Original Communications. ON A CASE OF TREPANNING OF THE SKULL FOR THE paroxysms took place also in the morning, whereas at present they fall upon him at any hour of the day or night; the earliest four or five were immediately followed by vomiting, not now present, and on no occasion has he had the least premonition of the coming convulsions. When I first examined him, the 15th of January, he had just got over two severe attacks, which occurred in the course of the previous twenty-four hours, and his condition was as follows: countenance rather pale, BY M. GONZALEZ ECHEVERRIA, M.D. SUPERINTENDENT OF THE MAHOPAC HOUSE FOR THE RELIEF AND CURE OF pupils of equal size and enlarged, slight though per NERVOUS DISEASES, AT LAKE MAHOPAC, N. Y.-LATE PHYSICIAN IN CHIEF Epilepsy occurring fourteen years after injury to the skull, with incomplete paralysis of the left facial and sixth nerves, and diminished sensibility and temperature of the skin extending to the arm on the same side; tonic contraction of the right muscles in the cervical region with lateral distortion of the head; great frequency of the pulse, and polyuria. Removal of part of the occipital bone with inner exostosis pressing upon the brain, violent epileptic convulsions when the trephine penetrated the diploic tissue. THE following notes are taken from records carefully kept by Dr. L. B. Edwards, Assistant Physician to the Institution. The patient, male, 21 years of age, born in Johnston, Rhode Island, unmarried, and by occupation a clerk, entered the Institution the 15th of January, 1868. Height five feet ten inches, weight 145 pounds. Complexion dark, eyes and hair black, beard thick. Head regularly shaped, high forehead, limbs well proportioned, muscular system strongly developed. Parents both living now, in good health, and none of their family have had epilepsy or insanity. Has since childhood a right oscheocele. Infantile and adult health perfectly good, with the exception of an attack of typhoid fever in the autumn of 1863. Habits regular. No venereal excess, or syphilis. ceptible converging strabismus of the left eye, minute ecchymoses on forehead and eyelids. Incomplete left facial paralysis, with distortion and elevation of the right angle of the mouth. Muscles of the paralyzed side flaccid-if an attempt is made to blow with mouth shut the left cheek soon yields to the effort; the saliva does not dribble, however, from the mouth, and he can whistle without difficulty. But the tongue-not furred -when protruded deviates to the left. Soft palate, firm and natural. Speech never embarrassed. Hearing, smell, and taste unimpaired. Excepting the occasional double vision from the strabismus, there is no other derangement about his eyes. The æsthesiometer shows sensibility deadened on the left side of the face and throat, no loss of feeling in either half of the tongue, with papillæ small and red. The temperature (90° Fahrenheit) is two degrees lower on the left than on the right side of the face and neck. Head inclined to the right; on this side, the trapezius, splenius capitis, and complexus, are in rigid contraction determining the lateral distortion, with prominency of the integuments on this part of the cervical region. No evidence of paralysis, numbness, or abnormal sensations in the upper or lower limbs, nor is there any difference in the comparative size of their respective muscles; but when the epileptic paroxysm is over, the arms remain powerless for a shorter or longer time. Sensibility and temperature are less on the left than on the right arm, which is two degrees warmer (88° Fahrenheit). This difference is more evident at the hands, usually cold, and inclined to In August, 1852, being six and a half years old, he turn livid. No such diminution of sensibility and temfell from a low swing and deeply wounded the scalp, perature is detected on the legs, excepting, however, just on the left of the occipital protuberance. Remain- the feet, which are cold. Walks steady even with eyes ed unconscious for a while, but apparently recovered closed. The temperature over the cicatrix of the scalp completely. The cut bled very freely, did not heal up is three degrees more (92°) than that of the rest of the in six weeks, on account of exuberant fungosities, and head. The increased heat is quite perceptible to the left a transversal cicatrix, extending about two inches hand laid over the spot. The cicatrix, as already to the left of the occipital protuberance, rather abundant remarked, is not painful; in fact it has never before atwith inodular tissue of a dull rose color, painless, and tracted his attention. Three quarters of an inch above of a fibrous consistence and hardness. Suffered from the superior curved line, and more than one inch to the severe and persistent headache after the fall, and has left of a line prolonging the occipital crest, directly since continued subject to it, the