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Malaysia, Singapore & Brunei
Contents
PLAN YOUR TRIP

Welcome to Malaysia, Singapore & Brunei

Malaysia, Singapore & Brunei’s Top 21
Need to Know
First Time
What’s New
If You Like…
Month by Month
Itineraries
Outdoor Adventures
Eat & Drink Like a Local
Regions at a Glance

ON THE ROAD

KUALA LUMPUR
Sights
Activities
 Courses
Festivals & Events
Sleeping
Eating
Drinking & Nightlife
Entertainment
Shopping

SELANGOR & NEGERI SEMBILAN

Selangor
Batu Caves
Forest Research Institute Malaysia
Genting Highlands
Bukit Fraser
Putrajaya
Petaling Jaya & Shah Alam
Klang & Pelabuhan Klang
Kuala Selangor
Negeri Sembilan
Seremban
Kuala Pilah
Sri Menanti
Port Dickson

PERAK
 Ipoh
Gopeng & Around
Cameron Highlands
Pulau Pangkor
Kuala Kangsar
Taiping
Kuala Sepetang
Belum-Temenggor Rainforest

PENANG
George Town
Greater Penang
Air Itam & Penang Hill
Batu Ferringhi
Teluk Bahang & Around
Balik Pulau & Kampung Pulau Betong
Southeast Penang Island

LANGKAWI, KEDAH & PERLIS

Kedah
Pulau Langkawi
Alor Setar
Around Alor Setar
Kuala Kedah
Perlis
 Kangar
Around Kangar

MELAKA
Melaka City
Ayer Keroh
Alor Gajah

JOHOR
Johor Bahru
Muar
Mersing
Seribuat Archipelago
Endau-Rompin National Park

PAHANG & TIOMAN ISLAND

Pulau Tioman
The Coast
Tanjung Gemok
Pekan
Kuantan
Cherating
The Interior
Temerloh & Around
Jerantut
Taman Negara
 Kuala Lipis
Raub

PENINSULAR MALAYSIA’S NORTHEAST

Kelantan
Kota Bharu
Around Kota Bharu
Terengganu
Pulau Perhentian
Pulau Redang
Pulau Kapas
Kuala Terengganu
North of Kuala Terengganu
South of Kuala Terengganu

SABAH
Kota Kinabalu
Tunku Abdul Rahman National Park
Pulau Manukan
Pulau Mamutik
Pulau Sapi
Pulau Gaya
Pulau Sulug
Northwestern Sabah
Mt Kinabalu & Kinabalu National Park
 Around Mt Kinabalu
Northwest Coast
Island Getaways
Eastern Sabah
Sandakan
Sepilok
Sandakan Archipelago
Deramakot Forest Reserve
Sungai Kinabatangan
Lahad Datu
Danum Valley Conservation Area
Tabin Wildlife Reserve
Semporna
Semporna Archipelago
Tawau
Tawau Hills Park
Maliau Basin Conservation Area
Southwestern Sabah
Interior Sabah
Beaufort Division
Pulau Tiga National Park
Pulau Labuan

SARAWAK
Kuching
Western Sarawak
Bako National Park
Santubong Peninsula
Semenggoh Wildlife Centre
Annah Rais Longhouse
Kubah National Park
Bau & Around
Lundu
Gunung Gading National Park
Tanjung Datu National Park
Talang-Satang National Park
Batang Ai Region
Central Sarawak
Sibu
Batang Rejang
Bintulu
Similajau National Park
Niah National Park
Lambir Hills National Park
Miri
Northeastern Sarawak
Gunung Mulu National Park
 Kelabit Highlands
Limbang Division

BRUNEI DARUSSALAM
Bandar Seri Begawan
Tutong & Belait Districts
Tutong
Jalan Labi
Seria
Temburong District
Bangar
Batang Duri
Ulu Temburong National Park
Brunei Survival Guide

SINGAPORE
Sights
Activities
Courses
Tours
Festivals & Events
Sleeping
Eating
Drinking & Nightlife
Entertainment
 Shopping
Singapore Survival Guide

UNDERSTAND

Malaysia, Singapore & Brunei Today

History
People, Culture & Politics
Religion
Arts, Architecture & Media
Environment

