occasional formication in various parts of the right face, hand, and
leg, which ceased after he suspended the use of tea and coffee; soon
after this he noticed that his writing began to lack ease and that the
letters became crowded toward the end of the line; later, a fine
tremor appeared in the fingers of the right hand; crampy sensations
then appeared in the hamstring muscles of right leg, chiefly while
sitting with the knee bent at right angles; writing with the right
hand was sufficient to cause, or at least aggravate, this. In 1882 the
right arm lost its automatic swing during walking, although holding
the left arm still would enable the right arm to swing automatically.
Lately the symptoms have ceased advancing, and some seem to improve.
His present condition is an inability to write with right hand without
paying great attention and making each letter separately, and a
trembling of fingers during excitement of any kind. Coarse movements
of co-ordination can, as a rule, be well performed; there is no
increase of reflexes, nor are they absent; there is no ataxic gait,
and there are no trophic changes. Galvanic reaction is normal, and
alike on both sides. There is no history of hereditary disease or of
venereal taint.
In this connection it is proper to mention tremor mercurialis and
{526} tremor saturninus, which might possibly lead to mistake should
proper attention not be paid to the history and to the symptoms.
Paul[51] reports a case of the former affection, and gives a specimen
of the handwriting of the patient.
[Footnote 51: C. Paul, _Bull. et Mém. de la Soc. de Thérap._, Paris,
1881, xiii. pp. 129-131.]
Traumatisms, etc. of the various nerves of the arm usually interfere
with the proper play of the muscles supplied by them, and although
certain of the milder forms of inflammation or of congestion, as
previously mentioned, are sometimes present in cases of
copodyscinesia, it is manifestly improper to include all cases of
impairment of hand-and-arm movement from nerve-injury under this head.
Palsy from pressure, as from sleeping with the head resting upon the
arm or with the arm hanging over the back of a chair, is a frequent
cause of paresis or paralysis of the muscles supplied by the
musculo-spiral.
Tumors pressing upon the nerves in any part of their course, or
neuromata, may be mentioned among the more ordinary affections that
possibly might mislead.
Tenosynovitis which is described by 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.