Neurological Diseases

The disease is more frequent in males than females [...]. It is chiefly a disease of adult life, commencing usually between twenty-five and forty-five [...]. Hereditary is to be traced in only less than half of cases [...]. The definite symptoms of the disease are often preceded by aching pain in the part afterward wasted, rarely severe. Sometimes there is such pain in the spine or elsewhere, especially [...] in the cases that are due to exposure to cold. Rarely some sensation other than pain precedes the local symptoms [...]. Weakness and wasting usually come on together [...]. In the upper part of the arm the loss of power is usually first noticed [...]. In the hand the wasting is often first noticed, but sometimes it is the impairment of some delicate action, such as writing [...]. The affected muscles lose their proper shape, and there is flattening, or even depression, where there should be a prominence [...]. From the part first affected, the disease spreads to other parts of the same limb. Before it has attained a considerable degree in one limb it usually shows itself in the corresponding limb on the other side [...].

As the muscles waste, voluntary power is lessened, and paralysis results of various character and degree, corresponding to the atrophy [...]. In most cases the wasting early involves the muscles of the back, and it often begins in them [...]. The muscles that extend the head on the spine often suffer in considerable degree, and from this there results a difficulty in the carriage of the head [...]. The muscles of respiration supper in the majority of cases. And their impairment constitutes a grave source of danger to life [...]. Wasting in the legs is much less common than in the arms [...]. the legs are often paralyzed when they are not wasted [...]. The face almost always escapes general wasting [...]. All trace of muscle may disappear from parts of a limb or even from an entire limb, and there is usually wasting of the adipose tissue as well as the muscle, so that bone seems to only be covered by fascia and skin [...]. The ‘claw-like’ hand develops in extreme degree [...]. Moreover, spontaneous flickering contractions of parts of the muscles are very common [...]. Lordosis is very common [...]. By far the most frequent complication is bulbar paralysis, weakness of the lips, tongue, pharynx, and often of the laryngeal muscles [...]. The malady, in most cases, is steadily progressive [...] but in the rate of its progress it varies in different cases and in the same case at different periods.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 351-360.

Entered by: Sonia Y. Khan, 6/17/2020

Males are more frequently affected than females. [...] The disease is most common at the middle period of life. The chief causes are: (a) endarteritis, either simple or syphilitic, which leads to weakness of the wall and dilatation; and (b) embolism. [...]

The aneurism may attain considerable size and cause no symptoms. In a majority of the cases the first intimation is the rupture and the fatal apoplexy. Distinct symptoms are most frequently caused by aneurism of the internal carotid, which may compress the optic nerve or the commissure, causing neuritis or paralysis of the third nerve. A murmur may be audible on auscultation of the skull. Aneurism in this situation may give rise to irritative and pressure symptoms at the base of the brain or to hemianopsia. [...] Aneurism of the vertebral or of the basilar may involve the nerves from the fifth to the twelfth. A large sac at the termination of the basilar may compress the third nerves or the crura. [...] The larger sacs produce the symptoms of tumor, and their rupture is usually fatal.

Osler, W. (1892). The Principles and Practice of Medicine. New York: D. Appleton & Company. Pg. 883-884.

Entered by: Ayushi Chintakayala, 7/2/2020

While diplegia and paraplegia are occasionally seen, the great majority of cases are acquired cerebral palsy of the hemiplegic variety. […] The onset of the paralysis is almost invariably sudden, with convulsions, which are usually repeated, and in severe cases followed by loss of consciousness. In the secondary cases these are generally the only symptoms. […] When the paralysis is apparent primary, fever is usually present, and in addition to the convulsions there may be vomiting, delirium, and other symptoms, strongly suggestive of an acute inflammatory process in the brain, which continue for a variable time, usually two or three days, before paralysis is seen. […] It is rare that the face is much involved, and often it escapes altogether. The paralysis of the arm and leg is at first complete, but may improve very rapidly in the course of a few days. Disturbances of sensation are usually of a transient character. […]

With lesions of the left side of the brain, speech may be affected, and not infrequently in young children when the lesion is upon the right side. The reflexes are increased upon the affected side, and slight ankle-clonus may be present. In the course of a few weeks the child may be able to walk, dragging the affected leg’ the recovery in the leg is sometimes complete but in most cases a slight halt in the gait remains. The arm usually recovers more slowly than the leg. […] Aphasia is common in right hemiplegias, and it is not very rare in those of the right side, because infants appear to use both sides of the brain with nearly equal facility. […] The mental condition of these children is usually normal, in striking contrast with the cases of congenital diplegia.

Holt, L Emmett. The Diseases of Infancy and Childhood: for the Use of Students and Practitioners of Medicine. Appleton and Co, 1897. Pg. 747-748.

Entered by: Erin Choi, 6/30/2020

Edited by: Bernardo Galvan, 9/7/2020

In different cases of external meningitis the symptoms vary much, and they are usually complicated with those due to the cause of inflammation [...]. In other acute cases, the manifestations of the processes are nearly the same as those of internal meningitis [...]. The chief pain in the back, increased by movement, accompanied by the stiffness of the muscles in the spine, and by the cutaneous hyperaesthesia. Another important symptom is the “eccentric” pain, radiating into the parts supplied by the nerves which pass through the inflamed membrane, and due to the irritation of their roots.

The pains [...] are usually associated with spasm [...] anesthesia, and sometimes by paralysis of the muscles supplied by the nerves. In addition there may be indications of interference with the functions of the cord itself, due to its compression or inflammation. There are then pain in the limbs, often so great as to prevent walking, paraplegic weakness, and increased reflex action when the disease is above the lumbar enlargement [...]. Trophic lesions may occur [...]. It is in the most acute form that the cord suffers and corresponding symptoms are developed. In such cases there is usually much pyrexia. In chronic cases, although the pain may be considerable [...] symptoms resemble those due to bone disease.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 194.

