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in this class of cases, the result of which under these circumstances, is always very gratifying and often truly astounding. The question is more difficult in the second class, in which free intervals alternate with the periods of nasal obstruction.

The results are: Abundant nasal or pharyngeal catarrh and impairment of hearing or attacks of earache in the advent of acute or subacute otitis media. This is a category in which hypertrophy of adenoid tissue is moderate, producing when free of catarrh, not marked nasal obstruction symptoms or others, but in which in the slightest catarrhal provocation so much congestion and engorgement occurs that for a time all the symptoms of the first class are evident. In these cases there is some difficulty in giving the correct advice in regard to operation, because the view-point of the various advisors may diametrically differ according to the time at which the little patient is seen, be it in the relatively favorable interval of grave symptoms or during the acute attack of engorgement of the adenoids along with its consequeances (profuse catarrh, earache, impaired hearing, and obstruction of the nasal passage). To be a good and impartial adviser, we should resort to a thorough digital or mirror examination and to an exact investigation of the history of the case. If we find that in addition to small adenoids, that there are repeated attacks of cold in the head with persistent catarrh, attacks of earache with or without perforation of the drum; with the presence of enlarged or painful deepseated cervical glands; with a family history of tuberculosis, we then advise the operation. Repeated attacks of transitory deafness or earache due to colds in the head or abundant catarrh, should always indicate operation.

These subacute middle ear inflammations without perforation, are often overlooked and produce, if neglected and often repeated, slow and gradual thickening of the lining mucous membranes of the middle ear, organization of the retained exudation and fixation of the drum and chain ossicles. If the above mentioned attacks are infrequent, and if the child in the meantime should enjoy good health, with free nose breathing, no sign of deafness and only some soft swelling of the adenoids in the vault of the pharynx with no suppuration, it is advisable to postpone the operation. If the attacks be often repeated, it is evident even in small sized adenoids without marked obstruction of the nasal passage, but with a tendency of the adenoid tissue to become inflamed and produce a muco-purulent or purulent discharge, we should operate in order to prevent the constant occurrence of colds, chronic pharyngeal and nasal catarrh,

reflex coughing and consequent bronchial catarrhs.

Concerning the third class of adenoids, I have only to repeat that those which do not cause any symptoms, do not require removal. We often, in the course of methodical exaшination of the upper air passages, discover a considerable amount of lymphoid tissues in the vault of the pharynx which evidently has never done any harm, just as one often sees somewhat enlarged tonsils which have never caused inconvenience. Such innocent hypertrophies one should never tamper with. On the other hand, in pharyngeal catarrh of adults we should always examine the vault of the pharynx to detect a possible diseased remainder of adenoid tissue. Reflex coughing and stringy purulent discharge dropping down and irritating the pharynx, will never cease until all the diseased adenoid tissue is removed.

Finally in regard to the question of the necessity of the adenoid operation on account of the reflex neuroses, I must confess that I have not been able to bring myself to the belief that asthma, epilepsy, enuresis and similar neuroses which have been ascribed to adenoids were really due to them.; hence I would not advise operation in small adenoids, if there are no other pathognomonic symptoms as the above mentioned reflex neuroses. If there were besides reflex neuroses, other tangible symptoms of respiratory or auditory obstruction and catarrhal symptoms, one has to explain in order to avoid disappointment, that the operation is to be undertaken for the sake of removing the obstruction which interfered with breathing, hearing, general development, but that no strict promise can be given as to the cure of the reflex neurosis.

Naturally, the improved state of health following the removal will have a sedatory influence in the neurotic condition, which causes the reflex neuroses. In regard to the diagnosis of the existence of adenoids, we never should rely upon a diagnosis "per distance," that is, drawing conclusions from the facial appearance-the adenoid's faceor the nasal obstruction, as deformities of the nose itself and of the hard palate as well as enlargement of the posterior extremities of the lower turbinated bodies, which may closely simulate the symptoms produced generally by adenoids. Before we decide for operation, we should make a thorough examination by means of a small mirror, the soft palate being lifted and pulled forward by means of a blunt hook. If this process is impossible, a thorough digital examination should be made in order to determine the extent of the adenoid tissue, especially to

what extent the upper arch of the choanae is filled, and the tube lips or Rosenmueller's fossae are covered.

