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THE TREATMENT OF TONSILS AND ADENOIDS.
48 infection of this lymphatic tissue of the naso-pharynx is only one manifestation of a general loss of vitality due to defective nutrition. I am, Sir, yours faithfully, PHILIP FRANKLIN, F.R.C.S. Wimpole-street, Cavendish-square, W., Jan. 2nd, 1922.
WHAT IS THE TOXIN? To the Editor of THE LANCET. SIR,-The article which appeared in your issue of Dec. 24th, 1921, from the pen of Sir Arbuthnot Lane, dealing with the subject of respiration, raises issues which are of great interest to the biochemist and bacteriologist. Reference is made to some powerful toxin which depresses the muscles and so impairs the
movements of the thorax. One would like to know what the nature of this substance is, where it comes from, and how it acts. Does it affect the muscle fibres themselves or their associated nerves ? Is its site of action peripheral or in the central nervous system ? The common occurrence of stasis in the intestines and of putrefactive products in the urine of the patients under discussion leaves little room for doubt that the alimentary tract is the source from which the poison comes. It may arise, like the amines and ptomaines, from the decomposition of food by the bacteria of the bowel, or it may be a true bacterial toxin synthesised by the micro-organisms from the chyme. The asthenia of the muscles closely resembles that which occurs in a more acute form in enteric fever, when the small intestine is infected by B. typh08U8. This analogy suggests a solution of the mystery surrounding the toxin which we seek. When stasis persistently recurs in the ileum bacteria ascend from the caecum into the small intestine. So far as the saprophytes are concerned, the density of this invasion is in a general way proportional to the severity of the stasis. The higher the pollution spreads the greater is the putrefaction which results. Soluble organic poisons are readily absorbed through the mucosa of this part of the bowel. It would seem very natural that toxins arising in this way from an infection of the ileum with B. coli should be similar in many respects to those absorbed when the same region is infected with B. typhosus, which belongs to the same group of bacteria. Future research will determine the precise chemical nature of the poisonous substance concerned, and in the meanwhile this explanation furnishes a working hypothesis of where and how it is produced. I am, Sir, vours faithfully, N. MUTCH. Cavendish-square, W., Jan. 2nd, 1922.
THE TREATMENT OF TONSILS AND ADENOIDS. To the Editor oy THE LANCET. SIR,-According to a recent leading article in THE LANCET (Dec. ] 7th, 1921) a Council has been formed apparently to combat the opinions and deeds of those who are in the habit of operating on cases of nasal obstruction, and from the information given in this article it would appear that the necessity for the removal of tonsils and adenoids is principally in question. To one who is in the habit of removing tonsils and adenoids it would seem obvious that if the presence of these growths is causing symptoms of sufficient gravity to warrant operative interference, they should be removed. The symptoms that are undoubtedly due to this condition, leaving out the more debatable ones of epilepsy, asthma, rickets, &c., are the following - (1) Mouth-breathing ; (2) catarrhal otitis media ; (3) recurrent attacks of suppurative otitis media ; (4) chronic suppurative otitis media ; (5) palatal deformity and prominent incisor teeth ; (6) recurrent sore-throats: (7) cervical adenitis. It cannot be denied that these symptoms are due in practically all cases to the presence of enlarged and diseased tonsils and adenoids. In the last decade many discussions have taken place and many articles
have been written
tonsils, and
a
on
the
necessity for enucleating
great many methods of enucleation have
been described.
