ADENOID VEGETATION IN THE NASO-PHARYNX OF

CHILDREN.

CLARENCE WARFIELD, M. D.,

SAN ANTONIO, TEXAS.

In taking up this subject I am well aware that it is one that has been threshed threadbare by many writers whose experience has been both varied and exhaustive. The text-books as well, have gone into this subject with a detail to thoroughness that would seem to leave but little to be said. Consequently there will enter into this short paper much that is a repetition of what has already been brought many times to your attention heretofore. Yet, if we stop to consider, these same repetitions are what impress upon the mind indelibly, subject matter, that when cases come before us we are glad of the patience shown at a time when it was more or less tiresome to listen or to read.

Roughly speaking, the naso-pharynx is bounded below by the velum palati. Its roof is formed by the basilar portion of the sphenoid and occipital bones. The posterior wall, by the atlas and axis, anteriorly presents the chona. In the lateral walls are found the pharyngeal openings of the eustachian tubes. At the level of the posterior extremity of the lower or middle turbinate bones from the lower, a ridge formed by the lavator palati muscle runs downward and upward to the soft palate, and from there runs a groove upward and outward towards the vault and posterior wall of the pharynx, called the fossa of Rosenmüller. The pharynx is composed of three coats, first a muscular as a base, then a fibrous and then a mucous. The mucous coat of the naso-pharynx above the level of the floor of the nares is covered with ciliated columnæ epithelium. Below the level by squamous epithelium, and contains simple and compound follicular and racemose glands. Trautmann & Gray.)

Throughout the pharynx are numerous crypts or recesses, the

walls of which are surrounded by lymphoid tissue similar to that which is found in the tonsils. Across the upper and back part of the pharyngeal cavity, between the two eustachian tubes, a considerable mass of this tissue exists, and has been named the pharyngeal or luschkas tonsil. (Gray.) In a normal state this pad or tissue should at least leave enough space for the free passage of air from the nose to the larynx without calling upon the mouth to perform a function nature little intended it should do. Corresponding to the thickness of this pad or abnormal additions to same, so is this absolutely necessary breathing space curtailed, thus leading as a primary cause to more pathological effects and defects than any other one cause in the entire category, of a nature whose character is directly dangerous to health and life, as well as producing deformities, easily remedied if taken in time; lasting throughout life in spite of treatment, if not.

My plea and excuse for this paper is not to tire you with anatomical details, but as to method of handling these cases with the least degree of injury to the patient or parts involved or near by; the dispatch with which it is done, and the satisfaction as to ultimate results when the after treatment is carried out. Ordinarily one is led to believe that adenoid tissue in the naso-pharynx hangs in this space in a way that an instrument, such as Gottstein curette, will snugly fit and cut away in a manner that will afterwards need no repetition of the procedure, but the facts are, that this hyperplastic mass is not situated nor found in any two cases exactly alike. To follow a fixed rule as to position of instrument is simply waste of time. We may find upon diligent examination a soft pulpy mass occupying anything from a localized spot to filling entirely the naso-pharynx, feeling like a mass of soft liver tissue. This is more the case the younger the patient. As they get older this comparatively soft mass changes. The softer elements are absorbed or thrown off and what remains are roughened, lobulated or corded folds of hyperplastic tissue, fibrous in character. It is claimed by Trautmann that adenoid tissue continues growing until the third year, the tendency being to shrink after puberty.

