by, become to-day a destroying host that
may carry by assault the very citadel of
life. A slight catarrhal condition of the
respiratory tract, some small change in the
intestinal mucosa and that which was an
iron wall becomes an open gate.
These conditions concern a man's every-
day life, and if such things happen in the
green tree, what of the dry?
Antitoxin is valuable in many diseases,
germicides and antiseptics are invaluable
in many ways and places, but they all have
in view the seed or its products and leave
undisturbed, or further injured, the all
important soil.
It has been proven by experiment that
it is impossible, by the most painstaking
and thorough method, to absolutely sterilize
the skin ; at the site ot proposed operation
for instance. Is aseptic and antiseptic sur-
gery a farce then ? By no manner of means.
Spend only ten minutes in reading the sur-
gical history of i860 to be forever con-
vinced. But the germs which caused so
much mischief in the trail of our fore-
father's knife were those that could be seen
almost with the naked eye and which soap
and water would have removed. In other
words they were not clean in the ordinary
meaning of the term.
It is not meant that we may discard the
manner of cleaning the skin or mucous
membrane and hands which the modern
surgeons have taught us was necessary but
rather with the most scrupulous care and
delicate regard should we carry out the
minutest detail. This is not so much on
account of the seed, but because we de-
liberately and with aforethought prepare
430
THE CHARLOTTE MEDICAK JOURNAL.
the soil for the growth and development of
the seed.
The skin is a barren desert, but the in-
cision of the surgeon is a garden bed well
sodded, warm and mellow.
But even if an impossible task we must
try to destroy all the germs we can and,
like the youth of our school-boy days, if
at first we don't succeed, let us try, try
again, because there is always somewhere
a prepared soil that they may chance upon.
It is also a plain, and in some respects, a
practical duty, to limit and control in every
possible way the method and means of in-
fection. Yet this is only the mint, anise
and cummin, the weightier matters of the
law is the careful husbandry of the soil.
Any man in this free and easy land may
have the tubercle bacilli in his every breath
and the doctor who will precribe some
stereotyped cough syrup for even the sim-
plest bronchial catarrh is as competent to
practice medicine as the counter-prescribing
druggist, not more so. Cough mixtures are
good, are often indicated, but they have
helped so many al'^ng the road to the con-
sumptive's home and the strangling death.
How many cases of improper feeding has
pepsin and its comoinations relieved until
the typhoid bacilli gained an entrance
through the diseased gland? A very small
abrasion of the external skin may be
the determining cause of infection as a prick
in dissecting, as a mosquito bite in malaria,
so may a little crevice of the internal skin,
the mucous membrane, serve as the start-
ing point of disease.
What shall we do then with our patients
who have a slight cough or the heartburn
after meals?
For the first it is better to send him to
bed after washing his feet in hot water than
to dose him up with sugar and opium in
nauseous mixtures. For the latter give
bread and water only for nine days together
with a lecture on dietetics that he will re-
member and tell his great-grand children.
We doctors can be so careless and indif-
ferent at the beginning and so solemn and
wise at the end. What has been said in
regard to injuries in certain parts of the
body may be truthfully said of all the con-
ditions for the relief of which we are con-
sulted, none are so trivial but that the out-
come may be serious and none are so des-
perate but they may be helped by skill and
sympathy,
12 South Caldwell.
"He told his audienee that ne was wholly
unprepared." "Do you believe it?" "Yes,
he had his speech in his pocket, but he
hadn't learned it,"
Hypertrophy of the Pharyngeal Tonsil.*
By Walter W. Duson, M. D., Asheville, N. C.
This condition, more commonly called
Adenoid Vegetations, is a true Hypertrophy
of that glandular structure in the vault of
the pharynx known as Luschka's tonsil.
This tonsil, in its normal state, is found
in the upper and posterior part of every
pharynx and forms a soft cushion of ag-
glomerate glands in no way obstructing the
passage of the air current or interfering in
any way with the functions of the pharynx.
The diseased condition of this structure
was first described as early as i860 by
Czermack, who failed, however,, to find
out its clinical significance.
This subject was fully covered some years
later in a report of 103 cases by Wilhelm
Mayer of Copenhagan, whose report was so
exhaustive that very little if anything, has
been added since his paper was read.
