THE ELECTRIC LIGHT IN Surgical Diagnosis. By ROSWELL PARK, M.D., OF CHICAGO, SURGEON TO THE MICHAEL REESE HOSPITAL ; PRESIDENT OF THE CHICAGO ELECTRICAL SOCIETY. REPRINTED FROM THE ANNALS OF ANATOMY AND SURGERY« MARCH, 1883. BROOKLYN, N. Y. ANNALS OF ANATOMY AND SURGERY. 1883. THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. By ROSWELL PARK, M.D., OF CHICAGO, SURGEON TO THE MICHAEL REESE HOSPITAL; PRESIDENT OF THE CHICAGO ELECTRICAL SOCIETY. IT has been tacitly recognized for centuries as a surgical aphorism that the nearer to the light we bring a dis- eased part the easier the diagnosis. The ancients had a variety of specula. During the middle ages these were im- proved. In modern times Garcia taught us how to use the laryngoscope; Helmholtz devised the ophthalmoscope ; and the endoscope, in one form or another, has been in use for a considerable time. With all of these instruments light had to be reflected from a source outside the body into the part to be examined, while provision had to be made for a direct return of the light to the observer's pupil. Obviously, then, the field of vision was extremely limited, and that for practice of the method greatly re- stricted. With the development of the application of electricity to surgery and to general illuminating purposes came crude efforts to employ the hot wire as a source of light for diag- nostic purposes. The white hot loop may be readily used to shed forth light, but it also gives out heat in proportion ; hence its disadvantages. Those who have used the thermo-cautery in deep parts will appreciate the advantage which its brilliant glow is at 4 ROSWELL PARK. times to the operator. But, for purposes of pure diagnosis, we desire illumination without heat, or the heat must be absolutely manageable. Among others, Lazarewicz, Schramm and Bruck had worked at the problem of trying to make parts translucent by a powerful light, either reflected or electric. A simple form of Bruck's diaphanoscope is represent- ed in Fig. i. At h is the battery furnishing the cur- rent which shall heat the platinum coil g to incan- descence. Two glass tubes, one enclosed in the other, hermetically sealed at their bases, give an open space through which water from the reservoir c, en- tering by tube d, circu- lates and passes out at e. Thus the external temper- ature of the instrument may be regulated at will. Such an instrument, con- stri'cted for no particular organ save the oral cavity, can be very seldom put to service. But it illustrates the principle upon which most of the other instruments about to be described are constructed. Before speaking of the large instrument to which this paper is to be especially devoted, I wish to describe briefly fig. i. bruck's diaphanoscope. THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. 5 a small one made by Trouve, of Paris, and called by him a polyscope. It consists of a variety of small reflecting cups, containing fine platinum strips which, when heated, give out quite a bright light. According as these cups are arranged the light is thrown in different directions. The one shown in Fig. 2 is used to illuminate the pharynx, or by means of proper specula the rectal and vaginal walls. With a different arrangement of the cup and the addition of a mirror we have an admirable laryngo- scope and rhinoscope. An- other reflector permits thorough examination of the mouth and teeth, and even diaphanoscopy of the latter. All these parts, with a num- ber of small galvano-caustic knives and points fit in the small handle shown in the figure. The source of elec- tricity is a secondary or " storage " battery enclosed in the hard wood case also shown in the cut. This is a Plante' cell with h'aure's coat- ing ; the one in the writer's possession, when properly charged, will keep a small wire red hot from thirty to fifty minutes. The galvanometer B is a constant and reliable index as to the condition of the battery, while at J a resistance coil is introduced, by whose aid the strength of the current is regulated. The little in- strument is very serviceable, but examinations made with it FIG 2.1 THE POLYSCOPE. 1 This cut has been kindly loaned by J. W. Queen & Co., of Philadel- phia, who import these instruments. Their price is $75. 6 ROSWELL PARK. must be intermittent, since there is no provision for cooling the metal save by breaking the current. Still, for office work, nothing can be found at the same expense to do all the work of which this is capable; and the writer can com- mend it warmly. This is not the place to discuss the matter of secondary batteries and the so-called " storage of electricity." For information on this point, the writer would refer to his paper on the subject read before the Chicago Electrical Society January 15, 1883.1 The subject is of prime im- portance to every surgeon who employs electricity in his work. The successful application of the principle involved in Bruck's original diaphanoscope to the examination of visce- ral cavities required not only great ingenuity in device, but also workmanship of very high