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BRAIN:
A JOURNAL OF NEUROLOGY.
EDITED BY
■\
J. C. BUCKNILL, M.D., F.R.S.,
J. CRICHTON-BROWNE, M.D., LL.D.,
D. FERRIER, M.D., F.R.S., and
J. HUGHLINGS-JACKSON, M.D., F.R.S.
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VOL. III.
April 1880 to January 1881.
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MAC MILL AN AND CO. 1881.
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LONDON: PRINTED BY WILLIAM CLOWES AND SONS, LOOTS*
8TAMFOKD STliEKT AND < IIAIUNU C'UOSS.
CONTENTS.
ORIGINAL ARTICLES :—
A Plea for the Neurotic Theory of Gout. By Dyce Duckworth, M.D.
(Edin.) . . . ' . . . . . . . 1
The Conditions of the Unipolar Stimulation in Physiology and Thera- peutics. By A. de Watteville, M.A., B.Sc. . . . .23
The Anatomy and Physiology of the Chorda Tympani Nerve. By
Horatio R. Bigelow, M.D 43
On the Paralysis which Results from Angular Curvature of the Spine.
By John Duncan, M.D. ........ 48
On Some Varieties of Cervical Paraplegia. By Thomas Buzzard, M.D. 57 Distribution of the Arteries of the Spinal Cord. By James Ross, M.D. 80 On the Form and Topographical Relations of the Corpus Striatum. By
Professor J. C. Dalton (New York) . . . . . .145
Nystagmus. By R. P. Oglesby 160
On Muscular Spasms known as " Tendon-Reflex." By A. Waller, M.D. 179 On Right or Left- sided Spasm at the Onset of Epileptic Paroxysms, &c.
By J. Hughlings- Jackson, M.D., F.R.S 192
Notes on Left-handed ness. By William W. Ireland, M.D. . .207
Optical Illusions of Motion. By Professor Silvanus P. Thompson, B.A.,
D.Sc 289
On some Points in the Diagnosis and Treatment of Brain Disease. By
Julius Althaus, M.D 299
Recurrent Headaches in Children. By Francis Warner, M.D. . . 309 On the Methods of Preparing, Demonstrating, and Examining Cerebral
Structure in Health and Disease. By Bevan Lewis, L.R.C.P. 314, 502 Nervous Diseases in Victoria. By James Jamieson, M.D. . . 337
A Plea for the Minute Study of Mania. By J. Crichton-Browne, M.D. 347 On Temporary Paralysis after Epileptiform and Epileptic Seizures. By
J. Hughlings-Jackson, M.D. 433
Piscidia Erythrina. By Isaac Ott, M.D. 452
Cerebral Amblyopia and Hemiopia. By David Ferrier, M.D. . . 456 Visible Muscular Conditions as Expressive of States of the Brain and
Nerve-Centres. By Francis Warner, M.D. .... 478
Tetanus. By Surgeon-Major Ratton, M.D 496
On the Methods of Preparing, Demonstrating, and Examining Cerebral _ Structure in Health and Disease. By Bevan Lewis, L.R.C.P. . 502
a 3
VI CONTENTS.
CRITICAL DIGESTS AND NOTICES OF BOOKS:—
PAGE
Nothnagel on the Regional Diagnosis of Diseases of the Brain. By D.
Ferrier, M.D 85
Huxley on the Crayfish. An Introduction to the Study of Zoology.
By F. Jeffrey Bell, M.A 99
Gowers on Pseudo-hypertrophic Muscular Paralysis. By Robert
Saundby, M.D 109
The Index Medicus. By J. Crichton-Browne, M.D Ill
Morris on Skin Diseases. By J. Crichton-Browne, M.D. . . . 112 Bastian on the Brain as an Organ of Mind. By John Charles Bucknill,
M.D., F.R.S. . . . . . m ■ . . .215
Lindsay on Mind in the Lower Animals, in Health and Disease. By
F. L. Benham, M.B 225
Landouzy on Paralysis in Acute Disease. By A. de Watteville, M.A.,
B.Sc. 233
Mickle on General Paralysis of the Insane. By J. C. Bucknill . . 239 Erlenmeyer on the Physiology and Pathology of Writing. By H. de
Watteville, M.D . r . .363
Brissaud on Hemiplegic Contracture. By David Ferrier, M.D. . . 365 Scientific Transcendentalism. By F. L. Benham, M.B. . . .374 Heidenhain on Animal Magnetism. By David Ferrier, M.D. . . 383 Vulpian's Maladies de la Moelle. By A. de Watteville, M.D. . .516 Aitken on the Science and Practice of Medicine. By J. Crichton- Browne, M.D 528
CLINICAL CASES:—
Arrest of Development in the Left Upper Limb, in Association with an
Extremely Small Right Ascending Parietal Convolution. By H.
Charlton Bastian, M.D., F.R.S., and V. Horsley . . . .113 Case of Nerve-Splitting. By Surgeon-Major K. M'Leod, A.M., M.D. . 117 Cases of Intra-Cranial Tumour. By James Ross, M.D. . . . 121 Case of Alternate Hemiplegia, with Conjugate Deviation of the Eyes.
