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THERAPY OF DIARRHŒA IN CHOLERA
1045 follows in a small percentage of cases, but the repair advised by Cattell has robbed the operation of much of its difficulty. The poor cosmetic result of the paramedian incision is partly concealed when the patient is examined on a couch. In the erect position an ugly transverse fold appears at the upper limit of the sear. For this reason I have taken incision for to using the Pfannenstiel or " bikini exploring the lower abdomen in girls whose face and figure may play a part in their fortune. It gives very good access, is immune from hernia, and is much "
appreciated.
Barnet General Hospital.
V. J. DOWNIE.
SiE,—If I say that the plea of Mr. Ewing and 111’..Monro for the
of the gridiron incision in what Mr. Punch calls " another appendicitis glimpse of the obvious," I am not unmindful that many surgeons still make large paramedian holes and that the reminder is salutary. Many think that one cannot deal with the appendix through a gridiron incision in young children and even in babies, whereas the procedure is not nearly as difficult as it in theory might appear. I have pointed out elsewhere’ the advantage of this incision in dealing with long-standing recurrent abdominal pain in children where the diagnosis is not firm, but where parents are kept in continual suspense lest the next attack may be a fulminating appendicitis. By the time it is decided that intervention is necessary, any lesion in any other part of the abdomen will almost certainly have manifested itself ; and through a gridiron incision one can see and remove the appendix, examine the mesentery for adenitis, and withdraw enough small bowel to exclude a Meckel’s diverticulum. These are the three likely organic causes of such recurrent pain when the kidney has been excluded. The morbid result described by Ewing and Monro following a paramedian incision reminds me that someone once said that no-one who had had a paramedian incision It may ever played on the centre court at Wimbledon. be an overstatement ; but the sequelae to large laparotomies, especially in the presence of sepsis, make me think that any exception is likely to be a rarity. On Mr. Shemilt’s dictum (Oct. 31) that the abdomen should never be drained in appendicitis I will confine
is to
use
me
myself to parliamentary language and only register grief, as he also in time will, certainly if he persists with such practice in children. too long that does harm.
It is the drain that is left in
CHARLES DONALD.
London, W.l.
SiB,—Mr. Shemilt’s letter moves me to support his plea for Battle’s maligned incision. It has served I do not recommend it for me well for forty years. opening an abscess or for very fat patients, and I prefer an oblique muscle-cutting incision for the high-lying retrocaecal appendix. With Battle’s incision the nerves are clearly seen and
should not be cut.
Their distribution seldom conforms
to the
diagrams in anatomy books. Caution must be used in extending the incision upwards ; but, after controlling the deep epigastric vessels, it can be carried down to give excellent access to the pelvis. Hernia is rare after Battle’s incision, and my impression is that it is more often seen after McBurney’s. Colt and Morrison,2 in an inquiry into the relationship between the death-rate after operation for acute appendi-
citis and the incision
lowest mortality article is worth
occurs
used, found that " much the with the Battle incision." Their
studying. C. C. HOLMAN.
Northampton. 1.
Practitioner, 1952, 168,
41.
2. Colt, G. H., Morrison, M. M.
Brit. J. Surg. 1932, 20, 197.
