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watch at a distance varying, according to circumstances, frorabout half an inch to a few inches, he will, after it has bee:opened, perceive the ticking at a distance of one foot, or amost of a few feet.These results, so far as regards the general drift of thes

remarks, occur with such marked uniformity, that hithertoamongst some hundreds of cases carefully examined in reference to the point in question, I have only found exceptions i]two instances of highly tuberculous individuals.

2nd. A further highly important and interesting observatioistands in close connexion with what precedes-namely, tha:in these cases of subsided chronic inflammation in the cavitof the tympanum with perforated membrane, the opening ancrestoration to a normal condition of the passage of the tubEustachii produces in most instances an equal improvement irthe power of hearing-the effect being in few cases less, morffrequently greater-to that which ensues on the application oithe so-called artificial ear-drum.

Definitive observations on the nature of this coincidence Ihave as yet not made, still (seeing that the application of theartificial ear-drum is relatively but seldom effectual, whilst theopening of the tube is a remedy which nearly always affordsrelief) the agreement between the results which ensue on theemployment of the several remedies will be found mainlywhere there is a wider range of hearing, whilst in extremecases of difficulty of hearing, arising in the manner referred to,the remedies cease to be equal in their effects, or even to pro-duce uniformly, when combined, the sum of their separateeffects.

I have endeavoured to arrive at an explanation of this strikingfact; but even from the most distinguished physiologists whohave occupied themselves with investigations of the organs ofhearing, with whom I have entered into correspondence on thissubject-namely, Professor Helmholz, of Heidelberg, and Pro-fessor Henle, of Gottingen, I have failed to receive such anexplanation ; nor have I been able to discover the cause whythe Eustachian tube should prove to be of such eminent im-portance where the membrane of the tympanum is wanting, asused only to be assigned to it where that organ is preserved.What I surmise in reference to these striking phenomena-

though my views require for their confirmation the collectionof yet further experiments and observations-is this, that thetube acts in these cases in the manner of a sounding-board, orrather as a resonant pipe, in connexion with the cavity of themouth. This idea, founded on investigations and experimentswhich are reported in the celebrated Joh. Muller’s Physiology,I have also communicated to Professor Henle. The reply Ireceived was, that he could no longer think of advocating thisopinion, since he had learnt from dissections that the parietesof the Eustachian tube, from the isthmus down to the orificein the throat, ordinarily (except during the act of swallowing)lie flat together, so that there can hardly be any question ofresonance or resonant connexion with the cavity of the mouth;we might, he adds, .rather explain the phenomena in questionby supposing that, in the particular cases referred to, the tubeattains a physiological importance which it does not ordinarilypossess.

I could never share this view, because the state of the organin the dead body by no means proves that the same appliesalso during life, when the vital tension of the parts of theorgan and the various degrees of pressure to which they aresubjected alter the mutual relations of the parts.

I have been accordingly most agreeably surprised in thisrespect by the results of some quite recent labours in referenceto the Eustachian tube, published by the prosector of theUniversity of Munich, Dr. Riidiger, which prove that even inthe dead body-contrary to the received opinion-the smallerupper part of the bore of the tube is always open through itsentire length, and that therefore there is an unbroken columnof air in communication with the organs of respiration. Onechief objection to my explanation is thus removed.The effect of the artificial ear-drum has also been explained

by some on the principle of resonance ; whilst others think itmust be attributed to a pressure which the artificial drum (ofToynbee) or the pellet of wadding (of Yearsley) exerts uponthe remaining fragments of the tympanic membrane, or of theossicula auditus, and thereby mediately upon the labyrinth.Much may be said in favour of each of these explanations,

and much also against their exclusive adoption. Thus, forinstance, the artificial drum proves effectual in cases wherethere can be no question at all of the pressure above alludedto; whilst, on the other hand, the phenomena of resonance inmost cases predominate greatly; and during the applicationof the little instrument in question patients chiefly complain

that the sound hums and reverberates too much, and thatevery noise is heard as if proceeding from a hollow cask.Well, then, this resonance theory, which, though it may be

open to objections, is alone applicable in both cases, explainswhy the two remedies, differing so widely in their physio-logical and therapeutic effects, produce nevertheless inter.ferences which frequently coincide.Now, without dwelling further on the manner in which this

conception of the mode of operation of the artificial drumharmonizes with the account which Toynbee so ingeniouslygives of the normal membrana tympani (according to whichthe drum with its ossicula, like the iris in the eye, must beregarded only as a kind of adjusting apparatus for the correctperception of the highest as well as the lowest sounds), I amof the opinion that it is reserved for further investigations toarrive at a correct solution of the problem.

