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A CASE OF PANCREATIC GLYCOSURIA.
1149
any
external signs of decomposition, nor was there very decided wasting either in the muscular or adipose tissues. On opening the chest recent pleural adhesions were BY MALCOLM MACKINTOSH, M.D. GLASG. found all round the base of the left lung, involving both the diaphragm and the chest wall, and the pleural The IN March, 1893, a previously healthy man was suddenly ’cavity contained two ounces of reddish-brown fluid. adhesions were broken down with comparative ease, and it - seized while at work with a sharp pain at the lower border of was noticed that the lung as a whole was pushed upwards the ribs on the left side in the line of the nipple. He became towards the clavicle, so that its apparent bulk as faint and breathless and the pain was increased by each (compared with that of its fellow was very appreciably inspiratory effort. Next day there was some fever, dyspncea,diminished. On removal of the lung it was found that the .and pain in the side, whilst percussion at the left base was lower lobe was deeply congested, but crepitant and buoyant. contained a quantity of frothy mucus, but The air dull, the respiratory murmur was distant, and vocal resonance otherwisevesicles the organ was healthy. The right lung showed no ,and fremitus were diminished. The heart was not displaced pathological alteration, there being a complete absence of .and its percussion-area was normal. Over the whole of thistuberculous disease in the thoracic cavity. The pericardium dull area a coarse superficial crepitus was heard at the end ofcontained a small quantity of serous fluid and the heart was the right by the same inspiration, due, as subsequent events proved, to peritoneal healthy, though it also was pushed to friction. After three weeks’ rest in bed the man got well cause which produced displacement of the lung. The dome-. and resumed work as usual. It may be added that duringshaped bulging of the diaphragm, to which reference has this attack the patient lost over fourteen pounds in weight. been made, was entirely confined to the left side of the floor Cough and expectoration were both present, but the former of the thoracic cavity, upon which it encroached equally in was not particularly troublesome and the latter was scanty,all directions, occupying a space rather larger than a goodwhilst the fever, which never reached a point higher thansized orange. Upon opening the abdomen the stomach and -102’F., gradually declined, until at the end of ten daysit intestines were considerably distended, but the peritoneal had altogether disappeared. On making particular inquiry cavity was free from fluid, nor was there any trace of recent subsequently the man stated that the pain and the cough lymph effusion. The whole of the organs occupying the left had left him, his former standard of weight was again half of the abdominal cavity, however, were matted together reached and slightly surpassed, the appetite was good but and bound down to each other and to the abdominal not voracious, thirst was not abnormal, and the secretion of wall and diaphragm by old strong adhesions. The left portion_ .urine remained as it always had been. The man’s explana- of the omentum was adherent to the oesophageal end of the tion of the attack was that he had strained himself while stomach, and the latter was firmly bound down behind and lifting a heavy sack, his reason for saying so being that he also in the direction of the spleen. So firm were the, felt the pain come on almost immediately afterwards. adhesions that the organs could only be removed by dissectOn Aug. 20th of the same year the patient complained ing them out. The spleen was embedded in a mass of similar of pain in the head, back, and limbs, but went to work material and was ruptured in the effort to dislodge it. To all appearance it was healthy and of normal size and weight. on the 21st, 22nd, and 23rd, when he was obliged to give He then complained of headache, backache, and Below and behind the spleen a large fluctuating mass was felt, up. pain in the left iliac region just above the crista ilii, which on being opened was found to contain about two pints in which region there was slight tenderness on pressure, of thin, sticky, slimy-looking fluid, none of which, unforThe cyst was but no swelling could be detected. The temperature tunately, was preserved for examination. was 102° and the pulse 120 and feeble. On the 24th multilocular, and extended backwards towards the vertebral the whole of the base of the left lung, both in front and column and inwards towards the middle line behind the behind, was dull to percussion, the breath sounds were stomach and left lobe of the liver. Besides the fluid already distant, though not entirely absent, and the apex beat was mentioned there was a large quantity of recent lymph which plainly to be felt to the right of the sternum in a straight could be extracted in masses of from three to four inches in line