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with the wound. The lung having been separated,there remains a large extrapleural cavity whichmust be filled. This he does with adipose tissue,fresh or preserved, Beck’s bismuth paste, or

bismuth paraffin. The foreign substance mustbe maintained in place, which is a difficulty.Complete suturing of either the fibrous or musculartissue, or between the intercostal muscles and

periosteum, or autoplasty is performed. Thedetachment of the lung from the ribs permits ofobliteration of a septic pulmonary cavity by facili-tating retraction of the lung towards the hilus, andthe retraction is rendered permanent by the filling.In a case seen four months after operation the fatused was found to have retained its vitality. The

operation was first performed in March, 1912, andsubsequently 15 times. In one case it was bilateralfor disease progressing on both sides. On the right450 c.c. of adipose tissue, which had been kept fivedays on ice, was grafted into the pleuro-parietalspace; on the left bismuth paraffin in about thesame quantity was introduced. The symptoms wereameliorated and the cough disappeared. Of theother 14 patients, secondary suppuration occurredin four and the graft was eliminated in the abscess.In the remaining ten decided benefit was shown bylowered temperature and diminished expectoration(in one case complete suppression). But as all thecases date from only a few months the value of themethod still remains to be decided. Recently Jessenhas reported six cases of pneumolysis with resultsgenerally satisfactory.2 M. Tuffier thinks that thismethod should be adopted early in the disease, justas in a tuberculous joint the surgeon does not waituntil suppuration occurs and sinuses form.

MYASTHENIA GRAVIS WITH PSYCHIC SYMPTOMS.

THE pathogeny of this strange, but by no meansvery rare, disease is still rather obscure. There is,however, little doubt that the glands of internalsecretion cannot escape some responsibility. Theweakness of the muscles is not dependent solelyupon the pathological " lymphorrhages," smallcollections of small lymphocytes which are dis-tributed in an irregular manner amongst themuscular fibres; the condition is not altogether ona par with the muscular dystrophies. The evidencethat the secretory glands are concerned is suggestedby several facts. In a very considerable number of

myasthenia cases there is enlargement of the

thyroid gland; the thymus is often larger thannormal; in some cases of Basedow’s disease the

myasthenic muscle reaction is obtained. There isin both myasthenia gravis and Basedow’s diseasean increase of oxygen metabolism and nitrogenoutput. Finally, the extraordinary exacerbationsin myasthenia, shown by the way in which thesepatients may on occasion completely recover, mayfluctuate in the intensity of their symptoms, andmay be subject to both a chronic and, in someinstances, very acute onset of the condition, suggesta close clinical analogy with the similar vagariesseen in Graves’s disease. Simple muscular changecannot explain all these variations, for the

dystrophies are characterised by their peculiarlyinsidious onset and their progressive and chronicclinical course. They are associated, too, with nomental disturbance. There has lately beendescribed a case of myasthenia gravis in whichthe patient had occasional lapses of consciousness, 1

2 Münchener Medizinische Wochenschrift, July 22nd, 1913, p. 1591.

and in the proceedings of the Societe de Neurologiede Paris (Dec. 4th, 1913) MM. Souques andMignot record a case of somewhat similarcharacter. The patient was a man aged 35.He was well in every way till four yearsago. Then he noted feebleness of the legs, andlater this weakness extended to the arms, trunk,and neck. Such an onset is not unusual. Thereoccurred, however, when in this state a violentparalytic crisis. It involved, not only the abovemuscle groups, but also the face and the eyes,which showed ptosis and diplopia. Mastication andswallowing became almost impossible. Speechbecame diflicult. In this paralytic state the patientremained for three and half months; then slowrecovery ensued, and a year later he was able toleave the hospital. He then had no signs of

paralysis. For three months he remained well.and even did some work. But again many signs ofweakness gradually returned. Since then for thelast year he has remained in an enfeebled state,showing varying degrees of improvement and

retrogression. During this time he had two crises.It was in these that he showed mental symptoms.There was marked diminution of the power of

memory; his intellect was dimmed; volition im-

paired. There was also impairment of the sensesof taste and smell. The case is instructive in

showing the range of variation in intensity of thedisease; it shows also that the central nervous

system may participate in the response to whateveris the responsible cause of the condition. Adrenal

gland was given in this case, but without noticeablebenefit.

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ATROPHY OF THE MUSCLES OF THE HANDFROM COMPRESSION NEURITIS.

IN the Review of Nezcrology and Psychiatry for, April Dr. J. Ramsay Hunt, of Columbia University,,

New York, contributes another paper on an interest-ing subject to which he had previously directedattention. Atrophic paralysis of the small musclesof the hand is a very common neurological symptom.It may occur in spinal cord diseases, such as pro-gressive muscular atrophy, syringomyelia, andlocal lesions in the lower cervical and upper dorsalregions. It may follow involvement of the anteriorspinal roots, as in hypertrophic cervical pachy-meningitis, and it is often seen in lesions of or

after injuries to the brachial plexus or to the ulnarand median nerves. The association of the muscularatrophy with sensory changes, when the latteroccur, usually aids in the determination of the topo-graphical localisation of the lesion. Dr. RamsayHunt draws particular attention, however, to a

type of wasting of the small muscles of the handin which sensory changes are not found, so

that it presents a certain resemblance to an earlymyopathy or myelopathy. It is due, nevertheless,essentially to a peripheral lesion of purely motorbranches of the median and ulnar nerves, and maybe divided into a thenar and a biypothenar variety.In the first of these, compression of the thenarbranch of the median as it passes behind theanterior annular ligament of the wrist results ina secondary atrophy of the abductor pollicis,opponens pollicis, and outer head of the flexorbrevis pollicis. Sensibility in the distribution ofthe median nerve is normal, while fibrillation isabsent. A reaction of degeneration in the affectedmuscles is obtained. It is this strict limitation ofthe atrophy which suggests a local lesion, and it isnot likely to be confused with any other condition,