J. Russell (John Russell) Reynolds.

A system of medicine online

. (page 157 of 238)
Online LibraryJ. Russell (John Russell) ReynoldsA system of medicine → online text (page 157 of 238)
Font size
QR-code for this ebook


occur. When there are signs of disease
already present in other directions, such
as strabismus, torticollis, weakness of the



corresponding leg, and the like, the prog-
nosis should be extremely guarded.

_ Pathology. — The exact locality of
disease, and the precise nature of the
change which constitutes it, have not
been yet demonstrated with regard to
Writers' Cramp. Its closest clinical
affinities are with stammering, spasmodic
wry-neck, and histrionic spasm, or " mus-
cular tic" of the face. Analogous mala-
dies, but moving in a yet wider range,
are sometimes encountered, such as cer-
tain forms of rotatory movement, of
chorea, and of locomotor ataxy ; and be-
yond these there are anomalous cases,
which every physician occasionally meets
with, but does not know how to designate.
One patient cannot make the attempt to
walk without performing, or i-unning in
danger of performing, sundry rotatory
movements, which terminate in a fall :
another, a hard-working clergyman, can
only speak, though he has the voice of a
Stentor, when on a level with his audience ;
and this not from any fear, or shyness, or
sham, but from definite aphonia. Some
of the spasmodic movements induced in
frogs by injury to the auditory nerve are
of similar character ;' and the experiments
of Magendie, Flourens, Longet, and
Schiff afford further illustrations of analo-
gous disturbances in the physiology of
motion.

In order to understand Writers' Cramp,
it is necessary to remember what is, phy-
siologically, involved in the education of
the muscles to perform complicated acts,
such as those of writing, speaking, or
playing on musical instruments. The
will does not pick out the muscles which
are to be brought into play to hold a pen ;
it simply directs itself to the result. The
boy who plays at marbles directs his
movements in the same manner, and
with as much accuracy and nicety, as the
professor of anatomy directs his when he
is writing a description of the muscles of
the hand. The combination or co-ordina-
tion of muscular contractions is determined
by the will, but is affected by another
agency. Each is conscious of a wish to
do a certain thing, and of a will to do it,
but a knowledge of the mode in which the
movement is brought about does not help,
and may sometimes hinacr, its produc-
tion. Experimental physiology and clin-
ical pathology combine to teach us that a
certain portion of the nervous system, the
cerebellum, has the power of effecting the
co-ordination that is required ; and they
also unite in proving— what is often lost
sight of— that this co-ordinating faculty
is guided by sensations, and can act effl-

I Brown-Sgquard, Lectures on the Physi-
olo.^y and Pathology of the Central Nervous
System, p. li)*.



T36



writers' cramp.



ciently only when they are normal in
kind and intensity. The production of a
movement such as writing is therefore a
very complicated process, requiring for its
efficient performance the integrity of a
great number of different parts : viz. , that
of the will and its immediate exponent in
the cerebral hemispheres ; that of the
nerve-fibres between it and the muscles,
together with that of the ganglia which
exist on certain nerve-trunks ; that of the
muscles themselves ; that of the cerebel-
lum, as the centre of co-ordination, also
that of all the "sensory" nerve-fibres
which place it in relation with the organs
of special sense and with the muscles
themselves ; and, lastly, integrity of the
organs of sense, so that they, at the peri-
pheral expansion of their special nerves,
can. receive impressions in a normal man-
ner. It must be remembered, also, that
not only the fact but the degree of con-
traction is under the control and guidance
of the same organs or parts of organs.
Failure in any one portion of this appa-
ratus interferes with the production of the
movement that is required ; and the kind
of failure is determined by the locality of
the lesion ; or, in other words, by the na-
ture of the process or function which is
lost or disturbed. If the contraction of a
muscle be acutely painful, the man cannot
write, the act would be impossible in
Home cases of rheumatism ; if the muscle
be wasted, it cannot be put into the same
amount of contraction as in health ; if the
skin have lost its sensitiveness, all fine
movements are awkwardly performed,
and the finest are rendered impossible ;
they may be partially guided by the eye,
but the guidance is defective for the most
complicated acts ; if the motor nerve be
damaged, the muscle is pro tanto palsied ;
if the sensory nerves be injured, sensation
is defective ; if the sense of muscular con-
dition be in abeyance, the power to control
either the kind or force of contraction is
without its guide : but locally, i. e., so far
as that limb is concerned, all other nerve,
muscular, and sentient properties may be
intact, and yet spasm or paralysis, or
both, are present. If the will be deficient,
and this from any cause, there is palsy, or
irregular movement ; if the flbces coming
between it and the nerve-trunks be in-
jured, there is paralysis in the ordinary
sense of the word ; if the cerebellum be
diseased, there is loss of co-ordination,
while power and sensation persist ; if the
Spinal cord be injured, there may be, in
relation to the nature and locality of the
injury, almost any one of the conditions
that have been enumerated.

