and as they were followed by the precise train of phenomena which were sought to be obtained, and which led immediately to the consolidation of the aneurism, there is no doubt that this was a case of cure by manipulation; and in this opinion Sir W. Fergusson concurred.

Two other cases were referred to, one published by Mr. Oliver Pemberton, in his Address on Surgery, of aneurism of the external iliac artery, treated and cured by direct pressure on the tumour itself; and the other a case under Mr. Gant, of aneurism in the groin following a fall, in which distal pressure, by means of Carte's tourniquet applied for two hours daily during ten weeks, effected a cure.

The lecturer next passed to the subject of arterio-venous aneurism of the femoral artery and vein. This, Mr. Holmes remarked, is not on the whole a very uncommon affection-at least, there are, he tells us, a good many examples on record, spontaneous as well as traumatic, though the latter are of course by far the most numerous.

Referring to a case of Mr. Beaumont, of Canada, described in the Medical Times and Gazette, July 27, 1867, the preparation of which is in the College of Surgeons Museum, the lecturer drew attention to the fact that the sac was ossified; as was the case in Mr. Perry's patient, an account of which is given in the Medical and Chirurgical Transactions, vol. xx. It is of importance to notice, too, that, although the superficial femoral vein was occupied by coagula, and the deep femoral vein was so pressed upon as hardly to transmit any blood, yet the anastomosing veins with the saphena so completely carried on the circulation that there was neither gangrene nor even oedema of the limb. This is a fact not to be overlooked in considering the propriety, in circumstances otherwise desperate, of tying up the artery and the vein together in operations for arterio-venous aneurism. The Professor referred next to Mr. Oliver Pemberton's case, reported in the Medical and Chirurgical Transactions (vol. xliv.), and remarked that the obvious inferences derived from a study of these three and other similar cases would be two. First, that the treatment must be directed to obliterate the orifice of communication between the artery and the vein, as it is from this communication that all secondary consequences of the affection seem to proceed-viz., varicosity of the veins, degeneration of the artery, oedema, pain, and loss of function of the limb. This communication may be obliterated in one of three ways (1) by laying open the sac and tying the artery above and below: (2) by tying the artery above and below without opening the sac; (3) by compression applied to the venous orifice and to the artery above the tumour. This is best done simultaneously after Vanzetti's method; but cases have been successfully treated by first compressing the venous orifice until the latter has been obstructed by coagulathe arterio-venous is thus converted into a simple arterial aneurism, which is afterwards treated in the usual manner. Secondly, all cases which have been dissected at a late stage of the disease prove that the artery becomes so attenuated and enlarged above the tumour that no operative interference can then be successful. Hence the necessity for treating the disease decisively at first, and for abandoning operative interference if the case is not seen sufficiently early. It is a fatal mistake to delay treatment until the artery has become thinned and dilated above the sac and unfit to bear a ligature, and until the tumour has advanced to a large size and the operation for its cure becomes both complicated in its execution and almost inevitably fatal in its results. Such traumatic arterio-venous aneurisms, treated in good time by the double method of pressure devised by Vanzetti, would, in all probability, be found usually amenable to treatment; and if this fail, then Professor Spence's method is preferable to laying open the tumour, which, however, in its turn is, Mr. Holmes considers, to be preferred to the Hunterian operation.

Mr. Spence's method consists in making an incision long enough to admit of the artery being tied as it enters and as it leaves the tumour, which itself is to be left untouched. This operation of tying the artery above and below the sac of an arterio-venous aneurism appears to have been practised by Lister. In cases of spontaneous arterio-venous aneurism, we may confidently expect the artery in the immediate neighbourhood of the sac to be diseased. It is, therefore, greatly to be doubted whether such cases, if not amenable to pressure, ought to be treated at all.

Having thus completed his remarks upon aneurisms of the external iliac and common femoral trunk, the lecturer passed

on to the subject of aneurism of the profunda femoris and of the smaller arteries in the thigh.

