To cut or not to cut

The debate of if and when to ‘cut’ (remove part, or even a whole organ or part of the anatomy) is one that has featured significantly in the Semon Lectures. One such example of this debate is that which surrounds removal of the tonsils. In 1932, Kahler began that ‘There is scarcely another problem which has been written or spoken as much as the tonsil problem’. He argued that this problem concerned not just laryngology, but general medicine as well. At the time there was question as to the efficacy or removing the tonsils, and this question still persists today.

Kahler pointed out that in the preceding 50 years, the suitability of tonsillectomy had changed several times, and nearly 50 years after that, Pracy (1980) stated that for many years, the answer to most problems of childhood illness was to remove the tonsils, but in the ‘…in the closing years of the 20th century… If the eye offends, we no longer remedy the offence by plucking it out’.

Wright (1949) drew attention to the considerable amount of surgical hours that was dedicated to the removal of lymphatic tissue, such as the tonsils, adenoids and appendix. He argued that the results of these surgeries could lead one to conclude that the function of such organs is to ‘bear the brunt’ of attack by microorganisms, but that patients were no worse off after their removal. Pracy agrees that removal of the tonsils does prevent recurrent acute follicular tonsillitis (i.e.: swollen infection of the tonsils), but if done prematurely, it can also result in harm.

The debate also raged in consideration of partial or full laryngectomy in the treatment of laryngectomy. In 1927, Colledge began by claiming that laryngectomy was frequently in unsuitable cases, and high levels of mortality. In this instance, the debate was not over when to cut, but how much to cut. Omerod (1953) advocated against partial laryngectomy, claiming it was ineffective. Som (1969) advocated for conservative surgical treatment, and Semon himself resented ‘that there still exists amongst continental and North American surgeons—a measure of latent opposition to this conservative operation, in place of which the mutilating removal of the entire larynx is preferred’.

With the introduction of endoscopic, laser and robotic surgeries, the prevalence of total laryngectomies has reduced drastically. In 2013, Shaha reviewed the case, and noted that whilst between 1951-1965, all but a minute fraction of surgeries were full laryngectomies, by 1995-2000, more than half of cases were treatable with functional methods.