Another interesting case was that of a young lady with severe headache in left frontal region, she was unable to breathe any through left side of nose. I first removed the middle turbinate and about fourteen days later I did a second operation. I found a growth completely filling posterior nares and adherent on all sides, I took an elevator and separated the growth all the way around and

with scissors.

The middle turbinate lies over the openings of frontal sinus, anterior ethmoid cells and maxillary sinus, and when it becomes enlarg ed, according to degree there is partial or complete loss of drainage from these cavities, and this gives rise to symptoms of from a slight full feeling to a very acute pain, and these pains are often diagnosed as eyestrain, neuralgia or sun pains. Removal of the middle turbinates provides drainage and gives patient relief if case is not of too long standing, it would seem from following case that even long standing has no effect on good results.

Man, age forty-five. history catarrh and severe frontal headache for two years, in this time bone had decayed and perforated and he had a lump half the size of a hen egg at upper and inner corner of eye. I lanced through skin and a quantity of very foulsmelling pus escaped. I kept this place open till discharge had practically ceased, and then removed his middle turbinate, opening on outside was then closed up, this was two years ago and patient has had no further trouble.

*Read before the Kentucky State Medical Association, Louisville, September 21-23, 1915.

afterward the patient returned and said she still had difficulty in breathing through her nose. I reexamined her and found another growth which I removed, it is the smaller of the two specimens shown in the bottle, and it is in reality part of the growth that I missed before, as you see growth removed at first operation is large enough that it does not look like there would be room for anything else, in fact it was so large that I could not bring it forward through nares but had to push it back into the throat, and patient expelled it through her mouth, in this case the after-re

sults were very satisfactory, patient was re

about fifteen pounds in weight.

lieved from headaches and colds, gained I find that most patients relieved of chronic cold in the head make considerable gain in weight, one gaining thirty pounds, the above-mentioned case also had some inflammation of middle ear and this also disappeared.

Another case came to me with intense pain under right eye which had been diagnosed as neuralgia, I examined nose and found enlarg

ed middle turbinate. I contracted it with co

caine and this promptly relieved trouble by giving drainage to the maxillary sinus, this patient had no more trouble, likely because his trouble was acute and brought about by exposure, and while speaking of dilatation of nose with cocaine, I wish to emphasize the necessity of a thorough dilatation of nose when making an examination, because in many cases it is impossible to tell exact condition without this. And in conclusion, on the frontal and maxillary sinuses and the anterior ethmoid cells will say that I have not had any cases so severe that removal of the middle turbinate would not relieve the trouble, and while I find that in some cases one sinus is involved worse than the others, I find when one is involved that there is more or less involvement of the others.

In speaking of posterior ethmoid cells and sphenoid sinus, I make the diagnosis by pus

coming from above middle turbinate and covering posterior wall of naso-pharynx, it is practically impossible to get at or see the sphenoidal sinus without the middle turbinate has previously been removed, and I have had but one patient whose symptoms from inflammations of these sinuses were severe, he

also had severe involvement of frontal sinus, I removed middle turbinate relieving his frontal headache but occipital headache continued till I put him on a spray of fresh silver nitrate solution, four grains to the ounce and this in a short time gave him relief.

Deflected septums are frequently the source and main cause of colds in the head, and they as a rule press against one of the middle turbinates and stop drainage from sinuses opening under it, and in this class of cases submucous resection will, as a rule, give patient relief.

The naso-pharynx gains importance under the subject of colds in the head from the fact that the openings of the Eustachian tubes are here and that a great many cases of middle ear trouble and the partial or complete deafness that sometimes result, originally started from infection introduced into the EusAlso tachian tubes from a cold in the head. the naso-pharynx in children often is full of adenoids, and the removal of adenoids is, as far as results are concerned, all that could be asked, a child will stop having a cold all the time, breathes through its nose, is brighter in school, gains in weight, and parents will say child does not look like same child.

