With regard to emphysema, Bamberger thinks that it is sometimes not the cause, but the result, of the Bright's disease, and arises in consequence of capillary bronchitis secondary to the latter. Sometimes the two affections may be merely collateral, and both dependent on the patient's age. The condition of the heart he considers the best guide to the determination of their causal relationship to each other. "If the emphysema is the primary disease, the right side of the heart is hypertrophied, the left normal. If the left side is also hypertrophied, the emphysema cannot be the primary disease, but either a sequela or a chance com. plication of the nephritis, and the nephritis is probably primary, seeing that secondary Bright's disease very rarely leads to cardiac hypertrophy." The other sections of the table need not detain us; we need only observe that Bright's disease as a sequela of scarlet fever is so sparingly represented in it because at Vienna, as a rule, children under twelve years-who, of course, are its chief victims-enter the St. Anne's Children's Hospital, instead of the General Hospital. Turning now to the common factors which must exist in all the diseases that are found to give rise to Bright's disease, Professor Bamberger points out that they can be arranged in three groups, each of which is based on a distinct pathological element. In the first group, which is also the most important of the three, this element is of a poisonous nature. The kidneys are damaged by some chemical substance which passes through them as the great excretory organs of waste products, and which may either be introduced into the system from without, or be manufactured in the system itself. Of the former class alcohol is the chief representative; other bodies which irritate the kidneys, such as cantharides and squills, are known, but their effects are temporary, and it is uncertain whether their prolonged use in small doses would excite actual nephritis. Bamberger is sceptical as to the toxic action of lead, whereas it is admitted by Weigert in his essay. Would Bamberger deny that there is some causal relationship between lead-poisoning, gout, and granular contracted kidney? The poisons manufactured in the system itself are probably more important factors in the production of chronic Bright's disease than those external to it. They are the products "of selfinfection, caused by the absorption of organic material destroyed by suppuration or gangrene, and of the lowly organised, rapidly proliferating bodies which cling closely to it." In this category we have scrofula, tuberculosis, and phthisis, caries and necrosis of the bones, suppurative inflammation of the joints, skin, and subcutaneous connective tissue, ulcerating cancer, typhoid ulcers of the bowel, etc. "More than a third of all the secondary forms of Bright's disease," says Bamberger, "may probably be referred to it." The element in the second group is venous congestion due to heart or lung disease. It needs no detailed discussion. In the third, and the numerically smallest group, the exciting cause of nephritis is retention of secretion owing to mechanical obstruction, such as urethral stricture, pressure on the ureters, and the like. It is difficult to decide whether the stagnating secretion exerts a chemical as well as a mechanical action on the kidney. Bamberger inclines to the belief that it does both; and he also considers that in some cases of chronic Bright's disease a combination of two, or even of all three of the groups, may have been at work. Thus, in pregnancy, venous stasis and pressure on the ureters may both co-operate, and in puerperal inflammations the toxic element of the first group may be superadded. In another article we shall offer our readers the results of Bamberger's investigation of the primary form of Bright's disease, which are no less instructive than those we have just been discussing. THE WEEK. TOPICS OF THE DAY. It will be remembered that some months since considerable discussion was evoked in medical circles, consequent upon an announcement that the authorities of St. Thomas's Hospital had been considering the advisability of adapting a portion of their new building for the reception of paying patients. At that time the scheme was not regarded with general favour, more especially as the Home Hospitals Association had just been brought to the notice of the public, and it was felt that a large public institution, designed for the accommodation of the sick poor of the metropolis, was thus, as it were, entering into competition with a society which was endeavouring to meet the great want of public infirmaries for the middle classes. It is, therefore, with some feeling of surprise that we notice the report that the authorities of St. Thomas's have submitted to the Charity Commissioners a scheme for filling their vacant wards with paying patients. It is stated that the proposal is to have two different systems. The first is intended for those who are able and willing to pay, for the treatment of whom a separate part of the Hospital shall be set aside; they will have separate medical administration, and a special medical officer to superintend this portion of the establishment, who will be paid out of the funds supplied by the payments of the