PISTOL-SHOT WOUND OF THE ABDOMEN, INVOLVING THE LIVER, STOMACH, SUPERIOR MESENTERIC- ARTERY AND VEIN, SMALL INTESTINE, AND KIDNEY: laparotomy; nephrectomy; death on THE FIFTEENTH DAY; AUTOPSY. BY W. W. KEEN, M.D., PROFESSOR OF SURGERY IN THE WOMEN'S MEDICAL COLLEGE OF PENNSYLVANIA, SURGEON TO ST. MARV'S HOSPITAL. FROM THE MEDICAL NEWS, May 14, 1887. [From The Medical News, May 14, 1887.] PISTOL-SHOT WOUND OF THE ABDOMEN, INVOLVING THE LIVER, STOMACH, SUPERIOR MESENTERIC ARTERY AND VEIN, SMALL INTESTINE, AND KIDNEY : LAPAROTOMY ; NEPHRECTOMY ; DEATH ON THE FIFTEENTH DAY ; AUTOPSY.1 BY W. W. KEEN, M.D., PROFESSOR OF SURGERY IN THE WOMEN'S MEDICAL COLLEGE PENNA., SURGEON TO ST. MARY'S HOSPITAL. Miss B., in Vineland, N. J., a plump and healthy, well-developed girl of nearly eighteen, shot herself with a pistol, calibre No. 32, at 6.30 a.m., April 1, 1887. In a few minutes she was found by the family who had been roused by the shot, lying on the floor of the room next her bedroom, bleeding slightly, and conscious, and was carried to her bed. Dr. O. H. Adams who arrived in a few minutes found that the ball had entered over the liver, and after a careful search found it lying under the skin of the left flank. She was pale and weak and suffer- ing considerable pain. Giving her one-quarter of a grain of morphia subcutaneously and directing that no food be given her, he telegraphed for me. I reached there at 2 p.m. She was perfectly conscious, very pallid and weak, 1 Read at the American Surgical Association, Washington, D. C., May 12, 1887. 2 KEEN, suffering moderately. Her night dress was black- ened and burned over a space four to five inches in Fig. i. ® Wound of entrance. x Point of lodgement of ball. diameter. She told me that the wound was self- inflicted, hence the pistol had been almost in con- PISTOL-SHOT WOUND OF ABDOMEN. 3 tact with the body, and the ball had probably passed in a straight line. The small, blackened wound of entrance was seen over the ninth rib, which was fractured, four and a half inches above the level of the navel, and three and three-quarter inches to the right of the median line. Skin not burned. The ball was located eight inches to the left of the median line one and a half inches above the level of the navel. There was moderate tender- ness over the entire belly, hepatic dulness not changed, stomach resonant from fifth interspace, no cough, no rales, vocal fremitus normal, renal dul- ness began at tenth rib on left side, and was the same on the two sides. There was severe pain in the left shoulder. She had vomited a drachm and a half of clear, bright blood, she told me, immedi- ately after the accident. This had been lost, but I saw what she had twice vomited later. It was ordinary mucous and bilious vomiting, streaked with a few drops of blood. About a pint of urine, the first since the accident, was drawn by the catheter. It was not bloody. Pulse 104, respiration 30. No material rise of temperature. As after consultation with Drs. Adams and Bidwell it was deemed almost certain that the belly was invaded by the ball, ex- ploratory laparotomy was advised, consented to and begun at 3 p.m., and terminated at 6 p.m. Operation.-The instruments were in 5 per cent, solution carbolic acid, the sponges had been lying in a similar solution for five days; hands and nails were cleaned by soap and water and corrosive sub- limate 1: 1000; the wall of the abdomen was thor- oughly washed with the sublimate solution, especi- ally at the wound of entrance and the navel, an easy hiding-place for dirt and mischief. Plenty of towels in a warm sublimate solution were provided. 4 KEEN, The sponges were placed in The sublimate solution during the operation. Ether given by Dr. Beck. The ball was easily removed just under the skin. Neither wound could be traced positively into the belly. An incision was then made in the median line from the epigastrium downward three inches Fig. 2. Wounds of stomach. The wound of exit is dotted, as it did not show in this view of the stomach, being on the inferior and pos- terior surface. long, subsequently prolonged to eight inches, and in such a position that it crossed a line joining the two wounds, so that, if the ball had passed in the belly wall only, its track would be found. On opening the belly neither blood nor serum escaped, nor was any extravasated food or feces noticed. There was no peritonitis. Two fingers PISTOL-SHOT WOUND OF ABDOMEN. 