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FOREIGN AGENCIES:

LONDON:--H. K. LEWIS, MEDICAL PUBLISHER, 136 GOWER STREET.

PARIS: ADRIEN DE LA HAYE & EMILE LE CROSNIER, 23 PLACE DE L'ECOLE DE MEDECINE.
VIENNA: JOSEF SAFAR, VIII SCHLÖSSELGASSE, 24.

CATALOGUED, E. II. B.

3/26/87

MAR 26 1887

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joint, I grasp the arm and move it in various directions. There is some stiffness of the right arm, but no anchylosis. The left humerus has

TWO CASES of disease oF THE been broken and badly treated. There is here

NERVOUS SYSTEM.

BY WILLIAM PEPPER, M.D., LL.D.,

a large mass of callus, and there is more stiffness than on the opposite side. As a result of

Provost of and Professor of Theory and Practice of Medicine and the adhesions and pressure on the brachial

of Clinical Medicine in the University of Pennsylvania. DELIVERED AT THE HOSPITAL OF THE UNIVERSITY OF PENNSYLVANIA. [Reported for THE BULLETIN by WM. H. MORRISON, M.D.] ENTLEMEN:

cords, there has been increased weakness and interference with nutrition. The deltoid muscle is distinctly wasted. There is no impairment of sensation.

The first patient presents There is another symptom, and that is marked

the following history: J. A., æt. 64 years, a teamster by occupation. His general health has been good. When thirty years of When thirty years of age he had typhoid fever. After that he seemed as well as ever. In 1876 he had an attack of articular rheumatism, followed by a second attack one year later. His habits are good, but he drinks rather freely. In 1862 he had gonorrhoea, but apparently has had no syphilitic disease. He now complains of pains in the arms, back, and across the shoulders; the pains being worst in the left arm. For the past two years he has noted a loss of power in these limbs, which has become so marked as to necessitate his stopping work.

As he moves his arms, you notice a certain slowness and weakness in their movements, but there is no true paralysis of any muscle. There is impairment of power, but no actual palsy. The term paresis is often used to indicate impaired power; but I do not think it desirable to have such a special term, as the degree of impairment varies. I prefer to say slight, moderate, or marked impairment of power.

In order to determine whether or not this impairment is due to trouble in the shoulder

tremor of the muscles. On close watching
fibrillar twitchings are seen in different posi-
tions.
tions. When he attempts to move the arms,
there is marked muscular tremor. This is quite
distinct on both sides.

The symptom tremor is connected with a number of diseases. I have pointed out to you the muscular quivering and fibrillar twitching which come before progressive muscular atrophy. This is one of the earliest symptoms of that condition. The muscles begin to twitch, then become weak and waste. I have indicated the tremor which is seen in sclerosis. This is different from the tremor seen in progressive muscular atrophy, in the fact that in progressive muscular atrophy the tremor occurs when the limb is quiet, while in sclerosis the tremor occurs during motion.

Tremor may be the result of chronic alcoholism. It may also result from the effect of various metallic poisons, such as mercury, arsenic, or copper. Of these toxic agents, alcohol alone could be suspected of being the toxic agent in this case.

Again, there is a form of disease known as paralysis agitans, in which tremor is the

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