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: