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A SIMPLE OPERATION FOR VARICOCELE.
521
greater extent in every inspiration. Taking, for example, the recorded were done by way of experiment. Some time seventh costo-cartilagic angle on the leftsiae, I found that an previously I had removed the enlarged right half of the inch and a half above the apex of the angle with a deep thyroid gland with strict Listerian antiseptics, using sevenThe teen silk and six catgut ligatures for vessels, &c. FIG 15. wound healed rapidly (almost by first intention), although
inspiration the transverse distance was
increased
as
Male, aged " a
)
39 52
...
...
"
40 ... " 47
"
)
"
" 47...
"
)
"
between rib and
cartilage
follows
...
18 32
...
...
Normal ;:
chest,
l,, inch. "
;?
2 g Slight Bronchitis,4/8 " T%"
"
Mitral "
"
,,
disease, "
ea
5/15" g
"
after the first day I used a dressing of salicylic wool without the spray, the wound having become fully exposed during the first night. Here not one of either the catgut or silk ligatures came away or gave any evidence of their presence under the skin ; nor have they done so yet, nearly a year after operation. In thinking over this case, it occurred to me that the scrotum, from its position and structure, would be a good field in which to study (as far as this is possible in the living body) the behaviour of ’such ligatures embedded in healthy ti,sues. If no suppuration tonk place around them, we might be able by manipulation to ascertain how long they. remained unabsorbed, and how much plastic change they provoked, with some other interesting points. If, on the other hand, they should suppurate and come away sooner or later, the patient would be in no worse condition than if operated on by one of the ordinary methods where suppuration is necessary. I also thought that it would be interesting to try whether it was not possible in this ligation to attain to and maintain perfect asepticity without the usual elaborate dressings of the Listerian method. The operation of tying the veins of the testicle, in short, appeared to offer a simple but fairly good means of testing practically whether it was possible, without the spray, to introduce a perfectly pure ligature into the tissues of the body, and to maintain such conditions of purity around it as might enable the silk to remain there without provoking any excessive reaction; also of observing what became of the knotted ligature eventually in the soft textures of thelcrotum. Having these three cases to operate on last autumn, I dealt with them as follows : two on one day, the other five days later. The skin of the scrotum was thoroughly cleansed with a 5 per cent. carbolic lotion, as also all instruments and the surgeon’s hands, no spray being used. The scrotum was then pinched up between finger and thumb in the usual way, so as to include the veins and exclude the vas deferens; it was then notched with a scalpel, and through the opening thus made a needle bearing a medium-sized twisted silk ligature (previously soaked for about an hour in the same carbolic solution) was passed. The veins were then allowed to slip backwards, and the needle was made to carry the silk forwards again through the same puncture, but this time in front of the veins. The latter were thus, of course, included in the two loops of silk leaving the scrotum by the same aperture. The ends of these were now tied tightly over the veins about one-eighth of an inch apart. They were then cut short and allowed to slip into the scrotal tissues. Everything was in the meantime protected from any contamination by frequent wiping with a carbolised sponge. A little padding of salicylated wool was the only
The mechanical difficulty introduced by the curved form of the spine and the inclined position of the sternum is thus obviated in a most effective and beautiful manner by a means that in no way militates against the great object that is in view in the elevation of the costal parietes-the increase of the thoracic capacity. On the contrary, this very expedient dressing. in itself increases the internal area-the cartilages being, in need only be briefly alluded to. There was a fact, the representatives in man of the sternal ribs of birds, very trifling swelling around the seat of ligature for a few in virtue of which they are enabled to meet their enormous days, together with slight tenderness on pressure, otherrespiratory wants. And this is another instance showing wise nothing was complained of in the first two cases. In the conservative principles on which nature proceeds in all the third, considerable pain was felt for a day or two, and relating to mechanics, that here, instead of introducing some there was a little more swelling and tenderness. But in new and special mechanical expedient to convert an othernone of the three cases was there the slightest threatening wise rigid framework into a freely movable machine, she of suppuration. The first left the house in ten days, the merely retains so much of the sternal rib as will suffice; and second within a fortnight, the last on the fourteenth day. as if further to show her economical tendency, the cartilages They were then walking about without any discomfort, of the upper two ribs, where adaptive assistance is scarcely except the third, who, having had a very large varicocele, still felt a good deal of dragging in the loin on returning to required, are in most instances quite rudimentary.
