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tinued or paroxysmal dyspnma ; but in the absence of urgentsymptoms a week or ten days may be given after one side ofthe chest is full, on the chance that absorption may set in,and a longer period still when the lung has not greatlyshrunk. Old age, phthisis, or a phthisical tendency, are

reasons for early tapping, as also is the existence of diseaseof the kidneys. The spot for puncture is the eighth space,in a line with the angle of the scapula, and he had cometo prefer the common trocar and cannula, with antisepticprecautions to the aspirator. The whole of the fluid shouldnever be removed, or attempted to be. Where the effusionhas lasted some time frequent partial emptyings are to bepreferred.-Dr. C. T. WILLIAMS referred to a case of pleuraleffusion with presence of marked bronchial breathing andvocal vibration, and alluded to the valuable aid in dia-

gnosis rendered by the use of a hypodermic syringe.-Dr. DE HAVILLAND HALL mentioned a case of sarcomatousgrowth filling the pleural sac and collapse of lung, yet withpresence of vocal fremitus. In one case he had withdrawn107 ounces of fluid, and he asked the author as to theamount he would recommend to be withdrawn.-Dr. MUIRasked for information as to other modes of treatment.-Dr. HABERSHON spoke of the various forms of pleuraleffusion-e.g., in renal and in cardiac disease, secondary topneumonia or due to primary pleuritis. He recalled a caseof Dr. Addison’s where a small area of bronchial breathingexisted, surrounded by complete dulness and absentbreath-sounds. The autopsy revealed a portion of lungadherent to the chest-wall at that spot. He pointedout that many cases recover if left alone. If there werehigh temperature, hectic fever, and tendency to tuber.cular disease, and if dyspnoea were present, he wouldadvise paracentesis, especially if empyema were suspected.- Dr. HARE said the physical signs were often misleading,especially in children ; the presence of vocal fremitus andrespiratory murmur on the affected side was only to be ac-counted for by conduction from the healthy side, throughthe compressed lung and fluid.-Dr. WHARRY asked howfar vocal fremitus and tubular breathing were indications ofthe existence of uncollapsed lung in the fluid. He had seenat least one such case where these signs were absent. Whatwere the author’s reasons for assuming that exudation tookplace from the lung into the pleura in certain cases.-Dr.GILBART SMITH agreed with Dr. Hare as to the difficultyof diagnosis in children. He instanced a. case where thelung was wholly collapsed, notwithstanding presence offremitus and tubular breathing, and asked whether apurulent effusion did not conduct vibrations better thana serous one. He also asked whether the disappear-ance of these signs would not be better explained byan increase in the effusion and pressure on the lung than byan exudation from the lung itself.-Dr. BROADBENT, in

reply, said he had not seen cases of vocal vibration and bron-chial breathing with collapsed lung, nor could he explainsuch. The persistence of vesicular breathing implied theexistence of a non-collapsed lung. He did not consider thatincrease of pressure explained the disappearance of bronchialbreathing, for almost invariably improvement quickly fol-lowed-ushered in by returning apical resonance. He hadnot practised injections into the chest in serous effusions,but had frequently and with benefit employed solutions ofiodine’ in cases of empyema. He now preferred to use thesimple trocar inserted near the angle of the scapula ; thisallowed of the withdrawal of the right amount of fluid, whilethe entrance of air did no harm. If the aspirator were usedit was his practice to stop as soon as the patient became dis-tressed or attacked with cough. Eighty-four ounces was thelargest amount he had ever drawn off.

ASSOCIATION OF SURGEONS PRACTISINGDENTAL SURGERY.

Se1’OUS Cysts-Cases of Neuralgia dependent uponNon-erupted Teeth.

ON Wednesday, November 17th, 1880, A. W. N. CATTLIN,Esq., President, in the chair, brought forward a case oftwo separate Serous Cysts, complicated with an alveolarabscess, all in different parts of the superior maxillary bone,and each unconnected with the antrum. The palate on theright side was enlarged, and the first right upper molar andthe right and left upper lateral incisors had been removed.

Over this latter spot were two small openings in the alveolarprocess through which flowed a clear serous fluid. Prior tothe patient’s leaving England Sir James Paget was con-sulted, who considered the case to be one of extremely rarecystic disease, and recommended the immediate extractionof the lateral teeth and further treatment deferred until hisreturn from abroad. The President remarked he did notever remember having seen a case in which the dischargefrom the cyst passed by a pulsating movement in jerks as itdid on both sides in this particular instance.Mr. AUGUSTUS WINTERBOTTOM then read a paper On

