THE NEURAL DISORDERS OF WRITERS AND ARTISANS.
BY MORRIS J. LEWIS, M.D.
DEFINITION.—These neural disorders consist of a certain train of nervous symptoms, such as spasm, paralysis, pain, tremor, vaso-motor disturbances, etc., either alone or in more or less complicated combinations, which follow certain muscular acts and are occasionally accompanied by a marked condition of general nervousness; they occur in many of the occupations of every-day life that require for their performance a constant muscular strain combined with more or less delicate movements of co-ordination continued for long periods at a time.
SYNONYMS.—Among the terms used to designate the various forms of the affections produced in the manner just stated may be mentioned the following:
Special Terms.—Writers' cramp, Scriveners' palsy, Steel-pen palsy, Chorea scriptorum, Paralysis notariorum, Graphospasmus, Mogigraphia, Crampe des écrivains, Nevrose des écrivains, Schreibekrampf, Le mal télégraphique, Crampe télégraphique, Klavierkrampf, Pianists' cramp, Tailors' cramp, Loss of grip, etc.
General Terms.—Professional dyscinesiæ, Professional impotence, Anapeiratic paralysis, Nevrose co-ordinatrice des professions, Functional spasm, Fatigue diseases, Professional hyperkineses, etc.
None of these terms are satisfactory, and, in fact, it is difficult to fine one that will include the various symptoms arising from the habitual use of a muscle or group of muscles, in the same way for long periods at a time, in the different occupations known to give rise to these neuroses, without including diseases belonging to entirely different classes.
It is with some hesitation that I suggest the term copodyscinesia (κόπος, toil, weariness, fatigue; and δυσκινησια—δυς, faulty, difficult, hard, and κινησις, motion, movement) as signifying difficult or faulty motion due to constant repetition of the same act.
HISTORY.—Some of these neuroses have been recognized for years; this is particularly true of writers' cramp, the earliest notice of which I have been able to discover is in a small work by Ramazini,1 printed in 1746.
1 Bern. Ramazini, Treatise on the Diseases of Tradesmen, etc., translated by Dr. James, London, 1746.
Most of the articles upon this subject have been written during the last fifteen or twenty years.
ETIOLOGY.—Many of our every-day actions, which we perform almost automatically, are the result of months and even years of practice; this is well exemplified in the act of writing. At first each letter is made by a separate and deliberate act of volition, and considerable thought has to be expended upon its formation; but little by little the preponderance of the volitional element decreases, until at last we write with but little consciousness of each separate movement, and the act becomes almost an automatic one, the sentence being conceived and the hand committing it to paper with but little thought of the intermediate muscular acts. In a somewhat analogous manner do we learn to walk, each movement being laborious and requiring much thought for its execution: in addition to this, we must regulate the amount of the movement and keep in abeyance all associated muscular action.
This last is spoken of by Hasse2 as an important factor in the etiology of these affections. When, however, any one of the various muscles whose integrity is necessary for the automatic performance of any act becomes affected, let the lesion be in the muscle itself or anywhere in the nerve-substance between it and its centre, or in that centre itself in such a way as to hinder its free response to the nervous stimulus, then the will has to be especially directed to the act in order to counteract the effect of the disability, and some other muscle or group of muscles must be substituted in the place of the one incapacitated. That which was previously performed easily and without fatigue now becomes difficult and exhausting.
2 Handbuch der speciellen Pathologie u. Therapie, “Krankheiten des Nervensystems,” 1te A., Bd. iv., 1869.
It will be in place here to consider in detail the action of the muscles concerned in performing one or two of the acts most prolific of the affections under consideration.
The first of these that will be examined is the act of writing.
Generally speaking, the methods of writing may be divided into two: 1st, where the fingers do all the stroke movements, the arm remaining quiescent except for the lateral movement; 2d, where the pen is held steadily by the fingers and the letters formed by the movement of the whole arm. In the latter the muscles of the hand and forearm are used almost entirely for pen-prehension and poising, although there is generally a slight finger movement for the long strokes; the forearm is allowed to rest upon the bellies of the flexor muscles as a sort of movable fulcrum, the pectorales, teres major, and latissimus dorsi, together with the biceps and triceps, being mainly employed in forming the letters.
This last method of writing is the one mostly taught in the public schools at the present day; and as a large number of muscles are brought into play, and as there is a more even division of the work, it is claimed that fatigue is not so soon complained of as in the first or older method.
The act of writing is primarily divisible, according to Poore,3 into three acts: 1st, the act of prehension; 2d, the act of moving the pen; 3d, the poising of the forearm and hand. The muscles concerned in the act of prehension are—the first two dorsal interossei, the opponens, abductor, and flexor brevis pollicis, and, to some extent, the flexor longus pollicis and the extensors of the thumb. The adductor should also be included in this enumeration.
3 G. V. Poore, Electricity in Medicine and Surgery, London, 1876.
The muscles employed in the movement of the pen differ somewhat according to the method of writing. In the finger movement Poore enumerates the following muscles as the ones used, viz.: flexor longus pollicis, extensor secundi internodii pollicis, flexor profundis digitorum, extensor communis digitorum, and also, to a lesser degree, the interossei.
In the second method of writing these muscles are comparatively quiet, except in making the letters which extend far above or below the line, while the muscles previously mentioned when describing this method are the ones called into play. The poising of the arm and hand is mainly accomplished by the supinator longus, supinator brevis, and possibly by the extensors of the thumb.
From a study of what has been written it will be seen that there are two classes of muscular actions concerned: 1st, the steady contraction of the muscles that poise the hand and hold the pen; and 2d, the intermittent contractions of the muscles concerned in moving the pen: both of these classes are equally important in the etiology of writers' cramp.
Chronic fatigue of the muscles is undoubtedly, in some cases, a precursor, if not a cause, of copodyscinesia, and, according to Poore,4 is occasionally the expression of hyperæmia or mild inflammation of a motor nerve. Acute local fatigue has symptoms which are well known to us all after having taken violent exercise, cramp and pain being the two most prominent ones.
4 “Writers' Cramp and Impaired Writing-Power,” Medico-Chirurgical Transactions, vol. lxi.
Any student who has dissected much has experienced the intense feeling of fatigue in the muscles required to hold the dissecting forceps, particularly when the spring is a little too strong. Much the same thing is noticed when one who has not been accustomed to write much is for some cause compelled to do so; he will probably notice that in a few hours he is exerting a greater amount of muscular force in pen-prehension than usual, and may even find that he is producing a disagreeable feeling in the distal phalanges by the pressure he is using; he will also probably be aware of a burning sensation between the shoulder-blades.
These symptoms are in all probability dependent upon, or are at least coincident with, a hyperæmia of the nerves and spinal cord, and, if persisted in for a long time without proper intervals of rest must sooner or later interfere with the healthy condition of the spinal cord, as well as of the nerves and muscles of the hand and arm.
Poore, while considering the symptoms of fatigue as in large part peripheral in origin, readily admits that they must generally be accompanied by central changes.
The manner of writing and of holding the pen is of considerable influence in the causation of this trouble. Practically, the fluent writer is more apt to contract this affection than he who writes badly, for the latter seldom obtains a position where steady copying is to be done; theoretically the reverse is true if the amount of work in the two cases is the same.
When the pen-holder is allowed to drop below the head of the first metacarpal bone the movements of the fingers are restricted; the middle and fore finger upon one side of the holder and the thumb on the other act upon the principle of the toggle-joint, so well known in mechanics, and, as the pen-holder is drawn backward to make a stroke, bind the distal phalanges tightly against the holder: this in a short time causes fatigue and awkwardness in writing; but if the holder is made to cross the proximal extremity of the first phalanx of the fore finger the toggle-joint movement is destroyed.
These remarks apply of necessity more strongly to the finger movements than to the conjoined finger-and-arm movement.
Writing with a pencil is not as liable to bring on fatigue and nervous trouble as pen-writing, this being mainly owing to the fact that with the former no particular angle is required to be maintained between the point and the paper; there is therefore less effort at poising, as the pencil may be rotated at pleasure, while with the pen one angle has to be maintained. The same remarks should apply to the fluid pencils (stylographic and Mackinnon pens) now so universally used; in fact, they have been considered by Putnam5 as much easier to write with than the pencil, as less weight need be applied upon the tip in order to write.
5 J. J. Putnam, M.D., “A New Adjuvant in the Treatment of Writers' Palsy,” Boston Med. and Surg. Journ., vol. ci. p. 320, 1879.
The idea that these troubles of writers were due to using steel pens, as once thought, is manifestly without foundation, as the affection was recognized before the time of the introduction of steel pens, which was from 1800 to 1820.
Fine sharp pens are, however, more productive of evil than composition pens or those with a broad soft nib, as they do not move as easily over the paper, and therefore introduce a difficulty, although a slight one, in the act of writing. The theory that the chemical action between the ink and the metallic pens, and the friction of the pen on the paper, generate sufficient electricity to affect the fingers through the medium of the metallic portion of the pen-holder is too preposterous to mention, except to show what curious reasons are given in attempting to explain obscure and difficult subjects.
The next occupation which very frequently gives rise to these affections is telegraphy.
The invention of the Morse telegraph in 1844, and its general introduction, both here and abroad, a few years later, has proved a most fertile source of copodyscinesia, although but little has been written on this form of neurosis, Onimus,6 Robinson,7 and Fulton8 being among the few to describe it, although several later writers mention its existence.
6 “Le Mal télégraphique ou Crampe télégraphique,” Compte Rend. Soc. de Biol., 1878, 6, S. V. 92-96; also “Crampe des Employés au Télégraph,” Gaz. méd. de Paris, 1875, p. 175.
7 Edmund Robinson, M.D., “Cases of Telegraphists' Cramp” (4 cases), British Med. Journ., Nov. 4, 1882.
8 Thomas Weymss Fulton, “Telegraphists' Cramp,” Edinburgh Clin. and Path. Journ., Feb. 2, 1884.
Telegraph operators, particularly those employed in large cities, whose time is nearly all taken up with their work, are more exposed to the causes of copodyscinesia than those following other trades. They are not only exposed to the danger of contracting the affection by using the telegraph-key in transmitting messages, but when not so employed are receiving messages by sound and writing them down, frequently at the rate of thirty to forty, or even more, words per minute. Thirty words a minute is good telegraphy: this would require, on the average, nearly 600 separate contractions. This would be 36,000 contractions per hour, while to write the same sentences would require about 10,000 less.
The operators employed by the Associated Press, although comparatively few in number, two hundred probably including all in the United States, write for hours at a time, using a stylus and manifold writing-books, making as many as twelve copies at one writing; this obliges them to grasp the stylus very firmly and to press with considerable force, making the act of writing much more difficult.
In addition to the work mentioned above, those who have large numbers of messages to transmit become so expert that to save time they make a record concerning the last message sent with the left hand, while they are telegraphing the next one with the right hand. A complicated act of co-ordination is thus being performed with each hand, the difficulty of which may be appreciated by any one if he but try to perform it.
An editorial in the London Lancet9 states that “telegraphers' cramp will, we have little doubt, take its stand among the last-mentioned curiosities” (milkers' cramp, hammer palsy, etc.), and "that the telegraph clerk usually enjoys repeated intervals of complete rest, and runs consequently hardly any risk.”
9 1875, vol. i. p. 585.
Hammond10 likewise states that telegraphers' cramp is rare in the United States, but a slight investigation proves these two statements to be, unfortunately, very far from the truth. According to recent statistics,11 the Western Union Telegraph Company employs nearly twenty thousand operators, who transmit annually over thirty-five million messages, and as investigation seems to prove that a very large number, if not the majority, sooner or later show some symptoms of copodyscinesia, it becomes evident that this neurosis is far from rare, although hitherto almost entirely overlooked by the medical profession.
10 Wm. A. Hammond, M.D., Dis. Nervous System, 6th ed., New York, p. 789.
11 J. B. Abernethy, Commercial and Railway Telegraphy, Cleveland, Ohio, 1883, 2d ed.
Operators are very loath to confess that they are suffering from loss of grip, as they have termed it, for then they are considered as less efficient than formerly, and may be asked to resign in favor of one not affected, or be lowered in their salary—a point of great moment, as telegraphy is their means of support. This accounts for the apparent small number of the cases.
In telegraphing, the knob of the key, a circular disc of hard rubber more than one inch in diameter, and placed about one and a half inches above the level of the table, is grasped, as a rule, between the thumb and middle finger, with the tip of the index finger resting on top, the position being quite analogous to the method of pen-prehension, the strain, although much less, falling on the same muscles, but as all lateral movements of the key are impossible, the muscles employed in poising are not brought into play as in writing. The arm is either allowed to rest upon the table, upon the flexor mass of muscles of the forearm near the elbow as a kind of movable fulcrum, or is held with the forearm parallel to the table and a short distance above it.
