exposed for an inch, and there was apparently no injury to the cord, yet there was this complete paralysis there was nothing to indicate that the cord had been injured or the coverings; the cicatricial contractions of the old wound could be seen. It therefore occurred to him that perhaps the contusion to the cord had caused an extravasation of fluid within the cord and the pressure of the blood inside of the cord has caused the paralysis. Looking on it in that light perhaps Dr. Reder is wrong in his statement that nothing can be done after the spine had been exposed and that longitudinal incisions in the membranes might permit expansion and prevent degeneration and destruction.

Dr. Drechsler was very much interested in the paper. He felt that Dr. Reder was correct when he stated that the responsibility of the surgeon rests on the question whether to operate or not. He mentioned a case now under his care who was injured in March. Immediately following the injury there was paralysis of all the extremities which lasted for twenty-four hours, the patient then regained the use of the arms; for about two weeks had incontinence of urine; after three weeks of rest she gained a little motion in both feet; she is unable to stand and has now a complete anesthesia from the crest of the ilium down. No break in continuity could be made out, but there is intense pain from slight pressure in the dorsal and lumbar regions. There is no question as to the diagnosis, but an injury to the spine with severe hemorrhage into the cord. He had suggested an operation, but did not hold out any hope from that.

Dr. J. C. Morfit said his experience in these cases was merely that of an observer. He had seen two of Dr. Carson's cases and two of Dr. Nietert's, besides an indefinite number in the Baltimore hospitals. He believed that an immediate operation was called for, but unfortunately for the patients, this could not be arranged as promptly as the symptoms and gravity demand. A question was brought up by Dr. Sharpe as to waiting for shock to subside before operating. The speaker believed that if there was one surgical condition in which we might disregard shock it was in these cases. The first thing to do is to relieve the pressure even at the risk of shock plus the operation. The tendency in spinal and cranial injury is more and more to disregard the shock and operate at once for the relief of pressure.

Dr. A. M. Bliss thought Dr. Carson had cited a sufficient number of cases to show that it is hardly possible to formulate any set of rules for our guidance as to when to operate, and we must take the case as we find it, with the total paralysis and hyperesthesia yet no break in continuity. Where we do find a break in continuity then the earliest possible operation seems to be indicated. It often happens in spinal surgery, as it does in abdominal surgery, that we do not know just what condition we shall meet with until we enter the cavity. He believed that in many instances it would be impossible to differentiate whether there was a break in the cord, or pressure on the cord, from bone or hemorrhage. In the event that it is outside of the cord relief may be given, and as Dr. Carson has indicated, the operation of laminectomy is not a particularly dangerous procedure and does not add any more risk for the patient who is already in as bad a condition as he can be. Where direct violence to the spinal column itself can be demonstrated he thought the operation was indicated at the earliest

possible moment. In regard to making a diagnosis of injury to the cord, as suggested by Dr. Glasgow, he thought this would be a difficult thing to decide positively. We can surmise, perhaps, that the cord has not been totally crushed, that there are certain indications of continuity of function of the cord, but in a great many instances it would be impossible to make any differentiation of the condition of the cord and the neural arch.

Dr. Bliss asked Dr. Carson to give his view of what he would do in a case like that reported of the young man who fell into a ditch followed by total paralysis from a point high up in the column.

Dr. Carson, in closing, replying to Dr. Bliss's question said it might be rather embarrassing, but he did not think he would shirk any responsi bility in meeting a case of that kind, believing, as he does, that the operation is comparatively devoid of danger, that the paralysis is due to some pressure which could not be recognized, he would not hesitate to advise an operation. These operations are exploratory, but if there is any class of cases in which an exploratory operation is justifiable it is in these cases, when we consider what Keen says, "that the slightest injury may be followed by the severest consequences. If he were to open the spinal column and find a cord enlarged and had reason to believe there was hemorrhage in the cord causing this enlargement he would not hesitate to lay open the cord and attempt to remove the pressure in this way. He had never seen such operation advised, and of course could not know that one would ever see a case which would justify such procedure, but he thought he would do this under such circumstances.

