Tetany

The occurrence of tonic and clonic spasms in the flexors of the arms, in the muscles of the calf, and in the muscles of the abdomen as a complication of "dilatation of the stomach" (ischochymia) was first pointed out by E. Neumann1 and shortly afterward by Kussmaul.2 Frequently the muscles of the face, of the jaws, and of the neck are likewise affected by the spasmodic contractions. The eyes are turned upward and occasionally emprosthotonus of short duration occurs. The crampy contractions are painful; consciousness is either undisturbed, partly disturbed, or entirely absent. In one of Kussmaul's cases, which was published by Gassner,3 the attacks had a distinctly epileptiform character. Several cases of this complication, which have been described mostly under the name of tetany, have been published by Leven,4 Dujardin Beaumetz,5 Hanot, Muller,6 Ger-hardt,7 Renvers,8 Bouveret and Devic,9 Ewald,10 Albu,11 Boas,12 and Fleiner.13 Real tetany is characterized by the sudden appearance of mostly bilateral tonic contractions of the muscles, beginning at the fingers and toes and progressing thence centripetally. The flexor muscles are principally affected, and the hand usually assumes a position which has been characterized by Trousseau as the obstetrical hand.

Only in rare instances are the extensor muscles also affected. As a rule, the knees are bent and the toes turned downward, while the heel is turned upward and somewhat outward (pes equinus). The muscles of the femur and the thigh are only very rarely involved. The duration of the attacks may vary from five minutes to several hours. The following symptoms, which exist for some time after the attacks, are characteristic of tetany:

1 E. Neumann: Deutsche Klinik, 1861.

2 Kussmaul: Deutech. Arch. f. klin. Med., 1869, Bd. vi 3 Gassner: Inaug. Dissert., Strassburg, 1878.

4Leven: Gaz. med. de Paris, 1881, p. 646.

5Dujardin Beaumetz: L'Union medic, 1884, Nos. 15and 18.

6 Muller: Charite Annalen. Bd. 13, 1886.

7 Gerhardt: Berl. klin. Wochenschr., 1886, No. 86, and 1888, No. 4.

8 Renvers: Gesellschaft der Charite Aerzte, 1887. 9Bouveret et Devic: Rev. de raedecine, 1802, p. 48.

10Ewald: Berl. klin. Wochenschr., 1894, No. 2. 11Albu: Berl. klin. Wochenschr., 1894, No. 2. 12Boas: loc. cit, 107. 13Fleiner: Arch. f. Verdauungskrank., Bd. i., Heft 3.

1. Compression Of The Main Nerves

Compression Of The Main Nerves or blood-vessels of the affected extremities for one to two minutes will produce an attack (Trousseau); 2. The electrical irritability of the nerves and muscles is greatly increased (Erb); 3. The mechanical irritability of many nerves of the extremities, and especially of the facialis, is increased. Tapping with a finger in the region of the facial nerve produces quick contractions of the corresponding muscles. Kneading of the face from top to bottom evokes contractions of the subjacent muscles (Chvostek).

The prognosis of tetany is quite bad. In the cases collected by Bouveret and Devic there was a mortality of seventy per cent.

It seems that this complication is of quite rare occurrence, for all the cases mentioned in literature scarcely exceed thirty. Tetany-like convulsions and epileptiform attacks with loss of consciousness are met with far more frequently. According to my experience, the latter complications occur not only in cases of chronic ischochymia, but also in other affections of the stomach.

Thus I have observed one case in a man, 28 years old, who suffered for a great many years from a chronic gastric catarrh. In August, 1895, during a hot spell, he was obliged to drink large quantities of ice-water. At that time he began to suffer from attacks of tetany, alternating with epileptiform convulsions and loss of consciousness. During an attack of tetany the patient would notice that his arms and legs became contracted against his will and would remain in this condition for about ten minutes, he being perfectly conscious, but unable to change the assumed position of the affected extremities.

The epileptiform attacks would begin with a premonitory stage of pain in the gastric region and a restless condition which would last only a short while. Thereupon the patient would lose his consciousness entirely and convulsions of all the muscles in the body would ensue. He would remain in this state from twenty to forty minutes, would frequently bite his tongue, and after awakening usually had no idea of what had happened. The patient had such attacks of either tetany or epileptiform convulsions once or twice a week, and felt utterly prostrated for a day or two after their occurrence. He also complained of a very disagreeable taste in the mouth between the attacks. On examining the stomach in the fasting condition, I found that it was perfectly empty. One hour after a test breakfast free hydrochloric acid was present, but the degree of acidity was somewhat diminished. Under lavage and a general tonic treatment, the patient's condition improved and the attacks became milder in form and appeared at much longer intervals; thus for a period of six weeks the patient had no attacks whatever.

The attacks sometimes occurred without any apparent cause, sometimes, however, they could be referred to some gross dietetic error: thus, for instance, the patient once took a very large piece of salted herring with bread and cheese at twelve o'clock at night before retiring. He awoke at two and called his brother, who slept in the adjoining room, telling him of his restless condition and of the painful sensation within his stomach, and a few minutes later was seized with a severe convulsive attack, which lasted for half an hour, and during which he again severely bit his tongue.

I have observed a similar case of epileptiform attacks in which there was likewise no ischochymia, but hyperchlorhydria and erosions of the stomach. In this case, however, the attacks, as a rule, appeared after an accidental overloading of the stomach, alcoholic drinks apparently playing a great part therein. In a third case I likewise noticed epileptiform attacks in a lady of forty years of age, who suffered from chronic ischochymia, due to a benignant stenosis of the pylorus.

The prognosis of these epileptiform attacks seems to be far more favorable than that of real tetany, for in none of the three cases mentioned have the attacks thus far resulted in a fatal issue.

With regard to the etiology of either tetany or the epileptiform attacks accompanying severe gastric disorders, three theories have been expounded: 1. One theory has been given by Kussmaul, explaining the symptoms of tetany and similar conditions by the great loss of fluids to which the system has been subjected, for this condition is most frequently found in patients who have vomited for a long time and in this way lost a great deal of liquid, in consequence of which the blood has been much thickened, while the nerves and all other tissues have become thoroughly dry. The thirst which is met with in these patients and the greatly diminished urinary excretion speak in favor of this view. This theory has lately gained a warm supporter in Fleiner, who pointed out that in most of these conditions of stenosis of the pylorus, besides the slight quantity of liquid which is able to pass from the stomach into the small intestine, there is often a state of hypersecretion, owing to which abundant quantities of gastric juice are poured into its cavity.

The latter circumstance increases the great deficiency of water in the system.