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their children operated upon privately or in Hospital should be
warned of the need for after-care and asked to notify the School
Medical Officer of the date of operation. He could then arrange
for the school nurse to visit the child and give the necessary instruction.
This would not involve any great increase in the
work of the department and it would probably make all the difference
between success and failure in between ten and thirty per cent.
of children.
"The next indication for operation which requires consideration
is Rheumatism. A history of rheumatic pains or other symptoms
was asked for among the questions put to the parents, thirty
children being found to have had rheumatic symptoms before
operation. Of these, twenty had improved since tonsillectomy
and ten had not. Among the last 266 children investigated,
however, 51 had a history of rheumatism and thirty-five of these
had shown no symptoms till after the operation.
"The records of all children in the borough noted as rheumatic
at School Medical Inspection were next investigated. Of these
there were 96, 43 having had their tonsils removed. Out of the
43, 21 had had no symptoms till after operation, 14 had been improved
by operation, and 8 had not. As regards the children with
tonsils in situ, 30 of the 53 had apparently normal tonsils, 19
slightly enlarged ones and 4 grossly enlarged or septic tonsils.
"These figures are inconclusive, and it would be unwise to be
dogmatic about them. They give no warrant for the course
practised by some people, removal of the tonsils in all cases of
rheumatism, however slight, but they throw little light upon the
vexed question of the relation of the tonsils to rheumatism generally
They may be regarded as giving ground for the suggestion that
the protective function of the tonsils extends to rheumatic conditions
and that premature removal may actually increase the child's
susceptibility. On the other hand, the greatest age of incidence
of rheumatic conditions is not earlier than eight and, as some of
these children had lost their tonsils before that age the protective
function had not really been tested.
"The last indication and, taking the medical practitioners in
this country as a whole, the commonest accepted indication, is
enlargement of the tonsils, whether associated with symptoms or
not. Some practitioners hold it as an article of faith that an