tongue in the backward sweep of the tongue in each act of deglutition.

Then we nearly always find in such throats the diverticuli or pockets between the anterior pillar and the tonsil, some times posteriorly, as well as enlarged crypts that are real culture tubes for the ever-present flora of bacteria and are receptacles for lodgment of foods and the detritus of the throat. This is all a peritonsillar condition and if we accept the trend in the conclusions of the many investigators that the most logical channel of infection is through the mucous follicles, ducts and the peritonsillar chain of lymphatics, we may largely exclude tonsillar culpability and say it is peri, rather than intratoncillar.

The teachings of Jacobi even years ago, when he said that in membranous throat disease, whenever the membrane is limited to the tonsil there is little, if any, glandular swelling in the neighborhood. Whilst if the membrane extends from the tonsil, or starts at a distance from the tonsil, the neighboring lymph nodes swell at once. His clinical observations have stood the test of time and must still be reckoned with in the direct absorption by the tonsil.

Then Rosenow lately found the abscesses following poliomyelitis infections to be extratonsillar, which also points to the peritonsillar route.

Dr. Lilly, of the Mayo Clinic, said in a recent number of the JOURNAL that where there were diseased teeth and tonsils, the teeth should be removed first, and when done the tonsils would become normal in most cases.

Demonstrations in the injection of soot into the gums and nose and the new oxygen treatment for pyorrhea are demonstrating the courses of infection and we may soon have to vie with the dentist in the removal of the foci of infection. From the current medical literature the removal of a healthy tonsil is becoming a mooted or debatable question.

In the normal tonsil we do not find the plica triangularis in evidence, and thereby are led to believe by this exemplary conditioned organ that in the removal of that membrane we have both a prophylactic measure and cure for most tonsillar troubles, especially in children, singers and speakers.

The association and range of the physiological life of the tonsil, according to Wright, is depend

ent upon the active metabolism of childhood, and he points out also a functional relationship between the teeth and tonsils. That when dentition is completely accomplished, both the cervical glands and tonsils recede without treatment or operation. Like the physiological life of many tissues of the organism, the tonsils are not co-extensive with the life of the individual. Serving their functional purpose from infancy to puberty, when other lymphoid structures take on their periodical activity, they should then take on their decline, so that the function of the tonsils cannot be said to be ended before puberty is well established.

The mechanical function of the tonsil in the way of a support to the surrounding muscles never ends and is essential to a good throat. Therefore to ruthlessly remove these important organs of childhood, where they are normal, or can be made so, savors too much of commercialism, and cannot be too strongly condemned.

Dr. Kenyon, of Chicago, has made a searching investigation as to the foundation of voice impairments resulting from removal of the tonsils. Asking your indulgence, I will make a condensed quotation from his report.

STUDY OF TONSILLECTOMIZED THROATS The following report on tonsillectomized throats is based on the systematic study of 161 tonsillectomized patients. The patients were of all ages, operated on by the various well known instrumental and technical methods, and by about twenty operators. The surgeons were mostly thoroughly experienced and some were unusually skillful; a small but unknown proportion were interns.

1. Neither palatoglossus nor palatopharyngeus muscles show more than very slight retraction, namely, the faucial region on both sides, including pillars and palate, were left essentially normal; six patients, 4 per cent.

2. Both palatoglossi slightly to moderately retracted, both palatopharyngei only slightly retracted, or normal; two patients, 1 per cent.

These two groups, representing essentially one in every twenty of the patients, include all that showed the clean, free, practically normally appearing and acting fauces, such as operators theoretically attempt to secure. All others were cases presenting very evident, though by no means necessarily serious, deformity.

3. Palatoglossi moderate to marked retraction, functioning in some cases slightly, and in some cases not at all; 150 tonsils, 47 per cent.

4. Palatoglossi completely obliterated, having dis

appeared into the lateral wall; 122 tonsils, 39 per cent. 5. Palatopharyngeus not perceptibly impaired; 149 tonsils, 49 per cent.

6. Slight to moderate adhesion of palatopharyngeus to lateral wall, and moderate impairment of muscle; 106 tonsils, 45 per cent.

7. Marked to complete adhesion of the palatopharayngeus to the outer wall; decided and in some cases total incapacitation of muscle (with inevitable resulting tension and shortening of palate); 47 tonsils, 15 per cent.

As to the palatoglossus, then, in more than 50 per cent of the cases the muscle had ceased completely to functionate, let me repeat, and in 14 per cent the muscle seemed quite free from impairment. The palatopharyngeus was almost or completely incapacitated in 15 per cent, and practically not at all impaired in 49 per cent. The amount of tension, retraction, and destruction to the palate was very important, and will be brought out in other connections.