Theresults
work, which was very hard, and some neuralgic pain. These, however, passed off later, under the use of laxatives for obstinate constipation from which he suffered, though he A SIMPLE OPERATION FOR VARICOCELE. continued to work for long hours as a grocer’s assistant. I BY ARTHUR E. BARKER, F.R.C.S.ENG., watched all these three cases for several months, the last until ASSISTANT PROFESSOR OF CLINICAL SURGERY, AND ASSISTANT SURGEON quite recently, about a year after operation, and now regard AT UNIVERSITY COLLEGE HOSPITAL. all danger of the ligatures coming away as quite over. The latter could be felt under the finger as small knots deep in IN the last three cases of varicocele upon which I have the scrotal tissues, which appeared quite normal. Whether been called to operate, the method adopted has been very they will ever come away remains to be seen, but this is simple, and has been followed by such good results that it immaterial, as far as the patient is concerned, for they give appears worth brief notice. It seems, too, very unlikely to no trouble now. Comparing these operations, as far as they go, with the be followed by any of those ill results and dangers of which older methods, their extreme simplicity is worth noting, as most surgeons have seen something who have practised the well as the small amount of trouble or inconvenience to the his
older
procedures.
I may say that the three
operations
now
patient.
It is also of
some
interest to note
that,
in these
522 three cases at all events, it was possible to manipulate freely with s’lk ligatures, and yet introduce them in a suflicietitly pure state to produce no suppuration of any kind ; and all this with only the simplest precautions as to absolute cleanliness, and without the carbolic spray. There is also a satisfaction in knowing that the veins are thoroughly occluded, and that there is no possibility of the ligatures slipping or being too soon absorbed, as might be the case with catgut. If nothing else, the operation appears an interesting experiment, and worthy of further trial.
Harley-street, W.
CASE OF STRUMOUS ULCERATION OF THE INTESTINES, PRESENTING THE CLINICAL FEATURES OF ACUTE GENERAL BY
TUBERCULOSIS. SAMUEL WEST, M.B., &c.,
SENIOR ASSISTANT PHYSICIAN TO THE CHEST HOSPITAL VICTORIAPARK, ETC.
healthy, except for the presence of a small cyst (a, quarter of an inch in diameter) in the middle of the nuclets. This cyst had a firm Jibrous capsule, with smooth lining, and round it the nerve substance was perfectly healthyso that there was no suflicient explanation in the
presence of the cyst for the sudden occurrence of uncon. sciousness. All the other organs were sound, except the which were in a most extreme condition of intestines, " tubercular" ulceration. In the whole cæcum round the valve, and for the lower six inches of the ileum, the mucous membrane was completely ulcerated away, and at frequent intervals in the small intestines large tubercular ulcers were found, many completely encircling the gut. The last ulcer, and that too of considerable size, was at a distance of only two feet from the duodenum ;the character of the ulceration was typical of the so-called tubercular or strumous ulcers of the intestine, and the glands of the mesentery were also in the condition usual in this affection. The uncertainty of diagnosis between many cases of acute general tuberculosis and typhoid fever is generally recognised, but this case is an instance of an intestinal lesion, not typhoid, which presented the same difficulties. Wimpe le street, W.
