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She remained at home for four months, and after this lapseof time, during which she had suffered from tic as usual, shecame to the hospital for the purpose of paying a visit to thenurse who had previously taken care of her. Whilst thepatient was in the ward, it was discovered that she had ery-sipelas of the right leg; this was immediately attended to.She remained in the house, and four days after this secondadmission, Mr. Holt, in examining the leg, found that theright ankle was now likewise dislocated. This second dis-

placement had happened without the patient being aware ofit, without pain, and according to all appearance, whilst shewas in becl. The inflammatory attack soon subsided, and nodoubt was left concerning the luxation which had occurred inthe ankle, the joint being just as easily dislocated and re-duced as had been the case with the knee.No direct mechanical means were used, except gutta percha

casing for the knee, and tight bandaging for the ankle; theformer of these articulations, when last examined, presentedthe following appearances:-The patella is drawn upwards,and rests on the lower third of the femur; the tibia is dis-located inwards; the two articular surfaces of this bone arevery prominent in front, and the internal one projects con.siderably inwards, having slipped from the internal condyle ofthe femur. Both joints are now fixed and unyielding; there isno pain on pressure, and the patient complains principally ofher tic, which is troubling her now as much as it ever did.Now, it might fairly be asked, whether the last-mentioned

disease has had much, or any, influence on the production ofthe above-named dislocations ? Without venturing to decidethe question, we would suggest that a purely nervous affectionis not likely to engender or excite a pathological change injoints, and that gradual alterations, both in the structure ofthe synovial membranes and ligaments, have had a largeshare of influence on the occurrence of the two luxa-tions. We are aware that this is not looked upon as a

common cause, and we firmly believe that this case could notbe easily classed among the spontaneous dislocations mentionedbv authors.

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If we refer to some writers on the subject, we generallyfind that kind of spontaneous luxations mentioned as arecaused by the elongation of the ligaments and capsule, wherethe reduction and a fresh dislocation follow each other withgreat ease, and the joint is far from being fixed. It isprincipally to the instructive paper published by Mr. Stanley,in the twenty-fourth volume of the Medico-Chirurgical Trans-actions, that we should turn for information on this subject.The author mentions seven cases of spontaneous dislocation,which arose from various causes, independent of externalviolence, or any destructive process in the joint. In the firstand second case, the displacement of the head of the femurtook place from impaired nervous power. In th6 third andfifth case, the dislocation of the hip must be viewed as theconsequence of rheumatic inflammation; and in the fourth,the dislocation had the same cause, though treated for sciatica.In all the three latter there was elongation of the capsule.Mr. Stanley states that his colleague, Mr. Wormald, directedhis attention to the following case:-A man, about forty,stated to Mr. Wormald, as out-patient, that about three yearspreviously he caught a severe cold, immediately after whichhis knee became weak and swollen, and that there succeededa very gradual alteration in the form of the joint, but un-accompanied by pain or other sign of inflammation. Thearticular surfaces were displaced to such an extent that the headof the tibia projected a full inch on the inner side of, and a littlebehind, the inner condyle of the femur, with a correspondinghollow on the outer side of the joint, and some fluid in thecavity of the articulation could be felt on either side of thepatella.Whether Mr. Holt’s patient met with her dislocations from

impaired i2ervozis p<Koe?’, as happened in one of the cases men-tioned by Mr. Stanley, we do not pretend to decide, but wehave had much pleasure in laying the case before our readers,as embodying valuable facts connected with gradual dislocations.

ApPOINTMENT.-TOWER HAMLETS DISPENSARY.-Mr. W. J. Williams, of University College Hospital, has beenelected resident and visiting surgeon, at a salary of .6100 perannum, in the room of Mr. Vertue Edwards, appointed to thehospital for Consumption, Brompton. At a special generalmeeting of the governors, held at the Dispensary on the 27thHit,, Mr. Edwards was unanimously elected an honorary life-governor of the institution, as an acknowledgment of thefaithful and efficient manner in which he had discharged theduties of his office for a period of upwards of six years.

