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start from their orbits. Violent inspiratory efforts culminatedin general convulsions. Soon all was still, the pulsevanished from the wrist, impulse and sound ceased over theheart, and general muscular reaction took the place ofcontraction.Treatment.-The child was shaken, its face mopped with

a wet handkerchief, its back and stomach slapped with thewet hand, attempts to excite vomiting were made, the

tongue was drawn forwards, and the vapour of chloroformblown down the throat from the palm of the hand, whenmuscular relaxation took place ; artificial respiration wascarried out for some time, while endeavours were made toexcite anew the heart’s action. Tracheotomy was proposedearly, but no reasonings would induce the mother to giveher consent.

Remarks.—The tongue of a child is fitted to the arch ofthe palate; it breathes through its nose; in crying the tongueis flattened, depressed, and drawn backwards. Laryngealobstruction took place after a violent expiration, or at thecommencement of an inspiration. Sudden falling of theepiglottis would be thus easily induced, this would in-duce spasm in the irritable muscles which guard theentrance of the windpipe, while further inspiratory effortswould tend to perpetuate obstruction, especially in theyielding larynx of a child.Park-lane-terrace, W.

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. BARTHOLOMEW’S HOSPITAL.THREE CASES OF ACUTE RHEUMATISM COMPLICATED WITH

PERICARDITIS AND PLEURO-PNEUMONIA ; REMARKS.

(Under the care of Dr. SOUTHEY.)

Nulla autem est alia pro certo noscendivia, nisi quamplurimas et morborumet dissectionum historias, turn aliorum turn proprias collectas habere, etinter se comparare.—MORGAGNI De Sed. et Caus. Morb., lib. iv. Proœmium.

THE following notes and remarks illustrate the superven-tion of some grave complications in acute rheumatism:-CASE 1.—Letitia T-, aged sixteen, a machinist, single,

an anaemic strumous-looking girl, was admitted on Oct. 5thwith rheumatism and pericarditis, having been laid up athome with articular rheumatism since September 28th(eight days). This was the first attack of rheumatism shehad had, and with the exception of scarlet fever and whooping cough she had never been laid up before.Condition on admission.—Perspiring profusely ; tempera-

ture 1026°. Decubitus dorsal ; no pain in chest, no cough;she lay very still quite low in bed ; mind clear. Tonguewhite and furred ; breath foul ; bowels costive. Micturitionnatural, urine high coloured, otherwise normal. Catameniajust ceased, always regular. Heart apex beat in the fifthinterspace below the nipple. Thrill felt with systole, andfriction rub heard all over the cardiac region. Pulse 144,soft. Lungs presented no abnormal sounds or dulness.Respiratory sounds clear; respiration 90. Abdomen natural.Large joints, as shoulders, hips, and knees, were more

affected than the small ones.Treatment by twenty grains of salicylate of soda, and

seven drops of tincture of opium every four hours. Thetemperature fell the following morning to 986°, and onlyrose to 100’2° on that and the next day. Her painspromptly subsided. There was no anxiety ; no restless-ness. On the thirteenth day of the rheumatism the tempera-ture fell to normal and remained so for three days, but thefriction rub became less distinct, and the præcordial dulnessincreased. She was very drowsy, but woke up to takeher nourishment. The opiate wae now diminished, and thesalicylate given less frequently. There was effusion enoughto produce marked præcordial dulness on the twelfth day ofillness,and contemporaneously, or nearly so, bronchial breath-ing and bronchophony were noticed at the root of the rightlung, and over more than two-thirds of the left lung. Thedorsal position was maintained. Temperature 102’6°; pulse120. Symptoms of more active implication of the left pleura

were noticed on the nineteenth and twentieth days of theillness. Pain stitchlike and friction rub. At the same datethe dislocation of the heart’s apex upwards and outwards,and its disappearance from the chest-wall, too, were wellmarked. The heart’s impulse being felt on the level of themammæ, she was advised to make some effort herself to lieon both sides alternately, and was directed to be proppedby pillows into such position. Slight ægophony was noticedover the area of bronchial breathing.Treatnaent.-Twenty grains of salicylate of soda, and five

