S^ftr^nr^ ICtbrarH [oa..'). . Dr. Alliott^ of Sevenoaksj kindly sent me a man, aged 65, wlio had dislocated Ms left shoulder-joint five months previously. On examination of the arm, almost complete paralysis of all the muscles was found, with but little alteration of sensation. The elbow, wrist, and fingers were all somewhat flexed, and incapable of extension ; but still there was no active contraction of muscles. Even the strongest faradic current produced no effect whatever in them. In certain cases of long-standing facial paralysis, the muscles on the affected side are evidently shortened, for the angle of the mouth is drawn to that side, and the orbicularis orbis partially closes the corresponding eye. And yet the effect produced by speaking or by laughing is most curious, the affected side remaining motionless. In these cases, the electric reactions of the muscles supplied by the diseased facial nerve show almost complete degeneration, which has been accompanied with permanent shortening. If so many cases of distortion are due to other causes than active contraction of the muscles supplied by the affected nerves, the question suggests itself : Does chronic muscular spasm occur at all from direct irritation of motor nerves ? Let us take some of the most frequent and familiar examples of peripheral nerve disease. Musculo- spiral paralysis is often seen in quite the early stages ; but we do not see, nor do we hear the patient describe, muscular spasm as one of its symptoms. The same may be said of most cases of facial paralysis due to peripheral causes. In chronic poisoning by lead and alcohol, various nerve-symptoms are met with, including paralysis, and even muscular rigidity occasionally ; but, as has already been pointed out, this is due to the contraction of antagonists, and not of the diseased muscles themselves. In sciatica, from various causes, we meet with twitchings and sudden muscular contractions ; but they are very transitory. Again, if we look at those cases where motor or mixed nerves are pressed upon and irritated by new growths, 76 SPASM m CHKONIC NERVE DISEASE. pain is a very prominent symptom, and spasm seems scarcely to occur, though, twitchings and transitory con- tractions are observed. A case which I have already related affords a good example o£ a tumour pressing upon a purely motor root. The new growth was a myxoma, which grew in connection with one of the left anterior spinal roots, and gave rise to symptoms in the left arm. These were weakness and attacks from time to time of pain and cramp ; but no prolonged spasm was ever pro- duced. Dr. Bristowe has written a paper on Painful Paraplegia in the ' St. Thomases Hospital Eeports,^ vol. xii, in which he relates several cases of paralysis accompanied by pain, which owed their origin to malignant tumours involving peripheral nerve-roots. Some of these cases I saw myself and also examined post mortem. Evidence of spasm occurs in only one case, where the limbs are said to have become stiff occasionally. Clonic spasm is not unfrequently seen in late stages of facial paralysis, when there is shortening of the muscle from atrophy. Electric examination shows that the latter condition is present, and also that a certain amount of mus- cular tissue, capable of active contraction, remains. The clonic spasms result from irritation of the nerve and muscle which has survived the process of destruction. In cases of meningitis at the base of the brain, spasm of the muscles supplied by the motor nerves involved is not observed. In spinal meningitis, on the contrary, it is a very marked symptom. Here, however, it is not improba- bly of a reflex origin, and not due to direct irritation of motor nerves. Tetany (Fig. 15) is a disease in which the presence of some, although generally trivial, alteration of sensation, increased electric irritability of nerve and muscle, and prolonged muscular spasm, suggest a peripheral cause. The pathology of this affection cannot be said to be known, and opportunities of examining cases post mortem rarely fall to the lot of pathologists. Dr. Hadden kindly SPASM IN CHRONIC NERVE DISEASE. 77 gave me the opportunity of examining microscopic sections of tlie nerves and muscles of the affected parts, which were taken from a child who died from diarrhoea, while suffering from tetany. At first I thought there were changes to be made out ; but, on procuring sections from the same parts, in a healthy child of the same age, 16 Fig. 15. — The Hand in a case of Tetany. months, who had died of an acute disease, and, comparing them with those from the subject of tetany, I came to the conclusion that there was very little difference between them. Looking at my own experience, I should say that, while occasional spasm occurs not unusually in peripheral nerve disease, from direct irritation of the motor filaments and may even be permanent in disease of the facial nerve, it is quite the exception to find muscular contractions among the marked phenomena of such cases. Weir Mitchell, who has had a very large experience of injuries and diseases of peripheral nerves, writes thus on the subject (' Injuries of Nerves and their Consequences,' 78 SPASM IN CHRONIC NERVE DISEASE. 1872) : — "Increase of bulk, proliferation of connective tissue, and wasting of nerve-tubes, are consequences of clironic neuritis.^' "The nerve-tubes in large part perish or waste, and the syniptoms affect at first rather the sen- sory sphere than that of motility. We have pain and anesthesia, or hypersesthesia, but not, as a rule, local convulsions." " In certain cases, the nerve-wound, in place of causing primary loss of motility, occasions either sudden muscular contraction, followed by instant loss of power, or, in very rare instances, long-continued spasm. Tonic contractions of muscles are occasionally met with at a later stage of these injuries, but are, perhaps, among the rarest of the secondary symptoms." Looking, then, at the experience of Weir Mitchell and others, we may safely conclude that muscular spasm is rarely caused directly by chronic disease of peripheral motor nerves. 