or to her mother, etc.; at other times it seemed as if the crying and singing coexisted. Yet, when asked if the pain in the joints was constant or intermittent, invariably stated that it was of the former nature, and was not subject to any marked exacerbations. Upon asking the parents if the child had ever suffered with the globus hystericus, I was told that she often complained of a choking sensation in the throat, and particularly so after she had been crying from some slight cause. * hysterical affections in general. Rosenthal, the only one of half a dozen authors on nervous diseases with whose works the writer is familiar, refers to this pseudo-febrile condition in speaking of hysterical vaso-motor disturbances, and he says that in several cases he noticed that the temperature did not rise in the axilla above 37.4° -37.6° C. [99.3°99.7° F.], despite a pulse of 100 to 120; yet, in the present case, the temperature was decidedly in excess of this. The marked tolerance of morphia and purgatives, and the inefficiency of the usual febrifuges to reduce the fever, were no doubt due to the hysteria, and were but symptoms of its existence; while the immediate and marked improvement following the use of the so-called anti-hysterics is 106 HALSEY STREET, NEWARK, N. J. A CASE OF UTERINE DISPLACEMENT. By M. F. PRICE, M.D., ACTING ASSISTANT SURGEON, U.S.A., FORT STOCKTON, TEXAS. The case now appeared to me to be a clear one of hysterical arthritic hyperesthesia, the general family history and the paralytic seizure of the mother, with her subsequent entire recovery, confirming my diagnosis. Consequently, the child was put on twenty minims of fluid extract valerian, every three hours, and, as re-equally as suggestive. markable as it may seem, after the second dose had had time to operate the fever rapidly subsided, the skin became natural, the kidneys active, and the pain in the joints considerably diminished. The following morning (Thursday) found the child a different being. She had passed a good, quiet night, slept well, and was refreshed; not a trace of the fever was present, the urine became natural in color and quantity, with no pain in the joints, although considerable stiffness remained, and the patient was able to move the left foot a little, which, as will be remembered, hung a few hours previously as if lifeless. Passive movements of the joints were made and the muscles manipulated. The patient was put on general tonic treatment in connection with the valerian, and told that on the morrow she must sit up a little, and be sitting up when I called; but she assured me that she was certain she could not do it. However, without going into the details of the moral treatment with which we are all so familiar, I found her sitting up when I arrived, and in five minutes more, after a determined effort, had her out of bed and, with my support, was walking about the floor, although she stoutly protested a few minutes before that she could not possibly straighten her limbs, or use her left foot. ABOUT December 4, 1879, a Mexican came to me and said his wife was sick, and he wanted some medicine for her. My interpreter was not a good one, and about all the information I could get was conveyed in the term "agua caliente" (hot water), and motions made toward the genital organs. I finally learned that the urine was hot and there was frequent desire to void it. As gonorrhoea is quite common among the Mexicans here, both married and single, I took it for granted this was such a case, and prescribed accordingly. December 6th. The man returned and said his wife was no better. I now had a more efficient interpreter, and, after some conversation about the case, I came to the conclusion my diagnosis was wrong, and that I had better see the woman. I therefore rode out to the ranch, and in one of the adobe huts found This case is an exceedingly interesting one, as be- my patient lying on the ground, apparently in great ing an illustration of that very rare class of the distress. She was a medium-sized, well-built Meximultitudinous forms of hysteria in which a well-can woman, about twenty-two years of age. I asked marked pseudo-febrile condition is attended by de- her where her pain was, and she took my hand and cided symptoms and signs of serious organic or ar- passed it over her abdomen to the groins and around thritic lesion. Hysteria in a child so young is indeed to her sides, saying, "Aqui!" "Aqui!" (here, here). interesting of itself, and but few cases have been re- I made examination externally and found a tumor ported. Willis, Hoffman, and others of the older (seemingly) above the pubis, which felt like the authorities, give us but few instances; and even uterus, but flattened posteriorly. Passing a finger Briquet, with all his extended experience, has only into the vagina, I found what appeared to be a tumor seen eighty-seven cases occurring before the twelfth between the recto-vaginal walls, which extended year; and of 351 cases analyzed by Landouzy, not down to and rested on the perineum. The bladder one was below ten years of age. Hysterical affections was apparently full, but felt peculiarly puffy. For a of the joints have been referred to by Brodie,* Skey,† long time I could not reach the os uteri, and had Barlow, Meyer, and others. Meyer states that one about concluded I had a pelvic hæmatocele to deal of the leading phenomena which distinguishes hys- with. After persistent effort for some time I finally terical from other affections of the joints is, that in found the