These discussions and articles have of the tonsils, but the question of adenoids has, to a great extent, been allowed to drop into the background, and adenoids are of equal, if not of greater, importance in the production of adverse symptoms. Tonsils should be removed when they cause symptoms, and it is my practice to remove them, even if they are not a source of great trouble themselves, provided the symptoms caused by the adenoids are sufficient to justify operation. It is less trouble to the operator and more satisfactory to the patient’s friends to have them removed at the same time rather than at a later period, for as Dr. Merrall has stated there is a definite tendency for tonsils to hypertrophy after operation on the adenoids alone. Now let us take the main symptoms enumerated above in order. (1) .l’J;Iouth-Breathing.-It cannot be denied that adenoids cause this symptom by mechanical obstruction, and provided that there is no other cause of nasal obstruction-e.g., deflected nasal septum, &c.removal of the adenoids must relieve this condition. Besides their mechanical effect adenoids, of course, produce nasal obstruction in other ways, by causing post-nasal catarrh and giving rise to hypertrophy of the inferior turbinates, especially the posterior ends. There is no doubt that many children with adenoids can breathe through their noses if they will make an effort, but it is a conscious effort; the child finds that it can breathe more easily with its mouth open, and consequently does so. If the cause is not removed the habit becomes permanent, and all the defects associated with ths condition are liable to follow with serious results. (2) Catarrhal Otitis ed’ta.—This is a very common symptom of enlarged tonsils and adenoids ; the infection takes place from the naso-pharynx via the Eustachian tube. The condition usually starts as an acute catarrh with an exudate of mucus into the middle ear, recurring at intervals, especially when the child is suffering from a nasal cold. If the adenoids are not removed the condition is apt to become chronic, and resulting in a certain degree of permanent deafness, and a tendency towards extreme deafness in later life. It is a matter of everyday experience that the majority of these cases are completely cured by operation, provided it is undertaken before the catarrh has had time to assume a chronic nature. (3) Recurrent A.cute Suppurative Otitis 1’ledia.-11 the remarks made above apply equally to this condition, with the added risk of a chronic suppuration which may lead to a mastoiditis or even an intracranial complication. (4) Chronic Suppurative Otitis Media.—I think it is recognised by most medical men that if tonsils and adenoids are present, their removal is the first step in the treatment of this condition in children, and a surprising number of cases dry up and heal after this has been done, even if they have hitherto resisted all forms of local treatment. (5) Palatal Deformity and Promine7zt Ineisor Teeth.The results of operation on this symptom are the least satisfactory of any, because the children are for the most part older, and the bony structure has become more permanently affected before much notice is taken of it. Several cases which have resisted the dental surgeon’s treatment havebeen referred to me for operation, and in all of them an improvement and a readier response to treatment has been noticed afterwards. If these cases are left alone in the hope that the child will grow out of it the results are often very distressing, the high arched palate and prominent incisors amounting to an absolute disfigurement; the appearance of many an otherwise good-looking child is quite spoilt by this condition. (6) Recurrent Sore-Throats.—Nearly all the sorethroats of children are due to tonsillitis, and if the tonsils are enucleated the condition obviously cannot
satisfactorily disposed
1
THE LANCET, 1921, ii., 994.
49 indicates the presence of some lymphoid thickening in the naso-pharynx. The contrary does not hold good-i.e., a large mass of adenoids may exist without any marked palatine tonsils."
properly removed do not grow appendix. again, any (7) Cervical Adenitis.-In the great majority of cases enlargement of the cervical glands is due to septic infection from the tonsil. No doubt a great many patients acquire a secondary tuberculous infection, which accounts for those cases in which the glands do not subside after tonsillectomy. Many cervical glands entirely disappear after operation, and many are improved, but there is no doubt that quite a definite percentage remain unaltered. recur.
Tonsils
once more than an
In conclusion, every throat surgeon will have noticed the enormous improvement in the general health of children after this operation-an improvement confirmed in nearly all cases by the statements of parents and medical advisers. I consider that spontaneous disappearance of symptoms does not occur if the symptoms have been of any magnitude. No doubt many children have a slight trace of adenoid tissue which gives rise to no trouble and which will disappear in time without doing any harm. In a hospital where the out-patient department greatly exceeds the inpatient accommodation children have to wait much longer than is desirable for the operation, and one rarely sees a case that does not need operation when its turn arrives, however long it has been waiting. I do not think I have overstated the case in favour of operation, and the benefits conferred by it are in such contrast to the harm done by withholding it, that I shall never hesitate to advise it in cases where, in my opinion, it is necessary, at least until it is definitely proved that the same result can be obtained with the same certainty by other means. It will be interesting to see what evidence is produced by the Council and what methods of treatment are suggested as an alternative to operation. I am, Sir, yours faithfully. F. G. WRIGLEY, M.D., Hon. Surgeon, the Manchester Ear Hospital; Aural Surgeon, the Royal Deaf Schools, Dec. 21st, 1921. Old Trafford, Manchester.
