The best test to find out whether smelly breath is caused by these little deposits is simply to run a finger or a cotton bud over the tonsils and then sniff it. If it smells unpleasant, it is time to go hunting for tonsil stones. Ear, nose, and throat doctors can also remove them, which is the safer and more convenient option. Those with a strong stomach and a love of barely watchable videos can visit YouTube to see various techniques for squeezing tonsil stones out and view some extreme examples. But be warned! These videos are not for the fainthearted.
There are also other household remedies for tonsil stones. Some people gargle with salt water several times a day; others swear by fresh, raw sauerkraut from the health-food store; and yet others claim cutting out dairy products will prevent them from forming. There is no scientific basis for any of these remedies. A more thoroughly researched medical question is that of when a tonsillectomy can or should be carried out. The answer turns out to be—not before the age of seven.
Seven is the age by which we have probably seen it all, or all that is important for our immune cells: being born into a completely unfamiliar world; being kissed and cuddled by Mom; playing in the garden or the woods; touching animals; having many colds in quick succession; meeting a load of new people at school. And that’s about it. By this time, our immune system has finished its schooling, so to speak, and can go to work for us for the rest of our life.
Before we reach the age of seven, our tonsils are still an important training camp for our immune cells. Building a healthy immune system is not only important for warding off colds, it also has an important part to play in keeping our heart healthy and in controlling our body weight. For example, removing the tonsils of a child younger than seven can lead to an increased risk of obesity. Why this should be the case is something doctors have not yet discovered. However, more and more researchers are now becoming interested in the link between the immune system and body weight. This tonsil-tubbiness effect can be a boon for underweight children because the associated weight gain can propel them into the normal weight range, but for all other children, parents are best advised to make sure their child eats a healthy, balanced diet after a tonsillectomy.
So the tonsils of children below the age of seven should stay in, unless there is a very good reason for taking them out. If the tonsils are so large that they impede normal breathing or sleeping, for example, the tonsil-tubbiness effect is secondary. It may seem sweet of our immune tissue to want to defend us so loyally, but in such cases, it does more harm than good. Often, doctors can use lasers to remove only that part of the tonsils that is causing the trouble. They no longer have to leave patients completely tonsil-less. Chronic or repeated infections are a different story altogether. In such cases, our immune cells are kept constantly busy, with no time for a bit of R&R, and that is not good for them if it continues for too long. Whether we are four, seven, or fifty years old, an oversensitive immune system can benefit from saying goodbye to those tonsils.
One example of those who benefit from having their tonsils removed is psoriasis sufferers. In psoriasis, an overreaction of the immune system causes itchy skin lesions—often starting at the head—and painful inflammation of the joints. Psoriasis patients also have an above-average vulnerability to sore throats. One possible factor in this is bacteria, which can hide in the tonsils for long periods of time and needle the immune system from there. For more than thirty years, doctors have described cases of psoriasis patients whose skin condition improved or cleared up entirely following a tonsillectomy. In 2012, this prompted researchers from Iceland and the United States to investigate the phenomenon more closely. They split twenty-nine psoriasis patients who also suffered frequent sore throats into two groups. One group had their tonsils surgically removed, the other didn’t. Thirteen of the fifteen “detonsilized” patients reported a significant long-term improvement in their skin. Those still in possession of their tonsils reported little or no change. Some sufferers of rheumatic diseases are also now advised to have their tonsils removed if they are suspected of being part of the cause of the condition.
Tonsils in or tonsils out? There are good arguments for both. Those forced to bid farewell to their tonsils at an early age need not worry that their immune system has missed an important lesson from the oral cavity. Luckily, there is still all the rest of the tissue at the base of the tongue and back of the throat. And those whose tonsils are still in place need not worry that they have been left with nothing but a trap for bacteria. Many people’s tonsillar crypts are quite shallow and so are less likely to cause problems for their owners. The other parts of Waldeyer’s ring are actually very bad at providing a refuge for bacteria: they are constructed differently and have glands to help them clean themselves regularly.