Referring to Dr. Reder's question in regard to the so-called lumbagoes he said he was often in doubt as to how to account for them. He had thought there might be pressure on the origin of the nerve as it merges from the cord. In other cases referred to there might be a neuritis resulting from exposure, and again he had thought these cases might be due to some little hematomyelia. As to operation during shock it was his experience that the cases which recover from shock recover quickly, and if the operation is done in the hospital where it ought to be done, they have generally sufficiently recovered from the shock to allow of the operation. However, in some cases the shock is so great that it almost kills the patient, and here the operation would not be justifiable. It was of course impossible there to go into a discussion of the regeneration of the nerves, whether central or peripheral; but a sufficient number of cases have been reported where the spinal cord has been completely divided and yet almost complete restoration of function has occurred; so that we are justified in believing that regeneration does take place. Then we have the case of Stewart and Harte, where three-fourths of an inch of the cord was removed and the patient, while still in the hospital, is able by bracing herself be tween two chairs and sliding them along on a smooth floor to move about. By bracing herself on the chairs, or crutches, which she uses to maintain the erect posture, she can lift one limb a little from the floor; but as to performing any functions or duties, that is out of the question. It is net so. It is a remarkable case when we take everything into consideration, that the patient is still alive and that she is in a comfortable condition, she is able to pass her water and feces, and has sensation, and can get about, even though it is with support. If we can bring about such results we are perfectly justified in doing any operation.

A Case Simulating a Perforated Gastric Ulcer.-(Tiverton, British Medical Journal, Aug. 15, 1903.)-The author reports the case of a girl, 18 years of age, who, upon his first visit, was found to be in a state of collapse, a reduction of body temperature, almost pulseless, a marked abdominal expression (facies abdominalis) and complaining of severe abdominal pain. On examination the abdomen was found retracted with an abscence of abdominal breathing. On palpation the abdominal muscles were very hard and pressure caused severe pain which was referred chiefly to the epigastric and left supra-clavicular regions. The history given by the patient was that at 6:30 a. m., after having taken a cup of tea she gave a scream and said, "Oh, my stomach," whereupon she fainted. Upon the administration of some brandy she revived, presenting the condition previously described, accompanied with nausea and retching, but no vomiting. During the day the patient fainted twice from pain. The day following, her condition had materially improved and four days later was practically well, save some slight tenderness upon pressure. The treatment consisted of hypodermic injections of morphine with the abstinence of all food and drink. From the first appearance the condition looked like a clear case of ruptured gastric ulcer, but the subsequent course and the following recovery showed that this condition did not exist. In regard to this case Adamson (Brit. Med. Jour. August 22, 1903) writes the following:

Sir.-In the case under the above heading, reported by Dr. Tiverton in the British Medical Journal of August 15th, it seems highly probable that there actually was a perforation (the most favorable variety), and the ordinary recovery under the judicious treatment employed. I can recall a very simliar case in which the abdomen was opened and a small perforation found on the upper and anterior part of the stomach with practically no extravasation of contents and protected somewhat by old adhesions. It was the opinion of those who saw the condition that recovery would likely have ensued without any operation. Cases are recorded in which perforation, followed by recovery under medical treatment, has been proved by post-mortem examination. So that the patient's easy recovery does not forbid the diagnosis of perforation. The points mentioned in this case against perforated gastric ulcer are not nearly so strong as the clinical facts in favor of it, and it seems to me worth while to at least suggest the alternative to Dr. Tiverton. It is possible the future history of the patient some day may throw light on this important association of symptoms and be recorded. One point with regard to the liver dullness, mentioned by Dr.

Tiverton to be "normal," although when first seen it was too early to expect that to disappear." If it was normal throughout, then it proves nothing either for or against perforation. But is hardly precise to write about its being "too early to expect that to disappear." The disappearance of the liver dullness may be practically instantaneous, if a large amount of gas escape from a perforation in the stomach or bowel. I have recently had a case of perforated intestine in which this was exemplified-malignant disease of the bowel. In any case the alteration of liver dullness is always an early symptom, and the earlier the more reliable. It is true the gradual disappearance of the liver dullness can be watched when the leakage of gas is steadily and gradually taking place, but the "fallacy of the distended abdomen" must ever be guarded against, whenever later on in the case the least paralytic distention of the bowels occurs; and for this reason it is true to say that the alternations in the liver dullness are the most important, if present at all, of the earliest symptoms."