Medical Societies.

ROYAL MEDICAL AND CHIRURGICAL SOCIETY.

TUESDAY, NOV. 26, 1850.&mdash;DR. TODD IN THE CHAIR.

CASE OF SOFTENING OF THE SPINAL MARROW IN A BOY AFFECTEDWITH CHOREA. By ROBERT NAIRNE, M.D., Physician to St.George’s Hospital.

) A Boy, aged seventeen, was admitted into St. George’s Hos-t pital, on the 27th of June last, with symptoms of acute. rheumatism, and presenting, at the same time, well-marked

symptoms of chorea. A mitral systolic murmur could beL heard. The boy had suffered from previous attacks of rheu-

matism since the age of twelve, but his friends had neverl seen him " in this way" before. The last attack of rheumatism,

was about Christmas, 1849. During five weeks before he. came to the hospital, convulsive motion of the hands had been! observed; during the last two weeks he had stuttered much,. and frequently contorted his mouth. Five days before admis-sion he had been to market in a cart; he complained much of! the jolting, and the next day was unable to leave his bed.He did not attempt to walk afterwards, and was said to have

had a fit on the morning of the 24th. He was somewhat re-lieved by the treatment employed during the first day or two;

he then became worse, more restless, delirious, more feeble,and violently convulsed. For two days he passed his motionsunder him. Some hours before his death the convulsivemovements ceased, and he became comatose. The body was

examined twelve hours after death. There was congestion ofthe veins of the spinal canal, and of the veins and sinuseswithin the cranium. About an inch of the entire t7tickwsof the spinal cord, opposite the third and fourth dorsal verte-brae, was white, softened, and almost diffluent, the rest of thecord being in its natural state. The brain was of firm con-sistence,and injected with blood. The pericardium adherent;the mitral valve fringed with small vegetations. The lungscongested. The author remarks upon the points of interestof the case:-Chorea associated with acute rheumatism, andpalsy of the lower extremities, depending upon softening ofthe spinal marrow. He refers to four cases on record, wheresoftening of the spinal marrow existed in persons who hadbeen affected with chorea. He does not consider there isany reason for supposing that in these cases the softening ofthe spinal marrow was the cause of the chorea. His obser-vation of this disease would deter him from connecting itwith disease of the brain or spinal cord. He believes a.

careful study of the phenomena of the disease during life tobe the best means of gaining a more correct insight into itsnature than we are possessed of at present. He, refers tothree other fatal cases of chorea which have been observedby him in the wards of St. George’s Hospital: one occurredin his own practice, and the other two were patients of Dr.Macleod. He concludes by remarking, that the curious factof the existence of sensation, and the transmission of nervousimpressions to the palsied muscles of the lower extremities,although the spinal marrow had undergone the change ofstructure above described, shows that there is yet much forus to learn respecting its functions.

Dr. WEBSTER said that as Dr. Nairne had alluded toseveral authors who have written upon this subject, hewould add other authorities who entertained somewhatopposite sentiments. Serres found the corpora quadrigeminaand striata diseased in four cases of chorea. lB1ajendie andBouillaud limited its seat to the cerebellum. Dr. Copland,about thirty years ago, published a case in which there wasan effusion of coagulable lymph, nearly the whole length ofthe spinal column, with inflammatory appearances of themembranes. Dr. Aleprandi considered the spinal cord to bechiefly implicated; whilst Dr. Prichard had met with morbidalterations of structure of the same kind in four instances,and from all he (Dr. Webster) had ever seen of this complaint,the medulla oblongata seemed to be the true seat of chorea.The sex and age of Dr. Nairne’s patient were also interestingpoints, and especially as the disease in this instance ter-minated fatally. The disease is less frequently fatal in ladsthan girls. These conclusions were founded upon good evi-dence-namely, that in twenty-one cases which had comeunder his (Dr. Webster’s) own care, sixteen were girls, andonly five boys; amongst the former of whom one died; but aspermission was not obtained to examine the body, the morbidchanges could not be ascertained. Respecting the compara-tive mortality in each sex, he might state, that of twenty-four

