quarter of an hour. During the following forty-eight hours the fits were frequently repeated, and three days afterwards (June 12) the child was admitted into the East London Children's Hospital. The temperature on the evening of admission was 102.8. On examination of the chest on the following day, signs of consolidation were found at the upper part of the right lung, and the respiration in the right axilla was tubular.

The fits continued, and were very violent. During the attacks both sides of the face twitched, the tongue was bitten, and all the limbs became rigid and were convulsed. Between the fits, consciousness was not restored; the eyeballs oscillated, and the eyes were often turned upwards. There was no squint. The convulsions continued with short intervals until the evening of June 16, when they ceased. The temperature all this time was over 1022, both morning and evening. The pulse was quickenel, but remained regular, 140 to 150; and the breathing was harried and irregular, with deep sighs.

June 17.-No fit since yesterday evening. Child quite unconscious; face pale; nares act; eyeballs oscillate, turned rather upwards; pupils contracted, but act slowly with light; tongue ulcerated from being bitten during the fits. Breathing very rapid (75), but not laborious; intercostal spaces sink in rather deeply during inspiration. Pulse 157, regular. Skin wet with perspiration; very little flushing on irritation of the skin. On examination of the chest, dulness was found at the upper half of the right side. The respiration in the axilla was intensely tubular; elsewhere on that side it was covered by a fine crisp bubbling rhonchus, which was heard all over both sides of the chest. There was also dulness at the lower half of the left back, and the respiration was blowing, becoming tubular at the base. 9 a.m.: Temperature 104-8'; pulse 174; respirations 75. 7 p.m.: Temperature 105. The child died quietly the next day. Temperature, a few hours before death, 105.8°.

On examination of the body, numerous small grey granulations were found in the pia mater, the lungs, and the spleen. The pia mater was much injected at the base of the brain, and a patch of effused lymph was seen on the left side. The whole brain seemed softened, and the lateral ventricles contained a large amount of fluid. Both lungs were the seat of pneumonic consolidation, and in the right were several small cavities.

In this case the occurrence of a convulsive attack was the first alarming symptom noticed by the mother. Before this event took place, although the child was no doubt feverish, and was, as we know, troubled with cough and some oppression of breathing, there was yet nothing in its condition which appeared sufficiently urgent to require medical advice.

On admission, the obstinate recurrence of the fits, the continuance of insensibility between the attacks, the oscillation of the eyeballs, and the other symptoms, made it evident that the convulsions were not merely sympathetic with the condition of the lung. In certain forms of pulmonary disease in the child, sympathetic convulsions are not uncommon. Thus in the course of acute capillary bronchitis they are often observed, especially if that disease be complicated by collapse of the lung. They are also not unfrequent at the close of acute catarrhal pneumonia; and at the beginning of many acute diseases in the child convulsions may occur, taking the place of the rigor which often ushers in an acute disease in the adult; but it is very rare for sympathetic convulsions to appear first in the course of an acute pulmonary consolidation. Where this happens we should always, as in the present case, suspect the existence of some complication. All the symptoms here pointed to meningeal inflammation, and the history of the attack, combined with the pulmonary symptoms, made it evident that the case was one of acute general tuberculosis. Where, as in the present instance, the first symptoms pointing to the brain are those of the third stage, it is rare to find a slow pulse. In the third stage of acute hydrocephalus, the pulse, as a rule, has become rapid and often regular, the period during which it is slow and intermittent having gone by.

Louisa P., aged six months, born of a healthy family, had been herself a healthy child up to the age of five months, when, after a severe attack of acute diarrhoea, she began to waste, and for the following month seemed low and ailing. She was then (December 1) admitted into the East London Children's Hospital. The child was thin and weakly-looking, weighing only twelve pounds three ounces. The fontanelle was rather depressed, and she was very peevish and fretful. The cervical glands were enlarged and also those of the axilla and groins. The abdomen was very firm and tense, and the

Her bowels

liver and spleen seemed to be slightly enlarged. were opened twice a day. There were signs of slight consolidation of the right apex, and all over the right back the respiration was weaker than on the opposite side. Large bubbling rhonchus was heard all over the chest. The evening temperature at first varied between 99 and 100°, the pulse was small and rapid (120), and the breathing hurried (40).

The child remained very fretful until December 14, when she became more composed, her appetite improved, and she seemed generally better. She coughed less, and the bronchitis from which she had been suffering appeared to be subsiding. Her weight on this date (December 14) was exactly the same as on the day of her admission into the hospital.