SURVIVAL GUIDE

Directory A–Z
Accessible Travel
Accommodation
Children
Customs Regulations
Electricity
Embassies & Consulates
Insurance
Internet Access
 Legal Matters
LGBT+ Travellers
Maps
Money
Opening Hours
Photography
Post
Public Holidays
Safe Travel
Telephone
Time
Toilets
Tourist Information
Visas
Volunteering
Women Travellers
Work

Transport
Getting There & Away
Getting Around

Health
Language
Behind the Scenes
Our Writers
Welcome to Malaysia,
Singapore & Brunei
Entwined by shared history, Southeast Asia’s
terrific trio offer steamy jungles packed with
wildlife, beautiful beaches, idyllic islands, culinary
sensations and multi-ethnic culture.

Ancient Rainforests
For many people this region is defined by its equatorial rainforest – among
the most ancient ecosystems on earth. Significant chunks are protected by
national parks and conservation projects. Seemingly impenetrable foliage
and muddy, snaking rivers conjure up the ‘heart of darkness’ – but join a
ranger-led nature walk, for example, and you’ll be alerted to the mind-
boggling biodiversity all around, from the pitcher plants, lianas and orchids
of the humid lowlands, to the conifers and rhododendrons of high-altitude
forests.

Urban Adventures
Singapore is an urban show-stopper that combines elegant colonial-era
buildings with stunning contemporary architecture and attractions such as its
Unesco World Heritage–listed Botanic Gardens. Malaysia’s capital, Kuala
Lumpur (KL), is a place where Malay kampung (village) life stands cheek
by jowl with the 21st-century glitz of the Petronas Towers, and shoppers
shuttle from traditional wet markets to air-conditioned mega malls. Brunei
Darussalam’s surprisingly unostentatious capital, Bandar Seri Begawan,
offers the picturesque water village Kampong Ayer – the largest stilt
settlement in the world.
Cultural Riches
Unesco World Heritage–listed Melaka and George Town (Penang) offer
unique architectural and cultural townscapes, developed over half a
millennium of Southeast Asian cultural and trade exchange. Both cities
embody the region’s potpourri of cultures, principally Muslim Malays,
religiously diverse Chinese, and Hindu and Muslim Indians, but also
indigenous tribes known collectively as Dayaks on Borneo, and the Orang
Asli on Peninsular Malaysia. Each ethnic group has its own language and
cultural practices which you can best appreciate through a packed calendar
of festivals and a delicious variety of cuisines.

Sensational Wildlife
The icing on this verdant cake is viewing wildlife in its natural habitat.
Alongside the multitude of insects and colourful birdlife, you could get lucky
and spot a foraging tapir, a silvered leaf monkey, or an orangutan swinging
through the jungle canopy. The oceans are just as bountiful: snorkel or dive
among shoals of tropical fish, paint-box-dipped corals, turtles, sharks and
dolphins. Even in urban centres there are excellent opportunities for wildlife
watching at the world-class Singapore Zoo and the KL Bird Park.

Mt Kinabalu | LANO LAN / SHUTTERSTOCK ©

Why I Love Malaysia, Singapore & Brunei
By Simon Richmond, Writer
For Southeast Asia in a microcosm, you can’t beat this trio of fascinating
countries. I’ve always enjoyed the diversity of cultures, the delicious cuisine,
combining Malay, Chinese and Indian dishes, as well as the dynamic arts and
architecture of the principal cities of Kuala Lumpur and Singapore. One day
you can be exploring the heritage cityscape of George Town, the next riding
longboats into the deepest recesses of Sarawak or scuba diving off gorgeous
tropical islands – it’s all one huge adventure in the company of welcoming
people.
For more, see Our Writers
Malaysia, Singapore & Brunei’s
Top 21
Street Food
White tablecloth? Confounding cutlery? Snooty waiters? A roof? No
thanks. In Malaysia, the best food is served in the humblest
surroundings and involves the least amount of fuss. Countless
vendors serve delicious dishes from mobile carts, stalls and
shophouses, many still employing recipes and techniques handed
down from previous generations. And in addition to informality,
ubiquity and quality, you’re also spoilt for choice – on a single street,
such as Lorong Baru in George Town, Penang, you’re likely to
encounter Malay, regional Chinese, Indian (pictured) and Western
cuisines.
JURAJ LONGAUER / SHUTTERSTOCK ©
Top Experiences

