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ABSTRACT OF THE Presidential Address
161 On this point we may often gain instructive information from the optic neuritis that is so often present. Syphilomata always causes an acute form of optic neuritis, becomes intense. A rapid growth never causes a chronic form of neuritis, although now and then a slow growth may cause an acute form. Hence, while acuteness of the neuritis is of little diagnostic value, chronicity-a neuritis that remains for a long time moderate or slight in degree-is distinctly opposed to the diagnosis of a syphilitic growth, and adds considerable weight to the similar indication afforded by great chronicity of other symptoms. This indication is especially valuable when the early symptoms are equivocal, and we find it difficult to say how long the tumour has existed. These growths are among the specific lesions in which the effect of treatment is of most diagnostic value. It usually causes a prompt diminution in the symptoms, but, to be of significance, this effect should be considerable, and should involve both sets of symptoms, the local and general. It is a remarkable but certain fact that a considerable diminution in the symptoms of other kinds of tumours, and especially in the general symptoms, sometimes follows the administration of iodide. The effect is most frequent in gliomata, and these are the growths that otherwise give rise to most difficulty in diagnosis. Sometimes even the optic neuritis lessens, but more often it is unchanged, and this should put us on our guard. In estimating the significance of the subsidence of the neuritis, we must remember that every intense inflammation, when it has reached its height, tends to subside into a cicatricial atrophy, although the tumour that has caused it continues to grow. We must not mistake this natural subsidence for the result of our treatment. But this difficulty can often only be met by waiting. If any of the symptoms return or increase, if any symptom persists that would be readily influenced were the growth syphilitic, we must assume that this nature is not probable. The delay involved cannot be avoided, but it is a grave disadvantage, since the progress of surgery has so greatly increased the need not only for exact but for prompt diagnosis. The chronic local meningitis of syphilis causes distinctive symptoms chiefly when it affects the base of the brain and damages the cranial nerves, or when, at the convexity, it implicates the motor region. The symptoms are such as indicate a surface lesion, and the absence of the signs of any considerable loss of function of the subjacent tissue, such as considerable compression would cause, is the chief distinction from a gumma in the same situation. Especially when the symptoms indicate a wide area of irritation with merely superficial damage, the diagnosis can be made with considerable probability. This focal meningitis is probably less frequent at the convexity than is the growth, and itis certainly less frequent than it is at the base of the brain. In the latter situation the most important symptoms are due to the damage to the cranial nerves, and the most important diagnostic points are well known. The therapeutic test is available only in recent cases of meningitis. When the development of the new tissue into fibres has set in, this seems to go on in spite of treatment, and the inevitable cicatricial contraction may perpetuate the damage produced in the more active stage. In a case of focal meningitis that has lasted for some months, although it may afterwards be found to be syphilitic in nature, the symptoms are generally influenced but little, and occasionally not at all, by anti-syphilitic treatment, however energetic. The other forms of meningitis, interesting and important as they are, I am compelled to pass over.
syphilitic.
(To
be
concluded.)
HARROGATE BATH HOSPITAL.-The governors and
subscribers held their annual meeting at the Prospect Hotel on the 19th inst., Mr. Basel T. Wood in the chair. The annual report (the sixty-third) stated that 5180 baths had been administered during the year, a decrease on the previous year of 590. The honorary medical officer’s report sets forth that 603 cases had been treated in the hospital, including skin disease 218, rheumatism 329, and diseases of the liver 45. No deaths had occurred. Great progress had been made in the new buildings, and the committee hoped they would be ready for occupation by the end of March next. Lord Harewood had presented to the charity three-quarters of an acre of land, including a small wood of pine trees, which would be added to the gardens.
ABSTRACT OF THE
Presidential
Address
Neurological Society of London, January 24th, 1889,
Delivered at the
BY JONATHAN
on
HUTCHINSON, F.R.S., LL.D.