DR. STURGES remarks in his article on Acute Tuberculosis in THE LANCET of September 16th, that "tubercular PURULENT DISEASE OF THE EAR; individuals, children at all events, will present the clinical die in the and PRODUCING CEREBRAL ABSCESS, PURULENT MENINGITIS, of tubercular usual meningitis, symptoms AND OBLITERATION OF THE RIGHT LATERAL SINUS, nor neither tubercle but inflammatory post mortem way, WITH STRIKING CHANGES IN THE INTERIOR OF exudation will be discovered." The following case is an THE TEMPORAL BONE.1 illustration of this. BY THOS. BARR, M.D., F.F.P.S. GLAS., On August 17th a child, nine years of age, was brought to the Chest Hospital, Victoria-park, by its mother, who LECTURER ON AURAL SURGERY, ANDERSON’S COLLEGE, AND DISPENSARY SURGEON FOR DISEASES OF THE EAR, WESTERN INFIRMARY, stated that though never strong, the child had been in its GLASGOW. usual health until the last six weeks, when it became weak and languid; that for the last fourteen days it had been W. C-, a boilermaker, aged thirty-seven years, was feverish, and had suffered from pain and sickness chiefly a remarkably strong man, of great muscular development after food, and a little diarrhoea. There was no history of and of medium height, weighing in ordinary health between illness. The child was and thin any previous feverish, looked dull, and had an aspect whien suggested typhoid fourteen and fifteen stones. He suffered from purulent fever. The pulse was rapid, 100-120 ; the temperature disease of the right ear from the age of twelve till his death was high, with marked evening rise, 101.5° to 1025°, the -that is, for twenty-five years. There was almost total morning temperature being nearly normal. The child deafness on the affected side. The disease was supposed to was listless, heavy, and slept much. The condition remained the same for some days. Diarrhoea, spots, and have originated in the blow of a cane received on the right abdominal pain were absent, and the abdomen retracted. side of the head, and inflicted by a schoolmaster by way of At the right apex the percussion was slightly impaired. chastisement. This injury was followed by great pain, The respiratory sounds were increased, especially the exfor several weeks and culminating in the forma, piration sound, which was remarkably long aud harsh, continuing of an abscess which was opened behind the auricle. tion accompanied by occasional fine crepitation. The absence of abdominal symptoms and the presence of pulmonary About the same time a discharge of matter appeared from canal. The purulent discharge from the external signs led to the probable diagnosis of acute general the opening auditory behind the ear continued, with variations in tuberculosis, which was confirmed, it was thought, by the further course of the case. For the apex dulness increased quantity, till six years ago, when the opening closed, leaving behind a cicatrix. The discharge from the canal sligbtly, some general bronchitis set in, and the patient of the ear,depressed which had usually an offensive odour, continued, and lost flesh on the 6th of strength ; rapidly September- with slight intermissions, till the patient’s death. It was i.e., at the end of the fifth week of seveie illness, and nine slighter, however, 6 uring the ninemonths before hisfatalillness. weeks from the commencement of failing health, the child, cold weather to attacksof hoarsenesswith liableduring having for some dayspreviously grown more and more sore-throat. At the age of seventeen he suffered from acute the became suddenly unconscious, eyes remainirig drowsy, attacks in the right ear, when it was supposed wide open, the pupils equally dilated and not responding to inflammatory his life was in danger. He noticed that when the disthat the feet and were There continual slight twitchings of light. for a short time he suffered from severe headhands with irregular movement of the eyeballs; the respira- charge ceased and became ache, very dull and fretful. Indulgence in tion was noisy and harsh ; the urine and fæces were passed alcoholic stimulants produced the same effects, and he was two days the temperature therefore very temperate unconsciously. For the next in their use. In the middle of rose higher than usual, above 103°, the general condition November last there a series of morbid processesbegan 9th the temperature first in the left remainrug the same. On September then in the in the courseof ear, began gradually to fall, the twitching ceased, the pupils three months terminated fatallyright,-which by extension of the purulent were observed to dilate and contract spontaneously, as in process to the interior of the cranium. The many cases of meningitis, and several loose motions were inflammatoy left ear, which previously had been always healthy, and in there the 10th a in bed On was passed unconsciously. which he eujoyed good hearing, became at that time dull slight return of twitching, m the eyelids and arms, the and discharged slightly without any distinct pain. This was respiration became embarrassed, and in the evening the associated at the beginning with sore-throat and hoarsepatient died. The history of the case, the retraction of the abdomen, ness. The dulness and slight discharge in the left ear conthe absence of diarrhoea, the presence of lung symptoms, tinued for two months, at the end of which an acute - and their gradual increase, and, lastly, the occurrence of inflammatory process began in the ear. While at work Monday, Jan. 23rd of this year, and particularly on unconsciousness, with slight convulsions, were all thought on his way home at the end of the day, be experienced to point conclusively to the diagnoses of acute general tubergiddiness, s-o that at times he staggered in walking. culosis. This diagnosis, the post-mortem exami- great On the morning at four o’clock he awoke with not establish. did In no nation organ was there the severe following in the head, with great giddines", and he looked pain of tubercle. The trace of the grey apex right lutig slightest was indurated by some old pigmented nbious ti-sue, but I I am indebted to my friend Dr. McConti))f, the medical attendant there was no recent mischief. The brain was absolutely of this patient, for the ohief facts given in the clinical history,
He was
however,
greater extent in every inspiration. Taking, for example, the recorded were done by way of experiment. Some time seventh costo-cartilagic angle on the leftsiae, I found that an previously I had removed the enlarged right half of the inch and a half above the apex of the angle with a deep thyroid gland with strict Listerian antiseptics, using sevenThe teen silk and six catgut ligatures for vessels, &c. FIG 15. wound healed rapidly (almost by first intention), although
inspiration the transverse distance was
increased
as
Male, aged " a
)
39 52
...
