A greater degree of enlargement of the tonsils occasions deafness from pressure on the passage leading to the internal ear, and is also apt to give rise to a troublesome hacking cough which sometimes excites apprehension lest the child's lungs should be diseased. When still more considerable the enlarged tonsils block up the passage through the nostrils, and air consequently enters the lungs but very imperfectly. The nostrils thus disused become extremely small, narrow, and compressed, the upper jaw does not undergo its proper development, the teeth are crowded and overlap each other, the palate remains narrow and unusually high-arched, and the face assumes something of a bird-like character. Besides this the child grows pigeon-breasted, owing to the lungs not being filled sufficiently at each inspiration to overcome the pressure of the external air on the yielding sides of the chest.
When any considerable enlargement of the tonsils exists, each cold that the child may catch aggravates it, and if diphtheria, scarlatina, or severe sore-throat should occur, the temporary increase of the swelling may become the occasion of serious danger. The question arises, what are the chances that a child whose tonsils are enlarged will outgrow the condition, or when is it necessary to have the enlarged tonsils removed?
It scarcely ever happens that any such enlargement of the tonsils exists in children under six years of age as to call for their removal. There is almost always ground for the hope that after the irritation caused by cutting the first four permanent grinding teeth has completely ceased, the tonsils may return by degrees to their former size. A similar shrinking of the enlarged tonsil sometimes takes place, especially in the boy, at the time of approach to manhood, when the vocal organs undergo full development. This can be counted on, however, only in cases where the tonsils are not of extreme size, and have not undergone frequent attacks of inflammation. Whenever the hearing is habitually dull, and the voice always thick, when cough is frequent, the nostrils narrow, the chest pigeon-breasted, and the child feeble and ill-thriven, removal of the tonsils is absolutely necessary. In cases where the question is doubtful, its decision must turn on whether the tonsils have often been inflamed. So long as their surface is smooth, and their substance soft and elastic, delay is permissible. When their substance is hard, like gristle, and their surface uneven and corrugated, they have undergone such changes that absorption is impossible, and their removal absolutely necessary.