The use of the iodide of potassium in combination with the bromides is of great service in symptomatic epilepsies or those of syphilitic origin. The iodide should be pushed, so that the patient may take three or four drachms daily, and its injurious gastric action and unpleasant taste may be done away with by administering it in large quantities of milk or some mild alkaline water, such as Vichy. Among the other remedies used and advocated by various writers are hyoscyamine, the salts of zinc, chloral, the ammonio-sulphate of copper, picrotoxin, strychnine, curare,—all of which have little or no effect in permanently changing the course of the disease. Cerebral galvanism, if properly employed, is certainly worthy of a trial as an adjuvant.

As abortants we may resort to diffusible stimulants—ammonia, alcohol, or some carminative. If the aura be perceived, a drachm of the aromatic spirits of ammonia or a glass of sherry will often prevent subsequent developments, and the inhalation of ten or fifteen drops of nitrite of amyl will avert the attack. Nitrite of amyl may be conveniently used in the form of pearls, which may be first crushed in the handkerchief. The nitrite of soda, which has been recommended as a substitute, is an unstable and dangerous drug, and is not to be recommended.

I called attention some years ago to the virtues of nitro-glycerin as an abortant in epilepsy. It may be given in alcoholic solution or tablets from ¹/50–¹/25 of a grain at a dose, to be perhaps repeated. Great care should be taken to procure a reliable preparation.

When a sensory aura proceeds from a particular locality in preference, the application of some local form of irritant is strongly recommended. A blister or light touch of the button of the actual cautery will do, and if the point of origin be one of the extremities a circular blister or cautery-line, after the method recommended by Buzzard, will be serviceable in the treatment of the case.

Buzzard has observed the fact, in several of his patients who complained of a sensory aura in the biceps, that when an encircling blister was applied just above this spot the attacks were aborted. In more than one of his cases of partial epilepsy the extraordinary result of a transfer of the convulsion to the other extremity is noted. He found that the circle should be complete, for a blister which half encircled the arm did no good. I have used the same treatment in cases of writer's cramp with marked benefit.

Brown-Séquard has pointed out the good effects of forcible and painful extension of one finger or toe if the aura is of sufficient duration to enable the individual to resort to this procedure.

The condition known as the status epilepticus is best treated by amyl nitrite, which can be administered frequently. Repeated doses of nitro-glycerin, so that its full effects are produced, do more good than chloroform or any of the well-known anæsthetics.

Of setons I have very little to say. At best, they are a barbarous and painful mode of treatment, and, although cures have been effected, I have never been much encouraged by their so-called influence.

Certain intractable cases are helped by surgical procedure, and trephining has sometimes resulted in a cure. I know of one brilliant result obtained by Leo of this city in an old epileptic, in which the use of the instrument over the occipital region resulted in a complete removal of the disease. It is especially recommended in cases in which the form of the attacks bears some relation to the probable disturbance of the cortical motor-centres; and even in such cases there must be constancy in the method of expression of the convulsion. So often do we find meningeal thickening of an extensive district that it is manifest that trephining would do little or no good. The statistics of the operation are unsatisfactory, for in the large mass of testimony there is great want of exactness as to the pathological suggestions of the attack, and a great deal about the method of procedure and recovery from the operation itself, and very little about the phenomena of the disease.

The diet of the epileptic should be of the most simple kind. Merson,⁴⁹ whose carefully-prepared paper is full of valuable statistics, is strongly in favor of vegetable diet, and his results are encouraging. I am convinced that many children never would have become hysterical or epileptic but for injudicious indulgence in animal food. Whenever possible, I confine my patient to a diet of fish, poultry, and fresh vegetables, with fruit. As an exciting cause the overloading of the stomach has so often precipitated attacks as to lead Paget and others to invent the term gastric epilepsy for this form of the disease. The greatest care must be paid not only to diet, but to the general habits of the patient—over-exercise, especially after eating, the avoidance of hot places and high altitudes. A residence by the seashore is preferable to mountainous places; and excitement, over-study, and all agencies favoring cerebral congestion are to be avoided.

⁴⁹ West Riding Reports, vol. v. p. 1.

