386 [na~.lgnral Address.

seem therefore that our best chance lies in assisting nature to carry on the war, by increasing the health and strength of the tissues. And although in the case of other parasites there could be very little prospect of a successful issue of the contest, it is quite certain that in the case of the tubercle bacillus the tissues are, under favourable conditions, able to gain the victory. Bearing this in mind, our great efforts should be to promote nutrition, to encourage circulation, to aid expansion of the lung, to check catarrh, and--most important of all--to supply the real food of the lung, and therefore indirectly the best antiseptic, pure air, and plenty of it. And if the general acceptance by the profession of the view that pulmonary phthisis is a disease intimately de- pendent upon the presence of micro-organisms, together with a recognition of all that is involved in that belief, should promote a wider adoption of these therapeutic measures, then the discovery of the tubercle bacillus will lead to great results.

ART. XVII I . - -Address at the Opening of the Session 1885-6. Delivered in the Theatre of the Meath Hospital, November 2, 1885. By ARTHUR WYNNE FOOT, M.D., Univ. Dubl. ; Senior Physician to the Meath Hospital; Fellow of the King and Queen's College of Physicians in Ireland; Professor of the Practice of Medicine, Royal College of Surgeons in Ireland, &c.

GENTLEMEN,--The duty has been entrusted to me by the Medical Board of inaugurating this Session, in the manner sanctioned by long-established custom, by the delivery of an Inaugural Address.

The obligation about to be undertaken is one which has more than once fallen to my lot, but my ideas ~s to the intention and aims of such an address have undergone no change in the time which has elapsed since I first essayed the task.

The course which I have marked out as suitable for the occasion is one which has reference to the interests of those who are making, or who are about to make, their first acquaintance with the practical realities of sickness as met with in a hospital. I t is proposed to occupy your time, and possibly to engage your attention, with a few considerations relative to the object and method of your studies here, which may at least be assumed to concern, even if they fail to interest, the pupils.

This course has been adopted from a conviction that it is for the benefit of beginners undertakings such as the present are

By DR. FooT. 381

intended. I t is to and for beginners these addresses are introduc- tory, their purport being to indicate the safest lines on which to work, the best methods of study, the stern necessity of early and continuous diligence, and the childish folly of idleness at any time, but most of all in the infancy of your career, when your seemingly superfluous time is often frittered away from ignorance of its value.

Though the faces of many present are familiar, and have been often seen at the bedside in the past or even previous sessions, yet I make no discrimilmtion as respects your all being still beginners. I have no apprehension that any will take offence at the term, feeling certain that the further advanced any one of you may be, the more readily will he admit the propriety of the designatlon--the more freely will he assent that he is a beginner, because he will have already learned enough to see that the period of study, to which very artificial limits are assigned, is but the commencement of a course of education which ceases only with life itself. Willingly and with all sin- cerity I will myself head tile category. In this hospital I began to learn, and in this hospital I continue to learn, day after day, and that so obviously that it would be the grossest form of self- deception to consider myself anything but a beginner. F o r with all true knowledge there comes, as the very surest sign and test of its reality, an ever-present sense of a still larger ignorance. The work of medical education by no means ceases with qualification-- we are all students, or ought to be so, to the end of "our lives.

There are, however, on the present occasion some words of appropriate greeting to be offered to the students, divided chrono- logically into new and old. The new are welcomed to the ranks of a profession whose progress in modern times has been equal to that of any other. During the last thir ty years more has been achieved in it than in any previous century. A higher standard of education, better and more practical clinical teaching, and more thoroughness of acquirement, are telling favourably on its students. Silent workers--and they are many-- in the wards, the laboratory, and the study, are evolving great truths, and con- tinually fortifying the busy practitioner with fresh facts of inestimable value. The medical profession is being held in higher and higher estimation. There never was a time in which more zeal, more ability, and more loyalty, were found among its mem- bers, and there never was an age in which our exalted vocation

388 Inaugural Address.

was pursued with such success as it is at the present day, for never was it able more certainly or more successfully to wage war against the ravages of disease and death !