One word in closing on vaccines. My experience has been very limited with them. The influenza bacterin for cure and prophylaxis of colds while not recommended to remove middle turbinates and correct deflected

septums, I have been unable to get any results from it in any class of cases, however, in a case of acute inflammation of the throat and soft palate, so swollen that patient could not swallow, patient suffering severe pain, temperature 102 1-2, patient kocking and spitting a very tough, tenacious phlegm, no sleep in 48 hours, I gave 20 c.c. antistreptococcic serum subcutaneously one evening and next morning patient was so much improved that he was practically well.

DISCUSSION.

Isaac Lederman, Louisville: The doctor in selecting the title of his paper has, I think, chosen wisely because the term "cold in the head" is one that the public have assumed to be of very minor importance, and which may under certain conditions and certain circumstances, as we all know, assume very serious proportions.

The doctor has also dwelt upon the condition of the middle turbinals and upon the sinuses, and in the short time at my disposal I wish to emphasizes this point only. First of all, that in practically all severe cases of acute rhinitis, socalled "cold in the head," there is involvement of the sinuses. There is involvement of the frontal sinus in the form of frontal sinusitis in a great number of cases, and there is certainly congestion in the antrum of Highmore. in a great

many more. One attack of acute rhinitis does not amount to anything as a rule. We know that it has a tendency to recover; that with or without treatment it will be relieved in a few days provided the patient's general condition and surroundings are good and the cause of the original infection has been removed. However, in a nose that has been deformed, one in which there are already hypertrophied turbinals, or in which there is a deviated septum, we are likely to get a chronic condition. We are very likely in cases of this kind to have as a

sequel of our acute rhinitis probably an abscess of the antrum which may be symptomless for a while until it is lighted up again by an acute infection, or we may have ethmoid or frontal sinus disease which may bring on future trouble. The subject of sinus discase is an important one.

Next to this is the point the doctor brought out that in all case of acute rhinitis we must look to the naso-pharynx for direct extension, and we usually have inflammation of the nasopharyngeal mucous membrane. The location of the Eustachian tubes gives us direct communication with the middle ear. Acute rhinitis or "cold in the head," so far as the disease itself is concerned, is of no particular importance except as being the cause of complications which may be serious. It is for this reason worthy of our efforts to lessen its severity and shorten its course.

S. G. Dabney, Louisville: I have enjoyed the paper of Dr. Moss very much. I think he has chosen a very attractive subject and has clearly presented it in a practical way. He has shown how little ordinarily can be expected from the use of sprays; that they do little more than act as cleansing agents in the chronic cases. If I should make my choice of nasal operations as the one most often useful I would take resection of the anterior portion of the middle turbinate bone. I have seen reflex symptoms about the cye and face relieved in that way, and it helps to promote drainage from the sinuses. It frequently gives us knowledge of the underlying cause which we would not previously have, namely, the existence of polypus or ethmoid disease.

I want to congratulate the doctor on his excellent paper and to say that I have enjoyed it very much.

Will some

President Kincaid, Catlettsburg: one be good enough to tell us what his success has been in the treatment of common colds with vaccines. We have one specialist, not far away from where I live, who is said to be curing a wonderful lot of cases with vaccines I would like to hear the experience of any member in regard to the use of these vaccines.

If there is no further discussion, I will ask Dr. Moss to close.

C. A. Moss, (Closing): I wish to thank the gentlemen for their discussions, and I will not burden you with any further remarks.

