Persistent Traumatic Dislocation of Both Hips.

Kofend (Wien. klin. Woch., August 20, 1896), records a case which appears to be unique in literature. The patient was admitted to Gussenbauer's clinic for malignant disease of the right lower jaw, which was operated on with success; the special interest of the case, however, refers to the condition of the lower limbs. Thirteen years before, the man being then 42 years old, was holding up a wagon with both hands; just as he was putting forth his utmost strength to prevent it toppling over he felt a crack in both hips, and was thrown backwards, the cart overturning beside him. He was picked up and carried home, where a bonesetter unsuccessfully endeavored to correct the displacement by pulling and over-extension, with the aid of four men. Cold applications were used, but no bandages; the patient was confined to bed for 14 weeks, then went on crutches for 8 months, and with a crutch and stick for 7 more. Since then he had been able to get about with the aid of a stick, and even to do light field work; he had never received any medical attention. When examined the right thigh was flexed, adducted and rotated in, the foot pointing forward. The region in front of the acetabulum was much flattened, but the head and trochanter could be easily felt bulging behind it. The trochanter was 4 inches above Nélaton's line, and the head lay in a capsule somewhat above and in front of the great sciatic foramen; the acetabulum was not palpable. Complete flexion was possible, the head slipping behind the situation of the acetabulum. Adduction was also perfect, but abduction was impossible, and the limb could not be straightened. The left thigh was bent almost at right angles on the body, the head being beneath the obdurator foramen, so that its movements could readily be felt per rectum. The limb was abducted and rotated out; it could be flexed and adducted, but extension was impossible and rotation limited. There was much creaking, and the acetabulum could not be felt; the dimensions of the pelvis were unaltered. There was also an old fracture of the left tibia, which had united with more than half an inch of shortening. The patient stood mainly on the right foot; the left sole could then only be brought to the ground by tilting the pelvis forward and to that side, so that the hip and knee were flexed, and the limb in the position of genu varum. To compensate this there was lordois and scoliosis, with the convexity to the left of the lumbar and lower dosal vertebræ. His gait was oscillatory, and walking only possible with the aid of a stick held in the right hand. The mechanism of the condition ap

the left in front, with over-extension of the body, causing the pelvis to slip off both femora. The patient refused an operation for the relief of the deformity. Kofend has collected 8 cases of acute traumatic dislocation of the hips, but has not been able to find an instance in which the condition had become permanent.— British Medical Journal.

Treatment of Rupture of the Kidney.

Keen (Annals of Surgery, August, 1896), in concluding an elaborate paper on the "Treatment of Traumatic Lesions of the Kidney," based on tables of 155 cases, discusses the indications for operative intervention in cases of subcutaneous rupture of this organ. Of 118 cases of this injury that have been published since 1878, 50 were fatal. On excluding 12 cases of associated injuries of other organs, 2 cases in which death occurred very soon after the injury, I case in which the patient possessed a single kidney, and an uncertain case, 34 cases are left, in 14 of which the fatal result was due to primary, continuous and secondary hemorrhage combined with shock, while suppuration, including peritonitis, destroyed 16. In 4 cases only was death caused by coma, anuria and nephritis. These figures support the view held by the author, that the dangers of rupture of the kidney are especially hemorrhage and sepsis. A more frequent resort to primary nephrectomy would, it is held, have avoided a number of deaths from both of those causes. The duty of the surgeon, it is pointed out, seems clear. Where the symptoms are threatening, particularly if there be decided evidence of hemorrhage, or probable danger of sepsis, an exploratory operation should be performed without delay. The great mass of recoveries in rupture of the kidney are the slighter cases; the graver cases do not recover unless an operation is done. In any case, therefore, with severe or dangerous symptoms the surgeon should lean toward exploration and in severe laceration toward early nephrectomy. Hæmaturia is regarded as being valuable only as a symptom showing the fact of rupture of the kidney, but not as a symptom by which to decide on operating. Not the visible loss of blood by the bladder, but the easily overlooked, but far more dangerous bleeding into the perinephric tissues, or into the peritoneal cavity, should receive the chief attention. If, then, a tumor form quickly in the lumbar region, an exploratory operation in the loin should be immediately made, and if the kidney be found hopelessly destroyed, or the hemorrhage such as to require ligation of the renal vessels, nephrectomy should be practiced.-British Medical Journal.

