With regard to the question of remedies. It would obviously be absurd, after what has been said, to name a remedy for osteo-arthritis. The remedy must be selected in connection with the whole group of signs and symptoms. In connection with the case of poisoning by arsenical wall-paper, it is certainly significant to note that so acute an observer as Dr. Hilton Fagge has left it on record that if any drug does any good in rheumatic gout, that drug is arsenic.

Last, but certainly not least, at all cost of suffering, movements of various kinds must be kept up; rest must be sedulously avoided—it is simply fatal. In mild cases active exercises, involving all possible movements of all the joints, should be enforced at least twice a day. In graver conditions, where these are impossible, an attendant should perform complete passive movements. The surgeon should throw the whole of his energy into the scale against the seductive charm of the easy-chair, and perpetual movement of every kind and variety should be the watchword of the rheumatic subject.

It is quite possible that these movements, while tending to increase of appetite, to improve circulation, and blood aëration, may also stimulate the red-corpuscle factories which are supposed to exist in the

marrow.

Electro-massage has opened the door to an entirely new world in the treatment of osteo-arthritis. No drug nor mineral water, not even hydropathy, can compare for a moment with the exceedingly swift results which follow well-applied massage. The pain, the rigidity, the crepitation, and the local edema often disappear with astonishing rapidity; even old-established, hardened nodes are sometimes reduced in size. Severe general chondritis, after resisting every kind of medication, has been known to improve to a surprising extent.

If pain predominates, the continuous current is to be preferred. The negative pole is attached to the arm of the operator, while the positive is applied to the nape of the patient's neck or to the trunk of the sciatic nerve when doing a lower extremity.

If paralysis be the most salient feature, the interrupted current is, of course, indicated. When using the faradic current the poles should be much nearer together, just including one muscle at a time. As a matter of fact, it answers best usually to employ a continued current of voltaism with faradism, and we should always commence with a mild

one.

At first the massage should be slow and very gentle, usually centripetal, the pressure gradually increasing. To avoid furrowing, a different route should be selected each time. If the skin be moist and greasy, French chalk is a convenient application to diminish the friction.

If the skin be harsh and dry, vaseline combined with some appropriate medicament may be employed.

Gentle traction, combined with rotation or circumduction, is exceedingly useful to overcome the tendency of the limbs to shorten and to prevent or remove adhesions. When the cartilage loses its elasticity and becomes dough-like, the constant traction exerted by the muscles tends to cause a lateral expansion.

In dealing with the fingers a damp cloth may be wrapped round the digit; it is then quite easy to apply the needful pulling power.

These processes, which are tedious and tiring, may be varied by enforcing an occasional full-breath exercise.

After rubbing, each joint should be put through all its varied movements, and it is well, if possible, that the patient should rest for a time warmly covered.

Electric hot baths with a continuous current of from 20 to 200 milliampères have proved to be most valuable. No salt nor acid should be used. The bath should be of wood.

Turkish baths do not invariably benefit cases of rheumatic gout.

The fact is that osteo-arthritic patients, though the pain may increase, appear to be better in cold air than in hot, if the atmosphere be not charged with moisture.

Mountainous and arctic regions are said to confer an immunity from rheumatism, while warm places like Cairo are very subject to it. Speaking of that town, Lombard' says, on the authority of Drs. Hartmann and Pruner Bey: "Le rhumatisme et la goutte se rencontrent assez souvent," etc.

Dr. Davies' says: "In Cairo ordinary chronic rheumatism is very common, both among natives and Europeans. There and nowhere else I experienced it myself."

APHASIA DUE TO SUB-DURAL HEMORRHAGE WITHOUT EXTERNAL SIGNS OF INJURY; OPERATION; RECOVERY.

BY L. BREMER, M.D., AND N. B. CARSON, M.D.,

OF ST. LOUIS.

THE history of the patient, H. T. K., a healthy and well-built man of about twenty-one years, is as follows:

There is neither heart nor kidney disease. Two weeks previous to my seeing him he went to a wedding, got intoxicated, and on his way home

1 Climatologie Médicale, vol. iii. p. 566.

2" Rheumatism in Egypt." Sidney Davies, M.A., M.D., Oxon., late P. M. O. Egyptian Police. Lancet, 1890.

fell between the joists of a new building. This was his statement subsequent to his recovery after the operation. He went home and was found asleep in the kitchen of his parents' house the following morning. Except what appeared to be the effects of the liquor, he seemed in his usual health. In fact, nothing was mentioned by him as regards the fall. Being out of work, he stayed at home and rarely left the house, complaining off and on of a dull headache on the left side of the forehead, with exacerbations in the afternoon. Occasionally he vomited, but had generally a good appetite. All this while there was not the slightest suspicion on the part of his family of any serious trouble.

About one week after he had begun to stay at home, while walking on the street, one block away from his home, he suddenly became unconscious and fell. This attack did not last long, however, and he was assisted home by a person who happened to be near at the time. When he arrived at the house he was able to undress himself and went to bed. Shortly afterward it was discovered by his family that he had some difficulty in speaking. He now for the first time intimated to his family that he met with an accident on the night of the wedding. Dr. H. F. Hendrix was called in, who, in addition to the dysphasic disturbance, noted other symptoms, especially a slow, laborious pulse indicative of brain lesion. He observed that the patient was more or less speechless in the afternoon, when a moderate fever of about 101° would set in, whereas in the morning, when free from fever, the difficulty of speech would be much less, and he had many more words at his command than in the afternoon.

When I saw him for the first time, thirteen days after he first commenced to complain, it was stated that for the last three days he had been entirely unable to speak. On the day previous to my visit Dr. Hendrix had found his pulse to be 54.

