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124                  THE PHARYNX AND NASOPHARYNX

History plays a vital part in the assessment for surgery, and history depends
on the case records of the general practitioner and upon the parents. Thus the
letter from the family doctor, especially if it is documented, may play a vital
role in the surgical opinion. Only he can assess the effect on the general health
of the child of repeated infections. Parents vary in the way that they describe
the illnesses of the child. Those who are anxious for,surgery will exaggerate
the frequency and severity of the sore throats, while parents opposed to
surgery may minimize them. By the same token results are difficult to assess
because the parents who have successfully pressed for surgery may well paint a
different picture from those who have had reservations about the operation
and who may ascribe many subsequent illnesses as dating from the operation.
Between these two extremes is the vast majority of cases in which the practi-
tioner's letter and the parents* story are in agreement.

On the question of taking a history one must not confine this entirely to the
throat. Many parents have been led to believe from casual conversation with
friends and relatives that the removal of tonsils and adenoids will cure all
manner of illnesses. So convinced of this do they become that they may not
mention these conditions specifically unless asked about them. It is thus wise
to take a history in depth regarding such things as poor appetite, speech
defects, nasal catarrh or colds, hearing loss, chest troubles, etc. because, while
the operation may in certain cases be helpful, in others it may have no effect.
Poor appetite may be due to other causes than tonsillar size or sepsis. Speech
disorders may even be aggravated by the operation if the soft palate is
inadequate and depends on a large adenoid pad for closure of the naso-
pharynx. Nasal catarrh may be due to allergy and will be unaffected by the
operation, and this holds good for bronchospasm. Deafness may be con-
genital, or may be due to high tone loss, or to a sensorineural loss over the
range of hearing, and none of these will be any better for the removal of
tonsils or adenoids.

The history should be taken methodically and with care, and any chance
remarks should be followed up. The frequency of sore throats is noted, as is
their severity, their effect on the general health of the child, the need for
antibiotics, including any history of antibiotic sensitivity, the length of
absences from school, etc. The question of the catarrhal child has been
discussed (p. 50) and one would want to discover whether sore throats only
began with school attendance, whether they were the transient precursors of
head colds and whether they occurred throughout the year or only during the
winter months.

^Appetite is investigated, and in particular any change in appetite associated
with the onset of a sequence of tonsillitis. Loss of appetite may be an indication
of tonsillar sepsis^and nranychUdren eafmuch better following tonsillectomy.
"If has beenjhownjthat on average they n^dce a sudden gain in weighfafter the
operation, and that this, levels out later^On the other "hand, a poor appetite is
no indication for tonsillectomy if the tonsils are healthy. ^~
- Speech may be affected by the size of tonsils, especially the large buried
tonsils whose upper poles are embedded in the soft palate. If one asks a child
with such tonsils to say 'ah* it is noticeable how little the soft palate can move
to close the nasopharynx. Removal of such tonsils, in spite of the post-
operative scar tissue formation, will release the soft palate and allow it to
recover its normal function. But in such cases the soft palate is often relatively