A CASE OF TONSILLITIS COMPLICATED BY ACUTE NEPHRITIS. BY CAROLUS M. COBB, M. D., The following case is so typical of the cases of acute nephritis which are caused by inflammation of the tonsils that it seems desirable to publish it. On Jan. 8, 1917, I was asked by Dr. W. L. Hearn to see a case with him in the Lynn hospital. The house physician's notes are very complete and are given in full as follows: E. F. aged 6 years. Family History.-All living, mother and one brother have just recovered from tonsillitis. Personal History. Cervical glands enlarged at one and one-half years, whooping cough at two years, measles at four years, German measles at five years, tonsillitis in August, 1916, sick ten days. Present Illness.-On afternoon of Dec. 22, 1916, complained of headache; Dec. 23, throat sore and Dr. Harris of Cliftondale ordered him to bed. Child remained in bed, on Dec. 28, cervical glands near angle of right jaw became enlarged. Suffered from persistent headache; very restless at night; temperature 101 to 103 higher at night. Jan. 1, he passed water about every half hour, in large quantities and the next evening the mother noticed considerable blood in the urine; she had not seen any previously. Physical Examination.-Well developed and nourished; skin hot and dry; eyes negative; throat inflamed, tonsils enlarged and inflamed, follicles of right tonsil filled with plugs of mucus. Tongue clean and moist; several carious teeth; lungs negative. Heart-apex-fourth interspace, nipple line; sounds regular; good quality. Abdomen-flat, tympanitic, tender just above the symphysis. Nervous system-reflexes normal. Glands-cervical glands enlarged on both sides, one very large gland on the right side. at the level of the angle of the jaw; inguinal glands palpable. Diagnosis. Cervical adenitis; tonsillitis; acute nephritis. Jan. 5th. Some follicular secretion remains in the right tonsil; ice cap to the throat; glands somewhat softer; no local redness. Jan. 8th.-Seen by Doctor Cobb; ice pack changed to 25% ichthyol sol. and hot applications of clay or flaxseed. Jan. 10th. Urine shows some pus cells; no microscopic evidence of bladder cells; casts and blood persist; glands slightly improved; tonsils still enlarged. Jan. 11th.-Epistaxis from left nostril. Jan. 19th.-Omitted poultice as glands have softened and practically disappeared; urine contains hyaline, granular, and cellular casts; numerous small, round nucleated cells; a few caudate cells; an occasional red cell; a few pus cells, and leucocytes. Feb. 3rd.-Examination of the urine every two days shows that it has gradually cleared and at present there is no albumen; an occasional cellular cast; a few round epithelial cells; and a few pus cells. Feb. 7th.-Discharged; condition good. I have given the treatment only so far as it related to the disease of the throat and the lymphatic infection of the neck. So far as the treatment of the tonsils went, they were let alone because experience has shown that it is not safe to undertake manipulation of diseased tonsils when they are the source of infection until the secondary · disease has subsided. How soon after the patient has recovered from the secondary disease it is safe to remove enlarged tonsils is a serious question. That such tonsils must be removed if we are to safeguard the future health of our patient is very evident, but when? I am inclined to wait, not only for the disappearance of the secondary disease, but until the tonsil is in as healthy a condition as can reasonably be expected. Generally there is a danger of operating too soon, and in this way exposing the patient to another infection. Absorption from the denuded surface left in the throat after the removal of tonsils, takes place very readily. Our patient went home with his tonsils and will have them removed later. We did not use sprays or gargles, because it seemed perfectly useless to gargle or spray a throat after the infection was deep enough in the tissues to infect the lymph glands and the blood stream. The use of ichthyol with heat and pressure applied over it certainly works very well. It is much more effectual used in this way than any other with which I am familiar. TREATMENT OF INFECTED WOUNDS. (Carrel Method). BY B. SHERWOOD-DUNN, M. D., Officier d'Académie; Member Correspondent Société Obstétrique et Gynécologique; Surgeon (Colonel) Service de Santé Militaire de Paris; Physician to Cochin Hospital, Paris, France. My service at the front was located seven miles beyond Compiègne, where Doctor Carrel has established his hospital, and I profited by my nearness to visit him several times and study in detail his method of continuous irrigation of wounds with his modified Dakin solution, now commonly