os, which was turned forward toward the the former the pain ceases in the night; but in the symphysis pubis and pressed firmly against the bladpresent case it was unmistakably present. Yet, with der, so that it felt like a slit lying crosswise. The the other characteristics which he points out, the cervix uteri was likewise flattened and shortened. phenomena of this case are in harmony; such as the The apparent tumor back of the vagina, and the one transient swellings of the joints, changeability of above the os pubis, I found to be connected; in fact, the temperature of the part, the fact of pressing the were one and the same. This condition of things joints being no more painful than gentle handling, was somewhat puzzling for a time, to say the least. and the rapid disappearance of the trouble following My diagnosis was, finally, that the uterus was much usual or known methods of curing or alleviating enlarged from some cause, and that the fundus had been by some violence pushed down toward the os, thereby flattening the uterus from above, causing it Illustrations of Certain Local Nervous Affections, London, 1837. A Treatise on Diseases of the Joints. * Diseases of the Nervous System. to assume the shape and position shown in the drawing, and pressing the walls-anterior and posterior-to the positions in which I found them, one to the perinæum and the other above the pubes. Acting upon this diagnosis, I passed the right hand into the vagina from before, and, after drawing it down as far as possible, placed the ends of my fingers against the dependent uterine wall and carried it up, at the same time gently making counter-pressure with the left hand on the anterior portion above the pubes. Persisting in this manoeuvre until the posterior wall was carried well up to the promontory of the sacrum, while I was still using considerable force, it suddenly left my fingers and went in its proper place with an EXTIRPATION OF CANCER OF THE-. RECTUM. BY CHARLES B. KELSEY, M.D., YORK, ETC. SURGEON TO THE INFIRMARY FOR DISEASES OF THE RECTUM, NEW IN a certain number of cases cancer of the rectum has been removed, and has not returned for so long a time as to justify the statement that the patient has been radically cured. In many more cases, length of life and freedom from suffering have been though the disease has ultimately returned, a greater obtained by the entire ablation of the growth than could have been hoped for by any other method of treatment. The operation is, therefore, both a curative and palliative measure, and should be studied from both these standpoints. The first case of extirpation of the rectum of which we have any record was by Faget, in 1739, and was not for cancer, but simply a removal of the lower portion of the bowel, which had been completely surrounded and denuded by an abscess beginning in one ischio-rectal fossa, and subsequently extending into the other. From that time until 1826 the operation, as a means of treatment of cancer, will occasionally be found mentioned in surgical literature; generally, however, only in condemnation. In 1826 Lisfranc performed the first successful operation for cancer; and three years later his student, Pinault, in a thèse reported nine cases, and gave to the procedure a permanent place in literature and practice. In 1833 Lisfranc himself embodied the same ideas in a paper read before the Acad. Royale de Médecine,* and from that time the operation became widely known. Since then it has had its advocates and opponents, and has been subject to many modifications in its performance. For a long time it was coolly received by British surgeons, but within the past decade it has received a new stimulus from the Germans, and at the time of writing it seems about to be fairly tried by the surgical world and judged on its merits. audible "swoosh"-the anterior wall simultaneously passing from under my left hand. On further examination I then found the uterus normal in shape and position, but large enough for about three and a half or four months' pregnancy. I now turned my attention to the enlarged and puffy bladder; passed the catheter and drew off about two ounces of pure blood, when the instrument became clogged with clots. I administered an anodyne, enjoined quiet in the recumbent position, and returned to the post. December 7th.-Found my patient quite comfortable. Drew from the bladder -which was much reduced in size and in a more natural condition-about three ounces of blood. After a thorough examination to-day, I decided that the woman was certainly pregnant, advanced about four months. Almost every surgeon whose name is prominently associated with the operation has had his own favorite way of performing it; and we shall, therefore, speak in detail only of those which have proved Volkmann in his Klinische Vorträge for March 13, most acceptable, and first of those described by 1880. He describes three different operations, depending on the location of the disease. The first is is accomplished by dilating the anus, dragging down for the removal of a circumscribed spot only. This the disease, and excising it in such a way that the wound shall not cause subsequent stricture. When the growth involves the anus the edges of the wound are carefully brought together, stitched with catgut, and a drainage-tube inserted between them. When the growth is entirely within the sphincter, the edges are brought together with equal care, but the tube is inserted through a track made for it, which communicates with the wound above and perforates the healthy skin at a point outside of the border of the sphincter. When dilatation does not suffice, the anus is freely divided down to the coccyx, and this wound is subsequently carefully closed under the antiseptic precautions. In the second class of cases, where the growth involves the whole circumference of the bowel, but not the anus, the latter is divided forward into the perineum and backward to the tip of the coccyx when necessary to give room for December 8th.