A system of practical medicine. By American authors. Vol. 5

by Unknown

—— ——, 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.