2. Spasm produced in a Reflex Manner hy Disease of Afferent Nerves. — There is scarcely a more difficult subject in the whole range of nerve-pathology than that of reflex spasm. Cases of general convulsions, as well as of local spasm, are so frequently explained in this way, and are in so many instances quite insuflSciently supported by scientific evidence, that one cannot help coming to the conclusion that many cases are accepted as of reflex origin which, at any rate, carry very little conviction with them. Some reasons can be adduced for the difficulties which beset the diagnosis. Many of these cases occur where some sensory nerve is the seat of severe pain ; or where a part is diseased which is painful to move. A good example of the former class is spasm of the muscles of the face, accompanying facial neuralgia ; and, of the latter, rigidity in joint disease. But the most ordinary method of expressing pain is by some overaction of the facial muscles ; while the ordinary way of preventing pain in joint-disease is by keeping the joint still, and opposing attempts at movement by contrac- tion of muscles which produce an opposite effect. This is so natural a contrivance, not only in man but in lower SPASM IN CHRONIC NERVE DISEASE. 79 animals, that it must be looked upon as almost an involun- tary act. Reflex muscular acts are in very different degrees capable of being controlled or modified by the will ; and even if it be allowed that the latter plays a part in the limitation of the movements of a diseased joint, this does not prove that the act is altogether involuntary and reflex. In many cases, it is very difl&cult to form a definite con- clusion with regard to this question. No one who observes the great variety in the degree of reflex muscular contraction produced by similar stimuli applied to different individuals, can be surprised at finding evidence that persistent spasm may sometimes occur as the product of a reflex act ; or that a stimulus, which produces no motor result in one person, gives rise to definite mus- cular contractions in another not equally healthy. Thus, in hemiplegia accompanied by descending sclerosis in the lateral columns, deep reflexes are much more brisk than they were before the hemiplegia occurred ; and contrac- tures, Brissaud says, may be suddenly increased by com- paratively slight injuries. If this increased reflex excita- bility be due to the hyperphysiological activity of the spinal centres, which have been loosed from cerebral con- trol, similar disorders of nerve-centres rather than of nerve-fibres are probably the most fruitful causes of reflex spasm. Hence, it is scarcely too much to say that the injury, or disease, which supplies the stimulus to the sen- sory nerve in such cases, though apparently the principal agent, is really so in many instances only from a particular point of view. That is to say, a mine exists in the patient which has been accidentally exploded by a stimulus applied to a nerve in connection with it ; but, had the same nerve been connected with a healthy and stable centre, no spasm would have ensued. In speaking, therefore, of the present division of the subject, namely, spasm produced in a reflex manner by disease of afferent nerves, we can scarcely deal with it apart from the next division, namely, spasm produced by disease of ganglionic cells. For it is questionable how far 80 SPASM IN CHEONIC NERVE DISEASE. stimuli applied to afferent nerves in clironic disease would produce muscular spasm if tlie centres were healthy. I am not aware tliat there is evidence to show that gross or demonstrable disease of ganglionic cells produces spasm. But impalpable disorders do ; such, for instance, as those resulting from their separation from the cerebral centres. Non-demonstrable disorders, however, are what we pre- sume to be the basis of so-called functional spasms, and to these we shall revert presently. Eeflex spasm no doubt occurs, but how frequently it does so, or how far the afferent or efferent nerves, or the nerve-centres, take the leading part in its production, are points which can scarcely be estimated. As good an instance as I know of reflex spasm is recorded by Mr. Glutton in the ' St. Thomas's Hospital Reports,' vol. x, p. 64. A boy, aged 14, had been bitten in the face by a dog eighteen months previously. The spot had been painless until a month before his appearance at the hospital; but, since that time, he had suffered from constant shooting pains in the neck, which always started from the scar. At the same time that the pain was felt, the angle of the mouth was drawn outwards, and the skin of the neck was wrinkled by the action of the platysma ; the whole side of the face and neck blushed, and then became bathed in perspiration. This succession of symptoms recurred every time the scar was pinched. Croton-chloral-hydrate in five-grain doses twice a day soon cured the affection. Weir Mitchell, in his work on ' Injuries of Nerves,' gives instances of reflex muscular spasm ; and this condi- tion is often referred to intestinal, uterine, or other irrita- tion, but not always with suflBcient reason. Charcot has written a good deal in support of the view that various affections of joints may give rise to rigidity of muscles in a reflex way; and it certainly is very difficult to explain them otherwise. The following case appears to me to be one of the kind referred to. Case of Persistent Muscular Spasm due to Joint Dis- gase, — F. W — , set. 16, was an out-patient at St. Thomas's SPASM IN CHRONIC NERVE DISEASE. 81 Hospital^ under the care of Mr. Glutton, in February, 1884. I saw the case with him, and the following is the clinical record which he took while she was under his treatment, and which he has kindly put at my disposal. The patient was sent to him by Mr. Merces, of the Bath Mineral Water Hospital, with the following history. During May, 1883, she had had rheumatic fever, and the joints chiefly affected were the wrists and ankles. For three months the wrists were placed in splints, and in the autumn of the same year she was sent to Bath with perfectly stiff fingers and wrists. Passive movement was employed, which made the fingers pliable, but which left the wrists as stiff as ever. Both hands were in the same condition. On attempting to move the wrist-joint, the flexors and extensors alike resisted, and could not be overcome. Taking them by surprise produced no better results. When the patient was placed under ether, the muscles yielded to attempts at flexion and extension, but the rigidity did not entirely disappear. There were but few adhesions in the joint, and these readily gave way under the anaesthetic, but left the state of affairs prac- tically the same as before. That is to say, the wrist could be flexed or extended, but, on removing the force, the hand again assumed the same position. When the wrist was extended, the fingers always became flexed, and when it was flexed, they became extended. The patient could voluntarily extend or flex the phalanges, and could separate the fingers. The thenar muscles also acted normally. The wrist was rigid, and could not be moved in any direction, and there was slight hyper- extension at the metacarpo-phalangeal joints, which was easily overcome voluntarily when the patient flexed