patients. Every patient admitted to these wards will have the option of engaging the services of his own medical attendant. The other arrangement is for the less wealthy, who are to be scattered promiscuously throughout the general wards of the Hospital, and who will be called upon for a scale of payment only sufficient to defray the cost of their maintenance. We have already given our views) at length on this subject in general, and must wait for fuller information before judging of the new hybrid scheme for filling up with paying patients the wards of this Hospital built for the sick poor. The Board of Health of the Canton of Zurich have just taken an important step with regard to the prevention of infectious diseases. They have issued an order that every case of such disease, however slight, is to be reported direct to them, and for this purpose they have furnished every medical man in the district with books provided with counterfoils. Sanitary commissions, instituted with this object, will be obliged to send instructions to the medical men when the cases are considered serious, and will prescribe the means of disinfection, the isolation of the sick, and other precautionary measures. The results of the information sent by the practitioners will be published every month under the direction of the Board of Health. An attempt is at last to be made to provide the inhabitants of London with a long-talked-of luxury. A private Bill is to be presented to Parliament next session for the purpose of legalising a scheme for supplying the metropolis with seawater. If it be carried through, every householder desirous of availing himself of this aid to health will have nothing to do but to turn on a tap to secure for himself a bath of genuine sea-water delivered straight from the English Channel. According to the views of the projectors this luxury need not be confined to the rich only; they calculate that for a payment of 30s. a year on a £50 rental a constant-not an intermittent-supply can be placed at the disposal of as many householders as may choose to subscribe to the undertaking. The Bill ought to have few, if any, opponents, and its passing will be a great sanitary triumph for those innumerable hardworking persons who have neither time nor money to avail themselves of even the nearest and cheapest health-resorts on our coasts. A singular case of accidental death formed the subject of an inquiry held last week by Dr. Hardwicke in Marylebone parish. The deceased, a carman, was driving his van through Maddox-street, Regent-street, when the horse, through the slippery state of the roadway, stumbled, and deceased was thrown with some violence to the ground. He was picked up and placed in the van, but as he was only partially sensible he was taken to the Middlesex Hospital, where he was seen by one of the resident medical officers. After a time the man recovered his senses, and expressed a wish to go home. He did so, and the same afternoon he became insensible, death supervening in a few hours. Upon a post-mortem examination being made, it was found that two of the bones of the skull had separated at the sutures, from the violence of the fall. The medical evidence proved that the injury was of a very exceptional character, only two other cases being on record of the bones of the head separating at the sutures without any injury to the bones themselves being apparent. The jury returned a verdict of accidental death. A Committee representing the Cardiff Corporation has recently effected the purchase of the Cardiff Waterworks for £300,000. This amount is to be raised in sums of not less than £500 at 4 per cent., and repayable in five, seven, ten years, and upwards. The shareholders received from their directors £200 per cent. on their shares, and the directors are going to Parliament to ascertain what is to be done with the large surplus, there being a dispute among the shareholders as to how it should be apportioned. Of the shareholders' capital £100,000 remains on mortgage. If the profits of the Cardiff Waterworks Company are not exceptional—and we have no reason to suppose they are,— the luckless ratepayers all over the kingdom may well look forward with impatience to the day when the sale of water shall no longer be a monopoly, and this primė necessity of life may be procured at a reasonable price. Another large and seasonable distribution of funds to medical charities in this country has recently been announced by the executors of the late Miss Harriet Hurst. This lady died a few months ago, leaving a sum of nearly £70,000 to be divided at the discretion of her representatives, and amongst the institutions benefited we may mention the London Hospital, which has been awarded £5000; Middlesex Hospital, £3500; St. George's Hospital, £3000; University College Hospital, £3000; the Stamford and Rutland Hospital, £3000; the Westminster Hospital, £2000; the Cancer Hospital, Brompton, £1000; the Charing-cross Hospital, £1000; St. Mary's Hospital, Paddington, £1000; the Hertford General Infirmary, £1000; the National Hospital for the Paralysed and Epileptic, £1000; the Hospital for Sick Children, Great Ormond-street, £1000; the Brompton Hospital for Consumption and Diseases of the Chest, £1000; the City of London Truss