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middle line, and by puffiness of the face fmd neck, andenlargement of the lymphatic glands of both sides of theneck. On the same day that the membrane on the tonsilswas first detected, there was a trace of albumen in the urine.A week later the membrane on the tonsils and the puffinessof the face had disappeared, but the albumen in the urinehad greatly increased, so that it amounted to as much astwo-thirds. The child was never very prostrate, and aftera week’s illness he began to convalesce.

Sixteen days after the onset of the illness all signs of thediphtheria had apparently disappeared, except that therestill remained a trace of albumen in the urine (this con-tinued for six weeks longer); but on this day it was noticedthat there was some difficulty in reading small print, theletters becoming confused. No other evidence of post-diphtheritic palsy, however, was then manifested. The nextsymptom was the loss of knee-jerk on the twenty-fourthday after the onset of the illness. This symptom persistedmost markedly for two months and a half, and was still tobe detected even three months later. On the thirtieth daythe voice assumed a nasal twang, and the movement of thesoft palate was found impaired ; and some of his fluid foodoccasionally came back through the nose. On the forty-fourth day after the onset of the angina the voice wasreduced to a whisper, no fluids could be swallowed, and thesoft palate was absolutely immovable. All food (which wasnow administered entirely in the solid form) was vomited,and for twenty-four hours nutrient enemata had to beresorted to. Going back to the thirty-seventh day, thediaphragm was found to be contracting feebly, and onthe forty-fourth day it had entirely ceased to act. Thechild’s condition was now critical--with shallow irregularrespirations, with an occasional ineffectual cough and

very slight entry of air into the bases of the lungs;the heart’s action was feeble, though regular. He wasordered one minim of liq. atropise every four hours. Fromthe forty-fourth to the forty-sixth day the condition wasextremely grave ; although sensible, he was drowsy andprostrate, and bluish because of partial impairment of theintercostal muscles, in addition to complete paralysis ofthe diaphragm. From the forty-sixth day, however, hebegan to improve; the action of the diaphragm and inter-MRtn.ls rAt.ll1’nA&Ograve;. hA WflR lB,n1A to take food (fl.t. first solid, butsoon thickened liquid food) by the mouth without vomiting Iand without regurgitation, and his voice became stronger Iand less nasal, and his power of coughing more effectual. <

Three days later the pupils were dilated, the skin of the face Iand chest flushed, and the child complained of thirst; hehad been taking drop-doses of liq. at-ropiee for five days.From this date he rapidly improved, and on the twenty-fifthday after the onset his voice had resumed its normal tone andstrength, and there was no trace of albumen in the urine.The knee-jerks, however, still remained absent.Throughout the child’s illness there was no alteration of

cutaneous sensibility, and the intensity of the palsy fellupon the muscles of deglutition and respiration. It was

only on the forty-fourth day that weakness was foundin any other muscles-namely, the external rectus of theleft eyeball, and in certain facial muscles of expression.During the illness the left knee became nearly straight,and three months after his admission he was dischargedwith his leg in a Thomas splint, and getting about with apair of crutches and a high boot. He returned to showhimself two months later, when the limb was straight,though still wasted, and there were fairly free painlessmovements at the joint. At this time the knee-jerk wasstill feeble, otherwise no trace remained.

- Rem.)’ by Mr. OWEN.-It is hardly conceivable that achild could be more severely affected with diphtheriticparalysis than was this boy, and then recover. He hadparalysis of muscles of vocalisation and deglutition; thestomach was so irritable that it could, for a while, hold nofood; the diaphragm was completely paralysed, and theintercostal muscles, and even the heart itself, seemed tothreaten cessation of action. If cardiac paralysis can be sooften the cause of sudden death, even in children who areapparently convalescent from diphtheria, one had almost toexpect its supervention in such a case as that just narrated.The occurrence of oedema of the lungs and pneumonia wasalso feared, not only because of the feebleness with whichrespiration was carried on, but also because of the risk of thepassage of fluids through the paralysed glottis. The fact ofthe nerves of the pharynx, larynx, heart, and stomach all

