588 THE TREATMENT OF DISEASES. 



instrument, other movements of the same limb being perfectly easy of performance. 

 The patient experiences at first a sense of stiffness or weariness after unusually pro- 

 longed exertion. The author or copyist finds that his pen no longer readily obeys 

 the mandates of the will, it will not move as it ought to, and the writing is altered 

 in character and looks unnatural. The pianist makes blunders in striking the 

 chords, the fingers falling on the keys they were intended to avoid. The move- 

 ments, which from years of constant practice had become almost involuntary a kind 

 of second nature are now performed with effort and difficulty. The violinist can 

 no longer control the movements of his left hand, and his fingers feel cramped and 

 stiff. The poor needlewoman can no longer ply her needle, she pricks her fingers 

 in her now bungling efforts, and the stitches are irregular and the work badly done. 

 The premiere danseuse is seized with severe pain or cramp in the calves of her legs, 

 and is temporarily obliged to desist from her efforts. 



The disturbances of movement which render writing or similar acts difficult or 

 impracticable are highly characteristic. Such disturbances are in the first instance 

 slight, and are only perceived when the effort has been long continued, being then 

 felt as a sensation of extreme weariness. By degrees the symptoms become more 

 and more marked, and make their appearance very soon after the commence- 

 ment of the exertion, and ultimately directly the pen is taken in the hand, or even 

 when the hand is merely placed in the required position. At first the difficulty 

 may be overcome by a vigorous effort, but soon no amount of determination will 

 enable the sufferer to perform the desired act. Other things are done without 

 trouble, but that combination of movements, the performance of which is necessary 

 for the patient to obtain a livelihood, resists every effort. In a fully developed case 

 of writers' cramp, the patient may be unable to write a dozen lines to save his life, 

 and yet he may be able to paint, or play the pianoforte, or carve without the 

 slightest difficulty. So long as he refrains from attempting to perform the special 

 act, whatever it may be, he differs in no respect from a healthy man ; immediately 

 he attempts to follow his pursuit he is reduced to a condition of perfect helplessness. 

 The moment he abandons his effort and desists from the attempt he is all right 

 again, and feels nothing abnormal. After a time, prolonged effort to perform the 

 desired act brings on distinct cramp, or a jerking or shaking of the part. The 

 cramp movements, which are at first limited to the thumb and fingers, are some- 

 times temporarily avoided by the writer, who adopts some mechanical device which 

 leaves them at rest. The positions assumed by the patient in order to facilitate his 

 writing, and the means he employs to prevent the occurrence of the spasm, are 

 often very curious. One man will rest only the wrist on the paper, raising the 

 elbow in the air ; another supports the arm on the elbow, and writes with the wrist 

 raised and free ; a third steadies the right hand with the left ; whilst a fourth takes 

 the pen between the index and middle finger, or sticks it into a cork which he 

 seizes with his whole hand. As a rule, no sooner has the patient trained himself 

 to write in some such awkward manner, than the muscles of the forearm become 

 subject to spasm, and he is no better off than before. Sometimes the sufferer 

 succeeds with infinite trouble in learning to write with his left hand, but no sooner 

 have his efforts been crowned with success than that hand too becomes affected. 



