calibre than normal. been noted.

Small hemorrhages have occasionally

The theories to account for this remarkable condition are as numerous as they are unsatisfactory. It is supposed by some that syringomyelia always develops in a congenital defect of the cord; that the central canal is unduly distended with fluid at birth, and that around this the epiblastic elements proliferate, and afterwards extend into the normal tissue. This would account for the cylindrical epithelium lining the cavity. Other observers consider that during the closure of the central canal in the embryo, a second canal is formed, about which occurs neuroglial hyperplasia, and subsequent degeneration. There are not wanting, too, those who would attribute the gliosis to toxic or to bacterial causes, some color being given to the latter theory by a consideration of that peculiar form of syringomyelia called Morvan's disease, occurring with comparative frequency in some of the French fishing villages. In a number of instances, cavities have been found subsequent to disease of the spinal arteries. This would, perhaps, explain those cases following injuries of the back. But it is well to bear in mind, in considering these theories, the fact which Weigert has emphasized, that the neuroglia is merely a substance which nature uses to fill up a space, and that its proliferation is only a sign that nerve tissue has been destroyed. His studies of neuroglia lead him to the conclusion that the wall of the cavity is not a true glioma, that, in other words, the gliosis is not the essential feature, but only a secondary result. Lastly, it must be mentioned that sarcomata and other tumors of the cord may degenerate and give rise to cavity formation. (Bertholet.)

From a consideration of the paralysis, and the areas of analgesia and thermic anesthesia in this patient, the lesion must be located in the 6th, 7th and 8th cervical and 1st dorsal segments.

Symptoms. Although the clinical features are complex, there are three characteristic symptoms which are usually present together. These are (1) A loss of thermic and painful sensations in some part of the body, but the muscular and tactile senses are retained. This has been named by Charcot, "dissociated anesthesia." (2) Paralysis of the amyotrophic type. (3) Trophic disturbances of the muscles, bones and skin. Starr makes the statement that one of these symptoms alone should excite suspicion, but the presence of any two of them make the diagnosis probable. Besides this triad, we often find a spastic paraplegia, the initial stage of which is shown in our

patient by the increased knee jerk. The distribution of the symptoms will, of course, depend upon the location of the spinal lesion, and if the whole segment of the cord is involved, the general features of transverse myelitis will be present. The thermic anesthesia which was the first clinical sign of the disease in this case, showed itself about one year ago, but did not attract any attention. The sense of pain has probably been absent for some months, for he has injured his hand frequently without causing himself any inconvenience. The distribution of the dissociated anesthesia is always irregular, and only rarely symmetrical on the two sides. In the early stages there may be only a blunting of the thermic sense, and the analgesia may be patchy; but when the disease is well developed, the patient cannot distinguish between iced water and boiling water, and a surgical operation might be performed without pain. Progressive muscular atrophy, usually invading the hands, and giving rise to paralysis of the ulnar type, is present in more than one-half the cases of syringomyelia. The condition you see in the patient's right hand, has developed in about eight months. The muscles of the forearm are already involved, to some extent, and I fear the process is also beginning in the left hand. Although the Aran-Duchenne paralysis is the most common, occasionally the shoulder muscles may suffer first. Later, the muscles of the spine are invaded, producing a scoliosis-a frequent complication of the disease. But the legs, for the most part, escape damage. The degenerating muscles exhibit fibrillary contractions, but the electrical reaction is retained for a long time. Of the trophic disturbances, those affecting the skin are most common. In this case, we have a hyperemia of the skin of the arm and abnormal sweating. The abrasions, too, have been long in healing. The nails may be hypertrophied and brittle; the bones and the joints are often involved, chiefly those of the upper extremity. Charcot's joint is found in this disease almost as frequently as in tabes. The spinal reflexes are, as a rule, disturbed, diminished or entirely lost in the affected arm, while the knee jerk is increased. Only in rare cases are the sphincters involved.

Course. The course of syringomyelia is essentially chronic. Sometimes the condition will proceed a certain distance and then remain stationary for years. Unless the medulla is involved, the patient usually dies of intercurrent disease.

Diagnosis. At first the disease is often mistaken for amyotrophic lateral sclerosis, which, however, has neither sensory nor trophic symptoms. Anesthetic leprosy has also to be

taken into account, and may be distinguished by the thickening of the nerves, the finding of the bacillus, and the absence of sensory dissociation. Progressive muscular atrophy is usually symmetrical and is attended by no disturbance of sensation. There is an absence, too, of spasticity of the legs. But rare cases of tumor of the gray matter of the cord may give rise to symptoms identical with those of syringomyelia, and must be taken into account in this case.

