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practice of passing my finger into the mouth and behind the palate, for I believe it to be seldom necessary and not only that, but it is a barbarous procedure. Other signs are seen in the narrow undeveloped nose and stupid expression. The child cannot apply itself to work or play, is often irritable, is troubled with indigestion, and often with cough.. The most frequent and grave complications are those connected with the ear, viz., earache, deafness, caused by obstruction of the mouths of the eustachian tubes, and acute suppuration of the middle ear. Earache and occasional deafness are frequent, and in those children who are subject to recurrent attacks of earache the naso-pharynx should always be examined for a probable cause. Acute suppurative inflammation of the middle ear frequently finds its immediate cause in adenoids, and in all cases of such inflammation, when not apparently due to some other cause, especially if the child has any of the symptoms of nasal obstruction, the naso-pharynx should be explored. I seldom operate for adenoids during an attack of earache, or of acute suppuration, preferring to wait till the more acute symptoms have subsided. Deafness due to obstruction of the eustachian tubes is one of the most frequent complications. This deafness persists for a variable length of time after the obstruction has been removed. The relief, however, is immediate, but in bad cases good hearing is not established for a period varying from a few days to several weeks. Here let me call your attention to the well known fact of the unreliability of children's statements in regard to hearing. You may carry your watch away ten feet and put in your pocket and they will still say that they can hear it. The best test is the voice, and the statements of the parents. Calling the child by name when he does not expect it, and when his back is turned, etc. The parents always notice whether the child hears like other children or not, and their statements are more to be relied upon than those of the child itself. Another complication is asthenopia. Children are often complaining of their eyes and examination of the eyes reveals nothing, but the removal of an adenoid will remove the symptoms of blurring, spots before the eyes, lachrymation, headache, etc. Sometimes we find nocturnal incontinence of urine relieved by the removal of an adenoid.
Method of operating: I always when possible operate with the patient chloroformed. Patient is placed upon the back
on a level, firm table, or operating chair, and chlorform given in the usual manner, though profound narcosis is not desirable. I do not want the cough reflex abolished. I have an assistant hold the patient's hands and feet, the physician who gives the chloroform turns the child's head towards the light, tips it slightly backward, and fixes it firmly with his hands. I use a Tieman's tonsillotome and remove the lower tonsil first, then the blood does not obstruct the view when removing the other tonsil. I then, if the patient has aroused trom the chloroform to any extent, either from delay in operating, or from insufficient narcosis, allow the child to inhale a little more chloroform, then I pass the Gottstein curette behind the palate and thoroughly curette the naso-pharynx, though the main growth is situated in the center it is always best after removing the central growth to pass the curette toward each opening of the posterior nares for any small pieces that may be situated on either side. The entire growth is usually brought forward upon the tongue, sometimes, however, it is swallowed. It is always best, when possible, to bring it forward with the curette, for the parents always want to see it. It is also a good plan to tell the parents before the operation that the growth behind the palate may be swallowed by the patient. The bleeding following the operation is sharp, more so from the adenoid than from the tonsils, though it is of short duration. I have never met with but one case where the hemorrhage was at all alarming.
After treatment.-In my mind the best after treatment is to let the patient entirely alone, except perhaps a gargle of a solution of salt and soda, where they are old enough to use it. I would never spray the nose or naso-pharynx unless I got a case where for some reason the discharge became offensive. This has never happened to any of my patients, and I have never sprayed or powdered a case after operation. I simply leave them alone.
In regard to anæsthesia and the position of the patient during the operation, I prefer chloroform when it can be given, but I have used nitrous oxide in a few cases, and I do not like it, both on account of the rigidity of the muscles of the jaws and of the brief period of anesthesia, making it necessary to use a mouth gag, which is always in the way. The best position is on the back with the face turned toward the light of a good window. I never operate with the patient in
a sitting posture, and never directly on the back, but on the side, and as quickly as possible after operating the patient is turned upon the stomach.
Results of operation.-I could mention cases by the dozen with a history like the following:
A. B., age ten, always a mouth-breather, several attacks of earache and deafness, one year ago severe earache, terminating in acute suppuration. Last attack began three months ago with slight pain and marked deafness. Patient hears loud conversation at three feet. Examination revealed enlarged tonsils and adenoid. Operated under chloroform. Mother said that hearing was much improved the same day. Hearing normal in ten days. No recurrence. This is a typical case, and the results are what we are to expect, and what we usually get. I have never operated on the same case twice in but two instances. One of them was a patient of mine, the other a patient of a colleague. I have never faile to relieve or cure the ears in but one case, and he is still under treatment, but is very poorly situated; has frequent colds and relapses.