The movements of telegraphing are made by the alternate action of the triceps, which depresses the wrist by extending the forearm, assisted by the flexor carpi radialis, flexor carpi ulnaris, flexor sublimis, and flexor profundus digitorum on the one hand, and the biceps and supinator longus, which elevate the wrist by flexing the forearm, assisted by the extensor carpi radialis longior, extensor carpi radialis brevior, extensor carpi ulnaris, and extensor communis digitorum on the other.
The movement of the key-knob, being about the one-twenty-fifth of an inch, is so slight that it may be entirely ignored, so that with the fingers upon the key and the forearm resting upon the table near the elbow the motion must be a downward and upward one of the wrist; when, however, the arm is held above the table and parallel to it, the motion is more extended, the shoulder-muscles being used to support the arm.
The wrist is held in a supple manner, and not rigidly, the momentum of the downward movement being used to close the circuit; this, as before stated, is made mainly by the triceps, and is checked by the flexors and supinator longus.
The extensors of the wrist and fingers have a double duty to perform, for, besides assisting in recovering from the downward stroke, they have to support the hand during the whole act of telegraphing, in order to prevent the weight from resting on the key, which would prevent quickness in making and breaking the circuit.
On long circuits, particularly in wet weather, when much electricity escapes from the line, the movements have to be made with much more decision than usual in order to make the signals intelligible at the distant station.
The accompanying diagram shows well the movement of the wrist as above described, the hand and wrist moving into the position of the dotted lines when the downward stroke is made.
FIG. 28.
Our hand is essentially a prehensile organ, and as such causes us to educate the flexors the most; the extensors, being mainly used to relax the grasp of the fingers, are weaker, and the constant strain spoken of above, being thrown upon them, explains the fact that in telegraph operating these are the muscles most frequently attacked by cramp. (See Symptomatology.)
The following figures are of interest as proving the great superiority, in point of strength, of the flexor over the extensor muscles of the wrist and fingers. The measurements were made by the dynamometer of V. Burq, great care being taken to apply the instrument upon corresponding points of the palmar and dorsal surfaces of the hand. The grasp of the average man, which includes all the flexor muscles of the fingers and thumb, equals 125 pounds, while the power of the flexors of the wrist, exclusive of the fingers, equals 40 pounds. In marked contradistinction to this the extensors of the wrist register 35 pounds, and the extensors of the fingers only 7. The total power of all the flexors is therefore 165 pounds, and that of the extensors 42 pounds, nearly four times less (3.92). In women the ratio is the same, although the number of pounds registered is about half.
From the foregoing enumeration of the muscles used in writing and telegraphing it may be seen that the brunt of the work does not fall on the same muscles in the two acts, so that operators are seen utterly unable to telegraph more than a few words intelligibly who can still write a fluent hand. The two forms of neuroses often coincide in the same subject, as all telegraphers are of necessity scriveners; in fact, the majority suffer from both forms, and as a rule the most difficulty is experienced in telegraphing, and not in writing, although the reverse is frequently seen. But rarely does one see an operator who, unaffected as far as telegraphing is concerned, has difficulty in writing on account of this curious neurosis.
Of the muscles enumerated in the foregoing discussion, six are supplied, either wholly or in part, by the ulnar nerve—namely, the first two interossei, adductor pollicis, flexor brevis pollicis (inner half), flexor carpi ulnaris, and flexor profundus digitorum (inner part); and seven by the median nerve wholly or in part—namely, the opponens and abductor pollicis, flexor brevis pollicis (outer half), flexor longus pollicis, flexor profundus digitorum (outer part), flexor carpi radialis, and flexor sublimis digitorum.
The remaining important muscles are supplied by the musculo-spiral and its branches, except the biceps, which is supplied by the musculo-cutaneous.
The ulnar nerve supplies fifteen of the muscles of the hand; many of these are not prominently brought forward in writing, but are more or less used in keeping the hand in the required position.
Poore, after a careful study of 32 cases of undoubted writers' cramp, found the muscles affected in the following proportions:
| Interossei | (supplied by the ulnar nerve) | 18 times. |
| Extensors of the thumb | (supplied by the musculo-spiral) | 10 times. |
| Flexor brevis pollicis | (supplied by the median and ulnar) | 7 times. |
| Abductor pollicis | (supplied by the median) | 7 times. |
| Flexor longus pollicis | (supplied by the median) | 4 times. |
| Adductor pollicis | (supplied by the ulnar) | 3 times. |
| Opponens pollicis | (supplied by the median) | 2 times. |
| All the muscles of the forearm, more or less, | 2 times. | |
—showing that the muscles supplied by the ulnar nerve were affected more often than those supplied by the others.
The musculo-spiral and its branches supply the extensors of the thumb, fingers, and wrist, besides the two supinators; and by referring to the muscles most called into action in the act of telegraphing it will be seen that the majority are supplied by this nerve and by the median, which supplies the majority of the flexors. This statement explains to a great extent the fact that telegraph operators may be unable to telegraph and yet be able to write, as the muscles most important in the two acts have not the same nerve-supply.
The integrity of these nerves is therefore of the first importance in all cases requiring the use of the fingers and forearm, and many cases of copodyscinesia undoubtedly have a subacute inflammation of these nerves, or at least a congestion of the same, as their foundation, the neuritis or congestion being overlooked, owing to its mild type.
S. Weir Mitchell12 states that subacute neuritis is often incapable of distinct clinical discrimination when of a mild type and when there is an absence of traumatic cause. Mills13 states that “a lesion of the sensitive fibres profoundly affecting this power of conducting impressions may not cause pain, and that pain is not a necessary symptom of inflammation of a mixed nerve: this is an important fact, as I think too much stress is often laid on pain as a symptom of neuritis, leading to error in diagnosis and treatment.”
12 Injuries of Nerves, and their Consequences, by S. Weir Mitchell, M.D., Philada., 1872.
13 F. T. Mills, M.D., “On Two Cases of Neuritis of the Ulnar Nerve,” Maryland Med. Journ., vol. viii. p. 193, 1881.
Other Forms of Copodyscinesia.—In violin-playing the bow is held steadily between the fingers and thumb for long periods at a time, and the left arm is forcibly held in supination in order to bring the fingers upon the strings—actions well calculated to cause trouble if persisted in, not taking into account the rapid movements of the fingers which are necessitated in playing and the movements of the arm in bowing. The violinist is therefore liable to suffer in both arms, but in a different manner in each, as different muscles are used in bowing and in fingering.
The other musical instruments necessitating great education in the movements of the fingers and wrist are also liable to cause these neuroses, but this is not true of those wind instruments which require education of the movements of the lips and tongue. Piano-playing is a frequent cause of these troubles, which have been known to appear quite suddenly during the practising of some difficult piece.
In fact, all occupations which require a muscle or a group of muscles to be kept in a constant more or less firm contraction, together with fine movements of co-ordination in themselves and in the neighboring muscles, may be expected to furnish cases of this class of disease; the muscles affected necessarily varying with the work done, mere routine work being more liable to cause trouble than that which is new and original, as in the latter case time has to be taken to elaborate it, thus giving temporary rest to the muscles.
Besides the forms already mentioned these neuroses have been known to effect compositors, engravers; seamstresses, tailors, from using the needle or scissors; cobblers; bricklayers, from using the trowel; artificial-flower makers; weavers; milkers; painters; dentists; ballet-dancers, from standing on their toes; blacksmiths and those using the hammer; carpenters, from using the saw and screw-driver; electrical-instrument makers, from winding coils; turners; watchmakers; fencing-masters; cigar-makers; makers of photographers' gelatin plates; knitters and those using the crochet-needle; billiard-players; counters of money; dressers of hides; pedestrians; and a few others.
Writers, telegraph operators, and musicians are those which by far are the most frequently affected, the others being almost curiosities. Among the latter may be mentioned the case, recently coming under my notice, of pain in the right forefinger and arm, with cramp in the former, upon any prolonged attempt to read with this finger the raised letters of the alphabet of the blind. The patient was a blind woman depending for her living upon crocheting, which occupation was also seriously interfered with by this trouble.
After inquiring, in factories, etc., I find that the disease is by no means a recognized one among the workmen. Among telegraphers, however, it is so well known that they have called it the loss of grip, while in France it is known among them as le mal télégraphique.
Gardner,14 after a careful investigation, finds no proof that physical disease originates in, or is even aggravated by, the use of the sewing-machine, and he has “never even heard of a case of cramp.” He comes to this conclusion after having visited many large factories where sewing-machines are used and worked by foot-power; his remarks apply to those machines where the feet are worked together, and not alternately, which last has been known, according to Down,15 to cause serious troubles, of an entirely different kind, however, from the one under consideration, and with which this subject has nothing in common.
14 A. K. Gardner, M.D., “Hygiene of the Sewing-Machine,” Am. Med. Times, Dec 15-29, 1860.
15 “Hygiene of the Sewing-Machine,” London Lancet, 1866, vol. ii. p. 447.
PREDISPOSING CAUSES.—Tobacco and Alcohol.—Both of these articles exert a powerful effect upon the nervous system, tobacco particularly being a factor in the causation of many cases of neurasthenia. The first effect of tobacco and alcohol in small doses on the brain and spinal cord is, according to Boehm and Von Boeck,16 that of an excitant; subsequently it acts as a depressant. Eulenburg17 mentions tremor as of very frequent occurrence, and states that he has frequently noticed it in young cigar-makers who smoke to excess.
16 Ziemssen's Cyclopædia, Amer. ed., vol. xvii.
17 Ibid., vol. xiv.
Cigarettes are more injurious than other forms of tobacco used in smoking, as the smoke is nearly always inhaled, a greater effect being thus produced by a given amount of the drug. Besides this, cigarettes contain a large amount of other substances deleterious in their effects. Trembling of the fingers and hand is frequently seen in those smoking cigarettes freely.
The majority of the cases of copodyscinesia that are in the habit of using either of these articles acknowledge that their use increases their disability; in very exceptional cases the moderate use of tobacco appears to soothe and quiet, and thus relieve some of the symptoms.
Age.—Copodyscinesia is a disease of early adult life; it is rare in old age. In 39 out of 43 cases of telegraphers' cramp coming under my notice the age of the patient at the outset of the disorder could be accurately determined. The average was 23.94 years. The average age of all cases of the various forms of copodyscinesia seen by me up to the present time (1886) is 25.96 years.
Sex.—The influence of sex as a predisposing cause of these affections has not been studied with sufficient care, although a few authors allude to it.
Onimus18 states that women are more frequently affected than men with telegraphers' cramp. Erb19 states that writers' spasm is met with more frequently in men, much more rarely in women, and that pianoforte-players' spasm occurs more frequently in women, and particularly in neuropathic persons who belong to nervous families. Hasse20 and Romberg21 consider that writers' cramp especially occurs in men, women being affected very rarely. Of the 75 cases of impaired writing-power reported by Poore,22 only 17 were women, while of the 31 cases of undoubted writers' cramp included in the 75, all were men.
18 Loc. cit.
19 “Writers' Cramp and Allied Affections,” Ziemssen's Cycl., Amer. ed., vol. xi.
20 Loc. cit.
21 Nervous Diseases, vol. i. p. 320.
22 Loc. cit.
It may be seen that the male sex has been employed far more frequently than the female in most of the occupations previously mentioned, so that a larger percentage of men would naturally be affected; but now that women are being employed more generally a larger number of the female sex may be expected to suffer in this way.
Whether sex, per se, has much influence as a predisposing cause is difficult to say, as statistics are wanting, but it is probable that with the same amount of work given to each sex a large proportion would be found among women.
Women are being employed to a considerable extent in telegraphy, and although I have been able to collect but 4 cases of this form of copodyscinesia affecting women out of a total of 43, I have reason to believe it is quite common among them, my mode of collecting statistics (soliciting replies to printed questions) being much more likely to give a larger percentage of answers from men.
Hereditary Influence and Nervous Temperament.—Both of these factors seem to play an important rôle as predisposing causes to these affections. Cases are on record where several members of the same family were the subjects of writers' cramp. The statement made by Erb (vide supra), that neuropathic persons and those who belong to nervous families are more subject to these affections than others, seems to me to be true, at least to a great extent, for a careful inquiry into the history of cases coming under my knowledge has quite often elicited the statement that migraine, functional spasm, epilepsy, hay fever, neuralgia, writers' cramp, telegraphers' cramp, or general neurasthenia has existed either in the immediate family or in the patients themselves. Hasse23 is also of the same opinion.
23 Loc. cit.
Whittaker24 states that many of the cases coming under his notice, if not the majority, occurred in individuals of irritable nervous temperament, subject themselves to, or the descendants of parents afflicted with, migraine, chorea, epilepsy, paralysis, or some form or other of neurosis, but that a certain contingent of the minority of cases occurred independently of any neurosis or any abuse of alcohol or sexual excess.
