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oophorectomy for epilepsy had been performed in vai.n.The operation was by a surgeon eminent in the department;yet it is not a good test case, for menstruation is regularnow, years after the ovaries were, as it is believed, takenout. Again, curious hysterical convulsions or tetanic pheno-mena-hystero-epilepsy-have been declared to be governedby pressure on the ovary by the practitioner’s hand appliedover it, the phenomena disappearing when the pressureis exerted vigorously, and recurring when it is takenoff, much as water from the tap is stopped or flows asyou turn the cock this way or that. These observationsI merely mention. They are so unsatisfactory and so badlycontrolled as to be worthless. Directions are given to findthe ovary by the intersection of lines on the abdomen; theyalso are worthless. Pressure over the supposed position ofthe ovary is made while the abdominal muscles are in

tetanus, and such pressure is worthless. The observationsare, indeed, poor exhibitions of the power of a clever doctorto educate a woman into a hysterical 11 humbug."But though the particular observations and experiments,

of which I have been speaking, have given us little instmc-tion, the restless work of many neurologists has not beenwithout result. The observed grouping of symptoms andconsequent ranging of affections into categories is a sure

step to farther progress. Already we seem to have reacheda great clinical distinction between hysteria and neur-

asthenia ; and we have also made out the anorexia nervosaof Gull-an interesting malady, and rare, at least in itshighest degree.

’

The meaning of this recently introduced term, neurasthe-nia, lies on the surface : its exact definition is a difficultmatter. It is a common and therefore an importantdisease, and it is of great practical or clinical interest todistinguish it from hysteria. I have said that its definitionis a difficult matter, and this arises greatly from the fact,that it is used indiscriminately, or has been so used that it- -is only gradually crystallising into any kind of definition.It has been and is much used as an alternative word for’hysteria, to avoid using that often offensive term. But1hysteria maintains its place, and neurasthenia has to find-,or has found-its own. Confusion often arises from thetwo conditions being combined. A woman may exhibit no,hysterical symptoms until she has become neurasthenic.Her neurasthenia cured, the hysteria disappears. To seeclearly the distinction between the two diseases, you musttake characteristic uncomplicated examples of each. Hys-teria may affect strong, robust, vigorous women, with no. other functional disorder. It would be a contradiction interms to say this of neurasthenia. A neurasthenic may befat and healthy-looking, and have no other functional dis-order; but generally such patients lose flesh, are sallow orlook unhealthy, and they often suffer from distinct forms ofindigestion and from constipation. A hysterical woman. often shows great power and capacity of both mind andbody. A neurasthenic has lost elasticity and power, or

endurance, both of mind and body; the nerves are weak.Above all, a hysterical woman is selfish-slie wants atten-tion and sympathy ; while in a neurasthenic no such

special demand for sympathy is made. The hysterical arefound chiefly, though not exclusively, among the pampered,the lazy, the unemployed. The neurasthenic are found.chiefly among the intellectually overworked, and theworried or morally overworked.

Considering these differences between hysteria and neur-asthenia, you need not to be told the great difference oftreatment. In hysteria drugs are of little avail directly;often injurious, misleading the patient as to the nature and ,,

management of her case. Valerian, assafcetida, musk, icastor, and other stinking things may have some mysterious ’,potency, and so may the so-called nervine tonics. But your Ireliance is to be placed mainly and often exclusively on i,maintenance by regimen of health of mind and body. Iis chiefly by moral influence that hysteria is to be cured ;and the first place in moral management is held by the z,.discreet use or disuse of attention and sympathy. Neur- iasthenia is to be managed in a different way, and amongremedies the first place is held by rest, especially rest ofmind ; then come change of air and scene, and the remediesdemanded by any special disorder of health.

Before concluding, let us return to consider for a few ’,minutes the anorexia nervosa which I have already men-tioned. What is it ? To answer this question, let us takebad or characteristic cases; for less marked examples,though more common, are not suited for helping to form a ’,

picture of it. A good example is one of the most ghastlyspectacles you will meet with in practice, but the sadnessof the picture is relieved by the fact that they all recover,and recover completely. I daresay the disease occurs inmen, but I am not aware of a case. The patient losesappetite and becomes emaciated. The catamenia cease,and, if the woman is married, fecundity is arrested. Thebowels are very constipated, the stools dry and hard. Thereis no increase of desire for attention and sympathy; on thecontrary, the patient is rather inclined to reserve andseclusion. The patient makes little or no complaint; it isher friends that complain for her. There is no noticedweakening of mind. There is great desire for exercise,especially walking exercise ; the patient has a degree offestinatio, and does not get tired, does not want to rest.Here you recognise a disease quite different from hysteriaand neurasthenia.The best example which I know of occurred in the grand-