First, as to aneurisms of the profunda artery. Some of the cases in which the treatment of femoral aneurism has been unsuccessful, and which have been diagnosed as affecting the common or superficial femoral, have turned out to have been of the profunda; and there can be little doubt that the same has been true of several of those in which no anatomical examination has been made because the treatment has been successful. The Professor referred to two cases, both of which were successfully treated by compression of the common femoral, and in both the diagnosis of aneurism of the profunda was made from the circumstance that the femoral artery lay over the tumour, and that the circulation in its lower part and terminal branches was unimpeded. If an aneurism lifts up the femoral artery without interfering with its circulation, it can hardly be growing from that vessel itself, and must affect either the profunda or one of its branches-a conclusion which is further strengthened if the aneurism is cured and the femoral still less unaffected. In two cases of the disease recorded by Mr. Cook in the Guy's Hospital Reports, third series, vol. x., one point is common to both-viz., the intimate connexion between the tumour and the femur. In both the bone had been so pressed upon that its periosteum was destroyed for some distance. No doubt this close connexion of the tumour and the bone must much increase the resemblance to cancer.

What we know of profunda-aneurism justifies us in looking upon it as a disease whose differential diagnosis is often difficult, but which under favourable circumstances may be, and probably has been, accurately distinguished from cancer on the one hand and from disease of the femoral itself on the other.

As to treatment, it seems clear from recorded cases that aneurism of the profunda is favourably situated for the successof treatment by compression, on the failure of which the surgeon must use his own discretion whether he will tie the common femoral or the external iliac artery. In traumatic aneurism, however, if the sac seems imperfectly formed, or if there is any reason to suspect a venous communication, it would be better, Mr. Holmes thinks, to perform the old operation.

Spontaneous aneurism sometimes, though rarely, affects the branches of the femoral artery, and a case illustrative of this disease was given at some length. Cases of traumatic aneurism of the secondary branches of the external iliac or femoral were also related, attention being especially drawn to the celebrated case of the unfortunate officer operated upon by Mr. Lister, the history of which is recorded in the twenty-ninth volume of the Medical and Chirurgical Society's Transactions. The case described by Mr. Lawrence in the Medical Times and Gazette, July 2, 1853, was closely analogous to Liston's. In both the external iliac artery was tied, and in both death resulted.

Mr. Holmes forcibly argues against this line of treatment, and adds the remark that other cases more or less analogous are not wanting in surgical literature to show that a more cautious practice than Liston's may lead to a happier result. Thus a case is recorded in the New York Medical Record, in which the wound of a branch of the femoral artery gave rise to a traumatic aneurism, and which was treated successfully by compression.

On a review of the whole subject of femoral aneurism by the light of our present experience, the following are the main conclusions to which Professor Holmes is led :

1. That the operation of ligature of the external iliac artery has been, on the whole, fairly successful, as evidenced by a very small mortality in uncomplicated cases of hæmorrhage and a mortality of about one-fourth in published cases of aneurism-a conclusion supported by the unpublished records of hospital practice, though a few cases of recurrence of the aneurism have occurred.

2. That the operation on the superficial femoral, for aneurism situated in Hunter's canal, is a very successful operation.

3. That the ligature of the common femoral is a perfectly justifiable proceeding; though whether more or less trustworthy than that of the external iliac artery we are not as yet in a position to judge.

4. That ruptured aneurism in the thigh has been treated with a large amount of success by the old operation.

5. That ilio-femoral and femoral aneurisms have been treated with a very fair proportion of cures in the few instances on record by rapid compression applied to the aorta or common iliac, but that there is no evidence to show that this treatment

is less dangerous or more successful than the operation on the external iliac artery, when the latter is feasible.

6. That compression, especially digital pressure, has been applied to the treatment of inguinal and femoral aneurism with striking success, though in what proportion of cases we do not as yet know. That the comparative ill-success of this method in our hospital practice is more calculated to raise doubts of the efficiency of the application than of the soundness of the method itself.

7. That in rare cases direct pressure or even manipulation may be advantageous.

8. That arterio-venous femoral aneurism should be treated by double compression, applied to the vein and artery; which failing, Mr. Spence's method of tying the artery above and below is the most hopeful measure; and when this is impracticable, either the old operation should be preferred or the case abandoned.

9. That spontaneous aneurisms of the profunda have been diagnosed and successfully treated by compression.

10. That recent traumatic aneurisms of branches of the external iliac or femoral are best treated as wounds of these vessels-i.e., either by compression or by ligature at the wounded part.

ORIGINAL COMMUNICATIONS.

TUMOUR OF LATERAL

PORTIONS OF THE LOWER JAW REMOVED WITHOUT EXTERNAL WOUND.

By C. F. MAUNDER, Surgeon to the London Hospital.

(Concluded from page 4).

Case 2.-Fibrous Epulis.