-Urine passing freely without blood. Uterus normal, bladder nearly so. The woman said she was "muy bueno" (very well). I did not see her again until March 27, 1880. At this time she was very well, and appeared to be advanced to at least seven months' pregnancy. I have not seen her since, but have learned that she was delivered, May 10, 1880, of a large, healthy boy. I refrain from making any comments on the peculiarities of this case, and simply give a description of the condition and the results. *Mém. de l'Acad. Roy. de Méd., 1833. III., p. 296. manipulation. The latter of these two incisions is carried as far into the bowel as the lower border of the disease, which is then removed. The mucous membrane above is stitched to that below, the preliminary incisions carefully closed, and a drainagetube left in the posterior one. In the third class, where the disease involves all, or nearly all of the anus, and of the circumference of the rectum, the entire tube is separated and removed in a cylinder. The same preliminary incisions may be made as in the second class, and the anus is surrounded by a circular cut, which runs outside the sphincter. From this as a starting-point the dissection is carried parallel with the bowel till the upper portion of the disease is passed. By the use of knife, scissors, and fingers the bowel is completely freed, then drawn down to the anus and cut off above the disease, the healthy apper end being stitched to the margin of the skin. In case the peritoneum is opened, the wound is at once stuffed with carbolized sponge, and afterward carefully closed with catgut. The coccyx and part, or nearly all of the sacrum, are removed when necessary to make room, as a preliminary step. The risk of hemorrhage is one of the great objections to this operation, and later on we shall describe another procedure, which is preferred by many, in which the knife is supplanted by other and bloodless instruments. It is no doubt true, as Allingham says, that the deep dorsal incision is the key to the operation, and greatly facilitates the securing of bleeding vessels; yet the hemorrhage may be so great as to impede the operator and endanger the life of the patient. It will be seen that at every step in this operation union by first intention is aimed at, and Lister's methods are carefully followed. If the elements of success in Listerism are, as I believe, cleanliness and drainage, these are certainly better met by a deep posterior wound, which is left open and syringed out frequently, than by carefully closing that safety-valve with catgut sutures and inserting a drainage-tube. It will also be observed that the bowel is always brought down and stitched to the free edge below. To do this much dissecting is necessary, and but little permanent good is gained, as the stitches soon tear out. Of the freedom with which the peritoneum is opened, and of the operation in general, as practised by the German surgeons for cases of the most advanced disease, we shall speak later. Maisonneuve described, in L'Union médicale of 1860, an operation which he named the procédé de la ligature extemporanée, and which differs from the preceding in being almost entirely bloodless, although it differs little from the operation previously described by Chassaignac under the name of l'écrasement linéaire. In the latter the rectum is divided into two lateral halves by the chain écraseur, and each half of the disease is then attacked in the same way and removed. In the operation as done by Maissonneuve a strong cord is substituted for the chain, and the disease is removed in the following manner the skin and subcutaneous tissue are divided by a circular incision which completely surrounds the anus. The operator is provided with several strong curved needles, each of which is to be threaded through the point as often as used, with a strong silk ligature about a foot in length. One of the needles with the ligature in its point is then passed from the external incision into the bowel above the growth, going wide of the gut to clear the tamor. The loop of string in the eye of the needle is seized within the rectum and drawn out of the anus, while the needle is drawn back out of its own track. The result of this is a double uncut ligature, passing from the point where the needle entered the external incision, outside of the tumor, into the rectum above it, and then out of the anus; and this manoeuvre is repeated eight or nine times at points around the circumference of the anus equidistant from each other. A strong whip-cord or bow-string is the next requisite, about two yards long, and to this all the loops hanging from the anus are attached at points nine inches distant from each other. Each of the original ligatures is then withdrawn by the same course it entered, carrying a loop of the whipcord with it. When all are drawn out, the rectum above the disease is surrounded by a series of loops of strong cord, and the ends of each loop hang out from the original incision. The ends are then attached to an écraseur, and each