During the next fortnight the temperature varied between 99 and 101, and the child seemed growing daily weaker. Her cough, too, returned and was very troublesome. On December 29 inuch consolidation was found on the right side. In addition, however, she had begun to squint with the right eye, and had occasionally slight twitchings of the muscles of the face. The temperature rose, and both the pulse and the respiration became quickened.

On December 31, 8 a.m., temperature 103°, pulse 150, respirations 60; 6 p.m., temperature 103.22, pulse 156.

On the following day she seemed about the same; the squint, however, had ceased, and the pupils were equal. The temperature remained high (103 at 6 p.in.), and the fontanelle was much elevated.

On January 3 she had a violent convulsive fit early in the morning, after which the left pupil was noticed to be larger than the right. In the evening the fits returned, and the child died in the course of the night. The evening temperature during the last three days was 103°, 103', and 102.8'.

A post-mortem examination showed the body to be the seat of acute general tuberculosis. The lungs were studded with grey granulations, and there was pneumonic consolidation of the right lung, which had softened into a small cavity towards the base. Numerous grey granulations were also found in the heart, kidneys, intestines, and in the meninges of the brain. The lateral ventricles were full of fluid, and there was besides a yellowish nodule the size of a small pea in the white matter of the brain near the lateral ventricle of one side.

The two preceding cases furnish very good examples of the way in which the earlier symptoms of acute hydrocephalus are obscured when the disease occurs in the course of an attack of acute tubercular phthisis. In such cases the occurrence of marked brain symptoms is a sign that the disease is about to run a rapid downward course, and that the end is not far distant. The case of Louisa P. is interesting as showing that the emaciation does not always proceed with regularity, for during the first fortnight of the child's residence in the hospital her weight remained stationary. The patient's appetite was good, and the quiet, and the better food she was taking at the time, no doubt contributed to this result.

(To be continued.)

ORIGINAL COMMUNICATIONS.

TUMOUR OF LATERAL

PORTIONS OF THE LOWER JAW REMOVED WITHOUT EXTERNAL WOUND.

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

So far as I am aware, the instructions usually given by authors to guide surgeons in the removal of portions comprising more or less of the whole depth of the lower jaw, when the seat of tumour is not merely the symphysis, involve section of the skin. Some advise certain incisions to be traced so as to form a flap; in one case to be turned up, in the other to be turned down, in order to expose the condemned piece of bone. Some, in making the flap, carry the incision into the mouth, either at its angle or some point of the lower lip, and thus deform this feature. Others are content with incision of the cheek, leaving the mouth untouched. Some of the instructions, if followed, must disfigure the patient very seriously. Free incision of the cheek, as is recommended, entails free bleeding and delay in arresting it, the formation of unsightly scars, and an unnecessary interference with the nervous supply to the muscles

of expression. The mode of proceeding which I have practised in two instances is here described, and the result illustrated.

Case 1.-Myeloid Tumour of the Lower Jaw.

The patient, C., ten years of age, referred to me by Mr. Owen, of Leatherhead, is a female. The left base of the jaw was enlarged to the size of a hen's egg, the swelling projecting outwards, and inwards to the floor of the mouth, displacing the tongue somewhat, and deforming the lower part of the face. The tumour had a history of two years, was painless, smooth on the surface, and hard and resistant to the touch, and gave one the impression that a growth within was expanding the jaw. It had enlarged rather quickly of late. The teeth usually found at that age were present did not pretend to make a diagnosis beyond suggesting that it was probably benign. I thought it possible that I might have to deal either with a cyst or with a fibrous or cartilaginous growth, and, if so, that I might be able to evacuate the one and enucleate the other, and, at the same time, preserve the line of the jaw unbroken; in this I was disappointed.

