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MONG the cases I present to you to-day is this young girl of nine years, who is brought to me because she suffers from "catarrh." Now catarrh, as I have shown you in numerous instances, is never to be regarded as a disease per se-is not a distinct pathological entity but is merely a symptom which, intelligently followed up, points to the existence of some morbid condition of the upper respiratory tract. What that morbid condition is, it is our duty to discover. In the great majority of cases we shall find the cause of the catarrhal symptoms to be some obstruction

*A Clinical Lecture delivered to the Senior Class of the St. Louis College of Physicians and Surgeons, November 9, 1896.

to the free passage of the air through the upper tract. You have already been shown cases in which the catarrhal symptoms have been caused by such widely varying conditions as nasal polypi, septal deformities, various foreign bodies. in the nostrils, hypertrophied tonsils, etc., the surgical re

moval of which have left the air passages free and results in a cure. of the catarrh.

The little girl before you belongs to that great class of people who, especially in the Mississippi Valley, suffer from catarrh. You observe that the upper lip and the alæ of the nostrils are reddened and excoriated by the constant

discharge of mucus, often purulent in character, which is poured out by the nostrils. You observe that her efforts to blow her nose are unsatisfactory, because she seems unable to blow a strong blast of air through the nostrils.

You observe, too, that she breathes with widely parted lipsa most significant sign of adenoid disease. Further, you notice that there is a general heaviness and dullness in her facial expression, that the nose is broad and flat between the eyes, the transverse vein being somewhat prominent. It is also noticeable that the child's dentition is faulty-that she is somewhat "overshot." That is to say, when the upper and lower molars are firmly articulated, the upper incisors considerably overlap the lower ones. The upper incisors in such patients frequently project at an extreme angle and an apparent shortening of the upper lip results, causing a serious deformity and resulting, especially in girls, in great marring of beauty. I need hardly point out to you that the efforts of the dentist, however skillful, to improve the line of the dentition by "jumping the bite" or by other means, must fail of permanent result so long as the cause of the patient's mouth-breathing is allowed to persist.

Another of the strongly significant signs of adenoid disease is the "dead" voice. That is, the voice in the production of certain sounds, notably m and n, is thick, muffled and indistinct, the sounds made by

the patient resembling b and d, respectively. In the case before you the enunciation is fairly good. Yet the word money is pronounced more like buddy; never is sounded as dever and man as bad.

Let us examine the anterior nares. We find that both nostrils are patulous and free. Thus far there is no obstruction to nasal respiration. It must be further back. We will now examine the throat and the naso-pharynx. The tonsils are not in the least hypertrophied, but, on placing the rhinoscopic mirror in position, we see a rather large mass of tissue, lighter in color than the surrounding mucosa, and covered with a tenacious coat of mucus. I recognize this mass as the hypertrophied pharyngeal tonsil. The little patient is extremely tolerant of the use of the rhinoscopic mirror. In a large number of cases you will be unable to get a view of the naso-pharynx with the mirror. In such cases the forefinger should be pressed up into the region in the following manner: The head of the child is steadied against my body by my left hand and the right forefinger, having the nail closely trimmed, is quickly introduced and passed back into the naso-pharyngeal space. The region is quickly but thoroughly explored and the situation of the growth noted, especially with reference to the orifices of the eustachian tubes. If adenoids are present, as in the present cases, the finger encounters a soft, spongy mass of tissue which

occludes to a greater or less degree the naso-pharyngeal space. The physician should accustom himself to explore for adenoids in all probable cases. The maneuver is so easily, quickly and painlessly performed that it cannot be said to be anything more than momentarily uncomfortable to the child. Some operators guard. against the danger of being bitten by using various forms of mouth-gags for the exploration. Hovell, of London, has devised a very simple and effective guard for the finger. It may be made of an ordinary piece of rubber drainage tubing, large enough to admit the forefinger. I will show you its manner of construction. Personally, I have discarded all of these guards, and, by proper care, am never bitten by the patient.

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Some of the effects of adenoids you see in the case before you. They are the sole cause of her "catarrh," which will persist until the growths are removed. must reserve for another day a more detailed statement of the morbid conditions resulting from adenoids. I may briefly say, however, that very many cases of simple croup are due to the presence of those growths, that nocturnal enuresis exists in a large percentage of children thus affected and is cured by the operation, that the serious deformity known as "pigeon-breast" may result from the growths, as may torticollis and many other conditions. A condition seen in many children with adenoids is known as aprosexia and

consists in the inability of the patient to fix and confine his attention to any one subject. It is needless to say that such children do not stand an equal chance with their fellows in school. The ears, however, are the chief sufferers from the existence of adenoids. The great majority of cases af otitis media, both catarrhal and purulent, and almost every case of recurrent otitis media co-exist with adenoids of the naso-pharynx, and I need hardly point out to you that all treatment directed to the ears alone, while the adenoids are left in situ, is merely temporizing with a constant danger to the child's health and hearing.

Having now established the diagnosis of adenoids the little patient will be photographed by Mr. Workman, and will then be given chloroform for the operation.

I will occupy this interval by showing you some of the instruments employed in the operation, and in speaking of the various phases that have culminated in the modern procedure. We find to-day, just as Meyer and those who followed him found, that parents are not quick to submit their children to the ordeal of a surgical operation if any method can be devised to escape the necessity for such a step. I may as well say to you now, as plainly as possible, that any efforts to reduce the size of a hypertrophied pharyngeal tonsil by sprays or any of the endless series of astringent applications must result only in final failure. No matter