Cases of Neuralgia dependent upon Non-erupted Teeth,"and stated that the diagnosis of the true seat of nerve pain issometimes attended with extreme difficulty, and often (not-withstanding our utmost endeavours) its real cause remainsburied in obscurity. The author then narrated three casesas bearing upon the subject :-Case 1 was that of a youngwoman, aged twenty-one, suffering from neuralgic paroxysmsaffecting the left side of the face. On examination a secondbicuspid was found carious, which was extracted. Thepatient was not again seen for a year, when she returned andstated that she had suffered continuously more or less sincethe operation. A small fistulous openii.g was discovered inthe position lately occupied by the bicuspid, and on probingthere was a sinus about one inch and a quarter in depth,with a substance closely resembling dead bone at the bottom.The sequestrum, however, did not appear movable, but anoffensive fluid could be pressed out from the antrum. Itssolution was attempted, unsuccessfully, by means ofsulphuric acid, and at length an operation was imperative.Under ether, Mr. Winterbottom introduced into the sinus along, narrow-bladed pair of forceps, and succeeded in grasp-ing a small roughened semi-detached fragment, which, onwithdrawal, was found to be the partially developedgerm of the second premolar tooth. The wound healedrapidly, and the pain did not return. Case 2 wasthat of a lady, age forty, with persistent neuralgia affectingthe left upper jaw. The left upper central incisor, beingloose, was extracted and the pain subsided. The patient re-turned in about eighteen months, having been free fromsuffering in the interim, but annoyed by a continual dis-charge proceeding from a small fistulous orifice over wherethe tooth had been taken out. On probing a piece of ap-parently carious bone could be detected, seemingly immov-able. On dislodgment with strong stump forceps it wasfound to be a carious upper canine tooth; and the patientrecovered her health.-Case 3 was one of greater severity,and demonstrates the fact that removal of the first cause doesnot always permanently cure the disease. D. B-, agedforty, was admitted into St. George’s Hospital suffering fromintermittent facial neuralgia ; and medical treatment failing,he was referred to the author prior to resorting to nerve-stretching. The disease had been active for twelve years,and the patient had to throw up his employment. On ex-amining the mouth nothing abnormal presented itself, thegums being healthy, with the exception of a small fistulousorifice (which required a magnifying mirror to discover), nolarger than a pin s-head, over the position of the right centralincisor. On pressure a little glairy fluid could be squeezedout ; and the sinus, some half an inch long, on probing asmooth round body could be felt. Mr. Winterbottomdivided the tissues down to the bone, and excised a

small portion of the alveolar process, and grasped whaton examination proved to be a partly disorganisedcanine tooth, lying with its long axis parallel to thelower margin of the jaw. At the end of three weeks hewas discharged cured, and for nine months remained freefrom pain, when his former symptoms recommenced. Abouta year from the date of his previous admission he re-enteredSt. George’s Hospital, when Mr. Pollock removed a piece ofbone from the superior maxilla, comprising that portioncorresponding to the interval between the left central andcanine teeth inclusive, leaving a chasm in the mouth someone and a half inches long and half an inch wide, with itsdeeper portion opening up the floor of the nares and interiorof the antrum. The excised mass revealed nothing abnor-mal, and the man’s condition was in nowayimproved. At thisstage he again saw the patient and endeavoured to ascertainwhether another buried tooth existed, but no resistingmaterial was met with. The next step consisted in anoperation for nerve-stretching, performed by Mr. Pollock,who cut down upon the second division of the fifth in theposition of its emergence from the upper jaw, and, seizingthe main trunk, applied considerable traction, This treat-

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ment availed nothing, and the patient returned home in aworse plight than when he set out ; Mr. Winterbottomhad since been unable to gather any further particulars. Inconclusion, the author remarked that often an exciting causemay be overlooked, and its removal, as in Case 3, be insuffi-cient to establish a cure ; that, as a rule, he couldnot too strongly insist upon the necessity of eradi-cating the source of mischief at the earliest opportunity ;that often great difficulty is experienced in determiningwhether diseased bone or a carious tooth lies at the bottomof the sinus, and that it is sometimes advisable to cut downupon foreign bodies and attempt their extraction, even ifnot movable. The deductions to be drawn from these casesare, that careful microscopical examination should alwaysbe made of the mouth and gums, and that the presence ofdiseased bone alone does not usually produce persistentneuralgia ; that when we find in the mouth a sinus leadingdown to exposed roughened material (coincident with con-tinually-recurring neuralgic paroxysms), our suspicion shouldbe aroused, and that it is our duty to cut down upon andinvestigate the true state of affairs.-The PRESIDENT, onbehalf of the Fellows, thanked Mr. Winterbottom for hisinstructive paper, and stated that in these cases he alwaysused and preferred trephines (of various sizes) to cuttingforceps. A discussion ensued, in which Mr. HamiltonCartwright, Mr. Edgelow, Mr. E. Bartlett, Mr. Keene, &c.,took part.

Reviews and Notices of Books.tJroonian Lecttlres on some Points in the Pathology

and Treatment of Typ7boid hever. By ’WILLIAMCAYLEY, M.D., F.R.C.P. London : J. & A. Churchill.1880.