THE DISEASED TONSILS, WHAT SHALL WE DO WITH THEM?*

By C. E. PURCELL, Paducah.

one

To the average physician, no doubt, the question here asked would appear very easy to answer. In fact, each has already answered it to, at least, his own personal satisfaction. But have we answered it correctly? Have we had enough experience with the progress and evolution of tonsil surgery in its rapid advance during the last ten years to say what is productive of the most accurate diagnosis of tonsillar disease, what is the best line of procedure, operative or otherwise; and finally, what is the safe position for us to assume toward the subject to entitle us to the confidence and respect of the whole profession? There was a time when layngologists were considered an army of swobbers and sprayers, whose opinions carried little prestige with scientific men. Fortunately, that day is past. There was a time when each one could have told, with recognized authority, that all it was necessary to do was to clip off part of each tonsil with most any instrument, and the patient would become and remain permanently well. This was advised and practiced for many years. Then we had our advocates of the complete removal of tonsils, many men adding new technique and new instrumnets. This too, all appeared quite logical and in keeping with progressive surgery. It was argued that if the tonsils were diseased, that the whole should be re

moved and not a part. It was further urged that it was imperative that the operation go beyond the capsule-in other words, the tonsils should he extra-capsular tonsillectomized.

It might be of more than passing interest to inquire why the committee on program. should, from year to year, keep this question before the profession. It seems to be not only a current but a recurrent question. Those of us who do this work and see the results, for good or otherwise, know it is not only a live subject, but that there are many points unsettled and that we are working along many lines for an agreement of the solution, for we must address ourselves to the unsettled question in medicine and surgery if we are to keep up with the advance of progression. Settled scientific facts need no comment and no discussion.

Unfortunately for us, the science of medic ine and diagnosis have not reached that point where we can, in every case, say what are diseased tonsils and what are not. The success

ful and correct diagnosis of tonsillar disease is as essential to treatment and cure of this

*Read before the Kentucky State Medical Association, Louisville, September 21-23, 1915.

disease as is the diagnosis of any other trouble. Medical men, I mean scientific medical men, have from the earliest times urged the importance and necessity of correct diagnosis. Every medical man must stand on his ability to make correct diagnoses and every treat. ment-medical or surgical-must be based upon the knowledge of what is wrong. The dignified specialty of laryngology is not for those having the vision of Cyclops-one eyed. It is not for those who see and remove tonsils from every throat regardless of what other diseased conditions there may be in the upper air passage that may be, and no doubt are, causing all the symptoms which lead the patient to seek medical relief. Who of you would advise and operate on tonsils of one far advanced with pulmonary tuberculosis or of you would attempt the removal of tonsils one afflicted with tubercular laryngitis? Who in cases of diseases of the sinuses-pus in the frontal maxillary, ethmoid or sphenoid sinuses? Shall we operate if there be hypertroPhy of the tonsils or cryptic degeneration with symptoms of systemic focal infection and absorption? Have we cooperated sufficiently with the dentist and have we given sufficient attention to the alveolar process and the possible pathologic conditions associated with it, to justify our position of complete investigation when we have given our decision to operate? Many pains in the head and throat are caused by carious teeth, as well as the alveolar process.

And again, who of you would operate for tonsillar disease caused by systemic infection from tuberculosis and syphilis? Imagine the plight of one who had removed an enlarged tonsil not keeping in mind its possible malignant nature and who had not made use of the proper diagnostic measures and who had not given a guarded prognosis. And, finally, who of you would diagnose diseased tonsils and advise removal in case of enforced mouth breathing due to various causes and especially those due to hypertrophied turbinates and deviated nasal septa? These mouth-breathers have, practically all of them, chronic trouble with the throat and especially the tonsils appear to be chronically diseased.

Do you thing it reflects any credit on our profession to attack, surgically, such tonsils? And yet, we see this practiced with great frequency. Would it not be better to put aside some of this zeal and attack the causes of tonsillar disease. if it is possible to do so with discretion? The harmful effects of mouth breathing on the upper air passages is not rec

gnized, much less emphasized, by every physician. We all know that most frequently the establishing or re-establishing of sufficient

nasal respiration does away with all symptoms of throat trouble.