3rd. Meanwhile, the physiological fact already establishedleads to a still more important practical application in thera-peutics. Whilst I acknowledge how, to the praise of its in-ventor, the so-called artificial drum produces an almost magicaleffect, yet everyone familiar with the subject will admit thatin the majority of cases, often quite contrary to expectation,the magnificent effect fails to ensue on the application of thatlittle instrument; that its use is, under any circumstances,for many patients very disagreeable, and in unskilful handsaffords a doubtful relief-nay, is even prejudicial; that it isonly when the patient or the physician accidentally hits upon"a certain" right spot that improvement in hearing ensues;that all sounds and noises are heard frequently with disagree-ably loud reverberations and hummings ; and that, especiallyin the hands of not very cautious laymen, its constant applica-tion for a series of years always, as an irritant, as a foreignbody, operates prejudicially upon the exposed mucous mem-brane of the tympanic cavity and the edges of the membrane,and thus reproduces and keeps up the state of suppuration. Iaccordingly only employ it as an occasional resource, whilsthabitually the methodical treatment of the tube, with theobject of restoring its passage to as n01-mal a condition as pos-sible, by means of bougies (often combined with injections ofastringents and nitrate of silver, and with treatment of themucous membrane of the tympanic cavity and the throat)effects elJerything, often more than any other means, and alzvaysmore harmlessly, and of course affords a more constant unin-terrupted relief than can be rendered, in the majority of caseswhere the tympanic membrane is ruptured, for the merelytemporary heightening of the power of hearing, by means of.the so-called artificial drum.

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

LONDON HOSPITAL.CLINICAL REMARKS ON EMOTIONAL AND INTELLECTUAL

LANGUAGE IN SOME CASES OF DISEASE OF

THE NERVOUS SYSTEM.

(Under the care of Dr. HUGHLINGS JACKSON.)

Nulla antem est alia pro certo noscendi via, nisi quamplurimas et morborumet dissectionum historias, turn aliorum, tum proprias collectas habere, et interse oomparare.—MoMiGJM De Sed. et Caus. 2forb.. lib. iv. Procemium.

AT a recent visit to the London Hospital, Dr. HughlingsJackson pointed out to us the case of a man who had lostspeech, and who was paralysed on the right side. We have

already given a résumé of Dr. Jackson’s views on cases of thiskind (THE LANCET, Nov. 26th, 1864) ; and now we speak ondifferent aspects of the same subject as illustrated by casesunder his care at the London Hospital and at the NationalHospital for Epilepsy and Paralysis.The patient we saw could only say the word " dick," and

this word he uttered whenever we asked him a question. We

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were told that when the man was vexed by the other patientsin his ward he would swear. He generally used the commonexplosive sound so much in favour with English swearers. Hecould not, however, say the word when required to do so,even whilst it was well kept before his mind by frequent repe-tition. He seemed to make efforta to say it, but the word"dick" always came out instead. The oath was only utteredunder the influence of emotion, and could never be repeatedat will. Oaths-that is, as they are vulgarly used-are littlebetter than more or less highly compound interjections. It is