Concerning the operation itself, I think that that mode is best by which the adenoids can be removed in the most thorough manner with the slightest amount of hemorrhage and with the least danger with regard to asphyxia, by dropping of adenoid fragments into the larynx. In former years I employed the German method of operating, in the sitting position with or without ethyl chloride or brom-ether narcosis. This position gives us the best opportunity to reach the pharyngeal vault with our curettes in the most favorable position, but the operation in this position must be carried out in a very short time, due to the short anesthetic. On the other hand, the hemorrhage covers the field of vision and is liable to coagulate with fragments of the adenoid and produce asphyxia. tion by dropping into the larynx.

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Especial difficulties arise when fragments of adenoids partly severed adhere to the pharyngeal wall. They must be carefully detached from the pharyngeal mucous membrane by means of a scissors. To perform the operation without an anesthetic is possible in a very few strong children if they are easily controlled and not sensitive at all, as is sometimes the case, and then the sitting position is the best. The English method is the recumbent position of the patient, the head well bent over the back of the operat ing table. Here the danger of loose adenoid fragments, or of blood entering into the larynx is excluded. However, the hemorrhage is extremely severe, due to the engorged neck and face veins, and the field of vision is covered by the blood running down, so that one cannot recognize shreds or portions of the growths adhering to the posterior wall or lateral folds of the pharynx. In recent years, therefore, I have followed the suggestion of Holmes of Cincinnati, to operate with the child lying on its left side. The left arm and shoulder being drawn back so that the former lies on the table behind its back. The right arm being grasped near the shoulder joint by an assistant on the opposite side of the table who forces that half of the shoulder girdle away from the chest, so as to secure ample breathing space. table is raised at the foot and rests upon blocks eight inches high. In this position all the blood flows out of the mouth, none getting into the larynx, and the field of vision is clear. The only drawback is, that this position does not give favorable access for the introduction of the instruments of the operator, as the latter has to be in a strained and unnatural position. I always use chloroform

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carefully, but producing a deep anesthesia, so that the reflexes of the pharynx just begin to disappear. The chief factor in this operation is thoroughness, especially not neglecting the upper arches of the choanae or Rosenmuller's fossae behind the Eustachian tube lips. Due to the difficulty of introducing instruments into these spaces adenoid tissue is apt to be overlooked, later on giving rise to an abundant secretion and suppuration of the underlined submucous tissue which is here very elastic. Loewenberg's forceps are resorted to in this locality, and in order to clean out the upper arches of the pcsterior nares, we have to apply a very slender biting forceps, inserting it through the lower meatus of the nose.

To repeat, the adenoid operation if carried out in such a manner that entirely all adenoid tissue is removed is a difficult operation. It is a fact that one-third of the patients coming to a specialist for this condition have been previously operated upon by general practitioners and there has been a recurrence. One of the most important phases, and that which is most neglected by the unskilled post-operative treatment. This cannot be begun until three days have elapsed after the operation because of the hemorrhage of the cut parts. After the lapse of three days cocaine is applied to the tissues and with a Loewenberg's forceps, any small unremoved particles may be removed with little or no pain. Nothing has so much damaged the reputation of this operation as the fact, that so often are these small particles overlooked and the patient discharged as cured. The old symptoms will arise again after a lapse of several weeks if the operation has not been successfully carried out. The parents then seek other advice, and when they are told that the operation must be performed again, it is but natural that they should exclaim, "But don't they always grow again."

I saw the other day, a case in which the operator had gone to such an extreme of thoroughness that ugly adhesions had formed in the nasal pharyngeal cavity and between the soft palate and the pillars of the fauces, the entire posterior wall resembling that of the cicatrisatide in tertiary congenital syphilis.

