No. 3125.

JULY 21, 1883.

Clinical LectureON

T E T A N Y.Delivered at University College Hospital,

BY W. R. GOWERS, M.D., F.R.C.P.,ASSISTANT-PHYSICIAN AT UNIVERSITY COLLEGE HOSPITAL, AND PHYSICIAN

TO THE NATIONAL HOSPITAL FOR EPILEPSY AND PARALYSIS.

GETLEME,—I propose to show you to-day an exampleof a very rare disease-the spasmodic affection which istermed tetany."

" So rare is it, that probably none of youhave hitherto seen a well-marked case, at least in an adult-Because a disease is uncommon it is not, therefore, to bedisregarded. There are few diseases, however infrequent,which some of you will not meet with in the future. It is

necessary for you to be acquainted with the diseases whichare rare, as well as familiar with those which are common.The patient before you is a cook by occupation, single, and

forty years of age. There is nothing in her present healthyaspect to suggest that she is the subject of any malady.But it was otherwise, as some of you may remember, whenshe first came into the out-patient room, about six weeksago. Her arms and hands were then fixed by spasm in apeculiar manner. The elbow-joints were slightly flexed,the wrist-joints in somewhat greater degree, while the

fingers were strongly flexed at the metacarpo-phalangealjoints and extended at the others, the thumb being ad-ducted and pressed against the side of the first finger sostrongly that its last phalanx was bent backwards. Thespasm was attended by a painful sense of traction in theaffected muscles; it could be overcome by force, but theattempt gave much pain, and the hands afterwards at onceresumed the same posture. The legs were free from spasm,and she could walk well. She told us that for three months

Isimilar attacks of spasm had come on each morning, whichpassed away in an hour or so. During the day she wouldbe free, but each evening the spasm recurred. In some ofthe previous attacks the legs also had become stift. On theday on which she came to the hospital the spasm had con-tinued without remission. Inquiry into her history elicitedno symptoms of hysteria, and nothing in the past, save over-work, to which the affection could be ascribed. The nextday the spasm resumed its intermitting type, coming on inthe morning and passing away, to recur in the afternoonand evening. Since then the attacks have gradually becomeslighter and briefer, and there is now only a little stiffnessof the hands for half an hour after rising in the morning.From the first, when the hands were free from spasm, thiscould be readily induced by pressure on the position of thenerves of the arm. I will show you this effect. The righthand, you observe, is now quite free from spasm. I pressfirmly on the nerves just below the brachial plexus. Atfirst no change is seen; but now, about a minute havingelapsed, you may notice a slight quivering of the abductorindicis, and then the index-finger becomes slowly flexed atthe metacarpo-phalangeal joint; the thumb is graduallypressed against it, and next the other fingers are flexed inthe same manner; last of all, the wrist also becomes flexed.The pressure being discontinued, the spasm lasts for a fewminutes and then passes off. If I compress in the same waythe nerves of the left arm, the spasm is induced in likemanner in the left hand. No such effect is produced inhealth by similar compression. There has been much dis-cussion whether the result is due to the compression of thenerves or of the brachial artery which runs beside them.But that it is due to compression of the nerves is proved bythe fact that in this patient I can produce it by pressingon the ulnar nerve, away from the brachial artery. Amorbid irritability of the nerves is also conclusively shownby the effect of percussion of the nerves. If I give a

smart tap to the nerves of the arm, it causes a single quickcontraction of the muscles. This is still distinct, althoughless than it was a few weeks ago, as the patient is recover-ing, and it was then even more conspicuous in the facialthan in the brachial nervea. The slightest tap on the facialnerve in front of the auditory meitus caused an instant