order. This has been finally accomplished by JOSEF LEITER, the well known instrument- maker of Vienna.. To his personal skill and energy we are indebted for the instrument we are about to describe, this being the first adequate description which it has received in English ; while to his personal friendship the writer is in- debted for all but two of the illustrations which serve to elucidate it, they being a selection from the eighty-one illustrations in his brochure " Beschreibung einer Instrumente und Apparate zur direkten Beleuchtrmg menschlicher Korper- hohlen durch elektrisch.es Gliihlicht (pp. 65, Wien. 1880, Brau- miiller und Sohn). Before Leiter entered upon the construction of this appa- ratus, Dr. Nitze, of Dresden, had devised, and his instru- ment-maker, Deicke, had constructed instruments for exami- 1 Published in the Chicago Medical Journal and Examiner, February, 1883. Also to a paper by Morton, Harper s Magazine, December, 1882, and to standard works on Electricity. THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. 7 nation of the urethra, bladder, larynx and stomach. Of these only the first named proved serviceable on the living patient, the next two could be used on the cadaver, and the last named was useless. His experiments showed correct- ness of principle, but faulty device and make. Conversant with these facts, Leiter undertook the recon- struction of Nitze's urethroscope, and the construction de novo of the instruments for the bladder, larynx and stomach, as well as those of entirely original plan for other parts of the body. The present forms are the result of more than two years' persistent effort, and an expense to which but few would have been willing to go. Up to last autumn but three of these instrumentshad been sent to this country ; one is the property of a New York instrument firm, another is in San Francisco, and the third is a part of the magnificent equipment of the Michael Reese Hospital in this city. Personal familiarity with the latter, as well as with the instrument in Leiter's own expert hands, a desire to do justice to his skill and the feeling that the instrument ought to be more widely known and used, have induced the writer to briefly describe the same. The problem in construction to be overcome was a com- plex one ; to secure a neat and easily manipulated model, to combine in this the insulated conductors for the electric current, the two tubes for the free passage of cool water about the heated wire without touching it, and in most of the instruments a free and unobstructed tubular passage for light to pass to the observer's eye, and finally, to make the instrument thoroughly practicable and not too expensive- to accomplish all this was to overcome no small mechanical difficulties. Without detailing the earlier efforts to facilitate the cold water stream, and to make the whole apparatus easily transportable, I will simply describe Pig. 3- 8 ROSWELL PARK. which represents Leiter's latest model of combined battery and hydrostatic apparatus. B is a hardwood box containing three large Bunsen cells with double zinc plates exposing a large surface. They are so arranged in a hard rubber cell, with large bottles of battery fluids on either side, that by means of a rubber bulb and glass tube they can be filled or emptied by simply siphoning the fluids in and out. Simple directions enable the operator to connect one, two or three elements as desired. For ordinary endo- scopic purposes, two, or even one, suffice; for galvano- cautery all three are needed. Wires from I and 2 on the battery box run to I and 2 at R, which is the rheostat- With the pointer at o, the position it occupies in the cut, there is no current ; as it is turned around on the index scale the resistance is diminished, until with the pointer way round the circle all resistance is out of the circuit. At 3 and 4 are the wires which run to the instrument in use, as for instance the laryngoscope at L. By a simple spring- clamp they are put on or removed in an instant. S is a metallic tubular reservoir about one meter in height, also shown in cross section. This is filled with four liters of cool water. A heavy leaden weight or plunger (10 kilos.) bg is swung from the under surface of the cover by pulleys ro ; the cord attached to the little handle gr serves to hoist it ; ko is a closely-fitting piston having a valve ve, which allows the weight to be raised, but causes it to rest on the surface of the water, which, by its weight, is driven up through sr, its flow beingchecked or regulated by the stop- cock /at its upper end. Water being thus caused to flow, passes around the rheostat and through the tube h by flexi- ble rubber tubes into the instrument, around the heated wire, back through the tube k at m, where it drops back into the reservoir at tr, and can be used over and over again. With proper adjustment the weight need not be raised oftener THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. 