ADENOIDS, WITH A DESCRIPTION OF NEW INSTRUMENTS 
FOR THEIR EXCISION.* 
By ARTHUR G. HOBBS, M.I)., Atlanta Ga. 
A post-pharyngeal adenoid is as truly an overgrowth of 
Luscka’s tonsil as is a wart an overgrowth of a papilla of the 
epidermis. The two differ in all respects only as thecorium of 
(he skin differs from the lymphoid cushion in the pharynx 
whence each has its respective origin. The resemblance be- 
tween them may be seen in the different degrees of consistency 
that each presents, due in both cases to the rapidity of growth, 
the age, and the peculiar condition of irritation to which 
either may have been subjected. These vegetations are found be- 
tween and just posterior to the orifices of the Eustachian tubes, 
they rarely push forward enough to encroach upon the choanse 
and enter these orifices. When felt with the finger, introduced 
through the pharynx as wrell as when seen with a posterior 
rhinoscopic mirror, the mass resembles brain tissue in its con- 
si Lency and in its furrowed surface. While it is a so-called 
hypertrophy it is but little like the hypertrophies that-we en- 
counter elsewhere, except in long existing cases, and in older 
subjects than it is ordinarily found. In such cases the growth 
is comparitively small and does not obstruct breathing to any 
*Read before the “Tri-State Medical Association,” October, 1894, in 
Atlanta. 2 
Adenoid*, and New Adenoid Force})*. 
great extent although it may decidedly alter phonation and 
cause a dead or muflled voice-tone. By common consent an- 
other name is usually applied to this particular condition viz: 
—hypertrophy of the pharyngeal, third, or Luscka’s tonsil. 
This is, however, a distinction without a real difference. It is 
this form of adenoid growth that in so many ways resembles a 
verruca. 
Nothing is definitely known as to the cause of adenoid 
growths, unless an hereditary tendency, as a predisposing cause 
together with often-recurring colds as the excitant, can be re- 
garded as a satisfactory etiology. They occur much more fre- 
quently in children, and often in such cases disappear spon- 
taneously when the subject has nearly or quite reached maturity 
still it is not a rare occurrence to find them in young adults or 
even in those who have reached middle age. 
The diagnosis is easy, indeed by exclusion, the nature of the 
growth and character can always be reached. Digital examin- 
ation is the surest means in al) cases, but particularly so in 
children where posterior rhinoscopy is often impossible. The 
finger finds a mass in the superior pharynx that is yielding 
and gelatinous, with a furrowed surface that imparts somewhat 
of a wormy feeling, except in older subjects where the growth 
has undergone fibrous changes when the finger detects consid- 
erable hardness. 
Posterior rhinoscopic examinations will often reveal the con- 
dition in this post-palate space perfectly, but it can rarely be 
successfully used with young children. Anterior rhinoscopy 
will occasionally reveal the growth, but as a rule the turges .ice 
of the turbinates which exists as one of the many sequela*, will ob 
struct the view through the nose. The diagnosis is, however, usu- 
ally so easy when we consider the age of the patient, the deafness, 
the open mouth, the vacant expression of the face, the retarded 
chest development, the small ala*, the inability to blow the nose, 
together with the history of snoring or difficult sleep-breathing Arthur G. Hobbs, M.D. 
3 
that a farther examination, by touch or vision, is necessary 
only to confirm an opinion already formed, and to discover the 
extent, the situation of the vegetations and the probable 
sequela?. An examination by sight or touch may be necessary 
to exclude polypi, which are mostly confined to adults ; or post- 
nasal abscesses, not often seen in children ; or bony growths, 
rarely found at this time of life; or foreign bodies such as but- 
tons, beans, etc., thrust into the nostrils by young children. 
To glance at the child and" hear his nasal tone is often suffi- 
cient to form a measurably sure diagnosis. On the other hand, 
it does not always follow that the child has adenoids, because 
he snores and keeps his mouth open, and is constantly enjoined 
by his mother to close the mouth and blow the nose, etc., as 
catarrhal tumefactions of the turbinates with enlarged tonsils 
may be the cause. In either case the treatment that succeeds 
in restoring an opening to the nature’s normal breathing space 
—the nasal cavity—and thus enables its large mucous mem- 
brane surface, in an adult about thirty-six square inches— 
to perform its double functure of supplying moisture and 
warmth to the inspired air, will accomplish good results in 
many ways that are often-times unexpected. 
Coincident and sequelse symptoms may be revealed by 
physical examinations, such as lymphoid granulations of the 
pharynx and tonsils; a general catarrhal condition of all the 
nasal and throat mucous membranes ; middle ear inflammations, 
either from direct pressure on the orifices of the Eustachian 
tubes or from extention of the inflammation by continuity to 
the middle ear. More or less deafness often results, whether it 
be due to the direct pressure of the growth on the orifices, or to 
the inflammatory extension through the tubes to the drum, and 
in some cases, though not often, when the result is a suppura- 
tion and bursting of the drum membrane. 
In the treatment of adenoid vegetations it has not seemed to 
me an absolute necessity to make a complete and thorough 4 
Adenoids, and New Adenoid Forceps. 
excision, although that end should always be accomplished if 
possible. A thorough removal is more to be desired in Eus- 
tachian tube and middle ear complications than when a nasal 
stenosis is the chief symptom. Atrophy of a small remaining 
portion of the mass will usually follow the operation that has 
decidedly interfered with its blood supply. 
It w'as my first intention, to speak only of the treatment of 
adenoids and describe the new instruments made for me by the 
Tiemanns, of New York, for their excision, but at the request of 
the President I have added what 1 .have just read. The me- 
chanism of these instruments, which I shall presently discribe 
has rarely, if ever, been applied before to surgical instruments. 
