Part 15 (1/2)

It is notoriously the fact that hypochondriasis especially affects the rich and idle cla.s.ses; but it would be a great mistake to suppose that it never attacks the poor or the hard-worked: only, in the latter instances, it apparently needs, for it development, the existence of strong family tendencies to neurotic disease, and especially to insanity. Among the numerous debilitated persons who attend the out-patient rooms of our hospitals we every now and then encounter as typical a case of hypochondriasis as could be found even among the rich and gloomy old bachelors who haunt some of our London clubs. I have one such patient under my care now, who has been a repeated visitor at the Westminster Hospital during many years: he has had pseudo-neuralgic pains nearly everywhere at different times; but his most complaint has been of pain in the groin and s.c.r.o.t.u.m of the right side. The existence of what seemed, at first, like the tender points of lumbo-abdominal neuralgia, at one time led me to believe it was a case of that affection; but I was soon undeceived by finding that the tenderness did not remain constant to the same points, but s.h.i.+fted about. This man has professed, by turns, to derive benefit from nearly all the drugs in the Pharmacopoeia; but the only remedies that have done him good, for more than a day or two at a time, have been valerian and a.s.safoetida, with the prolonged use of cod-liver oil. He will never be really cured; and I suspect that the secret of his maladies is an inveterate habit of masturbation acting on a nervous system hereditarily predisposed to hypochondriasis.

Sometimes it happens that the starting-point of hypochondriac pains, simulating neuralgia, is a blow, or other bodily injury acting on a predisposed nervous system. Another of my patients at the Westminster Hospital was a policeman, who had received a severe kick in the groin; he suffered pains which at first seemed to wear all the characters of true neuralgia in the pudic nerve, but afterward s.h.i.+fted to other places and exhibited all the intractability of hypochondriasis; the patient also developed the regular appearance and the characteristic hallucinations of the latter disease. On the last occasion when I saw him, he struck me as likely to become really insane, in the melancholic form; and the probability is that the casualty which he suffered was only accidentally the starting-point of a malady which was inherent in him since birth, and would have been developed, in any case, at some period of his life.

CHAPTER IV.

THE PAINS OF LOCOMOTOR ATAXY.

Considering the vast amount that has been written about this disease during the last few years, it might be thought superfluous for me to give any description of its general features. But it unfortunately happens that there is still great divergence of opinion among authorities as to the true limitation of the group of cases that can properly be ranked under this t.i.tle, and, indeed, as to the propriety of employing the t.i.tle at all. The phrase ataxie locomotrice progressive, as every one knows, was applied by d.u.c.h.enne de Boulogne to a cla.s.s of cases which really only form a subdivision of the group known under the older t.i.tle of _tabes dorsalis_ and the most advanced German pathologists maintain that the old word was better, and that d.u.c.h.enne was altogether wrong in making the one symptom, ataxy of locomotion, the bases of a new phraseology;[49] more especially as his theory as to the seat of the morbid changes was undoubtedly erroneous.

In this country, however, there is as yet no disposition to give up the phrase locomotor ataxy, and it only remains to define with sufficient care the cla.s.s of cases to which the word is here meant to apply. The disease is understood to depend upon a degeneration of the spinal cord, of which the following description is given by Lockhart Clarke:[50] ”In true locomotor ataxy, the spinal cord is invariably altered in structure. Its membranes, however, are sometimes apparently unaffected, or affected only in a slight degree; but generally they are much congested, and I have seen them thickened posteriorly by exudations, and adherent, not only to each other, but to the posterior surface of the cord. The posterior columns, including the posterior nerve-roots, are the parts of the cord which are chiefly altered in structure. This alteration is peculiar, and consists of atrophy and degeneration of the nerve fibres to a greater or less extent, with hypertrophy of the connective tissue, which give to the columns a grayish and more transparent aspect; in this tissue are embedded a mult.i.tude of corpora amylacea. Many of the blood vessels that travel the columns are loaded or surrounded to a variable depth by oil-globules of various sizes. For the production of ataxy, it seems to be necessary that the changes extend along a certain length, from one to two inches of the cord. The posterior nerve-roots, both within and without the cord, are frequently affected by the same kind of degeneration, which sometimes extends to the surface even of the lateral columns, and occasionally along the edges of the anterior. Not unfrequently the extremity of the posterior cornua, and even deeper parts of the gray substance, are more or less damaged by areas of disintegration. The morbid process appears to travel from centre to periphery, that is, from the spinal cord to the posterior roots. In the cerebral nerves, on the contrary, the morbid change seems to travel in the opposite direction, that is, from the periphery toward the centres. From the optic nerves it has been found to extend as far as the corpora geniculata, but seldom as far as the corpora quadrigemina.

With the exception of the fifth, seventh, and eighth pair, all the cerebral nerves have occasionally been found more or less altered in structure.”

The symptoms which occur in cases in which the above are the morbid appearances found after death are (roughly speaking) as follows:[51] ”A peculiar gait, arising from want of co-ordinating power in the lower extremities, a gait precipitate and staggering, the legs starting hither and thither in a very disorderly manner, and the heels coming down with a stamp at each step.”

No true paralysis in the lower extremities or elsewhere. Characteristic neuralgic pains, erratic paroxysmal in the feet and legs chiefly--pains of a boring, throbbing, shooting character, like those caused by a sharp electric shock.

More or less numbness, in the feet and legs chiefly, in all forms of sensibility, excepting that by which differences of temperature are recognized.

Frequent impairment of sight or hearing, one or both.

Frequent transitory or permanent strabismus or ptosis, one or both.

No very obvious paralysis of the bladder or lower bowel.

No necessary impairment of s.e.xual power.

No tingling or kindred phenomenon.

No marked tremulous, convulsive, or spasmodic phenomena.

No marked impairment of muscular nutrition and irritability.

No impairment of the mental faculties.

Occasional injection of the conjunctivae, with contraction of the pupils.

The probable limitation of the distinctive phenomenon of locomotor ataxy (the want of co-ordinating motor power) to the lower extremities.

The above description includes all the necessary facts for the recognition of the disease, except one, namely, that the use of the eyesight is always needed in order to prevent the patient from falling during progression; and is usually necessary even to enable him to stand upright without falling.

The pains of locomotor ataxy are early phenomena in most cases, and they are usually present, more or less, throughout the course of the disease.

They are often preceded by strabismus, with or without ptosis; the strabismus, is usually accompanied by amblyopia. It may happen, however, that neuralgic pains are, for a considerable time, the only noticeable phenomena; or they may be attended with a certain amount of anaesthesia.

The most frequent type of the pains is lancinating or stabbing; they are like violent neuralgias occurring successively in various nerves; s.h.i.+fting about from one to another. Sometimes it will happen that the pain remains fixed to one particular nerve for hours together; but it never continues long without showing the characteristic tendency to move about. Most commonly our diagnosis is soon a.s.sisted by the occurrence of a greater or less degree of ataxy. But, even before the setting in of definite atactic symptoms, the s.h.i.+fting character of the pains, and the development of a very noticeable amount of anaesthesia, together with the absence of anything like positive motor paralysis, will have given us the necessary clew.