Notices and Reviews.

The Physicians' Visiting List, (Lindsay & Blakiston) for 1897. Philadelphia: P. Blakiston Son & Co.

This well-known visiting list comes to us this year with additional improvements, which will make it more acceptable than ever. The cover has been strengthened without increasing its bulk. The number of pages set apart for cash account has been increased besides other minor changes. As heretofore it can be had in five different styles. The regular form for 25 patients per week sells for $1.

An American Text-book of Applied Therapeutics for the Use of Practitioners and Students. Edited by J. C. Wilson, M. D., assisted by A. A. Eshner, M. D. Philadelphia: W. B. Saunders, 1896. One volume, large 8vo, pp. 1,326.

This book contains 78 articles on the therapeutics of medical diseases, written by 42 different authors, and all American except two. The aim seems to have been to create a strictly practical work of a high order devoted almost exclusively to the therapeutics of the different diseases as the writers respectively would teach or apply them, rather than to give a complete history of the therapeutics or any full account of the diseases themselves. The corps of contributors is an excellent one, the articles are in the main well studied and appear to be up to date, and the work is well edited. The book is well printed and a delight to read, although the volume is so large. No such work, the product of so many writers, can be perfect or even; this one is not. Some have written with refreshing fullness and detail, a few with regrettable brevity. Doubtless some things of importance have been omitted. The articles overlap in places, and perhaps some matters of minor significance are not treated. But the work contains more accurate, practical wisdom of the hour on the subject than any single author could hope to have put together and is altogether a book of superior excellence. A few of the writers may have forgotten that the basis of pathology has changed of late, but in the main the treatments recommended are based on the modern doctrines of the causation and nature of disease, and this is one of the chief charms and greatest merits of the work. We have been moving forward in the study of etiology and pathology and lagging behind in therapeutics. To-day no man can write a true account of human disease except in full view of all the meaning and possibilities of infection and the intoxications. This may not be the correct basis, but it is the best we have so far attained, and our treatment of the sick ought to be in accordance with it. If future discovery shall give us a better basis we ought to be frank to change our therapeutic methods, and one of the best things a truly mod

"A New Dressing for Fracture of the Clavicle," by M. L. Harris, M. D. Reprinted from the Chicago Medical Recorder, September, 1896.

"Chorea," by Henry Hatch, M. D. Reprinted from The Journal of the American Medical Association, October 17, 1896.

"The Diagnosis of Tuberculosis from the Morphology of the Blood-An Original Research, with Report of Cases," by A. M. Holmes, A. M., M. D. Reprint from the Medical Record, September 5, 1896.

"Gonorrhea in the Puerperium," by Albert H. Burr, M. D. Reprinted from The Journal of the American Medical Association, August I, 1896.

"Infantile Scorbutus," by Albert H. Burr, Ph. B., M. D. Reprinted from The Journal of the American Medical Association, November 7, 1896.

"Optic Neuritis," by William H. Wilder, M. D. Reprinted from International Clinics, Vol. II, Sixth Series.

"Chloroform in Labor," by Frank B. Earle, M. D. Reprinted from the Chicago Clinical Review, April, 1896.

"The Use of Cicatricial Skin Flaps in the Operation for Ectropion of the Upper Lid," by F. C. Hotz, M. D. Reprinted from The Journal of the American Medical Association, September 19, 1896.

"On the Importance of Physical Signs Other than Murmur in the Diagnosis of Valvular Diseases of the Heart," by James B. Herrick, M. D. Reprinted from Medicine, October, 1896.

"Report of a Case of Typhoid Fever Complicated by Extrauterine Pregnancy," by James B. Herrick, M. D. Reprinted from the Medical News, October 17, 1896.

"Thyreoid Therapy," by James B. Herrick, M. D. Reprinted from Medicine, August, 1896.

"Hypnotic Suggestion as a Cure for Asthma," by Thos. Bassett Keyes, M. D. Reprinted from the Medical World, July, 1896.