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deaths registered from chorea, throughout England andWales, during a recent year, twenty were females, only fourbeing males. Hence, this disease appeared, not only morecommon, but of a much severer character in the former thanthe latter class of patients. The author had not enlarged uponthe treatment of this frequently intractable complaint; Dr.Webster would observe, however, that the purgative methodrecommended by Dr. Hamilton proved the most successful,according to his experience, the purgatives being accom-panied, in most cases, or at least soon followed, by tonicremedies; especially steel, where any uterine derangementprevailed. Some stimulating applications to the spine wereemployed occasionally, with considerable benefit, the dietbeing light and nutritious; whatever opinions might be enter-tained in regard to the pathology of chorea, all must admitthat its treatment is always of great interest to practi-tioners.Mr. BARLOW said that Dr. Nairne’s case seemed important,

as showing that disease of the spinal cord might go on unsus-pected, with symptoms simulating those of chorea, and that inspite of every care on the part of the physician. He took theliberty of doubting whether what had been called fatal chorea,-a thing which happened very rarely,-could, when spinallesion was found after death, be termed a true instance of thatdisease. It might have appeared like it in its course; but post-mortem examination seemed to claim for it a classificationamongst organic spinal affections. Of course one means ofdiagnosis during lifetime consisted in a close examination ofthe movements; those of chorea were quite peculiar, andtotally different from that quick, spasmodic, sometimes quiver-ing movement, which was seen in epilepsy and some other affec-tions. The elements of the disease were complex; the blood,the spinal cord, the will, the passions, seemed occasionally allto take their part in causing and completing the symptoms ofa given case. He was surprised at the rate of mortality ofchorea to which Dr. Webster had referred. Were the caseshe had alluded to really chorea?-had any of them beenexamined after death ? 1 Mr. Barlow thought that all suchcases as those of Dr. Nairne deserved to be recorded andcarefully considered.

Dr. WEBSTER, in reply to Mr. Barlow, observed, that thetwenty-four deaths by chorea, which he mentioned were givenon the Registrar-General’s authority; the facts there reportedbeing conclusive evidence. As Mr. Barlow seemed to havemisunderstood his (Dr. Webster’s) observations respectingthe sexes of the twenty-one patients treated by himself, it be-came necessary again to state, that sixteen were girls, andonly five boys; all being, however, younger than the patientwhose case was related that evening by Dr. Nairne. Regard-ing the remarks of Dr. Crawford, he would observe, thatwherever chorea occurred during advanced life it was gener-ally in females, of which an instance is reported in a womanupwards of eighty; as also another from fifty to sixty years ofage; whilst he (Dr. Webster) had been consulted respectinga full-grown female between eighteen and nineteen, who wasthe oldest patient he had seen affected with this malady; Dr.Crawford’s opinions were consequently fully borne out by ex-perience. Some physicians thought chorea was occasionallyan hereditary complaint. It might be so, but although he hadmade inquiry on this point, no traces of the kind could heever establish; however, he would mention, that two of thecases previously alluded to occurred in a brother and a sister;the former having been of a very severe description. Dr.Webster then said, chorea most frequently affected the ill-fedchildren of the poor, living in dirty, unhealthy localities; andthat it was much less common amongst the middle or upperranks of society.

Dr. SIBSON said, that this case was not the less a case ofchorea because of its fatal issue, and the presence of softeningin the spinal cord. (During eleven of the thirteen years thathe resided in the Nottingham Hospital, eighty-four cases ofchorea were admitted, of which five died from exhaustion.)He need not say that those were chiefly the worst cases thatwere admitted. This fact supported the accuracy of the re-gistrar’s returns of deaths from chorea, quoted by Dr. Web-ster. Chorea, like apoplexy, is rather an assemblage of symp-toms proceeding from various morbid causes, than a diseaseitself. The choreal movements, irregularly alternate, invo-luntary, and increased by emotion, are allied to those move-ments which often take place in a paralyzed limb, under theinfluence of emotion; they are allied also to those remarkableand alternate reflex movements of the whole body, observedby Sir Benjamin Brodie, in a decapitated dog during artificialrespiration. Here the control of the brain over the reflexmovements was withdrawn, while those movements were ex-

cited vigorously by the circulation. In chorea, the control ofthe brain over the reflex movements is lessened at the sametime that the general movements are excited by emotion. Thecause disturbing the balance of the cerebral control over thenervous forces might exist in various morbid conditions, anyof which might excite the choreal movements.