By Alexander M. McAldowie, M.D. . . . . .125
Crural Monoplegia — Limited Cortical Lesion of Opposite Hemisphere.
By David Ferrier, M.D., F.R.S 128
Case of Microcephalic Idiocy. By A. R. Urquhart, M.D. . . . 246 Case of Cerebral Tumour. By Arthur W. Fox, M.B., and Ernest Field,
M.B 252
Case of Progressive Muscular Atrophy. By Byrom Bramwell, M.D. . 396 Case of Compound Fracture of the Skull. By T. Pridgin Teale, MA.
Oxon 400
Case of Athetosis. By Lewis Shapter, M.D. . .402
CONTENTS. Vll
PAGE
Case of Congenital Absence of the Corpus Callosum. By A. E. Urqu-
hart, M.D 408
A Case of Epilepsy. By Charles Mercier, M.B 532
Case of Hemiplegia and Hemianesthesia in au Idiot, as the Result of
Paralysis of the Left Cerebral Hemisphere. By Donald Fraser, M.D. 536
An Obscure Case of Brain Disease. By M. Handheld Jones, L.R.C.P. 542
ABSTRACTS OF BRITISH AND FOREIGN JOURNALS :—
Innervation des Vaisseaux Cutanes (Dastre et Morat). Etude sur la
Physiologic des Nerfs des Muscles Stries (Tschiriew). By A.
Waller, M.D . . .132
Primary Athetosis (Gnauck). By W. J. Dodds, M.D., D.Sc. . . 136 A Case confirming Cerebral Localisation (Tamburini). Caizergue's Case
of Cerebral Localisation. Lactic Acid as a Hypnotic. By W. W.
Ireland, M.D 137
Relations of Brain, Mind, and Higher Nerve Function. By W. G.
Thompson, M.D 141
Traumatic Insanity. Bullet Wound of the Brain. By Robert Lawson,
M.B 143
Method of Preserving the Brain (Giacomini). By Allen Thomson,
F.R.S 257
Krueg on the Sulci of the Zonoplacental Mammalian Brain. By
H. Obersteiner 259
Fere sur le DeVeloppement du Cerveau, &c. Amidon on a New Study
of Cerebral Localisation. By A. Waller, M.B 260
Visceral Neurology. By J. Mitchell Bruce, M.D 263
Buzzard on certain Points in Tabes Dorsalis. By J. Hughlings-Jackson 266 Abstracts of the Gulstonian Lectures on Epilepsy. By W. R. Gowers,
M.D 268
On the Disease called Sturdy in Sheep, in its relation to Cerebral
Localisation. By George T. Beatson, B.A., M.D. . . .282 Tripier on Anesthesia from Cortical Lesions. Sommer on Diseases of
the Cornu Ammonis. By D. Ferrier ..... 286 The Central Sulci in the Carnivora -The Brain of the Hippopotamus
—The Brain of the Bush Dog. By J. C. Galton, M.A. . . 413 Exner on Cerebral Localisation. By H. Obersteiner . . . . 416 Brachial Monoplegia — Pitres on Cerebral Localisation — Kronecker and
Nicolaides on Irritation of the Vaso-Motor Centres by Summation
of Electrical Stimuli — Marckwald and Kronecker on the Respiratory
Centres — Ferrier and Yeo on the Cerebral Visual Centres — Debove
and Gombault on the Decussation of the Sensory Tracts in the
Medulla Oblongata — Debove and Boudet on Ataxic Incoordination
— Gaskell on the Tonicity of the Heart and Blood-vessels — Gombault
Vlll CONTENTS.
PAGE
on Segmentary Peri-axillary Neuritis — Grasset on Locomotor Ataxy and Heart Disease — Tschiriew on Lesions of the Spinal Cord and Skin in a Case of Anesthetic Leprosy — Pott's Disease and Progres- sive Muscular Atrophy. By David Ferrier, M.D. . . . 417
Kahler and Pick on the Pathology and Pathological Anatomy of the
Central Nervous System. By W. J. Dodd, D.Sc. . . .427
Boyer and Decaisne on Cortical Lesions. By A. R. Urquhart, M.D. . 430
Magnan on Word Blindness — Delaunay on Memory. By A. R.
Urquhart, M.D 552
Buzzard on Transfer-Phenomena 'in Epilepsy produced by Encircling
Blisters. By J. Hughlings-Jackson, M.D. .... 554
Luederitz on Experiments on the Effect of Pressure on Motor and Sensory Nerves, &c. — Brieger on Paralysis from Fright. By R. H. Pierson, M.D 555
Onimus on Modifications in the Excitability of the Nerves and
Muscles after Death. By A. Waller, M.D 556
Striiinpell on the Pathology of the Spinal Cord — Westphal on Syphilis and Tabes Dorsalis — Pick on Agenesis of the Spinal Cord — Moeli on Amyotrophic Lateral Sclerosis — Shaw on Sub-acute Myelitis of the Anterior Cornua. By W. J. Dodds, M.B., B.Sc. . . 560
Erlenmeyer on Nerve-Stretching in Locomotor Ataxia — Muller on the Early Stage of Locomotor Ataxy — Erlenmeyer on the Paradoxical Muscular Contraction — Schulz on Injury of the Spinal Cord — Dujardin-Beaumetz on iEsthesiogenic Properties of certain Woods applied to the Skin — Berger on the Nosology of Tabes Dorsalis — Ballet on Facial Monoplegia. By A. de Watteville, M.D. . . 569
Maragliano on the Nitrite of Amyl in Epilepsy. By W. W. Ireland, M.D. 575 *
( ix )
LIST OF CONTRIBUTORS.