the fingers. Dr. Kilner tested the electric condition of the nerves and muscles, and found it normal. Let us here briefly refer to a class of spasmodic affec- tions which appear to have the same explanation as tendon- reflexes. Whether explicable as a reflex or as a purely local phenomenon, contraction of muscles occurs when they 6 82 SPASM m CHEONIC NEEVE DISEASE. are put on the stretch by their antagonists ; and this has the effect of controlling and steadying* movements which might otherwise be jerky and uncertain. When the influence of the lateral columns of the cord is removed^ the spinal centres^ in which reflex acts are produced in relation with parts below the level of the lesion^ are brought into a state of excessive activity^ and stretching of a tendon produces an abnormally sudden and extensive contraction. This is very probably the cause of the tremors in the direction of movement seen in cases of disseminated, sclerosis. But it is probable that some cases may have a peripheral origin. A medical friend of mine informed me that he once took a vehicle, in order to drive to a house where he was going to stay for a while. The driver put ■ him down two and a half miles from his destination, and drove off. The medical man had rather a heavy bag, and, being unable to get another conveyance, he carried it himself. For four days after this walk he suffered from, pretty constant contractions of the triceps muscle of his right arm whenever he flexed it. In this instance, the muscle had been what we call strained, the tendon had been unduly pulled upon, and, when the arm was flexed, the slight increase of tension made the triceps contract. Such a case represents a very small departure from the normal, but suggests an explanation of more troublesome affections ; such a one, for instance, as the following. Case of Persistent Rhythmical Contraction of the Pal- maris Longus, due to Injury. — On July 7th, 1878, I saw a girl, aged 19, who had had her wrist bent backwards and sprained five years previously. The parts injured had swelled, and she had been obliged to carry her arm in a sling for some weeks. Ever since that time she had suffered without intermission from twitchings of the arm and palm of the hand. On examination, I found that the g-eneral power of the arm was unimpaired, but that there were spasmodic contractions of the palmaris longus muscle, occurring with perfect regularity ninety times in the minute. The contractions were energetic, and showed the SPASM IN CHRONIC NERVE DISEASE. 83 muscle and its attaclinients very beautifully. In this case probably tlie palmaris longus had been stretched, and the peripheral nerves ending in it had been rendered more irritable, the result being that the slight tension of it which occurs ordinarily in the act of extending the wrist, caused the muscle to contract. This occurring frequently, gave rise to a neuro-muscular habit. The following is a somewhat similar instance. Mr. Glutton once showed me a girl, aged 10, who had fallen down a week previously and slightly sprained her right wrist, but had done herself no other damage. I found her suffering from an affection which had come on imme- diately after the fall. Her right arm was in a position midway between pronation and supination, and was the seat of perfectly regular tremors of very small excursion, such as one sees in paralysis agitans, occurring in a direc- tion transverse to the longitudinal axis of the limb. Other pathological conditions, as well as injuries, may produce these rhythmical spasms. In January, 1886, a girl, aged 14, was in St. Thomas's Hospital, under the care of Dr. Bristowe, for rhythmical contraction of the occipito- frontalis muscle on both sides, which occurred from fifty to sixty times in the minute, and had been going on for some months. The history she gave was that she had had a very bad attack of " erysipelas of the face," commencing on the forehead and spreading downwards. The onset was sudden, and the description she gave of the affection corresponded with that of erysipelas. Eoughness and pig- mentation of the skin of the forehead could still be seen. As the disease got well, the contraction of the occipito- frontalis muscle supervened, and continued for months without intermission, except during sleep. The original cause of this condition was probably an irritable state of the muscle and tendon owing to inflammation, and an in- voluntary neuro-muscular habit was soon developed. Although the girl showed no evident hysterical peculiari- ties I found that she had marked localised tenderness over those regions which Charcot has found to be unduly 84 SPASM IN CHEONIC NERVE DISEASE. sensitive in hysterical subjects. Moreover^ information wliicli I subsequently obtained proved tbat at least one other member of ber family was bysterical. For^ wbile tbe patient was still in tbe hospital, her sister, aged 11, was admitted under Dr. Bristowe's care, suffering from a similar affection. The latter had been under me as an out-patient for fits, which were evidently hysterical ; and, at the early age of eight years, she had had an attack of rhythmical spasm of the occipito-frontalis muscle which lasted three months, and then got well. When I saw her in the hos- pital during the second attack, I found that the muscle was contracting pretty regularly 120 times per minute, and this condition was accompanied with sighing, yawn- ing, slight movements of the tongue, partial loss of sensa- tion on the left side, pain in the left hip and knee, and drawing up of the left leg so as to produce distinct shortening. Other cases of spasm from peripheral injury are more complicated, but appear to be reflex in their origin, whether the pathological stimulus acts upon the nerves which exist in muscles and tendons or upon other afferent paths. The following is an example. Case of Spasmodic Movements of the Jaiv, the Floor of the Mouth, 8fc., due to Injury. — On November 20th, 1877, a boy, aged 10, came to St. Thomas's Hospital, on account of a peculiar affection which he had had for five days. There was nothing noteworthy in his family or personal history, except that he had suffered from incontinence of urine. Five days before coming to St. Thomas's he had been in a playground where his schoolfellows were having a game of football. He happened to be in their way, and one of them took him by the back of the neck, and threw him to one side. His neck pained him at the time, but by the following day the pain was gone. In its place, however, was a peculiar affection, consisting of constant movements of the lower jaw and of the floor of the mouth, and they had increased since then. As he stood in front of me, I saw the lower jaw and the floor of the mouth SPASM IN CHEONIC NERVE DISEASE. 