class of cases, that it is only by persistent and repeated examinations of the urine that we get positive evidence of interstitial nephritis. It is an easy matter to find a man with interstitial nephritis in which the urinary examination would be negative. A negative diagnosis should not be made upon one examination of the urine, nor even upon the second, if there are other symptoms to bear out the assumption that Bright's disease exists, because we all know it is by repeated and continued examinations that we will be able to clear up the diagnosis in these cases.

If I understood the paper correctly, I am a little surprised at the prognosis given by the essayist in interstitial nephritis; when the diagnosis is made by the specialist by the appearance of the eye, that the time these patients live should be so short. Interstitial nephritis is a disease which, while it is not very amenable to cure-perhaps none of the cases are ever cured -is of a chronic character; yet my observation appears to bear out the statement that they do not all die, or at least a great proportion of them, within eighteen months after the diagnosis is made.

A point about which I would like to inquire is, does it appear that there is any thing in that class of cases of interstitial nephritis when the symptoms are first shown in the eye to make the prognosis worse? If so, my attention has not be called to it before, and I would like to hear that feature of the subject elaborated a little further. It is nothing unusual for a man with interstitial nephritis to live for many years, if he lives the correct kind of a life.

Dr. J. A. Ouchterlony: The question put by Dr. Cecil is one that naturally suggests itself, and I think the explanation is this, at all events it is my experience: eye symptoms do not occur very early in interstitial nephritis; it is of comparatively late development. And I am sure that my experience agrees with Dr. Cheatham's. I remember one case in evidence, a gentleman who had not seen his family physician, who happened to be myself, but came to Dr. Cheatham to see about his eyes. Dr. Cheatham discovered very pronounced retinal lesions, and sent the man to me. We both made a very unfavorable prognosis, which was received with very bad grace; the family was very much displeased; at all events, neither Dr. Cheatham nor myself were ever connected with the case after that, which suggests the propriety of being a little reserved as to both diagnosis and prognosis.

One point that interested me in the paper in connection with the

remarks that have been made was the subject of cystic degeneration. This is a disease in which I have taken a great deal of interest. All the cases of cystic degeneration I have seen have died of uremia, yet so far as I know nothing is said in the books about ocular symptoms in connection with that disease. I would like to know from some of the ophthalmologists of the Society if that is not so. It seems to me there ought to be some experience in that direction. The diagnosis of cystic degeneration is not always easy, certainly not easy in the early stages of the disease. I remember one case that came under my notice; a man was supposed to have syphilitic disease of the brain, but it turned out that he had cystic degeneration, two of the largest cystic kidneys I have ever seen. When the eye symptoms become prominent I think the prognosis is always very bad.

I remember a case of Bright's disease of pregnancy where frequent examination of the urine was absolutely negative. All of a sudden I was called to the house, and found the patient with that wasky pallor indicative of renal disease; she had nausea, headache, etc. I saw her about II o'clock and made an examination of the urine, finding it loaded with albumen, and there were numerous casts. About 1 o'clock convulsions began and continued to recur until she died.

I believe it a good plan to get the aid of the oculist whenever there is a suspected case of renal disease, for the reason not only that it aids in confirming the diagnosis, but the revelations of the ophthalmoscope are of decided prognostic value.

Dr. S G. Dabney: Dr. Cecil asked me whether I found marked ocular symptoms in the wife of the physician at Brandenburg, and I told him that I did not. I stated that the chief ocular symptom was photophobia, which she had induced by staying in a dark room. The lady is still living, and still has photophobia, but Dr. Cecil says she has no nephritis. It is a little odd, however, that both the father and daughter should have had Bright's disease, and in both the diagnosis was first made by the ophthalmoscope, and both died within a year afterward.

In regard to the albuminuria of pregnancy, this has been impressed upon me by the death of a patient lately with her second child. I do not know the cause of death. I saw her when in her first pregnancy, three years ago in June. She was sent to me for examination of her eyes. She was then in the fifth or sixth month of utero-gestation, and I found marked albuminuric retinitis, the sight of one eye being

reduced to one sixth of what it ought to be, being two thirds in the other. Labor was induced, followed by puerperal mania lasting several months. She was sent to a sanitarium in Ohio, and made a perfect recovery. I saw her frequently after her return, and her vision was perfect; it was astonishing to see how the retinal lesions had cleared up. She died this winter, and, I have heard, was again pregnant. I do not know the cause of death.