ache being general under the cicatrix and firmly united to it, the cranium over the head. In 1862, was troubled with seizures of presents an irregularly delimited elevation, rough to the sudden jerkings and spasms of the arms, they being touch and painless upon pressure. If this spot is sharpstretched out and involuntarily thrown above the head, ly percussed with the fingers the patient experiences a making objects fall out of the hand. These seizures sensation as if it were "a large white plain with a were particularly observed in the morning, after arising central black spot "-this percussion, even though tried from bed; is unable to recollect if they troubled him several times, does not awaken such a sensation on any on any date prior to the above. Has never had giddi- other part of the cranium, but always starts it when ness or vertigo, nor does he remember having ever repeated over the cicatrix. Pulse quick, firm without awaked with headache or sore tongue, or wetting his bed tenseness, not uniform, and ranging from 108 to 120, at night. The first epileptic attack happened early in according to different observations at distinct hours of the morning in July, 1865, without any circumstance the day. This frequency greatly abates after the paroxwhich can be regarded as its exciting cause. It was ysms; I found it 87 after the attack shortly to be deushered in by the acute cry which has invariably pre-scribed. Heart sound, increased in activity, there is no ceded all subsequent attacks. These were repeated oppression, nor feeling of faintness, chest well formed, five times during the three years following the initial lungs equally sound, respirations 20 per minute. Diges one, but now come on every third or fourth day. The tive functions regular, seldom inclined to costiveness. jerking and twitching of the arms never ceased during Appetite good. Drinks considerable quantity of water. the period intervening between the attacks, and always Remarks that he passes a large amount of urine, and with its morning character. Originally the convulsive that he has done so long before this. Has been on a few occasions troubled with erections after the attacks. Careful measurement and investigation, carried on by Doctor Edwards, show the quantity of urine voided in twenty-four hours to be 210 fluid ounces. The liquid at a temperature 82° Fahr. was perfectly transparent, of a pale amber color, without any flocculi. Specific gravity 1010. Acid reaction. No evidence of sugar with Trommer's test. Abundance of chlorides. The foregoing description needs to be completed with an account of symptoms during the paroxysm. I will presently narrate them as they were during one attack he had, the fourth evening after coming to the institution. He was at the moment playing whist, and I happened to engage him in conversation as he was shuffling the cards. Suddenly he stops his discourse; the cards drop out of his hand; becomes pale, unconscious, eyes fixed and converging, with pupils largely dilated, and then gives out a prolonged expiratory cry, concomitant with increased lateral distortion of the head, and rotatory movement of the body to the right, with arms firmly flexed on the chest, and mouth wide opened by spasmodic contraction of the muscles of the neck. Cold water dashed on the face roused him at once out of this condition; but the arms remained twitching, his countenance lost all expression, the eyes rolled continually, did not hear what was said, smacked his lips, and there was a strangeness in his manner as consciousness gradually returned, with relapses into momentary oblivion, to be entirely recovered in about twenty minutes. Along with this last stage there was profuse perspiration of the face and hands, and repeated contractions of the diaphragm, with efforts at deglutition and raising of frothy mucus. There was, in addition, an increase of facial paralysis, strabismus, and lateral distortion of the head, and the arms hung powerless for some time after the paroxysm passed over without leaving any headache or drowsiness. The pulse was 87, extremely irregular and at moments imperceptible. As on former occasions, there was not the slightest premonition of the attack, neither knowledge nor remembrance of it, and every symptom corresponded with those related by his father in connection with the other fits. Furthermore, Dr. Edwards had a new opportunity of observing again identical phenomena during another attack, which occurred the next morning, while the patient was about being packed in the wet sheet. In reference to the attacks, I must add that their frequency has made memory defective, and the patient's disposition very irritable and overbearing. It is unnecessary to state that he has resorted to every kind of remedy for epilepsy. From August, 1866, to last January, he discontinued eating meats; also went on a long pedestrian journey during which all