I

Operation (March 9, 1870).-The child being under the influence of chloroform, recumbent, with the head well forwards, I penetrated the tumour at the most resilient spot with a drill by way of exploration. A little blood only flowed. With a chisel and mallet I perforated the thin, bony wall at this spot, and extracted a small portion of a growth. This was at once submitted to a microscopic examination by Dr. Sutton and Mr. Tay, and pronounced to be myeloid. The bleeding from the growth, now increasing, was checked by the introduction of a bit of sponge. I determined to remove the portion of bone containing the growth, and if possible through the mouth, and without cutting the skin of the cheek and lip at all. Standing somewhat behind, and on the right side of the patient, the integuments of the chin, including muscular attachments and periosteum, were first turned down off the symphysis, partly with a scalpel and partly with a raspatory, so as to expose the right side of the jaw opposite the right canine tooth (which was then extracted by Mr. A. W. Barrett) to the action of the saw and cutting forceps. At the back of this position the soft parts were also detached from the bone, and the floor of the mouth was perforated so as to admit of the introduction of a narrow spatula passed behind the bone to protect the soft parts from injury by the saw. The section here being completed, the mucous membrane and periosteum covering the tumour both in front of and behind the alveolus, as well as along the lower half of the anterior edge of the ramus, were severed down to the bone; and a raspatory introduced separated the periosteum, and with it the muscular attachments to the required extent. By a little manoeuvring the end of the raspatory was made to pass round the base of the jaw and to appear under the floor of the mouth, and with the aid of the forefinger similarly introduced, the soft parts on the deep surface of the bone were detached from it. It was found to be possible to turn the soft parts covering the chin literally inside out. While the bone was being cut by the forceps the thin shell containing the tumour cracked, and so the condemned fragment came away in two portions. This fracture did not facilitate the operation. The next step consisted in cutting across the ramus about its middle, and this was effected with forceps alone (guided into position by the point of the left forefinger), but not without some longitudinal splintering. During the operation the mouth was kept open by a gag. Before detaching the frænum linguæ and muscles at the back of the symphysis, the tongue was secured by a ligature passed through it near the tip, and held by an assistant to prevent the possibility of the organ falling back upon the larynx. Also before the patient left the theatre the tongue was firmly secured with its raw surface in apposition with the raw surface of the integuments of the chin by a harelip-pin, and also by fastening the ends of the ligature previously passed through the tip of the organ on either side to either end of the pin. Bleeding was trifling, no ligature being requisite.

Progress of Case.-During the early days following operation there was a good deal of swelling about the mouth, with fetid discharge. The child was sustained in a semi-recumbent posture with the head well forwards. The buccal cavity was repeatedly syringed with Condy's fluid and water, and liquid nourishment was plentifully administered. The case progressed favourably throughout; and before three weeks had elapsed, she could protrude her tongue tolerably well and articulate; and was running about the ward. Subsequently a very small

piece of necrosed bone came away from the sawn surface of the remnant of the base.

Examination of Bone.-My colleague, Mr. Barrett, examined the diseased bone, and discovered a misplaced second bicuspid tooth; it was lying at right angles to its natural position. This malplaced organ may have been the cause of the growth; but inasmuch as the corresponding tooth was also absent, the fact was comparatively valueless from an etiological point of view.

Remarks. The patient was recumbent during the operation, but no sign of danger from blood passing into the larynx was exhibited. Bleeding was comparatively trifling, the blood coming chiefly from the tumour when this had been broken into, but this was arrested at once by the introduction of a piece of sponge. A groove in the gum having been made with a scalpel so as to admit the end of the raspatory, the periosteum and chief muscular attachments, such as those of the masseter and internal pterygoid, were separated, and the bone being bared, awaited section only. By this proceeding a very large piece of the lower jaw (Fig. 1.), containing a growth of the size of a hen's egg was removed through the mouth, without any section whatever of skin, with trifling bleeding, and without division either of the facial artery or of branches of the facial nerve. And what is of great importance in the female, at all events, there is no scar. Fig. 1 shows on the healthy jaw, included by the dotted lines, the extent of bone removed. (By an error of the artist the right instead of the left side of the jaw is represented.) FIG. 1.

Postscript (April 19, 1874).-To-day, in company with Mr. Owen, I visited the child, the subject of the above remarks, and who had been operated upon rather more than four years ago (March 19, 1870). I found her wonderfully grown, being unusually tall for her age, but thin. Although possessed of only three teeth in the remnant of the right half of the lower jaw, she masticates tolerably well, and enjoys good health. She works at her needle many hours daily; and notwithstanding this cramped position she carries herself well, being very upright. Twenty months subsequent to the operation, when her photograph was taken, of which the woodcut (Fig. 2) is FIG. 2.

the face has become enlarged in all directions, while the fragment of the lower jaw has probably remained nearly stationary. The immediate effect of the operation was (two-thirds of the semicircle of bone being removed) to allow the remnant to fall in towards the centre of the mouth, and to make the chin somewhat pointed. Now, by reason of her growth, the pointed chin is more marked, as though she were the subject of a congenital want of development of the lower jaw, whilst when the muscles about the mouth are in a state of repose, the mouth falls away to the left. Her mother says this is especially evident during sleep. The maximum of deformity will be reached when the patient is full-grown, which may be expected if the operation be performed in early life; while the minimum will accrue to an adult submitted to a similar operation.