drops of tincture of opium, every four hours, were repeated.Her temperature fell gradually from the nineteenth day ofillness, and her pulse improved. She has been able to situp in bed and do needlework. Since the twenty-fourthday her pulse has been from 74 to 84; respiration 24;and temperature below normal. Heart-sounds have beenclear, and no friction sound has been heard over front ofchest. She has had no fever and no cough, but there is stilla friction sound synchronous with respiration behind overleft lung, some dulness and evidence of feeble air entry atbase of lower third of left lung. She entered upon conva-lescence on the twenty-fourth day of her illness.The facts in evidence of the course of this patient’s

disease are:—Pericarditis; pericardial effusion; imperfect airentry into lower lobe of left lung. Bronchial breathing;no rusty expectoration, followed by lateral and posterior fric-tion rub and slight ægopbony; rheumatic pleuro-pneumonia,with slight pleuritic effusion. Her temperature fell from102 6° to 99’4° on the ninth day of her illness, pericarditisnotwithstanding, and it was not till ten days later that itrose at all high again, 100’6° and 101°, when she had somefever from her left pleuro-pneumonia. This febrile disturb-ance lasted four days, and she has since convalesced withone slight relapse. - - _ _ - - _ - - -

CASE 2.-Eliza P-, aged forty-six, and fairly nourished,prematurely grey-haired woman, single, entered on her

menopause at the age of forty-one. She had small-pox atnine years old, and her first attack of rheumatism at

nineteen, which laid her up for some weeks; second attack atthe age of forty-five, dming which she was laid up six weeks.The present illness began three weeks before her admis-sion by swelling and pain in her left foot, which shiftedto her shoulders, calves, knees, and lastly wrists. She wasfeverish, had no appetite, and the pain made her feel sick.

Condition on ceclmission.-Sept. 9th : Lying flat on herback, unable to help herself; all the joints of her arms stiffand painful; both wrists swollen; the right red and verytender. Knees and right hip - joint very painful ; anklesswollen, red, and hot to feel. Pulse 108; respiration 18;temperature 100° to 101°. Bowels open four times freely ;tongue coated with usual thick white fur, and inclined to dry;urine high-coloured; skin moist; pupils large.

Pla,ysacccL examination.—Fauces and abdomen yieldednegative signs : heart impulse feeble, apex-beat indistin-guishable, systolic apex murmur ; praecordial dulnessincreased over both lungs before and behind : rhonchus andcatarrhal sounds, but resonance un ed. She wasplaced on the usual slop dietary, and tr ent by salicylateof soda was pushed to salicylism, an ent established intwenty-four hours.

Course and progress.-Three days ater her pains weregone ; but she complained much of her head, and her coughwas troublesome. She took her nourishment fairly, butslept very 1’-ttle. Pulse 78, small and weak ; respiration 20.Good resonance over luogs, front and back, and fewer moistsounds. Joints still swollen, and painful upon least move-ment. General condition extreme weakness ; lies alwaysin the same posture. After she had been under treatmenttwelve days, and therefore on about the thirty-third of herillness, we noticed that her pulse had risen to 96, respirationto 36, and temperature, which had gradually fallen to belownormal, rose to 100’50. Her cough was more troublesome,and she had a relapse of pains. Pericardial friction wasnow audible all over the cardiac region in front, and thedulness increasing. The following day the effusion wasobviously increased and her temperature went up to 104°,but no physical signs as yet of pressure upon thelungs were observed. The relapse of pains lasted forthe usual three days ; improved on the fourth, whenshe slept well without any opiate. But we observedmarked dulness on percussion on this the thirty-seventhday of her illness at the base of the left lung. Peri-cardial friction and prsecordial dulness still well marked infront. Since her pericarditis had been ascertained beyond

