laris, which are so resistant to treatment are primarily infections of this nature.

The disease is in nearly all cases a local infection, and it is rare that complications occur, although it is said that the same complications may occur as are seen in cases of ordinary tonsillitis. Personally I have never seen any complications what

ever.

The differential diagnosis of the disease is of course important. It is to be differentiated from diphtheria, lacunar tonsillitis and syphilis. The finding of the characteristic organism is diagnostic.

The treatment of Vincent's angina is as a rule simple and satisfactory. In the tonsillar form of the disease, local applications of 12 per cent silver nitrate solution once or twice daily is almost specific. Aspirin or phenacetin for the constitutional symptoms should be given as in ordinary cases of ton sillitis. The extra tonsillar form of the disease is more refractory, and sometimes lasts for weeks in spite of all treatment. Silver nitrate is here also the best form of local treatment, but at times in spite of all efforts, persistent ulceration at the alveolar margin will remain, with recurrence after recurrence of membrane formation. In these cases the aid of the dentist should be sought, the teeth should be thoroughly cleaned and areas of chronic inflammation curetted.

The points I wish to make in this paper are the following: First, Vincent's angina is not a rare or uncommon condition. It is a frequent occurrence and should be recognized oftener than it is. Second, it is not an infection confined to the tonsil, nor starting invariably here, but occurs frequently as an extra-tonsillar infection spreading along the gums. Third, while usually a primary local disease of the throat or mouth, it is frequently a secondary infection upon a previously existing inflammation, and finally, in all cases of sore throat or mouth, which look at all suspicious, a smear should be made and these organisms looked for, or at least the possibility of the presence of the disease should be considered.

324 Bee Building.

Pennsylvania's seven-year-old official war against tuberculosis has given that state the lowest death rate from that disease. Having the largest mountain forest reserves, 550,000 acres, with three great camps and a widespread dispensary system for such sufferers, explains this enviable record.

ON THE TECHNIQUE OF EVISCERATION OF THE EYE-BALL.

H. GIFFORD, M. D., Omaha, Neb. Professor of Ophthalmology and Otology. University of Nebraska.

The question of when and how to do an evisceration or an enucleation is of some importance for the general practitioner because in the case of some injuries in which the eyesight is totally destroyed, his decision to get rid of the dangerous part of the globe at once may save the patient much suffering, time and expense; and even the sight of the other eye. It may be stated without qualification that whenever either from a rupture or a penetrating wound the eye-ball is so opened that the interior is exposed to infection from the outside, the physician is justified in advising an enucleation or an evisceration, if he finds that the eye has lost all perception of light, i.e., if the patient with the other eye tightly closed cannot perceive strong light concentrated on the injured eye. Of course there are many cases when much slighter injuries demand an enucleation or evisceration, but these involve considerations of a subtle nature and would lead to discussion of the whole question of sympathetic ophthalmis; while the above rule is one about which there can be no discussion in qualified circles and on which the practitioner can rely with absolute confidence. On the other hand, he must be careful not to insist on the operation, as if declining it would certainly lead to injury of the other eye, be cause many such wounds while they result in a deformed and sightless eye, never cause any trouble with the other. Granting that the above conditions are fulfilled, the only valid reason for the physician to call in some one else to do the operation is the fear that he cannot do it properly himself. Now it so happens that this is one of the few emergencies, in connection with the eye, in which a physician with no special training can do the patient practically as good a service as a specialist, since the only operation necessary is one which requires no special training and no special instruments; an operation which it is practically impossible to do wrong if the simplest rules be followed. I refer to what I have called the simple evisceration of the eye-ball.

Evisceration was originally proposed and executed by Alfred Graefe as a substitute for enucleation on the ground of greater safety; he having had a death from meningitis following enucleation; but as he proposed it and as it is generally performed

As

today, the operation is not simply an evisceration but an evisceration plus an excision of the cornea. His operation consisted in loosening up the conjunctiva, then excising the cornea, then scooping out all the rest of the eye except the sclera, and finally drawing the conjunctiva together over the opening, with a tobacco-pouch stitch. thus performed the operation is generally followed by a great deal of pain with much swelling of the conjunctiva; so great and so persistent, in rare cases, as to demand the removal of the stump; while the stump finally obtained, instead of being, as one might expect, of good size and of use as the basis for an artificial eye, generally shrinks to the size of a small pea, giving a cosmetic result in no way superior to that obtained after an enucleation.