known and called the Carrel solution. His method has met with a good deal of opposition in the Army Surgical Corps and rather widespread ridicule has been directed at his solution. It has been commonly dubbed "Eau de Javel" and called the "washer-woman treatment," because the "Eau de Javel" has the same base as his solution and is universally used by French laundries to eat up and destroy the linen of their customers. Those who have travelled in France will acutely appreciate this statement. Nevertheless, Carrel's method of sterilizing wounds forms the most valuable contribution to this end that has ever come to the surgeon, and in point of cost and successful results is superior to all others. A great many surgeons have stated that their employment and observations of the treatment in their service was unsatisfactory, until it is now recognized by the surgical inspectors that, to secure good results, the practitioner must have the solution properly prepared, free from deleterious elements, and in the correct percentages, together with an adequate and practical idea of the "technic" of the treatment which must be applied methodically, intelligently and unceasingly, until the desired results are obtained. The Solution.-The Carrel solution is somewhat difficult to prepare because of the instability and variation in quality of the chloride of lime, forming its chief ingredient. The quality of this element, in commerce is extremely variable, ranging from 20 to 40 per cent. in the amount of active chloride contained and to this variation can doubtless be attributed the unsatisfactory results reported by various surgeons. After much experimentation and observation, Carrel has arrived at the following formula, as offering the maximum of simplicity and best results.1 1°-To prepare 10 litres of solution, weigh carefully chloride of lime (25% of active chloride) 200 grammes; dry carbonate of soda 100 grammes, or, in its place carbonate of soda, crystals 285 grammes: bicarbonate of soda 80 grammes. 2°-Into a glass container, holding 12 litres, and containing 5 litres of ordinary water, place the 200 grammes of chloride of lime shake it up well several times and allow it to stand over night. 3°-In another 5 litres of water, dissolve the carbonate and bicarbonate of soda. 4° On the following day, pour this solution into the glass containing the lime solution and shake it thoroly for a minute or two, then set it aside and allow the sediment to settle. sable to know the percentage of active chloride possessed by that which it is proposed to make use of in order to calculate the exact amount required to produce the correct proportion in the solution. This dosage is arrived at in the following manner: Take 20 grammes of the chloride of lime and thoroly dilute it in one litre of water, 5°-At the end of half an hour, siphon off for several hours. FIG. 1.—Adductor tube closed at one end and having perforations extending upward as far as required. (1) FIG. 2. Glass tube intended to connect two rubber tubes of same caliber. FIG. 3. Glass tube in Y intended to connect the supply tube with adductor tubes. FIG. 4. Glass tube connecting several adductor tubes to the supply tube; this tube is closed at one end. FIG. 5.-Used for the same purpose as Fig. 4. FIG. 6. Glass tube used in the supply tube to lengthen same when necessary and to show the free flow of the solution when the clamp is opened. FIG. 7. Glass tube in Y to afford two branches to supply tube when required. the clear liquid and filter thru a double filter paper to obtain a perfectly limpid liquid, which should be kept in a dark place, away from the light. The solution so prepared should contain 0.45 to 0.50 per 100 of the hypochlorite of soda with traces of neutral soda salts and is sensibly isotonic to blood serum and therefore in no way interferes with the processes of repair. Because of the great variations in the commercial chloride of lime, it is indispen (1) Figures after Desfosses. Take 10 cm. of this clear solution and add 20 cm. of a 10% solution of iodide of potassium and 2 cm. of acetic acid, or hydrochloric acid. Into this mixture let fall drop by drop a decinormal solution of the hyposulphite of soda (2.48 per 100) to the point of decolorization. The number of cm. employed of the hyposulphite of soda, multiplied by 1.755 will give the weight N. of active choride contained in 100 grammes of chloride of lime. The chemical sterilization of the wound is secured by the aid of rubber tubes, onehalf centimeter in diameter closed at one end, open at the other, the walls of the closed end having round perforations irregularly disposed for a certain distance on all sides. (See Figure 1). The quantity of solution