Vol. CXIL, No. 2.

AUGUST, 1896.

No. 292.

THE

AMERICAN JOURNAL

MEDICAL SCIENCES.

EDITED BY

EDWARD P. DAVIS, A.M., M.D.

WITH THE CO-OPERATION IN LONDON OF

HECTOR MACKENZIE, M.A., M.D., F R.C.P.

PHILADELPHIA AND NEW YORK:

LEA BROTHEES & CO. 1896.

PUBLISHED SIMULTANEOUSLY IN THE UNITED STATES AND GREAT BRITAIN.

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A TREATISE ON SURGERY

FOR STUDENTS AND PRACTITIONERS

BY AMERICAN AUTHORS.

Edited by ROSWELL PARK, M.D.,

Professor of the Principles and Practice of Surgery and of Clinical Surgery in the Medical Depart- ment of the University of Buffalo, Buffalo, New York.

IN TWO LARGE AND VERY HANDSOME ROYAL OCTAVO VOLUMES COPIOUSLY ILLUSTRATED WITH ENGRAVINGS AND FULL-PAGE PLATES IN COLORS. VOL. I. 794 PAGES, WITH 356 ENGRAVINGS AND 21 FULL-PAGE PLATES IN COLORS AND MONOCHROME. PRICE, PER VOLUME, CLOTH, $4.50 ; LEATHER, $5.50. NET. VOL. II. IN PRESS FOR EARLY ISSUE. *

THE early publication of Park's '^Surgery by American Authors'' will place in the hands of students and practitioners a work thoroughly reflecting the science and art of surgery in its most modern and cosmopolitan development, and fitly sustaining the honorable position universally accorded to America in the surgical world. The Editor's recognized eminence has brought him the willing co-operation of gentlemen of the highest ability and experience, and his accurate acquaintance with their special lines of distinction has been skilfully utilized in the assignment of subjects, so that the work as a whole will be regarded as a production of the highest authority.

Numbering in its list of authors the surgical teachers in many leading colleges, Park's Surgery will exemplify the best methods of placing its topics clearly and com- pactly before the mind. Space will thus be available for full practical details concerning everything of importance. From these considerations it will be obvious that the work will at once become a standard text-book for students and an indispensable guide for the general practitioner as well as for the specialist in surgery.

In point of richness and beauty of illustration Park's Surgery will mark a departure in surgical literature, the engravings and colored plates being largely original, and introduced wherever clearness and fulness of information can be aided by pictorial eflect.

IN PRESS.

DAVIS' OBSTETRICS.

A TREATISE ON OBSTETRICS. FOR STUDENTS AND PRACTITIONERS. By EDWARD P. DAVIS, A.M., M.D.,

Professor of Obstetrics and Diseases of Infancy in the Philadelphia Polyclinic, Clinical Professor of Obstetrics in the Jefferson Medical College of Philadelphia.

IN ONE VERY HANDSOME OCTAVO VOLUME OF 700 PAGES, WITH OVER 200 ENGRAVINGS IN THE TEXT AS WELL AS 16 FULL.PAGE PLATES IN COLORS AND MONOCHROME.

IN this new work, shortly to appear, medical students and practitioners have assurance of a treatise of the highest excellence. The author is eminently koown in con- nection with the teaching and practice of this great and responsible department of medicine. Clearness and practicality of instruction will be marked features of the text, and equally noteworthy will be the series of illustrations, among them being a large number of photographic reproductions of obstetrical scenes carefully selected in view of the amount, vividness and permanence of the instruction which can be conveyed thereby. Ample use will be made of colors.

LEA BROTHERS & CO., PUBLISHERS, {',j>f^/„f^^^^^^^^

BUFFALO LITHIA WATER,

SPRING No. 2,

In BRIGHT'S DISEASE, GOUT, STONE IN BLADDER, and DISEASES GENERALLY OF URIC ACID DIATHESIS, &c., &c.

Dr. WiLIJAM a. Hammond, of Washington, D. C, Surgeon-General U. S. Army {retired), Professor of Diseases of the Mind and Nervovs System in the University of Neio York, etc.

"I have for some time made use of the BUFFALO LITHIA WATER in cases of AFFECTIONS of the NERVOUS SYSTEM, complicated with BRIGHT'S DISEASE OF THE KIDNEYS or with a GOUTY DIATHESIS. The results have been eminently satisfactory, Lithia has for many years been a favorite remedy with me in like cases, but the BUFFALO WATER CERTAINLY ACTS BETTER THAN ANY EXTEMPORANEOUS SOLUTION OF THE LITHIA SALTS, and is, moreover, better borne by the stomach. I also often prescribe it in those cases of CEREBRAL HYPERiEMIA resulting from ovee-mental WOEK— in which the condition called NERVOUS DYSPEPSIA exists — and generally with masked benefit."

Hunter McGuIRE, M. D. , LL. D. , Late Professor of Surgery, Medical College of Virginia, Richmond.

"BUFFALO LITHIA WATER, Spring No. 2, as an ALKALINE DIURETIC, is invaluable. In URIC ACID GRAVEL, and, indeed, in diseases generally dependent upon a URIC ACID DIATHESIS, it is a remedy of EXTRAORDINARY POTENCY. I have prescribed it in cases of RHEUMATIC GOUT, which had resisted the ordinary remedies, with wonderfully good results. I HAVE USED IT ALSO IN MY OWN CASE, BEING A GREAT SUFFERER FROM THIS MALADY, AND HAVE DERIVED MORE BENE- FIT FROM IT THAN FROM ANY OTHER REMEDY."

Dr. Wm. B. ToWLES, Professor of Anatomy and Materia Medica, in the Medical Department of the University of Virginia.

"BUFFALO LITHIA SPRINGS, No. 2, belongs to the ALKALINE or, perhaps, to the Alkaline Saline Class, for it has proved far more efficacious in many diseased conditions than any of the simple Alkaline waters.

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"//s effects are marked in causing a disappearance of Albumen from the urine. In a single case of Bright's Disease of the Kidneys I witnessed decided beneficial results from its use, and from its action in this case I should have great confidence in it as a remedy in certain stages of this disease.''^

Dr. G. HalSTEAD BoYLAND, Late Professor of Surgery, Baltimore Medical College, Late Surgeon French Army {Decorated), Member Baltimore Academy of Medicine, Member of American Medical Association.

"In x^right's Disease of the Kidneys, Acute or Chronic, BUFFALO LITHIA WATER, Spring No. 2, is, in my experience, without a rival, whether in the Parenchy- matous form or Interstitial Nepheitis. Iu cases in which the Albumen in the Ueine reached as high as 50 per cent., I have known it, under a course of this water, to gradually diminish and finally disappear; at the same time other alarming symptoms were relieved, and the sufferers restored to health.

"In Stone in the Bladder of the Red Lithic Acid and the White Phosphatig Deposit, the Solvent power of this water is unmistakable.''^

Water in cases of one dozen half-gallon Bottles $5.00, f. o. b. here.

THOG. F. GOODE, Proprietor.

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COIVIPEISING THE PRONUNCIATION, DERIVATION AND FULI. EXPLANATION OF MEDICAL TERMS; TOGETHER

WITH MUCH Collateral Descriptive Matter, Numerous Tables, Etc.

By ALEXANDER DUANE, M. D.,

Assistant Surgeon to the New York Ophthalmic and Aural Institute ; Reviser of Medical Terms for Webster's International Dictionary.

Second edition. In one large square octavo vol. of 690 double-columned pages. Cloth, |3.00 ; half leather. |3.25 ; full sheep, $3.75. Thumb-letter Index, 50 cents extra.

Dr. Alexander Duane, who is well-known as a medical writer of wide experience, and who has had special training as the Reviser of Medical Terms for Webster's International Dictionary, has issued a work which proves to be a model of conciseness, convenience and thoroughness. The book is brought accurately to date by extended research. The definition of diseases includes a brief synopsis of their etiology, symj)- toms ajid treatment ; the anatomical and physi- ological terms are accompanied by outlines of the essential features of structure and function, and each drug is described with its action, thera- peutic uses and pharmacopoeial prei^arations. Although contained within the limits of a handy volume of 650 pages, many of the definitions possess encyclopaedic value. Useful anatomical tind other data are tabulated with originality and precision. Under the word Artery, for example, is found a table covering eight pages, presenting

the origin, lateral and terminal branches and their distribution, of each vessel. Twenty tabu- lar pages are allotted to the origin, direction and insertion of the muscles, with their action and nerve-supply ; wliile thirty-two more are given to the " Table of Bacteria and Fungi," with their origin, morphological characters, proper temperature for culture, properties, etc., as well as a complete list of all bacteriological diseases. The latter is the most comprehensive and service- able table of the kind yet issued. The system of pronunciation is simple, and the spelling is in accordance with the best usage. Derivations from foreign tongues are given, those from the Greek being in English text for the benefit of readers unfamiliar with tlie original. The au- thor is to be congratulated upon the production of a work combining such practical utility with a fund of most extensive research. — 3Iedical Record.

New (2d) Edition,

Musser's Medical Diagnosis-SiT

A Practical Treatise on Medical Diagnosis. For the Use of Students and Practitioners. By John H. Musser, M.D., Assistant Professor of Clinical Medicine. Univer- sity of Pennsylvania, Philadelphia. In one octavo volume of about 950 pages, with about 200 engravings and 10 colored plates.

THE great value of Professor Musser's Practical Treatise on Medical Diagnosis has been recog- nized in the early exhaustion of the first edition. This new issue has been thoroughly revised, every page bearing evidence of the author's complete command of this important subject, in- cluding its latest developments. The series of illustrations has been much enlarged, and the list of colored plates has correspondingly increased and enriched with many instructive pictures. Eeaders of this work, will find in it a complete working guide to an art underlying any rational and contin- ued success in treatment.

VOLUME I. IN PRESS.

The American System of Medicine.

In Contributions by Eminent Specialists. Edited by Alfred L. Loomis, M. D., late Professor of Pathology and Practical Medicine in the New York University, and William Oilman Thompson, M. D , Professor of Materia Medica, Therapeutics and Clinical Medicine in the New York University. To be completed in four large octavo volumes, con- taining about 1000 pages each, with illustrations in colors and in black.

THE appropriate time is at hand f()r the presentation of an entirely new and encyclopaedic work emanating from acknowledged leaders of the American medical profession and dealing witli the vast subject of Practice in a manner re])resenting the world's latest knowledge and in the full development of clinical application for which this country has so enviable a reputation This service cannot be satisfactorily performed exce]>t by those who are in actual touch with our people and practically acquainted with the special features of disease developed by the social and climatic conditions of this continent. The eminent editors of the American System of Medicine have secured the willing assistance of gentlemen of the highest ability and experience, and have assigned the various subjects to those who are recognized as peculiarly qualified to speak with full authority. The work will therefore be regarded as representative in the best sense and as occupy- ing a i)lace which can be filled in no other manner. The first volume will shortly be ready fi)r issue and the remaining volumes will promptly follow.

BROTHERS & CO., Publishers J?N7rZ!:X.'ISr-;'sM;'Nrvork.

READY IN A FEW DAYS.

HARE'S PRACTICAL DIAGNOSIS.

The Use of Symptoms in the Diagnosis of Disease. By Hobaet Amory Hare, M. D., Professor of Therapeutics in the Jelferson Medical College of Philadelphia, Laureate of the Medical Society of London, of the Koyal Academy in Belgium, etc. In one handsome octavo vol. of 566 pages, with 191 engravings and 13 colored plates. Cloth, |4.75.

THE experience of the author in both didactic and clinical teaching has shown that the all-im- portant subject of diagnosis can be relieved of much of its difficulty by treating it exclusively from a clinical standpoint. The object of this volume is to place before the physician and student a guide to this art as it is actually used in practice. To accomplish this the symp- toms used in diagnosis are discussed first, and their application to determine the character of the disease fallows. Thus, instead of describing locomotor ataxia or myelitis, there will be found in the chapter on the Feet and Legs a discussion of the various forms of and causes of paraplegia, so that a physician who is consulted by a paraplegic patient can in a few moments find the various causes of this condition and the differential diagnosis between each. So, in the chapter on the Tongue, its appeai'ance in disease, both local and remote, is discussed. In other words, this book is written upon a plan quite the reverse of that commonly followed, for in the ordinary treatises on diagnosis the physician is forced to make a supposititious diagnosis, and, having done this, turn to his reference book and read the article dealing with the disease supposed to be present, when if the description fails to coincide with the symptoms of his case he must make another guess and read another article. In this book, however, the discovery of any marked symptom will lead directly to the diagnosis. Thus, if the patient is vomiting, in the chapter on Vomiting will be found its various causes and the diagnostic significance, and the differentiation of each form of this affection from any other.

The two indexes form an especially valuable and practical portion of the work. In the Index of Diseases under each heading will be found annotated references to the various symptoms which constitute its clinical picture. Conversely, the Index of Symptoms, Organs, and Terms furnishes a ready-reference list of the various diseases in which any given symptom may appear as a feature. It would be difficult to conceive of a work of greater utility. In connection with it the same author's Practical Thera2)eutics (see page 8), may be most advantageously consulted for the best treatment.

Simon's Clinical Diagnosis — Just Ready.

A Manual of Clinical Diagnosis by Microscopical and Chemical Methods.

For Students, Hospital Physicians and Practitioners. By Charles E. Simon, M. D., Late Assistant Resident Physician, Johns Hopkins Hospital, Baltimore. In one very handsome octavo volume of 504 pages, with 132 engravings and 10 colored plates. Cloth, $3.50. rpiIIE art of determining a disease from the evidences it presents as to its character must logically I underlie any merited and continued success in treatment. To this end it is incumbent upon the physician to avail himself of all the methods and facilities for precision in diagnosis which modern research has placed so readily at his command. Among them none are more impor- tant than those afforded by microscopy and chemistry, and it is the purpose of this volume to describe such methods in detail so that the student or practitioner who has not had special training in such manipulations, may nevertheless be enabled to obtain satisfactory results. The volume will be found to be richly illustrated in black and colors and replete with practical information repre- senting the most advanced knowledge obtained in American and European laboratories, clinics and

The American Text= Books of Dentistry — In Press.

In Contributions by Various Authors. Opekative Dentistry, edited by Edward C. Kirk, D.D.S., Professor of Clinical Dentistry in the Department of Dentistry, University of Pennsylvania. Prosthetic Dentistry, edited by Charles J. Essig, M.D., D. D. S., Professor of Mechanical Dentistry and Metallurgy in the Department of Dentistry, University of Pennsylvania, Philadelphia. In two very handsome octavo volumes of 700 to 800 pages, profusely illustrated.

FOE many years the dental profession and teachers in dental colleges have expressed a desire for works which would clearly and thoroughly reflect the practice of dentistry as it is known in America. Recognizing the justice of these expressed needs, the publishers have placed in the hands of gentlemen of peculiar fitness the task of editing two volumes intended to furnish a practical working knowledge of the two main departments of dental science and art. It will be found that these two works combine the features of text-books with those of laboratory manuals. With their guidance any student of avei-age intelligence will be able to follow and perform any of the multifarious procedures in operative and prosthetic dentistry. Combined with a wealth of thoroughly practical and technical instruction, there is an unfailing recognition of the rationale in dental practice, and the student is thereby guided not only to technical skill, but also to a broad intelligence in the application of principles.

The several contributors to these volumes are teachers of distinctive a>^ility in their respective fields. The chapters will, accordingly, be found replete with material which the advanced yet conservative members of the jirofession accept as fact and sound theory. The features long demanded by the advanced teacher, namely, accuracy and fulness of clinical teaching, complete detail in the technique, and a clear exposition of foundation principles are so happily combined in these new works that their recognition as the standard text-books on their subjects is already assured. They will be equally favorite reference works for dental 2:)ractitioners.

LEA BROTHERS & CO., Publishers, ^?^p^rA«„"!8^ts™^^

2

New (8th) Edition. Thoroughly Revised. Just Ready.

SMITH ON CHILDREN,

A Treatise on the Diseases of Infancy and Childhood. By J. LEWIS SMITH, M. D.,

Clinical Professor of Diseases of Children in the Bellevue Hospital lledical College, New York.

New (8th) edition, thoroughly revised and rewritten and much enlarged. Handsome octavo of 983 pages, with illustrations and 4 colored plates. Cloth, $4.50; leather, $5.50.

The advances in our knowledge of the etiology, therapeutics and pathology of the diseases of children have called for a thorough revision of this classical work. The author, in order to perfect the subject in every possible way, in- trusted the surgical diseases of children to Dr. Stephen Smith and assigned certain of the topics to Dr. Frederick M, Warner. The chap- ter dealing with intubation was specially pre- pared by Dr. Joseph O'Dwyer, and Dr. A. R. Robinson contributed to the text and the illus- tration of the portion of the book dealing with skin diseases of children. In other words, the distinguished author with rare modesty deter- mined to secure assistance in the elucidation of

those portions of the book wherein he felt others were more competent to speak with the weight of authority, giving us a treatise which in every respect can more than hold its own against any other work treating of the same subject, be it elaborate composite system or more modest text- book. The result is that the practitioner will still, as he has for long in the past, look to Smithes Diseases of Children for that accurate portrayal of symptoms, that lucid exposition of treatment which stand him in good stead at the bedside of his little patients. For years the work under review has been the favorite, and under the present auspices we question not that it will remain such. — Am.Medico-Surg. Bulletin.

Parvin's Science and Art of Obstetrics — New (3d) Ed.

The Science and Art of Obstetrics. By Theophilus Parvin, M. D., LL.D., Professor of Obstetrics and the Diseases of Women and Children in Jefferson Medical Col- lege, Philadelphia. New (3d) edition. In one very handsome octavo volume of 677 pages, with 267 engravings, and 2 colored plates. Cloth. $4.25 ; leather, |5.25.

The book is complete in every department, and contains all the necessary detail required by the modern practising obstetrician. Many prac- tical suggestions are otfered for physicians, both young and old. Great stress is laid on the im- portance of strict asepsis in obstetrical work, and considerable space is devoted to the various complications following infection. When treat- ment is indicated, Dr. Parvin is explicit in di- rections, the remedies suggested being those which have given the best results in his own practice, and the experience of other obstetri- cians is never disregarded. The book deserves our highest praise ; we consider it one of the most comprehensive of its class published, and

take pleasure in recommending the same to students and to physicians. — International lled- ical 3Iagazine.

This most excellent treatise on the art of ob- stetrics has arrived at its third edition. In the present issue about one-third has been re-written, and every page bears evidence of revision in con- formity with the latest scientitic advancement. The distinguished author and teacher has given to the American profession a work on which they can rely, and it is safe to say that it ranks second to none in the English language. The series of illustrations has been increased, render- ing the work still more complete. — Annals of Gynecology and Pediatry.

Yeo on Food in Health and Disease. — New (2d) Ed. just Ready.

Food in Health and Disease. By I. Burney Yeo, M. D., F. R. C. P., Profes- sor of Therapeutics in King's College, London. In one 12mo. volume of 592 pages, v^ith 4 engravings. Cloth, $2.50.

PROPER feeding has rightly come to be recognized as one of the natural methods of combat- ting disease and on that account more important even than the use of drugs. Conversely, errors in recommending diet may be quite as serious as errors in prescribing. Physicians will therefore value this convenient and authoritative manual, which approaches its subject rationally, showing the proper use of foods in health and giving full information for the judicious pre- scription and preparation of foods best suited to the needs of the system in the various diseases.

Treves' System of Surgery— Complete Work. Just Ready.

A System of Surgery. In Contributions by tvrenty-five English Authors Edited by Frederick Treves, F. R. C. S., Surgeon to and Lecturer on Surgery at the London Hospital, Examiner in Surgery at the Univ. of Cambridge. In tvv^o large octavo vol- umes, containing 2322 pages, with 950 engravings and 4 plates. Per volume, cloth, $8.00.

Careful and acciinitc wi-iiing, close attention to practical usefulness, well-balanced distribution of space and material, and tliorough editorial supervision, characterize this volume from cover to cover. An excelk'iit level is maintained throughout, and practical information brought

up to the latest knowledge upon each subject abounds on every page. The book will make a most useful addition to the library of the suri^-eon and of the practitioner. '^Phe illustra- tions are most creditable; the majority of them are original. — Annals of Surgery.

LEA BROTHERS & CO., Publishers,

Taylor on Venereal Diseases —

The Pathology and Treatment of Venereal Diseases. By Robert W. Tayloe, A.m., M.D., Clinical Professor of Venereal Diseases in the College of Physicians and Surgeons, New York. In one very handsome octavo volume of 1002 pages, with 230 engrav- ings and 7 colored plates. Cloth, |5.00; leather, $6.00. Net

The best work on venereal diseases in the En- glish language. It is certainly above everything of the kind. Nothing is omitted and every- thing carefully noted. Illustrations are numer- ous and well chosen. The colored plates are superior in execution. Every physician who desires a complete and reliable library on the subject of venereal diseases should avail him- self of the opportunity of obtaining Taylor's work. — St. Louis Medical and Surgical Journal.

Dr. Taylor's personal reputation is so high, his experience has been so wide and full that it is but natural that one should have the highest expectations of the work which must be regarded as the mature result of his ex])erience. It meets the highest expectations. Treatment is taken up at length. All the various methods and sugges- tions are fully described and given careful con- sideration. The whole subject of gonorrhoea is dealt with in the broadest light. The subject of chancroid is completely considered. All the varieties of syphilis are considered. The ex-

position of the subject is clear, distinct and broad, and is marked by the same practicality and rational conservatism that characterize the rest of the work. In treatment nothing has been neglected. In its completeness the book leaves almost nothing to be desired. It is a veritable storehouse of our knowledge of the venereal dis- eases. It is commended as a conservative, prac- tical, full exposition of venereal diseases of the greatest value. — Chicago Clinical Review.

This is by long odds the best work on venereal diseases it has ever been our fortune to read. The subject is treated in an exhaustive and com- prehensive way that leaves nothing wanting. Every possible information that could be desired in the treatment of these diseases will be found in this most excellent work. In this new work Taylor has done much to render the services of the non-specialist successful. Much praise is due the illustrations, the colored plates being particularly fine. — Louisville 3Iedical Monthly.

VAUGHAN & NOVY ON

Ptomains and Leucomains, Toxins and Antitoxins.

New (3d) Edition. Just Ready.

Ptomains, Leucomains, Toxins and Antitoxins ; or the Chemical Factors in the Causation of Disease. By Victor C. Vaughan, Ph.D., M. D., Professor of Hygiene and Physiological Chemistry in the University of Michigan, and Frederick Gr. NovY, M. D., Junior Professor of Hygiene and Physiological Chemistry in the University of Michigan. New (third) edition. In one 12mo. volume of 603 pages. Cloth, $3.00.