Society, £1000. Amongst a large number of charities to which the sum of £500 has been allotted we find the names of the Huntingdon County Hospital, the St. Peter's Hospital for Stone, the Royal Medical Benevolent College, the Royal Free Hospital (Gray'sinn-road), the London Lock Hospital, the Lincoln Hospital, the Kent and Canterbury Hospital, the Royal London Ophthalmic Hospital, the Hospital for Women (Soho-square), the Evelina Hospital for Sick Children (Southwark-bridgeroad), the Hitchin Infirmary, and the Metropolitan Convalescent Institution at Walton-on-Thames. The Samaritan Free Hospital for Women and Children, the National Ophthalmic Hospital, and the Charity Organisation Society receive £300 each. A very sad tale of the death of a medical officer in India has reached us, but the particulars, as described, have not yet been officially confirmed. The gentleman in question, Dr. Dumbleton, formerly a student of St. Bartholomew's Hospital, who had only joined the Indian Medical Service in March last, was recently ordered to proceed to Peshawur, and from there proceeded in medical charge of a draft en route to join the Kurram Valley force. Being but an indifferent horseman, he was much galled by the long ride, and in addition he suffered from a severe attack of fever-so much so that on the detachment meeting the 13th Bengal Lancers, their medical officer assured Dr. Dumbleton of his utter unfitness to proceed. Dr. Dumbleton managed to reach Ali Kheyl, where his appearance was so distressing that the staff officer consented to make arrangements for some other surgeon to go on with the detachment. Dr. Dumbleton accordingly went off to his tent, threw himself down in his clothes, and fell asleep. Early next morning the officer in command of the detachment woke him up and informed him that no other medical officer had been appointed, that the troops could not march without a surgeon, and consequently that he must make an effort to proceed. Dr. Dumbleton explained his unfitness, and the officer left his tent, but he had only proceeded a few yards when the report of a pistol made him hurry back, to find the doctor dead with his revolver beside him a too sensitive nature had given way under an accumulation of illness and worry. : There can be but one opinion as to the treatment to which Dr. Farr has been subjected, and we think that his dignified and temperate letter to Major Graham, the retiring RegistrarGeneral, deserves to be known by all: "December 23.Sir,-Having now heard from you that Sir Brydges Henniker is to be the new Registrar-General, and thus having lost all chance of being your successor, I shall be glad if the Lords of her Majesty's Treasury will allow me to resign my appointment, and will grant me superannuation allowance to the extent of my full pay. I have served under you nearly forty years, I have taken with you three censuses, and I feel confident that I can leave my case in your hands. -(Signed) William Farr." The Government doubtless has its reasons for passing over Dr. Farr cut and dry, but by ordinary people no valid reason can be found for passing over the claims of one who has earned a world-wide reputation in the discharge of his duties, in favour of a mere political partisan, possessing, so far as is known, not a single qualification fitting him for the important post of RegistrarGeneral. THE "GUY'S HOSPITAL GAZETTE." OUR Contemporary, the Guy's Hospital Gazette, ventured in October last to admit some unfavourable comments upon the changes in the nursing system of the Hospital. Whereupon the Treasurer intimated to the Editors that no such comments or complaints could be permitted to appear in the journal in the future, and that articles must be submitted for his approval before publication. The Editors have very rightly decided that under these circumstances they will be unable any longer to continue the publication of the Gazette · "in a way that would do justice to the subscribers and to themselves." The only remark we will make upon this despotic act of the Treasurer is, that it is a most telling reflection upon his own conduct, and a fatal confession of weakness. The Treasurer is evidently afraid of discussion or comment. ANOTHER BREAK-UP OF A COMBINATION OF SANITARY AUTHORITIES. WE regret to have to record another example of what we must consider a shortsighted and retrograde policy in reference to the sanitary progress of the country. As our readers are aware, many; local sanitary authorities having adjoining areas of jurisdiction are enabled, by forming voluntary combinations, to secure as medical officer of health for each combined area an able and technically trained expert, when they could not, separately, be served by officers so well equipped for the prosecution of sanitary work. But we have recently observed with regret that paltry local jealousies or trifling money questions have been allowed to disturb these very useful and sensible combinations. The consequent secession of one or more of the combined bodies has had the disastrous result of compelling those specially trained experts to resign their appointments, and of leaving the sanitary work of these local areas, with its pittance of pay, to local general practitioners-in many cases already overburdened with other work, in most cases