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 {512} 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.
[Footnote 14: A. K. Gardner, M.D., “Hygiene of the Sewing-Machine,”
_Am. Med. Times_, Dec 15-29, 1860.]
[Footnote 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. Eulenburg[17] mentions tremor as
of very frequent occurrence, and states that he has frequently noticed
it in young cigar-makers who smoke to excess.
[Footnote 16: _Ziemssen's Cyclopædia_, Amer. ed., vol. xvii.]
[Footnote 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.
Onimus[18] states that women are more frequently affected than men
with telegraphers' cramp. Erb[19] states that writers' spasm is met
with more {513} 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.
Hasse[20] and Romberg[21] 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.
[Footnote 18: _Loc. cit._]
[Footnote 19: “Writers' Cramp and Allied Affections,” _Ziemssen's
Cycl._, Amer. ed., vol. xi.]
[Footnote 20: _Loc. cit._]
[Footnote 21: _Nervous Diseases_, vol. i. p. 320.]
[Footnote 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. Hasse[23] is also of the same opinion.
[Footnote 23: _Loc. cit._]
Whittaker[24] 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.
[Footnote 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?).
[Footnote 25: “Ueber Reflexionsfingerkrampf,” _Oesterr. Jahrb._, März
u. April, 1844, quoted by Hasse, _loc. cit._]
Beard[26] holds an opinion directly the reverse of the vast majority
of the authorities upon this subject, and states that this disease
occurs mostly in {514} 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.
[Footnote 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.
Mitchell[27] 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.
[Footnote 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 Runge[28] as giving rise to symptoms closely allied to
this affection. Seeligmüller[29] mentions a case where the symptoms
came on after an insignificant grazing bullet-wound of the knuckle of
one of the fingers.
[Footnote 28: “Zür Genese u. Behandlung des Schreibekrampfes,” _Berl.
klin. Wochensch._, x. 21, 1873.]
[Footnote 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. {515} 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 Poore[30] and S. Weir
Mitchell.[31]
[Footnote 30: _Electricity in Medicine and Surgery_, London, 1876, p.
209.]
[Footnote 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.
Gallard[32] reports a case of a street-pavior who had associated spasm
of {516} both sterno-cleido-mastoid muscles, which came on only when
using the instrument to settle the stones. Dally[33] 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. Reynolds[34]
reports such a case.
[Footnote 32: “Crampe des Écrivains,” _Progrès médical_, v., 1877, p.
505.]
[Footnote 33: “Traitement des Spasms professionnels,” _Journ. de
Thérapeutique_, No. 3, 10 Fèvrier, 1882.]
[Footnote 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 {517} ending with dots,
such as _b_ (—...), _d_ (—..), _8_ (—....). Some of the spaced
characters are also difficult to make, such as _z_ (... .), _&_
(. ...), _y_ (.. ..).
[Illustration: 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.
Duchenne[36] likewise reports some curious cases of functional spasm
analogous to the foregoing.
[Footnote 35: _Loc. cit._]
[Footnote 36: Duchenne (de Boulogne), “Note sur le Spasm functionnel,
etc.,” _Bull. de Thérap._, 1860, pp. 146-150.]
{518} 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.
[Footnote 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. Zuradelli[38] considers this condition to be the one
ordinarily found in this disease.
[Footnote 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.
Duchenne[39] calls attention to this form of trouble, which he styles
paralysie functionelle, and states that it is much less common than
functional spasm.
[Footnote 39: _Loc. cit._]