but feel that the medical side of the question has been neglected and in many cases overlooked. Here, as on the surgical side, we must not let our zeal outrun our discretion. Here, as on the surgical side, we must exhaust every means at our command to arrive at a correct diagnosis before we apply therapeutics. Here, as on the surgical side, we must be Argus-eyed, to avoid injury and the wrong therapeutics. As I have repeatedly urged, we must cooperate, not only with the internist, but the pathologist. We must know that all membranous deposits of the tonsils are not the same pathologically and therefore, different therapeutically. Here, as in other fields, We must not treat symptoms. Let us seek the laboratory and heed its voice, provided that voice is in accordance with the clinical findings. The tonsil question has opened up an enormous field for speculation and investigation. Someone has said, "Let us be radical when we must and conservative when we may." Let us see to it that no operation that injures and no treatment that endangers is done.

DISCUSSION.

W. B. McClure, Lexington: In the very excellent paper of the essayist, which he did not have time to finish reading, he has some questions which are not easily answered, and in the short time at my disposal I shall only address myself to one phase of the paper. It is true that in oth breathers, to remove the tonsils with hope of getting results is often beginning at the tail end. My own practice in these cases is to begin at the gateway and ascertain whether or not there be a deviated septum, hypertrophy of the middle or inferior turbinates, nasal spurs or ridges, going into the posterior nasal chamber, and whether or not there are adenoids, all of which should be eliminated before the removal of the tonsil. If it is a chronic condition of the tonsil, the probabilities are, after having corrected all these conditions, you will still have to remove the tonsil. Especially is this true if it be the so-called submerged tonsil. In these cases the tonsil will have to go, but in my judgment you should attend to the removal of other conditions which may produce the tonsillar condition.

The essayist spoke of injury to the voice. I believe he overestimates the danger of injury to the voice from the removal of the tonsils. It is a well known fact that all celebrated singers of the past have had their tonsils removed, notably Madame Patti.

S. G. Dabney, Louisville: It seems to me, that Dr. McClure misunderstood what Dr. Purcell said. I think what he meant to say was that accidents occurring in the removal of the tonsils may injure the voice. refer

C. E. Purcell,

Paducah: I had

ence to accidents occurring through a lack of proper technic in the removal of the tonsil itself.

S. G. Dabney: In regard to the question of injury to the voice, I do not think it occurs as frequently as we have been led to believe. I have seen many cases where there was a good deal of scar tissue. It is not easy to do an ideal operation in the throat as elsewhere, but fortunately I have rarely seen a serious ill result, hardly ever, even though there has been cutting of the pillar. One might imagine that it would occur in singers, but my experience has been that it is not of as frequent occurrence as some practitioners believe. If I were to sum up the indications for tonsilleetomy, I would put quinsy at the head of the list, especially where the attacks recur, and the sooner the operation is done the better it is for the patient. I would put next to quinsy, recurring attacks of tonsillitis with enlarged glands at the angle of the jaw, which are more frequent in children, but they are frequent enough in adults. Next I would put those vague systemic infections which are sometimes attended with a low grade of fever, sometimes but not always with enlargement of the cervical lymphatics, that come and go, provided no other cause can be found. The teeth or gums may also cause such disturbance.

J. F. Reynolds, Mt. Sterling: I have been very much interested in the paper of Dr. Purcell, as I am in all this subject. I do not agree with him on three or four points he has made.

First. I do not believe that systemic infection from tuberculosis and syphilis should bar as from removing diseased tonsils. In my opinion incipient and moderately advanced cases of tuberculosis always do better after the removal of these tonsils. My experience has been that the healing after the removal of a syphilitic tonsil is almost if not quite as rapid as the non-syphilitic. Second, the essayist says that he has adopted and practiced the immediate suturing of the pillars to prevent hemorrhage. This, in my opinion, is unnecessary surgery and should be discouraged by every operator.

After the surgeon has consumed thirty minutes or more in doing a tonsillectomy under general anesthesia, dissolution is near enough at hand without taking up fifteen or twenty minutes more to suture the pillars, thus increasing the danger of the life of the patient. I have not found it necessary to suture the pillars in more than onehalf of one per cent. of my cases. With a very few exceptions I have succeeded in stopping the bleeding with Boettcher's tonsil forceps. I am not in the habit of removing tonsils in children under six or seven years of age.

In young children the tonsil secretion as well as the secretions from all other glands in the throat is very great. The antitoxic properties of the tonsil secretions will protect these young children against poisons of different origin, such as the different pus-producing germs.

