capsule take place; and the fluid, whether synovia, pus, or plastic lymph, becomes effused into the surrounding tissues, burrowing in various directions, and forming femoral abscesses. The peculiar change that takes place in many instances, upon the rupture of the capsule, in all the symptoms, and the suddenness of the occurrence, have led to the false idea that a luxation had taken place. When the capsule is thus ruptured, if no attachments have already occurred, the limb becomes apparently shorter, adducted, inverted, flexed in hip only, pelvis raised and projected backwards. In fact, the position is almost the reverse of what it was in the second stage. This change from the second to the third stage is sudden when the opening in the capsule is large, and allows of the rapid and total escape of its contents into the surrounding tissues; and gradual, if the opening is small and fissure-like. I have seen the former take place in a night, and the latter require weeks to accomplish the change. There are extreme cases, in which this change may not take place, although the effusion may have escaped from the joint. Such cases are those in which the head of the femur has broken through the acetabulum, by which it is held firmly in its place. I will take the trouble, even at the expense of being considered tautological, of arranging side by side, for more easy reference, the symptoms of the two last stages of the disease.

Nates low and flat.
Linea inter nates inclined to-

wards affected side.

Pain most intense.

Nates high and round. Linea inter nates deviates from affected side. Pain greatly diminished. Diagnosis-Morbus coxarius may be confounded with sacro-iliac disease. In the first and second stages of coxalgia we may have elongation of the limb; this always occurs in sacro-iliac disease; but in coxalgia the elongation is discovered by measurement from the anterior-superior spinous process of the ilium, to the internal malleolus, the elongation being caused by effusion into the hip-joint. If the disease is between the sacrum and ilium, this measurement between the malleoli and superior spines of either side will be equal, and the elongation will be found to be dependent on the displacement of the diseased ilium itself, which is tilted forwards, and rotated or slipped downwards, owing to the swelling and destruction in the affected articulation. The anterior spine is not only lower down than its fellow of the opposite side, but is pushed forward, and is much more prominent; and this is not produced by any obliquity of the pelvis consequent on a twist of the spine, as in hip disease, but by the tilting forwards and rotation downwards of the whole of the diseased side of the pelvis. The seat of pain is also different in the two diseases. hip disease it is most acute when pressure is applied firmly above and behind the trochanter major, or when compression is exercised against the anterior part of the hip-joint through the pectineus muscle. In sacro-iliac disease little or no pain is experienced when pressure is made in these situations; but tenderness is elicited by pressure upon the sacrum, and along the line of the sacro-iliac synchondrosis, behind and altogether away from the hip-joint. The movements also which occasion pain in the two diseases are entirely different. In hip disease, abduction or rotation outwards aggravates to a greater or less degree, often to an

In

intolerable extent, the sufferings of the patient; but in sacro-iliac disease the thigh may be moved in all directions, abducted, adducted, rotated, flexed, or extended, when the patient is on his back, without any increase of pain, provided the side of the pelvis be immovably fixed by an assistant at the time. Should this precaution of holding the pelvis immovable not be observed, the movements of the thigh will be communicated to the diseased articulation of the ilium and sacrum, and necessarily occasion suffering.

For a differential diagnosis of most of the other diseases with which morbus coxarius may be confounded, and which are too numerous to be mentioned at this time, I will refer you to my forthcoming report on "morbus coxarius," which contains an elaborate collection of such diseases, in a convenient, tabulated form.

Treatment-Until within the last few years, little had been done by surgeons in the treatment of this disease. It was customary to leave it to the vis medicatrix naturæ, a force that was sometimes found so conservative as to save the life of the patient, preserving for him a withered, malformed, anchylosed limb, specimens of which we have doubtless all seen. It was an opinion entertained by some surgeons of respectable position, that if the bones of the joint are involved in caries, there is little or no hope for the patient. Even so high an authority as Mr. Syme, asserted that if the head of the femur be carious (which implied, in his estimation, a carious condition necessarily of the acetaBut it affords me great bulum), the patient must die! pleasure, gentlemen, to be able to-day to disprove in the most unanswerable manner, that broad assertion of Mr. Syme. And this pleasure does not arise from a consideration of being able to point out the errors and refute the statements of so deservedly great a man as Mr. Syme, but rather from the fact that I am able to give you such tangible, such cheering evidence of the progress of conservative surgery.

