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tion, his whole frame was thrown into the most immoderateconvulsive actions. He was ordered to keep his bed, to beexposed to no disturbing causes, to have good diet and wine,and to take small doses of iodide of potassium.

This plan of treatment was soon followed by very satis-factory results; the man recovered the power of walking withan uncertain gait, the tremor became less violent, the appetiteimproved, and about a month after admission the principaland most distressing symptoms had disappeared.The patient will probably be discharged with a certain

amount of tremor remaining upon him, and if he shouldagain expose himself to the noxious influence which hasalready done him so much harm, it is likely that his healthwill gradually become deteriorated. It is, however, but fairto add that it is not easy for a man, who has to support himselfand family, to change his trade and calling. This points tothe necessity of preventive measures.

ST. GEORGE’S HOSPITAL.

Pleuritic Effusion; Death; Autopsy.(Under the care of Dr. WILSON.)

THERE is a remark in the letter of one of the correspondentsof this journal, inserted last week, (p. 227,) which has struckus as being extremely just, and founded upon facts of a verymelancholy nature. The writer alludes to the rapidity andincompleteness which must necessarily characterise the exa-minations made in the out-patients’ rooms of our hospitals,and cites as an example that a young woman may presentherself with incipient pleurisy, (which affection, we hardlyneed say, can in that state be detected only by very closeand deliberate physical examination,) and being but cur-

sorily looked at, may be told to take some cough mixtureand return in a few days. But cough mixtures neither checkthe inflammation of the pleura, nor the consequent hyper-secretion, and in the space of a few days almost irreparablemischief has been done.Now, this very pertinent remark applies fully to cases

treated in private practice with an insufficient physical ex-amination, or to such patients as completely neglect to seekfor medical advice. In cases like these, the disease makesrapid and unsuspected progress, the pleura becomes enormouslydistended with fluid, the lung is compressed, double work isthrown on the corresponding organ, the latter is attackedwith pneumonia, and the patient dies. Such was very pro-bably the succession of symptoms in Dr. Wilson’s patient, andfrom the physical signs on admission, as well as from thepost-mortem examination, it is clear that the poor man wasperhaps past recovery when admitted into hospital.We feel the more interested in this case, as there are now

under our observation two others of the same kind-the firstat St. Thomas’s Hospital, under the care of Dr. Bennett; thesecond at St. George’s, under the care of Dr. Bence Jones.-In both of these did we see paracentesis thoracis performed.With Dr. Bennett’s patient the fluid was of a serous nature;but the pleura, in the case at St. George’s, was filled withhorridly foetid pus. We are watching these patients withmuch solicitude, as the question of tapping of the chest is one

. of vital importance, and not as yet quite settled.In Paris, M. Trousseau, formerly physician to the Children’s

Hospital, and now attached in the same capacity to the HotelDieu, has taken a prominent part in advocating early tapping,and careful exclusion of air; and there is no doubt that whenpractitioners shall study the writings of that physician andthe cases which he cites, they will be induced to follow asimilar line of treatment. One stumbling-block has, however,not been removed as yet-viz., the liability of confoundingserous effusion with empyema. As to the latter event, wemust say that of all the cases which we have seen at Guy’s,St. George’s, and other hospitals, none of the patients whomwe were enabled to watch recovered after the operation ofparacentesis; whilst we recollect some cases of serous effusion(especially one treated by Dr. Wilson, at St. George’s Hos-pital, about two years ago) the issue of which was favourableafter tapping of the chest.

