throat is sometimes difficult, especially in the edematous variety, although the edema in these cases is usually of a slight amount in the pillars and more marked in the uvula and soft palate. In quinsy there is a bulging forward of the anterior pillars. The bulging is tense and usually fluctuates. The proper procedure in quinsy is to open and drain. It has been shown that incision of the tonsils or peritonsillar tissue in these epidemic throats simply aggravates the condition. This was shown especially in one case. The disease had been in progress for more than a week and was growing steadily worse. It looked as though there might be some pus about the tonsils in the peritonsillar tissue. A small opening was made and a drop of pus obtained. The patient's condition rapidly grew worse and the prostration was more marked. Furthermore, local applications, except for gargles, in these cases are not only absolutely useless, but often harmful. Silver nitrate, tannogen, et cetera, causes pus to collect in the deeper parts of the tonsils and there being no drainage from the crypts absorption takes place in greater amount. There is so little to do for these patients that they oftentimes feel as though nothing was being done for them. Symptomatic treatment is all that is indicated. The pain should be relieved and sleep and rest procured by the use of soporifics. Cocain and adrenalin may be used intratracheally for the edema that occurs in some cases. If the edema is not relieved by intratracheal injection and the patient is in danger of suffocation surgical treatment is required. One set of these tonsils was removed about ten days after the symptoms cleared up, but as yet we have not had a report on them. There were many adhesions about the tonsils, but whether these were due to this particular attack or to several attacks of tonsillitis one cannot say. It will be interesting to know if there will be any sequel to these cases as there were to the epidemic of la grippe that passed over the country some time ago. DOCTOR LUTHER F. WARREN: The condition of septic sore throat seems worthy of discussion, for most of us have seen cases of this kind. In the last medical section there was a student who was attending five cases. There are various clinical forms, but all the cases I have seen have been of the edematous type. So marked was the edema that the whole throat filled up. Some of the throats showed a membrane, others showed crypts filled with pus and ulceration of the mucous membrane. In two cases where I have made cultures from the throat, short chains of streptococci have been found. Some of these cultures show the streptococci in long chains and in pairs. DOCTOR FERRIS N. SMITH: One point has occured to me during the discussion, namely, that most of the fatal cases have resulted from the simplest type of infection several days after the onset, and frequently several days after the apparent cure of the patient. A man has an attack of tonsillitis which apparently clears up, he feels better and resumes his work, the trouble recurs and proceeds to a fatal issue. In the discussion of the cardinal symptoms of these cases I did not consider the cases that progressed to a fatal termination or those that had general involvement. The pulse rises rapidly in cases of general sepsis. In all those cases which we have seen with a purely local process, the general symptoms are the result of toxemia; the pulse in only one case exceeded 100-114 with a temperature of 105°. Two hours later it was below 100°. In all of the cases we have noted a pulse which has been exceedingly slow and full and out of proportion to the temperature. The organism has been worked out rather definitely by Rosenberg, of Chicago, and he locates it between streptococcus pyogenes and streptococcus mucosus. In the Baltimore epidemic an attempt was made to show that it was a pneumococcus. I would like particularly to report one other case, that of a student, who was sick for ten days and was brought to the hospital with an attack belonging in group one; there was a most marked cellulitis that made one think of mumps. The area of infiltration was on a line with the ear. The patient had remittent temperature for four days. Yesterday the throat was clear, but the cellulitis in the neck still persisted. One day the area of infiltration would be just above the clavicle and about two inches in diameter, while the tissues at the angle of the jaw and below would be perfectly normal; possibly the next day, the entire area of involvement would be shifted to include the whole of the neck to the median line but never crossed to the right side. The area has varied from the size of a marble to that of an orange and has involved the whole side of the neck. REPORTS OF CASES. FRACTURE OF THE FRONTAL BONE, MUCOCELE OF RECOVERY. R. BISHOP CANFIELD, M. D. History.--The patient comes to the University Hospital on account of swelling of the left eye and forehead. Nine months ago he was struck in the left frontal region by a baseball. The forehead swelled up and later the swelling disappeared showing depression over the left eyebrow. Some time later the swelling reappeared and remained for a couple of weeks and then disappeared. With this disappearance of the swelling the patient complained of a bad cold and discharge from the nose, although he does not associate the disappearance of the swelling with the discharge. About ten days ago the swelling reappeared and was lanced, considerable matter being evacuated. The patient has had no headache, no sense of sickness, no disturbance of equilibrium, loss of memory, no pain, that is, no subjective symptoms of involvement. Examination. This shows the left eyelid red and swollen and somewhat drooping. The line of incision is one-half inch below the centre of the eyebrow. The eye apparently is on a slightly lower level than the right eye. There is an area of considerable depression over the left eyebrow, especially marked over its middle third and extending well up on the forehead. This area is not sensitive to pressure. Examination of the nose shows hypertrophy of both inferior turbinates and both nostrils containing some pus. An r-ray examination showed enormous frontal sinuses with moderate depression over the left frontal region, but was not particularly instructive. The operation had to be somewhat in the nature of an exploratory one. The r-ray proved of no value; all that was known was that there was a fracture of the anterior wall of the frontal bone. Incision through the left eyebrow and retraction of the soft tissues upward revealed a depressed area in the left frontal region with an irregular, roughly stellate, slightly depressed fracture. Removal of the area of depressed bone showed an enormous frontal sinus filled with edematous and infected mucous membrane with some pus. Examination of the septum between the right and left frontal sinuses showed a defect through which a large quantity of mucopus escaped from the right side into the left frontal sinus. It became necessary to increase the incision to the right and to make a second one along the bridge of the nose upward three quarters of the way to the hair line in order to reach both frontal sinuses. These cavities extended from points well outside the lateral extremity of the eyebrows more or less straight