ship and in due proportion to the positions and degrees of the changes in the second nerve.

The objective appearance of the peripheral ending of the living nerve, with its small vascular circle and its surrounding retinal area as revealed by the ophthalmoscope, next demands attention. Here the effects of an optic neuritis, or of a secondary optic nerve atrophy with or without retinal change, may often be seen. The two varieties of picture, as shown in a measure by the degenerate appearance of the nerve-head, its apparent bloodlessness, the contraction of the retinal vessels, and the few remnants of past hemorrhagic extravasation, can hardly be mistaken; while the irregularity of the shrunken disc surface, the slight blurring of the borders, and the opacities along the retinal lymph-channels when "choked disc" has been present, can seldom be misconstrued. Upon account of their almost certain appearance during some period in the course of an intra-cranial neoplasm, they form one of the most important objective symptoms in this affection.

Leaving the sensory groupings, we reach the motor. Taking the objective findings first, we shall soon notice that they are the ones which are most completely within our grasp here much of this character of the symptomatology becomes visible without resort to artificial means it is to a greater extent noticeable to naked-eye observation, and thus calls for less dependence upon the assertions of the patient. If careful study be made of the ordinary methods of examination necessary for the ascertainment of the symptoms, and if the various and frequent modifications of technique, so desirable in most instances, be taken into consideration, the procedure for the study of the objective groupings will readily resolve itself into one of the easiest and most comprehensive that can be offered to the ophthalmic clinician. Far different is it with the subjective symptoms. Here there is so much at variance, there are so many details of structure and peculiarities of action to remember, there is so much that is inter-related and hidden, that the most accurate knowledge of the subject, with the most tedious and at times apparently most contradictory courses of examination, are necessary before any useful data can be obtained. Difficult as it is to understand the average degree and relative proportion of muscle innervation so requisite for monocular balance and binocular adjustment; hard, for the less well informed, to comprehend the actions and peculiarities of correcting prismatic forms; and tedious, in most instances, to study the amounts of combined muscle action necessary to give what is known as proper equilibrium and extreme of normal working power in any certain direction-the various plans, though aided by the most ingenious and useful mechanical contrivances, are not only perplexing to the beginner, but often present insurmountable obstacles to even the bestequipped and most practised ophthalmologist.

Proceeding in the same manner as with the sensory symptoms, we will first consider the irritation types. Both clonic spasm of the ciliary muscle of probable central origin, such as is possibly seen in some cases of chorea, and tonic spasm of the same fibres, such as has been described as appearing during the cyanotic stage of an epileptic attack, are curious and interesting. These observations, if correct-which can be decided only by proper generalization-may prove of the utmost value. In the former, the degree and duration of alteration of the muscle-tone and its irregularly repeated contractions can be determined by the retinoscope and the test-lenses; whilst the latter, which, by reason of want of frequent opportunity to the advanced ophthalmologist for study and the increased difficulty of examination, is so rarely encountered, can be made evident by the ophthalmoscope.

Temporary spasm, not only of the iris and of the ciliary muscles, but also of the extra-ocular series, may at times assert itself. Again, involuntary spasmodic contractions of certain physiologically related musclegroupings may take place. Prominent among the latter are those which in association with contrary and similar rotations of the head and neck accompany the general convulsive seizures so often seen in cases of focal epilepsy. Here the character of the uncontrolled motions and their relative directions of movement offer important objective signs as to the probable position of the intra-cranial site of irritation-a disturbance which in this class is "more apt to be caused by lesions in the motor zones and in the centres which are devoted to the action of the involved group or groups of muscles." Even more, the rare cases of clonic spasm not only involving the intra-ocular and extra-ocular muscles, but also at times combined in greater or less degree with similar movements in the muscles of the ocular appendages, as seen in some cases of nuclear disease, serve as useful indices in differential diagnosis. The peculiar recurrent spasm of the orbicularis, and the less well understood and more complicated motor changes reported from time to time, should all be taken into consideration and noted whenever found.