Summary and Conclusions

1. In view of the foregoing facts, any sound, conservative conclusion must show that, unless through the exercise of better technic or of greater skill the deformities from tonsillectomy can be diminished, tonsillectomy is in a situation which if not alarming is at any rate serious. If one case of important functional impairment, for example, of the speaking voice, were known to occur inevitably in each hundred or 200 or even 300 cases of tonsilectomy, our attitude toward the operation would become much more attentive and careful than it is today.

2. In removing the tonsillar capsule we take out an important supportive structure on which the normality of the physiologic action of the soft palate largely depends. Cases in which operation has been performed, as they exist, show a frightful amount and degree of postoperative deformity, dependent in large part on the very principle of the operation.

3. Uncertainty as to operative complication leading to increased deformity is inevitable.

4. Danger to the speaking voice necessarily lurks in the very nature of the operative conditions, and impairment to the speaking voice is inevitable in an as yet unknown percentage of cases.

5. The danger to the singing voice from stiffness and adhesions begins, theoretically, long before that to the speaking voice.

6. The present situation calls for further intelligent efforts applied to technic and delicacy of procedure, and possibly to greater care in lessening postoperative scar tissue, in the hope that the adhesions and tensions may be decreased. In the meantime the dangers to the possibilities of the artistic voice in children must apparently continue. But, until the situation is further cleared up, for the surgeon to go on performing indiscriminately tonsillectomies on the throats of adults with singing voices of great beauty or of great importance to their possessors is for him

to take risks which the artist himself would not consent to take did he know clearly the situation.

7. The weakness of the present professional attitude in favor of the exclusive employment of the extra-capsular operation lies in the fact that no evidence exists which proves that an operation aiming at a clean complete intercapsular lymphdectomy, namely, complete removal of lymphatic tissue within the capsule, might not prove to be practically as capable of eliminating infective dangers as the present extracapsular operation. And such an operation would not only be free from serious deformity, but would be altogether a less serious operative procedure. The opinion of French that 80 per cent of tonsils could as well be operated on without extreme radicalism is probably true, and could probably be verified.

8. In view, then, of the whole situation, and granting for the moment the correctness of the facts herein presented, must not the profession in justice to its scientific aims and mission turn toward the matter of developing a thorough though relatively conservative operation, which preserves undisturbed the tonsillar capsule? If such an experimental attempt should meet with success, as it probably would, the operator would have at his disposal both a conservative and a radical operative procedure, between which in the individual case he could make a rational choice. Such an operation could practically always be employed in singers.

I have seen quite a good many cases that confirm the report made by Dr. Kenyon, which leads me to believe that the real method for removing the faucial tonsil has not yet been fully established.

I also believe the intra-capsular method thoroughly practical, especially in children and some young adults, where we have follicular hypertrophy, and it is not fraught with the dangers of crippling the surrounding muscular arrange

ment.

I would not decry the removal of really disorganized tonsils, which, from their size, or otherwise, are menacing the health and welfare of the patient. Probably the time will never come when the operation for complete removal of the tonsil will not occasionally be performed. However, like Dr. Murphy of Iowa, who has contributed so much to our literature on this subject, I feel that more than ninety per cent of the tonsillectomies performed today should be abandoned for a more scientific, practical and safe method.

If the "ounce of prevention be worth more than the pound of cure," try the drainage treatment, which we know to be so efficient that failures are almost negligible.

DISCUSSION

Dr. A. M. CorWIN (Chicago): We may not waste time in discussing this paper, except to express our surprise that this very good fellow practitioner should lend himself to the folly of going back to the scrap heap of the past, to collect a lot of discarded notions to put before this scientific body.-Is it possible that he has gone to sleep, say twenty-five years ago, like Rip Van Winkle, but that, unlike Rip, he has not waked up?-If the doctor had paraded an antivivisection essay or a creed on "Why I am against vaccination," the matter would not have been more out of place. The word "unwarranted" in the title applies to the paper itself, not to tonsillectomy well done, which the doctor would like to banish.

If there is one theory established upon rock bottom of proven fact, it is our modern conception of focal infection, which has revolutionized the practice of medicine, sweeping away the empiricism with which many of us graduated twenty-five years ago. Furthermore, among the dozens of recognized foci + which pathogenic bacteria are known to enter and produce their selective deviltry,-deviltry which we have been pleased to label rheumatism, or it's this or itis that, the tonsil takes satanic place next to the teeth.

But the term "unwarranted slaughter," misused by the doctor, might very well be used to express the careless sacrifice of these agencies of health, youth, comfort and good looks, the teeth. Too many of them are being pulled, innocent ones, with scant courtesy. On the other hand, to remove tonsils even upon suspicion will do no harm, providing always that such removal be properly done. To leave a morbid tonsil or part of one in place to multiply trouble is a calamity. We would personally rather sacrifice a hundred so-called innocent tonsils, than overlook one source of endocarditis, nephritis, arthritis, gastric ulcer, and all the rest. Healthy tonsils are rare birds. serve even these in bottles as curious specimens. This is a good use for alcohol.

