The condition of purulent rhinitis in children, which is a not uncommon disease, has been attributed by Herbert Tilley and others to adenoids, but in an article on "The Rôle of Purulent Rhinitis of Childhood in the Production of Atrophic Rhinitis," published in the New York Medical Journal for June 30, 1900, I reported two cases of this condition, occurring in brothers, followed by turbinal atrophy, in which there was no hypertrophy whatever of the pharyngeal tonsil, thus enabling me to offer evidence of a more or less conclusive nature that an adenoid is not always to be found where there is a purulent rhinitis. It is not to be denied, however, that a purulent discharge from the nose frequently accompanies adenoids.

The immediate effects of adenoids are not the most urgent indications for their removal, but they are remotely responsi ble for some ill consequences, which render early and proper treatment for the condition one of the most important considerations that we as specialists and general practitioners encounter in our juvenile patients.

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In the first place it may be stated that the gravest of all affections induced by adenoids are the disorders of the ears. Indeed, Woakes, who has gone quite extensively into this subject, states that less than 5 per cent. of adenoid sufferers escape ear complications. This statement seems to me overdrawn, but it at least illustrates the fact that ear compli cations must play a very important rôle in patients who are thus afflicted. Deafness, which is a predominant symptom among those which we are called upon to relieve, in a young child produces inattention, stupidity and a general listless state, called by Guye, of Amsterdam, aprosexia. This condition in young children is one in which the most brilliant. results follow the removal of adenoids. Another condition in which the operation is satisfactory, but perhaps not so sensational in its results, is that of the correction of mouth breathing. In this connection, however, I should like to express myself as convinced that hypertrophied faucial tonsils are also a factor in producing mouth breathing. Despite the statements of some who claim that wherever hypertrophied faucial tonsils are found there will likewise be hypertrophy of the pharyngeal tonsil, and that mouth breathing is due to the

latter condition, I have observed cases where there could be no question as to the absence of the naso-pharyngeal adenoid, but where the faucial tonsils were markedly hypertrophied and there was concomitant mouth breathing.

Taking out of consideration the relief of ear conditionsnotably bad hearing-and acute and chronic purulent otitis media and mouth breathing by the removal of adenoids, and the improvement in chest capacity and general physical development following the operation, which latter assuredly is not questioned by me, who have seen its effects in extended observation, in my opinion there is practically no other functional disorder or pathological state that is commonly benefited by this operation. In this statement I realize fully that I am controverting the opinion of some prominent men of the profession, for you who have kept en rapport with the literature of the past decade have no doubt noticed the great variety of conditions that it is claimed are relieved by resort to this operation. Epilepsy, nocturnal enuresis, asthma and almost the entire pathological category are comprised in this series of diseases which it is asserted are relieved by the removal of a bunch of adenoid hypertrophy from the naso-pharynx.

It is here that I would raise a warning cry as to the extreme radicalism of the views concerning adenoid pathology now almost universally held. No frequent operator who follows his cases can long remain deluded by the extravagant claims of many whose enthusiasm is the result of limited experience, excess of zeal or insufficent observation of their cases following operation.

One of the chief causes of failure to obtain pronounced. benefit after removal of a naso-pharyngeal adenoid is found in the fact that where complaint of failure is most often heard the patient is beyond the age at which active reorganization and restoration are most likely to set in. The best results in these cases are obtained in patients from two to five years of age, and this limit may be raised to seven years under some conditions; but with inverse ratio to the increase of age, failure to secure results may be expected. When a child from ten to fourteen years of age is brought to us, we would be very unwise to give assurance of marked benefit following

the operation, and I have many times in my earlier experience been confronted with the question of making satisfactory explanation to parents of the lack of beneficial results adequate to their expectation. In any case it is well to state before operating that definite changes cannot be expected immediately, but that improvement may be gradual and extending over a long period. Occasionally it will happen that improvement follows the operation, but a short while afterward there is a return of the symptoms which occasioned its advisement. This can in most all cases be attributed to incomplete removal, with recurrence of the growth, of which I shall say more presently.

We are told there is a tendency for adenoid growths, as well as hypertrophied faucial tonsils, to atrophy with the approach of puberty. This is truer of the naso-pharyngeal hypertrophy than it is of that of the faucial tonsils, for while the former condition is not particularly common in adults, the latter is very common at all ages. But if we wait for an adenoid to atrophy, which is by no means sure to occur, we are rendering the child liable to ear diseases, arch of the vault of the palate produced by insufficient respiration, poorly developed chest, etc., which may be avoided or rectified to a certain degree by a very simple operative procedure where this is done at an early age.