The elder students are welcomed back, after a well-earned diastole af relaxation, to a renewal of their studies, in the full assurance that the foretaste they have had of clinical duties will have whetted their appetite for fresh and enlarged experience. Your primary difflculties--those attendant on the birth of effort-- have been overcome, and with the elasticity of youth you are ready to spring forward to fresh work and new undertakings. I do not say the difficulties in your path this year will be less, but the problems will be more interesting for you, and your capacity for solving them will be greater. Your return here cannot but be regarded as testimony of your approval of the efforts made for your instruc- tion, and it is certainly only natural that your teachers should feel more than ordinary interest in those who thus umnistakably show a sense of appreciation of their exertions. Some of you on your return may have felt as if you had forgotten all or a great part of the lessons of the past session, as if the knowledge previously acquired had become irrecoverably latent. This feeling of retrogression is due to the difficulty with which knowledge finds a real entrance into the mind so as to become permanently resident there. I t is a common experience in mental evolution, and one at which you have no reason to feel dismayed. The knowledge which you felt last session was dissolved in your minds may not seem now to per- meate you as it did then; but it is not lost, it has crystallised into perhaps a smaller bulk, but is there compact and secure. No know- ledge gained by personal observation is or can be really lost, though it may not be instantaneously recalled to mind at a given time and moment. Repetition of the mental exercise by which it was first obtained will soon revivify the impression, and stamp it upon the memory in an ineffaceable manner. For the pictures drawn in our minds are laid on in fading colours, and if not from time to time refreshed are apt to vanish and disappear. Fa r better is it to be insensible to the progress you have made than to contem- plate your advance with the bland self-satisfaction, which is the last doom of ignorance and folly.

Your teachers would be but indifferent observers of what is passing before them had they failed to perceive among the senior, and even among the junior students, many indications of promise afforded by unusual diligence, punctuality, and genuine interest in

Bv DE FOOT. 389

their business on the part of not a few. These evidences of aptitude and inclination for work are hailed with pleasure, both as prognostic of the success of those who exhibit them, and also on account of the great benefit such examples are to the remainder of the students. The example of a few industrious men acts like a ferment and spreads in epidemic form through a class; and the great tidal waves of work which from time to time have arisen here, have been much more due to the influence and example of a few earnest workers among the students than to that of any energetic or impressive teacher. The idle and careless feel the influence of the contagion of work, and are often induced at the eleventh hour to dig up their buried talent, and to change an attitude of listless indifference into one of interested activity. And do not think that I have laden my tongue with the coarse brown sugar of flattery, or that [ am saturated with the fretful vanity which lays traps for compliments, if I express an opinion that we are fortunate at present in having an unusually large number of working bees in this hive. I remember sessions when there were many such and when there were few such, but none when there were, taking them all round, a greater number of earnest, thoughtful, capable students--good examples to the junlors--ready and willing to work, considerate and respectful to the sick.

Beginners here are like children laid at the gates of a new world, of which the sights and sounds, and even the smells, are novel sensations. Hovering between the wish and the inability to do something, the beginner may well feel perplexed and bewildered with the strange variety of experiences among which he finds himself placed. I t is very necessary, therefore, that a beginner should have definite notions of his object in coming here, and of the best way of accomplishing it. The object of your study here is Disease in all its relationships, meaning by disease every devia- tion from the normal condition of the body, either as regards its structure or its funct ions-in other words, your object in coming here is to learn the Art of how to heal, cure, or minister relief to men, women, or children who may have come to harm from sick- ness, accident, or any other bodily or mental calamity. An endless panorama of disease will pass before your eyes in the wards of this or of any other large general hospital, affording realistic presenta- tions of all the ills that flesh is heir to. Any failure to recognise typical disease when you meet it at a future time will generally be due to neglect of your present opportunities of impressing its

390 h~augural Address.

characters on the mysterious retina of the memory, or perhaps to your having looked at it through the spectacles of books in preference to studying the original at the bedside.

The reason why hospital attendance is a matter of such vital importance, such indispensable necessity, is this," that it is only ill such a place, where each and every form of illness and injury can be seen and examined, that you can acquire the familiarity with the ways of the sick, and the skill in the management of disease which are the essential qualifications for a medical life. Elsewhere you may read about sick people or hear about sick people, but here you can see them with your own eyes, and it will not take you long to find out how much more vivid and lasting are your impressions of disease when derived from attentive inspection of living illustrations than when based on what are at the best but second-hand descriptions or paper copies. All you may read or hear about sickness and sick people, if it is to be of any practical use, must be supplemented by the information obtainable here (or in similar institutions) beside and among the beds of the patients. The Art of Surgery, Medi- cine, and Midwifery, is learned and is practised at the bedside, whether the object of your assistance be lying on a straw pallet upon the ground, or " in the perfumed chambers of the great, under the canopies of costly state." To those who look forward to practising their profession the hospital is what the dissecting-room is to the anatomist, the laboratory to the chemist, the gymnasium to the athlete--it is the place where they have the opportunity of acquiring sk~ll, practice, and knowledge of their Art.