loop made to cut its way out in turn. After all have been cut out, the lower end of the bowel and the diseased mass are of necessity completely separated from their attachments. The operation performed by Cripps * is a modification of the two preceding ones, and would seem to possess several advantages in facility of performance. The preliminary dorsal incision is made from within outward, by passing a strong curved bistoury into the rectum, bringing its point through the skin at the lip of the coccyx, and cutting all the intervening tissue. The buttock is then drawn away from the anus to put the tissues on the stretch, and a lateral incision made from the preliminary cut behind, around the rectum, to the median line in front. The site of this incision, whether inside or outside the anus, will depend upon the location of the disease, and whether or not the anus is implicated. The cut itself should be made boldly, and deep enough to reach well into the fat of the ischio-rectal fossa. The forefinger in this incision will readily separate the bowel from the surrounding tissue, except at the attachment of the levator ani muscle, which should be divided with the knife or scissors. A piece of sponge is pressed into this cut to restrain the bleeding, while the opposite side is treated in the same way. The anterior connections give more difficulty, and the dissection in the male is aided by having a sound in the urethra. The knife and scissors replace the finger in this part of the operation. When the dissection has been carried to a point above the disease, the bowel is drawn down, and held while the wire écraseur is passed over it, and the section made at the required level. After this there may be free, but seldom serious, hemorrhage. The vessels divided in the first steps of the operation all come from the wall of the bowel, and, if ligatured when first cut, are again opened with the écraseur. When the disease is located to one side of the bowel the operation is modified accordingly. The preliminary dorsal cut is the same, and the lateral incision is made on the affected side. At the farther end of this lateral incision, away from the dorsal one, a needle carrying a cord in its point is passed around the disease and into the rectum above it. The loop of cord is brought out of the anus, attached to the chain of the écraseur, and withdrawn as it entered. The chain is then made to cut its way out, and a rectangular piece of the rectum is thus included between two longitudinal incisions, one posterior with the knife and one lateral with the chain. this rectangle is the cancer, and it is dissected up *Cancer of the Rectum. London, 1880. In ward from below, and separated above by again using the écraseur. Instead of the chain or wire écraseur, the wire of the galvanic cautery may be used, heated to a dull red, and not a white heat, if the desire is to avoid hemorrhage. Or, again, instead of the wire the galvanic cautery knife may be used, and the operation performed with bloodless incisions. This is the operation favored by Verneuil. The rectum is first divided into lateral halves with the écraseur, as in the method of Chassaignac, the cut dividing both the anterior and posterior walls. Then with the galvanic cautery blade the lateral halves are separated from their attachments stroke by stroke, until a point is reached above the level of the disease. The chain is again slipped over the end of each, and the final section made. An ingenious and simple method applicable to certain cases has been recorded by Emmet.* The growth in the case in which it was used was an epithelioma the size of a hen's egg, situated on the posterior wall of the rectum an inch above the sphincter, with considerable surrounding infiltration. The sphincter was stretched, and the mass seized with a double tenaculum and drawn well down by an assistant. "A steel grooved director, as the most convenient instrument for the purpose, was pushed through the skin in front of the coccyx and just behind the outer edge of the sphincter, into the cellular tissue of the pelvis, and then made to puncture the rectum, in healthy tissue, just beyond the upper edge of the tumor. The end was turned out of the gut, and pushed far enough forward to rest on the perineum while the other end was over the coccyx. Then a second director was pushed around from the outer side of the muscle on one side, through the cellular tissue into the rectum, across to the other side, through the cellular tissue and skin again to the opposite side of the muscle. So that the mass, with a portion of the rectum above, was now brought through the anus and fixed by the two directors, which had been passed behind the mass at right angles to each other, with their ends resting outside on the soft parts. The chain of an écraseur was placed behind these two instruments and slowly tightened till the whole mass, as transfixed, was cut through along the course of the directors. By this means I removed the entire sphincter muscle, about three inches of the posterior wall of the rectum, and about an inch and a half of the rectal surface of the recto-vaginal septum. The immediate result was a most formidable opening in the connective tissue of the pelvis, about three inches in diameter, and cone-shaped from below." Regarding the immediate dangers of the operation, the first thing to be feared is hemorrhage, and the second, a wound of the peritoneum. Allingham says he has learned not to fear hemorrhage in operation on the rectum; and yet he warns against