Treatment. No drugs can have the slightest influence, but some months ago two German physicians reported an apparent cure from the use of the X-rays, applied to the part of the spine immediately over the cavity. This treatment is now being carried out on this patient by Dr. R. A. Thomas, in the electro-therapeutic department of Grace Hospital, and I hope to be able to report success at some future meeting of the Academy.

OPERATING ROOM.*

JOHN HUNTER, M.B.

How great would be the amazement of a barber-surgeon of the medieval ages, when his operating-room was any place wherein the patient might happen to be the living-room in the hovel of squalid misery, or in the richly-draped palatial chamber of the rich,-if he were to step into a modern operatingroom, with its polished or mosaic floors, enamelled furniture, marble seats, brass railings, glazed walls and glass domes. With the barber-surgeon the buccaneering germs were free to gratify their insatiable appetites, whilst the modern surgeon forbids even their presence, and if, peradventure, they are found about the wound they are speedily exterminated by antiseptics. The modern operating-room is an evolution of scientific surgery. To Lord Lister, Pasteur and a legion of other notable scientists, we of the twentieth century are greatly indebted. The heritage to which we, as members of the medical profession, become the legitimate heirs, brings with it great privileges, but also equally great responsibilities. This fact naturally leads up to the ethics of the operating-room.

ETHICS.

Since ethics can be defined as " a system of rules for regulating the actions and manners of men in society," and as we are members of a great fraternal circle, the ethics of the operating-room rest on the common basic principles so tersely summed up in the so-called "Golden Rule." But as every nation has its own language to give expression to its needs, emotions, and aspirations, so every calling has to evolve its own code of ethics. from common fundamental principles, e.g., the theft of money in social life finds its counterpart in the unprofessional taking of a patient from another physician. The work of the operating-room is of an exceedingly complicated character, as it involves the relationship of the surgeon to his patient, to his confreres, and to his profession. In no other vocation in life is a man's honor put to a more severe test than in the operatingroom. The subtle temptation comes to unduly urge on an operation that the surgeon's reputation may be enhanced, a large fee obtained, or some one else prevented from getting

*Post-graduate clinic, Western Hospital.

the case. The ethics of the operating-room imperatively demand that the interests of the patient must alone decide the question of operation. Flagrant violations of ethical laws may, and sometimes do, occur after the operation. Dr. A. is asked by Dr. B. to operate on his patient. Some months after Dr. B. finds that his patient, instead of coming back to him, goes to Dr. A. with his minor ailments. Dr. A. ignores Dr. B.'s claims altogether and treats the patient, and by so doing begins a life-long feud between Dr. B. and himself. Dr. A.'s conduct only becomes ethical when he has arranged with Dr. B. as to who the attendant should be.

The question of fees is often a much-mooted point. When the patient's means are limited and when there has been need for lengthened attendance before the operation, if the surgeon charges a high fee, the attending physician is deprived of a large share of his just reward. In all such cases ethics demand that in regard to remuneration the interests of both physician and surgeon be duly respected. Fees again come up as a factor in the relationship of the surgeon to the anesthetist. Is an inexperienced man ever chosen to save to the surgeon the fees that would otherwise go to an expert anesthetist? Ethical laws would hold that the safety of the patient is never to be jeopardized by the mercenary interests of the surgeon.

The importance of surgical work, as compared with the medical care and treatment of a case, involves an ethical question. The surgeon may not say so in words, but he may be quite willing to have the patient imagine that his work is of considerably more importance than that of the physician. In fact, it is not at all uncommon for the physician to find that his status is never quite the same with the patient or family as it was before the operation. In these cases the surgeon's ethical sin is one of omission in that he has failed to correct an erroneous impression that militates against his medical confrere.

The list of ethical problems that project themselves into the operating-room might be very much extended, but time will only permit of the discussion of one more, and it probably the most debatable one that confronts the surgeon in his work,— viz., who should do the operation? In isolated districts the one man must be both physician and surgeon, but the erection of hospitals in towns and cities has caused some division of labor, one section of the profession becoming better known as surgeons and the other as physicians. This division enables men to obtain a larger experience, and other things being equal,