This disease, although in some cases con-
gental, more often developes in early child-
hood as a sequel to some one of the exan-
thematous fevers, or to repeated attacks of
inflammation due to colds.
The condition is oftener found in children
with some tubercular family history, having
a general tendency to enlarged lymphatic
glands; but this is not by any means the
rule, as the diseased tonsil is often found in
stout, healthy children with not the sligh-
test tubercular taint.
It is often accompanied by enlarged
faucial tonsils, follicular pharyngitis or a*
hypertrophic condition of the turbinated
bodies.
The disease often disappears altogether
after puberty, but remains in quite a large
percentage of cases well up into adult life.
Pathologically this hypertrophic condi-
tion is the same as an hypertrophy of the
faucial tonsil, except that in the former
there is a greater hyperplasia of lymph
tissue, while in the latter the fibrous con-
nective tissue predominates.
The division of the enlargement into
lobules can in most instances be distinctly
seen or felt; then again, the enlargement
takes a more flattened form and can scarcely
be differentiated from the pharyngeal mem-
brane.
It consists, microscopically, of a covering
of columnar ciliated epithelium, covering a
myxomatous mucosa, crowded with lymph
corpusles, connected by light fibrous tissue.
In some cases the lobular condition is so
pronounced that the lobules appear as
iRead before Buncombe County Medical
Society, April, 2, 1900
THE CHARLOTTE MEDICAL JOURNAL,
431
polyps, seeming to have pedicles and hang-
ing loose in the naso-pharyngeal space.
In cases where the growth is of a large
size the condition is readily recognized by
the facial expression of the patient, which
is so characteristic as to enable an experi-
enced eye to make a diagnosis while the
patient is walking along the street.
The expression is due entirely to the in-
terference with nasal respiration, thereby
causing the patient to keep the mouth open
for breathing purposes. This in itself is
sufficient to cause the idiotic expression so
often found.
Beside this, there is usually a broadening
of the base of the nose, a narrowing of the
nostrals and a flattened appearance of the
cheeks, all due to the lack of development
of the parts from interference with the
nasal function.
The above symptoms are only found in
cases where the growth is sufficiently large
to almost entirely occlude the nasal pas-
sages.
Ordinarily the most prominent symptom,
and the one we are called upon to relieve,
is the excessive discharge of mucus and
muco-pus from the enlarged tonsil, thereby
keeping the pharyngeal wall continually
bathed in this secretion and sometimes
giving rise to quite a cough by the irrita-
tion of the pharynx and larynx.
The patient is constantly hawking- and
clearing the throat and seems to develop a
fresh case of naso-pharyngitis upon the
slightest exposure.
Unless the growth is very large the secre-
tion rarely comes forward through the nos-
trils, but passes back over the pharyngeal
wall and is either swallowed, as in the case
of young children, or expectorated.
Another prominent symptom and a con-
stant one, is the impairment of the voice.
We are all familiar with this condition
which occurs from the nose being stopped
when we have taken cold, — the condition
when an M, and N, can only be pronounc-
ed as eb and ed.
This symptom is found to some extent in
all cases however slight, because the post
nasal space is not a large one and the
smallest infringment upon it will interfere
with the sound waves, causing some im-
pairment of them.
Another quite prominent symptom, and
one that is far reaching in its results, is the
involvement of the ears. This, to my mind,
is the greatest danger point in adenoid
disease.
Ear complications are so often found in
some form that we may say it is the excep-
tion not to find them. The complications
may vary from the slightest catarrhal condi-
tion of the internal ear, presenting almost
no symptoms, to a violent purulent inflam-
mation, accompanied with all the symptoms
usually found in such conditions.
Authorities differ as to the reason why
disease 'in the vault of the pharynx should
so often be accompanied by diseases of the
ear. Some claim that it is due to pressure
on the eustachian orifice by the adenoid
growths; others claim that the ear symp-
toms are due to the extension of the catar-
rhal inflammation from the pharynx into
the eustachian tube.