As to the after-treatment: I only advise injections and not sy ringing in cases of persis tent slight hemorrhages. For this injection I use normal salt solution containing 2% dioxygen, dropping it into the nares. Since my disuse of antiseptic syringing, I never have any middle ear complications. If there is to be any pus formation, it will appear the third day. To counteract this I prepare an argyrol solution to be used three times daily,

pouring in each nostril four to five drops of 5% argyrol solution. This will in all probability prevent further suppuration. In the cases of children afflicted with adenoids, the fact that they have never breathed through the nasal passages before, will make it necessary that this should be made a practice after the operation. The children should be constantly told to keep the mouth closed, and if the children do not obey strictly, some simple contrivance to keep the mouth closed should be obtained.

Breathing exercises, cold sponging of the chest and back, followed by brisk friction, games and exercises in the open air are all further aids to the establishment of the normal respiratory modus.

The breathing may also be aided by insisting upon slow, thorough and prolonged mastication, as during this act respiration becomes automatically nasal. Out of this reason Friedenburg considers the otherwise awful habit of gum chewing for children, to be used temporarily after operation, as a valuable aid in re-establishing nasal respiration.

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IT is needless for me to come before you with a defense of the Rest Treatment, for any treatment which for nearly thirty years has maintained the place in rational therapeutics, which it occupies, is its own defense. rest treatment has been adopted in all countries where progressive medicine claims attention and receives the homage due it. was evolved by S. Weir Mitchell, of Philadelphia, the Nestor of American Neurology, whose genius prompted him to the original and painstaking observations, from which was originated the rest treatment with its technique, now so universally adopted and practiced throughout the civilized world. Those of you interested in the history of medicine and especially of events which mark an epoch in the practice of medicine, will find in Dr. Mitchell's recital of the evolution of this treatment, a source of interest and of enthusiasm, such as comes to us all when we read of historical triumphs in other fields of

Read before the Tri-State Medical Society (Alabama, Georgia and Tennessee) at Chattanooga, Tenn., September 28, 1905.

progress and inquiry. Dercum, in speaking of the inauguration of the rest treatment to apply to the treatment of neurasthenia and hysteria, says: "It is difficult at this day, more than a quarter of a century after Weir Mitchell's first utterance upon this subject to appreciate the importance and the radical character of this innovation in therapeutics. In the treatment of chronic affections, as in that of acute diseases, physicians had been in the habit of relying almost exclusively upon medicines; and, when other remedies, such as massage and electricity, were employed, they were used in an independent and isolated manner. They were not incorporated as parts of any one method or plan of treatment, and, as regards rest, it is safe to say that up to the time of Mitchell, no one had had any adequate conception of its importance or of its great therapeutic power. No one had ventured to employ it in so radical a manner nor in a way involving weeks and months of continuous stay in bed. The ill effects of excessive rest, of insufficient exercise, had been vaguely recognized, but no one had attempted to combat the disadvantages of rest, to rob it of its harm by the application of corrective procedures; no one had attempted to formulate a plan of treatment in which rest should be the main therapeutic measure, rest so guarded and corrected that none of its evils, only its benefits should accrue to the patient. It is in this achievement which belongs to Weir Mitchell, an achievement which is distinctly and solely his. The rest cure is essentially a oure by physiologic methods and this alone is sufficient to give it the stamp of originality."

Now, what is meant by the rest treatment? It is a treatment founded upon the principles of rest with such adjuvants as will contribute to keep simultaneously and methodically both physical and mental factors in view, so that in restoring "fat and blood," under appropriate envirnoment, the will-loss, moral delinquency and perverted emotional states, will range of treatment is perhaps limited to the be overcome. The foregoing implies that the neurasthenic and hysterical classes of cases. This in part is true, but I have found it applicable to a wider range of cases of mental disease; so much, in fact, that I have for the past four years used it extensively in this line of practice. This mode of treatment has proven remarkably efficient in borderline mental cases, especially the mental disorders of adolesence; in serious and seen.ingly inveterate senile forms of mental disorder; in manic-depressive cases of mental disease; in melancholia, simple and mixed forms; in subacute states of delirium (amentia); in exhaustion psychoses and in habit cases.