daughter of a great physician, whose perplexity was

heightened by sympathy and the utter novelty of the case.The patient was generally healthy, even robust. She hadbeen for some years married, and had borne a child. Thedate of the commencement and of the termination of herillness cannot be given; both were so gradual. The diseaselasted for about three years. During all the time there wasamenorrhoea and very obstinate constipation. The patientlooked like the corpse of one dead from starvation. Theskin was cold, sallow, and without lustre; the eyes healthy,sunken, and with a dark surrounding areola; the tongueclean; the pulse very slow, and only perceptible at thewrist; the breathing slow and very shallow; the urinehealthy. The emaciation was not removal of adipose tissuemerely, but also of muscle; for example, it is scarcely anexaggeration to say there was no gastrocnemius. Sheforced herself to take a fair amount of nourishing food, butalways would prefer to alstain. She had great desire forwalking and great sustained power of doing it, and shewalked very quickly, not at her usual pace. She preferredgreatly walking to driving with her grandfather, whonaturally had difficulty in consenting to allow her to walkso much as she did, seeing the shrunken atrophied state ofthe thighs and legs. Drugs were used in vain. She wasurged to eat and drink. She was anointed and rubbed withoil. She was pressed to lead an inactive life. In course oftime her health was in all respects restored-gradually.She began again to bear children, and is now a healthy,plump woman.

ABSTRACT OF THE

OrationON THE

CLINICAL USES OF RARE DISEASES.Delivered at the Medical Society of London,

May 6th, 1889,

BY JONATHAN HUTCHINSON, F.R.S., LL.D.,CONSULTING SURGEON TO THE LONDON HOSPITAL, AND TO

THE ROYAL OPHTHALMIC HOSPITAL, MOORFIELDS.

II MR. PRESIDENT AND GENTLEMEN,-In addressing theMedical Society of London, it is not necessary to say any-thing as to the importance of the cultivation of a clinicalknowledge of disease. It was for that very object that theSociety was long ago instituted, and in the pursuit of whichit still holds on its prosperous career. My object on thepresent occasion is not to speak of the value of clinicalresearch in general, but ask attention to its paramountimportance in one special direction. I refer to the carefuland systematic study of rare maladies. Amongst thealmost infinitely varied derangements of structure andfunction which make up the total of human maladies, wehave some which are constantly before us, and others soinfrequent that a man may live through a long professionallife and scarcely see a single example of them. All willadmit that the first must be studied as a matter of duty byevery conscientious practitioner; but respecting the latter

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there is a widely spread and veiy natural feeling that it doesnot matter much whether we understand them or not. Itis against this form of apathy that I wish to protest, and Iam not without hope of making it clear that these raritiesare often the most instructive ; that they stand in closerelation with the common ; and that it is the duty of all, sofar as possible, to understand them, and to try also to furtherthe knowledge of them.The more we reflect upon the matter the more clearly

we shall see that the rare is often of the utmost value asillustrative of the common. We have no isolated maladies ;all diseases are the product of pathogenetic influences, pre-senting u-; ultimately with results which are in realityclosely allied, though differing widely in appearance. Thediseases which present the most apparent peculiarity areoften, if correctly understood, the most definite examplesof evolution under ordinary laws. A large number of dis-eases ranked as rare are simply exaggerated or overgrownexamples of those which are common, presenting nothingreally novel, but showing us rather everything stronglymarked, thus striking the imagination more, and impressingthe lesson far better than their congeners, whose featuresare less definite. In Graves’ disease, for instance, thestarting eyes, the throbbing carotids, the full neck, theirritable heart, and the general failure of strength present agroup of features which it is impossible to overlook ; butfor one such fully developed case there are twenty in whichthe condition is only threatened, there being no law underwhich it necessarily acquires its full characteristics, it beingonly a name given to extreme examples of a certain dis-turbance of vaso-motor function, of which minor instancesare of every-day occurrence. Female patients especially areapt to fail for a time in health, showing irritability ofcirculation in head and neck, such as want of control oftemper, proneness to flush &c., and then to recover com-pletely, and I submit that there is no improbability what-ever in the suggestion that they belong to the family groupof undeveloped exophthalmic goitre, and in this case thecommon helps the rare as offering illustrations of treatment,for in both prolonged change of climate is probably the onlyspecific.

