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even a child. All or most of these conditions are obviated by the method advocated here, and I venture, once tried, the first named method of doing this work will soon become obsolete, as far as that operator is concerned.
DR. W. A. HARPER, Austin: This question of removing adenoids in the naso-pharynx is one that the general practitioner, as well as the specialist, should know something about. As regards the giving of chloroform, I think it is very rare that it is necessary to give chloroform to remove adenoids. I think a mistake is often made by not treating the parts after the removal of the adenoids, as Dr. Warfield brings out, after operation.
I can not add anything to what the doctor has said in his paper, to which I listened with a great deal of interest.
DR. J. C. LOGGINS, Ennis: As a general practitioner, there is one point in the doctor's paper that I want to endorse very positively. In trying to remove adenoids with the finger, it is unsafe, unless you use the mouth gag, for if you are operating on a boy three years old without the mouth gag, you will soon find that you are being operated on also.
DR. W. A. RAPE, Victoria: I want to know if the doctor gives the anæsthetic in the sitting posture, or did I understand the author of the paper to say that he did not administer an anesthetic for adenoid operations in children?
DR. CLARENCE WARFIELD: I do not favor the giving of anesthetics to children for this operation.
DR. JOHN T. MOORE, Galveston: I speak from the standpoint of the general practitioner with reference to adenoids. I have enjoyed listening to Dr. Warfield's paper. I think he has chosen a very interesting subject, and it occurs to me that this subject is left too much with the specialist, and it leads me to say that we fail to recognize this condition largely because we do not make a careful examination of our patient. I have now for the last three years made it a rule to examine the nose and throat of most cases that come into my office, and in many cases I have been surprised to find adenoids that had been treated for other conditions. We, as general practitioners, are at fault when we fail to equip ourselves to make these examinations, whether we care to do this work or not. I do not agree that it belongs to the specialist, but I think he can do this work very much better than we, as he is ordinarily better qualified than the general practitioner. I do not see any reason why a well equipped prac titioner can not do this operation, and in the manner as Dr. Warfield has
described, with perfect safety, always bearing in mind the total and complete removal of these growths must be done if we want good results. I do not think that adenoids can be removed in every case in this way. There are cases in which they can not be removed with the finger; forceps or the curette must be used. It has occurred to me that the difficulty of sterilizing our fingers is an important one. Our fingers are put in all sorts of places and may become contaminated, and especially these finger nails that are allowed to grow long to act as a curette. I think that there are cases, and the specialist will agree with me, that nothing short of a complete removal, under anæsthesia, will do any good. It has been my fortune, or misfortune, to see a number of these cases where the finger was used, in which the adenoids were not completely removed. It may be, as Dr. Warfield suggests, that the treatment following the operation, in regard to astringents not being followed out, added largely to their recur
With reference to diagnosis: The general practitioner should be so well trained at the school of medicine that he attends that he can recognize these adenoids and can do the operation. He ought to be prepared to do it. I believe in sending many of our cases to the man who is doing that sort of work continually, for they can do it better than we. But let us, by all means, see that our medical schools do teach us enough so that we, as general practitioners, can make out these cases, and have them treated properly.
Warfield has chosen a very says in regard to the effect The almost immediate relief
DR. HENRY C. HADEN, Galveston: Dr. important subject for his paper. What he obtained by the removal of adenoids is true. from symptoms which often follows is seemingly marvelous.
I must, however, disagree with him as to methods of treatment of this condition. I do not believe that the pharyngeal wall can be thoroughly cleansed of adenoid tissue by curetting with the finger nail. I consider that the cases in which the growth returns are those in which it had not been originally completely removed. It is useless to depend upon astringent applications to complete its removal.
I also believe that no satisfactory operation for this purpose can be performed upon children without the use of a general anaesthetic, and that that anæsthetic should be ether. It has been shown by statistics that a great per cent of deaths from chloroform have been in those possessing adenoids, or excessive amount of lymphatic tissue.
Ether, I believe, is safe, provided it is administered by a competent anæsthetist. The patient should be thoroughly under the influence of the anæsthetic, for one is more likely to have a bad result if the patient is
permitted to recover from the influence of the ether and struggle, making it necessary to again and again to give more ether.
If the anesthetic is carefully administered, and the position of the patient is correct, the blood will not enter the larynx. The patient should be in a recumbent position, the head well thrown back and the body slightly elevated. If this precaution is observed and the throat is sponged, the blood will be made to flow through the nose and mouth. Of course it is necessary to sponge rapidly, and a good assistant is of great help. One of the objections stated to the use of a general anesthetic is that it necessitates an assistant. I consider that the advantages gained by the use of an anesthetic, and the character of the operation, warrant the employ. ment of an assistant. The choice of instruments lies in a sharp cutting one, such as the Gottstein curette, not one size alone, but three or four different sizes, and a small part of post-nasal forceps.