"The Treatment of Dipsomania, Morphiamania and Onanism by Hypnotism," by Thos. B. Keyes, M. D. Reprinted from The Journal of Materia Medica, April, 1896.

"How to Cure Rheumatism," by Elmer Lee, A. M., M. D., Ph. B. Reprinted from The Journal of the American Medical Association, July 25, 1896.

"The History of the Discovery of Anæsthesia," by Burnside Foster, M. D. Reprinted from the Northwestern Lancet, 1896.

"A Series of Articles on Speech Defects as Localizing Symptoms, from a Study of Six Cases of Aphasia," by J. T. Eskridge, M. D. From the Medical News, June 6 to September 19, 1896.

"Electro-Diagnosis and Electro-Therapeutics Simplified," by Hugh T. Patrick, M. D. Reprinted from Medicine, November, 1896.

Miscellany.

The Marine Hospital Service.

There will be held in Washington, D. C., on February 3, 1897, a competitive examination of candidates for appointment to the position of assistant surgeon in the United States Marine Hospital Service. Candidates are required to be not less than twenty-one years of age, and no appointment is made of any candidate over thirty years of age. They must be graduates of a reputable medical college and furnish testimonials as to character.

Successful candidates, having made the required grade, are appointed in order of merit as vacancies arise during the succeeding year. A successful candidate, when recommended for appointment, is commissioned by the President of the United States as an assistant surgeon. After four years of service and a second examination he is entitled to promotion to the grade of passed assistant surgeon, and to the rank of surgeon, and after a third examination, according to priority, on the occurrence of vacancies in that grade.

The salary of an assistant surgeon is $1,600 per annum, together with furnished quarters, light and fuel; that of a passed assistant surgeon, $1,800 per annum, and that of a surgeon, $2,500 per annum. In addition to these salaries, after five years' service, an additional compensation of ten per cent of the annual salary for each five years of service is allowed medical officers above the rank of assistant surgeon, the maximum rate, however, not to exceed forty per cent.

When an officer is on duty at a station where there are no quarters furnished by the government, commutation of quarters is allowed at the rate of $30 a month for an assistant surgeon, $40 for a passed assistant surgeon, and $50 for a surgeon. The successful candidates, after receiving appointments, are usually ordered to one of the larger stations for training in their duties.

Full information may be obtained by addressing the Surgeon-General of the Marine Hospital Service, Washington, D. C.

Irritable Stump.

At a recent meeting of the New York State Medical Society Dr. Joseph D. Bryant of New York County, read a paper on this subject. He stated that, according to the military statistics of the late war, of 287 amputations of the leg examined five months after the operation, in twelve per cent the stumps were still unhealed, and in fourteen per cent they were imperfect. Of 132 amputations of the thigh, according to the same authority, there were 21 unhealed and 21 with imperfect stumps at the end of the same period. So far as he had been able to ascertain from makers of artificial limbs and from a study of the subject, the three main requisites in securing a good and useful stump were: (1) Such a length of flap that undue traction would not be made on the stump; (2) a movable cicatrix, and (3) a periosteal covering for the divided ends of the bone. The first was the most important, because, if it was attended to, the evils of the others were reduced to a minimum. Dr. Bryant then described the method which he had found satisfactory in dealing with an irritable stump in the lower third of the leg. It was, briefly, as follows: A circular flap was made in the lower third of the leg, of a length a little greater than one-fourth the circumference of the limb at the point of division of the bone. This flap was reflected upward for about half an inch, and then a transverse incision was made across the subcutaneous surface of the tibia, at the line of reflection of the flap, down through the periosteum. The periosteum was also divided by incision in the log axis of the tibia. The periosteum was then pushed up instead of being dissected up with the flap in front. In this way a portion of flap corresponding to the subcutaneous portion of the tibia was lined with periosteum, and this fell over the end of the bone when the flaps were coaptated. The tibia was divided transversely on a line with the periosteal reflection, and the fibula a quarter of an inch higher up. The flaps were coaptated obliquely on a line with the subcutaneous surface of the tibia. It was important, Dr. Bryant said, that the periosteal flap should remain connected with the superimposed tissue, otherwise it would slough away or become absorbed.

an

Dr. Marcy said that one very common cause of irritable stump-the presence of a neuroma -could be largely avoided by covering over the nerve with periosteum. Where the various layers of tissue were closed by separate rows of sutures, it would usually be found that the stumps were more serviceable.

tion, untrustworthiness, etc.; assertions that will apply much more forcibly to the methods that are now so universally used-loose woolselection at one or two meters' distance.