IT is now generally recognized that those diseases which cause the greatest mortality and conse- quently are of the greatest importance are in reality cases of poisoning; that pathogenic germs are living poisons and that every infectious disease is actually an intoxication. Not only are there chemical factors in the causation of disease, but furthermore, specific chemical agents are now being employed in its prevention and cure. In the present volume will be found a systematic expo- sition of etiological, preventive and curative chemistry. The widespread interest in its department, and the acceptance of this volume as the standard authority has led to the demand for three editions. These opj^ortunities have been utilized by the authors to keep it always abreast with the rapidly advancing knowledge in its dejsartment. The j^resent edition has not only been thoroughly revised throughout but also greatly enlarged, s]3ace being given to the new subjects of Toxins and Anti- toxins, which have assumed great and merited j^ractical importance of recent years.

Abbott's Bacteriology— New (3d) Edition. Just Ready.

The Principles of Bacteriology : a Practical Manual for Students and Physicians.

By A. C. Abbott, M.D., First Assistant, Laboratory of Hygiene, University of Pennsylvania,

Philadelphia. New (third) edition, thoroughly revised and greatly enlarged. In one very

handsome 12mo. vol. of 492 pp., with 98 illustrations, of which 17 are colored. Cloth, $2.50.

As a practical compend on the principles of bacteriology this treatise has no superior among American works, and has accoi-dingly come into very general use as a laboratory manual among students. All that portion of the book that re- lates to technical procedures is very satisfactory, and directions are stated with sutficient minute- ness to guide any ordinary beginner. Of special value to the student of bacteriology are the out- lines of experiments to be followed in the study of the various species. The chaj^ters on animal experimentation contain descriptions of all the newer apparatus and procedures, and will be found invaluable to anyone who is not perfectly

familiar with the ditficulties of this work. Not only are the needs of the student considered, but the advanced worker will find a very full choice of all the newer staining methods, instruments, and procedures for diagnosis. In the descrip- tions of several important species many recent additions to our knowledge have been properly incorporated and these chapters may be consid- ered as giving all that is certainly known on the subjects. It only remains to rejDeat our unre- served recommendation of the work for the use of all laboratory workers in bacteriology. — New York Medical Journal.

LEA BROTHERS & CO., Publishers, I^FTrA^^^oris^^^^^

4

Dercum on Nervous Diseases-Just Ready.

A Text-Book on Nervous Diseases. By Twenty-two American Authors. Edited by F, X. Deecum, M.D., Clinical Professor of Diseases of the Nervous System in the Jefferson Medical College, Philadelphia. In one handsome octavo volume of 1046 pages, with 341 engravings and 7 colored plates. Cloth, |6.00 ; leather, |7.00. [Net.)

The work is representative not only of Ameri- can neurology, but likewise of the best methods of teaching as developed in the leading medical colleges ot this country. Actual experience with our social and climatic conditions is essen- tial as a qualification in those who would sjjeak with authority upon this especial subject. — Alienist & Neurologist.

Here is a volume which bespeaks present-day neurology in no uncertain or unauthoritative voice. There is here gathered the very cream of our knowledge of to-day. Most of the writers are, or have been, associated with various leading schools, and consequently bring to their aid the faculty of lucid statement, always forcible and understandable. The book wiJl remain the stand- ard one in its line. — Chicago Clinical Review.

The best text-book in any language, especially adapted to the wants of the student and the gen- eral practitioner. — Medical Fortnightly.

The whole book is the most thoroughly up- to-date treatise that we have on its subject, and should be in every hospital and asylum. — American Journal of Insanity.

This volume is made up of the writings of twenty-two authors including most of that band of workers which has lifted neurology in this country up to the high plane which has made it command the respect and admiration of workers in all departments of medicine. The book is the most comprehensive of its kind yet pub- lished in the United States, and will be found a safe guide either as a text-book or work of reference. — The Pittsburgh 3fedical Review.

Hayden on Venereal Diseases— Just Ready.

A Manual of Venereal Diseases. By James R. Hayden, M. D., Chief of Venereal Clinic College of Physicians and Surgeons, New York; Professor of Genito-Urinary and Venereal Diseases, University of Vermont, etc. In one 12mo. volume of 263 pages, with 47 engravings. Cloth, $1.50.

PRACTITIONERS as well as students will welcome this authoritative and compendious guide to the diagnosis and treatment of the three venereal diseases : Gonorrhoea, Chancroid and (Syphilis.

Foster's Physiology— sixth American Edition.

Text-Book of Physiology. By Michael Foster, M. D. , F. R. S , Prelector in Physiology and Fellow of Trinity College, Cambridge, England. New (sixth) and enlarged American edition, with notes and additions. In one handsome octavo volume of 922 pages, with 257 illustrations. Cloth, |4.50 ; leather, |5.50.

Dr. Foster's text-book has long held its place at the very forefront of physiological teaching. We will admit that for the purpose of a text- book for the medical undergraduate the sixth American edition is superior to any of its prede- cessors, and is unquestionably the best book that can be placed in his hands, and as a work of reference for the busy physician it can scarcely be excelled. — The PhUadelphia Polyclinic.

The great popularity of the work is shown by the fact that it is included as a text or reference book in nearly every medical college annual announcement. For physician, student or teacher this is and long will remain the stand- ard, up-to-date work on physiology. It needs

no recommendation beyond its own merits to establish its claim as the physiological text- book of the day. — Virginia Medical Monthly.

Every practitioner, whether general or vSpecial, should have at hand a new up-to-date physi- ology. There can be no mistake in selecting a Foster, either on the part of the medical student or practitioner. — Pacific Medical Journal.

In the new American edition just at hand additions have been made to render the volume suitable for junior as well as advanced students, so that this single volume contains all that will be necessary in a college course, and it may be safely added all that the physician will need as well. — Dominion Medical Monthly.

Mitchell on Nerve Injuries and Their Treatment— ^'^^^ady.

Remote Consequences of Injuries of Nerves and Their Treatment.

An examination of the present condition of wounds received in 1863-65, with additional illustrative cases. By John K. Mitchell, M. D., Assistant Physician to the Orthopaedic Hospital and Infirmary for Nervous Diseases, Philadelphia. In one handsome 12mo. vol ume of 239 pages, with 12 illustrations Cloth, $1.75.

Cases of such long duration and of such severity are so seldom reported that every case presents individual symptoms of great interest, which cannot, hovever, be enumerated in a brief re- view. The work has been admirably done and it will prove indispensable to every neurolo- gist and surgeon. — Boston Medical and Surgi- cal Journal.

The work before us is an unusual one, if not absolutely uni<iue. It is a study, thirty years after the war, of the cases of gunshot and other injuries of nerves collected l)y the elder Mitchell during the war. In spite of the enormous diffi- culties in following up the cases after sucli a. long period, the author has given us an elabor- ate study of fifty-two cases of gi-eat interest.

LEA BROTHERS & CO., Publishersjrr7rAir:X.T87HSM:''^^^^^

York.

5

New Edition. With Appendix. Just Ready.

DUNQLISON'S

Dictionary of Medical 5cience.

A Dictionary of Medical Science. — Containing a Full Explanation of the Various Subjects and Terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar- macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Surgery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecology, Obstetrics, Pediatrics, Medical Jurisprudence and Dentistry, etc., etc. By Eobley Dunglisox, M. D., LL.D., late Professor of Institutes ot Medicine in the Jefferson Medical College of Philadelphia. Edited by Richaed J. Dungli- SON, A. M., M. D. New edition, thoroughly revised, greatly enlarged and improved, with the Pronunciation, Accentuation and Derivation of the Terms. With Appendix. In one magnificent imperial octavo volume of 1225 pages. Cloth, |7.00 ; leather, |8.00. Thumb-letter Index for quick use, 75 cents extra.

It is a fact recognized by all those interested in the medical sciences tliat Dungiison's Medical Dictionary is the most satisfactory and authori- tative guide to the derivation, definition and pronunciation of medical terms. Everybody is familiar with this dictionary. It has i)assed through twenty-one editions. — The Charlotte Medical Journal.

Covering the entire field of medicine, surgery and the collateral sciences, its range of useful- ness, can scarcely l)e measured. Perhaps the most valuable feature in the present work is the addition of a vast amount of practical matter. — Medical Record.

There has been a i>raiseworthy attemi>t to render the work an epitome of the existing con- dition of medical science. Tlius, under the heading Hernia, besides tlie definition of the condition, a condensed tal)le is given of the various forms, and a l>rief resume is given of the therapentie indications. Under the heading Murmurs, l)esides a deseri]>tion of the various forms, a table is given of the significance of the murmurs of valvular origin. Under Bacteria

the leading classifications are recorded, and a l)aragraph is devoted to the questions of the de- termination of the pathogenic properties, and anotlier to modes of culture of the bacteria. In addition, the work is for the first time made a l>ronouncing dictionary. — Montreal Medical Journal,

The new "Dunglison" is new indeed. The vast amoiuit of new matter and the thoroughness with whieli the work has been brought down to date cannot fail to strike even the least observant reader. The immense advances made in all branches of medical science here find representa- tion. In respect to accuracy the book quite equals and usually surpasses any of its contem- poraries that we are acquainted with. — The American Journal of the Medical Sciences.

So fully have derivations and definitions been considered, and so great is the amount of practi- cal matter, such as symptoms, treatment and prognosis of many of the diseases described, that the volume is entitled to be called an en- cyclopsedia rather than a dictionary. — Brooklyn \ Medical Journal.

Gray's Anatomy— 13th Ed. ''TrTnbuack

Anatomy, Descriptive and Surgical. By Henry Gray, F.R.S , Lecturer on Anatomy at St. George's Hospital, London. Edited by T. Pickering Pick, F.R.C S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Eoyal College of Surgeons of England. A new American from the thirteenth enlarged and improved London edition. In one imperial octavo volume of 1118 pages, with 636 large and elaborate engravings on wood. Price of edition with illustrations in colors : Cloth, $7.00 ; leather, $8.00. Price of edition with illustrations in black : Cloth, $6.00 ; leather, $7.00.

Teachers of anatomy are almost unanimous in recommending " Gray " as the standard work for the student. The illustrations are conceded to be the best that have yet been given to the profession. In short, Gray'' s Anatomy is the ideal text-book on this subject, and it is sufficient to say of the present edition that it is fully equal to the previous ones, with many valuabie addi- tions, and that it fully deserves the same un- qualified commendation it has received in the past. — Cleveland 3Iedical Gazette.

Gray has been the unvarying standard for anatomical study by the vast majority of English-speaking medical students. — Medical Fortnightly.

It has thoroughly and completely established itself as the anatomy ^jar excellence. — Brooklyn Medical Journal.

In modern times no book on any medical sub- ject has held the position of a standard so long

as Gray^s Anatomy. It is a complete atlas of anatomy. The physician or student who requires but one work on anatomy will not need to ask which. The work is admitted to be easily first on anatomy in any language — The American Practitioner and News.

We always had a kindly regard for the illus- trations in Gray, where each organ, tissue, artery and nerve bear their respective names, and in this edition, color has been worked to advantage in bringing out the relationship of vessel and nerve. — Buffalo Medical and Surgical Journal.

The matchless book of the doctor's or surgeon's library is and has been Gray^s Anatomy. It has held the leading place in all colleges as a text- book, and has been the one central figure in the many text-books in anatomy that have claimed attention. It is still the standard text-book. — Kansas City Medical Index.

LEA BROTHERS & CO., Publishers,

CULBRETH'S Materia Medica and Pharmacology — Just Ready.

A Manual of Materia Medica and Pharmacology. Comprising all Organic and Inorganic Drugs, which are and have been official in the United States Pharmacoposia, together with important Allied Species and Useful Synthetics. For Students of Medicine, Druggists, Pharmacists and Physicians. By David M. R. Culbketh, M. D., Professor of Botany, Materia Medica and Pharmacognosy in the Maryland College of Pharmacy. In one handsome octavo volume of 812 pages, with 445 illustrations. Cloth, |4.75.

ALL the several classes of readers for whom this work is intended will find in it a thorough, authoritative and systematic exposition of its most important domain. Etfective treatment by means of drugs necessarily depends upon knowledge of the agents employed. To place this most easily and rationally at command the author has grouped the various substances according to their natural relations, giving the classification, name, source, constituents, adulterations, preparations, manufacture, properties, medical uses, dosage and allied drugs. The materia medica of the animal, vegetable and mineral kingdoms are thus exhaustively and practically described, including the new and important additions with which organic and synthetic chemistry has increased the powers of the physician. The volume closes with sections on use of the microscope, poisons and antidotes, various useful tables, maximum doses, customary abbreviations and a very full index. The series of illustrations is exceptional for the number and beauty of the engravings.

Caspari's Pharmacy — Just Ready.

A Text-Book on Pharmacy. For Students and Pharmacists. By Charles Caspaei, Jr., Ph. G., Professor of the Theory and Practice of Pharmacy in the Maryland College of Pharmacy. Baltimore. In one handsome octavo volume of 680 pages with 288 illastrations. Cloth, $4.50.

The author is widely and favorably known as ioint-editor of The National Dispensatory, and as Professor of Pharmacy in one of the foremost pharmaceutical colleges of this country. His exceptional opportunities for knowing the needs of students and pharmacists and how to answer them in the best manner are conspicuously em- bodied in this work. It has been possible to include in a convenient volume all the theoreti-

cal and practical information which the student and pharmacist will need. The multifarious details of every-day work are described and illustrations have been liberally employed wherever they could elucidate manipulations and processes. It is the most practical book possible. The working formulas are models of their kind. — Pacific Record of Medicine and Surgery.

JUST READY.

The National Dispensatory ^i^^airgSi^ror The National Formulary.

The National Dispensatory. Containing the Natural History, Chemistry, Phar- macy, Actions and Uses of Medicines, including those recognized in the Pharmacopoeias of the United States, Great Britain and Germany, with numerous references to the French Codex. By Alfred Stille, M.D., LL.D., Professor Emeritus of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania ; John M. Maisch, Phar. D., late Professor of Materia Medica and Botany in Philadelphia College of Phar- macy, Secretary to the American Pharmaceutical A^ssociation ; Charles Caspabi, Jr., Ph.G., Professor of Pharmacy in the Maryland College of Pharmacy, Baltimore; and Henry C. C. Maisch, Ph. G., Ph. D. New (fifth) edition, thoroughly revised and incorporating the new U. S. Pharmacopoeia (Seventh Decennial Revisioa) and likewise embracing the new edition of The National Formulary. In one magnificent imperial octavo volume of 2025 pages, with 320 engravings. Cloth, |7.25 ; leather, $8.00. With Ready Reference Thumb-letter Index, cloth, $7.75 ; leather, $8.50.

The careful examination of this large volume will strike the reader with surprise at the great number of new articles added, and the amount of useful and accurate information regarding their properties, methods of preparation and therapeutical effects. The large number of new articles containing all the latest synthetic remedies and unofficial remedies, compass the entire range of available information in the line of the work. A number of very complete tables together with all the official re-agents and sohi- tions for qualitative and quantitative tests,

appear in the appendix. Altogether this work maintains its previous high reputation for accuracy, practical usefulness and encyclopaedic scope, and is indispensable alike to the phar- macist and physician. Every druggist knows of it and uses it, and almost every physician properly consults it when desirous of settling- all doubtful questions regarding the properties, preparation and uses of drugs. — Medical Record.

It is the official guide for the medical and pharmaceutical professions. — Buffalo Medical and Surgical Journal.

LEA BROTHERS & CO., Publishers, jrrp7rAr„!:X^';":8u:'N'r^

York.

Hare's Text-Book of Practical Therapeutics -New (gth) Ed.

A Text-Book of Practical Therapeutics ; With Especial Reference to the Application of Remedial Measures to Disease and their Employment upon a Rational Basis. By HoBART Amory Haee, M. D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. With special chapters by Des. G. E. de ScHWEiNiTZ, Edward Martjn and Barton C Hirst. New (fifth) edition. In one octavo volume of 740 pages. Cloth, |3.75 ; leather, $4.75.

Five editions in as many years constitute a remarkable record for any book, aud further- more, an evidence that medical teachers and practitioners appreciate a work closely adapted to their requirements. Professor Hare is well known as a progressive and able therapeutist and teacher, and his ability in both directions is attested in the highly original plan of this work, as well as in its execution. His purjiose has elearly ])een to bring a knowledge of the remedial agents into close relation with a knowl- edge of disease. The book consists essentially of two x^arts, the first being a, treatise on thera- peutics, both medicinal and non-medicinal ; the second being a treatise on disease, its symptoms, varieties, treatment, etc. The two parts are brought into direct connection by means of refer- ences so that a knowledge of any subject treated is easily gained. Ease of reference is, moreover, l^rovided for in the highest degree by the ali)ha-

betical arrangement of the book and by the two full indexes. Practitioners will find the Thera- peutical Index, in which all the remedial mea- vsures are listed with brief annotations under the headings of the several diseases, most suggestive and serviceable. Like preceding issues, the present edition has been revised to the latest date. — Columbus Medical Journal.

We have stated in public through previous reviews, and often remarked in private, that Hare's Practical Therapeutics was one of the most useful books which a physician could have in his library. It is this combination of the theoretical and the practical which makes the book so valuable to the practitioner especially. It is a book precisely adapted to the needs of the busy jjractitioner, who can rely upon find- ing exactly what he needs. — The National Med- ical Review.

Simon's Chemistry— Fifth Edition.

Manual of Chemistry. A Guide to Lectures and Laboratory work for Begin- ners in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine. By W. Simon, Ph. D., M. D., Professor of Chemistry and Toxicology, Coll. of Phys. and Surg., Baltimore ; Professor of Chemistiy in the Maryland College of Pharmacy. Fifth edition. Jn one 8vo. volume of 501 pages, with 44 engravings and 8 colored plates illus- trating 64 of the most important chemical tests. Cloth, $3.25.

The exhaustion of tlie very large fourth edi- tion in less than two years indicates the leading position achieved by professor Simon's Chem- istry as a text-book in medical and i)harma- ceutical colleges. It furnishes an admirable selection of material bearing upon the bnvs and phenomena of chemistry. As an aid to labora- tory work a number of exixriments have been added. Physicians as well as students will appreciate the value of the colored ] dates of reactions, which give a permanent and accurate series of standards for comi)arison of tests, a matter not susceptible of satisfactory explana- tion in words. In medical ])ractice important pathological and toxicological questions depend-

ing on the test-tube may with certainty be referred to this series of colors and color-changes. The new edition has been most carefully re- vised in accordance with the advance of science and in order to bring it into complete harmony with the new Pharmacopoeia. All chemicals mentioned in the last issue of that work are included. Special care has been taken to detail the most modern methods for chemical examin- ation in clinical diagnosis. The author's ex- perience as a physician and as a teacher of medi- cal and pharmaceutical students is reflected in the special adaptation of his book to the needs of all concerned with the applications of chemistry to the art of healing. — Southern Practitioner.

Maisch's Materia Medica — Sixth Edition.

A Manual of Organic Materia Medica ; Being a Guide to Materia Medica of the Vegetable and Animal Kingdoms. Eor the use of Students, Druggists, Pharmacists and Physicians. By John M. Maisch, Phar. D., Professor of Materia Medica and Botany in the Philadelphia College of Pharmacy. New (sixth) edition, thoroughly revised by H. C. C. Maisch, Ph. G. In one very handsome 12mo. volume of 509 pages, with 285 engravings. Cloth, $3.00.

Maiseh's Materia Medica is too well established in the favor of pharmacists, druggists and botan- ists to need introduction. New matter has been added, and the whole work has received careful revision, so as to conform to the new United States Pharmacopceia. The great value of the work is the simplicity of the style and the accu- racy of each description. It considers each article of the vegetable and animal pharmacopceia, and, where important, sections on antidotes, etc., are added. Several useful tables are incorpor- ated.— Virginia Medical Jfonfhly.

The best handbook upon pharmacognosy of any published in this country. The revision

brings the work up to date, and is in accord with its previous high standard. — The Boston Medical and. Surgical Journal.

AVe can add nothing to our previous commen- datory notices of this standard text-book of materia medica. It is a work of such well-tried merit that it stands in no danger of being superseded, but will always remain a splendid monument to the genius and untiring industry of one to whom Americian pharmacy is under a great debt for many notable contributions to the sum of our knowledge of vegetable drugs. — American Druggist and Pharmaceutical Record.

LEA BROTHERS & CO., Publishers, ZVZ.'^^lT^lZ.rsT^T^^^^^^^^^^

8

Complete Work Just Ready.

A SYSTEM OF SURGERY.

BY AMERICAN AUTHORS.

Edited by Frederic S. Dennis, M. D. , Professor of the Principles and Practice of Surgery, Bellevue Hospital Medical College, New York ; President of the American Surgical Association, etc. Assisted by John S. Billings, M. D., LL. D., D. C. L., Deputy Surgeon- General, U. S. A. In four imperial octavo volumes, containing 3652 pages, 1685 engravings and 45 full-page plates in colors and monochrome. Price per volume : Cloth, $6 ; leather, $7 ; half morocco, $8.50, For sale by subscription only. For prospectus with order blank address the Publishers.

We very much doubt whether any work has ever appeared in the English language which better represents the height to which American surgery has attained. The authors are types of American surgeons, and they deal with the sub- jects allotted to them in a masterly manner. — Brooklyn lledi'ccU Journal.

The authors are all men who, from their positions as teachers of surgery, either clini- cally or systematically, can claim to be ^ble to speak with authority on the subjects which they have undertaken, and the names of many of them are well known in this country. It is not possible to judge of the whole work from this first volume ; but we may say of it that it gives a careful and accurate account of that part of surgery of which it treats, and that it is worthy

of the position to which surgery has attained in the great republic whence it comes. — The London Lancet.

The whole is the work of American surgeons, and it may be fairly said to represent the most advanced condition of American surgery. — Annals of Surgery.

Its intrinsic worth is of such a character that no progressive and intelligent operator could well do without it. — St. Louis 3Ied. and Surg. Jour.

It is almost an act of supererogation to at- tempt to criticise a work of this importance, every chapter of which is written by an ac- knowledged authority in his sphere. It is the most valuable contribution that we have had of late years to the subject of general surgery. — American Medico-Surgical Bulletin.

Politzer on Diseases of the Ear — New Edition.

A Text-Book of Diseases of the Ear and Adjacent Organs. By Dr.

Adam Politzer, Imperial-Eoyal Professor of Aural Therapeutics in the University of Vienna, Chief of the Imperial-Royal CJaiversity Clinic for Diseases of the Ear in the General Hospital, Vienna. Translated into English from the third and revised German edition, by Oscar Dodd, M. D.. Clinical Instructor in Diseases of the Eye and Ear, College of Physicians and Surgeons, Chicago. Edited by Sir William Dalby, F.K.C.S., M.B., Consulting Aural Surgeon to St. George's Hospital, London. In one large octavo volume of 748 pages, with 330 original illustrations. Cloth, |5.50.

