Then for some days he was apparently free from the trouble. Then for several days he complained of his ears. There were noises all the time— sometimes buzzing, sometimes like the sound of a shell held to the ear. Now for five days all these symptoms have been absent. Aside from the symptoms described the case is going on in the usual way. Dr. Packard Dr. Sutherland's paper interested me very much indeed, especially the suggestion that anterior poliomyelitis may be a constitutional disease. I should rather question that and take a little exception to the analogy existing between beriberi on the one hand and anterior poliomyelitis on the other, because beriberi and pellagra are acknowledged as constitutional diseases and result in starvation, while we all know that anterior poliomyelitis from what we can find is a bacterial disease. That does not prove that Dr. Sutherland's doctrine is not a true solution of the reason why poliomyelitis gets a foothold and we have an epidemic. This brings up the subject of resistance. I became much interested in observations along this line a number of years ago. The idea that resistance must depend on the character of the nutriment taken in seems very plausible. If the system does not have strong healthful material, it is weaker in its resistance. I really think that much may develop from this suggestion of Dr. Sutherland's that there is something in this constitutional side. I feel like preaching with all the vehemence in my power the use of cereals which have not been robbed of their life-giving properties. As I travel around I find that I can now get in hotels whole wheat bread. And I have been much gratified that one of the largest flour concerns in the middle west with which some years ago I took up the matter of making whole wheat flour, only to have my ideas flouted by them, has within the year sent me a circular stating that they are putting out the best whole wheat flour made in the country, together with a letter asking my coöperation in introducing the flour and my recommendation. BLOODLESS TONSILLECTOMY* By EVERETT JONES, M.D., Boston, Mass. There is probably no operation in the entire field of rhinolaryngology which is more frequently performed than the operation for the removal of the faucial tonsils; and I think I am safe in saying there are more operations upon the tonsils than upon any other organ. According to the latest report of our Homœopathic Hospital, of 772 operations on the nose, throat, and mouth, 696 were for hypertrophied tonsils. ANATOMY OF THE TONSILS Let us consider very briefly the anatomy of the faucial tonsil. It is a globular mass of lymphoid tissue, lying one on either side of the oropharynx, in fosse formed by the palatal arches. It is the largest of the lymphoid nodules of the respiratory and alimentary tracts. The outer wall or bed on which the tonsil rests is the superior constrictor of the pharynx; and the so-called capsule of the tonsil, which, according to Dr. Patterson * Read before the Boston District of the Mass. Hom. Medical Society, Dec. 7, 1916. of London and Dr. Hudson Makuen of Philadelphia, is merely a portion of the intrapharyngeal fascia, or aponeurosis of this muscle, having its attachment at the base of the skull and extending down into the region of the oesophagus. Folds of this membrane protrude between the pillars and palate, forming the plica triangularis or plica tonsillaris. THE BLOOD SUPPLY OF THE TONSIL Arteries. The tonsil is an extremely vascular organ, receiving its blood supply from the tonsillar and palatine branches of the facial, the descending palatine branch of the internal maxillary, a branch from the lingual, and from the ascending pharyngeal. Its chief blood supply, however, is from the tonsillar and ascending branches of the facial. The veins of the tonsil form a plexus lying in the walls of the sinus, and is of great importance from the operative standpoint, as troublesome bleeding may result if this plexus is injured. The lymphatics draining the tonsil empty into the deep cervical chain beneath the sterno-mastoid muscle, from here to the thoracic glands, and eventually to the thoracic duct. Before it is decided that the tonsils should be removed, one or more of the following conditions must be present: 1. The tonsil must show a disease of its structure. 2. The tonsils must be so large as to cause obstruction. 3. The patient's general condition must be unfavorably influenced by the diseased condition of the tonsil. 4. Recurrent acute catarrhal infections of the throat or peritonsillar abscess. I believe the removal of any structure of the body, even a tonsil, is a more or less serious matter; and I believe in the exercise of great care, and in the acquirement of great skill, in the performance of this difficult and important operation. If the theory above advanced relative to the capsule of the tonsil is a correct one, and I believe it is, it has a very important bearing upon the surgery of this region. There is probably no other part of the body where so many different kinds of operations have been tried. Notwithstanding the many tonsil operations, I am introducing another in Boston, and, as far as I know, to New England, which seems to me to enucleate the tonsil more easily, with less damage to the surrounding parts, usually bloodless, and, what is of the greatest importance, with less of the so-called capsule of the tonsil than any other operation with which I am familiar. This operation is easily done in five or six minutes. One half minute is used in engaging the tonsils in the fenestra of the instrument, and the other five in making it a bloodless operation. This instrument is a modification of the MacKenzie and Sluder instruments, by Drs. LaForce of Iowa and Skillern of Philadelphia. It has a blunt blade for splitting the capsule and crushing the blood vessels and a sharp one to sever them. TECHNIC With slight modifications the technic is that used by Dr. W. E. Dixon of Oklahoma and Dr. Skillern. The patient is flat on the back, if under general anesthesia, and nearly in the erect position if local anesthesia. The head may be held firmly by the anesthetist to prevent rotation, and the mouth kept open with a gag, using good