tion in nasal obstruction seems to depend on periodic turgescence of the posterior end of the turbinals. Occasionally this can be seen in the post-nasal examination. It explains why it sometimes takes days or even weeks before the full benefit of a satisfactory operation is realized, because the wound keeps up a reflex turgescence.

The variable turgescence explains likewise why the characteristic adenoid "dead" voice is not equally pronounced in all patients. It is always characteristic in case of large hypertrophies, but may occur even in a normal person during a severe coryza. On the other hand, the inattention or want of mental concentration of some adenoid children-"aprosexia"-depends on the size of the hypertrophy and not on vascular distension. It was observed in about 15 per cent. of my patients, and only in cases of large growths, but not in every instance.

The writer recalled the distress and restlessness often caused by adenoids during sleep, which may lead to night terror and nightmare. Two instances of asthma were stopped, as far as the observation went, by the removal of the growth. Cough, so frequently present with adenoids, is usually due to a subacute bronchitis. But many instances are seen, too, in which it is a reflex cough, as it ceases immediately after operation. Enuresis is a very common symptom, sometimes promptly stopped, sometimes only gradually, by operation, and occasionally not influenced at all.

According to the writer's experience, much of the mischief started by adenoids is due to their periodic state of inflammation. This is not necessarily continuous. During a quiescent period, a moderate growth may cause scarcely any symptoms except slight blockage. But all adenoids are subject to frequent spells of inflammation, often subacute from the start, and sometimes lasting as long as the inclement season. Carefully taken histories show that attacks of bronchitis and inflammatory lesions of the ear are preceded by this inflammatory condition in the enlarged tonsil. Even the subacute involvement of the Eustachian tube, commonly called Eustachian catarrh, the writer does not attribute to the mere presence of, or pressure by, the adenoids, for they do not ordinarily extend close to the Eustachian orifice.

It is the extension of the inflammation from the pharynx which proves the menace to the ear.

The writer called attention to the relation of adenoids to phlyctenular disease of the eye. A large proportion of children with phlyctenular keratitis have adenoids, and in the writer's experience the immediate removal of the latter is often of unmistakable influence upon the course of the eye disease.

The writer confirmed the striking influence of adenoids upon the general nutrition in some instances. In about 20 per cent. weight and growth were below par and the children were frail and anæmic. This influence does not depend on the size of the growth. It may be due to a small tonsil which caused very little obstructive symptoms. Some instances suggest that adenoids may exert a poisonous influence on the system. The gain in weight and growth and the recovery from anæmia are often very striking after operation.

While in young children the operation is always followed by immediate and striking benefit, the results are not invariably so satisfactory, or at least so prompt, in older children. This is due to the complication by other hyperplastic lesions often induced by adenoids in the course of time. The faucial tonsils which are so often enlarged in connection with the pharyngeal tonsil, shrink not infrequently to a moderate extent and lose their irritated appearance after adenotomy. But spurs and ridges on the nasal septum and hypertrophies of the posterior turbinals, which seem to be favored by the long persistence of adenoids, continue, of course, in producing symptoms even after removal of the latter.

The writer considers the enlargement of the pharyngeal tonsil the consequence of repeated attacks of coryza during the first few years of life. He has observed this mode of origin in all instances which he could personally watch or trace. If no morbid growth of the tonsil has taken place within the first three or four years of life, there seems to be no further tendency to hypertrophy. The predisposition is often hereditary. It is also marked in instances of degeneracy, especially in imbeciles and in deaf-mutes.

Adenoids are strikingly common in scrofulous children. There are some instances in whom the so-called scrofulous

stamp is practically the outcome of the enlarged pharyngeal tonsil and disappears with its removal. But, on the whole, we must assume that real scrofulosis is the result of slight chronic poisoning of the system from some tubercular focus in the lymph glands. The enlarged pharyngeal tonsil is, as a rule, itself not tubercular. Only in about five per cent. of instances are tubercles found anatomically which cause no symptoms during life. The frequency, however, of enlarged lymphatic glands in the neck, in connection with adenoids, raises the suspicion that the diseased tonsil may permit the tubercle bacillus to enter the system without its causing local manifestations in the tonsil itself.