There is something happening every second in our mouth: salivary papillae shoot out nets of mucin, take care of our teeth, and protect us from the effects of oversensitivity. Our tonsillar ring keeps watch for foreign particles and uses them to train its immune army. But we would need none of this if the story didn’t continue beyond our mouth. The mouth is simply the gateway to a world where the external becomes internalized.
The Structure of the Gut
SOME THINGS TURN out to be a disappointment once you get to know them better. Those chocolate wafers from the television commercial are not lovingly hand-baked by housewives in country dresses—they come from a factory with neon strip lighting and workers at production lines. School turns out to be much less fun than you thought it would be on the first day. It’s warts and all in the backstage area of life, where there is a lot that looks much better from a distance than up close.
That is not the case for the gut, however. Our intestinal tube looks rather odd from a distance. Beyond the mouth, a 1-inch- (2-centimeter-) wide esophagus, or gullet, leads down from the throat, misses the top of the stomach, and passes into it somewhere at the side. The right-hand side of the stomach is much shorter than the left, which is why it curls up into a crescent-shaped, lopsided pouch. The small intestine meanders with no particular sense of direction, sometimes to the right, sometimes to the left, for all its length (about 20 feet, or 6 meters) until it eventually passes into the large intestine. That’s where we find the apparently useless appendix, which seems to be incapable of doing anything except getting infected. The large intestine is also full of bulges. In fact, it looks a little like a sorry attempt to replicate a string of beads. Seen from a distance, the gut is an unsightly, charmless, asymmetrical tube.
So, let’s forget the view from a distance and zoom in for a closer look. There is scarcely another organ in our body that becomes increasingly fascinating the closer you get. And, the more you know about the gut, the more beautiful it appears. So, let’s look at some of those strange structures a little more closely.
The Lanky Esophagus
THE FIRST THING we notice about this long, slender organ is that it can’t aim properly. Rather than taking the shortest route and aiming for the middle of the stomach, it enters the organ on the right-hand side. This is a smart move. Surgeons would call such a connection terminolateral. It may mean taking a little detour, but it’s well worth it. When simply walking normally, we tense our abdominal muscles, doubling the pressure in our abdomen with every step we take. When we laugh or cough, for example, that pressure increases by several times. Since the abdomen presses against the stomach from below, it would be a bad idea for the esophagus to dock directly onto the top end of the stomach. Connected as it is at the side, it has to deal with only a fraction of the pressure. It is thanks to this arrangement that we can take a walk after a heavy meal without having to burp with every step. This clever angle and its closing mechanism are also to thank for the fact that, although a fit of laughter might result in us losing a little control over our outer sphincter and inadvertently letting out a little “laughing gas,” few people have been known to vomit from laughing.
A side effect of this lateral connection is the so-called gastric bubble. Th
is small bubble of air at the top of the stomach can be seen clearly on X-rays. Air rises vertically, after all, and does not search out a side exit. This bubble is the reason many people find they have to swallow a little air in order to burp. This swallowing motion moves the opening of the esophagus a little closer to the bubble, and—hey presto!—the burp can make its upward journey to freedom. Those who need to burp while lying down can make the process easier by lying on their left side. So, if you’re kept awake at night by a bloated stomach and you are lying on your right side, the best thing to do is simply to turn over.
In order better to illustrate the stomach bubble, this illustration does not show the correct distribution of black and white in a normal X-ray image. Normally, denser materials, such as teeth or bone, show up white, while less dense materials, such as the stomach bubble or the air in the lungs, show up as dark areas.
The lanky appearance of the esophagus is also more beautiful than it seems at first glance. Looking very closely, it can be seen that some muscle fibers run around the esophagus in a spiral pattern. They are the reason for its elasticity. If you extend these fibers lengthways, they constrict spirally, like a telephone receiver cable. Bundles of fibers connect the esophagus to the spinal column. Sitting up straight and looking upwards stretches the esophagus along its length. This causes it to narrow, in turn allowing it to close more efficiently at each end. That is why sitting or standing up straight can help prevent heartburn after a large meal.