However, the rest treatment is best known as associated with the class of cases for which it was primarily designed, viz: the neurasthenia of women in which the mental asthenia and the denutrition of the body that follows on insufficiency in the amount of food taken; these lend one another mutual support and combine in keeping up indefinitely the nervous exhaustion. Mitchell's

originality in the rest treatment, to which he modestly claims, lies in the systematic association of isolation, rest, massage, electricity and special regulation of diet or diotherapy. The success or failure of the treatment depends upon how rigidly these essentials are emphasized and insisted upon. Again, the selection of cases suitable for such treatment requires careful consideration and an accumulated experience in nervous diseases. Mitchell, himself says, regarding this last point, "It runs, indeed, the risk of being employed in cases which do not need it and by persons who are not competent, and of being thus brought into disrepute." To bring before you the technique of treatmer.t, I want to briefly touch upon the essential elements of treatment and the reasons for their adoption. Of the first importance in successfully managing a case wherein rest treatment is indicated, it is necessary that the patient be isolated from the environment in which she has generated the nervous exhaustion and where conditions even at best cannot be made suitable for proper rest treatment. Isolation or seclusion, as Mitchell calls it, must be complete. Comparative isolation is not worth the time or money spent to keep it up and only brings trouble upon all concerned in its execution and ends in the condemnation of the "rest treatment." My rule is imperative, isolation, and in explaining to the patient's friends, I liken the isolation to a splint, which when once applied correctly is not to be removed daily to see how things. are doing. No! isolation is necessary, and I quote the reason for it as explained by Mitchell-"It is needful to disentangle them (the patients) from the meshes of old habits and to remove them from contact with those who have been the willing slaves of their caprices. I have often made the effort to treat them where they have lived and to isolate them there, but I' have rarely done so without promising myself that I would not again complicate my treatment by such embarrassments." This has been my unfortunate experience and I now prefer to retire from a case, than, in a haphazard way, attempt to carry out rest treatment at home. Dr. Mitchell further says, "Once separate the patient from the moral and physical surroundings which have become part of her

life (the patient's life) of sickness, and you will have made a change which will in itself be beneficial and will enormously aid in the treatment which is to follow." This applies to that class of women, "a large and troublesome class of thin blooded emotional women for whom a state of weak health has become a long and almost, I might say, a cherished habit." For them there is often no success possible until we have broken up the whole daily drama of the sickroom, with its selfishness and its craving for sympathy and indulgence." Nor should we hesitate to insist upon this change, or not only shall we then act in the true interests of the patient, but we shall also confer on those near to her an inestimable benefit."

How true these remarks are can only be appreciated by physicians who have had to face such a problem and have attempted to care for such a case at home. I see in consultation many of these sad pictures and many of them have come under my care after exhausting every conceivable tentative measure that would put off that inevitable day when the patient's friends exhausted in strength, resolution, and depleted in purse, have come to the realization that not only must systematic and intelligent care be had for physical reasons, but moral decrepitude which is paramount must be met by forcible means. Isolation is the only way to meet that difficulty, but it must be secured under hopeful, helpful and intelligent surroundings where nurses trained to meet the exigencies of such cases can, under the physician's directions, lead these apparent hopeless invalids back to life of usefulness. The nurses function, then, is of a high order and requires character, good sense, intelligence and tact, as prerequisites for success from the nurse's standpoint. The possession of a diploma does not make a nurse for nervous and mental cases, for, in my judgment, it requires the highest order of intelligence to successfully handle a patient, condemned, as the patients claim, for six weeks or months or more isolation from the world with no one but the nurses and physicians as mediums to the outside world. No other visitors are allowed. Upon the physician rests the cultivation of will power, the sub-conscious self by hopeful and intelligent helpful suggestions and by actual demonstration at their side, the improvement and gain of their health of mind and body. The length of time isolation is to continue depends on the progress of the case, an average, I should say, of from six weeks to three or four months or more. My records of about four hundred cases will show an average stay of isolation of about two months, but

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some have remained as long as a year, some six months some four months and some six weeks. Men do not endure isolation as well

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women; first, because domestic life is not their natural habit; and second, because it is difficult to seclude them, they will break over the rules when convalescence is being established.