Dr. TODD said that though there might be some differenceof opinion respecting the pathology of the disease under-consideration, still we could discuss the treatment. The case,though curious, was not very uncommon. He would inquireif any one had tried the influence of chloroform on chorea ?’It had been used in some convulsive diseases, and with markedeffect.

Dr. SNow had tried chloroform, in one case of chorea, afCharing-cross Hospital. The patient was a little girl, under-the care of Dr. Chowne. It removed the spasmodic action atthe time, but he was not aware whether it exerted any per-manent influence on the little patient. He had had no,

further experience on the subject.Dr. SIBSON had used chloroform, in one case, in the Not--

tingham Hospital. The patient was relieved, but not cured.He had found in cases of chorea, that the application of tepidwater to the head afforded more relief to the convulsions thanhad any other remedy.Mr. STREETER hoped that the discussion would not termi-

nate without some allusion to diagnosis. Wishing to speakwith diffidence, on cases not personally seen, he would saythat there was something more than chorea here. He wouldsuggest the spinal arachnitis or myelitis of Ollivier. Achronic disease, involving the neurilemma of the fibrillm of thecord, had been the primary disease, and the supervention ofthe ordinary symptoms of chorea arose from the extension ofirritation above and below the local affection. This disease,in its acute form, was rapidly destructive to the nervous tissue,and its immediate diagnosis, from rheumatism or commonnervous irritation, was essential to save the sufferer from beingcrippled for the remainder of life. Several years ago he met-with such a case of spinal meningitis, in a youth, who appliedto him one morning with unusual movements in the fingers,attended with numbness. Pressure over the spine, betweenthe shoulders, gave great pain, and was followed before nightby rapid aggravation of the symptoms, and development of-the true nature of the attack. In consultation with Dr.Robert Willis, the most active treatment was pursued,-bleeding from the arm, purging, leeching, ptyalism, andblistering. The symptoms disappeared, but a long period ofquietude from active exertion, and a country residence of twoyears, elapsed, before complete restoration of his usual mus-cular powers. Had a few hours been lost in the diagnosis ortreatment, this young man had been a cripple for life. Thedanger of the acute form he trusted would excuse his digres--sion ; but the case related by Dr. Nairne he believed was aninstance of the same disease in an insidious chronic form,,complicated with other and more obvious forms of functionalirritation, which had masked the more dangerous local organicdisease that was going on in the neurilemma of the spinal’cord.

Dr. NAIRNE said, that looking at the history of the case re-lated, and to the presence of articular rheumatism and endo-carditis, he thought, notwithstanding the remarks that had’been made, that the diagnosis he had come to was the mostnatural one to form. With respect to Mr. Barlow’s question,as to whether the spasmodic movements were really those ofchorea, or not, he (Dr. Nairne) could only observe, that theyhad all the distinctive characteristics of that affection; andthe tongue was put out violently, and suddenly retracted, in amanner which we did not observe in any other disease. Incases where spasmodic movements resulted from disease ofthe spinal marrow, he had not seen them so much influencedas they were, in this case, by emotion. He still considered-his view of the case correct, and he was convinced that iwphysician could mistake the movements for any other dis-ease.