momentary contraction in all the facial muscles, exactlysimilar in character to that produced by the stimulation of ahealthy nerve by a single induction shock. The increasedirritability of the nerves was as great to electrical as tomechanical stimulation. It was equally marked to faradismand voltaism. The voltaic current, for instance, from asingle Coxeter cell, caused contraction in the muscles suppliedby the nerve. There was also a qualitative change in themode of reaction. In health, as you know, if the strengthof the current is slowly increased, the first contraction isobtained when the negative pole (kathode) is on the nerveand the circuit is closed, or, in the usual terminology, theK.CL.c. (kathodal closure contraction) is the earliest, and astronger current is required to cause contraction when thepositive electrode ie on the nerve and the circuit is closedor opened (A.CL.C., A.o C while a still stronger current isnecessary to cause contraction when the negative pole is onthe nerve and the circuit is opened (K.O.C.). In this patient,however, the earliest reaction (with one cell) was the positiveopening contraction (A.O.C.), and two cells caused not onlypositive and negative closure contraction, but also distincttetanic contraction the whole time the current was passing.

Such, gentlemen, are the main points in the case. As the edisease is rare, it may be well briefly to mention the chieffacts regarding its causation and clinical features. Thegeneral history of the disease has been ably sketched byTrousseau,l Riegel,2 and Weiss,3 abroad; and in thiscountry by Buzzard4 and Abercrombie.5 The conclusionsof these observers I have endeavoured to verify and extendby an examination of the details of 150 cases, eight of whichhave come under my own observation, and the others havebeen recorded by various writers.s 6 I need not trouble youwith statistical results, except as regards age and sex. Onother points I will merely give you the chief conclusionswhich a comparison of these cases suggests.Tetany is rather more frequent in males than in females,

the ratio being as 7 to 6 ; but this relation, as we shall see,does not obtain at all ages. The disease occurs at all periodsof life, from infancy to old age, but is most frequent in earlychildhood and in early adult life, as is shown by the follow-ing table of the cases in which the age is mentioned :-

Thus the disease is most frequent in infancy and in thesecond decade of life. More than half the cases occur

during the first twenty years. During early childhood thedisease is far more frequent in males than in females (as3 to 1). Between the ages of twenty and fifty, however, theliability of the sexes is reversed, and females suffer twice asfrequently as males. Over fifty, on the other hand, theaffection is practically confined to males. A neuropathicheredity can rarely be traced; but that a family tendency tothe disease may exist is shown by some facts recorded byAbercrombie, who, in an interesting description of thedisease as it occurs in children,7 has mentioned one familyin which three cases occurred, and two others in each ofwhich four children suffered.A direct exciting cause can be traced in about three-fourths

1 Clinical Lectures, Bazire’s Trans., p. 373.2 Deut. Archiv f. Klin. Med., Bd. xii., 1863, p. 405.3 Volkmann’s Klin. Vortrage, No. 189.4 Clinical Lectures on Diseases of the Nervous System, p. 411.5 On Tetany in Young Children. London : Bailliere. 18SO.6 Abelin, Abercrombie, Aran, Berthelot, Broadbent, Brunniche,

Burresi, Buzzard, Cheadle, Chvostek, Cruveilhier and Herard, Caimann,Dance, Da la Berge, Depaulaine, Eisenlohr, Falkson, Frey, Fuekel,Gauchet, Gluzinski, Green, Grisolle and Gery, Guersant and Bsude-locque, Haddon, Herard and Gauchet, Imbert-Goubeyre, Jadelot,Kjellberg, Kussmaul, Larquet. Lisegne, Lussana, :.BI.1Ccall, &bgr;Ltrfan,Marotte, M’kshtok, Miller and Seitz, Moxon, Noncben, Perrin, Piogey,Quincke, Rabaud, Revillont, Riegel, Rilliet and Barthez, Ritchie,Sacre, Silomonsen, Sndraa, Schultze, Skoda, Sonrier, Stich, Tobiesen,Tonellé, Trousseau, Van der Espt, Verdier, Weiss, Weisse, Wilks. Ihave only included the cases of which full particulars are given.