I t is the only place in which you can acquire some experience of the working of disease on human bodies. This quality is highly thought of by the public, and is by them very generally assL~med to be a special and essential attribute of age. There is nothing which makes a young man feel more keenly the chilling disadvant- ages of juniority than his supposed deficiency in this commodity, when his assumed lack of it is made an objection to his being given some appointmen~ he is in search of. Yet the amount of experience-- real, useful, clinical experience--which an attentive and observant student can acquire during his permd of hospital study, is often ample provision ibr him to start in life with. I am strictly within the limits of veracity when I say that on mo~e than one occasion I have known the experience of an industrious student to have been quite large enough to contrast very favourably with that of some

By DR. FOOT. 391

who were certainly older, and who passed for Mser persons. A want of experience in those who undertake any practical art is so frequently attended with disastrous results that it cannot be felt unreasohable that some ellnical information should be forthcoming on the part of tllose who hope shortly to practise the art of medicine. The value and the cost of experience are indicated in many trite and well-known aphorisms. Experience is the very best of teachers, but she charges very high for her instruction. Experience sometimes costs much more than it is worth, but many refuse to learn at any less price. I t is often dear and bitter to the purchaser, who may have to repent in sackcloth and ashes, the price he has paid for it, for it may have been purchased at the cost of human life. Experience thus obtained cannot but be an unwelcome subject of reminiscence at such times as the burial places of the memory give up their dead, and the thoughts arise that it might have been otherwise :

" :For of al l sad words of t ongue or pen, Tile saddes t are t h e s e - - ' I t m i g h t have b e e n . ' "

The hospital is your school of experience. I t is for each of you a garden of the Hesperides, into which you may at any time enter and pluck the golden apples from the laden boughs. Though the dragon of responsibility is there he will not meddle with you. It is your teachers he keeps his eyes on.

I t is pitiably tbolish to neglect hospital attendance, and to throw away the invaluable opportunities it affords you of aequMng experience without risk or trouble. There is no profession, art, or even trade, in which any but a madman would embark unpro- vided with a store of practical knowledge, such knowledge as alone will lead to his doing well whatever particular work he undertakes.

Hospital attendance, under the new system of study, is wholly optional for a student in his first year ; it is not eompulso,y. But it will be no encroachment upon the time devoted to his technical pursuits to spend an hour or two in the hospital wards every morning in the week. Although he may not take in a great deal of what he hears, he can see there much which will be intelligible, and he will be but imperfectly adapted for the profession if his regular daily visits fail to be of unmistakable advantage to him. Trousseau, one of thewisest physicians and best clinical teachers of modern times, emphatically says . . . . From the day on which a young man wishes to

392 l,~augural Address.

be a physician he ought to attend the hospitals." If you want a man to become a tea merchant you do not tell him to read books about China or about tea, but you put him into a tea merchant's office where he has opportunities of handling, smelling, and tasting te,. Without the sort of knowledge which call be gained only in this practical way, his exploits as a tea merchant will soon come to a bankrupt termination. I f you want a man to be a doctor he must frequent a hospital. I t is only there he can gain proficiency iu the inner art of medicine. Anatomy, physiology, and chemistry, indispensable though they be in medical education, are not the A B C of practical medicine. One may know them all and yet be unfit to treat a common case of disease. "Mere anatomists." says Mery, "are like the porters of Paris, who are well acquainted with all its streets, and even its lanes and alleys, but know nothing of what is going on within the houses." However, by attending hospital you will be enabled to pursue each of these contributory sciences with a pleasure not othewise to be enjoyed, for you will get glimpses of their profound applications, and with benefits which cannot otherwise be calculated upon, for you will have re- peated proofs of their intimate relationship to the art of medicine. A beginner here may possibly do little more at first than accustom himself to the routine and discipline of the house by attending, at the stated hour, the teacher on duty. He m:ty not be able at first to do much more than look about him. But even that will be of use to him. People have always looked, or tried to see, when they wished to acquire information about any new thing. I t is a truism, on which it is needless to dilate, that the way to the understanding is through the senses, that in the young the senses are more alert than the intelligence, and that the earliest teaching should be addressed to the eyes and ears rather than to the reflective powers. By taking pains to be in the wards as much and as regularly as possible, a beginner will at least be able to hear what the patients complain of, to pick up the elementary characters of disease, to take notice of the signs of sickness, to observe the symptoms of danger, or of the approach of death, to watch the effects of treatment and the evidences of recovery. By following your teachers at their appointed hours, imitating their manner, noting their proceedings, picking up the odds and ends of their experience, and looking with both your eyes when they say, " See here," o r " See there," you will unconsciously accumulate a stock of knowledge, multifarious it may he, but the