Entered by: Sonia Y. Khan, 6/10/2020

The facial changes accompanying this lesion are so characteristic and constitute a deformity so pathognomonic as to overbalance in diagnostic importance all other clinical features. Owing to the paralysis of the facial muscles corresponding to the side of the aural lesion, the normal facial folds are obliterated. Thus the wrinkles or lines of the forehead and about the eye and the nasolabial fold disappear wholly. The skin, therefore, presents a smooth and lineless surface in conspicuous contrast to the opposite side of the face. In children and young adults this may not be conspicuous while the face is in repose, but becomes unpleasantly noticeable as soon as the sound facial muscles are called into activity,—-e.g., in laughing, crying, etc.

The patient cannot close the eye on the affected side, and cannot contract the labial muscles. In cases of complete paralysis, the affected side of the mouth may droop to such an extent as to allow a more or less constant escape of saliva. As a result of the physical changes above noted, the patient may experience the following disturbances of the special senses: The inability properly to close the eyelids leaves the eye unprotected, and the conjunctiva and even the cornea may become inflamed or congested. Owing to paralysis of the nasal muscles and collapse or flaccidity of the ala nasi, the passage of air to the upper nasal chamber is diminished or prevented, and to this extent the olfactory sense is disturbed. Paralysis of the chorda tympani nerve is responsible for loss or disturbance of taste in the corresponding half of the tongue. Finally, paralysis of the stapedius may result in a very annoying disturbance of the auditory function, which takes the form of a loss of auditory balance or power of accommodation to various sounds rather than of an actual diminution of hearing.

In many cases the paralysis of the stapedius in persons whose hearing has previously not shown great impairment is said to result in an appreciable hyperacusis for the lower musical tones… When the paralysis is complete and attended by characteristic electrical reactions of degeneration, marked atrophy of the paralyzed facial muscles may add to the disfigurement.

Kerrison, P. D. (1923). Diseases of the Ear (3rd ed.). Philadelphia: J.B. Lippincott Company.

Entered by: Bernardo Galvan, 6/28/2020

A rare disease which may be hereditary as well as occurring in a family without disease in the ascendants. Anatomically there is marked degeneration of the anterior horns in the spinal cord, of the anterior roots, and less marked changes in the peripheral nerves, with widespread atrophy of the muscular fibers. While in many cases the disease resembles muscular dystrophy, anatomically it appears to be a progressive central muscular atrophy. It presents a close similarity to Amyotonia Congenita (Oppenheim's Disease). The onset is early, even before walking. The proximal muscles of the limbs and the muscles of the trunk are first involved. There's no pseudo-hypertrophy. Fibrillary tremors may be present. The disease is progressive, sometimes with great rapidity, and death usually occurs before the sixth year.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 926.

Entered by: Sonia Y. Khan, 6/15/2020

Description 1

Preceding the fits there is usually a localized sensation, known as an aura, in some part of the body. This may be somatic, in which the feeling comes from some particular region in the periphery, as from the finger or hand, or is a sensation felt in the stomach or about the heart. The epigastric sensations are most common. In these the patient complains of an uneasy sensation in the epigastrium or distress in the intestines, or the sensation may not be unlike that of heart-burn and may be associated with palpitation.

Occasionally the fit may be preceded not by an aura, but by certain movements; the patient may turn round rapidly or run with great speed for a few minutes, the so-called epilepsia procursiva. At the onset of the attack the patient may give a loud scream or yell, the so-called epileptic cry. The patient drops as if shot, making no effort to guard the fall.

The fit may be described in three stages: (a) Tonic Spasm.—The head is drawn back or to the right, and the jaws are fixed. The hands are clinched and the legs extended. This tonic contraction affects the muscles of the chest, so that respiration is impeded and the initial pallor of the face changes to a dusky or livid hue. The head and neck are rotated or the spine is twisted. The feet are extended and the knees and hip-joint are flexed. The arms are usually flexed at the elbows, the hand at the wrist, and the fingers are tightly clinched in the palm. This stage lasts only a few seconds, and then the (b) Clonic stage begins. The muscular contractions become intermittent; at first tremulous or vibratory, they gradually become more rapid and the limbs are jerked and tossed about violently. The muscles of the face are in constant clonic spasm, the eyes roll, the eyelids are opened and closed convulsively. The movements of the muscles of the jaw are very forcible and strong, and it is at this time that the tongue is apt to be caught between the teeth and lacerated. The cyanosis, marked at the end of the tonic stage, gradually lessens. A frothy saliva, which may be blood-stained, escapes from the mouth. The contractions become less violent and the patient gradually sinks into the condition of (c) Coma. The breathing is noisy or even stertorous, the face congested, but no longer intensely cyanotic. The limbs are relaxed and the unconsciousness is profound. After a variable time the patient can be aroused, but if left alone lie sleeps for some hours and then awakes, complaining only of slight headache or mental confusion.

Osler, W. (1892). The principles and practice of medicine: Designed for the use of practitioners and student of medicine. New York, NY: D. Appleton and Company.

Entered by: Kate Holder, 6/25/2020

Edited by Erin Choi, 7/8/2020

 

Description 2

It is thus with regard to the disease called Sacred: it appears to me to be nowise more divine nor more sacred than other diseases, but has a natural cause from which it originates like other affections. Men regard its nature and cause as divine from ignorance and wonder, because it is not at all like other diseases. […]

[…] the brain is the cause of this affection, as it is of other very great diseases. […] the patient loses his speech, and chokes, and foam issues by the mouth, the teeth are fixed, the hands contracted, the eyes distorted, he becomes insensible, and in some cases the bowels are evacuated. […] The patient kicks with his feet. […]

Hippocrates (1849). On The Sacred Disease. (Adams, F., Trans.). Syndeham Society. (Original work published 400 BCE).

Created/Entered by Rachel Johnson, 08/01/2021

The first and the chief manifestation of the disease is a gradual impairment of coördination, first in the legs and afterward in the arms [...]. The ataxy is shown by unsteadiness in standing and walking [...] like one under the influence of alcohol [...]. There is irregularity in the voluntary movement of the arms and fingers, and the ataxy has often a distinctly jerky character [...]. In most cases the knee jerk has been found absent [...]. As the disease progresses, some jerky irregularity develops in the movements of the neck and head [...]. Speech is also impaired [...]. Occasional jerky movements have been noted in the tongue [...]. In most cases (but not in all) there is nystagmus when the eyes are moved laterally [...]. Paralysis of the ocular muscles does not occur, nor does optic nerve atrophy. Sensory symptoms are very variable. Lightning pains and any severe pains are extremely rare, but slight dull or rheumatoid pains in the legs are not uncommon [...]. There has been slight anaesthesia in the legs [...]. Sensation may, however, be unaffected even when the ataxy and weakness have become extreme [...]. Increased sensitiveness to pain is occasionally met with.