THE NEURAL DISORDERS OF WRITERS AND ARTISANS.

DEFINITION.—These neural disorders consist of a certain train of nervous symptoms, such as spasm, paralysis, pain, tremor, vaso-motor disturbances, etc., either alone or in more or less complicated combinations, which follow certain muscular acts and are occasionally accompanied by a marked condition of general nervousness; they occur in many of the occupations of every-day life that require for their performance a constant muscular strain combined with more or less delicate movements of co-ordination continued for long periods at a time.

SYNONYMS.—Among the terms used to designate the various forms of the affections produced in the manner just stated may be mentioned the following:

Special Terms.—Writers' cramp, Scriveners' palsy, Steel-pen palsy, Chorea scriptorum, Paralysis notariorum, Graphospasmus, Mogigraphia, Crampe des écrivains, Nevrose des écrivains, Schreibekrampf, Le mal télégraphique, Crampe télégraphique, Klavierkrampf, Pianists' cramp, Tailors' cramp, Loss of grip, etc.

General Terms.—Professional dyscinesiæ, Professional impotence, Anapeiratic paralysis, Nevrose co-ordinatrice des professions, Functional spasm, Fatigue diseases, Professional hyperkineses, etc.

None of these terms are satisfactory, and, in fact, it is difficult to fine one that will include the various symptoms arising from the habitual use of a muscle or group of muscles, in the same way for long periods at a time, in the different occupations known to give rise to these neuroses, without including diseases belonging to entirely different classes.

It is with some hesitation that I suggest the term copodyscinesia (κόπος, toil, weariness, fatigue; and δυσκινησια—δυς, faulty, difficult, hard, and κινησις, motion, movement) as signifying difficult or faulty motion due to constant repetition of the same act.

HISTORY.—Some of these neuroses have been recognized for years; this is particularly true of writers' cramp, the earliest notice of which I have been able to discover is in a small work by Ramazini,¹ printed in 1746.

¹ Bern. Ramazini, Treatise on the Diseases of Tradesmen, etc., translated by Dr. James, London, 1746.

Most of the articles upon this subject have been written during the last fifteen or twenty years.

ETIOLOGY.—Many of our every-day actions, which we perform almost automatically, are the result of months and even years of practice; this is well exemplified in the act of writing. At first each letter is made by a separate and deliberate act of volition, and considerable thought has to be expended upon its formation; but little by little the preponderance of the volitional element decreases, until at last we write with but little consciousness of each separate movement, and the act becomes almost an automatic one, the sentence being conceived and the hand committing it to paper with but little thought of the intermediate muscular acts. In a somewhat analogous manner do we learn to walk, each movement being laborious and requiring much thought for its execution: in addition to this, we must regulate the amount of the movement and keep in abeyance all associated muscular action.

This last is spoken of by Hasse² as an important factor in the etiology of these affections. When, however, any one of the various muscles whose integrity is necessary for the automatic performance of any act becomes affected, let the lesion be in the muscle itself or anywhere in the nerve-substance between it and its centre, or in that centre itself in such a way as to hinder its free response to the nervous stimulus, then the will has to be especially directed to the act in order to counteract the effect of the disability, and some other muscle or group of muscles must be substituted in the place of the one incapacitated. That which was previously performed easily and without fatigue now becomes difficult and exhausting.

² Handbuch der speciellen Pathologie u. Therapie, “Krankheiten des Nervensystems,” 1te A., Bd. iv., 1869.

It will be in place here to consider in detail the action of the muscles concerned in performing one or two of the acts most prolific of the affections under consideration.

The first of these that will be examined is the act of writing.

Generally speaking, the methods of writing may be divided into two: 1st, where the fingers do all the stroke movements, the arm remaining quiescent except for the lateral movement; 2d, where the pen is held steadily by the fingers and the letters formed by the movement of the whole arm. In the latter the muscles of the hand and forearm are used almost entirely for pen-prehension and poising, although there is generally a slight finger movement for the long strokes; the forearm is allowed to rest upon the bellies of the flexor muscles as a sort of movable fulcrum, the pectorales, teres major, and latissimus dorsi, together with the biceps and triceps, being mainly employed in forming the letters.