deficient in the aptitude and special acquirements necessary for sanitary investigation, and in every case hampered and impeded in that work by the mere fact that they must at the same time devote most of their energies to what may be their conflicting interests as local general practitioners. We are not aware what may have been the exact cause or causes that led to the breaking-up of the North Devon Combination of Sanitary Authorities; but the melancholy fact is that, on account of the secession of the Okehampton and the Torrington Authorities, Mr. Wynter Blyth has been obliged to tender his resignation as Medical Officer of Health to what remained of the Combination. It is satisfactory to learn that at the last meeting of the South Molton Authority the resignation of Mr. Blyth was the subject of regret, and a resolution was unanimously carried "to thank him heartily for his valuable services, rendered all the more efficient as well as acceptable from the pains he has always taken to explain to those who were to be affected by them the reasons for his recommendations." SOCIETY OF MEDICAL OFFICERS OF HEALTH: ANNUAL REPORT. THE annual report of the Society of Medical Officers of Health for the year 1878-79 records the number of meetings held during that period. Many changes are noted as having taken place in the list of members of the Society during the past year : the Society is stated to consist of 166 members, including 37 metropolitan and 66 extra-metropolitan members, 23 retired medical officers of health, 22 associate and 18 honorary members. Mr. Liddle expressed his wish to retire from the office of treasurer, the duties of which he had performed to the advantage of the Society for a period of six years. A cordial vote of thanks was passed to him for his valuable services, and Dr. J. W. Tripe having consented to undertake the duties of the office, he was unanimously elected Mr. Liddle's successor. Dr. Thomas Stevenson, who has so efficiently presided over the Society during the last two years, intimated his desire not to be again nominated to that position, and has been ably succeeded by Dr. Bristowe. Dr. Corfield also expressed a wish to be relieved of the duties of joint secretary of the Society, which he had performed for the past five years. The report contains copies of the addresses delivered and papers read during the session, but as notices of several of these have from time to time appeared in these columns, it will not be necessary to do more here than mention the fact. ERNEST CARR JACKSON, M.R.C.S. ENG. WE very much regret having to record the early death of Ernest Carr Jackson, the eldest son of the late well-remembered Thomas Carr Jackson. Ernest Jackson received his professional education (as his father had received his) at St. Thomas's Hospital; and visited the medical schools of Paris. In 1875 he became a Member of the Royal College of Surgeons, England, and a Licentiate of the London Royal College of Physicians, and afterwards was for some time Resident Surgeon to St. Mark's Hospital, London. His father's death, at the age of fifty-three, forced young Jackson at once into practice, and he obtained the appointments of Surgeon to the National Orthopedic Hospital, and of Medical Officer to the British Equitable Assurance Society; and soon showed himself to be a good and able surgeon. He was fond of his profession, possessed good abilities, was well educated and a hard worker; and his bright, cheerful, frank temperament won him friends everywhere, so that a happy and prosperous career seemed assuredly before him. But he was ambitious of gaining the highest surgical qualification, and therefore, though not strong, struggled to combine hard study with the daily demands of practice. It was not long before the effects of the strain on his powers became apparent, in lowered health, restlessness, and sleeplessness; and then, like so many others, in order to obtain sleep he took to that most pernicious drug, chloral. This helped to weaken him still more by degrading nutrition, and he became highly anæmic; but he still fought on, till at last, on December 26, at the residence of his father-in-law, Dr. Barnes, he sank and died. at the early age of twenty-six. THE ST. ANDREWS HOSPITAL FOR MENTAL DISEASES, IN publishing the annual report of the St. Andrews Hospital PATHOLOGICAL SOCIETY OF DUBLIN. Ar the recent meetings of this Society the following morbid specimens were shown:-On December 13, Dr. J. K. Barton presented a specimen of extensive disease of the right knee-. joint in a girl aged fourteen. The cartilages were eroded, and there was remarkable caries of the head of the tibia. Hæmorrhage occurred from arteries of a small calibre after amputation, and the patient sank. The mitral valve was puckered, and the right side of the heart was filled with pale blood-clot. Mr. Stokes exhibited a tumour which he Me lical Times and Gazette. had removed from the lower jaw of a woman aged fiftyseven. It was of thirty-four years' growth, but within the Zast six months had grown quickly. The tumour was referred to the Committee of Reference for a report on its nature. The President (Dr. E. H. Bennett) submitted the trachea and lungs of a child aged two years, on whom tracheotomy for croup had been performed. Rapidly