not safe, then, to conclude that a patient who has lost speechis regaining power of language because he begins to swearwhen he is excited. By such words no part of a propositioncan be conveyed; that is, they add nothing to precision ofexpression in delivering an idea, although they may help thespeaker to show states of feeling, and thus to excite sympathy.Where no proposition is conveyed, there is no intellectuallanguage. It is true that some oaths, considering the merearrangement of the words, are in the form of a proposition ;but they are used without any thought as to their real mean-ing. They are, in effect, but signs of states of feeling, likeinterjections, and do not help an affirmation or a denialof any quality about anything. The utterance of such inter-jections as "ah !" "oh!" is certainly no proof that thepatient has any power of language in the sense of being ableto convey an intellectual proposition. The same remarkapplies to any real words which the patient utters withoutbeing able to use them, and evidently to the fragmentaryjargon some speechless patients utter so copiously. A patientwho had been under Dr. Jackson’s care at the Hospital forEpilepsy and Paralysis, and who is still under his observation,can utter such words as "lor," "deah," "me." " It wouldbe safer to call these fragments " sounds" rather than words,as they are but rags and tatters of talk. They are certainlynot what are properly called "parts of speech," and are of nouse whatever to this patient in the way of conveying any intel-lectual meaning. She can utter the words "yes" and " nobut can hardly be said to use them, so that even these arescarcely words to her. Dr. Jackson said that he could neversatisfy himself that she had any power of conveying a pro-position, either by words or even by more simple signs thanthe conventional sounds of spoken words. Latham says,"Without propositions there are no questions, commands, ordeclarations; and without questions, commands, or declara-tions, there would scarcely be such a thing as language. Thelittle there would be would consist merely of exclamations like’oh!’ ’ah!’ ’pish!’" Max Miiller says, "Language beginswhere interjections end." And even if language may havearisen from interjections, according to the theory which MaxMiiller calls the Pooh-Pooh Theory-and which theory he triesto disprove,-interjections are not, in the present developedstate of language, parts of speech in, the sense that nouns ornames are. "It is in names," says Hegel (quoted by MaxMuller), "that we think." If so, it is in names only thatwe can speak. But although interjections and analogoussounds are not parts of intellectual language, they are im-portant parts of the framework of emotional language, andthus help the proposition in a subordinate way.Here Dr. Jackson referred to Mr. Herbert Spencer’s essay,

"The Origin and Function of Music," to which essay he was,he said, indebted for anything of value he might have arrivedat as regards the distinctness of intellectual and emotionallanguage, and their relations to one another. The followingquotation gives but an incomplete idea of Mr. Spencer’s views,but it will serve our present purpose :-" All speech is com-pounded of two elements, the words and the tones in whichthey are uttered-the signs of ideas and the signs of feelings.While certain articulations express the thought, certain vocalsounds express the more or less of pain or pleasure which thethought gives. Using the word cadence in an unusually ex-tended sense, as comprehending all modifications of voice, we emay say that cadence is the comttaentcery of the emotaons on thepropositions of the intellect."The jargon the poor woman could utter, although of no use

in conveying her ideas, helped her to show her varying statesof feeling. Indeed in this instance intellectual language wasnearly if not entirely wanting, whilst emotional languagewas quite perfect; moreover in this instance the latter washighly developed. She could easily show that she was pleasedor vexed; but the cause of her pleasure or vexation could onlybe guessed at.When excited she could vary her tones in the most remark-

able way, and would say "ah, ah ! me, me !" in the mostviolent, or at times in the most plaintive, manner. It nny

be just remarked, in passing, that her emotional expressionwas in great part natural to her, and was not of that sortone so often sees in cases of softening and of extensive braindisease generally. She had always, her husband said, beenexcitable and fond of excitement. She would, before herillness, at any time get up in the night to go out to a fire.Now it will be observed that some speechless patients can

sing. Dr. Jackson did not allude to this fact in order to showthat voice was unaffected when speech was affected, as, so faras he knew, there was no d priori reason to expect thatvoice would be lost when speech was lost. The distinctnessof voice from articulation is well recognised, and with lossor defect of speech from disease of the hemisphere, aphonianever occurs, so far as Dr. Jackson has observed. The diffi-culty of articulation from paralysis of the tongue and palatewhich occurs with aphonia from paralysis of the vocal cordsclearly depends on disease in the medulla oblongata, and isquite a different thing. It is only mentioned here in orderthat it may be expressly excluded. It is needless to say thatdeaf mutism is a kind of loss of power to talk which is notconsidered in these remarks.There is now attending at the Hospital for Epilepsy and

Paralysis a boy suffering from epilepsy, three years old, whocan only say the words "main, mam," and "dad, dad." Itwas evident from his general conduct that the boy’s mentalcondition was much below par. Dr. Jackson remarked this tothe child’s mother, as it was very desirable that the real stateof things should be recognised in order that the child mighthave proper training. The poor mother said eagerly in reply,"But he has such a wonderful idea of music." She averredthat he could soon learn to hum any tune he heard his fatherplay on his flute. He would, however, never hum a tunewhen he was told to do so, nor indeed would he do as he wasbid at any time, partly from inability, but also from wilful-ness. Dr. Jackson has also seen another boy who had hadloss of speech after attacks of epilepsy or epileptiform convul-sions, and who it was said could sing, although he could nottalk. As, however, in neither of these instances had he heardthe child sing, he would again take the woman’s case as anillustration. She could sing, and readily sang a song her hus-band told her to sing "about Boney party," using the sounds"lor," "deah," "me," instead of words. She varied her voiceproperly.