85 descend in regular andfrequently recurring jerks, and wlien the child's mouth, was open it was seen that the tongue was likewise jerked spasmodically downwards and back- wards. In addition to this, the larynx descended slightly, and the depressor muscles in the neck could be seen con- tracting. Each downward movement was accompanied by a sound like the croaking of a frog. Neither the faradic nor the galvanic current applied from the nape of the neck to the parts below the jaw had the slightest effect on this curious condition. I gave the child some bromide of potassium, and sent him away. Nine months after that I saw him, and he was nearly, but not quite well. As I have already said, it is a matter for speculation how far such causes would give rise to spasm, if the nerve-centres were in a normal condition. What is really developed in these cases is an involuntary neuro-muscular habit. We are all familiar with the ankle-clonus which is set up sometimes in healthy people when sitting with the toes on the ground and the heels a little raised. If we start the clonus voluntarily, or if it has occurred several times in succession involuntarily, it may be difficult to stop it by an effort of the will, unless the position of the legs be altered. This is probably a physiological representative of certain cases of muscular spasm which assume pathological dimensions. I have now come to the end of the remarks I have to make upon the first two divisions of spasmodic affections in connection with chronic nerve disease, those, namely, which result from pathological changes in the cerebral motor mechanisms, on the one hand, and the spinal motor mechanisms on the other. The third division, and that the most difficult of all, remains still to be dealt with, and is co-extensive with what are called functional spasms. As I have already pointed out, the first two divisions should, and we may hope some day will, cover the whole field of spasmodic affections ; and, by placing functional diseases under a separate heading, we publicly confess our 86 SPASM IN CHRONIC NERVE DISEASE. ignorance and proclaim tliat ttere is a very long list of spasmodic affections wliicli have been carefully observed witliout success^ so far as tbeir pathology is concerned. In lectures professing to deal, however perfunctorily, with spasm, it would be impossible to pass by in silence the class referred to. It remains, therefore, for me to con- sider how far these functional diseases are capable of explanation or reasonable classification. III. Functional Spasms. The result of our consideration of those diseases which produce many varieties of spasm, and which are represented by gross lesions of the nervous system, is, that a very large proportion must be put down to the credit of the cerebral system of fibres, or pyramidal tract. The spinal mechan- isms are less prolific causes of these affections ; but those spasmodic conditions which do occur in connection with them have been considered under the heads : (1) peripheral motor nerves ; (2) afferent nerves ; (3) centres. It is only reasonable to suppose that, if functional spasms resemble those which result from gross lesions, they may admit of a similar explanation. In nerves and muscles which during life have been the seat of motor disorders, we may find no naked-eye or microscopic pathological changes after death. But clinical observation shows that, so far as function is concerned, marked changes have occurred. Now, we know that healthy function must depend upon fine molecular 1 1 arrangements, which are at present a closed book to us ; and we. conclude that, if molecular changes form the basis of healthy function, they form that of pathological condi- tions also. If this be so, it is legitimate to argue that the molecular changes in question might affect the same parts which are the usual seats of the grosser lesions, and con- sequently give rise to similar abnormalities of function ; and then the anatomical classification which has already been attempted in the case of tangible disease, might serve SPASM IN CHRONIC NERVE DISEASE. 87 also for those cases whicli are tlie result of impalpable alterations in nerve and muscle. I propose^ therefore^ to consider shortly certain forms of functional spasm^ and I shall use the same divisions for classification which I have already used for grosser diseases. 1. Do functional disorders of the cerebral motor mechan- ism^ or pyramidal tract, produce spasmodic conditions at all resembling those resulting from gross disease ? They do. In hysteria, not only does hemiplegia occur, but hemispasm, both fixed and mobile, is not uncommon. There is this difference between the hysterical conditions and those which are seen in gross disease ; the leg is affected most, the arm less, and the face not at all. But the facts observed in gross disease, where the leg is usually less affected than the arm, are probably to be explained mainly by the fact that the vessels which bleed most frequently, and interrupt the functions of the internal capsule, are those which are situated towards the anterior part of its motor division, that part, in fact, which contains the fibres controlling the face and arm. But apart from these points, the spasmodic contractions of the leg and arm are similar in the two conditions. In functional diseases, there is simply removal of the voluntary impulses which, in health, travel down the pyramidal tract. The muscles and nerves of the limbs remain practically healthy ; and if rigidity be not too great, the tendon-reflexes are increased. Fevers and other exhausting conditions, such, for instance, as that of the patient with ansemia to whom I have already referred, may give rise to increased reflexes, and even to clonus and rigidity. Moreover, absence of portions of the motor area of the cortex, such as is occasionally seen con- genitally, is accompanied by non-development of the corre- sponding portion of the pyramidal tract, and gives rise to spastic conditions like those found in hemiplegia. Absence of the voluntary impulses, then, is enough to give rise to the phenomena in question ; and certain cases of hysteria have died after long-continued contraction of limbs, and the most careful examination with the microscope has failed OO SPASM m CHEONIC NEEVE DISEASE. to disclose any palpable pathological changes. Sucli a case is recorded by Dr. Bristowe in ' Brain ' for October, 1885. This case I often saw myself , and, as Dr. Bristowe remarks, " at tbe end of lier two years, slie seemed as well in general bealth as wben she first came to the hospital ; but she was suffering from