The Use of Atropine in the Treatment of Localized Muscular Spasm. BY WILLIAM M. LESZYNSKY, M. D., LECTURER ON MENTAL AND NERVOUS DISEASES AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL J - NEUROLOGIST TO THE MOUNT SINAI HOS- PITAL AND DEMILT DISPENSARIES. REPRINTED FROM Neto ¥orft JHetocal journal for March 1891. Reprinted from the New York Medical Jaurmal for March Ilf, 1891. . THE USE OF ATROPINE IN THE TREATMENT OF LOCALIZED MUSCULAR SPASM* By WILLIAM M. LESZYNSKY, M. D., LECTURER ON MENTAL AND NERVOUS DISEASES AT THE NEW YORK POST-GRADUATE MEDICAL SCHOOL ; NEUROLOGIST TO THE MOUNT SINAI HOSPITAL AND DEMILT DISPENSARIES. In a paper read before this society in March, 1884, and published in the Medical Record March 25th of the same year, I reported a case of clonic torticollis successfully treated by the subcutaneous administration of the sulphate of atropine. The following is a brief synopsis of the case Female, twenty-one years of age, unmarried, clonico-tonic spasm affecting the right sterno-cleido-mastoid muscle of nearly two months' duration. The initial dose was one eightieth of a grain, which was daily increased in amount until on the twentieth day she was receiving nearly the one sixth of a grain (the maximum dose), which was continued in the same quantity daily for four days, when recovery supervened. No decided improvement was manifested until the in- jection of nearly the one sixth of a grain. All other treat- * Read before the New York Neurological Society, February 10, 1891. Copyright, 1891, by D. Appleton and Company. 2 ATROPINE IN LOCALIZED MUSCULAR SPASM. ment was deemed auxiliary to the atropine. In the discus- sion which followed, it was claimed that, as a number of other remedies (galvanism, bromides) were used in conjunc- tion with the atropine, it would be difficult to determine which effected the cure. From the close observation of this case, I felt confident, and so expressed myself at the time, that the recovery could be attributed to the effect of the atropine. Subsequently the long-wished-for opportunity presented itself, which enabled me to test the efficacy of the drug in a similar form of spasm, untrammeled by the objectionable association of other remedies. I therefore take pleasure in submitting the history of the following case for your consideration and criticism : Charles 0., born in the United States, thirty-seven years of age and a painter by occupation, presented himself for treat- ment June 2, 1888. Three years previous, muscular spasm began on the right side of the neck, arising six w eeks after an abscess had been opened at the angle of the jaw on the right side. The force of the spasm is increased by mastication and closure of the jaw, and it is more active upon mental excite- ment. He is frequently aroused from sleep by the severity of the paroxysm. There is no complaint of pain, but only of numbness in the right lower lip. His occupation frequently brought him in con- tact with lead, but he never suffered from colic or paralysis. There is no history indicative of trauma or syphilitic infection. Formerly' alcoholic excesses. The bowels are constipated, but his appetite is good. He was treated by means of medicines and electricity for four months without relief. He is a fairly nourished man of average height. There is well-pronounced clonico-tonic spasm affecting theright platysma, forcibly drawing downward the fascia about the chin and the lower angle of the mouth. The clonic character of the spasm preponderates, and is al- most constant. The muscle is hypertrophied to nearly four ATROPINE IN LOCALIZED MUSCULAR SPASM. 3 times its normal size, and its outline is distinct and well defined. There is an area of complete anaesthesia one centimetre and a half by three centimetres at the vermilion border of the lower lip, near the angle of the mouth on the right side, which ex- tends inward over the mucous membrane and over the alveolar process in the low er jaw.. The mechanical irritability of the facial muscles is well marked. The jaw-jerk is demonstrable. There is no apparent caries of the teeth. There is no abnormity evident in other por- tions of the body. Treatment.- A cantharides plaster was placed over the affected muscle. June 9th.-One week has elapsed since treatment was be- gun, but there is no improvement in the spasm. The mechan- ical irritability of the facial muscles has diminished. He sleeps better. Injected of a grain of sulphate of atropine into the platysma. 10th.-Gr. 11th.-Sleeps well, and the spasm is less frequent. Gr. 12th.-Vertigo was complained of half an hour after the in- jection. He says he is very much better. The exaggerated mechanical irritability of the facial muscles has markedly de- creased. There is also some abatement in the frequency of the spasm, which was formerly produced or aggravated by closing the jaw or turning the head to the left. These movements can now be accomplished with impunity. Sensation is returning in the anaesthetic area. Only one slight spasm occurred to-day. The tonic character of the spasm has entirely subsided. Gave gr. -^5. 13th.-Gr. -gtg-. 14th.-Spasm is induced by pressure over the alveolar pro- cess in the right inferior maxilla, in the locality of the second bicuspid tooth (which has been lost). Atropine, gr. -gL. 15th.