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doubt she had taken repeated moderate doses of morphia,and was propped up in bed. The following day fine pneu-monic crepitation could be heard over the dull area of herleft lung, with bronchial breathing, transmitted also to theright lung. The colour of the sputum was distinctly rusty.Meantime, notwithstanding the pneumonic complication,the temperature fell to nearly normal. Three days laterboth legs were anasarcous, and pitted widely. Stimulantshad been given, but were now increased. Two days laterimprovement commenced, and gradually the dulness receded,and more air entered the affected lung ; but her cough, shesaid, " tore her to pieces." Pulse 96 ; respiration 42. Her

improvement steadily went on; the cough subsided, andshe was free from all pain on the forty-eighth day, on whichshe was able to wash herself.On the fiftieth day the pericardial friction gradually dis-

appeared, but a pleural rub remained at the left base,and in the left lower lateral region for some days longer.She got up for a short time a few days ago, the sixty-sixthday of her disease.

In this case again there was pleuro-pneumonia of themiddle or lower portion of the left lung occurring shortlyafter the evidence of a considerable pericardial effusion hasbeen established. Yet it ran a favourable-nay, more, aspeedy-course to entire resolution, so that in a fortnight orthree weeks afterwards the woman was convalescent.CASE 3.-Emma W-, aged nine, a poorly nourished

strumous child, with dark hair and pasty ansemic look, wasadmitted into Faith ward on October 3rd, suffeting withacute articular rheumatism and pains in her chest. Herillness had lasted a week, and the pains and swelling hadbegun in her right hand.

Condition on admission.—Temperature 102’6°; skin hotand moist; cervical glands enlarged. Tongue moist, butfurred; abdomen nil; bowels confined; urine scanty. Chiefseat of pain and rheumatic inflammation in left hip-joint.Pulse 112; respiration 33.Physical examination.—Heart’s apex in fifth interspace

outside the left nipple, systolic murmur at apex; pericardialfriction at base ; praecordial dulness scarcely increasedabnormally. Lungs : no morbid sounds, but enfeebled vesi-cular sounds, and slight dulness at both baes behind, and,laterally, over the right. She was treated with salicylate,and for four days went on remarkably well; her tempe-

rature fell to below normal, and pericarditis and endo-carditis notwithstanding, she had four days’ intermission ofher fever ; but then her temperature gradually rose, in forty-eight hours, from 97° to 100’6°; pulse 108. The pain inher heart region was greatly increased, and the præcordialdulness increased also, showing no inconsiderable pericardialeffusion, extending all across the chest in front, and well upinto the left axilla. She had to be propped up in bed toget her breath, and we recognised dulness, with bronchialbreathing, all over the middle portion of the left lung;posteriorly in scapular, interscapular, and subscapularregion, also across the root of the right lung. The cardiacregion was painted with iodine and poulticed, and somemorphia was given in small doses, 1/24th of a grain everyfour hours. For four days she was extremely ill, thensuddenly began to improve. Her temperature fell to 99° ;her skin acted, and her pulse was 108 ; tongue moist andclearing. Dulness on percussion; bronchial breathing, andbronchophony still marked the area of the left lung consoli-dation ; but there was no redux crepitation, and no expec-toration, and very little cough.Again the mode of recovery was in the order which I have

exactly observed-namely, that as the præcordial dulnessdiminished and the effusion was reabsorbed, so the lungconsolidation lessened, and air re-entered it, with here andthere a little bronchial crepitation; on the twenty-eighth dayof her illuesq, having had no further elevation of tempera-ture or increase of rheumatic pains, sleeping and eatingwell, the pericardial friction rLib became re-establishedall over the chest in front. Breathing sounds were faintlyheard over the area of previous lung consolidation, and shesteadily convalesced. Yesterday, however, and for the lastweek, we have been able to recognise a distinct pleuriticfriction sound over the left lung base.Remarks by Dr. SOUTHEY.—I have taken three cases of