Rest.-The second and next importance to isolation in the success of treatment is rest. Now rest, as I understand it and as taught by Weir Mitchell, is not simply reclining on a sofa, nor sitting in an easy chair, nor simply staying in bed. This must be understood if we are to succeed in this part of the treatment; all the time remembering that success as a whole in rest treatment depends upon how intelligently each detail of treatment is carried out. Mitchell in speaking of the rest says: "Whether we shall ask a patient to walk or to take rest is a question which turns up for answer almost every day in practice." "Most often we incline to insist on exercise and are led to do so from a belief that many people walk too little and that to move about a good deal is well for everybody." Mitchell thinks that we are as often wrong as right. A good brisk walk is for well folks a tonic; the same is true for some sick folks, but if exertion gives rise to increase of trouble, to extreme sense of fatigue, to nausea, headache, eto., what are we to do? For these cases, rest, absolute rest, is necessary. Hardly a day goes by but that I meet in my consulting room or in consultation with physicians, cases of abnormal fatigue.

Cases where crdinary physiological rest does not relieve them from the very apparent exhaustion. It is evident that to advise exercise, as is too frequently done, will only add fuel to the flame, and to meet intelligently these problems we must recognize or differentiate normal from abnormal fatigue. The one is overcome by physiologic rest, the other is continuous, as the patient is as tired in the mornings, after rest in bed, as they were on retiring, and so goes the interminable story until the whole problem is realized by the physician and proper means applied to restore normal functions.

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Rest as a therapeutic measure is to be prescribed with consideration of the indications in each case. Rest is a relative term and has a wide range of application. Rest, as applied to nervous and mental cases, properly selected, means absolute rest in bed. means, first, a state of total inactivity; the patient is fed, bathed and cared for in bed. All activity is suspended; no occupation, nor reading, no writing; she must not get up nor even use her hands; in fact, she is treated

as if she were the victim of typhoid fever. This rest gives the body an opportunity to re-establish normal functions; it rests the mind, the sense, the muscles, and soothes all pains and other disturbances. With regulated diet, the very varied stomach and intestinal disturbances disappear, but in order to accomplish this and to overcome the disadvantages of inactivity, the gastro-intestinal atony, constipation and general regulation of the muscles and to insure the digestion and assimilation of food, there must be some means to aid in overcoming these serious disadvantages of rest. Disadvantages, too, upon which hinge the failure of the treatment; disadvantages which too many physicians recognize, but go no further in their endeavor to overcome them. It was here where Mitchell's originality showed forth with the genius of a true scientist and observer, when, recognizing these conditions he sought relief in the application of massage.

Massage.-Massage, too, we must remember, which he evolved to meet the special indications as found in these cases of neurasthenia, hysteria and mild mental diseases. The chief indication "was to deprive rest of its evils." For, in the intelligent application of rest, it is found that its usefulness depends upon the care and attention given to massage and electricity. Massage is a much misunderstood physiologic therapeutic measure, even today. There are comparatively few trained in massage according to the methods as evolved by Mitchell, and what passes for massage as given by many nurses, is not satisfactory in nervous and mental cases. I wish that time would permit me to go over every detail of massage manipulations, according to Mitchell's teaching. I would say it requires skill to administer massage, and it requires daily practice to attain the perfection of the art. The technique of Mitchell has a definite purpose in every movement and is free from the over-zealous activity found in Swedish movements or the crude manipulations of osteopathy. It is to be remarked that such movements have no place in the treatment of nervous people; they increase excitement, produce exhaustion. instead of ameliorating the conditions. Massage is to be given by trained graduates in the principles and practices of the art. Why massage does good is explained by Mitchell as follows: "The secretions of the skin are stimulated by the treatment of that tissue; under massage the flabby muscles acquire a certain firmness, which at first lasts only a few minutes, but which after a time is more enduring and ends by becoming permanent. The muscles are exercised

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