This edition of the eminent Vienna professor's well-known work will be welcomed by those who wish to obtain a complet'* account of all that is known in connection with aural diseases. Whoever peruses it carefully cannot fail to be struck with the details, the extensive references, and especially the valuable pathological data, which underlie the clinical remarks and details of methods of treatment. The anatomy and physiology of each part of the organ of hearing

are carefully considered, and then follows an enumeration of the diseases to which that special part of the auditory apparatus is especially liable. The indications for treatment are clear and reliable. We can confidently recommend it, for it contains, as stated by the editor in his preface, all that is known upon the subject. — London Lancet.

A safe and elaborate guide into every part of otology. — American Journal of the Med. Sciences.

Norris & Oliver's Text=Book of Ophthalmology.

A Text-Book of Ophthalmology. By William F. Norris, M.D., Pro- fessor of Ophthalmology in the University of Pennsylvania, and Charles A. Oliver, M.D.,

Surgeon to Wills Eye Hospital, Philadelphia, engravings and 5 colored plates Cloth, $5.00

We take pleasure in commending the " Text- book " to students and practitioners as a safe and admirable guide, well qualified to furnish them, as the authors intended it should, with " a working knowledge of ophthalmology." — Johns Hopkins Hospital Bulletin.

The first text-book of diseases of the eye writ- ten by American authors for American colleges and students. Every method of ocular precision that can be of any clinical advantage to the e very-day student and the scientific observer is offered to the reader. Ilules and procedures are made so plain and so evident, that any student can easily understand and employ them. It is practical in its teachings. In treat- ment it can be accepted as from the voice and the pen of a respected and recognized authority.

Very handsome octavo, 641 pages, with 357 leather, $6 00.

The illustrations far outnumber those of its con- temporaries, whilst the high grade and unbiased opinions of the teachings serve to give it a rank superior to any would-be competitor. Wonder- fully cheap in price, beautifully printed and exquisitely illustrated, the mechanical make-up of the book is all that can be desired. After a most conscientious and painstaking perusal of the work, we unreservedly endorse it as the best, the safest and the most comprehensive volume upon the subject that has ever been offered to the American medical public. We sincerely hope that it may find its way into the li&t of text-books of every English-speaking college of medicine. — Annals of Ophthxdmology and Otology.

LEA BROTHERS & CO., Publishers, ^?^p7^Arn!:X^*8rH^«:'Nr'v

York.

NEW (SECOND) EDITION.

Gray on Nervous and Mental Diseases.

A Practical Treatise on Nervous and Mental Diseases. By Landon C!artee GrRAY, M. D., Professor of Diseases of the Mind and Nervous System in the New York Polyclinic. New (2d) edition. In one very handsome octavo volume of 728 pages, with 172 engravings and 3 colored plates. Cloth, |4.75 ; leather, $5.75.

We have here what has so often been desired — an up-to-date text-book upon nervous and mental diseases combined. Although, as re- garded to-day, these branches constitute two distinct specialties, yet they are intimately con- nected. Therefore the presentation of a well- written, ter^e, explicit and authoritative volume treating of both subjects is a step in the direc- tion of popular demand. The glossary of words and terms is of much importance to the student, readily enabling him to become familiar with terms frequently encountered in neurological study — The Chicago Clinical Revieiv.

It is a pleasure to write a notice of a book of this character. The well-known literary attain- ments of the author, the fine paper and beautiful text, the elegant illustrations, many of which are in colors, make it easy to understand why this book has passed to a second edition. Five new chajiters have been added in this edition. "The word treatment," says the author, " has been con- strued in the broadest sense to include not only medicinal and non-medicinal agents, but also

those hygienic and dietetic measures which are often the physician's best reliance." This edition will be found carefully revised and brought up to date. The book will be found as interesting as its predecessors, and retaining all of the charac- teristics which made the first edition popular. — The Jour, of the American Medical Association.

This treatise has principally been written for the benefit of the general practitioner. Mental diseases have been considered from the stand- point of the general physician. Therapeutic suggestions in the book are detailed and precise, and only such knowledge has been admitted to the pages of the book as has stood the test of exj)erience. Unlike many other text-books, due attention has been paid to the medico-legal as- pects of nervous and mental diseases. The term- inology is rendered easy of acquisition by the derivations and definitions given in an appended glossary. The mimerous illustrations are very good. The work will be found a most useful and valuable addition to the library of every practitioner and student. — Medical Revietv.

Stimson's Operative Surgery • — New (3d) Edition. Just Ready.

A Manual of Operative Surgery. By Lewis A. Sttmson, B.A., M.D., Pro- fessor of Clinical Surgery in the New York University. New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 illustrations. Cloth, $3.75.

The book contains clear and concise descrip- tions of the most important oj^erations of mod- ern surgery. It is well illustrated, and we take pleasure in recommending it to the profession as a handy descriptive manual of operative surgery. — Annals of Surgery.

This compact, tersely written manual has been almost rewritten in the laudable eftbrt to note the imj^ortant changes in the science and prac-

tice of operative surgery. The illustrations are plentiful, and the descriptions of technique are admirable for their clearness. — Medical Record.

The thorough, concise and clear manner in which it is written, with its accurate illustra- tions, make this aji indispensable book for all busy operators and students. — The Medical Fortnightly.

Ashhurst's Surgery. — Sixth Edition.

The Principles and Practice of Surgery. By John Ashhurst, Jk., M. D., Barton Professor of Surgery and Clinical Surgery in the University of Pennsylvania, Surgeon to the Pennsylvania Hospital, Philadelphia. Sixth edition, enlarged and thoroughly revised. In one octavo volume of 1161 pages, with 656 illus. Cloth, $6.00 ; leather, $7.00,

We have yet to see the same amount of scholarly and extensive inf(trmation on the sub- ject of surgery in any other single volume — and seldom in a number of volumes. As a masterly epitome of what has been said and done in sur- gery, as a succinct and logical statement of the principles of the subject, as a model text-book, we do not know its equal. It is the best single text-book of surgery that we have yet seen in this country. — New York Post- Graduate.

The fact that a book has reached its sixth edi- tion should speak volumes in its favor, and an examination of the work before us will soon reveal the reasons of its popularity. It is sys- tematic and takes up and treats subjects in logical order, Avhich makes it esi^ecially valu-

able, because the subject thereby becomes more clearly understood and easily remembered. The author has not l^een content merely with giving his own favorite notions, but has presented the views of other surgeons as well, always, how- ever, indicating his own judgment or prefer- ence. This makes it valuable and suggestive as a reference book for the jjractitioner. In fact, it is surprising what an encyclopsedic amount of information is condensed within its eleven hun- dred and sixty-six pages. In the present edition fifty pages of new matter have been added. In short, it is about what one would expect in an up-to-date edition of a standard American text- book.— Cleveland 3Iedical Gazette.

lEA BROTHERS & CO., Publishers, ;?^p7^A":„!:"^7.^'8^\^?;rNrv.*.

10

SEVENTH EDITION.

Flint's Practice of Medicine.

A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. By Austin Flint, M. D., LL. D., Professor of the Principles and Practice of Medicine and of Clinical Medicine in Bellevue Hospital Medical College, N. Y. Seventh edition, thoroughly revised by Frederick P. Henry, M. D., Professor of the Principles and Practice of Medicine in the Woman's Medical College of Pennsylvania, Philadelphia. In one very handsome octavo volume of 1143 pages, v^ith illustrations. Cloth, $5.00 ; leather, $6.00.

Its peculiar excellences and its breadth of conception have made it a recognized authority. The author was a born teacher, an indefatigable observer, a painstaking worker and a thorough medical philosopher. His clinical pictures of diseases are models of graphic description, minuteness of detail and breadth of treatment. This may appear to be high praise, but the work has so well earned its leading place in medical literature that but one view can be expressed concerning its general character as a text-book. The editor has done his part in bring- ing it up to date, not only in reference to treat- ment and the adaptation of the newer remedies, but has made numerous additions in the shape of the newly discovered forms of disease, and has elaborated much in the commoner forms which the recent advances have made necessary. The element of treatment is by no means neglected ;

in fact, by the editor a fresh stimulus is given to this necessary department by a comprehensive study of all the new and leading therapeutic agents. — Medical Record.

The leading text-book on general medicine in the medical schools of the United States. It is of all books the book of an American physi- cian, looking at disease as it is seen in this country. A great charm about Flint is the clear and straightforward way in which he goes at the work of describing disease from the clin- ical standpoint, arranging it all as the ])racti- tioner himself would handle a case, and follow- ing out the train of thought that arrives most quickly and surely at the important results of diagnosis, prognosis and treatment. The revision has been well done by Professor Henry, who has added much that is new. — Northwestern Lancet.

Thomas & Munde on Diseases of Women — Sixth Ed.

A Practical Treatise on the Diseases of Women. By T. Gaillaed Thomas, M. D., LL.D., Emeritus Professor of Diseases of Women in the College of Physicians and Surgeons, New York, and Paul F. Munde, M. D., Professor of Gynecology in the New York Polyclinic. Sixth edition, thoroughly revised and rewritten by Dr. Munde. In one large and handsome octavo volume of 824 pages, with 347 illustrations, of which 201 are new. Cloth, $5.00 ; leather, $6.00.

The best practical treatise on the subject in the English language. The original work is preserved as a basis, but amplified and enriched with the results of modern research. Much has been interspersed with the old material and several new chapters added. It is, as we have said, the best text-book we know, and will be of especial value to the general practitioner as well as to the specialist. The illustrations are very satisfactory. Many of them are new and are particularly clear aiid attractive. The book will undoubtedly meet with a favorable reception from the profession. — Boston Medical <ind Surgical Journal.

This work, which has already gone through jfive large editions, and has been translated into

French, German, Spanish and Italian, is too well known to require commendation now upon the appearance of this, the sixth edition. It has been thoroughly revised and brought up to date by Dr. Munde, who is announced as joint author. Many new illustrations have been added, and the text has been increased by the addition of new chapters. The distinctive fea- tures of the work, which made it so attractive when first issued, have in a measure been re- tained, so that it continues to be the most prac- tical and at the same time the most complete treatise upon the subject in print, the changes that have been made only increasing its value. — The Archives of Gynecology, Obstetrics and Pediatrics.

Merrick's Handbook of Diagnosis — Just Ready.

A Handbook of Diagnosis. By James B. Herrick, M.D., Adjunct Professor of Medicine, Rush Medical College, Chicago. In one handsome 12mo. volume of 429 pages, with 81 engravings and 2 colored plates. Cloth, $2.50.

It is an excellently arranged, practical, concise and well-written treatise on the subject, brought U]) to date, and eminently well fitted for the use ■of the practitioner as well as of the student. — The Chicago Medical Recorder.

We commend the book not only to the under- graduate, but also to the physician who desires a ready means of refreshing his knowledge of diagnosis in the exigencies of professional life. A number of illustrations, comprising many characteristic engravings in black and two plates in colors, add much to the practical value of the text. — Memphis Medical Monthly.

It is a pleasure to say, after a careful ex- amination and comparison, that this volume

accomplishes its objects more thoroughly and completely than any similar work yet pub- lished. Good judgment is displayed in the allotment of space, the commoner ailments being treated of with sufficient fulness while the rarer forms are by no means ignored. Each section devoted to diseases of special systems is preceded with an exposition of the methods of physical, chemical and microscopical exam- ination to be employed in each class. The tech- nique of blood examination, including color analysis is very clearly stated. Uranalysis re- ceives adequate space and care. The volume is deserving of high commendation. — Neic York Medical Journal.

LEA BROTHERS & CO., Publishers,

706, 708 & 710 Sansom Street, Philadelphia. Ill Fifth Avenue (Cor. 18th St.), New York.

11

NEW (Sd) EDITION-JUST READY.

Wharton's Minor Surg. & Bandaging.

Minor Surgery and Bandaging. By Henry E. Whaeton, M. D., Demon- strator of Surgery in the University of Pennsylvania, New (third) edition. In one 12mo. volume of 594 pages, with 475 engravings, many being photographic. Cloth, $3.00.

THIS work covers a considerably greater range of subjects than usually implied in the main divisions noted on its title page. The reader will tind in it an exceptionally clear and com- plete seetio]! on Bandaging with an excellent series of photographic engravings, showing in the most instructive manner the application of all such dressings. The department of Minor Surgery includes the preparation and use of materials employed in antiseptic aad aseptic surgery, the procedures in minor surgery, ansesthetics, use of trusses, catheters and bougies, sutures ancl ligatures, the treatment of hemorrhage, abscesses and the dressing of wounds, burns, bedsores, sj^rains, etc. Subsequent jjarts deal with fractures, dislocations, ligations, amputations, excisions,, resections and special operations, such as trephining, tracheotomy, intubation, operations on the kidney and colon, lithotomy and osteotomy. The demand for three large editions shows the value attached to this authoritative and convenient work by teachers, students and surgeons, and the au- thor has thus been enabled to keep it continually abreast of the latest surgical progress. The series of illustrations is exceedingly rich and instructive, the volume containing no less than four hun- dred and seventy-five.

Young's Orthopedic Surgery.

A Manual of Orthopedic Surgery, for Students and Practitioners. By

Jajmes K, Young, M. D., Instructor in Orthopedic Surgery, University of Pennsylvania, Philadelphia. In one octavo volume of 446 pages, with 285 illustrations. Cloth, $4.00 leather, $5.00.

The author of this work has styled it " A I oughly modern and the paragraphs on treatment Practical Treatise on Orthopedic Surgery," with j are replete with judicious conservatism. The- which title we fijid no fault. It is a thorough, i author having fully accomplished his objects as a very eoni]»i'ehensive work upon this legitimate set forth in the Preface, and having also given

surgical specialty and every ]»age al)()unds with evidences of practicality. We find an immense amount of thoroughly u})-to-date information upon more than the usually limited number of common deformities. The pathology is thor-

ns the clearest and most modern work upon this growing department of surgery with which we are familiar, we can but add an unqualified commendation for this manual. — The Chicago Clinical Revieiv.

Seiler on the Throat and Nose — Fourth Edition.

A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. By Carl Seiler, M. D., Lecturer on Laryngoscopy in the University of Pennsylvania. Fourth edition. In one handsome 12mo. volume of 414 pages, with 107 illustrations and 2 colored plates. Cloth, $2.25.

This little ]»(»(>k is eminently practical, and will jtrove of interest not only to the specialist, but to the general practitioner as well. It deals with the subjects in a clear and distinct manner, and the text is copiously illustrated with dia- grams and colored i)lates. So little attention is paid ordinarily to the examination of the larynx that the heed of such a book has long been felt. By consulting its pages anyone can learn the necessary manii^ulations, and, by a little prac-

tice, soon become expert in the use of the laryn- geal mirror, a method of examination too often neglected. The anatomy of the larynx is ex- plained with especial care, and the operative procedures for various diseases of the throat,, tonsils, etc., are carefully explained. Approved methods of treatment are dealt with in a very satisfactory way, and all the most useful reme- dial agents are described. — International Medi- cal Magazine.

Field's Manual of Diseases of the Ear— Fourth Edition.

A Manual of Diseases of the Ear. By George P. Field, M.E.C.S., Aural Surgeon and Lecturer on Aural Surgery in St. Mary's Hospital Medical School, London. Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75.

a work as is needed by every general practitioner to enal)le him to treat intelligently the large class of cases of ear disease that comes jjroperly within his province. The illustrations are apt and well executed while the make-up of the work is beyond criticism. — The American Practitioner and News.

To those who desire a concise work on diseases of the ear, clear and practical, this manual com- mends itself in the highest degree. It is as far removed as well may be from the character of a compilation, every page giving evidence that the author writes from his own careful observa- tion and thoughtful experience. It is just such

LEA BROTHERS & CO., Publishers, IJ^pI^h A.^ufZ^s^h'tu iit'^

12

NEW (2d) EDITION-JUST READY.

Jackson's Ready = Reference Handbook of Skin Diseases.

The Ready-Reference Handbook of Diseases of the Skin. By George Thomas Jackson, M. D., Professor of Dermatology, Woman's Medical College of the New York Infirmary. New (2d) edition In one 12mo. volume of 589 pages, with 69 illustrations and a colored plate. Cloth, $2.75.

THIS volume fully deserves the title aptly chosen for it. The classification of skin diseases ac- cording to their natural relationship is appropriately explained, but the body of the volume is devoted to the various aftections under aa alphabetical arrangement. The practitioner and specialist will thus find it a prompt and ready source of knowledge on all the points of terminology, symptoms, varieties, etiology, pathology, diagnosis, treatment and ])roghosis of dermal affections. Tables of differential diagnosis and standard prescriptions will be fouiKl scattered through the text and the work ends with an appendix of well-tried formulse. Tlie series of illustrations is rich and instructive.

Green's Pathology and Morbid Anatomy — Eighth Edition.

Pathology and Morbid Anatomy. By T. Heney Geeen, M. D., Lecturer on Patholog7 and Morbid Anatomy at Charing-Cross Hospital Medical School, London Seventh American from the eighth and revised English edition. In one handsome octavo volume ot 595 pages, with 224 engravings, and a colored plate. Cloth, $2.75.

A work that is the text-book of probably four- fifths of all the students of pathology in the United States and Great Britain stands in no need of commendation. The work precisely meets the needs and wishes of the general practi- tioner.—2Vie American Practitioner and News.

Greenes Pathology is the text-book of the day — as much so almost as Gray's Anatorny. New illustrations and a colored frontispiece have been added, so that altogether we have now a text- book fully up to date in the record of fact, and so profusely illustrated as to give to each detail of text sufficient explanation to be easily under- stood. The work is an essential to the j^racti-

tioner — whether as surgeon or physician. The work is the best of up-to-date text-books. — Vir- ginia 3Iedicnl Monthly.

If a total issue of fifteen editions of a Avork is any criterion of its value the volume before us must surely take a foremost place among its kind. An inspection of the book reveals the secret of its success, namely, real, practical merit. Comj^lete without verbosity or rejieti- tion ; comi^rehensive and everywhere lucid, it is an excellent every-day manual for medical stu- dents and practitioners — one which they will find always interesting and profitable. — The Den ver Medica I Times .

Fuller on Male Sexual Disorders— Just Ready.

Disorders of the Sexual Organs in the Male. By Eugene Fullee, M. D., Instructor in Venereal and Genito-Urinary Diseases, New York Post-Graduate Medical School. In one very handsome octavo volume of 238 pages, with 25 engravings and 8 full- page plate''. Cloth, $2.00.

From time immemorial this department of human maladies has afforded charlatans their most lucrative business, a fact which it may be wholesome to consider as reflecting somewhat upon the comparative success of the regular practitioner. Against rational methods empiri- cism should have no chance, and a work based on sound knowledge performs a service of moral and physical value to the patient, and of finan- cial value to the profession. The author's wide experience in this special line has convinced him that male sexual disorders arise more fre- quently from pathological states of the organs

concerned than from neurological or mental causes. He has endeavored to place the litera- ture of sexual pathology on a par with that of sexual neurology, and to deal with etiological factors in the order of their real importance. His treatment, founded upon a grasp of the whole subject, can be regarded with confidence by those to whom this large class of cases apjily for relief. The work is of value to the physician in general practice, as it is he who first encoun- ters the cases of this character. It treats as real a class of cases too often ridiculed as imaginary by regular physicians. — llie Ohio Med. Journal.

Morris on the Skin.

Diseases of the Skin. An Outline of the Principles and Practice of Derma- tology. By Malcolm Moeeis, F.R.C.S., Surgeon to the Skin Department, St. Mary's Hos- pital, London. In one ]2mo. volume of 572 pages, with 19 chromo-lithographic figures and 17 engravings. Cloth, $3.50.

Entirely new and thoroughly modern iu all its teachings. It is compact, essentially clinical and practical in its sco))e, and the reputation of the author and his vast exi:)erience as a dermatolo- gist are a sufficient guarantee of the soundness of his views. There are nineteen chromo-litho- graphic figures and seventeen engravings, all of which are good, and there is no other branch of

medicine in which these can be used to better ad- vantage. The book will l)e a valuable one to both students and practitioners. — Med. FortnigJitly.

The details of diagnosis, special and general symptoms, individual i)athology and, finally, spe- cial treatment, are full in their discussion. The well-selected ])lates add to the value of the book. — Neiv Orleans Medical and Surgical Journal.

LEA BROTHERS & CO., Publishers., JJ^/i^rA^lMr. r^iu '^'^^^^^^

13

Hyde on the Skin — Third Edition.

A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. By J. Nevins Hyde, A.M., M.D., Professor of Dermatology and Venereal Diseases in Rush Medical College, Chicago. Third edition. In one octavo volume of 802 pages, vs^ith 108 engravings and 9 full -page plates, 3 of which are colored. Cloth, |5.00 ; leather, |6.00.

The third edition fulfills all the expectations warranted hy the great accumulation of derma- tological material since the earlier editions were brought out, and puts his work at the head of the modern American treatises on skin diseases. The excellence of the chapters on treatment, to- gether with the care that has been bestowed on subjects that have acquired new interest, make the book one to be warmly recommended. — Boston Medical and Stirgical Journal.

Dr. Hyde's book may be heartily recom- mended to the student and practitioner alike as one of the liest exponents of the subject now before the profession. — The American Journal of the 3Iedical Sciences.

The qualities that have contributed so much to its previous popularity still remain. The chief of these unquestionably are the standpoint of practical medicine from which it speaks and its wealth of therapeutical information. The

writer knows no book in which one can seek more satisfactorily for information as to how to manage his patients with skin diseases. The present edition may be commended as being an exposition of the subject fully up to the present state of our knowledge. — Chicago Clin. Review.

The volume in its new form commends itself more than ever to those requiring a treatise on the skin well up to the times. — Medical Record.

Dr. Hyde is an experienced scholar as well as a competent author, and his former editions were received with approval by dermatologists as well as by those general practitioners who are inter- ested in the study and treatment of diseases of the skin. The treatise is one that affords much satisfaction in that it is a safe guide for both students and practitioners, either general or spe- cial, and particularly does it adapt itself to the use of dermatologists. — Buffalo 3Iedical and Surgical Journal.

King's Manual of Obstetrics — Sixth Edition.

A Manual of Obstetrics. By A. F. A. King, M.D., Professor of Obstetrics and Diseases of Women in the Medical Department of the Columbian University, Washing- ton, D.C., and in the University of Vermont, etc. Sixth edition. In one 12mo. volume of 532 pages, with 221 illustrations. Cloth, |2.50.

This is und()u])tedly the Ijest manual of ol)stet- rics. Six editions in thirteen years show not only a demand for a book of this kind, but tliat this partieuhir one meets the requirements for popu- larity, Ix ing clear, concise and practical. The l)resent edition has been carefully revised, and a tuimber of additions and modifications have been introduced to bring the book to date. It is Avell illustrated, well arranged ; in short, a model manual. — The Chicago Medical Recorder.

