Medical Times and Gazette solicitors, and men of letters who throng the vicinity. Any special outbreak amongst such a class could hardly have been overlooked. None has ever been recorded. But evidently all the conditions for generating an epidemic were here to hand, with one exception—that is, impregnation with typhoid discharges. But it is this very risk of specific contamination which should, as we have said, be carefully avoided. Where sewage can go, typhoid germs can go. The risk of both should be cut off at once by filling up, not merely by closing, this and such like water-sources. ASSOCIATION OF SURGEONS PRACTISING DENTAL SURGERY. The following is a list of the names of gentlemen proposed by the Council as officers of the Association for the year 1881:-President: *T. Edgelow, Esq. Vice-Presidents: J. A. Baker, Esq., *W. A. N. Cattlin, Esq., S. Cartwright, Esq., *Francis Brodie Imlach, Esq., S. J. A. Salter, Esq., F.R.S., and John Smith, Esq., M.D., F.R.S. Edin. Treasurer: *S. Hamilton Cartwright, Esq. Hon. Secretary: J. Hamilton Craigie, Esq. Council: E. Bartlett, Esq., J. Fairbank, Esq., F. Fox, Esq., C. Gaine, Esq. (Bath), *W. A. Hunt, Esq. (Yeovil), W. D. Napier, Esq., W. G. Ranger, Esq., and Augustus Winterbottom, Esq. An asterisk is prefixed to the names of those gentlemen who did not hold the same office the preceding year. DEATH OF PROFESSOR JULIUS VOGEL. PROF. JULIUS VOGEL, the father of the Medical Faculty at Halle, died in that city on November 7, in consequence of a rupture of the heart. He was born in June, 1814, and two years after taking his degree at Göttingen he was made an extraordinary professor in that University. In 1846 he was made an ordinary professor at Giessen, and nine years later he was selected as Director of the Medical Clinic and Professor of Special Pathology and Therapeutics at Hallę. Both these posts he had eventually to give up on account of bad health. Vogel was a good representative of German medicine in the provinces of pathological anatomy and general pathology. His most important work is his contribution to the first volume of Virchow's "Handbuch der speciellen Pathologie und Therapie," 1854; and the "Anleitung der qualitaten und quantitativen Analyse des Harns," published in conjunction with Neubauer, has reached its seventh edition. Of late years he was chiefly engaged with popular works, the best known of which is his description of the Banting cure in his work on Corpulence, which has reached its eleventh edition. OBSTETRICAL SOCIETY. IT may be useful to point out that the next meeting of the Obstetrical Society will be held on January 12, not on the 5th. An alteration in the by-laws has decreed that the January meeting in future shall be held on the second Wednesday instead of the first, as heretofore. PITTING OF SMALL-POX.-Dr. Schwimmer advises a mask to be formed of very pliable linen cloth, leaving apertures for the eyes, nose, and mouth. The inside of this is to be smeared with one of the following liniments:- (1.) Carbolic acid 4 to 10, olive oil 40, and prepared chalk 60 parts. (2.) Carbolic acid 5, olive oil and pure starch, of each 40 parts. (3.) Thymol 2, linseed oil 40, and chalk in powder 60 parts. The mask should be renewed every twelve hours. Compresses impregnated with one of these mixtures may also be placed on the hands, and on any parts of the face with which the mask does not come into exact contact.-Gaz. des Hop., December 18. FROM ABROAD. WASTING OF YOUNG CHILDREN. DR. STARR, of the Philadelphia Children's Hospital, contributes a useful paper to the Phil. Med. Times, November 6, entitled "On Wasting, or Simple Atrophy, as it occurs in Young Children from Insufficient Nourishment," embracing a class of cases which in their more advanced stage are comprised by Prof. Parrot under the term athrepsia. Cases are frequently met with among out-patients of children's hospitals, in which, either owing to an insufficient supply of food, or to the food being of unsuitable quality, simple wasting, or wasting with irritation of the gastro-intestinal canal, is a prominent result. Simple wasting is most frequently seen in children nursed at the breast of feeble or over-worked mothers, in whom the milk is often scanty and of poor quality. There is a gradual loss of plumpness, the muscles grow flaccid, and there seems to be an arrest of growth. The face is pale, the lips pale and thin, the skin harsh and dry or too moist, and the anterior fontanelle is level or slightly depressed. The temper is usually irritable. The child first seizes the nipple ravenously, but if there is but little milk, he quickly drops it, to cry passionately; but if the milk is abundant, though thin, he will lie a long time quietly at the breast. The bowels are inclined to constipation. No indication of disease in any of the organs is discoverable. It is, however, more common to have the wasting combined with gastro-intestinal irritation, especially in children brought up by hand. This is oftenest met with when farinaceous food is employed, to the exclusion in great part of milk, when the infant is allowed to bolt bits of table food and drink tea, and particularly when faulty feedingbottles are employed. These bottles have, in place of a plain gum nipple, an arrangement of fine glass and rubber tubing. The glass tubing extending to the bottom of the