being affected betokens grave and extensive implication of

the pneumogastric nerve; and the question is, of course,whether this implication was central or peripheral. Hadopportunity for microscopic examination of the medullaunhappily occurred, it is possible that hsemorrhagie or dis-integrating patches might there have been discovered, andso one might have been inclined to regard the paralysis asof central origin. But the temptation, on the other hand,is strong to accept Senator’s theory of peripheral neuritis.Thus, the primary affection was of the palate, tonsils, andpharynx; nerves of these areas come from the pneumo-gastrics, glosso-pharyngeal, and sympathetic. The"neuritismigrans," as affecting the vagus, has already been referredto. The implication of the cervical sympathetic, extendingthrough the carotid canal, reaches the ciliary ganglion (asshown by the loss of power of accommodation) and theabducens; whilst the partial paralysis of the facial nerves-a rare complication-would be explained through the asso.ciation of the branches of the portio dura with the softpalate through the Vidian.

Medical Societies.CLINICAL SOCIETY OF LONDON.

Contraction of the Metatarso-Phalangeal Joint of the GreatToe.&mdash;Acute and Chronic Internal Suppuration withoutFever.-Glandular Swelling curable by Arsenic.AN ordinary meeting of this Society was held on the

25th ult,, Sir Dyce Duckworth, F.R.C.P., Vice-President, inthe chair.

Mr. D .u’lE.s-Co LLEY desired to call the attention of the

Society to the condition of Contraction of the Metatarso-Phalangeal Joint of the Great Toe, of which he had beenunable to find any description in surgical writings. He hadhad five cases under his care during the last nine years. Thedisease consisted simply of flexion of the first phalanx of thegreat toe through 30&deg; to 60&deg;, with extension of the secondphalanx, and some swelling and stiffness of the metatarso-phalangeal joint. All the cases were in young men. Itseemed probable that later in life the deformity tended tochange to hallux valgus. There was no paralysis of theextensor proprius hallucis, and, as far as he could judge, theflexors of the first phalanx and the plantar fascia were notprimarily affected. The two causes to which he would attri-bute the condition were-(1) an injury to the joint, followedby contraction similar to that which is observed in the knee-joint ; and (2) the pressure of short rigid boots upon anabnormally long great toe. The condition is very painful,and the patients walk with difficulty, resting their weightupon the outer border of the foot. In those cases he hadsubcutaneously divided the inner band of the plantar fasciaand the short muscles of the sole about three-quarters of aninch behind their insertion into the sesamoid bones and firstphalanx. All these cases were for the time cured, but onereturned in two years in a still worse condition as regardsflexion, with some outward displacement in addition-in

fact, in an incipient state of hallux valgus. In this case a

good result had followed resection of the metatarso-

phalangeal joint. In two other cases he had excised theproximal half of the first phalanx, leaving the head of themetatarsal bone, with the sesamoid bones, and interfering aslittle as possible with the attachments of the muscles.Primary union had followed, and the patients were soonable to walk upon the flat sole. In one of them, twenty-two months after the operation, there was no appearanceof deformity, and the patient had walked twenty mileswithout any difficulty on the day preceding. Mr. Davies-Colley would suggest that the deformity should be calledhallux flexus, and that if the cases were too bad for treatmentwith rest and a splint, resort should be had to subcutaneous

section of the muscles and fascia, or, in more severe cases,to the removal of the proximal half of the first phalanx.Sir Dycr DucKwoBTH said that the subject of deflections ofjoints was interesting to him rather from the point of viewof such constitutional causes as gout, rheumatism, and thelike, than from such local causes as tight boots, whoseinfluence in the causation was doubtful.-Dr. HBBBiNSHAM

mentioned a case of the kind in a young girl aged fourteen.His colleague, Dr. Weiss, had also met with a similar case,