Bosworth believes that the ear disease is
not caused by either of the above condi-
tions, but is due to the interference with
renewal of air in the middle chamber caused
by the nasal stenosis. This interference, by
preventing the constont renewal of air
causes a rarefaction of the air contained in
the middle chamber and a consequent con-
gestion.
It matters very little which of the above
theories may be correct as it makes no dif-
ference whatever in the treatment of the
case, — the first step in the treatment of the
ear complication being in all cases to re-
move the enlarged tonsil.
When the growth is not of a very large
size the patient may be able to breath
through the nose sufficiently during wak-
ing hours, but when night comes the mouth
is opened, and most of these patients are
mouth breathers during sleep.
In some few cases where there is no en-
largement of the turbinated bodies and the
nasal chambers are quite free, it is some-
times possible to see the diseased tonsil by
anterior examination of the nose, but this
is very seldom the case.
Except in the cases of very young child-
ren it is always possible to make the exam-
ination posteriorly by means of the rhino-
scopic mirror. This shows to the practiced
observer, the exact condition of the parts
and the diseased tonsil, if any can readily
be seen and examined. Instead of the
round smooth pharyngeal vault, there are
seen glistening protuberances of varying
sizes, more or less filling the cavity and
obstructing the view of the nasal septum
and posterior nasal orifices.
In very young children, and in all cases
where there is any doubt as to the diagno-
sis, an exploration of the pharyngeal vault
can be made with the index finger. The
proceeding appears to be rather a barbarous
one and is attended with some danger to
the physician's finger from the child's
teeth, unless proper precautions are taken,
but there is scarcely any pain attending it.
There are quite a number of other
methods of diagnosing the condition ad-
432
THE CHAKLOTTE MEDICAL JOURNAL,.
vocated by different writers, but tlie rliino-
scopic mirror and the finger, in my experi-
ence, have been sufficient means for all
cases.
It is remarkable, in most cises, what
good results follow the remov il of these
growths. It almost always has i beneficial
action on all ear complications, the catar-
rhal condition of the nose and throat is
relieved and the seemingly semi-idiotic
expression gives place to a normal one.
The latter improvement probably due to
the ability to keep the mouth closed, more
than anything else.
In treating this disease much time is
wasted in the use of medicated sprays,
vapors and douches ; they only alleviate the
symptoms to a more or less extent, but
have no curative effect upon the diseased
gland. A surgical operation for the entire
removal of all the offending enlargement is
indicated and, to my mind, the only proper
course to pursue.
For this operation I prefer the use of
Gottstein's curette as being simple, easy of
manipulation and thorough in its results
when properly handled. If, after the use
of this instrument, there are a few points
remaining, it has been my habit to remove
them with the Lowenberg forceps which
has a cutting edge. The above named
instruments and a mouth gag are all that
are necessary for their entire removal.
The tonsil can be removed by the use of
caustic applications, such as nitrate of
silver, chromic acid, or better still, the
galvano-cautery, but the process is a slow
and painful one.
Many operators have devised cutting
instruments and snares for the removal of
these growths, but I will not take up the
Society's time by an enumeration or dis-
cription of them.
My greatest objection to the snare is,
that with it, only the pendulous growths
can be removed, and the removal, even
then, is not a thorough one.
As to the use of an anasthetic for the
operation, it has been my rule to suit the
patient or the parent. In very young
children and those who cannot be managed
and particularly where the faucial tonsils
are to be removed also, I prefer the anas-
thetic.
The patient is placed upon the operating
table with the held hanging over the end
so no blood can get into the larynx. In
case the faucial tonsils are to be removed
also, I always attend to them first, as,
otherwise, the field is obscured by the blood
resulting from the adenoid operation.
Or, the patient may be held by an assis-
tant in such a way that his struggling will
amount to nothing and the operation per-
formed in that way.
The index finger alone is often used for
the removal of these growths, but this seems
to me to be rather an un-surgical proceedure.
As a rule these is very little hemorrhage
following this operation. In my experience
there has never been a single case where any
attention whatever was given to it.
Rarely there is an acute otitis following
the operation. There is no after treatment
needed for the operation itself other than an
alkaline wash or spray. Usually the parts
heal without any trouble, but I have some-
times seen the site of the operation covered
with an exudation and some rise of tem-
perature in consequence. When the oper-
ation has been thorough the diseased con-
dition does not return.