I
THE ÆTIOLOGY OF ADENOIDS. To the Editor of THE LANCET. SIR,—Your leading article on adenoids in THE LANCET of Dec. 17th, 1921, calls attention to my paper of Nov. 12th. In reference to the controversial opinions therein indicated I should like to state :1. That enlargement of the palatine tonsils has always been secondary to enlargement of the pharyngeal tonsil in the cases I have noticed of recent years-i.e., since my attention was roused to this sequence. The reverse, however, does not hold good. It is safe to assume affection of the pharyngeal tonsil in cases where the palatine tonsils are enlarged, but it cannot be argued that if the palatine tonsils are not enlarged therefore there are no adenoids. If my suggestion is correct that the pharyngeal tonsil is the first to provide the means of defence against the organisms which cause catarrh as well as against those which cause the various exanthemata, to say nothing of its possible action in providing the means of sterilisation of the inspired air, then it naturally follows that it will be the first to be overworked, and that the other members of the inner of Waldeyer’s ring of lymphatic glands will be affected secondarily. I Cervical adenitis, itself so common a symptom of adenoids, only means that the members of the outer of these rings, these first lines of defence, have been brought into action and have been overworked. But this is by no means an original observation. In that wonderful example of what a scientifictextbook should be, by Sir StClair Thomson,’there occurs :" The pharyngeal tonsil shares in all catarrhal attacks of the nose and throat, and any hypertrophy shows a marked increase after such auto-infections as measles, scarlatina, diphtheria, and whooping-cough. The discovery of the presence of enlargement of the palatine tonsils always
2. Adenoids are attended by leucocytosis and anaemia. The haemoglobin and alkalinity of the blood are less than normal. Given anaemia, there is less energy. Habits of lounging and standing with the weight mainly on one leg follow, and I think this is the cause of the flat-foot I ’so generally find in children suffering from this affection. 3. As for the curing of epilepsy, chorea, and nocturnal enuresis by operation. Epilepsy is a rare result of adenoids. I hope I am not taken to mean that epilepsy can ordinarily be cured by curetting the naso-pharynx. But I have known two bad cases of epilepsy respecting which I came to the conclusion that there was a possibility that irritation originating in the naso-pharynx might have something to do with the recurrence of the convulsions, and where operation was in each case followed by a complete cure. Chorea and nocturnal enuresis may result from the blood changes, and to quote Sir StClair Thomson again : " The blood condition has always improved after operation." Much, however, depends on the nature of the operation performed. I have a shrewd suspicion that many recurrencies of adenoids are due, firstly, to the operation not being properly completed. And this is likely to be the case when there is a difficulty with the respiration, a difficulty which I guard against by making sure that the coughing reflex is in active operation from start to finish ; and secondly, to no steps being taken by the surgeon in the way of instructions to the patient and relatives with the object of curing the habit of mouth-breathing after the completion of the operation for removal of the I am, Sir, yours faithfully, adenoids. HARRY MERRALL. Manchester, Dec. 17th, 1921.
To the Editor of THE LANCET. SIR,-Dr. Sim Wallace, usually so illuminating, gives me no help in his recent letter ; nor does Dr. Merrall. My conclusion that faulty dietetic customs are preponderatingly responsible for " adenoids " follows logically from my data, and the only way to shatter that conclusion is successfully to attack my data. This neither of these gentlemen has done. To adopt any other method of argument is merely to obscure by words what is a perfectly clear issue-the greatest danger in controversy. Let us, then, end this controversy on the aetiology of adenoids and face the logical conclusion that it is largely, at least, dietetic in origin. Of nothing am I more assured than that by feeding our children on sane lines we shall confer an immense boon on our race, and very greatly diminish the incidence of adenoids, enlarged tonsils, diseased teeth, and numerous other evils. I write as one who has given this subject constant thought for a quarter of a I am. Sir. vours faithfullv. centurv. HARRY CAMPBELL.
Wimpole-street, W., Dec. 24th, 1921.
LÆVULOSE AS A TEST FOR HEPATIC INEFFICIENCY. To the Editor
THE LANCET.
SIR,—Although we are not disposed to criticise those parts of the paper by Dr. J. C. Spence and Dr. P. C. Brett’ directly bearing on the title, as they confirm our observations on dogs, 2 we cannot let their remarks other work pass unanswered. In the first paper was entitled Some Factors Controlling the Normal Sugar Content of the Blood, since we did not wish to imply that there were no other influences At work, as there undoubtedly are. One, which we purposely did not discuss as the data available were not sufficiently definite for a decided opinion either upon
our
place, our
1
1 Diseases of the Nose and Throat, second edition, p. 319.
of
THE 2 THE
LANCET, 1921, ii., 1362. LANCET, 1921, i., 1017.