Passing to the degenerative types of objective symptoms, we find them somewhat easier to study. One cannot fail to notice how plainly visible are the degrees of tonicity and the amounts of movement of the muscular tissues of the irides. Graphic in the extreme, recognizable in the majority of instances by the merest novice, and frequently well obtained. under the most difficult circumstances, these special groupings become more valuable guides for the detection of related intra-cranial disturbance than their associated irritative motor expressions of disease. Excluding the so-called Argyll-Robertson pupil and the many and bizarre pupillary changes found in general paralysis of the insane, the muscle tone and movement of this portion of the visual apparatus are not merely indicative of fault in sensory channels, but become of peculiar

value in the determination of trunkal and nuclear disturbance situated in the connected and related intra-cranial regions. So, too, with the extra-ocular groupings: breaks in muscle-motion during definitely associated physiological acts, apparent failure of expression in supposed monocular and binocular response of single and combined motor impulses, and even absolute negation of all response to any form of stimulus, are here found. Varying from the slightest paresis to the most complete paralysis, and appearing in sequence that should be carefully considered from the very first indication of functional loss, they present themselves, in combination with the other symptoms, for careful and repeated study. Though difficult of comprehension in the great majority of cases, and yet easy to make plain to naked-eye inspection in many instances, they should always be sought for and carefully studied. If this be done, the greatest possible value can be attached to them as indicative of central disease.

With proper and extended study of these four series of symptoms, which, as we now can understand, are expressive of both sensory and motor changes in an apparatus that extends throughout so vast an intracranial area and with careful reasoning and accurate noting of the many and varied changes that must constantly arise in the numerous combinations of their associated conditions and actions, much may be expected. In conclusion, we can broadly assert that when any part of this special sensory channel is irritated or inflamed, there may be hyperæsthesia, as evidenced by symptoms of increase of functional activity such as phosphenes, etc., associated at times with coarse objective changes in the fundus of the eye; but if it be lowered in vitality by any cause whatever, anesthesia will be present, as shown by decrease of physiological action, such as dimming and actual loss of macular and circum-macular vision, which frequently may be connected with visible degenerative lesions in the ocular background. If there is motor involvement, both clonic and tonic spasm show themselves as the results of irritation, etc., while paresis and paralysis announce themselves if degeneration exists.

As the writer has once before had occasion to say: "Each ocular symptom, however, in itself, is not etiologically self-answerable. Careful study must be made of all the conditions, so that by the process of exclusion adequate data can be obtained upon which to base answers as to the character, the type, and the situation of the supposed intra-cranial lesion."

Here instruments of ocular precision, in combination with the tact of an acute observer and the ingenuity of close questioning, will frequently unravel the many ocular threads of query and help to give practical answer as to the position of intra-cranial lesion.

REVIEW S.

REGIONAL ANATOMY IN ITS RELATION TO MEDICINE AND SURGERY. By GEORGE MCCLELLAN, M.D., Lecturer on Descriptive and Regional Anatomy at the Pennsylvania School of Anatomy, etc. Illustrated from photographs taken by the Author, of his own dissections, expressly designed and prepared for this work, and colored by him after nature. In two volumes. Vol. I. Philadelphia: J. B. Lippincott Company, 1891.

THE appearance of a new and comprehensive treatise on anatomy in the English language is an important event, especially when the author is well known as a distinguished and successful teacher, and the book itself is the fruit of great labor and expense. The book itself is a large and handsome one. The type is large and very legible, the lines far apart, the margins broad, and the paper thick. The fine colored plates are on separate pages. When such a book is brought out we must suppose that the author believes he has something important to say; that either new matters are to be presented, or new methods of presentation are to be used. We must look, first of all, for the author's intent; criticism then must deal with the worth of the purpose itself, and with the degree of success which the author has attained.