It is not intended in this article to point out what are and what are not diseased conditions of the tonsils. That has been fully covered in the text books and in many able articles by men everywhere. It is intended to call attention to the question in the title of the paper assigned me "What Shall We Do With Them," and it is also intended as a note of warning against the too frequent and especially the overzealous radical operations that are constantly being performed. Because there has been so much written, and especially by the lay press, about the harmful effects produced upon the child, both physically and mentally, by the presence of adenoids and tonsils, parents and their friends frequently make their own diagnosis without the advice of the layngologist. Parents should be advised to accept with great caution all that is said or written about the subject, for should we heed all of this, every child should be operated upon or become a physical, moral or mental degenerate. Understand, I do not attempt to minimize the importance of the tonsil question or the urgency or advisability of their removal when their presence is a menace to the physical or mental development of the individual. Your own experience must guide you in this direction. Because every child five and six years old has some enlargement of the tonsils does not justify the position that every child should be operated upon. The fact that a child is a habitual mouth-breather does not justify a diagnosis of enlarged tonsils and adenoids.

At the present time, the discussion of this question, without taking into consideration the possibilities of injury to the patient's voice, if tonsillar surgery be contemplated, would be very incomplete. The lymphoid tissue found in other parts of the body is similar to that of the upper air passages, though there are characteristically structural differences. Some of the most important vocal organs are in close proximity to this tissue and since this tissue varies so much during the individual's life, it is difficult to say just when it ceases to be normal and becomes abnormal and, hence normal conditions are often mistaken for diseased ones and are so treated. The voice is very necessary to physical and mental development and all surgery that ultimately injures the voice must be condemned unless such surgery be undertaken in an effort to save or conserve life. As has been pointed out, there are three different ways in which the lymphoid tissue of the upper air passages may affect the voice and have marked bearing on its development; First, its use in lubricating the pharynx; Second, its use upon the action of

the muscles employed in phonation; Third, its effect upon the resonant chambers of the voice. Therefore, in its normal condition it is an aid to the voice; but in its abnormal condition it is harmful to the voice. Now, have all the operations in the hands of all operators been free from damage to the surrounding structures? Like the observations of other men, I have also seen, in the last few years, various mutilations of the pharynx caused by the so-called tonsillectomies. Before our local society I have called attention to these mutilations, injury to the pharyngeal muscles, amputation of the uvula and irreparable injury to the soft palate, not only from cutting it unnecessarily, but by stripping the mucous membrane from it. This results from the incomplete and faulty separation of the tonsil from the pillars. Operations for the removal of tonsils and adenoids should not be looked upon as a simple procedure, as so regarded by some; but should have the same thought and care as any other major surgical operation. I have seen, as most of you, many damaged throats which would otherwise have been better had they never been touched. It requires great surgical care and delicacy of touch and manipulation to avoid the possibility of damage to the soft palate and pillars; and to operate hurriedly, blindly and entirely by sense of touch, as advocated by some, is certainly to be cautioned against. Every good operator has his own method to which there can be no objection provided the technique accomplishes the results desired and does no injury to any of the neighboring structures. My idea, personally is that we have not considered these possibilities for permanent injury, not only to the throat but to the voice, but in the future we should look with favor to those timely articles calling attention to the various defects in speech and function which may follow the faulty removal of the faucial tonsils. At different times I have advised the radical removal of tonsils as being sound surgically, but I did not then know of the possible serious complication that might follow if a technique was adopted or followed whereby innocent and unoffending structures were injured. In my own hands, dissection with the sharpest instruments gives the very best results. I have for obvious reasons avoided those instruments and methods that produce traumatism, however slight, and have had no case of sloughing or gangrene following.