5 were passed in and an effort made to discover the wound of entrance or exit without any being re- vealed by touch. The wound was then enlarged and the stomach drawn out. A small round wound near the pylorus was found and was closed by four sutures (Lembert) of the finest iron-dyed silk a round ordinary sewing needle being used, only the peritoneum and muscular coat being caught by the sutures. This wound was practically closed by the pouting mucous membrane. As the ball had entered the stomach, search was made for the necessary wound of exit. None was to be found, but the manipulation showed that a small amount of bloody serum existed in the belly, and a large area of extravasation was seen in the mesentery. The cause for this bleeding was then sought. The bowels were carefully drawn out and placed on the belly wall wrapped in towels kept wet with the warm sublimate solution. The blood extended fan shaped in a moderately thick layer between the two layers of the mesentery, its periphery extending almost two feet along the bowel and its point being at the mesenteric attachment to the spine just below the head of the pancreas and in the line of the wound. But little blood had escaped into the peritoneal cavity. The mesentery was care- fully torn through and a small artery tied. The chief bleeding came from a hole nearly one-eighth inch in diameter in a large vein, so large and lax that at first I thought it the vena cava, but its posi- tion just below the head of the pancreas convinced me that it was the large superior mesenteric vein just before it forms the portal vein. After much difficulty I seized it with hemostatic forceps and placed a lateral ligature of chromicized catgut on it. Meantime the manipulation had revealed a mode- rate bleeding point in the omentum near the wound 6 KEEN, of entrance. This was tied with catgut, and the ligatured part cut off. The anterior border of the liver had been scalloped by the ball, but as there was no bleeding it was let alone. In addition, a large wound in a coil of small intestine in the left flank had been found. This was one and a quarter inches by half an inch, the long axis in the axis of the bowel, almost at the mesenteric attachment, its edges ragged, the mucous membrane pouting into the wound, but not closing it, the peritoneal wound extending beyond that in the muscular coat. No Fig. 3. Perforating wound of the small intestine x% inch laceration of peritoneum beyond the wound, pouting of the mucous mem- brane. bleeding was going on. The bowel and mesentery here were carefully examined on both sides, and upward and downward, to find any other wound, but neither did the bowel nor the mesentery show the slightest lesion. A little bilious matter escaped during the closure. This was quickly caught on a PISTOL-SHOT WOUND OF ABDOMEN. 7 sponge and the bowel carefully cleansed. Ten Lem- bert sutures were used in closing it. Returning now to the stomach, a very careful search was again made for the wound of exit. Two small patches apparently of extravasation had been seen before, in the lower border, about four inches from the pylorus, and it was now found that one of these, instead of being an extravasation, was the Fig. 4. A B A Shows the wound in the kidney. B Shows its depth. small, round wound of exit, obscured by a slight coating of blood. This was closed by three black 8 KEEN, silk Lembert sutures, as in the case of the other wound. Thus far, one lesion after another had been attended to as found, and in the order of urgency. Asystem- atic investigation was now made of the entire bowel, from the stomach to the sigmoid flexure, and no other wound discovered. Each coil as it was drawn out was examined first on one side and then on the other. The wound of exit from the peritoneal cavity next received attention, while the bowels were lying on the belly wall. It could now be found after a mode- rately easy search. I passed my finger in, and dis- covered that the left kidney was badly lacerated, and I immediately removed it, peeling it out of its capsule, and tying the pedicle with a stout silk liga- ture. No difficulty attended this step. On removal, the kidney was found to be ploughed through by the ball, on its anterior surface, from the hilum to the opposite border half way through its entire thickness one-third of its length above the lower end. Very little blood, and, so far as I could determine, no urine, was found at the site of the kidney. A rubber drainage tube was inserted through the wound of exit into the abdominal cavity. Her condition by this time was such that no time was to be lost in completing the operation. The abdomen was therefore washed out by a hot subli- mate solution (no0 to 1150) till the water flowed out clear ; the amount of blood so washed out being but little, some of which had passed into Douglas's cul de-sac. The bowels were replaced, the omentum carefully spread out over them, and the abdomen closed. This was done by nine deep silver-wire stitches, including the peritoneum, and eight inter- vening ones of silk. I should have sutured the peri- toneum at the site of the removed kidney, and also PISTOL-SHOT WOUND OF ABDOMEN. 