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The Question of Operation and After-Care
Removal by surgical operation should be adopted when adenoids produce nasal obstruction or other symptoms. After-treatment, which must be largely carried out by the parents, is of immense importance, and much detailed advice is here given on that subject. The reader should also consult the headings.
Behind the cavity of the nose there is a space, the naso-pharynx, which is continuous behind the soft palate with another space, the pharynx, or the back of the throat. In the lining of the naso-pharynx there are masses of lymphoid or adenoid tissue, a kind of tissue which also occurs in the lining of the alimentary tract, in the tonsils, the lymphatic glands, and elsewhere in the body. In the roof of the naso-pharynx there is a particularly large mass of adenoid tissue which is sometimes spoken of as a third tonsil. When these masses of adenoid tissue become infected and inflamed they swell, and it is such swellings in the naso-pharynx which constitute adenoids
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Vertical section of the mouth and nasal cavities show normal position of the pharyngeal tonsil, enlargement of which is considered adenoids.
To begin with, the swellings may be merely temporary, disappearing with the inflammation which causes them, but with chronic infection they tend to persist, and may be found as finger-like growths or as flattened bosses projecting into the naso-pharynx. Repeated attacks of inflammation are the rule, as adenoids readily inflame, and often the naso -pharynx is the seat of conatant irritation. In front of this cavity is that of the nose, and on either side is the opening of a narrow passage, the Eustachian tube, which leads up to the middle ear, that is to say, the part of the hearing organ which lies within the drum-membrane of the ear. The openings from the nose into the naso-pharynx and into the Eustachian tubes may be blocked by adenoid masses, and infection and consequent inflammation may thus extend up the Eustachian tubes and so into the inner parts of the ear.
It may result from this that a child suffering from adenoids always has a"wet" nose, and that, from the blocking of the nose, the child becomes what is known as a mouth-breather. A habit of this kind brings other evils in its train. The nose is the natural route for air entering the lungs, and the air which passes through it is, when necessary, moistened and warmed and to some extent filtered before it passes into the lower air passages; while air taken in through the mouth may be cold and dry, and may actually take up bacterial and other impurities, more especially when some of the teeth are septic. The mouth-breather is therefore liable to bronchitis and to laryngitis, or inflammation of the lining of the voice box. Also the mouth and the throat become dry and uncomfortable, and an irritating dry cough is not uncommon.
Children who are mouth-breathers do not sleep peacefully; they snore and may suffer from nightmare and night terrors. In consequence of the disturb ance of their sleep they become nervous and suffer in general health, although doubtless the swallowing of discharges and absorption into the blood of poisons from the inflamed structures play a part in impair ing an already lowered state of health.
It has already been said that inflammation may extend from the naso-pharynx up to the Eustachian tubes, which become blocked, thus leading to deafness But the effects may be more far-reaching than this. If infection reaches the ear, the result in some cases is the formation of an abscess which may discharge through the drum or may infect the bony structure (see Mastoid) round the ear. In others a non-suppurative chronic inflamma tion of the ear may ensue. In either case there tends to be impairment of hearing, of a greater or lesser degree. Amongst other disorders which may be provoked by adenoids mention may be made of asthma and bedwetting.
An ailing child as a result of neglected adenoids; and after eight months after surgical removal of the growths.
If adenoids remain untreated for several years, the child acquires a characteristic appearance. The nose looks pinched, the lower jaw hangs down, the mouth is alwaysopen, and the upper front teeth become prominent like those of a rabbit. The expression may be dull and stupid. In many cases there is a poor development of the chest. Such children do not eat well; they tend to become anemic, and frequently are ailing. At school they are in attentive, partly, no doubt, because of deafness, and they make slow progress with their studies. The presence of adenoids and the enlargement of the tonsils which usually accompanies them are said to render a child particularly liable to common colds, in fluenza, scarlet fever, diphtheria, and other infections. Adenoids certainly render ear complications more likely when such diseases are contracted. Children suffering from adenoids often have enlarged glands in the neck, and there is always a risk of tuberculosis infection in these chronically inflamed glands.