...
"
40 ... " 47
"
)
"
" 47...
"
)
"
between rib and
cartilage
follows
...
18 32
...
...
Normal ;:
chest,
l,, inch. "
;?
2 g Slight Bronchitis,4/8 " T%"
"
Mitral "
"
,,
disease, "
ea
5/15" g
"
after the first day I used a dressing of salicylic wool without the spray, the wound having become fully exposed during the first night. Here not one of either the catgut or silk ligatures came away or gave any evidence of their presence under the skin ; nor have they done so yet, nearly a year after operation. In thinking over this case, it occurred to me that the scrotum, from its position and structure, would be a good field in which to study (as far as this is possible in the living body) the behaviour of ’such ligatures embedded in healthy ti,sues. If no suppuration tonk place around them, we might be able by manipulation to ascertain how long they. remained unabsorbed, and how much plastic change they provoked, with some other interesting points. If, on the other hand, they should suppurate and come away sooner or later, the patient would be in no worse condition than if operated on by one of the ordinary methods where suppuration is necessary. I also thought that it would be interesting to try whether it was not possible in this ligation to attain to and maintain perfect asepticity without the usual elaborate dressings of the Listerian method. The operation of tying the veins of the testicle, in short, appeared to offer a simple but fairly good means of testing practically whether it was possible, without the spray, to introduce a perfectly pure ligature into the tissues of the body, and to maintain such conditions of purity around it as might enable the silk to remain there without provoking any excessive reaction; also of observing what became of the knotted ligature eventually in the soft textures of thelcrotum. Having these three cases to operate on last autumn, I dealt with them as follows : two on one day, the other five days later. The skin of the scrotum was thoroughly cleansed with a 5 per cent. carbolic lotion, as also all instruments and the surgeon’s hands, no spray being used. The scrotum was then pinched up between finger and thumb in the usual way, so as to include the veins and exclude the vas deferens; it was then notched with a scalpel, and through the opening thus made a needle bearing a medium-sized twisted silk ligature (previously soaked for about an hour in the same carbolic solution) was passed. The veins were then allowed to slip backwards, and the needle was made to carry the silk forwards again through the same puncture, but this time in front of the veins. The latter were thus, of course, included in the two loops of silk leaving the scrotum by the same aperture. The ends of these were now tied tightly over the veins about one-eighth of an inch apart. They were then cut short and allowed to slip into the scrotal tissues. Everything was in the meantime protected from any contamination by frequent wiping with a carbolised sponge. A little padding of salicylated wool was the only
The mechanical difficulty introduced by the curved form of the spine and the inclined position of the sternum is thus obviated in a most effective and beautiful manner by a means that in no way militates against the great object that is in view in the elevation of the costal parietes-the increase of the thoracic capacity. On the contrary, this very expedient dressing. in itself increases the internal area-the cartilages being, in need only be briefly alluded to. There was a fact, the representatives in man of the sternal ribs of birds, very trifling swelling around the seat of ligature for a few in virtue of which they are enabled to meet their enormous days, together with slight tenderness on pressure, otherrespiratory wants. And this is another instance showing wise nothing was complained of in the first two cases. In the conservative principles on which nature proceeds in all the third, considerable pain was felt for a day or two, and relating to mechanics, that here, instead of introducing some there was a little more swelling and tenderness. But in new and special mechanical expedient to convert an othernone of the three cases was there the slightest threatening wise rigid framework into a freely movable machine, she of suppuration. The first left the house in ten days, the merely retains so much of the sternal rib as will suffice; and second within a fortnight, the last on the fourteenth day. as if further to show her economical tendency, the cartilages They were then walking about without any discomfort, of the upper two ribs, where adaptive assistance is scarcely except the third, who, having had a very large varicocele, still felt a good deal of dragging in the loin on returning to required, are in most instances quite rudimentary.