Reflex action from the sole is usually preserved, but may be lost when there is anaesthesia. The cremaster reflex is often lost [...]. There is no tendency to trophic changes in the skin or joints [...]. It [muscular strength] usually becomes impaired as the disease progresses, and sometimes weakness comes on, with the ataxy, at the onset of the disease. The loss of power is always greatest in the legs and may be confined to them. The flexors suffer more than the extensors [...]. Lateral curvature of the spine, and talipes equinus, or equino-varus, of the foot, been observed [...] and contraction of the flexors of the knees has also resulted [...]. Frequency of the pulse has been noted [...] and curious vasomotor symptoms (flushing, oedema, sweating, polyuria, and salivation) [...]. There is no mental change that can be regarded as part of the disease [...]. The rate of progress of the malady varies much, even in different members of the same family [...]. Now and then the disease is stationary for many years. The duration of the malady is correspondingly variable. It is always long, even more than thirty years [...]. On the other hand, death may occur at the end of ten or twelve years. The end has generally come from intercurrant affections [...].

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 345-346.

Entered by: Sonia Y. Khan, 6/16/2020

Acute— Slight pain in the back, and malaise, may precede the acute onset of the symptoms. This is usually marked by a rigor, by pyrexia, and by severe pain in the back [...]. It [pain] is often felt along the whole extent of the spine [...]. This [the pain] is paroxysmal and very intense; sharp, darting, burning, or constricting. The pain in the back is usually constant with exacerbations. It is often increased by movement, usually also by pressure [...]. Muscular spasm usually comes on at the same time as the pain [...]. first in rigidity of the muscles of the back. There is usually great hyperaesthesia of the skin to all forms of sensation, and also increased sensitiveness of the muscles, especially in the lower extremities [...]. Reflex action is usually increased at the beginning. There are constipation and often retention of urine [...] the result of reflex spasm [...]. Dyspnea may result [...]. The pulse may be frequent or retarded [...]. The temperature is raised, sometimes, however, to only a slight degree. Cerebral symptoms, headache, delirium, coma, occur when inflammation has extended within the skull. The ‘Cheyne-Stokes breathing’ may be present, from implication of the medulla. As the disease progresses, the symptoms of irritation give place to those of paralysis, which may be most marked where the rigidity was greatest [...]. Reflex action disappears, and death may occur from asthenia, or from paralysis of the respiratory muscle [...]. In some cases the symptoms become less progressive and the diseases passes onto a less acute stage [...]. Symptoms above described vary in their grouping, according to the position of the disease [...]. The symptoms of tubercular spinal meningitis resemble those which have been described, but are usually less intense [...]. Herpes along the course of an intercostal nerve has been spotted.

Chronic— The common symptoms are these: There is pain in the back, increased by movement, sometimes, however, amounting only to heavy, dull discomfort, and accompanied by some stiffness of the back, and, when in the cervical region, by some retraction of the head. The pain is increased by pressure on the spines, and its increase by movement may cause a fixation of mobile parts, as the neck, in some abnormal position. Still more conspicuous, in many cases, are the radiating or eccentric pains due to the irritation of the nerve roots, and referred to the region in which the nerves are distributed . . . according to the position of the disease. These pains are often very severe, sharp, darting, burning, or rheumatoid in character, paroxysmal in occurrence, and sometimes worse at night. They may be accompanied by [...] numbness, tingling, formication, in the same areas. Hyperaesthesia may also exist [...]. Cutaneous eruptions [...] have also been observed. In the same regions, muscular twitching, tremor, or even spasm, may result from irritation of the motor root fibres [...]. These pains having lasted for a time, weeks or months, certain paralytic symptoms manifest themselves. The pain sometimes persists, but cease when the paralysis comes on [...]. Entire groups [of muscles] may atrophy [...]. As the disease progresses, the cord itself suffers [...]. Power over the sphincters may be lost and bedsores may form.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 198-206.

Entered by: Sonia Y. Khan, 6/10/2020

Occurs usually between the ages of 20 and 30, more often in males, also, rarely, in infants and children. There is often an inherited neuropathic tendency. The most important causative factor is infection. […] Onset slow and gradual. First noticed are rigidity and weakness in the legs, perhaps with some numbness; or a tremor in the hands. Soon follows ataxia of the legs, which, with the weakness and rigidity, increases the difficulty of walking. There may be some incontinence of urine. […] The speech is slow, syllabic, and scanning in character. Deglutination may be impaired. Occasional pains may occur in the joints and extremities, with some numbness of slight tactile anesthesia in the limbs. The gait is awkward and stiff, and there is, perhaps, slight hemiplegia. […] The ataxia is due mainly to the inability to co-ordinate and control the movements, weight and pressure senses being unimpaired.

The jerky tremor of the hands may be so marked that the patient finds it difficult to dress himself, or to carry a glass of water to his mouth without spilling it. There may be tremor in the muscles of the neck, causing a constant movement of the head, or in those of the face. The tongue is protruded in a jerky manner, and the thick, slow speech may be nearly unintelligible. there are exaggerated knee-jerks and ankle clonus. Nystagmus is present, perhaps only to be seen when the eyes are turned far to one side, but may be manifest when looking directly at an object, perhaps with diplopia. The pupils react normally. Optic atrophy may be present, chiefly in the temporal half of the disc, which may become complete later in the disease, followed, as results, by weakness of vision, contraction of the visual fields, and scintillating scotomata. Occasionally there may be attacks of vertigo, and apoplectiform and epileptiform seizures. There may be mental slowness, perhaps slight melancholia, or impulsive laughing or crying. The course of the disease is irregular, usually lasting about 5 years, occasionally 3 times as long.

Butler, G.R. (1901) The Diagnostics of Internal Medicine: a Clinical Treatise upon the Recognised Principles of Medical Diagnosis. D. Appleton & Company. Pg. 1003-1004.