wounding the "middle hemorrhoidal (sacral?) artery" by approaching too near the sacrum; an accident which has occurred to himself, and which was followed by so free and so sudden a gush of blood as to convince him that in a weak patient it might easily have been fatal. The arterial supply to these tumors is often very free, and a spirting vessel four inches up the rectum is not an easy thing to secure in spite of the preliminary incision. I know of but one case in which death is said to have been due directly to the hemorrhage, although in many it is reported to have been very profuse, and no doubt contributed to the fatal result which followed in the course of the first few days. A wound of the peritoneum is not an uncommon accident attending the operation, although it is one to be greatly deplored, and which has contributed more to swell the list of fatal results than any other. The deaths from this cause alone nearly equal those from all others combined; and whatever may be said of the impunity with which this serous cavity may be opened in other parts of the body, does not seem to apply here, for there are few cases recorded in which the accident has not ended fatally. A wound into the vagina, though always to be avoided when possible, may often be necessary in order to fully remove the disease. When the fistula thus made is not too extensive, it may be closed immediately after the operation. If large, it must be left. A wound of the urethra in the male, when slight, is to be treated as though the patient had submitted to an external urethrotomy, by the frequent passage of the sound, to prevent contraction. When a large piece has been taken from the urethral wall a permanent recto-urethral fistula is the necessary result, though the danger of fatal inflammatory action is greatly increased, from the presence of the urine in the rectal wound. As for the cases reported by Nussbaum and others, in which the whole neck of the bladder, the greater part of the prostate, and the seminal vesicles have been removed, and the patients have lived for years in comfort, they are merely curiosities of literature. That such a thing may happen has been proved, but that the operation should ever be undertaken in any case where such a result is necessary for the entire removal of the disease, has yet to be proved. After peritonitis, the most frequent causes of death are blood-poisoning and deep pelvic inflammation.* Dr. Rousef has recently called attention to a simple To account for this, we have only to remember the method of avoiding a wound of the sphincter, which free venous supply of the rectum, the extent of the is applicable to some of the slighter cases. A curved wound, and the lax cellular tissue filling the pelvis. incision is made parallel with the outer border of the It has happened to good surgeons that a patient has sphincter, and on a line with its outer limit. By died of diffuse pelvic inflammation after a simple introducing the finger through the rectum, the growth operation for fistula in ano. How much greater, may be everted through this incision, and removed then, must be the danger in an extensive operation with the part of the rectal wall to which it is adherent. such as is now under consideration. The best way Perhaps, as Molliere is inclined to believe, the best to avoid such an accident has already been pointed of all the operations we have spoken of is the com-out-leaving the wound open for the free escape of bination of the écraseur and galvanic cautery knife, fluids, and the frequent use of disinfecting fluids inas used by Verneuil. But the operator is at liberty|jected into all its pockets and sacs. to choose from among them all the one he considers easiest of performance, and most free from the risk of hemorrhage, or of wounding surrounding parts. * Principles and Practice of Gynecology. Ed. 1879. + Lancet, Oct. 2, 1880. Regarding the ultimate condition of the rectum in case of recovery from the operation, stricture to a troublesome extent is very rare. In one case, re See An Analysis of One Hundred and Forty Cases of Excision of Cancer of the tectum," by the author, New York Med. Journal, December, 1880. ported by Verneuil, a special plastic operation was performed to relieve this condition, an account of which may be found in the work of Marchand.* The opposite condition of incontinence is much more common, but it is no contraindication to the operation, because in the great majority of cases it is no more marked than after the only other surgical procedure applicable-lumbar colotomy. As a fact, in a very large proportion of cases the incontinence is not sufficient to cause any great amount of trouble, the patient being able to keep himself clean and avoid accidents by immediately attending to the call of nature as soon as felt. Only one element in the act of defecation has been removed-the sphincter. There are many others, so that, though the patient may not be able to resist the call to empty the bowel, there is still a call, and a certain amount of time to attend to it, except in cases of diarrhoea and fluid motions. In a few cases there will be a constantly unconscious discharge, which can only be met by the wearing of a bandage or apparatus. The operation of excision has not yet been accepted by the entire profession as the best means of treating those cases of cancer of the rectum to which it is manifestly most applicable. By American surgeons, as a rule, colotomy is considered preferable, as giving greater relief, and more surely staying