rules as to diet were disregarded, and for eleven months before July, 1867, he had no fits, although the morning twitching of the arms persisted. Meantime he used bromide of potassium, and has faithfully continued with it to the present day, now exhibiting on the face and body the peculiar eruption induced by the salt. Since the above date, the attacks, with increasing tendency and detriment to the mind, have incapacitated him from any pursuit. the serious risks of the operation, which I would not, however, undertake unless acknowledged justifiable on consultation with some other physician. Waiting for further decision, the case was kept on observation, and ordered: Potass. bromidi gr. xxx., ammon. brom. gr. vj., liq. potass. arseniti m. iij., Aquæ dest. f. 3 ss. M. To be repeated three times a day; in addition, to take morning and evening, one pill: Ergot., ext. gentianæ aa gr. ij., pulv. acaciæ q. s. M. He was to be packed every morning in the wet sheet for three-quarters of an hour, before going under a cold shower bath for six or eight seconds, and which should be repeated in the evening. I will depart from the main subject to remark, that the association of liq. potass. arseniti, m. ij. to m. v., seems to prevent the unpleasant eruption of the bromide of potassium. I have tried it for about two years on several occasions with private patients and at the Hospital for Epileptics and Paralytics, New York, and tested it when there was quite an extensive eruption in large conglomerate pustules, the results being in every case satisfactory. Under the latter circumstances, I discontinued the bromide for a few days, gave the patient some alkaline baths, and then exhibited the mixture as above. In instances like the present of an ordinary eruption, the bromide needs not be suspended, as with the addition of the arsenite of potash the eruption gradually vanishes, and the salt is carried to its highest doses without causing trouble on the skin. I am not aware if any other has pointed out before the counteracting efficacy of this combination. On February 2d, my friend Dr. L. A. Sayre, of New York, was called in consultation, to which Dr. Edwards also assisted. Having heard the history of the case, and carefully investigated the condition of the patient, Dr. Sayre observed the very same symptoms before detailed. He distinctly detected the irregular elevation on the left side of the occipital, under the cicatrix of the scalp, and corresponding to a smooth surface on the opposite side. The heat of the part was most manifest to the hand, the thermometer marking at this examination 94°, whereas it did not go beyond 90° in other regions of the head. The diminished sensibility and temperature on the left side of the face and hand, the facial paralysis, strabismus, and lateral distortion of the head with contraction of the muscles on the right side, were again noticed. The patient was equally explicit as to the sensation experienced when the cicatrix was tapped with the ends of the fingers. His pulse was 110. Respirations 18 per minute. I was gratified to find that my diagnosis agreed in every respect with that of Dr. Sayre; consequently, he asserted that, in his belief, no medical treatment could be available unless the degenerated portion of bonewhich was the true source of trouble-were removed from the skull, and that this operation, though serious, was, however, the only way capable of reaching and most probably curing the disease. Endorsed by such an unreserved opinion, and with previous consent of the patient, I determined to operate. Therefore, assisted by From the preceding symptoms, I judged without hes- Dr. Edwards, I proceeded to remove the portion of itancy that the injury sustained by the skull was the bone affected, on February 10th, at 3 o'clock P.M., unsuspected origin of the epilepsy in question. I sup-weather being very clear and cold. The patient took posed that a growth on the inner table of the occipital, a light breakfast in the morning, had bowels thoroughly corresponding to the external cicatrix, was the very source of all derangement; consequently, persuaded that no medical treatment could ever be capable of eradicating the structural changes undergone by the bone, I thought the best course would be to remove the evidently diseased portion of the occipital, and expressed candidly this view to the patient and his father, with relieved by an injection, and the hair from the back part of the bead cleanly shaved, previous to the operation. Ether was administered, and anesthesia shortly completed after the usual period of excitement. He was laid on the right side, with head resting on a hard pillow. A perpendicular cut, about two inches, was carried down to the bone, and crossed at right February 12th.