(D.): Oysters, plain roast; cream; cheese; Boston brown bread;

water.

January 21-(U.): Almost normal.

(B.): Cold corned beef; coffee; Boston brown bread; butter; water. (L.): Sirloin steak; tea; fried potatoes; butter; Boston brown bread; water.

(D): Lyonnaise tripe and mashed potato; cheese; water.

January 22.-(U.): Normal, save slight bile.

(B.): Rump steak; one-half pig's foot; coffee and cream; water; rolls; butter.

(L.) Sirloin steak; fried potatoes; coffee.

(D.): New England boiled dinner; orange; water.

January 23.—(U): Slight bile; one fatty epithelium; catarrh.

(B.): Banana; Pettijohn's wheat; coffee and cream; baked potato; graham rolls; butter.

(L.) Roast mutton; mince pie; coffee; cheese; mashed potato. (D): Oysters, plain roast; cream; graham bread; honey; orange. January 24.-(U.): Yellowed by bile.

(B.): Roasted apple; coffee and cream; beefsteak; corn bread. (L.): White of egg, brandy and cream; corned beef; roast beef, cold; coffee and cream; baked potato; banana pudding.

(D.): Clam chowder; water; cold ham; boiled turnip; potato; string beans; mince pie; tea and cream.

January 25.—(U.): Casts, both kinds, but few. Too much vegetable food.

(B.): Banana; coffee; beefsteak; baked cream of wheat; butter. (L.) Sirloin steak; fried potatoes; coffee; Boston brown bread; crullers; cheese.

(D.): Oysters, plain roast; cream; crackers; cheese; ginger bread; honey; water; white of egg; dates.

January 26.—(U.): Normal.

(B.): Ham and eggs; coffee; Boston brown bread; butter.

(L.): Tomato soup; turkey, dark meat; Lima beans; cranberry sauce; water; tea; cheese; mince pie.

(D.): Cold roast pork; grape jelly; oyster stew; baked potato; biscuit; butter; water; cheese; dates.

January 27.-(U.): Some false casts-one long wire coiled speci

men.

(B.): Two bananas; cream of wheat; beefsteak; baked potato; corn bread; butter.

(L.) Hamburg steak; coffee and cream; fried potatoes; Boston brown bread; butter.

(D.) Roast mutton; coffee; baked potato; peas; turnip; dates; three whites of eggs.

January 28-(U.): Slight albumin.

N. B.-No sugar used in drinks in all these studies.

(B.): Mutton chops; coffee and cream; baked potato; corn and wheat bread; butter.

(L.) Sirloin steak; fried potatoes; Boston brown bread; butter. (D.): Oysters, plain roast; crackers; cheese; cream and water. January 29.-(U.): Normal.

(B.): California prunes; coffee and cream; tripe; egg; beefsteak; corn rolls.

(L.): Clam chowder; New England boiled dinner; butter; bread; dates.

(D.): Cranberry sauce; roast mutton; coffee and cream; potatoes; banana fritters; mince pie; cheese; dates; nuts.

January 30.-(U.): Normal. The New England dinner was borne this time.

(B.): Beefsteak; mackerel; coffee; potato.

(L.): Small sirloin; fried potatoes; coffee; Boston brown bread; butter.

(D.): Oysters, plain roast; crackers; water; cheese.

January 31.-(U.): Normal.

(B.) Beefsteak; codfish; coffee and cream; baked potatoes; corn bread; butter.

(L.) Same as January 30. (D.): Same as January 30.

February 1.—(U.): Almost normal; very slight catarrh.

[TO BE CONTINUED.]

ADENOIDS.*

BY CALVIN R. ELWOOD, M. D., MENOMINEE, MICHIGAN,

It is my pleasure to present for your consideration a condition so prevalent as to be thought unimportant by the laity and which I fear for the same reason receives far less attention than it deserves from the general practician, notwithstanding that its neglect fre quently results in conditions incompatible with the comfort and disastrous to the development of the patient. Like suppurative otitis media, mouth-breathing is considered insignificant in children because so many are afflicted, and as comparatively few cases are followed by distressing sequelæ, the child is neglected.