Still, having reference to Spencer’s views, it seems, Dr.Jackson said, that we may conclude that our muscles maybe used in two kinds of language, one intellectual and theother emotional. But the muscles may, in some cases ofdisease of the hemisphere, be readily put in action for mostpurposes, when they cannot be used to make signs by wordsor by pantomime. Although this woman’s vocal and articu-latory muscles are quite unimpaired, so that she can smile,laugh, chew, eat, drink, swallow, cough, sing, &c., she cannot

repeat words said to her, and cannot in any way-puttingwords out of the question-make signs by her lips, &c. Again:although she can gesticulate, and does so frequently, she cannotmake signs with her hands, or at the most only with very greatdifficulty. The following extract from Dr. Jackson’s notes

gives a good illustration of how well she can use her muscles invarying emotional conditions. It ought to have been men-tioned that this patient had had hemiplegia of the right sideat the date of the first attack several years ago. From this,however, she soon recovered.

" in order to develop her gabble, her husband said: ’Goand talk to the bird.’ She went to the cage, which was hang-ing from the ceiling in one corner of the room, and, standingup, cried: ’Ah ! ah ! 0 deah ! deah ! deah ! Pittymy, pit-timy. Lor, lor, lor,’ &c. She seemed quite delighted withher task, and varied her voice wonderfully, uttering one set ofthe gabble in one tone, and the others in other tones. At thesame time she gesticulated incessantly, throwing her arms upand down, seeming to accompany her voice with a sort ofdance of the arms."These rhythmical movements are of importance in their rela-

tions to cadence. Spencer says: " A smile, which is thecommonest expression of gratified feeling, is a contraction ofcertain facial muscles; and, when the smile broadens into alaugli, we see a more violent and more general muscular ex-citement produced by intenser gratification. Rubbing to-

gether of the hands, and that other motion which Dickenssomewhere describes as washing with impalpable soap in in-visible water,’ have like implications. [Was it not Hoodwho said washing his hands with invisible soap in imper-

ceptible water ?’] Children may often be seen to ’jump forjoy.’ Even in adults of excitable temperament an action ap-

G 2

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proaching to it is sometimes witnessed. And dancing has all Ithe world through been regarded as natural to an elevated Istate of mind."The woman would dance when a barrel-organ was played in

front of her house. Thus, then, she could use her laryngealmuscles not only to utter single sounds like " ah ! oh!" but alsoin the complex process of singing. Again, she could not onlyuse her hands in simple gesticulations, but could use her legsin the more cultivated movements of dancing.There was no reason to suspect that this patient was hys- i

terical. Dr. Jackson said he had no reasonable doubt thatthere was disease of the convolutions near the left corpusstriatum. Perhaps the corpus striatum was itself somewhatinvolved, but not very much, as the hemiplegia had been buttransitory.

ST. MARY’S HOSPITAL.ANEURISM OF THE AXILLARY ARTERY; EXAMINATION

BY THE SPHYGMOGRAPH.

(Under the care of Mr HAYNES WALTON.)

IT was proposed by Mr. Walton to tie the subclavian arteryin the following case, and the patient was admitted for thepurpose, but he lost courage, and quitted the hospital. He

attends now occasionally as an out-patient. Our especial ob-ject in referring to the case upon the present occasion is to notethe results of a sphygmographic examination of the two radialpulses.Mr. Lynch, house-surgeon, has obliged us with the follow-

ing account of the patient :-J. C--, a carter, aged forty-two, single. About two years

and a half ago, while driving his cart, the " dicky" gave way,and he fell into the road. Since that time, at intervals, he feltpain and numbness in the right shoulder, but attributed it torheumatic pains. About three or four weeks ago he first no-ticed a throbbing sensation, and fancied he perceived a swel-ling under the clavicle of the right side, but thought it of nomoment. Since then it has steadily increased in size, accom-panied with pain in the shoulder and numbness about theelbow and fingers. There is a large round swelling occupyingthe fossa from the clavicle to the fourth rib, approaching theshoulder rather than the sternum; about four inches across,and four inches and a half from above downwards. The clavicleis raised with each pulsation, and this is increased on inspira-tion. There is a distinct thrill and pulsation extending andexpanding in every direction. Pulse smaller in right radialthan in opposite arm. Pressure on subclavian at the first rib

. controls the pulsation. Has very little pain. Has had rheu-matic fever and small-pox twice.The two radial pulses of this patient were examined by Dr.

