agraphia, in not being able to write to dictation, and some paragraphia. He apparently knows the article and its use, but cannot name it, though he can write the name; partial word-deafness. There is absence of mind-deafness. In concluding the analysis, this case should come, to the best of my judgment, under division 4. (Butler's Diagnostics of Internal Medicine, p. 255.) Conduction aphasia. "If the patient uses the wrong words or talks jargon (paraphasia), and makes similar mistakes in writing, but can speak voluntarily, understand spoken words, read, and write, it is indicative of an interruption of the association tracts between the various centers, and the lesion is ordinarily in the island of Reil or the convolutions about the fissure of Sylvius." It generally coexists with auditory or visual aphasia. In this series of cases it is notable that the subjects were all men, and that the left brain only was affected.

[August 1, 1902, I am informed that this patient has had several severe epileptic convulsions since his attack, and is now making no progress toward recovery.]

The diseases suggested by the latest authorities are hemorrhage, thrombosis, embolism, abscess, tumor, gumma, or a depressed fracture of the skull.

In the cases above, all these causes may be excluded, except hemorrhage, or, perhaps in the fifth case, embolism. It is hard to conceive of a hemorrhage which would practically disappear in two days. As the arm, leg and speech focal centers lie near together, it is natural and usual for all to be affected by the same cause. If that cause is hemorrhage, what is the condition of the left cerebral vessels, which renders them more vulnerable than those of the right brain? Or was it merely a coincidence, and may the next six cases be all left-sided without aphasia?

DISCUSSION

Dr E. G. Carpenter, Columbus: Inasmuch as the writer of the paper spoke of the strangeness of these cases all being right-sided paralysis, I would just like to mention the fact that this is accounted for from an anatomic standpoint, that

the left common carotid artery arises from the aortic arch directly at its highest point, so that the caliber of the vessel is a direct continuation of the arch of the aorta, while on the right side the right common carotid artery is not a direct continuation of the arch of the aorta, but a branch of the innominate which arises from the arch of the aorta at a right angle with it, so that it is much easier for vegetative growths from the valves of the heart, or infection of bacilli, or any foreign substance to pass directly from the heart through the left common carotid into the left internal carotid and into the brain, that is the left side of the brain, and produce a cerebral hemorrhage, etc., while it is more difficult for foreign bodies to pass through the innominate, etc., to the right side of the brain, on account of the mechanic obstruction.

Dr Charles J. Aldrich, Cleveland: I feel very grateful to the essayist for this analysis of cases which he has presented to the Society. There is one point, however, to which I wish to call attention, and that is, we may occasionally have left hemiplegia and aphasia in people who are supposed to be right-handed. While they are extremely rare, yet it is a point to bear in mind, that a man can be born practically ambidextrous and by imitation alone pass as a dexter, although his speech center is on the dextral side.

The last case reported by the essayist, and the one which was so completely discussed from the standpoint of aphasia calls to my mind a traumatic case of aphasia which I had the pleasure of seeing with Dr G. W. Crile. The man received a bullet-wound which penetrated the left side of the skull just anterior and superior to the aural grove. He immediately developed a pure type of concept aphasia, a complete loss of power to recall nouns, common and proper. Immediately after his injury he was able to talk intelligently with everybody, and when brought into the hospital, in answer to the questions as to who shot him, he would answer, "Why Mr ah Mr ah--, oh I can't tell his name!" He could not by any kind of effort recall the name, although his assailant was a near and lifelong friend. He told all about his accident, could use verbs, adjectives and all the parts of speech except nouns, but when it came to speaking names he was completely at sea. I would hold up a pencil, . and he said, "Why, that is a-is a—a cannon." He could not tell the name of his mother. The diagnosis was that the ball was lying in the cortex of the middle of the third

temporal convolution impinging upon the concept or naming center. Upon trephining the bullet was found imbedded in the cortex of the middle of the third temporal convolution and removed. He made a complete recovery. I had the pleasure of examining him after he had left the hospital and he could tell the names of everything just as well as ever.

CHAPTER VIII-RHINOLOGY

Acute Suppurative Ethmoiditis

By JOHN A. THOMPSON, M. D., Cincinnati

As research and clinical observation increase our knowledge of pathology, regions of the body previously ignored gain new interest and importance to the student and practician of medicine. More exact observation and analysis of cases enable us to trace one group of symptoms to many causes, and later, to distinguish the underlying cause in any case. A few years ago appendicitis, salpingitis, suppuration of the gall-bladder, perforating ulcers of the stomach and intestines, and tubercular peritonitis were all grouped under one title in our medical text-books and called "idiopathic peritonitis." More exact knowledge of intraabdominal conditions makes it doubtful if there is such a disease as idiopathic peritonitis. What was formerly believed to be a distinct disease is now known to be a symptom, secondary to various primary morbid processes.

A similar change in our views is evident in regard to the causation of intracranial inflammations. We are coming to regard them as secondary infections. Physicians are trained exclusively to deductive reasoning. If this were not so, when it was proven that meningitis and brain abscess were often secondary to suppuration in the mastoid antrum the induction would have been drawn that similar brain lesions might come from suppurations in the accessory sinuses of the nose. Instead of this justifiable process of reasoning, we have waited for postmortem observations, and in the ordinary postmortem examination no attention is paid to the accessory sinuses. From these considerations we understand why cavities, whose inflammations are frequent and severe and some

times attended by fatal results, are usually ignored in the diagnosis of disease. Perhaps the workers in the special field of rhinology are to blame for this oversight in not publishing their observations in a manner to appeal to the profession generally. Most of the papers relating to the accessory sinuses of the nose are technical and of interest only to the specialist. The present paper is an attempt to present the subject of the acute suppurations in the ethmoid in a manner that will interest and profit all practicians of medicine. It will not be technical, but largely a report of typical cases.

The predisposing cause of acute suppuration in the ethmoid cells is usually a slight chronic rhinitis extending to the lining mucosa of the cells. An attack of acute rhinitis or of influenza is the exciting cause. Numerous pyogenic bacteria grow in the secreted fluids and in the superficial layers of the inflamed membrane, adding greatly by their presence to the intensity of the process. The swelling of the membrane at the cell openings blocks them so the mucopus cannot escape into the nose. The retention of the secretion in a most sensitive region causes the intense pain which is the most characteristic symptom of the disease. The pain is deep-seated, throbbing, felt most acutely at the root of the nose but extends to the orbit and at times to all the affected side of the head. It persists for several days, if not relieved by treatment, before there is a spontaneous discharge of the retained secretions through the nose. Coincident with the pain is fever often reaching 103° F. The fever, like the pain, is lessened with the evacuation of the ethmoid cells unless general sepsis has occurred, when it will persist for days after the local condition has improved. Profuse sweats and occasionally severe diarrheas are symptomatic of the general septicemia. Respiration through the nostrils is impeded; the sense of smell is lost; the patient is dull and stupid and it requires great effort for him to think clearly. Acuteness of vision is lessened, particularly on the affected side. Occasionally the orbital tissues are inflamed, the conjunctiva reddened and the eye sensitive to light.