If this viscid secretion destroys bacteria then why should we remove the tonsil until after the patient has passed the age when he is most susceptible to the diseases of childhood.

Hypertrophied adenoid tissue should be removed from every child regardless of age even as early as the second or third week.

In young children remove the adenoids and the tonsils will take care of themselves. I do not want to be understood as being opposed to the removal of tonsils. Remove all diseased or hypertrophied tonsils after the patient has passed his seventh or eighth year. If they are not removed the time is not far distant when they will cause trouble.

I remove tonsils under both local and general anesthesia. There is always more or less danger under general anesthesia especially in staticus lymphaticus.

If you are going to have trouble under general anesthesia, you will get it when you make the first cut, therefore to be sure that the patient is ready I use strong pressure with the adenoid curette on the tonsil and in the post-nasal region. If this does not interfere with the breathing I feel safe in going on with my work. I advise my patients to have this work done under local anesthesia, though the pain is sometimes a little severe but why should they not share a part of the responsibility?

In 1902 and 1903 I removed these tonsils by tonsillectomy almost exclusively. After having had three or four troublesome hemorrhages, I abandoned the operation of tonsillectomy for several years. For the past four or five years I have been doing both tonsillotomy and tonsillectomy.

I grasp the tonsil with a tenaculum and pull it well into the pharynx, then with a pair of scissors carved at an angle of about forty-five degrees, I cur the capsule in the sub-tonsillar fossae, then pass one blade of the scissors down behind the tonsi! and the other on the outer surface behind the anterior pillar, then cut the capsule. The posterior part of the capsule is separated in the same way, then slip both blades of the scissors down behind the tonsil and dissect it out. By doing this operation I so eftaes Lave a small piece of the tonsil attached to the `over pait but this can be removed in the same panner.

Wiliam J. Thomasson, Newport: I have listened to Dr. Purcell's paper with a great interest and agree with him on many ports We admit that it is not always easy to determine the pathology of a tonsil. But in the majority of the cases that we see it is not difficult to determine the condition of the tonsils providing eare is taken in makong the examination.

It is far more difficult to find a perfectly normal tonsil than a diseased one. I doubt if there is one tonsil in ten thousand that is perfectly normal.

All tonsils should not be removed, but when this gland is diseased and when you can trace the systemic infection to foci within the ronsil or when the young child or adult has an acute otitis media, or has had tonsillitis or quinsy, then the tonsils should be removed.

Providing there is no systemic trouble that would contraindicate the operation, there is no danger of any man who knows his business removing a tonsil that is malignant nor will he operate during an acute inflammatory condition of the tonsil. Neither will he operate on a patient with active tuberculosis.

I cannot agree with the doctor that a tonsil operation can be too radical. Disrepute has been brought on this operation by the old clipping method, and in the hands of many the Beck and Sluder operation has destroyed vital tissue that not only reflects upon the operator, but the individual in many cases is worse off than before the operation.

We do not believe that our clinical experience has taught us that this operation has injured the voice, but in many instances that the singing voice has been improved, and wherever you find a case that the voice has been injured you wil! find that the operation was bungled and the pillars or soft palate has been mutilated.

Just so long as the tonsil operation is looked upon as a miner operation to be performed in the home by the general practitioner, by the general surgeon, or by the genito- urinary man, just so long can we expect the wrong tonsil to be removed at the wrong time.

E. D. Wells, Hinton, West Virginia Dr. Purcell's paper has been of more than passing interest to me because I heartily agree with him as to the importance of correct diagnosis in tonsil work, and also as to the importance of tonsil study.

Why should we not place more study on a point of entrance for infection causing diseases of such grave nature as arthritis, osteomyelitis, adenitis, chorea, otitis media, etc.

In all our study of tonsil cases we should bear constantly in mind that all tonsils are subject to the following classification: First, healthy; Second, Diseased or Surgical.

It is admitted by all that the healthy tonsil is of probable aid to health. And, also it is known that the diseased tonsil is the focus of entrance for infection causing the conditions of arthritis, osteomyelitis, adenitis, chorea, otitis media, etc., and this diseased tonsil is also spoken of as the surgical tonsil because surgery (and radical surgery at that) is the only remedy offering permanent relief.