24 Cincinnati Lancet and Clinic, N. S., vol. iv. p. 496, 1880.
Fritz,25 after studying 25 cases of writers' cramp, found 7 who either stuttered, squinted, or had choreoid movements or œsophageal spasm at the same time; but it is probable that a few of these cases at least were due to some central lesion (post-paralytic chorea?).
25 “Ueber Reflexionsfingerkrampf,” Oesterr. Jahrb., März u. April, 1844, quoted by Hasse, loc. cit.
Beard26 holds an opinion directly the reverse of the vast majority of the authorities upon this subject, and states that this disease occurs mostly in those who are of strong—frequently of very strong—constitution, and that it is quite rare in the nervous and delicate; and when it does occur in those who are nervous it is easier relieved and cured than when it occurs in the strong.
26 G. M. Beard, M.D., loc. cit.
That in the majority of the cases there is an emotional factor is evident to every one who has seen a considerable number, the knowledge that some one is looking on and will notice the disability being almost sure to aggravate the symptoms. This is frequently noticed among telegraph operators, and is well exemplified in the following answer made by a female operator: “If I am working with a disagreeable or fault-finding operator, who I know will make unpleasant remarks about my sending, and break me (break the circuit) on certain difficult letters, it is almost impossible to make those letters correctly with either hand.” Again she says, “If I come to the difficult letters without thinking about them, I can make them much easier than if I look ahead in the message and see them; for instance, some time after I had ceased using my right hand on account of the cramp, an outside occurrence made me very angry; just then a message was placed on my desk, and with my mind fully occupied with my grievance I sent the message with my right hand very easily and quickly.”
Wasting Diseases.—These favor the production of these affections in those predisposed to them by occupation or otherwise, by the constant drain upon the system. Numbness of the fingers and stiffness are occasional symptoms of renal disease, and would naturally aggravate any difficulty of writing and so-forth that the patient might have. Mitchell27 reports two cases of writers' cramp dependent upon or coincident with albuminuria, which were treated in vain until the condition of the kidneys was discovered: under appropriate treatment for this condition one recovered entirely from the cramp and the other improved greatly.
27 S. Weir Mitchell, M.D., “Nervous Accidents in Albuminuria,” Philada. Med. Times, Aug. 1, 1874, p. 691.
Traumatism, etc.—Injuries, etc. occasionally act as predisposing causes; thus cases are on record where the starting-point seemed to have been an ingrowing thumb-nail, and others where it was the pressure of large sleeve-buttons upon the ulnar nerve; and tight sleeves seem to have been the starting-point of inflammatory troubles ending in writers' cramp. An inflammation of the periosteum of the external condyle (node) and a painful ulcer upon the forearm are reported by Runge28 as giving rise to symptoms closely allied to this affection. Seeligmüller29 mentions a case where the symptoms came on after an insignificant grazing bullet-wound of the knuckle of one of the fingers.
28 “Zür Genese u. Behandlung des Schreibekrampfes,” Berl. klin. Wochensch., x. 21, 1873.
29 Adolph Seeligmüller, “Lehrbuch der Krankheiten der Peripheren Nerven, etc.,” Wreden's Sammlung, Kurzer Med. Lehrb., Band v. p. 29.
SYMPTOMATOLOGY.—Owing to the fact that various causes give rise to these affections, and that the different groups of muscles implicated differ with the varying occupations of those suffering, no one stereotyped set of symptoms can be described as applicable to each case, and no one symptom can be looked upon as diagnostic.
The symptoms most frequently seen may be classified under five heads—viz.: I. Cramp or spasm; II. Paresis or paralysis; III. Tremor; IV. Pain or some modification of normal sensation; V. Vaso-motor and trophic disturbances.
These may, and generally do, exist in various combinations, and they may be accompanied by other symptoms of nervousness; they are not of necessity confined to the hand or arm, but may become more or less general. At first they are usually only seen after long continuance of the occupation which produced them, but later any attempt to perform this act will cause their appearance, although it may not be noticed in any other of the daily avocations.
In some of the rarer cases the neurosis makes its appearance suddenly after a prolonged siege of work. It has been generally stated that writers' cramp, for instance, only manifests itself on attempting to write, but this is due to the fact that there is no other occupation which exactly needs the same co-ordination of the muscles, for others can be substituted in the place of those affected. This is particularly seen in the early history of the cases, but when it has become pronounced in character any analogous movement, such as holding a spoon or fork or paint-brush, will be sufficient to produce it. Difficulty in buttoning the clothes with the fore finger and thumb is frequently noticed.
I. Cramp or Spasm (Spastic Form).—The first form of this disease to be considered is that in which cramp or spasm is present. This is one of the most frequent symptoms, and when present usually attracts the most attention. In most of the articles written upon these affections great importance has been given to this symptom, which, however, may be absent during the whole history of the case, but when it does appear it usually indicates an advanced stage. The term writers' cramp is an evidence of the widespread opinion of the importance of this symptom.
The cases that present themselves to the physician have usually been affected for some time, and where cramp is present an earlier examination would probably have resulted in the discovery of premonitory signs before the appearance of the spasm or cramp; and in fact it may be stated that this symptom is always preceded, or at least accompanied, by one or two more. The muscular contraction may be so slight as to amount to a mere occasional awkwardness, in writers' cramp an abnormal grasp of the pen-holder being all that is noticed; or it may be so severe as to cause a tonic contraction of the muscles affected, which may continue for some time after the exciting cause has been removed, as in the cases reported by Poore30 and S. Weir Mitchell.31
30 Electricity in Medicine and Surgery, London, 1876, p. 209.
31 “Functional Spasm,” Amer. Journ. Med. Sciences, Oct., 1876, pp. 322, 323.
As might be supposed, these spasms affect most usually the upper extremities, although they may affect the lower, as is occasionally seen in workers on the lathe and in pedestrians. Other muscles than those necessary to perform the act that has become difficult may also be seized with spasm coinstantaneous with the spasm of the affected part; thus the left arm may be the seat of associated movements while the right is being used: these are, however, most frequently seen in the affected arm when the other is being used to relieve it; they may also be noticed in the legs, although much more rarely.
Gallard32 reports a case of a street-pavior who had associated spasm of both sterno-cleido-mastoid muscles, which came on only when using the instrument to settle the stones. Dally33 reports a case of a woman who had spasm of the left sterno-cleido-mastoid muscle at the time the right hand was seized with cramp in writing. More rarely all the muscles on one side of the body may be affected. Reynolds34 reports such a case.
32 “Crampe des Écrivains,” Progrès médical, v., 1877, p. 505.
33 “Traitement des Spasms professionnels,” Journ. de Thérapeutique, No. 3, 10 Fèvrier, 1882.
34 System of Medicine, “Writers' Cramp,” vol. ii. p. 287.
In the spastic form of the disease an early investigation usually shows a rigidity or spasm of one or more of the fingers, coming on when an attempt is made to perform the act which originated the trouble, and occasionally only on performing that act; but this statement, so strongly insisted upon by some authors as a diagnostic symptom, does not universally obtain.
The contraction may affect either the extensors or the flexors; in the former case—in writing, for instance—the pen can with difficulty be kept upon the paper, and the stroke movement is interfered with; if the spasm is of the flexors, which is of the most common occurrence, it usually affects the fore finger and thumb; the pen is then forced downward, and upon attempting to make the upward movement catches in the paper; besides, there may be with this a flexion and adduction of the thumb, which causes the pen-holder or pencil to be twisted from the grasp, occasionally with sufficient force to throw it to some distance. The other fingers may be similarly affected. The supinator longus is quite a common seat of spasm, the pen being thereby drawn from the paper by a partial supination of the forearm.
Sometimes the character of the spasm cannot be described, the hand seeming to run away with the pen.
The patient who feels these spasms or contractions coming on soon changes the manner of holding the pen-holder, so as to relieve the affected muscles and to use those which are but slightly or not at all affected. Many grotesque manners of writing may thus be encountered. One sometimes employed by those seriously affected is to grasp the holder in the closed hand, holding it nearly at a right angle to the forearm, all movements being made with the whole arm, thus relieving the finger-muscles. The diagram on p. 457 shows the method of writing adopted by a patient who has a marked spasm of the flexors of the fingers and thumb, preventing his writing in the ordinary manner; he is also the subject of telegraphers' cramp.
These means, however, give but temporary relief, as, sooner or later, if writing is persisted in, the muscles of the arm and shoulder become implicated.
In telegraphers the extensors of the wrist are frequently affected, so that the operator is unable on account of the spasm to depress the key of the instrument with sufficient force to close the circuit, the signals being made, so to speak, in the air, or else a dot (.) is made in place of a dash (—). The extensor spasm seems to be the most frequent form of the cramp among telegraphers, many of them saying that they are unable to keep their fingers upon the key-knob. It will generally be found that the characters that are the most difficult to make are those which are composed entirely of dots, such as h (....), p (.....), 6 (......), or those ending with dots, such as b (—...), d (—..), 8 (—....). Some of the spaced characters are also difficult to make, such as z (... .), & (. ...), y (.. ..).
FIG. 29.
Occasionally one finger will become rigidly extended during telegraphing, and any attempt to prevent this will bring on great discomfort and greater disability. When, more rarely, it is the flexors which are affected, the key is depressed with undue force at the wrong time, and a dash is made where a dot was intended, or an extra dot or so introduced, or the proper spacing of the characters prevented, thus rendering the message unintelligible.
The telegraph operators who experience the most difficulty in transmitting usually have a cramp of the extensors, and those having the most difficulty in receiving (writing) usually have a cramp of the flexors, although the reverse is occasionally seen.
In some cases of the spastic form of copodyscinesia the contraction almost becomes tetany; thus there may be a contraction of the flexors of the wrist, which comes on whenever any attempt is made to use the hand, although the fingers may be entirely unaffected, or there may be a more or less constant contraction, greatly exaggerated on any attempt at motion.
Lock-spasm, as described by Mitchell,35 is a rare form of this affection: in this the fingers or hand become locked, so to speak, in a strong contraction, even stronger than the patient could ordinarily produce by an effort of will; this lasts for a considerable time, and after its disappearance the customary work may be resumed. Duchenne36 likewise reports some curious cases of functional spasm analogous to the foregoing.
35 Loc. cit.
36 Duchenne (de Boulogne), “Note sur le Spasm functionnel, etc.,” Bull. de Thérap., 1860, pp. 146-150.
II. Paresis or Paralysis (Paretic Form).—More or less weakness of some of the muscles of the hand or arm is frequently seen in cases of copodyscinesia; this is, however, less common than the spastic form, and, like the latter, is preceded or accompanied by other symptoms. This form occasionally follows the spastic, or it is seen in those cases where the cause of the trouble has been a preceding neuritis, or it may be due to professional muscular atrophy as described by Onimus,37 where, contrary to the ordinary rule, excessive use of a muscle or set of muscles produces, instead of hypertrophy, a condition of considerable atrophy, usually of the larger muscles first, which is preceded for some time by pain and cramp in the affected parts, with fibrillary twitchings; this is amendable rather rapidly under appropriate treatment, and thus differs from progressive muscular atrophy, with which it is apt to be confounded.
37 E. Onimus, “On Professional Muscular Atrophy,” Lond. Lancet, Jan. 22, 1876.
Some of the cases of this group may be confounded with those of the former, as there may be an apparent cramp or spasm of the unopposed healthy muscles. Zuradelli38 considers this condition to be the one ordinarily found in this disease.
38 Crisanto Zuradelli, Gaz. Med. Ital. Lomb., Nos. 36-42, 1857; also Ann. Universali, 1864.
A paretic condition of one muscle may coincide with a spastic condition of another not its opponent, the paralyzed muscle being the one first affected.
When a patient with paresis or paralysis as the most prominent symptom attempts to write, an intense feeling of fatigue usually appears, and the writing becomes difficult or impossible—not from a too ready response and spasm, but from an inability of the muscles to obey the will; the pen-holder is held in a feeble manner, and sometimes falls from the grasp. There may be a sense of utter weakness and powerlessness, the arm feeling as if glued to the table.
Duchenne39 calls attention to this form of trouble, which he styles paralysie functionelle, and states that it is much less common than functional spasm.
39 Loc. cit.
New methods of holding the pen are as constant in this form as in the spastic, as it is as necessary in one as in the other to avoid as much as possible the use of the affected muscles. A carpet-weaver, seen by myself, was obliged to tie the knots in the warp on the distal extremity of the second phalanx of the thumb, as the extensor secundi internodii pollicis was partially paralyzed, so that he was unable to keep the distal phalanx extended. This condition came on when he was a compositor, and compelled him to change his trade. A condition of spasm had preceded the paralysis.