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What has just been said as to Graves’ disease probablyapplies with at least equal force to the malady known asmyxoedema. Not that the two are in any way allied. Theone is a functional nerve disorder, attended in extremeexamples by very distressing developments, but whichalways, if the patient’s life is prolonged, passes off in time;the other is a slowly insidious change in structure, pervadingalmost all parts, and leading, without any tendency to

spontaneous amelioration, to gradual abolition of all thehigher endowments of humanity, and ultimately under-mining even the processes essential to the continuance oflife. They are examples of diseases very different in kind,but each may probably be taken as a good type of itsgroup. I expect that it will be admitted, even more

readily than in the case of Graves’ disease, that the domainof myxoedema is not well defined. For one case that iswell marked there are twenty that are not so. So common,indeed, are some of its features-the flabby, thickenedskin, the featureless face, the general obtunding of in-tellect-that we might be tempted to suspect that it is onlyone of the ordinary forms of premature senility to which alarge proportion of women are liable.

If it be true that many of the diseases accounted rare aresimply exaggerated specimens of what is common, it is alsotrue of others that they reveal individual idiosyncrasies ofexaggerated intensity. The malady known as xerodermapigmentosum is a noteworthy instance of this. The affectedchildren are born with skins apparently healthy, but in a fewyears freckles develop on exposed parts in a most unusualdegree, and these may coalesce, inflame, ulcerate, destroy thefeatures, produce neoplasms, and even pass into epithelialcancer. But we have in this disease no pathological noveltywhatever; it is simply an exaggeration of what is common,receiving its final intensification under those laws of hereditywhich evoke family diseases. We may assert that all ex-amples of unusual freckling, indeed perhaps all frecklingwhatever, denotes a minor form of Kaposi’s disease.

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It is perhaps not possible to find a better illustration ofthe doctrine of exaggeration as explanatory of rare diseasesthan is afforded by the phenomena of what is known asReynaud’s disease. Everyone who gets a dead finger fromputting his hands too long in cold water, or a blue nose fromexposure to a wintry wind, illustrates in those occurrences

all that is essential to the malady in question. The con-ditions, which were at first functional and transitory only,may gradually produce structure changes ; and the case,which was simply asphyxia of the extremities at first, mayslide on into one of diffuse sclerosis of the skin. The variouslinks in the chain, the steps which connect that which isvery common with that which is very rare, are here welldisplayed for our instruction. It is veiy interesting to notehow the study of one rare disease helps us to the under-standing of another-how Raynaud’s phenomena explain apart of what we see in scleroderma-how Kocher’s discoveryof the consequences of removal of the thyroid helped us tounderstand myxoedema.As illustration of what we may sometimes learn in

reference to anatomical and physiological laws from thecareful observation of rare cases, I have met with threeexamples which demonstrated the position of the spinalcentre for the act of copulation. It is higher than, anddistinct from, that which supplies muscular force to thesphincters and regulates micturition and defecation. Phy-siologists agree in this, and one or two other cases similarto my own are on record. It is not necessary to set suchobservations in any position of rivalry with the gainsresulting from direct experiment on living animals. Bothare useful, and it is desirable to collate side by side theresults obtained by both, although, however, we mustalways indicate in the clearest possible terms our right asscientific men to avail ourselves of direct experiment onanimals when needful.The remarkable affection recently named " dry mouth,"

or xerostoma, is another example of the illustration by arare disease of physiological law; it is only another instanceof a rarity constituted chiefly by exaggeration, for it repeatsin all details the state of temporary dryness of mouthinduced by emotion, with the difference that it is morepronounced and of indefinite duration.Another most valuable proof of the rare as illustrating

the common I found in the case of a man who, after anordinary operation for haemorrhoids, had immediate, com-plete, and permanent paralysis of his anus and urethra.Disturbance of innervation is of course common aftervarious operations on this region, but we lack close observa-tion of the precise phenomena. A certain influence brought,.to bear on the spinal centre in my case produced simul _taneous and permanent paralysis of the rectum and bladdercentres, and my belief, from certain observations in othercases, is that similar disabilities in less degree occur in allcases of retention after operations.