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He did not know whether the joints in all cases of deflectionexhibited internal changes.&mdash;Mr. CiiABi’Mms SYMONDS saidthat he had had many cases of derangement of this joint.The symptoms are pain, swelling of the joint and of thearticular ends of the bones. It occurred in youngboys, especially those with flat feet. Some of theboys had a long great toe. As to anatomy, there was noevidence of vascularisation of the cartilage; the changeswere like those met with in the early stages of rheumaticarthritis. He thought that overwork of the joint was acause.-Mr. CLUTTON inquired whether Mr. Davies-Colleyconsidered that the deflection was due to muscular con-traction. The ligaments seem to be the efficient causes ofthe deformity in "hammer toe," and he suspected that thechange described by Mr. Davies-Colley was allied in itspathology, and was the outcome of subinflammatorychanges, chiefly in the ligaments.&mdash;Mr. H. CAYLBY said thatbare-footed races had the toes in a perfectly straightdirection, although flat-foot was very common amongstthe natives of India.-Dr. B. O’CoNNOR thought that theextensor tendons had some share in the causation of thehallux valgus.-Mr. R. J. GODLEE said that in examination ofthree contracted fingers he had found the cartilage vascularand eroded where it had been in contact with th e capsule. Hehad seen mild cases of this kind’; the cause was unknown.-Mr. A. E. BARKER had removed a wedge-shaped piece fromthe inner aspect of the head of the metatarsal bone forballux valgus. This would probably be a better operationthan removal of a portion of phalanx, by which the jointwould be opened.-Mr. DAVIES-COLLEY, in reply, said thatat first he divided all the soft parts; the next time heperformed complete excision of the joint ; and lastly hedecided on removal of the proximal half of the first phalanx.The cartilage of the joints frequently lost its pearly lustreand was fibrous-looking ; the ligamentous tissue was

thickened. The muscular contraction and the ligamentouscondition were secondary to the joint derangement. Noneof the cases had flat foot.

Dr. SAMUEL WEST read some cases of Internal Suppura-tion, Acute and Chronic, without 1’ever. Case 1 : Female,aged twenty-one, admitted with a swelling on the lowerpart of the abdomen and pelvis, with but little pain ortenderness. There was no history of acute inflammation.The swelling slowly increased, but the temperature wasnever raised; there were no rigors and no sweatings. The

swelling was opened behind the peritoneum, and severalounces of fetid pus evacuated, after which recovery wasrapid and complete. Case 2: Male, aged sixteen. Case ofsuppurative pericarditis (described in the Medico-ChirurgicalTransactions for 1883), in which the pericardium was twicetapped and then laid open. The boy recovered completely.The temperature was never raised, either before or after theoperation. Case 3: Female, aged ten. Case of suppuratingperitonitis (described in the Clinical Society’s Transactionsfor 1885). The case was very acute. The abdomen was

opened, and fetid pus evacuated. The patient did not rallyafter the operation. The post-mortem showed the case wasone of primary peritonitis. The temperature throughoutwas not raised. Case 4: Female, aged forty-eight. Abscessbetween liver and diaphragm and abdominal walls connectedwith the rupture of a duodenal ulcer. The temperature wasnot raised. Case 5: Male. aged thirteen. Case of empyema.Twice tapped, with removal of twenty-four and ten

ounces of pus. Chest laid freely open. Recovery complete.The temperature was normal throughout. Cases and 3were very acute. In Cases 4 and 5 the development of puswas very rapid. Collapse was absent in all. Though theexplanation is not forthcoming, the fact must be borne inmind, for forgetfulness of it may lead to error in diagnosis.-Dr. RyLE asked whether there was scope for the pus to moveabout in the cases in question; the tension of the pus in theabscess might influence the occurrence of pyrexia.-Dr.ANGEL MONEY suggested that an alkaloid, like antipyrin,might counteract the influence of the pyrogenic agent whenacute suppuration did not cause fever.-Dr. CUARLEWOODTURNER thought it was not the pua, but something, probablymicro-organisms, in the pus, which were effective in thecausation of the fever.--Mr. BARKER thought that informa-tion was needed concerning the causation of subnormaltemperatures, occurring at times when usually a high tem-perature was registered. In a case of abscess of the brain avery low temperature was registered at that period in theevening when, with suppuration, it was most common tofind high fever.&mdash;Mr. F. S. EVE agreed with the suggestion

of Dr. A. Money, and thought that alterations in the stateof the wall of the abscess might alter the conditions underwhich absorption took place. In some cases the stomatawould become blocked, and the pyrogenic substance there-fore less easily absorbed. The evidence available went toprove that no pus existed without the presence of micro-organisms. In suppuration without fever in serous mem-branes, the inflammation may be at first plastic, so that alayer of lymph is formed first on the serous membrane, andthis may prevent absorption.Mr. FREDERICK TREVES read a paper on a Form of