THERAPY OF DIARRHŒA IN CHOLERA
SiR,łThe diarrhoea and vomiting of cholera lead rapidly to a great loss of body-fluid and electrolytes and
ultimately to progressive shock which is often irreversible and fatal. During the last few decades workers on cholera have been trying every available remedy to check this diarrhoea, but without any appreciable success. The sulpha drugs,1-3 and the antibiotics chloranlphenicol,45terramycin,6-9 and aureomycin,210 have little or no effect in checking the diarrhoea or in reducing the mortality-rate of cholera, although the antibiotics can render the stools bacteriologically negative. Consequently, the present tendency in cholera therapy is to disregard the diarrhoea and to concentrate on the replacement of fluid and electrolytes.3 11 During the severe epidemic of 1953 in Calcutta the cholera patients in my ward were given by mouth the crude juice from the leaf of a plant Bengal called pathorchur (Coleus aromat-
common
of
"
"
icus), green
a
short
plant
about 2 ft. high with thick crenate leaves giving off a
camphor-like odour (see figure). The juice from the leaf is a greenish fluid with a pleasant taste and smell and without any deleterious effect on any physiological system. The dosage consisted of the following hourly doses : 1st dose, 4 teaspoonfuls ; 2nd If the diarrhoea and 3rd doses, 2 teaspoonfuls each. continued after eight hours on the first day, the doses were repeated in the evening. On subsequent days the above doses were repeated unless there was constipation. Every 6th case in order of admission was tested as a control. The 40 controls were not given any leaf juice, but the routine treatment of shock and other complications In addition, were just the same as in the treated cases. the control cases received four doses daily of a routine suspension containing kaolin (gr. 30) and bismuth carbonate (gr. 20) in each dose. The following results were obtained :
(1) Of 200 treated cases twenty-four hours in 40%,
the diarrhoea was checked within within forty-eight hours in 74%, and within seventy-two hours in 92-5%. Of 40 controls the diarrhoea was spontaneously checked within twentyfour hours in 5%, within forty-eight hours in 12-5%, and within seventy-two hours in 30%. (2) Stool cultures showed a peculiarity-i.e., rough colonies of the vibrio appeared comparatively early, in the second culture, after twenty-four hours’ leaf-juice therapy. The proportion of rough colonies to smooth continued to increase in the successive cultures, the smooth colonies being scanty 1. Lahiri, S. C. Brit. med. J. 1951, i, 500. 2. Chaudhuri, A. K. R., Chaudhury, A., Chadha, V. N. Antiseptic, 1952, 49, 717. 3. Konar, N. R., Sen Gupta, A. N., Baksh, E. Calcutta med. J. 1953, 50, 212. 4. Gauld, R. L., Schlingman, A. S., Jackson, E. B., Baston H. C., Cambell, C. C. J. Bact. 1949, 57, 349 5. Chaudhuri, R. N., Ghosal, S., Rai Chaudhuri, M. N. Indian med. Gaz. 1950, 85, 398. 6. Chaudhuri, R. N., Ghosal, S. C., Mondol, A., Chakravarty, N. K. Ibid, 1953, 87, 455. 7. Das, A., Ghosal, S., Gupta, S. K., Chaudhuri, R. N. Ibid, 1951, 86, 437. 8. Konar, N. R., Sengupta, A. N. Ibid, p. 469. 9. Das, A., Ghosal, S. C., Mondol, H., Gupta, S. K. J. Indian med. Ass. 1953, 22, 268. 10. Seal, S. C., Ghosal, S. C., Ghosh, M. M. Indian med. Gaz. 1951, 86, 287. 11. McRobert, G. Practitioner, 1952, 169, 420.
1046 absent in the fifth or sixth culture. In the controls smooth colonies preponderated up to the twelfth culture. (3) The mortality-rate was 85% (17 cases out of 200) with eaf-juice therapy 20% (8 cases out of 40) among the control cases ; and 19-7% (215 cases out of 1093) among all the patients with cholera admitted to the ward. or
This treatment of diarrhoea, combined with the treatment of vomiting withAvomine,’ plus the use of antihistamines and vitamin C for their preventive and curative effects against uraemia,12 made it possible to dispense with parenteral and intravenous injection of fluid in a substantial number of patients who would otherwise have required this. Chittaranjan Hospital, Calcutta.
HEMENDRA NATH CHATTERJEE.
DRIED BONES hesitate to intrude on your columns with so SiR,-I small a matter, but surely Dr. Davies and Dr. Harvey (Oct. 24) are maligning the Far East in fathering upon it their anthrax-infected bones (even though they were shipped from somewhere East of Suez). East is East, Near East is the Levant, Middle East Babylonia, and the These bones Far East Malaysia and the China Seas. came from India and Pakistan, which are no sort of East on this reckoning. One of the minor snags of the partition is that it has left us with no convenient name for the subcontinent, but to misuse the term Far East is no answer to the problem. Postgraduate Medical School of BERNARD LENNOX.
London, W.12.