This last method of writing is the one mostly taught in the public schools at the present day; and as a large number of muscles are brought into play, and as there is a more even division of the work, it is claimed that fatigue is not so soon complained of as in the first or older method.

The act of writing is primarily divisible, according to Poore,³ into three acts: 1st, the act of prehension; 2d, the act of moving the pen; 3d, the poising of the forearm and hand. The muscles concerned in the act of prehension are—the first two dorsal interossei, the opponens, abductor, and flexor brevis pollicis, and, to some extent, the flexor longus pollicis and the extensors of the thumb. The adductor should also be included in this enumeration.

³ G. V. Poore, Electricity in Medicine and Surgery, London, 1876.

The muscles employed in the movement of the pen differ somewhat according to the method of writing. In the finger movement Poore enumerates the following muscles as the ones used, viz.: flexor longus pollicis, extensor secundi internodii pollicis, flexor profundis digitorum, extensor communis digitorum, and also, to a lesser degree, the interossei.

In the second method of writing these muscles are comparatively quiet, except in making the letters which extend far above or below the line, while the muscles previously mentioned when describing this method are the ones called into play. The poising of the arm and hand is mainly accomplished by the supinator longus, supinator brevis, and possibly by the extensors of the thumb.

From a study of what has been written it will be seen that there are two classes of muscular actions concerned: 1st, the steady contraction of the muscles that poise the hand and hold the pen; and 2d, the intermittent contractions of the muscles concerned in moving the pen: both of these classes are equally important in the etiology of writers' cramp.

Chronic fatigue of the muscles is undoubtedly, in some cases, a precursor, if not a cause, of copodyscinesia, and, according to Poore,⁴ is occasionally the expression of hyperæmia or mild inflammation of a motor nerve. Acute local fatigue has symptoms which are well known to us all after having taken violent exercise, cramp and pain being the two most prominent ones.

⁴ “Writers' Cramp and Impaired Writing-Power,” Medico-Chirurgical Transactions, vol. lxi.

Any student who has dissected much has experienced the intense feeling of fatigue in the muscles required to hold the dissecting forceps, particularly when the spring is a little too strong. Much the same thing is noticed when one who has not been accustomed to write much is for some cause compelled to do so; he will probably notice that in a few hours he is exerting a greater amount of muscular force in pen-prehension than usual, and may even find that he is producing a disagreeable feeling in the distal phalanges by the pressure he is using; he will also probably be aware of a burning sensation between the shoulder-blades.

These symptoms are in all probability dependent upon, or are at least coincident with, a hyperæmia of the nerves and spinal cord, and, if persisted in for a long time without proper intervals of rest must sooner or later interfere with the healthy condition of the spinal cord, as well as of the nerves and muscles of the hand and arm.

Poore, while considering the symptoms of fatigue as in large part peripheral in origin, readily admits that they must generally be accompanied by central changes.

The manner of writing and of holding the pen is of considerable influence in the causation of this trouble. Practically, the fluent writer is more apt to contract this affection than he who writes badly, for the latter seldom obtains a position where steady copying is to be done; theoretically the reverse is true if the amount of work in the two cases is the same.

When the pen-holder is allowed to drop below the head of the first metacarpal bone the movements of the fingers are restricted; the middle and fore finger upon one side of the holder and the thumb on the other act upon the principle of the toggle-joint, so well known in mechanics, and, as the pen-holder is drawn backward to make a stroke, bind the distal phalanges tightly against the holder: this in a short time causes fatigue and awkwardness in writing; but if the holder is made to cross the proximal extremity of the first phalanx of the fore finger the toggle-joint movement is destroyed.

These remarks apply of necessity more strongly to the finger movements than to the conjoined finger-and-arm movement.

Writing with a pencil is not as liable to bring on fatigue and nervous trouble as pen-writing, this being mainly owing to the fact that with the former no particular angle is required to be maintained between the point and the paper; there is therefore less effort at poising, as the pencil may be rotated at pleasure, while with the pen one angle has to be maintained. The same remarks should apply to the fluid pencils (stylographic and Mackinnon pens) now so universally used; in fact, they have been considered by Putnam⁵ as much easier to write with than the pencil, as less weight need be applied upon the tip in order to write.

