arm, father died of paralysis agitans, and one brother has writers'
cramp. From nine to twelve years of age he was considered an expert
penman, and was employed almost constantly, during school-hours,
writing copies for the scholars. At the age of eleven he began to feel
a sense of tire in right forearm and hand when writing; soon after
this the flexors of right wrist and hand began to contract
involuntarily and become rigid only when writing. He remembers being
able to play marbles well for two years after the onset of the first
symptoms. The trouble gradually increased until every motion of the
forearm became involved. At the age of nineteen he became a
bookkeeper, using his left hand, but at the end of one year this
became affected also. Since then both arms have been growing gradually
worse, and at one time exhaustion would bring on pain at the third
dorsal vertebra. At the age of thirty a period of sleeplessness and
involuntary contractions of all the muscles of the body came on,
accompanied by difficulty in articulation from muscular
inco-ordination. After persistent use of the cold douche to spine
these symptoms ameliorated, but the general muscular twitching
sometimes occurs yet, and overwork brings on spasm of the extensors of
the feet. The condition of his arms in December, 1882, was as follows:
At rest the right forearm is pronated, the wrist completely flexed and
bent toward the ulnar side, the thumb is slightly adducted, and the
fingers, although slightly flexed, are comparatively free, enabling
him to use the scalpel with dexterity. This contraction can be
overcome by forcibly extending the fingers and wrist and supinating
forearm, but if the arm be now placed in supination the following
curious series of contractions occur, occupying from one to two
minutes from their commencement to their completion: gradually the
little finger partially flexes, then the ring, middle, and fore finger
follow in succession; the wrist then slowly begins to flex and to turn
toward the ulnar side, and finally the arm pronates, in which position
it will remain unless disturbed. The contraction is accompanied by a
tense feeling in the muscles, but is painless. The left arm behaves in
a somewhat similar manner, and if this is placed in supination a
gradual pronation of the arm begins; then follows the flexion of the
fingers, commencing with the little finger and ending with the thumb;
the wrist also flexes, but not as much as the right, although the
flexion of the fingers is more marked. There is no pain on pressure
over {540} muscles or nerves. The extensor muscles of both arms,
although weaker than normal, are not paralyzed, those of the right
responding more readily to both faradic and galvanic currents than do
the left. There is no reaction of degeneration. The flexors respond
too readily, the right showing the greatest quantitative increase.
In 1879, while abroad, his condition being essentially as above
described, he consulted Spence of Edinburgh, who as an experiment
stretched the left ulnar nerve at the elbow; immediately after the
operation the muscles were paralyzed and the arm remained quiet; in
twenty-four hours the nerve became intensely painful, and remained so,
day and night, for three weeks; this gradually subsided, and ceased
with the healing of the wound two weeks later. Forty-eight hours after
the operation the spasm of the muscles returned, and in a short time
became as bad as ever, proving the operation to have been a failure.
An interesting point to decide in this case is whether the symptoms
point to an abnormal condition of the nerve-centres, first manifesting
itself in difficulty of writing, or whether the constant writing
induced a superexcitability (for want of a better term) of the spinal
cord in a patient markedly predisposed to nervous troubles. This last
hypothesis I believe to be the correct one.
It might be considered at first sight that the symptoms presented by
this patient were due to a paralytic condition of the extensors, and
not a spasm of the flexors, or at least that the latter was secondary
to the former. While the extensors are somewhat weaker than normal
from want of use, a careful study of the mode of onset of this
affection and the symptoms presented later prove this idea to be
erroneous.
In regard to the operation and its results, it seems that a fairer
test of the efficacy of nerve-stretching in this case would have been
made if the median and not the ulnar nerve had been stretched, as the
latter only supplies in the forearm the flexor carpi ulnaris and the
inner part of the flexor profundus digitorum, while the former
supplies the two pronators and the remainder of the flexor muscles.
Of the mode of action of this operation we are still much in the dark,
but it would seem to be indicated in any case where the contractions
are very marked and tonic in their nature—not, however, until other
means have failed to relieve.
In the ordinary forms of copodyscinesia, it is needless to say, the
operation would be unjustifiable.
