ORIGINAL LECTURES.

LECTURES

ON

THE SPINAL CORD,

DELIVERED AT

The College of France,

DURING THE SUMMER SESSION 1860,

By M. CLAUDE BERNARD,

Member of the French Institute; Professor of General Physiology at the Faculty of Sciences, &c.

LECTURE XIII.

ON THE ORIGIN OF THE SYMPATHETIC NERVE. Summary: The Spinal Cord is the Source from which all the Peripheral Ramifications are derived-Opinions of Anatomists on the Nature, Origin, and Functions of the Sympathetic Nerve-Remak's Fibres-The Sympathetic Nerve arises from the Spinal Cord-Experiments of Pourfour-Dupetit, Duprey, and Magendie-The precise Origin of the Cervico-Cephalic Portion of this Nerve ascertained by Budge and Waller -Bernard's Experiments on this Subject-Discovery of the Augmentation of Temperature which follows the Division of the Sympathetic Nerve-Jacubowich's Opinions on the Nervous Cells of the Spinal Cord. GENTLEMEN,-The central axis from which the nerves of sensation and motion, or animal life, are derived, gives birth to other nerves, which regulate a totally different order of functions, and direct the operations which take place in the very depth of our tissues. You have witnessed the experiments which prove the existence of the connexion between the spinal cord and the nerves of animal life; it now remains for us to convince you that the chemical phenomena which arise within the system are also placed under the influence of the same centre.

The sympathetic nerve, a few years ago, was generally viewed as a distinct and independent nervous system. Anatomists were struck not only with its distribution, which differs from that of the cerebro-spinal nerves, but also with its appearance: its colour is not the same; its disposition is peculiar; and Remak has described certain histological characteristics which he considers as belonging exclusively to this portion of the nervous system, while other micrographers suppose them to be the vestiges of an imperfect state of development. All these views, however, are now completely laid aside; and the spinal cord is positively acknowledged to be the origin from which all the peripheral ramifications of the nervous system arise, whether they extend to the muscular apparatus, to the skin, mucous membranes, and organs of sense, or to the viscera of organic life.

The experiment which has brought this fact to our knowledge is not a recent one, although its results were formerly interpreted in a different sense. In the course of the last century, Pourfour-Dupetit discovered that the division of the sympathetic nerve in the cervical region was attended with contraction of the pupil, and vascularisation of the conjunc. tiva, on the corresponding side. He thence inferred that the animal spirits were conveyed to the eye by the sympathetic nerve, and that, after dividing it, they were prevented from ascending to the head, as before. From this experiment he drew an important conclusion: viz. that the animal spirits, instead of descending from the brain to the lower parts of the body, followed the opposite direction, and rose from the chest into the head. In the scientific language of that period, this was equivalent to saying that the sympathetic nerve (or its cervical portion at least) did not arise from the brain, but was derived from another and a lower region of the body: for in those days, the nervous system of organic life was believed by anatomists to spring from the third pair of nerves, which are in fact anastomosed with some of the ramifications of the carotidian plexus, an off-shoot of the cervical branch of the sympathetic nerve.

This experiment was successfully repeated by Duprey, Magendie, and numerous other observers; but the real origin of this important division of the nervous system remained undiscovered till lately, when the interesting researches of Budge and Waller proved its cervico-cephalic branch to be derived from the spinal cord, on a point which they designated under the name of the ciliary spinal region, their VOL. I. 1861. No. 567.

attention having been exclusively directed to the ocular phenomena which lie under its control: it corresponds to the junction of the cervical and dorsal divisions of the spinal axis. These gentlemen were led in the following manner to ascertain this important fact. In examining the alterations which arise in compound nerves, when divided, Waller had observed that the peripheral extremity alone degenerates, the central portion retaining its usual structure and properties; but on dividing both the sympathetic and pneumogastric nerves at once, in a dog (for in this animal they are too closely connected to be easily separated) he found that part of the common trunk was atrophied, in the upper extremity, and the remaining portion in the lower. On comparing this modification with the results of his former experiments, he thought it probable that although parallel, the two nerves followed opposite directions, the one ascending to the head, the other descending to the lower parts of the body. On following up this discovery, he was enabled by the same method to trace back the cervical branch of the sympathetic nerve to the thoracic ganglia, and the apparent branches of these to the spinal cord.