MR. HUTCHINSON’S address, after thanking the Society for the honour of electing him president, proceeded to deal with certain subjects in which surgery and dermatology were concerned in diseases of the nervous system. He mentioned a case which had recently come under his care, in which a man, after the ordinary operation for piles, suffered from permanent incontinence of urine and faeces. The incontinence was attended with loss of sensation in the skin about the anus, and complete paralysis of the sphincter. Similar conditions being apparently present in the urethra, the history made it probable that this condition of paralysis had been present from within a day or two of the operation. After discussing the associated innervation of the two sphincters, attention was asked to the very common occurrence of inability to empty the bladder after the operation for piles, and the question proposed as to how such occurrences were to be explained. The subject next considered was that of " dry mouth," for which the name "xerostomia"" was proposed in substitution for that of "aptyalism."" The cases which have recently been under the consideration of the Clinical Society, with some others, were briefly reviewed, and the whole question considered as an important illustration of the inliuence of the nervous system in controlling and entirely arresting the secretion ot glands. It was suggested that what we see demonstrated in the mouth in cases of xerostomia may occur in other regions and viscera, and that there may possibly be a neurotic arrest of secretion of the Some remarks were made on liver, pancreas, testes, &c. the converse condition of excessive secretion of fluids into the mouth, or "hydrostomia." It was thought that this was much more frequently a symptom of aggressive disease of the nervous system than the opposite condition of dry mouth appeared to be. Attention was next asked to the nervous phenomena in Raynaud’s disease, and to of blood to various cognate conditions in which the different parts of the skin is injuriously influenced through the nervous system. The chief subject matter of the address was, however,, the consideration of those diseases of the skin which. should be classed as neurotic. Putting aside derangements of nutrition of the skin which may follow upon injuries, it was proposed to class the disorders referred to under three heads. First, those due directly to disease of the nerves themselves, or to some trophic influence exercised by them ; secondly, those due to disturbance of the circulation produced through nerves; and lastly, those
supply
in which the nervous system, although not being directlyconcerned, still took some share in the way of general redueIn the first and by far the most definite tion of tone. group, herpes and morphcea, or scleroderma, were the principal examples, and concerning both of these Mr. Hutchinson entered into considerable detail. Attention was asked, in reference to herpes, to the remarkable fact that while common zoster rarely occurred twice in the same patient, and rarely twice in the same place, there were forms of herpes of which the peculiarity was liability to recurrence. It was asserted that, while arsenic very frequently caused zoster, it acted almost as a specific in preventing recurrences of the other forms. The theory was upheld that herpes zoster was always due to a peripheral neuritis, which involved the end organs; that it was, in fact, as had been long ago said, a neuritis attended by an eruption. It was suggested that one great difference between zoster and the recurrent forms consisted in the severity of the neuritis in the former, which disorganised the nerve affected and thus prevented the possibility of its being again attacked. In dealing with the subject of scleroderma (morphoea), Mr. Hutchinson took 6 rst the localised form, remarking that it was very different, bhough perhaps not belonging to a wholly distinct class,
.
162 from that in which the affection is symmetrical, diffused, and d At the conclusion of the address a number of drawings in greater or less degree of severity universal. He repeated d were exhibited illustrating various points which had been an assertion which he had made, he said, many years ’s adverted to. With them was shown a very remarkable s ago, that all the main facts which are here as regards and, it was believed, unique skull in which all the bones on the development and evolution of zoster are here alsoo one side of the head show exostoses with other evidence of as regards morphcea. He held that it was certainly y overgrowth, of which on the opposite side there is not the located in, and in all probability produced through,, slightest trace. In this specimen the right half of the jaw, nerves. Its remarkable differences from zoster were itss as well as the bones of the skull, are affected. The state of slowness of evolution and its long persistence; takenn hyperostosis ending precisely at the symphysis of this together with the fact, it was not at all uncommon to find:l remarkable unilateral asymmetry, it was suggested that it affecting several parts of the body or limbs at the samee two explanations were alone possible : either that the time. believed that its earliest manifestation wass disturbances of nutrition were located by the distribution of always in the form of a cluster of spots, and that the largee the fifth nerve, or that they were due to some influence patches often seen at a later stagewere always due to as, exerted probably during foetal development. Of the latter confluence of these. He drew attention to the circumstancee nothing was known as to its precise nature, and the former that fascia, muscles, and bones were not unfrequently’{ appeared the most probable. A contrast was suggested affected together with the skin, whilst comparatively littlee between the condition of unilateral overgrowth exhibited loss of sensation attended the stages. He