976,1mbun1KUM",LJOURNAIMANIACALCHOREA.iLemarksMANIACALCHOREA.*ByJ.MAGE - PDF document

976,1mbun1KUM",LJOURNAIMANIACALCHOREA.iLemarksMANIACALCHOREA.*ByJ.MAGEEFINNY,MD.DUB.,F.R.C.P.,PHYSICIANTOSIRPATRICKDIJN'SHOSPITAL;PRESIDENTOFTHEROYALACADEMYOFMEDICINEINIRELAND.CHOREAisoneofthecommonestofallnervousaffectionsmetwithinhospital,aswellasinprivatepractice,andisveryoftenassociatedwithrheumatism.Itpresentsvary-ingdegreesofseverity,fromthemildestform,consistingofawkwardnessofmovementandfacialgrimaces,toincessant,irregularmovementsandcontortions,withsuchjerkingandthrowingaboutofthelimbs,thatthepatientmustbeconfinedtobed,andwatchedtopreventherfrominjuringherself.Intheselattercases(choreagravis)somedelirium,withdelusions,isnotuncommon.Butthereisyetastillmoregraveformofchorea,inwhichmaniamaysuperveneandsocompletelyovershadowthemotordisturbancesthatthetruenatureofthediseasemaybeoverlookedandthepatientsenttoanasylum.Sowideisthedifferenceinthesymptomsthatitseemshardtorealizethatitisreallynotanotherandanewdisease,butonlyanexaggeratedvarietyofthechoreasimplexofSydenham.Thefollowingisanexampleofmaniacalchorea,orchoreainsaniens":CAsE(FromnotestakenbyMr.Thos.Graham,Residentpupil).-AnnieO.,aged17years,unmarried,wasadmittedtoSirPatrickDun'sHospitalonJune14th,1906,sufferingfrommarkedchoreiformmovements,particularlyoftheleftarmandhand.Sixyearsagoshewastreatedinanotherhospitalforenlargedcervicalglands.Shehadenjoyedgoodhealtheversinceuptoafortnightago,whenshewastreatedforrheumaticpainsinthelegs;twodaysbeforeadmissionthesepainslefther,andthenthechoreicmovementsbecamemanifest.Thepatientherselfsaidshehada"fright,"butcouldgivenoex-planationofitsnature,andtheaccuracyofherstatementwasquestionedbyhersisterandmother,withwhomshelived.ahereferredhertroubletoherhead,andsaidhermindwasbeingaffected.Themotordisturbancewasnotconfinedtoanypartofthebody-thetrunk,head,armsandlegsparticipating,buttheleftsidewasmostaffected;theeyesrolledabout,andshecontinuallyutteredasortofsob,andhaddelayanddiffi-cultyinansweringquestions,whichshedidinasudden,jerkyfashion,butwithintelligence.Thedeepreflexeswerenotincreased.Thepulsewasabout80,andoflowtension;temperature980.Asystolicmurmurwasdistinctlyaudibleinthemitralarea.Theskinoverthelumbarvertebraewascongested,butnotbroken,andthetoeswereofaduskybluecolour.Amixtureofammon.brom.andliq.arsenicaliswasordered;andchloral15grainsgivenatbedtime.Shedidnotsleep,butbecamesonoisyandobstreperouswithshoutingandscreamingthatshewasmovedintoawardbyherself,andourhouse-surgeonconsideredshewasacaseofacutemania,andsuggestedherremovaltotheRichmondLunaticAsylum.Thechoreicmovementsnextdaywereveryviolent,andinadayortwoafteradmission,inspiteofallcare,shebarkedherelbows,rubbedherheelssoreagainstthebed-clothes,andwiththeheelofonefootabraidedtheskinoftheoppositeinstep.Herbackwasalsostrippedoverthesacrum.Shecouldhardlyspeak,butattimeswouldbecomecalmforafewminutes,andcouldbefedwithsoft,thickfood.ShewasgivenNugrainhyoscinehydrobrom.withgoodresultsforafewhours,butaseconddosewasuselesseithertocalmthemotorexcitementortoprocuresleep,while20grainschloralgaveaboutthreehours'sleep.Shewasquitemaniacalattimes,strikingout,shoutingandscreaming,orutteringdeep,raucoussounds,refusingfoodattimes,andthentakingitreadily.Shepassedhermotionsandwaterinvoluntarilyinthebed,as,owingtotheextremeviolenceofthemuscularsystem,theuseofabed-panwasoutofthequestion.Theurineobtainedononeoccasionwasfoundtobeacid,specificgravity1014,andfreefromalbumenandsugar;itcontainedcalciumoxalatecrystals.Duringtheshortsleepsobtainedbychloralshewasperfectlymotionlessandherbreathingquiet.Thetemperature,whichwasnormalonadmission,roseto1000ontheeveningofthe18th,thefourthday,andfellagainto97.50nextmorning.Itremainednormaltilltheeveningofthe2lst,whenitshotupto103.40.Thepulse,whenpossibletocountit,wasusuallyabout80-90,butonthemorningofthe21stitroseto103.Themurmurintheheartwasaudibleallthrough,andproportionatelyastheheartbeatmoreviolentlyinthetimesofgreatmotorexcitementitbecamemoredistinct.Duringthe19thand20thherconditioncontinuedinmuch*ReadbeforetheRoyalAcademyofMedicineinIreland.thesamestate-periodsofcalm,inwhichshewouldsaysome,wordsintelligently,suchas"No,thankyou,sir,"alternatedwithperiodsofwildactivityinwhichshehadtobehelddowninthebed,andinwhichsheflungherlegsandarmsaboutinthestrangestfashion.Owingtotheinvoluntarybitingbyherteeth,andtherubbingofthembyherhands,herlipsweresoreandbleeding.Shewasindeedapitiableobject.Thementaldisturbancewasmaniacalintype-atonetimewithdelusions,andagainwithhallucinations,andlastlyoneofsemi-coma.Intheafternoonofthe21stshebecameparticularlyviolent,afterarathercalmerforenoon,andremainedinacontinuousstateofturbulentactivitytillabout9.30p.m.,whenIwenttoseeher.Shecouldnotberestrainedbysixattendantsfromknockingherselfabout,andallthewaddingandpaddingandbandageswhichhadbeenputaroundherlimbstopreventherinjuringherselfwererubbedortornloose.Astrait-waistcoatwasthenputonandherlegswrappedroundinasheet;althoughthesemeanspreventedherspringingoutofbedandinjuringherlimbs,shekeptup,nevertheless,anincessantwrigglingandmovement,whileshewasbathedinperspiration.Shehadhadchloral,ahypodermicofmorphine,hyoscine,buttheonlyremedythatsucceededincalmingherwaschloroforminhalation.Underitshebecamequitequiet,andthevariousappliancestokeepherinbedwereloosenedsothatshewasnotoppressedinanywaythatnight.Shesleptquietly,andtooknourishmentfairlywellattimes.Rectalfeedingcouldnotbemanaged.Nextdayshelooked,however,veryill.Theheartwasbeatingexcitedly(themitralsystolicmurmurbeingpresent),thepulsewas140,verycompressible,respiration44,andtemperature,whichhadrisento10340at7p.m.thepreviousevening,was102.40at7a.m.,101.80at10a.m.,and101.40at2p.m.Themotordisturbancewasmuchless,andshewasquiet,butin'asemi-comatosecondition.Lossoffleshhadbeennoticeableforsomedays,butnowthatthelimbswerequiettheywereseentobeextremelyemaciated.Thiswastheninthdayofhersojourninhospital.At4p.m.shesuddenlybecameun-conscious,herrespirationsverylaboured,andherextremitiesandfacecyanosed;TUgrainofdigitalinandA,grainofstrych-ninewereimmediatelyinjectedhypodermically,butwithoutavail,andshediedinfiveminutes.Po08tmortemexaminationwasmadeonJune24th.Dr.O'Sullivan,FT.C.D.,PathologisttotheHospitalandLectureronPathologyinTrinityCollege,Dublin,haskindlysuppliedmewiththefollowingreport:Thelongitudinalsinuscontainedasmallquantityofmixedclot.Thevesselsofthecortexofthebrainwereengorged.Averysmallamountoffluidwasfoundinthelateralventricles.Thebrainpresentednoabnormalappearancestothenakedeye.Itwasfixedinformalinandpiecesweresubsequentlyremovedfromvariouspartsandexaminedmicroscopically.TheonlyportionwhichpresentedanyabnormalappearancewasintheRolandicarea.Heresomeofthesmallvesselsinthecortexwerethrombosed.Inotherscollectionsofcellswithovalnucleilayheapedupintheperivasoularlymphaticspaces,andtherewereclumpsofwhatappearedtobebrokenupnuclearmaterialinthesespaces.Thespinalcordwasalsoexaminedandpresentednothingabnormal.Thecerebro-spinalfluidwasexaminedbacteriologicallyinthemediare-commendedbyWassermannforthecultivationofthecoccusfoundbyhiminrheumaticcases,butthecultureremainedsterileandnomicro-organismswerefoundinthemeningesonsection.Theotherorgansofthebodyshowednoabnormality,withtheexceptionoftheheart,whichwasinaveryatrophiccondition,andsomecalcifiedtuberculousglandsinthemesenteryandintherootofthelung.Theprominentfeaturespresentedbythiscasewere:Rheumaticpainsinthelegsforafortnight,uponwhichchoreasupervened.Amitralsystolicmurmur,audibleonadmission,ofvaryingloudness,andlastinguptotheninthday-thedayofherdeath.Thepulsequietandregular,about80eachdayuptothelastthreedays,whenitroseto110,130,140.Thetemperaturenormalorsub-normaluntilthedaybeforedeath,whenittouched103.40.Thechoreicmovementswereslightforaboutforty-eighthours,andthenbecamesoviolentthattwospecialnurseswererequiredtowatchherandpreventherfromfallingoutofbedandfromstrikingherlimbsagainstpartsofthebed.(Theideaoftreatingherbyplacinghermattressonthefloor,withpillowsaround,wasconsideredbutdiscardedinfavourofthebedwithnursesateitherside.)Thepsychicalphenomenawereprominent,outofallproportion,andatfirstquiteovershadowedthemotorial.Theydiffered,however,bytheabsenceofincoherentspeechandwildgarrulity,fromtheformsoneisaccus-tomedtoassociatewiththeacutedeliriumoffeveroracutemania.Anotherpointworthnotingwastheoccasional,thoughtemporary,mentalcalm,whichmyvisits,onceortwiceadayuptothelastthreedaysofherlife,seemedtopro-duce.Atthesetimesshewouldceaseshouting,themovementsbecamequieter,shecouldalwaysunderstandrAPRIL27,1X7.L-------II-'Y-l-II APRIL27,I907.1MANIACALCHOREA.[TMuBstmuu[AIDRUWornxi&977whatwassaid,andsometimesshesucceededinspeakingandmakingintelligentreplies,suchas"Yes,sir,""No,sir,"and"Thankyou,sir"Treatmentbymedicinestotallyfailedtohaveanyeffectonthecourseofthisterribledisease,andtheonlyhelpitgavewasbysecuringsomehoursofsleep,andmuscularrestduringsleep.Thedrugwhichseemedmostusefulforthatpurposewaschloral.Ontwodays2yLgrainhyoscinehydrobrom.(oncerepeated)wassuccessfulincalmingtheviolenceofthedelirium,butit'failedtohaveanyeffectthelasttwodaysofherlife;whilemorphinehypodermicallywaspracticallyuseless.Theoccurrenceofasystolicmurmuratthemitralarea,whichwasconsideredonadmissiontobeprobablyduetorheumaticendocarditisofsometwoorthreeweeks'duration,mustnow,inthelightoftheautopsy,bejudgedtohavebeendynamic,andduetosimpleandacuteventriculardilatation.Itisnottobeexplainedonthegroundsgenerallyaccepted-namely,anaemiaandchoreiccardiacexcitement.Theforegoingcaseisanexampleofoneoftherarestdiseasestobemetwithinthepracticeofmedicine.Itisoneofthemostgraveofthevarietiesofchorea,whetherregardbepaidtotheextremeviolenceofthemuscularmovements,thepsychicaldisturbance,oritsacutecourse,usuallyterminatingindeath."Trulyaterriblediseaseismaniacalchorea"(Osler).Inevidencethatthisvarietyofchoreais-veryuncom-monIwouldpointtotheveryscantliteratureonthesubject,thepaucityofpublishedclinicalrecords,andtheveryphortdescriptionitreceivesinstandardworksofreferenceonmedicineandoninsanity.TwoofthemostrecentworksIhavebeenabletocon-sultareTheTextbookofPsychiatry,byBianchiandMacDonald,1906;andClinicalPsychiatry,byKraepelinandJohnston,1904.Noreferenceto"maniacalchorea"appearsintheindexofeither,whileunderthetitleof"Choreicinsanity"averydifferentconditionisdescribed.Bianchiwrites:"Achoreicsubjectisalwaysmentallyaffected,thecharacterofthechildoryoungadultischanged;hebecomesirritableandfearful,hissentimentsarealtered,hispowerofattentionisdefective,andhemaysufferfromhallucinations."Kraepelinwrites:"Senselessnessandbewilderment,withchoreicmovements,occasionalhallucination,amorbidlycheerfulmoodandgreatrestlessness,withrapidphysicalsinking,areparticularlydiagnosticofchoreicinsanity."Fromtheseexcerptsitisevidentthattheseauthorsnevermetwithacaseofmaniacalchorea,anditisamatterofregret,ifnotofnegligentomission(tosaytheleastofit),thattheyshouldnothavemadethemselvesfamiliarwithpublishedcasesofthisdiseaseintheBritishIsles.ThesameadversecommentisapplicabletothemajorityofbooksIconsulted,betheywrittenbyspecialistsinmentalandnervousdisease,ortextbooksonthepracticeofmedicine.ThusMercier,BevanLewis,HackTuke,Ziemssen,Quain'sDictionary,Reynolds'sSystemofMedicine,Striimpell,andmanyothertextbooksinmedicine,givenodescriptionofanysuchmarkedpsychicalcomplicationaswasportrayedbymycase.Insome,suchasRossandAllchin,itissaid"Choreainadultsissometimesfollowedbyacutemania."Gowersmakestheshortcomment:"Thementalstatemaynotappeartillthediseasebewelldeveloped,oritmayprecedethechorea.Thelattermaybeslightorquicklycease,whilethementaldisturb-ancecontinuesinanintenseform.Thereareoftendelusions,sometimeswild,violentexcitementwithoutthegarrulitycommontoordinarymania.Thisexcite-mentmaybefollowedbyapathyordullness."However,HiltonFagge,CliffordAllbutt,Roberts,andOslerarenotableexceptions,andtheyattesttotherealityoftheextentandthegravityofmaniacalchorea;whileClouston(MentalDiseases)givesindetailatypicalcaseofrheumaticchoreawithacutemaniacalinsanity.Afatalterminationofchoreainchildrenispracticallyunknown,butitmayoccasionallyoccurbetweentheagesof15and25.Dr.Handford1inthirteenyears(1875.88)had154casesofchorea,with4deaths-thatis,2.6percent.Thisnumbertalliesverycloselywiththe2percent.ofthecollectiveinvestigationreportoftheBritishMedicalAssociation2(439cases,with9deaths).Theassociationofpregnancyorparturitionwithchoreagravisismorethananaccidentalcoincidence,andsuchcases,morethanothers,addtothedeathrollinchorea.But,perhaps,ofallthegravevarietiesmaniacalchorea(choreainsaniens)isthegravestaswellasthemostfatal.Of23casescollectedfromvarioussourcesbyWilliamGay,M.D.,3completerecoverytookplacein10,deathoccurredin8,1wasfollowedbypermanentweakminded-ness,and4werelostsightof,havingbeensenttoasylums.Thedurationofthesecasesmaybeveryshort;deathoccurredinmycaseontheninthday;insomecasesithappensasearlyasthesixth,oreventhesecondday,althoughgenerallynotuntilaftersomeweeks.Themodeofdeathseemstobeduetotheexhaustionresultingfromthewildmuscularmovements,inanition,andwantofsleepandrest.Manycasesendinunconsciousnessandcoma,althoughtheintellectmayremainclearalmosttothelast-afactfirstnoticedbyWilks,andconfirmedbysubsequentobservers.Dr.Tuckwell4hadhisattentionfirstcalledin1861tomaniacalchorea,inawomanaged24,byProfessorTrous-seau.HesawasimilarcaseinViennain1862,inapreg-nantwoman,aged20;andhedescribesacaseofaboy,aged17,underhisowncare-"probablyembolic"-in1867.Allthreehadfuriouschoreicmovements,maniacaldeliriumsetinearly,anddeathensuedwithintendaysoftheonset,aftersemicoma,withpartialorcompletecessationofthemovements.Ineachofthesecasesamitralsystolicmurmurhadbeenaudibleduringsomepartoftheillness,andafringeofbeads,orbrightwartyvegetations,thesizeofapin'shead,wasfoundatthemitralvalve.Dr.Tuck-wellanalyses34fatalcases,recordedupto1867,towhichanautopsywasattached.In4theheartwashealthy,in5nomentionwasmadeofitscondition,andoftheremain-ing25,20hadvegetationsonthevalves.Heattributesthefatalresultstothevegetationsbeingsetfreeandbecomingembolicinthebrain,andprobablyalsointhecord,andthusfavoursthetheoryattributedtoKirkeandsupportedbyHughlingsJacksonandSirWilliamBroadbent.Ontheotherhand,asnegativingtheembolictheory,andasbearingacloseresemblancetothecaseofAnnie0.,Iwouldrefertotwofatalcasesofacutechorea,withinsanity,reportedbyDr.EvanPowell,5MedicalSuper-intendent,NottinghamBoroughAsylum,inwhichtherewasacompleteabsenceofvalvulardiseaseorcerebralembolism.Thefirstwasamale,aged19,whohadbeencuredofasecondattackofrheumatismtendaysbeforethechoreadeveloped.Inthreedays'timeacutemaniasetin,withdelusionsandhallucinationsandgreatviolence,anddeathensuedbycomaafterfifteendays,duringwhichtherewerelullsinthetempest,andinthesequietintervalsthemindwasquitecleartoallthathadoccurred.Amitralmurmurwaspresent.Thesecondcasewasafemale,aged20,withoutanyhistoryofrheumatismorheartdisease.Afterfourteendaysofchorca,insanityandhallucinationsofhearingandsightsetin,andittookfourpeopletoholdherinbed.Shewassenttotheasylum,anddiedinaweek,butshewasquiteconscious,andhermindwasclearuptothelasttwodays.TheautopsyineachcasewasmadebyH.Hanford,M.D.,6andtheonlyabnormalfeaturepresentwashyperaemiaofthebrain.Afterhardeninghefound(a)thrombosedvesselsintheanteriorcornuaofthecord;(b)haemorrhagesintothelymphsheaths;(c)haemor-rhagesintotheanteriorhorns,causingdestructionofthenervetissue;(d)haemorrhagesintothedeeptransversefibresofthepons.Heconcludesthatthe"numeroushaemorrhagesfromsmallvesselsaswellascapillaries,thethromboses,andgeneraldilatationofvessels,affordevidenceofaveryunusualdegreeofvascularengorge-mentofthenervouscentresduringlife."Thesecases,whiletheybynomeansconclusivelyprovethatthepathologicalchangesdiscoveredinthenervouscentreswerethecauseofthepsychicaldisturbances,negativethetheoryofemboli,astherewasanabsenceofmitralvalvediseaseineither.StillmorerecentlyfurtherevidenceagainsttheembolictheoryhasbeenadducedbyDrs.PoyntonandGordonHolmesintheiradmirablecontributiontothepathology 978.TurnlomuN1THEDIAPHRAGMANDTHECIRCULATION.[APRIL27,1907-.ofchorea(Lancet,1906).Theyfound,onmicroscopicalexaminationofthreecasesoffatalchorea,"verylittleevidenceofembolism,"althoughgreathyperaemiawaspresent,withthrombosedvesselsinallpartsofthebrain.Mycaseispracticallyanotherofthesametype,astherewasneithermitralvalvediseasenorcerebralembolism.FromwhatIhavestated,theembolictheoryascausativeofchorea-beitchoreamajor,choreaminor(Sydenham'schorea),orthemaniacaltypeillustratedbymycase-canbenolongertenable.Rathermustwerecognize*thedifferenceintheseverityofthechoreicmanifestationstobeduetothepresenceofatoxin,andtothevirulenceormildnessofitsactiononthenerveelementsofthecerebralcortexandofthelowernervouscentres.Indirectproportionasthepsychicalandthehighercentresofideationandvolitionorthemotorcentresarethosemostinvaded,sothesymptomseachcasemaypresentwillbeeitherthoseofmaniaandotherdisorderedmentalstates,orthoseofinco-ordinatemuscularcontractionsandmovementsofthebodyandthelimbs.Theintimateassociationofchoreaandrheumatismhasbeenlongrecognized,andhasoflateyearsbeenmoreandmoreinsistedon,andtheconsensusofopinionofmanycliniedlobserversisinfavouroftherebeingonecommonunderlyingcauseforeachofthem.ltisawell-recognizedfactthatthefirstindicationofrheumaticfevermaybechorea,andthatmyocarditis,endocarditis,orpericarditismayequallyoccurineither.SirDyceDuckworth,7inhispaperreadbeforetheMedicalCongressatLisbonlastJune,emphasizedtheviewthatchoreashouldbeconsideredas"cerebralrheumatism."Hehasformanyyearsconsistentlymain-tainedtheintimaterelationshipbetweenthetwodiseases,andclinicalexperiencetends,withincreasedauthorityeveryyear,toconfirmthetruthofthatrelation-ship.In1892,Clouston,8writinguponthevarietiesofinsanity,undertheheadingof"RheumaticInsanity,"describesthetypicalcaseofrheumaticchoreawithacutemaniacalinsanitytowhichreferencehasbeenmadeabove,andasksthequestion,"Wastherheumatismthetruecauseofthementalsymptomsofthechoreaorofboth?"andassertshisview,fromaclinicalstandpoint,thatthepoisonofrheumatismwasthetruecauseoftheinsanity.Itmaybeinterestingtonote,enpassant,thatthisviewisbynomeansanewone.Itsimplyreassertswhatwas'propoundedin1850byM.GermainSde.9Hisexpressionis,"thatchoreawasduetotherheumaticdiathesisactingonthebrainandspinalcord."Trousseau,10whoquotesS6e'sview,andacknowledgesitsprobability,didhisbesttorefuteitandtoprovethatchoreawasapurelyfunc-tionalderangement,similartohydrophobiaandtetanus.Thegrounduponwhichhebasedhistheorywasthatnogrossevidencesofinflammationofthebrainoritsmembranesarepresentinfatalcasesofanyofthesediseases.Itiscurioustoseethatnow,intheselatterdays,theolderviews-basedonclinicalobservation-haveagaingainedground,andthatthekeenandexhaustiveresearchesofscientificminds,combinedwithhighlyskilledbacteriologicaldexterityandacumen,haveshownthatthepathologicalconditionsoftheseso-calledfunctionalnervousdiseasesarereallyduetomicrobicinfectionandtoxicinfluencEs.Thefirstrayoflightwhichilluminedthisdifficultsubject-afterwhichsomanythoughtfulphysiciansweregropinginthedarkandfeelingafterthetruth,ifpossiblytheymightfindit-wasthediscoverybyWassermann,in1899,ofadiplococcuswhichhehadisolatedfromthecerebro-spinalfluidandinflammatoryexudationsofapatientwhohaddiedofacuterheumatismandchorea.Withthisdiplococcushehadexperimentallyinoculatedrabbitsandproducedinthempo]yarthritis.Drs.PoyntonandPaine,in1900,confirmedtheob-servationsofWassermann,andfoundthediplococcusinacaseofchorea.In1905theyrepbrtedanothercaseoffatalchorea,inwhichtheydemonstrateditspresence.Isolatingthediplococcusfromthecerebro-spinalfluid,theyhadproducedbyinoculationarthritis,endocarditis,andpericarditisinarabbit.Inavaluablepaper1'lDr..Beattieacceptsthetheoryofabacterialoriginofrheumaticfever,anddealswiththeobjectionsraisedagainstit,whilehecallstheorganismMicrococcusrheumaticus.Itisnotmyintentiontofollowfurtherthismostinterestingbranchofthesubject,butwouldrefertothelucidandconvincingcontributiononthepathologyofchorea-whichDr.F.J.PoyntonandDr.GordonM.Holmespublishedin'theLancet,October13th,1906.andfromwhichIhavealreadyfreelyquotedabove.Theseobserversfoundthediplococcusinthebrainanditsmembranes,andalsointhediseasedvalvesoftheheart,in3fatalcasesofchoreaandrheumatism,andtheyassumethatthepresenceofmicro-organismsgoesfartoprovethattheseinflammatorypathologicalchangesareduetoatoxinderivedfromthesemicro-organisms,andthatchoreaiscausedbytheactionofbacterialpoisonsonthebrain."Theconclusionstheycometo,intheirresearchonthissubject,inthefirstplacesupporttheclinicalevidencethatchoreaisamanifestationofacuterheumatism;andsecondly,thatthedemonstrationofdiplococciineachoftheirthreecasesisastrikingconfirmationoftheasser-tionthattheDiplococcusrheumaticusistheinfectiveagentin-acuterheumatism."Mycasedoesnotexactlyaddsupporttotheviewsjust,stated,insofarasnomicro-organismwasdiscoveredbyDr.O'Sullivaninhiscarefulbacteriologicalexaminationofthebrainandspinalcord.Ihave,however,feltitmydutytorecordit,asacontributiontotheliteratureandclinicalhistoryofthismostinterestingsubject,sinceitisonlybytheaccumulatedrecordsofcasesofchorea,inwhichafullandreliablepathologicalreportismadebycapablebacteriologists,thatasurefoundationcanbelaidandatruepathologyerected.REFERENCES.'Brain,vol.xii,p.129.2BRITISHMEDICALJOURNAL,February,1887.3Brain,vol.ii,p.151.4Med.-Chir.Review,vol.xl,1867,p.506.5Brain.vol.xii.p.157.6Ibid,vol.xii,p.151.7BRITISHMEDICALJOURNAL,p.1454,1906.8MtentalDiseases,p.485.3rdedit.,1892.9DelaChoreeMemb.andl'Acad.deAld.,Tomexv,1850(quotedbyTrousseau).10CliniqueMedicale,1868,vol.ii,p.786.11BRITISHMEDICALJOURNAL,December,1905.ONTHEVALUEOFANABNORMALRISEINTHEAVERAGELEVELOFTHEDIAPHRAGMASAGUIDETOTHEVOLUMEOFTHEBLOODINACTIVECIRCULATION.*ByT.STACEYWILSON,M.D.EDIN.,M.R.C.P.LOND.,PHYSICIAN,GENERALHOSPITAL,BIRMINGHAM.THEobjectofthispaperistobringforwardclinicalevidenceinfavourofthefollowingpropositions:1.When,fromanycause,thetotalvolumeofthebloodincirculationismateriallydiminished,the.totalbulkoftheintrathoracicvisceraiscorrespondinglydiminishedbytherelativeemptinessofthethoracicbloodvessels,especiallythoseofthelungs.Thisdiminutioninthebulkoftheintrathoraciccontentsshowsitselfbyanelevationofthediaphragm,whichhastobemaintainedatahigheraveragelevelthanthenormalinorderitoadjustthecubiccontentofthethoraxtothealteredvolumeofitscontainedviscera.2.Thatsuchariseofthediaphragmmayfrequentlybedetectedclinically,and,whenpresent,isofvalueindiagnosis,andafforduimportantindicationfortreat-ment.NORMALPOSITIONOFTIHEDIAPHRAGM.Thepositionofthediaphragmcanberecognizedclinicallybyascertainingtheupperlevelofth?gastricresonanceintheleftnippleline,oroftheupperborderoftheliverintherightnippleline.Inbothcasesper-cussionisbestdonewiththepatientrecumbent,andinthecaseofthegastricresonancetherecumbentpostureisessentialtoaccuracy,becauseintheerectposturethegaseouscontentsofthestomach,ifscanty,mayriseupintothearchofthediaphragm,andthedullnessoftheliquidcontentsofthestomachbecontinuouswiththedullnessoftheleftlobeoftheliverandtheheart.Ofthetwomethodsnamed,thepercussionofthegastricresonanceiseasierandmorereliableforthefollowingreasons:1.Thereismuchvariationintheupperleveloftheliverdullnessofhealthyindividuals,dependentupon*ApaperreadbeforetheBirminghamBranchoftheBritisbMedicalAssoziation.