ASPHYXIA IN THE NEWBORN
SiR,-Professor Pask (Oct. 31) quite properly draws attention to the defects in the explanation and diagram in my letter of Oct. 17, and I am sorry that he feels he has been misquoted. The details of the apparatus could be only briefly described in a letter, so perhaps I may add some further explanation. The endotracheal tube used most often is a MeGill size 00. The needles are those supplied by the Canadian Red Cross and are somewhat larger than the needle in the standard giving-set. Rebreathing in the anaesthetic sense-namely, to conserve an anaesthetic agent-is not required. The infant does not rebreathe to any great extent, for the supply of oxygen is more than adequate. Sometimes the fingers of the glove have been taped off and the glove attached to a branch piece of suitable diameter, and then rebreathing was really taking place. However, most often the setting of the oxygen-supply is such as to inflate the glove partly. This works well as an indicator of spontaneous respiration, as well as being all that is necessary for gentle inflation. It should be remembered that an infant face-mask is manufactured and widely used. It fits the standard Boyle’s machine and in the resuscitation of infants it is commonly used with the adult rebreathing bag. My diagram showed a tube leading to an oxygen-supply, but the oxygen is not connected directly : two release needles intervene and a reducing valve supplies oxygen at a low pressure. A water manometer is not used, for I think that there is a real risk that the first (and most important) spontaneous inspiration might result in the aspiration of water. The endotracheal tube is never a tight fit in the infant trachea and allows further leakage. Obviously, great care must be taken to avoid undue pressure.
Just as no anaesthetic agent is safer than the person who employs it, so no emergency ventilation method is foolproof. Neonatal asphyxia is a desperate emergency and forthright methods are justified. There is certainly a risk of overinflation, as Professor Pask emphasises, but it depends very largely on the diligence and care of the operator. At all events, complete anoxia is a graver risk. It is unfortunately true that the securing of an airway by an accurately placed endotracheal tube may not be sumcient. Positive-pressure ventilation is a vital and immediate necessity in some cases of neonatal apnoea ; 12.
Chatterjee, H. N.
Lancet, 1952, ii, 90.
and with the widespread use of pethidine, apncea due to narcosis is possibly on the increase. Post-mortem examinations are carried out after all neonatal deaths, and the pathologists have been par. ticularly requested to report in detail any respiratory injury. No such injury has been found. On the other hand, lungs have been described as completely atelectatit when adequate inflation had been used. The intravenous needles are a more substantial safe. guard than may be immediately apparent. In 1942 some medical officers of fighter squadrons were asked to submit reports on an oxygen economiser then in use. I used a Spitfire Mk. Vb kindly loaned by No. 71 Squadron at Martlesham. A too generous setting of the oxygen cylinder-which in those days was out of the reach of the pilot behind his armour-plating-provided me with personal experience of overinflation. I used intravenous needles to provide a blow-off, and know that it is a sound and practical device. I gather from the accounts of Lieut.-Commander Lithgow’s recent troubles in North Africa that oxygen-valves still give annoyance sometimes, Watford
Maternity Hospital.
J. NOEL JACKSON.
CERVICAL SPONDYLOSIS SIMULATING MOTOR-NEURONE DISEASE
SiR,—Dr. Morris’s letter (Oct. 31) on the diagnosis of motor-neurone disease seems to imply that a brisk JM. jerk is the absolute criterion of this condition, and that a normal jaw-jerk is incompatible with a diagnosis of motor-neurone disease. I am sure, however, that Dr. Morris will agree that in " progressive muscular atrophy" no alteration will be found in the jaw-jerk until a late stage in the development of the process, and indeed the reflex may never be abnormal. Even in the amyotrophic lateral sclerotic " form of motor-neurone disease. briskness of the jaw-jerk may follow briskness of othel reflexes only after an appreciable interval. To complete the factual record, however, may I add that in our cases of cervical spondylosis the jaw-jerk was not increased. The Royal Infirmary, L. A. LIVERSEDGE. Manchester.
RISKS OF TONSILLECTOMY
SIR.,—Mr. McKenzie’s article last week stirs memorie,
quarter of a century old. As house-surgeon in a London children’s hospital I was responsible for the twice-weekly reception of 12 children, aged from 2 to 10 years, and for their care during the three daysof their stay. Anaesthesia was by ethyl chloride (2 ml. in a bag) : tonsillectomy was by blunt guillotine, really used as a holder whilst the forefinger of the hand was swept round the end of the erect guillotine and invariably found the capsular plane. I was called during the night, as occasion demanded, to control haemorrhage by pressing directly into the tonsillar fossa with a prepared swab the size of a walnut and soaked in spirits of turpentine. During my six monthsiu residence no vessel had to be ligatured and no child died of haemorrhage or was given a blood-transfusion, I do not attribute this to the turpentine, but to the fact that the vessels were torn by the dissecting finger. With regard to pain following tonsillectomy, I recall the removal of the tonsils of a girl of 18. One tonsil was held in the blunt guillotine and removed by sweeping the forefinger behind the guillotine, and the other tonsil was removed by dissection : she had pain in the dissected fossa and none at all on the guillotined side. The reason is that the pharyngeal muscles are subjerr to long-continued and repeated damage on the distected side, whereas a blunt guillotine, slowly closed, finds the capsular plane with little trauma, the finger merelv disrupting the various vessels which bind the tons to the pharyngeal wall. a
appropriate
appreciated.
