turbance of memory and affections. Narcolepsy, mania, and coma are well known. All these nervous symptoms, according to the author, have little prognostic significance, as they appear in many different degrees in different patients at various stages of the disorder. 1 Apomorphin as a Hypnotic.-Douglas 1 calls particular attention to the use of apomorphin as a hypnotic, used hypodermically in doses that produce no nausea. About of a grain, more or less, adjusted according to the requirements, he finds quite harmless, and perfectly competent in mild insomnia and in furious delirium, producing sleep within 25 minutes. No disagreeable after-effects were noted and no possibility of acquiring a drug habit exists, as an increase of the dose leads to violent vomiting. He has used the remedy in 300 cases, failing of good effect in only 2 or 3 instances, in which, moreover, large doses produced no emetic effect. [In restlessness not due to pain or mental disturbance apomorphin in the foregoing dose acts well.] Adiposis Dolorosa.-F. X. Dercum 2 returns to this subject, having had an opportunity for autopsic investigation in one of the cases formerly reported by him in various journals. Microscopically the fatty tissue presented nothing to distinguish it from ordinary fat, but the peripheral nerves found in it showed undoubted interstitial neuritis. The spinal cord presented slight degeneration of the columns of Goll in the cervical and upper thoracic regions. The thyroid gland was made up of 3 or 4 different kinds of secreting tissue, modifications of a normal state. In two other cases of this affection the thyroid was also apparently involved, though never microscopically examined. Charles W. Burr 3 also reports a case of adiposis dolorosa with autopsy. Clinically the case conformed closely to those described by Dercum. The patient finally died, after a prolonged somnolent and comatose state, from uremia due to nephritis. In the right lobe of the thyroid gland there was a spheric concretion as large as a hickory-nut. On microscopic examination of the thyroid colloid degeneration and absence of secreting cells in many acini were found. There were also many areas of small round-celled infiltration and indications of active inflammatory processes. The muscles showed marked degeneration by the osmic acid method, probably secondary to degeneration of the nerves, as a medium grade of interstitial neuritis of the intramuscular nervebundles was present. There was acute parenchymatous nephritis. The ovaries were also diseased; they were sclerosed and not performing their great function. In this case, as well as in that of Dercum, there was disease of the thyroid gland and of the finer nerve-branches. The condition of the ovaries is suggestive, as after castration there is a tendency to obesity. The author concludes that at present we can only say that "adiposis dolorosa is a clinical entity, having definite signs and symptoms, but with as yet no known pathology." 4 W. H. White reports a case of adiposis dolorosa, and the illustrations strongly recall the instances published by Dercum. The case 1 Merck's Archiv, June, 1900. Jour. Nerv. and Ment. Dis., Oct., 1900. 2 Jour. Nerv. and Ment. Dis., Aug., 1900. 4 Brit. Med. Jour., Dec. 2, 1899. reported differs from the majority in the literature in having appeared early in life and with painful symptoms more marked in the early stage than lipomatosis. Recurrent attacks of mental disorder were presented, but the patient did not give the usual history of syphilis, alcoholism, and the indications of neuritis, though there was a suggestion of some toxic factor. Symmetric Adenolipomatosis.-Launois and Bensaude 1 under this title make an extensive contribution to the subject of multiple symmetric fatty deposits unattended by general symptoms of illness or physical disorder, though they have noticed some exceptions to this rule. For instance, a general feeling of weakness or of fatigue is reported in numerous observations, and in some cases irritability, apathy, and even hypochondriasis. These local masses of fatty tissue, as the authors well point out, seem to enjoy an individuality, preserving their volume during conditions under which the patients generally become cachectic, and even in the presence of considerable emaciation secondary to tuberculosis, Bright's disease, etc. As a rule, they are without painful symptoms or sensory disturbances, though in this connection the analogous or identical adiposis dolorosa described in this country should perhaps be borne in mind. The authors find about 80 cases described in the literature. It is much more common among men than among women. In women the neck is more frequently spared, the lipomatosis having a tendency to invade the shoulders and hips. It usually makes its appearance