If we mistake not, however, there is a rule generallyadhered to in our hospitals, which is, to give a fair chance to

diuretic medicines before considering the subject of operativec evacuation. And here we would repeat what we said a shorttime ago, touching the benefit which might be derived fromthe vapour-bath, which certainly is a simple and effectual

- mode of abstracting a large. quantity of fluid from the system,and exciting the absorption of a superabundant pleural secre-

tion. But the great point will ever be, for every practitioner(since all agree that prevention is better than cure) to prevent,as far as lies in his power, the occurrence of effusion by earlyand vigorous antiphlogistic measures, when the principalsymptoms of pleurisy are complained of. And even supposingthat our diagnosis were not quite correct, and that pleurisywere supposed to exist where mere pleurodynia had takenplace, is it not better that the patient should, even unneces-sarily, lose a few ounces of blood, than that lie should runthe risk of pleuritic effusion, and its fearful and distressingconsequence 1 Having said thus much, we now turn to Dr.Wilson’s case, the details of which, as noted down by Dr.Barclay, the medical registrar, are as follows :-Edward C-, aged forty years, was admitted June 15th,

1853. The patient had been suffering from cough for sixweeks before admission. He was emaciated; his skin feltsoft and thin; the pulse was quick and feeble; the voicerather hoarse, and the bowels costive. He stated that hewas subject to a winter cough, but had never spat blood; hewas low and depressed, the appetite bad, &c. A mixture ofammonia and emollients was ordered, as well as morphia atnight, and a gentle aperient.On examining the chest, dulness was found very general

over the right side, with great deficiency of breathing; thevoice-sounds were nowhere exaggerated, except under theclavicle, where prolonged expiration was also heard. Thepatient complained much of the examination, which wastherefore very incomplete; it was on that account not re-peated, as the general symptoms appeared to point to tuber-cular infiltration.For some days after this, the man complained of pain under

the clavicle, stating that he had been hurt there some yearspreviously; he was in a low, desponding state, and unable toeat his ordinary diet. A few alterations were made in themedicines, but he became gradually weaker, and on July 9th,(twenty-four days after admission,) the cough, with muco-purulent expectoration, was still very severe.At that time the patient lay constantly on his right side,

and slept a good deal; blood soon appeared in the sputa, thepulse became quicker and feebler, the face dusky, and thebreathing oppressed. He had been lately taking wine andporter, and the haemoptysis had been checked by lead andopium. The patient died on the 29th, forty-four days afteradmission.

Post-mortem examination, (by Dr. Ogle, one of the curatorsof the museum.)-The body was rather emaciated, and therewere petechiae or maculae on various parts of the skin. In-teguments of the face and neck very livid. Chest: Pleuraladhesions existed to a great extent on both sides; somelight-yellow fluid was found in the left pleural sac, and alarge quantity on the right side, which also contained muchthick, recent fibrin in various parts. The left lung, pos-teriorly, and low down, was very congested and heavy, andcontained a great deal of red-brick-coloured fluid, but did notsink in water. The right lung was almost entirely compressedby the surrounding fluid, and was of a tough, leathery consist-ence ; the lining membrane of the bronchi was very vascular,and the bronchial glands contained much black carbonaceousmatter. The visceral pericardium was in places ratheropaque, and the flaps of the mitral valve, as well as theroot of the aorta, were slightly occupied by opaque yellowpatches. Abdomen: The omentum was adherent to theparietal walls, and there was also omental hernia on the leftside, the epiploon being firmly adherent to the neck of the sac.Nothing worthy of note was found in the rest of the viscera.

CHARING-CROSS HOSPITAL.

Purpura Hœmorrhagica in a debilitated subject; ExtensiveSloughing of the lower Lip and of the Integuments of theleft Forearm and Hand; Closure of the Mouth; Operation;Recovery.