headache, sickness, ophthalmoplegia externa, complete aneesthesia of the right side, with rigid paralysis of the arm and leg, and repeated hsemorrhages of both ears." Dr. Hadden made a complete micro- scopical examination of the central nervous system in this case, but found no evidences of disease. As we know, however, that mere absence of the voluntary motor impulses along the pyramidal tract is sufficient to give rise to this condition, it is legitimate to conclude that suppression of the functions of this tract is the cause of functional hemi- spasm. We are still further supported in this view by cases like that just quoted, where there is at the same tiine clear evidence of the suppression of the functions of the sensory area as well. Clinical and pathological observation has shown that monospasms having similar characters may be produced by certain limited lesions of the motor convolutions ; and, after what has already been said, it is not too much to assert that when spasm limited to a leg or arm occurs in hysteria it is due to suppression of the functions of the pyramidal tract, which in health controls the action of the affected member. In discussing the question of athetosis and other allied mobile spasms, we arrived at the conclusion that they were due to affections of the same tract of fibres which were not severe enough to stop the passage of voluntary impulses. Now, similar conditions occur in hysteria, and may probably be explained in the same way. Weir Mitchell, in his work on ' Nervous Diseases,' records cases of " hysterical motor ataxy " and of " hysterical athetosis.'" It appears probable that changes, ending in greater or less functional abeyance of the pyramidal tract, lie at the root of unilateral, and sometimes of bilateral spasm, both in functional and in gross disease. The only difference is SPASM IN CHRQNIC NERVE DISEASE. 89 that, in tlie latter case, "we can appreciate, by our present metliods of investigation, the alterations whicL. have been wrought, while in the former, they are hidden from our view. There is another class of functional spasmodic affections which are hardly represented among the forms of spasm due to gross lesions, and which, I believe, have their origin in suppression of the functions of certain portions of the pyramidal tract. I refer to those conditions which are sometimes termed " professional hyperkineses.'^ They include histrionic spasm, writers' cramp; pianists' cramp, telegraphists' cramp, &c. The striking peculiarity of these affections is that, when a voluntary effort is made to perform the accustomed muscular acts, spasm of the muscles involved occurs and prevents further efforts. Before this stage of the affection is reached, great fatigue often accompanies endeavours to work. In a considerable number of cases, at any rate, the muscles can be employed in other ways without difficulty. What has occurred is probably that, after long-repeated acts of the same kind, that part of the pyramidal tract which is used becomes fatigued and its functions are partly suppressed, so that a condition of ''''latent contracture" of the muscles, over the voluntary actions of which it presides, is developed ; the lower centres are "let go," as Hughlings Jackson says, and are in a state of " hyperphysiological activity," just as the spinal centres of one side are in hemiplegia accompanied by slight rigidity. In describing "latent contracture" in connection with hemiplegia from gross disease, Eoss says : " The patient may perform all the simple movements of the limb, and probably with undiminished power ; but when his attention is specially directed to the movements, as when he wishes to perform any manual operation requiring a little dexterity, the muscles instantly become rigid, the fingers are flexed on the palm, and the deformity, which was present during the period of fixed contracture reappears." Surely this description suggests the true explanation of professional 90 SPASM m CHRONIC NBEVE DISEASE, spasmodic affections^ wMcli present symptoms resembling very strikingly those whicli Ross portrays. Erb divides tbe professional byperkineses into spastic, tremulous, and paralytic. The tremulous cases are perbaps due to similar but slighter paralytic affections of tbe pyra- midal tract, and tbe condition probably resembles in kind, tbougb not in degree, paralysis agitans. Tbe patbology of tbe latter disease is not known, but tbose cases wbicb one meets witb wbere rigidity of limbs and exaggerated reflexes occur, suggest forcibly degeneration in tbe pyra- midal tract as tbe physical basis of tbe affection. Tbe paralytic variety of tbe professional byperkineses is pro- bably tbe result of extension of disease to tbe motor cells in tbe anterior cornua of tbe spinal cord, at any rate in tbose cases wbere marked atrophy occurs (see ' Brain,* vol. vi, 233, a " A Case of Sawyers' Cramp,'' by Gr. Y. Poore, M.D.). I should remind my bearers, in passing, that the term pyramidal tract, as used here, includes not only fibres, but the motor cells of the cortex in which they originate. 2. We have seen that spasms of muscles resulting from gross disease of the pyramidal tract has its representative among functional diseases ; let us now consider that which owes its origin to affections of peripheral motor nerves. Is it likewise represented among functional disorders ? Actual gross pathological changes in motor nerves give rise to muscular spasm, as has already been pointed out, in two ways — the one direct, and the other indirect. In the latter case, certain muscles atrophy and disappear, and undergo cicatricial shortening, producing distortion ; or else their opponents being left to act in their absence, give rise to abnormal positions of the limbs. Now, one of the striking peculiarities in functional nerve disease is the absence of such degeneration and destruction of muscles. Hence we should not expect to find any functional spasms due to such indirect causes ; nor do we, so far as I know. We also came to the conclusion that direct irritation of motor nerves is a very rare originator of spasm ; and there SPASM IN CHRONIC NERVE DISEASE. 