7 Cambridge Thesis on Tetany in Young Children. London : Baiilisre.1980.

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of the cases, and the absence of such cause renders the caseI have shown you somewhat exceptional. The most frequentexcitant is diarrhoea, long-continued and exhausting. Nextin frequency are exposure to cold (especially when conjoinedwith fatigue), acute disease, and lactation. A series of casesin women who were suckling led Trousseau to propose forthe disease the name of "nurse’s contracture"; but this cause,as he afterwards found, is not so frequent as to justify thedesignation. Tetany may also come on during pregnancy,usually in the second half, and after delivery. The relativefrequency of the disease in adult women is due almostentirely to these various influences of maternity. Otheroccasional causes are simple anaemia, prolonged muscularefforts, alcoholism, and sexual excess, especially mastur-bation. I have once seen it as a consequence of lead

poisoning. In young children it is usuatly associatedwith rickets, and is evidently closely allied to the " carpo-pedal contractions," which are so common in that disease.JLaryngtsmus stridulus and convulsions are frequent accom-paniments. In three recorded instances the affection wasapparently due to tapeworm, and ceased when this wasexpelled. Traumatic causes are extremely rare, and yet,strange to say, one surgical operation, excision of an enlargedthyroid, has been followed by an attack of characteristictetany in four instances, 8 Although an association withhysteria has been occasionally observed, it is certainly in-frequent and exceptional. The acute diseases during orafter which tetany has been observed, are (in the order offrequency) typhoid fever, small-pox, cholera, rheumaticfever, measles, febiieula, catarrh, and pneumonia. In someepidemics of typhoid fever it has been comparatively fre-quent, coming on in the latter period of the disease or duringconvalescence. Lastly, singular epidemics of tetany havebeen met with, and in some of these hysteria has probablyplayed a larger part than it does in the sporadic cases. In agirl’s school in France, in 1876, thirty cases occurred. Astill more singular epidemic occurred in certain Belgianprisons in 1846.The symptoms of the disease, in a moderate degree of

severity, are well exemplified in the case I have shown you,and I need not redescribe them. The peculiar posture ofthe hands during the attacks of spasm is that almostinvariably observed, but in a few recorded cases the fingershave been flexed at all joints and the fist thus closed. Stillmore rarely the wrist and fingers have been extended. Incases of slight and moderate degree the spasm is confined tothe hands and forearms, but in the more severe form thelower limbs are also involved. The feet are extended at theankle-joint, and are inverted in the position of talipes equino-varus. The toes are strongly flexed. The knees are usuallyextended, rarely flexed. In cases of still greater severitythe muscles of the trunk and head participate in the spasm.In the trunk the abdominal muscles, the flexors, suffer morethan the extensors of the spine. The thorax may be fixedby the spasm, and even the diaphragm may be involved.Hence respiration is interfered with to the degree of causingcyanosis, and even loss of consciousness. The sterno-mastoids may be rigid, and the head bent forwards. Notunfrequently the jaws are closed by spasm in the masseters.The angle of the mouth may be drawn outwards, and theeyes are half shut by contracture in the facial muscles.Movement is interfered with by the spasm, and in proportionto it. Tnere is no paralysis.

Slight contracture may be painless. When considerable,there is usually an unpleasant sense of traction in theaffected muscles, sometimes amounting to cramp-like pain,and sharp pains dart up the limb, often taking the courseof the nerves. Tingling in the extremities may precede oraccompany the attacks of spasm, and sometimes persist inthe intervals, accompanied, very rarely, by an actual loss ofsensibility to toach, or pain, or both.The spasm is usually, as in this case, paroxysmal. The

attacks are separated by intervals of perfect freedom. Theduration of each attack may be a few minutes, hours,or rarely one or two days. The intervals between theparoxysms may be a few hours or a day or two. As a rule,the briefer the paroxysms the more frequently do theyrecur. Sometimes a slighter degree of spasm continuesduring the intervals, usually in the arms, rarely in the legs.In other caes, again, in both children and adults, the spasmmay continue, scarcely varying in degree, for several days.Thus we may distinguish intermitting, remitting, and con-

e Weiss.