ALTHAUS, JULIUS, M.D. BASTIAN, B. CHARLTON, M.D. BEATSON, GEORGE S., M.D., BELL, F. JEFFREY, M.A. BENHAM, F. L., M.B. BIGELOW, HORATIO R., M.D. BRAMWELL, BYROM, M.D. BRUCE, J. MITCHELL, M.D. BUCKNILL, J. C, M.D. BUZZARD, THOMAS, M.D. CRICHTON-BROWNE, J., M.D. DALLEN, J. C, M.D. DE WATTEV1LLE, A., B.Sc. DODDS, W. J., M.D. DUCKWORTH, DYCE, M.D. DUNCAN, JOHN, M.D. FERRIER, DAVID, M.D. FIELD, ERNEST, M.B. FOX, ARTHUR W., M.D. FRASER, DONALD, M.D. GALTON, J. C, M.D. GOWERS, W. R., M.D. HORSLEY, V. HUGHL1NGS-JACKSON, J., M.D.
IRELAND, W. W., M.D. JAMIESON, JAMES, M.D. JONES, M. HANDFIELD, L.R.C.P. LAWSON, ROBERT, M.B. LEWIS, BEVAN, L.R.C.P. McALDOWIE, A., M.D. McLEOD, KENNETH, M.D. MERCIER, CHARLES, M.B. OBERSTEINER, II., M.D. OGLESBY, R. P. OTT, ISAAC, M.D. PIERSON, R. H., M.D. RATTON, J. J. L., M.D. ROSS, JAMES, M.D. SAUNDBY, ROBERT, M.D. SHAPTER, LEWIS, M.D. TEALE, T. PRIDGIN, M.A. THOMPSON, ALLEN, M.D. THOMPSON, SILVANUS P., D.Sc. THOMPSON, W. G., M.D. URQUHART, A. R., M.D. WALLER, A., M.D. WARNER, FRANCIS, M.D.
( xi )
LIST OF ILLUSTKATIONS.
Distribution of the Arteries of the Spinal Cord : — page Fig. 1. Schematic Representation of the Distribution of the Blood- Vessels in the Cord ( Woodcut) . . . . .81
Arrest of Development in the Left Upper Limb : 3 Figures (Plate) . 113
Form and Topographical Relation of the Corpus Striatum ( Woodcuts) : —
Fig. 1. Brain in Transverse Vertical Section .... 147
Fig. 2. Brain of Fox (Profile view) . . . . . .148
Fig. 3. Human Brain (Profile view) ..... 149
Fig. 4. Human Brain ; Median Surface of the Right Hemisphere . 151 Fig. 5. Longitudinal and Vertical Section of the Right Hemisphere,
showing Cavity of Lateral Ventricle (seen from the Inner Side) 153 Fig. 6. Longitudinal and Vertical Section of the Right Hemisphere, through Corpus Striatum and Surcingle (seen from the Inner
Side) 156
Fig. 7. Horizontal Section of the Brain, through the Anterior Com- missure and Lower Part of the Cerebral Ganglia . . . 158
■ Tendon-ReBex " ( Woodcuts) :—
Fig. 1. Nerve Transmission Rapidity ..... 186
Fig. 2. Knee-Clonus 187
Fig. 3. Ankle-Clonus 187
Fig. 4. Tendon-percussion Latency of Rectus .... 188
Fig. 5. Tendon-percussion Latency of Gastrocnemius . . . 188
Fig. 6. Electric Latency of Rectus 189
Microcephalic Idiocy : —
Head-measurements (half Life-size) of E. F. . . . . 250
Optical Illusions of Motion (Four Woodcuts) .... 292-295
Functional Athetosis 402
XI I LIST OF ILLUSTRATIONS.
Cerebral Amblyopia and Heminpia (Plates) : — page
Plate 1. Field of Vision, R. and L., of Thomas H. . . 460
Plate 2. Field of Vision, R. and L., of Hannah 0. . . . 462 Plato 3. Field of Vision, R. and L., of James S. 475
Charcot's Scheme of Optic Tracts ( Woodcut) ..... 464
Visible Muscular Conditions as Expressive of Slates of the Brain and Nerve Centres ( Woodcuts) : —
The Nervous Hand ; the Energetic Hand ; the Hand at Rest ; the Straight Hand 494
Cerebral Structure in Health and Disease; Diagram Illustrative of the
Effects of Embolic Plugging: after Kindfleisch (Woodcut) . . 511
Hemiplegia and Hemianesthesia in an Idiot Boy ( Woodcuts) : —
Cells of the Brain . . .540
Obscure Case of Brain Disease (Woodcut) ..... 547
BBAIN.