This disease is not dangerous as far as the
life of the patient is concerned, but when
we take into consideration the damage
done ; whether it be facial expression, nasal
disease, or, most common and far-reaching
of all, a diseased condition of the ears we
are justified in attaching great importance
to it, and insisting that the general practi-
tioner as well as the specialist be always on
the alert for it, thereby saving himself much
trouble and the patient much suffering by
its timely removal.
DISCUSSION.
Dr. Pearson. — "The doctor has so thor-
oughly covered the ground that there seems
very little left for me to say. There were
two points that were not mentioned. One
of them is asthma occurring from the pres-
ence of adenoid growths. I have had oc-
casion to see two cases of asthma which
were due to adenoid growths in the pharynx,
and upon the removal of those growths the
asthma was relieved. Second, the relation
of adenoid growths to deaf-mutism. Al-
most all cases where the growths have ex-
isted for any length of time complicates the
ear, as the doctor has said, and I believe
Frankenburg has made this a subject of in-
vestigation, and says out of 158 inmates of
the deaf-mute institute in Prague, he exam-
ined, there were 50% with these growths.
So far as the treatment is concerned, I agree
with the doctor fully that operative proce-
dure should be established, rather than try-
ing the sprays, and the curet is as a rule, I
think, the best instrument to be used. The
only cases where the snare would be appli-
cable are those cases of fibrous growth, as-
suming more of the form of a polypus.
These can some-times be removed with the
snare, then treat the base with chronic acid,
I use the Bosworth snare, and then caute-
rize the base of the tumor. We get then a
THE CHARLOTTJfl MEDICAL JUOKJNAL.
433
slough that is easly thrown off. In the case
I spoke of I did not have to give a general
ancesthetic, but used cocaine as a local anses-
thetic. I see that Bishop, in regard to
anaesthesia, recommends bromide of ethyl.
With this you have to operate very rapidly
as it only produces complete anaesthesia, for
about five minutes. The operation can be
done in that length of time, however, by
having proper assistance and having every-
thing ready before starting, but I have used
cocaine in some cases and have also used
general anesthesia. I think the doctor has
gone over the ground in regard to treat-
ment and complications so thoroughly that
1 have nothing further to say.
Dr. Battle. — My experience has not
been very large with aenoid, though I have
perhaps had my share. I would like fo ask
the doctor if he has not seen those growths
disappear without operation, especially
when they follow something like scarlet fe-
ver and diseases of that character. It has
been my experience that those growths
sometimes disappear. Sometimes there is
objection on the part of the parent to hav-
ing an operation, and I have known them
in the course of two or three weeks to grow
smaller and in two or three instances have
disappeared, so I take it they must have
given no further trouble. I have a case
now that is certainly much less. The moth-
er objects very much to having anything
done, and I have only in a tentative way
kept the nasal passage clean, and the growth
is going down. I have nothing special to
add to the doctor's paper, because he cover-
ed the ground. A few years ago we knew
very little of this. The general practition-
er I am sure sees very little of it now.
Dr. Ambler. — The pharyngeal tonsil is
simply one of a chain of lymphatic glands
which encircles the whole pharynx, with
the vault of the pharynx as the upper por-
tion of the circle ; this gland is liable to any
such disease as any of this circle might
develop. As Dr. Battle has stated, we do
have an acute trouble of this gland, the
same as we do in the tonsil or in those at
the base of the tongue, but I do not believe
that the paper was read with an idea of sur-
gical interference where there is a tempor-
ary diseased condition of this gland. I
think the Dr. was refering more especially
to the chronic cases, where the disease had
been present for months, or even years, and
has resulted in the first place in nasal ob-
struction and in the second place change in
expression of the face of the child. Writ-
ers have given this expression of the child
the name of "Mayers" face, because it was
he who first described this condition in a
child who had advanced adenoid. The
child becomes idiotic looking. You see
them on the street with the lower jaw drop-
ped with a narrow nose, the face pinched
and the cheeks sunken ; the eyes half closed
and the whole expression of the child one
of almost complete idiotic expression as the
Doctor stated. I agree with him, and as
Dr. Battle stated, surgical interference is
the only thing that is going to produce any
good, and although the parents of the
child are always opposed to an operation,
at the same time it is so simple that their
objection is not well taken. Many of the
cases can be operated on in from one to two
minutes. I believe we frequently have
operated on cases without giving anesthe-
tics, where the whole case is over in one or
two minutes. With the right kind of a
curette it only takes a few strokes to thorough-
ly free the pharynx from these vegetations.