Barnet General Hospital.
V. J. DOWNIE.
SiE,—If I say that the plea of Mr. Ewing and 111’..Monro for the
of the gridiron incision in what Mr. Punch calls " another appendicitis glimpse of the obvious," I am not unmindful that many surgeons still make large paramedian holes and that the reminder is salutary. Many think that one cannot deal with the appendix through a gridiron incision in young children and even in babies, whereas the procedure is not nearly as difficult as it in theory might appear. I have pointed out elsewhere’ the advantage of this incision in dealing with long-standing recurrent abdominal pain in children where the diagnosis is not firm, but where parents are kept in continual suspense lest the next attack may be a fulminating appendicitis. By the time it is decided that intervention is necessary, any lesion in any other part of the abdomen will almost certainly have manifested itself ; and through a gridiron incision one can see and remove the appendix, examine the mesentery for adenitis, and withdraw enough small bowel to exclude a Meckel’s diverticulum. These are the three likely organic causes of such recurrent pain when the kidney has been excluded. The morbid result described by Ewing and Monro following a paramedian incision reminds me that someone once said that no-one who had had a paramedian incision It may ever played on the centre court at Wimbledon. be an overstatement ; but the sequelae to large laparotomies, especially in the presence of sepsis, make me think that any exception is likely to be a rarity. On Mr. Shemilt’s dictum (Oct. 31) that the abdomen should never be drained in appendicitis I will confine
is to
use
me
myself to parliamentary language and only register grief, as he also in time will, certainly if he persists with such practice in children. too long that does harm.
It is the drain that is left in
CHARLES DONALD.
London, W.l.
SiB,—Mr. Shemilt’s letter moves me to support his plea for Battle’s maligned incision. It has served I do not recommend it for me well for forty years. opening an abscess or for very fat patients, and I prefer an oblique muscle-cutting incision for the high-lying retrocaecal appendix. With Battle’s incision the nerves are clearly seen and
should not be cut.
Their distribution seldom conforms
to the
diagrams in anatomy books. Caution must be used in extending the incision upwards ; but, after controlling the deep epigastric vessels, it can be carried down to give excellent access to the pelvis. Hernia is rare after Battle’s incision, and my impression is that it is more often seen after McBurney’s. Colt and Morrison,2 in an inquiry into the relationship between the death-rate after operation for acute appendi-
citis and the incision
lowest mortality article is worth
occurs
used, found that " much the with the Battle incision." Their
studying. C. C. HOLMAN.
Northampton. 1.
Practitioner, 1952, 168,
41.
2. Colt, G. H., Morrison, M. M.
Brit. J. Surg. 1932, 20, 197.
THERAPY OF DIARRHŒA IN CHOLERA
SiR,łThe diarrhoea and vomiting of cholera lead rapidly to a great loss of body-fluid and electrolytes and
ultimately to progressive shock which is often irreversible and fatal. During the last few decades workers on cholera have been trying every available remedy to check this diarrhoea, but without any appreciable success. The sulpha drugs,1-3 and the antibiotics chloranlphenicol,45terramycin,6-9 and aureomycin,210 have little or no effect in checking the diarrhoea or in reducing the mortality-rate of cholera, although the antibiotics can render the stools bacteriologically negative. Consequently, the present tendency in cholera therapy is to disregard the diarrhoea and to concentrate on the replacement of fluid and electrolytes.3 11 During the severe epidemic of 1953 in Calcutta the cholera patients in my ward were given by mouth the crude juice from the leaf of a plant Bengal called pathorchur (Coleus aromat-
common
of
"
"
icus), green
a
short
plant
about 2 ft. high with thick crenate leaves giving off a
camphor-like odour (see figure). The juice from the leaf is a greenish fluid with a pleasant taste and smell and without any deleterious effect on any physiological system. The dosage consisted of the following hourly doses : 1st dose, 4 teaspoonfuls ; 2nd If the diarrhoea and 3rd doses, 2 teaspoonfuls each. continued after eight hours on the first day, the doses were repeated in the evening. On subsequent days the above doses were repeated unless there was constipation. Every 6th case in order of admission was tested as a control. The 40 controls were not given any leaf juice, but the routine treatment of shock and other complications In addition, were just the same as in the treated cases. the control cases received four doses daily of a routine suspension containing kaolin (gr. 30) and bismuth carbonate (gr. 20) in each dose. The following results were obtained :