APRIL, 1880.
Original fortifies. A PLEA FOE THE NEUROTIC THEORY OF GOUT.
BY DTCE DUCKWOKTH, M.D. EDIN.,
Fellow of the Royal College of Physicians, Assistant-Physician to St. Bartholomeio's Hospital.
" The difficulties and refinements relating to the disease itself .... I will leave for Time, the guide to truth, to clear up and explain."
A Treatise on Gout and Dropsy, Sydenham, 1683.
I venture in the present essay to put forward some argu- ments which tend, in my opinion, to sustain the thesis, that gout is a malady of neurotic origin.
In the first place, I wish to clear myself from a charge that may be brought against any one who seeks to promulgate such a view. I must confess that I am not bound to any one-sided theory of disease, in general ; that I am not a rampant neuro- pathologist ; and that I am constantly endeavouring to seek exactness and truth in medicine. And, having said this nuch, I may pass on to state that, having been a pupil and intimate friend, for many years, of the late Professor Laycock, I have not failed to imbibe, and to weigh very carefully, the doctrines laid down by him on many matters of profound interest in practical medicine and pathology. I have carried these views along with me, and have applied them, day by day, to the facts which have come before me in the course of hospital experience. At my hands, therefore, these views have received the roughest and most work-a-day application.
VOL. III. b
2 A PLEA FOR THE NEUROTIC THEORY OF GOUT.
* Grout is primarily and pre-eminently a neurosis." So wrote Laycock to me a year before his death. His great predecessor in the Edinburgh Chair of Practice of Physic, Cullen, taught the same doctrine.
" Gout is manifestly an affection of the nervous system, in which the primary moving powers of the whole system are lodged. The occasional or existing causes are almost all such as act directly upon the nerves or nervous system, and the greater part of the symptoms of the atonic or retrocedent gout are manifestly affections of the same system. This leads us to seek for an explanation of the whole of the disease in the laws of the nervous system, and particularly in the changes which may happen in the balance of its several parts. Of the several pyrexiae which are diseases of the sanguiferous system, some are with, and others without a considerable affection of the nervous system : pyrexia and neuroses, therefore, are necessarily and unavoidably mixed more or less with one another. Of those which are mixed, gout is a principal instance, in so far as it is an inflammatory disease ; like rheumatism, it is placed among the pyrexiae, but it is among the limits between pyrexia and neuroses, and shows more than any other pyrexia does of an affection of the nervous system." *
Cullen states that he adopted his views as to the nervous causes of gout from Stahl.2
Within the last few years, large progress has been made in the study of nervous disease, and quite recently, in particular, has light been shed upon various affections of the joints, which can now with certainty be relegated to disorders of the central nervous system.
Few writers have approached this subject since Professor Laycock put forward his views, and these, indeed, were never fully developed by him.
His most minute description is given as follows : " Ex- cessive activity of the nervous system, or of portions of it, becomes a highly predisposing cause of the neuroses, as of
1 ' First Lines of the Practice of Physic,' vol. ii. part i. chap. xiv. Edited by John Thomson, M.D. Edin., 1827.
2 < Theoria Medica Vera,' &c. G. E. Stahl. (Halle, 1737.) " De Doloribus Spasticis Arthritico-Podagricis," § xxxviii. p. 1040.
A PLEA FOR THE NEUROTIC THEORY OF GOUT. 3
other general diseases. . . . These excesses, when habitual or long continued, are apt to develop hereditary tendencies. Thus, great mental labour, drunkenness, strain on special nerves, and the like, of parents, are often manifested in children as neuroses. Here the influence of the nerve-centres on the nutrient forces of tissue is shewn, as in hereditary insanity, epilepsy, hysteria, angina pectoris, and even, gouty diseases in general, which, primarily, are neurose degenerations in the nutrition and transformation of certain tissues." l
The exceptions I have alluded to, I must pause to refer to briefly. The first consists in a paper which was written by Dr. Austin Meldon of Dublin,2 in which he makes objection to the uric acid theory as explaining fully the cause of gout. He quotes cases to show, as is well-known and recognised, that uric acid and urates may exist in the blood to large extent without giving rise to gout, or being the result of gouty taint or inheritance, and he invokes the nervous portion of Cullen's theory to "complete the chain.'.' His theory is as follows. He believes that the presence in the blood of uric acid and of soda, in some form, constitutes the predisposing cause of gout. " Nerve-force, when in a healthy condition, preserves these two in a fluid state, separately, in a condition in which they may be eliminated by the skin, kidneys, or bowels. As soon, how- ever, as this nerve-influence is lessened, these two substances unite in the tissues most removed from the brain and centre of circulation. Irritation and inflammation excite the nervous system to increased energy, and the disease, for the time, is arrested." Dr. Meldon lays stress upon the fact of the attacks occurring mostly at night, when the nerve-force and circulation are feeblest, upon the common implication of the big toe, and notes the marked effect of depression of the nervous power as an important factor in their production. This theory, then, is a compound or humoro-neurotic one.