after 20 years of age; the youngest case was 21 and the oldest 58. Alcoholism was found in 30% of the cases. The disease often coincides with syphilis, albuminuria, cancer, gout, asthma, and varicose conditions. The authors do not believe, contrary to the statement of Madelung, who first in Germany gave prominence to the disorder, that the affection never coincides with obesity. Generally, however, obesity is not marked. They adduce numerous points of resemblance between the condition of adenolymphocele and adenolipomatosis, and make the following arguments: (1) That the fatty infiltration penetrates along the lines of the lymphatic vessels. (2) That the aptitude of these tumefactions to increase and decrease with astonishing rapidity can be explained only by intimate connection with the circulatory system. (3) That the lymphatic theory explains much better than the nervous theory all the facts that have been accumulated in relation to the disorder. It explains the general localization of the tumefactions, their symmetry, their frequency, and especially their constancy in the neighborhood of the neck, axillas, and groins. They would denominate it, at least for the time being, a disease of the lymphatic system. DISEASES OF CEREBRAL MENINGES AND CRANIAL NERVES. Trifacial Neuralgia.-W. H. Bennett 2 reports 9 cases of trigeminal neuralgia treated by the injection of osmic acid into the substance 1 Nouv. Icon. de la Salpêt., 1900. 2 Lancet, Nov. 4, 1899. of the nerve. His plan appears to have been to uncover the nerve at some point where it is subcutaneous and then to inject into the nervetrunk from 5 to 10 minims of a 1.5% solution of osmic acid. In every instance the pain was immediately controlled, and spasm of the muscles, when associated with pain, also subsided at once. Recurrence took place in one case after some months, and was again relieved by the same simple expedient. Sufficient time, however, has not elapsed in any instance to justify a statement as to ultimate results. 1 L. F. Barker, after giving a detailed report of several Gasserian ganglions removed in neuralgic conditions, concludes: (1) If a ganglion be entirely removed, there need be no fear of a return of pain from irritation of the stump of the nervus trigeminus left behind, for all the axons of this stump will degenerate to their terminations in the pons and medulla, down as far as the cervical cord. The end of a nerve in an amputation stump is not analogous. (2) Complete removal of a Gasserian ganglion utterly abolishes the possibility of calling forth sensations in consciousness by applying stimuli to the domain of peripheral distribution of the nerves connected with the ganglion of the corresponding side; retention of sensation on peripheral stimulation after operation indicates incomplete removal. (3) If pain persists, paroxysmally or continuously, after complete removal of the ganglion, or after evulsion of the nervus trigeminus from the pons, the ganglion being left in situ, a lesion of the central neurons of the second or of the higher orders of the trigeminal afferent conduction path is indicated. (4) In tic douloureux due to disease of the peripheral set of trigeminal sensory neurons relief should be as complete and permanent by cutting the nervus trigeminus between the ganglion and the pons, and evulsing the central end without removal of the ganglion, as when the ganglion itself is excised. Articles 2 on this subject by a number of American authors include one by Robert Abbé, of New York, who describes modifications of older methods of operation, which promise better results. Charles L. Dana, in discussing the natural history and treatment of the disorder, says: "I should say that the early forms of tie douloureux, such as I have called a migrainous tic,' occurring usually in women, should not be operated on. There are some exceptions to this, however, in which tic douloureux occurs in early life, due to a distinct local disease, such as inflammation of the nerve, or of the antrum, or of the jaws. In true tic of the degenerative period of life prompt medicinal treatment will usually control the disease, and operation is rarely indicated at first. In tic which has lasted three or more years it may be safely said to the patient that medicinal treatment may produce a remission, and that this remission may be repeated, and that eventually the disease may be controlled by repeated treatments, but this is not at all sure. It may be said here, too, that a minor operation may give more relief than medicinal treatment. The question of prescribing major operations must be decided in each individual case, on its special merits." F. Krause, of Berlin, in the Section of Surgery at the recent Inter 1 Jour. Am. Med. Assoc., May 5, 1900. 2 Jour. Am. Med. Assoc., May 5, 1900. |