This valuable little work on Obstetrics has now reached its sixth edition, and justly merits the popularity whicli it enjoys. For clearness of diction it is not excelled by any book of simi- lar nature, and by its system of captions and italics it is abundantly suited to the needs of the medical student. The book, as a whole, is undoubtedly the best manual of obstetrics extant in English. — The Philadelphia Polyclinic.

Hayem & Hare's Physical and Natural Therapeutics.

Physical and Natural Therapeutics. The Remedial Use of Heat, Electricity* Modifications of Atmospheric Pressure, Climates, and Mineral Waters, By Georges Hayem, M. D., Professor of Clinical Medicine in the Faculty of Medicine of Paris. Edited, with the assent of the author, by Hob art Amory Hare, M. D., Professor of Therapeutics in the Jefferson Medical College of Philadelphia. In one handsome octavo volume of 414 pages with 113 engravings. Cloth, $3.00.

This ver}^ excellent work by two such eminent authorities should be upon the shelf of every physician. It opens up a field which, while much written upon, has never before been pre- sented in the form of a standard book. Written largely in this edition and entirely in the ori- ginal "by one of the foremost therapeutists of the day, not only are his views expressed, but also those of standard writers on thermic agents, climate, electricity, etc. An authoritative work upon these great branches of therapeutics has until now been a desideratum. The author and editor of this work enjoy equal standing, and the volume is certain to command attention and to render widespread service. The section on climate, rewritten by Professor Hare, will, for the first time, place the abundant resources of our own country at the intelligent command of American practitioners. The extended section on medical electricity, likewise rewritten, con-

forms to the American development of this sub* ject, and explains the many excellent forms of apparatus readily available in this country. — The 3Iedical Progress.

In this compact and substantial volume we find a satisfactory rendering of the work of its distinguished author. The editor has supplied the articles on American climate and mineral springs, added much valuable matter upon the subject of electricity, and supplemented the work of the author at many places in the text with judicious and instructive interpolations. We note the Therapeutic Index, which is use- ful quite as much for the determination of con- traindications as for indications. We welcome this book as a worthy supplement to the text- book which treats of therapeutics in the ordinary acceptation of the term, and we be- speak for it a cordial reception. — TJie Post- Graduate.

LEA BROTHERS & CO., Publishers, ;?^T^Ar„!:";^o".^*8^\^M:'Nrv,H<.

Playfair's Midwifery— New (8th) Ed.

A Treatise on the Science and Practice of Midwifery. By W. S. Play fair, M. D., F R C P., Professor of Obstetric Medicine in King's College London. Sixth American from the e ghth English edition. Edited, with additions by Robeet P. Harris, M. D. In one very handsome octavo volume of 697 pages, with 217 engravings and 5 plates Cloth, $4.00 ; leather, $5.00.

The author's object has been to place in the hands of his readers an epitome of the science and practice of midwifery, which embodies all recent advances, and especially to dwell on tlie practical part of the subject, so as to make his book a reliable guide to the doctor in the practice of this most imijortant and responsible branch of medicine. The demand for this eighth edition of the work testifies to the success with which the author has executed his pur- pose.— The Medical Fortmghtly.

Since 1877 Playfair has been accepted as au- thority in the department of obstetrics. When

his first edition was issued it was found to be such a clear exposition of the subject that Playfair's treatise was readily adopted by our colleges as a text-book. Students therefore be- came familiar with it at once, and obstetricians have followed it through its several editions with interest and satisfaction. This work of Playfair must occupy a foremost place in obstetric medi- cine as a safe guide to both student and obstetri- cian. It holds a ])lace among the ablest English- speaking authorities on the obstetric art. — Buf- falo Medical and Surgical Journal,

Hamilton on Fractures and Dislocations — Eighth Ed.

A Practical Treatise on Fractures and Dislocations. By Frank H. Ham- ilton, M.B., LL.D., iSurgeon to Bellevue Hospital, New York. Eighth edition, revised and edited by Stephen Smith, M.D , Professor of Clinical Snrgery in the University of the City of New York. In one octavo volume of 832 pages, with 507 illustrations. Cloth, |5.50 ; leather, $6.50.

Its numerous editions are convincing proof, if any is needed, of its value and popularity. It is preeminently the authority on fractures and dislocations, and universally quoted as such. In the new edition it has lost none of its former worth. The additions it has received by its recent revision make it a work thoroughly in accordance with modern practice theoretically, mechanically, aseptically. The task of writing

a complete treatise on a subject of such mag- nitude is no easy one. Dr. Smith has aimed to make the resent volume a correct exponent of our knowledge of this department of surgery. The more one reads the more one is impressed with its completeness. The work has been accomplished, and has been done clearly, con- cisely and excellently well. — Boston Medical and Surgical Journal.

Taylor's Medical Jurisprudence — Twelfth Edition.

A Manual of Medical Jurisprudence. By Alfred S. Taylor, M.D., Lec- turer on Medical Jurisprudence and Chemistry in Guy's Hospital, London. New American from the twelfth English edition. Thoroughly revised by Clark Bell, Esq., of the New York Bar. In one octavo volume of 787 pages, with 56 illustrations. Cloth, $4.50 ; leather, |5.50.

This is a complete revision of all former American and English editions of this standard book. This edition contains a large amount of entirely new matter, many portions of the book having been rewritten by the editor. Many cases and authorities have been cited, and the citations brought down to the latest date. The book has long been a standard treatise on the subject of medical jurisprudence, and has gone through many editions — twelve Englisli and eleven American. Mr. Clark Bell has en- larged and improved what already seemed com- plete, by bringing his many citations of cases down to date to meet the present law ; and by adding much new matter he has furnished the

medical profession and the bar with a valuable book of reference, one to be relied upon in daily practice, and quite up to the present needs, owing to its exhaustive character. It would seem that the book is indispensable to the library of both physician and lawyer, and particularly the legal practitioner whose duties take him into the criminal courts. The editor has given to two professions a reference-book to be relied upon. — The Amer. Journal of the Med. Sciences.

No library is complete without Taylor's Medi- cal Jurisprudence, as its authority is accepted and unquestioned by the courts. — Buffalo Medi- cal and Surgical Journal.

Attfield's Chemistry— New (14th) Edition.

Chemistry, General, Medical and Pharmaceutical ; Including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. By John Attfield, M. A., Ph. D , F.I.C., F.C.S., F.K.S., etc., Professor of Practical Chemistry to the Phai maceutical Society of Great Britain, etc. Fourteenth edition, specially revised by the Author for America to accord with the new U. S. Pharmacopoeia. In one handsome royal 12mo. volume of 794 pages, with 88 illustra- tions. Cloth, $2.75 ; leather, $3.25.

There is no otlier book on chemistry tliat contains so imich valuable matter coiideiiscd into such small space. — American Journal of Pharmacol.

It is the most comprehensive siugU^ volume on tlie subject we have ever seen, contiiiiiing in

addition to the principles of the science of chemistry a notice of every substance of interest to medical and ])harmaceutical students as well as a 2)racti('al coni'se in urinalysis. A N'olnniinous index renders the hook valuahlc as a dictionary of chemistrv. — The Denver Medical Timcx.

LEA BROTHERS & CO., Publishers,

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15

We should be glad to have you write for a sample of

Taka=Diastase.

Acts more vigorously on starch than does Pepsin on proteids.

RELIEVES

Starch Dyspepsia.

We are now able to relieve a large number of persons suffering from faulty digestion of starch, and can aid our patients, during con- valescence, so that they speedily regain their weight and strength by the ingestion of large quantities of the heretofore indigestible, but nevertheless very necessary, starchy foods. We trust that the readers of the Gazette will at once give this interesting ferment a thorough trial, administering it in the dose of from I to 5 grains, wdiich is best given in powder, or, if the patient objects to the powder, in capsule. — TJie Therapeutic Gazette.

Pepsin is of In ailments arising from Faulty Digestion

no Value of Starch.

PARKE, DAVIS & CO.,

BRANCHES:

NEW YORK: 90 Mniden Lane.

KANSAS CITY : 1008 Broadway. Manufacturing Chemists,

BALTIMORE : 8 South Howard St. * '

NEW ORLEANS: Tchoupitoulas and Gravier Sts. nCTDniT iMir'H

BRANCH laboratories: DETROIT, MICH.

LONDON, Eng., and WALKERVILLE, Ont.

16

CONTENTS.

ORIGINAL COMMUNICATIONS.

PAGE

Practical Application of the Rontgen Eays in Surgery. By J. William White,

M.D., Arthur W. Goodspeed, Ph.D., and Charles L. Lkonard, M D, . . 125 Painful Points in Gouty Compared with Rheumatic Arthritis. By W. 11. Thomson,

M.D,LL.D 148

On the Functions of the Neuron, with Especial Reference to the Phenomena Pre- sented by Hysteria and Hypnotism. By F. X. Dkrcum, M.D. . . .151

Extrauterine Foetation. Report of Fifteen Cases Treated by Operation. By

Andrew J. McCosh, M.D 169

On the Treatment of Aneurism by Electrolysis Through Introduced Wire: Report

of a Successful Case. By D. D. Stewart, M.D., and J. L. Salingkh, M.D. . 170

Compound Depressed Fracture of the Skull. By Charles L. Scudder.M.D. . 177

Diagnosis of Chronic Abscess of the Brain. By J. T. Eskridge, M.D. . . . 179 The Differential Diagnosis of Ursemia and Meningitis, with Report of Obscure

Cases. By Arthur R. Edwards, A.M., M.D 191

REVIEWS.

An Introduction to Pathology and Morbid Anatomy. By T. Henry Green, M.D. 197

Histopathology of the Diseases of the Skin. By Dr. P. G. Unna 199

Epidemic Ophthalmia : Its Symptoms, Diagnosis, and Management. With Papers

upon Allied Subjects. By Sidney Stephenson, M.B., F.R.C.S. Ed. . . . 201 Geschichte der Volksseuchen wach und mit den Berichten der Zeitgenossen, mit

Beracksichtigung der Thierseuchen. Von Dr. B. M. Lersch .... 203 Deaf-mutism. A Clinical and Pathological Study. By James Kerr Love, M.D. . 203 Les Suppurations de I'Apophyse mastoide, et leur traitement. Par A. Broca and

F. Lubet-Barbon 204

Spectacles and Eyeglasses: Their Forms, Mounting, and Proper Adjustment. By

R. J. Phillips, M.D 204

A Pictorial Atlas of Skin Diseases and Syphilitic Affections . . . . . 205

The Functional Examination of the Eye. Ly John Herbert Claiborne, Jr., M.D. 205 A Manual of Operative Surgery. By Lewis A. Stimson, B.A., M.D , and John

Rogers, Jr., B.A., M.D 200

PROGRESS OF MEDICAL SCIENCE.

THERAPEUTICS.

	PAGE		PAGE
Treatment of Pulmonary Tuberculosis	207	Treatment of the Dyspepsias	212
Action of Sodium Bicarbonate .	207	Immunity in Asiatic Cholera .	214
Action of Salicylic Acid and Salicylates 208	Use of Antitoxin in Private Practice	214
Effect of Diphtheritic Toxin	209	Death from Behring's Antitoxin	215
Action of Quinine in Paludism .	210	Treatment of Scarlet Fever	215
Gastric Crises of Tabes Dorsalis .	210	Death from Antidiphtheritic Serum	216
Guaiacol in Diphtheria	210	Death from Antitoxin Injections	216
Death from Diphtheria Antitoxin	211	Antivenene for Snake-bite .	216
Treatment of Cancer and Sarcoma .	211	A Smallpox Antitoxin	217
Treatment of Enteritis	211	The Use of Vaccine Virus .	217
Use of Glycerin for Hepatic Colic	212	Administration of Thyroid Gland	217
VOL. 112, NO. 2.— AUGUST, 1896.	9

11

CONTENTS.

MEDICINE.

	PAGE		PAGE
Changes in Blood in Hsemoglobinuria	218	Gliosis in Epilepsy . . . .	224
Gaucher's Disease ....	219	Two Cases of Cerebral Spastic Diplegia	225
Tetragenus Septicsemia	219	Cerebral Hemorrhage in Whooping-
Hemorrhagic Myxoedema .			99fi
Fericarditic Pseudo-cirrhosis of Liver	221	Diphtheria and Antitoxin .	225
The Etiology of Serous Pleurisy	221	Urgemic Aphasia . . . .	226
Gastroscopy	222	The Mobility of Abdominal Tumors .	227
Diagnosis of Cysticercus in the Brain	222	Hepatic Neuralgia . . . .	227
Paroxysmal Hgemoglobinuria .	223	Fibrinous Bronchitis . . . .	228
	223	Percussion of the Heart	228
Croupous Pneumonia in Diabetes	224	Eespiratory Neuroses . . . .	229
Symmetrical Gangrene	224	The Thoracic Organs in Chlorosis	229

OPHTHALMOLOQY.

Optic Nerve Atrophy in Three Brothers 230 Eecurrent Oculomotor Palsy . . 230 Supernumerary Caruncle . . .231 Eye-lesions in Myxoedema . .231

Detachment of the Eetina . . 231

Treatment of Ulcers of the Cornea . 231 Non-existence of a Separate Cortical

Color-centre 232

DISEASES OF THE LARYNX AND CONTIGUOUS STRUCTURES.

Stricture of the Larynx . . . 233 j Nasal Tuberculoma .... 235 Multiple Papillomas of the Larynx . 234 | Suppuration of Maxillary Sinuses . 235

OBSTETRICS.

Removal of Old Ectopic Gestations . 236 Treatment of Face- presentation by

A Study of Fcetal Excretion . . 236 Manipulation 237

Pregnancy and Labor Complicated by Albuminuria and Eclampsia . . 237

Cancer of the Cervix . . . 236 Ten Operations for Ectopic Gestation 238

GYNECOLOGY.

Shortening of the Sacro-uterine Liga- [Vaginal Fixation .... 240

ments for Retroversion . . . 239 Diagnostic Curettage .... 240

Hysterectomy with the Cautery . 239 Treatment of Pruritus Vulvae . . 241

€olporrhaphy in Prolapsus Uteri . 240 ; Cancer and Tuberculosis of the Uterus 241

PAEDIATRICS.

Increase in Weight of Premature Infants 242 Bacteriology of the Anginas of Scarla-

Tuberculosis of Intestine by Ingestion 242 tina 244

Primary Sarcoma of Vagina in Children 243 A Variety of Streptococcus Refractory

Bacteriology of Vagina of Newborn Girls 244 to Marmorek's Serum . . . 244

PATHOLOGY AND BACTERIOLOGY.

Spirillum of Asiatic Cholera . . 245 Alimentary Tuberculosis . . . 247 Death in Acute Lobar Pneumonia . 246 j

HYGIENE AND PUBLIC HEALTH.

Toxicity of Alcoholic Beverages . 248 | Dust in Consumptive Communities . 249

THE

AMERICAN JOURNAL OF THE MEDICAL SCIENCES.

AUGUST, 1 896.

CASES ILLUSTRATIVE OF THE PRACTICAL APPLICATION OF THE RONTGEN RAYS IN SURGERY.

By J. William White, M.D.,

PROFESSOR OF CLIMICAL SURGERY, UNIVERSITY OF PENNSYLVANIA ;

Aethur W. Goodspeed, Ph.D.,

ASSISTANT PROFESSOR OF PHYSICS, UNIVERSITY OF PENNSYLVANIA ; AND

Charles L. Leonard, M.D.,

ASSISTANT INSTRUCTOR IN CLINICAL SURGERY, UNIVERSITY OF PENNSYLVANIA.

The Rontgen method is, of course, in its infancy. It has, however, already reached a degree of usefulness that makes it obvious that the necessary apparatus will be an essential part of the surgical outfit of all hospitals and will be employed constantly in a variety of cases. Those to which the method can now be applied with advantage may be sum- marized as follows, emphasis being placed on the fact that what is written to-day may require revision or reversal to-morrow, so rapidly are improvements and discoveries taking place :

1. Foreign bodies imbedded in any of the tissues of the body. This is at once the most obvious and the simplest application of the skiagraph to surgery. Hundreds of cases have already been reported. Bullets, fragments of metal or of glass, needles, etc., are easily found, and, even if they are lodged in bone, the varying density of the shadows cast by substances of different permeability or of different chemical constitution will serv^e to define and locate them. It is desirable, if the foreign body be in a locality containing important surgical structures, that skiagraphs be made from at least two points of view, so that the depth from the surface and the exact relations of such body can be determined by measurement. A single skiagraph of a piece of steel in the arm, for example (Case X., Plate VIII.), taken from the front sliows merely

VOL. 112, NO. 2 —AUGUST, 189G.

12G WHITEj GOODSPEED, LEONARD: RONTGEN RAYS.

its relation to the inner or outer edge of the arm, not at all its depth. A second view taken laterally would make the precise situation evident.

2. Foreign bodies in certain of the organs and viscera are likely to be discovered and located with a degree of accuracy that will vary with the region or structure involved and with the thickness of the enclosing tissue. Waggett and Rowland have shown (^British 3IedicalJournal,M.a.YG]i 19, 1896) that a fish-bone and a small nail attached by plaster to the side of the neck in the position of the ventricle can be skiagraphed with ease. The larynx itself did not show at all, but by the aid of a chart of the region the exact position of a foreign body in the larynx ought to be easily determinable. It is obvious that extension of the method to the location of such bodies in the trachea, bronchi, and other portions of the air-passages is sure to come with further improvements in technique. In the digestive tract, except, perhaps, the first third of the oesophagus, the difficulties are greater ; but the presence or absence of foreign bodies can doubtless be determined, although below the stomach it is questionable whether any definite information as to the exact situation can be obtained. In many cases, however, especially in children, it is a matter of grave doubt as to whether or not some foreign body has been swallowed. As the most uncertain cases occur in the youngest children, and as the ease of skiagraphy of the whole body is in direct proportion to the thinness and softness of the tissues, we may expect in just these cases to get the exact information which is so often lacking in the history given by anxious })arents or nurses. AVithin the cranium neither experimental tests nor trials in actual cases have yet given any practical results in the discovery or location of foreign bodies, but there is every reason to believe that this Avill become possible in the near future.

3. Foreign bodies formed within the organism itself include chiefly gall- stones and renal, vesical, and prostatic calculi.

Gallstones skiagraphed without the body cast very faint shadows ; cal- culi of oxalate of lime, of phosphate of lime, and of triple phosphate cast shadows as dense as those of bone or metal ; uric-acid calculi cast easily recognizable but somewhat fainter shadows (British MedicalJour- nal, London, April 4, 1896).

No practical results have yet been obtained in the discovery of these forms of calculi, but it seems within bounds to expect that after we be- come more familiar with the shadows cast by the normal viscera and the normal skeleton, we may be able to distinguish gallstones from malignant disease involving the ducts ; may locate or exclude renal calculi in doubt- ful cases ; and may see encysted vesical or prostatic calculi even through the shadows cast by the pelvic bones themselves. Many skiagraphs show in outline the shadow of one bone through the shadow of another (Case YI., Plate V.), and it is not improbable that after a time accurate diagnoses can be made in this manner. At present it is not possible.

c>2

PLATE VII.

Case IX. The Results Obtained in Excision of the Knee.

Case X. Foreign Body in the Arm.

X

WHITE, GOODSPEED, LEONARD: RONTGEN RAYS. 139

4. Inflammaiory sivellings and neio growths (except when bony) have not yet been shown to offer any special features diagnosticating them from normal structures. Bony tumors can plainly be seen, and as the method improves it is to be expected that intracranial and intraspinal osteomata may be discovered and located and possibly even periosteal thickenings due to tubercular, syphilitic, or pyogenic infection. Dead bone cannot as yet be distinguished from living bone, but it is reasonably certain that by greater perfection in detail we shall soon be able to out- line the exact position and extent of a sequestrum, this again being made possible by the transparency of the bone-shadow itself ; so that, for ex- ample, in a case of necrosis of the femur the shadow of that bone and the shadow of a sequestrum contained within it may be superimposed and plainly separable on the skiagraph. Abscess in bone can be made out perfectly.

Comparison of the normal limb with that which is the subject of tuber- cular or other chronic bone-disease will often reveal the full extent of the latter better than any method of exploration, and in a recent case led me to perform amputation through the hip-joint instead of through the upper third of the femur, the condition found abundantly justifying the procedure.

5. Fractures and dislocations at present offer the greatest field for the every-day use of the Rontgen method. It- is impossible at this time to present exhaustively the conditions under which it should invariably be used, or to separate them from those in which it is a matter of interest rather than of necessity ; but it is safe to say that it will be wise to employ it when possible.

a. In all fractures in or about joints either as a preliminary to the reduction of the deformity, or as evidence that such reduction has been accomplished. These fractures are, for unavoidable reasons, often fol- lowed by some limitation of motion and a more or less imperfect func- tional result. They have, therefore, on innumerable occasions been the basis for suits for malpractice. It will be both a satisfaction and a safe- guard for the surgeon if he can see that his work has been accomplished properly and can retain definite evidence of that fact.

h. In doubtful cases or cases supposed to be of great rarity, it will be of inestimable value (Case VII., Plate VI.), both as aiding diagnosis and as demonstrating and recording the conditions present.

c. In cases of old injury in which, as so frequently happens, no reliable clinical history is obtainable and no accurate diagnosis can possibly be made by the ordinary methods. (Cases III., IV., and V., Plates II., III., and IV.)

d. In cases of ununited fracture, both to show the exact position and relation of the fragments prior to operation, the presence or absence of interposing structure, etc. (Case II., Plate L), and also to show after

VOL. 112, NO. 2.— AUGUST. 1896. 10

140 WHITE^ GOODSPEED, LEONARD: RONTGEN RAYS.

operation the degree of efficiency of the wire, or of the peg or screw, or of the splint, or other retaining-apparatus. We may frequently determine in such cases whether or not open operation is needed, union often being obtainable, where the fragments can be brought into good position and nothing is interposed, by mere friction and the reapplica- tion of the splint or other dressing.

6. In cases of excision of joints at the time when, for example, in the knee it is desirable to demonstrate that bony union has been obtained and in the elbow that it has been avoided. (Case IX., Plate VIII.) (Case V.)

7. In cases of deformity of all sorts affecting the bones, their epiphy- ses, or diaphyses, and requiring careful investigation before surgical interference is declined or advised. (Case VI., Plate V.)

8. In many obscure cases of the type of metatarsalgia, in which the demonstration of the cause of the nerve-pain and the indication for sur- gical treatment are equally clear and convincing. (Case XII.)

ILLUSTRATIVE CASES.

I. — The patient, W. S., Avas admitted to the wards on January 23, 1896. Seventeen weeks previous to his admission he sustained a com- pound fracture of both bones of the right forearm. The flesh-wounds healed rapidly, but the bones remained ununited and at an angle, although they were treated by fixation in a plaster-dressing for some time.