bottle, the necessity of keeping this at a proper angle during feeding is avoided an advantage counterbalanced by the fact that the child continues sucking long after the bottle is exhausted, and that the tubing can never be kept clean. In almost every instance, notwithstanding the most careful and complete cleansing, the milk in such bottles will be found to have a sour smell and to be filled with small curds; while, when care is not taken, the odour becomes intolerable, and the tubing is encrusted with a layer of altered curd. In bottles provided with a simple nipple, on the contrary, the milk is nearly always found perfectly sound and the nipple itself clean. The cleansing in these is easily performed, while in those provided with twelve or more inches of fine tubing this is impossible, and the successive supplies of milk rendered acid and curdled induce irritation of the mucous membrane, and interfere seriously with digestion and nutrition. In some cases the emaciation progresses to an extreme degree: the skin becomes dry, yellowish, and harsh, and hangs in loose folds over the bones-and this, although a large quantity of food, such as it is, may be consumed. This combination of great wasting with a voracious appetite is very striking. Wasting children sometimes have what are termed "inward spasms." When these spasms occur, the upper lip becomes livid, somewhat everted, and tremulous, the eyeballs rotate or there is a slight squint, and the fingers and toes are strongly flexed. They frequently usher in true convulsions. These "inward spasms," together with restlessness and irritability of temper, are ordinarily the only indications of involvement of the nervous system. In treating these cases the first thing to be attended to is the diet. Dr. Starr has found that children under twelve months, who have to be partially or entirely brought up by hand, ordinarily do well on cow's milk with lime-water or barley-water. It should be given from a bottle capable of holding half a pint, made of colourless glass, so that the least particle of dirt may be readily seen, and provided with a soft india-rubber nipple. The whole quantity of food intended to be given in a day should never be prepared at once, each portion being made separately and freshly at the time wanted. The bottle made as nearly absolutely clean as possible, may be filled with a mixture of one part of limewater or barley-water to two or three of sound milk, to which may be added from one to four teaspoonfuls of cream 18 egg, and one or two lumps of sugar. The nipple, also quite clean, is put on, and the bottle is placed in hot water until its contents become sufficiently warm. The degree of dilution of the milk and the proportion of cream added vary with age. Lime-water is used as the diluent when there is frequent vomiting or acid eructation.. Barley-water (made by putting two teaspoonfuls of washed pearl barley in a pint of water, boiling down to two-thirds of a pint, and straining) is given when it is desired to prevent the formation of a large compact curd. After the digestion has been brought into a good condition, the food may be cautiously increased to the point suitable for a healthy child of the same age-for instance, at eight months, from two to four fluid ounces of thin mutton or chicken broth, free from grease, may be added to the milk; at twelve months, the yolk of a soft-boiled rice and milk, and carefully mashed potatoes; and after sixteen months, a small quantity of finely minced meat. Once daily the patient should be bathed in, or at least sponged with, warm water, and every morning and evening a teaspoonful of warm olive oil or cod-liver oil should be gently rubbed into the skin, especially over the abdomen and chest. The belly should be completely covered with a soft flannel binder, and the feet should be kept warm. In this way, attacks of colic, if not entirely prevented, are rendered much less frequent and severe. Of medicines, bicarbonate of soda, pepsin, and cod-liver oil are the most useful; but cod-liver oil should not be given until the digestive powers have been brought into a comparatively normal state by proper food, antacids, and digestants. It seems to be most easily borne when given in emulsion, and may be advantageously combined with lacto-phosphate of lime or with the hypophosphites. REVIEWS. Eyesight, Good and Bad. A Treatise on the Exercise and Preservation of Vision. By R. BRUDENELL CARTER, F.R.C.S. London: Macmillan and Co. 1880. SEVERAL endeavours have been made of late years to popularise, by means of short manuals, a knowledge of the structure of the human frame and its physiology, and to diminish the ignorance which prevails in these subjects. The volume before us, although it may be classed as one of these attempts, as dealing with the special topic of the eye and its functions, has been written, as we gather from the few lines which preface its pages, with a somewhat more limited object. The author finds that much valuable time is consumed in repeating to successive patients instructions and injunctions which ought to be universally known, and which an elementary knowledge of the fundamental laws of vision would render superfluous. To remedy this, and to afford to those who are specially concerned in its acquisition some knowledge of the subject, is the aim of the present volume. It