The first dorsal interosseus muscle is frequently the seat of paresis; this is readily discovered by measuring the power which the patient has of lateral movement of the index finger and comparing it with that of the sound hand.
III. Tremor (Tremulous Form).—Trembling or unsteadiness of the fingers is occasionally seen, usually most marked in the fore finger when the hand is at rest with the fingers slightly separated. In some cases this may be sufficient to cause unsteadiness in work, prolonged work and over-fatigue being most apt to produce it; as previously mentioned, this is one of the premonitory symptoms of professional muscular atrophy. An oscillatory trembling, due to implication of the supinators and pronator, is described by Cazenave,40 which interfered greatly with the act of writing. Tremor is of itself rarely complained of by those affected with copodyscinesia, unless it becomes sufficiently marked to cause interference with work.
40 “Observations de Tremblements oscillatoires de la Main Droite,” Gaz. méd. de Paris, 1872, pp. 212-215.
A peculiar form of nystagmus occasionally seen in miners may be considered as belonging to this category. According to Nieden of Bochum41 it is caused by eye-strain in the defective illumination of the mines, and consists not of a spasm, but of a defective innervation, like the tremor of old persons. C. B. Taylor42 of Nottingham and Simeon Snell43 also speak of this as a fatigue disease.
41 “The Pathogenesis and Etiology of Nystagmus of Miners,” Am. Journ. Med. Sci., Oct., 1881.
42 Quoted by Poore, loc. cit.
43 “Miners' Nystagmus,” Brit. Med. Journ., vol. ii., 1884, p. 121.
IV. Pain, or Some Modification of Normal Sensation.—Every case of copodyscinesia, without exception, has at one period or another of the disease some modification of normal sensation in the hand or arm. Usually the very first symptom that attracts the patient's attention is a sense of fatigue or tire in the hand or arm, which at first appears only after a considerable amount of work; if rest is taken now, the part regains its normal condition, but if the work is continued the sensation increases, and the amount of labor necessary to cause the disability gradually grows less and less until any attempt suffices to produce it. A painful sensation or a sense of heat may be experienced in the shoulders or in the cervical or upper dorsal spine at the time the foregoing symptoms are felt.
These symptoms are due to chronic fatigue in many instances, this being an important factor in the causation of these troubles. An expression frequently used by those affected is that the hand or arm becomes lame; this sense of tire may be slight or may be of an intense aching character, almost unendurable.
Should spasm supervene, then there will be a sense of tension and pain in the rigid bellies of the muscles. When a subacute neuritis is present, as frequently occurs, all the symptoms common to that condition appear—viz. pain over the various nerve-trunks and at the points of emergence of their branches, either spontaneous or only solicited on pressure; areas of hyperæsthesia or anæsthesia; a sense of itching or tingling or pricking in the arm or hand; or a sense of numbness, causing the part to fall asleep.
As previously mentioned under Etiology, pain may be absent in some cases of subacute neuritis. Occasionally, the distal phalanx of the fore finger or thumb becomes exquisitely sensitive to pressure, and there may be a burning or stinging pain under the nail, severe enough to make the patient think local suppuration is about to take place.
Sensory disturbances in the region of the hand supplied by the radial nerve are quite common, less so in the region supplied by the median, and least of all in the ulnar distribution. This last having never been seen by Poore, although, as pointed out by him, the muscles supplied by the nerve are those most frequently implicated in this disease when it affects scriveners, his explanation is that the deep motor branches are widely separated from the sensory branches of the nerve, while this is not true of the radial.
One case of impaired sensation affecting the ulnar distribution, and consisting of slight numbness of the palmar surfaces of the ring and little fingers, has come under my observation. The patient was a young woman affected with pianists' cramp, having as its foundation a subacute neuritis of the musculo-spiral and ulnar nerves; the trouble had lasted five years.
A curious form of pain, as of a bar thrust diagonally through the hand, has been complained of; again, the arm, hand, or fingers may be the seat of a subjective sensation of weight, so that one arm will feel very much heavier than its fellow, or the hand may feel as heavy as lead. A soreness and sense of tightness, as of a band around the wrist, a throbbing and pulsation, or a tense feeling as if the skin would burst when the hand was closed, have been noticed occasionally.
V. Vaso-motor and Trophic Disturbances.—Among the rarer symptoms seen are vaso-motor and nutritional changes; these never occur alone, but are accompanied by cramp and fatigue or by some evidence of nerve-lesion.
When a patient with this symptom attempts to perform the task which produces the disability, in addition to the fatigue, spasm, or pain the veins on the back of the hand and fingers will be seen to slowly enlarge; this may gradually increase until it extends over the whole arm, the parts becoming more or less turgid with blood, the temperature at the same time being somewhat increased. A marked sensation of throbbing accompanies these symptoms.
Other parts more distant may become affected, the face becoming flushed, palpitation of the heart and profuse perspiration, either local or more or less general, ensuing, followed by exhaustion.
When there is a marked hyperæsthesia of the distal phalanges of the fingers, there may be a glossy appearance of the skin, or the parts may appear inflamed and as if about to suppurate, or there may be chilblains. A rare symptom is change in the character of the nails, which become brittle and crack off like shell, either spontaneously or when an attempt is made to cut them.
GENERAL SYMPTOMS.—Besides the various symptoms above enumerated, there may be others more general in character, such as intense headache and great general nervousness, the emotional character being generally well marked, as is shown by the disability being greatly increased when the patient knows some one is watching and criticising. There may be also vertigo and sleeplessness. When there is an associated spasm of the analogous muscles of the other arm and hand, although there is no apparent trouble in the arm which is being used, it shows that the hitherto almost automatic act is losing some of its automatism: this, although rare, is an important premonitory symptom.
A rare symptom, which, as far as my knowledge allows me to say, is confined to telegraph operators, is an inability to mentally grasp the proper number of dots and dashes composing certain Morse characters: this usually coincides with the difficulty experienced in making those characters after they have been thought of, and also makes it difficult for them to recognize them by sound even when properly made by another person. The characters composed entirely of dots seem to cause the most trouble in this way.
Electrical Reactions.—In those cases where spasm of one or more muscles is a more or less marked symptom electrical examination shows, both to the faradic and galvanic current, a quantitative increase in the reaction, both in the nerves and muscles; with the galvanic current the cathodal closing contraction is more marked than the anodal closing contraction, as in health (KaSZ > AnSZ); only this formula is most marked in the affected arm. When paresis is present there will be a quantitative decrease in the reaction, the formula still being KaSZ > AnSZ. In the same arm some muscles may show a quantitative increase and others a quantitative decrease. Where there is a neuritis present the electrical examination will show a quantitative increase, but where the disease has advanced to degeneration of the nerve the reaction of degeneration will be found, and the formula will be AnSZ > KaSZ; there is, therefore, a qualitative change, but this must be looked upon as rather uncommon in this class of diseases.
Poore44 is of the opinion that increased irritability shows an early, and decreased irritability a late, stage of the same condition. According to his tables, but very few of his 75 cases of impaired writing-power showed this quantitative increase, while every case showing the least evidence of cramp that has come under my observation has shown it in one or more muscles; in a few cases the antagonistic muscles showed a decrease. Increased sensitiveness to both currents is sometimes noticed.
44 “Writers' Cramp and Impaired Writing-power,” by C. V. Poore, M.D., Medico-Chirurgical Trans., vol. lxi, 1878.
COURSE.—The course of the disability is slow and, unless appropriate treatment is instituted, progressive, although at times there are periods during which the symptoms ameliorate without assignable cause, thus giving rise to false hopes. The usual history is that group after group of muscles becomes implicated as these are in turn used to relieve those first affected, the left arm, should this be used, becoming disabled in the same manner as the right, and the unfortunate sufferer is then compelled to give up his calling or else to lessen very materially the amount of his labor.
DURATION.—As might be inferred from what has been written, those who have suffered for years with this affection may expect it to continue for the remainder of their days; but the later investigations upon this subject give rise to much hope that in future the duration of this troublesome complaint will be materially shortened when the disease is recognized early and treatment instituted at the very first symptom.
DIFFERENTIAL DIAGNOSIS.—Although many of the cases of copodyscinesia are diagnosed with comparative ease, there are others which require much study, as there are several disorders which are apt to mislead by the similarity of symptoms.
Any affection of the finger-joints or of the muscles of the hand or arm, or any disease of the nerves or of the spinal cord, from which these nerves arise, or of the corresponding part of the brain, will necessarily interfere more or less with the finer movements of the hand, and yet all these, manifestly, cannot be considered cases of this affection.
Where the symptoms are undoubtedly caused by over-use of a part, by the constant repetition of the same muscular act, although the lesions may vary considerably in the different cases, they may be classed with propriety under the above head; but there is a second class which cannot be so considered, in which there has been a central lesion which has arisen entirely independently of the occupation which has become difficult to perform, and which disability is only one of the many symptoms that have arisen on account of the aforesaid lesion: these are the cases that it is important to differentiate from cases of true copodyscinesia.
When a patient is suffering from a difficulty in performing a fine act of co-ordination where previously there had been no trouble, much information as to the cause may be gained by examining critically the method in which that act is attempted to be carried out; thus, if the patient has a difficulty in writing, his method of holding the pen and his style of writing may throw some light upon the diagnosis; if he holds his pen too firmly or if the down strokes are too heavy, or the writing gradually grows smaller and smaller toward the end of the line, there is a spasm of the flexor muscles; if, on the contrary, the down strokes are imperfectly made or the thumb rises upon the holder, or one finger shows a tendency to straighten itself, the extensors are at fault. Each muscle should then be examined. By asking the patient to make the different movements possible with the fingers and hand of the affected side, and comparing them with those of the sound side, a feebleness of one or more muscles may be detected. The offending muscle may also be detected by electrical examination—by its reacting more or less strongly than its fellow on the other side to the faradic current or showing a quantitative change to the galvanic current.
By stripping the patient to the waist, or at least the arms, and making a careful examination, atrophy or local lesions may be detected that will aid in clearing up the diagnosis.
In telegraphers the mode of manipulating the key should be noted if possible, and the faults made in the different Morse characters studied; this will show as much in this form of the trouble as the mode of writing does in scriveners' palsy.
The condition described by Mitchell45 as post-paralytic chorea may easily be mistaken for these affections, especially where the cerebral lesion was coincident with much manual work (as writing or telegraphing), and was so slight in extent that the paralysis was transient and overlooked, the choreoid movements appearing later, and affecting, as they may do, only the hand. Of this condition Mitchell states “that it may exist in all degrees, with partial loss of power and with full normal strength—that it may consist in mere awkwardness, or exist to the degree of causing involuntary choreoid movements of the parts.”
45 “Post-paralytic Chorea,” by S. Weir Mitchell, Am. Journ. Med. Sci., Oct., 1874.
The diagnosis can, in most cases, be satisfactorily arrived at by careful consideration of the history of the case, the mode of onset, the presence of some other signs of cerebral lesion, and the examination of the heart and of the urine.
Some cases of paresis of the arm or hand from lesions of slight extent affecting the arm-centres in the brain (minute emboli, disease of the finer vessels, etc.) might possibly be mistaken for the paretic form of copodyscinesia. Two cases46 will illustrate this point:
Case I.—Mr. G.——, æt. 58, dentist. A great writer, although writing was always a difficult task and soon fatigued him. One day, after excessive writing the day previous, he awoke with a loss of power to write from an inability to properly co-ordinate his muscles; his hand was not unsteady, motion was apparently unimpaired, and his power good, but after laboring for ten or fifteen minutes he would drop the pen. He was treated for writers' paralysis, and gradually improved. One year later he was seized with aphasia and entire loss of power in the right arm and leg. His further history is that of right hemiplegia, and not interesting in this connection.
Case II.—Mr. W——, civil engineer, æt. 54. Until July, 1881, he considered himself a healthy man, although very excitable; he was then engaged in calculating and writing almost steadily for one week, which exhausted him exceedingly; following this, he was engaged in an abstruse calculation lasting another week, and at the end of this period he awoke to find himself powerless to extend or flex his wrist, and, to use his expression, his thumb would gravitate into his palm. The movements of the shoulder and arm were comparatively unimpaired, and with the exception of occasional dimness of vision of the right eye there was no other symptom noticed. In one week he considered himself well again. In July, one year later, after again passing through a period of exceedingly hard work, he awoke to find that he had lost sensation on the right side and had some difficulty in articulating (muscular). Although thus warned, he worked steadily for twelve hours the next day, in consequence of which he completely broke down. After this he would occasionally write down a wrong word or put down a wrong figure in calculating, etc. One month later he had a transient attack of loss of power in right leg and other signs of partial right hemiplegia, which was in all probability due to an embolus, as there was a marked aortic systolic murmur.
