trephining has sometimes resulted in a cure. I know of one brilliant
result obtained by Leo of this city in an old epileptic, in which the
use of the instrument over the occipital region resulted in a complete
removal of {503} the disease. It is especially recommended in cases in
which the form of the attacks bears some relation to the probable
disturbance of the cortical motor-centres; and even in such cases
there must be constancy in the method of expression of the convulsion.
So often do we find meningeal thickening of an extensive district that
it is manifest that trephining would do little or no good. The
statistics of the operation are unsatisfactory, for in the large mass
of testimony there is great want of exactness as to the pathological
suggestions of the attack, and a great deal about the method of
procedure and recovery from the operation itself, and very little
about the phenomena of the disease.
The diet of the epileptic should be of the most simple kind.
Merson,[49] whose carefully-prepared paper is full of valuable
statistics, is strongly in favor of vegetable diet, and his results
are encouraging. I am convinced that many children never would have
become hysterical or epileptic but for injudicious indulgence in
animal food. Whenever possible, I confine my patient to a diet of
fish, poultry, and fresh vegetables, with fruit. As an exciting cause
the overloading of the stomach has so often precipitated attacks as to
lead Paget and others to invent the term gastric epilepsy for this
form of the disease. The greatest care must be paid not only to diet,
but to the general habits of the patient—over-exercise, especially
after eating, the avoidance of hot places and high altitudes. A
residence by the seashore is preferable to mountainous places; and
excitement, over-study, and all agencies favoring cerebral congestion
are to be avoided.
[Footnote 49: _West Riding Reports_, vol. v. p. 1.]
{504}
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.
[Footnote 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.
{505} 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 Hasse[2] 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.
[Footnote 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.
[Footnote 3: G. V. Poore, _Electricity in Medicine and Surgery_,
London, 1876.]
{506} 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.
[Footnote 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, {507} 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 Putnam[5] as much easier to write
with than the pencil, as less weight need be applied upon the tip in
order to write.
[Footnote 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
Fulton[8] being among the few to describe it, although several later
writers mention its existence.
[Footnote 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.]
[Footnote 7: Edmund Robinson, M.D., “Cases of Telegraphists' Cramp” (4
cases), _British Med. Journ._, Nov. 4, 1882.]
[Footnote 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 {508} 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 Lancet_[9] 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.”
[Footnote 9: 1875, vol. i. p. 585.]
Hammond[10] 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.
[Footnote 10: Wm. A. Hammond, M.D., _Dis. Nervous System_, 6th ed.,
New York, p. 789.]
[Footnote 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 {509} 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.
[Illustration: 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 {510} 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 ( " " " musculo-spiral) 10 "
Flexor brevis pollicis ( " " " median and ulnar) 7 "
Abductor " ( " " " median) 7 "
Flexor longus " ( " " " " ) 4 "
Adductor " ( " " " ulnar) 3 "
Opponens " ( " " " median) 2 "
All the muscles of the forearm, more or less, 2 "
—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 {511} 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 Mitchell[12] 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. Mills[13] 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.”
[Footnote 12: _Injuries of Nerves, and their Consequences_, by S. Weir
Mitchell, M.D., Philada., 1872.]