9 than once in twenty to thirty minutes; but the water must be kept steadily flowing or there is danger to the instru- FIG. 3. COMBINED BATTERY AND HYDROSTATIC APPARATUS. ments. At / is a metal loop in which the tubes and wires ROSWELL PARK. 10 may rest, so that their weight is hardly noticed. At 11 are handles by which the whole instrument can be moved about as desired. Instead of a Bunsen battery may be used a secondary battery. The writer uses the one referred to in connection with Fig. 2, which, when properly charged at leisure, can be made instantly serviceable, and is, moreover, much lighter and more transportable. With a proper amount of resist- ance in the circuit the divided current from a dynamo, as used for ordinary electric lighting, might be employed. THE URETHROSCOPE. Beginning now the consideration of the particular endo- scopic instruments, we will take first the urethroscope. This is shown exact size in Fig. 4-presented on the large Plate I. At m is seen the canula-an ordinary straight metal tube-into which fits the balance of the instrument, this tube being the size of an ordinary catheter, say No. 21, French. The portion b b, containing the illuminating and cooling arrangement, is pushed into the same. At its end is seen the loop c of platinum wire. The main body of the metal-work is made to serve as one of the conductors, the other being an insulated wire concealed with the water tubes. Between /"and g, the rings upon which the clamp e fits, is a hard rubber plate which keeps perfect the insula- tion between the two conductors. The water tubes are seen at h and z, the connections with the reservoir being made just below by means of what the workmen call " Dutch screws." The cold water entering at h passes down one tube clear to the extremity at r, and then back by another and out at i. This instrument is passed into the tube w, the projection / fitting into the slot seen at the larger end of the tube, the latter being then in position represented by the dotted outline in the main figure. The eye is applied PLATE I . FIG. 5. AN ENLARGED SECTIONAL VIEW OF THE URETHROSCOPE. See description on page 11. FIG. 4. THE URETHROSCOPE. EXACT SIZE. See description on page 10. FIG. 7. THE CYSTOSCOPE. See description on page 12. THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. 11 at the funnel k. 1 ubes of varying size may be used accord- ing to the calibre of the urethra. The tubes n and o repre- sent those especially intended for the prostatic portion, the fenestrum in n being open, that in o hermetically sealed with a small glass plate. Fig. 5-presented on large Plate I-gives an enlarged sectional view of the instrument, show- ing the construction more in detail, and not only of this particular one, but of several others, as those for the nose and the oesophagus. It needs no particular description. At m is the hard rubber plate, around which is the metal ring n connected with the insulated wire i and h. With this urethroscope can be seen all that is ever seen with any instrument devised for the purpose. In connec- tion with the cystoscopes, to be next described, it permits the c o m p 1 ete examination of the whole uri- nary tract up to the mouths of the ureters. Fig. 6 shows the instrument as in actual use. It is used precisely as any other, and is capable of thoroughly illuminating 30 mm. of length of the urethra and a surface 1 cm. square at one time. FIG. 6. THE URETHROSCOPE IN POSITION. THE CYSTOSCOPES. Obviously the deeper we investigate the more compli- cated the instrument must be. Fig. 7-shown on large Plate I-represents that form of the cystoscope intended for the b.as fond. The tube a a is of ordinary catheter size, the straight portion 17 cm. long. The rounded cup-shaped end c maybe removed to insert fresh platinum wire, should that in use be melted by intensity of current-a frequent result of 12 ROSWELL PARK. carelessness. The loop d of wire gives out the light. A plate of glass e, hermetically sealed, prevents ingress of fluid. At /ends the straight tube through which the ob- server gazes. The water tubes are seen at h, and the elec- tric connection is made at g. The principles of construction are virtually the same as those of the urethroscope. A long tube, carrying a series of amplifying lenses, can be inserted through the mouth-piece and pushed on till its extremity is FIG.® 8. THE CYSTOSCOPE IN POSITION. close to f. This permits enlargement of the image. The arrangement at the lower end, by which new wires can be inserted, is most ingenious, but can hardly be described here. The mate to this instrument is another, similar in most respects, but having its window on the other side of the beak, thus allowing those portions of the bladder wall, which cannot be viewed with one to be seen by means of the other. In this one, as in the other, a prism inserted op- posite the window in the lower end, permits the deflection of light up the tube to the observer's eye. Its upper end is also arranged so as to permit absolutely free rotation without interfering with the tubes and wires. THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. 