is written in a lucid and agreeable style, and succeeds in conveying to the non-professional reader a sufficiently ample and easily comprehensible account of the structure of the eye and of the function of vision, and gives a description of the principal anomalies of the latter, at the same time inculcating such salutary advice as may be beneficial for the preservation of sight and assist in dispelling much popular ignorance and many time-honoured delusions. In illustration of the necessity of some such general diffusion of knowledge, an incident is related by the author in the introductory lines of the first chapter. During the trial of a medico-legal case certain drawings of the fundus of the eye were produced as evidence. The question was asked by the presiding judge why these were depicted of a red colour; the explanation, that they were drawn as they actually appeared to the delineator, being, in absence of any knowledge of the eye, the least rational and acceptable to the querist. The volume is composed of thirteen chapters, the first five of which are occupied in briefly describing the normal state and condition of the organ of vision and its function, as introductory to treating of certain pathological deviations from these. Those chapters which are devoted to a consideration of the anomalies of refraction contain much information which, by wider dissemination, ought to be instrumental both in the prevention of the extension of already existing defects and in relieving troublesome symptoms which result from ignorant misuse of the eyes. In describing the methods in vogue of testing the acuity of central vision, the author insists on the necessity of doing this in the case of all children, in order that any defect may be recognised as early as possible; and he recommends for this end that the parents should do this from time to time, and, to facilitate its performance, appends appropriate test-types at the end of the book. Much of the dulness and slow perception displayed by children labouring under any considerable defect, and which is not unfrequently attributed to stupidity and mental sloth, might in this way be remedied and removed. With special reference to myopia, such an examination is of the more importance, since by judicious limitation of, and guidance in the use and training of, the eyes, combined with a proper adaptation of spectacles, much may be done during the earlier years of life to retard the progress and limit the extension of an affection which is frequently fraught with danger to the integrity of the eye. The use of spectacles in myopia is especially urged both for distant and near vision. To the non-professional myope the utility and advantage of these for the former purpose is at once obvious; but he is slower to comprehend the necessity of their use for the latter purpose. It is only by obtaining a clear conception of the importance of over-convergence and accommodation as primary factors in the increase of this defect, and of the utility of concave glasses in removing the necessity for this convergence, that their necessity in this respect is appreciated. In the opposite anomaly of refraction, hypermetropia, the convergent strabismus which is so frequently its consequence is familiarly explained, and an early interference recommended. Parents are frequently loth to submit their children to an operative treatment, from a hope and expectation that the deformity may disappear during the growth and development of the eye and the orbit. This protracted recovery, when it does occur, is effected at the expense of the sharpness of sight in the squinting and unused eye. On this ground alone, apart from the removal of an unsightly deformity, early interference is to be strongly urged. A separate chapter is devoted to the subject of asthenopia, and in that variety which is due to weakness of the muscular apparatus (after carefully correcting any existing anomaly of refraction), regular training and systematic use of the debilitated muscles is insisted on as a valuable adjunct in the treatment, just as it constitutes an important factor in restoring tone to muscles weakened from disuse elsewhere in the body. A description of a process by which this end is to be attained, and which is somewhat extensively followed in America, and from the name of its author has been de signated "Dyerising," is here inserted. It consists of actively employing the muscles by means of reading at certain producing discomfort. In this way the nutrition and tone intervals during the day, and for a length of time short of of the muscles are gradually improved until the individual is able to converge and to read for half an hour three times a day without exciting any of the previous uncomfortable symptoms. All rapid improvement is to be discountenanced, and the treatment, at the rate of increase of a minute a day, lasts about three months. The concluding chapters are by far the most valuable for general perusal. They deal with a topic-the care of the eyes in infancy, childhood, and adult age-which is unfortunately far too much neglected, and which deserves closer consideration than it has hitherto received. For much of his information the author is indebted to the excellent work of Professor Arlt on the same subject, "Die Pflege der Augen," in many places reproducing the text of