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The speech is considered characteristic, it is jerky, scanning, so that the patient hesitates. There are irregular jerky movements of the muscles of the mouth and tongue, and the teeth are uncovered in utterance. The localizing symptoms are as various as the functions of the nervous system. In general terms, it may be said that if a sclerotic patch implicates a motor tract it will cause paralysis. In very few cases is the gray matter of the cortex affected. So that when there are localizing symptoms as dementia, which is referable to lesions of the gray matter, as a rule, disseminated sclerosis should be excluded except in children.
If the cerebellum is affected the characteristic symptoms of cerebellar disease will be added to the general symptoms. If there is a sclerotic patch destroying the functions of certain spinal areas, symptoms of impairment of such areas will be present, and the most frequent of these seem to be some of the symptoms of locomotor-ataxia, such as loss of the knee jerk and marked ataxia. Strabismus is frequently an early symptom. Nutrition is usually umimpaired throughout. The etiological factors are: Age, sex, heredity, exposure, emotions, trauma and febrile disease. Most cases are found between the ages of twenty and thirty-five years, but it also occurs in children. The disease is much more common among adult females than males. Premissing this brief description of the disease, I will submit a report of a case under my observation, and endeavor to call attention to the points of similarity and dissimilarity with the general description of disseminated sclerosis.
March 22nd last was called to see Mrs. P., age 35, mother of several children, whom I found complaining of some pains in head and back of neck, not severe, and slight paresis (both motor and sensory) of the entire right half of the body had vertigo unaccompanied with nausea, temperature normal. The paresis (both motor and sensory) was, however, only partial, as she could move upper and lower limbs, but with greatly diminished activity or force as compared with the arm and leg of the tleft side; the anesthesia was also partial, as she was able to feel he prick of a pin, but less acutely than on the other side. Inquiry elicited the following personal history:
Confinement nine months before, after which recovery was imperfect, although she was up at the usual time. She did not
regain her usual vigor, though there was no definite ailment, yet a sort of general weekness which after a time was especially noticeable on the right side. This, however, did not give alarm until the day I was called. While standing before the mirror arranging her hair the numbness or partial anesthesia came suddenly, and was the cause of my immediate summons. She was an inveterate user of tobacco snuff, but prior to her last confinement had always enjoyed good health.
I can not give the treatment in detail, as I failed to take notes of the case, and have written from memory, but suffice to say that the pain in the head was easily relieved and was never a prominent symptom. Not so, however, the paresis, which continued, and though never becoming complete, was never mitigated in the least, notwithstanding strychnia was used freely and continuously for weeks. In two or three weeks there was added symptoms of ptosis, not complete; and following this, in a short time, was convergent strabismus of the left eye, together with beginning atrophy of the optic nerve, as evidenced by defective vision in the eye; then ataxia, incoördination, and, finally, paralysis of the entire left side of the face.
Now, for the first time, was it possible to locate with something like certainty the seat of the lesion, for it is in lesions of the pons that we have paralysis of sensation or motion, or both, of the side of the body opposite the lesion and paralysis of the trigeminus, abducens, facial, hypoglossal, and possibly the auditory nerve, all upon the same side of the body as the lesion. Vertigo, also, is an accompaniment of lesions of the pons, and in this case was a constant symptom, as was, also, exaggerated patellar reflex on the side opposite the lesion and absence of mental disturbances. If, however. the disease should be situated high in the pons, near where the crus passes into it, there would be a unilateral paralysis, i. e., cranial nerves, and limbs would be affected upon the same side opposite the lesion.
About the middle of July the left side of the tongue became paralyzed, so that mastication became difficult on account of inability to move the food about. August 10th, suddenly, in the night, death closed the scene, probably by implication of the nerves of respiration. No post mortem was had, but the case was diagnosed "Disseminated Solerosis."
Differentiation.-Tremor, incoördination, increase of tendon reflexes, optic nerve atrophy, peculiar speech, and vertigo, were all present in this case. The tremor, however, was not so prominent as writers are accustomed to describe as belonging to disseminated sclerosis, was not nearly so noticeable as the incoördination, which was very marked. Whenever the patient attempted to carry a glass of water to the mouth she always spilled more or less of it, or touched some other part of the face before getting it to the mouth. The speech, although peculiar, was not jerky, tremulous or scanning, described as belonging to sclerosis, but more like that belonging to paralysis agitans, that is, slow, deliberate, monotonous. Nystagmus and contracture, frequent symptoms of dissiminated sclerosis, were not present. The duration of the disease is another point of dissimilarity. It is described as being exceedingly chronic; the shortest duration I can find is by Gowers, twenty-one months, while this case lasted only five months from the time I first saw it; how long it had been in progress I could not find out certainly.
