practitioners, many of whom still believe that thoracic diseases, with the exception of pleural effusion and empyema, are to be treated by palliative measures. Some who know of the value of surgical treatment hesitate because they do not have a differential pressure apparatus and the technic supposed to go with it. While all of this is valuable, it is not strictly necessary to the general surgeon, and the following lesions may well come within his field: Foreign bodies in the bronchi, bronchiectasis, empyema, injuries associated with hemothorax, tuberculosis, pulmonary abscess, pulmonary gangrene, echinococcus cysts, actinomycosis, tumors of the chest wall or pleura, and damage to the lining itself. A few years ago, the death rate in attempting to remove foreign bodies by bronchotomy from the bronchi was one hundred per cent. The development of proper instruments and the x-ray have secured many brilliant successes without cutting. Empyema is still a much neglected disease and should be attacked in the acute stage. The most common form is that following pneumonia. The fluid or pus should be removed as early as possible and permanent drainage established by removing a bit of rib so that a good sized drainage tube may be inserted. Cases that are allowed to become chronic require many operations, usually requiring resections of the chest wall. A keen surgical judgment is necessary to produce a cure. Injuries, such as stab and gunshot wounds, require prompt and active aid. In serious hemorrhage, the thorax should be opened and the bleeding stopped by packing or by ligature, under differential pressure, if possible. Excision of a portion of the lung for tuberculosis has not proved a success, but the injection of nitrogen into the pleural cavity, as advocated by Murphy, may be of value.

Doctor T. B. Lund, of Boston, at the same meeting, presented a paper on the treatment of empyema. The treatment consists of incision, evacuation of pus and providing for free drainage. Early incision is recommended before the patient becomes weakened by the disease, also before strong adhesions have fastened the lung to the chest wall to prevent proper expansion. We should drain from the most dependent part of the cavity, the ninth or tenth interspace-well back. To prevent collapse of the drainage tube a portion of the rib should be removed. There is greater danger from the anesthetic. In extreme cases local anesthesia should be produced. Chloroform should not be given. Mark the lower angle of the scapula on the skin, then elevate the arm and incise on the rib at this point. The rib section is removed large enough to admit two fingers. Pus must not escape too rapidly or it will produce shock. The position of the lungs should be ascertained by the fingers and all adhesions should be broken up as far as the finger can reach. Insert a large tube and close the wound with the fewest stitches possible. As complications following, there may be abscesses in the abdominal wall, which should be opened. The drainage tube should be just long enough to enter the cavity. It should always be fixed to the skin. Never use a cigarette drain in these cases as it acts as a plug to

retain the pus. The use of the blow bottle is begun early to cause expansion of the lung. The drainage tube should not be removed until the temperature has been normal for a week or ten days, until the lung can be felt and the discharge is reduced to such an amount as might with reason come from the sinus. Irrigation should be employed only in exceptional cases. He has tried various forms of suction, but cannot advise others to use them. In old cases the size of the cavity may be determined by the probe and the x-ray plates. The adhesions between the lung and chest wall must be supported so that the lung may expand and fill the cavity. Decortication of the lung, by means of the finger, is recommended in all cases where the disease does not improve and the condition has not lasted more than one year.

Doctor Samuel Robinson, of Boston, presented a paper on "Bronchiectasis and Abscess of the Lung." He considers these together because practitioners not infrequently fail to differentiate the two conditions. This may lead to misapplied treatment. A bronchiectatic cavity should almost never be drained, as a fistula may persist and renewed secondary infection occur. The surgery of bronchiectasis has two possibilities: Immobilization of the lung or resection, both of which are useless when both lungs are involved. To immobilize, in a conservative way, introduce nitrogen. into the pleural cavity. The radical method consists in an extensive resection of ribs over the affected part. The pleuropneumolysis method of Friedrick was employed in three cases with unfavorable results. Complete resection of the diseased lobe is the best theoretically. This may be done in one or two stages. There are at present five cases of complete recovery, following the removal of the lobe of a lung. "In acute abscess of the lung, the internist should transfer the responsibility of the case to the surgeon," even when he is unable to locate the abscess. This is due to improved surgical methods of exploration.

Doctor H. T. Murphy, of Boston, writes about penetrating wounds. of the chest. In crushing wounds of the chest, meet the most pressing emergency with the least shock. Stab and gunshot wounds present four important points worth emphasizing: Abdominal pain, even though the peritoneum is not injured; possible serious hemorrhage from a wound of the intercostal artery; the great power of accommodation of the lungs to hemorrhage or pneumothorax, if the change comes on slowly; relatively slight danger of fatal hemorrhage, cause of the collapse of the lung, and the adherence of the pleura. The first down grade is shock; interference at this time would be fatal. When the return tide has set in, exploration may be useful. "I cannot but feel, though, that as a routine, rest, morphia and the swathe will give us a lower mortality than any thing like routine operative treatment."

C. G. D.

GYNECOLOGY.

REUBEN PETERSON, A. B., M. D.

PROFESSOR OF OBSTETRICS AND GYNECOLOGY IN THE UNIVERSITY OF MICHIGAN.

BENJAMIN ROBINSON SCHENCK, A. B., M. D.

CONSULTING OBSTETRICIAN TO THE WOMAN'S HOSPITAL OF DETROIT.

THE END RESULTS WHEN HYSTERECTOMY HAS BEEN DONE AND AN OVARY LEFT.

POLAK (Surgery, Gynecology and Obstetrics, July, 1911) contributes a paper on this subject based on his personal experience.