pericarditis that had well-marked pericardial effusion; norare, no exceptional cases, but all illustrating a rule soinvariable in my experience that I have often wondered itshould have escaped comment - the association of peri-cardial effusion with pneumonia of the lower lobe of the left

lung, or with pneumonia of the middle symmetrical portionsof both lungs. In slight pericardial effusion this complicationis not rnetmth; in large effusionit is invariable. The leftlungis that which is always first and most involved. Is it an effectof pressure ? Is it a consequence of dorsal decubitus ? Is ita result of the filling up of the posterior mediastinum andthat complemental space into which the lung ought to beexpanded in the inspiratory augmentation of the thoracicchamber? I believe the latter explanation is the correctone, because the order of physical signs is so very regular.Increased praecordial dulness in front, absence of respiratorysound first between the lower angle of the left scapula andthe spine, then dulness on percussion over the same area.The affair terminates in some cases with nothing more thaninexpansion of the lung; there is superadded no bronchialbreathing, while in others bronchial breathing is wellmarked. And in some of these, again, the morbid processadvances no further; effusion into air cells and solidificationof lung tissue a;e all; a little friction rub follows, but norusty expectoration, no attendant bronchitis, no fine orreduxcrepitation; while a third degree of the same lung diseasemay occur, as in E. P.’s case, attended by both rustyexpectoration and fine crepitation and redux crepitation,in other cases where the pericardial effusion is of longerduration or slower absorption. I do not remember to haveever found this pneumonic rheumatic complication inde.pendently of pericardial effusion, although I have seen

repeated examples of slight superficial rheumatic pericarditiswhich were not thus complicated. This rheumatic pneu.monia has a far more favourable prognoeis than either itsextent or occasion 11 doubleness would at first thought entitleit to. If my theory of its causation be correct, the treat.ment I adopted in the three cases I have brought before you,and which experitnce has taught me is good, is also rational-viz., subduing the j iut pains by opium, so tiiat the patientmay be moved into a less dorsal position ; propping up ofthe patient by pillows ; and administration of stimulants.Rheumatic pericarditis and rheumatic pneumonia, orpieuro’pneumonia are doubtless attended seldom nowadays by afatal issue, but when bleeding and mercury were priocipallyrelied upon for conducting these local inflammations toresolution, and even in the time when alkalies were chieflytrusted to in the treatment of rheumatism, death was farfrom being uncommon. That the lesser mortality of rheu.matism ot late years may be due to some alteration in typeof the disease I am not prepared to dispute. It may be so,but how can we prove it, and to what are we to refer suchan alteration? To better living, better clothing, less wetweather, better draining of our lands, and the more hygienichousing of our population ? This may be the case, but I seeno evidence of it. But as a hospital physician I avow thatwe admit no fewer cases of acute rheumatism than formerly;nor comparing the cases I see to-day with those I sawtwenty years ago can I perceive any ditference in the

sevrrity of the general symptoms, or in the degree or kindof its ordinary complication. Still I certainly fail to witnessso many autopsies upon cases of rheumatism, and havefewer butter-pat pericardial effusions aud sohdified lungs,with lymph-coated surfaces, to show my clinical clerks. Thecases complicated by pericarditis are less noisy, less restless,less wild in their delirium, often scarcely delirious at allthroughout their course. To what shall we attribute this!Is it to salicin, to the salicylates, or to a generally morerational treatment of the disease? I believe it is that weare biased by less theory in our conduct of each individualcase, that we do not aim at neutralising some possible lacticacid, destroying some ferment, or even oustmg some poison.We neither purge, nor sweat, nor diuretise, nor nourish ourpatients so much, nor use an exclusive milk, or alcohol, orbroth dietary. We seek, at least I can speak for myself,to eae pain by local sedative application’, and rest over.