with the nipple. From these signs and symptoms the length. No calculi were present. The pancreas was almost ’conclusion was arrived at that the left pleural cavity con- entirely destroyed, the only trace of it that could be found tained fluid. On the 25th an abundance of sugar was found being a small piece of pancreatic tissue in the upper and to be present in the urine, and for the next four days he posterior part of the wall of the cyst. The liver was normal. passed between 140 and 200 ounces of urine in twenty-four The left kidney was difficult to find as it was lying behind hours, of specific gravity 1035 and loaded with sugar. and below the cyst, and it also, like the spleen, was bound Thirst was very troublesome and the tongue was thickly down by adhesions. The right kidney was in its normal - coated, dry, and cracked. The pulse was weak and rapid, position and both were healthy. No sign of disease could be and faintness was readily induced by the slightest movement. discovered in the stomach or intestines. It is evident that the old-standing peritoneal inflammation, Dimness of vision supervened a day or two after the sugar was discovered, and an herpetic eruption made its appearexudation, and adhesion which were made manifest at The bowels acted the post-mortem examination occurred at the time of the first ance at the left angle of the mouth. regularly, but the character of the evacuations was not noted. illness in March whatever the cause of that may have been. There was no jaundice. As regards the physical signs, it It is to be regretted that the urine was not on that occasion may be said that the dulness cleared up slightly, whilst examined for sugar, but it is at the same time certain that the respiratory murmur was heard more distinctly over the there were none of the symptoms of glycosuria present which affected area, and the position of the apex-beat remained as were so marked during the fatal illness. On consideration it had been. The splenic dulness could not be satisfactorily of the fact that the spleen, colon, and left kidney were all determined owing to the distension of the abdominal viscera in working order while the pancreas was disorganised it with gas, and the stomach contained such a large amount as seems reasonable to suppose that the cause of the dis-’ to give rise to the suspicion of pneumothorax. Decubitus turbance is to be found in the latter; and from the sudden onset and subsequent history of the attack it would certainly was during the whole course of the illness on the right side cr on the back, but preferably the former. During the next seem that haemorrhage had taken place into the pancreas in three days the patient became gradually weaker and more the neighbourhood of the tail, this being followed by panand more apathetic ; the evacuations were passed uncon- creatitis confined to the left half of the organ and spreading sciously and the fever and glycosuria still continued. to the neighbouring peritoneum; or else that a previously ’On Sept. lst, although there were no symptoms calling existing pancreatic cyst had taken on inflammatory action urgently for the removal of the fluid in the pleural cavity, it which spread to the tissues in the vicinity. Perhaps on the whole the latter is the more likely supposition, both on was thought advisable to use the aspirator on the chance of the effusion being purulent. Fifteen ounces of odourless account of the distinctly one-sided direction which the inreddish-brown fluid were removed, the needle being inserted flammatory process followed and from the absence of any - in the mid-axillary line ; but this proceeding gave no relief, cause, such as injury or diseased bloodvessels, which would and the patient sank into a comatose state, death following be likely to produce hsemorrhage, though it is difficult to two days afterwards, on the fourteenth day of the illness and believe that a man could engage in laborious work for six months on end with a mass of exudation in the abdomen eleven days after sugar was discovered in the urine. - cT’opsy..— The necropsy took place thirty-six hours such as was present in this case without presenting a single after death, and although the weather was very hot symptom of disease. The course of events in the fatal illness probably was that and the body was in a small, close room there were no I
A CASE OF PANCREATIC GLYCOSURIA.
1150 inflammation was once more started in the old spot, being originated in all likelihood by an attack of influenza, which at that time was rife in the district ; effusion of fluid followed, and the whole of the pancreas was destroyed by the mechanical pressure exerted by the exudation. This case would seem to corroborate the conclusions arrived at by experiments on the dog-viz., that glycosuria only follows when the whole of the organ is destroyed or removed.l Sisters-avenue, S.W. __
THE EYE-SIGHT OF THE LATE MR. DU MAURIER. BY ROBERT BRUDENELL
CARTER, F.R.C.S. ENG.,
CONSULTING OPHTHALMIC SURGEON TO ST.
GEORGE’S
HOSPITAL.