When this ascending branch of the sympathetic nerve is divided, the application of galvanism to the lower, or central extremity has no effect upon the cephalic region: but on galvanizing its peripheral portion, the pupil, which was strongly contracted in consequence of the operation, dilates again with considerable rapidity. The radiated fibres of the iris, therefore, evidently correspond to the ascending ramifications of this nerve; it therefore arises from the spinal cord, being, as you perceive, directed upwards. But a still more indisputable proof of this appears, in the effects produced by the unilateral division of the central axis, between the seventh cervical and first dorsal vertebræ ; the radiated fibres of the iris are paralyzed in the corresponding eye and if it is desired to ascertain whether nervous influence is supplied in this case by the anterior or posterior roots, there is no difficulty in proving it to be derived from the former: for when the posterior roots of the eighth pair of spinal nerves are divided, the pupil remains in its usual state; when on the contrary, the experiment is performed on the anterior root, the effects just described immediately take place; the intensity of these phenomena is, however, much greater when the anterior root of the preceding pair are also divided; it is therefore evident that the ramifications of this nerve, which spread to the pupil, are derived from the motor roots of the seventh and eighth spinal pairs. Lastly, if the galvanic stimulus isapplied to the central extremities of the divided roots, no change occurs in the pupil, which is dilated at once when their peripheral extremities are galvanised. This series of experiments establishes on a firm basis the important fact, that the sympathetic nerve arises from the spinal cord.

In the course of my own researches on this subject, ten years ago, after having ascertained these data to be perfectly correct, I made the remark, that the division of this nerve produced an increased activity of the circulation on the corresponding side, which grew warmer, and in certain animals (the horse, for instance) was bathed with profuse perspiration; while, on galvanizing is upper portion, the contrary effect was produced. It was on this occasion that the influence exerted by the nerves of organic life upon the temperature of animals was for the first time brought to public notice; and numerous experiments have since then shown that considerable variations may in this manner be produced; they extend to 10° or 12° Cent. (18° or 22° Fah.).

Professor Jacubowich, whose labours on the structure of the spinal cord are well known to you, believes this nervous centre to contain three different kinds of primitive cells. Some of these are radiated, or multipole; they are also the largest ; he considers them as the source of the volunt ry motor nerves; others are of smaller dimensions, and provided in general with only three poles. These he believes to be exclusively connected with sent ent nerves; and, lastly, a third sort of cells is found in the spinal axis. They are lengthened and fusiform, and exhibit two poles or extremities; these cells, according to the ingenious micrographer, give rise to the nerves of organic life. It would therefore appear that anatomy confirms again, in this case, the results of physiology, by showing us, in the spinal cord, the primitive source of these distinct systems of nerves-that of sensation, that of motion, and, lastly, that which acts upon the vessels.

The researches of other physiologists with reference to the

remaining branches of the sympathetic nerve having fully | corroborated the above-mentioned results; we shall, in future, take them for granted, and proceed to examine, on these grounds, the influence of the spinal cord on the chemical phenomena of life, after performing, in your presence, the experiments on which these views are grounded.

ORIGINAL COMMUNICATIONS.

ON AURAL DIAGNOSIS AND DISEASES OF
THE MASTOID PROCESS.

By W. R. WILDE, M.D., V.P.R.I.A.,
Surgeon to St. Mark's Hospital, Dublin, &c.

I WISH to make a few observations upon Mr. Toynbee's communication in the number of the Medical Times and Gazette for March 16, upon "The Means of Preventing Caries of the Petrous Bone, and the Formation of Abscess within the Brain in Cases of Disease within the Ear." As everything appearing from so high an authority must be received and studied with attention by the Profession at large, it becomes the more necessary to examine carefully every assertion or dogma which may appear from the pen of my respected friend. The questions involved in Mr. Toynbee's paper are twofold-the means of diagnosis, and the best method for preventing the disastrous consequences specified in the heading of his communication. Some years ago Mr. Toynbee promulgated the doctrine that disease in certain portions of the middle and internal ear produced disease in certain portions of the brain; or, as he now himself tersely expresses it, that when matter "is pent up in the tympanum, it affects the cerebrum; when pent up in the mastoid cells, it affects the cerebellum; and when in the vestibule, it affects the pons varolii and base of the brain." From this doctrine I have long since dissented, on the principle of the Scotch verdict, non proven.''

