follicular tonsillitis. Tubercular adenopathy of the superficial and deep cervical lymphatics with secondary abscess formation at two points. Physical findings otherwise negative.

Surgical treatment: Tonsillectomy of left faucal tonsil according to my own technique, with scissors and forceps. Local anesthenia. Removal of all the

palpable tuberculous cervical glands under general anesthesia.

Subsequent removal of the right faucal tonsil and treatment of the nasal and pharyngeal catarrh, by incision, cauterization and topical applications will be instituted when the patient leaves the hospital.

Medical treatment: Systematic provision for pure air, fattening diet and relaxation.

Case 2-Mrs. K., a poorly-nourished blonde, aged 30, German descent; housewife. Family history not significant. Clinical history: Had enjoyed good health barring "colds" and acute follicular tonsillitis. Her present trouble began some five years ago, shortly after moving into a "flat" where a woman had recently died of tuberculosis of the bowels. The patient's attention was first called to her present illness by inability to raise her left arm from the body. Some swelling in the axilla accompanying this affection was not looked upon as of importance. There was no considerable pain in the shoulder nor involvement of any other joints. It was treated medically for rheumatism and for central motor paralysis; osteopathically for partial dislocation of the shoulder joint, and surgically for tuberculosis of the joint. These therapeutic measures covered a period of three years.

Physical examination: When I first saw the patient at the beginning of her fourth year of illness, her evening temperature was 99 1-2 and pulse 96. There was atrophy, from disuse of the deltoid muscle, and free passive motion in the joint in all directions, excepting that abduction was limited and voluntary abduction almost impossible. There was no pain, tenderness nor crepitus in the joint. The X-ray showed slight luxation of the head of the humerus. The axilla and infraclavicular space was filled with enlarged glands. A chain of small hard glands could be traced up the neck from the clavicle to the angle of the jaw of the same side. The tonsil of the same side was atrophied and the seat of a chronic infectious process. The teeth and gums were healthy. The nasal, auditory, buccal and pharyngeal cavities showed no other lesions, nor did the rest of the body show any.

Diagnosis: Primary tuberculosis of the left tonsil. Metastasis down a chain of cervical lymphatics to the infraclavicular and axillary groups, with cicatrization of the cervical glands and extensive softening of the glands of the other groups. Pressure paralysis of the circumflex nerve incident to axillary adenopathy.

Surgical treatment. Entire removal of left tonsil.

Removal of all palpable glands in the axilla and infra-clavicular spaces. Exploration of the shoulder joint in which no inflammatory lesion was discovered.

Medical treatment: Systematic provision for pure air, fattening diet and relaxation.

This patient has been cured and in sound health for nearly two years. She has recovored the use of her left arm so that she can dress her hair with the left hand and use it for all general purposes.

To summarize, the following general principles with reference to the treatment of tuberculous lymphadenitis in the neck and other parts containing lymphatics tributary thereto, should be observed:

1. The primary focus should in all cases be ascertained and the infection eradicated therein at the earliest possible moment. If the tonsils are diseased it is a positive indication for their removal.

2. The removal of the tonsils must be complete. Snipping them off with a tonsillotome does not fulfill the requirements of treatment.

3. All secondary foci should be as thoroughly dealt with surgically as the case will warrant.

4. All cases should be followed up with a vigorous course of anti-tubercular treatment, for in no case is it likely that the infected tissues are removed in toto.

LACTIC ACID BACILLI.

They Change Putrefaction Into Fermentation and Inhibit Proteolytic Activity. Kendall, in Pediatrics, thus summarizes the effects of lactic acid bacilli therapy:

(1) Objectionable proteolytic activity resulting in the absorption by the host of aromatic substances derived from protein decomposition by the action of proteolytic bacteria may take place in the intestinal tract.

(2) These aromatic compounds may be formed in the small or large intestines by the facultative or obligate proteolytic organisms.

or

(3) An excess of protein in the diet of the host, or any factor, causing stasis impaired absorption of protein, appears to be the direct cause of this condition. The result is an unusual amount of available food, which stimulated the development of these proteolytic intestinal organisms.

(4) The addition to the diet of easily fermentable carbohydrate, together with the restriction of the protein, is of material assistance in reducing the output of these putrefactive products in many instances.