IT has long been a matter of common knowledge that the late Mr. du Maurier suffered from impairment of sight, and that his charming work as an artist was accomplished under difficulties which would have proved insuperable to weaker men; but it is probably not known how much those difficulties were of a kind calculated to force themselves continually upon his attention, and to excite and maintain anxieties with regard to what the future might have in store for him. I think it will interest the profession to see a reproduction of a sketch which he made for me in the middle of 1895 as an illustration of his own visual state. I should premise that his left eye had no perception of light. Its vision was destroyed, totally and almost suddenly, many years ago by detachment of the retina, and the
retina had become useless and that the other was in a satisfactory state. In consideration of his one-eyed condition I did not think it desirable to dilate his pupil, a proceeding almost necessary to the discovery of inconspicuous retinal changes in the macular region, and all I could see with the ophthalmoscope was that his choroid was rendered visible by want of pigmentation in the external retinal layer. In reasoniiagupon the case it seemed to me that the appearances which he drew and described corresponded with retinal areas which were not blind, but only of subnormal sensibility to light. If the areas had been blind there would have been no consciousness of them, no more than there is of the normalblind spot. If we have dirt spots on a piece of paper, and look at it by transmitted light, the spots will be rendered visible because less light reaches the eye from the areas covered by them than from adjoining parts of the paper; and, in like manner, if we conceive groups or areas of retinal bacilli which are less sensitive than the neighbouring ones, an impression of comparative darkness will be produced over these areas when the eye is directed to Intermittent photopsia I a uniformly illuminated surface. take to be a result of irregularit:es of circulation acting upon arterioles of diminished elasticity ; and it is quite possible that the permanent spots might correspond with retinal areas which were under-nourished by reason of defective bloodsupply. I did not see my way to suggest any treatment for the assumed condition, and could only advise circumspection in visual work. I had a conversation with Mr. du Maurier a few weeks before his lamented death and heard from him that the conditions of his sight were unchanged. that
one
by no means
Harley-street, W.
A
CONTRIBUTION TO THE STUDY OF JACKSONIAN EPILEPSY. BY WILFRED J.
HARRIS, M.B.CANTAB.,
HOUSE PHYSICIAN TO THE NATIONAL AND
HOSPITAL FOR THE PARALYSED’ BLOOMSBURY.
EPILEPTIC, QUEEN-SQUARE,
EPILEPTIFORM fits are always interesting to study, but the of especial interest in that the first illustrates the fact that the abdominal muscles are unilaterally represented in each hemisphere for certain movements, while in the second case the unilateral spasms of the palate and tongue confirm in man the unilateral cortical representation of the soft palate and tongue movements shown by Beevor and Horsley to exist in the monkey. These experimenters have also shown1 that the abdominal muscles of one side,. especially the rectus abdominis, can be stimulated by excitation of the internal capsule of the opposite side in the monkey. A few cases have been observed of unilateral paralysis of the soft palate in hemiplegia, but I am unable to, find any record of unilateral convulsions affecting the soft, palate and tongue. I have to thank Dr. Buzzard and Dr. Gowers for their kind permission to make use of my notes on these cases. CASE I.-The patient was a girl aged five years, with A, Centre with scars of old scotoma all round. B, Punettim of probably multiple tuberculous tumours in both symptoms in coecum. +, Slight very imperfect. c, Black, varying Rolandic and in the cerebellum, and quite blind from areas a and visible now and then-since shape, fortnight.only G. DU MAURIER, July, 1895. post-neuritic atrophy. On Oct. 15th, 1895, she began to have convulsions early in the morning, and when seen half an hour blindness thus produced was followed by opacity of the lens. later she was found lying partly on her left side, with her The right eye was myopic to 1-50 D., with normal central head and eyes turned to the left, having regular clonic vision when the myopia was corrected, and was able to read spasms quite rhythmically about once a second of the left brilliant type unaided. It was, however, the subject of side of the face and of the arm, abdomen, and leg on the frequent photopsia, subjective sensations of light of a very left side. The head was turned to the left by regular clonic. its field of vision was broken by the varied character, and spasms of the sternal portion of the right sterno-mastoid, and appearances which he sketched-an appearance of lines, the eyes were turned to the left in conjugate deviation with spots, or clouds, distributed as shown in the drawing. The fine lateral nystagmus, the quick movement being to the fixing point, A, was surrounded by an irregular line, forming left. The pupils were equal and dilated as usual; the corneal an ellipse with its major axis horizontal and extending to reflex was present and consciousness was partly retained. the blind spot, B, and within this ellipse small dark spots The mouth was drawn to the left rhythmically with the other On either side the field was were irregularly distributed. and the left eyebrow twitched up, the eyelids blinkbordered by dark shading, which was most conspicuous on spasms, irregularly in an apparently semi-voluntary manner.. the nasal side, as at c. The result was that he could not ing The left hand was clenched, the thumb being turned in, and, look upon any uniformly illuminated surface, such as a sheet the forearm flexed. There were powerful rhythmic of white paper, without being reminded by these appearances contractions partially of the left great pectoral and of the left,
following cases are
1
Von
p. 448.
