"I should not make the proportion quite so large, for many ruptures occur in delivery of head and arms in head-last labors; but I should say that lacerations in the second and third degrees have been greatly increased in frequency by the more frequent use of the forceps which has characterized obstetric practice during the last decade. T. G. THOMAS."

Dr. Stedman said that rupture of the perinæum depended on the dilatability of that structure, and that he knew of no sure preventive except incision. He had tried all the expedients recommended without avail in certain cases, and had heard confessions of the same illfortune from better men than himself. He had followed the practice, for the last two years, of removing the instrument before the head was born (unless speedy delivery was imperative); but it made no difference in the result if the perinæum was not lax. He did not remember to have had a rupture into the sphincter. Fortunately, most of these lesions took care of themselves. Many ruptures were made by the after-coming shoulders, when the head had passed safely.

DR. LYMAN said that he was astonished at the statements of Goodell and Thomas. Of the many cases seen at the City Hospital almost all had been delivered without the forceps. He could not remember a single one of these cases in which the rupture had been traced to the use of forceps. An occasional bad rupture has no doubt been so caused, but not the vast majority. It should be noted that until recent years the laboring class had not been examined for the lesions so frequently as now.

DR. FORSTER said that he had seen several cases where no forceps had been used; very few where they had been employed.

DR. ABBOT said that the worst case coming under his observation had occurred without the intervention of forceps, the laceration extending into the rectum an inch above the sphincter, the child having been born before the physician reached the house. He had met with two pretty extensive lacerations under the use of the forceps, but these might fairly be called accidental. In Charlestown he had seen in consultation a young woman who at the time of his visit had been in labor forty-eight hours. The head was above the pubes, the face anterior, the os very rigid and not more than two inches across, the uterus being firmly contracted upon the body of the child. The pains had nearly ceased. At the urgent solicitation of the attending physician ether was administered, causing a relaxation of the os, and the forceps were applied; but the delivery for a time resisted the alternate efforts of the two attendants, until finally the head was suddenly extracted, tearing the perinæum to the anus. Three superficial stitches were put in, and complete union resulted. In another case, in which he had been consulted by Dr. Borland, a similar laceration occurred in a somewhat different way. The forehead was at the pubes, and the patient, fully etherized, lay in a dorsal position across the bed. The forceps

had thus far failed to effect extraction. It was then proposed to remit the ether and swing the patient about, to give her an opportunity of bracing her feet against the foot-board. While she was in this posi tion a pain came on, and she suddenly straightened herself out, bringing the child at once" into the world" by her own efforts, the forceps meanwhile being merely steadied by the attendant, who was standing behind the foot-board. In this case the laceration went through the sphincter. Sutures were employed as in the other case, and the parts healed well. In another case, which Dr. Abbot had visited with a member of this society, the patient had been in hard labor all night. The face was to the pubes. Forceps were applied, and Dr. Abbot supported the perinæum while extraction was made by the attending physician. The perinæum became so distended as to appear as thin as tissue paper, when suddenly a zigzag streak, at least four inches long, tore down on one side, and the delivery was accomplished. In the subsequently contracted condition of the parts the laceration proved to be insignificant, requiring no special treatment.

In the ordinary use of the forceps Dr. Abbot said that he felt that the physician had complete control. When the head was low it was his custom to unlock the forceps without taking them off, so that the tension on the external parts might be relieved, the instrument being in readiness for renewed application should farther extraction be required. He had employed forceps in ten and a half per cent. of his cases for the last twenty years, and his only regret was that he had not used them as freely before.

A NEW METHOD OF PERFORMING DECAPITATION. DR. RICHARDSON described in detail a new method of performing decapitation. He favored the combined use of Ramsbotham's knife and Braun's decollator: the latter being used for the purpose of breaking the cervical column, and the former for cutting through the soft parts. He claimed that decapitation was indicated in cases in which there was no hope of saving the life of the child, and the condition of the mother demanded operative interference, and in which delivery neither by version nor forceps could be easily effected, and the neck of the child could be reached.

AN OBSCURE LOCAL TROUBLE IN THE REGION OF THE STERNUM IN A CHILD.