46 From S. Weir Mitchell's notebooks.
The point brought forward by Axenfield47 that the paralysis in brain lesions manifests itself equally in all movements of the fingers, while in writers' cramp, etc. there is integrity of all movements except those necessary for the special act, cannot be accepted as diagnostic.
47 Des Névroses, par le Docteur Axenfield, Paris, 1864, p. 389.
Progressive muscular atrophy, as previously mentioned, bears a close resemblance to professional muscular atrophy (Onimus), which may be considered one of the forms of copodyscinesia. The resemblance, together with the few points of difference, may be best seen in the form of a table, thus:
The ordinary course of symptoms in this disease is not always followed out, and occasionally the resemblance of the initiatory symptoms to one of the forms of copodyscinesia is great; the following is a case in point:
W. F. G——, æt. 34, clerk, at one time an excessive smoker and a steady writer. In the autumn of 1883 he noticed a numbness on the ulnar side of the tip of the right index finger and on the radial side of the middle third of the right middle finger, at about the points touched by the pen-holder, which he held between these two fingers; this was soon accompanied by a hyperæsthesia to light touches, and the two together seriously interfered with pen-prehension; he then changed the pen to the left hand, and soon noticed a numbness on corresponding points on the left fingers. Any sudden extension of the right arm would cause a thrill to shoot down into the fingers. Weakness of the right opponens pollicis was present at the same time. These symptoms caused the first physician consulted to make a diagnosis of writers' palsy, but the later manifestations of the disease, six weeks subsequently, soon showed its true character: these were marked atrophy of the external portion of the thenar eminence (opponens pollicis) and weakness and partial atrophy, and finally total loss of power, of the anterior group of muscles of right leg (tibialis anticus, extensor proprius pollicis, and extensor longus digitorum); numbness and hyperæsthesia, as in the hand, appeared over instep. Fibrillary twitchings were absent. The affected muscles did not respond to the faradic current, while to the galvanic current there was a quantitative lessening, the reaction still being normal in kind—viz. KaSZ > AnSZ.
Paralysis agitans and multiple sclerosis both interfere with writing on account of the tremor of the muscles; the latter disease markedly so, as voluntary effort increases the trembling.
According to Sigerson,48 the flexors are the least affected in the former disease, and the extensors most so, especially the interossei, which are the earliest involved; the down strokes of the writing will therefore be made with comparative firmness, while the up strokes will show the tremor.49
48 Lectures on the Diseases of the Nervous System, by J. M. Charcot, trans. Philada., 1879, foot-note by Sigerson, p. 113.
49 Ibid., p. 112.
The writing in multiple sclerosis is much more wavy and irregular, although the same tendency to firmness in the down strokes may still be seen.50
50 Ibid., foot-note by Bourneville, pp. 153, 154.
Both these diseases, when well pronounced, should occasion no trouble in diagnosis, but there are cases where the symptoms are not typical, and where the sclerotic change is slight in amount and principally limited to the arm-centres in the cord, or at least to the anterior columns, the symptoms being confined to the finer movements of co-ordination of the hand and arm, and necessarily interfering with such occupations as writing much more than with those which only necessitate coarser movements. The following cases illustrate this point:
Case I.—J. S——, æt. 67, male. Two relatives had paralysis agitans (?). Previous health good; present trouble began nine years ago. Tremor first noticed in writing, and only then, but later any voluntary effort of right arm was accompanied by a fine tremor, which became particularly noticeable when the arm was semiflexed. This is now equal in both arms. When patient writes slowly and with great attention to each movement, he can write fairly for a short time; but if he attempts to write quickly, there is a marked tremor which renders the letters sometimes almost illegible. The up strokes show the most tremor. There is no festination, no change in voice, no loss of power over the sphincters, and no loss of reflexes; the reaction to the galvanic current is normal.
Case II.—W. H——, æt. 58, male. For fifty years the patient has been a hard writer, first as an editor and later as a cashier. In 1882 he noticed difficulty in raising arm to put away papers in pigeon-holes above his head; this movement caused pain in shoulder and arm. Shortly after this he found that his hand became tremulous when he attempted to write, and later any voluntary effort was sufficient to cause the tremor. There has been no cramp. The grip of both hands is good, nor is there any wasting of the muscles. Standing with eyes closed causes no swaying, although there are occasional vertiginous attacks. While walking he has noticed that the right arm does not swing with its usual freedom. No ataxic pains are present. Reflexes of right arm and shoulder are very much exaggerated; there are no changes in nutrition or sensation. Galvanic reaction normal and alike in both arms. The urine is non-albuminous.
The following case is in all probability one of diffused sclerotic changes in the right lateral half of the cord, where the disease has apparently ceased advancing:
Case III.—T. L——, æt. 45. In 1880, three years ago, patient noticed occasional formication in various parts of the right face, hand, and leg, which ceased after he suspended the use of tea and coffee; soon after this he noticed that his writing began to lack ease and that the letters became crowded toward the end of the line; later, a fine tremor appeared in the fingers of the right hand; crampy sensations then appeared in the hamstring muscles of right leg, chiefly while sitting with the knee bent at right angles; writing with the right hand was sufficient to cause, or at least aggravate, this. In 1882 the right arm lost its automatic swing during walking, although holding the left arm still would enable the right arm to swing automatically. Lately the symptoms have ceased advancing, and some seem to improve. His present condition is an inability to write with right hand without paying great attention and making each letter separately, and a trembling of fingers during excitement of any kind. Coarse movements of co-ordination can, as a rule, be well performed; there is no increase of reflexes, nor are they absent; there is no ataxic gait, and there are no trophic changes. Galvanic reaction is normal, and alike on both sides. There is no history of hereditary disease or of venereal taint.
In this connection it is proper to mention tremor mercurialis and tremor saturninus, which might possibly lead to mistake should proper attention not be paid to the history and to the symptoms. Paul51 reports a case of the former affection, and gives a specimen of the handwriting of the patient.
51 C. Paul, Bull. et Mém. de la Soc. de Thérap., Paris, 1881, xiii. pp. 129-131.
Traumatisms, etc. of the various nerves of the arm usually interfere with the proper play of the muscles supplied by them, and although certain of the milder forms of inflammation or of congestion, as previously mentioned, are sometimes present in cases of copodyscinesia, it is manifestly improper to include all cases of impairment of hand-and-arm movement from nerve-injury under this head.
Palsy from pressure, as from sleeping with the head resting upon the arm or with the arm hanging over the back of a chair, is a frequent cause of paresis or paralysis of the muscles supplied by the musculo-spiral.
Tumors pressing upon the nerves in any part of their course, or neuromata, may be mentioned among the more ordinary affections that possibly might mislead.
Tenosynovitis which is described by Hopkins52 as a congestion of the tendinous sheaths in the forearm, with insufficient lubrication of the same, causing pain and interfering with motion, might be mistaken for the disease in question, especially as it occurs in many of the same occupations which furnish cases of copodyscinesia.
52 Wm. Barton Hopkins, “Tenosynovitis,” Med. News, Philada., July 15, 1882.
The exciting cause of tenosynovitis is “usually the resumption of work to which the individual is thoroughly accustomed after a shorter or longer interval when he is out of practice,” and not the monotonous repetition of the same act. The differential diagnosis should occasion no difficulty, as there is soreness amounting to positive pain upon motion or pressure along the course of the affected tendons, and the peculiar creaking which is communicated to the finger on palpation.
PATHOLOGY AND MORBID ANATOMY.—Unfortunately for correct determination of the pathological conditions underlying these neuroses, there have been no reported examinations of the spinal cord and nerves in subjects affected with copodyscinesia dying from intercurrent diseases, although it is probable that no macroscopic lesion would be discovered.
Solly53 reports the post-mortem appearance in a case of impaired writing-power in which he found a granular disintegration of the cervical portion of the cord; but this case, from his description, was evidently one in which the impairment of power was merely one of the numerous symptoms dependent upon disease of the cervical cord from degenerative changes, and not a true case of writers' cramp. If such a condition underlaid these neuroses, the cures occasionally reported and the relief frequently felt after the use of the galvanic current could not be explained.
53 London Lancet, vol i. p. 113.
In default, then, of positive information upon this point, conclusions must be drawn from a study of the symptoms, the course, and the behavior of these diseases under treatment. An affection of such protean aspect is not likely to have one settled pathological condition underlying it.
Many affections considered hitherto purely functional have under our more advanced knowledge been found to have as a basis a positive organic change.
On the subject of fatigue, Poore54 concisely states that the symptoms “are referable to the muscles, but we must always bear in mind that muscles and motor-nerve are one and indivisible, and that recent experiments have given great probability to the idea that every muscle is connected with a definite spot in the brain; when, therefore, we speak of a sense of fatigue, we must necessarily be in doubt, notwithstanding the fact that the symptoms are referred to the muscles, whether brain, nerve, or muscle, one or all of them, be really at fault.”
54 “On Fatigue,” London Lancet, vol. i., 1875, p. 163.
There is a certain limit to which exercise of a given group of muscles may be carried without producing fatigue and local congestion, or perhaps even inflammatory results; this varies greatly in different individuals, but if it is continually and uninterruptedly overstepped, and insufficient time given for rest and recuperation, the centres in the spinal cord which regulate the action of the various muscles implicated become overstimulated, and the result is an undue amount of nervous energy induced by the peripheral excitation, or there is a distortion of the central impulses in passing through these centres: a perturbation of the co-ordinating power ensues and inco-ordination is the result. Under rest and appropriate treatment these symptoms may pass away, but if the part is continuously used it is highly probable that nutritive changes will be produced in that part of the spinal cord from which the nerves supplying the overtaxed muscles proceed.
In some cases of hemiplegia there is produced during gaping and sneezing an automatic movement of the paralyzed arm; this was noticed as early as 1834 by Marshall Hall,55 and in 1872, Onimus56 noticed that movements of the hand and fingers of the non-paralyzed arm produced similar movements in the paralyzed side.
55 Quoted by Charcot, Diseases of Spinal Cord, transl. by Comyges, Cincinnati, 1881, p. 110.
56 Ibid.
Erb57 states that these movements in certain spinal troubles are partly owing to the establishment of conditions of irritation in the neighborhood of the lesion.
57 Ziemssen's Cyclopædia, Amer. ed., vol. xi. p. 409.
Hitzig58 states that in certain pathological conditions where the ganglionic elements (in the cord) are superexcitable, the least disturbance produced on one side, and which determines there a voluntary movement, may be communicated to the other side, and provoke, according to the case, either movements similar to a voluntary one or a spasmodic movement which is really a contraction; and also in certain cases relations of the same nature may be established among cellular groups quite distant from each other; and we can comprehend that in these cases the voluntary movements executed by the sound side may be re-echoed in that which is diseased.
58 Quoted by Charcot, loc. cit., p. 124.
This apparent digression bears an important relation to the pathology of copodyscinesia, and lends force to the view that the associated movements which occur in the well arm, or in the affected arm when the sound side is used, or even in the face and legs, and which are quite often seen in these affections, are due to the fact that there is a central change.
Mitchell,59 in speaking of functional spasms, states that it will be found in all these cases that when an ordinary functional motor act gives rise to spasms elsewhere, these occur in muscles which have physiological, and therefore anatomical, relations to the muscles which by their normal use give rise to the morbid activities. He considers that there is a hypersensitizing of the sensory centre which takes record of the activities of the affected muscles.
59 “Functional Spasms,” Amer. J. Med. Sciences, Oct., 1876.
The fact that the left hand becomes implicated in some cases where it is used to relieve the right should be mentioned in this connection as lending weight to this hypothesis, especially as in a few cases of telegraphers' cramp the left hand has been found implicated in the very first attempt to use it in telegraphing.
Poore60 considers this transfer as no evidence that the change is central, and is one of the few who consider the pathological conditions as purely peripheral in character. Hamilton61 and De Watteville62 also consider the peripheral hypothesis the correct one.
60 Loc. cit.
61 Nervous Diseases, Philada., 1881.
62 “The Cure of Writers' Cramp,” Brit. Med. Journ., 1885, vol. i. pp. 323-325.
Fritz63 (and after him Poincaré64) considers the disease a reflected neurosis, due to a perversion of the muscular sense. Onimus and Legros65 incline to the same opinion.
63 Oesterr. Jahrb., März u. April, 1844.
64 Le Système nerveux-péripherique, Paris, 1876.
65 Traité d'Electricite médicale, Paris, 1872, p. 327.
The older theory that the disease is solely central in its pathology is advocated by Duchenne,66 Solly,67 Reynolds,68 Althaus,69 Wood,70 Vance,71 Erb,72 Dally,73 Axenfield,74 Whittaker,75 Waller,76 Gowers,77 Hammond,78 Romberg,79 Cederschjöld,80 Robins,81 Ross,82 and some others. Roth83 considers that there are two entirely separate classes, the central and the peripheral or local.