(Reported by Mr. J. H. TURTLE.)

F. S., AGED 35, married, was admitted into the London Hospital on May 15, 1873, having been referred to Mr. Maunder by Dr. Dove, of Pinner.

History. She stated that about a year and nine months ago, she noticed a decayed molar tooth on the right side of the lower jaw. She removed a portion of it at the time, and not long afterwards observed a growth springing from the situation of the decayed tooth. It gradually extended itself along that side of the jaw. A surgeon removed the tooth which was believed to be the cause of the growth, and afterwards the tumour. In six weeks from the time of removal it appeared again, and was a second time removed. It made its appearance a third time, and has gradually increased in size. She has been free from pain throughout. On examination, the growth was found to occupy the original site of the molar teeth. It had very much the appearance and consistence of gum tissue hypertrophied and indurated. It encroached considerably on the bone below the level of the alveolus, especially on the inner side, was very firmly adherent to it throughout its extent, as though growing from it, and the surface was continuous with the mucous membrane lining both the cheek and the floor of the mouth. Thus only some portion of the outer surface and the mere line of the base of this part of the bone were free from the growth. There was no evidence of glandular affection, and nothing to contra-indicate an operation, although the patient had not a robust appearance.

Operation (May 21, 1873).-The patient was seated in a dentist's chair, and the head comfortably and conveniently supported, in order that blood should readily flow out at the mouth rather than pass backwards towards the larynx and pharynx. Chloroform having been administered, the mouth was fixed open by a screw-gag, introduced and held by an assistant at the left commissure of the lips. This gag had also the beneficial effect of depressing the tongue. The operator standing in front, and somewhat to the left of the patient, placed the tip of his left forefinger on the anterior sharp edge of the right ramus immediately above the natural position of the last molar tooth. Along this, as a guide, a scalpel, its edge protected by adhesive plaster to within half an inch of the point, was carried and made to sever the soft parts down to the bone, just enough to admit the raspatory. The point of this latter was now passed through the wound made by the scalpel and pushed between the periosteum and bone, so as to

separate the former from the latter, first on one side of the ramus and then on the other. In this way, also, the portions of the masseter and internal pterygoid muscles attached to the condemned bone were separated. The cutting forceps, guided by the left forefinger, were next carried to this spot, and by a little care a blade was passed on each side of the ramus, but the bone could not be cut through at this stage. The possibility of this failure had been foreseen and provided against by a small, stout, straight, narrow-bladed saw, blunt at the extremity, but without a button. This instrument, having been placed under the periosteum, upon the outer surface of the ramus, was worked through the mouth, so as to cut a groove in the bone and prepare the way for the cutting forceps, which now with some difficulty completed the section. The next step consisted in making an incision in the soft parts down to the bone and on its outer surface, opposite the position between the first molar and second bicuspid teeth, so as again to admit the raspatory. This latter was then run along directly towards the angle of the jaw, to separate the soft parts, and manipulated so as to turn round the base and come up under the floor of the mouth with a similar object. The raspatory withdrawn, the forefinger completed the further separation of the internal pterygoid and stylo-maxillary ligament, etc. The anterior surface of the bone was now cleared opposite the original interval between the teeth mentioned, and having been partially severed by the saw used perpendicularly, its section was completed by forceps. It was now found that the means which had been employed to separate the periosteum and muscles from the bone had likewise nearly separated the growth from the bone, leaving the former almost solely connected with mucous membrane. There remained then only to divide the mucous membrane, reflected on the one side from the cheek, and on the other from the floor of the mouth, and the operation was finished. While the saw was being used the jaw was steadied by the finger and thumb of an assistant grasping it on the cutaneous surface. The bleedwas slight and soon ceased. Fig. 3. shows on the healthy jaw the extent of bone removed.

22nd. Slept for a short time during the night; swallows with difficulty; complained of slight pain in the abdominal region, which is tympanitic. Ordered. The mouth to be often washed out with a tincture of Condy's fluid and water, one drachm of the former to a pint of the latter. Should the deglutition become more painful, enemata only are to be used, consisting of half a pint of milk and half an ounce of brandy, every four hours.. Morning temperature 102.9°, pulse 136, respirations 36; evening, temperature 101-8°, pulse 120, respirations 22.

23rd.-Can swallow a little to-day, but the enemata are being used. Pain in the abdomen is very acute, and on inquiry it was found that a large quantity of air had been pumped into the bowel with the enema. To relieve the excessive tympanites present, Mr. Maunder ordered a large gumelastic catheter to be passed into the rectum. This soon gave great relief. Morning temperature 100-8°, pulse 116, respirations 22; evening, temperature 101.6°, pulse 122, respirations 20. Ordered.-Continue the wash for mouth, also the enemata. 24th.-Patient says she feels much better; has slept tolerably through the night; deglutition easier; no pain in the abdomen, and the catheter has been removed from the rectum; tympanites gone; can put the tip of her tongue out without pain. There is a free discharge from her mouth of rather an offensive

character. Morning temperature 102.8°, pulse 124, respirations 26; evening, temperature 101.4°, pulse 114, respirations 24 Ordered. The enemata to be discontinued. To take freely of beef-tea and milk. Continue the wash for mouth.

25th. Complained of a slight pain on the right side of her face; otherwise doing well. Bowels have not been relieved since the operation. Morning temperature 99.4°, pulse 106, respirations 20; evening, temperature 100-4°, pulse 110, respirations 16. Ordered an enema of soap and water.

26th.-Pain in the face is worse. She describes it as a continued aching pain located principally in the right ear and extending down the side of the neck about two inches. Morning temperature 100.6°, pulse 110, respirations 18; evening temperature 99.8°, pulse 106, respirations 22. Ordered-a hot fomentation of the neck.

27th.-Has had a fair night; pain in the face and neck is much relieved; the discharge from the mouth has still an offensive odour. Partook of some minced meat to-day.

30th.-Patient looks decidedly better; can put her tongue out a little more.

June 10.-Up to this day, when the patient got up for a short time, she has progressed favourably. She can masticate a little.

11th.-Has had pain on the right side of the face and chin since last night which has been very acute, the latter being swollen and tender to the touch. Morning temperature 100°, pulse 96, respirations 18. Ordered-a hot fomentation. 20th.-Gets up daily; some induration and tenderness still about the chin; scarcely any discharge from the mouth now. 28th.-Goes home to-day, but there is still swelling, induration, and slight tenderness about the right side of the chin. Here Mr. Turtle's report ends.

Postscript (July 25).-To-day Mrs. S. came up from the country to see me, her general health being very much improved. Just under the chin to the right side of the middle line there is a small wound, which had been artificially made a fortnight previously, and also about a fortnight subsequent to her leaving the hospital, to evacuate a small abscess. From this opening, and also from within the mouth, three or four small sequestra had come away, and even then a probe introduced detected a small portion of dead bone. Between this date and October 16, when the wound closed, two or three small fragments of bone came away. Doubtless the fact that the process of exfoliation occupied so long a period is in great measure due to the existence of pregnancy, the patient having been confined on November 21, six months subsequent to operation. The symphysis being unsupported on the right side has a tendency to that direction, and consequently, excepting during mastication, the teeth in the two jaws do not accurately correspond; still she masticates well. Fig. 4 is a copy (not flattering) of a photograph of the patient, taken twelve months subsequent to operation.

FIG. 4.

Remarks.-The growth was doubtless fibrous epulis, sessile, and, as already remarked, attached to a large surface of boneso much so, that it appeared impossible to remove the whole growth, and yet leave the line of the jaw unbroken; also two operations to eradicate the tumour had already. been performed elsewhere. As a rule epulis is pedunculated, and can be cut away without external wound with suitable forceps with the portion of bone involved; and I need scarcely insist that such

should be the practice. It is scarcely necessary to suggest that in all surgical operations as little blood as possible should be lost-for two reasons, one in the interest of the patient, the other in the surgeon's behalf. In many operations the presence of blood embarrasses the operator by interfering with his sight, even though it be only present in small quantity; and in operations about the mouth the flow of blood also adds. to this anxiety, lest any find its way into the larynx. The surgeon, therefore, will take care to select the most favourable position for his patient in which to allow the ready escape of blood by the mouth, and will so time his incisions and limit their extent with similar objects in view. It will thus be observed that the order in which the respective steps of the two operations above recorded were carried out, differs. The first operation was, as it were, tentative or experimental,. inasmuch as although contemplating the case, I determined to endeavour to remove the required extent of bone through the mouth; yet having never practised it on the dead subject, it was only by degrees as the operation progressed that the possibility of removing so large a portion of the lower jaw with a growth expanding its walls became evident. In the first case, the chief question was-how to lay bare the bone in order to bring the saw and cutting forceps to act upon it without serious injury to the soft parts. In the second case the chief difficulty appeared to be and proved to be-the section of the ramus. In the first case a free separation of the cheek and chin from the tumour favoured the turning down of the chin with unexpected facility, and the raspatory readily separated the periosteum from the ramus. All this being accomplished, the bone of the young subject was cut readily. Having thus acquired some experience, I reversed the steps of the operation in the case of the adult, in some measure, only cutting so much of the mucous and submucous tissues as were essential to the use of the forceps and saw; and reserving the division of the mucous membrane reflected from the cheek and from the floor of the mouth to the growth, till the bone had been divided. By this plan, although in neither instance was there hæmorrhage in the ordinary sense of the term, still I was less embarrassed by blood in the latter case. The report of the adult case is "The hæmorrhage was comparatively slight." No artificial means were required to arrest bleeding. In the case of the child an ordinary pair of cutting forceps was sufficient, but a similar instrument employed on the adult failed to divide the ramus. This portion of the bone is thin, but hard and brittle, and the aid of the saw is necessary. I employed the saw to make a groove in the bone, but of course to what depth it penetrated I could only surmise. I then completed the section with the forceps, but not without difficulty. My impression at the time was that the portion of bone left in situ, besides being a little rough at the cut surface, might be splintered longitudinally. At any rate, I tacitly determined, on future occasions, to use the saw more thoroughly, and the forceps perhaps not at all. With regard to the dimensions of the tumour of the lower jaw, which may be removed without division either of the cheek or lip, my opinion is-that such as do not prevent depression of the chin so that the mouth can be opened, or do not fill the cavity of the mouth so as to prevent the finger and instruments from reaching the ramus, may be so treated. Indeed, I should expect that in this latter event, section of the base of the bone having been effected at the required spot, the tumour and diseased portion of bone might then be so much depressed as to allow the operator to get at the ramus and divide it with a saw. Again, a tumour growing in a certain direction forwards, outwards, and downwards, as in the child above-mentioned, rather aids the operator by enlarging the buccal orifice as it drags upon the lower lip. It has been suggested that it is more desirable to remove the whole rather than to leave the upper portion of the ramus. If, in an individual case, it be thought desirable to act on this suggestion, my experience would lead me to make the attempt,. with the prospect of success. Next in importance to the saving of life and of the blood of a patient, stands the prevention of deformity, especially on the face of the female. Ugly scars are to be avoided, and nerves supplying muscles of expression are to be scrupulously preserved. All three desiderata are obtained by this method of operation. Throughout the operations my anxiety was to save the whole of the periosteum. Apparently I did so, the bone in each instance coming away quite bare. To my disappointment, the reproduction of bone in the child amounts only to a thin scale, about an inch long and half an inch wide, situated in the middle of the gap caused by the removal of bone. This new production, how

The

ever, is not connected with either fragment of jaw; a thin, fibrous band alone connects these latter. In each case when the patient was convalescent, some tenderness and swelling occurred about the chin; and, after a time, small fragments of bone either came away or were removed. In the child one very small piece exfoliated, in the adult several. In this latter complete recovery was long delayed by this process of necrosis, and a small abscess formed under the chin. In both instances the small exfoliations took place at the margin of the cut "body," and not at the damaged ramus, as sometimes happens to the edge of a bone divided by amputation. Possibly this drawback may be prevented by a more free use of the saw, and less of the cutting forceps, but it cannot be insured against. At any rate, should abscess form in connexion with necrosis, every effort should be made to open it within the mouth rather than externally, in order to avoid even a small scar. knowledge of the fact that this complication arose in the progress of both cases will put the surgeon on the alert. I might also add that both patients in the early days after the operation occupied a semi-recumbent posture, and were encouraged to favour the outflow of secretions from the wound by the mouth rather than to swallow them. In contemplating sub-periosteal ablation of large portions of the lower jaw, I anticipated the reproduction of a good portion of new bone as a foundation for a dental appliance, more especially in the young subject. In neither instance has my hope been realised, nor can I expect now that it will be, four years in the case of the child and one year in the instance of the adult having elapsed. Although in these two cases the periosteum was preserved, and practically no new bone was produced, yet some at present unknown accidental (and possibly in the future appreciable and avoidable) cause may have led to this; it would, therefore, be rash to come to a positive opinion on the subject from what may be regarded as insufficient data. If I were myself to hazard an opinion concerning the non-production of bone in these instances, I should suggest that inflammatory action subsequent to operation very probably destroys the periosteum. The pain in the ear complained of in the adult was probably reflex and consequent on irritation of the divided inferior dental nerve. The absence of bleeding from the inferior dental artery was doubtless due to the division of it by laceration. In proposing to remove large lateral portions of the lower jaw, it must be distinctly understood that I refer only to cases in which the bone is the seat of tumour and not in a state of necrosis. In the latter disease, the dead bone, when operative interference is called for, is no longer in continuity with living structures, but is generally retained in its position by more or less new bone, which has been formed to replace it. To remove this sequestrum is a matter, as is well known, of comparative facility. Nature has in great measure anticipated the work of the surgeon.

