TETANY: 
With the Report of a Typical Cate. 
BY 
GEORGE J. PRESTON, M. D., 
Professor of Physiology and Diseases of the Nervous System, 
College of Physicians and Surgeons, Baltimore. 
REPRINTED FROM THE 
Neto ¥orft fHeUfcal 
for June 8, 1895. Reprinted from the New York Medical Journal 
for June 8, 1895. 
TETANY: 
WITH THE REPORT OF A TYPICAL CASE* 
By GEORGE J. PRESTON, M. D., 
PROFESSOR OF PHYSIOLOGY AND DISEASES OF THE NERVOUS SYSTEM, 
COLLEGE OF PHYSICIANS AND SURGEONS, BALTIMORE. 
If, along with the name, we accept the description of 
tetany given by Trousseau, Dance, Corvisart, Steinheim, 
and other writers of fifty years ago, then it is a very rare 
disease. Of late years it has been the tendency to include 
under the head of tetany many different varieties of mus- 
cular spasm. It would seem best either to restrict the 
term tetany to cases presenting the classic symptoms or to 
discard the name altogether and class all cases presenting 
such symptoms under the general term of muscular spasms 
of unknown origin. While this affection is not uncommon 
on the continent of Europe, it is rare in England, and ap- 
parently still more rare in this country. The disease, if we 
may call it a disease, may appear at any age, but is far 
more frequently seen in childhood and youth. Apart from 
* Read before the Medical and Chirurgical Faculty of Maryland 
April, 1895. 
Copyright, 1895, by D. Appleton and Company. 2 
TETANY. 
the tetany of lactation, the true disease is very rarely met 
with in the adult. The classic symptoms are too well 
known to require any detailed description. Sometimes 
there are slight prodromal symptoms, such as numbness 
or tingling in the extremities, with some slight disturbance 
of motion. Then comes the tonic convulsion, which begins 
usually in the upper extremities. The thumb is strongly 
adducted ; the fingers are pressed closely together and semi- 
flexed over the thumb; the hand becomes conical in shape, 
assuming the form called by Trousseau the "accoucheur's 
hand." The wrist is next involved, being turned in. The 
forearm may be slightly flexed upon the arm. In the 
lower extremities the toes are bent toward the sole, the 
great toe being turned under the others, and the sole of 
the foot hollowed out. The heel is pulled up, the leg and 
thigh being in a state of extension. The muscles are 
firmly contracted and resist effoits to overcome the con- 
traction. The above is in brief the description given by 
Trousseau. 
Occasionally the lower limbs may be involved first, or 
one side may be chiefly affected. In severe cases the con- 
traction may involve other muscles, the diaphragm, oesoph- 
agus, larynx, muscles of the back and neck, producing- 
opisthotonus, and very rarely the facial muscles may be af- 
fected. The attack generally lasts but a few minutes, 
relaxation comes on, and there are no symptoms during the 
interparoxysmal state. In some cases the tonic spasm may 
continue for hours or days, though it is doubtful whether 
these cases should be called tetany. The attacks recur 
with greater or less frequency for months or even years. 
The frequency of the attacks varies very much ; in some 
cases they occur only three or four times daily, in others 
every few minutes. The following case conforms almost 
perfectly to the classic descriptions of tetany : TETANY. 
3 
The patient, a girl of three years and a half, was referred to 
me by Dr. George Strauss. The family history was perfectly 
good, and the child had always been healthy. There was not 
the slightest evidence of rickets. Physical examination was 
negative, and the child seemed very intelligent. When she 
was one year of age, or two years before I saw her, she had the 
first attack. There would be months in which she was per- 
fectly well, and then the attacks would come on for no appar- 
ent reason. While in my office she had an attack, beginning 
almost simultaneously in hands and feet. Iler hands assumed 
the typical form described above-wrist and elbow slightly 
flexed. The legs were extended, heels raised, and feet slightly 
inverted. Upon inquiry during the attack she said she had no 
pain, and except for the fact that she had to stop her play her 
father said she did not seem to mind the attacks. There was 
no involvement of the facial or other muscles. After a few 
moments of tonic contraction the attack passed off. At the 
time when I saw the patient she was having from ten to fifteen 
aitacks daily. There was no anaesthesia and the reflexes were 
unaltered. Pressure upon the inner side of the arm or at the 
bend of the elbow would bring on an attack. 