WHAT IS THE TOXIN? To the Editor of THE LANCET. SIR,-The article which appeared in your issue of Dec. 24th, 1921, from the pen of Sir Arbuthnot Lane, dealing with the subject of respiration, raises issues which are of great interest to the biochemist and bacteriologist. Reference is made to some powerful toxin which depresses the muscles and so impairs the
movements of the thorax. One would like to know what the nature of this substance is, where it comes from, and how it acts. Does it affect the muscle fibres themselves or their associated nerves ? Is its site of action peripheral or in the central nervous system ? The common occurrence of stasis in the intestines and of putrefactive products in the urine of the patients under discussion leaves little room for doubt that the alimentary tract is the source from which the poison comes. It may arise, like the amines and ptomaines, from the decomposition of food by the bacteria of the bowel, or it may be a true bacterial toxin synthesised by the micro-organisms from the chyme. The asthenia of the muscles closely resembles that which occurs in a more acute form in enteric fever, when the small intestine is infected by B. typh08U8. This analogy suggests a solution of the mystery surrounding the toxin which we seek. When stasis persistently recurs in the ileum bacteria ascend from the caecum into the small intestine. So far as the saprophytes are concerned, the density of this invasion is in a general way proportional to the severity of the stasis. The higher the pollution spreads the greater is the putrefaction which results. Soluble organic poisons are readily absorbed through the mucosa of this part of the bowel. It would seem very natural that toxins arising in this way from an infection of the ileum with B. coli should be similar in many respects to those absorbed when the same region is infected with B. typhosus, which belongs to the same group of bacteria. Future research will determine the precise chemical nature of the poisonous substance concerned, and in the meanwhile this explanation furnishes a working hypothesis of where and how it is produced. I am, Sir, vours faithfully, N. MUTCH. Cavendish-square, W., Jan. 2nd, 1922.
THE TREATMENT OF TONSILS AND ADENOIDS. To the Editor oy THE LANCET. SIR,-According to a recent leading article in THE LANCET (Dec. ] 7th, 1921) a Council has been formed apparently to combat the opinions and deeds of those who are in the habit of operating on cases of nasal obstruction, and from the information given in this article it would appear that the necessity for the removal of tonsils and adenoids is principally in question. To one who is in the habit of removing tonsils and adenoids it would seem obvious that if the presence of these growths is causing symptoms of sufficient gravity to warrant operative interference, they should be removed. The symptoms that are undoubtedly due to this condition, leaving out the more debatable ones of epilepsy, asthma, rickets, &c., are the following - (1) Mouth-breathing ; (2) catarrhal otitis media ; (3) recurrent attacks of suppurative otitis media ; (4) chronic suppurative otitis media ; (5) palatal deformity and prominent incisor teeth ; (6) recurrent sore-throats: (7) cervical adenitis. It cannot be denied that these symptoms are due in practically all cases to the presence of enlarged and diseased tonsils and adenoids. In the last decade many discussions have taken place and many articles
have been written
tonsils, and
a
on
the
necessity for enucleating
great many methods of enucleation have
been described.