66 De l'Électrisation localisée, 3d ed., pp. 1021 et seq.
67 London Lancet, Jan. 28, 1865.
68 System of Medicine.
69 Julius Althaus, London Mirror, vol. vii., Aug. 1, 1870; also, pamphlet, Scriveners' Palsy, London, 1870.
70 Practice of Medicine.
71 Reuben A. Vance, Bost. Med. and Surg. Journal, vol. lxxxviii. p. 261.
72 Ziemssen's Cyclopædia, vol. xi. p. 355.
73 Journal de Thérapeutique, Paris, 10 Fév., 1882.
74 Des Névroses, Paris, 1864.
75 Cincinnati Lancet and Clinic, 1880, N. S., vol. iv. p. 496.
76 Aug. Waller, Practitioner, 1880, vol. ii. p. 101.
77 W. R. Gowers, Med. Times and Gaz., 1877, vol. ii. p. 536.
78 Treatise on Dis. of Nervous System, 6th ed., New York, 1876.
79 Manual of Nervous Dis. in Man, Sydenham Society, vol. i.
80 Gustaf. Upsala läkarefören, förhandl. xv., 3 och. 4, S. 165, 1880, review in Schmidt's Jahrb., Bd. clxxxvii., 1880, p. 239.
81 “Writers' Cramp,” Amer. Journ. Med. Sci., April, 1885, pp. 452-462.
82 A Treatise on Diseases of the Nervous System, London, 1881, vol. i. pp. 464-469.
83 The Treatment of Writers' Cramp, by Roth, London, 1885.
The later theory, that the disease is at first peripheral, but that by abuse may become central (spinal), is advocated by Beard,84 Liebman,85 Bartholow,86 Frazer,87 and a few others. The latter theory, and not the idea that it is a disease of the co-ordinating centres in the brain or of the spinal centres only, best explains, in my opinion, the various symptoms encountered.
84 New York Med. Record, 1879, p. 244.
85 Maryland Med. Journ., June, 1880-81, vol. vii.
86 Medical Electricity.
87 Glasgow Med. Journ., 1881, vol. xv. p. 169.
Many others have written upon this subject, but upon the probable pathology they have been silent.
The experiments recently made by Dercum and Parker88 on the artificial induction of convulsive seizures are of considerable interest, and certainly tend to throw light on the point in question. These convulsions were produced by subjecting a group of muscles to a constant and precise effort, the attention being at the time concentrated upon some train of thought. The position most frequently adopted was to cause the arms to be held so that the tips of the fingers barely touched the surface of the table before which the subject was seated, the fingers not being allowed to rest upon the table, but maintained by a constant muscular effort barely in contact with it. After this position was maintained for a variable length of time tremors commenced in the hands; a little later these tremors became rapidly magnified into rapid movements of great extent sometimes to and fro, sometimes irregular; if the experiment was carried still farther, the muscles of the arms, shoulders, back, buttocks, and legs become successively affected, and the subject was frequently thrown violently to the ground in a strong general convulsion, the consciousness being always retained.89 The more frequently these experiments were performed, the more readily the seizures were brought on, and, other things being equal, with successively increasing intensity. One subject thus experimented upon became so susceptible that the jar of a passing wagon sufficed to induce a partial seizure. These experiments throw a new light upon the associated movements previously mentioned, and show how easily the phenomena noticed in one part may pass to another having physiological relationship with it. It is highly probable that some nutritional change in the cord would follow the too frequent repetition of these experiments.
88 “The Artificial Induction of Convulsive Seizures,” Dercum-Parker, The Polyclinic, Philada. 1884, vol. ii. pp. 95-97.
89 These experiments were subsequently repeated before the Philadelphia Neurological Society in 1885.
Peripheral pathological conditions undoubtedly exist in many cases of copodyscinesia; these may be so slight that they can scarcely be demonstrated, or, on the other hand, they may be marked, and even present a well-marked inflammation of one or more of the nerves of the arm, as evidenced by pain on motion, tenderness on pressure, and sensory and nutritive disturbances in the areas which they supply.
There are some cases where the disability is pronounced, and yet the most careful examination fails to reveal peripheral changes of sufficient gravity to account for the severity of the symptoms; these, in my opinion, are best explained by supposing a hyperexcitability of the spinal centres, as previously expressed.
The electrical reaction in many cases tends to prove an irritable condition of the spinal centres. In most of the cases of the spastic group there will be found a quantitative increase in the reaction of both nerve and muscle to the galvanic current. Gowers90 states that he has found such an increase in diseases regarded as functional, as paralysis agitans and chorea, and considers it an interesting proof of the molecular changes which underlie or result from functional maladies. He previously remarks91 that such a condition of exalted irritability is to be ascribed to a corresponding change in the nutrition of the nerve-cells of the spinal cord, secondary to the irritative influence which caused it.
90 Dis. of Spinal Cord, 2d ed., Philada., 1881, p. 40.
91 Med. Times and Gaz., London, vol. ii., 1877, p. 536.
Erb92 also considers that quantitative increase in the electrical reaction points to central lesion. Buzzard93 quotes several authors upon tetany—which some cases of copodyscinesia closely resemble—who state that the electrical reactions are increased quantitatively in that affection, and considers, himself, that the change is due to central lesion.
92 Loc. cit.
93 Thomas Buzzard, Dis. of the Nervous System, London, 1882.
It must be borne in mind, however, that in those cases of congestion of the nerves, or neuritis, previously mentioned a quantitative increase may be found, indicating a hypersensitiveness of the peripheral nerve, and not necessarily of the spinal centres.
Poore94 states: “Thus we see that alterations of irritability” (he especially alludes to depressions) “accompany many conditions, both central and peripheral,” and “there is no necessity for assuming that central change exists in every case of altered irritability, and we have no warrant for such an assumption in the absence of independent evidence of central change.”
94 “Impaired Writing-power,” loc. cit.
Exactly what the alteration in the condition of the spinal cord is which probably occurs in many of these cases it is impossible to state, but the view that it is a nutritive change of the upper dorsal and lower cervical portion of the spinal cord (that is, when the arm is the part affected, as it is in all but the rarer cases) is quite attractive, the condition being secondary to a peripheral irritation in many cases.
Althaus95 considers that there is a “constriction of the small arteries, dilatation of the veins, and slight serous effusions compressing the nervous matter in the cervical spinal cord.”
95 Loc. cit.
Pain in the cervical and dorsal spine during work may be mentioned here as an evidence that some of the symptoms are due to central alterations.
Those few cases that exhibit great difficulty in performing one set of movements that requires a certain combination of muscles, but are able to use those same muscles in combination with others with ease, are difficult of explanation by the peripheral theory of the disease alone; but less difficulty is encountered if a superexcitability of the spinal centres is supposed to exist, for here we can imagine that when all the centres so affected are called into use, and only then, there will be an undue amount of nervous energy transmitted to the periphery, and disordered movement be the result.
The explanation offered by those who believe in the peripheral theory is, that the affected muscle is always imperfect in its action, but that this imperfection is masked in other combinations by the action of the healthy muscles, so that it is no longer noticeable.
PROGNOSIS.—The prognosis in these affections varies with the conditions found and with the previous duration of the disease.
A favorable prognosis may generally be given where the case is an acute one, and where the disability can be proved to be due to some one of the peripheral conditions previously mentioned. When the condition is in the forming stage, when fatigue, stiffness, tremor, tingling, aching, sense of heat, coldness, or powerlessness are the only symptoms which exist, the disease is quite amenable to treatment and a good prognosis may be given; but, unfortunately, patients are loath to believe that these trivial symptoms, which do not prevent their work, are precursors of any serious trouble, and therefore pay but little attention, if any, to them, so that the physician is seldom consulted during this period.
When positive cramp has made its appearance, it is an evidence of a more advanced stage of the malady, and the prognosis becomes less hopeful, although still the symptoms may be greatly ameliorated, or a complete cure even be effected.
When the cramp has existed for years and is present in many of the finer acts of co-ordination, the case becomes almost hopeless as far as cure is concerned; and even though the part is rested, so far as the disabling occupation is concerned, for months or even years, it will be found to return upon resumption of the old work. Roth96 considers those cases due to central changes totally incurable.
96 Loc. cit.
When a congestion of the nerves or a well-defined neuritis is discovered to be the cause of the trouble, the probability of a favorable termination is rather more hopeful.
Paralysis is to be looked upon as an unfavorable symptom, pointing as a rule to a late stage of the disease.
It may be stated with positiveness that when the premonitory symptoms are neglected and constant work persevered in, the case will go on from bad to worse: periods of amelioration, it is true, may occur, but cramp usually supervenes, and the affection becomes gradually progressive as group after group of muscles becomes implicated, until the part becomes useless for all delicate work.
The probability of the left hand escaping, should it be used to relieve or replace the right, is slight; and for two reasons: 1st. The same predisposition which favored the trouble in the right arm still exists; and, 2d. The proximity of the spinal centres for the two arms is such that the morbid process may easily be conveyed from one to the other, as was shown while considering associated movements.
Poore disbelieves in the possibility of such a transfer, and with Gowers is of the opinion that the liability of the left hand to suffer has been overestimated.
In my experience, as regards telegraph operators, the majority who use the left arm soon notice symptoms of the disability in it. Of 43 cases of this form of copodyscinesia which have come under my observation, in 21 the left arm was implicated; in 12 there was no such implication, although the arm was used; of the remaining 10, 8 had never tried to telegraph or write with the left arm; 1 had only one arm, the left; and 1 was doubtful. Throwing out of consideration the last 10, 21 out of the 33 had this symptom, equivalent to 63.63 per cent.
PROPHYLAXIS.—The only prophylactic measures are the observance of the most easy and least fatiguing method of performing the act which it is feared will bring on the trouble, and the avoidance of overwork.
Tobacco and alcohol generally act injuriously, and therefore should be avoided as much as possible by those who are predisposed by occupation or otherwise to these disorders.
In writing it is advisable to avoid an awkward manner of holding the pen-holder, which should be of good size; large, moderately soft pens and paper of good quality should be used.
It is also important that the table or desk upon which the writing is done should be of a convenient height, with plenty of room for the arrangement of the paper; otherwise an awkward manner is inevitable.
As regards the position of the paper, R. Berlin97 (Stuttgart) states substantially as follows: In writing the head is almost invariably held so that the line passing through the two eyes, if projected upon the paper, shall cross at right angles the oblique line of the writing: when the paper is placed to the right and parallel to the edge of the table, as generally directed by teachers, the tendency is to twist the spine and incline the head to the right in order to conform to this rule, and a cramped position is the result; but by placing the paper in an oblique position directly in front of the writer—i.e. turned toward the left—this cramped position is avoided, and the least fatigue, both to the muscles of the spine and arm, produced. Tight sleeves or anything that might possibly impede the free play of the muscles or cause pressure upon the nerves should be discarded.
97 “Physiology of Handwriting,” Von Graefe's Archiv, xxviii. p. 259, review in Ophth. Review, London, vol. i. No. 14, Dec., 1882, and Jan. 1, 1883.
It is now almost universally conceded that the conjoint movement in writing—that is, the arm movement for all the small letters, and the finger movement only to assist in making the long ones—is least likely to produce fatigue.
It has been stated, and quite generally believed, that the slighter degrees of scriveners' palsy are relieved by avoiding contact with the metallic portion of the pen-holder,98 and one of the methods taken to avoid this contact, especially among telegraph operators, is to slip a piece of rubber tubing over the pen-holder; this certainly does relieve the fatigue slightly, but the cause is not the avoidance of contact with metal or the insulation, etc., but simply that the holder is thus made larger and softer for the fingers, and thus takes the place of a cork pen-holder, which for some time has been in use for this purpose.
98 W. Bathurst Woodman, St. Andrews Grad. Ass., 1872-73.
Holding the pen-holder or pencil between the different fingers is another prophylactic measure, and relieves fatigue considerably; for instance, when it is placed between the index and middle fingers there is much less effort at pen-prehension, and the fingers may be temporarily rested without any effort to hold the pen-holder, as the friction between the fingers keeps it in position. This method is frequently adopted by stenographers.
The stylographic and Mackinnon pens, although they destroy much of the originality in handwriting, are easier to write with than a pen, as less pressure is needed and no particular angle is required to be maintained between the point and the paper.
The type-writer is one of the newer inventions destined to come into extended use for the purpose of relieving the fatigue of writing, which it does to a marked degree, besides having other merits; and although one of these is said to be the immunity of its users from writers' cramp, I venture to assert that cases of this class of trouble will ensue from its over-use, exactly as they do in piano-playing.99
99 To print this article by this machine would require nearly one hundred and fifty thousand separate flexions of the fingers.