Mering and
Minskowski and
Freyhan,
The Medical Week,
1893,
I
1
Philosophical Transactions of the Royal Society, 1889.
any
external signs of decomposition, nor was there very decided wasting either in the muscular or adipose tissues. On opening the chest recent pleural adhesions were BY MALCOLM MACKINTOSH, M.D. GLASG. found all round the base of the left lung, involving both the diaphragm and the chest wall, and the pleural The IN March, 1893, a previously healthy man was suddenly ’cavity contained two ounces of reddish-brown fluid. adhesions were broken down with comparative ease, and it - seized while at work with a sharp pain at the lower border of was noticed that the lung as a whole was pushed upwards the ribs on the left side in the line of the nipple. He became towards the clavicle, so that its apparent bulk as faint and breathless and the pain was increased by each (compared with that of its fellow was very appreciably inspiratory effort. Next day there was some fever, dyspncea,diminished. On removal of the lung it was found that the .and pain in the side, whilst percussion at the left base was lower lobe was deeply congested, but crepitant and buoyant. contained a quantity of frothy mucus, but The air dull, the respiratory murmur was distant, and vocal resonance otherwisevesicles the organ was healthy. The right lung showed no ,and fremitus were diminished. The heart was not displaced pathological alteration, there being a complete absence of .and its percussion-area was normal. Over the whole of thistuberculous disease in the thoracic cavity. The pericardium dull area a coarse superficial crepitus was heard at the end ofcontained a small quantity of serous fluid and the heart was the right by the same inspiration, due, as subsequent events proved, to peritoneal healthy, though it also was pushed to friction. After three weeks’ rest in bed the man got well cause which produced displacement of the lung. The dome-. and resumed work as usual. It may be added that duringshaped bulging of the diaphragm, to which reference has this attack the patient lost over fourteen pounds in weight. been made, was entirely confined to the left side of the floor Cough and expectoration were both present, but the former of the thoracic cavity, upon which it encroached equally in was not particularly troublesome and the latter was scanty,all directions, occupying a space rather larger than a goodwhilst the fever, which never reached a point higher thansized orange. Upon opening the abdomen the stomach and -102’F., gradually declined, until at the end of ten daysit intestines were considerably distended, but the peritoneal had altogether disappeared. On making particular inquiry cavity was free from fluid, nor was there any trace of recent subsequently the man stated that the pain and the cough lymph effusion. The whole of the organs occupying the left had left him, his former standard of weight was again half of the abdominal cavity, however, were matted together reached and slightly surpassed, the appetite was good but and bound down to each other and to the abdominal not voracious, thirst was not abnormal, and the secretion of wall and diaphragm by old strong adhesions. The left portion_ .urine remained as it always had been. The man’s explana- of the omentum was adherent to the oesophageal end of the tion of the attack was that he had strained himself while stomach, and the latter was firmly bound down behind and lifting a heavy sack, his reason for saying so being that he also in the direction of the spleen. So firm were the, felt the pain come on almost immediately afterwards. adhesions that the organs could only be removed by dissectOn Aug. 20th of the same year the patient complained ing them out. The spleen was embedded in a mass of similar of pain in the head, back, and limbs, but went to work material and was ruptured in the effort to dislodge it. To all appearance it was healthy and of normal size and weight. on the 21st, 22nd, and 23rd, when he was obliged to give He then complained of headache, backache, and Below and behind the spleen a large fluctuating mass was felt, up. pain in the left iliac region just above the crista ilii, which on being opened was found to contain about two pints in which region there was slight tenderness on pressure, of thin, sticky, slimy-looking fluid, none of which, unforThe cyst was but no swelling could be detected. The temperature tunately, was preserved for examination. was 102° and the pulse 120 and feeble. On the 24th multilocular, and extended backwards towards the vertebral the whole of the base of the left lung, both in front and column and inwards towards the middle line behind the behind, was dull to percussion, the breath sounds were stomach and left lobe of the liver. Besides the fluid already distant, though not entirely absent, and the apex beat was mentioned there was a large quantity of recent lymph which plainly to be felt to the right of the sternum in a straight could be extracted in masses of from three to four