Glandular Swelling which is cured by Arsenic. He drewattention to the obscurity that attends both the pathologyand the clinical history of certain chronic glandular affec-tions. These affections are covered by such terms as thefollowing: hypertrophy of glands symptoms, malignantlymphoma, lymphadenoma, Hodgkin’s disease, and lympho-sarcoma. These glandular swellings are considered to beuninflammatory, have no relation to scrofula or syphilis,and are clearly separated from the gland disorders thatattend leukaemia. They possess the common characters ofa slow origin without apparent cause, a slow but progressivegrowth, and an absence of all inflammatory phenomena.Histologically there would appear to be no means of dis-tinguishing one of these affections from another. Apartfrom this, objection may well be raised to the terms hyper-trophy and lymphoma. Without limiting himself to anyspecial term, Mr. Treves desired to draw attention to theclinical aspects of a certain form of non-leuksemic glandenlargement that could be cured by arsenic. The patientsare usually past middle age; they present no peculiar con-stitutional defect; there is no suggestion of gout, rheu-matism, or scrofula. There is no leukaemia. The neck isusually involved. The gland tumours appear on both sideswithout disturbances in the periphery. The masses vary insize from a hazel-nut to a duck’s egg. They are soft, elastic,homogeneous, movable, painless, and free from tenderness.They show a disposition to spread without limit. The tem-perature is normal, and suppuration does not take place.Air. Treves gave instances of the cure of such cases by theuse of arsenic. The drug is given in the form of liq.arsenicalis, commencing with a dose of five minims andincreasing to twenty minims three times a day. The treat-ment has to be kept up for some months-one to six. Theglands waste, some few suppurate, and in such instancesthe resulting sinuses heal without further treatment. Incases where the whole neck has been filled with greatglandular masses the tumours have wholly disappearedafter a treatment of from four to six months. Some ofthese cases, at least, would probably be covered by the termHodgkin’s disease. Air. Treves concluded by an allusion toDr. K6bel’s paper on the treatment of malignant growth byarsenic administered by the mouth, and also hypodermically.-Sir D?CE DucxwoRrFi was well acquainted with thedisease. A process of disintegration rather than of suppura-tion was very liable to occur in the glands. Arsenic wasvery useful in some cases, but by no means in all. Injec-tions of Fowler’s solution were sometimes valuable, some-times useless. Dr. Warburton Begbie had praised chlorideof calcium in these affections. He did not agree that therewas a paucity of literature, and mentioned the works ofTrousseau, Gowers, and Southey. - Dr. STEPHEN MAC-KENZIE considered that the surgeon had usurped the pro-vince of the physician. In some cases arsenic was extremelyuseful, but in other cases of Hodgkin’s disease it was useless,and the distinction between the classes could only be drawnby a trial of the arsenic.-Dr. PAYNE considered that thesecases of multiple swelling of the glands, so well known toevery physician and designated as Hodgkin’s disease, couldnot be the same disease in all cases. Cases so diagnosedhave been found post mortem to be caseous degenerations. Adistinct poison or cause must have been at work, in many casesdoubtless the tubercular virus. A giant-celled structure wasoften to be detected in the glands. Reference was made toa paper in the Transactions of the Pathological Society byMurchison.-Mr. ARTHUR DAVIES had had considerable suc-cess with the chloride of calcium, which, as Dr. W. Begbie hadwritten, must be employed for a long period and in large andgradually increasing doses. Used in any other way the drugcould not be said to have had a fair chance.-Mr. C. SYMONDSsaid that he had cured cases of the kind occurring amongstchildren and others by the employment of arsenic, but heknew of no characters by which to distinguish the remedi-ab’e from the irremediable classes.-Mr. TREVES, in reply,

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said that he alluded only to a certain class of cases occurringin persons of either sex past middle life, and in which therewas no suspicion of inflammation about the enlarged glands.The suppurations mentioned only developed after theadministration of arsenic had been begun.