strained nerves by opiates. We wait till stomach catarrhsubsides, and then give peptonised or part-digested meats.For three or four days together, we have learnt, patientscan live very well on toast-and-water, and if theirtongues are very thickly furred will seldom take much elsethan warm tea or clear meat soups. A little weak brandy-and-water is often a much more suitable nutriment than’apint of milk, although this is thought and believed to be thesimplest, the most entire, and the most suitable of aliments.Pace my total abstainer ; alcohol is physic. In the treat.ment of acute rheumatism this gastric catarrh is no un-important affair ; and I believe that the real use of salicylateof soda lies in the good effect it appears to exercise upon The

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stomach. The tongue cleans rapidly under the repeateddoses of the remedy. There is another remedy which seemsto be adapted to the later stages of the malady, to therelapsing cases -the cases, too, which perspire very pro-fusely-this is salicin, which some of you have recentlyseen me prescribe pretty largely. I give ten grains with onegrain of the iodide of potassium and ten drops of the tinctureof iodide to an adult every four hours. And this remedydoubtless exercises what virtue it possesses upon the gastro-intestinal functions, for the appetite and digestion improveunder its use.

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SEAMEN’S HOSPITAL, GREENWICH.TRANSIENT RIGHT HEMIPLEGIA FROM INJURY TO THE HEAD.

(Under the care of Mr. G. R. TURNER.)FOR the following notes we are indebted to Mr. E. PENNY,

house-physician :-Maude M-, aged two year;>, was brought to the hos-

pital on August 7th, 1882, at 8.30 P.M., with the followinghistory :-At 5 P.M. on the same day she fell off the table,striking the left side of the head with some violence as shefell. She did not complain of feeling any uneasiness until6 P.M., when she became steadily but rapidly unconscious.Soon afterwards she was seized with convulsive movementsof her right arm, right leg, and right side of the face. Theseoccurred every few seconds. When brought to the hospitalshe had been in this condition an hour and a half.On admission she was quite unconscious, and could not

be roused in any way. Every few seconds she was seizedwith violent convulsive movements of the right arm, theright leg, and the right side of the face. Both pupils weredilated and insensible to light, but the right was larger thanthe left. Both eyes were turned to the left side, but thehead was quite natural. Her pulse was 60, aod very good ;respiration 29, deep, but no difficulty about it; tempera-ture 100° F. There had been no vomiting. Her head wasexamined, and a swelling found over the anterior and

inferior part of the left parietal bone, but there was noevidence of any fracture. She was put to bed and an icebag applied about 10 P.M. ; the right arm and leg ceasedtheir convulsive movements, and in the course of a fewminutes were completely paralysed, and the side of the facedropped. Her urine was passed in bed from time to time.Her temperature was now 98 4°; pulse and breathing un-changed. About 1 A M. she was noticed to move both rightarm and leg, and from this time the paralysis graduallypassed off, the face resuming its normal look last of all, andthe leg recovering first. At 8 o’clock in the morning shevomited freely, and almost immediately afterwards sherecognised her mother. From this time she rapidly re-covered, and left the hospital quite well in four days.

STROUD GENERAL HOSPITAL.OVARIOTOMY DURING PREGNANCY; SUBSEQUENT NORMAL

PARTURITION.

(Under the care of Mr. STORRY.)FOR the following notes we are indebted to Mr. R. D.

Cameron, resident medical omcer :—Emily B-, aged thirty, married, four children, was ad-

mitted on April lst, 1882, with an ovaiian tumour, theswelling of which she noticed eighteen months ago. Shelast menstruated in January, 1882. Being incapacitatedfrom following her household duties, and having larelysuffered considerable pain in her abdomen, on the llth ofApril (believing her to be pregnant), she was placed underthe influence of ether. Mr. Storry, with the assistance of hiscolleagues, and with the ordinary carbolic spray, opened theabdomen, torsioned one vessel in the abdominal walls, butfound no adhesions. He then tapped one large cyst and onesmall one, tied the pedicle with chromicised catgut, andremoved the growth. The uterus was found to be entarged inthe pelvis. The wound was brought together with chromicisedcatgut sutures. An india-rubber drainage-tube was lefchanging from the lower part of the wound, and communicatingat the other end with the abdominal cavity, and the usualgauze dressing and india-rubber bandage were applied.Eight hours after the operation two drachms of blood-clotwere removed with a syringe from the drainage-tube. Thetube itself was removed on the fourth day. The tempera-ture in the axillae was taken every two hours for the firstweek and it never rose above 99°.