9 have sutured it in front independently of the rest of the abdominal wall, but that the condition of the patient was such as to forbid the necessary delay. As a matter of fact, no added risk was caused. The wound of entrance was then cleansed, and closed by three stitches, and the wound of exit was closed by two stitches, except where the drainage tube passed out. Am Ende's sublimate gauze, rubber dam, and a wide flannel bandage completed the dressing, and she was then placed in bed with hot bottles and blankets. Pulse 175, and very weak. Some hypodermatic injections of whiskey had been given with advantage during the operation. During the night a little cracked ice and some ice water and half a grain of morphia were given. She had had considerable pain, but had slept about three hours. At 9.30 p.m. §iij clear urine had been drawn, but from then till 7 a.m. only gss was secreted. The morning temperature was only 99.4° ; pulse 146, and respiration 18. At the request of her mother, who had mean time arrived from New York, I asked my friend, Dr. Weir, of New York, to see her. He arrived the next day and coincided in the wisdom of the course taken, especially as to the kidney. Drs. Adams and Bidwell took charge of the case until I able to see her again with them on April 5. From their daily reports I condense her history as follows : During the day following the operation suppres- sion of urine was threatened, only ^iijss being se- creted. This was quite albuminous. The next day, however, the amount rose to gxxiv and on the third day to 5x1, and the albumen gradually disappeared. Her temperature fluctuated between 100° and 1010, rising once to 102.50, when a sponge bath and for a short time an ice bag to the abdomen brought it 10 KEEN, down to ioi°. For the first three days, as she was so fat and hearty, nothing was given her except a little cracked ice, ice water, and a little whiskey and champagne. On the fourth day peptonized milk in frequent but small quantities was allowed with rectal enemata of the same every four to six hours, and later of " liquid peptonoids," "beef peptonoids," and "bovinine." The rectal alimentation was pre- vented earlier by reason of a number of watery, but not bloody stools. She had also vomited several times, once on April 4th quite violently. The matter vomited was bilious with no blood in it. She had been in a great deal of pain which was fairly controlled by morphia. For a short time on the fourth also she was delirious. Menstruation appeared regularly when due on April 3d, and ran its usual course of four days. At my visit on the 5 th of April I found her, on the whole, doing well. Her temperature had that morning fallen to the normal, pulse 114, respiration 16, but I did not like her anxious expression and continuous pain and sleeplessness. She was thirsty, but not hungry. On changing the dressings I found the wound of entrance healed. From the wound of exit, which Dr. Adams had dressed on the the 4th, there was scarcely any dis- charge. It was healed except for the drainage tube. The abdominal wound was firmly healed at the upper and lower ends. The third, fourth, and fifth deep wire stitches had broken, presumably when the vio- lent vomiting took place the day before or possibly earlier. The intervening silk stitches prevented much gaping. Where the gaping took place the omentum was somewhat exposed, but as it and the belly walls were well glued together, I did not dis- turb them save to introduce one stitch of support at PISTOL-SHOT WOUND OF ABDOMEN. 11 the widest gap, but I did not approximate the edges, as there was a drop or two of discharge from small aseptic stitch abscesses, and I feared lest I might force it into the abdominal cavity. At my next visit, April 7th, I found the wounds doing well, no further gaping. Six stitches at the two ends were removed, as also the drainage tube, from which there had been no discharge. The pain in the left shoulder and at the epigastrium continued to a moderate extent. There was no peritonitis or tympany. But her temperature had risen to 101.3° and the pulse to 124. On the 8th, at noon, she had a chill lasting twelve minutes. The temperature rose to 1040, the pulse to 148, and the respiration to 32 ; the temperature, however, falling to 990 by 6 p.m. Her stomach and bowels had also became irritable, and much of her nourishment was lost. I did not receive the tele- gram calling me there till after the last train had left, so that I did not see her till the 9th. She had had another chill that morning, and her condition was most critical; temperature 104°, pulse 160, and very weak, respiration 36 and shallow. I suspected, of course, pus at some point and debated reopening the belly, but as the most careful examination revealed no spot of special tenderness, no dulness, no fluctuation, and she was almost, it seemed, in articulo mortis, I did not deem it prudent to do so, lest she should die at once. The next day, the 10th, she improved somewhat, her temperature falling to 990 from 101.50. She had a natural movement from the bowels with neither blood nor pus. She still vomited considerably. April 11. Dr. Weir saw her with me. Her temp, was 100.60 ; pulse 120; resp. 24. The most careful examination showed nothing locally that would 12 KEEN, guide us in reopening the belly, either in front or flank, especially in her then bettering condition. There was no pain except on very deep pressure, which produced diffused pain; nothing in Douglas's cul-de-sac; uterus movable, not tender; no peri- tonitis anywhere; only the stitch wounds were ten- der with slight suppuration about them, and on the surface of the exposed omentum. We thought it not impossible that the chills, etc., arose from those stitch wounds, and almost hoped she would still pull through. The wound was washed and redressed as before, rubber adhesive plaster supporting the belly wall outside the dressing. 