Dr. MERVYN CRAWFORD regarded chorea as usually a func-tional disorder, and more particularly so from the fact of itsoccurring later in life in women than in men. He had seeneight or ten cases in which it occurred in girls seventeenyears of age, and three or four in which the patients weretwenty-four years of age. He had not seen a case in a maleso old as the patient in Dr. Nairne’s case. Whatever thecause of the disease, we might all form some idea of the modeof treatment to be pursued. If cases were to be cured bypurgatives and steel, it was evident that congestion of thespine could not, as had been imagined, be present in all cases.With respect to age, he had some time since a man under

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his care affected with what he believed to be genuine chorea nature of chorea, said, that of seven members of a family ofat the age of sixty-five. He presented all the symptoms of which he knew something, five were paralytic, the eldest ofthe affection in a well-marked form, and the disease resisted whom was sixty, the youngest forty.every means of treatment which had been resorted to. The Dr. TODD said, that paralysis agitans was not a diseaseman’s intellects were quite clear. He thought that in this simply of the waking state; the movements might occur duringcase there was latent organic disease in the spine. He did not sleep.recollect to have seen a fatal case of chorea. The treatment Dr. OGIER WARD remarked, that the diagnosis betweenmust vary with circumstances; purgatives, tonics, the sulphates paralysis agitans and chorea was not always to be determinedof zinc and iron, and the shower-bath, were effective remedies by the influence of coercion upon these diseases. In a casein the usual run of cases. In a few instances the more power- of paralysis agitans of long standing, he had found, on everyful tonics, as the liquor arsenicalis, might be necessary; but occasion, that the agitation was increased if the wrist wasno plan could be laid down that would be applicable to every grasped in the attempt to feel the pulse.case. In females between puberty and twenty-four years of Mr. ATHOL JOHNSON inquired if the difffuent state of theage menstruation was usually in some way interfered with. cord was complete, and through its entire extent &icirc;This should be rectified, and the treatment for chorea resorted Dr. NAIRNE said that the centre of the cord was fluid, andto. It was interesting to inquire what were the circumstances the outer portion of it completely destroyed, being heldwhich contributed to death in the fatal cases. together by so disorganized a medium, that on a small stream.Dr. TODD inquired of the last speaker whether his patient of water being poured upon it from the distance of a few

might not be suffering from paralysis agitans ? This disease inches only, it became entirely fluid. He had seen cases ofin some cases simulated chorea; but in paralysis agitans the paraplegia from destruction of the spinal cord, but in no casemovements could be controlled by mechanical means, such as had he seen such complete destruction as was present in thislaying hold of the limbs, while in chorea any attempt to con- case.

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trol the movements only increased their violence. Dr. TODD was led to infer that the spinal cord was not soDr. CRAWFORD said all the symptoms of chorea were pre- extensively affected during life, from the fact of emotion

sented in his case in an aggravated form. The movements affecting the lower limbs. He should regard the changes aswere increased by attempts at coercion. The patient had not occurring post mortem, or just before death. It did not, how-suffered from previous illness. ever, follow, that because it was softened, its continuity should

Dr. SETH THOMPSON had found in violent cases, that the be destroyed. He regretted that no microscopical examina-tartar-emetic had been most effective in controlling the con- tion had been made. This might not, perhaps, have decidedvulsive movements. In the case of a young plethoric woman, distinctly the question of continuity; but if the vesicles of thein whom chorea supervened on miscarriage, he had, after grey matter and the tubes of the nerves could be distinctlyother means had failed, given her half-grain doses of the tartar- traced, there would be a strong presumptive proof that con-emetic, with a drachm of sulphate of magnesia, every two or tinuity was not destroyed.three hours. In twenty-four hours, the convulsions, which Mr. TATUM said that we never for the future could put anyhad been very violent, abated, and she was quite well in three confidence in any appearances observed post mortem, if wedays. In this case there was no doubt of its being chorea. laid such stress, as had been done in this case, on the changesThe intellect was clear, and there was entire loss of sleep. which took place in the body between death and examination.