THOSE who attended these lectures when they weredelivered will be glad of the opportunity given for a

perusal of the many suggestive facts and reasonings whichthey comprise. Dr. Cayley has constituted himself thechampion of the cold-bath treatment of typhoid fever. Heis almost the first among modern English physicians toadvocate this treatment in the thorough and systematicmanner in which it is carried out by Brand of Stettin andmany others abroad ; and the whole drift of his argumenttends in this one direction : that by the use of antipyreticmeasures (of which none is more reliable,or certain in itsaction than the cold bath), a very palpable effect is producedin lessening the mortality from typhoid fever. The distinctionwhich he draws between the primary fever following uponthe taking in of the poison and the secondary fever due tothe processes of intestinal ulceration and sloughing is one ofthe main arguments in favour of the early adoption of thesemeasures, and he claims to show that the good effects ofsuch treatment are better marked, and success more certain,when the febrile process is controlled almost from the be-

ginning. So far as statistics go, and with due allowance for

fallacies, it would certainly seem that the adoption of suchmeasures has lowered the rate of mortality ; but in order toget the best results it is necessary that every case should besubmitted to the treatment, for no one can predict at itsonset whether a case of typhoid fever will be severe or not.It seems hard to accept this, knowing that from pastexperience at least 80 per cent. of the cases of typhoid feverwill recover under careful nursing, diet, and "expectant"treatment ; but if it be true that at least a further 10 percent., if not more, will be rescued from death, there shouldbe no shrinking from the employment of a method, howeverirksome in its application, that leads to such a result. Asto the dangers of the treatment itself, these seem to be com-paratively few. Chronic pulmonary and cardiac diseasescontra-indicate the method; so also does intestinal

haemorrhage—not, Dr. Cayley thinks, because the ap-

plication of cold causes increased vascular turgescenceof the abdominal organs, but because of the absolute

necessity for complete repose to favour the arrest of the

haemorrhage.The lectures, however, are not limited to this one subject

of treatment, although that forms the main topic to whichthe others lead up, but they detail valuable facts in theetiology and pathology of the disease, and place the wholesubject in so clear a light that they will have a permanentvalue for reasons other than those involving the advocacy ofa particular line of treatment.

General Paralysis of the Insane. By WM. JULIUSMICKLE, M.D., M.R.C.P. London: H. K. Lewis.isso.

THE elucidation of the true nature of the morbid con-ditions resulting in "general paralysis of the insane" haslong been attempted by writers on mental pathology. The

subject is one of the most difficult in medicine; the viewspropounded have been most varied ; the lesions describedmost numerous. To collate all that has been written on the

subject, and to combine therewith the fruits of his own ex-perience, has been the effort of the author of this book. Asa solid contribution to the subject, the book is one of con-siderable value; but it is far too heavily laden with doctrineswhich have long been abandoned to be serviceable; and theauthor’s style is not attractive in itself. It testifies to a pro-found acquaintance with the literature of the subject, andwill be mainly valued as a work of reference. Nothingseems to have escaped his observation, and in the chapterson symptomatology, etiology, diagnosis, and morbid

anatomy, the facts that he has accumulated are detailedwith a degree of care that is at once commendable and pain.ful. The book, however, is not intended for the student;and the very features which would render it unsuitablefor him will make it more acceptable to the mental phy-sician.

Space will only permit us tostate briefly the views to whichthe writer has been led upon the pathology of this disease.It is primarily (in the majority of cases at least) an affectionof the cerebral cortex, the meninges being more or lessinvolved at the same time. In many cases the morbid

change is partial at first,in others it is more widely diffused,and the parietal and frontal regions chiefly suffer. The

change affects the nerve-cells ; it underlies their functionalderangement and exhaustion; and in so far as it involvesthose elements which are most concerned in mental opera-tions, and those which have to do with motor and sensoryfunctions, so in proportion do mental, motor, or sensoryderangement follow. This, in brief, is the sum and sub.stance of a long argument filling several pages. Nodoubt there is a definite and special lesion underlyingthe phenomena of general paralysis, but these phenomenaare so varied and complicated, involving, too, the mostas well as the least complex of the cerebral functions,that a satisfactory pathological interpretation is a mattersurrounded by the greatest difficulty. It would be de.

sirable, doubtless, to introduce a system of classificationand nomenclature whereby the different forms of this diseasecould be more clearly differentiated. This may be possiblesome day; and the data contributed by Dr. Mickle will befound of service to whomsoever undertakes the task; andwhen this is done for general paralysis a great step in

advance, as regards the pathology of insanity in general,will be made, for in its manifestations this complex diseasereproduces the characters of many of the forms of insanity.Dr. Mickle pushes the theory of cerebral localisation to itsextreme limits, applying it to account for mental dis.order as for motor; and in so doing he has given animpetus to inquiry (which may result in great gain to

knowledge.The volume concludes with full notes of several cases

illustrative of the various forms of the disorder.