The patient was catheterised every six hours for the firstweek. The bowels were opened by an enema on the eighthday after the operation. On the fourteenth day she wassitting in an arm-chair, and a fortnight after this shereturned home to her friends.On Oct. 18th Mr. Storry delivered her of a fine female child.

Medical Societies.MEDICAL SOCIETY OF LONDON.

Cctse of Intra-thoracic Aneurism. - Treatment of PleuralEffusion.

A MEETING of this Society was held on the 20th ult.,Mr. F. Mason, President, in the chair.

Dr. HAWARD showed a man suffering from Intra-thoracicAneurism. The case was that of a carpenter, thirty-eightyears of age, who had suffered from what was taken to beleft pleurisy in February, 1882, and had been unable to worksince. In June last he began to have throbbing in thechest, and came into the hospital six weeks ago. Thecardiac sounds were normal at the apex ; but in the secondleft interspace, half an inch outside the sternum, there wasa rough blowing bruit blending with the first sound. Therewas no bulging or thrill, but a faintly visible impulse." Each expiration is broken by a series of audible puffs, likethe distant snorting of a goods engine. These correspondto the cardiac contractions, and are slightly anterior to theradial pulsation. They are increased in loudnes by exer-tion, and are even felt, as well as heard, by the patient;but after prolonged rest in bed they disappear altogether,returning directly he rises." There was a small bronchocele.In reply to questions put by Drs. Habershon, Hall, andCavafy, Dr. Haward said that the thyroid enlargement hadnot increased; he was not aware whether the sound wasmodified by sleep or repose, and thought the disease to be inan early stage; no laryngoscopic examination was made.The case was referred to a committee consisting of Drs.C. T. Williams, de H. Hall, Thorowgood, and Cavafy, andthe author.

Dr. FREDERICK HICKS drew attention to an improvedform of Apparatu s for Paracentesis Thoracis. The advantages were:—1st. That it enabled any degree of pressure,high or low, to be used and maintained during the operation.2nd. That a manometer, for ascertaining the intra-thoracicpressure either at the commencement or during the opera-tion, could be employed easily and without encumbering theapparatus. Two forms of manometer were shown, and theiraction explained and demonstrated ; in one the fluid wasmercury, in the other coloured water. In the latter thedisarrangement of the apparatus by the oscillatings ofpressure during coughing were divided by a, mercuiial valve,so constructed as to allow a low current of air at anypressure to pass freely and affect the water-gauge only,whilst auy sudden gust of air acted on the column of mercury,and in doing so closed the tube connecting the trocar withthe manometer. The construction of this apparatus wasexplained, and model shown. The use of the manometerwas recommended in all cases of paracentesis thoracis.The intra-thoracic pressure was not proportionate to theamount of fluid present. In many cases the fluid wasunder slight or even no pressure, and in some therewas actually suction which might amount to half an

inch of mercury. Without a knowledge of this condition itwas impossible to estimate the force required to withdraw,which if too low rendered the withdrawal less complete, andincreased the liability to the sucking-m of air on the patientcoughing or taking a deep inspiration, which, if it were too

high, blood was easily expressed, especially so in tippingrecent effusions. The same apparatus was also adapted forwashing out fluid contained in cavities by alternatelvinject-ing from one bottle and drawing into another. This wasdone through the troctr by means of a three-way stopcock,and the opening or cl sing of the apparatus was unnecessaryduring the operation. It was important to prevent theaccidental introduction of air into the pleura during thevarious arrangements and manipulations. An instrumentwas shown for exploring, and if necessary introducing adrainage-tube into cavities in the lungs resulting fromphthisis or bronchiectasis, or introducing a drainage-tubeinto the pleura in cases of empyema when atL anaesthetic is