These discussions and articles have of the tonsils, but the question of adenoids has, to a great extent, been allowed to drop into the background, and adenoids are of equal, if not of greater, importance in the production of adverse symptoms. Tonsils should be removed when they cause symptoms, and it is my practice to remove them, even if they are not a source of great trouble themselves, provided the symptoms caused by the adenoids are sufficient to justify operation. It is less trouble to the operator and more satisfactory to the patient’s friends to have them removed at the same time rather than at a later period, for as Dr. Merrall has stated there is a definite tendency for tonsils to hypertrophy after operation on the adenoids alone. Now let us take the main symptoms enumerated above in order. (1) .l’J;Iouth-Breathing.-It cannot be denied that adenoids cause this symptom by mechanical obstruction, and provided that there is no other cause of nasal obstruction-e.g., deflected nasal septum, &c.removal of the adenoids must relieve this condition. Besides their mechanical effect adenoids, of course, produce nasal obstruction in other ways, by causing post-nasal catarrh and giving rise to hypertrophy of the inferior turbinates, especially the posterior ends. There is no doubt that many children with adenoids can breathe through their noses if they will make an effort, but it is a conscious effort; the child finds that it can breathe more easily with its mouth open, and consequently does so. If the cause is not removed the habit becomes permanent, and all the defects associated with ths condition are liable to follow with serious results. (2) Catarrhal Otitis ed’ta.—This is a very common symptom of enlarged tonsils and adenoids ; the infection takes place from the naso-pharynx via the Eustachian tube. The condition usually starts as an acute catarrh with an exudate of mucus into the middle ear, recurring at intervals, especially when the child is suffering from a nasal cold. If the adenoids are not removed the condition is apt to become chronic, and resulting in a certain degree of permanent deafness, and a tendency towards extreme deafness in later life. It is a matter of everyday experience that the majority of these cases are completely cured by operation, provided it is undertaken before the catarrh has had time to assume a chronic nature. (3) Recurrent A.cute Suppurative Otitis 1’ledia.-11 the remarks made above apply equally to this condition, with the added risk of a chronic suppuration which may lead to a mastoiditis or even an intracranial complication. (4) Chronic Suppurative Otitis Media.—I think it is recognised by most medical men that if tonsils and adenoids are present, their removal is the first step in the treatment of this condition in children, and a surprising number of cases dry up and heal after this has been done, even if they have hitherto resisted all forms of local treatment. (5) Palatal Deformity and Promine7zt Ineisor Teeth.The results of operation on this symptom are the least satisfactory of any, because the children are for the most part older, and the bony structure has become more permanently affected before much notice is taken of it. Several cases which have resisted the dental surgeon’s treatment havebeen referred to me for operation, and in all of them an improvement and a readier response to treatment has been noticed afterwards. If these cases are left alone in the hope that the child will grow out of it the results are often very distressing, the high arched palate and prominent incisors amounting to an absolute disfigurement; the appearance of many an otherwise good-looking child is quite spoilt by this condition. (6) Recurrent Sore-Throats.—Nearly all the sorethroats of children are due to tonsillitis, and if the tonsils are enucleated the condition obviously cannot
satisfactorily disposed
1
THE LANCET, 1921, ii., 994.
49 indicates the presence of some lymphoid thickening in the naso-pharynx. The contrary does not hold good-i.e., a large mass of adenoids may exist without any marked palatine tonsils."
properly removed do not grow appendix. again, any (7) Cervical Adenitis.-In the great majority of cases enlargement of the cervical glands is due to septic infection from the tonsil. No doubt a great many patients acquire a secondary tuberculous infection, which accounts for those cases in which the glands do not subside after tonsillectomy. Many cervical glands entirely disappear after operation, and many are improved, but there is no doubt that quite a definite percentage remain unaltered. recur.
Tonsils
once more than an
In conclusion, every throat surgeon will have noticed the enormous improvement in the general health of children after this operation-an improvement confirmed in nearly all cases by the statements of parents and medical advisers. I consider that spontaneous disappearance of symptoms does not occur if the symptoms have been of any magnitude. No doubt many children have a slight trace of adenoid tissue which gives rise to no trouble and which will disappear in time without doing any harm. In a hospital where the out-patient department greatly exceeds the inpatient accommodation children have to wait much longer than is desirable for the operation, and one rarely sees a case that does not need operation when its turn arrives, however long it has been waiting. I do not think I have overstated the case in favour of operation, and the benefits conferred by it are in such contrast to the harm done by withholding it, that I shall never hesitate to advise it in cases where, in my opinion, it is necessary, at least until it is definitely proved that the same result can be obtained with the same certainty by other means. It will be interesting to see what evidence is produced by the Council and what methods of treatment are suggested as an alternative to operation. I am, Sir, yours faithfully. F. G. WRIGLEY, M.D., Hon. Surgeon, the Manchester Ear Hospital; Aural Surgeon, the Royal Deaf Schools, Dec. 21st, 1921. Old Trafford, Manchester.