By DR. FooT. 393

good of which will not be fully known till after-years have explained and confirmed its worth.

After a short time the beginner will have to do something more than look on. He must commence to observe for himself in an independent and systematic manner. For merely to have seen disease and to really know disease are two very different things, and a casual passing glance at a case of sickness is not for a moment to be confounded with a knowledge of it. As well might one persuade himself that he was on terms of intimacy with a chance acquaintance because he had been once introduced to him in crowded room. Such a momentary introduction does not warrant any familiarity, and the presumption that it does may lead to an unpleasant rebuff ; so one who undertakes to meddle with disease, whose characters he only knows by sight, runs very great risk of finding his overtures terminate in a complication of disasters. As soon as the beginner feels equal to it, and the ability may be expected from any average man in the course of his first year, he should take personal charge of some simple and easy case. The teachers in either the surgical or medical wards are only too willing to recognlse this hopeful slgn of independent action in a student, and he has but to express such a wish to have it gratified. Ill this manner the pupil is brought into close quarters with the object of his study. By having immediate cognisance through his own, rather than mediate through his teacher's mind, of the materials of his study, he begins to comprehend as well as appre- hend his business (for the causes of things often lie deep beneath the sm'face of appearances), and he commences the actual practice of his art, free from the distracting influence of personal responsi- bility since he acts under the master's supervision and has his assistance to appeal to in perplexity.

Like any other art, that of medicine is to be learned only by its exercise and use. The sooner any student begins to employ his powers in its exercise the better. This is the real way to learn medicine in the opinion of the celebrated Sydenham, who is justly regarded as the chief of English practical physicians, considered by some to rank second to the divine Hippocrates alone, and whose name was held in such reverence by the illustrious Boerhaave that he never mentioned it before his class without raising his hat. In a letter to a medical friend Sydenham has left the following account of his early professional llfe : - - "Having returned to London, I began the practice of medicine, which when I studied

2 D

394 Inaugural Address.

anxiously with most intent eye and utmost diligence, I came to this conviction, which to this day increases in strength, that our art is not to be better learned than by its exercise and use ; and that it is likely in every case to prove true, that these who haw directed their eyes and their mind, the most accurately and diligently, to the natural phenomena of diseases, will excel in eliciting and applying the true indications of cure." All tile great men who have contri- buted to the lustre of the medical profession have proclaimed the absolute necessity of the observation of clinical facts; it is at the bedside the mind is brought into direct contact with the facts in question--living, breathing, speaking facts. The crowning ex- cellence in every branch of the profession is consummate ability in clinical observation. This ability cannot be transmitted to others, for it is incommunicable, but the way in which it is obtained can be indicated, and is over and over again indicated here by example as well as precept. I t is arrived at by attention, industry, and patience. The road is long, slow, and difficult, and there is no short, rapid, easy path to it. Many will not attempt it at all, and others give it up in despair.

That ability in clinical observation is the capital accomplishment of a surgeon as well as of a physician you may gather from the words of Sir Philip Crampton, who was for sixty years surgeon to this hospital, and whose name still stands without a rival in the aristocracy of Irish surgery. In an Introductory Lecture delivered in this hospital (]Nov. 4th, 1839) he used the foll#wing words : - - " Now, I am sorry to say that the path of clinical observation is neither short nor pleasant ; in truth nothing but a fuU and entire conviction that it is the only path (not the best), but the only path which leads to professional success, could ever induce the medical student to pursue it, and it will prove one of the chief objects of this address to press this conviction home to the understanding of every man who intends to devote himself to the practice of the healing art."