To remedy these defects to some extent, I have simplified the operation and performed it as follows: The cornea or what may be left of it is not removed, but is cut through by a horizontal incision which is carried out for one-fourth inch into the sclera at each side of the cornea. Through this opening the contents of the globe are scraped out with a sharp spoon, especial attention being paid to the ciliary region and to the region of the optic disk, for it is here that tags of uveal tissue are most apt to be left. Following this, the interior of the cavity is thoroughly swabbed with a somewhat globular gauze swab about threefourths inch in diameter; then it is irrigated with a strong stream of boracic solution; then the anterior scleral wall is pressed back against the posterior wall with one or two good-sized gauze swabs dipped in oxide of zinc ointment, and a compression bandage is applied. The swabs are removed at the end of 48 hours.

The operation is generally followed by some pain and quite a little conjunctival chemosis, for which hot applications and, rarely, incisions into the conjunctiva are used. The stump finally obtained is a flat firm disk from one-half to one inch in diameter which supports the artificial eye at the point where support is most needed, namely, at the periphery, and which gives on the average a decidedly better cosmetic

K

result than the old operation, or than an enucleation. In performing the operation the most important thing to keep in mind is the disability of getting out every shred of uveal tissue, i.e., iris, ciliary processes and choroid. It should be remembered that sympathetic ophthalmia has been observed after evisceration as it has after enucleation; and that in some of the rare cases in which the stump has been examined, shreds of pigmented tissue have been found, showing signs of the form of inflammation which is more or less characteristic of the infection which causes sympathetic ophthalmia. Consequently the region of the ciliary processes and that of the optic disk must be scraped and rubbed with especial care and vigor; and if the wound has caused any uveal tissue to become incorporated with the sclera, this bit of sclera should be excised.

The advantages of the operation are: (1) Simplicity. It can be done with the sharp bistoury, rat-toothed forceps and sharp spoon, which every physician has; and it is so hard to do it wrong that no physician need hesitate about doing it where it ought to be done. (2) Less reaction. (3) Better cosmetic result.

As to the advantage of evisceraion over enucleation it is only fair to say that this is a moot point on which there is much discussion; but there can be no question that the operation as described is simpler, gives a better cosmetic result and in my opinion it is safer, and equally efficacious as a prophylactic against sympathetic ophthalmia. Where sympathetic ophthalmia has broken out, I believe enucleation to have a slight theoretical advantage. I do not compare a simple evisceration with the operations of Mules and Frost and their various modifications, because these are not operations for the general practitioner, and furthermore, because I believe them to be more dangerous than simple evisceration. Whether the operation of Barraquez, which consist in implanting a piece of the patients fat into the cavity left by an enucleation or evisceration, will finally give any better cosmetic result than the simpler operation, remains to be seen.

LA GRIPPE, SOME OF ITS MOST IMPORTANT MANIFESTATIONS AND COMPLICATIONS.*

CLARENCE E. LEE, M. D., Oklahoma, Okla. Not that there is anything new, nor that there is anything of very great importance that can be added to our present knowledge of this too often entirely neglected affection; but with the idea that some good may be derived by at least a few of us should we recall the importance of remembering that this disease is fraught with manifold dangers at times not on account of the disease itself, but as regards complications and sequelae.

There is no doubt that the majority of us are too prone to look upon and speak of this disease lightly whether we ourselves are the victims or are addressing some of our patients.

It is not the object of this paper to set forth at great length the various phases of this malady, these are too well known. Neither do I wish to urge upon you the unpleasant task of recalling the numerous cases where you have had to treat its varied complications.

One of the most serious of all its manifestations is the pneumonic type, not so much on account of the patient's chances of recovery, but that the patient and the physician, is too often inclined to regard the affection as one of not very much import.

"Just a case of the 'grip" is too often what the patient has said to him, together with the assurance that he will of a necessity feel badly for a time and can expect nothing else.

Do not mistake a saying that one can cure this disease, but we can render the patient an invaluable service by making him comfortable while sick and see that the proper hygienic and dietetic measures are carried out during his convalescence.

*The following papers were read before the Medical Association of the Southwest at Hot Springs, Ark., Oct. 8-10, 1912.

When one is unfortunate enough to develop the pneumonic type, even though he apparently recovers from one, or even repeated attacks, there is the constant liability to that most common complication-tuberculosis.