13th. I saw her again. She had had another chill, with a temperature of 105.40, and had vomited several times, and also had some involuntary evacua- tions. But as her condition was fair, pulse 136, temp. 101.40, I decided to reopen the belly and explore it. No dulness, hardness, tenderness, or oedema existed to determine any opinion as to sup- puration, but I feared a possible mesenteric abscess. No ether was given, and very little pain was felt. The adhesions between the omentum and the belly - wall were broken up with very moderate force, and two fingers passed into the belly. The intestines were bright and glistening, and no peritonitis existed any- where. Surgical bimanual examination revealed no pus or special tenderness at the site of the removed kidney, or so far as it could be located at the intes- tinal wound. The stomach and liver were in good condition. The fingers detected a general hard mass at the site of the wounded superior mesenteric artery and vein, but there was no fluctuation, and when withdrawn the fingers showed no pus; nor did a sponge passed into the same point show any. The wound was then reclosed by sutures, care being taken PISTOL-SHOT WOUND OF ABDOMEN. 13 to replace the omentum and belly-walls in as nearly their former position as possible, and a glass drain inserted as a precaution. No shock followed. Her temperature fell temporarily during the evening, though it rose again during the night, and she slept nearly three hours. During the next day (April 14) she had two bloody movements; she began to have involuntary dis- charges of urine as well as feces, and though her temperature never rose beyond 102.20, she gradually failed, and died April 15th, at 1.30 p. m. The autopsy was made by the Coroner's direc- tion, by Dr. H. C. Smith, of Millville, twenty-one hours after death. Through his courtesy, as well as from Drs. Adams and Bidwell (for I was unable to be present), I obtained the following facts, as well as the stomach, bowel, and right kidney. There was general peritonitis, except in the pelvis, but no free pus was found anywhere. The wound in the liver was healed. Only one wound was found in the stomach near the pylorus, and this was healed, the four stitches being seen in place. The site of the other could not be found, nor could its three stitches be found anywhere. Search was made in the duodenum also, but no wound could be dis- covered. The duodenum, head of the pancreas, and mesentery were softened and matted together by inflammatory exudate, and the head of the pan- creas was cheesy. The blood in the mesentery was disintegrating and suppurating, though no abscess existed nor was there any free pus in the peritoneal cavity. The suppuration was chiefly marked along the mesenteric attachment of the intestine. The wound in the small intestine was found entirely healed, the stitches being in place and covered with a thin layer of lymph. On the other side of the 14 KEEN, mesentery, corresponding in position to the lower end of this wound, was a spot in the bowel-wall as large as a five cent coin, which was gangrenous, and in its centre was a double perforation of bowel with Fig. 5. Section of wound in small intestine at a in Fig. 3, showing the site of the gangrenous spot and perforations found at the post- mortem. The wound is represented open, as at the operation. pus in the calibre of the bowel. I have not received the mesentery, but I am told that it also showed local gangrene at this place. Very careful and sys- tematic search of the entire length of the bowel re- vealed no wound except that discovered at the operation. No trouble was found at the site of the removed kidney. The right kidney was removed and found healthy and enlarged. Both kidneys having been in the same bottle in alcohol, the right for two weeks the left for four, their measurements are: right, 4^ by 2^ inches; left, 3^ by inches; the right kidney is also thicker. The spleen was normal; right ovary cystic. Only the abdomen was examined. PISTOL-SHOT WOUND OF ABDOMEN. 15 Remarks.-The question of doing a laparotomy was not wholly easy to decide. Besides social cir- cumstances, which made me hesitate to assume any except urgent responsibility, neither wound could be positively traced into the belly cavity, though the nearness of the pistol made it almost certain that the ball had pursued a straight line, and if so, had pene- trated the abdomen. It is worthy of note, in this connection, that when the fingers were in the abdom- inal cavity the wound of entrance could not be felt, and later, when, by lifting the belly wall, the perfo- ration in the peritoneum could be seen, when the finger was placed there it still could not be felt. The amount of clear blood vomited at the time of the accident was very small, and we had only the state- ment of the wounded girl to depend upon. Even this, as well as the streaking of blood in the later vom- ited matters, could