hypertrophy of this structure. In typical instances it may be entirely absent. In the less pronounced forms of hypertrophy of the pharyngeal tonsil there is often the copious mucopurulent discharge described in ¶ 35 as the "scrofulous" form of purulent rhinitis.

If the adenoid vegetations are not removed, a hypertrophic condition of the turbinals, especially the posterior ends, as well as septal overgrowth, are very often found in older children. Hypertrophy of the pharyngeal tonsil is often accompanied by enlargement of the faucial tonsils. They are generally deep seated between the pharyngeal pillars, and hence do not apparently project far into the mouth as compared with their actual size.

160. The ears suffer in a large proportion of cases of adenoid vegetations. The most common condition is that of catarrh limited to the Eustachian tube, which form gives the least unfavorable prognosis. More serious are attacks of purulent inflammation. Serous catarrh of the middle ear is not common in younger children, but not so rare in the period preceding and following puberty. As a rule, the ears are involved in consequence of some transient acute or subacute inflammation, and not merely on account of the mechanical presence of the enlarged tonsil. The tonsillar hypertrophy, however, is the important determining condition, without which the temporary coryza or pharyngitis would scarcely endanger the ear. While the ear affections yield to the usual local treatment, relapses are almost sure to occur unless the hypertrophied tonsil is removed. Hence with neglect the hearing may become permanently damaged.

A common complaint of children with adenoid vegetation is cough. Generally this is due to frequent and often persistent attacks of bronchitis following acute nasopharyngeal inflammation. In other instances it seems to be a reflex disturbance without lesions in the lower respiratory passages.

161. Children with marked pharyngeal obstruction not merely look stupid, but often are so. They find it

difficult to concentrate their attention. This mental sluggishness has been termed aprosexia. Headaches— 'referred to the back of the head-are not uncommon during inflammatory exacerbations. Asthenopic complaints, difficulty in the use of the eyes,-fatigue, and strain are sometimes complained of. I have seen a fair number of instances in which low degrees of far-sightedness or astigmatism annoyed the children sufficiently to necessitate glasses, which could be discarded after the pharyngeal operation--which, of course, does not change the structure of the eye itself. The interference with nasal respiration disturbs sleep. Such children are often restless at night, toss about or wake with nightmare or frightening dreams. Nocturnal incontinence of urine is also not uncommon. Groenbeck observed it 26 times in 198 cases. In about one-half of the instances this annoyance ceases at once after the operation. In most of the others it improves gradually. The cervical lymphglands are frequently enlarged. How large a proportion of such indurated glands is tubercular has not been determined. In high degrees of pharyngeal obstruction the children may present a stunted growth and marked insufficiency of weight. The dependence of this impaired nutrition upon the blockage of the pharyngeal space is often shown by the satisfactory increase in the rate of growth following operation.

162. Attention has also been directed, especially by earlier French surgeons (Dupuytren, Chassaignac) to deformities of the chest observed in children having large tonsils. It is partly a constriction of the lower part of the chest as compared with the dimension of the upper part, partly a flattening of the thorax in the lateral diameter, with undue prominence of the sternum-the so-called pigeon-breast. Whether these conditions are not dependent on the coexistence of rickets is perhaps an open question. Undoubtedly, however, the interference with breathing and the resulting violent exertion of the diaphragm, together with undue pressure of the

external air upon the yielding infantile thorax during inspiration, account for the occurrence of these deformities. The respiratory obstacle is, however, not so much due to the enlarged faucial tonsils, as was formerly believed, as to the blockage of the pharynx by the adenoid vegetations, which the earlier observers had not recognized. Among my patients in this country, where rickets is not a frequent disease, I have seen but little of these chest deformities, and never in a very pronounced degree. Although most of the disturbances due to enlargement of pharyngeal tonsil are of mechanical origin and are hence pronounced in proportion to the degree of enlargement or its relative bulk compared with the (variable) size of the pharynx, still at times even very moderate growths will give rise to much interference with nutrition (Harrison Allen). I have sometimes seen improvement in the general health of children that seemed out of proportion to the small amount of adenoid tissue shown by the operative removal.