Entered by: Ayushi Chintakayala, 6/22/2020

Edited by Bernardo Galvan, 9/7/2020

Clumsiness in the movements of the child is the first symptom noticed and on examination certain muscles or groups of muscles seem to be enlarged, particularly those of the calves. The extensors of the leg, the glutei, the lumbar muscles, the deltoid, triceps and infraspinatus, are the next most frequently involved, and may stand out with great promise. The muscles of the neck, face, and forearm rarely suffer. Sometimes only a portion of a muscle is involved. With this hypertrophy of some muscles there is wasting of others, particularly the lower portion of the pectorals and the latissimus dorsi. The attitude when standing is very characteristic. The legs are far apart, the shoulders thrown back, the spine is greatly curved, and the abdomen protrudes. The gate is waddling and awkward. In getting up from the floor the position assumed, so well known now through Gowers’ figures, is pathognomonic. The patient first turns over in the all-fours position and raises the trunk with his arms; the hands are then moved along the ground until the knees are reached; then with one hand upon a knee he lifts himself up, grasps the other knee, and gradually pushes himself in the erect posture, as it has been expressed, by climbing up his legs. The striking contrast between the feebleness of the child and the powerful looking pseudo-hypertrophic muscles is very characteristic.

The enlarged muscles may, however, be relatively very strong. The course is slow, but progressive. Wasting proceeds and finally all traces of the enlarged condition of the muscles disappear. At this late period distortions and contractions are common. The muscles of the shoulder-girdle are nearly always affected early [...]. With the hands under the arms, when one endeavors to lift the patient, the shoulders are raised to the level of the ears, and one gets the impression as though the child was slipping through. These ‘loose shoulders’ are very characteristic. The abnormal mobility of the shoulder blades gives them a winged appearance, and makes the arms see much longer than usual when they are stretched out. There are no sensory symptoms. The atrophic muscles do not show the reaction of degeneration except in extremely rare instances.

 Clinical Forms—

 I. The pseudo-hypertrophic of Duchenne, most common in childhood and in family groups. The hypertrophy of the muscles is the striking feature, whether a true hypertrophy or lipomatosis. There is also a juvenile type with atrophy, affecting chiefly the shoulder girdles and upper arms. Isolated cases occur in adults.

II. The facio-scapulo-humoral type of Landouzy-Dejerine. The face is first involved, causing myopathic facies, the lips prominent, the upper one projecting, the eyes cannot be closed, nor the forehead wrinkled, the smile is transverse, from inaction of the levators of the lip. Later the shoulder-girdle muscles are involved, the scapulae are winged, the upper arms wasted, and lastly, the thigh muscles. With all this there may be no hypertrophy, though often, if carefully sought, there will be found areas of enlargement—the so-called muscle balls. This form may begin in adults [...].

In all forms, when the muscles of the trunk become involved there is flattening of the chest and the peculiar ‘wasp-waste’ described by Marie.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 924-925.

Entered by: Sonia Y. Khan, 6/15/2020

In women the disease usually occurs before the age of twenty-five, in males in middle life [...]. The muscles innervated by the bulb are first affected—those of the eyes, the face, of mastication, and of the neck. After effort the muscles show fatigue, and if persisted in they fail to act and a condition of paresis or complete paralysis follows. All the voluntary muscles may become involved. After rest power is recovered. In severe cases, paralysis may persist [...]. There are marked remissions and fluctuations in the severity of the symptoms. The diagnosis is easy—from the ptosis, the facial expression, the nasal speech, the rapid fatigue of the muscles, the myasthenic reaction, the absence of atrophy, tremors, etc., and the remarkable variations in the intensity of the symptoms [...]. The patient may live many years; recovery may take place.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 1124.

Entered by: Sonia Y. Khan, 6/24/2020

The disease is characterized by a peculiar rigidity of the muscles, which comes on when they are first put in action after a period of rest. The rigidity is transient, and when it has passed off it does not return as long as exertion is continued. The malady is usually congenital and often hereditary, affecting many members of the same family [...]. Both sexes suffer. In most cases the symptoms have been first noticed in early childhood [...]. They increase during the period of muscular development, and then remain stationary. In a few instances the patient has seemed free until about the age of puberty [...]. The characteristic symptom is tonic spasm of the muscles when they are put in action after a period of rest. As soon as the patient attempts to move, the muscles become rigid.

The rigidity may make movement impossible, while it lasts, or may nearly lessen the possible range of movement. After a few minutes or less the spasm passes away, to be renewed, but in slighter degree, by a fresh attempt, and if the movements are preserved in, the spasm, in a few minutes, becomes trifling, and does not return until after rest; the individual can walk for hours without fatigue when the spasm has passed off. The rigidity is always increased by attention and by nervous apprehension of it, and the more the sufferer tries to overcome the stiffness, the less he is able to do so. In a severe case, a slight impulse will make the person fall, and it may then be impossible for him, for some minutes, to rise from the ground. The arms are usually less affected than the legs, but in some cases the rigidity fixes the fingers for a short time on an attempt to use the hand. The muscles of the face are usually free; mastication may, however, be interfered with by the spasm in the muscles of the jaw. Rarely the tongue has been affected; still more rarely the muscles of the eyeball. Sometimes the spasm is greater on one side of the body than on the other [...]. They [the muscles] are often, indeed, above the normal size, and possess more than normal strength.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 345-346.

Entered by: Sonia Y. Khan, 6/16/2020

[...] There is a tendency to fall into sound sleep for a short time, usually for a few minutes, rarely for an hour or more. The condition is distinguished from trance by the brevity of the attacks of sleep, by their strong tendency to recur, and by the fact that the patient can commonly be roused at any time from the condition. In some cases the malady has been apparently the result of some peculiarity of the nervous system [...]. In other cases the affection comes on in adult life, and passes away after lasting for a few months or years [...]. She [a patient with narcolepsy] would suddenly feel drowsy, her eyelids drooped, in a moment she was sound asleep, and after about 5 minutes woke up quite fresh.

[...] Sometimes she would speak aloud in the dream. There was no change in the color of her face. After deficient sleep at night, the sleep attacks lasted longer, sometimes even half an hour. She could readily be awakened at any time and by an effort could keep off the attack, but then could not help yawning continually, and felt uncomfortable. There was never headache. Such attacks occurred four or five times a day, when she was engaged in sedentary occupations or studies, but when she led an active life, as, for instance, on a holiday, they would be absent for two to three weeks.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 1335-1336.

Entered by: Sonia Y. Khan, 6/29/2020

The symptoms of neuritis vary extremely according to its intensity, its extent, and the nerve that is affected [...]. The chief symptoms are local. The most prominent is pain, felt in the inflamed part of the nerve, and also often in the part to which it is distributed [...]. Sometimes the pain involves the whole limb, and in severe cases it may be most intense, burning, boring, rarely darting, in character; usually worse at night; increased by movement, by postures that involve tension or pressure on the nerve, and by whatever causes passive congestion of the limb, such as the act of coughing. Sometimes it seems to radiate into distant parts and not rarely pain is also felt in the corresponding region of the opposite limb [sympathetic neuritis]. The sensitiveness of the whole affected region is increased, and even the bone may be tender [...]. Occasionally the skin over it [the nerve] has been observed to be red, and rarely there has been slight oedema. Spontaneous sensations may be felt in the region supplied by the nerve, tingling, etc., and the skin may be hyperaesthetic [...]. sensation may be perverted, or even lessened; complete anesthesia is usually confined to small areas. The muscles supplied by the nerve become weak, tender, and present fibrillar twitchings [...]. Increased perspiration has been observed in the part of the skin supplied by the inflamed nerve, and sometimes, although rarely, eruptions occur. Herpes is not uncommon [...]. Effusion into joints has been observed in very rare cases. The constitutional disturbance, which may attend the onset, subsides in the course of a few days, but the pain and the other symptoms usually persist in undiminished severity for several weeks. They ultimately slowly subside into a chronic stage.

When the infection is chronic from the commencement, initial constitutional disturbance is absent [...]. The affection [...] are similar to those met with in the acute form [...]. Trophic changes in the skin are very common [...]. Slight alteration in the nutrition of the joints is also common, and adhesions form [...] corresponding to the muscular paralysis.

When neuritis ascends a nerve the symptoms gradually extend in area [...]. This “migrating neuritis” is not rare [...]. The inflammation may spread in the tissue outside the dura mater, or may extend to the cord, and cause subacute or chronic myelitis with or without meningitis.

The duration and course for neuritis vary much. A slight acute neuritis may run its course in a few weeks and then decide. Much more commonly the affection persists in a chronic stage for many weeks, or even months, and slowly passes off.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 76-77.

Entered by: Sonia Y. Khan, 6/09/2020

These [symptoms] may be entirely absent, especially in the case of multiple (true) neuromata, which are sometimes discovered post-mortem, when their existence has not been suspected. The most frequent symptom is pain referred to the distribution of the nerve, often acute, burning, or darting, and frequently intermittent. It may be increased by pressure on the tumor. In the case of the terminal neuromata (tubercula dolorosa, bulbous nerves) pain may be the only sensory symptom. When the nerve fibres suffer, paresthesia, numbness or formication, may be complained of, and ultimately sensation may be lessened or lost. Paralysis of the muscles supplied by the nerve is occasionally met with, the region paralyzed corresponding to the distribution of the nerve on which the tumor is situated, except in the case of neuromata in the cauda equina, where the nerves may suffer from pressure, and paraplegia may result. In all cases the distribution of the symptoms depends necessarily on the nerve affected [...].

More common motor symptoms are reflex spasms in adjacent or even distant muscles [...]. Occasionally epileptiform convulsions are produced [...].The occurrence of these symptoms has little relation to the size of the tumor.

When the neuromata are in accessible situations they may be felt. Sometimes they give rise to visible tumors, and in multiple neuroma the course of the superficial nerves may be marked out by lines of bead-like swellings. The cutaneous neuromata also cause visible swellings [...]. They are commonly not sensitive, although preëxisting pain may be increased by pressure. Pressure on the nerve above the tumor commonly lessens the pain.

The functions of the nerve fibres involved or not usually interfered with. Once or twice anaesthesia of the skin has been observed.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 83.

Entered by: Sonia Y. Khan, 6/09/2020

[Parkinson’s Disease] is a disease of the second half of life, characterized by [...] muscular weakness and tremor, and also by muscular rigidity. The symptoms usually commence locally and gradually, but tend to spread and to become general [...]. The head is bent forward and the expression of the face is anxious and fixed, unchanged by any play of emotion. The arms are slightly flexed at all joints, from muscular rigidity, and (the hands especially) are in constant rhythmical movement, which continues when the limbs are at rest [...]. The tremor is usually more marked on one side than on the other. Voluntary movements are performed slowly and with little power. The patient often walks with short, quick steps, leaning forward as if about to run [...]. Usually the initial symptoms come on very gradually, as tremor, stiffness, or weakness, in one hand.

The tremor may at first only occur on emotion or fatigue, but it afterward constant, and slowly spreads from the part in which it was first noticed [...]. The commencement is four times as frequently in the arm as in the legs [...]. This movement may be chiefly in the thumb and forefinger, which may move as in the act of rolling a small object between their tips [...]. Usually the head is free from tremor [...]. It [the tremors] is always slight at the commencement and increases with the progress of the disease [...]. The great characteristic of the tremor is [...] that it continues during rest [...]. A voluntary movement might stop the tremor for a few seconds, sometimes for many, but it recommences and accompanies the movement [...]. If the tremor is unilateral, and the shaking of the hand is prevented by force, the other hand, previously free, usually begins to shake [...]. Some tremor persists during sleep [...]. Although the weakness and rigidity are usually secondary to the tremor, they may come first [...]. Aching pains in the limbs [...] are occasionally complained of in the early stage [...]. The intellect may be unaffected throughout [...]. Pronounced mental symptoms are occasionally present, however, in the later stages of the disease, commonly limited to mental weakness and loss of memory, but sometimes accompanied by a tendency to delusions [...]. The disease is always chronic, usually progressive, in its course [...]. [Parkinson’s disease] does not directly cause death [...]. [Death occurs] more frequently from intercurrent affections, especially of the respiratory organs, facilitated by the progressive muscular weakness [...].

