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THE GASTROINTESTINAL DISEASES OF CHILDREN

2 drams in each twenty-four hours throughout the disease. The subgallate should be given in doses of from 2 to 5 grains every two hours. Or one of the various preparations of the finely divided oxyhydrate of bismuth in suspension (known as milk of bismuth, for instance) may advantageously be administered. But whatever bismuth preparation is given, it must be in a fine state of division, so as to be absolutely unirritating. When so given, these preparations are soothing and protective to the intestinal mucosa; they also tend to neutralize the acidity usually present.

When the stools are green and have an offensive, sour odor, intestinal antiseptics are in order. The phenolsulphonates (sulphocarbolates) are of especial value, but must be given well diluted, to avoid nausea. When the lower bowel is affected, sulphocarbolate enemata are also indicated. Copper arsenite, in doses of 1-200 to 1-100 grain every two to three hours, also is an intestinal antiseptic of value. Resorcin and salol also have a place as intestinal antiseptics.

As the symptoms abate and convalescence is established, a very little milk well diluted with barley water or arrowroot gruel may cautiously be added to the diet. Increasing the amount of milk must be done very gradually and with extreme caution; and alimentation must be reduced or temporarily entirely suspended at the first sign of a return of the former trouble.

When the trouble has extended to the lower bowel, and blood and mucus appear in the stools, enemata containing 1 ounce of the glycerite of tannin (U. S. P.) will promptly control the bleeding. Have the enema given every time blood is seen in the stools. One enema usually causes the prompt disappearance of blood from the stools for at least twenty-four hours.

Another astringent and antiseptic solution of great value in those cases involving the lower bowel is solution of aluminum acetate, adding 1 ounce of the solution to a pint of warm water and injecting slowly through a large catheter.

Cholera Infantum

Cholera infantum, so called, is undoubtedly due to a specific infection of the milk

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used as food, and the disease is characterized by profound toxemia and serous alvine discharges. Treat it as you would any other case of poisoning by an intense chemical irritant. Give no food whatever, and even no water to drink, for at least twenty-four hours.

Immediately, and most thoroughly, wash out both stomach and bowels with large quantities of sterile physiologic salt solution; gastric lavage, using a large catheter (No. 16, Amer.), being a safe procedure and attended with no great difficulty. It is well, after lavage, to throw a solution of tannin into the stomach and bowels, for the purpose of forming insoluble compounds with any toxins remaining. If vomiting and purging recur, repeat the lavage.

Stimulants are needed: give whisky, diluted with cold water, in small quantities, frequently repeated, either by mouth, or hypodermatically.

To stimulate the heart, quiet the nervous manifestations, and inhibit the enormous loss of serum from the intestinal bloodvessels, morphine, 1-100 grain, and atropine, 1-800 grain, given hypodermatically and repeated hourly to effect, seem the very best combination yet suggested; this being contraindicated only when there is stupor.

To allay the great thirst and replace the lost serum, physiologic salt solution is to be injected slowly and in large quantities into the subcutaneous tissues. Giving large amounts of water by mouth only increase the gastric irritation.

For the purpose of combating high temperature, spongings with cool diluted alcohol should be made. On the other hand, in collapse, with subnormal temperature, heat is decidedly indicated.

When the symptoms begin to abate and recovery seems probable, great care must be exercised as regards return to food, and strictest surveillance of diet kept up for several weeks; for recurrences are fairly common after very slight dietetic errors.

Some Bacteriologic Pointers

In closing, a few words should be said regarding bacterial therapy. It is usually impossible to ascertain what varieties of microorganisms are causing these gastro

intestinal upheavals, while the course of the disease is too rapid to make cultures, with the idea of producing an autogenous bacterin.

However, we can use stock bacterins containing the organisms known to be most often at fault, such as the colon bacillus, the streptococcus, the various staphylococci, and the pneumococcus. These bacterins cannot possibly do any harm, and

their employment with the idea of raising the little patient's resistance seems a logical procedure.