The second exception I have referred to above is a very notable one. I allude to the views of Dr. Edward Liveing which were published in his masterly exposition of the subject
1 • The Principles and Methods of Medical Observation and Research.' Edit. 2 (Edin. 1864), p. 338.
2 'Lancet,' vol. ii. (1872), p. 115.
B 2
4 A PLEA FOR THE NEUROTIC THEORY OF GOUT.
of megrim. Discussing the alliances, and the various sympto- matic forms, of megrim, he observes that — " There is much in the history of gout — its hereditary character, limitation to particular ages and sexes, periodicity, explosive character, sudden translations and remarkable metamorphic relations with nervous disorders — which seems to stamp the malady as a pure neurosis;" and even the fit itself, with its sudden nocturnal invasion, the late Dr. Todd was accustomed to compare to one of epilepsy or of asthma. Moreover, although the presence of uric acid in the blood of gouty subjects is no longer inferential and admits of ready demonstration, the dependence of the remaining phenomena of gout upon this associated condition, is, to say the least, far from proved ; and it is further certain that uric acid is also present in excess under other pathological conditions which have no connection whatever with gout. On the whole, there is much to be said in support of the view that gout in its various forms is the manifestation of a disorder which has its primary seat in the nervous system itself; and there is no more difficulty in con- ceiving that inflammation and pain may be an effect of deranged innervation in the case of arthritis, than in the analogous case of herpes zoster ; or that an excess of uric acid should be generated or retained in the system under a similar influence, than that sugar should in the parallel case of the dia- betes which follows a lesion in the floor of the fourth ventricle." ' As bearing on this subject, Sir James Paget 2 remarks that "disturbance of the nervous system in some form and part may be regarded as a factor in every case of gout. There are reasons enough for thinking that changes in the nervous centres determine the locality of each gouty process, while changes in the relations of the blood and tissues determine its method and effects ; and that thus we may explain the sym- metries of disease in gout, sometimes bilateral, sometimes antero-posterior, and thus its metastases. But these changes are a part of the pathology of gout which is not yet clinical." 3
1 ' On Megrim, Sick-Headache, and some Allied Disorders.' By Edward Liveing, M.D. Cantab. (Lond. 1873), p. 404.
a « Clinical Lectures and Essays.' Edit. 2 (1879), p. 382.
3 ' Studies of Some Irregular Manifestations of Gout ' (1879), p. 93.
A PLEA FOE THE NEUROTIC THEORY OF GOUT. 5
In a paper published last year in the 15th Volume of St. Bartholomew's Hospital Beports,1 I alluded to these views of Cullen, Lay cock, and Liveing, and quoted the teaching of Lay cock on this subject, showing how he regarded the per- verted chemistry of gout merely as an epiphenomenon of a more profound and overruling neurosis ; and I ventured to predict that at no distant period Cullen's assertions would be more completely verified and vindicated. Cullen's views have been vigorously combated by Dr. Garrod in his classical work on gout, but I venture to think that with additional evidence now forthcoming, and by the light of other modern doctrines established since Cullen's day, the teaching of that illustrious man, with certain modifications, may not unfairly be sustained at the present time.
Gout has certainly held its place for a long time in humoral pathology, and although Cullen's views tended to overthrow the theory of any special morbid state of the fluids, it does not appear that any marked attention was paid to the nervous part of his aetiology. More stress was laid by his followers upon that portion of his theory which embraced the tone or atony of the system. Cullen held that loss of tone occurred in the extremities, and that this atonic state was communicated to the whole system, but especially to the stomach. He believed that nature restored the lost tone by setting up an inflammatory affection in the extremities.
He further developed from this more fanciful theories, to explain different varieties of gout, such as atonic, misplaced, and retrocedent. Such views as these are hardly perused with patience in these days, and the promulgator of them is naturally regarded as an effete authority.2 But it is possible, I believe, to rescue from oblivion, and to develop more fully, Cullen's theory as to gout being first, "a disease of the whole system, depending upon a certain general conformation and
1 Mr. Spencer Wells has called attention to the highly developed nervous system of the gouty, and to the influence of irregular exercise of it, in inducing paroxysms. — 'Practical Observations on Gout,' etc. (1854), p. 21.
2 " The view of the solidists, represented by Cullen, who considered gout to be an affection of the nervous system, has never been able to hold its ground against the various humoralistie theories." Senator, 'Ziemsscn's Cyclopaedia,' Art. Gout, p. 101, Eng. Translation.
6 A PLEA FOE THE NEUROTIC THEORY OF GOUT.
state of body ;" 1 and secondly, that it " is manifestly an affection of the nervous system."