(The Editor.)-In regards to a diminished hepatic dullness as a diagnostic sign of a perforation in the gastro-intestinal tract, too much significance should not be attached to this symptom, as it sometimes leads to an error in the diagnosis, especially is this true in some cases of severe attacks of biliary colic associated with symptoms of collapse where the liver dullness is diminished, not due to a distention of the intestines with gas, but where the lower margin of the liver is slightly turned upon its axis pointing posteriorly (due to the weight of the gall-bladder containing stones) permitting a small space, which is occupied by intestines, between the lower margin of the liver and abdominal walls.

Chronic Nephritis Without Albuminuria.-(Elliot, Medical News, Sept. 19, 1903.)-With a report of several cases, Elliot concludes as follows: 1. Latency of symptoms is so constant a characteristic of chronic interstitial nephritis as to almost constitute its most salient feature. This obscurity involves all manifestations (symptomatic, physical and urinary) and prevails throughout the entire course of the disease. 2. Latency of symptoms does not constitute a point of absolute distinction between the early and the advanced stages, or between the mild and severe forms of the malady. 3. Symptoms are especially liable to be absent, and urinary signs uncertain during the early stages of chronic interstitial nephritis, consequently the diagnosis during this period must generally be made from physical signs rather than from symptoms or urinary signs. 4. Albumin is absent from the urine of this form of nephritis with great frequency. It may frequently be absent during the early stages. It may occasionally be absent until the disease enters the final stages. It may rarely remain absent from the urine throughout the entire course of the disease, the urine remaining free from albumin so long as no intercurrent disturbance apart from the nephritis arises to cause it to appear. Albuminuria, therefore, constitutes a very unreliable diagnostic sign in this disease. When present, associated with physical signs and other urinary indications, it serves to complete the diagnosis, but if absent no contrary inference is justifiable, and the diagnosis must be considered without its aid. 5. More reliable evidence of renal change is a diminution in the gross amount of urinary solids, and especially significant is the presence of casts.

Chronic interstitial nephritis never exists as a clinically recognizable condition without the presence of casts in the urine. Although a renal diagnosis cannot be founded on casts alone, they constitute a corroborative sign of high clinical value, when associated with other indications. 7. The secondary circulatory changes following chronic interstitial nephritis are so constant and characteristic as to furnish, in most cases, sufficient ground for the recognition of the disease before reference is made to the urine. The inconstancy of the urinary symptoms places them in much the same diagnostic category in chronic interstitial nephritis as that occupied by the murmur in valvular diseases of the heart. The diagnosis should be made, if possible, from the physical signs and symptoms, the urinary indications being regarded as corroborative rather than as essential evidence.

Tendon Reflexes in Inflammation of the Kidneys.-(Lion, Zeitschrift f. klin. Medizin, 1903, Bd. 50, Heft 3 and 4.)-Lion has given careful attention to this phenomena and observed in inflammatory lesions of the kidneys, with an absence of temperature, quite regularly an increase patellar reflex, increasing considerably with a threatening uremia, returning again to normal as the urinary symptoms improved. In an interstitial nephritis with a good diuresis the reflexes were normal. In cases of nephritis associated with fever the reflexes, excepting in a few cases, were not increased. In these cases it is difficult to say just what amount of influence the temperature had on the reflexes, as a moderate temperature causes increased reflexes, whereas a high temperature causes a diminution. Among 262 cases of nephritis the author found only 5 cases with a diminished patellar reflex. Lion regards this phenomena as a significant of a retention of toxic substances which should normally be eliminated by the kidneys, the reflexes diminishing as the lesion improves, or when interstitial changes take place.

An Experimental Contribution to the Pathogenesis of Ulcus Ventriculi. -(R. dalla Vedova, Referate, Prager med. Woch., 1903, No. 38.)-The author has extensively experimented on dogs, and found that in producing lesions of the coeliac plexus or its thoracic branches (splanchnic), necrotic, hemorrhagic, ulcerative, changes took place in the stomach walls which presented the characteristic necrobiotic features of an ulcer of the stomach. In addition, the microscopic characteristic of these experimentally produced ulcers, was an absence, or only a relatively slight reactive inflammation.

Anuria. (Apolant, Deutsche Med. Woch., 1903, No. 28.)-The author reports a case of a total suppression of urine for nine days ending in a recovery. Belladonna was administered on the supposition that there was an impacted renal calculus in one ureter with a reflex spasm of the other ureter. On the eighth day the symptoms became alarming and the right ureter was catheterized, allowing an evacuation of ten liters in twenty-four hours. As the patient was an elderly gouty subject a nephrotomy might have had serious consequences.