⁵ J. J. Putnam, M.D., “A New Adjuvant in the Treatment of Writers' Palsy,” Boston Med. and Surg. Journ., vol. ci. p. 320, 1879.

The idea that these troubles of writers were due to using steel pens, as once thought, is manifestly without foundation, as the affection was recognized before the time of the introduction of steel pens, which was from 1800 to 1820.

Fine sharp pens are, however, more productive of evil than composition pens or those with a broad soft nib, as they do not move as easily over the paper, and therefore introduce a difficulty, although a slight one, in the act of writing. The theory that the chemical action between the ink and the metallic pens, and the friction of the pen on the paper, generate sufficient electricity to affect the fingers through the medium of the metallic portion of the pen-holder is too preposterous to mention, except to show what curious reasons are given in attempting to explain obscure and difficult subjects.

The next occupation which very frequently gives rise to these affections is telegraphy.

The invention of the Morse telegraph in 1844, and its general introduction, both here and abroad, a few years later, has proved a most fertile source of copodyscinesia, although but little has been written on this form of neurosis, Onimus,⁶ Robinson,⁷ and Fulton⁸ being among the few to describe it, although several later writers mention its existence.

⁶ “Le Mal télégraphique ou Crampe télégraphique,” Compte Rend. Soc. de Biol., 1878, 6, S. V. 92-96; also “Crampe des Employés au Télégraph,” Gaz. méd. de Paris, 1875, p. 175.

⁷ Edmund Robinson, M.D., “Cases of Telegraphists' Cramp” (4 cases), British Med. Journ., Nov. 4, 1882.

⁸ Thomas Weymss Fulton, “Telegraphists' Cramp,” Edinburgh Clin. and Path. Journ., Feb. 2, 1884.

Telegraph operators, particularly those employed in large cities, whose time is nearly all taken up with their work, are more exposed to the causes of copodyscinesia than those following other trades. They are not only exposed to the danger of contracting the affection by using the telegraph-key in transmitting messages, but when not so employed are receiving messages by sound and writing them down, frequently at the rate of thirty to forty, or even more, words per minute. Thirty words a minute is good telegraphy: this would require, on the average, nearly 600 separate contractions. This would be 36,000 contractions per hour, while to write the same sentences would require about 10,000 less.

The operators employed by the Associated Press, although comparatively few in number, two hundred probably including all in the United States, write for hours at a time, using a stylus and manifold writing-books, making as many as twelve copies at one writing; this obliges them to grasp the stylus very firmly and to press with considerable force, making the act of writing much more difficult.

In addition to the work mentioned above, those who have large numbers of messages to transmit become so expert that to save time they make a record concerning the last message sent with the left hand, while they are telegraphing the next one with the right hand. A complicated act of co-ordination is thus being performed with each hand, the difficulty of which may be appreciated by any one if he but try to perform it.

An editorial in the London Lancet⁹ states that “telegraphers' cramp will, we have little doubt, take its stand among the last-mentioned curiosities” (milkers' cramp, hammer palsy, etc.), and "that the telegraph clerk usually enjoys repeated intervals of complete rest, and runs consequently hardly any risk.”

⁹ 1875, vol. i. p. 585.

Hammond¹⁰ likewise states that telegraphers' cramp is rare in the United States, but a slight investigation proves these two statements to be, unfortunately, very far from the truth. According to recent statistics,¹¹ the Western Union Telegraph Company employs nearly twenty thousand operators, who transmit annually over thirty-five million messages, and as investigation seems to prove that a very large number, if not the majority, sooner or later show some symptoms of copodyscinesia, it becomes evident that this neurosis is far from rare, although hitherto almost entirely overlooked by the medical profession.

¹⁰ Wm. A. Hammond, M.D., Dis. Nervous System, 6th ed., New York, p. 789.

¹¹ J. B. Abernethy, Commercial and Railway Telegraphy, Cleveland, Ohio, 1883, 2d ed.