The operation showed that the line of fracture was in the middle third of each bone. The extensor carpi radialis was found interposed between the fragments of the radius, where they overlapped one and one-half to two inches, eflectually preventing any chance of union. The upper frag- ment was in extreme supination, while the lower was in extreme prona- tion.

The fragments of the ulna showed an attempt at the formation of a false joint, the proximal end of the lower fragment containing a cavity in which the distal end of the upper fragment was held. Great diffi- culty was experienced in getting anything like a proper approximation of the bones on account of the extreme rotation in opposite directions of the two fragments of the radius and because the interosseous space was more nearly obliterated between the lower fragments.

The resected ends of the bones were held in position by wire sutures and the flesh-wounds closed by interrupted sutures. The flesh-wounds healed rapidly, but bony union seems doubtful as yet. The skiagraph shows the position of the bones and the silver sutures in position, and illustrates the ability we now have, without disturbing the wound itself, or the limb, or even the dressings, to obtain accurate knowledge of the exact position of the bones after an operation of this character. Such information might be of the very highest practical importance. It might lead to a change of apparatus, to an alteration in the position of the limb, to a second operative attempt, etc., and it would almost certainly aid in giving definiteness to prognosis and in determining without undue motion of the part the final result as to the presence or absence of bony union.

WHITE^ GOODSPEED, LEONARD: RONTGEN RAYS. 141

II. — H. P., aged thirty-three years. On February 7, 1896, the patient was caught in the belt of a pulley and thrown down about six feet. He fell upon his left hand, bending it under him in extreme flexion. The patient was taken to a hospital, which he left seven weeks afterward without the consent of the attending surgeon. On admission to the University Hospital an ununited fracture was diagnosed, with the for- mation of callus and an attempt at union ; preternatural mobility was, however, marked.

The operation showed the condition to be exactly that seen in the skiagraph, the lines of fracture were as they are there shown ; a fibrous union existed between the distal end of the upper fragment of the ulna and the proximal end of the lower fragment of the radius. This attempt at union was broken up, and the ends of the fragments were freshened and united by drills, which were left in situ. The skiagraph was here of distinct assistance during the operation, enabling me to cut down upon and to remedy the deformity with the least possible disturbance of parts.

III. — C. R. L., aged thirty-six years, was admitted to the University Hospital March 31, 1896, with an ankylosis of the elbow. He gave the following history : In the latter part of January, 1895, he fell down stairs, striking on his elbow. The arm was dressed on a splint in full extension. This was continued for three weeks, when the arm. was placed at an angle and dressed on a posterior moulded metal splint. After about four weeks passive motion was commenced, and a little later considerable force was used. The patient continued treatment for about three months longer and then stopped all treatment until he came to the hospital.

The diagnosis of dislocation of both bones of the elbow backward was easily made.

The skiagraph gave an apparently blurred and indefinite outline of the joint, which before operation seemed rather unsatisfactory. The operation, however, showed it to be exactly correct, the joint was dislo- cated, was ankylosed, and was surrounded by a large amount of dense callus, making excision of the joint with the arm in extension and fixed very difiicult. The callus was exceedingly hard and united the olecranon process to the humerus. It was necessary to divide the ole- cranon and cut it free from the humerus with a chisel. The joint was cut part way through and then broken, thus permitting the completion of the excision.

There can be no doubt that as we acquire greater familiarity with this method we shall be able to recognize exact conditions as shown by differ- ent depths of shadow, etc., with much more accuracy. In this instance, for example, the facts were before me prior to the operation, but except that I saw that my diagnosis of backward luxation was confirmed, I got no help from the skiagraph. In future cases of the same sort I shall profit far more by the picture — at least to the extent of anticipating — and, when necessary, providing for the special difficulties of the case. This patient has recovered with a most useful and satisfactory arm.

IV. — F. McD., a carpenter, aged twenty -four years, fell from the roof of a house, a distance of forty-four feet, four years previous to his admission to the University Hospital.

142 WHITE, GOODSPEED, LEONARD: RONTGEN RAYS.

There was a great amount of ecchymotic swelling ; a fracture was diagnosed and the arm dressed in a posterior moulded felt splint. It was kept in this position for ten weeks ; after this time the patient began by himself the use of passive motion, and succeeded in getting sufficient movement to enable him to pursue his occupation, although the arm was always tender, and cannot be flexed sufficiently for him to reach his mouth.

Two days before he presented himself at the hospital he heard, while at work, a loud snap which was followed by pain and increased disability. The skiagraph shows the normal outline of the bones, with in addition an amount of callus on the coronoid process of the ulna (?) and a free fragment of bone (?) above and external to the head of the radius. (See figure.)

This case has not yet been operated upon. It illustrates better than any I have ever seen the uncertainty which still exists as to the inter- pretation of the skiagraphic picture, and it also shows the obscurity of many of these combined bone- and joint-lesions. I exhibited this patient, with the skiagraph, at a recent meeting of a surgical society. He was examined by several skilful and able surgeons, each of whom reached a different conclusion as to what he saw in the picture and felt in the arm. They all differed from my own view. The case will be reported in full after operation.

V. Excision of the head of the radius. — This case, of excision of the head of the radius for forward luxation with limitation of the power of flexion, was sent to the hospital by Dr. D. P. Miller, of Huntingdon ; the history was obscure, as a previous injury had made a clear diagnosis impossible.

Excision of the head of the radius was decided upon and the opera- tion was performed ; the patient regained the power of flexion, with, however, only a very slightly increased amount of pronation and supin- ation.

The skiagraph, taken after the recovery of the patient, shows the radius after the excision of the head and also an old fracture of the ulna with adhesions to the radius, accounting for the limitation still remaining

Case IV.— External view, showing displaced fragment of bone.

WHITE^ GOODSPEED, LEONARD: RONTGEN RAYS. 143

in the power of pronation and supination. It also illustrates in a most marked manner the great usefulness of the Rontgen photographs in cases of old injury that are sent to hospitals for treatment, without a true his- tory or diagnosis of the condition of the parts at the time of the former accident. The failure to secure a greater amount of pronation and supi- nation was a disappointment to me at the time, and seemed inexplicable. The discovery of the old fracture and its adhesions completely cleared up all doubt as to the cause of the continuing disability and at the same time enabled me to decide that further operative interference was not indicated.

VI. Curvature of the radius due to arrested developmeut of the ulna at its distal epiphysis. — E. A., aged fifteen years, came to the hospital for advice in January, 1896. The family history showed one case of tuber- culosis, a paternal aunt, but there were no other cases in any other gen- eration. The paternal grandfather had an epithelioma of the lip, which was excised without recurrence.

The patient had had the diseases of childhood, but no severe or pro- tracted illness. The present trouble began in the seventh or eighth year, when a little lump was noticed on the arm and the patient complained of pain located at that point. There was no sign of curvature at that time, it has come on gradually since, while the pain has been inconstant and rheumatic in character, seemingly following a slight cold at each attack.

The patient has fair use of the hand and can write with it and do almost everything needful, so no operation was advised.

The skiagraph and the photograph show very well the condition and appearance of this forearm, and, if functional disability were greater, would serve excellently in locating the proper seat for operation if, for example, excision of a portion of the radius were decided upon.

VII. Diastasis of the distal epiphysis of the humerus, resulting from a fall on the hand. — W. McL., aged eleven years, came to the hospital on March 31, 1896, with fracture of the humerus.

The history was of a fall from a wall five feet high to the pavement, striking on the left hand. The patient weighed about seventy-five pounds ; he sustained no other iniury.

The case was diagnosticated and dressed before the skiagraph was developed, the latter demonstrating the correctness of the diagnosis and showing the position of the fragments resulting from this rare form of epiphyseal separation.

The new record that will now be made and kept of such cases as this will in time alter our statistics entirely as to the frequency of various forms of fracture or of epiphyseal injury. It will no longer depend on the skill and experience of the particular surgeon (though they will be of no less value to the patient than before), but will doubtless soon be made up of irrefutable testimony as to the exact conditions present.

VIII. Diastasis of the proximal epiphysis of the humerus, with over- lapping of the fragments and union in a faulty position. — S. B., aged six- teen years, fell heavily on the left shoulder, while playing football, in December, 1895. He passed through the hands of two doctors ; the condition was then recognized by Dr. E. M. Corson, of Norristowu, who sent him to the hospital for operation.

144 WHITE^ GOODSPEED, LEONARD: RONTGEN RAYS.

At the operation a longitudinal incision through the deltoid toward the anterior border showed the proximal end of the lower fragment overlap- ping the upper fragment by about two inches, with firm bony union between the two fragments. The upper end of the lower fragment lay beneath the coracoid process and interfered materially with the function of the joint. The upper portion of the lower fragment was resected, giving the joint free motion. The patient made a good recovery. The skiagraph showed the position of the fragments after the operation and their lateral union in a faulty position.

IX. The results obtained in excision of the knee. — This skiagraph shows the union between the femur and tibia resulting after an excision for marked tubercular disease. As in the cases of ununited fracture, it illustrates the advantage which may accrue from escaping the necessity of determining by an attempt to elicit motion whether or not bony union between apposed bones has been obtained. Very often while both patient and surgeon are anxious as to the result of operation it can only be deter- mined positively by the application of a degree of force which is in itself harmful. The progress of the case can be watched if necessary by the use of this method, any displacement of bones immediately remedied, and the final outcome seen Avithout the very least disturbance of the parts.

X. Foreign bodies in the arm,. — This skiagraph shows a piece of steel in the lower portion of the upper arm, which was easily located by the aid of the skiagraph. It shows, however, as has already been said, merely the relation of the steel to the inner border of the arm, leaving in doubt its relation to the anterior or posterior surface. The former point was easily made out by exact measurement, and, of course, in this case and in this locality, removal was easy. But it might be of vital importance to know the depth of the layer of tissue occupied by such a body. A second radiograph taken laterally would supply this informa- tion.

XI. Bullet in. the forearm. — This was an interesting illustration of the difierence in accuracy between the old methods and the present ones in the search for foreign bodies. The bullet (32-calibre, rifle) had entered the upper arm on the outer side, years before. An elaborate dissection had been made some time afterward in the attempt to find it. The patient was annoyed by the knowledge of its presence and complained of more or less vague nerve-pain afiecting the whole extremity, no local- izing symptoms being present. The arm was large and muscular. The skiagraph happened to include the forearm and by accident the bullet showed on the extreme edge of the plate. It lay on the inner edge of the ulna, partly overlapping the interosseous membrane. While Von Bergmann's warning against meddlesome surgery in these cases is timely and Avell-founded, it is certain that in this situation there were possibili- ties of later troubles if by a second traumatism the sharp edge of the missile had been driven against either the nerves or vessels of the part.

XII. Metatarsalgia. — Mrs. , a patient of Dr. S. Weir Mitchell,

had suflfered for years from pain about the metatarso-phalangeal junc- tion of the right foot.

The skiagraph shows that as a result of wearing pointed shoes there is a deformity consisting in part of the obliteration of the normal meta- tarsal spaces, with consequent pressure upon digital nerves and pain, sometimes intolerable. Walking in the bare feet or in stocking-feet as

WHITE, GOODSPEED, LEONARD: RONTGEN RAYS. 145

a systematic exercise is, in mild cases, sometimes curative. Resection of portions of the metatarsal bones is indicated in others. In either case the skiagraph is of great advantage as a guide to the surgeon.

XIII. Condensing osteitis. — This skiagraph shows the femur of a young adult, a patient of Dr. Pyle, of Wilmington, who has had a tubercular osteitis of the lower end of the femur with necrosis. Fol- lowing operation the wound healed entirely. The picture was taken some months later. It appears to show distinctly the area of condensing and formative osteitis which followed the operation, and also seems to show that no cavity and no sequestrum remain. Such deductions will, however, become more and more positive as we obtain larger numbers of skiagraphs, both of diseased conditions and of normal ones with which to compare them.

XIV. Subperiosteal abscess. — This skiagraph, taken from the diseased right and normal left thighs of a child, shows indistinctly on the right the outline of a very large swelling having every clinical characteristic of sarcoma, occupying its upper two-thirds. Months previously I had made a diagnosis of periostitis in this case. This fact led me to con- sider the possibility of abscess, although the physical conditions of the swelling seemed most unlike it. The skiagraph also seemed too indis- tinct in outline to represent a true bony growth, though as yet all this was problematical. At any rate the case proved to be an enormous abscess, stripping the periosteum from the femur throughout its entire length. At the time of operation the child had a temperature of 100° to 101°. It is apparent that even such swellings, while far more indistinct in the skiagraphs than normal bone, and probably not so definite as growths originating in bone, may yet easily be differentiated from the surrounding structures.

I confidently anticipate great improvement in this direction and the extension of the method to the differential diagnosis between abscess and new growths involving deeper portions of the body.

XV. Foreig7i body in the oesophagus. — This case was the first, so far as I know, either in this country or abroad, in which the presence of a foreign body in the oesophagus was revealed by the Rontgen rays. A child, aged two years and five months, a patient of Dr. Taubel, of Philadelphia, had been complaining for ten days of some difficulty in swallowing and had begun to reject all solid food, although it would still take small quantities of milk. Attempts at feeding it with even semi-solids invariably resulted in vomiting. There was no clear history of any foreign body having gained access to its digestive tract, but it was known that a plaything known as a jack-stone was missing from a set which the child had been using. When she was brought to me I sent her at once to Professor Goodspeed to have a skiagraph made, with the result of immediately obtaining the most accurate and definite information. The plate obtained after a three minutes' exposure re- vealed not only the presence, but the precise location of the body. The following morning, after carefully weighing the chances of the case after oesophagotomy or gastrotomy, I decided in favor of the latter, as the length of time which had elapsed made it probable that the jack- stone had become very firmly lodged and would be difficult to withdraw by the forceps even through an oesophageal wound. The result showed

146 WHITE, GOODSPEED, LEONARD: RONTGEN RAYS.

the correctness of this belief. After the stomach was opened a fine rub- ber explorer was passed through the pharynx and out of the stomach- wound carrying a long piece of stout silk attached to it. The explorer was withdrawn and wads of gauze of various size were tied to the silk ; some of these could not be carried either way beyond the jack-stone, but, whether pulled downward through the mouth and pharynx or upward through the stomach, were arrested when they reached it, even although very considerable force was used. Finally, however, the proper size was found and the jack-stone was pulled dowuAvard into the stomach, from which it was easily extracted. The mucous membrane was then at once stitched together with a continuous catgut suture and the whole wound was inverted by a continuous Lembert suture. The operation, including preliminary attempts at removal by forceps, took something less than a half hour. The child reacted well, and has entirely recovered.^

The propriety of attempting extraction by forceps, guided by direct inspection at the time with the aid of the fluoroscope, was considered by me ; but the attemj^t was not made on account of the presumably ulcerated and inflamed condition of the oesophagus, contraindicating instrumentation in that canal. The method will doubtless prove appli- cable in the future to many cases seen earlier.

A large number of other cases have occurred in my service, but these are sufficiently illustrative of the extent and variety of the application of this method of surgery.

Professor Goodspeed has kindly prepared the following account of the method by which he secured the excellent and helpful pictures of the foregoing cases :

The apparatus which has been used in the work illustrating this article consists essentially of four parts. The first is a storage-battery of twelve cells, arranged six in series and two in multiple arc, giving an electromo- tive force of about twelve volts. The second part of the apparatus is a current-interrupter of special construction run by a motor and arranged to give from one to three thousand breaks per second. The contact- points of the interrupter are made of thick pieces of platinum, and on either side are attached the terminals of a variable condenser in three parts to take up the extra current due to self-induction in the coil and thus to make the break more sudden. The third part consists of an inductorium of the Ruhmkorff" type, the primary coil of which is attached to the interrupted battery circuit. The secondary circuit is attached to the terminals of the fourth element of our set of apparatus, viz., the Crookes's tube. The tube which has been used in much of the work and found very efficient was made by the Knott Company, of Boston, from a plan made by the writer. It is a glass bulb about four inches in diameter, exhausted to such an extent that under the electric discharge no blue halo appears at either terminal. The glass fluoresces a brilliant green. The cathode or the terminal attached to the negative pole of the

1 This case was published in full iu the University Medical Magazine for June.

WHITE, GOODSPEED, LEONARD: RONTGEN RAYS. 147

secondary coil is a concave aluminum disk about one and a quarter inches in diameter. In the centre of the curvature of this, viz., about three inches from it, is placed the anode, consisting of a flat platinum disk. The wires to which these disks are fastened are sealed into the glass by German enamel and covered nearly their whole length within the tube by this material.

By this means internal sparking is almost entirely avoided. We have several coils capable of giving different intensity-effects. The one which seems best adapted to all grades of work gives a ten-inch spark in air. The exposures required depend, of course, upon various conditions, and were from a few seconds to three or four minutes. This leads us to an im- portant detail in connection with this work, viz., the sensitive plate upon which the negatives are made. We have made many experiments upon various plates on the market and have been associated with Mr. John Carbutt in the development of a plate especially adapted to this purpose. Upon the efficiency of the plate that Mr. Carbutt now makes depends, I feel sure, much of the excellence of the work that we have lately done.

For sharpness of detail it is necessary, of course, to have the part to be skiagraphed as near the film as possible. It is found convenient, therefore, to wrap the plate in two or three thicknesses of thin black rubber-covered cloth, which is quite effectual in excluding all light dur- ing the exposure. This plate is then bound tightly to the part with long ^auze bandages, film-side to the skin. The Crookes's tube is placed on the other side of the part from one to two feet away, according to circum- stances. It is probable that the resultant effect obeys the law of in- verse squares ;" so that to produce the same density in the negative in two experiments the times of exposure should be proportioned to the square of the distance of tlie tube from the plate.

Many details in the manipulation of the various parts of the apparatus have to be attended to continually, and the best results are obtained only when all the various parts are carefully and properly balanced. When the cathode is large the tube seems to be more powerful for the time, but it wears out soon — i. e., its exhaustion gets so high that the largest coil will produce no discharge through it. Under these circumstances it has to be opened and re-exhausted to the proper degree. It is clear, then, that the conditions necessary for the very best results cannot be realized very long at a time.

The fluoroscope, consisting of a screen of cardboard covered with cal- cium tungstate, is a very useful and almost necessary addition to the equipment. If such a screen takes the place of the photographic plate, and the eye, shielded from external light, be placed behind it, shadows of the bones or foreign bodies can be plainly seen on the screen.

In many simple operations the use of the fluoroscope would be quite sufficient to gain all needed information.

148 THOMSON: PAINFUL POINTS IN GOUTY ARTHRITIS.

PAINFUL POINTS IN GOUTY COMPARED WITH RHEUMATIC

ARTHRITIS.!

By W. H. Thomson, M.D., LL.D.,

PROFESSOR OP PRACTICE OF MEDICINE IN THE NEW YORK UNIVERSITY.

The differential diagnosis between acute gout and acute rheumatism is usually simple enough in typical cases, especially when of recent origin. In many chronic cases, however, particularly when gouty arthritis has become general, the differentiation may not be so easy, and in practice we frequently find gouty cases treated for rheumatism or rheumatic patients dosed with colchicum.

For a number of years I have been accustomed to point out that a careful manipulation, of the inflamed joints in these affections will show specific contrasts between them in the localization of the greatest tenderness on pressure. I supposed that this clinical fact had been noted before, but, not finding any reference to it in the works which I have been able to consult, I take this occasion to present the following obser- vations on cases of gout and of rheumatism occurring in my service at the Roosevelt and the Bellevue Hosj^itals, of New York, during the past few months, with some cases of gout in private practice.

Gout. Whole number of cases of gout, 34 : males, 27 ; females, 7. The first attack in the history of the patients began in the lower extremi- ties in 31, or 98.9 per cent. In two chronic cases the patients were uncer- tain where it first began. In one, a painter by trade, and affected with chronic plumbism, the first attack involved the left shoulder as well as his feet.

The first attack was monoarticular in 73 per cent., and polyarticular in 27 per cent. I am inclined to think, however, that the percentage of monoarticular first attacks was higher, particularly in the hospital patients, for the memory of some of the more chronic cases on this point was rather indefinite.

The pulse was noted as of high tension in 98 per cent., and not of high tension in 2 per cent. The arteries were found thickened in 44 per cent., and not thickened in 56 per cent.

Tophi were present in the ears in 12 cases, or 35.1 per cent.

As to painful points : There were 38 instances of inflammation of the knees. In every one of these cases, without exception, the points of greatest tenderness on pressure were on the condyles. The more acute the inflammation, the more distinctly is this tenderness pronounced. In the decline of the inflammation tenderness will persist there when it cannot be elicited elsewhere. This is in marked contrast with acute

1 Read before the American Association of Physicians, Washington, May 1, 1896.

THOMSON: PAINFUL POINTS IN GOUTY ARTHRITIS. 149

rheumatism, in which, as we shall see, increased tenderness on the con- dyles, as compared with the other parts of the joint, was not once found.

Of 23 cases of inflammation of the ankles, the points of greatest tenderness were found on the malleoli in 11, just below the malleoli in 10, and on the astragalus in 2. ;

On the great toe no uniformity in points of greatest tenderness was made out.

The hip-joint was affected in two cases, but without any localized ten- derness to pressure in either.

In the upper extremity, among the numerous phalangeal finger-joints affected, and in many instances distorted with gouty deposits, those of them which were painful enough to give indications showed, without exception, the points of greatest tenderness on the condyles — that is, on transverse pressure ; while pressure between the dorsal and palmar sur- faces did not occasion pain, or very slight pain, compared with pressure on the condyles. I have found this in private practice a valuable sign, in women especially, as these joints are frequently in them the only ones involved in gouty inflammation.

The elbows were affected in 12 cases. Of these the most tender points were on the condyles in 6, on the olecranon in 4, and on both the condyles and the olecranon in 2.

The shoulders were involved in 5 patients. In 2 of them both shoul- ders were attacked. No particular point of tenderness was noted except in 1, and that was on the acromion.

The cases of inflammation of the metacarpo-phalangeal joints were not enumerated, because their lateral tender points cannot be isolated. The same applies to the wrists, but in both cases of these joints there is more tenderness to lateral pressure than in rheumatism.

Rheumatism. Number of cases of rheumatism observed, 49. All of them hospital patients. Males, 32 ; females, 17.

Among these the heart was or had been affected in 18, or 36.7 per cent. Tonsillitis occurred shortly before or during the attacks in 11, or 22.4 per cent. Pleurisy occurred in 3 cases, or 6 per cent.

The pulse is reported as of low tension, or compressible, in 42, or 85.7 per cent. ; of high tension in 5, or 1.02 per cent. ; and in 2 not stated.

The first attack was polyarticular in 46, or 94 per cent. ; monoartic- ular in 3, or 6 per cent.