(Under the care of Mr. HANCOCK.)WE noticed a short time ago, at this hospital, a young girl,

whose mouth was contracted to a very small size, the partsaround being considerably puckered, drawn up, and somewhatthickened. On examining the patient, we found that the leftforearm and hand were covered by thick, bluish, tough, andunsightly seams, evidently resulting from extensive loss ofintegument and subcutaneous areolar tissue, and subsequentformation of a hard, longitudinal, raised cicatrix. Scars ofthe same description were also noticed on one of the legs, andwe were led to infer from these marks that from some cause

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or other the patient had had severe sloughing in the partsalluded to. It had, in fact, been one of the severest cases ofpurpura haemorrhagica with which we had for some time pastbecome acquainted.The history of the girl, who is no more than seventeen years

of age, was, indeed, somewhat similar to that which is relatedin the accounts of voyages of our circumnavigators, where sea-scurvy made such sad ravages among the crews deprived ofwholesome food, and sometimes of any nourishment at all.We may, however, state, without fear of contradiction, thatcases like the present are in our days very seldom met within practice; destitution is now but seldom allowed to go sofar as to destroy to such a fearful extent the vigour of thebody, and cause considerable portions of the frame to fall offin a state of gangrene and disorganization. The cases of

purpura which are sometimes seen in the wards of hospitalsare generally of a mitigated form, presenting slight fever andnumerous ha-morrhagic spots upon the trunk and limbs.Fresh vegetables, lime-juice, tonics, and opium generallysucceed in giving the affection a favourable turn, and thetnalady seldom proves fatal.One of the most severe cases with which we of late have

come in contact was a girl about fourteen years of age, underthe care of Dr. Hue, at St. Bartholomew’s Hospital. Thischild had been shamefully neglected, and presented all overher frame haemorrhagic spots so numerous that but a veryslight amount of sound skin could be distinguished. Extrava-.sation had even taken place under the conjunctivm, the gumswere much swollen, the patient considerably debilitated, andthe whole case presented a very unfavourable aspect. Thetreatment mentioned above succeeded remarkably well, andthe girl was discharged several months after admission, in avery favourable condition. But matters were still moredesperate with Mr. Hancock’s patient, as will be seen by thefollowing particulars :-

. Mary T-, aged seventeen years, the daughter of verypoor parents, and who had for some time past been very.scantily fed, applied for the assistance of Messrs. Meaden andWright, the parish surgeons at Islington, who have kindlyfurnished the details of the case. The girl was found coveredwith an eruption of what at first sight appeared petechise, butwhich soon were discovered to be haemorrhagic spots. Butnot only did blood ooze through the debilitated vessels, butalso large quantities of serum, which caused considerableswelling of both eyelids, nose, and lips. The fever ran veryhigh, the tongue was parched, shrivelled, and almost black,the prostration complete, and the restlessness so great thatthe patient could hardly be restrained and made to remain in.bed. The pulse was feeble, and the powers of deglutitionvery much embarrassed. Besides the serous and bloodyeffusions mentioned above, haemorrhage had also taken placealong the left shoulder, forearm, and hands, which parts wereof a livid colour, presenting here and there large bullse filledwith dark fluid. Some vesicles were also noticed on theknees. The case looked extremely unpromising, and verystrong doubts as to recovery were expressed. Some castor oilwas administered, and the girl made to take half a grainof morphine every four hours.On the second day, the patient was worse; there had been

no sleep, but much restlessness, tossing about, and attemptsto leave the bed. The bowels had been open, the girl passingher motions under her, &c. The morphia was continued, andegg beaten up with milk ordered to be taken in small quanti-ties.On the third day, the patient appeared in a dying state, the

sub-cutaneous haemorrhage had rapidly increased, thelividity of the parts was becoming deeper, the bullae larger,the delirium more intense, and deglutition more difficult.Brandy was now ordered, and one grain of morphia, to betaken in the evening.Two days afterwards, the poor girl presented, however, a

more favourable appearance, she was more composed,although no sleep had been obtained, the tongue was lessparched, and it could be slightly moved, the pulse wasfalling in frequency, and gaining in strength. As the.bowels were now confined, a small dose of castor oil wasordered, and the patient made to take yolk of egg mixedwith yeast.For the next fortnight the patient went on oscillating be-

tween life and death, and at the end of that period the lowerlip separated completely, with very trifling haamorrhage. Atabout the same time the large slough, which had formed onthe left forearm and hand were likewise cast off, leaving anextensive ulcerated surface. In other respects there was