extending pneumonia of the left side had commenced before operation, and speedily proved fatal. The operation was laryngo-tracheotomy, as proposed by Boyer. The advantages of it are that no damage is done to the larynx, and the voice is not imperilled. Dr. Ball presented an immense tumour which engaged the left side of the face of a man aged thirtyseven. The growth apparently originated in the lower jaw, and was in part a round-celled sarcoma with cells of very small size, in part a spindle-celled sarcoma. There was no glandular enlargement. Dr. Finny showed the viscera of a married woman, aged thirty-seven, who suffered from diabetes mellitus, attributed to mental anxiety. Eight to twelve pints of urine were passed daily, and on one occasion ten ounces and three quarters of sugar were excreted in twenty-four hours. The middle lobe of the right lung was indurated, and there were cavities along the anterior edge of the same lung. Rapid catarrhal pneumonia ending in caseation and ulcerative destructive disease had occurred. There was simple fatty degeneration of the kidneys. The liver was congested, but of normal size. The pancreas was not examined. There was nothing abnormal in the condition of the brain, nor was there any macroscopic change in its fourth ventricle. On December 20, Mr. Stokes showed an example of a dentigerous cystic tumour or membranous cystic growth from the inferior maxilla of a lad aged fifteen. The growth probably owed its origin to the irritation of a carious tooth. The tumour was lined internally by a thick leathery membrane, from which a honey-like fluid was secreted. Excision was performed, and the patient recovered without any deformity. Dr. W. G. Smith exhibited a specimen of intussusception of the ileum into the colon in a man aged thirty-three. An obscurely cylindrical swelling was found in the left iliac fossa. Nearly four months elapsed between the first appearance of symptoms and the patient's death. The intussusception could not be disentangled after death. The diagnosis was based on the history of the case, the tumour in the left iliac fossa, the results of a rectal examination, and the character of the motions, which consisted of mucus and blood. THE HEALTH OF THE WANDSWORTH DISTRICT. THE annual report for the year 1878 on the sanitary condition of the Wandsworth District, which comprises the parishes of East and West Battersea, Clapham, Wandsworth, Putney, and Streatham, shows that the death-rate for the year was considerably in excess of that for 1877. This is, however, accounted for by the fact that the mortality in the district during 1877 was exceptionally low, while the increase is entirely due to the greater fatality from measles, whooping-cough, diarrhoea, and lung diseases, and was confined wholly to the extremes of life, especially the period of infancy. The report again refers, as in some former years, to the fallacy of calculating the increase of population, between the times of taking the census, on the plan employed by the Registrar-General, and it submits that a method of calculating the population by the number of births occurring in a district during the year would give a more reliable result. Thus, the population of the Wandsworth district, gauged by the latter method, would be nearly 190,000, while, according to the Registrar-General's mode of estimating it, it is 164,812. The importance of this discrepancy is shown by the fact that officially the death-rate for the district has to be returned as 19.8 per 1000, whilst, according to the estimate of the medical officers of health, it was only 17·2 per 1000. The report shows that the number of uncertified deaths continues to rise in all fifty persons died and were buried in this district during the year 1878, and nobody was able to say with certainty what they died of; no medical man was in attendance, and the coroner thought it unnecessary to hold an inquiry over any one of them. This is not satisfactory, and should certainly be looked to. The medical officers, whose names are appended to the report, are Messrs. W. H. Kempter and Joseph Oakman, East and West Battersea; Mr. J. MacDonogh, Clapham; Dr. G. Nicholas, Wandsworth; Dr. Sutton, Streatham; and Dr. Walker, Putney. ASSOCIATION OF SURGEONS PRACTISING DENTAL SURGERY. THE annual general meeting of this Association for the election of the officers and Council for the ensuing year, and for transacting the usual business, will be held on Wednesday, January 28, at 4.30 p.m. The following is a list of the names of Fellows recommended by the Council to be appointed to the offices named below:-President: *W. A. N. Cattlin, Esq. Vice-Presidents: J. A. Baker, Esq., Samuel Cartwright, Esq., Alfred Coleman, Esq., John Smith, M.D., F.R.S., *S. J. A. Salter, M.B., F.R.S. Treasurer: T. Edgelow, Esq. Hon. Secretary: J. Hamilton Craigie, Esq. Council: *Edward Bartlett, Esq., S. Hamilton Cartwright, Esq., J. Fairbank, Esq., Francis Fox, Esq., W. Donald Napier, Esq., George Parkinson, Esq., W. G. Ranger, Esq., *Augustus Winterbottom, Esq. (An asterisk is prefixed to the names of those not holding the same office the preceding year.) The Fellows of the Society and their friends will dine together in the evening, at seven o'clock, at the Langham Hotel, under the presidency of