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neuralgia, and has one sister who suffers from paraplegia. Has done an immense amount of writing during the last thirteen years, often writing "against time." States that in the summer of 1868 he felt that he had lost control over his pen, and was obliged to grasp it tighter. He managed, however, to continue writing tolerably well till April 1872, when "he lost control over the fore-finger," and was obliged to begin holding his pen by interlacing it among the fingers. He cannot rest his wrist upon the desk when writing: if he does so, the fingers and thumb "start away from the pen." He complains of deep-seated pain in the wrist-joint, and in the carpo-metacarpal joint of the thumb. He has now completely lost the power of writing with his right hand, and has learnt to use the left; but, strange to say, he is quite unable to write with the left hand without making spider-like movements with the fingers of the right.
Any attempt to use the right hand causes agonising pain from the shoulder downwards. The pain is the pain of intense overfatigue, and does not follow the line of the nerves. On stripping him it was found that there was nowhere any detectable wasting of any muscle, but that both arms were soft and flabby, and the right rather smaller than the left. On being asked to write, the whole body seemed to take part in the exertion; the pen was grasped as tightly as possible, the fore-arm raised off the table, the shoulder elevated. An incomplete signature was all that could be effected, and the attempt caused great pain in the limb. On testing with faradism, it was found that the interossei, the abductor pollicis, the flexor longus pollicis, and the extensor primi internodii, contracted far less readily and less forcibly than their fellows of the opposite limb. Voluntary movements of these muscles were performed with the greatest difficulty, as was also the movement of supination, which could only be effected four or five times in succession, notwithstanding the strongest efforts to do so. The phalangeal joint of the right thumb has a curious habit of "snapping" audibly at intervals, which is due, apparently, to the spasmodic and unequal action of the muscles moving it. The nails of both hands are very bad being "pitted" in an extraordinary manner.
His condition is ever present to his mind, and his menta state is one of great depression, his writing-power being his
source of income. Lithographed fac-similes of this patient's handwriting are given, which show how rapid was his improvement under treatment. On the first application of the current the pain in his arm disappeared, and within a week of its first application he could manage to sign his name with tolerable ease. His writing from this time rapidly improved, and at present his handwriting, when he is allowed to use his right hand (which is very seldom), is, as far as appearances go, as good as it ever was. Samples of his handwriting are given in the accompanying lithograph. The first three samples were written respectively on the 5th, 12th, and 21st of October, and No. 4 on the 1st of November. The other two samples are dated. Although the handwriting is now very good, the pen-prehension is still faulty, and I have forbidden him to write until he can do so with the pen held properly and lightly between the thumb and first two fingers. Pen-prehension has gradually very much improved, and it was soon noticeable that the effort of writing had much decreased, and such efforts soon ceased to cause fatigue. First, the elevation of the shoulder disappeared; then the fore arm could be rested on the table during writing. Next, the phalangeal angle of the thumb no longer gave way, and now he can write very comfortably if he holds the pen only between the thumb and first finger (at one time the first finger could not be placed on the penholder), but any attempt to use the middle finger bothers him very much. On testing the muscles with faradism, it is now found that the dorsal interossei on either side of the middle finger respond far less readily than their fellows of the left hand, but that the other interossei, which were weak in the first instance, have recovered their normal irritability. Earlier in the case it was evident that the dorsal interosseous muscle on the radial side of the middle metacarpal bone was less irritable and more weak than the one on the ulnar side; and by placing a rheophore on the metacarpal bone so as to influence equally the muscles on either side, the first phalanx was flexed, but dragged by the stronger muscle towards the ulnar side.
The galvanism has been used in the manner stated above, and the variety of exercises which he has been made to practise is very great. Especially he has been made to hold a pen or pencil,
or my finger, and to perform with it the movements of writing a hundred times in succession, while the current has been applied alternately to the nerves supplying the muscles implicated. At first the difficulty of this exercise was extreme, the pen frequently slipping from the grasp of the fingers. At present it can be performed without any difficulty whatever. The only movement at present in performing which there is the slightest difficulty is the waggling of the middle finger from side to side by means of the interossei. It was noticeable very early in the case, that the fore-arm had got firm and muscular, and that the pitting had disappeared almost entirely from the finger-nails. The patient's enjoyment of the current is quite laughable, and during its application he frequently uses such expressions as "That's comforting,"" That seems to give me strength," &c. The general health has much improved, a fact which is attributable in great measure to the removal of the cause of his mental depression, as well as to the mixture of strychnine, perchloride of iron, and nitro-muriatic acid which he has been constantly taking. The snapping of the thumb has almost disappeared, and is now far less frequent and less loud.
