In rdcr to oln int( interference with I nt structures only sufficient press ure and force must be exerted as will ex Li, t grow th and nothing more. The int t ing dge of the curette must never be Larr (10WnWard on a direct line with the it ,terior wall of the pharynx; it must 1..e Lauscd to follow the course of the circle described by the naso-pharyngeal (um,. the concavity of the blade at the completion of the operation presenting underneath the palatine arch, with the uvula appearing in the fenestrum of the st rument.
If the operation is done in the manner indicated the existent collateral vegeta tions, as those in the fosstn of Rosen midler or along the lateral walls of the naso-pharynx, which were not brought within the grasp of the curette, can be taken away with the finger-nail, the op eration being performed under the influ ence of a general ansthetic. When with out antesthesia, the naso-pharynx pre viou=ly haying been illuminated, then ITooper's post-nasal cutting forceps can be us-ed.
Preferred treatment of adenoids al most alm ays: removal by cold wire snare introduced through the nose and controlled by means of posterior rhinos copy. Thiough the nose the nares are cocainized before operation. Bleeding is slight; pain is absent or insignificant. Of 163 private cases operated on solely by the snare, 66 were cured in one sitting, 56 in tw o, 33 in three, 7 in four or five, and 1 in nine. This procedure is absolutely free from danger, causes slight bleeding, is followed by no reae tion, is free from pain, and can be ap plied under cocaine anxsthesia. Chia; i Wiener klin. Woch., June 7, '94).
New method by which the naso-phar ynx can be exposed to direct examina tion: The patient reclines on a couch with the head ell thrown back; the operator then takes hold of the tongue and instructs the person under examina tion to breathe quietly, w Idle lie intro duces a book with which the soft palate is draw n forward, at first very gently and afterward more energetically. The operator is then able to perceive the whole surface of the naso-pharynx. It is possible by employing this method (1) to operate directly, without using a mirror, on naso-pharyngeal tumors, and (2) to catheterize the Eustachian tube by the aid of direct vision. Katzen stein (Archiv fiir Laryn., Jan., Feb., '97).
Complications accompanying the "cut ting away" of adenoid tumors are: tear ing away of nmcous membrane of the pharynx; removal of the basilar apoph ysis (Castex); death from hmorrhage (Delavan and Schmiegelow); dropping of tumor into the laryngeal cavity and causing suffocation. Instances have been
reported where teeth have been broken by improper manipulation of the curette and where the cutting-blade itself was broken and pieces swallowed by the pa tient (Castex). Convulsions also have been reported as a complication of the operation. It not infrequently happens that the ablated growth is swallowed by the patient after the use of Gottstein's curette. To obviate this occurrence a device was added to the instrmnent by Delstanche by means of which the growth is held within the fenestrum, thus pre venting its dropping into the throat. Considerable bleeding usually takes place immediately after curettement, but this seldom requires special attention.
SCriCS of 1000 cases of adenoid grow ths of the pharynx operated upon by au thor. Growths removea with Gottstein's ring knife. In no case was there severe bleeding. Max Schaffer (Deutsche med. Woch., July 16, '91).
Death from convulsions after removal of adenoids in a nervous and ancemie boy, Ni hose naso-pharynx was scraped under a. 10-per-cent. cocaine solution. Sanford (La Sem. vol. ii, No. 29. '94).
The immediate dangers in operating for adenoids are (1) of entrance of blood and the formation of a clot in the larynx, thus asphyxiating the patient, and (2) of damage to the Eustachian tubes and the setting np of an otitis. To avoid the first, operamrs are content with the pre caution to keep the bead lower than rest of the body, and the face downward. Where this has been done no report of fatalities recalled. J. E. Brown (Colum bus Med. Jour., Nov. 9, '97).
Case of fatal hannorrhage from the re moval of adenoid vegetations occurring in the practice of a surgeon Ivho had often done the operation without mis hap. The patient, a boy, 12 years old, showed nothing strikingly abnormal be yond a pronounced adenoid habitus and scrofulous glands in the neck. Operation was done without aniestlicsia, and the ordinary Gottstein annular knife used. Without any warning, a sudden gush of arterial blood issued from the mouth and nose. In spite of prompt tamponing and subcutaneous and intravenous saline in jections, death occurred in a few min ntes. The internal carotid artery was found have been opened just in front of its point of entrance into the carotid canal of the pars petrosa ossis temporis. Swollen glands had probably pushed the vessel forward, so that the pressure of the knife caused its rupture, for it was not cut. Schiniegelow (Monats. f. Ohrenh., lco. 3, '97).