The rhinoscopic mirror should invari ably be used, and, if its employment be conics impracticable, resort should be had to the digital method of examination, which is perfectly safe and easy, no pre vious preparation being required. Digital exploration of the cavity gives the surgeon an idea as to the situation, size, and extent of the growths and how much of the retronasal space is involved in the morbid prodess. Information is also obtained regarding the consistence of the vegetations: i.e., whether they are soft and friable or firm and fibrous. Sometimes more or less limmorrhage is induced by the examination. Certain precautions should always be observed: The finger must be rendered absolutely aseptic; this is readily done by the use of soap and water and immersion in ab solute alcohol and then in carbolized oil. In order to obviate injury to the finger by the teeth of the patient a metallic guard can be used, or, what is better still and more convenient, a piece of sterilized gauze wrapped sufficiently thick around the finger. The mouth-gag is preferred by some operators. The patient should be held and the head properly supported by an assistant.
Routine employment of palpation of the naso-pharynx recommended as supe rior, in many ways, to posterior rhinos copy. The necessary relaxation of the palate is secured by the pronunciation of the French "on." Zieni (Then Monats., Dec., '92).
If the patient is sufficiently old, a 2 or 5-per-cent. solution of cocaine, sprayed or brushed over the throat, may be used to diminish irritability. Frequently en larged faucial tonsils are present which prevent a good view of the naso-pharynx.
When this is the case the tonsils should be excised before proceeding further.
Occasionally the space between the soft palate and the posterior wall of the pharynx is so small that illumination of the cavity above becomes impossible.
Then, again, in rare instances post-nasal inspection with the mirror is facilitated by retracting the palate with a proper instrument. Yet, generally speaking, children do not tolerate such a procedure. The parts to be examined with the rhi noscopic mirror are the upper margin of the posterior nares or the, choanm, the vault and posterior of the post-nasal space. Chiefly concerned in the produc tion of the affection are the upper part of the posterior wall and the highest point of the roof. Sometimes, however, the growth occupies a position far for ward in the naso-pharynx, encroaching upon the turbinal structures.
Rosenmtiller's fossm and the spaces be tween the Eustachian cushions and the roof of the pharynx are sometimes the seats of the vegetations. Indeed, adenoid
growths in Rosennytiller's fosan exercise a greater interfering influence over the Eustachian patency than can be im agined. fnilateral deafness may be traced to this (Gibson). One of the most frequent forms of the disease to be seen by direct inspection is a cushion-shaped body generally situated in the median line of the vault, sometimes extending anteriorly toward the choanpe or poste riorly over the upper half of the pharyn geal wall. The free surface of this tumor may be smooth or corrugated. Its color, when the growth is not acutely congested, usually is a pale pink. Yet it may be intensely red.
The next variety are lobulated ina.sses separated by a central depression that sometimes makes it appear as if two dis tinct tumors were present, yet which, after removal en, masse, are found to have a common base.
.Not infrequently a number of these separate giowths are closely packed to gether and suggest the existence of but one mass. Then, again, the mucous membrane of the entire vault or of parts of the post-pharyngeal wall are studded with numerous adenoid excrescences.
The surface is never granular, though sometimes coarsely lobulated; no vessels are visible on the surface, as frequently happens with retronasal polypi. In adults, where the growths have under gone partial atrophy, they may appear as distinct excrescences studding the posterior wall, the vault, and even the lips of the Eustachian tube.
From fibrous tumors the following points serve to distinguish adenoids, viz.: (1) on rhinoseopic examination the latter are not sharply defined; (2) on palpation they feel soft. Malignant tumors in this situation are not common in any class of patients, and least so in children; they are usually associated, when soft, with frequent and violent haemorrhages, while other grave symp toms speedily ensue. ln children who show evidence of an inherited taint the possibility of adenoids should be borne in mind. P. McBride and A. Logan Turner (Edinburgh Med. Jour., May, 'US).
Occasionally bridges of tissue extend from the adenoid growths to the poste rior lip of the Eustachian tube.
This condition is invariably a source of aural disturbance. The band of tissue seems to be of the same nature as that of the lymphoid growth. In adults, in whom thc post-nasal growth has almost wholly disappeared as a result of atrophic process, lIosemniiller's fossEe still seems to be occupied by adenoid tissue.