this verbatim. It is especially during the periods of infancy and childhood that much may be done by those to whose care and supervision children are intrusted, to prevent temporary or permanent impairment or injury of vision. In infancy, neglect of proper precautions in the matter of cold, cleanliness, etc., not unfrequently leads to partial or complete blindThe disastrous results of the ophthalmia of the newlyborn could be avoided with almost certainty were a knowledge of its terrible risks to the affected eye more general, earlier recourse had to professional assistance, and less reliance placed on domestic remedies until the mischief became irremediable. During the period of childhood also the proper training of the eyes is all-important for the after-career and ness. comfort of the individual. By carelessness in this respect their efficiency frequently suffers to a degree from which they are incapable of recovering. The studies of children should not commence too early, or be too closely sustained; and especial precautions should be taken that they are carried on under conditions which entail the least amount of strain on the eyes; otherwise the possessors of visual organs thus overtaxed by lengthy tasks during childhood will, in the words of Professor Arlt, have occasion to deplore the doctrine of their teacher, that "by writing we learn." The care and treatment of the eyes during adult life is obviously on a different footing, inasmuch as, being under the control of the individual, much may be done by attention to the considerations and precautions laid down in this chapter to preserve their utility and prevent injurious consequences likely to accrue from their over-use. The question of working by natural and artificial illumination is one which is dealt with at some length by the author. In exemplification of the risks run by exposure to intense natural light, he adverts to the cases of central scotoma and partial blindness which have resulted from prolonged gazing at a solar eclipse through imperfectly smoked glass. Artificial light should be as perfect in illuminating power as possible. The weakness of all artificial sources of light lies in their deficiency in the violet rays of the spectrum, and the proportionate preponderance of the red and green rays; the greater amount of the violet present, the more perfect the illumination, and the more closely it approximates to solar or white light. The author relates some investigations made on different kinds of artificial light with a view of testing their efficiency, as judged by the amount of violet rays, and finds that the best illumination for close work is to be obtained from a Silber argand burner, consuming gas or oil, placed to the left side of the worker, a little above the level of the eyes, fitted with a shade to reflect the light on to the table, and, where the heat is objectionable, an interposed alum screen. The book concludes with a short chapter on the various kinds of spectacles. Whether the object of the author, as enunciated in the prefatory sentences, is likely to be attained, is, in our opinion, more than doubtful. We are inclined to believe that few patients who consult an oculist on account of their vision will be likely to anticipate this, or to educate themselves for such a visit by a careful perusal of a volume such as the present. Those who do will find their self-imposed task both easy and pleasant, from the clearness with which the subject-matter is treated, and the avoidance of all abstruse or difficult topics. SPECIFIC DISEASE-GERMS.-After noticing the results derived from the experiments of Profs. Pasteur, Sanderson, and others, the New York Medical Record (December 4) observes:-"While hoping that these experimenters are not deceived, we cannot but remember that the history of specific germs is full of the wrecks of brilliant hypotheses. From Hallier, with his rice-fungus, to Oertel, with the diphtheria spores, the story has been one of laborious experiment, alluring theory, then refutation, and finally collapse. There is a remarkable medico-geographical fact also in this connexion: it is that all the specific micro-organisms, except a few in Ohio, live on the other side of the Atlantic, and cluster around the laboratories of a few pathologists. Therefore it is not surprising that some incredulity be shown towards specific germs in whose geographical distribution there is so conspicuous a bias." PERFORATION OF THE VERMIFORM APPENDIX.-In allusion to a case of this, occurring in a boy in consequence of the irritation set up by seeds embedded in hard fæcal matter, Dr. Jacobi observed that in children from three to eleven years of age it was a normal occurrence to find a fold of mucous membrane at the entrance to the appendix, and that this fold, acting as a valve, would cause retention of such particles as may have accidentally entered the appendix. Moreover, it should be borne in mind that peritonitic adhesions frequently brought about permanent flexures of the appendix. The late Dr. Krakowitza believed that, as a rule, perforation of the appendix was preceded by local peritonitis. Dr. Jacobi added that in future he would practise abdominal section and drainage as soon as the diagnosis was fairly established. He should not consider it necessary to tie the appendix, because under antiseptic