In true Writers' Cramp, the will, the
co-ordinating power in all directions but
in one, the motor power, the muscular
nutrition and activity, as well as the sen-
sorial faculties, are uninjured ; the indi-



vidual is, or may be, " well" in all respects
but one. A particular kind of movement
is interfered with, by the occurrence of
irregular and spasmodic, instead of regu-
lar and co-ordinated, contractions. It
must be carefully remembered that the
malady is special; the muscles which can-
not be made to write can be controlled so
as to fasten the most tiresome buttons,
carve the toughest of pheasants, or pull a
heavy boat. The pianist cannot play on
the pianoforte, but he can write as well as
ever; the bricklayer cannot use his trowel,
but he can do everything else that he
wants to do ; and in order to understand
this, we must revert to what is included
in education, and what confers the dex-
terity which comes of special practice.
Many movements are "automatic;" we
adopt them without education and with-
out effort ; others are the result of labori-
ous "practice." It would seem that the
body is naturally endowed with certain
paths or lines of nerve-action, along which
all moves easily. The instinctive move-
ments of the child or of the animal are
examples of the mode in which, along
these lines, impressions from without pass
readily, and become converted into motor
impulses, which are, in their turn, con-
veyed to muscles, which contract, and so
perform these instinctive acts. I3ut the
process of education, so far as the per-
formance of writing, playing, stitching,
&c., is concerned, consisted in the fre-
quent repetition, by an act of the will, of
certain forced and complicated move-
ments. The repetition makes them easy,
until at length they are executed without
effort, and almost unconsciously. It would
seem that, by this education, new paths
are forced, so that what was once difficult
and required attention becomes day by
day more easy, and at last "secondarily
automatic." It cannot be doubted that
some changes take place in the nutrition
of the parts through which these lines of
nerve-action run; and that their education
involves structural alteration in the or-
gans. The perfection with which compli-
cated movements are performed in the
lower animals appears to be associated
with great keenness and remarkable de-
velopment of the organs of sense ; and in
man a similar relation may be observed.
No man writes well who has not keen
sight and a quick sense of touch ; no man
plays well on the violin who has not an
acute ear, and a delicate power of feeling
in his fingers. In all instances of educated
movement some "sense" is needed, and
is an important element in the process by
which the result is obtained.

In the present state of science it is not
possible to say, for every act, what part
of the nervous system is especially engaged
in this educational development ; but it
seems probable that the association of



CONVULSIONS.



737



movement is eflfected by ganglia which
are common to fibres passing through 'dis-
tinct but contiguous nerve-trunlss, and
that it is owing to some nutrition-change
in tliem — the result of persevering and
forced effort — that the perfection of \nove-
luent is produced ; associations at first
caused by the will, are at last produced
unconsciously. What happens, then, in
such maladies as Writers' Cramp, is a
perverted nutrition of these parts ; a
worn-out activity, or a degeneration which
may arise without over-exertion, and de-
stroy all that had been previously
achieved.' Neuromata have existed in
the arms of some patients. The disease,
as it has been shown, passes readily from
one side of the body to the other ; and it
must be carefully borne in mind that co-
ordination of movement is a most complex
process, requiring integrity of sensation
as well as of motor nerve and of cerebel-
lum. The real mischief may be some
want of limiting and guiding influence
ordinarily coming, through sensation,
from external impressions. The spasm
which occurs is very like that which !Mr.
Lockhart Clarke describes as taking place
in the legs of ataxic patients who cannot
regulate the /orce of their muscular con-
tractions.