Theresults
work, which was very hard, and some neuralgic pain. These, however, passed off later, under the use of laxatives for obstinate constipation from which he suffered, though he A SIMPLE OPERATION FOR VARICOCELE. continued to work for long hours as a grocer’s assistant. I BY ARTHUR E. BARKER, F.R.C.S.ENG., watched all these three cases for several months, the last until ASSISTANT PROFESSOR OF CLINICAL SURGERY, AND ASSISTANT SURGEON quite recently, about a year after operation, and now regard AT UNIVERSITY COLLEGE HOSPITAL. all danger of the ligatures coming away as quite over. The latter could be felt under the finger as small knots deep in IN the last three cases of varicocele upon which I have the scrotal tissues, which appeared quite normal. Whether been called to operate, the method adopted has been very they will ever come away remains to be seen, but this is simple, and has been followed by such good results that it immaterial, as far as the patient is concerned, for they give appears worth brief notice. It seems, too, very unlikely to no trouble now. Comparing these operations, as far as they go, with the be followed by any of those ill results and dangers of which older methods, their extreme simplicity is worth noting, as most surgeons have seen something who have practised the well as the small amount of trouble or inconvenience to the his
older
procedures.
I may say that the three
operations
now
patient.
It is also of
some
interest to note
that,
in these
522 three cases at all events, it was possible to manipulate freely with s’lk ligatures, and yet introduce them in a suflicietitly pure state to produce no suppuration of any kind ; and all this with only the simplest precautions as to absolute cleanliness, and without the carbolic spray. There is also a satisfaction in knowing that the veins are thoroughly occluded, and that there is no possibility of the ligatures slipping or being too soon absorbed, as might be the case with catgut. If nothing else, the operation appears an interesting experiment, and worthy of further trial.
Harley-street, W.
CASE OF STRUMOUS ULCERATION OF THE INTESTINES, PRESENTING THE CLINICAL FEATURES OF ACUTE GENERAL BY
TUBERCULOSIS. SAMUEL WEST, M.B., &c.,
SENIOR ASSISTANT PHYSICIAN TO THE CHEST HOSPITAL VICTORIAPARK, ETC.
healthy, except for the presence of a small cyst (a, quarter of an inch in diameter) in the middle of the nuclets. This cyst had a firm Jibrous capsule, with smooth lining, and round it the nerve substance was perfectly healthyso that there was no suflicient explanation in the
presence of the cyst for the sudden occurrence of uncon. sciousness. All the other organs were sound, except the which were in a most extreme condition of intestines, " tubercular" ulceration. In the whole cæcum round the valve, and for the lower six inches of the ileum, the mucous membrane was completely ulcerated away, and at frequent intervals in the small intestines large tubercular ulcers were found, many completely encircling the gut. The last ulcer, and that too of considerable size, was at a distance of only two feet from the duodenum ;the character of the ulceration was typical of the so-called tubercular or strumous ulcers of the intestine, and the glands of the mesentery were also in the condition usual in this affection. The uncertainty of diagnosis between many cases of acute general tuberculosis and typhoid fever is generally recognised, but this case is an instance of an intestinal lesion, not typhoid, which presented the same difficulties. Wimpe le street, W.