Another fallacy of which many physicians are guilty is to state that where there are hypertrophied faucial tonsils concurrently with a similar condition of the pharyngeal tonsil, removal of the latter will be followed by shrinkage of the former. This certainly has not been my experience, and in a paper on "Pathological Tonsils," read by me before the Tennessee State Medical Society at its meeting at Memphis, April 8, present year, I cited an illustrative case, occurring in a boy aged two years, from whose naso-pharynx I had removed a good-sized adenoid growth about three years ago, and whose faucial tonsils at this time were but slightly enlarged, who was again brought to me a short while since with the history of having developed symptoms similar to those occasioned by the adenoid, from which relief followed the previous operation, and who presented a pair of hypertrophied faucial ton

sils that almost occluded the throat. If removal of an adenoid will cause shrinkage in the faucial tonsils, assuredly it would appear to me that in this instance it would have prevented the considerable hypertrophy of the tonsils that ensued in this There is no evidence, I should state, of a return of the adenoid in this patient.

case.

The extraordinary tendency to declare a large proportion of the juvenile members of the human family to be afflicted with adenoids is illustrated in the citation of the opinion of Francis, as quoted in my opening remarks. That the observer mentioned is not alone in his belief of almost universal affliction with this disease is evidenced in the fact that practically every child who has a few rugæ of the mucous membrane of the naso-pharynx that is brought to some of our latter-day extremists is pronounced to have hypertrophy of the pharyngeal tonsil, and a vigorous curetting of what may very likely be healthy tissue follows. This no doubt tends to increase the percentage of adenoid sufferers. It is only a few days since there was brought to me a little girl twelve years of age, whose parents desired me to tell them whether the child had an adenoid. To my finger the naso pharynx was perfectly smooth. Yet the parents of the child informed me that a prominent specialist, in a not far-distant city, had pronounced the child to have an adenoid and had advised operation. It would indeed be an unkind nature and extraordinary state of environment that would produce an affliction so very common that nine out of ten children suffer with this disease. This demonstrates the necessity for a carefully educated and discriminating sense of touch in diagnosing this condition, for upon sense of touch must depend in almost every instance the making of a diagnosis in young children.

To secure good results in operating for adenoids, thoroughness of removal of the growth is absolutely essential, for if portions of the adenoid are left after operating, there is quite likely to be recurrence of the hypertrophied mass, with a return of its various manifestations, and the traumatism may set up an inflammation in the remaining portions which may give rise to a train of serious consequences.

This brings me to the last and concluding portion of this

rather rambling and discursive paper, that is, the best method of operating for removal of these growths. Primarily, I desire to express unstinted condemnation of a method that is used by a small number of specialists, and there are comprised within these ranks quite a few very able men. I refer to the use of the finger nail alone, which seems to me to be inadequate for the thorough removal of these masses, which at times are rather tough in consistence, and which method does not appeal to the latter-day surgeon as one as thoroughly aseptic as is demanded by the principles of cleanliness now in vogue. It has also been my observation that in a good proportion of those cases which present recurrence, it will be found that the finger-nail method of operating had been used. While there are numerous methods and various instruments devised for the performance of this operation, with me nothing has been so satisfactory as the Gottstein curette, or one of its modifications, which I follow with the finger in order to ascertain if every vestige of the growth has been removed. But it is not my purpose to discuss the operative treatment of adenoids at length, and in closing I would only endeavor to impress upon you the importance of early recognition of the disease, precaution in diagnosing and thorough removal.

Lyceum Building.

THE THERAPEUTIC VALUE OF NORMAL SALT

SOLUTION.*

BY JERE. L. CROOK, M.D.

JACKSON, TENN.

THAT water and salt are essential ingredients of the human system is an elemental teaching of physiology. We learn in the chapters devoted to the proximate principles of the body that water belongs to the inorganic class, and that it is the most important member of that class; while sodium chloride is rated as the most important of all the mineral constituents of the body. Physiologically speaking, we find that water constitutes 70 per cent. of the body's weight; that its presence in the blood and secretions is indispensable in order to

* Read before Tri-State Med. Assn. (Miss. Ark. & Tenn.) Memphis, Nov. 21, 1901