The Lopsided Stomach Pouch
OUR STOMACH SITS much higher in our abdomen than we think. It begins just below the left nipple and ends below the bottom of the ribcage on the right. Any pain felt farther down than this lopsided little pouch cannot be stomachache. Often, when people say they have stomach problems, the trouble is actually in the gut. The heart and the lungs sit on top of the stomach. This explains why we find it more difficult to breathe deeply after eating a lot.
One condition often overlooked by general practitioners and family doctors is Roemheld syndrome, when so much gas collects in the stomach that it presses up against the heart and the nerves in the gut. Sufferers can display a range of different symptoms, including dizziness and discomfort. In more severe cases, Roemheld syndrome can cause anxiety or difficulty in breathing, and may also lead to severe chest pain that feels like a heart attack. Doctors often write off undiagnosed Roemheld sufferers as overanxious malingerers whose symptoms are all in their mind. A more useful approach would be to ask patients if they have tried burping or passing wind. In the long term, it may be better for such patients to avoid any food that leaves them bloated or flatulent, take measures to restore the balance of the stomach or gut flora, and avoid drinking alcohol to excess. Alcohol can multiply the number of gas-producing bacteria by a factor of up to a thousand. In fact, some bacteria feed on alcohol (which is why rotten fruit tastes alcoholic). With a gut full of busy gas producers, a night on the town can lead to a morning chorus of the pungent kind. So much for the “alcohol is a disinfectant” argument!
Now let us turn to the stomach’s strange shape. One side is much longer than the other and so the entire organ has to bend double. That creates large folds inside it. The stomach could be called the Quasimodo of the digestive organs. But its misshapen appearance has a deeper meaning. When we take a drink of water, the liquid can flow straight down the shorter, right-hand side of the stomach to end up at the entrance to the small intestine. Food, on the other hand, plops against the larger side of the stomach. Our digestive pouch cunningly separates the substances it still needs to work on to break them down, from the fluids that it can wave straight on through to the next digestive station. So our stomach is not simply lopsided; rather, it has two sides with different specializations. One side copes better with fluids, the other with solids. Two stomachs for the price of one, so to speak.
The Meandering Small Intestine
THE SMALL INTESTINE meanders about in our abdominal cavity, twisting and turning for a distance of between 10 and 20 feet (3 and 6 meters). If we bounce on a trampoline, it bounces along with us. When the plane we’re sitting on takes off, it is pressed into the back of the seat like the rest of us. When we dance, it merrily wobbles along to the music, and when abdominal pain makes us wince, its muscles wince in a similar way.
There are few people in the world who have seen their own small intestine. Even doctors usually examine only the large intestine when they perform a colonoscopy. But those who do get the rare opportunity of seeing their small intestine by swallowing a pill-sized camera are likely to be surprised. Most expect to encounter a gloomy tunnel, but what they see is a very different creature: moist, pink, with a velvety sheen and somehow delicate looking. Most people do not realize that only the final three feet or so (about the last meter) of our large intestine has anything to do with feces—the preceding sections of our intestinal tract are surprisingly clean (and largely smell-free, incidentally). Our gut faithfully and tastefully takes on everything we swallow down to it.
At first sight, the small intestine seems rather more haphazard in its design than our other organs. The heart has its four chambers, the liver has its lobes, veins have valves, and the brain has specialized areas—but the small intestine just wanders aimlessly about in our abdomen. Its true design becomes clear at the microscopic level. We have here a creature that epitomizes the phrase “love of detail.”
Intestinal villi, microvilli, and glycocalyxes. One millimeter (mm) is slightly less than ⅟16 of an inch.