Here, instead of the test being made at what the present writer has designated as the distances that are requisite for future safety, they are performed at so close a range to the candidate that the results never can be depended upon as of any practical value for the safety of life and property when such eyes are engaged in actual service upon rapidly moving trains that follow one another in quick succession. That any previous test should be efficient when the visual organs are placed under such circumstance it is requisite that it should be made when they are situated under similar conditions and while the eyes are placed in the same positions as they would be when it becomes necessary that they should be the sole means of exercising prompt action in the avoidance of a threatening accident or imminent calamity.

One or two meters' distance away from the point which determines the presence or the absence of a catastrophe is, as all practical railway men know, entirely too close for the avoidance of unfortunate results during subsequent impending danger. A laden engine moving with the rapidity of 20 to 25 meters each second, would have been propelled into destruction long before any engineer could check its speed. In other words, the recognition of the signal must be determined at a safe point; it must be made at a sufficient distance to properly control the moving mass. To do this the visual organ which has almost sole charge of this function must necessarily be able to differentiate color when it is placed at a safe distance; it must have been previously tested to do it at that distance; and the testing must have been done when the eyes were placed under the same conditions and under similar circumstances as when they are employed during actual work.

In the acquired color defects produced by the introduction of toxic agents into the system, such as tobacco, and which appear in the part of the field of vision that is used when any object is gazed at, the testing with large massings of color placed at short distances from the eye as in the ordinary wool-tests, becomes useless; here another worse than inefficiency

comes into play. As the central blind or dimmed area in the field of vision does not always include the whole surface of any of the skeins of wool, the candidates may be passed, thus allowing this most dangerous class of subjects to be placed in service where the subject cannot differentiate the color of signal boards and lights or even distinguish them, as in one instance seen by the writer, where he found a case of tobacco amblyopia actually at work upon an immense railway-system after having successfully passed the near-wool test.

At about the same time that Wilson applied his findings to color-testing among railway employes, Lees of the Edinburgh, Perth and Dundee Railway pointed out another inefficiency. He stated that it was well known that the different degrees of vividity of equal areas of red and white illumination (in fact, of any color) produced alteration in impressions as regarding their relative distances from one another. Based upon this, he asserted that “a red light seen from a distance seems much further than a colorless light side by side with it, the eye assigning a less proximity to the less luminous lamp, in conformity with its experience of the different apparent brightness of lights of the same color and luminosity placed

at different distances from it.”2

To remedy this in railway color-testing, both the areas of reflected and transmitted colormaterial employed should be graded in size and intensity of tone into proportionate amounts, thus making every color used in the tests of the same distance-value.' That they are not is too well known; that they should be is an absolute certainty.

A third inefficiency in color-testing of this class of subjects is where there is the want of consideration of the situation in which the testing is done.

The examination should be conducted in

This, which is just as true, though somewhat less noticeable by diffuse daylight, where the colors as a rule appear darker, is markedly seen when the color hues are strengthened in brightness by being projected against the dark background of night.

2 These facts are well understood by painters and colorists, who make use of them in their disposition of strongly and weakly reflecting color-areas upon flat surfaces in order to give effects of perspective and so-called warm and cold tone-contrasts. The application of the rule of simultaneous contrasts to railway work may often be aggravated or even absolutely perverted when new color impressions produced by subjective after-color, as for example as commented upon in the case of a serious collision which occurred many years ago upon one of the Irish railways, in which it is stated that an engineer or stoker might, after gazing into the interior of a furnace box for a few moments' time, see all the color-signals of a greenish tinge.

1 This rule is equally true for the gradation of the ordinary color-signals used, not only in railway, but more particularly in inarine service where the danger is very great, especially in well filled and fog-laden harbors.