819

A MirrorOF THE PRACTICE OF

MEDICINE AND SURGERYIN THE

HOSPITALS OF LONDON.

GUY’S HOSPITAL.PATHOLOGICAL FACTS INDICATIVE OF THE CONVEYANCE

OF DISEASE BY DISORDERED NERVES.

(From Demonstrations by Dr. MOXON.)

Nulla autem est alia pro certo noseendi via, nisi quamplurimasetmorborumet dissectionum historias, tum aliorum, tum proprias collectas habere, etinter se comparare.-MORGAGNI De Sed. et Cau8. Morb., lib. iv. Procemium.

THE following observations afford interesting evidence in-favour of the transmission by nerves of irritations capableof producing, at their peripheral extremities, grave morbidchanges similar to those which have taken place at their’centres of origin. We join with Dr. Moxon in hoping thattheir publication may incite other pathologists to bringforward any facts bearing upon the subject which they mayhave met with in the course of their investigations.

In reference to these cases, Dr. Moxon says that the fact- of nerve-disturbance exciting certain kinds of nutritive

changes is illustrated by common examples of the statescalled 11 zoster"; by the not unfrequent occurrence of rheu-matoid inflammation in the joints of the lower extremitiesin subjects of paraplegia; by the changes occurring in theretina in intracranial disease; by ulceration of the duo-denum, or even of the stomach (of which he has recentlyseen a marked instance), in burn cases ; and by the powerof partial division of the fifth nerve to induce ulceration ofthe cornea, which has lately been reaffirmed. He thinks.also that the circumstances and characters of certain otherulcers of the cornea and of the stomach are but phases ofhyperaesthesia, and should be treated as being essentiallynervous.

CASE 1.—While the body of a boy was under inspection, it was noticed that in either side of the chest there was a Iremarkable band of old pleuritic thickening. This tookthe course of the third and fourth dorsal nerves, so exactlyon each side in the parietal pleura that Dr. Moxon was in-duced to examine the spinal cord at the point of origin ofthese nerves for some explanation of so remarkable an ap-pearance. It was then found that at the parts of the cord’which gave rise to the third and fourth dorsal nerves therewas an old dilatation of the ventricular cavity. This dila-tation would admit a No. 4 catheter, and was two incheslong. It was closed at its ends, and the medulla aroundappeared quite healthy. The wall of this hydro-myelocelewas a little thickened. There was no other dilatation of thecord’s ventricle, nor any other disease of the nervous- centres, discoverable. It was scarcely possible to regardthis as a mere coincidence. It was no common pleurisy.The peculiarity of its appearance led to the examination ofthe cord, which otherwise would not have been made. Theboy had exhibited no spinal symptoms.

CASE 2.-A woman died in the clinical ward of paraplegia. 4Dn inspection it was found that a tubercle, of the size of asmall marble, occupied and almost destroyed a part of thecord opposite the eleventh and twelfth dorsal intervertebralsubstance. In the abdomen a remarkable appearance waspresented: neither the upper part of the cavity nor theperitoneum of the true pelvis showed any tubercle, but azone of crowded miliary tubercles extended round the cavityin the peritoneum lining the false pelvis and hypogas-trium ; there were none on the viscera. The limitation wasremarkable, and the relation of these tubercles to that in thecorresponding part of the cord could scarcely be a coinci-- dence. It is known to morbid anatomists that tubercles onthe peritoneum, though they prefer the parietal to the vis-ceral layer (except in the case of the omentum), adopt thediaphragm as their favourite seat, and, as a rule, are rathergenerally scattered ; but Dr. Moxon did net recollect havingever before seen such a distribution of tubercles as in this

case. Their situation corresponded very significantly withthe affected portion of the cord.CASE 3.-A woman had painful paraplegia, with head-

ache, aphonia, and paralysis of the left side of the tongue.The post-mortem examination revealed a free scattering ofcancer (soft round-cell sarcoma) in the course of the spine,in the bones. A mass of this cancer grew in the basilarbone, and destroyed the eighth and ninth pairs of nerves onthe left side. There was no visceral cancer. The cricoidcartilage was in a singular state: the greater part of itsleft side was in a pulpy condition. This part was rathersharply demarked from the rest of the cartilage. Dr.Moxon made microscopical examinations on several occa-sions, but could not determine whether the state of thecartilage was or was not its sarcoma. There was some pro-liferation of the cells, but not very much. The inter-cellular substance was soft and fibrillar, and reduced inamount. But the appearance was different from that of theother cancer growths; and it was hard to say how far thevery unusual circumstance of a development of cancer incartilage determined the difference of minute structure, orwhether some other form of altered nutrition had been inoperation. Whichever view were true, it was scarcely pos-sible, Dr. Moxon thought, to avoid concluding that the dis-ease at the root of the eighth nerve of the same side hadcaused the change. The muscles were atrophied, and thenerves wasted.

HOSPITAL FOR SICK CHILDREN.CASES OF MALINGERING.

(Communicated by Mr. H. T. BUTLIN, Registrar.)CASES like the following are liable to be misunderstood,

and may for a long time remain wrongly, and therefore un-successfully, treated. The moral disease, and the moraltreatment which it demands, are overlooked; while allefforts are directed to the cure by drugs of a simulated orenormously exaggerated ailment, to which it becomes thechief object and only habit of the patient’s life to call theattention of sympathising spectators by more or less sensa-tional demonstrations. " It is difficult," says Dr. West,*"to assign any sufficient reason for this conduct. Mereindolence seems sometimes to be the chief motive for it;often vanity ; the sense of importance in finding everythingin the household arranged with exclusive reference to itselfappears to have led to it-a feeling which may sometimesbe observed to be very powerful even at an exceedinglyearly age. In many instances a morbid craving for sym-pathy is mingled with love of importance, and both thesesentiments are not unfrequently gratified and exaggeratedby the conduct of a foolishly fond mother. Real illness,however, in almost all these cases, exists at the commence-ment, though the child persists in complaining of its oldsymptoms long after their cause has disappeared." Thisdescription applies very accurately to the following cases.In each instance, Mr. Butlin informs us, the mother was adecidedly " weak woman"; and in each, it will be noticed,there was, or had been, a nucleus, so to speak, of genuinedisease. It is obvious that isolation from a foolish motherand indulgent friends must, in all such cases, be one of themost effectual remedial measures.

(Under the care of Dr. DICKINSON.)CASE 1.-Sarah J- was, on admission, seven years and

nine months old. The following history was elicited fromher mother:—With the exception of a violent attack of con-vulsions, which occurred in connexion with whooping-coughat the age of two years and a half, she has been quitehealthy until the onset of the present illness fifteen monthsago. She was then taken suddenly with sickness, purging,and pain in the bowels, which lasted for about a week. Eversince she has been subject to pain in the bowels. Aboutnine months ago she had another similar attack. The

purging lasted for about three weeks; and towards the lastshe passed nothing but " blood and jelly." A day or twoafter the return of the diarrhœa, the fits, from which shehas ever since suffered, first made their appearance; forabout half an hour she was " convulsed," her limbs became

rigid, her eyes rolled upward, she screamed, and frothed* Diseases of Infancy and Childhood, p. 253.