thought it highly’{ in this skull and the cases of unilateral undergrowth in the that the vaso-motor filaments, distributed in con- so-called hemiatrophy of the face. probable with those for motion and sensation, were the parts junction chiefly affected. The remarkable defects in the subsequent nutrition and growth of the parts affected were illustrated by photographs and drawings. Respecting the condition ON THE REMOVAL BY OPERATION OF NASOknown as hemi-atrophy of the face, it was contended that it i PHARYNGEAL TUMOURS.1 was always the consequence of morphoea affecting the fifth BY THOMAS ANNANDALE, F.R.C.S., nerve; and that it was not strictly an atrophy, but an arrest of development, to be explained by the fact that the diseaseREGIUS PROFESSOR OF CLINICAL SURGERY UNIVERSITY OF EDINBURGH. had occurred in early life before the parts had attained their full growth. A number of portraits were shown to illisTHE principal object of this paper is to describe a method trate the remarkable similarity of appearance in different of operating which was successfully carried out in three examples of this singular condition. of naso-pharyngeal tumour recently under my cases Some remarks next followed on the general principles which should guide us in respect to whether any given dis- care. After a study of the several methods suggested and ease was of neurotic origin or otherwise, and the need for practised by Maune, Nelaton, Whateley, Maisonneuve, increased caution in suggesting such origin was strongly Langenbeck, Chassaignac, Ollier, Roux, Huguier, Cheever, enforced. Diseases of the skin directly due to nerves should, Croft, and other surgeons, I believe that my procedure, it was contended, always display certain definite features in some of its details, is in its entirety These patches although not original as regards the distribution of their patches. It is true that such growths have been reached new. The coalescence ought always to be racemose or of such spots might produce a long oval patch, but such through the palate by Nelaton and others, but not in the patch ought always to be more or less irregular at its edge, simple way presently to be described. As far as I am and would almost always be attended also by outlines. No aware, my operations have demonstrated for the first time eruption produced directly by nerves could possibly assume the fact that when the alveolar margin and palatal pora rounded form. The terms areate and circumscribed could never be applicable to disorders of nutrition located tions of the upper jaw have been divided along their centre by the filaments of nerves. Under this rule it was held rom before backwards, and the bony septum of the nose that such diseases as alopecia areata and leucoderma were cut through, the anterior nares having first been exposed certainly not of neurotic origin. A second rule was that by Rouge’s plan, the two upper jaws can be separated to disorders originated by nerves never spread serpiginously- the extent of from half an inch to one inch, so as to give that is, they do not creep at their edges by infection of access to the nares and base of the skull. posterior adjacent parts, as lupus, psoriasis, and leucoderma, with It is freely admitted that a naso-pharyngeal growth may many others, so conspicuously do. On account of the slow- be successfully removed by other "than a cutting operation, ness of its evolution and the difficulty in making sure in its and there are a sufficient number of recorded cases to early stages of its precise limits, mistakes had occurred this ; but there is a very general agreement that in theprove case in respect to scleroderma on this point, and in not a few cases of the of these tumours some cutting procedure is majority it had been asserted to spread at its edge. That in a general necessary in order to expose and obtain access to the site of way such tendency to spread was conspicuously absent their origin, so that they may be thoroughly removed, and also could not be there the slightest doubt. in order better to control the bleeding which is often profuse Hebra’s observation as to the occasional corymbiform the separation of their attachments to the periosteum arrangement of the pustules of small-pox was next adverted during and bone. Naso-pharnygeal tumours have been removed by to, and with it were mentioned the disease described by the cold snare, by the galvanic wire, cautery, or ecraseur, Dr. Duhring under the name of "dermatitis herpetiformis," evulsion with forceps, by scraping with the sharp spoon, and certain forms of lichen ruber and of some syphilides, by and by means of electrolysis; but recent opinion by ligature, which may also assume the corymbiform arrangement. It was would seem to favour the use of the cold snare or galvanic admitted to be possible that in many diseases not primarily wire when the case is suitable for a operation. affecting the nervous system, a tendency to peripheral Even with improved instruments thenon-cutting success of these two neuritis might exist, which would explain the peculiar plans in completely removing the growth must be doubtful, arrangement of the foci of inflammation in the skin. to the difficulty of acting upon its connexion to the The question was next asked whether any disease pro- owing I am therefore inclined to think that these two and bone, duced by nerves could be arranged in lines or streaks, and, procedures might be made more certain if the site of the in reference to this, the very remarkable conditions prewas first exposed by such an operation, as I suggrowth sented in congenital ichthyosis in streaks were discussed. in this paper, so as to allow the wire to be accurately Although these streaks had been assumed to be neurotic, gest adjusted, and the tumour removed close to the bone. I there were, it was remarked, great difficulties in accepting have upon several occasions removed naso-pharnygeal such a theory. The streaks