fever is really typhoid, and good for three or four weeks, we should not be surprised nor compelled to confess a mistake in diagnosis if it should terminate in three or four days.

Osler says the death rate is 71⁄2 per cent.; yet if a conscientious confrère should publish a list of 100 cases without one death, we should not accuse him of mendacity or ignorance, nor should we conclude that he had an unusually good plan of treatment, but rather that he happened with a series of the mild type, which hospitals seldom see.

UNUSUAL FEATURES IN THE CLINICAL HISTORY OF

ADENOID DISEASE.*

BY PRICE-BROWN, M.D.,

TORONTO.

O much has been written during the last two or three years concern

this prevalent affection mass pharynx that refrain

entirely from speaking of the etiology, pathology, and symptoms of the disease, as it usually occurs; and confine my remarks to the clinical history of a few somewhat unusual cases.

In the experience of every physician, cases of more than ordinary interest are occasionally met with, and they are, as a rule, worth recording; as they stand out like landmarks, to help to guide him in his future contest with diseases of a similar character. It is of cases such as these that I wish to speak to-day. Possibly when brought to the light of the professional experience of the members of this section they may not be unusual at all. Still, as such cases can at the most only occur occasionally a brief statement of them can do no harm; while it may have the effect of putting an unwary brother on his guard, and possibly may stimulate him. to keener investigation when opportunity occurs.

ear.

CASE I. W. D, æt. 7 years, October, 1892. Has had right otitis media catarrhalis chronica for years, accompanied by deafness of the right No history of either scarlet fever or measles. All his lifetime had been a mouth breather. On examination I found imperfect hearing also on the left side. There was almost complete absence of right drum membrane, and a large papilloma was attached to the remaining margin. On examining the pharynx the vault was found to be filled with adenoids and the faucial tonsils greatly hypertrophied. There was little doubt that the pressure upon the Eustachian tube by the pharyngeal tonsil had produced the ear disease.

Under chloroform narcosis the papilloma was removed from the auditory meatus; the adenoids taken away by digital operation; and double tonsillotomy done by Mathieu's instrument—all during one administration of the anesthetic.

* Read at the Laryngological section of the American Medical Association, Atlanta, Georgia, May, 1896.

In this case the operative work was too late to restore the hearing in the right ear, though it improved that in the left. The nasal and throat symptoms disappeared, but the cataarh of the right ear continued, though in a minor degree. After some months the case was lost sight of.

CASE 2. Miss B. R., æt. 23 years, April 6, 1893. Has been gradually becoming deaf for two years. Both ears equally affected. Cannot hear tick of a watch on either side more than half an inch from the head. Impossible to open Eustachian tube on either side by Valsalva's method, Before coming to me she had been treated professionally for deafness without any improvement; Politzer's method of inflation being usedalso daily application of ear-drops.

Examination proved the pressure of a large hypertrophied pharyngeal tonsil, filling the upper pharynx, pressing the palate forwards and producing complete nasal stenosis. The faucial tonsils in this case were not particularly large. As the adenoids were soft and lymphoid in structure, I decided to operate digitally, believing that the entire growth could be removed more effectually this way than by the use of instruments. A 15 per cent. solution of cocaine was applied freely with a post-nasal cotton holder, modifying to some extent the pain of ablation. The first operation was confined chiefly to the right half of the growth, and was accompanied by considerable hæmorrhage. The nasal stenosis was relieved, but not the deafness.

April 7. Digital operation repeated, chiefly on left side. Hæmorrhage free as before. Nasal stenosis completely removed. No immediate improvement in hearing.

April 8. While blowing the nose after breakfast, the patient heard a sharp report in left side of head; and immediately could hear the conversation going on in the room-the first time that she had been able to do so distinctly for more than a year. The hearing, however, was confined to the left side, being caused by the accidental valsalva-dilatation of the left Eustachian tube, and entrance of air into the middle ear.

The return of hearing on the right side was more gradual, each day being slightly better than on the previous one.

April 11. Removed by finger-nail the remaining remnants of the adenoid tissue. The discharges from the naso-pharynx during the healing process were aided by spraying through the nose with albolene, the patient inhaling forcibly each time that the atomizer was used.

April 22. Came last time for examination and treatment. Hearing fully restored. Could hear watch tick on either side at a distance of six feet from the ear.

CASE 3. N. J. McK., æt. 20 years, June, 1893. Has been suffering for two years from buzzing in his left ear. Had been treated profession

ally six months previously, but with little improvement. He complained particularly of the effect of his own voice, whether used in ordinary speech or in singing. He said it sounded as though the voice reached the ear through the throat on the affected side, no similar effect being produced in the right ear. He had a worried, anxious expression of face, and said that during the period mentioned he had lost much in flesh.