REPORTS OF HOSPITAL PRACTICE

IN

MEDICINE AND SURGERY.

NORTH-EASTERN HOSPITAL FOR CHILDREN.

CASES ILLUSTRATING THE USE OF THE
PNEUMATIC ASPIRATOR.

(Under the care of Drs. CAYLEY and SANSOM.)
(Concluded from page 695, vol. i. 1874.)

Case 10.-Empyema-Paracentesis on three occasions-Relief after each Operation.

WALTER G., aged 9 years, was admitted as an in-patient on June 10, 1874, under the care of Dr. Sansom. Patient had been under medical treatment about six weeks before for "low fever," previous to which his health had been good. Since the "fever" left him he has been gradually wasting and getting weaker daily; is troubled with shortness of breath, cough, and copious expectoration of thick yellowish sputa.

State on Admission.-Absolute dulness of right side of the chest behind, also in front except at apex, where the resonance is increased; breath-sounds absent behind; in front abundant mucous râles to be heard around the nipple; slight ægophony at back; respiratory movement absent on right side; intercostal spaces lost. The chest gave the following measurements:-At nipple level-left side twelve inches, right side

thirteen inches; at base-left side twelve inches, right side thirteen inches and a quarter.

June 12.-Cough very irritable; expectoration abundant; appetite bad. Ordered tinct. camph. co. and oxymel scillæ āā mxxiv., vin. ipecac. mx., aquæ ss., 4tis horis.

13th.-Scarcely slept during the night, in consequence of incessant cough and dyspnoea. Physical signs unaltered. Aspiration was performed, and thirty-two ounces and a half of thick greenish pus evacuated. Whilst the pus was being drawn off, the cough was almost continuous; after each paroxysm the pus was observed to be streaked with blood. After the operation the cough ceased, and the breathing became quiet.

14th.-Slept well; scarcely any cough or expectoration; temperature normal; appetite good.

16th.-Much improved; has a ravenous appetite.

17th.-Coughs a little in the morning; slight frothy expectoration. Good resonance both in front and behind, as far as level of third rib; below, resonance is diminished. Exaggerated breath-sounds at apex, becoming bronchial lower down; bronchial expiration to base. Voice bronchial from second rib downwards, becoming slightly ægophonic in axilla. Condition generally improved. Puncture quite healed.

18th.-Has had a slight attack of diarrhoea; temperature 101°.

19th.-Morning temperature normal, evening 101.6°. 20th.-Morning temperature normal, evening 102°. Physical signs unaltered; dulness extends from level of third rib downwards; when lying down, resonance extends to level of fifth rib. 22nd.-General condition improved; eats and sleeps well; temperature 99.8°.

24th. Last night the temperature rose to 103°. The physical signs continued the same: there was tenderness on pressure over the axillary portion of the right base; cough and dyspnoea returned. Paracentesis by aspirator was performed for a second time to-day by Mr. Brown at Dr. Sansom's wish, and twenty-five ounces of thick, slightly greenish, odourless pus removed. Patient apparently much relieved. 25th.-Has had a good night. No cough.

27th. On right side, good resonance in front, diminished behind; breath-sounds good; mucous râles heard over left base; puncture healed.

30th.-Cough more troublesome; no dyspnoea; dulness on the right side extends from an inch above the nipple-level to the base. The last four days the morning temperature has been normal, but towards night it rises to a little over 100°.

July 1.-Aspiration repeated. The chest contained only four ounces and a half of brownish non-fetid pus.

2nd.-Appetite good; sleeps well; no cough; breathes quietly. During the last week the patient's general condition has much improved. He has gained flesh, and is anxious to get up.