(5) The beneficial action of the carbohydrate is a twofold one. First, the character of the metabolism of the facultative organisms tends to change from the putrefactive to the fermentative type, eliminating from the urine the putrefactive products referable to their activity; and, secondly, the lactic acid bacilli, either those given by mouth or those normally present in the intestinal canal, both, proliferate rapidly, forming considerable amounts of lactic acid from this carbohydrate and inhibiting the further development of the obligate proteolytic organisms by rendering the medium in which they are growing unsuitable for continued development.

or

(6) The proteolytic bacteria may be producing their harmful effects either in the small or large intestine; in the former case the introduction of organisms of the bulgarian type, may be reasonably expected to be of benefit, since we have seen that they tend to localize themselves in the small intestine. If, however, the proteolytic process is of large intestinal origin, the normal lactic acid bacilli of the acidophilus type are indicated. If there is reason to suspect that these normal intestinal lactic acid bacilli are enfeebled in their action, or absent, it will be necessary to feed fresh cultures by mouth, or introduce them per rectum.

THE TONSILS AND THE LUNGS.

J.

R. SCOTT, in the Medical Review of Reviews, says an attack of acute tonsillitis is precipitated when, for any reason, the vitality of the individual is suddenly lowered or the integrity of the cell wall is impaired to the extent that the defensive property of the epithelial cells is inadequate. The resulting irritation causes the tonsil to become reddened, swollen and tender, the heat causes a decrease in mucus, the proliferation and exfoliation of the epithelial cells become more rapid, the mouths of the crypts become clogged, and the rapidly multiplying bacteria overwhelm the resisting forces and find easy entrance. The toxins, also, are absorbed and produce more or less severe systemic disturbance.

Within a few days the defensive forces are marshaled and either gain the ascendancy, or pus forms. If pus forms, after its discharge the patient rapidly regains his health. The tonsil, however, seldom regains its former condition. In one or more of the crypts disease lingers, and gradually extends as a chronic lowgrade inflammation throughout the entire organ.

Often the disease begins as a chronic trouble, the patient never having had an attack of "sore throat." The tonsil substance and connective tissue elements multiply, and as one or the other element predominates, the tonsil becomes greatly enlarged and soft, or moderately enlarged and firm. Inflamed connective tissue inevitably contracts, and the resulting contraction in the tonsil distorts the lumen of the crypts, and narrows or obstructs them, thus retarding or preventing the discharge of the fermenting and decomposing contents.

The product of this chemical laboratory within the tonsil is absorbed with varying baneful results. The tonsils are intimately connected with the chain of glands lying back of the sternocleidomastoid muscle, and these are but a part of a rich network of lymphatics found in the cervical and clavicular region. Experimentation with solutions of coloring substances has shown that when they are injected into a tonsil they find their way quickly into the lymphatics of the neck, and the coloring soon reaches and stains the parietal pleura of the corresponding side.

Within eight or ten days after the injection, plastic adhesions between the pleuritic and pneumonic layers take place, and the apex of the lung becomes stained also. This, as a probable route for tubercular invasion, should be carefully considered, because the tubercle bacilli are often found in the tonsillar crypts, and tubercular lesions are present in from 4 to 10% of all tonsils removed, and, further, tubercular glands in the neck precede instead of follow tubercular disease in the lungs. That such infection occurs from inhalation of the specific germs seems hardly tenable when one considers that they are anerobic, and that the portion of the lung first affected is little used, especially by those most susceptible, and hence other parts of the lung would receive much the largest portion of inspired bacilli.

Recent experiments have shown that the tubercle bacilli rapidly disappear from the blood after the introduction into the blood current, hence infection of the lungs from that source presupposes an infection in some other part of the body. Some investigators believe that the bacilli are taken into the body with food and enter the circulation through the absorb

ent vessels of the alimentary tract. This is a rational theory, but leaves unexplained the peculiar liability of the apices to tubercular infection.

HYPEREMIA IN THE TREATMENT OF IMPOTENCE.

Silas T. Yount, in the American Journal of Physiologic Therapeutics, states that the influence of impotence on the man unfortunate enough to suffer from this disease is very widespread. The nervous vitality, mentality, digestion metabolism and, in fact, almost every normal function of the body is directly. or indirectly affected.

Drugs Useless in These Cases. The pernicious and altogether useless practice of administering a class of drugs given the deceiving title of aphrodisiacs has done much to bring the treatment of this condition into disrepute. All too often the sufferer falls into the hands of unscrupulous men and is mulcted of his means with little or nothing given in return.

The physical methods of treatment are of unquestionable value in the treatment of impotence. Judicious hydrotherapy, the use of several forms of electricity, massage and diet all may be used with evident advantage. There is one form of non-medicinal therapy, however, which seems most rational on the face of it. I refer to hyperemia, or the mechanical increase of the amount of blood in the part.