Treatment in First Stage.-In the treatment of this disease in its first stage, local depletion by cups or leeches is often necessary, with a relaxed condition of the bowels. But the most important of all, and on which all prospect of success will depend, is rest of the joint and perfect freedom from pressure of the inflamed synovial surfaces, together with such constitutional remedies and general support of the system as may be requisite in each particular case. Having subdued the inflammation in the joint by the means indicated, the child is placed in bed and subjected to the effect of extension in the manner in which I shall point out. Two pieces of strong adhesive straps are placed along the sides of the limb for nearly its whole length. These straps are held firmly in place by two additional straps going spirally around the limb, and a roller bandage extending from the toes to the pelvis. To the lower end of these lateral straps are sewed two pieces of narrow webbing, which are united below the foot. To this webbing is attached a cord running over a small pulley at the foot of the bed, and supporting a weight of from four to ten pounds. The weight at the foot of the bed acts as the extending, and the body of the child as the counter-extending force. And in this manner, pressure is entirely removed from the inflamed articular surfaces. This mode of extension is employed during the night only; during the day the child wears a splint, which is so constructed as to effect both extension and counter-extension, and at the same time allow the patient to take exercise in the open air.

The first person to construct a splint embracing these principles was Dr. Davis, of this city, which splint I here show you. It consists, as you see, of a steel bar extending from the crest of the ilium to near the ankle, with a hinge joint near its lower extremity, at its upper extremity having an eye through which plays a catgut, that is secured to the perineal band, thus making the counter-extension. The plaster before described, terminating in the webbing, is secured to the buckle at the lower extremity of the instrument, while bent at an angle. The instrument is then straightened at the hinge joint, by which means the exten

sion is produced, and locked, by means of a slide, which retains it in this position. The objections to Dr. Davis's splint are, the extension is not made until the instrument is brought perfectly straight, when it may be so severe as to produce excoriation of the groin, or not of sufficient power to relieve the joint from pressure. I have therefore constructed an instrument embracing the same principles, but the power is applied either by a screw, or a ratchet and cog wheel, by means of which extension may be graduated with much greater facility, by simply turning a screw, and can be increased or diminished, according to the requirements in the case, without removing the instrument. In addition to this, the pulley and ball and socket placed at the upper extremity of my instrument afford greater facility for motion, without destroying the cord playing through it. The perineal band is a strong India-rubber tubular cushion, and therefore not so likely to excoriate the parts as the flat webbing of Dr. Davis's instrument. As to the relative merits of the two instruments, it is not for me to judge; the profession will of course select according to their particular preferences. I deem these remarks necessary in order that the profession may not confound the two instruments, as they would be led to do by the remarks of Dr. A. C. Post, made in his clinical lecture, and contained in the Medical Times of December 15th, in which he says, "some modifications and improvements have been made in this splint (referring to Davis's) by Dr. L. A. Sayre, and among some it is known as Sayre's splint; " thereby confounding the one instrument with the other, and thus misleading the profession. I have therefore taken this opportunity of showing you the two instruments, in order that you may observe the essential differences between them, by which you will see that they are two perfectly distinct instruments, although both intended to accomplish the same object. I simply request that you will not confound the one with the other, as I have never made any claim to Dr. Davis's instrument.

[Dr. Sayre then exhibited one of his own splints, as well as one of Dr. Davis's, and showed the method of their application and working.

A diagram of the two instruments is here shown.]

have just shown you. The principle of extension and counter-extension embraced in it is identical with that of the original splint, with this improvement, that the extension is made from above the knee instead of below it, leaving the motion of the knee-joint entirely free. This is accomplishing a desirable object, and I now employ this instrument in every instance where it can be used. There are cases, however, in which it cannot be used, as for instance in a very young child whose thigh is too short to afford sufficient surface for the attachment of adhesive plaster: nor can it be used in a case where fistulous openings are so numerous and so situated as to present the same obstacle, In these cases the original long splint is employed.

