Clinical Lecture ON A CASE OF TAILOR'S CRAMP, AND OTHER TROUBLES AFFECTING THE FUNCTIONS OF THE HAND
Concluded from page 329.) CASE 3.-The next case I have to bring to your notice is one in which a man has been rendered unfit for following his trade owing to the toxic effects of the trade which he follows. It is, in short, a case of mercurial tremor. The patient is an Italian aged sixty-two. He came to this country when he was seventeen years old, and for the past thirty-four years he has been a looking-glass silverer. His duty is to " run the meicury over tinfoils spread upon sheets of glass.
... on sheets of glass. He is, therefore, constantly handling mercury, and is exposed to its fumes. He is a stronglybuilt, dark haired, olive-complexioned man, of cheerful manner and well nourished. He is hard working and temperate, and there are no facts in his imperfect family history which have any bearing upon his present condition. A careful medical examination leads to the conclusion that, with the exception of the tremor, the patient is in perfect health. The tremor affects the hands mainly and the right band more than the left. When the patient is at lirest the hands and arms are steady, but the instant that he attempts to use the hands the trembling and shaking become excessive. He cannot pick up a scrap of paper, he cannot feed himself, and is obliged to drink through a glass tube owing to the impossibility of holding a cup steadily to his lips. There is some slight tremor of the legs, but this is scarcely noticeable, and does not prevent him from walking freely about. There is no tremor of the face or tongue, and no marked change of speech. The eyesight is good ; no nystagmus ; no change in the discs. Turning to the hands, it is noticeable that the tremor is very coarse, and that when he attempts to use his hands they jerk to and fro through several inches of space. There is no wasting or paralysis of any muscle, no rigidity or contraction of any muscle, and no deformity of the hand. There is no marked tenderness of any nerve, no joint affection, no trophic change, and the muscles respond normally to electricity. This apparently is the third attack of " the trembles " from which the patient has suffered. The first was twenty-six years ago, and his arms, legs, and head shook equally. He was treated for thirteen weeks in the London Hospital and completely recovered. About eight years after the first attack (i.e., eighteen years ago) he had a second attack. In this the legs were mainly affected, and occasionally trembled to such a degree that he was obliged to crawl upon his hands and knees. The arms were also affected, but less so than on the present occasion, for he could always feed himself. At this time he lost several of the teeth, the gums were ulcerated, and there was tremor of the tongue and an affection of the speech so that he could hardly get his words out. From this second attack he aiao completely recovered and returned to his work. He was able to fellow his occupation (except during a short attack of "lumbago ' some eight years ago) until Christmas, 1888, when his arms began to tremble, and, his troubles increasing, he ultimately sought advice here, and after some three weeks' attendance in the out-patient department he was admitted as an in-patient at the end of February, 1889. Our patient was treated with hot sulphur baths and iodide of potassium, &nd left the hospital much improved and able to feed himself, but still far from well. Cases of mercurial tremor are of rare occurrence in this country, although cases are met with among workmen whose occupation brings them in contact with mercury or its salts. The danger appears to be greatest in those cases where (as in "water gilding") heat is employed to volatilise the metal; but. now that electro-plating has supplanted gilding by means of mercurial amalgams, such cases are rarely seen. Our patient is a mirror maker, and therefore belongs to a class of workmen who have always been recognised as liable, but not very liable, to chronic mercurial poisoning. Mirrors are, however, made largely now by means of chemical methods, in which the salts of silver and not those of mercury are employed, and mirror-makers by the old-fashioned method of using a tin-mercury amalgam are a dwindling class. Rare as these cases are, they are likely, therefore, to become more rare. The point of main interest in the case is the diagnosis. This is made for us to a large extent by a knowledge that the patient is exposed to mercurial fumes in his business, and by the patient's own experience, this being the third attack of " the trembles " from which he has suffered. But, without the history to guide us, should we feel sure as to the diagnosis? The tremor in this case is the only symptom of mercurialism, and is the tremor sufficiently characteristic to warrant us in attributing it to that cause? The tremor began in the hands, and is mainly limited to the hands. This is said to be characteristic of mercurial tremor, although it is no absolute rule, for even in this patient's previous attacks the legs mainly suffered upon one occasion, and upon another the head trembled and speech was affected, whuh is not the case now; for, although the patient speaks English like an Italian, there is no other peculiarity of articulation. The tremor is so coarse, jerking, and peculiar that it does not suggest tremor from alcohol, paralysis agitans, senile weakness, or "general paralysis." It only occurs when the patient attempts to use the hand for the purpose of a voluntary act. In this particular it resembles the tremor seen in cases of so-called " disseminated or insular sclerosis," and the diagnosis, judging only by the tremor, would be between that condition and mercurialism. That the tremor of disseminated sclerosis and mercurialism may be practically identical in form seems to be admitted by Charcot and other observers. The age of our patient is against the diagnosis of disseminated sclerosis, that disease seldom commencing after forty, and terminating fatally within a few years of its commencement. The absence of nystagmus is also against the diagnosis of disseminated sclerosis, as is also the fact that the superficial and deep reflexes are in the present case practically normal instead of being exaggerated, as is often the case in disseminated sclerosis. The absence of any speech difficulty is against the diagnosis of disseminated sclerosis, but since its absence is, so to say, merely accidental, and his present attack differs from his last in this particular, this is a point of not much value. Speech is often affected in both these conditions, so that changes in articulation are of doubtful value in the differential diagnosis of the two corfditions. CASE 4.-The last case is that of a mat-maker aged forty who was admitted to the hospital with his left arm stiff, contracted, and absolutely useless, so that he is quite unable to follow his occupation. On examining the arm it was found to be contracted and stiff. The humerus was adducted to the side of the chest, the elbow flexed, and the wrist and fingers flexed. On attempting to move the limb passively it was found that all the joints were very stiff, and creaked audibly. The power of voluntary movement was almost nil. Sensation but little impaired. The state of nutrition of the left arm and hand, especially the latter, was obviously defective. The limb as a whole was emaciated. All the muscles were small, but there was no muscle or group of muscles which was atrophied in any special degree. The left hand was very markedly smaller than its fellow, the skin harsh and dry, the finger-nails deeply grooved, pitted, and incurved. The state of the hand and the contrast in the two hands are well shown in the accompanying drawings kindly made for me by Mr. Wells, M.B. (See Figs. 2 and 3 .) The sensibility of the left arm and hand is slightly impaired. All the muscles of the left hand and arm respond normally to faradisation. With the exception of the arm the patient appeared healthy. He was somewhat thin, but all the organs appeared to be in a normal condition. It is not possible to form a judgment as to the pathology of this man's condition without reference to the history. The patient has had four attacks of rheumatic fever-viz., in 1876, 1879, 1881, and 1885, and it was after the last attack that the left arm and hand became stiff and powerless. The history of his last attack is very important, and I may add that it was elicited only after careful questioning-questioning which was instituted because (as will be presently explained) the condition of the left hand and arm was suggestive of cerebral msichief.