upward almost to the hair line and followed the hair line to the median line. They extended very deeply backward over the orbit almost as far as the optic foramen laterally to a great distance over the orbit. The entire anterior wall, the inner frontal septum, the roofs of both orbits and the anterior half of the internal walls of both orbits were removed. The passages into the nose were then enlarged and the ethmoids curretted although not radically. The entire operating field was then smoothed up with the electric engine. On account of the patient's poor condition, removal of the middle turbinates and posterior ethmoid cells was not completed. Two wicks of gauze were inserted into the frontal ducts and drawn out through the nose, and long wicks of gauze were packed into the frontal sinuses and their ends drawn out through the external edges of the initial incision. Atropin was put into both eyes. During the operation the periorbita of the right eye was found adherent to the bone of the roof and internal wall of the orbit. In separating this the periorbita was slightly torn. The patient suffered considerably from shock and required saline transfusion and coffee and whiskey enema. Recovery from the anesthetic was slow. This then completely obliterated the frontal sinus and anterior ethmoid. This offers the only method and technic that is successful in obliterating the frontal cavities and ethmoids-certainly the only one that permits such a radical operation without marked deformity. There is sure to be a certain amount of deformity with such large frontal cavities. If there is a marked depression it is remedied by the insertion subcutaneously of a wafer of paraffine of the proper size and shape. I wish to call attention to the fact that although these cavities are very deep, and although they extend laterally to the malar bones and almost to the optic foramen they can be obliterated. This case is demonstrated, first, to show the extent of the pathologic process, totally unsuspected before operation, and because it is one of the rare cases of involvement of the frontal sinus caused by anything except infection from the nose. There is one point in the technic that I want to bring out that is interesting to the ophthalmologist, which developed in the course of the operation. If the pulley of the support of the superior oblique is removed nothing develops. Formerly we took care not to remove the bone to which the pulley is attached but now we find that if the pulley is preserved in its attachment to the periosteum the bone may be removed with no interference with the function of the muscle. No diplopia, no sense of discomfort, so far as the otologist can find, although the ophthalmologist may be able to see some change in the action of the muscles. DISCUSSION. DOCTOR GEORGE SLOCUM: This is a very interesting case. I saw the right eye this morning; the other eye was covered with the dressings, which were not removed. The swelling about the right eye was interesting; considerable palpebral edema was present but it was evident that no infection of the conjunctival culdesac had occurred for while there was marked lachrymation, there was practically no inflammatory discharge. Edema and chemosis of the conjunctiva were so pronounced that the conjunctiva had swollen between the lids and considerable abrasion of the conjunctival epithelium had been produced by the continual efforts of the patient to wipe away the tears which were flowing down over the cheek. So far as I could determine the edema about the eyes is associated with the accessory sinus condition and the reaction due to operative interference and not to any disease of the eye itself. DEMONSTRATION OF THREE CASES OF PERNICIOUS ANEMIA. JAMES H. AGNEW, M. D. Case I.-Any one of these cases might furnish material for a good clinical report. They all show the entire symptomatology of pernicious anemia. We generally have two or three cases of it in the Medical clinic, and we do not think anything particularly of it. Some other hospitals have three or four cases a year and think it quite remarkable. It is thought to be more common here. The general opinion is getting to be that pernicious anemia is more common where it is more carefully sought after, illustrating very well the value of routine blood examination. Perhaps that is one reason why we see so many of these cases here. The first patient entered the University Hospital in March, 1911. He had been complaining for a couple of years of weakness, gradually increasing shortness of breath, and fleeting pains, particularly in the right thigh. His physical examination was practically negative with the exception that he exhibited slight loss of muscle sense in both great toes. The stomach examination showed achlorhydria, the urine was negative. The blood count disclosed 1,420,000 reds, and twentyeight per cent hemoglobin. There were no marked gastrointestinal symptoms. He was discharged two months later, at which time he had 2,630,000 reds and fifty-eight per cent hemoglobin. In December, 1911, he came back to the hospital and said that two months before he began to lose weight and had pain, particularly on the right side. At that time, he presented an anomalous picture of having a peripheral neuritis. His blood picture was practically negative and a diagnosis of pernicious anemia could not have been made. Of course, we had the blood findings of the time before which was perfectly definite. When he came to the hospital he had severe neuritis, confined particularly to the right sciatic region. He was transferred to the Neurologic clinic. Aside from some gastrointestinal complaints and some loss of weight previous to this he did not have anything except this neuritis which cleared up in about two weeks. He went home feeling well. About a month ago he noticed his strength failing, although he had not been doing very heavy work. He had stomach disturbance, particularly after eating. Hydrochloric acid controlled these symptoms but they finally drove him back here. When he entered his hemoglobin was sixty per cent and a blood count showed 2,140,000 reds. Probably he was in one of the exacerbations of the disease and he was seriously ill. Until the 31st his blood count was down to 1,700,000 reds and forty-five per cent hemoglobin. The diarrhea has been very severe until today. This afternoon he said that he was beginning to feel a little better. Today his blood (1,730,000 reds, forty-four per cent hemoglobin) is practically the same as a week ago. There are no nucleated reds to be seen. The patient was very sullen, morose, and intractable and was finally discharged for profanity and insubordination. respect, that after a period Whether or not it is the This history is very characteristic in this of severe diarrhea the symptoms clear up. elimination of the hypothetical toxin is not known. But after an unusually severe diarrhea the condition often improves. In fact, a severe and thorough purge is one method of treatment. Case II. This patient is fifty years of age. His physical examination is negative except for extreme paleness. Instead of the subcutaneous fat being well preserved, he is emaciated. In most cases there is a peculiar yellow color from the subcutaneous fat showing through the skin. In this case the pallor has come through. He has |