I have had a rather extended experience in treating this class of cases with an appliance which has been called the erectruss. Since 1907 I have used this method in the treatment of 95 cases of impotence. These cases I have divided into three classes according to the conditions present. Class A: Those completely impotent for at least one and up to ten years, the ages ranging from 56 to 75 years. These constituted 40 per cent of the whole number. Class B:

Class C. 90% cured or relieved.
10% no results.

These results were obtained by the hyperemic method alone. All aphrodisiacs, tonics, electricity or hydrotherapeutic measures were entirely eschewed. Nothing was used but hyperemia caused by the use of erectruss.

A number of those enumerated in Classes A and B have found that after the use of this appliance for six months or a year, they can functionate without it. In Class C a large percentage stopped the treatments because they did not require them after two or three months.

The Raison d'Etre of This Method.

The method under discussion relieves and cures on the now well-known principle first prominently brought forward by Professor August Bier, of the University of Berlin, under the name "Stauungs-hyperämie" or damming hyperemia, best called congestion.

Willy Meyer, in his book, "Bier's Hyperemic Treatment," says: "To employ artificial hyperemia means to increase the quantity of blood in a given diseased part of the body." Again: "Physicians must learn to recognize in the circulatory blood one of the most powerful factors in the human and animal system in bringing about "spontaneous cures." In another place he adds: "The blood must continue to cir

culate and there must never be a stasis of blood."

The practical results obtained with the hyperemic method of treatment have proved beyond a doubt the absolute correctness of the theories advanced by Professor Bier. What must be our sole aim in the treatment of impotence is to retard the return of the blood from the organ, in this way increasing the quantity of blood normally contained therein; but in no way interfering with the influx of blood from the dorsal artery and the artery of the corpus cavernosum.

Properly used, this method of treatment is, in my judgment, absolutely correct, there being no pain, no cyanosis and no inconvenience. In place of this there is a noticeable hyperemia of the organ followed by a normal erection. This treatment is strictly based on physiologic facts and is effective, harmless and satisfactory.

CULTIVATION OF TUBERCULOSIS BA

CILLI FROM SPUTUM.

There has always been much difficulty in cultivating the tubercle bacilli directly from the sputum, especially on account of the many secondary organisms. Brown and Smith, as reported in the Journal of Medical Research, have, however, by a simple procedure succeeded in obtaining pure cultures from the sputum in from nine to twenty days almost constantly in cases in which the organism was present. The secondary organisms were destroyed by treating the sputum with an equal part of 30% antiformin solution (equal parts of Javelle water and a 15% watery solution of sodium hydrate). After standing for one hour the sputum was centrifuged out and washed three times in distilled water, the sediment then being streaked on Dorset's egg medium. Blood serum and glycerin-agar gave negative results as far as tested for growing the bacillus after the antiformin treatment of the sputum. Fifty specimens of sputum were

studied. Of these, 35 showed microscopically tubercle bacilli, while 15 were negative. Positive cultures were obtained at the first attempt in 33, or 97% of the 35 cases showing tubercle bacilli, while the cultures were positive in 4, or 27% of the cases negative microscopically for tubercle bacilli. As the cultures were positive, as a rule, in from nine to twenty days, the authors suggest that the method may prove especially valuable as a means of obtaining an homologous vaccine for any patient in a comparatively short time.

DIETETIC TREATMENT OF CHOLELITHIASIS.

Kolisch, in Med. Klinik, believes that dietetic measures are very important in the treatment of cholelithiasis. The diet, according to Kolisch, should be so regulated that the liver is spared as much work as possible. Furthermore, it is important to keep the intestines active and free from catarrhal processes. He believes that intestinal catarrh may cause a similar inflammation in the gallbladder. He ascribes the benefit derived from the Carlsbad cure to the effect upon the intestines of the Carlsbad waters. Kolisch forbids all highly seasoned foods, very acid foods, raw vegetables and fruits, fat and salted meat, any fat that does not melt readily, and any food that is prepared with yeast or other ferments. The fats that are allowed are oil, cream, and butter. The amount of protein should be limited and given in small portions throughout the day. Care must be taken to avoid protein containing a large amount of extractive or purin bodies. Cold drinks are forbidden, but hot drinks have as favorable an action as hot external applications. Kolisch applies hot fomentations to the abdomen for two hours after dinner every day for two or three months after an acute attack. He also forbids any active exercise for a year following the acute attack, during which time also the dietetic measures are to be kept up.