come from contusion or her fall. There was no evidence of blood either by the bowel or the bladder. Her long continued and deep pallor, weak and rapid pulse pointed toward hemorrhage, but palpation and percussion did not give positive evidence of any. But, as everything seemed to point toward probability of the belly's being penetrated, I determined upon an exploratory laparotomy, in order to determine the facts absolutely. In this decision my colleagues coincided. Fortunately, the presumed course of the ball crossed the proper line of incision, and I was able to decide that it had not traversed the wall of the belly by not finding its path while I was making my first incision, and before opening the peritoneum. No food having been taken before the early hour in the morning at which the shooting occurred, for- tunately prevented any extravasation of food, and none of the wounds being in the lower bowel, no 16 KEEN, feces escaped. Although it was nearly ten hours from the accident to the time when the intestine and stomach were sutured, it is worthy of notice that no intestinal or gastric juice or fluid contents escaped, even though the intestinal wound was so large and gaping, and vomiting occurred three times prior to the laparotomy. The pouting mucous membrane well occluded the gastric wounds. The second opening in the stomach was difficult to find, and was at first mistaken for a simple ex- travasation, a fact already noted by Dr. Briddon1 as occurring in a case of his own. There was, how- ever, no doubt as to its existence, and I put three sutures in its edges. At the post mortem no evi- dence of its position could be found, though careful search was made both in the stomach and the duode- num, the possibility that I might have measured the wrong way being borne in mind. There is neither scar nor sutures to be found on the outer or inner surface of the stomach. The sutures in the other stomach wound are in place, and look as though they would remain for some time. Whether, in the other wound, the sutures disappeared internally after the healing of the small wound, or loosened and were lost in the belly cavity cannot be determined. The peritonitis, found at the autopsy, did not exist on the twelfth day, when the belly was re- explored. Nowhere was the glistening peritoneum then dulled. Two sources existed for the later peri- tonitis-the opening in the intestinal wall opposite the intestinal wound and the mesenteric pus. The former was the most likely source. At the operation the bowel and mesentery were carefully inspected on both sides, but no such opening existed. Had it 1 The Medical News, January 8, 1887. PISTOL-SHOT WOUND OF ABDOMEN. 17 been made by the ball, peritonitis would undoubt- edly have occurred quickly after the operation, and there would not have been two openings here, as the specimen shows. I have nodoubt that the fact was that the ball contused a part of the mesentery, especially probably an arterial branch. This did not show at the time, but later on produced a limited gangrene, and perforation took place a day or two before death. Dr. Smith, also, tells me that the mesentery itself was necrosed at this place. The bloody stools preceding death point in the same direction, especi- ally as she had had a natural movement of the bowels, with neither blood nor pus, on the ninth day after the wounding. Hereafter, however, in all cases of intestinal gunshot wound, whether single or double, I shall examine the mesentery more minutely for any possible evidence of contusion as well as per- foration. Possibly this necrotic process in the bowel, as well as the general softening of the duodenum, was pro- moted by the serious wound of the superior mesen- teric vessels, especially the vein. The artery was a small branch, but the vein was the main trunk just below the head of the pancreas, and so large that when I first seized the bleeding point and lifted the wall I thought it the vena cava. I placed a lateral ligature upon it, seizing the margin of the small opening, as large as the lead of a pencil, and secur- ing it by a catgut ligature. To dissect it loose and encircle it with the ligature would have required a considerable loss of time which I wished to avoid, and besides, I feared the effect on the bowel of obstruct- ing so large a vein. Whether a thrombus formed in the vessel, and occluded it, was not examined. The blood, curiously enough, did not find vent into the peritoneal cavity by the wounds in the mesentery, 18 KEEN, save to a very slight extent, but dissected the two layers of the mesentery, and was spread out, fan-like, from its source to two feet of bowel, in a moderately thick layer, thickest at the spine. This it was im- possible to remove, and I had to trust to its absorp- tion. I was not surprised that there was trouble at the site of the wound in view of the injury done by the ball, and the necessary manipulation to get at and secure the vessels. It is worthy of note, how- ever, that the chief trouble existed at the periphery of the clot near the bowel, where we would expect absorption most readily to take