In rheumatism, particularly when a joint is acutely inflamed, there is usually more superficial or cutaneous tenderness than in gout. This may mislead as to the existence of special points of tenderness unless the exam- ination be made with special reference to this subject, when in the great majority of instances, notably in some joints, rheumatism will be found to be scarcely less specific than gout in the localities of greatest pain on pressure, and, what is e(|ually important, that these are in only^a few

150 THOMSON: PAINFUL POINTS IN GOUTY ARTHRITIS.

joints the same as in gout. Thus, in the knee, the typical points of ten- derness are on the tendon of the quadriceps just above the patella, and below it also at the tendon insertion. Posteriorly equally characteristic points of tenderness are found along the tendons of the hamstring mus- cles. Out of 58 cases of inflamed knees in my list, 53, or 91.4 per cent., were thus typical, and in 5, or 8.6 per cent., the pain was uniformly diffused over the joint. In no case were the condyles the seat of most tenderness.

Rheumatic inflammation of the ankles is not so distinctive in the loca- tion of painful points as in the case of the knees. Of 32 cases my notes are that the most pain was elicited by pressure on the tendons of the dorsal aspect of the joint in 20, or 64.4 per cent. This pain, however, is not so pronounced as in the tendons of the quadriceps and hamstring muscles of the knees. In 3 cases, or 10.6 per cent., the most painful points were under the malleoli ; and in 8, or 25 per cent., there was no sjDecialized place.

The hips were affected four times, but no localized pain was noted in either.

Of the joints of the upper extremity, the shoulders were affected in 20 cases. In only one of these was a special tender point found on the coracoid process.

The elbow was affected in 13 cases. Of these in 9, or 70 per cent., the most painful point was elicited by pressure on the triceps tendon. In 4, or 30 per cent., there were no special points.

The wrists were affected in 24 cases. Of these the most pain was elicited by pressure on the tendons of the dorsal and palmar aspects in 20, or 83.3 per cent. It was uniformly diffused in 3, or 15 per cent. ; and one case complained of most pain on transverse pressure, as in gout.

In every case noted of inflammation of the finger-joints in the rheu- matic patients the pain was localized in the tendons and not on the con- dyles.

Why the hips and shoulders do not commonly show specially painful points may be due to these joints being so covered by large muscles.

It seems natural to infer that the difference between these two forms of arthritis in the respects noted, of pain on pressure, is because gout chiefly affects the periosteal, while rheumatism chiefly attacks the syno- vial structures.

With the exception of the hips and shoulders, therefore, it would seem that the distribution of pain on pressure may be often of use in the discrimination of these two articular inflammations. The ankles and wrists also do not present such marked contrasts as the more simple joints, apparently from the greater number of bones entering into the formation of these articulations.

dercum: the functions of the neuron. 151

ON THE FUNCTIONS OF THE NEURON,

WITH ESPECIAL REFERENCE TO THE PHENOMENA PRESENTED BY HYSTERIA AND HYPNOTISM.

By F. X. Dercum, M.D.,

CLINICAL PROFESSOR OF NERVOUS DISEASES, JEFFERSON MEDICAL COLLEGE ; NEUROLOGIST TO THE PHILADELPHIA HOSPITAL.

There has been noticeable of late years a tendency strangely to mis- construe the structure of the nervous system and to misinterpret the truths which that structure teaches. Curiously enough, this tendency has appeared with our increasing knowledge of the details of the intimate structure of the neurons and of the relations which they bear to each other. It is known, for instance, that the afferent fibres, those which convey impressions from without up to the cortex [themselves processes (axons) of peripheral neurons], terminate not in nerve-cells, but in the uppermost layer, the so-called molecular layer or molecular plexus of the cortex. Here in some way the minute divisions of the afferent fibres affect the fibres of this molecular plexus. The latter are in turn in direct communication with the nerve-cells of the cortex, are, in fact, themselves cell-processes. These facts suggested the idea that afferent impulses are diffused through the molecular plexus without involving or affecting the nerve-cells at all, and according to this interpretation the nerve-cells are left out of consideration entirely in studying nervous phenomena. This view has been especially advanced by Nansen, who maintains that the old manner of view relative to the composition of the reflex arc and the physiological importance of the nerve-cells can no longer be sustained, inasmuch as the cells are not in direct communica- tion with each other, and because direct communication between the central nerve-cells and the sensory or centripetal nerve-fibres is equally lacking. The reflex arc is constituted, according to Nansen,* first, by the centripetal nerve and its flbrillary ramifications passing directly into the nervous meshwork of the cortex — that is, into the molecular layer ; secondly, by the propagation of the excitation through this molecular plexus ; thirdly, by the transmission of stimuli to the minute lateral branches of the centrifugal or motor nerve-fibres. It follows that im- pulses are transmitted to the superior centres without passing directly through the nerve-cells. " We can admit in the same manner," con- tinues Nansen, " that the voluntary impulses emanating from the nerve-fibres which emerge from the superior centres transmit themselves directly to the centrifugal fibres of the inferior centres without passing through the nerve-cells of these centres." He says, further, that it is

1 Soury, Les Fonctious du Cerveau, p. 316.

152 dercum: the functions op the neuron.

impossible to admit that the iierve-cells of the inferior centres possess a direct importance either in relation to reflex movements or to the vol- untary movements, and that this seems to apply equally well to the nerve-cells of the suj^erior centres. This view forces us to the conclusion that the activity of the nervous system, intelligence, consciousness, etc., is seated really in a fibrillary meshwork of the cortex, the molecular layer, and has nothing to do with the nerve-cells of the cortex. The latter, indeed, deprived of their psychic functions, become simply " trophic " centres. They serve only for the maintaining of the nutri- tion of the nerve-fibres and their innumerable arborescent ramifications.

This view of Nansen's has been adopted by my esteemed colleague. Dr. Mills, who, in a discussion on cerebral localization at the last meeting of the American Neurological Association, and also in the Text-hook on Nervous Diseases by American Authors, has maintained this position ; he holds that " impulses are conveyed from processes to processes through the entire reflex arc, through the entire length of a cortico-efferent, or a corti co-afferent, projection-system," without passing through nerve-cells, and that " the function of the nerve-cell body is trophic;" that its * ' nuclei and nucleoli preside over the nutrition of the long or short fibres which 2)ass out of or grow into them ; " and, further, that cells are of enor- mous bulk in order that they may be able to sustain these processes. In his words, " the aggregations of gray matter at various levels of the nervous system are watering- and feeding-places, not places for renewing nerve-activity."

Certainly this view does violence to the fundamental principle that the properties of a given tissue depend upon its cells, and that the cells are the integral parts of the tissues. Nowhere in the whole range of biology do we find a similar anomaly obtain as is implied by this view. It asserts that merely incidental structural attributes are of greater value than the individual cells, whose building up constitutes the tissue. Surely there is here an intrinsic contradiction.

Not only upon general principles is this view untenable, subversive of all that we have hitherto learned ; but, if carefully analyzed, it is found to present insuperable difficulties. If it be true that a nerve-fibre diffuses the energy which it conveys : in a general way, scatters it though all the fibres or nerve-cell processes near which it happens to lie, it becomes im- possible to explain the definite and precise actions of the nervous system, properties which are so characteristic of it. Nothing but hopeless con- fusion of function could result if such a thing were possible. It would mean that nerve-currents course indiscriminately without relation to each other through this network of fibres. It would mean that everything that had been done by nature to conserve and isolate nervous impulses by enclosing the nerve-fibres in special sheaths of insulating material previous to their entrance into the cortex had, after all, no purpose,

DERCUM: THE FUNCTIONS OF THE NEURON. 153

because in the end the currents are turned wildly loose into a common receptacle.

The conservation of nerve-currents along cell-processes, no matter how long these may be, or whether they be in the cortex or below it, is an absolute requisite. Were it not so, the various commissural and associa- tion tracts, whose existence we know of upon anatomical as well as upon physiological grounds, would assuredly be unnecessary, would have no meaning if the loose and unrestrained diffusion of nervous energy in the cortex, such as is implied by Nansen's view, were possible.

Further, such facts as we possess are directly opposed to a diffusion of nervous energy. According to Berkley,^ by far the larger number of the finer fibres of the cortex are meduUated almost to the extremities of the end- terminations. It is highly probable that Berkley maintains " that in no instance except at the free termination is there actually such a thing as a naked axis-cylinder," and that " the conduction of the nerve- force from cell to termination and from termination to cellular proto- plasm again is only through the medium of the ending of the nerve-fibre, and that there is no diffusion of the dynamic forces through the cortex, but that the action is a direct one." In this connection he further says :

To suppose for an instant, that naked axis-cylinders are present in considerable numbers in the cortex is to me an impossibility, for we must necessarily suppose in such an event that in the closely packed arrangement of axons and dendrons presented by the outer portion of the pyramidal and in the molecular layer, where fibres and dendrites touch each other in all directions, the stimuli would quite as often be aberrant as direct, and as frequently reach the wrong as the right desti- nation. Naked axis-cylinders are in all likelihood a physiological im- possibility in the cerebrum, for were they numerous we can suppose nothing but a constant overflow of stimuli from one cell to another, and consequent in co-ordination, not only of thought, but also of action."

Far from lending support to the ^ iew of Nansen, that the cell is to be left out of account in the consideration of nervous action, the discoveries of Golgi, Ramon Cajal, Van Gehuchten, and others have shown exactly the reverse. They have demonstrated beyond all question that, as in all other tissues, the cell is the actual integral structure. And while it was formerly held that the various cell-processes anastomosed freely with each other, we now know as a matter of fact that such anastomoses do not occur. The nerve-cell is a cell entirely by itself. It is a cell as distinct and as self-limited as any cell of any tissue with which we are acquainted.

Far from being continuous through its processes with other cells, we learn that its processes nowhere fuse with other structures. Its processes are well limited, sharply defined, and bear no relation to those of other

1 Medical News, November 9, 1895, p. 50G.

154 dercum: the functions of the neuron.

cells save that of propinquity or perhaps contact. The individuality of the nerve-cell as a morphological integer is wholly preserved.

If we grasp this idea in its full meaning, our conception of the nervous system changes profoundly. It is no longer a stringing together of tele- graph wires and way stations, but it consists of an aggregation of cell- integers, each one of which does its share in the production and in the transmission of nervous energy. For instance, the impulse proceeding from a motor neuron in the cortex is transmitted by the neuron through its own protoplasmic extension (the efferent nerve- fib re) to a definite aggregation of cells in the spinal cord. It communicates its energy to these cells in the spinal cord without in any way fusing with their pro- toplasm or their processes. In the same way the impressions that come by the various sensory paths come from peripheral neurons, those situated in the skin, in the retina, in the ear, in the taste-buds, or in the Schnei- derian membrane, and are conveyed by fibres which are merely proto- plasmic extensions of these peripheral neurons up to the cortex. Here in turn these fibres transmit the energy they convey to the cortical neu- rons without fusing with the latter or with their processes. Everywhere, and no matter in what light we view the nervous system, the signal im- portance of the nerve-cell as an individual entity is strikingly apparent.

A consideration of the above facts has suggested to me the following thought : Can it be that the neuron is not an absolutely fixed morpho- logical element ? Can it be that it possesses a certain, though perhaps limited, power of movement ? Realizing the practical value and the wide application of this idea, I have examined the literature to see whether a similar interpretation of nervous phenomena has occurred to others, and to gather such facts, if any, as could be brought forward in its support. I found that this thought had occurred independently to three observers, one in Germany and two in France. I found that in 1890 Rabl-Ruckhard, in a short paper published in the Neurologische Centralblatt, had suggested the view that nerve-cells have an amoeboid movement, and he also hinted briefly at the possible significance of such a fact, if true, upon our interpretation of the phenomena of hysteria. Rabl-Riickhard's ideas attracted little or no attention, and in August, 1894, without any knowledge of Rabl-Riickhard's theory, in a paper on " A Case of Hysteria of Peculiar Form," published in the Revue de Medecine, Lepiue advanced the same view. In endeavoring to interpret the various shifting phenomena observed in his patient he advanced the idea that the neurons were capable of movement to such an extent as to enable them to vary the degree of their relation to each other. About half a year later Mathias Duval, without any knowledge of either the views of Rabl-Riickhard or those of Lepine, in a communication made to the Societe de Biologic, advanced the same theory. A week later Lepine, before the same body, repeated his former arguments in its support.

DERCUM: THE FUNCTIONS OF THE NEURON. 155

Curiously enough, this view, so suggestive, so pregnant with possibilities, did not meet with the indorsement either of that veteran histologist, Kol- liker, or that other high authority, Ramon Cajal. In a paper entitled " Some Conjectures on the Anatomical Mechanism of Ideation, Associa- tion, and Attention," published in the Revista de Medicma y Cirurgia Practicas, May 9, 1895, Ramon Cajal contended that the nerve-cells do not move, because (1) the terminal branches of the nerve-cells of the cerebellum, of the olfactory bulb, of the acoustic ganglia, optic lobes, etc., always present the same shape and the same degree of approxima- tion to the cell-bodies irrespective of the mode of death of the animal (chloroform, hemorrhage, curare, strychnine, etc.) ; (2) because the ter- minal nerve-branches of the retina and of the optic lobes in reptiles and bactrachians presented always the same appearance, no matter whether the organs mentioned had remained in a condition of rest (the animals having been killed after remaining in darkness for a long time) or whether they had been functionally active (the animals being killed after prolonged exposure to sunlight).

While Ramon Cajal thus opposes the theory of mobility of the neuron, he maintains, on the other hand, that the neuroglia-cells possess a great degree of mobility. He points out, for instance, that the neuroglia-cells of the cortex are at times stellate and at others much elongated. Their processes have numerous short, arborescent, and plumed collaterals. Two phases can be observed in them : first, a stage of contraction, in which the cell-body becomes augmented while the processes become shortened and the secondary branches disappear ; secondly, a stage of relaxation, during which the processes of the neuroglia-cells are again elongated. Ramon Cajal maintains that the processes of the neuroglia-cells in reality represent an insulating or non-conducting material, and that during the period of relaxation they penetrate between the arborizations of the nerve-cells and their protoplasmic processes, and render difficult or im- possible the passage of nerve-currents. On the other hand, when the processes of the neuroglia-cells are retracted, the various nerve-cell pro- cesses which they formerly separated from each other are now permitted to come into contact. To me it seems as though Ramon Cajal admits the very thing against which he contends. Evidently, if the nerve -cell processes are not at one time in contact, and at another are in contact, they must certainly move, and the question at issue is self -admitted It certainly does not matter whether the nerve-cell processes move little or move much, but that they move at all is the question at issue ; and this, it seems to me, Ramon Cajal admits, although he makes that movement a purely passive one and dependent upon the interposition of the pro- cesses of the neuroglia-corpuscles. It is certainly a minor point whether the movement of the nerve-cell processes is active or passive, though it seems tliat it is far from evident, from the histological facts at our

VOL. 112, NO. 2. -AUGUST, 1896. 11

15G dercum: the functions of the neuron.

disposal, that the neuroglia-corpuscles play the role of an insulating mate- rial. To me it further seems that a single positive observation outweighs all other negative observations, no matter how great the authority behind them, and this positive observation has actually been made. Wieder- sheim' actually saw in the living animal, leptodora hyalina, an entomo- stracan, the nerve-celle in the oesophageal ganglion move. The oesopha- geal ganglion may in one sense be regarded as the brain of the animal, inasmuch as it receives the fibres of the optic nerve and Wiedersheim saw its cells move and change their shape. He describes their move- ment as slow and flowing. Certainly this observation possesses a pro- found significance. Even if the animal in which the phenomena were observed is far removed from the vertebrates, it must be remembered that it is just in the lower forms that general biological truths must be sought for, and it is just in the lower forms that they have been found. I do not for a moment contend that the nerve cells of vertebrates possess a gross amoeboid movement as in the oesophageal ganglion of the entomo- straca ; but I do contend that it is in the highest degree probable that such facts as we have, scanty though they be, are in favor of the view- that a certain amount of movement does take place in the terminal por- tions of their processes, their dentrites and their neuraxons, although this movement is probably small in extent.

Let us turn our attention for a moment to the subject of hysteria, and let us see what a flood of light is cast upon this subject, heretofore so obscure and mysterious. Let us take the simple example of a hyster- ical paralysis, and see how easily it is explained, The neurons of a cer- tain area of the cortex, for instance, retract the terminal branches of the neuraxon to such an extent that the latter are no longer in contact, or sufticiently near to the neurons of the spinal cord which supply the mus- cles of the paralyzed part. It explains also the marvellous fact that a hysterical paralysis may at one time be so real, so genuine, as to be indistinguishable from a grossly organic paralysis, and yet the next moment upon a suggestion may absolutely disappear. The shifting of symptoms in hysteria, this sudden disappearance of paralysis or anaes- thesia, can be explained by the view here advanced as it can be by no other. When power is suddenly re-established in a hysterically palsied limb it simply means that the terminal branches of the cortical neur- axon, previously retracted, are again extended so as to re-establish the proper relations with the spinal neurons. Take again the example of a hysterical anjesthesia. How often do we see a segmented anaesthesia or a hemi-an?esthesia coming and going under the influence of no other stimulus than that which applies to the psychic make-up of the indi- vidual, namely, a treatment which we call mental or moral treatment, or

1 Anatomischer Anzeiger, 1890, p. 673.

dercum: the functions of the neuron. 157

that more powerful treatment, suggestion under hypnotism. It would be interesting, indeed, to follow out the ideas here brought forward in their application to the various phenomena presented by hysteria, its sensory, motor, and visceral stigmata. Even the hysterical convulsion, I contend, can be explained by the view here advanced. Time will not, however, permit more than to indicate the line of thought.

When we turn to hypnotism we can see what a ready explanation it affords for the phenomena presented. Under the fixed stare necessi- tated by the ordinary method of bringing about hypnosis, and under the suggestion of sleep, the neurons are thrown into certain fixed relations with each other, corresponding solely to the ocular strain and singleness of thought induced. At the same time such relations of the neurons as ordinarily bring them into true contact with the outer world are sus- pended, probably by retraction of cell-processes. We can easily under- stand, in the light of the theory here advanced, how under hypnotic suggestion a hysterical paralysis disappears, or how, under hypnotic suggestion, anaesthesia is produced in this or that part of the body. Fur- ther, the various stages of hypnotism itself — lethargy, catalepsy, som- nambulism— are all of them capable of a scientitic explanation upon this theory. Hypnotic lethargy, for instance, a stage so easily produced in the majority of patients, merely signifies that so general has been the retraction of the cortical neurons from each other that not only is sleep produced, but also a stage of general motor relaxation, due to the re- traction of the terminal branches of the neuraxons in the spinal cord. In hypnotic catalepsy, on the other hand, the reverse obtains. Here the relations of the cortical neurons to the spinal neurons (contact or in- creased proximity, whatever it may be) are established to a degree be- yond that which is normal, and the consequence is an enormous general increase of muscle-tonus. In somnambulism, again, certain of the neurons, especially those which stand in direct relation with the various sensory organs, form partial combinations with a limited number of other corti- cal neurons, so as to produce the various limited psychic phenomena characteristic of somnambulism, whilst the great bulk of the neurons of the cortex, the summation of whose action constitutes the ego and brings it into close relation with the outer world, have their processes retracted in sleep.

Leaving this interesting field, let us see for a moment of what enor- mous value this interpretation of cortical action is for normal mental phenomena. Sleep, instead of resulting from brain anaemia, or some other apocryphal condition of the circulation, merely means that when the substance of the cortical cells has been diminished by functional activity, which diminution we have reason to infer, from the researches of Hodge,^ (on the changes in nerve-cells in fatigue), there comes a time

1 Journal of Morphology, 1892, vol. vii p. 95,

158 DERCUM: THE FUNCTIONS OF THE NEURON.

when the cell-processes are retracted, so that the neurons no longer stand in active relation to each other. Interchange of action cannot then take place ; unconsciousness follows ; sleep is established. Spontaneous waken- ing merely means that after nutrition has reached a certain point, a point where the wasted cell has been replenished, extension of the cell-processes again takes place, and interchange of active functional relations is re- established.

Numerous other ideas also suggest themselves in relation with the view here advanced. Take, for instance, a train of thought. This appears to follow purely mechanical lines. Thus a sequence of sound-vibrations im- pinging upon the peripheral auditory neurons, the auditory cells, produces in them a change, which in turn affects the relations which their neur- axons bear to the auditory nuclei, and secondarily to the auditory cor- tical neurons. Not only are the latter affected by the impressions re- ceived from the afferent neuraxons, but they in turn react in such a way as to change their relations to each other, and the new positions assumed by them will depend largely upon the fact as to whether a similar se- quence of impressions has passed through them before. If so, the old combinations will be reformed, and as a corollary the recognition by the ego of the sounds as something heard before. From the cortical audi- tory centre there now passes through the general cortex a series of com- binations among the neurons, also along the oldest and best-travelled lines, so that a given sequence of musical sounds may suggest at first a familiar air, and a moment later a vivid recollection of an opera once heard and seen. Here is the physiology of memory.

A startling thought which also suggests itself in connection with the theory of cortical action advocated in this paper is that not all of the neurons are functionally active at the same time. It is exceedingly prob- able that the number varies greatly. For instance, in fatigued states fewer combinations are made — fewer are possible — because of the ex- hausted condition, the diminished volume of the cell-protoplasm. After rest, on the other hand, not only are combinations more readily made, but a larger number of neurons are active. It is further probable that in states of mental or emotional excitement the number of neurons that are active and the number of combinations accordingly formed enor- mously exceed those occurring during ordinary mental states.

Many other thoughts also suggest themselves, and some are extremely interesting. For instance, the receptivity and marvellous adaptability of youth and early manhood appear to depend upon the relatively great mobility of the cell-processes, while the retarded and restricted mental action so often seen in old age appears to be related to a much diminished mobility of these processes. Certain it is that the theory that the neuron is not an absolutely fixed morphological element renders clear and com- prehensive many of the Avell-known facts of mental physiology. The

mccosh: extrauterine fcetation.

159

application of this theory, for instance, to memory, sequence of thought, association of ideas, and even more complex mental processes, is evident, but the limits of this paper have forbidden any but a mere mention of them.

EXTRAUTERINE FCETATION.

REPORT OF FIFTEEN CASES TREATED BY OPERATION.

By Andrew J. McCosh, M.D.,

OF NEW YORK.

Within the past four years the following fifteen cases of extrauterine foetation have been operated on by me at the Presbyterian Hospital. The admission of so many cases to the service of one surgeon in a general hospital must indicate that an ectopic pregnancy is a compara- tively common occurrence. From the histories which follow certain facts have been derived. The youngest patient was twenty-three years of age, the oldest thirty-nine. Three were nulliparae. Twelve had previously been normally pregnant, nine having borne one or more children, three having had miscarriages only. Five had complained of more or less pelvic pain prior to the ectopic gestation ; ten gave no history of special distress in their pelvic organs.