(To be continued.)

NOTES ON SOME ANOMALIES OF
REFRACTION.

By CHARLES HIGGENS, F.R.C.S.,
Assistant Ophthalmic Surgeon, Guy's Hospital; Surgeon, Central London
Ophthalmic Hospital.

THERE are two anomalies of refraction of the eye, which, although recognised by ophthalmologists, appear not to have received sufficient attention as regards treatment, which, if properly carried out at first, will save the surgeon endless trouble, and will spare his patient much inconvenience, and in many cases prevent considerable suffering.

The anomalies alluded to are-first, high degrees of hypermetropia; secondly, the astigmatism which is met with in by far the greater number of cases of the distressing asthenopia of short sight. The treatment to be presently described, of the first of these, is insisted on by Mr. John Couper in his clinical teaching, and was, I believe, mentioned by him in his Oration before the Hunterian Society. The second has received no notice that I am aware of. Under the first class are 1 included cases of hypermetropia above which, if treated 12' in the ordinary way (that is, by neutralising the manifest hypermetropia), will give no trouble for a time; but sooner or later the asthenopia returns, and the glasses ordered are found too weak. Patients thus affected go from one oculist to another, getting stronger glasses ordered by each, but with the like result that the asthenopia returns and the glasses become useless.

The treatment I adopt in these cases is as follows:- Having diagnosed a high degree of hypermetropia with the ophthalmoscope, a solution of atropine gr. iv. ad 3j. is ordered to be used three times a day for four or five days. The accommodation being thoroughly paralysed, the defect in refraction is accurately neutralised, whether it be simple hypermetropia or complicated by astigmatism, vision being, if possible, made = The proper glass having been ascertained, is ordered be used at first for all purposes; but when the accommodation is restored only for near work, if the two eyes are alike, or nearly alike, a glass of the same description is given for both. If there is any considerable difference, a different glass is ordered for each.

20

20

There is one difficulty which patients complain of when first the accommodation returns-viz., that they have to hold objects too close. This is caused by inability to relax the accommodation, which the patient was before accustomed to strain to the utmost: he must be told to wear the glasses persistently, and in course of time all will come right. have now carried out this plan of treatment for some two years, and with the most satisfactory results.

I

The second class includes many, if not all, of the cases of socalled "apparent asthenopia" of myops. The uneasiness, and in some instances severe pain, in these cases is most distressing to the patients. The asthenopia does not show itself until after the eyes have been constantly used on near work for some considerable period-often two or three years; but, when once it has manifested itself, it increases so as to preclude all possibility of the patient continuing work. The pain would appear to be due to irregular and spasmodic contraction of the ciliary muscle. As a rule, the patients are only slightly myopic-in fact, many of them do not complain of near sight 20 20 at all, and have V= 50 40

or

The treatment adopted is as follows:-Having diagnosed myopic astigmatism by the ophthalmoscope, the patient is ordered to use a strong solution of atropine, as detailed under the first class of cases. The accommodation being paralysed, the myopic astigmatism, with any existing myopia, is accurately neutralised, and the proper glasses ordered for all near work. If a proper correction is obtained, the result is most satisfactory both to the patient and the surgeon. If the asthenopia return, we may rest assured that the defect in refraction has not been accurately neutralised, and must be worked out again. In this plan of treatment by paralysis of the accommodation, it is interesting to notice how many cases of mixed astigmatism are met with, which, without the use of atropine, appear to be cases of simple myopic astigmatism both by examination with the ophthalmoscope and by trial with lenses-showing that a certain tonic contraction of the ciliary muscle must exist, sufficient to mask in some instances even a considerable amount of hypermetropia. Subjoined are notes of a few illustrative cases :Case 1.-Extreme Hypermetropia.