Dr. NAIRNE had employed the tartar-emetic in his case at All structures, though not in an equal degree, must undergothe commencement, but it did not, after the second day, con- change, if one did; and hence any appearance observed aftertrol the symptoms, and pyrexia increased. He then gave the death was merely fallacious.boy calomel to a considerable extent; but all was of no avail. Dr. MARSHALL HALL having been repeatedly and pointedlyHe had not mentioned the treatment he had pursued in the alluded to, rose and said,-If I have been slow to speak onpaper, because he thought the physiology and pathology of this occasion, it is not because I do not highly value the com-the case the more interesting features of it. munication before the Society, but because I found it difficult

Dr. BLACK said the chief question of interest was the rela- to embody, in the few observations to which each speakertion that the anatomical changes bore to the symptoms of must limit himself, all the suggestions to which it has givenchorea. Chorea was often the result of fear, or of any other rise in my mind. Notwithstanding the post-mortem appear-sudden mental emotion, and in these cases we could not asso- ances in this case, it is impossible to admit the idea that aciate the symptoms with any pathological change; they then severed state of the spinal marrow is compatible with thebore some analogy to the tottering knees from alarm. occurrence of movements, the result of emotion, in the inferiorChorea might be an accidental complication with other dis- extremities. Movements from reflex or diastaltic action, oreases, from the latter of which the patient might die, and the from direct irritation, might occur if the disease were sodeath be erroneously attributed to the chorea. With respect situated as to leave a portion of the spinal marrow intact.to the disease being hereditary, it was possible that there But the author distinctly states, that the movements weremight be such a condition of original constitution as would, those induced by emotion. Such a pathological fact would beunder favourable circumstances, tend to the production of at variance with all experiment. Now, Sir, an experimentchorea, and this might, to a certain extent, be regarded as performed with due caution is free from all the doubts whichhereditary. are attached to cases of disease in which it is difficult to ascer-Mr. TATUM should regret if the debate terminated without tain what organic change may occur during the last hours ofsome further allusion being made to the state of the spinal life, or what degree of disintegration may be added to whatcord, and on the physiological points bearing on its alteration existed previously during the process of opening the spinalof structure. It was stated in the paper that a portion of the canal, a process attended with difficulty. I myself oncecord was in a diffluent state, and apparently without proposed an instrument for this purpose, consisting of a pro-coherence or organization. It was a remarkable and inter- jecting point to be inserted within the spinal canal, and of aesting fact, that the choreal movements in the lower limbs chisel, which was struck with a hammer. Fearing that thisshould have been influenced and modified by mental emotion, manipulation might induce apparent softening of the tendershowing that the chain of nervous communication was still texture of this nervous centre, I discarded this instrument,kept up between the brain and that portion of the spinal and have since devised one of a different kind, consisting of acord which was apparently isolated. In what way could curved cutting blade, acting as a lever upon a fulcrum laidthis be explained ? Was there any other channel for the across the spine. The case before us appears to have com-transmission of the nervous influence ? Was the cord, in its bined rheumatism, endocarditis, and choreic movements.state of diffluence, still able to transmit motor power ? &icirc; Was Whether these existed together as mere coincidences, orthere more coherence in it than its appearance indicated ; or were related, in any degree, as cause and effect; and whetherwas not coherence really necessary for the proper functions those choreic movements were really chorea in the ordinaryof the organ ? These were all questions of great interest. acceptation of that word, are questions entirely undetermined.Many present had seen cases in which many of the nervous In true chorea, the influence of volition is modified by emo-functions had been carried on, in which a portion of the spinal tion, and peculiar movements are produced by this modi-cord was apparently disorganized. He should like to hear fication. In paralysis agitans, the movements, though stillsome observations on this point. the effect of emotion, are independent of the influence of voli-

Dr. BLACK said, there would appear to be some connexion tion. At first, both subside during sleep, except there bebetween paralysis agitans and chorea, and also to the mercurial turbulent dreams. These movements, and those dependentaffection which attacked workmen who silvered glass, inas- on reflex and on direct action, are all peculiar and character-much as they were all diseases of the waking and not of the istic, and therefore diagnostic of different states of disease.sleeping hours. The physiology is become diagnosis, and we all know thatMr. CHARLES H.4.WKINS, on the question of the hereditary diagnosis is that pivot on which all legitimate practice turns.