CLINICAL FORMS OF SPASMOPHILIA For the history of this affection the reader is referred to Frankl— Hochwart's exhaustive article on the subject in Nothnagel's Encyclo pedia (Handbuch).
The chief symptom of the manifest form consists in tonic convul sions of the extremities, which are frequently accompanied by par msthesia in the affected limbs, while consciousness is always preserved. The convulsions always occur in the upper extremities and force the hands into what is known as the "obstetrical position," which is well shown in the accompanying figure tFig. 59). If, as is usually the case, the arms are flexed on the trunk, and the forearms and hands held in a position of flexion (the picture of "Pfotchenstellung"), the position assumed by a dog when he is "begging" (see Fig. 61) is produced. The lower extremities do not always share in the convul sions; if they do, they are usually flexed at the hip and knee, while the feet are in a position of varus or equinovarus with pes cavus con tracture, as illustrated in Figs. 60 and 61.
The convulsions appear s ud (1 enly and last several hours or even (lays, to reap pear after remissions of equal duration; or they may dis appear altogether. In well marked cases. in which (-edema gradually develops in the dor sum of the hands and feet, these latter are rigidly fixed, and every attempt to correct their position elicits a cry of pain. In milder cases the atti tude is the same (luring rest, but the resistance offered to passive movements is slight, and by exerting the will-power the children are able to over come the forced position from time to time, long enough to use their hands for grasping things. During rest the hands return to the obstet rical position. The same relaxation of the tonus is observed toward the end of an attack of tetany.
During a severe attaek the tonic contracture may spread to Ille muscles of the trunk and face, producing a rigid expression of counte nance, with wrinkled brow and mouth protruded like a snout (earp-mouth).
Among rarer events are re tention of urine from spasm of the sphincter of the blad der, disturbances of degluti tion, pupillary rigidity and dyspnaia, all of which have been described; all these phe nomena are regularly associated with the typical attitude of the extremities.
Although the position of the extremities is quite characteristic, it is not sufficient in itself to establish a diagnosis of tetany-, because it occasionally occurs both in hysteria and in organic diseases of the brain.
A positive diagnosis of tetany rests on the proof of abnormal exaggera tion of the mechanical and galvanic irritability of the nervous system. This ovorexcitability gives rise to a triad of symptoms, which are present either singly or together in the intervals of freedom, and are therefore distinguished by the term "latent" tetany from " manifest" tetany, the latter being characterized by the spontaneous attacks of convulsions in the extremities (carpopedal convulsions).
The latent symptoms of tetany are: Trousseau's, Clivos teck's, and Erb's phenomena.
Trousseau's phenomenon consists in the fact that pressure on the nerve trunks in the inter nal bieipital groove, or by elastic constriction of the arms brings on an attack. The constriction, which must be great enough to produce cyanosis of the distal portion of the extremity-, must be kept up for from one to SeV oral minutes before a convulsion makes its appearance, and the: procedure is attended with some pain. The phenomenon, how ever, is the most fugacious of the three named, and while its pres ence is a proof of totally, its ab sence is of no significance.
Chvosteck's, or the facial phenomenon (erroneously called facial reflex) is, like the preced ing, an expression of increased mechanical irritability of the nerves. When the facial nerve is tapped at a certain point on the cheek, about midway between the zygomatic process and the angle of the mouth, lightning-like contractions are produced in the entire region supplied by the branches of the facial nerve which is affected by the blow.