9th.-Patient has made good progress during the last week, except that for the last four or five days he has been troubled with morning cough and copious expectoration of yellowish pus-like phlegm. His appetite continues good, and he is able to sit up for a few hours daily. Good resonance exists over the right side of the chest to a little below the nipple-level. Breath-sounds can be heard over the whole chest, becoming feeble at the base. Measurements at nipple-level: Left side twelve inches and three-quarters, right side thirteen inches. The increased girth since admission is due to the patient having gained flesh.

Remarks. These cases illustrate the great value of the pneumatic aspirator in the treatment of empyema and effusion in the pleura, and there is no doubt its use is attended with much benefit in acute hydrocephalus. In the case of hydrocephalus (vide page 671, vol. i. 1874), the aspirator was used with. decided relief to the symptoms, and the fatal termination was in no sense due to its use-indeed, it is almost certain that it was the means of prolonging the child's life. It is worthy of note that in nearly all the cases the puncture quite healed in two or three days. The duration of cases of pleuritic effusion or of empyema is very much shortened by treating them with the aspirator, and another advantage in empyema is that it is not now necessary to establish fistulous openings in order to effect a cure-complete recovery not unfrequently taking place after two or three tappings. It will be observed that in some of the cases there was marked displacement of the heart. This is a most valuable sign in the diagnosis of fluid in the chest, but it is not always met with, even when the left pleural cavity contains

a considerable quantity of fluid; therefore, if the other signs of fluid are present, but the apex-beat remains in its normal position, it may be as well to make an exploratory puncture. The danger of the puncture with the aspirator is very small, whilst the relief afforded may be the means of preventing a fatal termination. That a considerable amount of fluid may exist in the chest without displacement of the heart will be seen on reference to Case 9, which was published in the Medical Times and Gazette of June 27. In this case the apex-beat being in its normal position rendered the diagnosis somewhat doubtful, in consequence of which paracentesis was postponed for a few days. Meanwhile the child died; and on a post-mortem examination being made, the left chest was found to be full of pus, and the right also contained a considerable quantity.

For the notes of the above series of interesting cases we are indebted to the late House-Surgeon of the North-Eastern Children's Hospital (Mr. Gill), and the present House-Surgeon, Mr. George Brown.

BIRMINGHAM GENERAL HOSPITAL.

A CASE OF LEFT HEMIPLEGIA WITH LOSS OF SPEECH, OCCURRING IN A LEFT-HANDED PATIENT.

(Under the care of Dr. RUSSELL.)

DR. HUGHLINGS-JACKSON inquired, in one of his articles some time ago, whether anyone had met with a case in which loss of intellectual expression in connexion with left hemiplegia occurred in a left-handed subject. The bearing of Dr. Jackson's inquiry on the subject of the almost invariable association of loss of speech or defect in that faculty, when occurring in connexion with hemiplegia, with disease in the left hemisphere of the brain, will be at once apparent.

I may quote a sentence from an abstract of Dr. Jackson's paper "On the Physiology of Language," read at Norwich to the British Association, and reported in the Medical Times and Gazette, September, 1868, p. 276, which has immediate reference to this subject. Having observed that it is certain that damage to the right side of the brain produces no defect of speech in most cases, it is stated that "the author has recorded a case of loss of intellectual language in a patient who was left-handed, but states that in other cases this explanation will not apply; and he admits that there are cases of defect of intellectual expression with left hemiplegia which cannot be explained. Some of the patients, however, have been previously paralysed on the right side, although perhaps without any accompanying defect of speech. Still, he has never seen a case of disease of the right hemisphere only as proved post-mortem, with defect of speech of any kind, but has recorded three cases in which this side of the brain (including Broca's convolution) was diseased without defect of speech."

In relation to the general connexion between loss of speech and disease in the left hemisphere of the brain, Dr. Jackson's explanation is, that though both sides of the brain are educated in speech, the left side of the brain is the leading side, and the right side is the involuntary or automatic side. In the left-handed subject of course this relation would be just reversed, and here it would be the right side of the brain which would take the initiative in intellectual expression, and injury to the right side would damage speech. Although in my present case there has been no post-mortem, there can be little doubt that the cause of the attack was hæmorrhage of moderate amount in the right hemisphere of the brain, in or near to the corpus striatum.