head light or reflected illumination. The surgeon stands on the patient's right. It is a very great advantage to operate on the right tonsil with the instrument in the right hand and on the left tonsil by holding it in the left hand. Assuming that the surgeon uses his right hand for both tonsils, for the right one he faces the patient's head, for the left one he must turn around so that he faces the patient's feet and stands somewhat above the head. With this method one must approach the tonsil at an angle of 45 degrees, which requires the shaft of the instrument to cross the mouth from the opposite side outward and backward, passing back until the distal part of the aperture is completely behind the tonsil. It is now brought slightly forward and upward into the region of the alveolar eminence. By rotating the handle a little upward the upper portion of the tonsil is everted through the fenestra. If the entire tonsil is everted through the fenestra there is a dimple in the anterior pillar readily seen and felt. If it is not entirely through it can be massaged through gently with the ball of the index finger, at the same time pressing the blunt blade across the fenestra, taking a small amount of the capsule with the tonsil, the blunt blade is held on the blood vessels for two or three minutes, then the knife worked by the smaller screw severs the vessels. The instrument is withdrawn and the tonsil completely enucleated resting over the fenestra. Looking into the throat we see the severed layer of the capsule slipping back behind the pillars as they separate. The tonsillar fossa has a soft velvety feel as the larger part of the capsule remains to line the fossa. Recovery is rapid, the patient usually taking solid food the day following the operation. I believe this method is applicable to all cases except those rare ones in which incomplete operation or inflammatory processes have left the parts bound in a network of rigid, unyielding scars, with little tonsil tissue present. The strong features in this operation which appeal to nearly every physician and surgeon, are: 1. It completely enucleates the tonsil without damage to the surrounding structures. 2. The tonsillar fossa is left lined with the larger part of the smooth capsule. 3. The patient makes a rapid recovery, as the sore throat is very slight following this method. 4. By this method tonsillectomy is nearly always bloodless and the anesthetist is all the assistance required. 496 Commonwealth Avenue. HIRSCHSPRUNG'S DISEASE, OR MEGACOLON * The subject of Hirschsprung's disease was assigned to me because of the fact that in the last six months there have occurred two cases in the wards of the Massachusetts Homœopathic Hospital. When one is confronted by the situation that such a case presents, the name of Hirschsprung's disease, or megacolon or giant colon, carries with it a great deal more of meaning than the book study of the disease is apt to convey. In fact, if one has not encountered the condition the name is not likely to mean anything. As one of our members told me a few days ago, whatever this subject might mean, he was "neutral." So I think it will be better if we start in and visualize the topic first by the exhibition of a specimen which was loaned to me by Dr. Stone of the Children's Hospital and by Roentgenographs of another case from the Homœopathic Hospital. This specimen, which you may examine more thoroughly later, is * Read before the Mass. Surgical and Gynecological Society, November, 1916. the entire colon including the cæcum, together with a small portion of the ileum, showing the anastomosis that was made between it and the upper portion of the rectum. The plates are of another case and show very well the distention of the abdomen in life, and the marked upward displacement of the heart. It should be defined as a congenital dilatation of either the entire colon or a part of it, the sigmoid being always involved, and in fifteen per cent. of all reported cases, the entire colon. It is better named megacolon or giant colon, but was very fully described in 1886 by Hirschsprung, though Parry in 1825 and others at intervals of every few years have since published accounts of undoubted cases. Though rare in occurrence, it presents so striking an appearance that a high percentage of the cases are reported and consequently there has developed an extensive bibliography. The disease as a rule manifests itself in the first few months of life, and the clinical features are very distinctive. The chief points are an intractable constipation and progressive enlargement of the abdomen, with both a tympanitic and doughy consistency present, due to the accumulation of large masses of fæcal material and quantities of gas in a greatly dilated colon. There is a failure of nutrition to the point of emaciation as intestinal intoxication proceeds, together with fœtid breath, dry, harsh skin of a yellowish color, with occasional vomiting. The peristaltic waves of the smaller intestine may easily be seen through the thin abdominal walls as in intestinal obstructions, yet fæcal vomiting has not been described in any cases I have looked up, in spite of the fact that there have been recorded intervals of from three, four and six weeks to three months between movements of the bowels. Boys are much oftener affected than girls, the proportion in a series of nineteen cases being sixteen to three. Ten were one year of age or under, and six between one and five years. The degree of all these symptoms depends upon the extent of enlargement of the colon, but is always serious in the cases that are brought for hospital treatment. At intervals a colitis occurs, resulting in a diarrhoea that results in temporary relief. To return to a description of the pathological changes in the intestine. On opening the abdomen an enormously dilated colon is at once seen and in the true Hirschsprung's disease there is no mechanical obstruction below to account for it, which distinguishes it from a condition sometimes seen in adults called pseudo-megacolon, which is a condition of dilatation depending upon some partially obstructing lesion and is not what we are just now interested in. The dilated portion, usually the |