Our gut wants to offer us as much surface area as possible. That is why it loves folds—including the folds we can see with the naked eye. Without folds, our small intestine would need to be up to 60 feet (18 meters) long to provide us with enough surface area for our digestion. So, here’s to folds! But a perfectionist like the small intestine doesn’t stop there. Each square inch of its surface contains about 20,000 tiny fingerlike projections (or about 30 projections per square millimeter). These projections, called villi by scientists, protrude out into the mush of partly digested food, the medical word for which is “chyme.” The villi’s size means they appear as a velvety structure to the unaided human eye. Under the microscope, the little villi look like large waves made out of cells. (Velvet looks very similar under a microscope.) Even greater magnification reveals that each and every one of those cells is itself covered with little protrusions—the microvilli: villi on villi, if you like. The microvilli are, in turn, covered with a velvety meshwork made of countless sugar-based structures that look a little bit like antlers. These are called the glycocalyxes. If all this—the folds, the villi, and the microvilli—were ironed out to a smooth surface, our small intestine would have to be some 4½ miles (7 kilometers) long.
Why does the small intestine have to be so huge, anyway? In total, the surface area of our digestive system is about one hundred times greater than the area of our skin. That seems a little excessive just to deal with a small portion of fries or a single apple. But this is what it’s all about inside our belly: we enlarge ourselves as much as possible in order to reduce anything from outside to the smallest size we can, until it is so tiny that our body can absorb it and it eventually becomes a part of us.
We begin that process in the mouth. A bite of an apple sounds like such a juicy idea because, when we take that bite, our teeth burst millions of apple cells like tiny balloons. The fresher the apple is, the more of its cells remain intact—which is why we can tell how fresh the fruit is by its crispness as we bite into it.
Just as we prefer crisp, fresh fruit, we also love hot, protein-rich food. We find steak, scrambled eggs, or fried tofu more appetizing than raw meat, slimy eggs, or cold bean curd. That’s because we have an intuitive understanding of how digestion works. If we swallow a raw egg, it will undergo the same processes in our stomach as it would in the frying pan. The white of the egg turns opaque, the yolk takes on a pastel color, and both set and become solid. If we were to vomit the raw egg back up after the right amount of
time, the results would look like almost perfect scrambled eggs—without any cooking! Proteins react to the heat in the hot pan and the acid in our stomach in the same way—they unfold. That means they no longer possess the clever design features that make them soluble in the liquid of the egg white, so they form solid white lumps. In this state, they can be digested far more easily in the stomach and the small intestine. Cooking food saves us the whole first burst of energy required to unfold those proteins, which would otherwise have to be expended by the stomach. By preferring cooked food, the body outsources the first part of the digestive process.
The final breakdown of the food we eat takes place in the small intestine. Right at the start of this part of the gut there is a small opening in its wall. This is the duodenal papilla—similar to the salivary papillae in our mouth, but bigger. It is through this little hole that digestive juices are squirted onto the chyme. As soon as we eat something, the liver and pancreas begin to produce these juices and deliver them to the papilla. These juices contain the same agents as the laundry detergent and dish soap you can buy from any supermarket: digestive enzymes and fat solvents. Laundry detergent is effective in removing stains because it “digests out” any fatty, protein-rich, or sugary substances from your laundry, with a little help from the movement of the washing-machine drum, leaving these substances free to be rinsed down the drain with the dirty water. That is more or less the same as what happens in our small intestine. The main difference is that the pieces of protein, fat, or carbohydrates that are broken down in the intestine ready to be transported to the bloodstream through the gut wall are huge by comparison. A bite of an apple is then no longer a bite of apple, but a nutritious pulp made up of billions and billions of energy-rich molecules. Absorbing them all requires a huge surface area—a length of 4½ miles (7 kilometers) is just about enough. That also leaves some space as a safety buffer, in case parts of the gut are temporarily put out of action by infection or gastric flu.
Gut: The Inside Story of Our Body's Most Underrated Organ (Revised Edition) Page 3