Prognosis. The prognosis is said to be bad in these casesnone ever recovering. This I am prepared to believe, for in spite of strychnia, iodide and bromide of potassium, ergot, and the entire class of remedies usually tried in such cases, there was never the slightest improvement in any symptom except the ptosis. This is especially a noteworthy feature, and one hard to account for in view of the progressive character of the disease, new areas all the while becoming involved; and, also, in view of the fact that the first symptom presented in the case, hemiplegia, never improved in the least, but grew rather worse all the time, never, however, becoming complete.
Proceedings of Societies.
TRI-STATE MEDICAL SOCIETY OF ALABAMA, GEORGIA AND TENNESSEE-FIFTH ANNUAL MEETING.
HELD IN CHATTANOOGA, BEGINNING OCTOBER 13, 1896.
President J. B. Murfree called the meeting to order, and it was opened with prayer by Rev. R. B. Garrett.
The first paper read was by Dr. Y. L. Abernathy, entitled "Convulsions in Children Treated by Large Doses of Morphine." He cited several cases which were about to die and recovered under large doses of morphine.
Dr. Andrew Boyd had used large doses of morphine in cholera infantum a dernier resort. In convulsions and cholerainfantum the cause seems to be entirely reflex, and the treatment seems to be correct and rational, no matter how heroic it may seem. He related a case where an infant six months old took seventy drops of tincture of opium in two and one-half hours and four quarter grain injections of morphine in six hours.
Dr. C. P. Colvin did not like to advocate large doses of morphine, as, if long continued, it would produce convulsions. These cases can be controlled by water, by sponge bath, or by wrapping in a blanket, the temperature of the patient being an indication of the temperature of the bath. In cholera-infantum small doses of mercury.
Dr. P. L. Brouillette said large doses of morphine could be tolerated in these cases. This does not cure the disease, but gives time to look for and treat the cause.
Dr. W. C. Townes thoroughly agreed in giving large doses in these cases. Being self-limited, the patient will recover if he
can be tided over the crisis. He had given one grain of strychnine with good effect. He had given one-half grain of morphine to children.
Dr. George S. Brown thought it dangerous to allow such claims of the harmlessness of large doses of morphine in children with convulsions to go unchallenged. He said that it was well known now that convulsions were due to the absorption of toxins from undigested food in the alimentary canal. These toxins were powerful irritants to the nervous system, and in this respect no morphine was an antidote, and just therein lies the harm. As long as the toxins are being absorbed there may be a great tolerance for the morphine, because their respective effects on the nervous system are exact opposites. Let a purgative be given and the poison-breeding material be swept away. Such doses of morphine as recommended in the paper would likely prove fatal.
Dr. W. G. Bogart said that he understood that this was not the only treatment the Doctor gave, but this with other treatment. He would give an active cathartic, a hot bath, a copious injection of hot water per rectum, and morphia (if the convulsions still continued) in doses large enough to control the convulsions.
In closing the discussion, Dr. Abernathy said that morphine was the most deadly, damnable and detestable remedies we have; like the vampire, it lulls its victim to sleep while it sucks its life-blood. He never uses it in children, except in these cases, which otherwise will surely die. Other treatment is indicated; nervines, cold applications if fever, eliminants, etc. The convulsion is only a symptom, but a very dangerous symptom, and if not relieved the patient will die. As causes he mentioned debility, gastro-enteritis, peripheral irritation, rickets, ptomaines, fever, congestion of brain, etc.
Dr. D. S. Middleton read a paper on "Cystitis; Report of Cases," being a statistical report, showing its frequency in wom. en, a discussion of the pathology, cause (microbic infection), the treatment by antiseptic injections, and report of cases.
Dr. G. A. Baxter would add only one remedy: a saturated solution of acetate of aluminum. Nitrate of silver sometimes produces tenesmus, and he no longer uses it.