We often have patients that tell us that they have had attacks of lagrippe for possibly the past three or four winters, and these same patients may not have felt the necessity of having had a careful physical examination.

It is too often the case that patients with such a history are given a prescription for the cough without going into their history, or making a careful examination to determine their chest condition.

The reason that I dwell so on this one particular point is because of the fact that if cases of incipient tuberculosis are diagnosed, treatment can be at once instituted and the patient given a chance for his life.

There is no class of cases that should be watched more closely than this one particular class, on account of the above mentioned complication. Allow me to recite one or two illustrative cases.

Per

Case I.-J.B. V., male, aet. 38. October 3, 1910. Family history negative as regards tuberculosis, neoplasms, etc. sonal history good up to within three or four months before calling on his family physician. After giving him a prescription for his cough, he heard nothing more from this patient until one night he was called to see him. I was called in consultation on account of his night sweats, and the excessive expectoration. Repeated examinations of the sputum revealed only the presence of pneumococci and the B. influenza. His physician gave him the proper alteratives and reconstructives, together with the proper dietetic and hygienic measures necessary, with the result that he recovered from that attack and has had no recurrences since.

Case II.-J.M., male, aet. 41.

Novem

ber 29, 1909. Family history negative as as regards chest or throat disorders. Paternal, maternal and preancestral good as to longevity. Personal History.-Had the usual exanthema of childhood-measles at 21 years. This patient had had for the past three or four years attacks of what he thought and had been told were la grippe. Cough quite constant, expectoration ill smelling and abundant. During the summer months he said he had only an occasional "cold." When I saw him with his physician he was quite emaciated coughing violently at times. Chest symptoms showed several varieties of rales, together with apical dullness in the right lung. Tubercle bacilli were found in the sputum. Patient was removed to the East Side Hospital where his treatment consisted of increased calories in feeding, rest, proper reconstructives and alteratives. Last winter the patient was free from cough; had gained forty-six pounds; was working and has been all summer, and at the present time is apparently free from the infection.

Case III.-J.S.A., male, eat. (51. September 29, 1912. Family history negative as regards tubercular infection, excepting possibly his mother having had this affection, dying in her 38th year. Longevity quite marked in ancestors. Personal History. Was a very robust child, had nearly all the usual exanthemata of childhoodmeasles at 17 years with bronchial complications, recovery apparently complete. Ten years ago had a severe attack of la grippe, since which time he has been a victim of asthma. This summer, on account of nasal and throat trouble, has taken quite large quantities of the mixed vaccines. Recent sputum examination showed presence only of pneumococci and B. influenza.

It is not a difficult task to deduct from a few of our own cases, the important fact that cases of la grippe, especially those of the bronchial or pneumonic types, should have as careful treatment as though they were indeed incipient cases of tuberculosis. Exogenous Bacterial Intoxication. In la grippe we have one of the so-called infections that is not, strictly speaking, an infection.

We can easily recall from the suddenness of the attack, fever of short duration, with the extreme disproportional prostration that we must be dealing with a toxic condition.

Since the B. influenza itself does not invade the tissues, excepting when there is a mixed infection, it necessarily follows that

there must be an endogenous process causing the well known symptoms.

The importance of thorough elimination in this disorder cannot be too strongly urged.

Some authorities claim that secondary infections occur by the direct transmission of the bacillus. However these same writers say that such complications as pleurisy, endocarditis, etc., may be due to the toxins. It is doubtless true that the latter part of this statement is true in the majority, if not in all cases. When speaking of the bacterial products in this affection, we should always refer to the same as endotoxins.

We must remember that most important fact, the tendency of la grippe to develop latent disease into active process and to make slight grades of organic affections more serious.

This is particularly noticeable in connection with heart disease and kidney disease. A slight albuminuria may become, after an attack of la grippe, a rapidly fatal Bright's disease. A mild cardiac affection scarcely noticeable by its symptoms may become a grave affection with degeneration of muscular substance and marked dilatation of the cavities.

A PLEA FOR LARGER ABDOMINAL INCISIONS AND LESS DRAINAGE.

W. E. DICKEN, M. D., Oklahoma City, Okla. Local Surgeon M. K. & T. Railway; Physician and Surgeon to the State Baptist Orphanage; Professor of Surgery in the Southwestern Post-Graduate Medical School.

Wonderful as have been the advances of modern medicine, the greatest achievements have accured to the department of surgery, which Chamisso terms "the seeing portion of the healing art."