In thinking of the diseased or surgical tonsil, please disabuse your mind of the fact that it is always the large hypertrophied tonsil. The mere fact of a tonsil being large is no cause to say it

should be removed. But there are two types of the surgical tonsil that cause most of the injurious effects. The first is the so-called submerged or buried tonsil-situated well in between the pillars and well up; in fact, about one-third of each tonsil being hid by the plica triangularis, where the plica is thickened and so adhered to tonsils and pillars as to offer a complete shield to upper third of tonsil. This tonsil, because of its high position makes pressure on the superior portion of the lymphatic ring surrounding base of tonsil and these lymphatics in turn make pressure on the Eustachian tube.

This is your type of tonsil responsible for the otitis media and cervical adenitis along with

other conditions.

The second division of the surgical tonsil is the small tonsil well bound down by adhesions to both anterior and posterior pillars-(these adhesions, of course, the result of former attacks of deep cryptic tonsillitis). These adhesions help to form deep pockets in which gather septic material, unable to drain outward, is absorbed thus establishing your focus of infection.

In regard to the question, "Would you advise the removal of tonsils in pulmonary tuberculosis?" I realize this is an open question--a question which has not received the full amount of study it deserves and, in my limited experience, I have not sufficient material to quote any per cent. of successes or failures, but in the last twelve months I have had six cases referred for examination of tonsils by specialists in pulmonary tuberculosis. In each case I found the tonsils diseased, history of repeated attacks, etc. each case I advised and did a tonsillectomy and I am glad to say there has been an improvement in each case with very marked improvement in three cases. So I must say I believe that in some cases of pulmonary tuberculosis that tonsillectomy is indicated. However, I should be very glad if Dr. Purcell would give us his reason why he advises in all cases of pulmonary tuberculosis against tonsillectomy.

In

As to the direct question "What shall we do with the diseased tonsil?" I want to say that personally, I don't believe any treatment will do any good whatever to a tonsil that has gone through repeated attacks of deep cryptic tonsil litis.

Those in favor of conservative measures, say "Why not spilt the tonsil or curette the crypts?'' Very well-but what is the result? You have scar tissue from where you split the tonsil or where you curette the crypt, and this scar tissue helps to form more pockets in which more septic material shall gather to be absorbed into the system.

But again, the conservatives say "But so many tonsils are removed upon a wrong diagnosis'allow me to answer this: Don't blame

the operation because a fault was made in diag nosis.

Let us diagnose our tonsil cases correctly as either a healthy tonsil or a diseased tonsil and remember that a tonsil once diseased from deep cryptic tonsillitis is always afterwards a diseased tonsil, and the only way of relief for a chronic, diseased tonsil is tonsillectomy.

C. E. Purcell, (Closing): If I could have finished the reading of my paper, I would have pre.. sented the method of suturing the pillars, a method not only for the control of hemorrhage, but one to prevent hemorrhage.

I had expected quite a lot of opposition from this, and perhaps it would have come if the paper had been read in full, but after trying this procedure for more than a year, and having changed the technic, so that there can be no objection to it, so that there is no deformity or impairment, or involvement of the important structures, I felt that I could present the matter to you, and if the technic I advocate is carried out, there can be no objection to the method.

As to the use of local anesthesia, I think we all realize that surgery is coming more and more to the use of local anesthesia, and if I may digress for a moment, I will prophesy that in a few years we will see more important operations done under local than under general anesthesia. It is true, some shock will follow the operation done under local anesthesia, and quite likely more shock will follow a general anesthetic. All things considered, the safety of the patient, and the freedom from any danger of the anesthetic, if the patient is old enough and brave enough to undergo the operation under local anesthesia, I think the advantages will far outweigh every other consideration.

Foreign Bodies in the Esophagus.-Ferreyra uses a urethra catheter, No. 16 or 18, and half a yard of coarse silk, No. 3 or 4. He lubricates the catheter profusely with petrolatum, and introduces it gently into the esophagus three or four times. This mobilizes the foreign body, arrests the spasm and lubricates the passages. Then he winds the silk, previously moistened, around the lower third of the catheter, that is, for about 10 cm. from the tip. The catheter and silk are then lubricated anew, and it is introduced again into the esophagus, very gently. When it is felt that the tip of the sound has passed the foreign body, he twists the catheter until he feels a slight resistance and then draws it out, having the head bent forward a little, and still keeping his forefinger in the larynx. The foreign body generally comes out at the first attempt; if not, he repeats the procedure until it does.

ROENTGEN RAY IN THE DIAGNOSIS OF BONE AND JOINT LESIONS.*

By J. B. MASON, London.