6

G. W., aged 25. Eyes have always been troublesome; has had many different glasses ordered, all of which gave relief for a time. Under atropine, H= diagnosed with ophthalmoscope, and also by means of convex lenses. Right eye 12 with convex V= Left eye extremely amblyopic; most 12 cyl. 18 improved by + sph. 6 Seen four months later, could read or do any kind of near work for any time without the least inconvenience. The left eye had somewhat improved.

6

Ordered convex for both eyes.

1 6

Case 2.-Extreme Hypermetropia.

Edwin T., aged 9. Has always been thought to be nearsighted; has learned to read, but with great difficulty, and by holding print close to the eyes. Can make out Snellen 6 at about four inches with either eye. Extreme hypermetropia diagnosed with ophthalmoscope. Under atropine, hypermetropia v = not improved beyond by any lens. When seen a fortnight later, could read Snellen 2 at about eighteen inches without difficulty. Ordered to use convex for all purposes for six months, and then to report himself.

15 30

Case 3.-High Degree of Hypermetropia.

6

20 20

20 30 Ordered to use con

20 left eye V = c. + 14 V = 70 vex 12 for both eyes. Seen two months later, could do near work for any time, and read small print (S. 1) easily.

Case 4.-Compound Myopic Astigmatism-Much Asthenopia. William L., aged 23, a compositor. Has suffered from moré or less pain in eyeballs and forehead for some years. Pain much increased by close application to his work. Has worn glasses, and had them frequently changed, but without relief. With the ophthalmoscope, myopia in the left eye, with myopia and astigmatism in the right, were diagnosed. Left eye with concave= V = ; right eye under atropine with con- 30 for left eye, Ordered

cave

1

15 15 15 15

cyl. 30 sph. 9

30 cyl. 30 V= sph. 9 for right eye-to be used for near work, and also for going about, if he likes. Seen six weeks later, says his eyes have not been so comfortable for years.

Case 5.-Compound Myopic Astigmatism-Much Asthenopia. Elizabeth B., aged 18, a bookfolder. Suffers great pain, more especially at night, in eyeballs and forehead, getting gradually worse for the last eighteen months. Is slightly near-sighted. V= =

15 15

15 sph.36 15 The pain was so com

Both eyes under atropine-Left, with concave, cyl. 40 right, with concave, cyl. 60 V= sph. 40 pletely removed by the atropine and rest that this patient objected to wearing glasses. Accordingly, none were ordered,

FRACTURE OF BODY OF SIXTH CERVICAL VERTEBRA-COMPRESSION OF CORD-PARALYSIS OF MUSCLES SUPPLIED BY PART OF BRACHIAL PLEXUS-PLEURISY, WITH EFFUSION-DEATH FROM EXHAUSTION AND ASPHYXIA.

(Under the care of Mr. BERKELEY HILL.)

GEORGE S., aged 23, carpenter, was admitted on December 20, 1873. At half-past six in the evening of that day, patient was in the act of conveying a heavy box upstairs, and on the third step from the bottom fell backwards, striking, as he thinks, the upper part of his neck and the back of his head. He was brought to the hospital at seven o'clock.

The following is a report of his condition soon after admission:-Lies on back, and takes no notice of anything round him, but can easily be aroused. Face cool.

Pulse small, but compressible. Skin of right upper limb and of right side of chest markedly cooler than that of left. Temperature of left lower limb higher than is natural-much higher than that of right. Can raise both arms, bring them across in front of him, and bend and extend the forearm, but cannot grasp at all; can extend wrist a very little. Can move the right leg, but there is some loss of power. Has no power over left leg at all. Sensation entirely lost in right leg and on right half of trunk as far as about the level of the nipple. Sensation normal in left leg. Says arms and hands feel numb; can feel the prick of a needle. No irregularity can be felt along spines of vertebræ. Has pain at lower part of back of neck and between shoulders. Says he feels as if his neck were coming off. Breathing 13 per minute, almost entirely diaphragmatic; lower ribs appear to move slightly, but upper ones are not raised at all in inspiration, while upper half of chest falls in. There is great rigidity of muscles at back of neck; can rotate the head slightly. Some amount of priapism. Fæces appear to have passed involuntarily.

December 21.-Patient says that one hour ago he could move his right leg, but now cannot at all; can now feel the prick of a pin in it. Sensation remains in the left leg, but less acute than it was last night. Intercostals do not act, and upper part of chest falls in during inspiration. Sensation and power remain about the same in upper limbs. Has no power to expectorate, while bronchial tubes are apparently loaded with mucus; feels as though he should choke; pain remains about the same. Has not passed any fæces.

