717

affection of the ocular muscles; the difficulty is not in

looking to one side in particular. Indeed, we see the samesort of thing in some people whose nervous systems are

sound. Some people are unable to draw in their breath

deeply when told to do so during stethoscopic examination;we have to tell them to cough. It is next to impossible toget some patients to frown (as in suspected one-sided facial

paralysis), even if we make a frown for them to imitate.Returning to aphasia. The Recurring Utterance is often"Yes" or "No," or the patient may be able to utter boththese words. Some of these patients can utter " No "emotionally, and some can do this and can also reply withit (use it propositionally). But of those who can replywith it there are some who cannot say it when told.After failing to get them to say it when told, we caneasily get the word out as a reply to a question re-

quiring dissent. Similarly of Occasional Utterances ofless automaticity: a patient may swear well on proper(scientifically proper) occasions, and yet be unable to repeatthe ejaculation or any word of it. The same applies toOccasional Utterances of still less automaticity, as is illus-trated by the following excerpt from an unpublished paperby Dr. Hughlings Jackson written ten years ago :—"I haveseen a patient who usually sat up in his room, whose facelooked intelligent, who was cheerful and merry, and whoseemed to understand all that I said to him, but who couldnot put out his tongue when he tried. His daughter re-marked that he could put the tongue out, as she expressedit ’by accident,’ and added, as an illustration of hermeaning, that when anyone was leaving him he couldsay good bye,’ but that he could neither put out histongue, nor say good bye ’ when he tried. He could say‘yes’ and no ’ at any time ; and, using the lady’s expres-sion, could say good bye,’ ’ well,’ ’never’ by accident. Shefurther remarked that the patient would sometimes swear.He uttered the short explosive word which is so much infavour with English swearers, but he could not, she said,repeat the word when he tried. She asked him to utter theexplosive sound when I was there, saying it herself for himto imitate. He laughed, and shook his head."In some cases, where there is not loss but defect of

speech, we see a similar sort of thing. The patient may getout a word, or even an elaborate phrase, and be quite unableto repeat it. This shows us that in our trying to appreciatean aphasic’s condition, we have not only to note what heutters, but whether or not he can say (repeat) what he hasuttered. We frequently find that he cannot. In some casesa patient gets out, in proper reply to a question, such aphrase as " I don’t know"-one, be it observed, of considerable automaticity. Afterwards he may go on uttering it inrejoinder to questions to which it is irrelevant. The patientmay show that he knows this by expressions of mirth orannoyance after its utterance. But sometimes we can stopsuch temporary Recurring Utterances by telling the patientto say "I don’t know," or whatever the phrase may havebeen. They often fail.All the above superficially different phenomena are funda-

mentally like; they all show a reduction to a more auto-matic condition.

NORTHERN HOSPITAL, LIVERPOOL.CASES OF RUPTURE OF ABDOMINAL VISCERA FROM FALLS.

(Under the care of Mr. PUZEY.)FOR the following interesting notes we are indebted to

Mr. James Allan, house-surgeon :-CASE 1. Complete Rupture through Pylorus.-D. M—,

aged eighteen, was admitted at 8 P.M. on September 13th,1877. About half an hour before admission he sustained aninjury to the abdomen by a fall from a considerable heightinto a ship’s hold. He complained of intense pain referredto a limited area on the borders of the epigastric and theright hypochondriac regions, and begged earnestly to be putto sleep. A small quantity of brandy administered to himcaused immediate intense pain in stomach. He felt sick,but did not vomit, and was much collapsed. He was easiestwhen lying in the prone posture. Percussion and palpationindicated presence of air and fluid in abdomen. He died at5 P.M. on the 15th, the second day after admission.Necropsy.-On cutting through the abdominal wall, air

escaped, and a large quantity of dark-coloured fluid withfeculent matter floating in it occupied the abdominal cavity.There was complete separation of stomach from duodenum

by a transverse rupture through the pyloric valve. Stomachquite empty, duodenum contracted at seat of rupture. Nohaemorrhage, very little escape of bile ; evidence of peritonitisby the presence of flakes of lymph on the intestines and alayer of lymph on upper surface of liver.