Anstie with Marey’s sphygmograph, and the tracings obtainedare here appended. These tracings are highly interesting. On

the right or aneurismal side, it will be noted that the pulse-waves have lost all their characteristic elements (line of ascent,summit, and line of descent), and closely approach the arc ofa circle-such an arc as might subtend an angle of 45°. Thefact is the more striking because the left pulse presents atypically normal character, and forms an excellent foil to theother. The arched form of the pulse-waves on the aneurismalside corresponds well to what Marey tells us of the effect onthe pulse of an aneurismal pouch situated upon the directcurrent of the blood towards the point at which the sphygmo-graph is applied ; and it contrasts remarkably with the casesin which there intervenes between the aneurism and the pointof application of the sphygmograph a division of the arteryinto branches of the first magnitude. Thus, in Sir WilliamFergusson’s recently reported case (" Mirror," Jan. 28th, 1866),in which the aneurism was aortic, the tracings indicatedscarcely any difference between the right and left pulses. (Wereprint the delineations of the pulses in the latter case.) Itwas possible, from tit!’. character of these tracings alone, withoutany other examination, to pronounce with much confidence

that the aneurism could not be situated on the subcla.via.nartery, as external appearances seemed to indicate. For inthe latter case the pulse-waves in the radial artery of theaffected side would have been modified in the manner whichis so well illustrated by our present case of axillary aneurism.

We hope shortly to publish illustrations of the use of thesphygmograph in acute disease, a subject in which Dr. Anstieis engaged in making some interesting observations.

KING’S COLLEGE HOSPITAL.TWO CASES OF NECROSIS; REMARKS UPON THE REMOVAL

OF DEAD BONE.

(Under the care of Sir WILLIAM FERGUSSON.)To the inquiry in many an operating theatre as to the nature

of the next operation, it is common enough to hear the reply,"Only removal of dead bone." The silent and attentive in-terest with which the amputation of a limb, for instance, isregarded gives place, under these circumstances, to a generalhum of conversation, whilst the surgeon struggles with anosseous fragment and succeeds or fails in removing it. Andthis apparent indifference evidently arises from other causesthan want of appreciation of the importance of the proceeding.We may safely say that the operation is more common thanany other which is required to be performed in our hospitals,whilst its results to the patient are often of immediate andlasting benefit. But it is not a showy operation; it requiresmuch patience as well as skill on the part of the surgeon, andit is difficult for the lookers-on to appreciate the various com-plications which often render the proceeding not only tediousto the operator, but dangerous to the patient. Severe hæmor-rhage has not unfrequently occurred in such cases from theextensive incisions necessary to expose the bone. In deal-

ing with a sequestrum in the space between the condyles ofthe femur-so common a seat of necrosis,-the popliteal arteryhas been wounded by the knife, or torn by the bony fragment.It is probable that a considerable portion of the difficultyattendant upon such cases arises from the long delay whichhas often occurred before they come under the notice of thehospital surgeon.We recently heard some interesting remarks upon this sub-

ject from Sir William Fergusson in connexion with the casesof two patients-a boy and a man-who were operated uponsuccessively in the theatre.The boy had presented himself as an out patient some three

months previously. He had suffered from inflammation inand about the humerus, especially its upper part, to a veryconsiderable extent; and this had ended in suppuration anddeath of bone. When first seen he was so weak from diseaseand bad living that no operation was at the time advisable.He was admitted, and had since improved in health. Therewas much thickening, and Sir William felt sure there wasdead bone which would require removal. He felt anxious asto when the bone would separate. Formerly it was consideredrather discreditable for a surgeon to operate and find no boneready for removal; but he (Sir William) thought it wise some-times for the surgeon who knows that dead bone may beexpected to make preparations for it. By long waiting, thenew bone deposited gets very hard, and the contained deadstrueture is difficult to separate; for the new bone may bethree times as thick as the original, and exceedingly dense.Under these circumstances the surgeon may become literallyexhausted, and the operation have to be carried over to a