He has continued to use the left hand for writing while he has been under treatment. The movements of the right fingers while writing with the left hand have quite disappeared. Once or twice he has complained of a feeling of awkwardness with the left hand, but this has always been immediately removed by the current. The amount of writing which he has done during the treatment has been about two hours a day, but this amount had to be performed often rapidly and against time.
In conclusion, I may be allowed to express my belief that chronic fatigue from over-strain will be found to be the cause of certain other progressive functional disorders. In fact, I have at present under my care a case of clonic torticollis, which I believe to have been clearly caused by the over-straining of the left sterno-mastoid and trapezius. I shall hope at some future time to touch upon this subject and report the above-mentioned
MIGRAINE FROM INJURY TO THE HEAD.
BY DOUGLAS MORTON, M.D.,
I WILL offer a number of facts, drawn from my own personal experience of migraine, that throw, I think, a flood of light upon part of the subject out of which arose the discussion between. Dr. Anstie and Dr. Dale.
In my judgment these facts very distinctly support the theory of a neurotic origin. The symptoms attending all my attacks, in order and character, have been just the same; and each attack, as far as I have been able to learn, may be properly regarded as a typical expression of the affection. But the point to which I would especially call your attention is, that my first attack was directly and immediately induced by an injury.
About fourteen years ago, while a student at college, I had a severe fall from a swing in a gymnasium, my head striking with great violence the hard, beaten earth beneath. At the moment I felt no pain, but experienced a horrible sensation, which I suppose is best described by the word stunned. I went at once to my room, and when, after a short time, my symptoms had improved a little, I took up a Greek book in which I had to prepare a lesson for that day. To my dismay I found that I could see only the left half of the open book; and if I directed my attention exclusively to a line or a word, only the left half of that. My first impression was that my right eye had been injured; and when I looked in a mirror to find out if this were the case, I was startled at not being able to see any part of the right side of my face. I held my hand over one and then the other of my eyes, and discovered, as I supposed at the moment,
that the injury to my eyes consisted in destruction of vision in the right halves of both, for with either closed I could see the left halves of objects I looked at with the other. As yet, as well as I recollect, my headache had not commenced. I returned to my book and tried to translate, but found this impossible-the meanings of the words had escaped my memory almost entirely. I could scarcely pronounce a word-the difficulty seeming to be that I could not well retain a conception of the sound represented by more than one letter at once. In a short time I began to suffer headache, but at first it was not severe, and I went out and joined a group of students on the college grounds, in whose conversation I ventured to participate. I found, however, that I was the subject of a peculiar kind of aphasia-I could intelligently follow their conversation, but had not the power to select words suited to the expression of what I wished to say. I hit upon words in a most curiously random way-a verb, perhaps, for a noun, or an adverb for a preposition. My headache continued to increase in severity, and in another hour became almost intolerable. Now I began to suffer nausea, and vomited, but the disturbance of vision had entirely passed away. I soon recovered from the sickness, though the headache lasted the remainder of the day-about eight hours.
Had I suffered no subsequent attack of migraine, I should now regard the condition which I have described as simply that to which "concussion of the brain" gives rise-the subjective symptoms of which, by the peculiar circumstances of my case, I could observe closely, and give a better account of than we can usually elicit from patients.
After an interval of about seven years I had my second attack, and on this occasion noticed phenomena that escaped my attention in the preceding one, viz. the appearance of such a figure as I have represented in the enclosed drawing,1 trembling in space, seemingly a few feet from my eyes, and a sensation of numbness in my right cheek and the right side of my tongue, which came on with the headache (if my memory is correct) after the optical phenomena had disappeared.
Since that time I have had several other attacks, each being expressed by essentially the same set of symptoms. The form 1 No drawing found in envelope.--ED. Pract.