A system of medicine / by many writers.

Date:
1911
Catalogue details

Licence: Public Domain Mark

Credit: A system of medicine / by many writers. Source: Wellcome Collection.

Provider: This material has been provided by UCL Library Services. The original may be consulted at UCL (University College London)

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    circumstances in each individual case. The acute bed-sore has just been imentioned as an example of a true trophoneurosis, on the ground that the same result cannot be brought about in the same space of time by other means. On this standard the chronic bed-sore can hardly be admitted to the list at all; it does not differ in mode of development or filial appearance, whether it occurs in a case of paraplegia or one of enteric fever; at the most the difference is one of degree only, and each case must be judged on its merits. Perforating ulcer is the most characteristic member of the class, but even it is not peculiar to diseases of the nervous system. An acute form has been described, but the recognised type is chronic. The most com- mon seat is under the ball of the big toe. It is preceded by a corn; not an unusual phenomenon in that region, but in these cases very often on kn exceptional scale which may itself be a result of changes in the nerve- pupply. The early stages may be altogether unobserved, as they consist of inflammatory or necrotic processes in the bursa beneath the corn, and by the time the pus makes its way through or by the side, the destruction of tissue has probably reached down to the bone and perhaps opened into a joint. In this way the perforating ulcer may have reached its full development at what appears to be its start. Its essential quality is painlessness, and it may be met with as a result of any lesion which interrupts the afferent path without interfering with locomotion. It is thus met with most commonly in tabes, but is found also in spina bifida and injuries to the sacral plexus. If the patient be put to bed at any stage of the disease the ulcer heals in precisely the same way as any other ulcer of corresponding depth. The painless whitlows of sj^ringomyelia and the mutilations of leprosy are the pei'forating ulcers of the upper extremities, and in them too is found that fatal lack of the warning sense of pain without the paralysis which would make tliat warning unnecessary. Dr. Head has shewn that the identical lesions which occur in certain cases of injury to the brachial nerves synchronise in their appearance and disappearance with tlie loss and regain of protopathic sensation (20). This is the limit of our certain knowledge of their causation. Mere absence of sensory impulses cannot cause death of tissue, and how far this absence may make a part more sensitive to the effects of injury, or how far it may interfere with its recovery, is by no means clear. That it has some influence of this sort is strongly suggested by an incident which recently came under my notice. In a case of tal)es a single application of linimentum iodi produced sloughing of the skin over the ankle, to which it had been applied for the relief of referred pain. The skin previously had a healthy appearance, and the general nutrition of the patient was good. This seems a clear example of lowering of nutrition from nervous causes without any apparent vasomotor change, but even this falls far short of a ])rimary necrosis from nervous causes. Conclusions. — (1) That the influence of the nervous system over nutrition is complementary to local and presumably non-nervous mechan-
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