91 is no reason to suppose tliat it is less rare as a cause of functional affections. Nerve-centres seem much more prone to functional disorder than nerve-fibres. I am not sure that the latter condition, originating in centres, may not so affect even peripheral nerves which are connected vsrith them, as to give rise to symptoms which are found in gross disease only when peripheral nerves are involved. Dr. Norris, of Windsor, sent to me, for treatment in the hospital, a girl, aged 16, who had lost the use of her left hand for eighteen months. She was a strong, healthy girl and free from evident hysterical tendencies. The affection commenced with swelling and blueness of the fingers, such as is seen in chilblains ; and the hand was cold and numb. When she came to me, the hand was completely paralysed, and had a swollen puffy look ; the skin was paler and smoother than that of the right hand, and the backs of the fingers far less wrinkled. The left hand was much more influenced by external conditions than the right, and rapidly became warm when covered, and cold when exposed. She suddenly recovered after the application of a blister to the wrist, but then lost power in the left leg. The latter also suddenly recovered power. But, although slight alterations, such as those which were observed in this patient, may occasionally occur in peiipheral motor nerves in cases of functional disease, I am not aware that they give rise to muscular contraction. 3. Nor is there any proof that chronic spasm is produced by molecular changes of afferent nerves alone. Even in gross disease of an afferent nerve giving rise to reflex spasm, the lesion is often so trivial as to make it very probable that functional disorder of the centres is present as well, and is the main factor in the production of spasm. When speaking of reflex spasm from gross disease, I pointed out certain cases of what appeared to be rhyth- mical spasm due to affections of tendons ; and I cannot help thinking that this class has frequent representatives among functional diseases. But they are due more to the 92 SPASM IN CHEONIC NEEVE DISEASE. abnormal condition of tlie centres tlian to tliat of tlie peri- jtlieral nerves. There can be no question that one of tbe peculiarities of nerve-centres in hysteria is their abnormal irritability ; so that slight afferent impressions give rise to muscular acts, which pass with great ease into neuro- muscular habits. Such a condition is well exemplified in cases due to imitation. The patient sees a certain form of muscular spasm, and the idea produces the same in her. For instance, a healthy girl, aged 17, came to my out-patient room complaining of involuntary movements in her right hand and tongue. On examination, it was seen that the thumb was rhythmically adducted, and there was simul- taneous flexion of the fingers, most markedly of the index, which moved in such a way that she appeared to be rolling something between it and the thumb. At the same time, she was troubled by being suddenly unable to finish a sentence, owing to the tongue refusing to act properly. The girl worked in a confectioner^ s shop, where one of her comrades became affected with uncontrollable movements in the left hand and catching in her speech. After a short time my patient became similarly affected. The following is another case of suddenly developed neuro-muscular habits, though it originated in a somewhat different way. A healthy, dark -haired girl, aged 16, who had never had any illness, and had no evident neurotic peculi- arities, went out for a row on the Thames with some friends in the summer of 1885. She rowed without much intermis- sion for five hours, which was to her quite an unaccustomed length of time for such recreation. She used to row every morning at Wandsworth, where she was at school, but only for an hour at a time. About an hour after returning from this long row, her arms began to twitch, and move- ments continued uninterruptedly, and remained of a pre- cisely similar kind up to December 29th, 1885, when Dr. Bristowe, under whose treatment she had been, very kindly asked me if I should like to see her. Both arms were the seat of similar and synchronous movements, occurring regularly about one hundred and SPASM IN CHRONIC NERVE DISEASE. 93 sixty times a minute. They consisted of rapid elevation and retraction of the arm at the shoulder and of the scapula, partial flexion at the elbow, and slight extension of the wrist ; in fact, they bore a very marked resemblance to the movements of the arms and hands in rowing, the extreme rapidity of the '' stroke '^ making up for the limited extent of the movements. In these rhythmical contr^iCtions it is not at all impro- bable that the slight stretching of the tendons of the affected muscles which naturally results from the action of their antagonists gives rise to another contraction, and so on, for an indefinite number of times. Such a condition, though much less marked, is sometimes seen when the spinal centres are cut off from connection with the cerebral cortex by gross disease. A case of caries of the cervical vertebrae was under my care in St. Thomas's Hospital last summer, in which para- plegia, with rigidity, had been present for five years. The legs were always flexed at the knee and hip, but could be extended by continuous, gentle traction. As this was being performed, movements of flexion and extension, which were involuntary, occurred. When the tendons of the flexor muscles were stretched, the latter contracted, and, in so doing, they put the extensor tendons on the stretch, and so caused their contraction. Weir Mitchell has noticed these '^ alternate spasms " in hysteria, in which, as he remarks, the action of the flexors calls the extensors instantly into play, and this, in turn, summons the flexors into activity. " These spasmodic motions," says he, "were the more curious in the last case I saw, because of the general and profound paresis, which made every volitional effort excessively difficult." Such an absence of voluntary power, in the case of which Weir Mitchell speaks, shows that the functions of the cortical motor centres were in abeyance. Instances of alternating spasms are far from rare in hysteria, and probably owe their presence to excessive irritability of the spinal centres, and the development of a habit through the intermediation 94 SPASM IN CHRONIC NERVE DISEASE. of tendon-reflexes. " Saltatory spasm " is a good instance of this class of cases. 