Under what circumstances is matter pent up in the cavity of the tympanum?--that is, with the membrana tympani intact,-otherwise it would not be pent up. In catarrhal and chronic inflammations of the mucous lining of that cavity, when the fluid is principally muco-purulent, it is either absorbed or makes its way into the external meatus by ulceration or rupture of the membrana tympani. In acute inflammation of the tympanum, attended with violent pain, and ending in suppuration, it usually produces, in a short time, rupture of the membrana tympani; but whether by ulceration, or like the bursting of an abscess through the skin by pressure from the rapidly accumulating pus, is more than I can say. Specific inflammations, such as those from scarlatina and measles, etc., may all be classed under these two heads, so far at least as the question in hand is concerned. Does disease of the bones of the ear or of the brain usually appear without previous otorrhoea, or rupture of the membrana tympani and profuse discharge? As a general rule, it does not; in some cases it so happens; but I cannot now discover in my notes the record of a single fatal case in which disease of the mastoid process, or the petrous portion of the temporal bone, or the brain or its membranes, as a consequence of aural disease, ensued, in which otorrhoea had not previously existed to a greater or less extent.

In cases, then, of otorrhoea, with perforate membrana tympani, is the discharge occasionally pent up and forced into the mastoid cells, and does it produce, from want of a means of external exit, disease of the brain? That it does is contrary to my experience; but Mr. Toynbee says, "I have met with several cases in which death occurred from diseased brain, where there was no other impediment to the free escape of discharge than the inspissated secretion itself, and where the free use of the syringe would have averted the mischief to the bone and the brain." This I think rather too mechanical an explanation; my view of such cases (which occur here very frequently) is that, from some cause-local or constitutionalat present unknown to us (but, in some cases attributable to improper interference), an unhealthy action is set up in the organ, which produces caries in the petrous, or disease of the mastoid process of the temporal bone presenting some of the various forms which I have already described in my "Aural

Surgery." I believe it much more likely that the inflammatory suppurative action spreads into the mastoid cells than that the discharge in the tympanum is forced in mechanically by being pent up. To obviate the consequences alluded to, Mr. Toynbee recommends, in cases of ruptured membrana tympani, "directing the stream of water [in syringing] through the orifice of the membrane into the tympanum in order to vacuate the latter cavity of its contents. This is an achievement, I am afraid, we cannot always lay claim to, as, in syringing, the stream of water fills the meatus, no matter how it is directed. The next proposal is "by means of a curved probe [passed into the mastoid cells], to endeavour to make exit for the matter though the natural channel into the tympanum. By this means it is possible, in some cases, where the mucous membrane is not very thick, to secure the withdrawal of matter from the mastoid cells." I have never performed such an operation, nor seen it performed by others ; I can, however, suppose it possible with the patient under chloroform, although not unattended with risk, if the probe could be pushed far enough and was curved sufficiently, and that the operator could succeed in thrusting it into one or other of the mastoid openings.

Mr. Toynbee objects to making an orifice in the membrana tympani, supposing it to be perfect in such cases as inflammation of the dura mater may be induced." Surely, thrusting a probe into the mastoid cells, the roof of which, although of very hard bone, is not much thicker than writing paper, would be a more hazardous proceeding! I have often thought that an aperture might with propriety be made in the membrana tympani in cases of acute scarlatinous tympanitis.

The foregoing methods failing or being inapplicable, Mr. Toynbee recommends the use of a seton, and quotes a case in which he used it, and in which he says, there had been “unmistakeable sgmptoms of matter in the mastoid cells, attended with attacks of giddiness, insensibility, and intense pain in the head," etc. I have carefully read the case alluded to in Mr. Toynbee's valuable work on "Diseases of the Ear,' and I confess I have failed to discover in the array of symptoms any which would enable us to make a differential diagnosis between matter in the mastoid cells, or disease going forward in any other portion of the bone of the ear; or, as would appear to be the case in that instance of disease of the brain and its membranes. In the majority of the cases in which I have had occasion to cut down upon the mastoid process, or into the mastoid cells (at least, of late years, when the Practitioner and the public are more alive to the importance of such cases, and seek relief earlier than formerly), but few of the symptoms related by Mr. Toynbee have been present, although there could be no doubt as to the seat or nature of the disease.