Treatment. — In an early stage abso-
lute rest may do much ; in a later stage



it may accomplish something; but I know
of nothing else which can be called a
therapeutic agent. I have tried every
form of general and nervine tonic, of sed-
ative, and of local application, but no one
of them has been of the least specific
value. I have used hypodermic injec-
tions of morphia, atropine, and of arse-
nic, and have found them incompetent to
cure the disease. The hypodermic injec-
tion of morphia appears sometimes to re-
lieve the spasm for a certain period, and
I have seen the writing become steadier
within five minutes of the application,
and increase in precision for half an hour,
but the effect has then, or soon after-
wards, passed away, and a frequent repe-
tition of the process has been without any
permanent result. It has, unfortunately,
happened that several patients in whom I
have used morphine hypodermically pre-
sented an intolerance of that medicine.
I have employed galvanism and electricity
in all their forms, and have seen no good
results. But in many cases perfect rest
has removed the symptoms, and it alone
seems worthy of being regarded as a
means of cure.

Mechanical contrivances for holding tlie
pen may render occasional writing possi-
ble, but they do not affect the disease ;
and persistence in their use has been fol-
lowed by an extension of the malady to
the muscles of the forearm and arm.



CO:^YULSTONS.

By J. HuGHLiNtis Jackson, M.D., F.R.C.P.



It cannot be kept too much in mind
that Convulsion is a symptom, not a dis-
ease. But it is the most striking member
of the series of symptoms in which it oc-
curs, and in many cases the only one
about which we have definite knowledge.
In other words, although we always be-
lieve a Convulsion to be symptomatic, we
too often know very little of the condition
of the system of which it is one of the
symptoms ; and this even after post-mor-
tem examinations. Let us glance at the
circumstances with which Convulsions
may occur.

Convulsions occur in association with

' Some of these points in the patliolo,o;y of
Writers' Cramp have I'een ably treated by
Mr. Solly, in the Lectures already referred to
in the Lancet of 1865.
VOL. I.— 47



organic changes in the nervous system of
the most varied kinds ; for instance, with
cerebral hemorrhage, and with intracra-
nial tumors. They follow injuries to the
head, either immediately or remotely :
immediately (within a few hours), as when
a blow leads to meningeal hemorrhage ;
and remotely (after weeks or months),
when diseased bone, the consequence of a
blow, causes cerebral abscess. They Avill
occur in a healthy but parturient woman
after sevejie loss of blood. They occur
with diseased kidney. They come on as
indirect results of syphilis, as in cases of
gummatous tumors in the hemisphere.
In children they are often associated with
rickets. Some beUeve that Convulsions
may be the results of disturbances of
parts of the body at a distance from the
central nervous system, the result of ec-



738



CONVULSIONS.



centric irritations, such as the irritation
occurring witli dentition, or tlie irritation
of worms. Finally, there are a large
number of cases of convulsive seizures
which (for want even of that approxima-
tive knowledge we have of such causes of
fits as are mentioned above) we are obliged
to speak of as essential, eclamptic, epilep-
tic, or epileptiform. AVhen we cousider
further that the symptom occurs at all
a^es and in many diseases, that there are
many varieties in part of the body affected
liy .spasm — it is unilateral or general —
niany degrees in severity — there may be
local spasm without lost of consciousness,
or general convulsion with profound coma
■ — and in times of recurrence — there may
be one fit a week, or fifty in a day — we
are forced to the conclusion that we can
only speak of Convulsion as a symptom.

The only things we can safely alHrm of
the symptom are certain truisms. It is
the phenomenon of an occasional discharge
of nerve tissue (no doubt of gray matter).
It points not to destroying lesions, but to
unstable nerve tissue — to "functional''
changes. But the most careful study of
the symptom (the paroxysm) tells us
nothing of the pathological process by
which such changes of instability are
brought about ; does not, for instance,
enable us to say whether these changes
are the result of "irritation," of tumors,
of urtemia, or whether they are not mi-
nute changes (epileptic) to the pathology
of which we have no clue. But clinical
study of the circumstances under which the
symptom occurs^ tells us very much. Al-
though it rarely leads us to a knowledge
of the pathological condition of the ner-
vous centres, it gives valuable information
as to the treatment of the patient, and
for the purposes of prognosis. There is a
practical convenience in studying this
symptom separately. Indeed, we are
forced to this narrow study, as it is very
often our only "way in" to a case; and
its distinct consideration will not be hurt-



ful if we use it as a point about which to
group not only our positive knowledge
for present action, but also, if such a
phrase may be permitted, our positive
ignorance for future research.