often did not follow the course tumours evulsion with strong forceps passed through the of any known nerves, nor was it easily comprehensible that anterior by the forceps being guided by two fingers of the nares, the transit of a nerve trunk deeply placed under the skin left hand introduced through the mouth behind the soft should evoke any phenomena along its course. It was but the difficulty of separating completely the palate; admitted that the explanation of these congenital streaked attachments of the growths in this way, and the serious eruptions was extremely diflieult. Their arrangement on bleeding which accompanies the operation, have convinced of walls the often so the chest and abdomen were extremely me that, unless in the case of a small or narrow pedunculated like that of zoster, that Mr. Hutchinson said he had himsuch a procedure is not advisable. growth, self many years ago tendered the crude suggestion that they 1 Read before the Edinburgh Medico-Chirurgical Society. might be due to intra-uterine herpes.
He
-
corymbiform.
"
j
syphilitic.
(To
be
concluded.)
HARROGATE BATH HOSPITAL.-The governors and
subscribers held their annual meeting at the Prospect Hotel on the 19th inst., Mr. Basel T. Wood in the chair. The annual report (the sixty-third) stated that 5180 baths had been administered during the year, a decrease on the previous year of 590. The honorary medical officer’s report sets forth that 603 cases had been treated in the hospital, including skin disease 218, rheumatism 329, and diseases of the liver 45. No deaths had occurred. Great progress had been made in the new buildings, and the committee hoped they would be ready for occupation by the end of March next. Lord Harewood had presented to the charity three-quarters of an acre of land, including a small wood of pine trees, which would be added to the gardens.
ABSTRACT OF THE
Presidential
Address
Neurological Society of London, January 24th, 1889,
Delivered at the
BY JONATHAN
on
HUTCHINSON, F.R.S., LL.D.
MR. HUTCHINSON’S address, after thanking the Society for the honour of electing him president, proceeded to deal with certain subjects in which surgery and dermatology were concerned in diseases of the nervous system. He mentioned a case which had recently come under his care, in which a man, after the ordinary operation for piles, suffered from permanent incontinence of urine and faeces. The incontinence was attended with loss of sensation in the skin about the anus, and complete paralysis of the sphincter. Similar conditions being apparently present in the urethra, the history made it probable that this condition of paralysis had been present from within a day or two of the operation. After discussing the associated innervation of the two sphincters, attention was asked to the very common occurrence of inability to empty the bladder after the operation for piles, and the question proposed as to how such occurrences were to be explained. The subject next considered was that of " dry mouth," for which the name "xerostomia"" was proposed in substitution for that of "aptyalism."" The cases which have recently been under the consideration of the Clinical Society, with some others, were briefly reviewed, and the whole question considered as an important illustration of the inliuence of the nervous system in controlling and entirely arresting the secretion ot glands. It was suggested that what we see demonstrated in the mouth in cases of xerostomia may occur in other regions and viscera, and that there may possibly be a neurotic arrest of secretion of the Some remarks were made on liver, pancreas, testes, &c. the converse condition of excessive secretion of fluids into the mouth, or "hydrostomia." It was thought that this was much more frequently a symptom of aggressive disease of the nervous system than the opposite condition of dry mouth appeared to be. Attention was next asked to the nervous phenomena in Raynaud’s disease, and to of blood to various cognate conditions in which the different parts of the skin is injuriously influenced through the nervous system. The chief subject matter of the address was, however,, the consideration of those diseases of the skin which. should be classed as neurotic. Putting aside derangements of nutrition of the skin which may follow upon injuries, it was proposed to class the disorders referred to under three heads. First, those due directly to disease of the nerves themselves, or to some trophic influence exercised by them ; secondly, those due to disturbance of the circulation produced through nerves; and lastly, those
supply
in which the nervous system, although not being directlyconcerned, still took some share in the way of general redueIn the first and by far the most definite tion of tone. group, herpes and morphcea, or scleroderma, were the principal examples, and concerning both of these Mr. Hutchinson entered into considerable detail. Attention was asked, in reference to herpes, to the remarkable fact that while common zoster rarely occurred twice in the same patient, and rarely twice in the same place, there were forms of herpes of which the peculiarity was liability to recurrence. It was asserted that, while arsenic very frequently caused zoster, it acted almost as a specific in preventing recurrences of the other forms. The theory was upheld that herpes zoster was always due to a peripheral neuritis, which involved the end organs; that it was, in fact, as had been long ago said, a neuritis attended by an eruption. It was suggested that one great difference between zoster and the recurrent forms consisted in the severity of the neuritis in the former, which disorganised the nerve affected and thus prevented the possibility of its being again attacked. In dealing with the subject of scleroderma (morphoea), Mr. Hutchinson took 6 rst the localised form, remarking that it was very different, bhough perhaps not belonging to a wholly distinct class,
.
