by William H. Bates, M. D. Д. БейтсReprinted from Medical Record, September 3, 1921, vol 100, pp. 415-417.
WRITER'S CRAMP: ITS CAUSE AND CURE
By W. H. Bates, M. D.,
Writer's cramp is one of a considerable group of so-called occupational neuroses occuring with more or less frequency among persons whose living depends upon their ability to use their hands rapidly and continuously for many hours a day, such as writers, telgraphers, pianists, violinists, seamstresses etc. It may affect only one or two muscles, or it may involve the entire hand, or the entire arm and shoulder. The chief symptom is inability to use the hand, or difficulty in using it, for writing or other occupational purposes. Writer's cramp, being the most common of these maladies, is usually treated as representative of the group.
There has been much discussion about the nature of this disease, but it cannot be said that much light has thereby been thrown upon it. About the symptoms the most astonishingly contradictory statements are made, and upon these contradictory observations contradictory theories are based.
Text-books often state without qualification that the difficulty in using the muscles is confined to the occupational act. Yet it is well known that there are many exceptions to this rule, and most writers state that in the advanced stages of the disease other actions may be affected, or that the occupational cramp may be complicated with other conditions which lead to difficulty in the performance of all finely coördinated actions. A few have reported that the trouble is never confined to the occupational act.
This last was the experience of Poore.1 "The writer's cramp of the text-books, in which failure of writing is the sole symptom, I have never seen," he writes, and adds very significantly: "The conclusion that the patient can do everything but write is often drawn rather hastily from the fact, for example, that he can cut his dinner or play the piano without difficulty. A little consideration will show how widely these acts differ from writing. A dinner-knife is held by flexing the ring and little fingers into the palm, and the first dorsal interosseous if used at all is only called upon for a momentary contraction when the food is being cut. Again, the positions of the hand in writing and piano-playing are quite different. The strain in piano-playing falls upon the extensors of the wrists and fingers and the flexors of the elbows, and it is evident that the momentary contraction necessary for striking the key could be effected by a muscle which might not be able to steady a pen. A patient will often assert that he has no trouble except with writing, because any other trouble he may have is insignificant in the annoyance which it causes him. … There is usually no difficulty in discovering some muscular movement other than writing which is impaired."
In a carefully tabulated report of seventy-five cases involving loss of writing power Poore notes loss of function for other acts in sixty, there being no record in the other fifteen. In one case, the patient, after having at first denied having any trouble except in writing, admitted that in holding a teaspoon his forefingers slipped up the handle, and that he experienced great difficulty in moving the regulator of his watch with a penknife. A third could not hold a coin between his thumb and forefinger without a sense of great effort.
Similar observations were made by Ross2 and Paul.3 The former says that "in those who suffer from writer's cramp the movements requisite for sewing, pianoforte playing, embroidery, buttoning up the clothes, and all actions requiring delicate manipulation are also impaired." The latter reported to the American Neurological Association in 1911 ten cases of occupational cramp in every one of which the difficulty extended to acts other than those demanded by the occupation.
The idea that the trouble is confined to the occupational act is the foundation of what is known as the central pathology. Duschenne of Boulogne,4 who was the first to present a comprehensive description of the condition and to attempt an explanation, believed that the difficulty was confined to the occupational act, and noting also that the disease was likely to occur in the left hand after the patient had learned to write with it for the purpose of sparing the right, he argued that the disturbance must result from a morbid state of the brain centers which control the coördination of the muscles used in writing.
This view still prevails, and has been embodied in the name given to these conditions, namely, occupational neuroses. "There can be no doubt," says Dana,5 "that the lesion in typical cases is central and involves the higher reflex centers and indirect motor and sensory paths." Oppenheim6 postulates "a disturbance of the innervation of the muscles, which occurs only in complicated movements which are acquired by practice, the muscles responding to the will in every other action." Starr7 regards the condition as a manifistation of a localized neurasthenia. "any finely coördinated act," he says, "requires the orderly and adjusted contraction of a series of muscles in proper sequence, and this is secured by impulses sent out from the educated set of interrelated nerve centers. If the act is repeated too often, fatigue results. If, in spite of the fatigue, the act is continued, structural changes in the mechanism underlying it may be caused. These changes may be in the cortical centers of direction; in the subcortical tracts of transmission, i. e. the motor tracts, the spinal neurons, or the nerves; or in the muscles. One or all give out under the excessive use." "In writer's cramp," says Stewart,8 "the patient can use his hand normally for piano-playing or for grasping and using a heavy tool. This is because the weakness is not due to muscular, but to cerebral fatigue."