-Gr. 16th.-No spasm since last note. Only slight vertigo after last dose. Gr. 19th.-Has been receiving daily injections of gr. without producing toxic symptoms. Injected gr. 4 ATROPINE IN LOCALIZED MUSCULAR SPASM. 21st.-He did not call yesterday. No spasm since last note. Gr. -fa. 23d.-No attack. Says he is well. Gr. fa. 26th.-No injection since last note. Spasm has not re- turned. The most energetic effort fails to produce any spas- modic action in the platysma. Administration of atropine discontinued. August 18th.-Reports to day that he has remained free from spasm. The successful treatment in this case extended over the brief period of two weeks, and was restricted to the daily administration of atropine. The solution used was- Ijl Atropinae sulph gr. j; Aq. destil § j. M. One minim of this solution represents of a grain of atropine. My method has been to give four minims (gr. tIo) first injection, and to be on the alert for consti- tutional effects. Upon discovering that there is no idio- syncrasy in regard to the drug, it is administered once daily, and the quantity gradually increased from day to day until the desired effect is produced or intolerance is estab- lished. The production of severe constitutional symptoms is not an essential feature in this plan of treatment. One of the experimental physiological effects of the drug, when given in sufficient quantity, is to paralyze the motor nerves, first affecting their trunk. I am not prepared to say whether the atropine relieves the spasm through its constitutional action and its ultimate paralytic effect upon the motor nerve trunk, or by its im- mediate local action. It seems to me, however, that, by injecting the fluid di- rectly into the substance of the muscle, it is not so rapidly absorbed, and thus has ample opportunity to act locally ATROPINE IN LOCALIZED MUSCULAR SPASM. 5 upon the intramuscular nerve elements. There appears to be no ground for the assumption that the atropine possesses an elective affinity for the hyperkinetic area after its ab- sorption into the general circulation. This remedial meas- ure deserves a fair trial in analogous cases before resorting to surgical procedures, such as nerve stretching or tenoto- my, the results of which are not always encouraging. The improvement in the following case of facial spasm seems worthy of note : On the 29th of May, 1888, I was consulted by M. M., a widow, fifty years of age, who stated that for nearly a year the left upper eyelid has been tremulous. Facial spasm developed four months ago. It is worse in wet weather and upon mental excitement. The cause of the spasm is unknown. She has suffered from occasional vertical cephalalgia during the last two years. Climacteric three years ago. She received galvanic treatment for six months without any perceptible change. There is constant tremor in the lower segment of the orbicularis pal- pebrarum, also frequent clonic spasm affecting all of the left facial muscles. There are no teeth in the left upper or lower jaw. They were lost during pregnancy. No tenderness over the alveolar processes. No spinal tenderness. The pupils are small, but react normally both to light and in accommodation. Hypermetropia, 2D. No fundus lesion. She was kept under observation until June 9th, when she received the first injection of T-j0- of a grain of atropine. The needle was introduced deeply into the tissues of the face, near the exit of the facial nerve at the stylo-mastoid foramen. June 10th.-The spasm is a little more frequent, but weaker. Gave injection of five minims. 11th.-Face was flushed for nearly two hours after the in- jection. There is decided improvement. TH,v. 12th.-Flushing of the face and dryness of the mouth and throat all of yesterday afternoon. She says she is much better, and the improvement is evident. Ulvj. 13 th.-m vij. llfth.-Doing well. TRviij (gr. 6 ATROPINE IN LOCALIZED MUSCULAR SPASM. 15th.-mix. 16th.-Tqx. Spasm in orbicularis palpebrarum is quite no- ticeable, but feeble. 19th.-Has had daily injection since last note. Much im- proved. The only symptoms following the injection are flushing and headache, which subside in a few hours. Since beginning the use of atropine I have never witnessed a well-marked facial spasm. The orbicularis palpebrarum is mostly affected, but not so much as formerly. Tremor has taken the place of the spasm in the other muscles. Tq, xij (gr- 4ff)> 23d.-Daily injection since last note. 30th.-She says she has an occasional spasm, as before, but neither so severe nor so frequent, utxv. October 13th.-She reports to-day, having discontinued treat- ment, and states that thus far the improvement has been per- manent. It is well known that, in this peculiar and obstinate affection with an obscure pathology, remissions occasionally occur independent of treatment. The improvement, however, in this case was sufficiently encouraging to commend this method of treatment for further trial. 61 East Seventy-fifth Street. $ REASONS WHY Physicians Should Subscribe fob The New York Medical Journal, Edited by FRANK P. FOSTER, M. D.,' Published by D. APPLETON & CO., 1, 3, & 5 Bond St 1. 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