Treatment in the Second Stage.-The treatment in this stage of the disease must depend upon the condition of the joint. If the disease is of a subacute character, and the quantity of effusion small, the treatment that has been advised for the first stage may prove entirely successful in the second.

To facilitate the absorption of the effused matter, it is often advisable to strap the joint firmly with adhesive plaster..

But if the inflammation is acute, the effusion abundant, the malposition of the parts extensive, and pain excessive, the prompt removal of the morbid contents from the joints for the division of the contracted muscles becomes absolutely necessary, and never fails to afford immediate relief of all the most prominent symptoms, and to restore_rest and comfort to the patient. In fact, it is the only anodyne that will assuage the pain. There are two ways of performing this operation, viz. puncture with the trocar, and free incision with the knife. If the effusion is serous, the former method is advised; if it is purulent, which may generally be determined from constitutional symptoms, the latter mode is preferable. After the contents of the joint are evacuated, the patient is placed in Dr. Bauer's "wire breeches" (for a diagram of which see my report), and treated antiphlogistically. When the inflammation is subdued and the parts healed, he is again subjected to the force of the extending weight at the foot of the bed during the night, and during the day he is placed in the splint, and allowed to go about, and avail himself of the benefit of out-of-door exercise, which, together with care and suitable after treatment, usually effects a cure in the course of a few months.

Treatment in the Third Stage.-This is the stage in which we find rupture of the capsule and escape of the effusion. It is in this stage of the disease, only, that we are driven to the extreme measure of exsecting the head of the femur, and the carious portions of the acetabulum, in order to save the life of the patient.

I had intended to show you, this afternoon, from my private patients, specimens in the three stages of the disease, but I have been too much employed otherwise to attend to the matter at this time. I have here, however, two children who came to my office to-day, whose history and treatment I will give you in a very brief manner; and as they both furnish specimens of the third stage of the disease, their history will be equivalent to a more didactic description of the treatment of that stage. This little boy whom you here see, is seven years of age. His parents informed me that he had enjoyed good health until some eighteen months ago, at which time, while playing upon the stairs, he fell about six feet, falling on his left hip. He soon after complained of pain, and could not walk without limping. A physician at that time being called, ordered a liniment to the part, which was applied, but did not alleviate the pain; and he could not walk without enduring much suffering. Some ten months ago he met with another fall, inflicting a second injury on the same hip; whereupon the symptoms of morbus coxarius became more aggravated. Some time after this last injury, the patient was placed under my care. This patient is evidently of a scrofulous habit, and his condition, at the time of which I speak, was truly pitiable. He was suffering from hectic, and was extremely emaci

ated. Extensive abscesses existed in the external portion of the thigh, which I opened, giving exit to a large quantity of flaky, strumous pus. The tensor vagina femoris muscle being firmly contracted, I divided its tendon subcutaneously; after which I was able to make a more perfect examination of the joint; in which examination I discovered a sort of subcrepitus, a kind of cartilaginous crepitation, which furnished evidence of considerable erosion of the cartilage of incrustation, and disorganization of the articulation. But as there was no bony crepitus, I concluded to attempt a cure in this case without resorting to exsection of the bone. I put this patient upon codliver oil and iron, together with the most nutritious diet, and made use of my splint, ordering him to be kept as much in the open air as possible. Under this treatment the abscesses readily healed, and he has continued gradually to improve, until, as you see to-day, he walks with ease in the instrument, feels quite free from all pain, and presents a tolerably healthy appearance, considering his strumous disposition. This patient is doing very well indeed, but it will be some time before he can abandon the splint, as you perceive when I take off the extension, and make pressure upon the heel so as to bring the head of the femur into the acetabulum, he experiences much pain; but as soon as the extension is re-applied, you see that he can support the weight of his whole body upon the affected limb without any suffering whatever. I find, however, that there is not sufficient abduction of the limb, owing to the contracted state of the pectineus and gracilis muscles. I will therefore divide the tendons of these muscles, which will at once relieve this condition. (Dr. S. then made a section of the tendons, after which the motion was quite free.)