tinuous forms. But cases are met with which present allgradations between these varieties.The remarkable alteration in the irritability of the motor

nerves has been already mentioned in the description of the-case before you. In some cases, as Erb first showed, it iscarried to a still higher degree. Not only, as in this patient:is the anodal opening contraction most readily produced,and continuous " tetanic" contraction attends the passageof the current, but a similar tetanic contraction may be-induced by the anodal opening stimulation-that is to

say, when the positive electrode is placed on the nerve,and the current is broken, so that the current ceases topass, a prolonged contraction results. This phenomenonis of peculiar interest, since in no other condition has.the " anodal opening tetanus" been observed in man.

The change in nerve-irritability usually persists a weekor two longer than attacks of spasm, but this ruleis not invariable. In this patient, for instance, althoughthe spasm still continues in the arms in a slight degree, theirritability of the nerves, is becoming normal; the earliestcontraction is no longer produced, as it was a few weeks.ago, by the anodal opening, but, as in health, by thekathodal closure stimulation.

0

When the paroxysms are very severe there may be copiousperspiration, and sometimes local vaso-motor disturbance,redness, and even slight oedema in the affected parts. Thepulse is quickened, and, in some cases, a rise of temperature(even to 101° F.) has been observed. But in cases of moderateseverity, and also in continuous tetany, these phenomena areabsent. The urine, as a rule, is normal, but transient albu.minuria has been twice observed,9 and once glycosuria coin-cided with the attacks.10The paroxysmal form of tetany may be either slight or

severe, but the continuous form never presents a very intensedegree. In young children tetany is usually continuous,,but the intermitting form is not unknown. In older childrenand adults it is rare for the spasm to be continuous forseveral days ; as a rule it is intermitting, or there are con-siderable remissions in its degree. Continuous tetany maypersist while the patient is asleep; in the intermitting form.attacks occasionally, although not frequently, come on duringsleep. The total duration of the disease varies much.Either the continuous or the intermitting form may last fora few days only. But it is not uncommon for the intermit-ting form to last for several months. In the patient beforeyou the affection has already lasted for more than fourmonths, and it will probably be another month before she iswell. But it is rare for the continuous form, in which thespasm goes on without interruption or considerable remissionfor several days, to last for more than a few weeks, inadults at any rate. In the majority of cases in which thespasm continues for more than three days, the patient hasonly one attack; in only a few cases have there been two-attacks, and the total duration of the disease has never ex-ceeded a month. The disease is prone to occur either under theinfluence of an obvious excitant, or sometimes without anyappreciable cause. A woman, for instance, suffered from itwhile suckling each of five children ;11 another patient had anattack in each of ten successive winters,I2 In some instancesseveral years have intervened between the attacks-three,six, and even eleven. 13Almost all cases end in recovery. Death, when it has

occurred, has usually been due, not to the tetany, but to itscause, as diarrhoea. In a very few instances the spasm hascaused death, either directly by exhaustion from its violence(as in a case recorded by Trousseau), or indirectly by the in-fluence on the lungs of the repeated interference with respi-ration, which has induced pulmonary congestion and a lowform of pneumonia. Nor does it, as a rule, leave behindany troublesome sequela. In a few cases weakness of theleg was persisted for a time. It has once been immediatelyfollowed by chorea,14 and once by acute and general muscularatrophy. 15The little that is known of the pathological anatomy of

the disease throws no light upon its nature. In a few casesminute changes have been found in the spinal cord,16 capil-lary haemorrhages, accumulations of lymphoid cells aroundthe bloodvessels, and minute foci of myelitis. These are,doubtless, of secondary origin, the result of the acute dis-turbance of function, and afford no indication of the morbid