4. The fourth and final heading, under which we have to compare spasmodic conditions arising in connection with gross nerve-lesions, with functional disorders, is disease of the spinal motor centres. We have already seen that tangible pathological alterations in these cells give rise to paralysis and subsequent atrophy of muscles, but we could quote no facts to show that muscular spasm ever originates from such disease. Those impalpable molecular changes^ which result from the anatomical separation of the cere- bral motor centres from the spinal centres, produce a con- dition of hyperphysiological activity of the latter, to which many spastic conditions are due. Does abnormal func- tional activity ever exist primarily in the spinal centres and result in spasm ? This is a question which is very difficult to answer. In the case of gross lesions which interrupt the continuity of the fibres of the pyramidal tract, even where no actual spasm has resulted, there exists a condition of excessive excitability of the spinal centres, which gives rise, on the slightest provocation, to rigidity of muscles. An injury, even of a trivial nature, may, in such patients, produce contracture. Exactly the same state of things is found in hysterical subjects; and Charcot, in his lectures on nerve disease, gives instances of the most trifling injuries suddenly producing spasmodic conditions of limbs in such patients. But we must remember that persons may have those peculiarities of their nervous system which are usually embraced under the term hysteria, without ever presenting striking emotional or other tendencies which are wont to call attention to the existence of the disorder. The first evidence of the latter may be the sudden supervention of spasm from a very slight external injury. If this condi- tion of the spinal centres depends mainly upon the amount of cerebral control exerted over them by the functional activity of the pyramidal tract, it is evident that there must be infinite gradations between the normal and SPASM IN CHRONIC NERVE DISEASE. 95 abnormal. Indeed, it is impossible to give any strict definition of health and disease. All we can say is, that the more cerebral control retires into the background, the more likely are spasmodic conditions to come to the fore. It is quite impossible to answer the question, whether hyperexcitability of the spinal centres occurs in the absence of diminution of cerebral influence to account for it ; but it probably does. We know that strychnine, in certain doses, produces an excitable condition of the spinal centres, which Charcot has likened to that which is seen in " latent contracture " due to gross lesions of the pyra- midal tract, and to hysteria. In comparing strychninism with the latter. Weir Mitchell says {' Lectures on Diseases of the Nervous System, especially in Women,^ page 100) : — " Perhaps I shall, in a measure, clear your minds as to the nature of what I mean by functional spasms if I recall to you the influence of strychnine in large doses, such as you have seen given here many times. You will remem- that in certain spinal maladies, such as those of syphilitic birth, it is my habit first to give iodide in heavy doses, then to suspend them for a time, and to give strychnine up to the limit of physiological endurance, that is to say, until I cause an approach to spasm. When, for example, you give hypodermically the one fifth to the one eighth of a grain daily, the patient will have little or no annoyance, if you are careful to insist that he remain at absolute rest in bed for two hours after each injection. If there be any tendency to spastic twitchings of the muscles, the will is competent to control them, unless — and this is the point I would make — the patient attempts to exercise. Should he do this the effort results at once in irregular move- ments of an inco-ordinate character, and in slight or more grave spasms of the muscles employed. While at rest there is no obvious trouble, but voluntary movement occa- sions spasms, which are the offspring of the poison. They are, in a word, functional spasms, and would not be seen at all with limited use of strychnine, were it not for the efforts of voluntary action." If, then, a substance circu- 96 SPASM IN CHEONIC NERVE DISEASE. lating in tlie blood can directly produce this condition of tlie spinal centres^ in wliicli they may almost be said to be watching their opportunity to produce muscular contrac- tiouj it is not improbable that molecular alterations may arise from other causes^ and produce a similar excitable condition of these centres. We know, however, little, if anything, about the changes which act thus. What are called phantom tumours of the abdomen, and sometimes of other parts, may have some such origin ; Weir Mitchell records one, in which all the abdominal muscles had remained violently contracted for a year. But whether this be the explanation of such cases or no, the hyper- physiological activity, due to lack of cerebral control, which exists in the spinal centres of some subjects, is probably the principal factor in a very large number of tonic and clonic functional spasms. In the comparison which has been attempted between the results of gross disease on the one hand, and mole- cular or so-called functional alterations on the other, the pyramidal tract stands prominently forth as the great offender in the production of muscular spasm. Its action is indirect, it is true, as it only looses the reins of the spinal centres, which it should keep well in hand. Still, it rules the situation. Spasm rarely ensues directly from injury or disease of peripheral motor nerves ; and, although it frequently results from reflex causes, it is very likely that the spinal centres are, in a considerable proportion of cases, more at fault than the afferent nerves. It may be thought somewhat curious that, in speaking of dimunition of cerebral control, the voluntary motor tract should alone have been referred to as liable to suffer from depression of its functions. But the only reason why it has been thus signalled out is, that these lectures have dealt with motor phenomena. The sensory functions of the brain suffer, too, in a very striking manner, so that complete hemianaesthesia is far from a rare occurrence in hysteria, the loss of function being evident in the realm of the special senses, as well as in that which has to do SPASM IN CHRONIC NERVE DISEASE, 97 with common sensation. And although at first sight these functional defects appear to be confined to one side^, careful investigations show that they are not. Por^ in cases of hemianaesthesia^ both fields of vision are con- tracted, although that on the anaesthetic side is the more affected. Again, in cases where the loss of function appears to be confined to the sensory area, a careful com- parison of the muscular power on the two sides may show that this is not so. In a case of the kind which I lately saw, I found that on the hemiangesthetic side the patient could only reach 45 on the dynamometer scale, although this was the right side, while with the left she reached 50, In such hysterical patients, it is probable that nerve power is deficient in all parts and on both sides of the brain, although this deficiency is more marked on one side than the other, and in some portions of that side than in others. Considering how late the pyramidal tract deve- lops in man, and what a high pitch of evolution it repre- sents, it is not to be wondered at