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in this class of cases, the result of which reflex coughing and consequent bronchial caander these ciroumstances, is always very tarrbs. gratifying and often truly astounding. The Concerning the third class of adenoids, I question is more difficult in the second have only to repeat that those which do not class, in which free intervals alternate with
cause any symptoms, do not require removal. the periods of nasal obstruction.
We often, in the course of methodical exawThe results are: Abundant pasal or phar. ination of the upper air passages, discover a yngeal catarrh and impairment of bearing or considerable amount of lymphoid tissues in attacks of earache in the advent of acute or the vault of the pharynx which evidently has subacute otitis media. This is a category never done any harm, just as one often sees in which bypertrophy of adenoid tissue is somewhat enlarged tonsils which have never moderate, produoing when free of catarrh, caused inconvenience. Such innocent hy. not marked nasal obstruction symptoms or pertropbies one should never tamper with. others, but in which in the slightest oatarrhal On the other hand, in pharyngeal catarrh of provocation so much congestion and en- adults we should always examine the vault of gorgement occurs that for a time all the the pharynx to detect a possible diseased resymptoms of the first class are evident. In mainder of adenoid tissue. Reflex coughing these cases there is some difficulty in giving and stringy purulent discharge dropping the correct advice in regard to operation, be- down and irritating the pharynx, will never cause the view-point of the various advisors cease until all the diseased adenoid tissue is may diametrically differ acoording to the time removed. at which the little patient is seen, be it in the Finally in regard to the question of the ne. relatively favorable interval of grave symp. cessity of the adenoid operation on account toms or during the acute attack of engorge- of the reflex neuroses, I must confess that I ment of the adenoids along with its conse- have not been able to bring myself to the queances (profuse catarrh, earache, impaired belief that asthma, epilepsy, enuresis and hearing, and obstruotion of the nasal pas. similar neuroses which have been ascribed to sage). To be a good and impartial adviser, adenoids were really due to them.; hence I we should resort to a thorough digital or would not advise operation in small ademirror examination and to an exact investi, noids, if there are no other pathognomonic gation of the history of the case. If we find symptoms as the above mentioned reflex neu. that in addition to small adenoids, that there roses.
If there were besides reflex neuruses, are repeated attacks of cold in the head with other tangible symptoms of respiratory or persistent catarrh, attacks of earache with or auditory obstruction and catarrhal sympwithout perforation of the drum; with the toms, one has to explain in order to avoid presence of enlarged or painful deepseated disappointment, that the operation is to be cervical glands; with a family history of tu
undertaken for the sake of removing the obberculosis, we then advise the operation. struction which interfered with breathing, Repeated attacks of transitory deafness or hearing, general development, but that no earache due to colds in the head or abundant strict promise can be given as to the cure of catarrh, should always indicate operation. the reflex neurosis.
These subacute middle ear inflammations Naturally, the improved state of health without perforation, are often overlooked and following the removal will have a sedatory in. produce, if neglected and often repeated, slow fluence in the neurotic condition, which and gradual thickening of the lining mucous
causes the reflex neuroses. In regard to the membranes of the middle ear, organization diagnosis of the existence of adenoids, we of the retained exudation and fixation of the never should rely upon a diagnosis "per disdrum and chain ossicles. If the above men- tance, that is, drawing conclusions from tioned attacks are infrequent, and if the child the facial appearance--the adenoid's facein the meantime should enjoy good health, or the nasal obstruction, as deformities of with free nose breathing, no sign of deafness the nose itself and of the hard palate as and only some soft swelling of the adenoids well as enlargenient of the posterior extremin the vault of the pharynx with no suppura
ities of the lower turbinated bodies, which tion, it is advisable to postpone the opera- may closely simulate the symptoms produced tion. If the attacks be often repeated, it is generally by adenoids. Before we decide for
. evident even in small sized adenoids without operation, we should make a thorough exammarked obstruction of the nasal passage, but ination by means of a small mirror, the soft with a tendenoy of the adenoid tissue to be palate being lifted and pulled forward by come inflamed and produce a muco-purulent means of a blunt hook.