Mechanical Appliances.—Most of the prothetic appliances have been
devised for the relief of writers' cramp, the other forms of
copodyscinesia having received little if any attention in this
direction. The relief obtained by their use is usually but temporary,
especially if the patient attempts to perform his usual amount of
work, which is generally the case.
These instruments are of undoubted benefit when used judiciously in
conjunction with other treatment, as by them temporary rest may be
obtained, or in some cases the weakened antagonists of cramped muscles
may be exercised and strengthened. They all, without exception,
operate by throwing the work upon another set of muscles, and failure
is almost sure to follow their use if they alone are trusted in, as
the new set of muscles sooner or later becomes implicated in the same
way that the left hand is apt to do if the whole amount of work is
thrown upon it.
{541} To accurately describe these instruments is out of place in this
article: those wishing to study this branch of the subject more fully
are referred to the article by Debout,[128] where drawings and
descriptions of the most important appliances are given.
[Footnote 128: “Sur les Appareils prothetiques, etc.,” _Bull. de
Thérap._, 1860, pp. 327-377.]
Their mode of action may be considered under the following heads:
I. Advantage is taken of muscles as yet unaffected, which are made to
act as splints (so to speak) to those affected, greater stability
being thus given and cramp controlled when present.
Under this head may be mentioned the simple plan of placing a rubber
band around the wrist, wearing a tight-fitting glove, or applying
Esmarch's rubber bandage with moderate firmness to the forearm. Large
cork pen-holders, by distributing the points of resistance over a
larger surface, are thus much easier to hold than small, hard
pen-holders.
Two of the instruments devised by Cazenave—one, consisting of two
rings joined together in the same plane (to which the pen-holder is
attached), and through which the index and middle fingers are thrust
as far as the distal joints; and another consisting of two rings of
hard rubber, one above the other, sufficiently large to receive the
thumb, fore and middle fingers, which are thus held rigidly in the
writing position—act in this manner, and are used when the cramp
affects the thumb or fore finger.
II. The cramp of one set of muscles is made use of to hold the
instrument, the patient writing entirely with the arm movement.
The simple plan of grasping the pen-holder in the closed hand, as
previously described, or of thrusting a short pen-holder into a small
apple or potato, which is grasped in the closed hand, occasionally
affords relief and acts in this way. The instruments of Mathieu,
Velpeau, Charrière, and one by Cazenave are based upon this principle.
The first consists of two rings rigidly joined together about one inch
apart, one above the other, through which the fore finger is thrust,
and of a semicircle against which the tip of the thumb is pressed; the
pen-holder is attached to a bar adjoining the semicircle and rings.
Velpeau's apparatus consists of an oval ball of hard rubber carrying
at one extremity the pen-holder at an angle of 45°; the ball is
grasped in the closed hand, and the pen-holder allowed to pass between
the fore and middle fingers. Charrière's instrument is a modification
of the last, having in addition to the ball a number of rings and
rests for the fixation of the fingers. The latter has also devised an
instrument consisting of a large oval ball of hard rubber; this is
grasped in the outstretched palm, which it fills, and is allowed to
glide over the paper; the pen-holder is attached to one side.
Cazenave's instrument is simply a large pen-holder with rest and rings
to fix the fingers.
III. The instrument prevents the spasm of the muscles used in poising
the hand from interfering with those used in forming the letters.
One of the instruments devised by Cazenave acts in this way: it
consists of a small board, moving upon rollers, upon which the hand is
placed; lateral pads prevent the oscillations of the arm due to
spasmodic action of the supinators. The pen-holder is held in the
ordinary manner.
IV. The antagonistic muscles to those affected by cramp are made to
hold the instrument, while the cramped muscles are left entirely free.
{542} But one instrument acts in this manner—viz. the bracelet
invented by Von Nussbaum,[129] which consists of an oval band of hard
rubber to which the pen-holder is attached. The bracelet is held by
placing the thumb and the first three fingers within it and strongly
extending them.
[Footnote 129: _Aerztliches Intelligenzblatt_, Munich, 1883, No. 39.]
The inventor claims great success by its use alone, as the weakened
muscles are exercised and strengthened and the cramped muscles given
absolute rest.