an

Three weeks ago, a woman, aged 55, who had long suffered from otorrhoea, walked some three miles into Hospital, and presented a large, reddish post-aural tumour, exquisitely painful to the touch, and of a brawn-like feel. There was no sense of fluctuation; but on pressing the finger firmly, as it was drawn over its surface from above downwards, an indentation could be perceived, the mark of which remained for a few seconds after the finger was removed. She had hemicrania and soreness of the scalp on the affected side, with some fever, sleeplessness, and the usual anxiety and distress of countenance so characteristic of such cases. The otorrhoea had not ceased, and there was aperture in the lower edge of the membrana tympani, which was thickened. On introducing a scalpel down to the mamillary process it sunk to the depth of an inch, and on drawing it upwards parallel to, and about half-an-inch from the auricle, it passed freely into the substance of the bone, which in this, and in all such cases, cuts like the crust of old Stilton cheese. A few thick drops of matter flowed out with the hæmorrhage, which in such cases is generally profuse, and the next day there was a copious discharge from the wound. The case recovered perfectly without any apparent exfoliation, although like all such cases there was subsequently an indentation over that part, as if from absorption of the bone. The week before last Mr. Dwyer, of Camden-street, formerly a pupil of mine, called upon me to "cut down upon a lady's mastoid process." On proceeding to her residence, I found an emaciated person, with languid circulation, great distress of countenance, slight otorrhoea, soreness of the scalp on the right side, and some pain, increased on pressure, over the mastoid region, and extending down

along the track of the muscles into the neck. Immediately behind the ear it was slightly pinkish and exquisitely painful to the touch, but not much swollen. I made an incision down to the bone for about an inch in length, incising the periosteum freely. No matter followed, nor did the wound even suppurate. The patient was put upon the use of bark and ammonia, with generous living. She experienced immediate relief, slept better that night than she had done the week previously. The pain and all the other local symptoms ceased gradually, except the swelling and soreness along the course of the sterno-mastoid muscle.

On Friday, March 22, a healthy young woman from the country, presented herself at St. Mark's Hospital, complaining of violent pain in and behind her ear, of three months' duration; not continuous, but seldom altogether absent; it occurred suddenly at night, and was very violent for a few days, both in the ear and mastoid region. She was very properly leeched in the latter spot by Dr. Wade, of Kilcock. That treatment was attended with relief, and was resorted to on two subsequent occasions. She has never had any discharge from the ear. The meatus was dry, and towards its distal extremity reddish; the membrana tympani had a dusky reddish-brown colour, especially towards the upper and back segment. It did not appear to be pressed outwards by any fluid or other substance in the cavitas tympani. The introduction of the speculum, for the purpose of examination, caused no annoyance. The whole seat of distress was the mastoid process, the pain of which was, she said, most exquisite. She would scarcely allow it to be touched, the integuments over it were thickened, oedematous, and of a dusky hue, giving a brawny feel to the fingers. The pain and swelling occupied a space of about three inches by two; the immediate angle with the auricle was neither so painful nor thickened as the other portions of the mastoid region; there was no feeling of fluctuation, no hemicranial soreness, but some swelling and tenderness, extending along the course of the sterno-cleido mastoid muscle. She had no headache or giddiness at any time during the progress of the case; her sole complaint was of the pain and tenderness over the mastoid process and in the ear. She presented the usual anxiety and distress of countenance peculiar to such cases.