the progress of the growth. Excision can never be judged in comparison with colotomy, being applicable properly only to an entirely different class of cases. It must be judged in the light of actual experience of results in those cases to which it is best adapted. What are those cases? The Germans have apparently no limits to its applicability. They perform it in cases of the most extensive disease, opening the peritoneum, exsecting the sacrum, when necessary to reach its upper limit, and removing the prostate and base of the bladder when they are implicated, balancing the risk of immediate death from the operation against the chance of radical cure, or prolonged immunity from return. Conservative surgeons will hesitate long before accepting this view, for, although very satisfactory results have been obtained in such cases, they can hardly be considered other than exceptional, and a study of cases shows that the frequency of the fatal result is in direct proportion to the extent of the operation attempted. The rules for the selection of cases laid down by Lisfranc were these: when the bowel is movable, in other words, when the disease has not involved surrounding parts, the operation should be undertaken. When, on the other hand, the disease is more extensive, and reaches higher, he leaves the question to be decided by future experience. I believe that experience has now decided against it. In deciding for or against the operation, an examination of the glands in the hollow of the sacrum and in the loins is of great value, for these receive their lymph directly from the rectum, and may be enlarged, while those in the groin, which are supplied from the skin around the anus, may still be uninvolved. Although the hope of radical cure is but slight, there is still some chance of such a result; but the operation, when done at all, is generally undertaken merely as a palliative measure. Labbé, in a recent article, rather argues against it, on the ground that, in ten of his cases, the average date of return was only ten months. This, I think, might be considered a very favorable result. Ten months Etude ur l'extirpation de l'extrémité inférieur du rectum, par le Dr. A. H. Marchand. Paris, 1873. of comfort, with the chance of painless death from return in the viscera, is certainly as good a result as any other treatment offers. 48 EAST THIRTIETH STREET. Progress of Medical Science. EYE-SYMPTOMS IN LOCOMOTOR ATAXY.-Dr. J. Hughlings-Jackson read a paper before the Ophthalmological Society, London, December 9, 1880 (Lancet, December 18, 1880), in which three well-marked non-ocular tabetic symptoms were considered in connection with certain ocular symptoms. Twentyfive cases, in different stages, furnished the materials for the communication. Of these there were twelve of optic atrophy. In two there were also ocular paralyses, and in one a history of it; in nine there was Westphal's symptom. In one of the three, without this symptom, there had been no pains; gait was slightly ataxic. In the second there had been double vision ten years ago; there is now paresis of the left third nerve; this patient had pains, but his gait was normal. The third case was one of atrophy of one disk, with limitation of the field outward and downward; this patient saw green as gray, and red as reddish brown; he had pains, but his gait was good. In one case, in which there was paralysis of those parts supplied by oculo-motor nerve-trunks, it was noticed that the patient had no positive symptom except Westphal's (tendon-reflex). This patient's pupils acted well to light and during accommodation; he had no pains of any sort anywhere. In one case, with normal pupils and Westphal's symptom, there had been paralysis of the third nerve. In one case of inactive pupils, with Westphal's symptom, there had been temporary double vision. In another, with inactive pupils and Westphal's symptom, paralysis of one sixth nerve. That condition of the pupil, observed by Hempel, Vincent, Erb, Hutchinson, and others, called the Argyll Robertson pupil, is a double condition, negative and positive, and in this way resembles the so-called disorder of co-ordination of locomotor movements. This symptom is not peculiar to tabes; it may be found in general paresis of alienists-at least, reflex pupillary immobility. Erb's diagram was exhibited to the society, which gave that physician's view of the central conditions corresponding to the double pupillary condition, and the following case was cited, which was considered a very rare one: A woman, aged twenty-six years, had sought advice, simply because her right pupil was larger than the left. It had been so for three years. The right pupil was dilated and absolutely motionless to light, and also during accommodation. Yet her ciliary accommodation on this side was perfect. She could read No. 1 Jaeger from fourteen inches up to five, or by effort to four. The field was perfect. The fundus was normal, except that the veins were large, and convoluted at the disk, probably physiological; the media were clear. Her sight with this eye was perfect. The pupil of the left eye was most active, and of normal size; the left disk was slightly paler than the right; the veins as on the right; macula normal; double slight limitation of nasal part of the field. She could read Jaeger No. 2 with the left eye, but the centre syllable of a long word seemed blurred. She seemed to be in perfect health, except for the ocular abnormalities mentioned. In testing her knees not the smallest trace |