-Was restless last night, frequently wishing to be turned in bed, and talking in his sleep. Pulse 140, full but not firm. Tongue furred with red edges. Skin hot and moist; has perspired during the last hours, and at 11 o'clock A. M., had a long chill. No pain in the head; wound sensitive, but without redness, swelling, or heat. Ordered the same diet, and to take in the evening: Potass. bromidi 3 ss., sp. ammon. arom. mx., aquæ dest. f. 3 ss. M. February 13th.-Four o'clock A.M. Pulse 143, after disturbing him in bed. At eight o'clock A.M., it was 115, irregular and soft, and came down to 105 during the evening. Ice bag continued to the head. No discharge as yet from the wound; the edges seem united by first intention, excepting where the serrefine was inserted. Diet: beef tea, soup, gruel. February 14th.-Has slept well through the night; at nine o'clock A.M., pulse 105, and weak. Sutures removed-wound gives no pain; ice has been incessantly applied to it, and the patient is in excellent spirits. Bowels moved with turpentine and assafoetida injection. Tongue clean and natural; appetite good. Diet: eggs, soup, rice. February 15th.-Pulse 102, soft. Bowels opened through the day. The incisions are healed up, excepting at the very point of their crossing, through which oozes a sero-purulent discharge. Continue ice to the head. angles by another horizontal incision of nearly three February 11th.-Slept tolerably well, after vomiting inches, running from the external occipital protube- discontinued. Pulse this morning, 132-136, irregular rance to the left. The incisions thus made bled quite and full. Skin dry and hot. Tongue slightly coated freely, the flaps were dissected, a small branch of the in the centre. Complains of being very thirsty, and occipital artery twisted, but hæmorrhage from other finds great satisfaction in swallowing small pieces of vessels continuing required us to mix alum with the ice. Urine in nearly equal quantity and with same ice water in which the sponges were wrung out, and reaction as before the operation. Ice bag kept all the to use compression to arrest the loss of blood. On ex- time to the head. Wound dry, with lips of a slightly posing the periosteum, it was found very much thick-red color. Diet: beef-tea, every two hours. ened, highly vascular, firmly adhering to the cranium and interspersed with hard granulations of a dark crimson color. The bone was scraped, and Galt's trephine applied, fixing the perforator in the middle of the bony eminence. No sooner had the instrument bored through the hard outer table and penetrated into the diploe, than the patient was suddenly thrown into an epileptic fit. He did not utter the peculiar cry of other attacks, but the limbs were rigidly stretched out, his body rolled over to the right, bit his tongue, had a great deal of froth at the mouth and venous congestion of the face, with deep snoring and, lastly, relaxation of the limbs. During this time, the operation had, of course, to be suspended: the bone was then bleeding most profusely. The stertor and other signs of the fit over, the trephine was. reapplied: most of the cone penetrated through without loosening the bone; on attempting to raise the disc with the elevator it gave way, leaving behind a resistant portion at the bottom of the perforation. Hæmorrhage increased at this moment, and, indeed, blood gushed out with violence from the vessels of the diploe. Cold alum water had to be steadily applied, and the opening plugged before application of the trephine to the portion left could be renewed. The elevator was then again and again tried after gentle turnings of the trephine; but the irregular shape of the protrusion made the bone, less and less resistant as we approached the dura-mater, break at every effort, and it was in this wise removed in small fragments. The last of these fragments were united by adhesions to the dura-mater. At the internal part of the opening made by the trephine, there was a conical indentation, pressing on the brain, and close to the superior longitudinal sinus. To take away such indentation, with its broad base and the abnormal looking bone around the perforation, was the most tedious stage of the operation. It had to be achieved with the bone nippers and the lenticular knife, in a very slow, careful way, holding up at every cut to stop the incessant hæmorrhage. Finally, all the apparently unhealthy structure was pared off from the occipital bone in an oval space, two by two and a half inches in diameter, and the finger gently slipped around between the membranes and the bone, showed no irregularity of the inner table pressing on the brain. The membranes looked healthy and uninjured, excepting at the very smail site of the erosion, caused by tearing the adhesions to the exostosis. The longitudinal sinus, uncovered about an inch, could be seen projecting inside the cranial opening, and along the lower edge of this opening the lateral sinus could also be felt. Every portion of thickened periosteum was excised, and when the raw surfaces ceased bleeding, the flaps were brought together by deeply inserted silver sutures, exclusive of the lower incision, that was closed with serrefines. The operation was completed in three hours and a half, and no more than six fluid ounces of æther were inhaled by the patient. The anæsthetic effects were soon dissipated, bringing about vomiting, which, with intermissions of from twenty to thirty minutes, persisted until two o'clock in the morning. Ice was constantly applied to the wound, and the following mixture exhibited :-Sp. ammon. arom. mxx., aquæ f. 3 ss. M. February 16th.