The literature on Roentgen ray in diagnosis has been so extensive recently, and advances in Roentgen ray technic so rapid, its field of usefulness so broadened, that one hesitates to speak on the subject unless he has something new, or at least, out of the ordinary to pre

sent.

The attention the subject is receiving is due to several causes, chief among which is the improved type of apparatus obtainable to-day as compared with that of a few years ago. Again, the profession has become better acquainted with its powers and possibilities, both for good and evil; they are more cautious in its use, safe-guarding both themselves and their patients from any possible harmful results that might follow its use, such as have occurred in the past.

Any bad results from a Roentgen ray examination to the patient to-day is unheard of, and should such occur, it would come as a very great surprise to the careful operator.

It is well to keep in mind at all times that it is only one method to be used in arriving at a diagnosis and no other source of information should be neglected. especially a careful history of a given case under consideration.

It is not within the scope of this paper to enter into any of the details or technic of Roentgen ray work, as this concerns the operator alone. Neither is it necessary at the present time to lay the same stress on a Roentgen ray examination as formerly, or to point out the advantages it offers to both patient and physician where such an examination is indicated, for it is recognized that it will often give us information not obtainable in any other way.

Particularly is this true of injuries about the joints where the possibility of a fracture must be kept in mind. It is the opinion of Roentgenologist, having large opportunities for observation, that the majority of injuries about the ankle and wrist joints of very marked severity, are fractures and not sprains.

The earliest use of the Roentgen ray was to diagnose fractures and locate foreign bodies, but its field of usefulness rapidly extended until it is now relied on to recognize all pathological changes taking place in the bones and joints. and what is more important, to differentiate one from the other.

This is well illustrated in a case recently

seen.

An 18 year old school girl was sent to me for an examination; she had been having trou

*Read before the Kentucky State Medica! Association, Louisville, September 21-23, 1915.

After making the diagnosis other confirmatory proofs were found.

Syphilitic bone lesions belong almost exclusively to the tertiary period, and are not. very common. We of the rural district see much less of its ravages than do our city conferee. On the other hand, we do see a very great deal of tuberculosis in all of its manifestations. This had much to do with not suspecting the true nature of the trouble earlier. The tibia, as was true in this instance, is the most frequently involved bone in these cases. The importance of a roentgenographic study in a case of suspected syphilitic osteitis can hardly be over-estimated, as in practically every instance, even though the clinical symptoms be misleading, a properly made roentgenogram. correctly interpreted, will make the diagnosis, as the bone picture is quite distinct from that seen in any other form of osteitis.

While the symptoms of fracture are well known, and they can often be diagnosed at a glance, their differentiation is not at all times easy from the symptoms obtainable alone. The profession is much more careful about making a diagnosis of sprain than formerly,

still there are cases where it is almost impos sible to arrive at a diagnosis without a roentgenogram, it does not matter how painstaking and careful you are. Unless seen early, there is usually marked swelling which tends to conceal the deformity that might be present, and crepitus is either not obtainable or often not recognized.

Such was true in the case of Mr. X., who was thrown from a buggy and sustained an injury to the left ankle. He was seen a short time after the injury by a competent physician who thought the injury a sprain. As the accident happened away from the patient's home, it was thought best to put it in a plaster cast. I did not see him until some time after the injury, when he came to me to see if we could find some reason for his continued disability, and the condition here

sent me with a suppurating elbow for examination. The history of the trouble dated back about two years; about a year previously he had had an operation by a surgeon, but had a sinus persisting. Dr. Pennington sent him to me for a roentgenogram before attempting other operative treatment. Following the usual custom of getting a two-way view of these cases, I made both a lateral and an antero-posterior view which shows a fracture of the internal condyle, (Fig. III), and the bone

FIG. III

condition as shown (Fig. IV). The operative treatment for the bone condition was carried out without disturbing the fracture and both made a satisfactory recovery.

Parker, (Journal A. M. A., Sept. 19, 1914), in reporting a fracture of the femur into an actively tuberculous knee-joint, says, "A fracture into an actively tuberculous joint can heal in a satisfactory manner, leaving only the original joint trouble for treatment, according to the usual methods pursued in such troubles." After finding the fracture in this young man, we learned that two days before consulting Dr. Pennington he had fallen from a bicycle, striking the elbow against a stone, and at the time suffered considerable pain, which accounted for his injury.

I have already referred to the use of the Roentgen ray in locating foreign bodies. This can be done with certainty and precision, pro