fection, and yet no man would use that as an argument at the present day against laparotomy; then why against laminectomy? Certainly it is no more dangerous to enter the spinal cord under asepsis than it is to enter the abdomen under similar conditions. The procedure that I believe ought to be done in these cases, provided the surgeon does not know that inevitable death will follow, regardless of his treatment, is to cut down over the injured region, remove the fragments, if they can be removed, and give the patient a chance to escape degenerative changes of the cord that must follow the pressure that continues to weigh upon it; or again we might put it, it is the surgeon's duty, if there is the remotest doubt, to cut down on that spinal cord purely for diagnostic purposes. Then, if he finds a condition that is capable of relief, he has done his duty and can do it. If he finds a condition that is incapable of relief, he has done the patient no harm, for the wound will heal kindly, if the ordinary teachings of surgical technique have been followed. If we expect to operate for diagnosis in a case of this kind, it should be done at once, or as soon as the patient can be properly prepared, for it is hopeless after we have waited weeks and may be months to give our patient the same benefit that we could have given him by an immediate operation. I saw a case about fourteen months ago, in whom two surgeons had refused an operation, and operated on him on the 22nd day after injury. I opened the dura and found that the cord which those men had diagnosed, more than three weeks before, as completely severed, was not completely severed, and yet it had been resting under this pressure all of those weeks. Of course at that time degenerative changes must have taken place. While the patient was benefited by the operation, and while he is yet alive, recovery with him is an impossibility. The case is merely reported that I may ask this question: What might have been his chance if he had been operated on immediately after the injury? Mr. Thorburn, in an article published by him in the British Medical Journal in 1894 says: "In compound fractures operate. In fractures of the spinous processes and laminæ, with injury to the cord, we always operate. In simple fractures and dislocations of the bodies of the vertebræ, if there is a reasonable

probability that the injury is due to hemorrhage, operation is advisable, but in all other cases of this nature, we cannot hope to do good save where the injury is below the level of the first lumbar vertebra. In such cases laminectomy is an eminently valuable surgical procedure. Munro of Boston gives out in a recent article of his the following statements:

"If we collect the various scattered cases that have been reported within the last few years, favorable results following operation come more and more into evidence. It is useless at this time to go into the discussion of the question as to the possibility of equally good results in corresponding cases treated conservatively. The partisans on both sides are still too unyielding in their views. Being a partisan on the side of interference, I merely wish to present, as fairly as I can, the question as it appears to me personally. Fractures in the lower dorsal and in the lumbar regions are especially open to surgical interference, because of the relative harmlessness of laminectomy and because there is no valid reason for not subjecting the elements of the cauda equina to the same operative relief as in the case of any peripheral nerve. In the cervical fractures, however, there is much greater risk to life, whether operation is done or not. In watching quite a considerable number of injuries at this level, in the last few years; not subjected to operation, I have been impressed with the fact that they die a day or so earlier and that they suffer no less than similar patients who have had a laminectomy. In several instances it has been possible to watch the progress of two patients - one operated on, the other not-as nearly similar in injury, age, and physical conditions as is possible, using one as a control experiment, as it were. This impression has not a scientific basis; it is merely the general impression of a partisan observing the cases in hopes of being convinced that he advocates interference unnecessarily.

"In studying the cases of cervical and high dorsal injuries treated without operation at the Boston City Hospital within the last ten years, I found that, of thirty patients, only one lived and partially regained his functions; twenty-four died within eight days of injury. The remainder, not including the one recovery,

lived from three weeks to five months. In that same period I have seen, at the same hospital, at least three practically complete recoveries where a laminectomy was done. I have included the high dorsal injuries with the cervical because clinically the progress appears to be exactly the same. When we get below the mid-dorsal region, however, the story is a far different one."

Lloyd, in 1901, and various authorities since that time, have reported recoveries after operation where the indications pointed to complete crushing of the upper cord. In addition, I have knowledge of a few more in the practice of my colleagues that help to confirm my views that if the patient otherwise is able to undergo operation, it is better in the long run to offer him that chance; but the surgeon and patient should realize all the time. that at the very best the outlook is extremely poor.