I
THE ÆTIOLOGY OF ADENOIDS. To the Editor of THE LANCET. SIR,—Your leading article on adenoids in THE LANCET of Dec. 17th, 1921, calls attention to my paper of Nov. 12th. In reference to the controversial opinions therein indicated I should like to state :1. That enlargement of the palatine tonsils has always been secondary to enlargement of the pharyngeal tonsil in the cases I have noticed of recent years-i.e., since my attention was roused to this sequence. The reverse, however, does not hold good. It is safe to assume affection of the pharyngeal tonsil in cases where the palatine tonsils are enlarged, but it cannot be argued that if the palatine tonsils are not enlarged therefore there are no adenoids. If my suggestion is correct that the pharyngeal tonsil is the first to provide the means of defence against the organisms which cause catarrh as well as against those which cause the various exanthemata, to say nothing of its possible action in providing the means of sterilisation of the inspired air, then it naturally follows that it will be the first to be overworked, and that the other members of the inner of Waldeyer’s ring of lymphatic glands will be affected secondarily. I Cervical adenitis, itself so common a symptom of adenoids, only means that the members of the outer of these rings, these first lines of defence, have been brought into action and have been overworked. But this is by no means an original observation. In that wonderful example of what a scientifictextbook should be, by Sir StClair Thomson,’there occurs :" The pharyngeal tonsil shares in all catarrhal attacks of the nose and throat, and any hypertrophy shows a marked increase after such auto-infections as measles, scarlatina, diphtheria, and whooping-cough. The discovery of the presence of enlargement of the palatine tonsils always
2. Adenoids are attended by leucocytosis and anaemia. The haemoglobin and alkalinity of the blood are less than normal. Given anaemia, there is less energy. Habits of lounging and standing with the weight mainly on one leg follow, and I think this is the cause of the flat-foot I ’so generally find in children suffering from this affection. 3. As for the curing of epilepsy, chorea, and nocturnal enuresis by operation. Epilepsy is a rare result of adenoids. I hope I am not taken to mean that epilepsy can ordinarily be cured by curetting the naso-pharynx. But I have known two bad cases of epilepsy respecting which I came to the conclusion that there was a possibility that irritation originating in the naso-pharynx might have something to do with the recurrence of the convulsions, and where operation was in each case followed by a complete cure. Chorea and nocturnal enuresis may result from the blood changes, and to quote Sir StClair Thomson again : " The blood condition has always improved after operation." Much, however, depends on the nature of the operation performed. I have a shrewd suspicion that many recurrencies of adenoids are due, firstly, to the operation not being properly completed. And this is likely to be the case when there is a difficulty with the respiration, a difficulty which I guard against by making sure that the coughing reflex is in active operation from start to finish ; and secondly, to no steps being taken by the surgeon in the way of instructions to the patient and relatives with the object of curing the habit of mouth-breathing after the completion of the operation for removal of the I am, Sir, yours faithfully, adenoids. HARRY MERRALL. Manchester, Dec. 17th, 1921.
To the Editor of THE LANCET. SIR,-Dr. Sim Wallace, usually so illuminating, gives me no help in his recent letter ; nor does Dr. Merrall. My conclusion that faulty dietetic customs are preponderatingly responsible for " adenoids " follows logically from my data, and the only way to shatter that conclusion is successfully to attack my data. This neither of these gentlemen has done. To adopt any other method of argument is merely to obscure by words what is a perfectly clear issue-the greatest danger in controversy. Let us, then, end this controversy on the aetiology of adenoids and face the logical conclusion that it is largely, at least, dietetic in origin. Of nothing am I more assured than that by feeding our children on sane lines we shall confer an immense boon on our race, and very greatly diminish the incidence of adenoids, enlarged tonsils, diseased teeth, and numerous other evils. I write as one who has given this subject constant thought for a quarter of a I am. Sir. vours faithfullv. centurv. HARRY CAMPBELL.
Wimpole-street, W., Dec. 24th, 1921.
LÆVULOSE AS A TEST FOR HEPATIC INEFFICIENCY. To the Editor
THE LANCET.
SIR,—Although we are not disposed to criticise those parts of the paper by Dr. J. C. Spence and Dr. P. C. Brett’ directly bearing on the title, as they confirm our observations on dogs, 2 we cannot let their remarks other work pass unanswered. In the first paper was entitled Some Factors Controlling the Normal Sugar Content of the Blood, since we did not wish to imply that there were no other influences At work, as there undoubtedly are. One, which we purposely did not discuss as the data available were not sufficiently definite for a decided opinion either upon
our
place, our
1
1 Diseases of the Nose and Throat, second edition, p. 319.
of
THE 2 THE
LANCET, 1921, ii., 1362. LANCET, 1921, i., 1017.