13 Fig. 8 shows it in operation. By means of these two instruments every point of the bladder surface-in either sex-can be illuminated and examined at convenience, while by aid of the lenses the image can be magnified if so de- sired. To use it to best advantage, the bladder should be washed out and then filled with clear luke-warm water. After proper practice in using it on living tissues so that an acquaintance with normal and abnormal colors is obtained, most of the diseases affecting that viscus may be easily diagnoised. It may be used after lithotrity or litholapaxy, to search for remnants of calculi. It is as easily introduced and manipulated as a stone-searcher, and in much the same manner. THE OTOSCOPE is figured in Fig. 9. The water tubes enter at d. At b is the platinum loop, while at c is attached the clamp for the battery connection. At f is represented one of a series of specula, made to fit into the ring e. By aid of this oto- scope the parts may be illuminated as completely as by any device now before the profession, while, the bother of the head mirror being avoided, there is greater freedom in performing any desired operation, one hand being also free. For class demonstration also the instrument is unrivalled. FIG. 9. THE OTOSCOPE. 14 ROSWELL PARK. THE LARYNGOSCOPE. We have seen that Dr. Nitze had already devised a laryn- goscope, which, however, was clumsy in model and of no great practical value. In Fig. io-shown in large Plate II- is portrayed Leiter's latest model. The handle /is of hard rubber. At i and h are rings for the battery connection ; at h and g the tubes for the water. The shank e contains the two water tubes and a separate compartment for one in- sulated wire, the balance of the metal-work being the other conductor. The loop of platinum wire is enclosed behind a small glass window at d. At a is the laryngeal mirror which is part of a lit- tle door swinging on hinges at b, which, being opened, per- mits access to the wire in case of acci- dent. Fig. 11 shows the laryngoscope in use. As thus made, it has to be held in the left hand-a simple thing for the expert-which leaves the right hand free for applications or operation. As indicating how well it works in skillful hands, I will add that Leiter showed me numerous photographs of the larynx taken by its aid. An instrument constructed on precisely the same principle, but having a smaller mirror, serves as a FIG. II. THE LARYNGOSCOPE IN POSITION. RHINOSCOPE, which may also be used as a laryngoscope for smaller THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. 15 throats. Upon its shank may be pushed a flat metal plate to act as a tongue depressor. Fig. 12-figured on large Plate II-shows an unique model for a STOMATOSCOPE. The mirror a is part of the tube b, containing the window c, from which shines out the light. At e is the wire loop, and close by are the water-conductors, which are all a part of the main portion d. If the mirror a be not desired, but, on the contrary, direct illumination, the tube b may be re- moved and replaced by the tube 'i. The arrangement at f is like that of the second cystoscope described, and permits free rotation in both directions. The instrument is in- tended especially for dentists' use, and serves its purpose admirably. Acting upon the advice of Prof. Zaufal, of Prag, Leiter constructed another series of rhinoscopes, much resembling the urethroscope, but having much shorter tubes for the ex- amination of the nasal cavities. They are of the same shape as Zaufal's nasal specula, arc introduced in the same manner, and throw a flood of light upon all those parts where they can be brought to bear. By their aid parts can be brought under the scrutiny of the observer's eye, which can be seen in no other way. THE CESOPHAGOSCOPE. The cesophagoscope, as now made, is simply an enlarged urethroscope. Prior to Nitze's efforts, as has been said, in- struments had already been devised by Lazarewicz, Schramm and Bruck, applicable only in an extremely limited way. Stoerk had also devised an cesophagoscope, by whose aid the upper end of the gullet could be examined, but all efforts to reflect light more than a few centimeters down that tube were, of course, futile. Following Nitze's lead, 16 ROSWELL PARK. Leiter first constructed a flexible tube of metal rings pivoted together. To this, and at right angles, a most complicated eye-piece was attached, the whole being equally ingenious and impracticable. More than six months were spent in efforts to improve this, until by Mikulicz's aid the present vastly simplified form was adopted. It consists, as already stated, of a straight tube of the size of a medium oesophageal sound. It is introduced by aid of an obturator, which is then with- drawn. If desired, a pledget of cotton, wound on a wire, may be passed in and the mucous surface cleansed. The illuminating portion is then passed in, just as in the case of the urethroscope (yid. Fig. 4). As the tube is slowly with- drawn every portion of the oesophageal wall can be exam- ined. By its aid strictures, foreign bodies and ulcers, as well as dilatations-and even aortic aneurisms-can be diag- nosed and located. Mikulicz claims that the lower portion of the oesophagus is never collapsed, as is the case with the vagina or the urethra, but remains always more or less open. The position required for the proper introduction of this instrument, and the cautions to be observed, are the same as for that next to be described, and will be mentioned later. Leiter has made long forceps, with " alligator jaws," for removal of foreign bodies that may be detected by its use. THE GASTROSCOPE. In the construction of this instrument the most difficult problem ever yet offered the surgical instrument-maker has been solved. How thoroughly satisfying the solution is may be a question open for discussion, but the above state- ment will hardly meet with a denial from any familiar with the problem. The earlier instrument figured in Leiter's brochure (p. 33) is probably the most complicated ever in- FIG. IO. THE LARYNGOSCOPE. See description on page 14 FIG 12. THE STOMATOSCOPE. See description on page 15. PLATE II. FIG. 13. THE GASTROSCOPE. See description on page 17. THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. 17 vented for the surgeon's use ; in fact, its complexity almost prevented its use even on the cadaver. Prof. Gussenbauer has told me how he was once trying to use it on a patient, and, in the effort to withdraw it, drew up a thin strip of mucous membrane nearly as long as the instrument. The patient, however, recovered without any trouble. The problem was in this stage of development when Lei- ter enlisted the aid of Mikulicz, then a privat docent of sur- gery in Vienna.1 They attacked it together regardless of outlay, and, with the result figured in Fig. 13-shown on large Plate II. The tube is 65 cm. long and 14 mm. thick, the angle at F corresponding to the curvature of the dorsal vertebrae. B is the spiral platinum loop, the battery connection being at C. The tip end of the lower portion unscrews, to allow the platinum to be replaced if necessary. At E is the window, back of which is a prism, through which the observer views the interior of the stomach. At A is a series of prisms, which keep the rays of light in the proper direction. The openings at B and E are closed by a sliding metal blind, worked through the interior of the tube from J. This blind is closed during its introduction. At D are the water con- nections. At L is a rubber tube connected with the bulbs K. This tube connects with one passing down inside and opening near H, and is used to inflate the stomach in order to make its inner surface unfold and spread out for exami- nation-after the instrument is introduced-just as the bladder is filled with water for the same purpose. At Ma little knob enables the observer to know the exact relative position of the instrument after it has been inserted. At G is the eye-piece provided with a lens system similar to others already spoken of. 1 Recently called to Krakow as Professor of Surgery. 18 ROSWELL PARK. As in the case of the cystoscope so there is another in- strument, mate to the above, with its window on the other side of the tube, the one being for examination of the py- loric end, the other for that of the cardiac end of the stomach. As preparation for the use of the gastroscope it is neces- sary that the patient shall have gone for some hours with- out eating. Half an hour previous to its use a hypodermic dose of morphia, say one-third grain, should be adminis- tered. Just prior to the examination the stomach should be washed out. The patient is then laid upon the left side on a table, having a head support, which shall keep the neck in its axial position. A small receptacle is placed under the mouth to catch the saliva which cannot be swal- lowed. The head is then thrown well back and the instru- ment, which has previously been lubricated with vaseline or glycerine, is guided by the finger of the left hand and passed downward with a gentle sweep. Previous practice on the cadaver with a hard rubber sound of the same di- mensions and flexure as the gastroscope will easily teach the necessary manipulations. The instrument being in place, the stomach is inflated to the desired extent, but not suffi- cient to distress the patient. The pointer on the rheostat being turned slowly, the metal blind is drawn (at and the observer has the field before him. By the curve at F not only is the introduction of the in- strument facilitated-it having been found impossible to pass a perfectly straight tube so far as is necessary for this purpose-but it will be seen that with partial rotation of the tube about the long axis of the straight portion the ex- tremity carrying the window and the light makes quite an excursion, and permits the view of a much more extensive surface than would be possible were no such excursion made. This fact will be still better appre- THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS. 19 dated from a glance at Fig. 14,1 which represents FIG. 14. THE GASTROSCOPE IN POSITION. the instrument in situ, the dotted lines showing its possible positions. 