Symptoms during the ectopic pregnancy. All had suffered from pain. In three the pain had been slight, in twelve severe. All had skipped one or more menstrual periods. In fourteen there had been irregular uterine bleeding ; in one there was no history of bloody vaginal discharge. In eight there had been signs of shock on one or more occasions indicating rupture, in two of these amounting to severe collapse. In seven there had been apparently no sign of shock. Seven had considered themselves pregnant ; eight had not suspected the existence of pregnancy.

Conditions found at operation. In two cases the foetus was in the tube, which was unruptured (eight weeks and ten weeks). In five rupture into the broad ligament had occurred (less than three months). In eight the foetus or its remains was found in the peritoneal cavity. • The duration of the pregnancy was under fourteen weeks in thirteen cases, over four months in two cases (four and a half and six and a half months).

It may be well to note that most of these patients were from the lower grades of life and would not be apt to pay special attention to either their menstrual dates or their signs of pregnancy, and perhaps not to pain unless it was severe in character.

It will be noticed from a review of the above symptoms that these cases emphasize the fact that the main points in the diagnosis of extra- uterine pregnancy are, first, delay of the menstrual period, with or

160 mccosh: extrauterine fcetation

without signs of pregnancy ; second, pain generally severe in character and sudden in its onset, sometimes agonizing, with signs of shock ; third, irregular uterine hemorrhage very commonly accompanying the first attack of pain.

Case X. is of special interest on account of the viability of the child, which was fairly robust for a six and one-half months' foetus. As both the head and extremities were deformed, an incubator was not employed. The history of this case is also of interest because of the frequent and severe attacks of hemorrhage in the cavity of the peritoneum. The placenta was removed at the operation instead of being left in situ, as is the usual custom.

Case XII. is of interest on account of the time selected for operation and the large amount of blood found in the abdomen. Laparotomy was done thirty-six hours after the gravest of three hemorrhages. Had the abdomen been opened on her admission to the hospital she would certainly have died on the operating-table. A delay of twenty-four hours enabled the patient to recover sufficiently to withstand the imme- diate shock of operation. Her depleted state was, however, unable to withstand the poison absorbed from the blood which was necessarily left in the abdominal cavity, and she succumbed on the fifth day. This was the only fatal case.

Case XIV. is of interest on account of three successive ruptures of the foetal sac, as is shown by the history of the case and by the condi- tions found at operation. The first rupture, that of the Fallopian tube, occurred presumably between the fifth and sixth weeks. Its contents apparently escaped into the broad ligament and a large blood-clot was left in the tube. The second rupture occurred about two weeks later. It was of the broad ligament, and resulted in a large hsematocele in the floor of the pelvis, which evidently became sacculated. This was also accompanied by severe pain and by a uterine hemorrhage. The third rupture occurred about the tenth or eleventh week and evidently was of the sac of the h[«matocele, and resulted in either a fresh hemorrhage or an escape of the already clotted blood into the free peritoneal cavity. The conditions found at the operation, consisting of an enlarged Fallopian tube, in the end of which was a cavity in which the foetus had formed, the distended broad ligament showing a tear in its superior layer, the hsema- tocele in Douglas's pouch with a rent in its fragile sac, and the free blood in the peritoneal cavity, form a chain which beautifully illustrates the history of the three ruputres, each one of which was accompanied by pain and " flow."

Case I. — Mrs. D., aged thirty-seven years ; married ; one miscarriage, six years ago ; no children. Menstruation regular and painless. Last normal menstruation November 1, 1891. Considered herself pregnant until January 27, 1892, when she thought she had a miscarriage, as

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there was sudden uterine hemorrhage lasting some days, accompanied by pain, and followed by severe " colic " which continued two or three days. From February 5th until February 20th felt well, but was then attacked with another " colic " and with vomiting. In a few days these symptoms disappeared, but there remained a continuous pelvic pain. A week later another colic," and again in another week. Admitted to the hospital on March 14th : Temperature 100° ; pulse 92. There had been no vaginal discharge since February 1st. Complained of general abdominal discomfort and enlargement. On examination, to the right of the uterus was a mass the size of a foetal head. Diagnosis — probable extrauterine pregnancy, which had ruptured.

Operation, March lijth. Ether. Median laparotomy. Omentum found tightly adherent to superior surface of tumor and to intestines ; ligated in three portions and cut away. Tumor then seen to occupy right iliac fossa and to be adherent to uterus, intestines, and floor of pelvis. It consisted of a thin sac, which was situated in the general cavity of the peritoneum. It was filled with blood-serum, and in it was a four and a half months' foetus, cord, and placenta. Sac was ruptured ; contents removed with moderate loss of blood. Sac peeled from its attachments with ease. The distended and thickened Fallopian tube ligated and removed. The abdomen closed by suture. The patient made a good recovery, was out of bed April 12th, and discharged cured April 20th.

Case II. — M. H., aged twenty-seven years ; married five years ; no children ; one miscarriage (second month) four years ago. With the exception of the abortion, never suffered from pelvic pain until present illness. Menstruation always regular and painless. Last normal men- struation March 11, 1892. April 10th, menstrual molimina for two days, but no flow ; noticed fulness of breasts and occasional nausea. May 7th, colicky pain in abdomen, which became localized into a constant pain, or rather a sense of discomfort, in the left iliac fossa. May 10th, when an examination was made a mass the size of a large orange, some- what soft to the touch and slightly sensitive to pressure, was felt in the left of the uterus ; uterus seemed enlarged and soft. Diagnosis of probable extrauterine foetation.

Operation, May 12th. Chloroform. Median laparotomy. To the left of the uterus and adherent to it was found a mass the size of an orange, which evidently contained fluid and blood-clots. On separating it from the adhesions it was seen to be a distended Fallopian tube. Partial rupture with the escape of some bloody serum occurred in extirpating the tube, which was clamped close to the uterus. Clamp was replaced by a ligature, and after cleansing of the pelvis the abdominal wound was closed. In the sac was found a shrunken foetus seven to eight weeks old. The temperature of the patient did not rise above 99.5°, and she was out of bed on the nineteenth day, and was discharged cured on June 7th.

Case III. — C. P., aged thirty years ; married ten years ; four children, last four years ago. Menstruation had been regular. For the past four years had suffered from dysmenorrhoea and pain in the right side. Last normal menstruation in the middle of August, 1892. At the next men- strual period, September 15th, the flow was profuse and continued more or less until her admission to the hospital on November 1st. During these six weeks she suffered from abdominal pain, frequently severe in character, and from fever every afternoon and evening. No suspicion of pregnancy. On admission morning temperature averaged 99° ; evening

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temperature 101°. Uterus was enlarged and attached to its right side, and posterior to it Avas a tumor the size of a cocoanut. Diagnosis of probable extrauterine pregnancy.

Operation, November Mh. Ether. In a preliminary examination of the patient by bimanual palpation for diagnostic purposes the tumor was felt to rupture and disappear. This rupture confirmed the diagnosis, as but slight force had been employed. Patient placed in Trendelenburg position and the abdomen opened by a median incision. In the right broad ligament and escaping from it through a tear in its posterior wall were found fluid and clotted blood sufficient to fill a ten-ounce measure, and there were also shreds of tissue which afterward on microscopical examination Avere found to contain chorionic villi. The right Fallopian tube Avas enlarged and thickened, and Avith the ovary was removed. After careful sponging of the cavity the peritoneal caA^ty was irrigated with salt-solution, a strip of iodoform-gauze inserted for drainage, and the abdomen closed. Recovery Avas uncomplicated. The gauze was removed on the fifth day. The patient Avas out of bed on the twenty- fifth day and was discharged cured December 8th.

Case IV. — O. G., aged thirty years ; married ten years ; three chil- dren, last fifteen months ago. Menstruation had been regular and free from pain. Last normal menstruation in beginning of September, 1892. After skipping period about October 1st, she considered herself pregnant and Avas " treated " by a midwife, the result after the second local treat- ment being severe pelvic pain and a slight bloody vaginal discharge. This continued, together with a feeling of discomfort referred to the rectum, from October 15th until November 14, 1892, when she was ad- mitted to the hosj^ital. On examination a mass the size of an orange was found behind and to the left of the uterus. No tenderness on pal- pation. Diagnosis -pyosalpinx or extrauterine pregnancy.

Operation., November 15th. Ether. Median laparotomy. Mass was situated in left broad ligament, and was found to consist of a blood-clot and shreds of organized tissue. Left tube much enlarged and adherent to the sac, which, with the left tube and ovary, Avas removed. Abdomen irrigated and closed by suture, a strip of gauze being inserted for drain- age. The patient Avas out of bed at the middle of the fourth week and was discharged cured December 25th. Foetal villi found on microscop- ical examination.

Case V. — R. L, aged thirty-three years ; married ; five children ; three miscarriages. Menstruation regular and no complaint of pain until pres- ent illness. Last normal menstruation October 11, 1892. Skipped period in November ; breasts swollen ; suspected pregnancy. December 13th, severe cramp-like pains in right side, followed by expulsion of large clots from vagina. Patient remained in bed ; had fever, and floAV con- tinued. Admitted to the hospital December 19th, complaining of severe pain in right side; temperature 101.5° ; pulse 100. On examination a doughy, tender mass the size of a fist felt to the right of the uterus, which was immovable. Diagnosis — pyosalpinx or extrauterine pregnancy.

Operation, December 12th. Chloroform. Median laparotomy. Mass to right of uterus proved to be a distended Fallopian tube adherent to intestines and uterus. In separating it from the adhesions the tube rup- tured and gave exit to an ounce or two of dark grumous blood and some organized tissue, Avhich on microscopical examination was found to contain chorionic villi. Tube extirpated with ovary. Left tube found

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to contain a few drops of pus, also removed. A strip of iodoform-gauze inserted behind right broad ligament and brought out through abdom- inal wound, the remainder of which was closed. December 27th, gauze removed, rather foul. January 20th, patient out of bed. Sinus healed slowly and did not close until April 1st, but patient was discharged from hospital on February 10th.

Case VI. — R. Z., aged thirty years ; married six years ; one child ; seven miscarriages. Had been curetted several times. Four years before suffered from an attack of pelvic peritonitis, which followed a severe uterine hemorrhage. Since that time menstruation regular and no complaint of pain until present illness. August 15, 1893, another severe hemorrhage, and again followed by the use of the curette ; in bed for a few days, but back at work in a week. Felt comparatively well until September 12th, when she was seized with severe pain in right iliac region, followed by a chill, fever, and sweating. These symptoms con- tinued until September 80th, when she was admitted to the hospital ; temperature 101.5° ; pulse 114. Complained of pain and tenderness in right iliac region. Uterus retroverted and immovable. In right broad ligament a fluctuating tumor the size of a large orange ; a smallar oae on the left. Diagnosis — extrauterine pregnancy. October 1st to 10th, temperature ranged between 100° and 102°. From the 10th to the 17th it remained normal. From the 18th to the 26th it ranged between 99.5° and 100.5°. Constant pain in right side.

Operation, October 26th. Chloroform. Trendelenburg position. Me- dian laparotomy. To left of uterus a mass the size of a cocoanut found firmly adherent to uterus, to walls of pelvis, and to intestines, and Avhich apparently consisted of a distended broad ligament. Rupture occurred in separating the adhesions and eight ounces of offensive bloody fluid escaped. Left Fallopian tube enlarged, and, with the ovary, removed, two clamps being left on the pedicles. Cavity cleansed, packed with gauze, and abdominal wound partly closed. Considerable shock followed, but patient rapidly rallied. November 2d, packing removed ; convalescence unin- terrupted. November 20th, out of bed. December 2d, discharged cured.

Case VII. — E. B., aged twenty-three years ; married two years ; never pregnant. Menstruation always painful and rather irregular. Since marriage more or leps sense of discomfort in right inguinal region. During the spring and summer of 1893 continuous pain in this region. August, 1893, on examination I found a mass to right of uterus and adherent to it the size of a billiard-ball and very sensitive. Last regu- lar menstruation in end of July. September 15th, slight bloody vaginal discharge ; mass increasing in size. November 1st, pain more severe ; mass larger, very tender; occasional "flow;" breasts tender; some vomiting. Diagnosis of intra-ligamentous cyst, and operation advised. Patient losing flesh and strength rapidly ; no fever. For the next two weeks pain and tenderness increased and general condition worse. No further flow. Possibility of extrauterine pregnancy considered, but diagnosis inclined to tubercular salpingitis.

Operation, November 14, 1893. Chloroform. Trendelenburg pos- ture. Median laparotomy. To the right of uterus spongy mass the size of a goose-egg, consisting of Fallopian tube, ovary, and broad ligament, surrounded by firmly adherent intestines. With considerable difficulty and much hemorrhage entire mass extirpated piecemeal, as it was so

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brittle and so adherent. Many ligatures employed. Tampon of gauze placed in the cavity from which the tumor had been removed. Abdo- men partly closed. On examination mass consisted of enlarged and much-thickened tube, of part of broad ligament, and remains of foetal tissue. Considerable shock. Slow convalescence. Discharged December 17th, with deep, narrow sinus, which persisted for months.

Case VIII. — J. M., aged thirty-one years ; married ; three children ; one miscarriage ; last child three years ago ; miscarriage eleven months ago, followed by a curetting of uterus. With these exceptions no com- plaint of pelvic pain or history of disease in pelvic organs. Last regular menstruation January 10, 1894. Skipped period due on February 8th. Morning nausea and fulness of breasts. Considered herself pregnant. No pain and no flow until March 10th, when after a hard day's work felt severe colicky pain in right iliac region and noticed a slight show. Remained in bed twenty-four hours, when pain ceased, and again moved about the house, but complained of a sense of discomfort in the right side of pelvis. March 18th, another attack of pain, not very severe, and described as " tearing " in character; a slight bloody vaginal dis- charge accompanied the pain, and as these continued she consulted Dr. S. Graber, who made the diagnosis of extrauterine pregnancy and sent her into the hospital for operation. Admitted March 23d, tempera- ture 99.5° ; pulse 90 ; abdomen not distended and not tender except on deep pressure in right iliac region, where, on vaginal examination, was felt a boggy mass to the right of the uterus the size of an orange, and it seemed adherent.

Operation, March 2Mh. Chloroform. Trendelenburg position. Omen- tum adherent to fundus of uterus and to top of right broad ligament. Uterus enlarged, position good. In right broad ligament a semi-fluctu- ating mass the size of an orange, somewhat adherent to floor of pelvis and to small intestine. In endeavoring to enucleate this tumor it rup- tured and gave exit to an ounce or two of semi-solid blood and a small oblong solid mass of organized tissue, which was afterward found by the microscope to contain chorionic villi and remnants of a foetus. The sac consisted of the layers of the broad ligament, with an enlarged and rup- tured Fallopian tube forming the roof. The latter, with the ovary, was removed, the cavity carefully cleansed, the layers of the broad ligament sutured, and the abdomen closed. Convalescence uneventful. Out of bed on the twentieth day, and discharged cured on April 20th.

Case IX. — A. S., aged twenty-eight years ; married ten years ; never pregnant. Menstruation normal, slight pain. Eight years before, mild attack of pelvic peritonitis. Since then six or eight similar attacks, the last one a year ago. Last normal menstruation February 15, 1894. Skipped period in March and considered herself pregnant. April 10th, severe cramp-like abdominal pain, especially in left inguinal region, fol- lowed by slight " flow." The pain increased in severity, the abdomen became very sensitive, and the flow continued. On April 18th she was admitted to the hospital. Temperature 99 5° ; pulse 100. On exam- ination a doughy mass, sensitive to pressure, was felt behind the uterus, which was crowded forward and to the right. Abdomen slightly tym- panitic and tender. Diagnosis — probable extrauterine pregnancy.

Operation, April 20th. Choroform. Trendelenburg position. Median laparotomy. To the left of uterus and behind it a mass the size of a duck's egg, adherent to floor of pelvis and to intestines. In separating

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this a rupture took place and a blood-clot with some shreds of tissue escaped. The Fallopian tube was enlarged and adherent to the right wall and roof of the sac, which, with the tube and ovary, was removed. Several silk ligatures used. Cavity cleansed. Abdomen closed without drainage. Convalescence rapid. Out of bed on the twenty-first day, and discharged cured May 19th.

Case X. — M. B., aged thirty-five years ; married seven years ; one child five years ago. No miscarriages. Menstruation has always been regular. Has complained of no pain in pelvic organs until present illness. Last normal menstruation in the middle of February, 1894. At next menstrual period, March 15th, the flow was very profuse and continued for twenty-five days and was accompanied by dull pain. This was followed by a foul vaginal discharge which continued until May 1st, when she was seized with a uterine hemorrhage and was taken to a hospital, where for ten days she suffered from frequent vomiting, severe abdominal pain, and tympanites. On May 12tli there was sudden attack of severe pain in the right inguinal region, followed by vomiting and collapse. A foul vaginal discharge persisted, until June 1st, when, being somewhat improved, she was removed to her home. On July 9th she was admitted to the medical side of this hospital. Abdomen was swollen ; she vom- ited frequently and suffered from more or less constant abdominal pain. On July 17th she was transferred to the surgical division for operation. Abdomen much distended, giving on palpation a feeling of irregular bogginess, especially to the right of the median line, where in the lumbar region could be felt a hard mass which proved to be a foetus. Tempera- ture 100.5° ; pulse 100.

Operation. Chloroform. Abdomen opened by median incision. Omen- tum adhered to abdominal wall and to the agglutinated intestine beneath. On separating adhesion a large quantity of dark blood poured out, and the peritoneal cavity was found to contain an enormous quantity of blood, both in clots and fluid, certainly as much as could be contained in a two- quart measure. Clots were adherent to the intestines, and as they w^ere removed considerable bleeding followed. The mass which occupied the right half of the abdomen was a foetus, with its placenta apparently encysted among adherent intestines. The placenta was implanted partly on intestines and partly on the lower border of the liver. The head of the foetus was pressed against the under surface of the liver. The hem- orrhage following the separation of the agglutinated intestines was severe. The live foetus was rapidly removed and the cord clamped. As there was no sign of cessation of the hemorrhage, which was venous and seemed to issue from all parts of the sac, the placenta was rapidly separated from its attachments and removed. This was accompanied by a tremendous hemorrhage, which was controlled by strong compression with gauze-pads, and by a few clamps which grasped the large veins. The right tube, enlarged and thickened, was removed. The abdomen w^as irrigated with hot water. Numerous gauze-strips were used as packing to control the bleeding, with the ends projecting through the abdominal wound, which was then partly closed. The loss of blood had been excessive and the shock was profound, but the patient rallied well, and at the end of forty- eight hours was in fairly good condition. The gauze was removed on the fifth day and the patient was out of bed at the end of the fourth week, and was discharged cured September 9th. The foetus moved and breathed vigorously ; it was apparently about six and one-half months old. The

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head was deformed and both legs were crooked. It was not placed in an incubator, and died at the end of a few hours.

Case XI. — K. K., aged thirty-two years ; married eleven years. Never pregnant. With exception of an attack of pelvic pain five years before, no complaint of uterine or ovarian trouble until present illness. Last normal menstruation July 8, 1895. July 15th, seized with severe pain in pelvis which continued for two days. August 6th, bloody vaginal discharge for six days, accompanied by slight pain. August 20th, attack of severe pain and return of " flow." Pain and flow continued more or less constantly until her admission to hospital on September 12th. Pain described as cramp-like, mainly on right side. Temperature 100° to 100.5° ; pulse 80 to 100. On examination moderate abdominal dis- tention and a boggy, ill-defined mass was felt extending out of pelvis well above its brim and as high as the right anterior superior spine of ilium. Diagnosis — probable extrauterine pregnancy. Immediate oper- ation advised, but refused. During following five days evening temper- ature ranged between 100° and 101° ; pulse 100 to 120.

Operation, September 17th. Ether. Trendelenburg position. Median laparotomy. Intestines agglutinated to each other and to the mass, which, the size of an orange, occupied the right iliac fossa, and was attached to uterus and floor of pelvis, and apparently consisted of a dis- tended broad ligament to which were adherent an enlarged tube and right ovary. Sac ruptured ; an ounce or two of bloody fluid escaped. Tube and ovary removed. Cavity cleansed and in it was placed a gauze-strip, the other end projecting through abdominal wound, the remainder of which was closed by suture. Convalescence uneventful. Gauze removed September 21st. Patient out of bed October 16th. Discharged cured October 26th.

Report of Dr. Thacher, pathologist, states : ' ' The Fallopian tube presents a dilatation one inch in diameter near its centre. This sac has ruptured and is filled with a solid blood-clot. Microscopical examina- tion : Villi of the chorion."

Case XII. — D. S., aged thirty-seven years ; married ; three children. Last normal menstruation September 6, 1895, after which no sign of bloody vaginal discharge until the day of her admission to hospital, No- vember 6, 1895. On October 25th she was seized with a severe attack of abdominal pain, chiefly located in the left iliac fossa, which was followed by leucorrhoea. On October 30th another sudden attack of pain, fol- lowed by syncope and vomiting. Great prostration and some abdominal pain and distention foUow^ed and continued until the morning of Novem- ber 6th, when she was seized with a third attack, in which the pain was agonizing, the patient losing consciousness and continuing in a condition of collapse until her admission to the hospital in the evening of that day. In the ambulance during transfer to hospital she had several attacks of syncope in spite of active stimulation. On admission her radial pulse was almost imperceptible. Abdomen considerably distended and tender. By vagina the pelvis was found filled with a boggy mass. Diagnosis — ruptured ectopic gestation. Collapse, however, was so great that opera- tion was for the present out of the question, as she would surely have died on the operating-table. During the night she rallied somewhat and on the next afternoon her condition was such that a laparotomy was deemed justifiable, as further delay probably meant a fresh hemorrhage. Under ether-ansesthesia in Trendelenburg position, the abdomen was

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rapidly opened. As soon as the peritoneum was nicked a spout of dark fluid blood spurted out, and on enlarging the opening it was found that the abdominal cavity was full of blood, both fluid and in clots. Two quarts at least of fluid blood were washed out and clots were removed in handfuls, certainly enough to fill another quart measure. After the greater bulk of blood had been removed patient was placed in Trende- lenburg position, and to the left of the uterus was seen a mass as large as a small orange, consisting of an enlarged Fallopian tube, with a rup- ture in its wall, and a thin, semi-transparent empty sac, also ruptured. These were removed and clamps left on the pedicles. Peritoneal cavity washed out with gallons of hot salt-solution. Irrigation could, however, not be continued until the fluid ran out clear on account of the patient's condition. Gauze was packed into the left iliac fossa and a large glass drainage-tube placed in the pelvis, and the wound partially closed. The shock of the operation was great, but the patient rallied and on the fol- lowing day was in fair condition, with a pulse of 140. There was a pro- fuse discharge of bloody fluid through the tube. Temperature 99° to 101°.