If this process is or purulent discharge, we should operate in impossible, a thorough digital examination order to prevent the constant occurrence of
should be made in order to determine the colds, chronio pharyngeal and nasal catarrh,
extent of the adenoid tissue, especially to
what extent the upper arch of the choanae is carefully, but producing a deep anesthesia, filled, and the tube lips or Rosenmueller's so that the reflexes of the pharynx just begin fossae are covered.
to disappear. The chief factor in this operaConcerning the operation itself, I think tion is thoroughness, especially not neglectthat that mode is best by which the adenoids ing the upper arches of the choanae or Rosen. can be removed in the most thorough manner muller's fossae bebind the Eustachian tube with the slightest amount of hemorrhage lips. Due to the difficulty of introducing in. and with the least danger with regard to struments into these spaces adenoid tissue is asphyxia, by dropping of adenoid fragments apt to be overlooked, later on giving rise to an into the larynx. In former years I employed abundant secretion and suppura tion of the the German method of operating, in the sit. underlined submucous tissue which is here ting position with or without ethyl chloride or very elastio.
Loewen berg's forceps are re. brom-ether narcosis. This position gives us sorted to in this locality, and in order to the best opportunity to reach the pharyngeal clean out the upper arches of the posterior vault with our curettes in the most favora. nares, we have to apply a very slender biting ble position, but the operation in this po- forceps, inserting it througb the lower meatus sition must be carried out in a very short of the nose. time, due to the short anesthetic. On the To repeat, the adenoid uperation if carried other hand, the hemorrhage covers the field out in such a manner that entirely all adenof vision and is liable to coagulate with frag- oid tissue is removed is a difficult operation. ments of the adenoid and produce asphyxia. It is a fact that one-third of the patients tion by dropping into the larynx.
coming to a specialist for this condition have Especial difficulties arise when fragments been previously operated upon by general of adenoids partly severed adhere to the practitioners and there has been a recurrence. pharyngeal wall. They must be carefully One of the most important phases, and that detached from the pharyngeal mucous mem- which is most neglected by the unskilled brane by means of a scissors. To perform the post-operative treatment. This cannot be beoperation without an anesthetic is possible gun until three days have elapsed after the in a very few strong children if they are operation because of the hemorrhage of the easily controlled and not sensitive at all, as is cut parts. After the lapse of three days cosometimes the case, and then the sitting caine is applied to the tissues and with a position is the best. The English method Loewen burg's forceps, any small unremoved is the recumbent position of the patient, the particles may be removed with little or no head well bent over the back of the operat. pain. Nothing has so much damaged the reping table. Here the danger of loose adenoid utation of this operation as the fact that so fragments, or of blood entering into the often are these small particles overlooked and larynx is excluded. However, the hemor- the patient discharged as cured. The old rhage is extremely severe, due to the en- symptoms will arise again after a lapse of gorged neck and face veins, and the field of several weeks if the operation has not been vision is covered by the blood running down, successfully carried out. The parents tben so that one cannot recognize shreds or por- seek other advice, and when they are told that tions of the growths adhering to the poster the operation must be performed again, it is ior wall or lateral folds of the pharynx. In but natural that they should exclaim, “But recent years, therefore, I have followed the don't they always grow again." suggestion of Holmes of Cincinnati, to oper. I saw the other day, a case in which the ate with the child lying on its left side. The operator had gone to such an extreme of left arm and shoulder being drawn back so thoroughness that ugly adhesions had formed that the former lies on the table behind its in the nasal pharyngeal cavity and between back. The right arm being grasped near the the soft palate and the pillars of the fauces, shoulder joint by an assistant on the oppo. the entire posterior wall resembling that of site side of the table who forces that half the cicatrisatide in tertiary congenital syph. of the shoulder girdle away from the chest, ilis. so as to secure ample breathing space.
The As to the after-treatment: I only advise in. table is raised at the foot and rests upon jeotions and not syringing in cases of persis blocks eight inches high. In this position tent slight hemorrhages. For this injection all the blood flows out of the mouth, none I use normal salt solution containing 2% di. getting into the larynx, and the field of vision oxygen, dropping it into the nares.