There were no consti

tutional symptoms present. She readily submitted to an operation. A scalpel was introduced near the mamillary process down to the bone, and drawn upwards, parallel with the auricle for about an inch and a-half. The depth of the wound was about half an inch. The bone felt softish under the knife, the point of which could be easily pressed into it at any point of the trajit of the incision. No matter was perceptible, neither did it appear that the periosteum had been detached. The cut edge of the wound had the usual brawnlike appearance. As there was rather smart hæmorrhage, the gap was plugged with lint. Immediately after the incision was made, the patient had a slight convulsive fit, but did not appear to be at any time perfectly unconscious. She was taken into Hospital, and placed in bed. When visited in the evening, she expressed herself greatly relieved by the operation, the pain being much less than formerly. She was put upon the use of bark and ammonia, with generous living, and a poultice applied over the wound, but the anxiety of face did not leave her for four days subsequently. No discharge appeared from the wound till the following Monday, and the pain over the mastoid region continued, although less intense. She was put on the use of calomel and opium, until the gums were slightly touched. On making pressure close to the wound on Tuesday the 26th, about a teaspoonful of matter was evacuated, and during the afternoon some more followed. The face had assumed its natural cheerful expression and the patient got the first sound sleep she had enjoyed for a fortnight; the discharge then ceased, the wound healed by granulation, and the case went on well till the 30th when she had rigors, and was very restless and sleepless, and complained greatly of pain and swelling immediately below

the ear.

That region was on the following day very much swollen, red, and painful, owing probably to inflammation of the dense fascia covering it. She was changed to a different apartment, and flannel wrung out of very hot water was kept applied to the seat of pain; the use of tonics was continued. In a few days all pain subsided, and she left the Hospital perfectly well.

Even in cases in which there is neither swelling nor redness, but pain decidedly increased on pressure over the

mastoid region, I either have leeches applied, or I cut down upon the bone as described above. Some time ago a professional friend waited upon me with his daughter, a delicate, light-haired, fair-skinned girl of about 15, who complained of pain and swelling behind each ear. The mastoid regions were exquisitely tender to the touch; a slight, pirkish blush overspread their surfaces, and on the right side there was a very manifest swelling, but no sense of fluctuation.

I cut down upon the bone in the usual manner, and in the hæmorrhage which followed could be discerned some streaks of pus. The surface of the bone felt rough as the point of the scalpel passed over it. As the young lady suffered a good deal from the pain and shock of the operation, it was agreed not then to incise the mastoid region on the other side, but to apply leeches instead. Three or four days afterwards I had to cut down upon the bone on the left side also; a considerable discharge ensued from both sides. She recovered perfectly in about three weeks, and has remained so since. She had had some slight otorrhea occasionally up to the time of her attack. She had no head symptoms previous to the time I saw her, and very little fever subsequently.

My late venerated friend, Andrew Retzius, having seen me in 1855, "as a matter of course, open the mastoid cells with a scalpel in a case of inflammation of their internal investing membrane, in order to give exit to the morbid inflammatory secretion, and thus remove the tension, relieve the severe pain, and allay the inflammation,' says, "I was glad to observe that the operation was very easily performed and that the results were favourable.' In consequence of this and other cases to which I drew the learned Swede's attention some years ago, he read a paper to the Scandinavian Scientific Congress in 1856, "On the Occurrence in Man of Cavities in several Different Parts of the Bony Wall of the Tympanum," of which a translation has been made by my friend, Dr. W. D. Moore, in the Dublin Medical Press for December, 1859, to which I would particularly direct the attention of my readers.

If there was any well-marked symptom, lccal or general, or any array of symptoms besides those which I have specified above, by which we could diagnose disease arising spontaneously in the mastoid cells or passing into them from the cavity of the tympanum, it would, I think, be a step in advance in Aural Medicine, less in importance only to that of the discovery of a means of the prevention of disease in these cavities.

RESULTS OF SOME TRIALS OF THE HYPOPHOSPHITES IN THE TREATMENT

OF PHTHISIS.

By JAMES RISDON BENNETT, M.D. Late President of the Hunterian Society.

(Continued from page 468.)

Peter H., aged 40, a gardener, residing at Surbiton, a man of dark complexion. Height, 5 feet 6 inches; weight, 9 st. 12 ìbs. His wife and a brother have died of phthisis. Has been failing in health six months, and has had hæmoptysis and night sweats, with alteration of voice, cough, and expectoration, and has lost flesh. The bowels are generally regular, the appetite tolerable. Pulse 104. The respiration was everywhere deficient in the upper and anterior region of the chest, but no moist sounds were heard. The treatment by the hypophosphite of soda was continued only fourteen days, when it was requisite to abandon it, in consequence of derangement of the digestive organs and the prominence of the laryngeal symptoms. He continued to get worse during his whole residence in the Hospital, and when he left, on June 11, had lost 5 lbs. in weight.