treatment adhesions would be likely to close the perforated point. -New York Med. Record, November 27. PROVINCIAL CORRESPONDENCE. MANCHESTER. December 21. NEW APPOINTMENT AT PENDLEBURY-ALTERATION OF THE INFIRMARY-NERVOUS DISEASES AT THE MEDICAL SOCIETY. YOUR readers will not have forgotten that when Dr. Humphreys' connexion with the Pendlebury Hospital ceased, it was considered undesirable to take any immediate steps towards the appointment of his successor. The funds of the Hospital, for one thing, were not very flourishing, and the medical profession was at the time so deeply moved with indignation at what it considered the ill-treatment which Dr. Humphreys and others connected with the Hospital had received, that it would have been next door to impossible to find a physician of any professional standing willing to come forward. In this crisis Dr. Borchardt undertook temporarily to fill the gap, in order to prevent the work of the Hospital coming to a standstill, and resumed for twelve months the active duties of honorary physician, which he had some time ago relinquished. The twelve months, thus provided for have now elapsed, and on Monday last a new appointment was made, the whole matter being arranged in the quietest possible manner, without even the publicity of an advertise ment. The plan is to invite a limited number of gentlemen, more or less known to the Committee, to send in applications. Unable to withstand such a signal mark of attention, they accept the invitation. Testimonials are printed and sent round; a day is appointed for the election; the favoured ones are in attendance; and one of their number receives a majority of votes. Such is the mode of procedure which has now on at least two occasions been, in its main features, adopted at the Children's Hospital, and which has now resulted in the appointment of Dr. B. J. Massiah to the post which Dr. Humphreys was the last to hold. However astonished we may be that anyone has been found venturesome enough to try his fortune at Pendlebury, it cannot be denied that the Hospital authorities have made a most wise and fortunate selection. They have secured in Dr. Massiah a gentleman who, as Resident Medical Officer at the Barnes Convalescent Home at Cheadle during the last two years and a half, has shown himself possessed of an altogether exceptional aptitude for hospital administration. The manner in which he has succeeded in rendering the Convalescent Hospital an attractive home to the patients has won everybody's admiration. To his powers of organisation Dr. Massiah adds a personal charm of manner and other qualities of a like nature which particularly fit him for work amongst sick children. Previously to coming to Cheadle, he had held the office of House-Physician in charge of Dr. Matthews Duncan's wards at the Edinburgh Royal Infirmary, besides having assisted Dr. Shuttleworth for some months in the medical charge of the Royal Albert Asylum at Lancaster; so that he enters upon his new career not without considerable hospital experience. The alterations at the Infirmary are being effectually, though somewhat slowly, carried out. All the patients have at last been removed from the wooden pavilions, two of which are now devoted to the accommodation of the nurses, and are likely to remain so until the long-talked-of Nurses' Home is built. The space occupied by the old out-patients' department has been utilised for the construction of two fine wards of fifteen beds each. These and other new wards, obtained by the absorption of small wards and the appropriation of other space, have rendered available an increased number of beds. There are now 317 beds in use, 122 medical and 195 surgical, being thirteen more than when the pavilions were occupied, and thirty-eight more than up to the time of the pavilions being opened. The old drains have been removed, with marked effect upon the purity of the air within the building; and a new mortuary, detached from the main building, has been erected, and is now in use. The general superintendent is sanguine enough to believe that when the reconstruction of the laundry, now in progress, is completed, the sound of the mason's hammer will for the present cease. A large gathering of members assembled at the last meeting of the Medical Society, when the experiment was for REPORTS OF SOCIETIES. the first time tried of setting apart a whole evening to the consideration of cases illustrating some special subject. On this occasion nervous affections were chosen for illustration. The paper of the evening was by Dr. Morgan on Lateral Sclerosis, and was rendered extremely interesting by the presence of two living examples of the disease. When the paper was concluded, Dr. Dreschfeld exhibited, by means of the magic lantern, some beautiful sections of the spinal -cord from a case of lateral sclerosis, which had also been under the care of Dr. Morgan. There were afterwards shown at the meeting two patients suffering from amyotrophic lateral sclerosis, three from disseminated sclerosis, and one, a child, from brain tumour with descending degeneration. The experiment was an undoubted success, and will be repeated. GENERAL CORRESPONDENCE. CASES OF FRACTURE FROM MUSCULAR ACTION. LETTER FROM MR. C. FOSTER. [To the Editor of the Medical Times and Gazette.] SIR,-With reference to Professor Vallin's and my own remarks on this subject, which appeared in the last volume of the Medical Times and Gazette, Dr. le Chevalier Lubelski, of Warsaw, informs me that he also has observed similar instances of spontaneous fracture, occurring more especially, however, in epileptic patients, and that this fact is already published, with a translation of the original article, in the Polish Kronika le Karska, and Russian journals. I am, &c., CLARENCE FOSTER. Park-place, Leeds, December, 1880. EPIDEMIOLOGICAL SOCIETY.