Thurber's kaligraph, which was invented before the type-writer, has never come into general use: it works upon the principle of a pentagraph, and all finger movements are done away with and the arm movement used exclusively, the motions of writing being much coarser than ordinary. This instrument is not as well adapted for prophylaxis in these troubles as it is for use in some deformities of the hand hindering pen-prehension, as rheumatoid arthritis, contractions after burns, etc.
In regard to the means to be taken to avoid the occurrence of telegraphers' cramp, but little can be said, except that if any of the premonitory symptoms of the neurosis should occur (fatigue, pain, tingling, numbness, flushing, associated movements, etc.) after performing the amount of work which previously caused no discomfort, it should be taken as a warning that the operator is attempting more work than can be done without detriment, and that a curtailment of the work is absolutely necessary if he or she wishes to avoid the disease.
Onimus100 has said that if further investigation proves that the operators upon the Morse instrument are more liable to suffer than those using other systems, it should be the duty of those in authority to abolish that system and adopt some other: he suggests for this object the Hughes, which is a printing instrument. That the operators upon the Morse are more liable to suffer than any others is self-evident after a very slight inquiry, and because of the very general introduction of that machine. This instrument is far more practical, takes up less room, and is less likely to get out of order, than any other yet invented, and no other, it is probable, will be introduced so generally. The telephone has not diminished the amount of work for the telegraph operator, but has given rise to a new industry. In all of the systems the instruments are manipulated at least in part by the fingers, so that all are liable to cause this disease.
100 Loc. cit.
The telegraph key should be placed some distance from the edge of the table, so that the forearm may have sufficient support, resting upon the bellies of the flexor group of muscles, and thus relieve the shoulder-muscles, which otherwise would have to support the weight of the arm. Some operators prefer to hold the arm raised from the table, but this method is more liable to cause fatigue.
Several keys have been invented for the purpose of lessening the amount of force needed to manipulate them, and to avoid the jarring caused by the metallic contact; and, although everything that lessens the amount of labor should be adopted, the movements of telegraphing must remain the same no matter which key is used.
Tapping upon the key or attempting to operate by flexing the fingers while the wrist is held still should be avoided.
It is needless to enumerate the other forms of copodyscinesia, as the same general principles apply to the prophylaxis of all.
TREATMENT.—Rest.—It is an assured fact that as long as the patient continues without curtailment the amount of work he was performing when the symptoms of this trouble appeared, treatment will be negative in its results. Rest in itself is powerless to cure, except in the very earliest stages of the disease, for many sufferers have found, to their dismay, that after having given the arm complete rest, as far as the disabling occupation was concerned, for months at a time, the symptoms reappear upon returning to the accustomed work.
During treatment rest is essential, but this need not of necessity be complete; a curtailment of the work will often be all that is needed in the lighter cases. This may be effected by using the unaffected arm for a part of the work at least, but great care must be exercised lest the symptoms appear on this side also, as the left arm, from want of use, is wanting in strength and dexterity, and is more liable to be overtaxed by an amount of work that could be performed without fatigue by the right; for should this happen the end sought for is defeated, and the condition of the patient rendered far worse than before.
In writers' cramp the type-writer, as mentioned under Prophylaxis, is an important adjuvant in the treatment; unfortunately, it is not applicable to much of the work done by clerks.
The other means described in the last section are also useful in the treatment as affording temporary rest to the affected muscles. Hamilton101 has seen occasional benefit from forced rest by fastening the hand upon a splint.
101 Loc. cit.
In telegraphing, besides using the left arm, the key may be grasped in a different manner, or if the operator has been holding his arm raised from the table, let him rest it upon the latter, or vice versâ.
These remarks only apply to those who are compelled to continue moderate work during treatment.
Electricity.—The majority of the later writers unite in considering electricity as one of the most important agents in the treatment of these affections: the form and the manner in which it is applied are, however, all important.
The faradic or secondary current has often been tried in undoubted cases of copodyscinesia, and in the majority has failed. It may be of great service in the paralytic group, where the affected muscle shows signs of atrophy and of being temporarily deprived of nerve-influence; it may be also of service in those apparent cases of the spastic group due to contracture of the unopposed muscles, but in the vast majority, where there is a true spasm of the affected muscles or a tendency in that direction, as evinced by rigidity more or less pronounced during work, or even where there is only a quantitative increase to either current (faradic or galvanic), the application of this form of electricity is contraindicated, as the muscular contraction is already excessive, and should this extra stimulus be applied the muscle may be exhausted, for we know how readily this effect may be produced by a too strong or a too lengthy application in a perfectly healthy subject.
It is hardly necessary to mention that the manner of applying electricity so often followed by individuals—viz. holding the electrodes in the palms of the hands—is unscientific and productive of no good. The proper method of application in the suitable cases is to place one electrode of the secondary coil (preferably the negative, so called) over the muscle that is weakened or over its nerve-point, and the other in some indifferent position, using a current that is just strong enough to cause a fair contraction, and employing a slow interrupter, which breaks the current from one to four times a second. The application should be short, five to ten good contractions of each muscle being sufficient.
Buzzard102 has used this current with success in two cases of impaired writing-power, one of these depending upon a local paralysis. Zuradelli,103 Meyer,104 and Haupt105 have also seen good results by this method. Duchenne106 states that he has “not even seen one success obtained by those who have praised this method of treatment.” The majority of the later writers coincide with this last opinion as regards the spastic form at least.
102 “Two Cases of Impaired Writing-power,” Practitioner, Aug., 1872.
103 Quoted by Erb and Poore, loc. cit.
104 Ibid., loc. cit.
105 Der Schreibekrampf mit Rücksicht auf Path. u. Therap., Wiesbaden, 1860, review in Schmidt's Jahrbucher, Bd. cxv. 3, 136, 1862.
106 Loc. cit.
The galvanic current has of late been considered one of the most important agents in the treatment of these affections, but there is considerable variance among authorities as to how it should be applied. The most efficacious method is the descending current (anode on the spine and the cathode at the periphery), as this has been found to be more soothing in its effects than the reverse. The anode should be placed upon the spine over the cervical cord, and the cathode in the hand of the affected side or over the affected muscles or nerves.
A stabile current—i.e. where the poles are not moved about—is to be preferred to a labile current—i.e. where the poles are moved constantly—as this is more stimulating than the former; but if a current of proper strength is used, one that can be plainly felt when the circuit is made and broken only, the importance of the stabile over the labile does not obtain.
The treatment should not be prolonged for more than fifteen or twenty minutes, and may be repeated three times a week or every other day.
Onimus and Legros107 recommend this mode of treatment, but from a different pathological standpoint, as they consider the neurosis to be an excitability of the sensitive nerves of the muscles, and employ the descending current to allay this.
107 Loc. cit.
All sudden shocks or reversals of the current should be avoided in the treatment, although this may be necessary in using the galvanic current for diagnosis.
As the seat of the trouble in many cases is probably in the cervical cord, it is well that special treatment should be applied to this part, and for this purpose Althaus108 recommends that the anode be placed, as previously mentioned, over the cervical cord, and the cathode in the depression between the angle of the lower jaw and the sterno-cleido-mastoid muscle, which position corresponds to the superior cervical ganglion of the sympathetic. The current should be allowed to flow from three to five minutes at a time; it should be a mild one, and not be broken or increased or diminished suddenly, as vertigo may be produced. Both sides should be treated should the left hand be suffering also. A reversal of this method—i.e. cathode to spine—does little if any good, according to the same author.
108 Loc. cit.
Poore109 employs the descending stabile current of a strength just short of producing muscular contraction when the current is broken, but at the same time he employs rhythmical movements of the muscles supplied by the nerve upon which the cathode is placed during the flow of the current.
109 Loc. cit.
A novel mode of applying the galvanic current in scriveners' palsy has been recommended by Imlach.110 He has an electric desk so constructed that when the patient makes the movements of writing the extensors and flexors are alternately galvanized, the muscles being thus assisted in their movements. While this might be of service in some cases, it is entirely too complicated for practical use. He reports one case benefited by its use.
110 Francis Imlach, “Automatic and Other Medical Electricity,” Practitioner, vol. ii. p. 270, 1879.
Franklinic or Static Electricity.—This form of electricity is now being much used, especially abroad, in the treatment of nervous affections, but does not appear to have been employed in the different copodyscinesiæ, as but few reports of such treatment have found their way into current literature. Romain Vigouroux111 states that he has cured one case by statical electricity. Another case is reported by Arthuis112 as rapidly cured by this treatment after many other means, carried on during a period of five years, had failed; but his brochure contains too many reports of cures of hitherto incurable diseases to be relied upon.
111 Le Progrès médical, Jan. 21, 1882.
112 A. Arthuis, Traitement des Maladies nerveuses, etc., Paris, 1880, 3me ed.
Gymnastics and Massage.—As those suffering from copodyscinesia are generally compelled by their vocation to be more or less sedentary, exercise in the open air is indicated, inasmuch as it tends to counteract the evil effects of their mode of life; but the use of dumb-bells or Indian clubs, riding, rowing, and similar exercises do not ward off the neuroses in question or diminish them when they are present.
Such is not the case when rhythmical exercises and systematic massage of all the affected muscles are employed, as marked benefit has followed this method of treatment. The method employed by J. Wolff, a teacher of penmanship at Frankfort-on-the-Main, which consists of a peculiar combination of exercise and massage, appears to have been wonderfully successful, judging from his own statements and editorial testimonials of such eminent men as Bamberger, Bardenleben, Benedikt, Billroth, Charcot, Erb, Esmarch, Hertz, Stein, Stellwag, Vigouroux, Von Nussbaum, Wagner, and De Watteville. The method is described by Romain Vigouroux113 and Th. Schott,114 the latter claiming priority for himself and his brother, who employed this method as early as 1878 or 1879. Wolff,115 however, states that he had successfully treated this disease by his method as early as 1875. Theodor Stein,116 having had personal experience in Wolff's treatment, also describes and extols it: 277 cases of muscular spasms of the upper extremities were treated; of these, 157 were cured, 22 improved, while 98 remained unimproved; these comprised cases of writers', pianists', telegraphers', and knitters' cramp.
113 Le Progrès médical, 1882, No. 13.
114 “Zur Behandlung des Schreibe- und Klavierkrampfes,” Deutsche Medizinal Zeitung, 2 März, 1882, No. 9, Berlin; also “Du Traitement de la Crampe des Écrivains, reclamation de Priorité, Details de Procedes, par le Dr. Th. Schott,” Le Progrès médical, 1re Avril, 1882.
115 “Treatment of Writers' Cramp and Allied Muscular Affections by Massage and Gymnastics,” N. Y. Med. Record, Feb. 23, 1884, pp. 204, 205.
116 “Die Behandlung des Schreibekrampfes,” Berliner klinische Wochenschrift, No. 34, 1882, pp. 527-529.
It must be borne in mind that Wolff, not being a physician, can refuse to treat a case if he thinks it incurable; and in fact he does so, as he has personally stated to the writer, so that his statistics probably show a larger percentage of cures than otherwise would be the case.
His method may be described as follows: It consists of a combined employment of gymnastics and massage; the gymnastics are of two kinds: 1st, active, in which the patient moves the fingers, hands, forearms, and arms in all the directions possible, each muscle being made to contract from six to twelve times with considerable force, and with a pause after each movement, the whole exercise not exceeding thirty minutes and repeated two or three times daily; 2d, passive, in which the same movements are made as in the former, except that each one is arrested by another person in a steady and regular manner; this may be repeated as often as the active exercise. Massage is practised daily for about twenty minutes, beginning at the periphery; percussion of the muscles is considered an essential part of the massage. Combined with this are peculiar lessons in pen-prehension and writing.
The rationale of this treatment is not easy, but any method which even relieves these neuroses should be hailed with pleasure, as they heretofore have been considered almost incurable.
The method employed by Poore, as mentioned under Electricity, of rhythmical exercise of the muscles during the application of the galvanic current, is worthy of further trial, as it combines the two forms of treatment hitherto found most successful.
Internal and External Medication.—Generally speaking, drugs are of comparatively little value in the treatment of these affections. This statement does not apply to those cases where the symptoms are produced by some constitutional disorder, or where there is some other well-recognized affection present which does not stand in relation to these neuroses as cause and effect.
In any case where an accompanying disorder can be discovered which is sufficient in itself to depress the health, the treatment applicable to that affection should be instituted, in the hope, however unlikely it is to be fulfilled, that with returning health there will be a decrease of the copodyscinesia. In the majority of cases no constitutional disease can be detected, and it is in these that internal medication has particularly failed.
The following are some of the remedies that have been employed: Cod-liver oil, iron, quinine, strychnia, arsenic, ergot, iodoform, iodide and bromide of potassium, nitrate of silver, phosphorus, physostigma, gelsemium, conium, and some others.