I think about one-half the children that I operate on suffer from ear complications, the others are operated on for the relief of distressed breathing and general symptoms.
I have in a few cases operated where there was an acute attack of suppurative otitis media. The following is one of these :
Child, female, age three years, never has learned to say a half dozen words, came to me with acute suppuration of the left ear; mouth-breathing marked; thick muco-purulent discharge from the nose. I told the mother that we would first allow the inflammation to subside before operating. Discharge kept up from the ear and nose for a week, when I decided to operate. Fixed the day but one following for operating. Patient returned, the mother stated that the right ear had ached the night before and broke that morning. Examination revealed purulent discharge from both ears. Thick muco-purulent discharge from both nostrils, throat full of mucous. Tonsils normal. Nasal obstruction complete. Chloroform was administered, and a large adenoid removed. On the third day the discharge had ceased in both ears. charge from the nose much better. In one week discharge from the nose had ceased, nasal breathing restored, patient. discharged cured.
Age. I never hesitate to cut tonsils at all ages, provided they are not so adherent to the pillars of the fauces as to require separating. In adherent tonsils I use the galvano-cautery. I have removed adenoids at all ages up to thirty-five years; tonsils up to forty-five. Have never operated for tonsils or adenoids under two years of age, though I have frequently seen nursing children, who, I am satisfied, were so afflicted. The larger number are from four to eight years of age when they are brought for treatment. The history is usually one of mouth-breathing from infancy, though some are claimed to be of short duration. I have removed several large adenoids when there were no symptoms of mouthbreathing or nasal obstruction, simply deafness, eye symptoms, or chronic nasal discharge which called attention to the naso-pharynx.
I should in very small children recommend the removal of the tonsils first and allow two weeks to elapse before removing the adenoid, then the loss of blood is not so much as it sometimes is if both are removed at the same time, and the hemorrhage is at all severe. Never attempt to remove an adenoid with a curette before removing enlarged tonsils; it is difficult to expel the adenoid, and it may be drawn into the larynx. Always have a long pair of dressing forceps handy with which to remove the growth from the throat in case it is not completely separated but hangs by a strip of mucous membrane. This will some times happen.
This, gentlemen, comprises the principal points in diagnosis and treatment of enlarged tonsils and adenoids, and i have found the method here given safe and reliable.
It has been ascertained by careful medical observations, that certain families in St. Ourn, a village in France, enjoy absolute immunity from tuberculosis. They are "autochthonous" gardeners, of excellent habits, who intermarry among themselves, and keep apart from the immigrant laborers. These latter suffer terribly from the disease. It is considered probable that hygienic conditions are not the sole cause of the difference, but that, by a kind of natural selections, a race immune from tuberculosis has been developed.
THE UTILITY OF THE X-RAY IN THE TREAT
MENT OF FRACTURES.
By J. B. Eagleson, M. D., Seattle, Washington.
[Read before the Washington State Medical Society, May 10th, 1898.]
With the discovery of the X-ray, a little over two years ago, a new method of diagnosis dawned upon the surgical world, which has been greatly utilized in various ways in diagnostic work until it has now become the next thing in importance to the sense of touch, and in many ways has superseded it, especially in the examination of bones.
It is not my puprose at this time to give a paper on general X-ray work, but to point out a few ways in which it has assisted me in the treatment of fractures.
That the swelling of the soft tissue in recent cases of fractures covers a multitude of surgical errors, there can be nɔ doubt, as one of the skiagraphs presents an excellent illustration. The case was a fracture of both bones of the forearm by a direct blow. When first seen the fore-arm was very much swollen, and it was dressed in the usual manner with a long anterior and short dorsal splint. After about two weeks, when the swelling was very much reduced and the bones appeared to the touch to be in splendid position, I thought we would try the X-ray on it and thus verify the success attained in reducing the fracture. You can imagine my surprise and chagrin when I saw the shadow. Both bones were fractured completely and were overlapping to a considerable distance. It was now too late to mend matters, as the union had become quite firm, and it was impossible to change the position without a complete refracture of the bones. Early and frequent manipulation preserved the motions and gave him a very good arm.