Lloyd places great stress upon withholding interference where shock is an element of danger, and I emphatically believe he is right. Some of these cases, as soon as they react from shock, show improvement in their cord symptoms, and should be let alone; but with a halt in the progress or a retrogression, operation should be done at once. His dictum that patients with a complete obstruction of the cord should be let alone ought to be modified, because these symptoms are occasionally misleading. This is shown in the recent report of two cases by Mixter and Chase. In one there were present all the clinical symptoms on which authorities had previously based their opinion that operation was contraindicated because it suggested total transverse lesion with a crush of the cord beyond repair." Nevertheless, there was marked and steady improvement following operation for eleven months, when death from septic nephritis took place.

B. Zinci sulph....

CONJUNCTIVITIS.

a day.

Morphia sulph..

Atropia sulph.

Aquæ dest...

Ms. Sig. A few drops in the eye two or three times

ECZEMA*

BY J. M. KING, M. D., of nashville, Tenn.

In presenting this subject I shall consider, first, the pathological changes found in the diseased parts with their clinical aspect; second, the causes of these changes or of eczema; and third, the principles governing the treatment of the different stages. Eczema is an inflammation of the upper part of the corium accompanied by the ordinary signs of inflammation. The increased blood flow to the part, and the different degrees of exudation following it are the immediate causes of the different clinical types of eczema, of which there are three primary and two secondary.

The erythematous type is one in which the exudation effects very slightly the cells of the epidermis; the cells are not bathed and softened by the serum, and separated from each other, as is the case in the more developed weeping types.

The surface is red, hot, and dry, and the epidermis is intact, and on account of increased nutrition there is a slight impetus given to the development of all the tissues, thus producing an increased mitosis of the rete cells, which is followed by a more abundant scale formation on the surface, and a slight hyperplasia of the structures of the corium. Swelling to some extent usually accompanies this type, and scratching and rubbing may produce weeping areas.

In the papular type the changes found are more exaggerated than those in the erythematous. The epidermis is more involved, inasmuch as papules are formed by increased exudation in certain areas, and usually a vesicle is found seated on the summit of the papule. Intense itching is nearly always met with in this type, and the scratching leads to rupture of the vesicles, and breaks off the summit of the papule; an outpouring of serum and blood takes place on the surface, and dries into a small blood cap, which covers the site of the vesicle. Papular eczema, as it is first seen, usually presents the papules studded with these small,

* Read at Meeting of Middle Tennessee Medical Association, Nov. 17, 1904.

dark blood caps. The papules may be discrete, or may coalesce to form an elevated, red, infiltrated patch several inches in diameter.

The vesicular type is the most typical form of true eczema, and it offers the best opportunity for studying the chain of pathological changes which take place in the lesion. Something unknown excites an inflammatory process, as in other types, resulting in an excessive edema, which affects the epidermis more extensively than in the other types. The cells of the rete are bathed and soaked in the serous exudate, and are wholly separated from each other, while serum collects in pools in the strata of the epidermis above, forming vesicles. These vesicles being ruptured, an outlet to the surface is made, through which flows, or weeps, a fluid made up chiefly of serum, and a fluid resulting from the dropsical degeneration of the rete cells, and this mixture of fluids stiffens cloth when moistened by it and dried. The cells placed in these surroundings cannot undergo the proper changes to form sound epidermis. Some undergo degeneration and others pass upward and reach the surface still edematous. and still retaining their nuclei, instead of being converted into flat, horny cells without nuclei. Unna has named this process parakeratosis. A serous exudate from an abraded surface on a healthy skin will dry, and the place will heal within a short time; not so in eczema. The weeping continues for weeks and months, the fluid drying, forming yellow crusts, and the surface weeps again when the crusts are removed. So long as this condition lasts no healthy epidermis can be formed, and one object in local treatment is to remove the serum by absorption, and thus enable the cells to return to a normal development and the formation of a healthy epidermis.

Eczema rubrum, or eczema madidans, is a severe secondary type, resulting most frequently from vesicular eczema. The surface is raw and red, and there is so much weeping that crusts cannot form.

Eczema squamosum is a sluggish secondary form resulting from any of the above named types. It presents some scaling and decided thickening of the epidermis, with infiltration and thickening of the corium.