Ann B., aged 33, a mould-maker, residing at Limehouse, was admitted February 4, 1860. Weight, 7 st. 4 lbs. Some relations on the mother's side have died of phthisis. She dates her present illness from twelve months ago, but admits that six years ago she had an attack of severe hæmoptysis, and for five years she has been out of health; and for three years has had more or less cough, which has been much worse for the last year, and attended by copious expectoration. Her general health has lately rapidly declined, and she has had much night-sweating. Her aspect is anæmic,

and the emaciation marked. Tongue pale, tolerably clean; appetite good. Bowels generally confined. Pulse 120, feeble. Catamenia absent three months. Cough urgent at night. The physical signs were marked as indicating extensive breaking down of the left apex, viz.-flattening, gurgling, amphoric cough resonance, etc.; and on the right side, deficient percussion resonance, harsh respiration, cough resonance, and crepitation, both above and below the clavicle. She was put on mixed diet, with half-a-pint of porter, and ordered a sedative draught at night for the cough, with fifteen grains of the hypophosphite of soda in inf. quassiæ ter die., liq. vesicat. infra clav. She lost weight, and steadily deteriorated under this treatment, so that on March 4, when her debility was becoming great, and the night sweats severe, she was ordered quinine and steel, and allowed wine, etc. On March

26 she left the Hospital at her own desire, having lost 8 lbs. in weight, and the disease rapidly progressing. Wm. B., aged 20, grocer. Residing at Ratcliff, light complexion, weight 8 st. 6 lbs. Dates his illness from two months back, and has since then been declining in health, but had hæmoptysis ten weeks ago. For six weeks has had copious expectoration and frequent night sweats. Loss of voice two weeks. His aspect is pale, and he is evidently emaciated. Tongue somewhat coated; bowels regular; appetite fair. Cough urgent at night, and expectoration tenacious and mixed with blood. Pulse 120. Percussion gives a certain degree of tympanitic resonance under the right clavicle, where there is cavernous respiration. Much creaking and rhonchus in the dorsal region, and more or less rhonchus throughout the chest. Under the left clavicle the indications are those of early tuberculization. Has old indolent ulcers of both legs. He was put on mixed diet with half-a-pint of porter, and was ordered gr. xv. of the hynophosphite of soda in water three times a-day. Subsequently a sedative draught at night was absolutely needed to obtain rest. Under this treatment his general condition deteriorated so rapidly, and the physical signs showed such advance of the local disease, that it was abandoned on the 14th March. At this time he was put on bark and dil. sulph. acid, with cod-liver oil and opiate astringents at night. For a brief period he appeared to be much relieved, and took his food much better; but on April 12 it is noted that his emaciation and exhaustion have gradually increased. The bowels are frequently relaxed to such an extent as to require the use of every available means to control them, and on the 13th, at his own request, he went home to die.

H. L., aged 22, female servant. Admitted February 3, 1860. Residence Chigwell. Complexion dark. Weight 7 st. 4 lbs. Previous health pretty good. Present illness began seven months ago by an attack of pleuro-pneumonia and some hæmoptysis. Cough and scanty expectoration. Catamenia have been occasionally profuse, but absent for six months. Her aspect is very pale. Appetite poor. Tongue coated and patchy. Bowels regular. Cough troublesome at night. Expectoration scanty. Pulse 140. The physical signs indicated the remains of pleurisy of left side, with some crepitation and deficient resonance under the clavicle. The case was marked as commencing phthisis, with remains of pleuro-pneumonia. She was placed on mixed diet, with halfa-pint of porter, and ordered a sedative draught for the cough at night, and twenty grains of hypophosphite of soda in infus. quassiæ, ter die. On February 28, there being a good deal of pain and tenderness, liq. vesicatorius was applied under the clavicle, and subsequently to the side also, for similar symptoms. Until towards the end of February she gained a little in weight, but about that time all the symptoms became worse. Crepitation under the clavicle was more extended, the cough worse, and the expectoration mixed with much blood, and the feet became edematous. On the subsidence of the more acute symptoms, she was placed on the usual tonic treatment. The disease, however, advanced, and when she left the Hospital on March 20 she appeared to be getting rapidly worse. This would seem to have been a very fair case for testing the power of the new so-called specific, inasmuch as the tuberculization of the lungs was apparently only commencing when the treatment began, and the constitutional powers so far unimpaired that they responded to the good diet and the favourable circumstances in which she was placed on first entering the Hospital. The pulmonary symptoms, however, steadily advanced, and the tuberculosis pursued its course.