It is not an unimportant assertion to be made in reference.to some diseases that there are absolutely none which areunique. However strange and bizarre may be the phenomenawhich are united in any individual case, we have but towait long enough, and look about us with proper care, andwe are sure to find their exact parallel. In this fact, and itis one which I could illustrate in many directions, we haveproof that ordinary laws, if we could interpret them,underlie all that we recognise by the name of disease, how-ever exceptional. Nothing results from chance ; there is.nothing but what we must expect concerning it-that whenlike factors of causation come into play a precisely similarresult will ensue. I have during the last few years beenmuch interested in a form of epithelial cancer of the face,,to which I have ventured to give the name" crateriform .ulcer"; and still more recently in the conjunction of whatmay be called the black freckles of the aged with cancer.I am enabled to relate two instances of this association,which could scarcely be a mere coincidence; I believe,indeed, that they illustrate, in the first place, the general lawthat in the aged process all local disturbances of nutrition,have a tendency to slide on into cancerous action; and, next,another law, as regards malignancy, that its precise formmay change with the precise tissue attacked. Just as we enot infrequently see pigmented moles finally attacked bymelanosis, so in this instance do we see common frecklesattacked by changes closely allied to that condition and in--ducing change in other structures of the adjacent skin, andbringing about the growth of a cancer which does not beginin the rete, is destitute of pigment, and is of an epithelialstructure.In connexion with these extremely rare examples of

malignant development in senile structures, and of the.gradual transformation of innocent hypertrophies intomalignant ones, I must not omit to say a few words as,

to another malady, which has been christened by the,

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unwieldy name of "granuloma fungoides." The skin is firstattacked by inflammatory thickening, and then graduallyarge fungating growths develop, which are in all clinicalfeatures malignant, and which cause the patient’s death.They are neither epithelial nor sarcomatous, but appear toconstitute connecting links, as it were, between inflam-matory disorders and those of truly malignant character.Some of them may possibly have derived their peculiarity inthe first instance from individual idiosyncrasy as regardsdrugs.All that has been said as to granuloma fungoides applies

with at least equal force to such maladies as pityriasis,lichen scrofulorum, lichen ruber, lichen planus, morphoea,and a whole host of others, the names of which, I fear, carryto the majority of professional observers but little definitenessof meaning, but which are to the instructed dermatologist fullof reality and abounding in clinical importance. If I prefer Ito mention affections of the skin as examples, it is simplybecause they being, on the outside of the body, admit moreeasily than others of investigation and accurate descriptionby word and pencil.A few words may perhaps be permitted me in reference to

the discovery, separation, and naming of new diseases. Asa rule, I fear it is the fact that we do not accept such dis-coveries with much gratitude. Take, for instance, the caseof acromegaly. The majority, perhaps, did not welcomethe addition of this name to our nosologies ; yet our annoy-ance at the mention of it and the discussion of the diseasenamed ceases as soon as we realise the thing, and we becomefilled with gratitude, which replaces the repulsion at firstfelt. Yet, without doubt, those who give new names havemuch to answer for if they do it injudiciously. The pedantrywhich has recently new-named many of the old masters inthe National Gallery is most vexatious, and a similar loveof needless and inconvenient change is at least equallyreprehensible in medical matters. I submit, however, with-out the least flinching, that there is no avoiding the intro-duction of many new names into all departments of clinicalobservation ; for we must classify diseases in far greaterdetail than has yet been attempted, and with far greateraccuracy. The confusion comes when different things arecalled by the same name. There is no objection for a timeto use the name of a discoverer as a designation for thething he has discovered ; it conveys no false impres-sions, and can be laid aside when further knowledgeenables a more definitely appropriate name to be applied.In order that the profession should be afforded the bestpossible means of identifying and distinguishing that whichis named, all new observations should be promptly illus-trated in the most prominent possible manner by drawings,photographs, models, &c., accessible to all ; and it is myprivate opinion that the new museum of the Royal Collegeof Surgeons is the most appropriate place for such an exhi-bition, and its funds the appropriate means of defraying theexpense. We want a clinical museum which should, asregards the various external phenomena of diseases, preservein perpetuity the transitory, and bring that which is veryrare within the range of common observation.In conclusion, Mr. President and Fellows of the Medical