JSfover)iber Sth. Temperature 100^ to 101° ; pulse 135 to 140. Free discharge of bloody serum Patient looks septic.

9th. Temperature 100° to 101.5^; pulse 130. Gauze-packing removed. Some vomiting.

10th. Temperature 100.5° to 102° ; pulse 140. Several movements of bowels. Abdomen less distended.

nth. Temperature 100° to 102° ; pulse 140. Patient weaker. No vomiting. Bowels moved.

12th. Died. Cause, exhaustion and saprsemia.

The pathologist reported foetal villi in the specimens removed.

Case XIII. — M. C., aged twenty-six years , married seven years ; no children. One miscarriage at second month, three years ago, after which uterus was curetted. Since then regular menstruation and 'freedom from pain until present illness. Last normal menstruation August 15, 1895. At the time of next period, September 13th, sudden profuse hemorrhage lasting a day or two, and since then more or less constant bloody vaginal discharge. Cramp-like pains in the pelvis and occasional vomiting, which continued until her admission to the hospital on October 21st, when the temperature was 99.5° and pulse 120. Abdomen distended and very tender. Mass felt most prominent on the right side, extending out of the pelvis nearly as high as the umbilicus. Diagnosis — either extrauterine pregnancy or an abscess.

Operation,, October 22d. Chloroform. Median laparotomy. Tren- delenburg position. Bladder found adherent to the anterior surface of the tumor and to the agglutinated intestines as high up as the umbilicus. A catheter had been passed previously to the operation, but there remained more than a pint of urine in the bladder, which was opened before it could be separated from the nuiss, which separation was accomplished with considerable difficulty. Tumor as large as a cocoanut found to right of uterus, firmly adherent to broad ligament and to neighboring intestines. In separating this the sac ruptured and about eight ounces of bloody purulent-looking fluid escaped. Right Fallopian tube ad- herent to the sac and nnich enhirge(l,au(l near its centre was an old tear. It, with the ovary, was removed. On a loop of small intestine which had foriued part of the sac-wall was a crater-like spot as large as a

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silver dollar, evidently the site of the placenta. Cavity sponged out, a strip of gauze packed into it and the end brought out through abdom- inal wound, which with this exception was closed. Patient suffered from considerable shock, but rallied well. Gauze removed on fifth day, and a fecal discharge indicated the existence of a fistula, most probably from a slough at the site of the placenta. With this exception recovery was uninterrupted. Fistula rapidly contracted. Fecal material ceased to pass on November 25th. Patient out of bed December 2d. Dis- charged cured December 14th.

Case XIV. — L. M., aged thirty-seven years ; married ; four children ; one miscarriage. Last child two years ago. Menstruation had been regular and painless. No special complaint of pelvic pain until present illness. Last normal menstruation September 16, 1895. October 1st, complained for a few days of pain in left iliac fossa, not severe. Skipped menstruation which was due on October 14th. November 12th, after a slight fall felt severe cramp-like pains in left iliac region, and twenty- four hours later there was a sudden gush of blood from vagina. The pain continued for several days, and there was occasional vomiting. She suspected that she might be pregnant. November 13th, another attack of severe pain accompanied by a " fiow," which latter continued more or less constantly until her admission to the hospital ( n December 13th. The pain continued for a few days, and afterward she was com- paratively comfortable until December 7th, when she was again seized with severe pain and pregnant- vomiting. This continued until Decem- ber 12th, when she was seen by Dr. Forbes Hawkes, who made the diag- nosis of probable extrauterine foetation which had ruptured, and he advised immediate operation. Temperature 101.5° ; pulse 110. Ou admission, December 13th, temperature 100° ; pulse 98. On examina- tion a boggy mass was felt in Douglas's pouch about the size of a foetal head. Just above and under the symphysis a solid mass the size of a hen's egg. Diagnosis — extrauterine fetation which had ruptured into abdominal cavity.

Operation, December VMh. Ether. Trendelenburg position. Median laparotomy. On opening peritoneum considerable blood, both fluid and clots, found in its cavity. Omentum adherent to pelvic mass, easily separated. In median line under symphysis pubis and projecting toward the left side, a firm tumor the size and shape of a short, thick sausage. To its left, apparently on top of broad ligament, a thin sac the size of a hen's egg Uterus pushed over to right side of pelvis. In Douglas's pouch, surrounded by adherent intestines, a soft mass the size of two fists. The sausage-shaped tumor above the symphysis found to be a distended Fallopian tube (left). It was removed, two clamps being placed on ped- icle. During this extirpation the sac to the left ruptured and an ounce or more of bloody fluid escaped. This sac apparently consisted of a distended portion of the left broad ligament and was afterward removed. The mass in Douglas's pouch consisted of black blood-clots enclosed in a fragile sac, through the wall of which some leakage had apparently occurred. The clots were scooped out by the hands. The table was then lowered and the abdominal cavity irrigated with gallons of hot salt- solution until it ran out comparatively clear. A large amount of blood was thus washed out. The pelvis was again elevated, the pedicle and a few bleeding points in broad ligament and omentum ligatured with catgut, one clamp remaining. A strip of gauze was packed^into Douglas's

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pouch and brought out through the abdominal wound, the upper half of which was closed by suture. On opening the tube it was found to be distended with a firm mass of clotted blood. The distal end was open and led into a cavity about the size and shape of the last two joints of one's index-finger, the walls of which were composed of solid blood-clots. Considerable shock followed, and on the following day condition of patient was serious. Temperature 103° ; pulse 130. Frequent vomiting.

December 15th. Temperature 102 ^° ; pulse 120.

December IQth. Temperature 10H° ; pulse 110. Gauze removed.

Convalescence uneventful. Out of bed January 12th. Discharged cured January 27th.

Case XV. — A. B., aged thirty-nine years ; married ; two children ; no miscarriages. Menstruation had been regular and painless, and no com- plaint of pelvic pain until present illness. Last regular menstruation December 20, 1895. Menstruation in January probably skipped. Feb- ruary 21st, menstrual flow appeared. February 22d, while sitting on a privy-seat was suddenly seized with severe abdominal cramps and vomit- ing, accompanied by profuse vaginal hemorrhage. Abdomen became swol- len and tender, and cramps continued. There was some evening tempera- ture, and vomiting was frequent. The vomiting, pain, and distention increased until March 26th, when she was seen by Dr. J. C. Jay, who made a diagnosis of peritonitis. I saw her on the same day, and we de- cided that her condition would not justify an operation. Vomiting was constant ; pulse 130 ; temperature 103° ; no movement of bowels for five days. Probable diagnosis — ruptured extrauterine foetation. Abdomen very sensitive, but by vaginal examination could be felt a boggy mass filling the pelvis and extending upward to near the umbilicus. Under Dr. Jay's care gradual improvement until April 25th, when he deemed a laparatomy justifiable. The mass extended well out of the pelvis and on the right side above the anterior superior spine of ilium. Pulse 110 ; temperature 100° to 100^°; stomach very irritable.

Operation. Chloroform. Median incision below umbilicus. Peri- toneum incised superior to mass, which was shut off" from general peri- toneal cavity by adherent intestines, and was adherent to anterior abdominal wall. Perixoneum closed by suture, and incision extended downward. Bladder adherent to anterior surface of tumor, pushed downward. Under peritoneum blackish-green mass. Peritoneum opened and large quantity of dark blood, fluid and in clots, poured out. Hand scooped out clots and a three months' foetus, with cord and placenta, which was easily separated. Total amount more than two quarts. The cavity, the roof of which was formed of agglutinated intestines, was irrigated and drained with tube and gauze. During the first week there was much vomiting and development of urinary suprapubic fistula. Otherwise convalescence was uneventful. Discharged cured June 16th.

170 STEWART, SALINGER: TREATMENT OF ANEURISM.

ON THE TREATMENT OF ANEURISM BY ELECTROLYSIS THROUGH INTRODUCED WIRE: REPORT OF A SUCCESSFUL CASE.

By D. D. Stewart, M.D.,

OF PHILADELPHIA,

PROFESSOR OF DISEASES OF THE STOMACH AND INTESTINE IN THE PHILADELPHIA POLYCLINIC ; PHYSICIAN TO THE EPISCOPAL HOSPITAL ;

AND

J. L. Salinger, M.D.,

OF PHILADELPHIA,

CHIEF OF THE MEDICAL CLINIC AT THE JEFFERSON MEDICAL COLLEGE HOSPITAL ; PHYSICIAN TO THE PHILADELPHIA HOSPITAL.

In a paper by one of us (Stewart) recently^ the unquestionable advan- tage of combining electrolysis with the introduction of wire, in the treatment of sacculated aneurism not susceptible of cure by medical treatment or by time-honored surgical means, was fully set forth. It was remarked as evident that the employment of galvano-puncture alone, however perfect the technique, had beyond doubt proved a failure in the therapy of aneurism. The introduction into the sac of filiform material, but especially of wire (Moore's operation), was shown to offer much to recommend it. The literature of the subject was then carefully surveyed in the paper, and individual cases in which wire had been used were analyzed. The conclusion seemed apparent that, given a proper subject, Avith proper technique, little risk attended the method and much promise of benefit. It was pointed out that failure in several of the cases reported lay in the direction of improper technique, such as the use of too great a quantity of wire,^ and to the occurrence of septic complications, as in Moore's case.^ These, present knowledge would lead us to avoid. The fact that in most of the cases the operation was un- dertaken as a forlorn hope, with the aneurism on the point of rupture, had also to be borne in mind, for it was apparent in nearly all of the fatal cases that any other issue was scarcely to be expected. As con- cerns result, Loreta's case and Morse's* plainly showed the great prom- ise of the method when other conditions were also propitious for cure.

1 The Treatment of Sacculated Aortic Aneurism by Electrolysis through Introduced Wire. American Journal of the Medical Sciences, October, 1892. - In Moore's case 108 feet of wire were introduced, and in Cayley's, 75 feet.

3 Death here occurred from pyaemia.

4 lu Loreta's case an abdominal aneurism, the size of a foetal head at term, contracted to the dimensions of a walnut, with obliteration of the sac-cavity, by the seventieth day after the introduction of two yards of silvered copper wire. Death resulted subsequently from rupture of the aorta below the sac. In Morse's case it is stated that eight weeks after the insertion of one and a half yards of one-half millimetre silver-plated copper wire into the sac of an abdom- inal aneurism the size of two fists, all indications of aneurism had disappeared, a hard nodule replacing the pulsating tumors. The patient remained well.

STEWART, SALINGER: TREATMENT OF ANEURISM. 171

Electrolysis combined with the introduction of wire, by which a strong galvanic current is conducted through coils of the same filling the sac, was shown to be an incomparably superior method of promoting prompt coagulation to the use of wire alone. Apart from the harmless- ness of the procedure, its advantages over the use of wire without elec- trolysis consisted in that " instead of a soft, unstable coagulum about the wire, tardy in appearing, there may be produced almost immediately a tough clot, which, in favorable cases, should tend by accretion to pro- duce prompt obliteration of the sac-cavity." Over mere galvano-punc- ture the superiority lay, as w^as remarked, in that in the former, if the wire were properly disposed, a firm coagulum, perhaps completely filling the sac, might be expected to occur promptly, instead of a few small nodules at the periphery which would have little effect upon a large mass of circulating blood.

The seven cases then on record were analyzed and a new one reported. It was shown that these scarcely bore collective review. Burresi-Corradi's case — a thin-walled, rapidly growing aneurism — had been regarded as utterly hopeless for any treatment prior to operation, as were those of Barwell, Roosevelt, Abbe, and my own. In another of the seven the sac was fusiform in character, and not, as remarked, suitable for the application of the method. In several the technique employed was most faulty. Far too much wire was used in two than could have been productive of ultimate good.^ The current-strength and the polarity employed in several were not mentioned. In these it seemed likely that the former was insufficient and the second scarcely the best. In Abbe's case, which had been regarded as utterly hopeless prior to operation, it was still unfortunate that a beneficial current of 50 milliamperes anode for a half hour should have been succeeded by one calculated to soften rapidly and 'separate the clot so induced — 100 milliamperes cathode the second half hour. On individual study of these cases it appeared obviously unfair to hold that the operation was of slight promise be- cause of the seven cases but two were cured. From the evidence these two were the only ones susceptible of cure.

In the senior writer's case the aneurism was of enormous size, showing advanced pressure-symptoms. A large part of the sac-boundary con- sisted no longer of arterial tunics, but of eroded ribs and vertebrse, and in the situation of the bodies of several of the last which had been largely absorbed lay spinal cord protected only by its membranes and by clot. In this case the operation had been attempted rather as a means of euthanasia than with idea of cure. Intense suffering from nerve- and bone-pressure rendering constant use of anodynes necessary

1 In Roosevelt's, 225 feet of wire were introduced ; in Abbe's, 150 feet, nine days after the insertion of 100 feet of catgut.

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172 STEWART, SALINGER: TREATMENT OF ANEURISM.

was hoped to be obviated for a time through the formation of support- ing coagula. This case proved fatal on the ninth day succeeding opera- tion, an indiscretion on the part of the patient causing rupture of the sac in a section of the aneurism some distance from the wire or the clots that engaged it. The enormous size of the sac had precluded the possi- bility of complete solidification by clot. In this case, as with all of the others in which the conditions were at least moderately favorable for clot-formation, decided evidences of this were evident soon after opera- tion. A necropsy, when obtained, strikingly demonstrated the value of the method.

It has since been Dr. Stewart's good fortune, through the kindness of his collaborator, to repeat this procedure. In the present case, here re- ported, there was a large and rapidly increasing innominate aneurism. Its anterior surface was unprotected by clot, and indications of early rup- ture were very evident. The patient's condition was most unfavorable otherwise. He was an inmate of Blockley ; had been for years of dissi- pated habits and had had syphilis. There were evidences of advanced nephritis, of greatly enlarged heart and of badly damaged aortic leaflets. Blood-pressure was persistently high and utterly uninfluenced by large doses of potassium iodide.

Although an absolute cure^ was here scarcely to be expected for these reasons, the result obtained well illustrates the usefulness of the method in promoting clot-formation, its innocuousness, and the benefit which may accrue in a case the duration of the life of which was then regarded as ephemeral. The patient after a few weeks in bed has since steadily been about. The aneurism, although still somewhat prominent and pulsating, can be handled with impunity. It causes no obvious pressure- symptoms.

History of the Case, by Dr. Salinger.

G. D., aged forty years ; white male. Syphilis in 1881. Very severe attack of acute articular rheumatism in 1887. A heavy drinker since early manhood. For a number of years worked in lead, but no history is obtainable of plumbic poisoning. Has been a stonemason lately. This occupation necessitates great physical strain. Had a bad fall (from the second story of a house) in December, 1891. Was injured about the body and extremities. States that he also bruised the right side of the chest in the situation at which the aneurism developed a year later. In December, 1892, severe pain was first felt in the neck on both sides, but especially on the right. Paroxysmal cough, and slight, although continuous dyspnoea, also appeared. In April, 1893, he first noticed a swelling below and to the right of the right sterno-clavicular junction. This steadily increased in size. Admitted to the writer's wards, Phila- delphia Hospital, June 23, 1893. The following was then also noted : Patient had dissipated appearance, suggesting a heavy drinker. Face

1 A cure as concerns complete obliteration of sac.

STEWART, SALINGER: TREATMENT OF ANEURISM. 173

swollen, cheeks flushed, conjunctivae injected. Dilated venules on face and upper extremities. Right pupil smaller than the left. Chest fairly well developed, Aneurismal swelling extends from the middle of right clavicle to left sterno-clavicular junction and from upper border of the second rib to two inches above clavicle. The prominence is four inches in vertical direction, four inches in transverse, and three-quarters of an inch above the level of the sternum. Dulness appears at the centre of the right clavicle. Transverse measurement of dulness seven and three- quarters inches. Tumor in shape that of segment of circle, curve down- ward, with radius three and a half inches. Expansile pulsation over all parts of tumor. Thrill and bruit present and transmitted into carotids.

Heart : Apex-beat diffused ; pulsation visible over large area ; to pal- pation most apparent in sixth interspace, a half inch outside mamillary line. Marked double aortic murmur, the diastolic part of which is transmitted to apex. Typical water-hammer pulse absent. Little differ- ence noted in the two pulses by finger or sphygmograph. Aneurismal character absent. Both pulses at times anacrotic, the left rather than the right shows tendency to complete obliteration of dicrotic wave, so common in aortic regurgitation. Both have usually great altitude of percussion-wave. Laryngeal examination negative. Patient has con- siderable cough, both dry and attended with expectoration. Sputum examination for tubercle bacilli and elastic tissue negative. Upper part light chest shows poor expansion, vesiculo-bronchial breathing, slightly impaired resonance. Blood-spitting occurs. Urine contains much albumin.

Patient placed on potassium iodide in ascending doses. Tuffnell's treatment was also adopted. Despite this aneurism rapidly increased in size. Rupture externally seemed imminent. Outlook apparently hope- less. Interference by deligation on the part of the surgeon on duty refused. Dr. Stewart invited to see the case with a view to treatment by his method of electrolysis through introduced wire.

History of the Operative Procedure, by Dr. Stewart.

I concluded in this case to adopt practically the same technique as in the other case detailed in my first paper. In this instance, however, in which apparently better ultimate results might be expected, I choose for in- sertion, by preference, a finer wire. In my first case, as I have elsewhere remarked, ' ' I concluded a better chance of immediate success lay in the introduction of wire of sufficient calibre to form large, supporting spirals in the sac, thus occupying considerable of its cavity, and affording a frame- work for clot, than in the use of a thinner, more pliant wire, which, though better calculated to permit of ultimate contraction of organized fibrin and sac-walls — apparently not to be hoped for here — might undergo deflection from its course in introduction through impingement on loose coagula already in the sac, thus perhaps rendering it necessary to repeat the process, which from the patient's enfeebled condition would have been impracticable." In the present case, with a much smaller sac, and one less likely to contain interfering clot, the interior of which, on all sides, could be reached by a few feet of properly drawn spirals, the ideal wire was one of as small a calibre as would, while maintaining its spiral shape, subsequently admit of coincident contraction with the large enveloping coagulum to be formed under the current's influence.

174 STEWART, SALINGER: TREATMENT OF ANEURISM.

I had at first intended employing silver wire ; but as difficulty then existed in obtaining it sufficiently firm of a suitable fineness, after con- sulting with Mr. Otto Flemming, I concluded to resort to gold wire, which latter seemed to meet better the indications. The chief objection to the use of gold wire, we agreed, lay in the fact that a greater strength of current was necessary to promote roughening of its surface, to induce the prompt coagulation about it desired. Iron wire was impracticable and even dangerous for use for the reasons fully cited in my paper, based on very convincing experiment. The wire w^as drawn hard to No. 30 gauge and so wound that when finally passed through the needle it formed separate spirals of moderate dimensions.

The procedure was carried out on July 27, 1893. Strict antisepsis was, of course, adopted. As in the other case, I determined upon the con- joint use of galvano-puncture, by means of several needles connected with the same rheophore as the wire, hoping thus better to secure an extensive coagulum from wire to needles and to sac-wall.^ Two plati- num needles of good calibre were first introduced toward the periphery of the sac. These were well insulated at their base to protect the skin. More than an inch penetrating into the aneurism was left uninsulated. About this from the wire to the sac-wall it was desired to promote clot- ting under the current's influence. One of the two needles after intro- duction could be freely moved about in the sac. Upheld after insertion it fell from the perpendicular to a horizontal position, showing how thin was the sac-wall in this position and that no supporting clot lay beneath it. The other, introduced at another point at the periphery several inches from the first, seemed less free, so that after a time it was with- drawn, blood flowing freely from the site of puncture. The receiving canulated needle was of as small a calibre as would admit the passage of the wire, and was insulated to its tip. This I introduced into the most prominent and central portion of the sac, at a point so thin-walled that blood spurted through the needle when penetrated to a depth of but a fifth of an inch. Blood continued to flow between canula and wire until the current was closed. Ten feet of wire were now sloivly passed into the sac and the points of contact connected by the anode. A large clay plate forming the indifferent electrode, was placed upon the abdo- men. Its position was changed from time to time without breaking the circuit. The current was, of course, controlled by a rheostat. The elec- trical outfit contributed by Mr. Flemming was in his care. The cuirent was passed without interruption for seventy-five minutes. It was grad- ually increased to 30 milliamperes in one minute to 65 milliamperes in five minutes ; to 75 milliamperes in ten minutes and 80 milliamperes in fifteen minutes, and maintained steadily at the latter point for one and a quarter hours. Both of the needles, which from their weight (the weight of the wire in the canulated one) tended to lay horizontal to the sac-wall unless upheld as they w^ere, at the expiration of half an hour remained perpendicular without assistance, showing well the wonderful clot-forming power of this strength of current through the anode. To- ward the end of the procedure it was generally remarked by all present that pulsation had quite markedly lessened over a large part of the sac. The patient was carefully watched by Dr. Salinger and myself during

1 See my paper in The American Journal of the Medical Sciences, October, 1892, p. 432,

STEWART, SALINGER: TREATMENT OF ANEURISM. 175

the operation. The procedure was well borne. No pain was felt at any time during it or subsequently, and there was no evidence of shock.

Subsequent History and Remarks. An Account of a Second Attempt at Introduction of Wire which Demonstrated Clot-formation.

Slight oozing recurred from the site of one of the punctures for a few days subsequent to operation. It was controlled by iodoform collodion and the application of ice. Pulsation in the sac steadily diminished, and showed little of an expansive character by the end of the second day. Thrill, too, was then noted to have largely disappeared. The patient complained only of stilfness in the neck, caused by lying so long- in one position. He swallowed fairly well. Respirations at first were stridu- lous, but later became normal. No elevation of temperature occurred. All who had followed the case noticed the decided lessening in pulsation in the sac, especially its lower half, through which the wire had been passed, and which previously had shown the most expansile movement. Potassium iodide was repeated after a time. It was thus hoped to assist in clot-formation through influence on blood-pressure. Later, for short periods, we also used calcium chloride in small doses, after Wright's method, measuring its effects upon blood-coagulability by the latter's apparatus. Little benefit was obtained from it ; we found that even in small doses its effect early was to delay the onset of coagulation after ephemerally having had the opposite effect.

At the expiration of three weeks, although we agreed that the lower half of the aneurism had unquestionably diminished in size, become firm and no longer showed expansile pulsation, so marked a change in the upper portion was not apparent. It was evident that clot-formation had been induced, although its extent seemed limited. The patient's bad physical condition, from the arterial wall-changes evident, the dam- aged heart, and very incompetent kidneys, did not render the outlook promising. Blood-pressure was constantly abnormally high, and rupture in the upper segment of the sac seemed still to be feared for a reason men- tioned by Dr. Stewart in his first paper' as the probable immediate cause of death in a certain number of cases in which filiform material was introduced, irrespective of any direct danger from injury by the