’ CASE 2. Rupture of Liver, Spleen, and one Kidney.-G. M-, a sailor, was admitted at 10 A.M. on December19th, 1877. Just before admission, fell from the rigging adistance of forty feet, and was doubled up by abdomenstriking some projecting body on deck. He was picked upinsensible. He had pain all over the abdomen, but mostsevere in the right hypochondriac region. Decubitus dorsal,with thighs flexed on abdomen. Respiration mainly costal.Anything swallowed was immediately rejected. Catheterintroduced showed bladder uninjured. There was disloca-tion of left clavicle at the scapular end.Dec. 20th.-Bowels moved during night. No blood in

stools. Experienced great difficulty in defecation, due toincomplete action of the diaphragm. No blood in urine.Died at 4 P.M.

Necropsy.—A small quantity of blood-stained fluill foundin abdomen ; no trace of peritonitis. The liver presentedthree parallel rents two and a half to three inches long,quite superficial, running antero-posteriorly on the upper sur.face of the right lobe; gall-bladder full. On the spleen,about the middle of its convex surface, were two superficialfissures about two and a half inches long, and running inthe line of its short diameter. There were two small rentson the convex border of the left kidney, situated near eachother and the centre, and along short diameter.CASE 3. Rupture of Spleen, Left Kidney, &c.-P. B-, ,

aged fifty, was admitted March 6th, and died in two hours.A short time before admission he fell into a ship’s hold, adistance of twenty-five feet, striking the left antero-lateralaspect of body, and fracturing a large number of ribs onboth sides of chest. He had extreme difficulty in breathing.Respiration diaphragmatic. No evidence of cerebral or spinallesion. Died of asphyxia.Necropsy.-The spleen presented two ruptures’ each one

and a half inches long, ON the hilum aspect, and runningalong the short diameter of the organ near the middle line,and about quarter of an inch deep; also a superficial fissurethree inches long on the convex surface. Spleen friable,twice usual weight. Considerable haemorrhage round thisorgan. On the left kidney, near the hilum, there was asmall pretty deep rupture running transversely ; largeamount of haemorrhage. Bladder intact, contracted.In this case, also, there was a rent in the pericardium,

opposite the apex of heart, two inches long. There werealso extensive ruptures of lungs from fractured ribs. In allthere was fracture of eighteen ribs : eight on the right sideand ten on the left. Those on the right side fractured infront of the angles, third to tenth inclusive ; second toeleventh on the left, the second fractured in anterior third,all the rest in middle or junction of middle and anteriorthirds; the third to ninth inclusive also fractured behind theangles. Collapse of left lung and haemorrhage into chest.

NORTH STAFFORDSHIRE INFIRMARY.STRANGULATED HERNIA RELIEVED BY OPERATION; RE-

CURRENCE OF VOMITING.

(Under the care of Mr. SPANTON.)

FOR the notes of the following case we are indebted toMr. W. A. Frost, house-surgeon.

Charlotte S-, aged thirty-nine, married, four children,was admitted Feb. l7th, at 12.30 P.M. Femoral hernia hadexisted on right side for three years. On several occasionsthere had been pain and difficulty in reducing it. She hadworn a truss for two years. The hernia descended on theday before admission between three and four o’clock in theafternoon, and she was unable to reduce it. In the eveningvomiting occurred, and recurred several times during thenight. Taxis was employed by a medical man the sameevening, and again on the morning of her admission. Thebowels acted on the morning of the 16th.On admission there was a rather tense swelling extending

from the saphenous opening to Poupart’s ligament ; no im-pulse on coughing ; over this the patient was wearing atruss. There was pain in abdomen. The pulse was smalland weak; tongue moist, slightly coated in centre ; tem-perature 994°.