slight improvement, and the patient had slept better. Themorphia at night was continued, and bark and acid were pre-scribed, with beef-tea, wine, &c.The ecchymosed state of the eyelids and nose now improved

likewise, the latter organ experiencing a slight loss of sub-stance by sloughing. The large sore on the left forearm andhand assumed a healthy granulating action, and the wholecase took on a more favourable aspect. The patient becameslowly and gradually better under the tonic treatment; largepuckered and seamy cicatrices begun to form in various partsof the body, and about eight weeks after the attack the girlwas enabled to leave her bed and sit up for a little while.The convalescence was very long; but the patient recovered

her strength by slow degrees whilst, however, the mouth wenton contracting. The loss of the lower lip caused the parts todraw in and to pucker at the corner of the oral cavity, somuch so indeed that the mouth became contracted to the sizeof a threepenny-piece. The cicatrices on the arm and legsbecame thick, cord-like, and raised above the surface, andafter several months’ convalescence the patient was admittedinto this hospital, under the care of Mr. Hancock, with a viewto rectifying the defective state of the mouth, as she hadmuch difficulty both of taking her food and of articulating.Mr. Hancock gave the girl good diet and tonic medicine,

and a few weeks after admission (June, 1853) performed anoperation for the opening of the mouth, the patient beinginsensible with chloroform, and proceeded in the followingmanner.

He commenced the first incision on the right side of thelower jaw, about half an inch anterior to the masseter muscle,and carried it across, below the chin, to the same spot on theleft side of the maxilla. A vertical incision was then madethrough the centre of what remained of the lower lip, down tothe last incision, and the flaps thus made were dissected awayfrom the bone, and raised sufficiently for their upper margins totouch the free edge of the upper lip. They were then retainedin this position by connecting their inferior margins by inter-rupted suture to the periosteum, after which they were unitedto each other by sutures at short intervals. This answeredextremely well, as far as forming a lower lip, because thedenuded space left below the chin by the removal of therequired integument granulated kindly.But the small opening of the mouth remained so contracted

and inelastic, being merely an inch in diameter, that thepatient, as stated above, was unable to articulate. Mr. Han-cock therefore determined, about one month after the firstpart of the operation, to increase the aperture by makingtransverse incisions opposite each angle of the mouth. Itwas, however, important, in the meanwhile, to ascertain thespot where the levators of the angle of the mouth were in-serted ; the girl was therefore desired to grin, and it wasnoticed that this insertion existed nearly three-quarters of aninch external to the edge of the contracted lips. Mr. Han-cock accordingly divided the parts to that extent with a pairof scissors, and next carefully sewed the cut edge of themucous membrane to the divided margin of the skin, not onlyalong the upper and lower lip, but especially at the anglebetween the two. These operative proceedings were followedby very satisfactory results; the parts healed kindly, and thesutures were removed on the third day. After a few weeks’careful dressing and attention to the general health of thepatient, the mouth had regained its original size and shape, alittle stiffness and puckering of parts being the only marks ofthe injuries which had been sustained. Articulation has be-come distinct, and the ingestion of food perfectly easy.

TWO CASES OF EPILEPSIA LARYNGEATREATED BY TRACHEOTOMY;

WITH REMARKS ON THAT OPERATION,

BY MARSHALL HALL, M.D., F.R.S., &c.

THE two following cases of epilepsy having been treatedby tracheotomy, according to my suggestion on several occa-sions, I think they may not be uninteresting to the readersof THE LANCET, as a contribution from two able Americansurgeons. In both cases the idea was to obviate laryngismusand its effects. In both cases the relief was so obvious, thatthe most favourable result was confidently expected. Theescape of the tube was probably the cause of an unfavour-able result in the first case, and the continued accumulationof mucus, the effect of paralysis of the pneumogastric nerve,