place. Probably the main absorbent trunks from this part, as they ap- proached the spine, may have been obstructed by pressure, or have been injured by the ball or during the operation. The kidney, I believe, has never before been re- moved at a laparotomy for gunshot wound, but it was clearly the right thing to do. Bloody urine is one of the most frequent signs in injuries of the kidney, and its absence here was remarkable. The wound extended entirely across the kidney, and half way through its thickness, yet the urine (§xvj) drawn eight hours after the accident (and none had been passed), was absolutely free from blood, the injury apparently arresting the function of this kidney, while the laceration of the renal substance was such that but slight bleeding occurred. Possibly the urine drawn had been mostly secreted during the night. The day following the operation the remain- ing kidney worked badly, only three and a half ounces of albuminous urine being secreted. But the next two days dispelled all anxiety on this score, the urine rising to twenty-four and forty ounces respe- tively, and the albumen soon disappeared. The early and marked compensatory enlargement of the 19 right kidney is also of great interest and importance, though, of course, now well known to follow nephrec- tomy. When the chills occurred, due, no doubt, to the necrosis and suppuration of the large mesenteric blood clot, naturally the first impulse would be to open the belly, anteriorly or in the flank, and search for the pus. But I was deterred from this course by her general condition, which then threatened almost immediate dissolution, and by the fact that no peri- tonitis existed at the spots most likely to be the seats of suppuration. The most careful external ex- amination revealed its absence. To this, possibly, the wounded vessels and effused blood should be an exception. Even here, however, there was no dul- ness, fluctuation, or hardness, and the slight tender- ness that existed was to be expected. When I did reopen the belly and examine this spot I only found a general matting of the tissues, and no accumula- tion of pus in an abscess. What pus did exist at the post-mortem was not free in the belly, nor accumu- lated in an abscess, but diffused between the mesen- teric layers. I did not suture the peritoneum at the site of the removed kidney, as the patient's condition did not allow of the delay, and no harm came of it. In view of the possibility of the giving way of stitches in the abdominal wound, which occurred here, and also in a case of Dr. Bull's (and exposed the intes- tines), I should hereafter take time to close the peri- toneum by a continuous catgut suture before suturing the abdominal wall, even if the patient's condition were bad. The avoidance of possible subsequent dangers would justify taking a certain amount of present risk. The reason for the severe and quite persistent pain in the left shoulder, I could not determine. PISTOL-SHOT WOUND OF ABDOMEN. THE MEDICAL NEWS. A National Weekly Medical Periodical, containing 28-32 Double- Columned Quarto Pages of Heading Matter in Each Issue. $5.00 per annum, post-paid. Uniting in itself the best characteristics of the magazine and the newspaper, The Medical News renders a service of exceptional value to the profession. It presents original articles, hospital notes and clinical lectures by the ablest writers and teachers of the day, discusses living topics editorially in a clear and scholarly manner, and employs all the recent and approved methods of medical journalism- the telegraph, reporters and a corps of special correspondents covering all the medical centres of the globe. It thus imparts, without loss of time, all advances of knowledge attained in the medical sciences. In short, it is the effort of all concerned in the publication of The News that it shall be indispensable to every physician in active practice. The American Journal of the Medical Sciences. Edited by I. Minis Hays, A.M., M.D. Published quarterly, on the first of January, April, July and October. Each number contains over 300 large octavo pages fully illustrated. $5.00 per annum, post-paid. In his contribution to A Century of American Medicine, published in 1876, Dr. John S. Billings, U. S. A., Librarian of the National Medical Library, Washington, thus graphically outlines the character and services of The American Journal-" The ninety-seven volumes of this Journal need no eulogy. They contain many original papers of the highest value; nearly all the real criticisms and reviews which we possess; and such carefully prepared summaries of the progress of medical science, and abstracts and notices of foreign works, that from this file alone, were all other productions of the press for the last fifty years destroyed, it would be possible to reproduce the great majority of the real contributions of the world to medical science during that period." COMMUTATION HATE.-Postage Paid. The Medical News, published every Saturday, J The American Journal of the Medical - in advance, $9.00. Sciences, quarterly, .... J LEA BROTHERS 6- CO., PHILADELPHIA.