The smaller number of writers who believe that the trouble is not confined to the occupational act agree in holding to the peripheral pathology. Paul argues for a probable peripheral pathology produced by trauma of peripheral nerve structures, and maintains further that occupation neurosis and occupation neuritis, so-called, are essentially the same in origin, but exhibitions of different degrees of trauma suffered at different loci. Poore1 says: "I have never seen a case without evidence of a peripheral change, and in the great majority of cases there was no reliable evidence of any pathological change except at the periphera." Beard9 advanced what he called a compromise view. "This disease," he says, " is primarily a peripheral and local disease of the nerves and muscles; secondarily and rarely it becomes central and general, or it may result from various central lesions; and it may affect any point between the extreme periphery and the center. The theory that writer's cramp is a result of lesions or disturbance of special coördinating centers in the brain is not sustained by a single properly understood fact; on every point it fails to account for and harmonize the phenomena."
In spite of these divergent views about the symptoms and pathology of the disease, all writers agree that the existing cause is the excessive use of the hand in the occupational activity; but, because this factor is manifestly inadequate to account for it, much importance has been attached to secondary causes. Duchenne laid stress on the importance of mental factors, and this view is now widely held, as it affords a convenient method of accounting for much that would otherwise be accountable. Meige10 puts mental factors in the foreground, holding that in many cases the motor trouble appears very distinctly as a consequence of the mental trouble. He believes that the condition is essentially allied to the tics. Jelliffe11 says: "Psychoanalysis is of great service for the strictly psychogenic cases, and a great many are such."
There is also a substantial agreement as to the value of rest in the treatment of the condition. "Abstinence from writing, in the writer's cramp form, is the first requisite," says Jelliffe11. According to Oppenheim6 the quickest remedy is "absolute avoidance of the act which brings on the spasm." Starr7 considers the prognosis good for recovery, "provided a sufficient period of rest can be enforced. This rest must, however, be absolute rest of the function affected," he says. "If it is writer's cramp, the pen or pencil should not be touched or the fingers placed in the writing position for two years." Even writing with the left hand he considers inadvisable, owing to the liability of the disease to develop in that hand after it has appeared in the right. "The wisest counsel one can give," says Meige10, "is the complete cessation of writing with the hand affected by the cramp." And so one might go on indefinitely.
My own experience with occupational cramps has convinced me that noen of the writers whose works are available to me has understood the cause of these troubles. My practice as an opthalmologist has brought me into contact with a number of persons who were suffering from occupational cramps, and in trying to help one of them, after the neurologist to whom I had sent him had failed, I discovered a remedy so simple that I hesitated to publish it, fearing that my colleagues, as on numerous other occasions, would not believe me. Yet, knowing how general these conditions are, and how disastrously they affect those who suffer from them, I now feel it is my duty to do so.
Case I.—About thirty years ago a court stenographer consulted me about his eyes. He was wearing glasses for myopia, and these, while somewhat helpful, were far from being satisfactory. He became able to see perfectly without his glasses, and was very grateful. A few years later he returned, very much excited and unhappy because he was suffering from writer's cramp and feared that he might be obliged to give up his work.
The trouble was not confined to the writing act, but affected the use of his hand for every purpose. He handled his knife and fork awkwardly, and even shaking hands was a painful ceremony. He had consulted a number of physicians and taken all kinds of treatment, such as electricity, massage, baths, and internal medication, but had obtained no material benefit, and he had now been told that the only thing for him to do was to stop work. He asked me to recommend a nerve specialist, and I sent him to a man who at that time was regarded as the highest authority on diseases of the nervous system in the city. This doctor confirmed the diagnosis of his colleague and prescribed the same remedy, absolute rest until the condition was cured.
The patient returned to me very much discouraged and also much puzzled. He did not understand why he should be told to rest when he worked only ninety days a year and a very few hours at that, while during long vacations the hand was worse than when he was working. Furtermore, it was always worse in the morning than after he had been at work for a while, and he sometimes had more trouble in the left hand than in the right, though he never tried to write with the former. He had told these things, he said, to the eminent neurologist, but the latter did not seem to attach any importance to them. To me the facts seemed highly significant, and I concluded that the man either did not have writer's cramp or that writer's cramp was not what the book said it was.
