An Address ON THE DIAGNOSIS OF SYPHILITIC DISEASES OF THE NERVOUS SYSTEM

six months. Each began with frontal headache for an hour; then extreme sleepiness came on, with vomiting at intervals. The temperature rose to 1010 or 1020; the tongue was much furred :but after thirty-six or fortyeight hours all the sympboms passed away. There was a strong double family history of gout. The attacks generally seemed to be excited by some indiscretion in diet. I doubt not you will remember such cases, which come chiefly under the notice of the practitioner rather than of the physician, and I should like to know whether you have not observed that they gradually acquire, as years go on, the characteristic features of true migraine. At the other end of life the prodroma of migraine frequently occurs without, or with but slight, headache, and sometimes with more brief headache than occurs during middle life. Occasionally the loss of power seems to be the chief symptom, and in these cases the headache is generally so slight as not to attract special attention. With many patients an error in diagnosis readily occurs in a first attack of this character, although another one is less likely to be mistaken. The weakness may be considerable. In one patient the attack came on wnen on a journey, and for an hour he walked with great difficulty. If we assume that vasomotor spasm is the cause of the prodroma, we may regard arterial spasm in the motor region as a sufficient cause of the loss of power. The same conclusion was reached by Dr. Langwill of Leith regarding two cases of this character in late life, in which symptoms quite like those of a grave organic lesion passed away after an hour's duration. Each patient had other similar attacks.2 Recovery may not always occur, even if the vasomotor hypothesis is correct. The arterial contraction prevents sufficient blood reaching the region of the brain to maintain its function. When the blood state favours rapid thrombosis this may occur in the vessel so as to preclude the return of the circulation, and enduring thrombosis, with all its consequences, may maintain the loss of function as permanent hemiplegia. Indeed, there is some danger of this in earlier life if any change in the blood promotes its coagulation. A woman of 29 had been sub. ject to migraine as long as she could remember, always on the right side of the head. During the fourth month of her second pregnancy an attack of her customary pain was followed by left-sided weakness, with ataxy of the hand, permanent left hemianopia, and impairment of sensibility on the left side. Pregnancy often involves an increased proneness to blool coagulation; there was no heart disease or albuminuria. Migraine abounds in problems of interest, but I have striven to confine your attention to the points on which additional and extended facts are much needed. A consideration of the cases I have mentioned will show how numerous and various are these features in every case. If these are not at first evident to you, I shall be only too glad to have an opportunity of pointing out the details on which any case may add to our knowledge, on information as to the general character of the premonition. The task is not easy, for the prodroma is brief and ever changing, and observation needs the perception of another person; but it is worth an effort and will reward the trouble it occasions. I may add another word regarding treatment. The benefit from nitroglycerine and strychnine, although often most conspicuous, is not invariable. Cases in which vasomotor disturbance is well marked externally sometimes derive no benefit. Why this should be the case it is not possible to say. Bromide taken regularly may then have more effect, or a small, long-continued course of salicylate. For the relief of attacks which are developing, a dose of antipyrin has often a quick influence, or Hochst's fused combination of antipyrin and caffein (migrainin), or a similar preparation made by Martindale of antipyrin fased with salicylate of caffein (migralgin). Nitroglycerine may conveniently be given in the form of the 1 per cent. solution, liq. trinitrini, but the mixture containing it must be kept acid. It may therefore be usefully united with a digestive tonic. Dyspepsia is common in some of those who suffer from migraine, and an error in diet may give rise to an attack some time after the previous one.