22nd.-Patient, when first seen by the registrar, Mr. Godlee (to whom we are indebted for these notes), was in a recumbent position, breathing entirely diaphragmatic, and considerably cyanotic. There was evidently a considerable collection of mucus in the trachea and bronchi. Skin very hot; equally so on both sides, moist. Temperature in both axillæ, 102-3; pulse 96, rather hard and bounding. There is complete paralysis of the lower ribs, of apparently all the intercostals, and of various branches of the brachial plexus, as follows:-The deltoid, biceps, brachialis anticus, and triceps all act, though the biceps only feebly. In the forearm, supination and extension of the wrist and fingers are apparently complete; pronation can only be conducted so far as to bring the thumb upwards, probably performed by the supinator longus. Flexion of the wrist is very imperfect, and is apparently performed by the flexor carpi ulnaris only. Flexion of the fingers is altogether

absent-that is to say, the function of the median nerve is perhaps abolished, that of the musculo-spiral, musculocutaneous, and ulnar more or less complete. There is power in the muscles of the neck. There is complete retention of urine; the bowels acted slightly yesterday, to-day not at all. There is no absolute loss of sensibility anywhere, but in the legs it is decidedly less than natural, the deficiency increasing downwards, so that on the dorsum of each foot, though he can localise firm pressure, he scarcely feels a prick with the tips of the nails. He complains of scarcely any pain, but there is a little tenderness opposite the middle and lower cervical vertebræ and in left shoulder. At eleven o'clock his body was gently raised and propped up at about an angle of 25° from the horizontal, when he expressed himself relieved from the suffocation produced by the mucus; however, the cyanosis is markedly increasing. Catheter tied in and arranged as a syphon, with a vessel placed underneath the bed. Urine coming by no means freely.

23rd. Yesterday afternoon, about 3 p.m., three ounces of blood were taken from the arm, as choking appeared imminent. Artificial coughing was also practised by compressing the chest-walls and abdomen simultaneously with the effort of the patient; this gave him great relief. The loud rhonchal fremitus felt in the morning disappearing. Urine acid, sp. gr. 1027; no albumen; a very little ropy mucus; rather high-coloured. Bowels not having acted since the day before yesterday, enema administered. Tourniquets were also applied to the femorals alternately, with a view to reducing the amount of blood in circulation. The artificial coughing was continued through the night. He slept for half an hour at a time. This morning he seems more comfortable than yesterday; much less cyanosis. Breathing quiet, 32 per minute; skin moist; temperature 101°; tongue clean; abdomen not distended; urine still acid. There is no improvement in the paralysis or in the numbed sensation of the limbs and body. Catheter taken out and passed every two hours. 4 p.m.: Urine acid, but more mucus observable.

24th. The patient was sick last night very frequently, but feels somewhat more settled to-day. Cyanosis almost disappeared, and breathing easier. Temperature this morning at 6.30 a.m., 102-2°; pulse 82. Temperature, 11 a.m., 102.6°; pulse 80, rather irregular. Feverish and thirsty; seems frequently half-choked by phlegm, which, however, he is able to get rid of by the artificial coughing. Urine acid on passing, with no albumen. Abdomen quite as tympanitic as before. No change in paralysis. 3.15 p.m. Both feet distinctly and much inverted, apparently from excessive relaxation of peroneal muscles. Some cedema of both feet, especially the right. Interrupted current applied to peronei longi shows that the irritability on right side is less than that on left. The irritability of tibiales antici is almost equal. The current applied over the course of peroneal nerve shows a distinct deficiency of irritability on the right side. Optic discs examined: veins large and dark; no optic neuritis. Pain in left shoulder increasing. Pupils small and equal. Catheter tied in as before, by Mr. Hill's orders.

25th.-Temperature, 5 a.m., 101°; at 11 a.m. 101°, pulse 80; temperature at 10 p.m. 101-3°. Urine acid; no albumen; light-coloured; ropy mucus. Enema. Has been sick often through the night after anything that he has taken. The tympanites is now very considerable. Pulse quiet; skin moist. No increase of oedema in feet, which retain the same inverted position. No alteration in paralysis.

26th.-11 a.m.: Temperature 100°; pulse 84. Galvanism applied; one sponge at anus, the other over abdomen. Flatus escaped four or five times; distension of abdomen less; breathing easier. Has not been sick since morning.