Severe hemorrhage has followed the removal of tonsils. and it is a complication to he expected if one does much tonsil surgery. Every operator I have talked to about this subject, has had either primary or secondary hemorrhage. Some operators have abandoned local anaesthesia altogether and resorted to general

anaesthesia. Where this is done, secondary hemorrhage should not occur. I do not recall that I have ever had a secondary hemorrhage following general anaesthesia for all bleeding should be controlled before the patient leaves the operating room. This can be quite effectively done either by twisting the bleeding vessel or by ligation of the bleeding point. Yet, in spite of these positive measures at our command, for the control of hemorrhage and which are used by general surgeons every where, we know that secondary hemorrhage does occur and that serious complicationssloughing, aspirated pneumonia, lung abscess and prolonged convalescence often follow. For various reasons and individual peculiarities, we cannot get all patients to submit to general anaesthesia in the hospital. In the first place, it adds an extra item of expense and there are some who abhor the thought of a hospital and general anaesthesia. However, if I could always have my way, I should never undertake to operate either under local or general anaesthesia. outside of the hospital. In other words, it should be classed as both a major and a hospital operation, strictly.

Barring the bugbear of secondary hemorrhage, there are many advantages and arguments in favor of doing the operation under a local anesthetic. First, because it is more attractive to the patient; Second, because the parts are in their normal relations; and Third, because the patient can take care of his cwn secretions and the slight hemorrhage, and thus advoid of sponging. Since, in addition to the local anesthetic, it is advantageous to use some of the agents that cause blanching of the tissues and constriction of the local blood vessels, it frequently happens, that in from three to five hours. there follows free and sometimes rather profuse hemorrhage. This is caused by a temporary paralysis of the walls of the blood vessels, due to the local hemostatic drug, thus, not permitting the vessels to contract and control bleeding. While this hemorrhage may not be alarmingly serious and in my own experience, I have had no great difficulty in controlling it, nevertheless, it causes both the patient and his friends much uneasiness and alarm. These emotions of the patient add very materially to the local condition and naturally contribute to longer and more difficult control of the bleeding.

Now, therefore, having noted the tendency to secondary hemorrhage following the use of local anaesthesia and desiring to save the patient and his friends the emotions of fear of serious bleeding and also to save myself many hurried and unnecessary trips to the hospital, I have adopted and practiced the immediate suturing of the pillars, not so much to control hemorrhage, as to prevent it. In apply

ing this technique, now for more than a year, I have not had a single secondary hemorrhage. So far as I know, this plan of preventing tonsillar hemorrhage has not been advocated or practiced by any one one but myself, though suturing, to arrest tonsillar hemorrhage, has been done from the earliest times. My technique after many trials and changes, is as follows; the tonsillectomy is done with sharp dissection, care being taken to remove no muscular or other tissue, except the tonsil itself, from the fauces. After controlling the bleeding, which is usually very slight, the fibrous aponeurosis covering the tonsillar fossa, is seized with suitable forceps, raised slightly and a curved needle armed with black silk thread is passed through the elevated portion of the fossa. Then a place just opposite where the thread now is, is selected and the needle passed as before. The threads are now tied with the operator's fingers in the patient's mouth. Two sutures to each side usually suffice, and I have had the same result with only one suture to a side. The needle does not penetrate the pharyngeal muscles and therefore can cause no injury to them. The sutures are removed at the end of about fifteen hours, as they have then served their purpose, and might after this time, invite infection.

The advantages claimed for this operation are: First, it prevents absolutely, any secondary hemorrhage, but is not intended to control hemorrhage, though it could be used advantageously for that purpose. However, the many drawbacks to suturing to control bleeding, are, difficulty of placing the sutures to avoid injury to the muscles, and the great inability to see in a throat, or do anything with a patient who thinks he is bleeding to death; Second, it certainly hastens healing by approximating the pillars for even twelve or fifteen hours. If we could prevent infection altogether, it would be ideal to close up the wounds and leave them as in other surgery; Third, it gives a great sense of security and satisfaction to know and feel your patient can have no occasion to alarm either himself or you.

I realize fully that this technique complicates and lengthens the operation, but why should we object to length of time when it fully compensates us for the loss, and why should we object to the extra effort to place the sutures, even though it be difficult of performance, when we can have such perfect security? Please don't conclude from what I have said that there is only the surgical side to the tonsil question. You must keep in mind that many constitutional troubles are caused by diseases of the tonsils, which are amenable to proper therapeutics. I cannot