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82
in Ealing itself although it remained low in comparison with that
of other areas. Before offering this guidance it was considered
desirable to study the subject according to the latest evidence
available, namely, that of the children themselves in attendance
at school who had been found to have on previous examinations
some degree of enlargement of the tonsils and who were advised
or not, according to the extent of the enlargement, operative
treatment. The enquiry was entrusted to Dr. J. D. Kershaw,
who received much help from other members of the staff, and whose
report is reprinted elsewhere in this report. In consequence of
this report, with the conclusions of which there can be wholehearted
agreement, a memorandum was issued to the medical
staff in which a general plan was formulated in noting degrees of
enlarged tonsils and in offering advice to the parents regarding the
advisability of operation. The memorandum to the staff is as
follows:—
" Enlarged Tonsils in School children.
"As a consequence of observation of cases of enlarged tonsils in school
children and of the results of operations, facts have been elicited which lead
to certain general principles being laid down with regard to cases of enlarged
tonsils discovered on school medical inspection.
" Some conditions appear to be consistently relieved by operation, such
as, susceptibility to colds or a winter cough, recurrent sore throats, mouthbreathing,
earache, otorrhoea and deafness. Whenever any one of these
conditions exists in a marked degree, associated with the presence of enlarged
tonsils or adenoids, and has no more obvious cause, it is advisable to recommend
operation.
" In children who have enlarged tonsils without symptoms, or with
symptoms of a less marked degree, a conservative policy should be adopted.
Enlarged tonsils should be divided into three groups and should be indicated
on the record cards as 1,2 and 3. 1 is slight—reaching half way to the
posterior pillar of the fauces, 2 is moderate—reaching to the posterior pillar,
and 3 is large—concealing part or all of the edge of the posterior pillar.
" ' Large ' tonsils (3) should be put down for observation if no symptoms
are present and for treatment if any of the above-named symptoms are found.
" Tonsils of the other two groups may be ignored if symptomless. The
presence of one marked symptom should cause the child to be put down for
re-examination after three or six months and the presence of two symptoms
/ should be regarded as adequate reason for operation.
" Tonsils showing evidence of sepsis such as exudate from the crypts,
or an inflammatory zone on the anterior pillar of the fauces, should, if associated
with no symptoms, be noted in the first place for observation. If
they are associated with any symptoms treatment by operation is indicated.
When operation is advised ' op ' should be marked after the letter indicating
the extent of the enlargement and ' Re ' for observation meaning re-examination.
A note indicating the reason for the recommendation of operation
is advisable under ' general observations.'
" This arbitrary scale is intended as a rough guide only. It should not
be allowed to over-ride any urgent indications or contra-indications in
individual children.