162 from that in which the affection is symmetrical, diffused, and d At the conclusion of the address a number of drawings in greater or less degree of severity universal. He repeated d were exhibited illustrating various points which had been an assertion which he had made, he said, many years ’s adverted to. With them was shown a very remarkable s ago, that all the main facts which are here as regards and, it was believed, unique skull in which all the bones on the development and evolution of zoster are here alsoo one side of the head show exostoses with other evidence of as regards morphcea. He held that it was certainly y overgrowth, of which on the opposite side there is not the located in, and in all probability produced through,, slightest trace. In this specimen the right half of the jaw, nerves. Its remarkable differences from zoster were itss as well as the bones of the skull, are affected. The state of slowness of evolution and its long persistence; takenn hyperostosis ending precisely at the symphysis of this together with the fact, it was not at all uncommon to find:l remarkable unilateral asymmetry, it was suggested that it affecting several parts of the body or limbs at the samee two explanations were alone possible : either that the time. believed that its earliest manifestation wass disturbances of nutrition were located by the distribution of always in the form of a cluster of spots, and that the largee the fifth nerve, or that they were due to some influence patches often seen at a later stagewere always due to as, exerted probably during foetal development. Of the latter confluence of these. He drew attention to the circumstancee nothing was known as to its precise nature, and the former that fascia, muscles, and bones were not unfrequently’{ appeared the most probable. A contrast was suggested affected together with the skin, whilst comparatively littlee between the condition of unilateral overgrowth exhibited loss of sensation attended the stages. He thought it highly’{ in this skull and the cases of unilateral undergrowth in the that the vaso-motor filaments, distributed in con- so-called hemiatrophy of the face. probable with those for motion and sensation, were the parts junction chiefly affected. The remarkable defects in the subsequent nutrition and growth of the parts affected were illustrated by photographs and drawings. Respecting the condition ON THE REMOVAL BY OPERATION OF NASOknown as hemi-atrophy of the face, it was contended that it i PHARYNGEAL TUMOURS.1 was always the consequence of morphoea affecting the fifth BY THOMAS ANNANDALE, F.R.C.S., nerve; and that it was not strictly an atrophy, but an arrest of development, to be explained by the fact that the diseaseREGIUS PROFESSOR OF CLINICAL SURGERY UNIVERSITY OF EDINBURGH. had occurred in early life before the parts had attained their full growth. A number of portraits were shown to illisTHE principal object of this paper is to describe a method trate the remarkable similarity of appearance in different of operating which was successfully carried out in three examples of this singular condition. of naso-pharyngeal tumour recently under my cases Some remarks next followed on the general principles which should guide us in respect to whether any given dis- care. After a study of the several methods suggested and ease was of neurotic origin or otherwise, and the need for practised by Maune, Nelaton, Whateley, Maisonneuve, increased caution in suggesting such origin was strongly Langenbeck, Chassaignac, Ollier, Roux, Huguier, Cheever, enforced. Diseases of the skin directly due to nerves should, Croft, and other surgeons, I believe that my procedure, it was contended, always display certain definite features in some of its details, is in its entirety These patches although not original as regards the distribution of their patches. It is true that such growths have been reached new. The coalescence ought always to be racemose or of such spots might produce a long oval patch, but such through the palate by Nelaton and others, but not in the patch ought always to be more or less irregular at its edge, simple way presently to be described. As far as I am and would almost always be attended also by outlines. No aware, my operations have demonstrated for the first time eruption produced directly by nerves could possibly assume the fact that when the alveolar margin and palatal pora rounded form. The terms areate and circumscribed could never be applicable to