I take unusual pleasure, gentlemen, in showing you my second patient-this smiling little rosy-cheeked girl, who was brought quite unexpectedly to my office to-day, from her home in the country. I wish I had a daguerreotype of her when I first saw her last August, that I might show you the remarkable contrast between her present healthy, happy, cheerful condition, and her previous spanæmic, exhausted, woe-begone appearance.

This little patient is seven years old. Her mother states that about a year and a half ago she was first observed to complain of pain in the knee, the pain not being referable to any known cause; that this pain appeared for a number of months to vacillate, now apparently better, and then again worse; until it became finally so acute as to oblige her to remain in bed. When I saw her about the middle of last August, she had hectic fever, nocturnal sweats, no appetite, and was extremely emaciated. The thigh was strongly adducted, flexed upon the pelvis, and immovably fixed in this position. Opening at different points on the hip and thigh, were a number of sinuses discharging pus freely, and connecting with the joint. Upon a careful examination, I found the articulation extensively disorganized, and came at once to the conclusion that the course of treatment to be pursued in her case, and that which held out the greatest prospect of success, was exsection of the joint; which operation I performed early in September last. I found the condition of the joint such as to fully confirm my diagnosis.

I exsected the femur through the trochanter major, and removed such portions of the acetabulum as were found carious. The little patient was then put into the "wire breeches" previously referred to, and the wound dressed in such a manner as to favor granulation from the bottom. Her nights, previous to this operation, had been passed in sleeplessness and pain, but the first night after the operation, as well as the succeeding nights, she slept well without any anodyne. She remained under my care some seven weeks after the operation, during which time her improvement was marked and constant. At the expiration of this time her general health being much improved, I sent her home in the wire breeches. I have not seen her since that time until to-day. You observe that the two limbs are nearly or quite of the same length, while the motion

of the mutilated joint is almost as perfect as that of the other, No one can determine from the appearance of the two limbs which is the imperfect one. The matter that has been thrown out with the design of subserving ultimately the purposes of the normal bone, is yet pliant, and the joint therefore requires mechanical support, until this matter shall have assumed its firm fibrous or semi-osseous nature. And as no mechanical contrivance has yet been devised which effects this object so perfectly as my own splint, we will employ that. (Dr. Sayre then put up the limb with the adhesive straps and roller, and applied the splint, after which the little patient walked about, and appeared very much pleased.)

This cut represents the case three months after the exsection of the head of the femur, and is engraved from a photograph taken by Gurney.

But we must not forget the cause that gave occasion for the remarks which I have just made, namely: the patient upon whom I am now about to operate. The patient is a young man, 23 years of age. When a boy he had what he calls "the white disease of the knee," with which he was laid up for a year or two, but eventually recovered the perfect use of the joint. Some years after this period, he had hip disease, which appeared after a time to subside spontaneously; but it again reappeared in a low chronic form, and finally produced the condition of things which we here observe. The disease exhausted itself, and became arrested in the second stage, a very fortunate affair for the patient. The disease at present can hardly be said to exist, although there is at times an undue amount of tenderness experienced in the joint, especially after inordinate exercise. The operation I am now about to perform is not therefore to relieve the disease, which, as I have said, has already subsided; but rather to remove the undesirable result of the disease. You perceive that this patient's hip-joint appears to be firmly anchylosed, at an angle of about 45°. The muscles of the part are rigidly contracted, and whether this is a true

bony anchylosis, or merely a fixed condition of the joint resulting from the contracted state of these muscles, I have not yet determined. I shall now, however, investigate the matter. I shall first divide the tendons of the contracted muscles, and then attempt to restore the limb to its normal position. If I am opposed in so doing by bony adhesions, I shall break up those adhesions and reduce the limb.