DR. HODGDON reported the case. The patient, who was first seen by Dr. Hodgdon in the last week in July, after a course of treatment by an irregular practitioner, was a child two and a half years of age, naturally healthy and of healthy parents, with the following history: It had been taken sick in the evening, vomiting, with high fever and great sensitiveness to touch. It continued in this condition for a week, when a small swelling was observed over the sternum. At the end of another week the then attendant informed the parents that an abscess had formed there and had opened internally. When Dr. Hodgdon first saw the pa tient there was a purplish prominence one and a half inches in diameter, half an inch in elevation, elastic, without fluctuation, situated over the lower part of the body of the sternum, at the site of the sternal foramen. When the patient was etherized it was found that the tumor could be pressed back through the sternum, but would return when the pressure was taken off. The patient was seen by Dr. Wyman, of Cambridge, in con

deeper puncture by two hundred and fifty cubic centimetres of red serum, which was thought to be pericardial. The patient recovered.

Dr. Roberts's interesting monograph, together with Dr. Hindenlang's recent clinical observations, and Dr. Rotch's original investigations with regard to the diagnosis of pericardial effusion published in the JOURNAL in October, 1878, have thrown new light upon one of the most important and difficult subjects in clinical medicine. The cases of rheumatic pericarditis, however, which require tapping appear to be very rare; perhaps more so now than formerly, since, with better methods of treatment, we have in many cases comparative control over the joint affection, upon the intensity of which, and the exhaustion arising therefrom, the pericardial inflammation is to a considerable extent dependent.

Health and Health Resorts is a sort of mild guidebook for searchers after health on the continent of Europe, interspersed with moral reflections, a little pathology and physiology, and with some remarks on the modus operandi of curative agents generally and individually. The reason the author gives for not touching upon the sanitary resorts of the United States, namely, that they have been already described in a number of able works, might have equally restrained him from writing about those of Europe, particularly as he expressly disclaims any pretension to better judgment or more extended observation than many writers who have preceded him. What he says, however, if not always new, is sometimes true, and will beat repetition, as when he suggests that very sick people would often do better to rely upon the resources of their own land than to risk the sufferings and dangers which expatriation so frequently entails. In the chapter on Expatriation a sensible and glowing tribute is paid to the varied advantages of health resorts which the citizen of this country enjoys at home. These advantages deserve and will receive greater appreciation.

By

Photographic Illustrations of Skin Diseases. GEORGE HENRY FOX, A. M., M. D. Parts VII., VIII, IX., X., XI., XII. New York: E. B. Treat, No. 805 Broadway.

The recent publication of the above parts, with a promptness unusual in a serial of its character, brings this work to a close. The subjects chosen for illustration are lupus vulgaris, lupus erythematosus, epithelioma superficiale, epithelioma rodens, epithelioma of the lip, tricophytosis capitis, tricophytosis corporis, lichen planus, lichen ruber; kerion, lepra maculosa, molluscum, erythema multiforme; phtheiriasis capitis, phtheiriasis corporis, scabies, porrigo e pediculosis; herpes facialis, hydroa bullosum, erythema circinatum, erythema exfoliativum, purpura simplex; cornua cutanea, alopecia areata, morphœa, scleroderma, sarcoma pigmentosum. The plates have the same general merit as those in the earlier parts of the atlas already described. Some of them are excellent, others are poor, because the subjects are beyond the reach of photography. Some things are to be felt, not seen.

An attempt to represent such an affection as scleroderma, for instance, by this process fails through want of judgment, not skill. In the matter of titles, too, it is to be regretted that such conditions as hydroa, kerion, and porrigo have been perpetuated in this way as individual affections. The descriptive text is by no means the least important part of the work. It contains many new and interesting views, for the author does not hesitate to hold and express independent opinions about skin diseases. Dr. Fox is to be congratulated on the completion of a work which is in all respects a most valuable contribution to dermatology.

In conclusion, he announces a companion work entitled Photographic Illustrations of Cutaneous Syphilis.

The Therapeutics of Gynecology and Obstetrics. Edited by Wм. B. ATKINSON, A. M., M. D. Philadelphia: D. G. Brinton. 1880. Pp. 365.

The object of the editor seems to be to present, under the head of each disease, the various methods of treatment which prominent members of the profession, at one time or another, have advised as the best course to be pursued. It is a volume of recipe and directions, and it is hard to imagine a more needless or impractical addition to a medical library. In many cases the bewildered practitioner, called suddenly to a case, would consult this volume, and find under the appropriate heading the most varied and contradictory advice. In many cases, the remedies suggested would appear in the light of to-day to be worse than useless. Convulsions, for example, occur after delivery. The first method quoted advises that the patient be fed carefully on milk diet for the first three or four days. Robust women, who have eaten well up to confinement, require an aperient within forty-eight or even twenty-four hours after confinement. Ergot should be used for the first week or two, if the uterus does not involute as it should. Just how this form of treatment is to relieve the convulsions we are at a loss to understand. If this advice should therefore puzzle the prac titioner, he can turn to another authority, who advises him to bleed, or to another, who says that bleeding is of no use, or even hurtful. The author has evidently devoted a great deal of time to the preparation of a book which strikes us as possessing more of a historical than a practical value.