I will try to show what meaning we can
give to this symptom under various cir-
cumstances ; how we should investigate
the condition of our patient who presents
it, and what we should try to do for
him. It maj' be well to say that I have
only to consider ei)ilcpsy so far as diag-
nosis is concerned. It is justifiable to
sacrifice some exactness to convenience
by dividing the subject into (1) Convulsions
in infants and young children, and (2)
Convulsions in persons above seven years
of age.



Convulsions in Children.

Convulsions may occur at any age, and
this remark applies not only to general
Convulsions but also to most kinds of con-
vulsive movements. Still, Convulsion is
par excellence the nervous symptom of in-
fants and young children.' The tendency
to Con^-ulsions gradually decreases with
increasing years. The following quotation
from West shows this: — " In proportion as
the brain increases in size, and its struc-
ture acquires perfection, and its higher
functions become displayed. Convulsions
grow less and less frequent, until, from
the tenth to the fifteenth year, they cause
less than three percent., and above fifteen
less than one per cent, of the deaths from
diseases of the nervous system." The
first line in the accompanying table (Dr.
West adds in a footnote) shows the pro-
portion per cent, of deaths from diseases
of the nervous system at different ages, to
the deaths from all causes at the same
ages in the metropolis ; and the second
line the proportion borne by deaths from
Convulsions, to deaths from diseases of
the nervous system in general : —



Under 1 year.


From 1 to 3
yi'ars.


From 3 to 5
years.


Total under 5

yours.


From .5 to 10
years.


From 10 to 15
years.


Total atove
Ij years.


30-5
73-3


18-5
24-9


17-6

17-8


24-3
54-3


15-1
9-9


10-6
2-4


10-4
■8



West says: "In a large proportion of
cases of Convulsion in the infant. Convul-
sions answer to delirium in the adult;"
and Trousseau saj's that there are chil-
dren who have Convulsions as easily as
some have delirium or even dreams.

We shall then, as a preliminary, speak
briefly of the physiologicnl peculiarities of
the child's nervous system. We may
affirm of it two things. (1) It is unde-
veloped. Besides the obvious fact that



the infant has to acquire such movements
as those of walking and talking, there is

' Meigs and Pepper write: "During the
five years from 1S44 to 1848 inclusive, 1729
children under fifteen years of age died in
this city (Philadelphia) of convulsions,
whilst, during the same time, 1611 died of
infantile cholera, 1060 of marasmus, 1041 of
dropsy of the brain, and 772 of pneumonia,
showing that eclampsia was the cause of a



CONVULSIONS IN CHILiJREN.



739



evidence from the special nervous dis-
eases of cliildren, tliat tlie parts of the
young nervous system are not knit to-
gether as closely as in the adult — incom-
plete neurification analogous to incomplete
ossification. The child is the subject of
certain limited palsies and limited spasms
which do not occur in the adult. Indeed,
there is a form of talipes varus, Dr. Little
tells us, which is always congenital. " In-
fantile paralysis" never occurs in adults.
After hemiplegia in childhood, a well-
known contraction (spastic rigidity) often
sets in which does not follow hemiplegia
in adults (p. 742). And lastly, coming
near to our immediate topic, spasm of
the glottis is a convulsion of a certain
limited region which is rarely met with
after the age of three or four years. Then
there are minor symptoms which are
almost peculiar to children, e. g. carpo-
piBdal contractions. As regards the last
two symptoms, there are the significant
exceptions that they occur in hysterical
women.

(2) The nervous system is developing.
It is in a state of active change. Its nu-
trition will be in considerable excess of its
expenditure, whilst in adults the two will
be more evenly balanced. For this reason
the child's nervous tissue will naturally be
more unstable than is that of the adult.
It will more easily discharge from a slight
cause, or, to use a common expression, it
is more excitable. It is believed too that
the equihbriumof the child's nervous sys-
tem is more often upset by nerve-trans-
mitted irritations than that of the adult is.
Hence very severe convulsions are ascribed
to irritation carried by the fifth nerve from
the gums during dentition, or to the irri-
tation of worms. The child's nervous
system is even believed by some to be
naturally so unstable that eccentric irrita-
tions so very local as those just mentioned
will produce a general convulsion in a
healthy child, i. e. will determine a sudden
and excessive discharge of nervous tissue
which is only physiologically unstable.
Others will qualify this opinion by the
supposition that the nervous system, or
some part of it, is pathologically unstable
prior to the action on it of the transmitted
irritation. Thus the late Dr. Hillier
says (I italicize some words) : " It is very
doubtful whether in a healthy child these
causes can produce convulsions at all ; in
& predisposed subject they no doubt often
excite them."