27th.-Temperature, 6 a.m., 102°; pulse at 11 a.m. 72, respirations 32. Temperature at 6.40 p.m. 101°. Incoherent in his talk: this state of things began on the night of the 25th. Was sensible yesterday, but incoherency came on during the night, and continues this morning. Tympanites relieved by galvanism. No vomiting since the morning of the 25th. Irritability of left peroneus longus greater than on the right side as per battery register, 11 to 6; peroneal nerves about equal. Patient had a slight rigor at 6.30, but has not been sick. Urine acid; no albumen; small quantity of mucus.

29th.-Temperature at 10.30, 99.9°; at 12, 99.4°; pulse at 10.30, 64; respirations 32. Patient was not sick at all yesterday, and feels better this morning; was not galvanised yesterday. Was moved this morning for the purpose of putting clean sheets on the bed, and suffered a good deal of pain in

the neck during the process. The left foot has now assumed the natural position of rest-viz., slight eversion. The position of the right is unaltered. The sensibility is distinctly less in the right foot than in the left; in the latter the power of localising sensation is pretty complete, in the former very imperfect. Pulse and respiration still quiet. Sputa as before, muco-purulent; power of coughing increases. Paralysis of arms no less; pain in neck more severe; bowels acted twice without assistance yesterday and this morning; no cyanosis now; odour of patient peculiar and fetid; urine acid.

30th.-Temperature 99-4°; pulse 64, rather feeble; respirations 32. Bowels open; passed some flatus this morning. No distension of abdomen; no change in position of feet, nor any in degree of paralysis in feet. He appears to have lost all extension movement in arms, and flexion muscles assume some rigidity on passive extension. Urine acid; no albumen. Tongue furred and dirty; appetite good; sleep pretty good, considering the frequent interruptions.

January 1, 1874.-Urine: Yesterday morning, as the catheter had not been acting, a full_beaker of urine was obtained immediately it was passed. It was acid to test-paper, and had a faintly disagreeable smell. On microscopical examination, it was found to teem with motionless bacteria of large size. Besides that, there were a considerable number of pus corpuscles. It was slightly turbid. Temperature 100-4°; pulse 72. This morning the man's condition is much the same as yesterday-namely, there is no increase or diminution in the paralysis. The left foot is now everted, and carries with it the leg, producing rotation outwards of the thigh. The right foot is still strongly inverted, producing a corresponding rotation inwards of the thigh. The arms, if left alone, assume a flexed position, the elbows being raised, and the hands touching the shoulders. The patient is emaciating rapidly. His skin is dry and rough, and he gives off an odour that is peculiarly disagreeable. His cough is becoming less troublesome; pulse still full, and fairly strong; tongue furred. Temperature 101.2°; pulse 76; respiration 36. Urine still acid; not so thick as yesterday.

2nd. Skin dry and hot; temperature 101.4°; pulse 64, very strong and hard. Sleep much disturbed last night by coughing. Bowels open, but tongue dirty; has not been sick. Urine acid, and somewhat clearer; not so much mucus. change in paralysis. Galvanism applied as before. Distension of abdomen decreased. Emaciation continues.

No

3rd.-Foot inverted again, though not quite so much as before. Temperature 100-4°. Bowels open; smell of the patient most disagreeable. Slept somewhat better last night, and looks more lively this morning. Artificial coughing still has to be kept up, though he is much better able than before to expel the mucus.

5th. On Saturday afternoon the patient passed a motion just as Mr. Hill made his round in the afternoon, and said that, for the first time since his accident, he was conscious of passing it-i.e., actually felt the fæces passing. This morning he is not so feverish-temperature 99.2°,-but seems more uncomfortable. For the first time since admission he was regularly lifted off his bed while it was made comfortable. His left foot has again become everted, though not absolutely, and his left knee slightly flexed; in the latter he has sensation of pain. His bowels have been open this morning, but his smell is still abominable, though he is in his clean bed-even worse than before. He reports that during the last week he has been subject to occasional twitchings of his lower limbs. When this began he finds it impossible to specify; but on last Tuesday being suggested to him, he states that that was about the right day. His urine is still tolerably clear, acid, with a faintly disagreeable smell. The catheter was taken out this morning, cleaned, and replaced. He has a very small attempt at a bedsore, half-way down the left side; otherwise his skin is perfectly whole.