Diving, Pulau Sipadan

Sometimes it seems as if the world’s most colourful marine life
considers the seawall of Sipadan to be prime real estate – from the
commonplace to utterly alien fish, molluscs and reptiles, creatures
seem to have swum through every slice of the colour wheel. They live
here, play here, hunt here and eat here, and you, lucky diver, may
dance an underwater ballet with them. For any diver, from the
amateur to seasoned veterans, Sipadan is the ultimate underwater
adventure.
RICHARD_NG / GETTY IMAGES ©
Top Experiences

George Town, Penang

Once abandoned by locals and dismissed by tourists, George Town
has managed to cling to its relatively newfound reign as one of the
region’s hottest destinations. The 2008 Unesco World Heritage
declaration sparked a frenzy of cultural preservation that continues to
this day, and the city’s charismatic shophouses have been turned into
house museums, charming boutique hotels and chic cafes. And did
we mention that George Town is also home to some of Malaysia’s
best food?

FILMLANDSCAPE / GETTY IMAGES ©

Top Experiences

Cameron Highlands
Misty mountains, Tudor-themed architecture, 4WDs, scones,
strawberries and tea plantations (pictured) all converge in this
distinctly un-Southeast Asian destination. Activities such as self-
guided hiking, nature walks and agricultural tourism make the
Cameron Highlands one of Malaysia’s more worthwhile and
approachable active destinations. The area also represents a clever
escape within a vacation, as the weather in the Cameron Highlands
tends to stay mercifully cool year-round.

AYARX OREN / SHUTTERSTOCK ©

Top Experiences

Snorkelling, Pulau Perhentian

Though eastern Peninsular Malaysia has several islands offering
unparalleled underwater activities, amazing Pulau Perhentian wins
flippers-down when it comes to attracting snorkellers. Perhaps it’s the
water itself: clear and ethereally blue, the seas surrounding
Perhentian draw a huge variety of colourful marine life. Coral beds lie
close to shore, and on most days you won’t have to swim much
further than the jetty at Long Beach before finding yourself inside a
veritable rainbow cloud of fish of all shapes and sizes.

VINCENT JARY / GETTY IMAGES ©

Another random document with
no related content on Scribd:
Franklinic or Static Electricity.—This form of electricity is now being
much used, especially abroad, in the treatment of nervous affections,
but does not appear to have been employed in the different
copodyscinesiæ, as but few reports of such treatment have found
their way into current literature. Romain Vigouroux111 states that he
has cured one case by statical electricity. Another case is reported
by Arthuis112 as rapidly cured by this treatment after many other
means, carried on during a period of five years, had failed; but his
brochure contains too many reports of cures of hitherto incurable
diseases to be relied upon.
111 Le Progrès médical, Jan. 21, 1882.

112 A. Arthuis, Traitement des Maladies nerveuses, etc., Paris, 1880, 3me ed.

Gymnastics and Massage.—As those suffering from copodyscinesia

are generally compelled by their vocation to be more or less
sedentary, exercise in the open air is indicated, inasmuch as it tends
to counteract the evil effects of their mode of life; but the use of
dumb-bells or Indian clubs, riding, rowing, and similar exercises do
not ward off the neuroses in question or diminish them when they
are present.

Such is not the case when rhythmical exercises and systematic

massage of all the affected muscles are employed, as marked
benefit has followed this method of treatment. The method employed
by J. Wolff, a teacher of penmanship at Frankfort-on-the-Main, which
consists of a peculiar combination of exercise and massage,
appears to have been wonderfully successful, judging from his own
statements and editorial testimonials of such eminent men as
Bamberger, Bardenleben, Benedikt, Billroth, Charcot, Erb, Esmarch,
Hertz, Stein, Stellwag, Vigouroux, Von Nussbaum, Wagner, and De
Watteville. The method is described by Romain Vigouroux113 and Th.
Schott,114 the latter claiming priority for himself and his brother, who
employed this method as early as 1878 or 1879. Wolff,115 however,
states that he had successfully treated this disease by his method as
early as 1875. Theodor Stein,116 having had personal experience in
Wolff's treatment, also describes and extols it: 277 cases of
muscular spasms of the upper extremities were treated; of these,
157 were cured, 22 improved, while 98 remained unimproved; these
comprised cases of writers', pianists', telegraphers', and knitters'
cramp.
113 Le Progrès médical, 1882, No. 13.