inches in line with the nipple. From these signs and symptoms the length. No calculi were present. The pancreas was almost ’conclusion was arrived at that the left pleural cavity con- entirely destroyed, the only trace of it that could be found tained fluid. On the 25th an abundance of sugar was found being a small piece of pancreatic tissue in the upper and to be present in the urine, and for the next four days he posterior part of the wall of the cyst. The liver was normal. passed between 140 and 200 ounces of urine in twenty-four The left kidney was difficult to find as it was lying behind hours, of specific gravity 1035 and loaded with sugar. and below the cyst, and it also, like the spleen, was bound Thirst was very troublesome and the tongue was thickly down by adhesions. The right kidney was in its normal - coated, dry, and cracked. The pulse was weak and rapid, position and both were healthy. No sign of disease could be and faintness was readily induced by the slightest movement. discovered in the stomach or intestines. It is evident that the old-standing peritoneal inflammation, Dimness of vision supervened a day or two after the sugar was discovered, and an herpetic eruption made its appearexudation, and adhesion which were made manifest at The bowels acted the post-mortem examination occurred at the time of the first ance at the left angle of the mouth. regularly, but the character of the evacuations was not noted. illness in March whatever the cause of that may have been. There was no jaundice. As regards the physical signs, it It is to be regretted that the urine was not on that occasion may be said that the dulness cleared up slightly, whilst examined for sugar, but it is at the same time certain that the respiratory murmur was heard more distinctly over the there were none of the symptoms of glycosuria present which affected area, and the position of the apex-beat remained as were so marked during the fatal illness. On consideration it had been. The splenic dulness could not be satisfactorily of the fact that the spleen, colon, and left kidney were all determined owing to the distension of the abdominal viscera in working order while the pancreas was disorganised it with gas, and the stomach contained such a large amount as seems reasonable to suppose that the cause of the dis-’ to give rise to the suspicion of pneumothorax. Decubitus turbance is to be found in the latter; and from the sudden onset and subsequent history of the attack it would certainly was during the whole course of the illness on the right side cr on the back, but preferably the former. During the next seem that haemorrhage had taken place into the pancreas in three days the patient became gradually weaker and more the neighbourhood of the tail, this being followed by panand more apathetic ; the evacuations were passed uncon- creatitis confined to the left half of the organ and spreading sciously and the fever and glycosuria still continued. to the neighbouring peritoneum; or else that a previously ’On Sept. lst, although there were no symptoms calling existing pancreatic cyst had taken on inflammatory action urgently for the removal of the fluid in the pleural cavity, it which spread to the tissues in the vicinity. Perhaps on the whole the latter is the more likely supposition, both on was thought advisable to use the aspirator on the chance of the effusion being purulent. Fifteen ounces of odourless account of the distinctly one-sided direction which the inreddish-brown fluid were removed, the needle being inserted flammatory process followed and from the absence of any - in the mid-axillary line ; but this proceeding gave no relief, cause, such as injury or diseased bloodvessels, which would and the patient sank into a comatose state, death following be likely to produce hsemorrhage, though it is difficult to two days afterwards, on the fourteenth day of the illness and believe that a man could engage in laborious work for six months on end with a mass of exudation in the abdomen eleven days after sugar was discovered in the urine. - cT’opsy..— The necropsy took place thirty-six hours such as was present in this case without presenting a single after death, and although the weather was very hot symptom of disease. The course of events in the fatal illness probably was that and the body was in a small, close room there were no I
A CASE OF PANCREATIC GLYCOSURIA.
1150 inflammation was once more started in the old spot, being originated in all likelihood by an attack of influenza, which at that time was rife in the district ; effusion of fluid followed, and the whole of the pancreas was destroyed by the mechanical pressure exerted by the exudation. This case would seem to corroborate the conclusions arrived at by experiments on the dog-viz., that glycosuria only follows when the whole of the organ is destroyed or removed.l Sisters-avenue, S.W. __
THE EYE-SIGHT OF THE LATE MR. DU MAURIER. BY ROBERT BRUDENELL
CARTER, F.R.C.S. ENG.,
CONSULTING OPHTHALMIC SURGEON TO ST.
GEORGE’S
HOSPITAL.