Samuel Cartwright, Esq. DUBLIN SANITARY ASSOCIATION. THE annual general meeting of this voluntary Association took place on Wednesday, December 17, in the Leinster Hall, Molesworth-street, Dublin. Mr. Jonathan Pim, the President, took the chair. From the report, which was read by Dr. J. W. Moore, acting Honorary Secretary, it appeared that the Association now numbers 258 members, being a decrease of six as compared with the previous year. The income for the eighteen months ending November 30, 1879, amounts to £250 10s. 9d.; the expenditure has been £242 6s.; leaving a balance to the credit of the Association of £8 4s. 9d. The report then dealt with the various topics of interest presented during the past eighteen months in the working of the Association, especially with the recent Royal Sanitary Commission, which the Association was mainly instrumental in obtaining at the hands of the Government. The Executive Committee has suffered serious losses through the resignation of three most valued members-Dr. Grimshaw, on his appointment as Registrar-General for Ireland; SurgeonGeneral Crawford, on leaving Dublin for India; and Mr. R. O'B. Furlong, barrister-at-law, on being appointed Secretary to the Royal Sanitary Commission. The adoption of the report was moved by Dr. Head, President of the College of Physicians, seconded by Mr. Frederic W. Pim. The election of officers for the ensuing year was moved by Mr. Maurice Brooks, M.P., seconded by Mr. William Findlater. Other resolutions were supported by Mr. Chas. H. Meldon, M.P., Dr. James Little, Mr. George R. Rice, barrister-at-law, Dr. J. W. Moore, and Mr. La Touche. THE INFLUENCE of DIFFERENT POSITIONS OF THE BODY ON ITS TEMPERATURE. THIS subject has been lately studied by Dr. Sassezky (Petersburger Med. Woch., No. 20, 1879). His method of experimenting consisted in placing the patient on his back, first with the arms folded on the trunk, and then with the same extended, the temperature being simultaneously measured in the ear, mouth, axilla, rectum, fists, and between the first and second toes. The pulse and respirations were noted at the same time. In other experiments the legs were raised instead of the arms, the patient lying on his back as before. The general conclusion arrived at was that elevation of the extremities, and especially of the legs, raises the temperature of the whole body, except that of the part elevated, some fraction of a degree, or even one or more degrees, centigrade. The effect is much more marked in sick people than in the healthy. The pulse and respirations are accelerated in both by raising the limbs. The greatest rise of temperature is observed in the axilla and rectum. The effect of posture is most decidedly seen in typhoid patients, especially where the fever has been severe and the nutrition of the heart is much impaired. Patients with true heart disease come next; then those with phthisis. The explanation of these facts seems a simple one. The flow of warm blood to the elevated limb is diminished, and that to the other parts of the body increased; and the weaker the condition of the heart, the more decided do the differences of temperature between the two regions become. THE subject of a clinical lecture delivered by Prof. Wood at the Philadelphia University Hospital (Philadelphia Medica Times, November 3) was an intemperate tailor, seventy-four years of age, who, ten or twelve years since, underwent amputation at about four inches below the knee on account of a senile gangrene of the left foot. A good stump resulted, which has never been painful or tender; and his general health has always been good. About five or six years after the amputation he felt movements in the stump, and some months later they commenced in the left arm. At the present time the stump is flexed at right angles to the thigh, and a clonic spasm of the flexors occurs a little oftener than one hundred times in a minute, drawing the end of the stump towards the thigh over an arc of from two to four inches. Rarely there is a spasm of the extensors, bringing the leg beyond the right angle, but never straight. There is no tenderness whatever over the stump nor along the popliteal or sciatic nerves. Occasionally there are choreic spasms of the glutei and other muscles moving the thigh. In the forearm the movements occur from eighty to ninety times in a minute. Much of the time the flexors of the fingers are especially affected, while at other times the adductors and the abductors jerk the hand to and fro. The muscles of the upper arm are every now and then affected, throwing the hand violently about, these movements at times being rapidly repeated. The muscles of the shoulder are rarely affected, as are sometimes the lateral muscles of the trunk. Occasionally, also, the muscles of the left side of the face suffer from decided clonic spasms, while at other times there are only some tremulous movements of the upper lip and the angle of the mouth, which is slightly drawn upwards, as though from habitual spasm. There are very slight choreic twitchings of the muscles of the neck. The right side of the body is entirely free from abnormal movements. The man sleeps with his arm elevated and placed under his head, evidently for the purpose of holding his arm; and when it is held