"Let us get more facts," I said. "We know what you do with your hands in the daytime. Perhaps it would be a good plan to find out what you do with them in the night."
So he had his wife watch him at night, with the result that he came back a little later and told me that he was cured. It appeared that he had been sleeping with his hands under his head. When this was discovered he tied his hands down at night, but so strong was the inclination to put them under his head that at first he tore them free in his sleep. His wife continued to keep watch over him, however, and saw that pressure on his hands and arms was prevented. Immediately relief followed, and in a week the cure was complete.
Thus it became clear why the cramp had been so much worse in the morning than after the hand had been in use for a time, why the left hand had been affected as well as the right; and why the condition had been worse during vacations than when the patient was working, for in the summer he had spent many daylight hours in the hammock with his hands under his head.
The patient was not only very happy over his cure, but very indignant with the eminent neurologist who had told him that the only remedy lay in giving up his work. He wanted to sue him for damages and show him up in courts, and it was only by telling him that the object of his animosity had treated thousands of poor people in hospitals and clinics without pay that I was able to persuade him to let the matter drop. The cure was permanent as long as the cause was avoided, and whenever symptoms of relapse were noticed, prompt relief was obtained by measures which prevented any pressure upon the hands during sleep.
Case II.—Another case of occupational cramp that came to my attention was that of a telegrapher. She suffered from fatigue and severe pain in her right hand and arm, accompanied at times by inability to do her work, and at such times she had difficulty, not only in manipulating the keys of her instrument, but in using her pen. After rest at night the trouble did not seem to be relieved, but after a few hours' work she was always better. She found that she was sleeping with her right hand under her cheek, and when this habit was corrected the cramp immediately disappeared.
Case III.—A third case was that of a violinist who was having trouble not only with his eyes but also with his hands. His symptoms were extremely variable. At times he would be all right. At other times he could not play at all. The fatigue varied within wide limits. The pain was also variable both in intensity and location. Sometimes it would be felt only in the fingers, sometimes it would be in one arm and sometimes in the other. Although the fingers of the left hand, which manipulated the strings, were subject to more strain than the bowing or right hand, the pain was sometimes more severe in the right hand than in the left. I suggested to him that his trouble was probably due to his posture in sleep, but he treated the idea as ridiculous, being convinced that he always slept with his arms lying straight by his side and never bent them under his head. I suggested to his wife that she watched him at night, as the wife of the patient previously mentioned had done, and she found him sleeping, first with both hands under his head, and later with his face resting on his hand. He refused to believe this when told, but was convinced when wakened in one of these postures. The same precautions were taken as in Case I and the cramp quickly disappeared.
I have never known a case of occupational cramp that did not yield to this simple treatment, and in addition to those I have cured myself, many others have been cured by cured patients. The court stenographer told me that he had cured fifty cases, and that many of these patients had cured others.
1. Poore, George Vivian: Trans. London. Med. Chir. Soc., 1878 vol. lxi.
2. Ross, James: Handbook of the Diseases of the Nervous System, 1885, p. 309.
3. Paul, W. E.: Jour. Ner. and Men. Dis., Aug. 1911.
4. Duchenne, G. B. A.: L'électrisation localisée, second edition, 1861, p. 298.
5. Dana, Chas. L.: Text-book of Nervous Diseases, ninth edition, 1920, p. 584.
6. Oppenheim, H.: Text-book of Nervous Diseases, authorized translation by Bruce, 1911, p. 1268, et. seq.
7. Starr, M. Allen: Organic and Functional Nervous Diseases, fourth edition, 1913, p. 859, et. seq.
8. Stewart, Sir James Purves: The Diagnosis of Nervous Diseases, fifth edition, 1920, p. 249.
9. Beard, George M.: Medical Record, March 15, 1879.
10. Meige, Henry: Bouchardt et Brissaud's Traité de médicine, second edition, 1905, vol. x, p. 345.
11. Jelliffe, Smith Ely: Modern Medicine, edited by Osler and McCrae, second edition, 1915, vol. v, p. 748.
40 East Forty-first Street.