(1) Of 200 treated cases twenty-four hours in 40%,
the diarrhoea was checked within within forty-eight hours in 74%, and within seventy-two hours in 92-5%. Of 40 controls the diarrhoea was spontaneously checked within twentyfour hours in 5%, within forty-eight hours in 12-5%, and within seventy-two hours in 30%. (2) Stool cultures showed a peculiarity-i.e., rough colonies of the vibrio appeared comparatively early, in the second culture, after twenty-four hours’ leaf-juice therapy. The proportion of rough colonies to smooth continued to increase in the successive cultures, the smooth colonies being scanty 1. Lahiri, S. C. Brit. med. J. 1951, i, 500. 2. Chaudhuri, A. K. R., Chaudhury, A., Chadha, V. N. Antiseptic, 1952, 49, 717. 3. Konar, N. R., Sen Gupta, A. N., Baksh, E. Calcutta med. J. 1953, 50, 212. 4. Gauld, R. L., Schlingman, A. S., Jackson, E. B., Baston H. C., Cambell, C. C. J. Bact. 1949, 57, 349 5. Chaudhuri, R. N., Ghosal, S., Rai Chaudhuri, M. N. Indian med. Gaz. 1950, 85, 398. 6. Chaudhuri, R. N., Ghosal, S. C., Mondol, A., Chakravarty, N. K. Ibid, 1953, 87, 455. 7. Das, A., Ghosal, S., Gupta, S. K., Chaudhuri, R. N. Ibid, 1951, 86, 437. 8. Konar, N. R., Sengupta, A. N. Ibid, p. 469. 9. Das, A., Ghosal, S. C., Mondol, H., Gupta, S. K. J. Indian med. Ass. 1953, 22, 268. 10. Seal, S. C., Ghosal, S. C., Ghosh, M. M. Indian med. Gaz. 1951, 86, 287. 11. McRobert, G. Practitioner, 1952, 169, 420.
1046 absent in the fifth or sixth culture. In the controls smooth colonies preponderated up to the twelfth culture. (3) The mortality-rate was 85% (17 cases out of 200) with eaf-juice therapy 20% (8 cases out of 40) among the control cases ; and 19-7% (215 cases out of 1093) among all the patients with cholera admitted to the ward. or
This treatment of diarrhoea, combined with the treatment of vomiting withAvomine,’ plus the use of antihistamines and vitamin C for their preventive and curative effects against uraemia,12 made it possible to dispense with parenteral and intravenous injection of fluid in a substantial number of patients who would otherwise have required this. Chittaranjan Hospital, Calcutta.
HEMENDRA NATH CHATTERJEE.
DRIED BONES hesitate to intrude on your columns with so SiR,-I small a matter, but surely Dr. Davies and Dr. Harvey (Oct. 24) are maligning the Far East in fathering upon it their anthrax-infected bones (even though they were shipped from somewhere East of Suez). East is East, Near East is the Levant, Middle East Babylonia, and the These bones Far East Malaysia and the China Seas. came from India and Pakistan, which are no sort of East on this reckoning. One of the minor snags of the partition is that it has left us with no convenient name for the subcontinent, but to misuse the term Far East is no answer to the problem. Postgraduate Medical School of BERNARD LENNOX.
London, W.12.
ASPHYXIA IN THE NEWBORN
SiR,-Professor Pask (Oct. 31) quite properly draws attention to the defects in the explanation and diagram in my letter of Oct. 17, and I am sorry that he feels he has been misquoted. The details of the apparatus could be only briefly described in a letter, so perhaps I may add some further explanation. The endotracheal tube used most often is a MeGill size 00. The needles are those supplied by the Canadian Red Cross and are somewhat larger than the needle in the standard giving-set. Rebreathing in the anaesthetic sense-namely, to conserve an anaesthetic agent-is not required. The infant does not rebreathe to any great extent, for the supply of oxygen is more than adequate. Sometimes the fingers of the glove have been taped off and the glove attached to a branch piece of suitable diameter, and then rebreathing was really taking place. However, most often the setting of the oxygen-supply is such as to inflate the glove partly. This works well as an indicator of spontaneous respiration, as well as being all that is necessary for gentle inflation. It should be remembered that an infant face-mask is manufactured and widely used. It fits the standard Boyle’s machine and in the resuscitation of infants it is commonly used with the adult rebreathing bag. My diagram showed a tube leading to an oxygen-supply, but the oxygen is not connected directly : two release needles intervene and a reducing valve supplies oxygen at a low pressure. A water manometer is not used, for I think that there is a real risk that the first (and most important) spontaneous inspiration might result in the aspiration of water. The endotracheal tube is never a tight fit in the infant trachea and allows further leakage. Obviously, great care must be taken to avoid undue pressure.