Better pre

The tonsil has for a very long time unwarrantably slaughtered hosts of people, and you all know it. In recent times, we got our heads together, we general practitioners, we urologists, we obstetricians and we pediatrists, and this is the one ground upon which all members of the profession stand together. To execute a good tonsillectomy for cause, local, regional or general, is one of the operations which is not thought unethical for a dermatologist or psychiatrist to do if he so elect. Any and all of the profession should be in a position, if they choose, to take out tonsils. But they should learn now.

Now the Doctor's talk here, referred to many accidents and malformations, possible disturbances of voice and what not after tonsil removal. This is a

the tonsil. If these glands are taken out properly, there is no slaughter of the environment, the pillars are all right, they are free to act, the supports are all there. So far as hypothetical functions of the tonsil are concerned,-as to their having crypts as culture tubes for the manufacture of autovaccine solutions to overcome infection, and what not,—we know all about those fifty-seven varieties of fanciful tonsil function.

The whole thing is here, the tonsils are in everybody as early blood makers, and ninety per cent of them become diseased. There are very few tonsils that hadn't better be removed. And to remove them well does no harm. Not to remove them leaves wideopen doors to trouble, preventable trouble.

We laryngologists have removed a very large number. We have set the pace very promptly and evolved the method. The general practitioner has removed a great many. So has the surgeon. Some of these millions have not needed removal, but I am here to say that when they were taken out without serious damage to the environment, the pillars, and palate, no harm was done. I, personally, have yet to see in thousands of cases, literally, I have yet to see a permanent serious complaint, let alone a serious effect from an efficient removal of tonsils; and we perfectly know that if this operation had been done ages ago, by the general surgeon, when he dissected long series of glands from the deeper cervical tissues and left the tonsil in to multiply lesions-if he had gone at the tonsil first, many of these cases of lymph gland dissection would not have been necessary, and the patient cured instead of sacrificed to tonsil infection.

Now I take the broad view that while the laryngologist trains himself notably to do this work, and has developed the technique, still he is quite willing that all medical practitioners, internists and all others who wish to do their own work along this line should learn to do it, and do it early, not hesitate to do it. The "slaughter of tonsils" is a cry raised by the faddist. the ultra conservative, the anti-surgical society. They are conservative in the wrong direction, because today the watchword is conservation of health and life, and that is just the reason we take out tonsils.

The paper does not reflect credit upon the essayist. This we say, frankly, is for the good of all concerned, including the author of the paper.

DR. KENYON (Chicago): I am very pleased that someone has had the courage to rise in this body and say that the present status of tonsillectomy was not wholly right; and yet I feel with Dr. Corwin that we must not become hysterical, and that there is no reason for becoming hysterical with respect to this operation.

Unfortunately, in all medical practice, we are confronted with a situation. Something has to be done. The patient has to be gotten well. Consequently, it seems to me that we cannot wait for theories with respect to the function of the tonsil or to the manner

in which infection from the tonsil is carried into the circulation, to be found out. The house is on fire, meaning the general house, and the fire must be put out.

When tonsils are presented to us for consideration, they come to us perhaps in three lots, first, with a history of acute tonsillitis in the past; second, with provable chronic tonsillitis; third, without history of acute tonsillitis and without provable chronic tonsillitis; fourth, adenoids with tonsils which appear not to be infected. Now then, my position is this, in every case where there is real reason to believe that the tonsil may constitute an infection atrium leading to some internal trouble which has been discovered, that tonsil whether it can be proven to be diseased or not, should be thoroughly extirpated. On the other hand, however, with those tonsils unassociated with general infection, whether there is, or is not, evidence of local disease in the tonsil, it seems to me that no good reason whatever exists why those tonsils may not be legitimately experimented upon by conservative methods.

I desire to say this, with reference to Dr. Harrison's paper, that if he or anybody else has intelligence enough to bring about a situation by which infection in the tonsil can be gotten rid of without complete extirpation of the tonsil, I wish him success. As for me, I have not been able yet to satisfy myself with respect to the advantage of this particular method which Dr. Harrison advocates.

One word more with respect to tonsillectomy itself. I take positive exception to Dr. Corwin's statement that where the surrounding structures are not injured there may be no serious mechanical result from tonsillectomy. That I know not to be true, and I wish to tell you why it is not true. To repeat, there may be a most serious mechanical result from tonsillectomy even when performed with the most supreme skill, such as Dr. Corwin employs. Why? For this reason, because the soft palate is not built equally long in all cases. There are patients who have constructively a relatively short, soft palate. In those cases, beware, for almost any tonsil operation will result in a permanently nasalized voice. Fortunately, they are rare. Practically, we as surgeons, should have such a possibility in mind when we consider a tonsil operation.