This was no isolated promulgation of his opinion, for for seven- teen successive years, prior to the one in which the Address, from which I have just quoted, was delivered, Sir Philip had opened the winter sessions here with a lecture, which (to use his own words) was "explanatory of the nature and importance of clinical observation and instruction." This annual reiteration of such an opinion, with all the emphasis his commanding position, with all the weight his vast experience, with all the charm his un-

By DR. FooT. 395

faltering eloquence, could impart to it, is ample proof that it should still be the key-note, or at least the dominant chord, of the theme on these occasions ; and though I neither think nor feel that it is within my competence in any way to rival the efforts of such a predecessor, still it may not be unreasonable to cherish a hope that some echo, however feeble, of this great master's sentiments, whispered down the corridors of time, may strike upon hearing ears to-day ] The path of clinical observation is long and slow and difficult, because such observation must be rigorously exact and minutely particular, but it is not from the rose the bee gathers most honey, but often from acrid and unattractive blossoms. All investigations into the phenomena of nature must begin by the observation of facts, yet few are fully aware of the difficulty of the art of simple observa- tion. To observe properly in the simplest of the physical sciences often requires a long and severe training. The difficulty of arriv- ing at the actual truth by direct observation is sometimes so great, when contrasted with the ease with which an hypothesis is made, that it ceases to be wondered at that theory takes the place of observa- tion in the views of those who are not devoted to bedside study. " The greatest thing," says Ruskin, " a human soul ever does in this world is to see something and tell what he saw in a plain way. Hundreds of people can talk for one that can think, but thousands can think for one who can see." The evolution of your natural power of observation, be it great or small, must be carefully superintended, if its growth is to be steady and if it is to arrive at maturity without succumbing to disease. I t should, at all events at first, be concentrated upon a few cases, and those of an element- al T nature. Looking at everything generally ends in remembering nothing except externals. Since, in the words of Locke, it cannot be hoped that the pupil " should have time and strength to learn all things, most pains should be taken about that which is most necessary ; and that principally looked after which will be of most and frequentest use to him."

The path of clinical observation must be long when you remember that there is no finality in medicine. Medical education can never be said to be completed. Even proficiency in it is the object of a life-long study. In the three or four years spent before the legal qualification is obtained, you can, at best, but learn the rudiments of an art whose bounds are never reached. Men of the highest ability, after continuous devotion of their lives to its service, find at the end that they are only on the outskirts of a

396 Inaugural Address.

knowledge of it, and are compelled to admit, with the Persian Philosopher, that the little they know is nothing, what they do not know is immense. You will find that it is difficult when you come to feel the strain of responsibility and anxiety on both mind and body, the frequent interruptions to your rest and pleasure, the efforts necessary to keep abreast of intellectual progress ; you will find that your real work has only begun when you have put on your pro- fessional harness, that your student work was but play to it, and you will perceive something of the force of the words which Velpeau whispered to N61aton, as his lips were quivering in death, "Travaillons toujours." I t is from clinical observation you will acquire proficiency in the inner art of medicine; the outer science is more or less optional for each man to pursue, according to his leisure, his opportunities, and his capacity; it need not be exagge- rated into a matter of necessity for all. Of this you may be certain, that though you may be conversant with all the mysteries of scientific medicine, if you are unprovided with the sagacity, and skill, and readiness'which are the outcome of bedside study, you will not be likely to be useful or successful practitioners.

The out-patient department affords a field of study in which a beginner can spend much time with advantage. The greater part of my first two years I spent at work in the Dispensary. The pabulum presented there is better suited for the lacteal period of study than the more serious and complicated cases under treat- ment in the wards. The student sees there the more trivial ailments, such as he will oftenest meet, and frequently be best remunerated by in after-life. He has constant opportunities, if he will take advantage of them, of educating his senses--touch, sight, smell, and hearing. There is some danger in ,this very instrumental age that a student may, by depending too much on mechanical aids, neglect the beautifully delicate apparatus he is provided with gratis by nature, aud so fall very far short of that ability which so largely contributed to the success of our medical predecessors, who had to rely on their unassisted senses. The aphorism--" Sine thermometro nulla therapeia" may be true, and I do not cavil at it, but in these days when we try to measure everything, there is some risk of losing the taetus eruditus of our ancestors, and if any would s a y - "Well , lose it, we have better to replace it with," ][ would remind him that these natural instruments have the great advantages of portability, that no emergencyis likelyto catch youwithout them, and that in a large proportion of cases nothing else is absolutely required.