Operators are very loath to confess that they are suffering from loss of grip, as they have termed it, for then they are considered as less efficient than formerly, and may be asked to resign in favor of one not affected, or be lowered in their salary—a point of great moment, as telegraphy is their means of support. This accounts for the apparent small number of the cases.

In telegraphing, the knob of the key, a circular disc of hard rubber more than one inch in diameter, and placed about one and a half inches above the level of the table, is grasped, as a rule, between the thumb and middle finger, with the tip of the index finger resting on top, the position being quite analogous to the method of pen-prehension, the strain, although much less, falling on the same muscles, but as all lateral movements of the key are impossible, the muscles employed in poising are not brought into play as in writing. The arm is either allowed to rest upon the table, upon the flexor mass of muscles of the forearm near the elbow as a kind of movable fulcrum, or is held with the forearm parallel to the table and a short distance above it.

The movements of telegraphing are made by the alternate action of the triceps, which depresses the wrist by extending the forearm, assisted by the flexor carpi radialis, flexor carpi ulnaris, flexor sublimis, and flexor profundus digitorum on the one hand, and the biceps and supinator longus, which elevate the wrist by flexing the forearm, assisted by the extensor carpi radialis longior, extensor carpi radialis brevior, extensor carpi ulnaris, and extensor communis digitorum on the other.

The movement of the key-knob, being about the one-twenty-fifth of an inch, is so slight that it may be entirely ignored, so that with the fingers upon the key and the forearm resting upon the table near the elbow the motion must be a downward and upward one of the wrist; when, however, the arm is held above the table and parallel to it, the motion is more extended, the shoulder-muscles being used to support the arm.

The wrist is held in a supple manner, and not rigidly, the momentum of the downward movement being used to close the circuit; this, as before stated, is made mainly by the triceps, and is checked by the flexors and supinator longus.

The extensors of the wrist and fingers have a double duty to perform, for, besides assisting in recovering from the downward stroke, they have to support the hand during the whole act of telegraphing, in order to prevent the weight from resting on the key, which would prevent quickness in making and breaking the circuit.

On long circuits, particularly in wet weather, when much electricity escapes from the line, the movements have to be made with much more decision than usual in order to make the signals intelligible at the distant station.

The accompanying diagram shows well the movement of the wrist as above described, the hand and wrist moving into the position of the dotted lines when the downward stroke is made.

The following figures are of interest as proving the great superiority, in point of strength, of the flexor over the extensor muscles of the wrist and fingers. The measurements were made by the dynamometer of V. Burq, great care being taken to apply the instrument upon corresponding points of the palmar and dorsal surfaces of the hand. The grasp of the average man, which includes all the flexor muscles of the fingers and thumb, equals 125 pounds, while the power of the flexors of the wrist, exclusive of the fingers, equals 40 pounds. In marked contradistinction to this the extensors of the wrist register 35 pounds, and the extensors of the fingers only 7. The total power of all the flexors is therefore 165 pounds, and that of the extensors 42 pounds, nearly four times less (3.92). In women the ratio is the same, although the number of pounds registered is about half.

From the foregoing enumeration of the muscles used in writing and telegraphing it may be seen that the brunt of the work does not fall on the same muscles in the two acts, so that operators are seen utterly unable to telegraph more than a few words intelligibly who can still write a fluent hand. The two forms of neuroses often coincide in the same subject, as all telegraphers are of necessity scriveners; in fact, the majority suffer from both forms, and as a rule the most difficulty is experienced in telegraphing, and not in writing, although the reverse is frequently seen. But rarely does one see an operator who, unaffected as far as telegraphing is concerned, has difficulty in writing on account of this curious neurosis.

Of the muscles enumerated in the foregoing discussion, six are supplied, either wholly or in part, by the ulnar nerve—namely, the first two interossei, adductor pollicis, flexor brevis pollicis (inner half), flexor carpi ulnaris, and flexor profundus digitorum (inner part); and seven by the median nerve wholly or in part—namely, the opponens and abductor pollicis, flexor brevis pollicis (outer half), flexor longus pollicis, flexor profundus digitorum (outer part), flexor carpi radialis, and flexor sublimis digitorum.

The remaining important muscles are supplied by the musculo-spiral and its branches, except the biceps, which is supplied by the musculo-cutaneous.