-At the next meeting of this Society, to be held in the Council Room of University College on Wednesday next week at 8 p.m., a paper will be read on "The Nature and Origin of Climatic Fevers," by Surgeon-Major Charles Oldham, M.D.; and one by Dr. J. Wm. Mackenna, on "The Cause and Origin of Fever." EUROPEAN AND AMERICAN LUNATIC ASYLUMS.-At the meeting of the National Association for the Protection of the Insane and the Prevention of Insanity, Dr. Beard stated that he had arrived at the following conclusions, after a visit to several asylums in Great Britain and Germany:1. That in the management of the insane Great Britain is ahead of all the world, with Germany close behind. In Scotland the insane are better treated than anywhere else. 2. Some method of central governmental supervision is practised in those countries and in France. The United States is alone in compelling its insane to depend on superintendents and local trustees. 3. In the best asylums mechanical restraints have been reduced to a small percentage, and the patients are employed at some kind of labour. The extent to which the insane are employed is almost incredible. 4. Patients in the best asylums are treated like children, with a watchful and guarded liberty. 5. The best asylums are not enormous or imposing buildings, but series of moderate-sized cottages. It is believed and asserted that this spreading of the insane over large areas gives immense advantages toward restoration. ¡6. The methods which have proved most satisfactory in Europe can, and will, be introduced into America, despite the present existing difficulties. The chief of these is the nature of the political system. At the same meeting, Dr. Morton spoke favourably of what he had seen during a visit at Gheel, and especially concerning a somewhat similar and very remarkable institution at Clairmont, in France. This consisted of two farms, 1500 acres each, and a central infirmary. Each farm was complete, having its own flour-mill, blacksmith's shop, etc., and live-stock. The men are employed in agriculture, etc., and the women in laundry work. Even the engineer and fireman of the laundry were lunatic women. All were happy, laughing, joking, and discussing various subjects. attendants were visible. The institution has 900 patients of all phases of insanity, all of the lower classes-not one being under any form of restraint. Dr. Wildbar stated that at a moderate estimate there were 50,000 lunatics in the United States. The State of New York, with 5,000,000 inhabitants, has 10,500.-New York Med. Record, November 20. No CLINICAL SOCIETY OF LONDON. FRIDAY, DECEMBER 10, 1880. Dr. E. HEADLAM GREENHOW, F.R.S., President, in the Chair. CASE OF PNEUMONIA, WITH REMARKS ON THE MR. W. J. TYSON (Folkestone) read a paper on a case of pneumonia, with remarks on the physical signs of the disease: -The following case of pneumonia illustrates the point in the physical signs of the disease to which I wish to draw the attention of the Society, the point being the lateness of the appearance of dulness, bronchial breathing, and bronchophony, in many cases of pneumonia. A. B., aged sixty-three, on Sunday, April 4, 1880, drove in an open cart the distance of forty miles. The day was cold, and he himself was thinly clad. During the drive he felt a distinct fit of shivering. The next day he was obliged to leave off work at noon, and remained indoors the rest of the day. Tuesday and Wednesday he felt ill, and on Thursday morning he sent for me. He had now a temperature of 103°, his pulse was 108, and respirations 30. His chest was carefully examined, but no abnormal physical signs could be made out. He was expectorating a little tenacious mucus. He complained of pain in his chest, but in no definite spot. His urine contained albumen. On Friday and Saturday he was getting weaker; his temperature varied between 102° and 103°. On Sunday there was slight dulness in the middle third of the right lung behind, also some bronchial breathing was heard On Monday, the 12th-eight days after the chill-there was well-marked dulness, bronchial breathing, and bronchophony. On Tuesday the dulness had increased in extent, and moist crepitations were heard with inspiration and expiration. The chest was not again examined on account of the feebleness of the patient. He died on Thursday (15th), eleven days from the commencement of his illness. The first time that lately-developed signs were noticed by me was in the case of a woman, aged twenty-five, who was admitted into Guy's Hospital, under Dr. Pye-Smith, on August 3, 1876. She was ill three days before coming in. On admission her temperature was 104°; the only physical sign present was tubular breathing at both apices. On August 4 and 5 the temperature varied between 103° and 105°. It was not until August 6 that dulness was noticed at right apex anteriorly