Adenoids may occur in an infant shortly after birth and may seriously interfere with suckling, but more commonly they manifest themselves between the ages of 3 and 10. In the large majority of cases they tend to wither and dis appear at the age of puberty.
When the adenoid growths are sufficiently definite to cause symptoms it is not justifiable, however, to wait for a possible natural cure, as by doing so irreparable damage may occur.

Something must therefore be attempted to cure the condition, and the earlier the better. In almost every case treat ment must consist of the removal of adenoids by surgical operation. This is a simple matter and can be done very quickly. It is also generally necessary to remove the tonsils.

Sometimes after the operation the patient vomits blood, but this need not occasion alarm, as it is usually blood which has been swallowed.
If the tonsils have been included in the scope of the operation, the throat will be painful for a little time. To relieve this, chips of ice may be sucked, and this will also help to lessen any tendency to bleeding. The diet for a day or two consists of milk, gruel and other bland liquids and semi-liquids. These should not be given very warm. The mouth should be washed out frequently with an antiseptic wash such, for example, as a weak solution of per manganate of potash or of borax. The patient remains in bed for two or three days and within doors for a few days longer, the actual time depending on the degree of recovery and on the state of the weather.
When the wounds have healed, say, in 7 or 8 days after the operation, it is necessary to begin what is called the after-treatment.
It can be said quite confidently that where the results of the removal of tonsils and adenoids have been disappointing, it has generally been because after-treatment has not been carried out at all, or only in a half hearted way.
Children who have become confirmed mouth-breathers do not necessarily begin to breathe through the nose even when an opera tion has made it quite easy for them to do so. It is necessary, therefore, to train them to breathe properly by exercises, and these may have to be kept up for weeks or even months. Much time and patience will be needed to ensure that the child breathes through the nose during the day, for the habit of mouth breathing will have become deeply engrained. Another matter which has to be attended to is the cleanliness of the nose. The treatment must not be left to the child; the mother or nurse must give it personal supervision.
Twice a day then, the patient will clean out the nose and, thereafter, for 10 to 15 minutes proceed to do breathing exercises such as those described in the opposite page. In cleansing the nose the child should stand erect, grasp the bridge (not the compressible part) of the nose with the fingers of the right hand, and after a deep breath blow down forcibly on to a piece of paper held in the left hand. This is repeated several times and the paper is afterwards burnt. The reason for insisting that the compressible part of the nose should not be held is that, if this is done, the pressure of air within the naso-pharynx is thereby increased, and infectious matter may be forced up the Eustachian tubes into the ears.
The breathing exercises should be simple, and the main thing to remember is that what counts in such an exercise is the range of expansion of the chest. Merely to throw the arms apart as in swimming has no effect in expanding the chest. Any exercise, however, which causes the patient to breathe more vigorously, skipping, for example, will improve the chest expansion. Backward skipping, the rope being turned from the front over the head, is the best.
A simple but effective exercise is to make the patient stand erect, but in an easy, un constrained attitude, with the arms stretched above the head. He must then slowly stoop as far as possible and then slowly rise. In stoop ing he empties his chest and in rising breathes in. These movements are carried out at the rate of 10 or 12 per minute for a few minutes. Then a short rest is taken, and the same exer cise is resumed or some other may be done. Some valuable breathing exercises are de scribed under that specific heading.
While any such exercise is being performed the mouth must be kept closed, and a close watch must be made to ensure that this is done. The exercises should be done in the open air or, if the weather does not permit of this, in a well-ventilated room. Clothing must be sufficiently loose to allow free movements of the chest and of the abdominal wall. Should it be found that a tendency to sleep with an open mouth persists; the lower jaw may be held up by the use of a bandage. It is often found that a tonic hastens recovery from the effects of adenoids, and a very useful one consists of a teaspoonful of cod-liver oil, or of cod-liver oil and malt, with a half to one teaspoonful of chemical food, taken thrice daily after food. A change to the seaside or to the country may also expedite recovery in many cases.
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n the first position, left, the child stands erect, feet together, hands above head. In the second position, keeping arms streatched out, slowly stooping forward and at the same time breathing through the nose. The mouth must be kept closed throughout. After the hands touch the ground, the upward movement begins, returning to the first position while inhaling through the nose with mouth closed.