SANITORIA AND THE PUBLIC HEALTH.

The statement has frequently been made that sanitoria for the treatment of those suffering from tuberculosis are of value, but that up to a comparatively recent date their value has been somewhat exaggerated. The sanitorium is needed in the fight against tuberculosis, but it is only one factor and probably not the most important. In the Canadian Public Health Journal, April, 1913, is a paper by W. B. Kendall, physician-in-chief of the Muskoka Cottage Sanatorium and the Muskoka Free Hospital for Consumptives, in which is discussed the value of sanatoria from the standpoint of public health. It is rightly shown that a person suffering from a communicable disease is a source of danger to the community, and as ignorance is possibly the greatest predisposing cause of any disease, it is at once necessary and important that sick persons should be taught, and this with all promptness and thoroughness. It is in this regard that sanatoria are of the greatest possible importance to the patients as well as to the general public.-Med. Record.

THE RESULTS OF TONSILLECTOMY UNDER LOCAL ANESTHESIA.

Dr. Bryan DeForest Sheedy, in an interesting paper under above caption, read at the meeting of the American Medical Association, June 17 to 21, says:

All of the one hundred cases reported upon by the author were examined several months after operation and no patient under fourteen years of age was operated upon under local anesthesia. There was no grouping of the patients examined as to whether the throat conditions were the result of operation under local or general anesthesia. The enucleation of the tonsils had been performed by some one of the

many methods in vogue for the last few years for the complete removal of the gland and as the operations were performed in practically all the public institutions in New York City, many men of prominence in Laryngology were the operators, so that the results could not be attributed to poor technique on the part of one man.

The writer arrived at the conclusion that tonsillectomy, so far as removing pathological tonsils is concerned, is a better operation than the old-time tonsillatomy, but pointed out that many of the throat defects tollowing the operation of enucleation are due to clumsy and non-surgical technique.

The writer also pointed out the normal relation of the surrounding parts to the tonsil and put up a strong argument against the use of sharp instruments for the dissection of the tonsil from its bed, that being the cause of injury to the muscles with resulting deformities.

Of the one hundred cases examined months after operation more than 80 per cent. of the patients had deformed throats. The 20 per cent. of patients were inconvenienced in no way at any time following the operation. Of the eighty patients, thirtyfour complained of speech defects for from one to three weeks after operation, sixteen complained of speech defects for more than three months after operation, while four had practically lost the singing voice. About 25 per cent. of the patients stated that their tonsils felt better, and that they could speak and sing better after operation than before. Inability to use certain words had continued with 5 per cent. of the patients for more than six months after operation.

The variety of deformities following enucleation were classified as follows:

(1) The pillars on both sides had disappeared with the soft palate tightened to

such an extent that the opening at the nasopharynx was narrowed.

(2) The pillars on both sides had grown together.

(3) The anterior pillar had wholly disappeared with a large amount of cicitrical tissue deposited on the posterior pillars.

In the four patients whose singing voice had been seriously affected the posterior pillar had disappeared through amalgamation with the anterior or with the lateral wall of the pharynx.

The author emphasizes the fact that he did not think the last word had been said in regard to tonsil enucleation and proposed as a remedy for preventing the unsatisfactory throat results an operation for removing the tonsils by what he called the "Eversion Method," and with charts and diagrams pointed out that the capsule of the tonsil is simply a bag, the bottom of which may be pulled through its mouth so that its inner surface becomes the outer, and that if the capsule with its glandular tissue is everted and a snare placed on, removed the tonsil with its capsule complete (there being no dissection and therefore no injury to the muscles surrounding) there would be no deformities.

The exception to the rule presented, viz., that the tonsil will evert on traction, were:

(1) Those cases in which the capsule was bound down to the surrounding tissues by previous attacks of inflammation.

(2) Those cases where the capsule was very much contracted and contained cicitrical tissue only.

(3) Those cases of hypertrophied tonsils which had everted themselves and the tonsil was found everted when the patient applied for treatment.

The points advanced in favor of the procedure were:

(1) Simplicity of the operation. (2) Practically no hemorrhage. (3) Little or no deformity following the procedure.

(4) Only three instruments necessary for the operation, viz., tonsil tenaculum, blunt pointed tonsil knife, tyding snare.

Veratrum viride in small doses is as much a "cardiac tonic" as digitalis is in large.

INFECTIONS OF THE UPPER URINARY TRACT IN INFANCY AND CHILDHOOD.

Dr. Robert D. Green, in the Boston Med. and Surg. Journal, May 1, 1913, after a review of the literature and the study of clinical cases, offers the following conclusions:

I. In infants and children infections of the upper urinary tract, though infrequent, are likely to occur without adequate apparent antecedent cause.

2. Their onset is acute, their clinical picture definite, their recognition often missed on account of their simulation of other infectious conditions.