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 995-1008.

Entered by: Sonia Y. Khan, 6/18/2020

This is epilepsy without the convulsions. The attack consists of transient unconsciousness, which may come on at any time, accompanied or unaccompanied by a feeling of faintness and vertigo. [Suddenly] for example, at the dinner table, the subject stops talking and eating, the eyes become fixed, and the face slightly pale. Anything which may have been in the hand is usually dropped. In a moment or two consciousness is regained and the patient resumes conversation as if nothing had happened. In other instances there is slight incoherency or the patient performs some almost automatic action. He may begin to undress himself and on returning to consciousness find that he has partially disrobed. In other attacks the patient may fall without convulsive seizures. A definite aura is rare. Though transient, unconsciousness and giddiness are the most constant manifestations of petit mal; there are many other equivalent manifestations, such as sudden jerkings in the limbs, sudden tremor, or a sudden visual sensation. Gowers mentions no less than seventeen different manifestations petit mal.

After the attack the patient may be dazed for a few seconds and perform certain automatic actions, which may seem to be volitional. As mentioned, undressing is a common action, but all sorts of odd actions may be performed, some of which are awkward or even serious. […] Violent actions have been committed and assaults made, frequently giving rise to questions which come before the courts. This condition has been termed masked epilepsy, or epilepsia larvata.

In a majority of the cases of petit mal convulsions finally occur, at first slight, but ultimately the grand mal becomes well developed and the attacks may then alternate.

Osler, W. (1892). The principles and practice of medicine: Designed for the use of practitioners and student of medicine. New York, NY: D. Appleton and Company.

Entered by: Kate Holder, 6/22/2020

Edited by: Sonia Y. Khan, 8/4/2020

Weakness of the legs, of very gradual development, is the first symptom. The patient finds that he gets tired more readily than before, and that the legs feel heavy. It is very common for one leg to become weak before the other. The progress of the weakness is very variable, but it is slow in all characteristic cases [...]. It will generally be found that there is very distinct loss of power in the flexors, often greatest in the flexors of the hip [...] knee, and ankle. The knee jerk is excessive and quick [...]. The tendency to spasm is at first noticeable as slight stiffness of the legs on first rising in the morning, but it gradually increases in degree as power lessens, until at last the legs, whenever extended, pass into a condition of strong extensor spasm, rigidly fixing them to the pelvis, so that, as the patient lies, if one leg is lifted from the couch by the observer, the other leg is moved also [...]. The spasm is, roughly speaking, proportional to the loss of power [...]. When the spasm, is great, a paroxysm may pass into a violent clonic spasm. This was termed ‘spinal epilepsy’ [...] but it has, of course, nothing to do with epilepsy [...]. The gait of the sufferers from spastic paraplegia is very characteristic. The legs seem to drag behind the patient, and, in walking, each is hauled forward as a rigid whole, the toes catching against the ground, and, when the ball of the foot rests on the ground, the limb may shake from clonus developed by the extension of the calf muscles.

When the patient sits, a similar trepidation occurs until the patient pushes the legs forward so that the heel rests also on the floor [...]. They [muscles of the leg] often seem, indeed, to be hypertrophied [...]. But they are not always large; they are sometimes moderately wasted [...]. The arms are often unaffected, but they suffer in some cases, and present the same progressive weakness and excess of myotatic irritability [as the legs]. Vigorous contractions are elicited by a tap on the tendon of a muscle, or on the bone to which the tendon is attached, provided the muscle is extended [...]. The muscles of the trunk may also suffer [...]. It is not common, in typical cases, for the symptoms to extend into the region of the cranial nerves, but in rare instances difficulty of swallowing and of articulation has existed, due to a similar palsy of the bulbar nerves. Excessive myotatic irritability has also been observed in the muscles of mastication, so that a tap on the chin causes a vigorous elevation of the depressed jaw [...]. Sensory symptoms are often entirely absent, with the exception of slight dull pain in the legs, or more frequently in the back [...]. The sphincters are often affected, and sometimes very early in the course of the disease [...]. Ocular symptoms are rare [...]. The course of characteristic cases of primary spastic paraplegia is usually very chronic, and the malady may, at any stage, cease to advance.

 Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 326-330.

Entered by: Sonia Y. Khan, 6/12/2020

The peroneal type, described first by Charcot, Marie, and Tooth, is a hereditary and familial disease beginning in childhood, affecting first the muscles of the peroneal group, leading to club-foot, either pes equinus or pes equino-varus. The pathology is not clear: the disease seems to occupy a position intermediate between central muscular atrophy and the muscular dystrophies, resembling the latter in the early onset and familial character, and the former in the occurrence of fibrillary twitchings [...] and the implication of the small muscles of the hand. Anatomically sclerosis of the posterior columns, atrophy of the cells of the anterior horns and alterations of the peripheral nerves have been found.

The disease may begin in the hands, but as a rule the upper limbs are not affected until after the legs, and then the trouble starts in the small muscles of the hand, so that claw-foot and claw-hand are very striking features. Disturbances of sensation are common. Fibrillary twitchings also occur; the deep reflexes are lost in the paralyzed muscles. The essential feature is implication of the distal with normal proximal portions of the limb, which gives a very characteristic picture [...]. Ocular symptoms are rare; occasionally there is atrophy of the optic nerves. The disease should be suspected in cases of acquired double club-foot.

Osler, W. (1892). The Principles and Practice of Medicine. New York and London: D. Appleton and Company. Pg. 926-927.

Entered by: Sonia Y. Khan, 6/15/2020

This is, as a rule, a neuritis either of the sciatic nerve or of its cords  of origin. It may in some instances be a functional neurosis or neuralgia. It occurs most commonly in adult males. A history of rheumatism or of gout is present in many cases. Exposure to cold, particularly after heavy muscular exertion, or a severe wetting are not uncommon causes. Within the pelvis  the nerves may be compressed by large ovarian or uterine tumors, by lymphadenomata, by the fetal head during labor, and occasionally  lesions of the hip-joint induce a secondary sciatica. […] The affection may be most intense at the sciatic notch or in the nerve about the middle of the thigh.