Lenox Brown advocates the use of the finger nail, or the 
gouge-shaped thimble. In using either, there is danger of 
detached pieces falling into the larynx as the pressure of the 
fingers upon the root of the tongue prevents the reflex resistence 
that would otherwise guard against such an accident. Gott- 
stein’s large ring curette is popular with many, especially in 
England and Germany. Griffin's malleable shank curretto 
which is much smaller than Gottstein’s is more popular in this 
country, and I think justly so. Bosw’orth’s rigid shank is per- 
ferable but not so generally adaptable, nor is it so safe in the 
hands of a novice. Meyer, who has the honor of first describ- 
ing adenoid vegetations and how to excise them, uses a ring 
shaped knife through the anterior nares, which means is resort- 
ed to now by some operators. .Justi and Hartmann have each 
their own particular side-to-side curettes which they apply 
through the mouth. Voltolini was, for a long time, partial to 
electric wire loop inserted beneath the palate; a very effective 
means but one involving ’considerable trouble and not now 
much used. ~ Blake’s operation through the anterior nares with 
the cold wire* has recently been’extolled by Chiari, of Vienna, 
who 'has used it to his own satisfaction in over 'two hundred 
cases. 1 have used Blake’s method in about sixteen to twenty Arthur G. ITobhs. M.D. 
5 
cases with some—even much—satisfaction as to the results, but 
have always chosen the cases suitable for its use. In no case 
have I ever tried it in a child with small nares, nor indeed on 
any subjects where I could not see the mass through the nares 
with a strong electric light. Gibbon’s adenotome—a guillotine 
in principle—would possibly not prove as successful in other 
than its author’s hands. Loenberg and Michael prefer forceps 
with bullet shaped jaws. Guillian’s, is somewhat simular 
to the preceding forceps, except it has horizontal cartrige- 
shaped jaws. Gleitzman’s forceps, and also Elsburgs, have 
been more popular in Germany, France and England than in 
this country. The Hodge forceps one of the few with fenestrse 
has not proven popular on account of the length of its blades, 
straightness of its handle, and smallness of the fenestrse, to- 
gether with its narrow uvula space. 
•I will not attempt to mention the many other valuable instru- 
ments that have been used in this operation. Notwithstanding 
their large number and variety, it would seem that no one in- 
strument has yet gained any decided preponderance of favor. 
The very nature of these cases, affording as they do, so many 
ways of being reached, and giving such brilliant results when 
successfully removed, is calculated to develop an individuality 
in the practiced operator. May I use this reason as my excuse 
for describing the two instruments below? 
The adenoid forceps as illustrated has a hinge and spring 
mechanism (B. B. & 0.) not generally applied to surgical in- 
struments. The obtuse angle at (B B) removes the hand below 
the line of vision when grasping the handle, and the space at 6 
Adenoid*, and Xew Adenoid Forceps. 
(D) allows the uvula to drop through and save it from con- 
tusion. The bladesat(C) (drawn too small in the illustration) 
have olive shaped edges, not sharp but sufficiently acute to pass 
through adenoid tissue. The object of the fenestrrc in the 
cupped jaws is to allow the soft tissues to be squeezed through 
and admit of a complete approximation of their edges. This 
obviates a tearing downward pull, and hence adislodgment of 
the instrument. With this advantage, several grasps at the 
growth may be made at one sitting, perhaps as many as may be 
necessary for the removal of the whole mass. The blades are 
so shaped lhat they will only grasp redundant and protruding 
tissue, hence the comparative safety of the instrument, even in 
the hands of a novice, or in other hands* when used without 
sight. The instrument may easily be inverted and used as in- 
ferior pharyngeal forceps, and on account of the short curve at 
(D) it is often better adapted to laryngeal purposes than the 
commonly used alligator forceps (Mackenzie’s) with its long 
curve. The makers will reverse the angle of the handle, when 
desired, for this purpose, or vary the form and shape of the 
blades from their model as illustrated. 
By a few turns of the screw at (0) the blades can bedetached 
in order to render them aseptic. The instrument is beautifully 
made by the Tiemanns, of New York, 107 Park Row. 
The small nasal or naso-adenoid forceps as illustrated, was 
designed to take many of the places now occupied by the Alli- 
gators, by supplying from eight to twelve times the power, 
and at the same time occupying no more space for small cavity 
operations. The mechanism (0 B) consists of a spring handle, Arthur G. Hobbs, M.D. 
7 
the upper part of which is rigidly joined to the upper shaft at 
an angle of forty-five degrees, while the lower part moves by a 
pivot through a curved slot in the lower shaft at their junction. 
The adaptation of this principle to surgical instruments is as 
new as was the alligator principle not many years ago. The 
jaws at (D) admit of even a greater variety of shapes, and in- 
deed the many times greater strength of this instrument, while 
its size is no larger, inspires a confidence in the operator that he 
could not feel while using the weaker alligator instrument. 
The downward turn of the handle (0 to B) removes the hand 
from the line of vision, and the thumb catch at (A) holds the 
jaws (D) firmly together without the fear of breaking or even 
of springing. The shank is made long enough to reach adenoid 
tissue through the anterior nares when desired. The instru- 
ment may be used as a needle holder when properly groved ; its 
jaws may be made with teeth for tearing; with sharp oval edges 
for cutting; vulsellum formed for using as tentacles; scissors 
shaped for clipping; with wedge and fenestra (Rongeur) for 
nipping; duck-billed for seizing; or indeed the jaws may be 
shaped to serve almost any conceivable purpose. 
While the instrument is modeled by the Tiemann’s, of New 
York, in the shape illustrated, this House will furnish it with 
jaws in any form, and still retain its strong and characteristic 
mechanism. 
[For want of space the proper heading for the department to which this 
paper belongs could not be inserted.—Editor,]