9 Kussmaul, Nonchen. 10 Stich. 11 Macca.11.12 Lussana. 13 Chvostek.

14 Salomonsen. 15 Bondet. 16 By Weiss, Langhans, and Ferraris.

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influence by which the function is disturbed. The onealmost solitary fact which we have to guide us in seekingfor the seat of the disease is the change in the irrita-

bility of the motor nerves. This proves beyond a doubtthat the nutrition of these nerves is changed. But sucha change in; he nerves suggests a similar change in themotor nerve cells of the spinal cord. Of these the motoraxis-cylinders are the processes, and share the changesin nutrition of the parent cell. Moreover, the spasm itselfindicates that there is a morbid state of grey matter,since we know that onlv nerve cells can liberate the energywhich causes spasm. We may feel sure, therefore, that themotor nerve cells of the cord and the fibres proceeding fromthem are in a morbid state. The tingling and impairedsensibility occasionally observed, suggest that the sensorycells of the cord may participate in the alteration. Buthere we must stop. Whether the morbid condition arisesprimarily in the cord, or descends from higher centres, wecannot tell, and opinions which have been put forward, thatthis or that part of the brain is the seat of the disease, arestill in the region of unsupported theory. In passing, how.ever, I may direct your attention to the peculiar positionwhich the hand almost invariably assumes during the con-tracture, a position determined by the predominant spasmin the interossei and some of the lumbricales. It is theopposite posture to the flexion of the phalanges at all joints,in which the" fist is closed." The posture is evidently oneof high physiological importance. It enters, in greater or lessdegree, into many delicate movements of the hands, as inwriting; whereas the flexion of the phalanges at all jointsoccurs especially in coarse movements of the limb, as inlifting a weight. Evidently the "interosseal flexion," as itmay be termed, depends upon well-organised nervous ar-rangements ; but where these are placed we do not know,and hence we are ignorant of its localising significance. Itis conspicuous in many cases of post-hemiplegic mobilespasm, an approximation to it is observed in paralysisagitans, and it is the most common posture of the handsduring epileptic fits. Probably it ultimately depends onnervous arrangements situated in the cerebral cortex ; butdoubtless, if so, there are corresponding subsidiary arrange-ments in the lower centres, even in the spinal cord, throughand by means of which it is effected. Hence this posture doesnot, in itself, justify us in going for the seat of the diseasebeyond the spinal axis (including the grey matter of the ponsand medulla), in which, as we have already seen, a morbidstate is indicated by other symptoms.Of the nature of the change in the nerves and theircentres we know almost nothing. The enduring alteration infunction, demonstrated by the change in mechanical andelectrical irritability, conclusively proves some change intheir nutrition, but the fact that this change remains limitedto increased irritability, and in the end passes away entirely,proves that it is comparatively slight in degree and probablylimited to such fine molecular changes as could not be reco-gnised by any means of investigation at present at our dis-posal. " Vaso-motor spasm " in the nerve centres has beeninvoked as an explanation of the attacks of contracture,but it seems to me without sufficient reason. There isaothing in the symptoms to suggest the hypothesis ; theadequacy of the mechanism is as unproved as it is impro-bable ; and it leaves unexplained the one fact of thefunctional alteration in the motor nerves, which is at presentthe only pathological indication we possess. But functionalexcitement in the nervous system often induces vaso-motordisturbance, both central and peripheral. The vaso-motor-symptoms which have been, in rare cases, observed at theperiphery, were clearly secondary in time, and we are justi-fied in assuming that the same is true of the slight andvariable traces of similar disturbances in the spinal cord(leucocytal aggregation about the vessels) which have beendiscovered in one or two severe cases.In chronic poisoning by ergot there is often contracture

which singularly resembles that of tetany, and the similarityhas struck many observers,!7 and has suggested the depen-dence of the disease we are now considering on some toxicinfluence. But the significance of etiological facts is on the’whole opposed to such an assumption. Although in somecases reflex irritation has appeared to excite the disease, itis doubtful whether this plays a large part in its pathology.rhe diagnosis of a case of tetny rarely presents any con-