George B., aged 30, saddler, residing at Paddington, was admitted on March 26. Weight, 7 st. 12 lbs.; complexion light; previous health, delicate. He states that for seven

years he has been more or less out of health; that about that time he had hæmoptysis; that for five or six months he has had constant cough, attended by expectoration, with only occasionally night sweats. His aspect is pale and emaciated; tongue somewhat coated; bowels confined; appetite fair; cough not urgent; expectoration moderate; pulse 130, very feeble. Physical examination of the chest revealed marked flattening and deficient resonance of both apices, with cough resonance and crepitation, especially on the right side. Mixed diet, half-a-pint of portar, soda hypophosph. gr. xv. ter die, in infusion of quassia, sedative draught at night. April 16.Confined to bed, debility rapidly increasing, tongue very red, bowels very irritable. Physical signs indicative of excavations rapidly extending in both apices. He was now put on the steel and quinine mixture, with small doses of laudanum, and allowed zij. brandy. Two days later, feeling that he was rapidly sinking, he left by his own desire.

Con

Eliza K., aged 19, female servant, residing at West Green. Her health was good till three years ago, since which time she has had more or less cough. Two months ago had severe hæmoptysis; latterly her health has declined rapidly, and has had night sweats to a great extent for three months. siderably emaciated, tongue coated and flabby, bowels regular, appetite pretty good, cough frequent, and attended by scanty, thick, yellow expectoration. Some time ago, she says that her expectoration was very great. Pulse 120, feeble. On the left side there is tympanitic resonance on percussion, with flattening; considerable cough resonance, and some small crepitation. Above the right clavicle there is increased vocal resonance, with harsh expiratory murmur, and under the clavicle an occasional click. She was placed on mixed diet, with half-a-pint of porter, and ordered steel and cod-liver oil, and the liq. vesicatorius was applied over the right apex. This treatment it was necessary to intermit on January 2, in consequence of dyspeptic symptoms. During the month of February she complained a great deal, at intervals, of pleuritic pains, and the tincture of iodine and liq. vesicatorius were frequently employed for their relief; but, towards the end of the month, she had gained 5 lbs. in weight, and her general health, as well as the dyspeptic symptoms, improved whilst taking the stomach mixture, i.e, infus. gentianæ et rhei. with soda and small doses of dilute hydrocyanic acid. On March 1, as her digestive organs still did not bear the ordinary tonic remedies, and she was not progressing, I ordered her fifteen grains of the hypophosphite of soda in infusion of calumba three times a day. On March 26 she had lost 3lbs. of the 5lbs. which she had gained, and the physical examination showed that the pulmonary disorganization was advancing. She, therefore, left the Hospital.

PRACTICAL HINTS ON THE
ACCOMMODATION OF THE EYE,

ITS ANOMALIES AND THEIR TREATMENT.
By Mr. J. SOELBERG WELLS.

(Continued from p 415.)

MYOPIA (Concluded.)

Short-sighted persons often inquire whether they may wear spectacles. Now, all Practitioners are, I think, agreed as to the advisability of allowing myopic persons spectacles, for the purpose of seeing distant objects. For we thus change their eyes into normal ones, and enable them to unite parallel rays upon the retina. We should, however, prescribe the weakest glass with which the patient can see clearly and distinctly at a distance, so that he may only make use of a minimum of his power of accommodation, and not have to strain it unduly when observing near objects. For we must remember that he will but seldom have to look for any length of time at a distance, but will alternately observe near and distant objects. One moment looking at something on the opposite side of the street, the next into a shop window, or at some object near at hand. Now, if the glasses are too strong, he is already obliged to use more than a minimum of his power of accommodation when observing distant objects, and will consequently have to make use of a still greater amount (perhaps