ter and the situation of the particular fault in the mechanism of the organ is of more importance than a technical knowledge of the methods, it also requires no little patience and perhaps more tact to make the subject realize that more than one examination is often necessary in order to determine upon a plan of treatment, if any, as well as to arrive at an intelligent answer to his eager questions about the probable results to his hearing, the time required, etc. Such answers can only be given with any degree of certainty after persistent and even painful examinations and tests. The impatient subject rarely considers that we must first find the cause and carefully consider all of its bearings if we would reasonably assure ourselves whether another method of treatment would be effective before a prognosis is possible.

"Tis not the new case of deafness, 'tis not at the time. when pain is the most pronounced symptom, 'tis not when the patient is most solicitous about his beginning failure to hear, nor is it in the old cases of necrosis or of exostosis or of ossicular anchylosis, that neither require nor will even admit of any decided operative procedures; 'tis not these that call for so much tact and delicacy. But it is one of those progressive, dry cases of chronic catarrh that has reached a high degree of deafness so slowly and so insidiously as to have been barely perceptible; it is one of those cases that has gone the rounds from one aurist to another, expecting each time some miraculous results in a week, at the hands of him who applies only the old conventional text-book methods; it is one of those cases where the family physician has so long advised the do-nothing plan or has told the parents to let the child's ears alone, that he will outgrow it, when the outgrowing process is usually reversed; the disease grows the fastest; it is one of those cases where the subject lacks persistence or is chronically

pessimistic. Indeed, it is in such cases as these that tact and delicacy alone can succeed.

By a rather peculiar coincidence, just at this stage in the preparation of this paper, I received a reprint from an article on "Modern Possibilities in the Treatment of Chronic Catarrhal Deafness," by Dr. Snow, of Syracuse, N. Y., in which his refrain is persistence as the price of success. If he would or has already included tact and patience in the one word persistence, he might well make this word his shibboleth; then no one could be surprised at the large percentage of success he reports.

If we should follow the text-books now-the majority of them and attempt to carry out their too often perfunctory instructions, we would not have the opportunity to daily inflate the Eustachian tubes (and do nothing more) by Politzerization or with the catheter for six weeks, for the very good reason that, in this day and age, our patients, at least those who are susceptible from a psychological standpoint, would not stay with us so long.

The older text-books on the ear seem to have fixed just six weeks as the limit of all human endeavor, and after thirty-six days (or forty-two days, if Sundays are not observed) of inflating the tubes (effectively possibly, ineffectively probably), they say no patient need again apply. The authors of most of the text-books, even those whose first or last editions are dated as late as 1898, do not seem to realize, as we may venture to predict they will in their future editions, that most ear diseases primarily have their origin in the throat or post-nasal spaces, and must be treated from that general etiological standpoint.

Ten years ago such a statement as this would have been regarded as rank heresy by the aurist, who even at that recent date chose to so call himself, before he began to learn, but still reluctantly to acknowledge that the open sesame,

pathologically speaking, to the ear is through the nasopharyngeal route. The aurist of to-day is neither tactful nor can he be successful if he is not first a rhinopharyngologist. Such patients would soon lose their patience with any aurist, and justly so, who did not treat them from this point of view. It must be remembered that I am speaking particularly of the non-proliferative form of deafness. Is it not worth a much longer treatment than the conventional six weeks, of patience and persistence, to gain relief from that hammering and nagging condition, known as tinnitus aurium, which is one of the most constant symptoms of this form of deafness?

The causes are numerous: it may be due to aural polypus situated in the canal and growing from a granulation, or a furuncle; a necrosis either external to the membrane, or as is most probable, having its origin in the middle ear, through a perforation in the M. T.; it may be a protrusion of the hypertrophied wall of the tympanum; a necrosis of the ossicles; a cicatrix, from an old inflammation; an anchylosis; a thickening or a stenosis of the Eustachian canal. Again, the cause may be nasal polypi; post-nasal adenoids, situated in the region of the Eustachian opening; an hypertrophied Luschka's tonsil, as well as the pressure of enlarged faucial tonsils. Or, indeed, the cause may be any form of nasal stenosis that produces mouth-breathing, especially when situated near the fosse of Rosenmuller. Some of these lesions, with their numerous sequelæ may cause only unilateral deafness, yet even they may require much delicacy in the selection of the means to the end. But it is that most lesionless condition, generally known as non-suppurative or non-proliferative chronic catarrh of the middle ear, to which this paper more particularly refers, and it is the one too that is calculated to place the aurist at

his wits' end and in some cases make him wish that he had never been born, or at least that he had not been born an aurist. It is in just such cases as these that the tactful and persistent adaptation of common sense methods succeeds.

Nowhere else is the potency of electricity so exemplified, but this presupposes, of course, a general knowledge of the many varieties of this subtle current in order to make a proper selection of the kind, the character, the amount, the direction of the current, and how to apply it, as well as the duration of the séance. This last, perhaps, requires the most tact, as the effects of electricity vary so greatly in different patients, and often in the same patient, that there can be no set rule; indeed, the desired effect may be reached and overdone, or it may not be reached at all within a certain number of minutes.

It requires more knack than tact perhaps to properly introduce a bougie into the Eustachian tube, but it requires more tact than knack to repeat the operation many times in the same case, since, as it is the patient who must exercise the patience here, as also in the introduction of liquids or gases into the tube, much delicacy is necessary in order to encourage the patient to exercise sufficient persistence for a second operation.

Can we not then say, in conclusion, that, in the treatment of chronic deafness, tact is the greatest common divisor, and patience the least common denominator?

ADENOID VEGETATIONS, WITH ESPECIAL REFERENCE TO THEIR INFLUENCE UPON THE EAR.

By A. W. CALHOUN, M.D., LL.D., ATLANTA, Ga.

Adenoid hypertrophy at the vault of the pharynx is by no means a new subject. Still it has many relevant features of sufficient importance to warrant emphasis points of interest which may be profitably discussed.

It is not my intention to dwell upon the minute pathology, nor upon the history of this nasopharyngeal foreign body; but, rather, to speak, in a disconnected way, of personal experience acquired through clinical investigation, which I trust may add to our present information upon this subject.

Hidden in the nasopharyngeal vault of many children are to be seen, with the help of a proper mirror, these adenoid growths, which, under certain conditions, exert a serious influence upon the child's future physical and mental development.

The nasopharynx is a small but important cavity—important because of its relation to the nose and ears. Being a part of the respiratory tract, it follows that any serious obstruction at this point to the free and easy passage of air to and from the lungs greatly impairs, almost to exclusion, the usefulness of this portion of the respiratory tract, for which, of course, must be substituted the mouth. In the act of respiration the nasal cavities perform vital