(The patient being chloroformed, Dr. Sayre then divided subcutaneously from two points of puncture, the tendons of the tensor vaginæ femoris, the rectus femoris, the sartorius, the gracilis and the pectineus muscles. After which the motion of the joint was found to be tolerably good; although it had been in this locked condition for two years, no bony adhesion existed. The limb was brought down at once almost as straight as the one of the opposite side. The patient was then taken to his ward, the limb dressed in the manner previously described, and the extending weight at the foot of the bed employed.)

Original Communications.

REMARKS ON DENTISTRY IN THE ARMY. By WM. B. ROBERTS, M.D.

OF NEW YORK.

Thus

THE sad misfortunes of the Crimean war, owing to imperfect attention to the sanitary condition of the British army, opened the eyes of the whole civilized world to the importance of a proper sense of duty in this connexion. It is not surprising, therefore, that humane and far-seeing men in this country should have taken an early opportunity in the present campaign, to press upon the government the almost incalculable importance of great care in the superintendence of the sanitary department of the army. every effort is being made to attach to each regiment all the requisite force with all the necessary equipments to perform the work given to them in an efficient and satisfactory manner. There is probably very little to be said in the way of advice to such gentlemen as are thoroughly imbued with the importance of the subject, and as thoroughly acquainted with all the means and appliances necessary to it; but there is one point which has apparently escaped the attention of persons in authority, on which we wish to say a few words. During the last twenty years, and owing principally to the efforts of our own countrymen, DENTISTRY has become elevated from a mere branch to a distinct science. Colleges have been founded, societies formed, conventions held, professorships endowed, and all to give the greatest insight possible into the structure, physiology, and pathology of the human teeth. It has been found, as men progressed in the study of these organs, that their disease spread its ramifications through the whole animal economy; all the functions of the body have been affected and indeed suspended by the existence of a foreign and improper condition in the teeth; the whole sanitary condition has been altered, and the most serious complications of disease have attended the existence

of diseased teeth.

Thus dentistry has been taken out of the hands of the surgeons and doctors, and has formed a separate profession of enlightened, educated, and scientific men, understanding as a necessity not only their own immediate calling, but also no small share of surgery and pathological anatomy. A few years since, the question was raised in England as to the propriety of attaching dentists to the British army and navy; a great deal had been said upon the subject, and it was well known that the teeth of the soldiers and sailors were in a deplorable condition; but after a temporary prospect of success the subject was dropped. Meanwhile, in the French army, with that sense of decency that always characterizes the French nation, means had been taken to extend a proper attention to the wants of the

body, and to the teeth; the men were supplied with brushes, and compelled to keep their teeth cleaned; and thus the matter stands in Europe at the present time. We have referred to this subject at the present time because it seems to us that it is proper that here, where dentistry has progressed more than in any other country, it is right that the first steps should be taken to still further advance it. And we desire especially to show the value that it might possess as a sanitary instrument, if proper efforts were made to invest it with the importance it deserves. It is almost needless to refer to the necessity for having good teeth in our army and navy; first, for mastication; and, second, but most important, for their effect upon the general health; and upon this last subject we desire to give some information.

Careful mastication is essential to perfect digestion, and this latter, more especially in the active life of the soldier or sailor, is a primal necessity for healthy existence.