Dr. J. M. Ray: A year or more ago I read a paper before this Society in which I reported cases of retinal hemorrhages, one occurring in a well-defined malarial subject and two in cases of profound anemia, one of them following pregnancy or during the period of lactation. In the paper referred to I stated that years ago, when I was a hospital interne, Dr. Agnew made the statement that he could not recall a case of retinal hemorrhages in a person over fifty years of age that lived over three years. After I started in practice myself I always gave a very guarded prognosis in cases of retinal hemorrhages in people past middle life. But I have seen a number of cases live indefinitely after retinal hemorrhages in people of this age, and as my observations increase the number of these cases increase. I believe that we see numbers of cases of arterio-sclerosis that present retinal hemorrhages in which there is no kidney disease, and yet the appearance of the fundus is strongly suggestive of Bright's disease; examination of the urine has failed to discover any kidney disease. I have a case on hand now, a gentleman who came to me a month ago with the statement that one eye was blurred, and asked me to examine it. I examined the eye and found a number of retinal hemorrhages. I referred him to the family physician, and made the suggestion that the ophthalmoscopic appearance was indicative of kidney disease, as was also his history, habits, etc., but the report was that a number of examinations of the urine had been made and no kidney disease discovered. The case went along until I was sent for again, to see him in consultation with two other doctors, and, upon examination, I found both eyes the seat of enormous hemorrhages. I understand now the man is in coma with hemiplegia. I report the case simply as one in which the condition of the fundus was strongly suggestive of Bright's disease, and the chances are the hemorrhages in the retina result from degeneration of the walls of the blood-vessels.

Case of Pneumonia. Dr. J. G. Cecil: I have under observation a case of pneumonia which has interested me very much; it followed the

Res

grip in a young woman twenty-six years of age, of tuberculous history, who has had three previous attacks of pneumonia. This woman was seized with evidences of pneumonia on Sunday a week ago. I did not see her until the following Wednesday; then she had the typical appearance of grip, nothing else. On the second day after I saw her there was bronchial breathing and evidences of pneumonia in the base of the left lung; in two days after that she had signs of consolidation of the right lower lobe; a day or two afterward she had evidences of consolidation of the right apex. She has maintained all through this a very steady heart, which has given me hope that she may eventually pull through. The heart has ranged from 100 to 130, with an average of 120. piration has gone as high as 60 to the minute, with temperature between 101° and 104° F. This is about as extensive involvement of lung tissue as I have ever seen for the patient to live as long as she has. She has now passed the critical time, and resolution is taking place in the first lobe involved. I think it must be this feature of the case which has enabled her to live. She became markedly cyanosed many times, which has been relieved by oxygen gas. The strength of the heart has been looked after with one-fortieth grain doses of strychnine every three hours, nitroglycerine when cyanosed, and whisky ad lib. I hope to have the pleasure of reporting the recovery of this case at a future meeting.

Amputation of the Hip (continued report). Dr. W. O. Roberts: A short time ago I reported a case of amputation at the hip-joint a few days after the operation was performed; amputation was done for injury received in a railroad accident. I merely wish to state that the man has made a complete recovery and has returned to his home.

Head Injury (continued report). Dr. Louis Frank: At the last meeting of this Society I reported a case of head injury in which trephining Iwas done. I think Dr. Grant mentioned at the time that the danger of suppuration Suppurated, not, however, extending to the deeper structures, merely involving the scalp. There was extensive suppuration two days after the last meeting, which was two weeks ago, and the man presented some marked symptoms of impairment of the arm and leg of the site side; also impairment of the muscles of motion about the face. There have been no symptoms referable to the tongue or of the eye, but there is loss seemingly of muscular power of the muscles of the

was still to be considered. The wound since then has

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jaw. About a week ago his temperature went up to 103.5° F., and he complained of severe headache, accompanied by inability to swallow, inability to open the mouth, and he suffered pain down the spine. I was inclined to think he was going to have an attack of tetanus, but under sixty grains of bromide of potassium every three hours he has improved; the temperature came down so that since Monday morning of this week it has been normal; his muscular power is improving; he is now walking about, and complete recovery will probably result in a short time.

Post-Anesthetic Paralysis (continued report). Dr. Turner Anderson: It may be interesting to know the further history of the case of postanesthetic paralysis of the arm which I reported two months ago. I am pleased to tell you the patient is now pursuing the course predicted at the time and endorsed by the Fellows of the Society. She is slowly improving; gradually getting the use of her arm. It is now nearly three months since the operation, and she is able to close her fingers and move them at will.

B. A. ALLAN, M. D., Secretary.

COLLEGE OF PHYSICIANS OF PHILADELPHIA—SECTION ON OPHTHALMOLOGY.

Meeting December 18, 1900. Dr. George C. Harlan, Chairman, in the Chair.

Dr. G. C. Harlan showed a patient with myosis and ptosis, due to a gunshot injury of the right cervical sympathetic received five years ago. The right pupil responded promptly to light, but was 2 mm. smaller than the left either in contraction or dilatation. The edge of the upper lid covered the upper margin of the contracted pupil. There were no other symptoms and no history of unilateral sweating. Under homatropin mydriasis the pupils retained the same relative size. The voluntary movements of the lid were normal. The patient was wounded from in front while in a stooping position and leaning forward, and the scar of entrance of a rifle ball was on the anterior margin of the sternomastoid at about the level of the cricoid cartilage. The ball, which was never traced and could not be located by X-ray examination, probably grazed the carotid and passed downward and backward.