The researches of Dr. Garrod seemed to place the modern pathology of gout upon a fresh and secure humoral basis. His facts respecting the uric-acid-excreting function of the kid- neys, and the relations between this acid and the disease, have not been controverted, and they constitute a solid advance in medical science, which must ever remain most honourably associated with his name. Still, Garrod, with a degree of caution becoming his scientific position, allows that his views are "in themselves insufficient to explain all the phenomena of gout." He has endeavoured to meet every difficulty which opposed itself to his own theory, and, it must be allowed, with great power and ingenuity. But he has no- where availed himself of any view which would admit the interposition of nervous influence, and he does not attempt to combat Cullen's particular theory of the specific involvement of the nervous centres. Sir Charles Scudamore, who criticised Cullen's views, also took no heed of the alleged implication of the nervous system, and adopted a humoral theory, starting from the stomach.2 In more recent times too, the late Dr. Murchison gave in his full adherence to a humoral theory of gout, and expressed himself thus : " I hold that what is called a 'gouty diathesis' always indicates, and is the result of hepatic derangement, and that many symptoms commonly referred to gout, would be more correctly ascribed to disorder of the liver. . . . Gout itself is merely one of the results of lithaemia."3 The idea that gout was in any way a mani- festation of disturbed nervous relations, seems never to have been contemplated by that very thoughtful and philosophical physician.
In a suggestive communication by Dr. Ord,4 on the relations of uric acid to gout, he offers the view that the malady is a
1 Op. cit., par. dxxx.
2 'A Treatise on the Nature and Cure of Gout and Gravel,' edit. 4 (1823), pp. 10 and 147. Cullen's " third observation " was, that the stomach was the internal part most frequently and considerably affected by gout, yet he repudiated any humoral pathology in connection with it.
3 ' Lectures on Diseases of the Liver.' Edit. 2 (1877), p. 568.
4 'Medical Times and Gazette,' vol. i. (1S74), p. 233.
A PLEA FOR THE NEUROTIC THEORY OF GOUT. 7
special form of degeneration or want of tissue-organisation in remote, and lowly vascular parts. He believes that the uratic deposits result from either general or local disintegration, and are not to be regarded as significant of their elimination from the blood : further, that the local processes are not dependent on these deposits, and that the latter are not the result of the inflammation. He takes cognizance of nervous influence so far as to affirm that " all authors, in one way or another, admit the direct influence of the nervous system " (which statement I can hardly agree with), and he believes that local gouty " degenerations and inflammation tend to infect the rest of the system through the blood, and to set up similar actions elsewhere through reflex nervous action."
Dr. Ord's theory is therefore mainly humoral, and he is chiefly concerned to combat Garrod's views.
To discuss more in detail the question of the humoral element in the pathology of gout, is not within the scope of the present essay.
It is, without doubt, the case that, hitherto, no theory has been set forth which appears to embrace all the multiform phe- nomena of gouty disease. The greatest advance of modern research has been to establish the certainty of some special relation to it, in the greater number of instances, of uric acid, and, so far, there is clear warrant for retaining a measure of humoral pathology in our conception of the malady. There is still much to be done in elucidating the causes of the renal inadequacy which must be taken into the consideration of a comprehensive pathology of gout.
The best approach to the line of argument I purpose to take up, will manifestly be to review the special characters of neuroses in general, and then to examine coincidently, how far the well-ascertained features of gout conform to such characters.
Before proceeding to this analysis, I would first assert that gout is something beyond the mere resultant effects of aberrant relations of uric acid ; that it consists in something more than a perversion of animal chemistry ; that it is not, by any means, to be explained as an outcome of gastric or hepatic distemper ; and that it is not the appanage only of the middle-
8 A PLEA FOR THE NEUROTIC THEORY OF GOUT.
aged or elderly high-liver and intemperate drinker, because, as is well known, it affects also, sometimes in early life, the high-thinker and the laborious bread-winner. Without doubt, while accepting all (and that is much) that it is good for, one is impelled to look beyond what may be termed the chemical pathogeny of gout. The researches into the nature and functions of the nervous system, as carried out during the past quarter of this century, come to our aid at this stage of our inquiry, and, amongst these, we have learned two main and important points respecting the neuroses in general. The first is, that they may be primary or central, and the other is, that they may be secondary or induced. In other words, it may be averred that a neurosis is implanted, or a tendency to it established, and this shall be handed down, hereditarily passed on, and thus, a diathetic tendency be formed ; or, owing to some toxsemic condition or blood-degeneration, a secondary or induced neurosis may be established.
I shall endeavour to sustain the neurotic theory of gout upon this basis.
Eepresenting special conditions, or rather special morbid modes of evolution, of nerve-force, neuroses are implanted in the individual as a part of his intimate nature. They belong to the individual, and are characteristic of him in the same degree that are his features and other physiognomical traits. An implanted neurosis is, as it were, the representative of a morbid physiognomy for the cerebro-spinal axis. A neurosis, then, is a peculiar disposition, or tendency, on the part of the nervous system, or some definite tract of it, towards morbid evolution or manifestation of nerve-functions. It does not necessitate the existence of any coarse disease, directly obvious to the eye, but it is a more or less abiding condition, ready to come into action upon suitable provocation.