Since is clear. The only drawback is, that this po. my disuse of antiseptic syringing, I never sition does not give favorable access for the have any middle ear complications. If there introduction of the instruments of the opera- is to be any pus formation, it will appear the tor, as the latter has to be in a strained and
To counteract this I prepare an unnatural position. I always use chloroform argyrol solution to be used three times daily, pouring in.eaob nostril four to five drops of progress and inquiry. Deroum, in speaking 5% argyrol solution. This will in all prob- of the inauguration of the rest treatment to ability prevent further suppuration. In the apply to the treatment of neurasthenia and cases of children afflicted with adenoids, the hysteria, says: “It is diffioult at this day, fact that they have never breathed through the more than a quarter of a century after Weir pasal passages before, will make it necessary Mitchell's first utterance upon this subjeot that this should be made a practice after the to appreciate the importance and the radical operation. The children should be con- character of this innovation in therapeutics. stantly told to keep the mouth closed, and In the treatment of chronio affections, as in if the children do not obey strictly, some sim. that of acute diseases, physicians had been ple contrivance to keep the mouth closed in the babit of relying almost exclusively should be obtained.
upon medicines; and, when other remedies, Breathing exercises, cold sponging of the such as massage and electricity, were em. chest and back, followed by brisk friction, ployed, they were used in an independent games and exercises in the open air are all and isolated manner. They were not incorfurther aids to the establishment of the nor- porated as parts of any one method or plan mal respiratory modus.
of treatment, and, as regards rest, it is safe to The breathing may also be aided by insist- say that up to the time of Mitchell, no one ing upon slow, thorough and prolonged mas. had had any adequate conception of its im. tication, as during this act respiration be- portance or of its great therapeutio power. comes automatically nasal. Out of this rea- No one bad ventured to employ it in so radi. son Friedenburg oonsiders the otherwise aw- cal a manner nor in a way involving weeks ful habit of gum chewing for children, to be and months of continuous stay in bed. The used temporarily after operation, as a valua. ill effects of excessive rest, of insufficient exble aid in re-establishing nasal respiration. ercise, had been vaguely recognized, but no
one bad attempted to combat the disadvan. tages of rest, to rob it of its barm by the ap
plication of corrective procedures; no one THE USE AND ABUSE OF THE REST had attempted to formulate a plan of treatTREATMENT.*
ment in which rest should be the main thera
peutic measure, rest so guarded and corFRANK PARSONS NORBURY, A.M.,
M.D. rected that none of its evils, only its benefits
should accrue to the patient. It is in this JACKSONVILLE, ILL.
aohievement which belongs to Weir Mitchell, Professor of Nervous and Mental Diseases, Keokuk Medi
an acbievement wbich is distinctly and solely cal College, College of Physicians and Surgeons ; Superintendent, Maplewood
bis. The rest cure is essentially a oure by Sanatorium; Neurologist Our Savior's Hospital.
physiologic methods and this alone is suffiIt is needless for me to come before you
cient to give it the stamp of originality.' with a defense of the Rest Treatment, for any
Now, what is meant by the rest treatment?
It is a treatment founded upon the principles treatment which for nearly thirty years has maintained the place in rational therapeutics,
of rest with such adjuvants as will contribute
to keep simultaneously and methodically both wbicb it occupies, is its own defense. The
physical and mental factors in view, so that rest treatment has been adopted in all coun
in restoring "fat and blood,” under appro. tries where progressive medicine claims at.
priate envirnoment, the will-loss, moral delintention and receives the homage due it. It
quency and perverted emotional states, will was evolved by S. Weir Mitchell, of Philadelphia, the Nestor of American Neurology,
be overcome. The foregoing implies that the whose genius prompted him to the original
range of treatment is perhaps limited to the
neurasthenic and hysterical classes of cases. and painstaking observations, from which
This in part is true, but I have found it ap. was originated the rest treatment with its
plicable to a wider range of cases of mental technique, now so universally adopted and
disease; so much, in fact, that I. have for the practiced throughout the civilized world. Those of you interested in the history of
past four years used it extensively in this line
of practice. This mode of treatment has medicine and especially of events which mark an epoch in the practice of medicine, will
proven remarkably efficient in borderline find in Dr. Mitohell's recital of the evolution
mental cases, especially the mental disorders
of adolesence; in serious and seen ingly invet. of this treatment, a source of interest and of
erate senile forms of mental disorder; in enthusiasm, such as comes to us all when we read of historical triumphs in other fields of in melancholia, simple and mixed forms; in
manic-depressive cases of mental disease; • Read before the Tri-State Medical Society (Alabama, subacute states of delirium (amentia); in Georgia and Tennessee) at Chattanooga, Tenn., September
exhaustion psychoses and in habit cases.
