Chapter M: M——, was a stout Irish woman about forty years of age. She had (3)

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 Hopkins[52] 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.

[Footnote 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.

Solly[53] 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.

[Footnote 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 {527} more advanced knowledge been found to have as a basis a positive organic change.

On the subject of fatigue, Poore[54] 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.”

[Footnote 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, Onimus[56] noticed that movements of the hand and fingers of the non-paralyzed arm produced similar movements in the paralyzed side.

[Footnote 55: Quoted by Charcot, _Diseases of Spinal Cord_, transl. by Comyges, Cincinnati, 1881, p. 110.]

[Footnote 56: _Ibid._]

Erb[57] states that these movements in certain spinal troubles are partly owing to the establishment of conditions of irritation in the neighborhood of the lesion.

[Footnote 57: _Ziemssen's Cyclopædia_, Amer. ed., vol. xi. p. 409.]

Hitzig[58] 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.

[Footnote 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 {528} 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.

[Footnote 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.

Poore[60] 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. Hamilton[61] and De Watteville[62] also consider the peripheral hypothesis the correct one.

[Footnote 60: _Loc. cit._]

[Footnote 61: _Nervous Diseases_, Philada., 1881.]

[Footnote 62: “The Cure of Writers' Cramp,” _Brit. Med. Journ._, 1885, vol. i. pp. 323-325.]

Fritz[63] (and after him Poincaré[64]) considers the disease a reflected neurosis, due to a perversion of the muscular sense. Onimus and Legros[65] incline to the same opinion.

[Footnote 63: _Oesterr. Jahrb._, März u. April, 1844.]

[Footnote 64: _Le Système nerveux-péripherique_, Paris, 1876.]

[Footnote 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. Roth[83] considers that there are two entirely separate classes, the central and the peripheral or local.

[Footnote 66: _De l'Électrisation localisée_, 3d ed., pp. 1021 _et seq._]

[Footnote 67: _London Lancet_, Jan. 28, 1865.]

[Footnote 68: _System of Medicine_.]

[Footnote 69: Julius Althaus, _London Mirror_, vol. vii., Aug. 1, 1870; also, pamphlet, _Scriveners' Palsy_, London, 1870.]

[Footnote 70: _Practice of Medicine_.]

[Footnote 71: Reuben A. Vance, _Bost. Med. and Surg. Journal_, vol. lxxxviii. p. 261.]

[Footnote 72: _Ziemssen's Cyclopædia_, vol. xi. p. 355.]

[Footnote 73: _Journal de Thérapeutique_, Paris, 10 Fév., 1882.]

[Footnote 74: _Des Névroses_, Paris, 1864.]

[Footnote 75: _Cincinnati Lancet and Clinic_, 1880, N. S., vol. iv. p. 496.]

[Footnote 76: Aug. Waller, _Practitioner_, 1880, vol. ii. p. 101.]

[Footnote 77: W. R. Gowers, _Med. Times and Gaz._, 1877, vol. ii. p. 536.]

[Footnote 78: _Treatise on Dis. of Nervous System_, 6th ed., New York, 1876.]

[Footnote 79: _Manual of Nervous Dis. in Man_, Sydenham Society, vol. i.]

[Footnote 80: _Gustaf. Upsala läkarefören_, förhandl. xv., 3 och. 4, S. 165, 1880, review in _Schmidt's Jahrb._, Bd. clxxxvii., 1880, p. 239.]

[Footnote 81: “Writers' Cramp,” _Amer. Journ. Med. Sci._, April, 1885, pp. 452-462.]

[Footnote 82: _A Treatise on Diseases of the Nervous System_, London, 1881, vol. i. pp. 464-469.]

[Footnote 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.

[Footnote 84: _New York Med. Record_, 1879, p. 244.]

[Footnote 85: _Maryland Med. Journ._, June, 1880-81, vol. vii.]

[Footnote 86: _Medical Electricity_.]

[Footnote 87: _Glasgow Med. Journ._, 1881, vol. xv. p. 169.]

{529} Many others have written upon this subject, but upon the probable pathology they have been silent.

The experiments recently made by Dercum and Parker[88] 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.