Dr. McClellan's purpose is to consider all the parts together, instead of the different systems successively, and to supplement his descriptions by colored plates prepared from photographs. The author plainly attaches great importance to these illustrations, which, in fact, are the characteristic feature of the book. His argument, as given in the preface, is essentially this: Anatomy is best learned from the "subject;" but owing to the difficulty of having enough material, and of bringing the students near enough to it in the lecture-room, there is need of something else. "Extempore drawings," says the author," are of great value in awakening and retaining the interest of students, whose memories are often overtasked, and have an advantage over the most carefully prepared diagrams, models, or preparations; but there cannot be any means of illustration equal to the real thing in teaching; and the best substitute is that which aims at producing the most realistic impressions. Such illustrations have been attempted in the plates of the present work." Further on he says: "It should be borne in mind, however, that no true picture of the actual subject will have the distinct demarcation and clearness of a diagram any more than the representation of a natural landscape indicates mountains, rivers, and boundary lines with the exactness of a map. Diagrams will, therefore, always be useful to the student in showing him what he ought to see, but such illustrations as are here attempted should be valuable in enabling him to recognize things as they actually are. These representations are intended to meet the need both of the beginner in dissecting, who is appalled by the want of

correspondence between that which he actually sees and that which he has been led to expect by diagrams or description, and of those whose time is too gravely occupied by the pressure of professional duties to warrant their dissecting for themselves." We make no apology for the length of these quotations, for here we have the root of the matter. Is the author's idea of the kind of illustration required the correct one? Do the plates in the book come as near to the ideal as is reasonably to be expected? With all deference to the text, which is in the main very good, we have no hesitation in saying that this book will stand or fall, according as the public answers these two questions.

To give our opinion on the second question first, we must say that, with some exceptions which leave much to be desired, the plates come quite as near the proposed standard as could be hoped for. Of some of them it is hard to speak too highly. They are beautiful, and they are true. One feels that he sees the dissection as it was. The want of outline, which rather oppresses us, is a necessary result of the method. We have found, moreover, that on looking at one of these plates for a considerable time, what at first is obscure becomes clear, as is the case with certain pictures of the impressionist school. There are several transverse sections which, to our mind, would have been better had they been made through frozen bodies, but they are, for the most part, very good as they are. There are some plates, however, which can have no share of this praise. The worst are those of the convolutions of the brain. After Dalton's achievements they cut but a sorry figure. What is worse is that they are quite inadequate to their purpose. It is inconceivable that a student could learn the convolutions on them.

Finding, then, that in spite of some shortcomings the plates as a whole are good, we come to the fundamental question whether this method is sufficient, especially for students. We regret to differ from the author in believing that it does not rest on a correct principle. It is not enough to have a picture that reproduces perfectly, were it possible, the image thrown on the living retina. For teaching purposes we need more. We want a representation of the concept in the mind of the teacher which has been acquired by more than the sense of sight. We want to have certain points emphasized. We would have certain facts, so to speak, put in italics in the plate. In studying these plates, we sometimes feel precisely as we have felt in looking at an operation or a dissection from a distance. We wish our eyes were a little sharper, or the light a little better, or that we could draw the tissues a little more asunder. The same feeling is instinctive with the student even close to a dissection. He is not content to look at it. He longs to touch it; to put his fingers into it. In short, he wants to bring another sense into play to help out his sight. Moreover, what we learn from a picture depends largely on our knowledge of the subject-matter. The whole story, if you please, is in the picture, but it gives one message to the expert, and a very different one to the beginner. The latter needs some guidance beyond the very complete set of references with which these plates are provided. For these reasons we regret very much that the author does not give a series of simple diagrams in the text, if he could not consent to a more diagrammatic handling in the plates themselves. The volume before us treats of the head, the thorax (excepting those parts of it which may be classed with the back), and the arm. Dr. McClellan's method is that of the practical anatomist. We feel