Just as no anaesthetic agent is safer than the person who employs it, so no emergency ventilation method is foolproof. Neonatal asphyxia is a desperate emergency and forthright methods are justified. There is certainly a risk of overinflation, as Professor Pask emphasises, but it depends very largely on the diligence and care of the operator. At all events, complete anoxia is a graver risk. It is unfortunately true that the securing of an airway by an accurately placed endotracheal tube may not be sumcient. Positive-pressure ventilation is a vital and immediate necessity in some cases of neonatal apnoea ; 12.
Chatterjee, H. N.
Lancet, 1952, ii, 90.
and with the widespread use of pethidine, apncea due to narcosis is possibly on the increase. Post-mortem examinations are carried out after all neonatal deaths, and the pathologists have been par. ticularly requested to report in detail any respiratory injury. No such injury has been found. On the other hand, lungs have been described as completely atelectatit when adequate inflation had been used. The intravenous needles are a more substantial safe. guard than may be immediately apparent. In 1942 some medical officers of fighter squadrons were asked to submit reports on an oxygen economiser then in use. I used a Spitfire Mk. Vb kindly loaned by No. 71 Squadron at Martlesham. A too generous setting of the oxygen cylinder-which in those days was out of the reach of the pilot behind his armour-plating-provided me with personal experience of overinflation. I used intravenous needles to provide a blow-off, and know that it is a sound and practical device. I gather from the accounts of Lieut.-Commander Lithgow’s recent troubles in North Africa that oxygen-valves still give annoyance sometimes, Watford
Maternity Hospital.
J. NOEL JACKSON.
CERVICAL SPONDYLOSIS SIMULATING MOTOR-NEURONE DISEASE
SiR,—Dr. Morris’s letter (Oct. 31) on the diagnosis of motor-neurone disease seems to imply that a brisk JM. jerk is the absolute criterion of this condition, and that a normal jaw-jerk is incompatible with a diagnosis of motor-neurone disease. I am sure, however, that Dr. Morris will agree that in " progressive muscular atrophy" no alteration will be found in the jaw-jerk until a late stage in the development of the process, and indeed the reflex may never be abnormal. Even in the amyotrophic lateral sclerotic " form of motor-neurone disease. briskness of the jaw-jerk may follow briskness of othel reflexes only after an appreciable interval. To complete the factual record, however, may I add that in our cases of cervical spondylosis the jaw-jerk was not increased. The Royal Infirmary, L. A. LIVERSEDGE. Manchester.
RISKS OF TONSILLECTOMY
SIR.,—Mr. McKenzie’s article last week stirs memorie,
quarter of a century old. As house-surgeon in a London children’s hospital I was responsible for the twice-weekly reception of 12 children, aged from 2 to 10 years, and for their care during the three daysof their stay. Anaesthesia was by ethyl chloride (2 ml. in a bag) : tonsillectomy was by blunt guillotine, really used as a holder whilst the forefinger of the hand was swept round the end of the erect guillotine and invariably found the capsular plane. I was called during the night, as occasion demanded, to control haemorrhage by pressing directly into the tonsillar fossa with a prepared swab the size of a walnut and soaked in spirits of turpentine. During my six monthsiu residence no vessel had to be ligatured and no child died of haemorrhage or was given a blood-transfusion, I do not attribute this to the turpentine, but to the fact that the vessels were torn by the dissecting finger. With regard to pain following tonsillectomy, I recall the removal of the tonsils of a girl of 18. One tonsil was held in the blunt guillotine and removed by sweeping the forefinger behind the guillotine, and the other tonsil was removed by dissection : she had pain in the dissected fossa and none at all on the guillotined side. The reason is that the pharyngeal muscles are subjerr to long-continued and repeated damage on the distected side, whereas a blunt guillotine, slowly closed, finds the capsular plane with little trauma, the finger merelv disrupting the various vessels which bind the tons to the pharyngeal wall. a
appropriate