The patient seemed to be quite rational, judging from the looks of his eyes and the expression of his face. There was no trace of an injury to his head. He understood every word that was spoken to him, every question that was asked. Unfortunately, although not entirely illiterate, the patient was not possessed of sufficient education to render the examination of this form of aphasia very profitable. Only the most elementary questions could be asked of him, the scope of his intellect being limited.

In order to test his mental calibre and ascertain the nature of the trouble of speech, a number of questions were put to him. The principal ones were:

Do you know what this is (showing him a glass)?

Ans. Zer

Q. Is it a glass?

Ans. Yes.

When a pitcher is shown him, he calls it a "tipper;" a "pen" he calls "riglah;" a spittoon "sempen;" a hat "sem.'

Q. Do you call this (the hat) "sem"?

Ans. No.

Q. Is it a hat?

Ans. Yes.

In order to demonstrate that he knows what it is, he makes the move

ment of striking a match. A book he calls "pok;" handkerchief, "sempence;" suspender, also "sempence;" for pocket-knife he gives the correct name; but when shown a bunch of keys, he also says "pocketknife." After this he calls everything that is shown him pocket, e. g., a watch and a button.

When ordered to repeat a word that is spoken to him, he is unable to do so.

He understands perfectly what he reads. He is handed a newspaper, and an advertisement of an entertainment in the Exposition Building is pointed out to him. By putting a variety of questions, some of them misleading, I convince myself that he is familiar with the location of the building, and the purposes it is built for.

He is asked to read the advertisement of a boxing-match. I point out the name of the prize-fighter, and ask him: What is he? Is he a preacher? This causes him to laugh.

In short, there is no flaw in his perceptive and reasoning powers as far as can be ascertained by a necessarily limited conversation, and as far as a short acquaintance will permit.

The most prominent of the other symptoms is a beginning obliteration of the naso-labial fold on the right side; on showing his teeth, the left naso-labial fold becomes much more marked than the right, and the left angle of the mouth is drawn considerably to the left; during an effort at whistling the right cheek puffs somewhat. The tongue deviates to the right. He cannot well draw the right angle of the mouth to the right, or make the right platysma muscle contract. On the latter symptom, however, not much stress is laid, because an effort on the other side is not very successful, and many people, even in absolute health, have not the power of contracting this muscle either singly or together with its fellow.

The grip of the right and left hands seems to be almost equal; he moves his arms with absolute freedom, and nothing abnormal can be seen in his walk. He stands on the right leg with the same ease as on the left.

On being told to alternately flex and extend the right index finger, there is an associated movement of the other fingers; and on trying to move the right thumb, the right index also moves in a rather clumsy, erratic manner. All such movements of the fingers on the left side are executed with precision, no associated movements of the others being noticeable.

Sensation (tested with a pin) is somewhat dulled on the whole of the right side. The main dulness is in the fingers, the palm and back of the hand, and the wrist; it is less higher up to the elbow and shoulder, and much less in the face. But, as just stated, the whole of the left side, including the leg, shows a defect in common sensibility. The same is true of the sense of temperature and pain. Passive movements of the fingers of the right side are not so well perceived as those of the left, showing a lowering of the muscle sense. The passive movements of the toes on the right side, however, are correctly stated. There is no ataxia in the right arm or hand; without hesitancy he carries his right index to the tip of the nose, the eyes being closed, and puts with precision the tip of the finger on the point of a pin.

But on being told to write, he holds the pen in an awkward manner, and drops it repeatedly. He never has been much of a penman, but

has been able to write simple letters. It is now impossible for him to express his thoughts in writing, and even the most commonplace and every-day expressions, when dictated, he fails to fix by letters.

The effort at writing his name is more of a success. While his inability to write words, even the most familiar ones, is very marked, he puts figures with comparative ease. Thus in writing what is meant for "April 28, 1891," he writes 28 and 1891 without the slightest hesitation. This facility of writing figures and difficulty, amounting often to impossibility, of penning words was tested in different ways, always with uniform results. There is no visible abnormality about the eyes; no inequality of the pupils, no hemianopsia. Nothing of a spastic character is observed in any of the muscles of the affected side. Patient is righthanded.

From the foregoing data the diagnosis was made: Blood-clot (probably extra-dural) pressing principally on the foot of the third frontal (Broca's) convolution and the foot of the second frontal (probable centre for writing), impinging also on the face and tongue centres of the left hemispheres.

The next day all the symptoms were more marked; the grip of the right hand was weaker than that of the left; pulse 43.

The operation of trephining was now set for the following day, and the patient transferred to the Mullanphy Hospital. While the preparations for operation were in progress, the patient was once more examined as to the general and localizing cerebral symptoms. As regards the latter, it was found that they had become more vague and indistinct. The patient did not answer questions as readily as on the preceding days; it took him a longer time to comprehend their import. While during the first half-hour of the examination he tried to read from the questioner's mouth, he grew listless and inattentive later on. Although there was no outspoken hemiplegia, he dragged the left foot, when told to walk, which had not been the case on the previous day. The grip of the right hand was also much weaker, the paresis of the right side of the face and the deviation of the tongue more marked. The dulness of sensation had increased in proportion to the motor weakness. How much, however, this was to be attributed to a want of attention and increasing mental hebetude was difficult to decide.

There could be no doubt that the pressure on the brain was rapidly increasing. During the last hour consumed in the examination, the patient grew more and more confused and listless; this was not entirely due to the fatigue attending upon keeping his waning mental faculties at work, for it could be distinctly ascertained that the grip of his right hand became more feeble, and that his right leg became unable to bear the weight of the body-so much so that he was unable to walk to the operating-room, and had to be carried there on a stretcher.