1 From Mikulicz, " Ueber Gastroskopie und Oesophagoskopie," Wiener Med. Presse, 1881, Nos. 45-52, to which the reader is referred for many details for which we have not room. Also to M.'s paper before the Congress of German Surgeons, Beliage zum Centralblatt fiir Chirurgie, No. 29, 1882. 20 ROSWELL PARK. Moreover, as it is provided with an optical system, it obtains that as the instrument is rotated towards a given point of the mucous membrane its image is enlarged, while as it is further removed, the image is diminished, while the field is enlarged. At a distance of 2 cm. the image is of natural size. The " definition " of this system is excellent, and, granted a tolerance of the instrument on the patient's part, and the requisite skill on that of the observer, a very satisfactory examination can be made. By means of the two instruments, nearly the whole inner surface of the stomach may be seen. There must necessarily remain some portions inaccessible to the observer's eye, but, fortunately, these are the portions of least interest, being least often the site of pathological changes. With this instrument I have seen the pylorus, for instance, much as one views the optic disc with the ophthalmoscope, and of a bright blood red hue like the retina, while whenever I have seen it, it has been in constant, almost peristaltic motion, as of opening and shutting. Whether this motion was in- duced by the presence of the tube, or not, I cannot say. The first question provoked by reading an account of these two instruments, will undoubtedly be: What can the surgeon learn by their use, that he could not otherwise determine? Have they practical value? Mikulicz who has most used them, states that with the oesophagoscope all the diseases affecting the oesophagus can be easily diagnosed. Diagnosis of the neuroses would have to be made by exclusion, of course. Concerning the gastroscope, we are not yet in possession of sufficient evidence to say positively. It resembles the ophthalmoscope in this respect-it must require no small practice to learn how to handle the instru- ment to best advantage ; it requires then still more to learn how to interpret correctly what may be seen. To do all this, the surgeon must have better opportunities than falls THE ELECTRIC LIGHT IN SURGICAL DIAGNOSIS 21 to the lot of any but continental clinicians with large clinics. On this account, the gastroscope can never come into general use. But relying a little on what I have myself seen, and very largely on the experience of others, I feel justified in saying that in expert hands, and with an expert's eye at the eye piece, the instrument may and ought to play a role in diagnosis which has never been filled before. It deserves a careful study of itself and an ex- tended trial ; until it has had both its merits should not be disregarded. OTHER ENDOSCOPIC INSTRUMENTS. Working on the same general principles as those involved in the above instruments, Leiter has constructed a Recto- scope, a Vaginoscope, and an Enteroscope. The two former are made similarly to the urethroscope or otoscope, save that the specula are much larger and of a variety of sizes and lengths. Their use and applicability will be sufficiently apparent without further notice. For the purpose of a Hysteroscope, the urethroscope can be used, in special cases, the cervix uteri being dilated. The Enteroscope is composed of a flexible tube of metal rings, on much the same principle as the old form of the Nitze gastroscope. It was intended for investigation as high as the sigmoid flexure. From the fact that it is not included in the full set of instruments, I gather that it has been found im- practicable, as its construction and purpose would suffi- ciently imply. The writer feels that no further words of his in commen- dation of the above instruments are needed. He would only add, that the more one uses the various parts, the more he will feel convinced, that they are of great practical value, and not mere scientific curiosities. Their use does not make up for lack of skill on the surgeon's part; on the 22 ROSWELL PARK. contrary it requires no small skill to attain good results with them; but they are undoubtedly capable of aiding us to a realistic knowledge of many diseased conditions to which we could not otherwise attain.1 1 The writer will be happy to give Leiter's address to any desiring it, and furnish any information in his power as well as to compare notes with those who have used or intend to use the apparatus. ANNALS OF Anatomy and Surgery. EDITED BY* L. S. PILCHER AND G. R. FOWLER, IN CONJUNCTION WITH NEWTON M. SHAFFER, of New York; OSCAR H. ALLIS, of Philadelphia ; HENRY O. MARCY, of Boston ; WM. M. MASTIN, of Mobile ; ROSWELL PARK, ofChicago ; and J.E.PILCHER, of Brooklyn. 1\ /[ AKING itsobject the promotion and -L*-*- concentration of surgical work, this journal is comprehensive and catholic in character, and an exponent of the best surgical thought and labor, in- cluding in its scope surgical anatomy and pathology. Terms: Annual subscription, $2.00, in advance ; single number, 25 cents.