Society of London, my object in this address, which throughyour favour I have been appointed to deliver, has been toenforce the paramount value of what is rare and exceptionalas illustrating general pathogenic laws. I have broughtbefore you in brief reviewthe facts which concern myxoedema,Raynaud’s disease, scleroderma, granuloma fungoides, anda number of rare maladies and symptoms, which appear toafford in a definite manner an insight into the common.I have argued that none of these affections stand alone,but that all are rather the results of partnership incausation, for the understanding of which we have butto apply patiently the processes of pathological analysis.The zeal which we often witness for what may be callednominal diagnosis, the anxiety to place every case undersome recognised name, leads sometimes to forgetfulnessthat the nature of the disease is of far more real importancethan its name, and that this may be recognised quite inde-pendently of the name in use, and possibly even betterwithout it. Several of the rare diseases which I havementioned illustrate in a striking manner the importantdoctrine that all inflammatory products are infective, muchin the same way that the products of malignant growth areso ; and, further, that the process of malignant new growthis, after all, nothing but a modification of that of chronicinflammation. We shall do well, in trying to study the

lessons of rare diseases, to rid ourselves utterly of all notionsof predestination. Such preconception will prove a hopelessencumbrance in the investigation, not perhaps of all, but of alarge majority of the diseases in question. In the early stagesof most maladies the ulterior development is by no meanscertain, but depends rather upon the as yet undeterminedincidence of a variety of contributory causes. There existsno such entity as granuloma fungoides, or pemphigus vegi-tans, or myxcedema. It is not the fact that the human bodyis ever taken possession of by some seed-like principle,destined in the future infallibly to evolve the phenomenawhich receive these names. Rather by these names we re-cognise the fully developed results of a complex chain ofcauses. The order of events which has in any given casesended in the production of such a malady was one whichmight have failed at any point or might have been broken byart. The right study of rare diseases will, I feel assured,induce us for the most part to forego the search for entities,to disuse such terms as sui generis, and find pleasure in thediscovery of laws of relationship rather than divergence.

ON THE OPERATIVE TREATMENT OFDISEASE AFFECTING MORE THAN

ONE JOINT.1

BY WILLIAM H. BATTLE, F.R.C.S.,ASSISTANT SURGEON TO THE ROYAL FREE HOSPITAL AND TO THE EASTLONDON HOSPITAL FOR CHILDREN, SHADWELL; FORMERLY RESIDENT

ASSISTANT SURGEON AND SURGICAL REGISTRAR AT ST. THOMAS’SHOSPITAL.

I PROPOSE to limit myself to one section of the largesubject which is suggested by the title given to this paper-namely, that of tubercular disease affecting more than onejoint, and requiring operative treatment for its cure. Dailywe see amongst patients evidence of the tendency oftubercle to commence in many parts of the body, eachseparate centre liable to pass through the various degenera-tive processes which characterise the disease, extendinglocally, but not exhibiting any strongly marked tendencyto affect the internal organs. Less commonly we find itchoosing the synovial membrane of more than one joint asits original seat, or extending into joints from one or otherof the bones which enter into their formation. Here, as inthe manifestations of the disease in more superficial struc-tures, it is possible to obtain a cure of the disease by localtreatment, which must, however, frequently be of severecharacter. During the last few years it has been my dutyto treat several cases which illustrate this fact, and as thenumber of them will not permit of my entering into a usefulaccount of them all, I have selected some examples inwhich the disease commenced primarily in the bone andonly secondarily involved the joints. I take this opportunityof thanking the surgeons mentioned for their kindness inpermitting me to take charge of the cases.The first case is one in which there was disease of the

left femur, suppuration extending to the hip- and knee-joints, and disease of the left sterno-clavicular joint. Excisionof the hip-joint, incision of the knee-joint, erasion of thesterno-clavicular joint, and Furneaux Jordan’s amputationat the hip were performed, and resulted in recovery.K. B-, a girl aged six years, was admitted under the

care of Mr. Sydney Jones into the Alexandra ward of St.Thomas’s Hospital on Sept. 24th, 1887, and was dischargedon Aug. 24th, 1888. The history of the case was that shehad come home from school ten days before admission,limping, complained of pain in the knee then and for threeor four days before the thigh began to swell. The familyhistory was good. She had had measles five months before,and had not been " like herself since.On admission, there was a large fluctuating swelling in

the upper and anterior part of the left thigh, which wasconsiderably enlarged. There appeared to be some thicken-ing of the femur. She complained of tenderness on pressureover this swelling, and of pain down the left thigh to theknee-joint. Both hip- and knee-joints appeared healthy.The temperature was raised to 100° at night.On Sept. 23rd Mr. S. Jones incised this abscess, and

1 Read at a meeting of the East Surrey Branch of the South-EasternDistrict at Croydon.