he advises immediate operation. “And it doesn’t make any difference how old he is or what season of the year it is,” he maintains. Continued on page 46

What Should You Do About Tonsils?

CONTINUED FROM PAGE 23

“The time to remove tonsils is when the patient needs it. If you were doing the job in the back yard you’d have to worry about the weather, but operating rooms are warm and cosy.” Brown once had the tonsils removed from a two-week-old baby, suffering from sinus complications, with no ill effects.

But the suggestion of an operation makes parents nervous. They think of the possibility of shock, of the voice being affected—and of the hemorrhage and anaesthetic deaths they’ve read about.

Why do tonsil patients die?

On June 23, 1952, George Gray, a four-and-a-half-year-old Toronto boy had his tonsils removed in a private hospital on Bloor Street by a surgeon who estimated he’d performed some fifteen thousand similar operations. Afterward George was put to bed and seemed to be doing fine. But later he became very pale and his pulse was weak. A nurse called the doctor but by the time he got there the child was dead.

Dr. Smirle Lawson, chief coroner of Toronto, reported that “the cut just wouldn’t stop bleeding.” A post mortem showed fifteen ounces of blood in the boy’s intestine.

In August 1951 in a doctor’s office on Bathurst Street in Toronto ten-yearold Helen Wasylewsky died of what was described by the coroner as “purely anaesthetic” causes. The doctor in charge stated afterward, “There is no reliable test for a person’s tolerance to anaesthetic.”

How many children die during or as a result of tonsillectomies? It is impossible to say. Sometimes the death is ascribed to some other condition such as heart trouble, for the relief of which the tonsillectomy was being performed. In 1949 when fourteenyear-old Nola Margaret Hammond, described as a “normal, healthy, active girl,” died in a doctor’s office from the effects of anaesthetic one minute before the operation started, coroner Lawson described it as “one case in ten thousand.” In Great Britain there are an estimated eighty deaths a year as a direct result of tonsil operation out of a total of about one hundred thousand operations. At the Sick Children’s Hospital in Toronto where an average of thirty tonsillectomies a day are performed, five days a week, there hasn’t been one death in over twenty years.

The tonsil operation has long been considered the simplest and most routine surgery. In his book, Your Tonsils and Adenoids, Dr. Martin Ross describes mass tonsillectomies in some American public clinics about fifty years ago. Screaming kicking youngsters were held down by a husky intern and the mothers while the tonsils were scooped out without benefit of anaesthetic. There was probably a certain amount of shock accompanying that procedure.

Many people will remember losing their tonsils on the privacy of the kitchen table at home or with plenty of company in an improvised operating room in a town hall or church. Thirty or so years ago it was common practice to gather all the tonsils cases, real or imaginary, in a district and have a wholesale cutting bee. Dr.S.H.Smith, of Streetsville, Ont., remembers one such held in a Presbyterian church during the first war, sponsored by the Women’s Institute. Beds were set up behind screens. A specialist came from the city to do the snipping. The local

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doctors handled the anaesthetic. “We did about twenty a day,” Smith stated recently. “There were no complications.”

Nowadays throat experts warn that the operation should not be regarded as a simple one. Dr. Whaley considers a tonsillectomy more involved than an ordinary appendectomy. A tonsil textbook lists no fewer than twenty-two possible complications, the most common of which are hemorrhage, heart stoppage and lung abscess caused by infected blood, pus or bits of tonsil debris getting into the lungs.

The Hospital for Sick Children has maintained its perfect record by guarding against all contingencies. For instance, considerable attention has been given lately to the possibility that shock and fear connected with an operation may lead to “behavior problems” later in life. Junior is told that he is going to have nothing more than a pleasant sleep. He wakes up with a flaming sore throat and a distrust of his parents. “The important thing in preventing shock or upset,” says Whaley, “is not to lie to the children about what is going to happen.” As an extreme example he describes one little girl who arrived at an English hospital all decked out in ribbons and bows in the belief that she was going to “a lovely party.”

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At the Hospital for Sick Children they provide the child with a coloring book called Going to the Hospital which describes the whole routine truthfully with phrases like “The nurse said lots of children throw up after their tonsils are out.” Very rarely do they encounter a child who must be given a sedative before the anaesthetic. “We have more trouble with the parents,” says Whaley.

Anaesthetic is an especially big problem in tonsillectomies because the surgeon is working in the air passages. Four decades ago ether was given through a cone held over the face. When the patient was unconscious the cone was removed and the operation begun. Often the patient began to revive before the job was done and ether had to be given again.

Continuous inhalation of anaesthetic has replaced the on-and-off procedure but anaesthetic deaths still occur. Medical men point out that when operations are performed in homes, doctors’ offices and private hospitals the anaesthetic is sometimes administered by another doctor who is not a specialist in anaesthesia, and is paid out of the over-all fee charged by the surgeon. (In Canada today the usual minimum surgeon’s fee for children is twenty-five dollars and up to a hundred, depending on whether a specialist is called in. For adults the fee is usually forty dollars and up.)

Anaesthetic administered by a nonspecialist works well in most cases but when trouble is encountered—when the patient is an undetected diabetic or has a heart condition—there often isn’t the skill or equipment available to avert tragedy.

At the Hospital for Sick Children anaesthetics are administered by specialists and staff doctors explain that

techniques have been developed to the point where anaesthetics can safely be given to any child regardless of age or condition. They use ethyl chloride flavored with eau de cologne, followed by continuous inhalation of ether mixed with oxygen. Ethyl chloride is quick and easy on the patient. Also it permits rapid return of throat reflexes so that the child does his first coughing on the operating table under the watchful eye of the surgeon. But ethyl chloride is also very tricky to handle and in the hands of a doctor not especially trained in its use can be extremely dangerous. The bleeding after a tonsillectomy is often so gradual as to be undetected and the child may keep swallowing without realizing what is happening. For this reason he must be watched and checked carefully for at least one day after the operation. At Sick Children’s every child is kept overnight under the constant supervision of nurses. Dr. Whaley maintains that tonsillectomies performed in homes, doctors’ offices or small private hospitals are just not safe. Contrary to one belief, the presence or absence of tonsils cannot affect the voice. A seventeen-year-old actress of my acquaintance plays the part of a six-year-old child on the radio once a week, a feat that calls for considerable vocal gymnastics. Not long ago she required a tonsillectomy. Several friends warned that her voice would be much deeper afterward. She went ahead anyway and found the operation had no effect one way or the other. Dr. Ernesto Vinci of the Royal Conservatory of Music, a medical man as well as a leading singing teacher, puts it this way: “If they get in the way, have them out. It can only be an improvement.” This still leaves the basic problem. Should you rush Junior to the hospital and have those enlarged tonsils removed? From the evidence available, the following seem to be the safest and sanest conclusions: 1. If the tonsils are causing no trouble leave them alone whether they are enlarged or not. They provide some protection against infection. 2. Tonsils that are causing sore throat, ear trouble, swollen neck glands, loss of appetite, fatigue, mouth breathing, bad breath, tonsillitis or quinsy, should come out. 3. Tonsils should be removed in a hospital by an expert, with the anaesthetic administered by a specialist. 4. Tonsils should never be taken out during a polio epidemic or before a child is completely recovered from an attack of tonsillitis or quinsy. 5. Each child has different natural immunity to infection. What happened when Willie Smith had his tonsils out is no indication of what will happen to your child. Only a good doctor can tell if they should come out or not. if