The two classes of cases to which conservatism is generally applied are pelvic inflammations and myomata. In the former class the great mass of clinical evidence, contributed by Dudley, Clark, Norris, Peterson, Hyde, Robb and the author, show that the results of salpingostomy, and other plastic work on the tubes are unsatisfactory; that pelvic inflammation should be subjected to a long period of preoperative treatment before any operation is attempted (except the drainage of pus collections through the vagina); that, whenever possible, healthy ovarian tissue should be preserved, provided it can be done without interference with the ovarian blood supply by misplaced ligatures and sutures.

To throw further light on the above points Polak compared the end. results of one hundred and thirty-two abdominal hysterectomies in which one, both or a part of one ovary was left with the results in a like number of cases subjected to hysterectomy and double salpingo-Oophorectomy. In making the comparison the following points were observed: (1) The general health after the operation; (2) the severity and duration of the nervous symptoms; (3) amount of pelvic pain or freedom from pain following conservation as compared with the comfort of the patient after complete extirpation; (4) the condition of the ovary or part of the ovary retained at the time of the final examination.

The author's technic comprises a low amputation, removal of all of the cervical epithelium, the fixation of the infundibulopelvic and round ligaments into the cervical stump, the raising of the conserved ovary by suture to the posterior surface of the round ligament, and the suture of the peritoneum over the stump.

It was observed that the severity of the nervous symptoms was less, subsequent to the operation and the general health of the patient better when hysterectomy had been done for pus conditions in the pelvis, than when the uterus had been removed for myomata. Also, that the myoma patients who prior to the operation had a low blood count had a less stormy convalescence than those who were in robust health at the time of the operation.

In ninety-six cases of fibroids, both ovaries were removed in forty-eight,

and a portion of an ovary, one or both ovaries, retained in an equal number. Of the first class, forty-three of the forty-eight patients were free from all pelvic pain or symptoms referable to the pelvis, except eleven who were relieved of lumbosacral backache by proper corseting. Thirtytwo of the second group of forty-eight patients had been followed and five found who complained of pain at the site of the retained ovary. One patient in the complete class and three in the incomplete had prenounced nervous symptoms, all of the four being over fifty years of age. The author's experience seems, therefore, at variance with that of Clark and Norris.

In thirty-one women radical operation was done for pelvic inflammatory disease. In only one case was an ovary conserved. All were under forty years of age and thirty-eight were in perfect health.

From a study of these cases, Polak concludes:—

(1) That the technic of the operation and the general health of the patient have much to do with the end results.

(2) That a conserved ovary, if unhealthy, will leave the patient in a worse state mentally, nervously. and physically, than if a total extirpation had been done.

(3) That when the woman is at the age at which the menopause should occur, or when she is past the menopause, a total ablation gives the best results.

(4) That the nervous phenomena are more marked when the patient is operated when in comparatively good health, with a high preoperative blood pressure, than when the blood picture shows anemia or toxemia.

(5) That the symptoms of the operative menopause are less after extirpation for pelvic inflammation than when the ablation is done for fibromyomata. This is probably due to the associated vessel changes which we find in fibrosia.

(6) When one or both healthy ovaries can be conserved it should be done; the younger the patient the more necessary the conservation.

OPHTHALMOLOGY.

WALTER ROBERT PARKER, B. S., M. D.

PROFESSOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF MICHIGAN.

GEORGE SLOCUM, M. D.

DEMONSTRATOR OF OPHTHALMOLOGY IN THE UNIVERSITY OF MICHIGAN.

B. R. S.

THE RELATION OF CEREBRAL DECOMPRESSION TO THE RELIEF OF THE OCULAR MANIFESTATIONS OF

INCREASED INTRACRANIAL TENSION.

DESCHWEINITZ (Annals of Ophthalmology, April, 1911) prefers to retain the term choked disc because the differentiation between papilledema and inflammatory neuritis is not at present justifiable and is still in dispute. Intracranial pressure is the one cause which is certain and release of the pressure cures the choked nerve head.

Decompression has been utilized, first, for tumors of the brain; second, other types of brain disease and meningitis; third, injuries of the skull; fourth, syphilis of cranial contents; fifth, renal disease and anemia.

The author's personal experience represents an investigation of seventyfive operations in the service, chiefly of Doctors Frazier, Mills, Spiller, Keen, Taylor, Davis and a few others. His conclusions are also based upon a study of the American literature of the subject which was reported to the Ophthalmic Section of the American Medical Association, June, 1909, by the author in conjunction with Doctor Holloway. As a result of the studies of two hundred and twelve operations upon the brain preservation of vision is reported in seventy-six and five-tenths per cent of the cases, while in twenty-three and five-tenths vision was not preserved.

The process may be divided into five stages. In the first two, vision

FIGURE A.-Fundus of the right eye of a patient with tumor of the brain and choked disc; swelling six diopters. (Service of Doctor Edward Martin in University Hospital.)

is perfect or still good, in the third stage vision declines, in the fourth and fifth stages vision is poor or lost. The best results are obtained when the operation is done in the early stages, especially when removal of the growth is possible either then, or at a later operation. Choked disc is present in about eighty per cent of brain tumors, but it does not usually appear early; the rapidity of the development of the swelling is variable and neither the amount nor rapidity of its development gives any index as to the duration of the intracranial lesion. During the period before the choked disc becomes manifest there is a stage in which the retinal veins become engorged, tortuous and darker in color. Cushing and Bordley maintain that there are also frequently present significant alterations of the