Also, buttermilk made with cultures of the Bulgarian lactic-acid bacillus, or the administration of tablets containing the living bacilli, in many instances has appeared to be of distinct benefit. When the bacilli are given in tablet form, a little milk-sugar should be taken with the tablets.

Diseased Tonsils, and Adenoids
With an Improved Operative Method

By A. B. MIDDLETON, M. D., Pontiac, Illinois

Lecturer on Pathology of the Eye, American Medical College, St. Louis, Missouri

EDITORIAL NOTE. We have come at last to realize that the operations for the removal of the tonsils and adenoids are not so free from danger as we once thought them. Every improvement in the operative technic is to be welcomed. Dr. Middleton presents some

interesting and novel ideas, which deserve the most careful consideration.

HE subject to be considered here is one that should interest every physician; not only should specialists pay attention to the tonsils, but the internists as well.

Modern research and investigation has proven that many a trouble you and I considered and treated as a primary affection a few years ago is now known to be a secondary ailment resulting from diseased tonsils and from adenoids. This fact alone explains why the therapeutic agents employed at that time were of no value, the patient recovering of his own accord in spite of the treatment.

Tonsils and adenoids, by virtue of their location in the throat, are continually exposed to contact with every morsel of food eaten, every drop of water drunk, and every atom of air entering the lungs. Also, being very vascular, they are constantly absorbing toxic products and pouring them into the blood stream and directly into the lymphatic spaces and channels.

Hence, the fact that the tonsils are diseased more frequently than any other

*Read before the North Central Illinois Medical Association, at Streator, Illinois.

gland in the body and that ten percent of all affected tonsils are tuberculous, is enough to fear these organs when they become diseased.

Tonsillectomy Must Be Radical}

Tonsils often, without apparent cause, become very much enlarged; but, if not diseased and not mechanically interfering with breathing, there is no more of an indication for their removal than the amputation of a normal foot would be indicated because it required a large shoe. On the other hand, if a tonsil is diseased, it should be removed en capsule, no matter how small or how large it may be; and, when it is properly removed, every vestige of the gland and its capsule should come out.

Incomplete tonsil surgery does more harm than good. At one time, a few years ago, all that was required to treat a diseased tonsil surgically was to remove a portion of it with the tonsillotome and trust to nature for the formation of enough scar-tissue to do the rest. Today, that kind of tonsil surgery is known to be incomplete, as it hopelessly fails to bring about the desired result and relief.

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The greatest harm following the removal of tonsils is not entirely to the subject himself, but often to friends who are in real need of this operation. Inasmuch as his hopes did not materialize, he becomes prejudiced (unaware that the operation was improperly done), and so advises his invalid friends against having anything done. If this bad advice is followed, the delay often may result in some permanent damage, such as impaired hearing or general tuberculosis.

Every doctor who has a tonsillotome should throw it away; then he will not be tempted to put it to use. The complete removal of tonsils en capsule is a simple and easy operation, making it ridiculous to continue the old way, when the results are so unfavorable.

Chronic Sore Throat, and Disease Many cases of muscular rheumatism are preceded by follicular tonsillitis, and during the attack the patient complains of sore throat; a symptom which often is called, by the attending doctor, rheumatic sore throat. These patients learn to notice

Also blood and mucus ejector.

that when the throat begins to get sore, rheumatism soon follows. They also learn that when the throat begins to recover, in a short time the rheumatic attack is gone. From these symptoms, they often make an accurate prophesy of their recovery.

Cases of this kind should interest the internist, as they frequently find slight rheumatic cases associated with throat trouble. Often, in such cases, the rheumatism is entirely secondary to the toxins produced by some form of diseased condition within the tonsil, which is constantly pouring into the lymph and blood stream an autogenous toxin which, in this particular individual, causes rheumatism. Patients with purely secondary rheumatic attacks of this kind recover beautifully after a complete removal of the tonsils.