From what I have seen of these cases I am led to believe the condition does not form after birth, but is there from previous to being born and simply increases in size, as Trautmann says, until the third year, this increase being corresponding to whatever element, heredity, inflammation or irritations may present, these irritations resultant from eruptive fevers, etc. We should consider the many pathological conditions set up by these vegetations-for instance, impairment of hearing and mouth breathing, leaving out hundreds of other equally important direct sequelæ. Kyle claims if this condition is allowed to remain until the bony nasal framework has become firmly united, then the removal will not increase nasal respiration other than by lessening the engorgement of the submucosa, subsequent to such obstruction, and this fixity of the bones of the face may leave the individual a confirmed mouth breather. This but emphasizes the importance of an early diagnosis and removal. It should certainly be done within the first three years of the child's life. Today and every day there are thousands of little children having nose sniffling, nose catarrh, serous and purulent discharges from the ears, etc., having the individual nose or ears treated regularly and faithfully by the physician, the family, or both in conjunction, for months, when in the great majority of cases of this kind time could be saved, suffering for the little ones alleviated and general satisfaction be felt by both the parent and attending physician, if the cause would be gotten at in the naso-pharynx, instead of losing time upon the individual organs, which are showing outward manifestations that are merely results and effects. Mothers say, "Doctor, when I was a child we did not have these things. I never had my throat touched and I am now strong and healthy." There is more truth than poetry in this, and is in a way due to the fact that the present generation of children seem to have less resistance, have weaker constitutions, are all the more prone to catarrhal conditions than the ordinary children born at the time our parents and ancestors Be that as it may, the fact is that now the great majority of children that it falls to the lot of the throat specialist to see

were.

and examine, are mouth breathers, either asleep or awake, and if the adenoid tissue is not removed they simply do not develop, are stunted in growth, the facial expression is entirely changed, they become hollow chested, pale and anæmic. Neither will I go into details in regard to how the symptoms can and do manifest themselves, but let me assure you our text-books do not exaggerate them in the least. If you are in doubt as to the importance of this subject, watch one of these little patients before and after operation, and note the changes nature brings about when there is a cessation of violating her laws. The most skeptical may receive an object lesson which will last them a lifetime. Enough as to conditions, and a word as to method of removal after diagnosis has been established.

The cut and dried rule seems to be summed up in the following: Chloroforming and curetting with an instrument made for that purpose the kind of instrument according to the preference of the operator. At times there have appeared articles by different writers in advocacy of the use of the index finger alone or protected by a metal contrivance fitting over its first phalanx, forming an artificial finger nail, and with this finger, protected or otherwise, not only making the exploratory examination but at the same time removing the growths entirely, at the one sitting. This is the method I advocate and always do. The orifices of the eustachian tubes are not the same distance apart in every child, so no fixed rule can be laid down to secure the curette operator from injuring one or both, even should he be lucky enough to get all the tissue with his instrument, which he will rarely do, as the instrument will not mould itself to fit the growth. On the contrary, in advocating the use of the finger alone in all cases, without exception, I do so because of repeated failures to get complete satisfaction by the method generally advocated. (Chloroform and the Gottstein curette or adenoid forceps.)

We have in the index finger, where the nail has. been allowed to grow until it has formed an ideal curette, a means by which the operation is done more quickly, thoroughly, and in every way

more satisfactorily than by any other means at our command. Of course the finger must be treated in very much the same manner as the instrument would have been-in other words, made aseptic -and it would be better, if practicable, to make the parts to be operated on as clean as possible. The child sits in a chair with a towel pinned around over the chest and a small basin held in the lap or near by, with a few small towels or napkins to be used to free the nose of blood clots after operating, the mouth gag held in the hand not operating; the operating finger introduced in the post nasal space, and in one minute at the most everything removed in throat cavity that should not be there, without injury whatever to the orifice of the eustachian tubes or anywhere else. This procedure is severe for just sixty seconds-all must be completed after the introduction of the finger. No child will be inclined to allow you to attempt a second trial when the operating hand has been once removed from the mouth. After the operation is over the patient's head is bent forward and the blood allowed to flow freely, as it will do, and clots gently blown from the nose. When the slight shock of the operation is over, then an astringent application (I prefer some salt of silver) is rubbed in the parts on a cotton tipped applicator. If this is not done daily for a week or so, quite a quantity of new tissue will spring up on the base laid bare with the finger nail, and here I believe we have the cause for reaccumulation of tissue afterwards, where an operation has been previously performed and left to take care of itself. This application of an astringent seems to cicatrize and cause to heal bared bases from which the mass has been removed, and as the patient grows older this tends to shrink even more, giving eventually all the space necessary to a proper functionating of these parts. With chloroform you need one or two assistants--you have an hour or more work. The little patient is placed head inclined downwards, but even thus placed must breathe, so more or less blood is drawn in the larynx. You have the generally broken up appearance after recovery from the anesthetic, etc., and providing everything goes all right there will enter a slight element of danger in chloroforming