The history of the man's left-handedness affords a curious exemplification of the difficulty with which he acquired the power of writing with his right hand, for it will be seen that in consequence of circumstances there were two important acts in his daily life in which he had trained himself to use his right hand; of these, writing was one. Now, writing is of course learned with trouble, but the account given by the patient of himself showed distinctly that in his case the difficulty of the education in writing was increased by the obligation to use the right hand. The right hemisphere in him, and not the left, was clearly the more forward in conducting educated movements.

During the attack the patient never attempted to employ writing as a substitute for speech; but there is every reason for believing that, had he made the attempt, he would have derived no advantage, from the fact of his having trained the right hand to perform that act. If, as Dr. Jackson has shown,

the essential defect which underlies all the peculiarities of speechlessness, under the circumstances now implied, is an inability to reproduce words mentally by voluntary effort, not only must actual speech be wanting, "but the internal speech, also, which corresponds to it" must be wanting, and hence all power of voluntarily translating ideas into verbal signs, whether by the lips and tongue or by the hand, is taken away.

In this respect writing and talking stand on the same level, or, rather, writing stands one degree further from the possibility of expression than talking, the individual who writes having (to use Dr. Jackson's language) to reproduce the verbal symbols internally before making the representative marks on the paper: "written or printed symbols are symbols of symbols.'

The whole subject of the position of the speechless patient (speechless from the form of disease now alone implied), as regards the faculty of expressing himself intellectually, is very clearly described by Dr. Jackson in a paper on "Hemispherical Co-ordination," Medical Times and Gazette, September 26, 1868. In an article on "Lord Denman's Aphasia" in the Spectator, January 17, 1874, the writer analyses the condition of the patient in a similar manner, and comes to the same conclusions; he, however, terminates with propounding the difficult question -"Will anyone maintain that in such a case language was essential to thought, as has been maintained so often?"

Case.-J. A., aged 69. He had an attack of left hemiplegia six months ago. He went to bed as well as usual, but on awaking found himself unable to use his left arm; his leg was also affected, and also the left side of his mouth. His son states that he could not speak to be understood for three weeks after the attack; then he gradually acquired power to speak a few words. At first he was perfectly unintelligible. "If he tried to speak, he made a bungle of it; the effort was too much for him, and he had to give it up as a bad job." They did not hear him miscall words at any time, but he often "stuttered and spoke thick." At present, though in slow talking his power of speech is perfect, at the least hurry he falls into considerable hesitation and stuttering. His left hand also has not fully regained power, and the left angle of the mouth is somewhat weak. He writes with the right hand intelligibly but badly, saying that he has become too weak to command his pen. The heart-sounds are healthy; urine is free from albumen ; his hair is quite white, but there is no evidence of degeneration of the arteries. Both he and his son state that he is lefthanded" using the left hand as others use the right." "From quite an infant the left hand always seemed the readiest." When at school he was compelled by his master to learn to write with his right hand, and consequently he has always written with his right hand. He could have written better at school with his left, but they would not let him; but he always used his left hand when he had a chance. In another act he also uses the right hand. Of late years he has only done fieldwork, but formerly he was a needle-filer, and the apparatus was arranged for a right-handed man. Here, again, he had difficulty in acquiring the power of employing his right hand with the file-"It was gainer with the left."

ENEMATA OF CHLORAL IN THE VOMITING OF PREGNANCY.-Dr. Simmons, of the Yokohama Hospital, Japan,. relates four cases in which chloral administered by the rectum in thirty-grain doses, in mucilage, proved of speedy efficacy. In future cases he intends commencing with larger doses, and he believes that the remedy so employed will be found useful in most cases of nervous or sympathetic vomiting, where thereis no inflammation present.-New York Med. Record, June 1. WADDING DRESSING AFTER AVULSION OF THE INGROWING TOE-NAIL.-M. Verneuil observed, in reference to a case on which he had just operated, that he produces in these cases local anesthesia by means of ether or pounded ice, and after having torn off the nail he applies a layer of wadding to the wounded surface, and then envelopes the whole foot in a thick sheet of the same material, subjecting it at the same time to strong compression. The patient suffers no pain except immediately after the operation, and this ceases when the compression is effectually made. After the second day the patient, with his foot thus protected, is enabled to makesome use of it in going about his affairs; and the bandage not requiring to be renewed for a week, he is spared the pain of daily dressing. At the end of that time a somewhat smaller picce of wadding may be applied.-Révue Méd., June 15.