Several of those present here have had the tonsils removed from some of their rheumatic patients, and so far as I have been able to learn not a single one of these patients operated upon in St. James Hospital last year has had a severe attack of rheumatism since. Just here I wish to say that, often, cases of myocarditis of an

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Fig. 2.

The Middleton platform for oral surgery when raised to place the patient upon his side. Also, his blood and mucus injector.

obscure origin are due to the toxins manufactured by diseased tonsils; the removal of the tonsils causing a cure of the heart trouble is the positive proof of this.

The tonsil is a part of the lymphatic channel which connects the intramuscular spaces, synovial cavities, and lymphatic glands. It is a gland having a very strong absorbing as well as a large secreting power, which makes it liable to cause almost any kind of secondary trouble when in an active pathologic condition.

It matters not by what method tonsils are enucleated every operator thinks his is the best. The one thing to bear in mind in tonsil surgery is to remove the entire tonsil and its capsule without doing injury to any of the contiguous structures.

The crypts in the tonsils, whose walls have a very thin cover of squamous epithelium, are eight to ten in number, and they constitute the real danger channels, for in them particles of food and all kinds of debris are retained, and nearly every kind of known bacteria.

A crypt often becomes closed, and then nature endeavors to rid it of its foreign

material, permitting an inflammatory condition to begin, this spreading until in a short time we have a case of parenchymatous tonsillitis, due to an extension of the infection. This, in a few days, produces enough toxins, which, when absorbed into the blood, causes the individual to suffer with a regular set of general symptoms that, often, we call grip.

Recurrent Tonsillitis Must Be Investigated

Patients with recurring tonsillitis frequently apply for treatment again and again. In these cases, the routine gargle is prescribed, the patient is made to feel better, the throat becomes less painful, and he is considered cured; still, many times this is not so. Now, supposing such a person's diseased tonsils are allowed to remain undisturbed, then this patient might innocently continue to carry within his throat a dangerous condition, not realizing his real danger until eventually some serious trouble develops.

By way of illustration, permit me to recite a unique and instructive case from my practice.

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Fig. 3. Team work in tonsillar operation. Nurse across table with right hand holds tongue-depressor, and with left controls the anesthetic. The anesthetist has both hands free for the head. Left hand of nurse behind operator holds blood and mucus ejector; right hand handles the instruments. When operator finishes with an instrument he lays it on his lap, thus avoiding the awkwardness of reaching to nurse or table.

A young man, 26 years of age, had a sore throat some eight years ago and was told by his physician that his tonsils were badly diseased and should be removed. This advice was not followed, the trouble being looked upon as trifling and the advice rather poor.

The man's throat continued to give trouble, this each year growing worse, and from time to time the attacks not only lasted longer but grew more severe; until eight years later, during an attack, a smear was made from a crypt of one tonsil, and it showed many pus-cells, streptococci, staphylococci, and other microorganisms. The whole throat was very much injected and inflamed at the time. The usual throat antiseptics, in the form of gargles, and so on, were prescribed, and the advice was repeated that the tonsils be completely removed after the subsidence of the acute inflammatory symptoms.

The patient was not seen again for three months, when he returned to exhibit what

he called a healthy throat, and thus hoped to prove how ridiculous it would have been to operate. A smear now taken was like the former one, which had been made during the inflammatory attack, except that there was a great reduction in puscells.

Several months later, this man returned with a troublesome hacking cough, with not much soreness in the throat, but complaining of a constant annoying glycerin-like phlegm accumulating in the throat, keeping him awake at nights and spoiling his appetite. He had many other disagreeable symptoms, and had lost fifteen pounds in weight. He said he was sick all over.

A smear made at this time was an almost complete duplicate of the first specimen, besides exhibiting many thousands of tuberculosis bacilli. In fact, the tonsils were like a regular culture-tube filled with the bacilli.

The presence of these organisms, together with other constitutional symptoms,

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