However, the rest treatment is best known life (the patient's life) of sickness, and you As associated with the class of cases for which will bave made a obange which will in itit was primarily designed, riz: the neuras. self be beneficial and will enormously aid in thenia of women in whioh the mental as- the treatment which is to follow.” This apthenia and the denutrition of the body that plies to that class of women, "a large and follows on insufficiency in the amount of troublesome class of thin blooded emotional food taken; these lend one another mutual women for wbom a state of weak health bas support and combine in keeping up indefin- become a long and almost, I might say, a itely the nervous exbaustion. Mitchell's cherished habit.” For them there is often originality in the rest treatment, to which he no success possible until we have broken up modestly claims, lies in the systematio asso. the whole daily drama of the sickroom, ciation of isolation, rest, massage, electricity witb its selfishness and its craving for symand special regulation of diet or diotherapy. pathy and indulgence." Nor should we hesThe success or failure of the treatment de. itate to insist upon this change, or not only pends upon how rigidly these essentials are shall we then act in the true interests of the emphasized and insisted upon. Again, the patient, but we shall also confer on those seluction of cases suitable for such treatment near to ber an inestimable benefit.” requires careful consideration and an accu- How true these remarks are can only be mulated experience in nervous
diseases. appreciated by physicians who have had to Mitchell, himself says, regarding this last face such a problem and bave attempted to point, 'It runs, indeed, the risk of being em. care for such a case at home. I see in conployed in cases which do not need it and by sultation muny of these sad pictures and persons who are not competent, and of being many of them have come under my care after Thus brought into disrepute.” To bring before exhausting every conceivable tentative measyou the technique of treatmert, I want to ure that would put off that inevitable day briefly touch upon the essential elements of when the patient's friends exbausted in treatment and the reasons for their adoption. strength, resolution, and depleted in purse, Of the first importance in successfully man. have come to the realization that not only aging a case wherein rest treatment is indi. must systematic and intelligent care be bad cated, it is necessary that the patient be iso. for physical reasons, but moral decrepitude lated from the environment in which she which is paramount must be met by forci. bas generated the nervous exhaustion and
Isolation is the only way to where conditions even at best cannot be meet that difficulty, but it must be secured made suitable for proper rest treatment. under bopeful, helpful and intelligent sur. Isolation or seclusion, as Mitobell calls it, roundings where nurses trained to meet the must be complete. Comparative isolation is exigencies of such cases can, under the phynot worth the time or money spent to keep it sician's directions, lead these apparent up and only brings trouble upon all con. hopeless invalids back to life of usefulness. cerned in its execution and ends in the con. The nurses function, then, is of a high order demnation of the "rest treatment.” My rule and requires character, good sense, intelliis imperative, isolation, and in explaining to gence and taot, as prerequisites for success the patient's friends, 1 liken the isolation to from the nurse's standpoint. The possession a splint, which when once applied correctly of a diploma does not make a nurse for neris not to be removed daily to see how things vous and mental ouses, for, in my judgment, are doing. No! isolation is necessary, and I it requires the highest order of intelligence to quote the reason for it as explained by Mitch. successfully handle a patient, condemned, as ell— "It is needful to disentangle them the patients claim, for six weeks or months or (the patients) from the meshes of old habits more isolation from the world with no one and to remove them from contact with those but the nurses and physicians as mediums who have been the willing slaves of their to the outside world. No other visitors are caprices. I have often made the effort to allowed. Upon the physician rests the cul. treat them where they have lived and to iso- tivation of will power, the sub-conscious self late them there, but I have rarely done so by hopeful and intelligent helpful suggeswithout promising myself that I would not tions and by actual demonstration at their again complicate my treatment by such em. side, the improvement and gain of their barrassments." This has been my unfortun. health of mind and body. The length of ate experience and I now prefer to retire time isolation is to continue depends on from a case, than, in a haphazard way, at- the progress of the case, an average, I tempt to carry out rest treatment at home. should say, of from six weeks to three or Dr. Mitchell further says, ''Once separate the four months or more. My records of about patient from the moral and physical sur- four hundred cases will show an average roundings which have become part of her stay of isolation of about two months, but
some have remained as long as a year, some as if she were the viotim of typhoid fever. six months some four months and some six This rest gives the body an opportunity to weeks. Men do not endure isolation as well re-establish normal funotions; it rests the women; first, because domestic life is
mind, the sense, the muscles, and soothes all not their natural habit; and second, because pains and other disturbances. With regulated it is diffioult to seolude them, they will diet, the very varied stomach and intestinal break over the rules when convalescence is disturbances disappear, but in order to acbeing established.