if it is one of the first parts to suffer in the process of dissolution. If we are right in considering deficient nerve-power, especially in the brain, as the condition which is at the root of functional nerve disease, the term neurasthenia, a product of modern times, would be a more suitable general title for such disorders than the older term, hysteria. When we review the history of nerve disease in families, we cannot but conclude that people are born with very different physical bases, both in their nervous and in their other systems. And no line can be drawn between those who are normally stable and enduring under unfavorable circumstances, and those who are liable to lose equilibrium. Some patients would remain perfectly well had they not accidentally met with some catastrophe ; and then they fall into the category of hysterical patients. And yet there are many of their friends and acquaintances who are as liable to functional disorder as they are, and who yet may never have their weakness brought to light, owing to their not having been exposed to a sufficiently severe trial. 7 98 SPASM IN CHKONIC NERVE DISEASE. Even small portions of nerve-centres may become hysterical^ if I may be allowed to say so^ as^ for instance^ in writers' cramp, pianists' cramp, and otber professional hyperki- neses. All that we know of this matter is, that functional nerve disease, even in the case of apparent exceptions, such as spasm, is due to deficiency of nerve-power. How the condition is actually brought about we cannot tell. Some think the centres are starved by contraction of their nutrient vessels. It seems to me more likely that the nerve-centres are exhausted by their own action. Thus, sudden emotional excitement may bring on hysterical phenomena, indicating nerve exhaustion, such as hemi- anaesthesia, paralysis, or spasm. It is important to remember, too, that exhaustion of one area seems to affect the whole system. This may indicate that the various differentiated centres draw nerve-force from some common supply. Considering the enormous amount of cells which are found in the cerebral grey matter, many without evident connections, is it going too far to suppose that a large number of these are factories for the production of nervous energy, which is necessary for the continuous and regular action of the highest centres, and which flows in increasing quantities towards those centres which are from time to time brought into action ? Constant supply would mean constant power in all centres ; and as the latter are all bound together so as to produce a physiological equilibrium, constant power would involve constant control of one by the other. Where the store of constantly produced force (represented, of course, by structural peculiarities) is by in- heritance small, or where it has been exhausted by unnatural calls upon it, there would be insufficient to supply all the centres ; and those to which the nerve-paths are most freely open by habit would command it, while others would be starved, and loss of equilibrium, or the natural control of one centre by the healthy action of others, would be the inevitable result. If we do not suppose any such reservoir of nerve-energy, how can we explain the exhaus- tion of all, by the excessive action of some, centres ? Why SPASM IN CHEONIC NERVE DISEASE. 99 is a person wlio has had excessive mental work less able for the time to do active bodily work ? and why^ when bodily fatigued, are we less ready to do intellectual work ? But I have gone, I fear, ,too far into a region of specu- lation, which it is hardly legitimate for me to have even entered with so small an equipment of facts. I shall therefore say no more, but bring these lectures to a con- clusion by offering an apology for having chosen a subject which is so extensive in range, and at the same time so obscure and little understood, that my treatment of it must fall far short of that which is expected on occasions like the present. PRINTED BY J. E. ADLAEU, BARTHOLOMEW CLOSE Catalogue B] London^ 1 1, Neiv Burlington Street February^ 1886 S E L E C T I O N FROM J. & A. CHURCHILL'S GENERAL CATALOGUE COMPRISING ALL RECENT WORKS PUBLISHED BY THEM ON THE ftKT A^D SCIENCE OF MEDICINE N.B. — As far as possible, this List is arranged in the order in which medical study is usually pursued J. & A. CHURCHILL puWish for the following Institutions and PuWic Bodies:— ROYAL COLLEGE OF SURGEONS. CATALOGUES OF THE MUSEUM. Twenty-three separate Catalogues (List and Prices can be obtained of J. & A. Churchill). GUY'S HOSPITAL. REPORTS BY THE MEDICAL AND SURGICAL STAFF. Vol. XXVII. , Third Series (1884). 7s. 6d. 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AvELiNG, M.D., Physician to the Chelsea Hospital for Women. 8vo, 6s. By the same Author. The Chamberlens and the Mid- ^wifery Forceps : Memorials of the Family, and an Essay on the Invention of the Instrument. 8vo, with Engravings, 7s. 6d. A Handbook of Uterine Thera- peutics, and of Diseases of Women. By E. J. Tilt, M.D., M.R.C.P. Fourth Edition. Post 8vo, los. By the same Author. The Change of Life In Plealth and Disease : A Clinical Treatise on the Diseases of the Nervous System incidental to Women at the De- clineofLife. Fourth Edition. 8vo, ids. 6d. The Principles and Practice of Gynascology. By Thomas Addis Emmet, M.D., Surgeon to the Woman's Hospital, New York. Third Edition. Royal 8vo, with 150 Engravings, 24s. Diseases of the Uterus, Ovaries, and Fallopian Tubes : A Practical Treatise by A. CouRTY, Professor of Clinical Surgery, Montpellier. Translated from Third Edition by his Pupil, Agnes McLaren, M.D., M.K.Q.C.P.I., with Preface by J. Matthews Duncan, M.D., F. R. C. P. 8vo, with 424 Engravings, 24s. The Female Pelvic Organs : Their Surgery, Surgical Pathology, and Surgical Anatomy. In a .Series of Coloured Plates taken from Nature ; with Com- mentaries, Notes, and Cases. By Henry Savage, M.D., F.R.C.S., Consulting Officer of the Samaritan Free Hospital. Fifth Edition. Roy. 4to, with 17 Litho- graphic Plates (15 coloured) and 52 Wood- cuts, ^i 15s. Backward Displacements of the Uterus and Prolapsus Uteri : Treatment by the New Method of Short- ening the Round Ligaments. By WIL- LIAM Alexander, M.D., M.Ch.Q.U.L, F. R. C. S. , Surgeon to the Liverpool Infir- mary. Crown 8vo, with Engravings, 3s. 6d. Ovarian and Uterine Tumours : Their Pathology and Surgical Treatment. By Sir T. Spencer Wells, Bart., F. R.C.S., Consulting Surgeon to the Samaritan Hospital. 8vo, with En- gravings, 2 IS. By the same Author. Abdominal Tumours: Their Diagnosis and Surgical Treatment. 8vo, with Engravings, 3s. 6d. West on the Diseases of "Women. 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