MEDICAL SOCIETY OF LONDON.

Hereditary Tremors. &mdash; Random Symptoms from CerebralSyphilis.&mdash;Facial Monoplegia.&mdash;Post-hemiplegic Chorea.&mdash;Jacksonian Epilepsy.&mdash; Ulceration of Palate.&mdash;Sarcomaof Tonsil.

A CLINICAL meeting of this Society was held on Mondaylast, Dr. Hughlings Jackson, F.R.S., President, in the chair.

Dr. SAMUEL WEST showed a case of Hereditary Tremorsin a man aged thirty, in whom the fine movements of thehand were first noticed at the age of eight years. Thefather was " shaky," and died at the age of fifty-eight I

of paralysis. The tongue and ocular muscles were notaffected. The tremors had the character of those seen indelirium tremens. The case was one of the same groupshown by Dr. West last year.-Dr. EWART asked what Dr.West’s views were as to the pathology of the tremor.-Dr. HADDEN said that the handwriting was a fair copy, anddid not show signs of tremor.-Dr. HERBiNGHAM alluded tothe tremors that occurred in the hand after carrying heavyweights, and thought there was a resemblance to those seenin the man.-Mr. HILL said that the tremors were akin tothose seen at the onset of the hypnotic state when arti-ficially induced.-Dr: HUGHLINGS JACKSON thought thecases Dr. Samuel West described formed a group of familynervous diseases, other groups being Friedreich’s disease,pseudo-hypertrophic paralysis, &c. He believed that theinheritance of a tendency to diseases was not that of atendency to any pathological changes, but the transmissionof small organs, of organs having too few functional elements.Insanity was often a family disease, and he believed thatthose who inherited a proclivity to it inherited a brain ofwhich the functional elements of the highest cerebral centreswere few. He could apply the same principle to the otherfamily diseases alluded to, believing that some parts of thelower divisions of the nervous systems of those succumbinghad fewer cells or fibres, or that in certain muscular regionsthere were fewer muscular elements. He thought thattremor always implied-that is, always coexisted with-paralysis. In the artificially induced tremor Dr. Herringhamhad mentioned, that from carrying something heavy, therewas, he held, paralysis in the sense of loss of some move-ments of the hand and over-development of other movementsof the same muscles-that is, tremor.

Dr. HUGHLINGS JACKSON showed a patient who had arandom association of Nervous Symptoms from Syphilis. Aman, thirty-four. Primary syphilis five years ago, followedby sore-throat; palate perforated three years ago. Fit ofsome sort five years ago. Present condition: No sense ofsmell; taste good; hemianopia; left fields blind [chart byDr. James Anderson exhibited]; optic discs normal; slightdistortion of the face to the left, with twitching in regionof right zygomatici, and narrowing of the right palpebralaperture (relics of old Bell’s facial paralysis ?) ; paralysisand wasting of the right half of the tongue, with turningof its tip to the right on protrusion, and to the left whenon the floor of the mouth; deafness of the left ear. The

palate was fixed to the back of the throat, the communica-tion of the mouth with the nose being by a hole. Therandom association of nervous symptoms would, Dr. Hugh-lings Jackson said, were there no direct and obvious evidenceof syphilis, point to intracranial syphilis. With paralysisand wasting of one half of the tongue there was nearlyalways paralysis of the palate and vocal cord on the sameside. In this case, for physical reasons, palatal paralysiswas not demonstrable. Dr. Semon at the meeting examinedthe larynx and found no paralysis.-Dr. F. SEMON said thata cortical lesion involving the "phonation centre " could notcause unilateral laryngeal palsy. Stimulation of one centrein the cortex always caused adduction of both cords.