DR. STURGES remarks in his article on Acute Tuberculosis in THE LANCET of September 16th, that "tubercular PURULENT DISEASE OF THE EAR; individuals, children at all events, will present the clinical die in the and PRODUCING CEREBRAL ABSCESS, PURULENT MENINGITIS, of tubercular usual meningitis, symptoms AND OBLITERATION OF THE RIGHT LATERAL SINUS, nor neither tubercle but inflammatory post mortem way, WITH STRIKING CHANGES IN THE INTERIOR OF exudation will be discovered." The following case is an THE TEMPORAL BONE.1 illustration of this. BY THOS. BARR, M.D., F.F.P.S. GLAS., On August 17th a child, nine years of age, was brought to the Chest Hospital, Victoria-park, by its mother, who LECTURER ON AURAL SURGERY, ANDERSON’S COLLEGE, AND DISPENSARY SURGEON FOR DISEASES OF THE EAR, WESTERN INFIRMARY, stated that though never strong, the child had been in its GLASGOW. usual health until the last six weeks, when it became weak and languid; that for the last fourteen days it had been W. C-, a boilermaker, aged thirty-seven years, was feverish, and had suffered from pain and sickness chiefly a remarkably strong man, of great muscular development after food, and a little diarrhoea. There was no history of and of medium height, weighing in ordinary health between illness. The child was and thin any previous feverish, looked dull, and had an aspect whien suggested typhoid fourteen and fifteen stones. He suffered from purulent fever. The pulse was rapid, 100-120 ; the temperature disease of the right ear from the age of twelve till his death was high, with marked evening rise, 101.5° to 1025°, the -that is, for twenty-five years. There was almost total morning temperature being nearly normal. The child deafness on the affected side. The disease was supposed to was listless, heavy, and slept much. The condition remained the same for some days. Diarrhoea, spots, and have originated in the blow of a cane received on the right abdominal pain were absent, and the abdomen retracted. side of the head, and inflicted by a schoolmaster by way of At the right apex the percussion was slightly impaired. chastisement. This injury was followed by great pain, The respiratory sounds were increased, especially the exfor several weeks and culminating in the forma, piration sound, which was remarkably long aud harsh, continuing of an abscess which was opened behind the auricle. tion accompanied by occasional fine crepitation. The absence of abdominal symptoms and the presence of pulmonary About the same time a discharge of matter appeared from canal. The purulent discharge from the external signs led to the probable diagnosis of acute general the opening auditory behind the ear continued, with variations in tuberculosis, which was confirmed, it was thought, by the further course of the case. For the apex dulness increased quantity, till six years ago, when the opening closed, leaving behind a cicatrix. The discharge from the canal sligbtly, some general bronchitis set in, and the patient of the ear,depressed which had usually an offensive odour, continued, and lost flesh on the 6th of strength ; rapidly September- with slight intermissions, till the patient’s death. It was i.e., at the end of the fifth week of seveie illness, and nine slighter, however, 6 uring the ninemonths before hisfatalillness. weeks from the commencement of failing health, the child, cold weather to attacksof hoarsenesswith liableduring having for some dayspreviously grown more and more sore-throat. At the age of seventeen he suffered from acute the became suddenly unconscious, eyes remainirig drowsy, attacks in the right ear, when it was supposed wide open, the pupils equally dilated and not responding to inflammatory his life was in danger. He noticed that when the disthat the feet and were There continual slight twitchings of light. for a short time he suffered from severe headhands with irregular movement of the eyeballs; the respira- charge ceased and became ache, very dull and fretful. Indulgence in tion was noisy and harsh ; the urine and fæces were passed alcoholic stimulants produced the same effects, and he was two days the temperature therefore very temperate unconsciously. For the next in their use. In the middle of rose higher than usual, above 103°, the general condition November last there a series of morbid processesbegan 9th the temperature first in the left remainrug the same. On September then in the in the courseof ear, began gradually to fall, the twitching ceased, the pupils three months terminated fatallyright,-which by extension of the purulent were observed to dilate and contract spontaneously, as in process to the interior of the cranium. The many cases of meningitis, and several loose motions were inflammatoy left ear, which previously had been always healthy, and in there the 10th a in bed On was passed unconsciously. which he eujoyed good hearing, became at that time dull slight return of twitching, m the eyelids and arms, the and discharged slightly without any distinct pain. This was respiration became embarrassed, and in the evening the associated at the beginning with sore-throat and hoarsepatient died. The history of the case, the retraction of the abdomen, ness. The dulness and slight discharge in the left ear conthe absence of diarrhoea, the presence of lung symptoms, tinued for two months, at the end of which an acute - and their gradual increase, and, lastly, the occurrence of inflammatory process began in the ear. While at work Monday, Jan. 23rd of this year, and particularly on unconsciousness, with slight convulsions, were all thought on his way home at the end of the day, be experienced to point conclusively to the diagnoses of acute general tubergiddiness, s-o that at times he staggered in walking. culosis. This diagnosis, the post-mortem exami- great On the morning at four o’clock he awoke with not establish. did In no nation organ was there the severe following in the head, with great giddines", and he looked pain of tubercle. The trace of the grey apex right lutig slightest was indurated by some old pigmented nbious ti-sue, but I I am indebted to my friend Dr. McConti))f, the medical attendant there was no recent mischief. The brain was absolutely of this patient, for the ohief facts given in the clinical history,
He was
however,