-Same treatment. Pulse 98, soft. Bowels moved naturally. February 17th.-Pulse 92, weak, not uniform. Wound still discharges a limpid serosity from the centre. Treatment and diet as above; bowels operated once this day. February 18th.-Pulse 80, regular and soft. Can now lie on back of head without discomfort. Central crossing of incisions still open. Wound dressed with glycerine and Venetian turpentine. Local application of ice discontinued; same diet. February 19th.-Pulse 71, soft and small. Wound dressed as yesterday; slight discharge. Bowels moved to-day. Urine reduced to three pints in twenty-four hours. Sat up for an hour in the afternoon. Diet: soup, roast beef, and coffee. February 20th.-No change to be noticed. Pulse 73, firmer and regular. February 21st.-Pulse 75, regular and larger than before. Slept very well all night. Opening of the wound completely closed. Same diet. In the afternoon gets irritable and fretful, from not having his own way. February 22d-Was restless last night. Wound feels sore. Pulse 92, contracted and irregular. Felt better in the afternoon; sat up, and being alone with his assistant, took a whim to go out of his room to converse with other patients. Complained that such undue over-exertion "tired him out." Had a chill, headache, and convulsions at three o'clock P.M., whilst sleeping in an easy chair. The wound, which had been swelling, bled considerably, and became excessively painful and hot. Had great pains across the head. Pupils dilated, checks congested, tongue moist, and furred in the middle. Pulse, after convulsions, 81, irregular and soft. Ordered illico turpentine and assafoetida injection, ice to the head, and mixture of potass. bromidi gr. xl., sp. ammon. arom. m x., aquæ dest. f. 3 ss. M., to be repeated in the evening. February 23d.-The above symptoms persisted until this morning Has been very fidgety; the convulsions returned twice-—at ten o'clock last night, and this morning at 11 o'clock, but less severe than the first. The wound being quite distended, I opened it at the middle, with a probe; a dark, bloody, purulent discharge came out, and from this moment the general irritability, headache, and other symptoms abated. Ordered: ergotine pill, and mixture brom. potass., as before the operation; turpentine and assafoetida injection; ice continued to the head; light diet and coffee. February 24th.-Pulse 78, regular and small. Says "he feels all well." Same treatment. Diet: soup, beef, and coffee. Wound discharged this morning about half an ounce of pus, and has run all day. February 25th, 26th, 27th.-The suppuration is lessening every day. Pulse from 76 to 78, regular and firmer. Same treatment, and nutritious diet. Head bathed every morning with cold water, and local application of ice maintained to the wound. Urine has not exceeded 72 fluid ounces in 24 hours. It is transparent, acid, without sugar, still abundant in chlorides, and with specific gravity 10.20. for, though the operation has succeeded to remove the cranial exostosis and some of the symptoms, yet it does not follow necessarily that the epileptic habit, or predisposition of the nervous system to the disease, has also at once been eradicated by taking away its exciting cause. To the confirmation of this result I now look forward with anxiety. Incomplete as it has to be on this account, the case, nevertheless, affords a peremptory demonstration of how peripheral excitations may cause epileptic convulsions. It might be perhaps adduced that such convulsive spasms, during the perforation of the bone, could have been as well determined by the anesthesia itself. The fact is not unfrequent; I have myself witnessed it on many occasions, and particularly remember one in which chloroform was administered to a young epileptic, under my care, for the operation of phymosis. Scarcely had insensibility been prolonged some minutes, when animation was suddenly suspended. My friend Dr. Wm. H. Van Buren, who was performing the operation, and myself, had to resort to Marshall Hall's and Sylvester's plans to restore the heart's action, and only after persevering endeavors respiration was re-established, along with the spasms of an epileptic paroxysm. The operation was finished without further inhalation of chloroform. This and similar observations would have but little