Very few persons are aware of the derangements which may be produced by diseased teeth, although the period of dentition in children is generally considered as one of the most critical in life. It is, indeed, estimated by some writers, that one tenth of all the deaths in the world occurs during the period of the first dentition. The animal frame is in infancy so delicate, that the least local irritation produces a sudden and universal sympathy throughout the whole body. Fever is a very frequent accompaniment of teething; also an affection of the skin, resembling measles; pustules sometimes appear, not unlike a mild form of small-pox; diseases of the scalp; diarrhoea; convulsions; diseases of the lungs; and in fact, symptoms of nearly every form of disease may be met with during the period, and resulting from dentition. If we know that this terrible catalogue of evils is attendant upon the growth of the teeth during infancy, is it not rational to suppose that a healthy condition of these organs is essential to adults, when we consider the close connexion existing between the teeth, alveolar process, the parotid, submaxillary, and sublingual gland, on the one hand, and the mucous membrane of the mouth, which is continuous with that which lines the pharynx, oesophagus, stomach, and intestines, on the other? It is well known to the dental practitioner, the physician and surgeon, that if a tooth becomes diseased, all these organs will to a certain extent sympathize with it, independent of the agonizing and excruciating pain caused by the exposure of the nerve. Cases have been given where inflammation of the mucous membrane has extended so far as to produce consumption; while dyspepsia with all its attendant horrors may be, and often is caused by improper and insufficient mastication, which must necessarily result from the possession of poor and imperfect teeth. Neuralgia and tie-douloureux, probably the most fearful pains which the human race ever suffers, often proceed in the first instance from exposed nerves; and other acute and chronic inflammatory diseases frequently spring from carious teeth and diseased gums, ruining health, and disabling their victims from performing even the most simple duties of life; and in the case of the soldier who is exposed night and day to every variety of inclement weather, and every quality of fare, the chances of such diseases establishing themselves through the means of diseased teeth are greatly multiplied.

It is well known to the dental profession that all the diseases common to teeth can not only be cured, but may be prevented by proper and timely treatment. After having thus enumerated the evils appertaining to a defective condition of the teeth, a condition which experience has found to exist among the army to an extraordinary extent, and having shown the importance of such diseased condition being avoided and changed to aid in establishing a proper sanitary condition among these men who risk their lives for their country's service, and have neither time, means, nor opportunity for themselves discharging their duty in this respect; we desire to urge upon the proper authorities, that a corps of dentists, or dental staff, should be attached

to the United States army, similarly organized with the surgical department, who would act in connexion with, and as an efficient aid to, that department, besides performing their own duties in a proper manner. Holding this to be a great sanitary measure, as well as an economical and humane movement in behalf of those affected by it, we would especially offer these suggestions to our "Sanitary Commission," believing that in the scope of their noble field of labor there could not be performed a more important act, than the procuring of the passage of a bill through Congress at the approaching session, which should incorporate into the army an efficient DENTAL staff, strengthened with all the powers necessary to enable it to become most serviceable to the cause of health.

Reports of Hospitals.

BELLEVUE HOSPITAL.

ANEURISM OF THE ABDOMINAL AORTA.-ABSCESS OF THE LIVER. [Reported by HENRY S. PLYMPTON, M.D., Assistant Surgeon, Bellevue Hospital.]

Aneurism of Abdominal Aorta.-Rupture.-Suspected Renal Calculus.-Peritonitis.-Death.-Post-mortem Examination. Henry M., native of Ireland. In the spring of 1860, he felt severe pain in the upper lumbar region. In a week the pain was less severe, but extended to left side. After a month's sickness he was at work again. He had occasional attacks of pain in his loins during the rest of the year, and found that his legs were growing weaker day by day. On the third of April, 1861, he was attacked by very severe pain in his back and left side. He could neither lie on left side nor walk, and was faint and weak. four days tried to work, but was too feeble.

In three or

April 17th.-Enters Bellevue Hospital in a state of prostration from obscure disease in lumbar region. His general appearance is good. Pulse, 100. Respiration hurried. Bowels constipated. Ordered laxatives and opiate.

April 18th. The pain is not less severe, and now runs down the course of the ureter, and round the left side towards the umbilicus. There is also severe pain in the left testicle, with retraction of that organ. The symptoms now seem to indicate strongly the presence of calculus in the ureter. The urine was examined, but contained no albumen or other foreign substance. He now passes less urine than formerly. Ordered cups to the back and opiates. April 20th. The patient has had a chill. Otherwise, he is about the same.

May 1st. His pains are decreasing. His bowels are costive. Ordered an injection. The treatment otherwise the

same.

May 20th. The patient is beginning to become emaciated, sleeps little, and the pain in his testis is more severe. May 26th. The patient lies on his back with his knees drawn up. His abdomen is quite full, somewhat tympanitic, and very painful. He has had no passage from his bowels for several days. He has had a chill. Pulse, 105. Ordered an injection, but there was no escape of fœces. Opium continued.