The nose is more important to the human economy as an organ of respiration than as an organ of special sense, as is demonstrated by numerous bronchial, gastric, aural and systemic disorders which frequently result from continued interference with its function. Nasal respiration is embarrassed or suspended in consequence of intranasal obstruction, as deviation of the septum or hypertrophy of the turbinated body, by nasophyaryngeal obstruction as adenoids, and by hypertrophy of the faucial tonsil.

The nasopharynx contains in addition to the posterior nares and Eustachian orifices, the pharyngeal or Luska's tonsil, the function of which is to furnish a lubricant to the pharynx and the hypertrophy *Read before the Fox RIVER VALLEY MEDICAL SOCIETY at its Marinette, Wisconsin, meeting.

of which gives rise to the condition under discussion. The resulting masses vary greatly in their consistency and may be classified into two groups-the soft or gelatinous and the hard or fibrous types. In growths of the first class the connective tissue is of a succulent character, rich in young cells surrounding numerous masses of lymphoid tissue, which are usually soft and break down under the pressure of the finger. The other is a variety of smooth fibrous tumors, irregular in shape, very vascular, containing lymph cells, and of a follicular structure resembling the faucial tonsil. There are all degrees of gradation between these two types.

Macroscopicly these masses vary greatly in situation, size and grouping. The most frequent situation is at the dome of the pharynx or upon its posterior wall, where they protrude as an inverted dome into the nasopharynx or present several more or less prominent masses protruding below the general mass like stalactites.

Adenoids are essentially a disease of childhood seen most frequently between the third and fourth years and often disappearing at puberty. Heredity is an important factor. Often several individuals. of the same family are afflicted. Repeated attacks of acute nasopharyngitis also tend to hypertrophy of this lymphoid tissue. We have all observed the parted lips, the more or less expressionless face, noisy respiration and nasal intonation (as if the patient had a perpetual cold in his head) of this type of patients. The child often may appear defective mentally when his condition is due to impaired hearing and necessary mouth-breathing. There is often further history that the child snores loudly, if a babe it cannot nurse without frequently stopping to breathe, suffers from recurrent attacks of coryza, ear-ache, and impaired hearing or otorrhea-the result of pressure on the Eustachian orifices, obstruction in the postpharyngeal space having caused extention of the disease into the middle ear through. interference with proper interchange of air in the tympanic cavity.

The diagnosis is readily made from the symptoms, digital examination and posterior rhinoscopy. The rhinoscopic mirror shows a rounded mass of a grayish red tinge hanging down and partly obstructing the view of the posterior nares, while digital examination conveys a sensation much like that experienced by passing the finger into a bundle of worms. Digital examination is condemned by many on account of its severity but with practice it can be done without very great discomfort. In cases wherein this is not practic, Semon, Meyers and others advocate injecting some aqueous solution into the nostril. If the postnasal space is clear the water will issue freely from the oppisite side, if obstructed it will escape into the mouth. The ear symptoms are among the most serious sequelæ of neglected. adenoids. As a result of their interference with normal respiration, rarefaction of the intratympanic air gives rise to a condition of hyperemia of the mucous membrane lining the Eustachian tube and middle ear. The Eustachian orifice is closed mechanicly by the adenoid mass, the air of the middle ear rarefied, the drumhead retracted, and further

changes in connection with the more delicate apparatus of the ear result in impairment of its function. In a very large number of cases, if this process is allowed to continue, it will lead to ankylosis of the ossicles and atrophy of the tympanic mucous membrane. In a smaller proportion, arising in the same manner from nasal stenosis and rarefaction of air in the middle ear, there originates a true catharrhal inflammation with hypersecretion. When there is catarrhal inflammation in a closed chamber, the process is frequently converted into one of suppuration. Why suppuration appears in one patient and not in another is a matter of conjecture. Frankenberg investigated one hundred fifty-eight deaf mutes and found fifty-nine per cent with adenoids filling the postnasal cavity.