It is specially characteristic of neuroses that, being thus primarily impressed upon an individual, they tend to be transmitted by heredity. It has been alleged that the female sex is more neurotically disposed than the male ; but facts do not support this opinion thus broadly put forth. Certain neuroses appear to prevail with greater frequency in males, and others in females ; and not only so, but in the case of those
A PLEA FOR THE NEUROTIC THEORY OF GOUT. 9
that are common to both sexes, the manifestation occurs at different epochs of life.
Thus, some outbreaks of neurotic disorders are seen to occur at the several septennial climacteric periods, at the times of dentition, puberty, and often at the grand climacteric. In this manner, an element of distinct periodicity attaches to neuroses in general.
Further, a most marked feature in all neurotic affections is that of paroxysmal tendency. Thus, there is the abiding element, with proclivity to recurring outbreak.
Again, it is certainly known that a law of alternation, or substitution, prevails in neuroses, and thus we meet with certain affections in the parent or ancestors, and with others, equally neurotic, in the collateral relations or descendants. We thus have to deal with distinct types of nervous impres- sion. These abiding conditions are more or less prone to be excited into activity according to various circumstances.
It is not difficult to understand the course pursued by a neurotic taint once laid down or impressed ; but it is not so easy to conceive the original implanting of such a morbid functional tendency. The mischief, however, is constantly originating in individuals, and as constantly undergoing further development, modification, or even repression.
Excessive activity of the nervous system, or of any part of it, as Laycock has shown, becomes a highly-disposing cause of the neuroses. Habitual or prolonged excess comes thus to develop hereditary tendency. Thus, undue mental labour, gluttony, alcoholic intemperance, debauchery, and other indulged evil propensities in the parent, come to be developed into definite neurotic taint and tendency in the offspring. Particular examples of this are not far to seek, and amongst them comes out the dis- order so widely and variously manifested as gout. According to this view, for which I plead, gout appears as a diathetic neurosis, and a link in the long chain of its phenomena, so long missing, is now forthcoming.
I have already stated that there is clear warrant for retaining, as part of the pathology of gout, a humoral hypothesis, and it may perhaps be applied and relegated to its proper place, as follows. Granting that gout in any individual is the outcome
10 A PLEA FOR THE NEUROTIC THEORY OF GOUT.
of a central neurotic taint, we have the ordinary manifesta- tions of it more or less severe. This we may term primary or central gout. The tendency may be transmitted or modified, or, conceivably, may be allowed to die out.
In another individual, gout may " grow up " where pre- viously there was no neurotic taint or tendency. A patient is commonly said to earn his gout by high-living and over- indulgence of appetites. In this instance a morbid blood- state is induced ; excess of uric acid is generated, and hyperinosis supervenes.
But is this all ? Is this enough to generate all the phenomena we recognise clinically in gouty disease ? I believe not. We are compelled at this point to widen our view, and are driven, perforce, to invoke the operations of the nervous system. Having arrived thus far at nothing beyond a special toxtemia, we must drop humoral pathology, and seek for the effects of the blood-dyscrasia upon the nerve-centres. And we have full warrant for this course in contemplating the analogy of other toxaemic states, together with their effects upon the nervous system. The nutrition of this system is plainly affected by morbid blood-conditions, and, thus, expres- sion is given to such poisoning in the form of convulsion and other nervous symptoms.
I believe, then, it may be conceded that a secondary affection of some nerve-centre occurs as a consequence of the altered blood-state ah intra, and that thus the order and particular process of the gouty attack is evolved. This we may term secondary or acquired gout. A diathetic neurosis is thus impressed upon the individual.1
It is certainly a matter of much interest to study side by side with gouty processes the several joint-affections, or arthropathies, which have come to be regarded of late as of distinctly spinal or otherwise nervous origin. It seems impos- sible to separate gouty arthritis from this connection. And if it be conceded that this particular form, which is but one
1 The frequency and severity of gout in England is explicable on the view of the impressed neurosis. The habits leading to gout, — high-living, intemperance in strong drinks (malt-liquors and wines), along with much mental energy, have certainly prevailed more, and amongst larger classes, in England than in either Scotland or Ireland.
A PLEA FOR THE NEUROTIC THEORY OF GOUT. 11
of many others, is truly and directly dependent upon nerve- influence, the greatest part of the difficulty in establishing a neurotic theory of gout is forthwith removed. I suppose no greater obstacle has stood in the way of the acceptance more generally of a nervous theory of this malady, than the impossi- bility hitherto of connecting arthritic disposition with any form of neurosis. So many of the other, and less obvious, manifestations of gout are plainly dependent on nervous influence, that the whole phenomena now appear to fall more naturally into their places.
It is, however, only right to mention here that thoughtful physicians have long ere now conceived the special action of nerve-influence on joints, and of arthritic affection on nerve- centre.1 The relation sometimes existing between rheumatic fever and chorea is an example in point, as Dr. Liveing has shown.
Much light has been thrown of late upon spinal arthro- pathies by the researches of Charcot, Ball, Weir Mitchell, and of Dr. Ord. The latter has recently contended for a more scientific revision of our present views upon the pathology of osteo-arthritis or rheumatic gout.