May 28th.-Patient is very thin, white, and covered with a cold sweat. His pulse is feeble, 110. His abdomen is very much swelled and tympanitic. He vomits constantly. His left testicle is firmly drawn up. There is slight dulness on percussion in the course of the descending colon. Impacted foeces are suspected to be present. Many injections given, but small amount of focal matter removed.

May 29th.--Vomiting continues. Ordered pills of croton oil and colocynth, but they were followed by no dejection. Opiates as before.

June 5th.-The patient is very weak. Pulse, 110. His abdomen is less tender, but he has had no dejection yet. He vomits less often. He takes beef tea and wine.

June 8th.-His pulse is stronger, 98. That part of the scrotum which covers the left testicle is blue. Ordered a charcoal poultice. Peritonitis is less, and his skin is becoming yellow. Region of dulness in abdomen has extended in two days to twice its former width. Now it reaches nearly to the umbilicus. He has had no dejection, nor any vomiting. His tongue is dry and his pulse weak.

June 12th.-A consultation was held and the tumor decided to be aneurismal. Pulsation was felt extending to all parts of the tumor, but no bruit was heard. His pulse is 100 and wiry, and his skin is very yellow. The patient is very much emaciated.

June 13th.-The patient died quietly this morning at halfpast five.

The

June 14th.-Autopsy at half-past four. The abdomen only was laid open. The flaps on the right side were easily laid back, but those on the left could be raised only about three inches, being held down by a tumor which was adherent to them. There were everywhere marked evidences of previously existing peritonitis in the shape of strong fibrous bands binding the loops of intestine together. There was but little fluid in the abdominal cavity. tumor filled nearly one-half of the abdomen, and extended from the diaphragm to Poupart's ligament, dipping also down into the pelvis. The tumor had adapted its shape exactly to that half of the abdomen, pushing the intestines and stomach over to the right side. It was of a dark-blue color, and was firmly adherent to the abdominal walls wherever it came in contact with them. The descending colon and a part of the ilium formed a part of the right wall of the tumor, as also did the pancreas above. The tumor posteriorly covered the whole of the vertebral column from two inches above the renal artery to the sacrum. It was then carefully dissected out, together with the aorta and kidney of left side. On examination of the exterior of the tumor the kidney was not seen. The aorta at the origin of the renal arteries was the seat of an aneurism which would hold about six ounces of fluid. The sac presented on its inner surface large atheromatous patches, but contained no clots. Opening out of this was a larger aneurism containing in it the kidney. The walls of this sac were composed of condensed areolar tissue, but the kidney formed no part of them. The ureter was strangulated where it passed through the walls of the aneurism. Thus the urine was prevented from flowing from the kidney, giving rise to a dilatation of its pelvis, and probably to the pains which simulated those caused by the passage of a renal calculus. On examination of the kidney it was found to be fatty, and to contain urine in its pelvis. Connected with this aneurism was still another, the walls of which were the abdominal walls on the left and in front; the abdominal viscera on the right, the pelvic fascia below, and the diaphragm above. This immense sac was filled with hard clots, many of which were entirely distinct from the rest of the mass, as if the blood had been poured out at different periods.

A Case of Abscess of the Liver.-C. H., born in Ireland. Has been a free drinker. Some time ago had an illness, accompanied by pain in the right side and fever. Since then has been more or less unwell. Abdomen has been growing large for some time.

April 24th.-His suffering is not very great. His abdomen is large and tender on right side over liver. Liver very much enlarged, and there is dulness also over inferior posterior portion of right lung. The patient has pain in loins and hepatic region. He had a diarrhoea. Ordered subnitrate of bismuth to check the diarrhoea, but it did little good. He has a cough, for which an expectorant has been given.

May 25th. He has continued much the same since he entered, except his abdomen has gradually become distended to its utmost capacity, and the rest of his body is much emaciated. Died at three P.M.

Autopsy. The right lung was compressed by the liver in its lower half. On opening the abdomen the liver was