oomplish this and to overcome the disadvan
tages of inactivity, the gastro intestinal Rest.-The second and next importance to atony, constipation and general regulation of isolation in the success of treatment is rest. the muscles and to insure the digestion and Now rest, as I understand it and as taught by assimilation of food, there must be some Weir Mitchell, is not simply reclining on a means to aid in overcoming these serious dissofa, por sitting in an easy chair, nor simply advantages of rest. Disadvantages, too, upon staying in bed. This must be understood if which hinge the failure of the treatment; diswe are to succeed in this part of the treat- advantages which too many physicians recog. ment; all the time remembering that success nize, but go no further in their endeavor to as a whole in rest treatment depends upon overcome them. It was here where Mitchell's how intelligently each detail of treatment is originality showed forth with the genius of carried out. Mitchell in speaking of the a true scientist and observer, when, recognizrest says: “Whether we shall ask a patienting these conditions he sought relief in the to walk or to take rest is a question wbich application of massage. turns up for answer almost every day in prac
"Most often we incline to insist on Massage.—Massage, too, we must remem exercise and are led to do so from a belief ber, which he evolved to meet the special that many people walk too little and that to indications as found in these cases of neurasmove about a good deal is well for every- thenia, hysteria and mild mental diseases. body." Mitchell thinks that we are as often The chief indication "was to deprive rest of wrong as right. A good brisk walk is for its evils." For, in the intelligent applicawell folks a tonic; the same is true for some tion of rest, it is found that its usefulness sick folks, but if exertion gives rise to in- depends npon the care and attention given crease of trouble, to extreme sense of fatigue, to massage and eleotricity. Massage is a to nausea, headache, eto., what are we to do? muob misunderstood physiologio therapeutic For these cases, rest, absolute rest, is neces- measure, even today.
There are comparasary. Hardly a day goes by but that I meet tively few trained in massage according to in my consnlting room or in consultation the methods as evolved by Mitchell, and what with physicians, cases of abnormal fatigue. passes for massage as given by many nurses,
Cases where crdinary physiological rest is not satisfactory in nervous and mental does not relieve them from the very apparent cases. I wish that time would permit me exhaustion. It is evident that to advise ex- to go over every detail of massage manipu. ercise, as is too frequently done, will only add lations, according to Mitobell's teaching. I fuel to the flame, and to meet intelligently would say it requires skill to administer massthese problems we must recognize or differ- age, and it requires daily practice to attain entiate normal from abnormal fatigue. The the perfeotion of the art. The teobnique of one is overcome by physiologic rest, the Mitohell bas a definite purpose in every other is continuous, as the patient is as tired movement and is free from the over-zealous in the mornings, after rest in bed, as they activity found in Swedish movements or the were on retiring, and so goes the interminable crude manipulations of osteopathy. It is to story until the whole problem is realized by be remarked that such movements have no the physician and proper means applied to place in the treatment of nervous people; restore normal funotions.
they increase excitement, produce exhaustion Rest as a therapeutic measure is to be pre- instead of ameliorating the conditions. Massscribed with consideration of the indications age is to be given by trained graduates in in each case. Rest is a relative term and has the principles and practices of the art. Why a wide range of application. Rest, as ap- massage does good is explained by Mitohell plied to nervous and mental cases, properly as follows: "The secretions of the skin are selected, means absolute rest in bed. It stimulated by the treatment of that tissue; means, first, a state of total inactivity; the . under massage the flabby muscles aopatient is fed, bathed and cared for in bed. quire a certain firmness, wbiob at first lasts
. All activity is suspended; no ocoupation, nor only a few minutes, but which after a time reading, no writing; she must not get up nor is more enduring and ends by becoming pereven use her hands; in fact, she is treated manent.
The muscles are exercised