siderable ditficulty. The symptoms are characteristic, and

17 Imbe-rt-Goubeyre (1844), Hasse, Moxon, Eulenberg.

in the paroxysmal form are unique. In spite of the unfor-tunate resemblance in name, it could be confounded withtetanus only in cases in which the spasm develops suddenlywith extreme violence, and such cases are so rare that onlyone or two have ever been recorded. It is sufficiently distin-guished in ordinary cases by the peculiar posture of thehands, by the invariable commencement of the spasm in theextremities, and by the fact that the masseters, which gene-rally are the first to suffer in tetanus, are always the last tobe involved in tetany. In organic cerebral disease, attendedwith contracture, this is usually unilateral, and continuesnot only for a day or two, but for months; there is paralysisas well as spasm ; and cerebral symptoms are never absent.Hysterical contracture may resemble tetany in form, but isalmost always unilateral. In ergotism the spasm issecondary to other symptoms, and the disease is fortunatelyscarcely ever met with in this country.Only under two conditions is the prognosis other than

favourable. If the paroxysms are extremely violent, andinterfere distinctly with respiration, the disease may be fatalfrom pulmonary complications. Secondly, if the tetany isdue to grave debilitating disease, there is considerable dangerto life from this came; but the prognosis in such a case dependson the primary disease, rather than on the secondary malady.The duration of the affection is often difficult to foretell. It

will probably be brief if the disease depends on a cause whichis speedily removable. It is likely to be long if there is adistinct alteration in the irritability of the motor nerves. If,in an adult, the individual attacks continue for several days,the disease is not likely to last more than two or threeweeks.The treatment must first be directed to the removal of any

derangement to which the disease is apparently due.Diarrhoea must be arrested; lactation stopped. If the affec-tion followed exposure to cold, and the case is seen early,warm baths and free diaphoresis should be employed. Thetreatment of the developed malady itself consists in the dimi-nution or arrest of the attacks by sedatives, and in the removalof the morbid state on which they depend by tonics. For theformer purpose bromide of potassium is the most effective,but it must be given in full doses, as half a drachm threetimes a day. Chloral, Indian hemp, and hypodermic injec-tions of morphia have also been found effdctive, but, as arule, thebromide answers best. The inhalation of chloroformat first increases the spasm, but all contractare disappearswhen the patient is fully under its influence, although thesubsequent recurrence of the spasm is not thereby prevented.Stimulating liniments to the extremities and ice to thespine have also been observed to lessen the spasm. The

voltaic current has been said to do good in some cases, butin others it has so distinctly failed that it is doubtfulwhether the improvement ascribed to its influence may nothave been due to other causes. Those of you who havenot read Trousseau’s striking lecture on the disease willbe startled to learn that the chief treatment for themalady in France twenty years ago was venesection, andwhat is still more surprising, it is said to have been fol-lowed by rapid recovery, even in weakly women. Butit was not invariably successful, and where it failed tonicsoften succeeded.The most useful tonics are, as might be expected, iron,

quinine, and strychnine. In very slight cases no other treat-ment is needed. The patient you have seen is taking onlytincture of nux vomica, and, as you have heard, she issteadily getting well, the disappearance of the augmentedirritability being a satisfactory proof of the reality of herprogress. The continuous tetany of young children is lessamenable to sedatives than the paroxysmal variety of adults;and the most important element in its treatment is thatof the rickety diathesis which accompanies it, and on whichit certainly to a large extent depends.

HOSPITAL SUNDAY AT RIPON. - The friendlysocieties of Ripon held a demonstration on the 8th inst. inaid of the two principal hospitals of the city-viz., Jepson’sHospital and the Dispensary. The members of the varioussocieties marched to the Cathedral, where the Dean of Riponmade an appeal on behalf of the two above-mentionedcharities, in the course of which he stated that during thelast year 489 cases had been recommended to the Dispensary,461 of which were cured or relieved, and only four died, theaverage cost per head being eight shillings. The collectionamounted to 923 Is. 6d.