larger number of deaths than any other of
the diseases just mentioned. It miTst be
recollected, however, that a very large num-
ber of these cases ought, beyond doubt, to
have heeu returned under other titles, as
many of them must have been a mere result
of organic disease of the cerebro-spinal axis,
and of other acute local or general diseases."



The above are phj-siolooical differences.
Disease finds the child's "nervous system
undeveloped, and it finds it developing.
But, so to speak, the attacking disease
itself has peculiarities, at all events nega-
tive peculiarities. A child is much less
likely to suffer from gross lesions in the
brain, such as hemorrhage, syphiloma,
and other new growths ; he is less hkely
to suffer from ursemia excepting from
acute changes of the kidney, especially of
scarlatinal origin ; or, putting it more
simply, we usually discover no pathologi-
cal changes in the nervous system of a
child who has died of Convulsions. Wilks,
speaking of diseases of children, says:
'' We meet with a large nundjer of cases
where the post-mortem appearances are
absolutely nothing ; and where, indeed, we
could scarcely expect to find it otherwise.
We allude especially to cases of Convul-
sions in children where no morbid changes
are discovered ; and when we consider
that a child may have several convulsive
attacks and speedily recover, which only
a degree more severe shall prove fatal, it
is clear that no very great change could
occur in an organ which would have per-
fectly recovered itself had the fit been only
one degree less in severity." Whilst it is
true that, as a rule, no pathological
changes are discoverable, we must not in-
fer that pathological changes do not exist ;
the probability is that there are minute
changes. Nor must we infer from com-
plete recovery from a convulsion, or a
series of convulsions, that there are no
pathological changes. Adults recover
even from hemiplegia, which subsequent
post-mortem examination shows to have
been due to obvious although very limited
destroying lesions — small clots, for in-
stance. Therefore recovery from Convul-
sions is no certain sign that there was no
real impairment of structure. It is a sign
only that no wide breaking up of structure
has happened. There must certainly be
local changes in those cases of Convulsions
in which hemiplegia follows, however
temporary it may be, since local S3'raptoms
of necessity imply local lesions. Still this
is only a necessary inference, as we rarely
discover any changes even in these cases.
Jv^ay, even in those rare cases where -sve
find gross disease, a tumor for instance,
we do not discover the minute and second-
ary changes on which the discharge pro-
ducing the Convulsion depends. We must
not say that the tumor was the direct
" cause" of the Convulsion, but that it led
to secondary changes in nervous tissue on
which the Convulsion depended, and these
secondary changes are inferred, not de-
monstrated.

It is true that there are found at exami-
nations after death from Convulsion abnor-
mal quantities of serum and blood in the
head, but these differences are quite as



T40



CONVULSIONS.



likely to be results of the fits as tlieir
causes — the results of the sudden interfer-
ence with respiration. Eftusion of serum
and congestion of the brain have not been
shown, either in adults or in children, to
have much to do in producing sudden and
Severe cerebral s3-mptoms of any kind.
Of course those cases in which, possibly
from obstruction to the vein of Galen, as
by tumors of the vermiform process of the
cerebellum, there is immense eifusion into
the cerebral ventricles, are not in ques-
tion.

To resume, we know nothing of the
causes of Convulsions in children in the
Sense of knowing what the patliological
changes are. This is so, however much
we may narrow our consideration to
groups of cases, either to those which
occur singly and at intervals over a period
of mouths or years, and which are often
called epileptic, or to those in which the
fits occur in considerable number for a
limited period, and are often called
eclamptic.

After these general remarks on the
symptom Convulsion as it occurs in chil-
dren, we have to consider what meaning
^ye can give it in particular cases. Our
task is twofold. We have first to note
carefullj- the kind of paroxysm. For in-



Online LibraryJ. Russell (John Russell) ReynoldsA system of medicine → online text (page 157 of 238)