when awake all movements cease in it, those of the stump becoming worse. When the stump is restrained it remains quiet and the movements of the arm become worse; and when both are held the movements of the muscles of the thigh become very strong. The faradaic current of considerable intensity, applied over motor points of the thigh and popliteal nerve, fails to develope any tenderness or to exert any influence upon the spasm. During sleep the arm is often quiet, even when not restrained; but the stump is always twitching, although the movements are very slight during sound sleep. It is evident that this man is suffering from one of the forms of what is called chorea of the stump. This, judging from the scantiness of the literature of the subject, must be a very rare affection, although painful or neuralgic stumps are but too common. In some cases the parts of limbs left after amputation are affected by peculiar local painful spasms of one or more muscles, and not unfrequently these cramp-like contractions co-exist with neuralgia of the stump. In the majority, if not all, of such cases the difficulty is a local disease of the nerve-fibres, and often there are distinct bulbous neuromatous enlargements at the ends of the several nerves. Very generally, under these circumstances, distinct tenderness exists in the end of the stump, and often it can be traced along the course of the nerves. The bond of common etiology and pathology between such cases and a painless chorea does not seem a very close one; and the complete absence of pain in this man's case widely separates him "from the patient in whose life-chart every north-east storm is marked by a day of intense suffering." Although it would not seem that any conclusion as to the nature of the lesion in this case can be drawn from our knowledge of neuralgic stumps, yet it is of importance to determine whether such lesion be peripheric or centric. It may be that there is a peripheral lesion which acts as a permanent irritation, and maintains such a permanent influence on the nerve-centres as continually to provoke discharges of motor nervous energy. That such an explanation is possible is seen in cicatricial epilepsy. "I have seen a bodily state, in which six to twenty convulsions occurred daily, removed almost at once by the cutting out of a seemingly unimportant and certainly insensitive cicatrix." But we may also inquire whether an amputation may in any way cause centric nervous disease. Vulpian and Dickinson proved, some years since, that after amputation a creeping structural change occurs in the nerve, which at last reaches and travels along the spinal cord. This has been confirmed by Hayem and others. The lesion is on the side of the injury, and consists in lessening of the grey matter of the anterior horn with atrophy of the multipolar cells, and changes in the white matter resembling those of chronic myelitis. But in this case a centric spinal lesion would not be sufficient to account for the symptoms. The whole motor apparatus of one side of the body is involved, and the lesion would have to extend into the medulla. Further clinical and experimental evidence seems to prove that choreic movements are never spinal. Then, again, there is no heightening of the reflex activity, the movements being distinctly not reflex-handling, tapping, tickling, the galvanic current, all forms of peripheral irritation, failing to magnify them. Any centric lesion causing the movements must be cerebral, and without doubt in the cortical substance. I believe, up to the present time no one has traced structural nervechanges, following amputation, beyond the cord into the brain. It would seem to me certain that in ordinary cases the nervous lesions do not go above the spinal cord. This does not prove that the lesions never ascend higher. The present is an extraordinary case. Two or three days ago a gentleman died, whom some years since I saw suffering from indubitable locomotor ataxy. A year or two later, symptoms of chronic cortical cerebritis, such as is seen in general paralysis of the insane, came on, and progressed to death. This is not the first case of the kind reported, and I believe that the microscope will show an ascending of chronic inflammation from the cord to the cerebral cortex. Again, Charcot and his pupils have abundantly proven that lesions of the cortex travel downwards. Whilst, therefore, we have no proof that the atrophic changes of the spinal cord following amputation ever reach the cortex cerebri, it is not at all unlikely that they sometimes do so. When we come to set one thing against another, we can only conclude that there is at present no proof, or disproof either, of the peripheric or centric origin of the choreic movements; either theory is commensurate with the now known facts. Dr. Weir Mitchell inclines to the peripheric theory, because the fits sometimes occur too soon after amputation.' It is not certain that he clearly distinguishes between painless and painful cases, and he says he never saw a case arise very soon after amputation. I can find no case like the present reported in which the pain was developed under several months. In this man five years were required. How fast a lesion under exceptional circumstances might travel, we do not know." |