Dr. Harrison, Quincy (closing discussion):

Where I was sitting I could not hear the discussion of the paper very well, but suppose I escaped fairly well from an encroachment on the time being forbidden ground.

It may seem to some like "Fools rush in where angels fear to tread." Yet "Fools make feasts and wise men eat them." However, I consider this subject timely and regret I did not make myself better understood by the use of the charts, which were excluded by the lack of time. I am absolutely opposed to the inordinate removal of tonsils, especially in children, as practiced by many today. The middle ground of reason will obtain sooner or later.

A SIMPLE AND ACCURATE TECHNIQUE
FOR FOREIGN BODY LOCALIZATION.
J. R. BUCHBINDER, M. D.

Associate in Surgery, Northwestern University Medical School
CHICAGO.

Operations for the removal of foreign bodies constitute a comparatively small part of the work encountered in civil surgery. The relative infrequency of such cases is perhaps the chief reason for the difficulties which we so frequently encounter. On the other hand, the past four years (because of the great importance of the work in military surgery) has seen the development of a host of methods and of apparatus. The great number of widely differing techniques described, tend to suggest the difficulties that we have repeatedly found on practical test. The basis of the suggestions that I wish to present in this paper consists of the study of approximately two thousand cases in a base hospital during the summer of 1916.

The various methods of localization, the vibrating magnet of Bergonie excepted, group themselves about and are directly dependent upon radioscopy as a central feature, usually some type of geometric apparatus being used to augment the latter. Cumbersomeness and lack of adaptability to all types of cases constitute the chief objections to most of them.

The ever-present probability of misinterpretation eliminated simple radioscopy as a method of any value, even in the simplest type of case. I refer particularly to the common method of taking two views in planes perpendicular to each other. I have several times seen necessary a prolonged search for a piece of needle in the hand when this method of localization had been used. I believe that the same objection holds good in the use of intermittent screen control, a method much mentioned in the French literature.

The various compasses, profundometers and radioscopimeters are, many of them, very ingenious mechanically, and by their use the depth of a foreign body from the surface may accurately be determined, results being obtained in centimeters or inches. It is not possible, within the scope of this paper, to include a description of the minutiae of these various types of apparatus. The universal objection to all methods of localization by geometric means is that they do not give the operator a clear mental picture of the

anatomic relations about the foreign body, nor do they clearly indicate, at all times, the most favorable place for incision. This latter point is often a most important one. Moreover, with the above mentioned methods, considerable time is consumed, usually thirty to forty-five minutes.

Fig. 1. A shrapnel bullet near the neck of the femur. One of the easier types.

We have used Furstenau's method of measurements and have found them to be universally applicable, but possessing the above mentioned objections.

In looking over the literature on this subject I have noticed that surprisingly little attention has been paid to a relatively simple procedure, but one far more accurate than any other method I know. I refer to a stereo-radioscopy, aided by "markers," and the identification of sinuses and of other fixed landmarks by means of probes and other objects impervious to the rays. The method that I wish to present is that which for the past five years has been used in the clinic of H. M. Richter at the Wesley Memorial Hospital. Its value was unappreciated until we faced the problems presented in hundreds of shell, shrapnel and bullet wounds, where rapid and accurate localization was a consideration of prime importance.

A marker in the form of a small piece of lead (of a definite outline to avoid confusion with the foreign body) is fastened, by means of adhesive, to some point on the skin, usually the wound of entrance, or if there be an exit wound,

both. In an article devoted to the localization of foreign bodies within the chest, Emil Beck suggests the use of wire netting.

An additional marker is now fixed to the skin overlying an adjacent subcutaneous bony prominence, such as a maleolus, or the anterior superior iliac spine, etc. The point of contact between skin and marker is designated by the use of an indelible stain, such as fuchsin. The marker may then be removed after the picture is taken, without losing relations.

The advantages of the method become obvious when such a "stereo" is examined. The markers, because of their peripheral location, intensify the stereoscopic effect of the picture to a degree of brilliance that is astonishing. In the one picture, the relation between foreign body, wounds of entrance and of exit, and of the adjacent bone can be seen as though one were examining a gelatine cast of the part. The distances between the fragments and the wounds as designated by the markers, can accurately be measured; the perspective rendered furnishes an exact idea as to depth. Our percentage of failures, with any but exceedingly small fragments, has been negligible.

There is a type of case worthy of special mention, namely, a foreign body in an anatom