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tonsillectomy
This chart presents a picture covering the period of nineteen years, 1920—1938 inclusive. The continuous line shows
e number of operations performed under the Education Committee's scheme for the removal of tonsils and adenoids.
I he interrupted line shows the number of children found each year at routine medical inspections, special inspections and
at the school clinic, to be suffering from otorrhcea or ear discharge.
The most striking feature of the chart is0 the great and sudden fall in the number of operations from an average of
a out 190 per annum in the four years 1925-1928 inclusive to about a dozen operations per annum in 1929 and
subsequent years.
The other striking feature of this picture is the steady continuous fall since 1921 in the number of children suffering
trom otorrhcea—one of the most tiresome, and objectionable ailments of school children in the old days, not only or
account of the damage to the child s health, but also the offensive odour of many ear discharges.
It is not claimed that this reduction in otorrhcea has been achieved by reducing the number of operations. Indeed
it is obvious that the fall in incidence of ear discharge set in many years before the fall of tonsillectomy in 1929. The
importance of presenting these two curves together is to demonstrate that the fall in otorrhcea has not been interferec
with by a drastic reduction in tonsil operations.
It is commonly believed that otitis media (inflammation of the middle ear) the precursor of otorrhcea (ear discharge
is caused by enlarged tonsils and that tonsillectomy is an essential part of the treatment of this condition.
e evidence accumulated in the last ten years in Hornsey furnishes conclusive proof that the great majority of cases of
ear discharge can be cured rapidly and permanently without resort to tonsillectomy. The same is true in regard to other
local conditions—such as nasal catarrh; nasal sepsis; sub-acute inflammation of the glands of the neck—for which
tonsillectomy is part of the routine modern treatment.
There is now also abundant evidence to show that equally fallacious are the views that physical growth and mental
development are in many cases interfered with by even moderately enlarged tonsils and adenoids, and that tonsillectomy
is an essential prerequisite to that healthy growth of body and mind which enables a child to obtain full benefit from its
education.
Tonsillectomy is one of the most highly controversial subjects in pediatrics (the special study of children's diseases),
and especially in school medicine. At one time the operation was rarely performed and seldom discussed. Then a
vogue set in in the early years of this century and it became the commonest operation "\n surgery. \\ was ^and \n some
quarters still is) regarded as a panacea for almost every abnormality or ailment, physical, mental and moral, which afflicts
school children. In recent years the operation has been performed more and more in pre-school children. Even infants
under one year have had their tonsils and adenoids removed.
While I take sole responsibility for the virtual abandonment of tonsillectomy in the scheme of treatment of ear, nose
and throat conditions in school children in Hornsey, I desire to express my faith in, and admiration for, the pioneer work
of Dr. A. R. Friel (until lately Ear, Nose and Throat physician to the Hornsey Education Authority). He introduced into
school medical practice in England the method of Zinc lonisation for the treatment of otorrhoea (ear discharge). With
him lies the credit of abolishing chronic ear discharge from the elementary schools. His weekly session of work, originally
known as the " otorrhoea clinic," ceased to be an otorrhcea clinic because the supply of cases of otorrhoea ran dry. In
the meantime Dr. Friel was turning his attention to incipient and minor forms of deafness in school and pre-school
children; and to chronic rhinitis (nose discharge) and antrum infection. He practised the method devised by Gautier, of
THE GREAT REDUCTION IN THE NUMBER. OF TONSIL OPERATIONS IN 19^9 SUBSEQUENT YEARS HAS
NOT INTERFERED VVITH THE DIMINUTION IN INCIDENCE OF EAR DISCHARGE. THERE 15 NO EVIDENCE
THAT THE FALL IN NUMBER OF OPERATIONS MAS HAD ANY ILL-EFFECT ON THE HEALTH OF THE
CHILDREN. ON THE CONTRARY THER.E. 15 AMPLE EVIDENCE THAT THE CONSERVATIVE METHOD5
OF TREATMENT ADOPTED HAVE BEEN BENEFICIAL.
Paris, called Diastolisation for the relief of nasal obstruction due to nasal catarrh. It has been found to be a valuable
remedy for many nasal conditions.
More recently Dr. Clarke, who succeeded Dr. Friel as Ear, Nose and Throat physician in 1937, has employed Peters
suction method for the treatment of enlarged and so-called " septic " tonsils. It is now possible for Hornsey children to
have their tonsils spring cleaned in situ by means of a suction apparatus, which extracts pus and septic material from
the crypts of the tonsils. A few treatments of this kind may reduce enlarged tonsils to one-half or one-third their size at
the commencement of treatment.
Hornsey's lead in abandoning tonsillectomy in 1929 in favour of rational conservative methods of treatment of
the ear, nose and throat ailments of school and pre-school children was quickly followed by a nation-wide movement in the
same direction. In an important paper on " The Incidence of Tonsillectomy " read to the Royal Society of Medicine in
1938, Dr. J. Allison Glover, Senior Medical Officer to the Board of Education, furnishes very interesting figures , of the
numbers of operations performed under Education Authorities—Counties, County Boroughs, Boroughs and Urban Districts
in England and Wales, including London.
The Borough of Hornsey has the lowest incidence of tonsillectomy of any authority in 1929 and subsequent years.
The rising tide of tonsillectomy reached its height in 1931, when 128,417 operations were performed in England
and Wales (including London). In 1932 (i.e., three years after the sudden fall in Hornsey) the number fell to 111,433,
in 1933 to 89,000 and in 1934 to 82,974. That is to say, in three years, 1932 to 1934 inclusive, there was a reduction ot
45,443 in the annual number of operations performed. Since 1934 there has been a tendency for the number to rise again
—no doubt chiefly on account of the emphasis laid in recent years on Septic tonsils as a cause o i ness. ecen
experience in Hornsey is showing that Peters tonsil suction technique is an effective method of dealing wit tonsi sepsis
and its supposed complications. Indeed, there is good reason to hope that the radical proce ure o remova o
extremely important and valuable lymphoid tissue from the throats of children may ultimately become an o s
operation. , .... , ,.
In the attainment of this ideal certain other measures for the improvement of the healt o t e c i popu a
are necessary, e.g., x n +U
(1) Sound nutrition from the beginning of life through every stage of infancy, childhood, a o escence o tu gr
(2) Adequate attention to posture, deep nasal breathing and full development of the respiratory appara
system of physical training in the schools and at home should pay special attention to these points in securing
healthy conditions in the nose and throat of growing children.
(3) Adequate dental treatment of pre-school and school children in order to keep the mout ree ro
decay and sepsis and to promote the full growth and maintain the correct shape of the dental arches, pa a,
and bony structures of the jaw and face. ... ~
(4) The highest skill in the use of conservative physiological methods of dealing with t e common ear, nose
throat infections and ailments of children. . . T,. u,
(5) Psychological insight into the focussing of maternal anxiety on the child s tonsi s an ® en01 s' ' ... ,
from too much tonsil talk and unless understood and counteracted the other measures indicated above wi n
satisfy the over-anxious mother. Even when it is fully understood and every effort made to c°rrect .t. jn some
cases the anxiety may be so acute that unnecessary tonsillectomy is performed in spite o a v.ce an