been a severe optic neuritis or papilledema. Of course, optic atrophy may follow optic neuritis which is not of the character of nor the amount of swelling sufficient in degree to consider the case one of choked disc or papilledema, but in these cases the evidences of secondary atrophy are not as strongly marked.

The white patches and the white spots about the nerve head given in the report of the ophthalmoscopic examination show that there have been hemorrhages most probably at the time of the optic neuritis, and they further show, when considered in connection with the character of the atrophy, that the swelling of the nerve head was marked and, therefore, strongly suggest the probability that there was true choked disc or papilledema present at that time.

REPORTS OF CASES.

A CASE OF BILATERAL CERVICAL RIB.

JOHN H. PETTIS, M. D.
Department of Surgery.

Mr. H., laborer, aged twenty-nine, presented himself at the University Hospital December 28, 1911, for diagnosis of a tumor on the left side of the neck.

His past history is without interest except possibly the fact that at eleven years of age and again eight weeks ago he had an attack of "suffocation" as he expressed it which was diagnosed by the attending physicians as asthma. These attacks lasted but an hour or two each time but left the patient feeling somewhat weak for a day or two. At the time of the last attack the attending physician discovered the tumor in the neck and diagnosed it as a cervical rib.

On examination a smooth, hard, slightly movable mass about the size of a pigeon's egg was felt just above the middle of the clavicle. Its anterior end was fixed but its place of attachment could not be made out. Posteriorly it was evidently attached to the vertebral column. There was no tenderness and no pulsation over the tumor.

The r-ray picture which I present shows a very interesting condition. You will observe that there is an extra rib on either side although the one on the left is much more prominent and is more easily made out. You will also notice that the left rib is made up of a proximal and a distal portion between which there is a distinct joint. Whether or not the distal portion is connected with the first rib cannot be definitely determined, although it very probably is. The proximal portion evidently articulates with the upper portion of the seventh cervical vertebra. The rib on the right side is lower and more obliquely placed, making its exact relations rather difficult to determine. This position of the right rib accounts for the inability to feel it on examination.

Since it seemed unlikely that the presence of these cervical ribs. had anything to do with this patient's symptoms operation was not advised.

DISCUSSION.

DOCTOR GEORGE L. STREETER: I do not know that I can add anything further to this particular case. I did not see the patient and I have only just now seen the radiograph.

These drawings illustrate the development of a typical vertebra and show how the cervical vertebræ have a part homologous to the rib as found in the thoracic region. All vertebræ have a pair of costal processes, but it is only in the thoracic region that they ordinarily form ribs.

The arrangement of the vertebræ at the lower end is usually influenced by the place where the limb lies. It is very apparent that we are descended from people who had a larger thorax than we and that we are on the downward grade with regard to development of the thorax. Our ancestors probably had thirteen ribs and more. The number of ribs is apparently dependent upon the size of the viscera. If we had more viscera we would have a greater number of ribs, and if we could experimentally displace the viscera and keep them up in the neck we would have ribs throughout that whole region. Their number and situation are determined by the position and size of our thoracic viscera.

With regard to the arm and leg we can perform such experiments and displace the arm or leg bud forward or backward. When the leg bud is thus experimentally altered in position, the lumbar plexus has been shown to be developed higher or lower according as we displace the bud. In the same way we can displace the arm bud.

In adults we usually find the variations in the ribs in the lower thoracic and lumbar regions; variations in the upper thoracic and cervical regions are much less frequent. I have not looked up the exact figures, but I think cervical ribs are found in one or two per cent of the cases. We may have just an enlargement of the costal process, more or less detached from the transverse process. This is common. There are all stages between this and the complete rib. The well developed seventh rib is reported in less than one per cent of the cases; they probably occur more often than that for they are often overlooked. We had a case of completely developed cervical rib in the dissecting room last year and did not see it until near the end of the dissection.

In the radiograph Doctor Pettis pointed out the presence of an apparent joint in this case which is an interesting feature, for in certain of the other vertebræ, in the sauopsida, joints of that kind are the normal occurrence. In birds as a rule one gets joints in the ribs, and this would be a reversion to that type, but it might also be interpreted that here one has the posterior part of the rib well ossified and that the apparent joint is due to the fact that the rest of the rib may be fibrous, that is, an imperfectly formed rib. Where cervical ribs are present the rule is that the scalenus muscles are attached to

their upper surface, that is, the cervical rib assumes the relations of the first rib. The subclavian artery and cervical plexus usually pass over the rib.

DOCTOR MATTHEW KOLLIG: I would like to demonstrate these two specimens which have a direct bearing upon the subject under discussion.

This first specimen is a seventh cervical vertebra showing a well marked costal element on both sides. The left costal element is longer than the right, is completely detached from the true transverse process, and resembles a rudimentary cervical rib.

The second specimen shows a complete cervical rib coming from the right side of the seventh cervical vertebra, resembling in form the ordinary first rib, possessing a well formed costal cartilage and has a sternal articulation in common with the first rib.

DOCTOR JAMES G. VAN ZWALUWENBURG: What is the explanation of an interpolated rib? We discovered one accidentally in an x-ray for diagnosis in a suspected case of tuberculosis. I think it lay between the seventh and eighth ribs on the left side. and had no attachment to the vertebræ at all. It articulated with the rib below by a definite articulation. There was a raised knob with a nice articular surface at about the position of the angle of rib below. The extra rib had a definite neck and angle, but the anterior attachment could not be made out. The radiogram was taken with the plate to the back and the image of the structures in front was so diffuse that it was impossible to make out exactly what became of its anterior extremity. The patient was a young woman and the condition had never been suspected.