weight, if we consider that in this instance the inhalation of æther lasted more than three hours, and that it had to be resumed and prolonged after the epileptic attack, without, however, inducing its renewal. Therefore, it seems legitimate to suppose that irritation with the trephine in the diseased bone was the true cause of the convulsions, most assuredly helped by the condition of the nervous centres in anæsthesia. I have not been able to examine with the microscope any of the bone removed. The portion of disc divided with the trephine has an uncommonly dense external lamina about four lines thick, covering a canvessel, about two lines in diameter. Putting the different fragments together, the disc of bone is nearly an inch from the outer to the inner lamina, a thickness, indeed, considerable, when we remember that at the site of injury the tables of the occipital run closer and closer to each other, until the middle of the fossa for cerebrum, where there is scarcely any diploic tissue. February 28th to March 6th.-The improvement progresses. The discharge decreases, and it only amounts to a few drops of lymph and pus. Incisions entirely cicatrized, with the exception of the small fistulous opening at their crossing. Pulse regular, 76; bowels act every day. Continue with ergotine and brom. pot. Nutritious diet. Says that he feels more the impression of cold water on the right than on the left of the top of the head. This morning, whilst pressing out the discharge from the wound, had a strange feeling in his head, as though the blood rushed to it, without, how-cellated structure containing the canal of a large bloodever, losing consciousness, and burst into a fit of crying, with deep sighing. This condition passed away in a short while, and was certainly the result of the cerebral pressure. The signs of facial palsy, strabismus, and distortion of the neck, have disappeared. The quantity of urine remains unchanged. May 7th.-On March 18th an abscess appeared under the old cicatrix of the scalp, with drowsiness, vomiting, and convulsive symptoms. A free incision let out a large amount of pus, the symptoms subsided, and the sinus left was dressed with Peruvian balsam. The parts soon healed up, and counter-irritation was applied to the back of the neck. However, the uncontrollable disposition of the patient, with the excitement due to a visit of his friends, brought about the recurrence of headache and convulsions on the evening of April 13th. No further derangement has occurred since that date; the cicatrix of the scalp is quite firm and painless, and the paralytic symptoms and polyuria have no longer existed. It being impossible, on account of his unwillingness, to manage the patient properly, he left for home on May 5th. He was directed to continue the same course of treatment. The bromide of potassium has been raised lately to a dose of forty grains, to be taken three times daily. It is not my purpose to enter here into the merits of trepanning the skull for the relief of certain forms of epilepsy. Let me, however, state that the analysis of several cases confirms, as established by Dr. Wm. H. Van Buren (Philad. Med. and Surg. Rep. Dec. 29, 1860), that this operation is comparatively a simple and harmless one, its seriousness being explained by the fact that it is usually performed in cases which, from their nature, are fatal. Nor do I give hastily this case as one of recovery; Now, as to the nature of the paralysis. Was the incomplete paralysis of the facial and sixth nerves reflex, as Brown-Séquard admits to be frequently the case with cerebral affections. It is unquestionable that the peripheral extremities of the trigeminal, distributed to the dura mater and bone, were implicated in the modification of structure discovered at the injured spot. The frequency with which irritations of this nerve, like those of the sympathetic, are apt to originate incomplete, and the so-called direct paralysis, has also been pointed out by the above distinguished physiologist. When we consider the relations between the origin of the trigeminal, the facial, and the sixth nerves, we can easily understand how excitations conveyed through the first, may as well involve the origin of the two other nerves, and impair their functions, by modifying the action of their common ganglionic cells. Stilling and Lockhart Clark have shown that the sixth and facial nerves arise from the same nucleus in the oblong medulla. Vulpian has also demonstrated by his interesting researches on the origin of the facial, its intimate connections with the sixth pair in the floor of the fourth ventricle. More recently yet, John Dean, in his valuable work "On the Gray Substance of the Medulla Oblongata and Trapezium," Smithsonian Contributions of Knowledge, 1864, p. 66, alluding to the nucleus from which the facial arises, says: "Several other cell groups are found, both on the neck