This I take to be a typical case of tetany, and I would 
be inclined to restrict the name to cases presenting in gen- 
eral such symptoms. So many different affections have 
been called tetany that it is difficult to arrive at any definite 
knowledge as to the frequency of the disorder. Griffith 
has collected all the American cases up to 1894, in number 
seventy-two. A cursory glance at these cases, as he has 
abstracted them, will show that many of them do not be- 
long under the name of tetany. In this list are what would 
seem to be meningitis, trauma, hysteria, and simple mus- 
cular cramps. Thus it will be seen that tetany is a very 
uncommon affection in this country, although it is not rare 
on the continent. 
Among the symptoms of tetany may be noted a curious 4 
TETANY. 
increase of electric excitability; this is so marked that an 
anodal opening tetanus can be obtained. Chvostek has 
called attention to the fact that pressure over the facial 
nerve at its exit from the foramen will produce contraction 
of the facial muscles. The question has been raised but 
never definitely settled as to whether the Trousseau sign is 
produced by pressure on the artery or the nerve. The 
altered electrical reaction would rather point to the latter 
as the most probable factor. 
The two interesting questions concerning tetany are, 
first, whether it is a sufficiently distinct affection to be 
separated from the many other forms of muscular spasm, 
and, second, what is its probable cause ? In regard to the 
first of these questions it may be said that so long as our 
knowledge of the nature of the disease is so uncertain it is 
best to hold to the clinical differentiation. The symptoms 
of such a case as the one related are certainly sufficiently 
distinct to give it at least a clinical place. 
With our present knowledge of tetany it is impossible 
to do more than speculate as to its cause. The symptoms 
point to the spinal cord as the seat of the disease rather 
than the brain. 
The four extremities are practically always involved, 
and when this is not the case the two upper extremities are 
affected. Tetany involving one side is very rarely if ever 
met with. Both motor and sensory nerve elements are in- 
volved, and decided trophic symptoms have been noted. 
A curious fact is the occurrence of tetany after the removal 
of the thyreoid gland, Wolfler having noted it seven times 
in seventy operations. In this connection it might be 
noted that both in tetany and Basedow's disease the elec- 
tric excitability is greatly exaggerated. 
Of the many causes to which the disease has been at- 
tributed, the most important seem to be diarrhoea and ex- TETANY. 
5 
hausting diseases generally, and in adults lactation and ex- 
posure to cold and wet. The theory that all cases are 
rhachitic is not borne out by observation. The causes 
above mentioned are just the ones that a priori we would 
expect to affect the nerve cells, perhaps using up their pro- 
toplasm. Again, the recovery from the disease may be 
rapid or, on the other hand, very slow, which, according to 
this theory, would mean that the protoplasm of the spinal 
nerve cells was only slightly or very markedly involved, 
these latter cases giving rise to nutritive disturbances. The 
autopsies that have been made by Trousseau and others 
are of no value whatever; certain spots of softening and 
the like are claimed to have been noted, but they were 
probably post mortem changes. 
The course of the disease is very variable, showing a 
tendency to reappear after months or even years of ab- 
sence. It is comparable in this respect to chorea vulgaris, 
though of longer duration. Gowers quotes several cases of 
tetany occurring in successive pregnancies, and Osler refers 
to a similar case {Trans. Am. Assoc, of Physicians, 1894). 
The prognosis is practically always favorable, only a few 
doubtful cases of death having been reported. The diag- 
nosis presents no special difficulties if we restrict the terra 
tetany to those cases that present the classic symptoms. 
Petit mat, tetanus, organic brain disease, and hysteria are 
the affections most likely to be confounded with it. It is 
not likely that true tetany is often mistaken for hysteria, 
but the opposite mistake probably frequently occurs. One 
feels convinced in reading many of the cases reported as 
tetany that the condition was hysteria. The unilateral 
character of hysterica] contractures and the presence of 
other stigmata are usually diagnostic. The treatment may 
be summed up in a few words: Good hygiene, proper diet 
and exercise, the bromides and electricity, and perhaps 6 
TETANY. 
local applications. Chloroform applied locally seems to 
have a good effect, as does ice to the spine. I have ven- 
tured to bring this case before the notice of this society in 
the hope that more cases of this rare and interesting affec- 
tion will be observed and reported. 
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