disorders of nutrition located tions of the upper jaw have been divided along their centre by the filaments of nerves. Under this rule it was held rom before backwards, and the bony septum of the nose that such diseases as alopecia areata and leucoderma were cut through, the anterior nares having first been exposed certainly not of neurotic origin. A second rule was that by Rouge’s plan, the two upper jaws can be separated to disorders originated by nerves never spread serpiginously- the extent of from half an inch to one inch, so as to give that is, they do not creep at their edges by infection of access to the nares and base of the skull. posterior adjacent parts, as lupus, psoriasis, and leucoderma, with It is freely admitted that a naso-pharyngeal growth may many others, so conspicuously do. On account of the slow- be successfully removed by other "than a cutting operation, ness of its evolution and the difficulty in making sure in its and there are a sufficient number of recorded cases to early stages of its precise limits, mistakes had occurred this ; but there is a very general agreement that in theprove case in respect to scleroderma on this point, and in not a few cases of the of these tumours some cutting procedure is majority it had been asserted to spread at its edge. That in a general necessary in order to expose and obtain access to the site of way such tendency to spread was conspicuously absent their origin, so that they may be thoroughly removed, and also could not be there the slightest doubt. in order better to control the bleeding which is often profuse Hebra’s observation as to the occasional corymbiform the separation of their attachments to the periosteum arrangement of the pustules of small-pox was next adverted during and bone. Naso-pharnygeal tumours have been removed by to, and with it were mentioned the disease described by the cold snare, by the galvanic wire, cautery, or ecraseur, Dr. Duhring under the name of "dermatitis herpetiformis," evulsion with forceps, by scraping with the sharp spoon, and certain forms of lichen ruber and of some syphilides, by and by means of electrolysis; but recent opinion by ligature, which may also assume the corymbiform arrangement. It was would seem to favour the use of the cold snare or galvanic admitted to be possible that in many diseases not primarily wire when the case is suitable for a operation. affecting the nervous system, a tendency to peripheral Even with improved instruments thenon-cutting success of these two neuritis might exist, which would explain the peculiar plans in completely removing the growth must be doubtful, arrangement of the foci of inflammation in the skin. to the difficulty of acting upon its connexion to the The question was next asked whether any disease pro- owing I am therefore inclined to think that these two and bone, duced by nerves could be arranged in lines or streaks, and, procedures might be made more certain if the site of the in reference to this, the very remarkable conditions prewas first exposed by such an operation, as I suggrowth sented in congenital ichthyosis in streaks were discussed. in this paper, so as to allow the wire to be accurately Although these streaks had been assumed to be neurotic, gest adjusted, and the tumour removed close to the bone. I there were, it was remarked, great difficulties in accepting have upon several occasions removed naso-pharnygeal such a theory. The streaks often did not follow the course tumours evulsion with strong forceps passed through the of any known nerves, nor was it easily comprehensible that anterior by the forceps being guided by two fingers of the nares, the transit of a nerve trunk deeply placed under the skin left hand introduced through the mouth behind the soft should evoke any phenomena along its course. It was but the difficulty of separating completely the palate; admitted that the explanation of these congenital streaked attachments of the growths in this way, and the serious eruptions was extremely diflieult. Their arrangement on bleeding which accompanies the operation, have convinced of walls the often so the chest and abdomen were extremely me that, unless in the case of a small or narrow pedunculated like that of zoster, that Mr. Hutchinson said he had himsuch a procedure is not advisable. growth, self many years ago tendered the crude suggestion that they 1 Read before the Edinburgh Medico-Chirurgical Society. might be due to intra-uterine herpes.
He
-
corymbiform.
"
j