Résumé of Treatment.—In the complicated cases of copodyscinesia rest
of the affected parts, as far as the disabling occupation is
concerned, must be insisted upon: this should be conjoined with the
use of the galvanic descending stabile current, combined with
rhythmical exercise of the affected muscles and of their antagonists,
and massage. Where there is evidence of a peripheral local congestion
or inflammation, this must be attended to; for instance, if there is
congestion of the nerves, or neuritis, flying blisters or the actual
cautery should be applied over the painful spots, followed by the
galvanic current. Where there is paralysis of one or more muscles,
with evidence of interference of nerve-supply, the faradic current may
be used with advantage.
Evidences of constitutional disease should lead to the employment of
the treatment suitable for those affections.
RÉSUMÉ OF 43 CASES OF TELEGRAPHERS' CRAMP.
Age at time of onset:
Under 20 years . . . . . . . . . . . . . . . . . . 7
Between 20 and 30 . . . . . . . . . . . . . . . . 25
" 30 and 40 . . . . . . . . . . . . . . . . 7
Doubtful . . . . . . . . . . . . . . . . . . . . . 4--43
Average age . . . . . . . . . . . . . . . . . 23.94 years.
" " of males . . . . . . . . . . . . . 24.22 "
" " of females . . . . . . . . . . . . 20.66 "
Average length of time before the disease appeared after the
commencement of telegraphing was—
In males . . . . . . . . . . . . . . . . . . 7.27 years.
" females . . . . . . . . . . . . . . . . . 4 "
The shortest period being . . . . . . . . . 6 months.
The longest " " . . . . . . . . . 20 years.
Left arm implicated in . . . . . . . . . . . . . . . 21
(Not counting case with amputation of right arm) . . 1
Never used left arm . . . . . . . . . . . . . . . . 8
Left arm not affected, although used . . . . . . . . 12
Doubtful . . . . . . . . . . . . . . . . . . . . . . 1--43
Percentage with left arm implicated . . . . . . . . 63.63
No. of cases with difficulty in telegraphing only . 9
" " " " writing " . 0
" " " " telegraphing most . 22
" " " " writing " . 11
" " " " both alike . . . . . 1--43
Use of tobacco or alcohol:
No effect in . . . . . . . . . 14
Bad " " . . . . . . . . . 16
Good " (in moderation) " . . . . . . . . . 3
Don't use either . . . . . . . . . . . . . . . . 10--43 {543}
Flushings in arm or face during work in . . . . . . 22
Brittleness of nails " . . . . . . 5
Emotional factor present " . . . . . . 29
Sympathetic movements in other parts " . . . . . . 9
Pain in back during work " . . . . . . 18
Trouble in performance of other acts " . . . . . . 19
Pain on pressure over nerve or muscle " . . . . . . 13
Cramp of flexor group of muscles:
In writing only . . . . . . . . . . . . . . . . 0
" " most . . . . . . . . . . . . . . . . 3
" telegraphing only . . . . . . . . . . . . . 1
" " most . . . . . . . . . . . . . 5-- 9
Cramp of extensor group of muscles:
In writing only . . . . . . . . . . . . . . . . 0
" " most . . . . . . . . . . . . . . . . 0
" telegraphing only . . . . . . . . . . . . . 4
" " most . . . . . . . . . . . . . 7--11
Doubtful as to character of cramp . . . . . . . . . . 11
No cramp . . . . . . . . . . . . . . . . . . . . . . 12--43
Manner of telegraphing:
Arm resting on table . . . . . . . . . . . . . . . 22
" raised from " . . . . . . . . . . . . . . . 12
Alternating one with the other . . . . . . . . . . 7
Doubtful . . . . . . . . . . . . . . . . . . . . . 2--43
Manner of writing:
Arm movement . . . . . . . . . . . . . . . . . . . 13
Finger movement . . . . . . . . . . . . . . . . . . 6
Combination of the two . . . . . . . . . . . . . . 24--43
{544}
TETANUS.
BY P. S. CONNER, M.D.
Tetanus (_τεινω_, to stretch) is a morbid condition characterized by
tonic contraction of the voluntary muscles, local or general, with
clonic exacerbations, occurring usually in connection with a wound.