and polyuria have been seen together by Vogel. Whether such relation existed in this case I will not venture to deny; but I rather think that the cervical contraction was induced by the permanent cerebral irritation. To this irritation may also, in a great measure, be ascribed the great frequency of the pulse. outer and inner side of the upper olivary bodies, and Concerning the rotatory movement of the body during the epileptic attack, it evidently was the effect of the local irritation to the cerebral hemisphere. It is well acknowledged that lesion of the cerebral hemisphere and other regions of the brain originates a rotatory movement of the body, the real cause of which is not yet satisfactorily explained. The deviation of the eye in this case was due to paralysis and not contraction, for I could ascertain its persistence when the head was raised or moved in any direction. It was most interesting to observe, after the epileptic paroxysm and before consciousness was recovered, the rolling or oscillating state of the eyes, reproducing the nygtasmus that accompanies the strabismus and rotatory movement of the body noticed on animals, upon injury of those parts of the brain capable of determining such a peculiar movement. ABSTRACT OF A PAPER ON DISEASES OF SYRIA, AND THE NA- BEFORE THE NEW YORK ACADEMY OF MEDICINE, BY GEORGE E. POST, M.D., PROF. ELECT OF SURGERY IN THE MEDICAL COLLEGE AT BEIRUT, AFTER a sketch of the physical geography and climate Diphtheria and diphtheritic croup are almost wholly unknown. Scarlatina is rare. Measles, which in our climate is prone to be followed by bronchial sequelae, there brings on cerebral and abdominal lesions. Among the common diseases of the country is dyspepsia. This is almost universal. It is due to the vicious diet of the people, which consists of indigestible substances, such as cracked wheat, boiled with large quantities of butter or fat until it becomes coated with the oleaginous material. Onions fried in butter, meat fried until it is quite indigestible, large quantities of sour milk, in addition to unripe fruit, which they prefer to ripe, and a preponderance of oil and salads during the long fasts, are among the causes of this disordered action of the stomach. The time of eating is also an element of disturbance. Laborers go out to their work on an empty stomach in the morning, and work for several hours without eating.. They then eat lightly, and not until night do they partake of hearty nourishment. This evening meal is inordinately heavy, and immediately after it they retire to sleep. The sedentary habits of the people, and their constant use of horseback travel, which is the only facility the country affords, give rise to hæmorrhoids, which afflict almost every resident, native and foreign. Diarrhoea and dysentery are very prevalent and fatal. They result from the inordinate use of green fruit and unripe vegetables, and other dietetic imprudences, coupled with the foul state of their streets and houses. The filth of Oriental streets and houses cannot well be described or imagined. The streets are a receptacle for every foul and worthless thing. Garbage is thrown into the public ways, and the latrines in many places empty into the streets, where the fæcal matters putrefy under the blazing sun and diffuse an abominable stench, and multifarious sporules of fungoid elements of disease. When the cholera breaks out in such localities, its rava In conclusion, the case is a curious instance of polyuria due to traumatic lesion of the head. The researches of Bernard, Schiff, Pavy, and others, have brought to light the influence of the vaso-motory nerves in the production of diabetes. From the striking coincidence here of polyuria, converging strabismus, facial palsy, and other trouble with the vaso-motory nerves, I cannot avoid surmising, what is perhaps a mere speculation, i. e., the possibility of a disturbance in the floor of the fourth ventricle, where is the origin of the nerves involved by the above paralysis, the diabetic centre (centre diabétique) of Bernard, and besides the centre of the visceral vaso-motory nerves, as demonstrated by the interesting anatomical investigations of Jacubowitsch. Cases are not rare of injury to the brain, spinal cord and nerves, as also to the sympathetic system, attended with diabetes. It has been remarked, as re-ges are frightful. gards injuries to the head, that this condition happens sooner or later upon the accident, and that it may change most suddenly from diabetes mellitus into polyuria. I have been unable to ascertain if such change did occur in this instance. Muscular disease of the These abdominal disorders are specially fatal to children. It is probable, in the absence of statistics, that births, in Syria, are more numerous in proportion to the population than here. This is due to early marriages, and a universal and intense desire for offspring. |