Hypodermic Medication.—Atropia hypodermically, as first suggested by Mitchell, Morehouse, and Keen117 in the treatment of spasmodic affections following nerve-injury, has been used with good effect in those cases where there is a tendency to tonic contraction; it should be thrown into the body of the muscle. Vance118 speaks very favorably of one-sixtieth of a grain of atropia used in this manner three times a week. Morphia, duboisia, and arsenic in the form of Fowler's solution have been used hypodermically with but little effect. Rossander119 reports a cure in one month of a case of two years' duration by the hypodermic use of strychnia. Onimus and Legros120 used curare in one case without effect.
117 Gunshot Wounds and Other Injuries to Nerves, Philada., 1864.
118 Reuben A. Vance, M.D., “Writers' Cramp or Scriveners' Palsy,” Brit. Med. and Surg. Journal, vol. lxxxvii. pp. 261-285.
119 J. C. Rossander, Irish Hosp. Gazette, Oct. 1, 1873.
120 Loc. cit.
Local Applications.—The apparent benefit following the local application of lotions, etc. to the arms in some cases appears to be as much due to the generous kneading and frictions that accompany them as to the lotions themselves. Onimus and Legros, believing the lesion to be an excitability of the sensitive nerves at the periphery, employed opiated embrocations, but report amelioration in one case only.
When there are symptoms of congestion of the nerves or of neuritis, then the proper treatment will be the application of flying blisters, or the actual cautery very superficially applied to the points of tenderness from time to time, so as to keep up a continual counter-irritation. This treatment may be alternated with the application of the galvanic current (descending, stabile, as previously mentioned) or combined with it. As these conditions are often found in nervous women, care should be taken lest this treatment be too vigorously carried out.
Considerable relief has been reported from the use of alternate hot and cold douches to the affected part—a procedure which is well known to do good in some cases of undoubted spinal disease; the application peripherally applied altering in some way, by the impression conveyed to the centres, the nutrition of the spinal cord.
Tenotomy.—Tenotomy has been but little practised for the cure of these affections. Stromeyer121 cut the short flexors of the thumb in a case of writers' cramp without any benefit, but in a second case, where he cut the long flexor of the thumb, the result was a cure. Langenbeck122 quotes Dieffenbach as having performed the operation twice without success, and states that there has been but one observation of complete success, and that was the one of Stromeyer. Aug. Tuppert123 has also performed this operation, and Haupt124 advises it as a last resource.
121 “Crampe des Écrivains,” Arch. gén. de Méd., t. xiii., 1842, 3d Series, p. 97.
122 Ibid., t. xiv., 1842, 3d Series.
123 Quoted by Poore, loc. cit.
124 “Der Schreibekrampf,” rev. in Schmidt's Jahrbuch, Bd. cxv., p. 136, 1862.
Very few would be willing to repeat the experiment in a true case of copodyscinesia after the failures above enumerated, for the temporary rest given the muscle does not prove of any more service than rest without tenotomy, which has failed in all the more advanced cases, which are the only ones where tenotomy would be thought of.
Nerve-Stretching.—It is curious that no cases have been reported (at least I have not been able to discover them) of nerve-stretching for aggravated cases of copodyscinesia, as the operation has been performed in several cases of local spasm of the upper extremity following injuries to the nerves.
Von Nussbaum125 alone mentions the operation, and states that it has been of no avail, but gives no references; he previously126 stretched the ulnar nerve at the elbow and the whole of the brachial plexus for spasm of the left pectoral region and of the whole arm, following a blow upon the nape of the neck; the patient made a good recovery.
125 Aerztliches Intelligenzblatt, Munich, Sept. 26, 1882, No. 39, p. 35.
126 London Lancet, vol. ii., 1872, p. 783.
This operation, according to an editorial in the American Journal of Neurology,127 has been performed seven times for spastic affections of the arm with the following results: 2 cures (1 doubtful), 3 great improvement, and 2 slight relief.
127 Am. Journ. of Neurology and Psychiatry, 1882.
This procedure would seem to be indicated in those cases of copodyscinesia where spasms are present which have a tendency to become tonic in their character, where other means of treatment have failed. One such case has fallen under the writer's notice, which, on account of its singularity and the rarity of the operation, seems worthy of record. The patient is a physician in large practice, and his account, fortunately, is more exact than it otherwise would be:
—— ——, æt. 36. Paternal uncle had a somewhat similar trouble in right arm, father died of paralysis agitans, and one brother has writers' cramp. From nine to twelve years of age he was considered an expert penman, and was employed almost constantly, during school-hours, writing copies for the scholars. At the age of eleven he began to feel a sense of tire in right forearm and hand when writing; soon after this the flexors of right wrist and hand began to contract involuntarily and become rigid only when writing. He remembers being able to play marbles well for two years after the onset of the first symptoms. The trouble gradually increased until every motion of the forearm became involved. At the age of nineteen he became a bookkeeper, using his left hand, but at the end of one year this became affected also. Since then both arms have been growing gradually worse, and at one time exhaustion would bring on pain at the third dorsal vertebra. At the age of thirty a period of sleeplessness and involuntary contractions of all the muscles of the body came on, accompanied by difficulty in articulation from muscular inco-ordination. After persistent use of the cold douche to spine these symptoms ameliorated, but the general muscular twitching sometimes occurs yet, and overwork brings on spasm of the extensors of the feet. The condition of his arms in December, 1882, was as follows: At rest the right forearm is pronated, the wrist completely flexed and bent toward the ulnar side, the thumb is slightly adducted, and the fingers, although slightly flexed, are comparatively free, enabling him to use the scalpel with dexterity. This contraction can be overcome by forcibly extending the fingers and wrist and supinating forearm, but if the arm be now placed in supination the following curious series of contractions occur, occupying from one to two minutes from their commencement to their completion: gradually the little finger partially flexes, then the ring, middle, and fore finger follow in succession; the wrist then slowly begins to flex and to turn toward the ulnar side, and finally the arm pronates, in which position it will remain unless disturbed. The contraction is accompanied by a tense feeling in the muscles, but is painless. The left arm behaves in a somewhat similar manner, and if this is placed in supination a gradual pronation of the arm begins; then follows the flexion of the fingers, commencing with the little finger and ending with the thumb; the wrist also flexes, but not as much as the right, although the flexion of the fingers is more marked. There is no pain on pressure over muscles or nerves. The extensor muscles of both arms, although weaker than normal, are not paralyzed, those of the right responding more readily to both faradic and galvanic currents than do the left. There is no reaction of degeneration. The flexors respond too readily, the right showing the greatest quantitative increase.
In 1879, while abroad, his condition being essentially as above described, he consulted Spence of Edinburgh, who as an experiment stretched the left ulnar nerve at the elbow; immediately after the operation the muscles were paralyzed and the arm remained quiet; in twenty-four hours the nerve became intensely painful, and remained so, day and night, for three weeks; this gradually subsided, and ceased with the healing of the wound two weeks later. Forty-eight hours after the operation the spasm of the muscles returned, and in a short time became as bad as ever, proving the operation to have been a failure.
An interesting point to decide in this case is whether the symptoms point to an abnormal condition of the nerve-centres, first manifesting itself in difficulty of writing, or whether the constant writing induced a superexcitability (for want of a better term) of the spinal cord in a patient markedly predisposed to nervous troubles. This last hypothesis I believe to be the correct one.
It might be considered at first sight that the symptoms presented by this patient were due to a paralytic condition of the extensors, and not a spasm of the flexors, or at least that the latter was secondary to the former. While the extensors are somewhat weaker than normal from want of use, a careful study of the mode of onset of this affection and the symptoms presented later prove this idea to be erroneous.
In regard to the operation and its results, it seems that a fairer test of the efficacy of nerve-stretching in this case would have been made if the median and not the ulnar nerve had been stretched, as the latter only supplies in the forearm the flexor carpi ulnaris and the inner part of the flexor profundus digitorum, while the former supplies the two pronators and the remainder of the flexor muscles.
Of the mode of action of this operation we are still much in the dark, but it would seem to be indicated in any case where the contractions are very marked and tonic in their nature—not, however, until other means have failed to relieve.
In the ordinary forms of copodyscinesia, it is needless to say, the operation would be unjustifiable.
Mechanical Appliances.—Most of the prothetic appliances have been devised for the relief of writers' cramp, the other forms of copodyscinesia having received little if any attention in this direction. The relief obtained by their use is usually but temporary, especially if the patient attempts to perform his usual amount of work, which is generally the case.
These instruments are of undoubted benefit when used judiciously in conjunction with other treatment, as by them temporary rest may be obtained, or in some cases the weakened antagonists of cramped muscles may be exercised and strengthened. They all, without exception, operate by throwing the work upon another set of muscles, and failure is almost sure to follow their use if they alone are trusted in, as the new set of muscles sooner or later becomes implicated in the same way that the left hand is apt to do if the whole amount of work is thrown upon it.
To accurately describe these instruments is out of place in this article: those wishing to study this branch of the subject more fully are referred to the article by Debout,128 where drawings and descriptions of the most important appliances are given.
128 “Sur les Appareils prothetiques, etc.,” Bull. de Thérap., 1860, pp. 327-377.
Their mode of action may be considered under the following heads:
I. Advantage is taken of muscles as yet unaffected, which are made to act as splints (so to speak) to those affected, greater stability being thus given and cramp controlled when present.
Under this head may be mentioned the simple plan of placing a rubber band around the wrist, wearing a tight-fitting glove, or applying Esmarch's rubber bandage with moderate firmness to the forearm. Large cork pen-holders, by distributing the points of resistance over a larger surface, are thus much easier to hold than small, hard pen-holders.
Two of the instruments devised by Cazenave—one, consisting of two rings joined together in the same plane (to which the pen-holder is attached), and through which the index and middle fingers are thrust as far as the distal joints; and another consisting of two rings of hard rubber, one above the other, sufficiently large to receive the thumb, fore and middle fingers, which are thus held rigidly in the writing position—act in this manner, and are used when the cramp affects the thumb or fore finger.
II. The cramp of one set of muscles is made use of to hold the instrument, the patient writing entirely with the arm movement.
The simple plan of grasping the pen-holder in the closed hand, as previously described, or of thrusting a short pen-holder into a small apple or potato, which is grasped in the closed hand, occasionally affords relief and acts in this way. The instruments of Mathieu, Velpeau, Charrière, and one by Cazenave are based upon this principle. The first consists of two rings rigidly joined together about one inch apart, one above the other, through which the fore finger is thrust, and of a semicircle against which the tip of the thumb is pressed; the pen-holder is attached to a bar adjoining the semicircle and rings. Velpeau's apparatus consists of an oval ball of hard rubber carrying at one extremity the pen-holder at an angle of 45°; the ball is grasped in the closed hand, and the pen-holder allowed to pass between the fore and middle fingers. Charrière's instrument is a modification of the last, having in addition to the ball a number of rings and rests for the fixation of the fingers. The latter has also devised an instrument consisting of a large oval ball of hard rubber; this is grasped in the outstretched palm, which it fills, and is allowed to glide over the paper; the pen-holder is attached to one side. Cazenave's instrument is simply a large pen-holder with rest and rings to fix the fingers.
III. The instrument prevents the spasm of the muscles used in poising the hand from interfering with those used in forming the letters.
One of the instruments devised by Cazenave acts in this way: it consists of a small board, moving upon rollers, upon which the hand is placed; lateral pads prevent the oscillations of the arm due to spasmodic action of the supinators. The pen-holder is held in the ordinary manner.
IV. The antagonistic muscles to those affected by cramp are made to hold the instrument, while the cramped muscles are left entirely free.
But one instrument acts in this manner—viz. the bracelet invented by Von Nussbaum,129 which consists of an oval band of hard rubber to which the pen-holder is attached. The bracelet is held by placing the thumb and the first three fingers within it and strongly extending them.
129 Aerztliches Intelligenzblatt, Munich, 1883, No. 39.
The inventor claims great success by its use alone, as the weakened muscles are exercised and strengthened and the cramped muscles given absolute rest.
Résumé of Treatment.—In the complicated cases of copodyscinesia rest of the affected parts, as far as the disabling occupation is concerned, must be insisted upon: this should be conjoined with the use of the galvanic descending stabile current, combined with rhythmical exercise of the affected muscles and of their antagonists, and massage. Where there is evidence of a peripheral local congestion or inflammation, this must be attended to; for instance, if there is congestion of the nerves, or neuritis, flying blisters or the actual cautery should be applied over the painful spots, followed by the galvanic current. Where there is paralysis of one or more muscles, with evidence of interference of nerve-supply, the faradic current may be used with advantage.
Evidences of constitutional disease should lead to the employment of the treatment suitable for those affections.
RÉSUMÉ OF 43 CASES OF TELEGRAPHERS' CRAMP.