IT has long been a matter of common knowledge that the late Mr. du Maurier suffered from impairment of sight, and that his charming work as an artist was accomplished under difficulties which would have proved insuperable to weaker men; but it is probably not known how much those difficulties were of a kind calculated to force themselves continually upon his attention, and to excite and maintain anxieties with regard to what the future might have in store for him. I think it will interest the profession to see a reproduction of a sketch which he made for me in the middle of 1895 as an illustration of his own visual state. I should premise that his left eye had no perception of light. Its vision was destroyed, totally and almost suddenly, many years ago by detachment of the retina, and the
retina had become useless and that the other was in a satisfactory state. In consideration of his one-eyed condition I did not think it desirable to dilate his pupil, a proceeding almost necessary to the discovery of inconspicuous retinal changes in the macular region, and all I could see with the ophthalmoscope was that his choroid was rendered visible by want of pigmentation in the external retinal layer. In reasoniiagupon the case it seemed to me that the appearances which he drew and described corresponded with retinal areas which were not blind, but only of subnormal sensibility to light. If the areas had been blind there would have been no consciousness of them, no more than there is of the normalblind spot. If we have dirt spots on a piece of paper, and look at it by transmitted light, the spots will be rendered visible because less light reaches the eye from the areas covered by them than from adjoining parts of the paper; and, in like manner, if we conceive groups or areas of retinal bacilli which are less sensitive than the neighbouring ones, an impression of comparative darkness will be produced over these areas when the eye is directed to Intermittent photopsia I a uniformly illuminated surface. take to be a result of irregularit:es of circulation acting upon arterioles of diminished elasticity ; and it is quite possible that the permanent spots might correspond with retinal areas which were under-nourished by reason of defective bloodsupply. I did not see my way to suggest any treatment for the assumed condition, and could only advise circumspection in visual work. I had a conversation with Mr. du Maurier a few weeks before his lamented death and heard from him that the conditions of his sight were unchanged. that
one
by no means
Harley-street, W.
A
CONTRIBUTION TO THE STUDY OF JACKSONIAN EPILEPSY. BY WILFRED J.
HARRIS, M.B.CANTAB.,
HOUSE PHYSICIAN TO THE NATIONAL AND
HOSPITAL FOR THE PARALYSED’ BLOOMSBURY.
EPILEPTIC, QUEEN-SQUARE,
EPILEPTIFORM fits are always interesting to study, but the of especial interest in that the first illustrates the fact that the abdominal muscles are unilaterally represented in each hemisphere for certain movements, while in the second case the unilateral spasms of the palate and tongue confirm in man the unilateral cortical representation of the soft palate and tongue movements shown by Beevor and Horsley to exist in the monkey. These experimenters have also shown1 that the abdominal muscles of one side,. especially the rectus abdominis, can be stimulated by excitation of the internal capsule of the opposite side in the monkey. A few cases have been observed of unilateral paralysis of the soft palate in hemiplegia, but I am unable to, find any record of unilateral convulsions affecting the soft, palate and tongue. I have to thank Dr. Buzzard and Dr. Gowers for their kind permission to make use of my notes on these cases. CASE I.-The patient was a girl aged five years, with A, Centre with scars of old scotoma all round. B, Punettim of probably multiple tuberculous tumours in both symptoms in coecum. +, Slight very imperfect. c, Black, varying Rolandic and in the cerebellum, and quite blind from areas a and visible now and then-since shape, fortnight.only G. DU MAURIER, July, 1895. post-neuritic atrophy. On Oct. 15th, 1895, she began to have convulsions early in the morning, and when seen half an hour blindness thus produced was followed by opacity of the lens. later she was found lying partly on her left side, with her The right eye was myopic to 1-50 D., with normal central head and eyes turned to the left, having regular clonic vision when the myopia was corrected, and was able to read spasms quite rhythmically about once a second of the left brilliant type unaided. It was, however, the subject of side of the face and of the arm, abdomen, and leg on the frequent photopsia, subjective sensations of light of a very left side. The head was turned to the left by regular clonic. its field of vision was broken by the varied character, and spasms of the sternal portion of the right sterno-mastoid, and appearances which he sketched-an appearance of lines, the eyes were turned to the left in conjugate deviation with spots, or clouds, distributed as shown in the drawing. The fine lateral nystagmus, the quick movement being to the fixing point, A, was surrounded by an irregular line, forming left. The pupils were equal and dilated as usual; the corneal an ellipse with its major axis horizontal and extending to reflex was present and consciousness was partly retained. the blind spot, B, and within this ellipse small dark spots The mouth was drawn to the left rhythmically with the other On either side the field was were irregularly distributed. and the left eyebrow twitched up, the eyelids blinkbordered by dark shading, which was most conspicuous on spasms, irregularly in an apparently semi-voluntary manner.. the nasal side, as at c. The result was that he could not ing The left hand was clenched, the thumb being turned in, and, look upon any uniformly illuminated surface, such as a sheet the forearm flexed. There were powerful rhythmic of white paper, without being reminded by these appearances contractions partially of the left great pectoral and of the left,
following cases are
1
Von
p. 448.
Mering and
Minskowski and
Freyhan,
The Medical Week,
1893,
I
1
Philosophical Transactions of the Royal Society, 1889.