and posteriorly, with bronchial breathing. No crepitation heard. She was too weak to speak. She died at 11 p.m. the next day. Post-mortem: The right apex was in a state of grey hepatisation; the middle and the lower lobes of the same lung were unaffected. The left lung and other organs healthy. In this case the dulness did not appear until the sixth day, and she died on the seventh day. Since I have been in private practice, other cases with lately-discoverable signs have come under my care. The following paragraph occurs in "Ziemssen's Practice of Medicine": Usually up to the third day after the chill the percussion note over the affected part becomes dull; the respiration of a blowing character; bronchophony now makes its appearance." I have quoted the above paragraph as representing the generally acknowledged time as to the appearance of these physical signs of pneumonia. From my present experience of pneumonia, and seeing the disease as I do in its earliest stages, I believe that the physical signs, such as dulness on percussion, bronchial breathing, and bronchophony, occur later in the course of this disease than is usually supposed, or perhaps it would be more correct to say that there is a larger percentage of cases with the above lately-discoverable physical signs than our reading and teaching have led us to think. What this percentage is I am not at all prepared to say. The author before quoted says further on in his essay that the characteristic physical signs of the disease may escape recognition from the inflammation having commenced in a central position in the lung. Probably this explanation may sufficiently account for, in many cases, the lateness of the detection of the aforementioned signs. Yet, allowing this to be the common cause, it is just as important for the treatment of the case to diagnose a central pneumonia as it is one of peripheral origin, the former being as dangerous in its prognosis as the latter. If these signs which have been mentioned are not unfrequently lately-discovered for all authors admit that occasionally these are either overlooked or lately found. out, then it becomes necessary in many cases to diagnose pneumonia by symptoms instead of by signs. A well-known author says, referring to pneumonia, that if the patient has had a chill, pain in the side, rusty sputa, and high temperature, there is scarcely any room for doubt, and even in central pneumonia these symptoms are generally present. In other cases, in which the only symptoms present are high temperature and abnormally quick breathing, the relation of the pulse to the respiration appears to be the most diagnostic point, in the absence of any other affection of the heart and lung. Dr. F. TAYLOR thought that many such cases occurred. In the case of a patient admitted to Guy's Hospital no physical signs were at first to be made out, but whilst being examined she coughed up a quantity of rusty sputa. After the fourth day the physical signs rapidly developed. Dr. ANDREW CLARK considered the paper a valuable one, as tending to illustrate the varieties, peculiarities, and what he might call the caprices of pneumonia. Men of experience, however, recognised the facts insisted on by Mr. Tyson, and he would mention three cases as tending to illustrate them. In the case of a gentleman, no signs beyond a slight increase of temperature and rather hurried breathing manifested themselves for seven days. After that the symptoms became marked and urgent, and the disease followed a normal course until recovery. A gentleman, aged eighty, got a chill, which was followed by slight malaise and feverishness, together with rather hurried respiration and irregular temperature. But on the twelfth day there was some friction below the angle of the right scapula, followed by marked friction and dulness. The patient ran through the ordinary course, and recovered. In the third case the patient was for six days only feverish, but on the seventh or eighth day the ordinary signs of pneumonia manifested themselves. Practitioners do recognise the existence of pneumonia without marked physical signs. Chill, variation and elevation of temperature, and disturbed breathing, should be enough to direct the medical attendant. Dr. HABERSHON also thought that general rather than special physical signs should in certain cases guide the diagnosis. When the mischief began at the root of the lung, the signs were often masked by intervening healthy substance, but when the disease reached the surface all obscurity disappeared. Dr. ANDREW CLARK further said that his desire was to enforce the impression that in a large percentage of cases the physical signs only became marked towards the close of the disease, when it had nearly run its course, and that consequently practitioners must, in coming to their conclusions, be largely guided by general indications. Dr. DE HAVILLAND HALL narrated some cases where for days the absence of physical signs had made him doubtful of their nature. He thought that those cases where the physical signs appeared late were more severe than those where they appeared earlier, having to spread from within the lung towards its surface. Dr. BURNEY YEO thought that these cases might depend on constitutional causes. Dr. GOODHART would regard these cases as examples of blood-poisoning. He referred to the case