I think this same condition is often over-
looked in cutting the tonsils. A great ma-
jority of our little patients whom we oper-
ate on for enlarged faucial tonsils also have
enlarged pharyngeal tonsils and if we at-
tempt to overcome the obstruction to breath-
ing, or the catarrhal condition by simply
removing the faucial tonsils I think we are
making a great mistake. I make it a rule
to always examine the pharynx in our or-
dinary tonsils operations, and in a great
many of those cases the worst symptoms
which are present do not come from the
faucial tonsils but from the pharyngeal ton-
sil : In regard to the application of chromic
acid, I have used it, and have also used the
galvano cautery, but I do not believe it is a
good plan to follow it out as a rule. Oper -
ative interference is the only successful
method of handling these cases. For the
ordinary hypertropoy operation it is not
even necessary to tie the palate forward. I
would state that my experience has been
that these cases do get well themselves.
Take a child four or five, 6, 7, 8 or 9 years
old, with a bad case of hypertrophy, if you
let that child alone, when he gets 14 or 15
or 16 that hypertrophy will go down, but
in the meantime the child has developed a
condition he will have as long as he lives.
He has developed trouble with the larynx
on account of his mouth breathing, and the
after effects of the disease itself are even
worse than the disease, and for that reason
I do not believe that in the chronic disease
it is well to let it alone.
Dr. S. W. Battle. — I asked the ques-
tion simply to bring out some little discus-
sion on the point of treatment. I did not
mean to make any special claim that these
cases should be left to themselves. On the
contrary, I believe very strongly that oper-
ative procedure is the thing, but I wanted
434
THE CHARLOTTE MEDICAL JOURNAL.
to know the experience of the gentlemen
present as to what would be the result in
leaving the acute cases alone. All of us
have had experience with children with
very large tonsils which interfere with the
breathing ever uow and again when they
take cold, but in a few years they cease to
have these out-breaks on taking cold. I be-
lieve the operative procedure is the only
thing to do, and as far as the doing of it is
concerned, I do not believe that anaesthesia
is very often required. The operation is
over in a minute, for it is only a matter of
of scraping out the growth, and while the
bleeding is very profuse for a few seconds
it is soon over. 1 have never used chromic
acid. With the ordinary thickening of mu-
cous membrane there is nothing that acts so
beautifully, but you never know quite how
much tissue it is going to destroy. 50%
solution once applied will go on with its
work until you thoroughly wash it out with
a spray. In making this application with
chromic acid as soon as I have painted my
surface and as speedilv as I can I get my
spray and wash out as much as possible, and
in the next day or two you can see your
slough, and in a few days they will blow it
out of the nose. I have had quite a little
experience with chromic acid. If you have
50% solution and take a fine camels hair
pencil with the nose speculum properly ad-
justed, you can make an application to any
point that you wish with a great deal of ac-
curacy. You have to be very careful not to
slather it all over the mucous membrane,
but if you choose your point and paint it,
and then with a moderate amount of haste
gather up your spray and wash off, on ex-
amination next day you will see a whitish
area where you have applied this chromic
acid, and in two or three days the patient
will blow the slough off, and it is really a
most satisfactory way of getting at some of
those enlargements, and where you have a
moderate amount of hypertrophy I recom-
mend it to your consideration.
Dr. Pearson. — In the case I had refer-
ence to there was a growth of the fibrous
nature. There are two kinds of adenoid
growths of this chain of glands. One is
mucous or lymphoid and the other is fibrous.
The growth I had reference to was one of
the fibrous tissue, and that I snared off and
then treated the base of this growth. I do
not apply the chromic acid in the wall of
the pharynx when there is a chain of en-
larged glands or vegetations but when the
area is limited you can apply your chromic