The pernicious influence of adenoid vegetations upon the blood (anemia) shows itself by a poverty in red globules and hemoglobin, with absolute increase of mononuclear and eosinophile leukocytes and lymphocytes, while after the operation there is a gradual return to the normal condition of the blood (Lichtwitz and Sabrazès).

163. While the enlargement of the pharyngeal tonsil is an affection of childhood, it does not necessarily disappear at puberty. Sometimes the respiratory obstacle, with all its resulting disturbances, lasts during middle life. As a rule, however, the pharyngeal space grows during the second decade of life at a faster rate than its adenoid tissue, and the latter often undergoes partial involution. This is evident by the rotundity which the surface of the enlarged gland presents in adults, compared with the coxcomb-shaped irregularities of the surface in earlier childhood. Hence, after adolescence the mechanical interference with breathing subsides somewhat as a rule. Yet secondary hypertrophic changes in the nasal

walls and Eustachian tubes, and hence liability to frequent inflammatory attacks of nose, ears, or bronchial tubes, are apt to persist after adolescence as the sequel of juvenile adenoids.

164. The diagnosis of enlarged pharyngeal tonsils. can be made with much certainty in more pronounced cases on noting the facial expression and the characteristic speech. If inspection shows no obstruction in the nose itself, the cause of the respiratory interference must be in the upper pharynx. With the exception of rare cases of excessive enlargement of the posterior ends of the turbinal, or the still rarer occurrence of fibroid tumors in the pharynx, the lesion will be found to be enlargement of the pharyngeal tonsil. The diagnosis is confirmed by examination with the finger. The surgeon presses the cheek between the teeth, so as to keep the mouth open and prevent the child from biting, and thereupon inserts the finger through the mouth into the upper pharynx by sliding in behind the palate, and observes the resistance met with in feeling for the upper rim of the nasal passage. In normal instances the relatively resisting posterior wall and roof are recognizable by touch, and the space will be found clear. When the adenoid tissue is enlarged, a soft cushion can be felt lining the pharynx and encroaching upon its caliber. As a rule, too, the finger gets bloody. The surgeon may be misled as to the amount of adenoid hypertrophy in case the body of the first cervical vertebra is exceptionally prominent in the pharynx.

The digital examination is very disagreeable to the patient. In the case of tolerant children a mirror examination may be attempted instead of palpation. Impracticable under the fourth year, it is quite feasible in many older children, especially after they have passed the seventh year. A partial view may also be obtained by direct inspection on retracting the palate with a hook and throwing the head back to the utmost extent. younger children the surface of the enlarged gland is

In

irregular. There are coxcomb-shaped ridges running anteroposteriorly, usually six in number, sometimes more by reason of branching or less by coalescence of the ridges. Most of the illustrations in text-books showing tufts and cauliflower-shaped projections are fanciful and do not correspond to what is actually seen. As puberty is approached the involution of the adenoid tissue smoothens the surface and the growth is more likely to appear as a semiglobular cushion relatively hard. The pharyngeal tonsil is to be considered pathologically large whenever its outlines are recognizable as an elevation above the level of the surface, since when perfectly normal, the edge of the adenoid area slopes so gradually as to be distinguishable from the rest of the mucous surface

FIG. 74. Enlarged pharyngeal tonsils removed in one piece by the author's adenotome (actual size): a, From a child four years old; b, from a child eight years old; c, from a young man twenty years of age.

only by its slightly darker tint and ridged and furrowed surface. Normally there appears a clear space of a few millimeters between the front end of the adenoid cushion and the upper rim of the choanæ. The more the tonsil is enlarged, the more does it project over the upper rim of the bony frame of the nose, while in pronounced cases it covers the entire posterior choanæ in the postrhinoscopic image. The enlarged gland can sometimes be seen by direct inspection on retracting the palate forcibly with a hook, while the head is thrown backward.

165. The structure of the enlarged pharyngeal tonsil is that of the normal gland with all its elements uniformly increased. In earlier childhood the tissue is soft, due to