Without elaborate reasoning, Dr. Noel Gueneau de Mussy, of Paris, expressed, some years ago, his opinion that the latter affection was related to gout, as a sort of cousin, but without in any way holding the view that the disorder was a compound of rheumatism and gout.2
Dr. Ord's views are not only eminently ingenious, but they accord remarkably with well-observed clinical facts, not hitherto correlated.
As Sir James Paget has remarked, the changes in the nerve- centres which determine the locality of the gouty process, are a part of the pathology of gout which is not yet clinical. They are, therefore, no more than speculative at present, but we gain much from the prosecution of an inquiry in this direction.
With respect to the particular locality affected in the
1 Liveing, op. cit. p. 247. Weir Mitchell, Charcot, &c.
2 Mr. Hutchinson believed in a "basic diathesis," for both gout and osteo- arthritis.
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arthropathy of locomotor ataxia there is some discrepancy of opinion. Charcot has declared for implication of the anterior cornua of the spinal chord. Dr. Buzzard, however, has not confirmed this opinion, and, guided by the noteworthy frequent association of gastric crises with these joint-affections in this malady, as previously observed by Dr. Ball,1 has suggested a sclerosing lesion, involving the roots of the vagus in the medulla oblongata, in close relation to some trophic centre that may be localised, there, presiding over the osseous and articular systems. And he further indicates the bond that may thus exist between implication of joints and such meta- stasis as may occur to the heart in rheumatic fever : also the occurrence of hyperpyrexia, which is sometimes present in such cases. We have yet to seek for this hypothetical nutrient centre for joints, but in the meantime we are fairly warranted in widening our view, and in directing attention to the high significance of predicating such a trophic centre.
" Discovery by true analogies is always progressive, . . . one analogy leads on to another investigation and arrange- ment of phenomena, and another analogy." 2
It remains now to be shown, more in detail, how the pheno- mena of gout conform to the recognised manifestations of the neuroses in general.
It can be shown, I believe, that the plea for the neurotic element in true gout is not difficult to establish.
First, there is to be considered the marked tendency of gout to be hereditarily transmitted. This is notorious. The dis- order may pass from either parent, and may be mingled with other taints and tendencies passed on from the progenitors. The outbreak may occur in slight or in graver degrees, and may be deferred, overtly, till even the thirteenth climacteric period. Thus, the first plain attacks of gout may not appear till the patient is sixty or over ninety years of age. In all such cases, however, I am convinced that many minor tokens of the disorder have been overlooked in previous years, all of which are sufficiently obvious to the trained clinical eye.
'Med. Times and Gazette,' vol. ii. (1868); vol. ii. (1869), p. 498. Laycock, op. cit. 190.
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As a rule, the manifestations are prone to occur at definite ages in each sex, most commonly in the fourth decade in men, and in the fifth in women. My own experience seems to show that gout is increasingly frequent in men early in the third decade.
Certain peculiarities attending gouty transmission are deserving of study. Mr. Hutchinson has called attention to one of these in a suggestive lecture published four years ago.1 He expresses his belief that what is transmitted is not the active gouty dyscrasia itself, but rather a susceptibility to the influence of certain exciting causes, together with some peculiarly disordered condition of the assimilating and excre- tory viscera, which renders them unable to deal with particular articles of food. Now, this special susceptibility to definite exciting factors is neither more nor less than a nervous peculi- arity, of which the chief character is its liability to break away in certain morbid directions, — its instability, in short. This is, I submit, the gouty neurosis. Mr. Hutchinson further believes that gout is wont to show itself with greater frequency and in more marked form in the younger than in the older members of a gouty family, the diathesis strengthening in the parent with advancing years. I think I can confirm this observation.2 Resemblance to the gouty parent has been specially recognised in those of the offspring most distinctly affected.3 In other members of the family the tokens of gout may be present, but less marked. These facts are, of course, in accordance with ordinary laws of hereditary transmission. Dr. Wickham Legg has called attention to the fact that gout, like haemophilia, pseudo-hypertrophic paralysis of Duchenne, and some other affections, is not unfrequently found to be transmitted by the female line, although especially manifested in males, the mothers themselves being unaffected.
A noteworthy feature in gouty ailments is their sudden supervention. As in epilepsy, not uncommonly, the patient often feels remarkably well, and realises his sense of Men etre, before the outbreak suddenly takes place. This euphoria, or
« 'Medical Times and Gazette,' vol. i. p 543 (1876).
2 Cases illustrating this are given by Mr. Spencer Wells, op. cit. p. 18.
3 ' Medical Notes and Reflections on Hereditary Disease*' Sir Henry Holland, Bt., M.D., F.R.S. Edit, 3 (1855), p. 29. ■
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delusive corporeal satisfaction, is itself a nervous derangement. Explosiveness is a distinct feature in several of the neuroses, and attaches to such ailments as angina pectoris, asthma, epilepsy, and various neuralgiae.
The time of the occurrence of the attack