3. Their two most usual forms are acute pyelitis and acute inflammatory nephritis.

4. The letter is most usually metatogenous in origin, the former probably proceeds by lymphatic extension from the intestine. 5. Predisposing causes are calculi, constipation, phimosis, anal fissures, and foci of infection elsewhere.

6. The classic signs of both are pyrexia, pyuria, and tenderness in the costovertebral angle.

7. Differential diagnosis depends on examination of the urine.

8. The treatment consists in rest, milk diet, aqueous diuresis, moderate catharsis, urotropin, with sodium benzoate, potassium citrate, or vaccine, in obstinate cases; surgery, only as a final measure.-Med. Times.

TREATMENT OF ERYSIPELAS BY MEANS OF CARBOLIC ACID AND ALCOHOL.

Dr. Aspinwall Judd, of New York Med. Record, recommends the use of strong carbolic acid painted on the surface in cases of erysipelas until the surface is whitened, and then followed by swabbing with alcohol. The treatment must go a half inch beyond the border of the eruption to destroy all the germs. The unbearable itching, burning, and throbbing are relieved at once, fever soon falls, and general symptoms are relieved. The author has treated successfully sixty-seven cases, and five cases in which it failed. No scarring results. The superficial layers of the skin come off as in mild sunburn, and the complexion is improved.

TREATMENT OF APPENDICITIS.

Editor Medical Summary:

I note on page 82 in your journal of May, under the head of "Medical Treatment of Appendicitis," the following: "Apply locally over belly warm flannels wet, wrung out, with alcohol and water (one part alcohol, three parts water-warm). Cover the wet flannel with rubber tissue. When the flannel is dry, wet it again with alcohol and water." We use no such treatment, but just the opposite. Ice bags filled with crushed ice, first, last and all the time. I have found this to give instant relief. In former days we used warm applications, but put them away a long time ago. No food of any kind is to be given to speak of. I know from long experience the ice application is far ahead of the warm applications.

Mr. T., aged 42 years, was taken suddenly sick on Wednesday about three o'clock in the morning. I saw him about 7.30 the same morning in much pain, very tender of the appendicital region-clear case of appendicitis. Anxious countenance at that early period in the case. Visited him the following morning; no better. Called in Dr. H., and he said the patient could not live. He thought general peritonitis had set in, and informed the family that the case would result fatally. We visited patient twice on Thursday, went back Friday and Saturday, when we found. him better. Discharged the case Monday.

Treatment-Cleaned bowels out with magnesia sulph., gave no more medicine, no water to speak of until Saturday, eat and drank. This was about three years ago. The man still lives.

Hats off! The SUMMARY is the greatest medical journal ever published. S. C. HATTON, M.D.

Riverton, Iowa.

CASES.

Editor Medical Summary:

The daily active practice of a general practitioner has many clinical experiences where he fails and succeeds.

His prognostic expectations of a successful issue in a case are often unexpectedly disappointed, and his faith in the remedies he may have employed receives a severe jolt. At other times, in the same character of illness, wherein he met with defeat may have brought about a cure with like remedies. The only way to account for the different results must be the difference in the constitution; the peculiar indiosyncrasy and more amenability and response to treatment. I lost a case of pneumonia a few days ago, the patient dying on the eleventh day. Resolution never began. The same treatment I gave to the fatal case has cured many who appeared to be just as bad. And let me say, no two cases of pneumonia may be treated alike. There is no routine treatment. In the congestive stage I use arterial sedatives; in the engorgement stage, ammonia carbonate, digitalis and local antiphogistic remedies. To be sure, the vital powers are supported. When resolution begins to use expectorants with ammonium muriate as a prominent ingredient. If the resolution seems much delayed, by red hepatization, I give stimulants and oxygen inhalations. Yet despite all this, some will die from engorgement, or from hepatization.

Another case, of severe orchitis, I began by large saline purgative, hot fomentations, and anodynes; finally shifted to hot antiphlogistine; it still being very painful and very much swollen and hard, I had an ointment of equal parts of ichthyol, belladonna ung., hydrarg. ung. and lanoline. It did fairly

well, but I finally used tincture iodine, and it began to go down promptly. The patient being bedfast and feverish, I kept the testicle supported, and gave 71⁄2 grains of salol, which reduced the temperature and corrected a very offensive breath. He was a robust young man, with gonorrheal affection. He attempted to cure himself by urethral injections, which accounts for his diseased testicle.

I have encountered several cases of fellicular tonsilitis this month, and the characteristic foul breath, concoctions and inflammation, with pyrexia, make them slow in recovering. I spray the throat with Dobell's, dioxygen, etc., and sometimes iron, potass. chlorate in water and glycerin. Give Parke, Davis & Co.'s syr. ferri chlor. internally. If there is much turgescense, I allow the patients to eat crushed ice and pineapple juice. They recover in about five or six days.