Of the symptoms, pain is the most constant and troublesome. The onset may be severe, with  slight  pyrexia, but, as a rule, it is  gradual and for a time there is only slight pain in the back of the thigh, particularly in certain positions of after exertion. Soon the  pain becomes more intense,  and instead of being limited to the upper portion of the nerve, extends down the thigh, reaching the foot and radiating over the entire distribution of the nerve. The patient can often point out the most sensitive spots, usually at the notch or in the middle of the thigh; and on pressure these are exquisitely  painful. The pain is described as gnawing or burning, and is usually constant, but in some instances is paroxysmal, and often worse at night. On walking it may be very great; the knee is bent and the patient treads on the toes, so as to relieve the tension on the nerve. In protracted cases there is wasting of the muscles, but the reaction of degeneration can seldom be obtained. In these chronic cases cramps may occur and fibrillar  contractions. Herpes may develop, but this is unusual. In rare instances the neuritis ascends and involves the spinal cord. The duration and course are extremely variable. As a rule it is an obstinate affection, lasting for months, or even, with slight remissions, for years. Relapses are not uncommon, and the disease may be relieved in one nerve only to appear in the other. In the severer forms the patient is bedridden, […]. In the diagnosis it is important, in the first place, to determine whether the disease is primary, or secondary to some affection of the pelvis or of the spinal cord. […] Pressure on the nerve trunks of the cauda equina, as a rule, causes bilateral pain and disturbances of sensation, and as double sciatica is rare, these circumstances always suggest lesion of the nerve roots.

Osler, W. (1892). The Principles and Practice of Medicine. New York: D. Appleton & Company. Pg. 818-819.

Entered by: Ayushi Chintakayala, 6/26/2020

Edited by Bernardo Galvan, 9/7/2020

In the cases which hemorrhage causes symptoms, these are, for the most part, those of meningeal irritation, and thus bear some resemblance to the symptoms of meningitis. They differ in the suddenness and violence of their onset [...]. These symptoms are nearly the same whether the hemorrhage is outside or inside the dura mater. The first indication of the lesion is usually sudden and violent pain in the back, corresponding in position to the seat of the hemorrhage, but sometimes felt along a considerable extent of the back, and often severe in the loins [...]. There may be abnormal sensations, tingling, etc., and hyperaesthesia, referred to the same parts. Muscular spasm usually coincides with the pain [...]. The convulsive moments are sometimes general [...]. Intense pain in the back and general convulsion have been known to be the only symptoms. Ultimately there may be complete loss of motion and sensation in the lower limbs, but such absolute paralysis is not common. Loss of power at the onset of symptoms usually indicates simultaneous hemorrhage in the cord or the effusion of a very large amount of blood [...]. The symptoms differ in their distribution according to the seat of the disease [...]. As a rule, in spinal hemorrhage, cerebral functions are not affected [...]. Occasionally, however, consciousness is lost for a short time, apparently from shock [...] or coma may come on, either as an indirect effect of the spinal lesion on the brain, or a consequence of a sudden increase in the intra-cranial pressure, due to the displacement upward of the spinal fluid by the effusion of blood [...]. The symptoms of acute cases usually reach their height in two or three hours, sometimes not for a few days. Death may occur when the symptoms are fully developed, or, after reaching their height, they may decline, to be increased, a day or two later, by secondary meningitis. This is accompanied by some pyrexia [...]. It is, however, very common for death to take place when the symptoms have existed for a few hours only [...]. [Death] is more often produced by interference with respiration.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 211-212.

Entered by: Sonia Y. Khan, 6/10/2020

Permanent or transient hemiplegia results. […] There are certain peculiarities associated with embolism and with thrombosis respectively. In embolism, the patient is usually the subject of heart-trouble, or there exist some of the conditions already mentioned. The onset is sudden, without premonitory symptoms. When the embolus blocks the left middle cerebral artery the hemiplegia is usually associated with aphasia. In thrombosis, on the other hand, the onset is more gradual; the patient has previously complained of headache, vertigo, tingling in the fingers; the speech may have been embarrassed for some days; the patient has had loss of memory or is incoherent, or paralysis begins at one part, as the hand, and extends slowly, and the hemiplegia may be incomplete or variable. Abrupt loss of consciousness is much less common, and when the lesion is small consciousness is retained. […] The hemiplegia following thrombosis or embolism has practically the characteristics, both primary and secondary, described under haemorrhage.*” * Hemiplegia from haemorrhage- “The face is involved on the same side as the arm and leg. […] The signs of the facial paralysis are usually well marked. There may be a slight difficulty in elevating the eyebrow or in closing the eye on the paralyzed side, or in rare cases the facial paralysis is complete. […] The hypoglossal nerve also is involved. In consequence, the patient can not put out the tongue straight but it deviates toward the paralyzed side. […] Even without marked aphasia difficulty in speaking and slowness are common. The arm is, as a rule, more completely paralyzed than the leg.

Osler, W. (1909). The Principles and Practice of Medicine (7th ed.). London: Appleton and Co. Pg. 978-979.

Entered By: Erin Choi, 6/18/2020

There are irregular pains, chiefly in the cervical region; muscular atrophy develops, which may be confined to the arms […]. The reflexes are increased and a spastic condition develops in the legs. […] The tactile sensation is usually intact and the muscular sense in retained, but painful and thermic sensations are not recognized, or there may be in rare instances complete anesthesia of the skin and of the mucous membranes. […] The special senses are usually intact and the sphincters uninvolved. Trophic troubles are not uncommon. Owing to the loss of the painful and heat sensations, the patients are apt to injure themselves. […] Loss of sensation had preceded the atrophy, and the terminal phalanx of the middle finger was charred, as he experienced no sensation whatever when the hot end of the cigarette neared his finger. Scoliosis also may be present in these cases.

Osler, W. (1892). The Principles and Practice of Medicine (pp.850). London: Appleton and Co.