Dr. HuGHLiNGS JACKSON also showed a patient recoveringfrom Facial Monoplegia of cortical or subcortical origin. Aman aged twenty-six, who denied venereal disease, who hadneither cardiac nor renal disease, had an attack of numbnessof the right arm and leg for about five minutes one week

before the attack on Feb. 8th, in which, with right hemi-plegia, he was aphasic. Une peculiarity of the case was therapid disappearance of the paralysis of the limbs (twohours), and of the aphasia (about two days); the patientfirst regained "yes" and "no." When admitted (Feb. llth)he had right facial paralysis and paralysis of the right sideof the palate. He did not feel very tight touches on theright hand, but did the prick of a pin. There was no

paralysis of the vocal cord (Dr. Semon). The patient’sspeech (except that he was occasionally at a loss for a word),reading, and writing were good; his articulation was con-siderably defective. He had lost smell on the left side onemonth. The facial paralysis was more marked than Dr.Hughlings Jackson had ever before seen it from any destruc-tive cerebral lesion. He exhibited photographs of the facetaken by Mr. Stedman, showing among other things the greatdifference in the facial attitude between a constructed"smile and a real smile when amused (a very important thingpointed out by Dr. Gowers). Dr. Hughlings Jackson hadnot seen such palatal paralysis as existed in this patient inany other case of cerebral facial paralysis, nor indeed in anysort of facial paralysis ; it was as marked as the one-sidedpalatal paralysis occurring in (its usual association) casesof paralysis of the tongue and vocal cord. The unin-structed might have mistaken the case for one of Bell’sfacial paralysis with paralysis of the palate, a combina-tion of symptoms he (Dr. Jackson) had not yet met with.The electrical reactions were normal. Dr. HughlingsJackson did not hold the current doctrine of abrupt localisa-tion, and considered that the transitory paralysis of theright limbs in this case showed that the part of the braindamaged represented movements of those limbs, although toa trivial extent. No doubt, too, the vocal cords are repre-sented in the region diseased, but their escape is (Horsleyand Semon) accounted for by their being also fully repre-sented in the other half of the brain. That the vocal cordsmight act well when (Horsley and Semon) one of the twophonation centres was destroyed showed that there mightbe loss of (one half of) the movements of a region withoutdisability in the muscles of that region.Dr. SAMUEL WEST showedacaseof Post-Hemiplegic Chorea,

and described the character of the movements, their violence,the shortening of the leg, and the long interval between thehemiplegia and the hemichorea. The movements had some-what the characters of atbetosis. As the result of a fright bya dog the movements involved the face, and increased inviolence.-Dr. HERRINGHAM said the movements had thecharacter of " struggling."-Dr. EwABT mentioned a case ina girl aged nine, which was congenital.-Dr. Smnts said thatsunstroke was very rare in the East Indies, and doubtedwhether this was the cause of the cerebral disease.

Dr. S. WEST also showed a case of Jacksonian Epilepsy ina woman. The fits began in May, 1885. She had had pinsand needles" in the left side. The fits had increased in fre-quency. The fit commenced with movements in the thumband fingers, then the arm, then the leg, and the whole sidetwitched in the order mentioned. Some paralysis ensued onthe fits. She had pain in the right side of the parietalregion. There was double optic neuritis. The deep reflexesincreased in degree. There was permanent left hemiplegia,involving the arm and leg. Did the lesion spread widely, orwas it more deeply situate, and involving the fibres pro-ceeding from the cortex?-Dr. HuGHLiNGS JACESON thoughtthat there could be no doubt of the correctness of thediagnosis Dr. Samuel West had made. Optic neuritis, thebest evidence of gross organic disease within the cranium,was not decisive of such disease. The kind of epileptiformattack the patient had did not necessarily depend on cerebraltumour; but the two things taken together, double opticneuritis and the epileptiform seizure, would make him feelas sure as he could be of anything medical that there was acortical or subcortical tumour in Dr. West’s patient. He

urged that, since optic neuritis might exist with good sight,the ophthalmoscope should be used by routine in cases ofnervous disease.

Dr. DE HAVILLAND HALL read two cases of Ulceration ofthe Palate and Pharynx occurring in young men aged nine-teen and twenty-three. They were of syphilitic origin, andpossibly of the hereditary variety.-Mr. LENNOx BROWNEreferred to a case of ulcerated gumma of the pharynx,in which there was choroiditis and notched teeth.-Mr.MARMADUKE SHEILD referred to cases of disease in whichthe evidence of syphilis was slight, though it was certainthat the disease was syphilitic. He suggested the possibility