On examination I found the uvula elongated, and the vault of the pharynx filled with a large flattened tonsil, the left side of it being attached by a broad cicatricial band to the superior-posterior lip of the corresponding Eustachian tube, binding it backwards. There had evidently been a shrinkage of a former tonsillar hypertrophy; which, dragging on the Eustachian attachment, had produced an almost funnel-shaped form to the orifice of the tube. This unusual condition appeared to be the cause of the voice-ringing complained of.

After applying a 15 per cent. solution of cocaine, I curetted out the adenoid enlargement; and then separated the attachment to the lip of the Eustachian tube with the finger-nail. The result was that the throat voice sounds diminished, and in a few days disappeared.

Four months later the patient, being in the city, returned for examina There was improvement in facial expression and in weight, as well as tone of voice. He said the throat sounds had never returned since the time of operation.

CASE 4. A. B., æt. 5 years, September, 1894. Mouth breather, suffering from nasal stenosis, owing to the pressure of adenoids in the naso-pharynx. Faucial tonsils not materially enlarged. A professional confrère administered chloroform. Not more than half a dram had been given when respiration suddenly ceased. On forcing the mouth open, the ball of the tongue was found resting well backwards over the larynx, filling the lower pharyngeal cavity. Cyanosis developed quickly; but drawing the tongue forward with forceps, and the practice of artificial respiration, soon restored the natural breathing. The operation was then performed digitally, without any further untoward result.

CASE 5 Alice G., æt. 9 years, June, 1895. Pale, flabby, exsanguineous girl, lacking in the energy usually possessed by children of her age, not from mental hebitude, but from impoverished blood. Faucial and pharyngeal tonsils unusually large. Chloroform being administered, double tonsillotomy was performed; and then the pharyngeal tonsil removed by digital operation. There was the usual amount of hæmorrhage at the time; but it abated, and became almost nil in a few minutes.

Three hours later, while resting quietly on the sofa, hæmorrhage from the upper pharynx commenced again; and, becoming profuse, alarmed. the parents. I was sent for and arrived at the house half an hour later,

to find the bleeding gradually becoming less. Interference was not necessary, and it did not recur again. This is the only case of recurrent hæmorrhage after ablation of the pharyngeal tonsil that I have ever seen.

A few days later, when I next saw the patient, there was extensive ecchymosis of the soft palate. This went through the usual stages of such an affection, and several weeks elapsed before it entirely disappeared. This is also out of a large number of operations for the removal of adenoids, the only instance in which I have observed ecchymosis as a result of operation.

CASE 6. V. R., æt. 9 years, February, 1896. Had a severe attack of diphtheria several years ago, since which time she has suffered from irritable throat and nasal stenosis. On examination, I found both faucial tonsils irregularly enlarged, and a copious supply of adenoids in the nasopharynx. My intention was to operate first on the faucial tonsils with the galvano-cautery; and then, while still under the influence of the anesthetic, to remove the adenoids.

A physician administered chloroform by dropping it upon the gauze of an ordinary inhaler. The patient took it quietly, and with very little resistance. Not more than thirty or forty minims could have been taken when it was noticed that breathing had stopped. I at once drew forward the tongue with forceps; while my assistant, after practising inversion, commenced artificial respiration by Sylvester's method. This had to be continued for fully fifteen minutes before breathing was properly restored. By this method air was drawn into the lungs and expelled again; but the slightest cessation of the artificial means would stop the breathing and increase the cyanosis. By the end of the period mentioned natural respiration had returned. The child was still unconscious, and the galvano-cautery operation on the tonsils was at once performed. Returning sensibility seemed to be indicated by moaning, but as the administration of an anaesthetic again, chloroform at least, would at any time in the near future be a dangerous procedure, the gag was again inserted, and the adenoids also removed. There was a good deal of hæmorrhage, and the child screamed loudly during the operation; but half an hour later, when consciousness had fully returned, she said she had experienced no pain whatever, and remembered nothing but the first application of the inhaler to her face. This prolonged insensibility to pain is somewhat remarkable, when the severity of the operation and the amount of screaming are taken into consideration. The prolonged artificial respiration required to sustain life, after breathing seemed to be re-established, is also worthy of notice.

In concluding this brief history of unusual cases, differing in one. respect or another from those which we ordinarily meet with, I will close with a glance at my general methods of treatment.