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5 Time Tables of
the London and South Western Railway & Ream Parkell
The title of this book
The Salace situated
"WRITER'S CRAMP" ITS PATHOLOGY AND
BY G. V. POORE, M.D.,
Assistant Physician to Charing Cross Hospital.
WE have assumed, in accordance with recognised physiological principles, that the functional activity of an overworked muscle is impaired. Muscles thus abused become tired out, and degenerate into a condition of chronic fatigue or irritable weakness; and we shall see, on comparing chronic fatigue with acute fatigue, that the symptoms which accompany both conditions are singularly alike.
The symptoms of acute fatigue are, first, loss of power to a greater or less extent; the irritability of the muscle being exhausted, it either refuses to respond, or responds but feebly, to the stimulus of the will. If the loss of power be total, we get practically a transient condition of true paralysis. If the loss of power be but partial, then the muscle becomes more or less " repugnant to the will," and we find that our power of adjusting the force to the act to be accomplished is lessened. Accuracy of movement and delicacy of co-ordination
are destroyed. Co-ordination may or may not depend upon the guidance of some ruling "centre," but it is certain that for the proper performance of complicated movements, each muscle requires to be educated to perform its exact proper amount of labour, so that the whole of them working together may do so in a state of harmonious concord. If one, or more, of the muscles concerned be fatigued, it fails (when required to take part in a complicated movement) to put forth its proper amount of force, and the co-ordinated movement becomes an inharmonious discord.
In certain rare instances excessive muscular exertion produces wasting of a muscle, and it is recognised as one of the occasional causes of progressive muscular atrophy.
A pianist of great eminence has informed me that after a prolonged practice he suffers from obstinacy of certain of the muscles which move the fingers. He finds himself incapable of accurately adjusting their movements, and is annoyed by an inability to strike the right note. This naturally irritates and worries him, and he finds that the mental condition thus induced only serves to make matters worse. A few hours' rest serves to restore the lost tone of the muscles, and on beginning to practise again he plays as well as ever.
Tremor of the muscles is a most common effect of acute fatigue, as everyone must have experienced.
Acute cramp-like contractions are equally commonly observed after excessive fatigue. Who has not been awoke from sleep after a long walk or a dance by painful cramp in the calves of the legs?
The pain accompanying acute fatigue must be familiar to everyone who has ever taken a long ride or has tried to hold out a weight at arm's length. This pain, be it observed, is peculiar in character and distinct from other varieties of pain.
The effects of chronic fatigue as observed in cases of "writer's cramp" are exactly analogous to those of acute fatigue. We find in all cases marked impairment of functional activity, but the evidence of such impairment is strangely different in different cases. In the past year I have seen ten cases of this disease. In all of them there was distinct impairment of power in one or more of the muscles of pen-prehension, or the muscles which poise the hand; but in all of the cases there was a remarkable
difference both in the muscles affected and the manner in which the weakness manifested itself. In four cases the most prominent symptom was tremor directly the attempt was made to write; in four others mere impotence to perform the act of writing was the only symptom; in one the act of writing was interrupted by the uncertain and irregular action of the muscles of pen-prehension, causing at intervals a peculiar quivering of the point of the pen; and in one other the attempt to write produced cramp-like contractions extending to many of the muscles of the fore-arm and arm. In more than half of these cases there was a feeling of fatigue, in some instances causing merely trifling annoyance, but in others amounting to pain, severe enough in one case to be described as "excruciating agony." This pain was in every case distinctly the pain of fatigue, a wearing pain more or less continuous, not following the lines of nerve-distribution, and always aggravated by the attempt to write.
The accompanying lithograph is a fac-simile of the handwritings of eight of these patients. Numbers 1 and 2 represent impotent attempts of two patients to write their names. Having, with the greatest possible difficulty and annoyance to themselves, accomplished so much, they were utterly unable to continue, being stopped, in the one case by general spasm of the whole arm, and in the other by a refusal, as it were, of the thumb and first two fingers to hold the pen. It will be observed that the lines composing the letters are shaky and tremulous, although the pen has in each case been pressed with evident. force upon the pages.
Number 3 is the writing of a lady whose loss of writing power had apparently been induced by excessive knitting. Here again the tremulous uncertainty in the formation of the letters is very evident. It will be seen that the sample of writing ends in the middle of a word, a fact due to the intense difficulty and annoyance experienced during the act. Number 4 is a somewhat similar sample; all the letters are tremulous, and become more and more illegible as the act, of writing is continued.
Number 5 is a very curious and interesting specimen. Here again the letters are tremulous and uncertain in their formation