Atlas of Histology. By E. KLEIN, M. D., and E. NOBLE SMITH, M. Ř. C. S. Part X. Philadel phia: J. B. Lippincott & Co. London: Smith, Elder & Co. 1879.

We have been rather remiss in noticing this last number, which is the less excusable as we have little to say about it. It is of the same excellence as its predecessors, but the subjects discussed do not call for much comment. It treats of the intestine, the pancreas, the liver, and the larynx, trachea, bronchus, and lung. The description of the epithelium of the larynx is very thorough. In the other sections we find men

tion of the work of numbers of observers.

SUITS FOR FEES.

A CASE recently tried in the superior civil court presents some points of interest to the profession. Dr. Edward de la Granga sued Samuel P. Bennett for professional services. The bill as itemized was as follows: 153 visits at $5, $765; two night visits at $20, $40; one extra visit, $10; one operation and sundries, making, with charge for interest, a total of $959.10. The bill was disputed by the defendant on the ground of excessive charge, and he also filed a claim in partial set-off. The case was referred to an auditor, who reported that the principal conflict of evidence was upon the question of price per visit, that these visits extended over more than three years, and that the plaintiff had for a long time previous to the first item of the bill been attending physician to the defendant and his family. Up to the date of the first item full settlement had been made, and the visits had been charged at the rate of three dollars, except in extraordinary cases; but the plaintiff claims that about this time he notified the defendant, who acquiesced, that his charges in future would be at the rate of five dollars. This the defendant denied, and he supposed the rate was the same as he had been charged before. Plaintiff's books and vouchers put in evidence show that for several months after the alleged change from three to five dollars per visit the visits charged to the defendant were at the rate of three dollars, which the plaintiff claims was a mistake on his part, which he corrected further on in charges made that year, where the visits were carried out at the rate of five dollars per visit. The auditor fails to find sufficient evidence of a special agreement that the plaintiff was, with the defendant's consent, to charge him five dollars per visit, and hence is compelled to resort to expert testimony in relation to the custom of the profession in such cases. A long and searching examination and cross-examination of Drs. Damon, Chase, Clark, Hall, Hastings, Holt, Stacey, Lamson, Fleming, Harris, and Cilley, all practicing physicians in the city of Boston, convinced the auditor that the usual and fair charge for such visits is and should be three dollars per visit. The auditor al lowed for 153 visits at $3, two night visits at $10, one extra visit at $5, and one operation at $10, in all $494. He allowed in set-off $171.14, awarding to the defendant $323.86, with interest from time of writ.

On objection by counsel for plaintiff the judge (Rockwell) ruled that it could not be introduced, neither could questions based upon it be put. The fee table was simply an agreement of a private nature between physicians, and no one was under any legal obligation to abide by it, neither was a patient obliged to pay fees prescribed by it. The only question for the experts was this: "What is a fair compensation per visit for a physician of the experience and standing of this physician for such services as described?" If a member of a particular association violates the provisions of the fee table of that association, he is accountable to the society alone. It is nothing with which the law has to do.

The jury awarded the plaintiff $290.86. As the plaintiff had refused an offer of more than this amount in court, the costs of trial fall upon him. There is no way to ascertain exactly on what basis the jury made the award, but comparing it with the items in the auditor's report, it is probable that they awarded on the basis of three dollars for the regular visits in attendance.

This case shows that none of the profession can go into court and claim their charges as just on account of the provisions of the local fee table. They must take what experts testify that such services are worth, or, rather, such part of such sum as a jury will allow. The case would apparently be different, however, by the statement of the auditor, if it could be shown that there had been due notice given of the charge per visit; and so it behooves every physician who expects to collect a higher fee than three dollars (and there are many cases where a charge of five dollars would be only reasonable) to make a special agreement beforehand if he is likely to be obliged to appeal to the courts for his payment.

It seems also as if there were quite a difference between what is a fair charge and what is a usual charge. There is no doubt that, taking the profession as a whole throughout the city, there are more fees under three dollars than of that sum itself. It may be disguised under the name of discount or deduction for the circumstances of the patient, or of extra visits not charged for, or in some other way, but Dr. Lamson was right in saying that the fee was often two dollars, especially for mechanics and others receiving the same rate of pay.

MEDICAL NOTES.