Created by: Ayushi Chintakayala, 09/29/2021

Entered by: Rachel Johnson, 11/30/2021

Males suffer far more frequently than females [...]. Among the individual causes, one overshadows all the rest—the influence of syphilis [...]. A typical case of tabes presents certain motor, sensory, and reflex symptoms. There is incoordination of movement [...]. There are pains in the affected parts, especially sharp momentary “lightening” pains; there is some loss of sensation; there is often loss or diminution of reflex action from the skin, and almost always entire loss of the myotatic irritability that is revealed by the so-called “tendon reflexes,” there are retention or incontinence of urine, constipation, and often less sexual power. Of this group of symptoms, two usually precede the others—the pains, and the loss of the knee jerk. These may exist alone, even for years, before the incoordination comes on [...]. Besides the symptoms above enumerated, others are occasionally present. Of these the most important are atrophy of the optic nerve, and occasionally of other cranial nerves, trophic changes in the skin, the bones and joints, and an ultimate extension to motor paralysis and muscular wasting.

The combination of symptoms present in different cases vary much [...]. The characteristic incoordination of movement develops gradually. It is always increased by closure of the eyes, and at first may only exist when the guiding influence of vision is withdrawn [...]. Sensory pains are prominent in most cases. They consist if subjective sensations, chiefly of pain and loss of sensibility [...]. When pains continue at one spot for some days, ecchymosis have been known to form there. In one case, after pain had been felt at one part of the scalp for some time, the growth of the hair was damaged [...] after the pains ceased, the growth of the hair became normal [...]. Visceral pains may also occur [...]. They [sensations] are various in character, described as ‘tingling,’ ‘pins and needles’ [...]. Sensations of cold or of heat are also common [...]. The reflex action of the iris to light is lost. In most of these [cases of tabes dorsalis] the contraction on accommodation [of the eye] is preserved—a characteristic first noted by Argyll-Robertson [...]. Deafness, having the characters of nerve deafness, is met with in some cases, sudden or gradual in onset, transient or lasting. The persistent deafness has been attributed to an atrophy of the auditory nerve [...]. Transient oedema of the limbs may occur without albuminuria [...]. Local sweating has been noted [...]. Blisters readily form beneath it [the foot] and may lead to indolent ulcers [...].

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 287-298.

Entered by: Sonia Y. Khan, 6/12/2020

The spasm may occur quite suddenly, or it may be preceded by various sensory disturbances, such as pain, numbness, or tingling. The upper extremities are usually first affected, the spasm gradually becoming more severe and finally involving the lower extremities. Both sides of the body are equally affected. The position assumed by the hands is very characteristic: the fingers are flexed at the metacarpophalangeal joint and the phalanges extended; the thumbs are adducted almost to the little finger; the wrist is flexed at an acute angle, and the whole and drawn somewhat to the ulnar side. No motion is allowed at the wrist, but movements at the elbow and shoulder are usually normal. The feet are strongly extended, sometimes in the position of typical equino-varus. The first phalanges of the toes are flexed, and the second and third rows extended; the plantar surface is strongly arched, and the dorsum of the foot is very prominent, standing out like a cushion. […] There are rigidity of the muscles of the calf and tension of the plantar fascia. The tendo-Achillis stand out prominently. […] The spasm in many cases is limited to the hands and feet; more rarely in the muscles of the thigh, usually the adductors, may be involved. […] Where the spasm is intermittent, and in some cases where it has subsided, it may be excited by making pressure upon the large nerve trunks and arteries of the parts affected. This is known as ‘Trousseau’s symptom’, and is characteristic of the disease. Pain owing to the spasm is frequently present. It is usually sharp and lancinating, and may be so severe as to cause children to cry out.

Holt, L Emmett. The Diseases of Infancy and Childhood: for the Use of Students and Practitioners of Medicine. Appleton and Co, 1897. Pg. 669-670

Entered By: Erin Choi, 6/30/2020

Edited By: Bernardo Galvan, 9/7/2020

The onset is usually sudden [...]. During the trance sleep the face is usually pale. The limbs are relaxed, as a rule, throughout the attack, but sometimes there has been brief initial stiffness, or occasional transient cataleptic rigidity; tonic spasm, and distinct hysteriod convulsions have occurred from time to time in some cases. The eyelids are closed, and attempts to open them are resisted. The eyeballs are usually directed upward and to one side; the pupils are moderately dilated or contracted, and almost always react to light.

Reflex action in the limbs has been lost in deep trance, increased in slight cases, and cutaneous stimulation sometimes induces muscular contracture. In profound trance the mental functions seem to be in complete abeyance [...]. Occasionally there is evidence of spontaneous mental action, analogous to dreaming, manifested by exclamations, and even by movements [...]. The pulse is small and the sounds of the heart are weaker than normal [...]. The duration of trance has been a few hours, a few days, or several weeks [...]. After prolonged trance has passed away, profound nervous prostration remains for a time, sometimes with mental dullness. The condition may recur, even many times [...]. Most cases end favorably.

Gowers, W. R. (1888). A Manual of Diseases of the Nervous System. Philadelphia: P. Blakiston, Son and Co. Pg. 1333-1334.

Entered by: Sonia Y. Khan, 6/29/2020

Vertigo or dizziness is a subjective sensation of loss of equilibrium. The patient feels as if he himself were whirling, sinking, or rising (subjective vertigo), or surrounding objects may appear to be rapidly revolving, sinking, or rising (objective vertigo). Horizontal vertigo is felt when reclining and disappears on rising. In a severe case the sensation may be so sudden and profound as to be likened to a blow; in the slighter degrees there is a swimming lightness in the head. The severe and acute forms are of brief duration, but in its lighter forms it may last for weeks and months (status vertiginosus). The gain is reeling or staggering, like that of a drunken man. Slight nausea often co-exists, and vomiting may follow a sharp attack. Loss of consciousness, if occurring, is only momentary.

Vertigo is a cause of so much alarm to the patient that the determination of its origin in a given case is of great importance. In by far the larger proportion of cases it is due to neurasthenia, especially the lithaemic form, gastric disorders, arteriosclerosis, aural disease, or eye strain […]. Very rarely the vertigo is essential, without discoverable cause.

Butler, G. R. (1901/1909). The Diagnostics of Internal Medicine: A Clinical Treatise Upon the Recognised Principles of Medical Diagnosis, Prepared for the Use of Students and Practitioners of Medicine (3rd ed., pp. 66). New York and London : D. Appleton and Company.

Created by: Taha Jilani, 09/30/2021

Entered by: Rachel Johnson, 11/20/2021