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larged tonsil is, ipso facto, a harmful one. Others, more rational,
regard size as an indication of sepsis and believe that the potential
and actual dangers of sepsis outweigh the advantages of the
protective function.
"For wholesale removal on principle there is no justification.
But prophylactic removal has a certain amount of theory behind it
and demands serious consideration. We know that the normal
tonsil tends to atrophy when its possessor reaches the age of puberty.
Does the enlarged tonsil behave in the same way, or does it remain
large ? And how often does the large, symptomless tonsil subsequently
give rise to symptoms?
"For some years a conservative policy has been adopted
towards tonsils in Ealing, though its application has been modified
in detail by changes in personnel. The general principle has been
to advise operation only in those cases where enlargement of the
tonsils is associated with symptoms such as those mentioned
previously. Enlarged tonsils not associated with symptoms have
been kept under periodical observation and the children falling into
this category are at present about 1,800 in number. Of these,
1,092 were examined ; 268 under 8 years old, 389 between 8 and 11,
and 435 over 11 years. They were classed under a scheme modified
from that propounded by Paton in 1928, his groups being reduced
to four. These are : very small—tonsils invisible or only just
visible, small—reaching half way to the posterior pillar of the
fauces, moderate—reaching to the posterior pillar and large—
concealing part or the whole of the posterior pillar.
"In evaluating the results, the cardinal symptoms considered
in the investigation of operative results were used. 'Large'
tonsils were set down for further observation and, if associated with
any one of the symptoms, for operation. In the other groups,
one symptom called for observation and two for operation. In
addition, even a small tonsil with the slightest sign indicative of
sepsis was treated as if it belonged to the ' Large ' group.
"In all age-groups the majority of the tonsils fell into the
'small' and 'moderate' classes. It was noteworthy, however,
that the 'very small' group comprised 10% of the youngest
children, 14.4% of the middle group, and 21.1% of the oldest group.
The 'large' class showed a corresponding fall—5.6%, 4.9%,
and 2.9%.