BY T. B. LAYTON.
Surgeon to the Throat and Ear Department, Guys Hospital, and Otologist to the Fever Hospitals of the London County Council.
(Extract from The Lancet, January 20th, 1934).
As I am one who as long ago as 1914 raised his voice against the increase of tonsil operations that was occurring even then, I would submit certain principles.
First let us note the Hippocratic maxim that in any course of treatment we must not only consider whether it will do any good but whether it can possibly do any harm. Lord Dawson accurately described with the eye of an accurate observer changes in the palate that impair its efficiency and that may result from an “operation of perfection” on the tonsils. No one can ever guarantee that this will not occur.
If this were the only evil result, we might discount it against quite small advantages. But the operation for the removal of tonsils has a greater number of complications to life as to immediate illnesses, and to post- operative impairment of function, than any other operation of the same magnitude.
So long is the list, that if it were read over at the time of consultation, any parent would hesitate to consent to the operation being performed. To say that it is devoid of risk cannot by any reasonable criterion be considered an accurate statement.”.
Next, the operation is never “absolutely necessary.” Strictly speaking this phrase is unsuitable for the type of surgery to which tonsillectomy belongs. It should be limited to the surgery of disorders in which death is reasonably certain if there is not performed of an operation that gives a good chance of recovery. Even in a wider sense it is too strong a term to use for this operation.
There is no case of rheumatism, nephritis, or other disease in which the tonsillectomy has not been performed at some time previously. Further, the operation of tonsillectomy is of such recent origin that those who may still look forward to a quarter of a century of active life are too old to have had it performed in childhood; yet there is no evidence as yet to show that the subsequent generations who have grown up in the age of tonsillectomy are fitter than that we can say is that the operation is advisable, perhaps strongly advisable, but never absolutely necessary.
Again, it is but seldom that one can say the tonsils “are obviously diseased”. If one does, and if for some reason the operation is deferred, it is likely that it will be found that no harm has come to the patient from their presence.
It is probable that there is no operation in surgery upon which a decision is more rapidly made in practice, nor one in which it is more necessary to weigh the pros and cons, not only of the local conditions but also of the general health, of the habit of mind and of body, and the hygienic conditions of school, home, and place occupation.
The words, “enlarged tonsil,” should be removed from our terminology. The tonsils for the enlargement of which the operation of tonsillectomy was devised, are not seen-today, yet succeeding generations of students read and hear about “enlarged” tonsils as an indication for their removal, without any criterion as to the size of which warrants it.
The conception of the “typical adenoid faces” should be dropped.
Finally as to function. There are those who say we know not the function of the tonsil, they call it vestigial, and demand of us that we should prove its functioning. But we know its function from its structure. It is a lymph gland differing only from the other lymph glands by its anatomical relationships.
Two rules of a clinical administrative nature may be enunciated: The first is that operations upon the tonsils should not be performed in the winter months. This is specially advisable in a year of epidemics. I look upon measles as the most serious complication of these tonsillectomies.
So highly infectious is it, and so long is the incubation period, that it is impossible to set up any organization for the continuance of tonsil operations during the prevalence of measles without the risk of a case being operated on during the incubation period so that the disease supervenes upon an unhealthy throat.
The second is not to operate upon a patient living in unhygienic surroundings.
Tonsillectomy is bad for children of the very poor. There are those who recognize that the squalor in which the child lives and the want of nourishment to which it is subjected are the primary causes of ill-health, but how think that some sepsis in the tonsils is also present; and feel that though they cannot prescribe the proper treatment of a new dwelling and a full stomach they must do the second best by removing the tonsils.
The augment is fallacious, for under these circumstances the operation is not a second best. In the vast majority of cases the defective hygiene and not the tonsils is the cause of the sepsis; and when there is some sepsis in the tonsils the lymphoid tissue is of greater value in protecting against the bad hygiene of the home than the organisms within it are harmful.
When all is said and done we laryngologists have the greater responsibility. If we think that the number of tonsil operations has increased to an alarming extent we cannot absolve ourselves entirely.