Cases of it may be classified according to cause (traumatic or
idiopathic); to age (of the new-born and of those older); to severity
(grave and mild); or to course (acute and chronic), this latter
classification being the one of greatest value.
Though known from the earliest times, it is in the civil practice of
temperate regions of comparatively rare occurrence, and even in
military surgery has in recent periods only exceptionally attacked any
considerable proportion of the wounded.
Occurring in individuals of all ages, the great majority of the
subjects of it are children and young adults. Women seem to be
decidedly less liable to it than men. That this is due to sexual
peculiarity may well be doubted, since the traumatic cases are by far
the most numerous, and females are much less often wounded than males.
The traumatisms of childbed are occasionally followed by it (puerperal
tetanus).
That race has a predisposing influence would appear to be well
established; the darker the color, the greater the proportion of
tetanics. Negroes are especially likely to be attacked with either the
traumatic or idiopathic form.
Atmospheric and climatic conditions, beyond question, act powerfully
in, if not producing at least favoring, the development of tetanus.
Places and seasons in which there is great difference between the
midday and the midnight temperature, the winds are strong, and the air
is moist, are those in which the disease is most prevalent; and it is
because of these conditions that the late spring and early autumn are
the periods of the year when cases are most often seen.[1]
[Footnote 1: In his account of the Austrian campaign of 1809, Larrey
wrote: “The wounded who were most exposed to the cold, damp air of the
chilly spring nights, after having been subjected to the quite
considerable heat of the day, were almost all attacked with tetanus,
which prevailed only at the time when the Reaumur thermometer varied
almost constantly between the day and the night by the half of its
rise and fall; so that we would have it in the day at 19°, 20°, 21°,
and 23° above zero (75°-84° F.), while the mercury would fall to 13°,
12°, 10°, 9°, and 8° during the night (50°-61° F.). I had noticed the
same thing in Egypt.”]
Cold has, from the time of Hippocrates, been regarded as a great
predisposing if not exciting cause, and the non-traumatic cases have
been classed together as those a frigore. It is not, however, the
exposure to simply a low temperature that is followed by the disease,
but to cold combined with dampness, and quickly succeeding to a
temperature decidedly {545} higher, as in the cool nights coming on
after hot days in tropical regions, or in the spring and fall seasons
of temperate latitudes, or in the cold air blowing over or cold water
dashed upon a wound or the heated skin. That such cold, thus
operating, does most usually precede the attack of tetanus is
unquestionable; and it has by many been held that without it no
traumatism will be followed by the disease. Observers generally are
agreed, with Sir Thomas Watson, that “there is good reason for
thinking that in many instances one of these causes (wound and cold)
alone would fail to produce it, while both together call it forth.”
In the low lands of hot countries (as the East and West Indies) the
disease is very frequently met with, at times prevailing almost
epidemically; and, on the other hand, it is rare in dry elevated
regions and in high northern latitudes, as in Russia, where during a
long military and civil experience Pirogoff met with but eight cases.
Trismus nascentium would seem to be an exception to the general rule
of the non-prevalence of tetanus in places far north, since, _e.g._,
it has been at different periods very common in the Hebrides and the
small islands off the southern coast of Iceland. But these localities,
from their peculiar position, are not extremely cold, and their
climate is damp and variable; so that, even if the lockjaw of infants
be accepted as a variety of true tetanus, the geographical exception
indicated is but an apparent one.
Traumatic cases are greatly more numerous than idiopathic, and no
class of wounds is free from the possibility of the supervention of
tetanus. Incised wounds are much less likely to be thus complicated
than either of the other varieties, though operation-wounds of all
sorts, minor and major, have been followed by this affection. So
frequently has it been associated with comparatively trivial injuries
that it has become a common belief that the slighter the traumatism
the greater the danger of tetanus. That this is not true the records
of military surgery abundantly show. Wounds of the lower extremity are
much graver in this respect than those of the upper. Injuries of the
hand and feet, especially roughly punctured wounds of the palmar and
plantar fasciæ (as, _e.g._, those made by rusty nails), have long been
regarded as peculiarly liable to develop the disease, and accidents of
this nature always give rise to the fear of lockjaw. Though there can
be no question but that more than one-half of the cases of tetanus in
civil life are associated with wounds of these localities, yet the
number of such injuries is so much greater than of those of other
parts of the body that the special liability of the subjects of them
to become tetanic may well be questioned. In this connection it is a
significant fact that during our late war of perhaps 12,000 or 13,000
wounds of the hand, only 37 were followed by tetanus, and of 16,000 of
the foot, but 57. A few years ago numerous cases of tetanus were
observed in our larger cities complicating hand-wounds produced by the
toy pistol—injuries that were often associated with considerable
laceration of the soft parts, and generally with lodgment of the wad.