of an old man who died after some slight fever, and where only a slight degree of pneumonia existed. This might have been taken for a case of pneumonia with late manifestation of physical signs, but as it was there was enough to show that blood-poisoning had occurred, and killed the patient in an early stage of the disease. Mr. TYSON, in reply, said that these cases must be taken as pneumonia throughout. In a case under his care, a child five years old was feverish for six days, and then the signs of pneumonia made themselves apparent. His object was mainly to call attention to the insufficient description of the disease in even standard works on medicine. A CASE OF APHASIA WITH HEMIPLEGIA ON THE LEFT SIDE AND TUMOUR ON THE RIGHT SIDE OF THE BRAIN IN THE THIRD FRONTAL CONVOLUTION. Dr. HABERSHON read a paper on a case of aphasia with hemiplegia on the left side and tumour on the right side of the brain in the third frontal convolution. The patient was a man aged fifty-two, who had had symptoms of languor for a year before admission. Seven weeks previously he had a sudden difficulty with his speech; he tried to say something, and could not speak the right word. This got worse, until three weeks ago, when weakness of the left arm and legs was noticed. On admission there was partial left hemiplegia, the pupils slightly contracted, urine free from albumen, bowels confined. His wife stated that he had always been left-handed. He was treated with iodide of potassium and mercury, but in a few days he became unconscious, and though he rallied for a short time, and appeared to understand questions, he became restless, trying to get out of bed, then comatose, and died thirteen days after admission. At the post-mortem examination a gelatinouslooking lobulated tumour was found on the right side of the brain, occupying the region of the island of Reil, and involving much of the hinder part of the third frontal convolution. It measured an inch or more on the surface, and extended two inches into the brain-substance so as to reach the lenticular bodies of the corpus striatum. The section had an orange tint, with numerous ecchymoses, and at the margin some yellowish gelatinous material. It was composed almost entirely of small, round, lymphatic corpuscles, but in some parts showed nothing but compound granulation corpuscles. There was broncho-pneumonia at both bases, and atheroma and calcareous change in the cardiac valves and aorta. The kidneys were rather granular. Dr. Habershon drew attention to the case as illustrating the view that the faculty of speech is associated in the brain with the muscular education of the most used arms, since the patient was left-handed, and suffered from aphasia, when a tumour developed in the right third frontal convolution. Some points in the history of his children seemed to indicate a syphilitic origin for his complaint, but the result showed that the tumour was a glioma. Dr. F. TAYLOR recalled to the Society a case he had reported at its last meeting-that of a child who had right hemiplegia, but spoke freely, though Broca's convolution was injured. This child had from birth distortion of the right arm and was left-handed. Dr. HUGHLINGS-JACKSON had seen a number of cases of right hemiplegia with aphasia, but in no instance where aphasia co-existed with left hemiplegia had he known a post-mortem examination made. In his experience, tumours affecting the brain rarely led to aphasia. The majority of the cases alleged to disprove Broca's theory were instances of tumour, and he recollected some years ago recording such a case where he subsequently made the discovery that the patient had been left-handed. No post-mortem was made. More recently he had recorded the case of a man in whom left hemiplegia co-existed with aphasia, but this individual also was left-handed. He noticed that Dr. Habershon's patient was said to understand the expressions used in speaking to him, although unable to reply; he was not wordless, but speechless. Both sides of the brain are instructed in words, and serve to reproduce them automatically, so that when one is affected the other retains the power of appreciating what is said, the left side alone being endowed with the faculty of initiating speech-movements. Even aphasic patients often preserve the power of uttering some few words or phrases. For example, a man accustomed to signalman's duties on a railway, who had been suddenly paralysed while on duty, constantly repeated "Come on," this probably being the last expression he had employed before his seizure. Again, patients have been known to say "Good-bye on parting from friends, though quite unable to repeat the words at other times, showing an appropriate fitting of speech to acts. The final conclusion enforced by such considerations is that both sides of the brain are educated in the use of words, but only one side in the expression of them. The PRESIDENT said he had a patient under treatment who made the constant answer, whenever spoken to, "God bless my soul!" and another, a lady, who, though quite understanding what is said to her, is unable to convey her own thoughts in words. Dr. HABERSHON had no doubt that his patient understood what was said to him whilst he remained conscious, but was incapable of expressing his ideas in return. A CASE OF VILLOUS GROWTH OF THE MALE Bladder |