[Footnote 88: “The Artificial Induction of Convulsive Seizures,” Dercum-Parker, _The Polyclinic_, Philada. 1884, vol. ii. pp. 95-97.]

[Footnote 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. Gowers[90] 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 {530} remarks[91] 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.

[Footnote 90: _Dis. of Spinal Cord_, 2d ed., Philada., 1881, p. 40.]

[Footnote 91: _Med. Times and Gaz._, London, vol. ii., 1877, p. 536.]

Erb[92] also considers that quantitative increase in the electrical reaction points to central lesion. Buzzard[93] 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.

[Footnote 92: _Loc. cit._]

[Footnote 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.

Poore[94] 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.”

[Footnote 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.

Althaus[95] 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.”

[Footnote 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, {531} 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. Roth[96] considers those cases due to central changes totally incurable.

[Footnote 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.

{532} 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. Berlin[97] (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.

[Footnote 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.

[Footnote 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, {533} 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]

[Footnote 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.

Onimus[100] 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.

[Footnote 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 {534} 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. Hamilton[101] has seen occasional benefit from forced rest by fastening the hand upon a splint.

[Footnote 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 {535} 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.

Buzzard[102] 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 Haupt[105] have also seen good results by this method. Duchenne[106] 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.

[Footnote 102: “Two Cases of Impaired Writing-power,” _Practitioner_, Aug., 1872.]

[Footnote 103: Quoted by Erb and Poore, _loc. cit._]

[Footnote 104: _Ibid._, _loc. cit._]

[Footnote 105: _Der Schreibekrampf mit Rücksicht auf Path. u. Therap._, Wiesbaden, 1860, review in _Schmidt's Jahrbucher_, Bd. cxv. 3, 136, 1862.]

[Footnote 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 Legros[107] 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.

[Footnote 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 Althaus[108] 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.

[Footnote 108: _Loc. cit._]

{536} Poore[109] 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.

[Footnote 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.

[Footnote 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 Vigouroux[111] states that he has cured one case by statical electricity. Another case is reported by Arthuis[112] 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.

[Footnote 111: _Le Progrès médical_, Jan. 21, 1882.]

[Footnote 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 Vigouroux[113] 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 {537} 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.

[Footnote 113: _Le Progrès médical_, 1882, No. 13.]

[Footnote 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.]

[Footnote 115: “Treatment of Writers' Cramp and Allied Muscular Affections by Massage and Gymnastics,” _N. Y. Med. Record_, Feb. 23, 1884, pp. 204, 205.]

[Footnote 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 Keen[117] 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. Vance[118] speaks very favorably of one-sixtieth {538} 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. Rossander[119] reports a cure in one month of a case of two years' duration by the hypodermic use of strychnia. Onimus and Legros[120] used curare in one case without effect.

[Footnote 117: _Gunshot Wounds and Other Injuries to Nerves_, Philada., 1864.]

[Footnote 118: Reuben A. Vance, M.D., “Writers' Cramp or Scriveners' Palsy,” _Brit. Med. and Surg. Journal_, vol. lxxxvii. pp. 261-285.]

[Footnote 119: J. C. Rossander, _Irish Hosp. Gazette_, Oct. 1, 1873.]

[Footnote 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. Stromeyer[121] 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. Langenbeck[122] 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. Tuppert[123] has also performed this operation, and Haupt[124] advises it as a last resource.

[Footnote 121: “Crampe des Écrivains,” _Arch. gén. de Méd._, t. xiii., 1842, 3d Series, p. 97.]

[Footnote 122: _Ibid._, t. xiv., 1842, 3d Series.]

[Footnote 123: Quoted by Poore, _loc. cit._]

[Footnote 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 Nussbaum[125] alone mentions the operation, and states that it has been of no avail, but gives no references; he previously[126] stretched the ulnar nerve at the elbow and the whole of the brachial plexus for spasm {539} 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.

[Footnote 125: _Aerztliches Intelligenzblatt_, Munich, Sept. 26, 1882, No. 39, p. 35.]

[Footnote 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.

[Footnote 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 {540} 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.

{541} 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.

[Footnote 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.