introduced into. the wound is never great-just sufficient to keep the surfaces bathed-and is absorbed and evaporated by the dressings. Two methods have been adopted to accomplish this: one, the drop by drop 9 Furnished with the correct solution, we now come to the "technic" of its application and the relation of these two to success in the treatment are of equal importance. Faultless technic with a faulty solution, and vice versa, are equally fatal. The first act is to carefully clean the patient, open largely the wound with all its sinuses and cavities, remove all foreign bodies and substances, resect all dead and badly diseased tissue and then install the continuous irrigation of every anfractuosity, FIG. depth and surface of the wound and it is because this sounds and seems so simple that the average surgeon unacquainted with the details of the application usually fails to secure the desired results. Once properly and correctly installed, the effects of the irrigation are observed and controlled by the bacteriological examination of the wound secretions by aid of the microscope. Carrel has thus introduced a mathematic and scientific control of treatment for wounds. 9.-Glass reservoir with supply tube, sup pression clamp and glass tube in supply tube and glass tube connecting supply tube with adductor tubes. method; the other, the intermittent method, which latter is most generally employed and is here described. The adductor tubes, those placed in the wound, are of different sizes. They are of red rubber, 20 to 40 centimeters in length, wall 1 mm. thick and from 3 to 6 mm. in diameter. They are equally resistant and flexible; sufficient to resist the pressure of the muscles and dressings and to penetrate into the anfractuosities and corners of the wound. (1). When not specially made with one end closed, it can be closed by a silk ligature, and from the closed end for the length of 5 to 15 cm. perforated by aid of a fine pair of scissors with 8 or 10 small holes all around. These holes are still better made by aid of a steel punch such as is used on leather. (2). Another sort of tube used is open at both ends and perforated its full length. These tubes are so attached that the solution enters at both ends. (See Figure 14). (3). Another sort of tube is open at the end and near this end a lateral opening is made quite large, permitting the liquid to escape, if the end becomes plugged up. (4). The fourth category of tube is the same as N° 1, but the end having the perforations is covered with a spongy material like turkish toweling wound about with silk thread to hold it in place. Any of these tubes can be lengthened by aid of a plain glass tube of the same caliber, surface of the wound. (See Figure 14). The glass tubes of three and four branches (Figures 4, 5) are composed of a main cannula, closed at one end, 6 to 7 cm. long and 7 mm. in diameter. Upon the side of this tube, at right angles, project the small branches, 2 cm. in length and 3 to 4 mm. in diameter. These cannulas resemble a comb; to these small branches are attached the perforated rubber tubes branching out into the wound. In addition, it is necessary to have a straight glass tube 5 or 6 mm. in length and those of Y shape, 8 to 10 cm. long, and 11. FIG. 10.-The suppression clamp. inserted between the end of a perforated and plain piece of tubing. (Figure 2). Glass Cannulas.-The perforated rubber tubes placed in the wound are united to the main supply rubber tube by aid of glass cannulas having two, three and four branches. (See Figures 3, 4, 5). The main tube of N° 3 is about 3 centimeters long and 7 mm. in diameter. The two branches are 2 cm. long and 3 to 4 mm. in diameter. To these branches are attached two perforated tubes branching out into the wound or, one single tube, open at both ends, and having perforations thruout its whole length; the two ends being attached to the two ends of the Y, forms a half circle of the perforated rubber tube upon the FIG. 11.-The nurse opening the clamp permitting the flow of solution into the wound. both of 7 mm. in diameter, (Figures 6, 7) to reunite the large rubber conductor tubes; then a conical glass tube, 5 to 6 cm. long, 7 mm. in diameter at one end and tapering to 5 mm. at the other (see Figure 8) to unite a conductor tube of 7 mm. to the 5 mm. adductor tubes disposed in the wound. The irrigating apparatus (Figure 9) comprises: (1). A glass reservoir holding one litre, tapering to a small opening at the top and a projecting spout 7 mm. in diameter at the bottom; this reservoir is supported on a metal standard or by a board fixed to the foot of the bed. (See Figure 11). (2). The rubber conductor, 7 mm. in diameter, is 1 m. 50 to 2 metres in length, |