7th.-Both feet extremely inverted to-day. Patient complains of great pain over his left shoulder. Left wrist and elbow and fingers are all in the position of extreme flexion.

8th.-Much difficulty in bringing up the mucus. Patient feels much more difficulty in breathing. Left leg is quite straight this morning; right leg extremely inverted. Early this morning the house-surgeon was called up on account of the patient's extreme difficulty in breathing.

9th.-Faradisation was applied by means of one pole up the rectum and the other over the surface of the abdomen. The patient has much more difficulty in getting up the

phlegm, even with the assistance of artificial coughing. Both feet in position of extreme inversion.

10th. Both legs extremely inverted. Complains of his legs "jumping" frequently in the day and night; no twitchings of the arms. Temperature 103.4°; respirations 32; pulse 72.

13th. When the catheter is out, the urine runs away involuntarily. Temperature 102-2°. No change in paralysis, but emaciation becoming more and more prominent. Tongue so dry that it cracks and bleeds. Urine is still acid, fairly clear, and of only faintly nasty smell. Some roughness of skin can be felt on the back (about the middle), which feels. something like a coming bedsore.

14th. Patient died at a quarter-past seven yesterday evening.

Post-mortem, twenty hours after Death.-The head was first. opened, and the brain was found pale and anæmic, and excess. of fluid under the arachnoid. Nothing abnormal to the naked eye about the brain. On cutting down on the spine it was thought that the sixth cervical vertebra was more movable than natural. The spines of the vertebrae were removed; there was no blood outside the dura mater, unless perhaps a little in the lumbar region; there was some extravasation in the muscles of the lower cervical region. On remoying the spinal cord it was seen that there was a prominence opposite the sixth cervical vertebra, which proved to be caused by the splitting of this vertebra in a vertical direction. The neural arch is split obliquely and on the left side behind the transverse process. On slitting up the dura mater, no blood was found between the membranes; there was a distinct depression of the spinal cord opposite the projection mentioned. The veins below this point were much gorged; those above it of natural size. On cutting the cord transversely at seat of injury, it was found to be very soft and pulpy; a narrow lineof extravasation ran from the anterior course of left side obliquely forwards and outwards. Above and below the seat of injury the cord presented a natural appearance, except in. lower dorsal region, where it was soft. The fourth, fifth, sixth, and seventh vertebræ were then removed, and it was found that the lower part of the body of the sixth and the intervertebral substance between that and the seventh were impacted one into the other. Before opening the chest the left side was seen to be greatly bulged, and on opening it the left pleura was found to be entirely filled with slight opaque yellowish serum, containing flakes of recent lymph. The left lung was completely collapsed, and coated with a layer of lymph; it presented no sign of pneumonia. There was no fluid in the right pleura. The right lung was somewhat congested, but presented no sign of pneumonia. Heart was rather large, and substance pale. Liver weighed 88 oz.; appearance normal, except that it was considerably congested. Spleen very soft, large, dark red colour; weight 18 oz. Right kidney congested and of rather large size; weight not taken. Left. kidney: Pelvis much dilated, not inflamed-in fact, a good example of a sacculated kidney; kidney-substance being in some places not more than one-eighth of an inch in thickness,. in others as much as an inch. Left ureter much dilatedlarge enough to admit the forefinger. Just behind the bladder a hard lump was felt, which proved to be a calculus. of spindle-shape, of black colour, with an accumulated yellow tip directed upwards; on it were one or two minute prominences; round it the ureter lay with a sharp turn, and was probably pretty completely obstructed. Bladder showed signs of recent subacute cystitis. On the right thigh were two deep sloughs on the inner and outer sides, probably caused by the tourniquet which was applied on his first day in the hospital.

WE regret to hear that Mr. Baker, a surgeon, of Junction-road, Holloway, died on Sunday morning from the effects of a dose of carbolic acid taken, by mistake, a short time previously, for a composing draught.

SOCIETY OF APOTHECARIES v. ANDERTON.-A penalty of £20, and costs amounting to £5 ls. 6d., have been recovered through the Halifax County Court from the defendant, a homœopathic chemist in Halifax, for illegally practising as an apothecary. This Mr. Anderton, some few years ago, was in business as a grocer in Halifax, and is, or was until quite lately, in some way connected with Mr. Ainley, the Medical Officer of Health for the borough of Halifax. The bills for Mr. Anderton's attendance were sent out in Mr. Ainley's name.