In all my experience the case from which I received the best results with the least work was one of pronounced middle ear complications following postnasal obstruction:

A boy seven years of age was sent to his grandparents in Menominee that he might take advantage of our excellent schools. It was noticed that he was a persistent mouth-breather and snored so loudly at night that his rest was disturbed thereby; he seemed dull, inattentive and was quite deaf. His teacher reported that he did not do well in his school work. He could not hear my watch when it was brought in firm contact with the external ear. Examination showed the nasal cavities unobstructed but somewhat contracted, the arch of the palate high and the base narrow, the lips somewhat thickened, and a chronic follicular pharyngitis resulting from persistent mouthbreathing. Posterior rhinoscopy was quite difficult as the pharyngeal inflammation had made the throat very sensitive. Digital examination revealed a soft yielding mass in the vault of the pharynx which bled from manipulation. I believe I did not state in giving the symptomatology of the disease that the wall of the pharynx is firm and the mucous membrane not very vascular; therefore, hemorrhage after digital examination is very suggestive of the presence of adenoids.

Under chloroform anesthesia the mass was completely removed with a Gottstein curet. The patient recovered from the anesthetic just as the noon bell was being rung in a neighboring church tower. He asked what the noise meant and expressed surprise when he was told that the bell had been rung all the time he had been living there, as he could not hear it before. The improvement was rapid and hearing became normal. The patient has from that time enjoyed nasal respiration and in consequence has improved greatly in general health.

The mouth-breather frequently suffers from bronchitis or pharyngitis or from both, for he is obliged to breath air not warmed and moistened by passing over the extremely vascular membrane of the turbinated bodies as nature intended he should. Adenoids pressing upon the Eustachian orifices have a somewhat similar effect of mechanicly interferring with the function of the middle ear, that pressure on the venthole of a drum has upon the resonance of that instrument.

In addition there is interference with the renewal of the air within the tympanic cavity and the proper equalization of air pressure, producing thereby conditions which result in either chronic suppurative or nonsuppurative otitis media.

Another case of considerable interest was that of a child which during its six years of life had been very frail and nervous and gave abundant evidence of malnutrition. On two occasions I had been called to see her when suffering from a suppurative otitis. Audition was defective, and sleep disturbed, as nasal respiration was impossible and oral breathing resulted in such discomfort that she would frequently awaken. Although for certain nonmedical reasons it was unpleasant for me to do any surgery for this patient, I finally advised the removal of the hypertrophied faucial tonsils and adenoid vegetations. The result was almost as satisfactory as in the case above cited. The patient has had no recurrence of suppurative otitis and sleep is undisturbed; she no longer makes the distressing noise she formerly did while eating and is much better nourished.

These cases are but types of several which have occurred in my practice and have led me to believe that the removal of this obstruction is one of the most strongly indicated surgical procedures. I have had but one unsatisfactory result and that was in the case of a spoiled child of rather unreasonable parents. The growth was of the fibrous type almost identical with the faucial tonsil. The father insisting upon taking the child to his home in a distant town the second day after the operation, I was unable to watch the case and the growth recurred.

The treatment in these cases is essentially surgical, and to be satisfactory must be thorough. The use of powerful chemic astringents and caustics is mentioned only to be condemned, as it is always difficult and sometimes impossible to limit their effect, and should the Eustachian orifices be cauterized thereby, serious complications might develop.

Various means of removal have been employed, including the wire snare of Bosworth, the small ring curet operated through the nostril as advised by Meyer, of New York, the Loewenberg forceps and the Gottstein curet. Since the perfection of the two latter instruments, these are the only ones needed in the majority of cases. The forceps if carefully used are of great value, but in unskilled or careless hands may be harmful by tearing away a portion of the pharyngeal wall. To guard against this the patient should be profoundly anesthetized and the insertion of the instrument be guided by the fingers inserted into the pharyngeal vault. When the forceps are closed little traction should be made, but with a to-and-fro movement the mass grasped by them should be detached without doing further damage. If the forceps are pulled away after incorporating the mass the pharyngeal mucous membrane may be torn. Hemorrhage produced thereby is sometimes profuse.

As soon as possible a curet of suitable size should be inserted

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