Not even the complete cicatrization of a wound altogether protects
against the occurrence of the disease, the exciting cause of which,
under such circumstances, is probably to be found in retained foreign
bodies or pent-up fluids.
ETIOLOGY.—Almost universally regarded as an affection of the central
nervous system, inducing a heightened state of the reflex
irritability, {546} though some have maintained that the reflex
excitability of the medulla and the cord is actually lessened, how
such affection is produced is unknown; and it is an unsettled question
whether it is through the medium of the nerves or the vessels, whether
by ascending inflammation, by reflected irritation, or by the presence
of a septic element or a special micro-organism in the blood.
That the disease is due to ascending neuritis finds support in the
congested and inflamed state of the nerves leading up from the place
of injury (affecting them in whole or in part, it may be in but a few
of their fibres), and in the inflammatory changes discoverable in the
cord and its vessels. But time and again thorough and careful
investigation by experienced observers has altogether failed to detect
any alterations in the nerves or pathological changes in the cord,
other than those that might properly be attributed to the spasms, the
temperature, or the drugs administered. The symptoms of acute neuritis
and myelitis (pain, paralyses, and later trophic changes) are not
those which are present in cases of tetanus. The evidences of
inflammation of the cord are most apparent, not in that portion of it
into which the nerves from the wounded part enter, but, as shown by
Michaud, so far as the cellular changes in the gray matter are
concerned, always in the lumbar region, no matter where the wound may
be located.
The much more generally accepted theory of reflex neurosis is based
upon the association of the disease with “all forms of
nerve-irritation, mechanical, thermal, chemical, and pathological;”
upon the direct relation existing between the likelihood of its
occurrence and the degree of sensibility of the wounded nerve;[2] in
the, at times, very short interval between the receipt of the injury
and the commencement of the tetanic symptoms; in the local spasms
unquestionably developed by nerve-pressure and injury; in the primary
affection of muscles at a distance from the damaged part; in the
already-referred-to absence of the structural lesions of inflammation;
and in the relief at times afforded by the removal of irritating
foreign bodies, the temporary cutting off of the nerve-connection with
the central organs, or the amputation of the injured limb. But that
something more than irritation of peripheral nerves is necessary to
the production of tetanus would seem to be proved by the frequency of
such irritation and the rarity of the disease; by the not infrequent
prolonged yet harmless lodgment of foreign bodies, even sharp and
angular ones, against or in nerves of high sensibility;[3] by the
primary affection of the muscles about the jaws, and not those in the
neighborhood of the wound; by the almost universal failure to produce
the affection experimentally, either by mechanical injuries or by
electrical excitations; by certain well-attested instances of its
repeated outbreak in connection with a definite locality, a single
ship of a squadron, a particular ward in a hospital, or even bed in a
ward; by the usual absence of that pain which is the ordinary effect
of nerve-irritation; and by the small measure of success which has
attended operations, even when early performed, {547} permitting the
taking away of foreign bodies pressing upon or resting in a nerve,
interrupting the connection with the cord, or altogether removing the
wound and its surroundings. Even in the idiopathic cases—many of
which, it would at first sight appear, can be due only to reflected
irritation—another explanation of the mode of their production may, as
we will see, be offered.
[Footnote 2: According to Gubler, the danger is greatest in wounds of
parts containing numerous Pacinian corpuscles.]
[Footnote 3: Heller has reported a case in which a piece of lead was
lodged in the sheath of the sciatic nerve. Though chronic neuritis
resulted, the wound healed perfectly. Two years later, after exposure
while drilling, the man was seized with tetanus and died of it.]