For the removal of adenoids the author recommends highly a personal modification of the Schuetz guillotineshaped pharyngotome. The ordinary-sized instrument can be used in all subjects older than about three to four years. For younger children a smaller pattern is required. With the head thrown back, the lower jaw well depressed, the guillotine pushed firmly upward and backward, the entire tonsil is bound to be cut off in one sweep. A slip, as it sometimes happens with the Gottstein knife, is almost impossible. In over 200 instances there were but two in which fringes of adenoid tissue were left of sufficient size to permit a second operation. With this instrument, persistence of hemorrhage was never observed. In former experience a lasting or relapsing bleeding recurred in about one per cent. and was always traceable to incompletely detached tags. As the adenotome makes a clean sweep this danger is removed.

The quickness of the operation makes narcosis entirely unnecessary, except when the faucial tonsils are to be removed in the same sitting. In view of the great fatality of chloroform, as shown by Hinkel, the author considers this agent inadmissible. Ether, far less dangerous, has its drawbacks. Nitrous-oxide narcosis is quite practicable for simple adenotomy. But the writer finds that with his method of operating the pain is not sufficient to necessitate narcosis. For the removal of remnants of the tonsil left by an incomplete operation, the cold snare is very serviceable and but little painful. He uses a straight snare through the mouth with the wire loop bent upward.

ON THE PATHOLOGY AND TREATMENT OF

CHRONIC PURULENT OTITIS.

I. INDICATIONS FOR THE REMOVAL OF THE HAMMER AND

ANVIL.

II. RELATIVE FREQUENCY AND LOCALIZATION OF DISEASE OF THE OSSICLES.

BY DR. SUCKSTORFF,

FIRST ASSISTANT OF THE EAR CLINIC IN ROSTOCK, GERMANY.

Abridged Translation from Zeitsch, f. Ohrenheilk., vol. xlv., p. 75, by Dr. ARNOLD KNAPP.

I'

I.

N 1879 Kessel placed the indications for the removal of

the hammer and anvil as follows:

I. Intractable stenosis of the tube.

2. Total calcification of the drum membrane.

3. Caries of the ossicles.

4. Anchylosis of the stapes if associated with disturbing tinnitus.

5. Cholesteatoma of the tympanum and of the mastoid process which is not improved by the usual methods of

treatment.

Stacke,' in his paper on the indications for the excision of the hammer and anvil, in 1891, came to about the same conclusions.

The first two indications are so rare that they may be disregarded. In the fourth, this treatment has been abandoned on account of the very questionable results obtained,

'Arch. für Ohrenheilk., vol. xxxi.

and, in the case of the fifth, the so-called radical operation is probably now universally performed. The third indication, however, especially brought forward by Schwartze and his pupils Ludewig and Kretschmann, has proved to be an excellent means of healing chronic purulent otitis with or without accumulations of epidermis which are localized to the attic. We think that this indication should have a broader use, as ossiculectomy not only is indicated in diseases of the ossicles and in caries of the attic even if the hammer and anvil be healthy, but also in cases of purulent mucous suppuration from the attic, if this has not given way to a careful and consistent treatment with the tympanic canula. The hammer and anvil, with their ligaments and mucous folds, make the attic a very complicated cavity from which it is often very difficult to remove purulent secretion either by irrigation with the tympanic syringe or by other means. After the removal of the ossicles, the many pockets will lie open, and the complicated cavities are converted into one cavity more accessible to irrigation, so that we are often able to heal the suppuration. The removal of the healthy ossicles in these cases will be undertaken the more readily if the ossicular chain be already interrupted, and consequently worthless to the function of the ear; the useless ossicles act like foreign bodies, complicate and keep up the suppurative process.

This indication has of course been mentioned by a number of others, though it seems to us, from the experience of the last few years in our clinic, it has not been sufficiently emphasized. We have observed a number of suppurations in the attic with and without accumulations of epidermis, with and without disease of the ossicles, where long-continued syringing with the tympanic canula was without avail, but where the extraction of the healthy hammer led, in a very short time, to a permanent cure. Some of the cases of this kind, which were not healed, were cases in which there was an associated disease of the bone in the antrum or in the mastoid process, or a focus in the lower part of the tympanic cavity. In these cases we have later been forced to perform the radical operation. Unsuccessful extractions of the ossicles in cases where bone involvement