A peculiar case is that of a primipara with a six-weeks-old babe, who got along all right till three weeks ago, when she seemed to develop all the symptoms of typhoid fever; loose bowels, high fever, abdominal tenderness, etc. After persisting thus for three weeks, the fever suddenly subsided, and she is now convalescent. I must have made a mistake in diagnosis, as it was probably a malarial attack.

I must mention another case, because it is rather unusual. About three weeks ago I was called on to prescribe for a young man, who was suffering with acute pain in his ankles. There was never any swelling, which is unfavorable. To my surprise, he suddenly developed endocarditis, from metastasis. To be sure, his case is hopeless. I name these among many I have on hand, because they are unusual.

Jeffersonville, Ind.

D. L. FIELD, M.D.

The diet in typhoid fever should consist of a small amount of protein, a small amount of fat, and a large amount of carbohydrate. The preferable protein food is milk and albumin water. The preferable fat is cream, and the preferable carbohydrate is lactose. A pound of the latter may be administered in twenty-four hours.-Dr. Brown in Interstate Med. Jour.

"DIFFERENT METHODS TO EXPEDITE LABOR" REPLY.

Editor Medical Summary:

In the June issue of your valuable journal, page 108, "Different Methods to Expedite Labor," Dr. Trabert suggests a few words, and I send them on. You are at liberty to use them or not, as you see fit.

For more than three years I have not intended to be without H. M. C. (Abbott) in my obstetric bag, and hypodermic case also, and splendid service have they rendered me. Last year I procured Lloyd's Specific Lobelin, and used it hypodermically with very satisfactory results; used it in three cases successfully, my first experience, thinking more and more of it.

On February 9th, last, was called eleven miles to assist Mrs. J. in her second labor; a very cold, rough, frozen ground; night. I found the patient in hard labor, much exhausted, discouraged and vomiting everything taken in stomach. Pains every five or ten minutes; very hard, explosive-like pains. Making an examination to my very great surprise I found os not large enough to admit small sound had I wanted to; considerable vaginal tenderness, hot and dry. So restless nervous and tired, she could not sleep or keep food or drink down. Opening my case for the lobelia, I saw a little tube of H. M. C., and the thought to combine them and use both at once, and so I measured out 40 minims of specific lobelia and one full-strength H. M. C. with hypodermic needle all in loose tissue between the shoulder blades; no more vomiting or retching-in twenty minutes she was asleep, and myself being very tired from a long enervating day and night, I slept also. The injection was given at 2.15 A.M. February 10th, at 6.10 A.M., I was awakened by groaning patient. She had just wakened in a strong, long expulsive pain. I examined again, and found head well engaged in lower straight; first presentation with a large bag of water protruding from vulva, and two more strong pains, and the head was delivered, followed soon by the body of a healthy, well-formed male child, weight eight and a-quarter pounds, without a tear or loss of more than a half pint of blood. The woman made a rapid and uneventful

recovery, with afterpains not sufficient to keep her awake one minute. I should state that with her first child she suffered a severe hemorrhage immediately following the delivery of the placenta.

I was more than delighted with the still, rapid relaxing and delivery in this case, and since that time have used the same combination in two other cases with most satisfactory results. Patients quickly gone on to delivery and recovery, both being multipara, and afterpains in both cases being nil. I would be glad to have the reader try this combination and report his experience through The SUMMARY columns. P. S. CARPENTER, M.D.

HEMORRHOIDS.

Editor Medical Summary:

In this short paper I am not going into a history of hemorrhoids. This can be found now in many special works, as well as in all the latest editions of surgery. What I wish to say relates particularly to the methods of treatment by injection into the hemorrhoidal tumors of carbolic acid. Though this method has been condemned many times, it has stood the test of time and adverse criticism and to-day stands on a par if not foremost of all treatments of internal hemorrhoids. Many who formerly discarded and tabooed this treatment among surgeons and rectal specialists are again using it extensively in selected cases. From my first using it until the present time, which is now nearly forty years, I have found it a good and successful remedy in many cases of internal hemorrhoids.

At first when the treatment was used it was thought by many that every case of hemorrhoids could be cured by it. Therefore we found it used, or it was used, in external hemorrhoids as well as internal, hence much damage evidently was done by the treatment. From the haphazard way the treatment was used, even in internal hemorrhoids, it deserved condemnation. Yet it was not very long before some definite system was adopted for its use, and since then in competent hands it has been successfully used.

The arguments which were brought forward to condemn it, such as heart clot, septicemia, too extensive sloughing, fistula producing, etc., we do not hear any more of. It is not long ago that I heard an eminent specialist say in a medical association that we had downed the hypodermic treatment beyond resurrection. An old gray-haired doctor arose and remarked, if the eminent surgeon who preceded him believed that the injection method of treatment of hemorrhoids was downed as he said, he was laboring under an erroneous idea, for he, the old doctor, believed there were more cases treated and cured by it than by all other methods combined.

Now, I will not go so far, as this old doctor did, yet from what I hear, and what I have seen myself, I verily believe that at