DOCTOR STREETER: Forked ribs undoubtedly do occur and we have such a specimen over in the laboratory. It is a forking of a rib and there is no real explanation except that we find it in the cadaver now and then. There is evidently disturbance in the growth and for some reason they become bifurcated, perhaps the presence of some small blood-vessel in the early stage bifurcates the blastomere. It is a pathologic condition. The forked rib has a distinct articulation. Where it is a forward bifurcation, we often find two costal cartilages each articulating with the sternum. Where the bifurcation. is not complete at the sternal end a joint is frequently formed with the next adjacent rib.

DOCTOR PETTIS (closing the discussion): As Doctor Kollig has said this condition is usually bilateral although one rib is usually much more developed and more prominent than the other. It has been estimated that only about ten per cent of the cases of cervical rib give rise to symptoms and these symptoms are very rarely bilateral but are confined to the side on which the rib is most developed. Whether or not these ribs give rise to symptoms depends upon their relation to the cervical plexus and the subclavian artery. When they are of considerable length, that is, five or six centimeters or more,

the plexus and artery usually pass over them and when this anatomic arrangement obtains certain vascular and nervous symptoms may arise. These vascular symptoms are due to disturbed arterial supply to the arm and consist of paleness, coldness to touch, et cetera. Rarely gangrene has occurred in the soft parts of the finger tips following thrombosis of the brachial artery which is said to occur in a considerable number of these cases. The nervous symptoms are such as are brought about by pressure on nerves such as pain, paresthesias, et cetera. Singularly enough, there is seldom swelling of the arm, probably due to the fact that the subclavian vein, owing to its lower and more median position, is rarely involved.

Another curious and interesting thing in connection with this condition is the fact that the artery, just distal to the point where it passes over the rib, is often very much dilated and this dilation often gives rise to the suspicion of aneurysm. Why this dilation should take place distal to the rib is not very clear but is possibly explained by a thrombosis of the brachial which is common in vascular disturbances of cervical rib.

The operation for the removal of a cervical rib is not a very difficult one. The incision may be made parallel to the clavicle or it may be vertical or obliquely vertical between the sternomastoid and the trapezius. Or a combination of the two incisions may be made, any incision that gives plenty of room. The dissection must be made carefully in order to insure against injury to the plexus and artery and also the pleura which is often attached to the lower portion of the rib. In general the results of the operation have been very satisfactory and no mortalities have been reported.

A FATAL CASE OF ECLAMPSIA.

HOWARD H. CUMMINGS, M. D.
Department of Obstetrics and Gynecology.

Mrs. M. E., aged thirty, a primipara, was brought into the hospital in an unconscious condition, on the morning of December 17, 1911. Her history, which was obtained from the husband, was negative until the day previous to her entrance. The patient had always been well and from the beginning of her pregnancy, seven and one-half months previously, had manifested no signs or symptoms of intoxication. On the evening of December 16, 1911, while seated in a chair she was seized with a terrific pain in the epigastric region. The patient described this pain as stabbing in character, beginning in front and passing through to her back. Her husband rubbed the chest and back with liniment and applied a mustard poultice. These measures gave no relief and soon she complained of a severe headache in the frontal region. In less than an hour from the time of onset of the epigastric pain, the patient fell to the floor and had a violent convulsion. During the night she had four convulsions and did not regain consciousness between the attacks. The

following morning she was conveyed eight miles in an ambulance and during this trip she had two more convulsions.

Examination.- The patient was very fleshy. Her face was flushed; the eyes were fixed with the pupils dilated; there was but slight edema of the eyelids. The lips were dry and blood stained, the tongue was swollen and bleeding, the breath was very foul. The breasts showed the usual signs of pregnancy. The abdomen was large and flabby. The fundus of the uterus was located about half way between the umbilicus and ensiform. The fetus could be mapped out in the occiput left anterior position, its heart beat could be heard in the left lower quadrant of the abdomen; the rate was about sixty beats per minute. On catheterization about eight ounces of very dark, smoky urine was obtained. Examination of the urine showed red blood cells, numerous granular casts and about one-half volume of albumin. The rectum was impacted with fecal matter. Pelvimetry showed a normal sized pelvis. A systolic blood pressure of 160 millimeters of mercury was recorded by the Faught instrument.

ment.

During the examination the patient had several severe convulsions. These attacks began as a slight twitching in the hands and facial muscles which gradually spread and increased in severity until the whole body was involved in a clonic convulsion. The face and neck became cyanotic, the superficial veins stood out prominently, the breathing became labored. The jaw was firmly set. Urine and fecal matter were voided during these attacks.

Treatment.-Heavy blankets were placed over the patient and she was surrounded with hot water bottles. A towel was forced between the teeth to prevent any further damage to the tongue and lips. Two enemas were given to clear the lower bowel. Without administering an anesthetic an attempt was made to empty the uterus rapidly. However, after the cervix had been exposed and seized with a tenaculum it was evident that vaginal Cesarean section was impossible because the cervix could not be drawn down into view. The child's head had descended so far into the lower uterine segment that the cervix was almost immovable. The cervix was soft and the convulsions had dilated it enough to allow two fingers to be inserted. The dilatation was completed by the manual method of Harris. This consumed twenty-five minutes. When the hand could be easily passed into the uterus, the membranes were ruptured and an attempt made to do an internal podalic version; however, the small amount of amniotic fluid and the tonic condition of the uterus made this impossible. Axis traction forceps were applied to the child's head and the delivery was accomplished without difficulty. Judging from the fetal heart rate the child was moribund before the operation was begun and all attempts at resuscitation were useless. The mother's pulse at the end of the operation was 148 per minute. One-half pint of blood was drawn from the basilic vein of the right