The ulnar nerve supplies fifteen of the muscles of the hand; many of these are not prominently brought forward in writing, but are more or less used in keeping the hand in the required position.

Poore, after a careful study of 32 cases of undoubted writers' cramp, found the muscles affected in the following proportions:

—showing that the muscles supplied by the ulnar nerve were affected more often than those supplied by the others.

The musculo-spiral and its branches supply the extensors of the thumb, fingers, and wrist, besides the two supinators; and by referring to the muscles most called into action in the act of telegraphing it will be seen that the majority are supplied by this nerve and by the median, which supplies the majority of the flexors. This statement explains to a great extent the fact that telegraph operators may be unable to telegraph and yet be able to write, as the muscles most important in the two acts have not the same nerve-supply.

The integrity of these nerves is therefore of the first importance in all cases requiring the use of the fingers and forearm, and many cases of copodyscinesia undoubtedly have a subacute inflammation of these nerves, or at least a congestion of the same, as their foundation, the neuritis or congestion being overlooked, owing to its mild type.

S. Weir Mitchell¹² states that subacute neuritis is often incapable of distinct clinical discrimination when of a mild type and when there is an absence of traumatic cause. Mills¹³ states that “a lesion of the sensitive fibres profoundly affecting this power of conducting impressions may not cause pain, and that pain is not a necessary symptom of inflammation of a mixed nerve: this is an important fact, as I think too much stress is often laid on pain as a symptom of neuritis, leading to error in diagnosis and treatment.”

¹² Injuries of Nerves, and their Consequences, by S. Weir Mitchell, M.D., Philada., 1872.

¹³ F. T. Mills, M.D., “On Two Cases of Neuritis of the 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 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.

¹⁴ A. K. Gardner, M.D., “Hygiene of the Sewing-Machine,” Am. Med. Times, Dec 15-29, 1860.

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. Eulenburg¹⁷ mentions tremor as of very frequent occurrence, and states that he has frequently noticed it in young cigar-makers who smoke to excess.

¹⁶ Ziemssen's Cyclopædia, Amer. ed., vol. xvii.

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.

Onimus¹⁸ states that women are more frequently affected than men with telegraphers' cramp. Erb¹⁹ states that writers' spasm is met with more 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. Hasse²⁰ and Romberg²¹ 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.

¹⁸ Loc. cit.

¹⁹ “Writers' Cramp and Allied Affections,” Ziemssen's Cycl., Amer. ed., vol. xi.

²⁰ Loc. cit.

²¹ Nervous Diseases, vol. i. p. 320.

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. Hasse²³ is also of the same opinion.

²³ Loc. cit.

Whittaker²⁴ 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.

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?).

²⁵ “Ueber Reflexionsfingerkrampf,” Oesterr. Jahrb., März u. April, 1844, quoted by Hasse, loc. cit.

Beard²⁶ holds an opinion directly the reverse of the vast majority of the authorities upon this subject, and states that this disease occurs mostly in 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.

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. Mitchell²⁷ 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.

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 Runge²⁸ as giving rise to symptoms closely allied to this affection. Seeligmüller²⁹ mentions a case where the symptoms came on after an insignificant grazing bullet-wound of the knuckle of one of the fingers.

²⁸ “Zür Genese u. Behandlung des Schreibekrampfes,” Berl. klin. Wochensch., x. 21, 1873.

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. 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 Poore³⁰ and S. Weir Mitchell.³¹

³⁰ Electricity in Medicine and Surgery, London, 1876, p. 209.

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.

Gallard³² reports a case of a street-pavior who had associated spasm of both sterno-cleido-mastoid muscles, which came on only when using the instrument to settle the stones. Dally³³ 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. Reynolds³⁴ reports such a case.

³² “Crampe des Écrivains,” Progrès médical, v., 1877, p. 505.

³³ “Traitement des Spasms professionnels,” Journ. de Thérapeutique, No. 3, 10 Fèvrier, 1882.

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 ending with dots, such as b (—...), d (—..), 8 (—....). Some of the spaced characters are also difficult to make, such as z (... .), & (. ...), y (.. ..).