power of throwing a letter into a letter-box by means of the usual supinating movement which he was accustomed to employ. If the power of the muscles be individually tested, it will be found that those which are chronically fatigued do not contract vigorously, that the movements which they produce are more or less ineffectual, and that the muscles are quickly tired out. In extreme cases of writer's cramp, where the disease has, as it were, crept some way up the arm, it is very common to find that many movements other than that of writing are interfered with. One patient, whose case I reported last year, could neither feed himself nor dress himself without much difficulty.

There is one interesting phenomenon connected with writer's cramp which I am unable to explain, viz., the "associated movements" which accompany the act of writing. Readers of "Pickwick" will remember that when Mr. Samuel Weller took upon himself to write a valentine, he found it necessary "to recline his head on his left arm, so as to place his eyes as nearly as possible on a level with the paper, and, while glancing sideways at the letters, to form with his tongue imaginary characters to correspond." These associated movements are always an expression of weakness, and are commonly noticed in those who are unaccustomed to write, or who, like children, are learning that art. They are commonly seen too in persons with writer's cramp, who are as regards the act of writing reduced to the condition of children. One elevates the shoulder in an extraordinary fashion, another gets the head down upon the paper, and a third finds it impossible to write with one hand without making similar kinds of movement with the other. These movements seem to disappear as the power of writing returns.

Next as to the mental condition of these patients, which is generally markedly peculiar. I should make a distinction between the primary mental state, to which is often due, in some measure, the primary failure of the muscles, and the secondary mental state, the state of anxiety and misery which is engendered by the failure of the hand. Cases of writer's cramp vary from those which are purely physical in their origin to those which appear to be purely mental. Between the pro

fessional scrivener whose muscles are exhausted by the endless labour of "quill-driving," and the bridegroom who is unable through "nervousness" to write his name in the register, we find all degrees of mental and muscular impotence. The usual primary or original mental condition is well described by one of my patients, who says of himself: "I am one of those persons who always want to do everything twice as vigorously as is necessary, and have always been noted in the office as being over-anxious about my work. When I had writing to do, I used to do it as if it were for dear life, and especially so when pressed for time, as was often the case." This description applies more or less to all my patients. They are as a rule over-anxious persons, and such as would be likely to use an excessive amount of mental stimulation for the production of muscular contractions. They are often nervous people, such as are easily startled by sudden noises and the like. Their power of writing is usually worse in the presence of spectators, or when the matter to be written is of unusual importance, and in these respects they very closely resemble stammerers. I have met with one instance, and only one, in which writer's cramp was hereditary and had passed through three generations. The grandfather, the father, and the son had all been afflicted with occasional writer's cramp, which supervened not only after excessive writing, but whenever called upon to sign documents of importance in the presence of others. One of my patients tells me that he can write better when merely copying than when composing, as though the act of writing could be accomplished satisfactorily only when it could receive the undivided attention of the mind. For the most part these patients are very sensitive as to their condition, and it is only when the disease has made considerable progress that they can bring themselves to confide their troubles to others. They are ignorant of the existence of any such disease as writer's cramp, and they commonly entirely neglect the first symptoms of the faltering grasp of the pen, attributing it to their own "foolishness," against which they often struggle resolutely with the determination "not to be beaten." Their state is a constant source of annoyance and irritation, and thus is commenced that mental condition which I have called secondary. The mental state of

a patient with fully developed writer's cramp is one of the most distressing which can be conceived. To be constantly plagued by a right hand which lags behind the will and refuses to obey its orders, must be no light mental torment; but when the obstinate right hand is the sole source of income, and the owner of it, with all the will to work, finds every attempt to earn his living baulked by no apparent cause, it is difficult to imagine any more potent source of mental agony.

One of my patients was in the most desponding state possible when first he came under my own observation, and was in fact upon the verge of suicide; and another had in a moment of fury taken a knife and stabbed his right arm at the wrist. It is needless to say that this secondary mental condition reacts upon the already damaged muscles, and that after its establishment the progress of the disease is rapid.

I have seen one case in which prolonged writing produces headache and neuralgia; and another in which a dull pain in the cervical region of the spinal cord follows prolonged efforts to write. In both cases the writing difficulty is extreme, and the worry and irritation it causes are excessive. The general health of these patients, especially when the disease has advanced, is generally below par. They are as a rule thin, their muscles are soft and flabby, and their sleeping power not good.

In five of my patients (the only five in whom I have looked to it) the condition of the finger-nails called for remark. In four of them the nails were remarkably thin and papery, very prone to break, and extremely useless for many of the purposes which nails serve, such as opening knives, &c. This condition of the nails would merely indicate that the nutrition of the limb was below par. In the fifth case, the nails were not only thin, but pitted and furrowed to a most remarkable extent. I certainly never have seen worse nails, and it has been curious to watch how, as the man's general condition and powers of writing improved, the nails improved likewise; and one could infer his writing power from an inspection of the nails.

It has been suggested that because the left hand is liable to suffer in those cases in which the patient finds himself compelled to write with it, therefore the disease is centric in its origin. I

cannot at all agree with this, nor do I see any necessity for such a theory. As Duchenne says, " One must always admit for the development of this malady, as for all others, a particular predisposition." Given this predisposition, with failure of the right hand already established, and with it that mental state which I have called secondary, it would be a matter of great surprise if the act which caused the right hand to fail should not d fortiori produce a similar condition of the left hand, which is generally the weaker of the two.

It is said that this disease is coeval with steel pens, and I should think that this is very likely the case; for a steel pen, with its hard point and rough friction over the paper, certainly demands from the muscles of pen-prehension a far greater effort to keep it steady, and the scrivener has not the opportunities offered by pen-making of resting his hand.

In the next paper I shall consider the treatment of this disease.

SOME OBSERVATIONS ON THE USE OF

PHOSPHORUS IN NEURALGIA.

ILLUSTRATED WITH EIGHTEEN CASES.

BY J. ASHBURTON THOMPSON,

Fellow of the Royal Obstetrical Society, Surgeon-Accoucheur to the Royal Maternity Charity, &c.

THE great difficulty in administering pure phosphorus in a reasonably palatable form, together with some doubt as to the kind of case likely to be benefited by it, and perhaps some apprehension of the effect of so powerful a poison, even in minute doses, may be among the reasons which have prevented the more frequent use of a medicine capable of sustaining comparison with the most active remedial agents with which we are acquainted.

So long ago as 1863 Dr. C. B. Radcliffe1 published an account of four cases successfully treated with the hypophosphite of soda.2 Two of them are cases of sick, or neuralgic, headache— migraine; one of trigeminal, and one of sciatic, neuralgia.

In 1868 M. Dujardin Beaumetz published the results of some investigations conducted by him in that year. These relate rather to the mode of administration than to the therapeutic action of the remedy, and accordingly will be found in brief under the former head.

Dr. Chapman,3 in his recent work, says: "Phosphorus is in my opinion more likely to intensify than to palliate neuralgia:"

1 Radcliffe, British Medical Journal, Nov. 7, 1863, p. 489.

2 For remarks on this substance vide infra.

3 Chapman, "Neuralgia and Kindred Diseases." 8vo. 1873, p. 267.