The sixteenth century opened the way for the checking of hemorrhage; the seventeenth accomplished great simplifications and improvement in the way of dressing wounds; the eighteenth gave a refining and elevating, tendency refining and elevating tendency to the study of applied practice and raised surgery to a level with other branches of science; while the nineteenth with the twentieth century, has established diagnosis of the body cavity, by large incisions, and made surgery the exact science to which every other has been made contributory.

The successful surgical operation is one that cures the patient of the various symptoms, for which the work was done, and how can this be accomplished without

thorough knowledge of the condition of the organ, touching upon the pathology and how can this knowledge be gained without large enough abdominal incision to admit. of the hand and arm.

Dr. James Moore, of Minneapolis, says in reference to his subject, "The average surgeon is prone to do his abdominal work through too small an opening. He points with pride to an inch and a half scar, after an appendectomy and a two and a half inch scar, after an operation for the relief of pathologic condition in the pelvis."

What doth it profit a man, if he placeth a small scar on the abdomen and accomplish nothing. Would not it be better for the purpose of the operation to be accomplished, even though the mark was left behind?

There has been no other factor which has served to discredit gynecologic and abdominal surgery, during the past twenty years, so much as has the failure to bring about symptomatic cures for those we operate upon. We have had patients to say, that they were worse, or at least no better than before the operation, which has been a discredit to surgery and disheartened the patient and her friends and repeated operations have had to be done in order to do what should have been accomplished in the first operation on account of failure to find important associated abdominal lesions.

In view of the fact that 7.1 per cent of pelvic cases have gall-stones, leads one to the belief that upon every pelvic case the hand should be passed to the gall-bladder to make sure of the gall-bladder conditions, as well as the condition of all other palpable organs.

From August, 1911, to August, 1912, out of one hundred laparotomies with a mortality of 3 per cent, including both pus and clean cases, the practise was to examine the stomach, gall-bladder, kidneys, pancreas and appendix, of every pelvic case and the pelvic organs together with the appendix with every stomach and gall-bladder case, provided this could be done without the contamination of pus to the surrounding peritoneum. And from these cases we have been surprised to find pathological lesions of other organs from the one which the operation was intended.

A case or two if you will allow me, I may briefly present at this point to better explain what has been said:

Case 1. A female, aet. 30, was diagnosed as a case of salpingitis, and the right tube was removed, which was distended with pus, together with the appendix and

upon examination of the gall-bladder it was filled with stones, which was emptied of its contents, although we had no suspected gallstones from the symptoms.

Case 2.-Female, aet. 55, was operated on for large ovarian cyst, and upon examination of the gall-bladder, it was found gall-bladder twenty stones were removed. filled with stones and upon draining the

Case 3.-Female, aet. 47, was presented with a severe pain in the right side at McBurney's point, with rigidity of the muscles and was pronounced acute appendicitis; we made the usual incision and upon exam· ining the pelvic organs and the appendix, we found the appendix normal, but the right ovary was cystic the size of an orange, which was removed. Now had the usual incision for appendicitis been employed and the coincident injective of that organ been accepted, as the sole cause of the symptoms, nothing but failure would have been the result.

The point may be raised that exact and detailed diagnosis should be made previous to the operation and that no operation should be undertaken, until such a diagnosis is made; to anticipate that it becomes necessary to state that an exact and complete intra-abdominal diagnosis of all the complications previous to the operation is on the face of it impossible, even when an exact diagnosis as to one diseased viscus is

easy.

He who aspires to abdominal surgery should be able to cope with every operation in the abdomen, that a systematic operative exploration shows to be necessary, and when his work is finished it must be absolutely complete, with nothing left undone." Regional abdominal surgery in a limited. limited field has had its day, as we all know.

Now with your permission allow me to touch upon the latter phase of my subject, namely, abdominal drainage. Is it expedient to drain the abdomen? If there is fluid is it necessary to get rid of it?

This will depend on the operator's opinion of the fluid. Dudgeon has shown that most of his fluid is harmless, even if not protective. It may be that more harm is done by getting rid of it, by sponging, or other means, than its characteristics warrant. Again, infection spreads by a vital process quite apart from its spread by the gravitation of foul fluid. A peritonitis can infect the whole abdomen without the presence of free fluid. In such cases drainage must be useless. The question then arises, whether surgical interference is to be encouraged in those cases of peri