With a rapid movement, the central mass may be removed and as a result the patient may be relieved of all symptoms for the time. Later on, in many instances, although relieved of mouth breathing, other manifestations occur, such as excessive secretion in the vault of the pharynx, and middle ear disease. This is because of the lack of thoroughness. After the large portion of the tonsil is removed, the finger should be entered into the pharynx and search made for pieces of tissue, which may lie above the eustachian tubes, or extend down into the fosse of Rosenmüller. When located, these should be removed with one of the smaller curettes. It may be necessary to re-enter the pharynx a number of times before it is entirely clean.
I am sorry to differ so radically from Dr. Warfield, but it is not with him alone but with other men of experience, who hold the same opinion.
DR. CLARENCE WARFIELD, San Antonio: I have tried to confine myself to the title of my paper; it was "The Removal of Adenoid Tissue in Children." While we have children over three years to operate on, most of the work that I referred to was done upon children before the third year. They are brought to the specialist generally, because they complain of some suppurative condition going on in the ear, which will not stop with the ordinary home remedies that are always used. I mentioned in my paper that as they grow older, the softer mass becomes absorbed and the fibrous portion of it becomes more manifest. When you find in an adult adenoids in the naso-pharynx, you invariably find that it is of the fibrous character, and nine time out of ten you find a thick, hard mass located in front or beneath, to form the back of the posterior section of the nasopharynx. But when you take a child around the third year (between the first, third and fifth), how many times do you find a fibrous mass there? In place of such you find a soft, bloody, bleeding bunch of grape-like
tumors. I have kept a memorandum of one hundred cases in small children, and do not know in a single instance of anything that I could not remove easily with my finger without any special trouble as far as detaching the mass from the posterior wall was concerned.
I do not speak of this as though it has to be; I merely state my experience. I simply know that when you have children coming to you with suppuration of the ear, nose and throat stopped up, probably nasal discharge; if you will just take your finger, clean it thoroughly and you can clean it thoroughly, for while it is true our fingers are into everything, so are our instruments-now, just suppose you used your fingers in place of your instruments, when you are preparing for and during a delicate operation in the abdomen, where you did not desire any infection, so it is just as safe to go into the post-nasal space, and infinitely more so, as the danger of infection is not the one-hundredth part as great as in the abdominal cavity, where you have absorption going on so quickly, and where you may have to cover your original wound. If you can make your finger clean enough to go into the abdominal cavity, you can, with safety, go into the post-nasal space as I said.
I never use chloroform, and do not use it in children, because I have never had to; never had any trouble in getting thorough satisfaction, and after suppuration of the ears, when you have removed the mass, the nasal discharge and nasal turgescence in children most always cease.
I draw my conclusions from the fact that most of the patients resided here, where I could watch them and test them. There were probably one or two exceptions where I have had to remove a little of it again, and with those it has been because of not applying the astringent to contract and draw it in upon itself.
In regard to chloroform, or the use of an anesthetic; if I remove from an adult, I do not use an anæsthetic; I find that the hard fibrous mass naturally can not be removed with the finger, so use the necessary instruments with a child; however, where you find one case of a hard tumor you will find a thousand with a soft, pliable mass, and it is about children I am talking, not adults.
SECTION ON DERMATOLOGY.
CHAS. F. MASON, M. D., U. S. A.,
FORT SAM HOUSTON, TEXAS.
The term, "dhobie itch," and the diseased condition to which it. is applied constantly confront us in the tropics. The name is applied by the laity to almost any form of itching skin eruption in the axilla, groins, or upon the feet, and the word "dhobie,” which in India means "laundryman," indicates the popular belief, more or less well founded, that the disease is spread through the filthy habits of this indispensable member of society. Certainly when those habits are considered there is ground for the belief; washing the clothes as he does in cold water without boiling, and then spreading them upon the ground to dry, might seem sufficient, but in the Philippines, at least, it is not unusual for the boy to wear your underclothes a time or two before he brings them back. There are at least three distinct forms of skin disease occurring in the regions indicated, which are commonly known as dhobie itch. Two of them are mycotic, those due to the microsporon minutissimum and to the trichophyton, and one bacterial pemphigus contagiosus. These diseases are very widespread in the tropics and often cause a considerable amount of suffering and discomfort. The germs, growing on warm, moist surfaces, such as the crutch, axillæ, and feet, causes intense irritation and itching, so that especially at night the patient can not sleep; the scratching leads to abrasions, and these becoming infected, to boils and small abscesses, so that the patient often can not walk, or even dress himself. With the advent of the cool season the irritation subsides somewhat, and upon return to a cold climate the disease disappears spontane