By DR. :FooT. 897

There are so many working men among the more advanced students that it perhaps might be better to leave the juniors to be inducted into the habit of work by the silent force of their daily example, than to endeavour by impassioned exhortation to stimulate them to exertion. And yet, I might appeal to you, by your filial regard for those who are making sacrifices for your advancement, not to allow this season of aptitude and inclination to slide away unimproved into the fathomless depths of the past, to mingle with the lost opportunities that are drowned therein. I might appeal to you, by all your hopes or dreams of success, not to sacrifice on the altar of neglect present advantages which may never again be offered to you. I might appeal to you by the time-honoured memories of this old Hospital, to emulate those youths who annually leave its walls, stamped with the hall-mark of its practical teaching, carrying their aid over sea and land to all who need it, irrespective of colour, creed, or character. And I will not lose this opportunity of pleading with you on e~ch of these grounds to make the best use of your privileges in tile interest of your. friends, yourselves, your profession. I have.been told it is in vain to do so, but with an earnes t /~ 7grotto, I deprecate the notion, for I have myself felt the influence of these Addresses when they had the ring of truth and sincerity, when precept was followed up by practice, when the cry was more " Come on" than "Go on." I know how their tones have startled the apathetic from the sleep of indifference, ]low the fervent air of emotion has fanned into a blaze latent sparks of zeal, how their arrowy words have pricked, as the touch of golden spurs, the eager to redoubled exertions; and am I to be told, or if so am I to believe that there are not here to-day fresh young hearts, as sensitive to the touch of sympathetic impulses, as ready to strike responsive chords consonant with the vibrations of the speaker's heart, as there were twenty years ago l

Gentlemen, it would have been much easier, and would have been a great economy of nervous force, for me on the present, occasion to have posed as a scientist, and poured on your bewildered ears a torrent of phraseology in the shape of a disquisition on the position or prospects of advanced medicine. Perhaps the entertain- ment, I will not venture to say the advantage, of the distinguished company who honour with their presence your inaugural ceremony, might have been better served, but I think your time would have been wasted, and your patience trifled with; and I fear the lion's skin assumed for the moment would soon have dropped from my

398 Arthritis, arising from Peripheral Nerve .Lesions.

shoulders when you would have found out the next day in the wards that I was but an ordinary learner like yourselves. I did not know any better way than that I have taken of discharging the duty entrusted to me, and should this Address prove only memorable for its weariness, only conspicuous for being "one more attempt to polish up a threadbare subject," I will ask for your indulgent consideration on the grounds of an implicit and unshaken belief in the inestimable value and in the absolute necessity of "Clinical Observation."

A~T. XIX--Arthritis, arising from Peripheral Nerve .Lesions. By J. M'ARozE, F.R.C.S.I. ; Surgeon to St. Vincent's Hospital.

I:~ using the name neurotic arthritis for the following, I do so with reserve, and less as an effort at representing my own opinion of the cases to which I wish to call attention, than as an endeavour to draw a line of distinction between them and those cases of doubtfill origin, usually styled rheumatic gout.

Many will, no doubt, look upon some of them as fairly typical cases of that affection; even should they do so, I shall not question the propriety of thus naming them, so long as I can prove that peripheral nerve lessions have, in each of them, produced the dys- trophy, and that the removal of the nerve disturbance effectually removed the joint trouble.

In reference to the pathology of rheumatic arthritis, I question if many of the cases so called could not be traced to a neural origin, and be treated more rationally were such origin more frequently remembered.

In his paper on chronic rheumatic arthritis, read at the meeting of the British :Medical Association, at Belfast, in 1884, Dr. Dyce Duckworth stated very clearly the chief views put forward in explanation of the origin of this affection, and in his concluding remarks he said : - -" The nervous system is markedly implicated in the arthritic diathesis, and many of the features, both of rheumatic and gouty disease, point to the probability of their being atrophie centre tbr the joints situated in the spinal cord ; and a morbid and irritable condition of this centre may result in a definite neurosis, which may be inherited, acquired, or modified." That the injury of this centre, in the course of spinal disease, is capable of pro- ducing destructive changes in joints, has been very clearly shown