114 “Zur Behandlung des Schreibe- und Klavierkrampfes,” Deutsche Medizinal

Zeitung, 2 März, 1882, No. 9, Berlin; also “Du Traitement de la Crampe des Écrivains,
reclamation de Priorité, Details de Procedes, par le Dr. Th. Schott,” Le Progrès
médical, 1re Avril, 1882.

115 “Treatment of Writers' Cramp and Allied Muscular Affections by Massage and
Gymnastics,” N. Y. Med. Record, Feb. 23, 1884, pp. 204, 205.

116 “Die Behandlung des Schreibekrampfes,” Berliner klinische Wochenschrift, No.

34, 1882, pp. 527-529.

It must be borne in mind that Wolff, not being a physician, can refuse
to treat a case if he thinks it incurable; and in fact he does so, as he
has personally stated to the writer, so that his statistics probably
show a larger percentage of cures than otherwise would be the case.

His method may be described as follows: It consists of a combined

employment of gymnastics and massage; the gymnastics are of two
kinds: 1st, active, in which the patient moves the fingers, hands,
forearms, and arms in all the directions possible, each muscle being
made to contract from six to twelve times with considerable force,
and with a pause after each movement, the whole exercise not
exceeding thirty minutes and repeated two or three times daily; 2d,
passive, in which the same movements are made as in the former,
except that each one is arrested by another person in a steady and
regular manner; this may be repeated as often as the active
exercise. Massage is practised daily for about twenty minutes,
beginning at the periphery; percussion of the muscles is considered
an essential part of the massage. Combined with this are peculiar
lessons in pen-prehension and writing.
The rationale of this treatment is not easy, but any method which
even relieves these neuroses should be hailed with pleasure, as they
heretofore have been considered almost incurable.

The method employed by Poore, as mentioned under Electricity, of

rhythmical exercise of the muscles during the application of the
galvanic current, is worthy of further trial, as it combines the two
forms of treatment hitherto found most successful.

Internal and External Medication.—Generally speaking, drugs are of

comparatively little value in the treatment of these affections. This
statement does not apply to those cases where the symptoms are
produced by some constitutional disorder, or where there is some
other well-recognized affection present which does not stand in
relation to these neuroses as cause and effect.

In any case where an accompanying disorder can be discovered

which is sufficient in itself to depress the health, the treatment
applicable to that affection should be instituted, in the hope, however
unlikely it is to be fulfilled, that with returning health there will be a
decrease of the copodyscinesia. In the majority of cases no
constitutional disease can be detected, and it is in these that internal
medication has particularly failed.

The following are some of the remedies that have been employed:
Cod-liver oil, iron, quinine, strychnia, arsenic, ergot, iodoform, iodide
and bromide of potassium, nitrate of silver, phosphorus,
physostigma, gelsemium, conium, and some others.

Hypodermic Medication.—Atropia hypodermically, as first suggested

by Mitchell, Morehouse, and Keen117 in the treatment of spasmodic
affections following nerve-injury, has been used with good effect in
those cases where there is a tendency to tonic contraction; it should
be thrown into the body of the muscle. Vance118 speaks very
favorably of one-sixtieth of a grain of atropia used in this manner
three times a week. Morphia, duboisia, and arsenic in the form of
Fowler's solution have been used hypodermically with but little effect.
Rossander119 reports a cure in one month of a case of two years'
duration by the hypodermic use of strychnia. Onimus and Legros120
used curare in one case without effect.
117 Gunshot Wounds and Other Injuries to Nerves, Philada., 1864.

118 Reuben A. Vance, M.D., “Writers' Cramp or Scriveners' Palsy,” Brit. Med. and
Surg. Journal, vol. lxxxvii. pp. 261-285.

119 J. C. Rossander, Irish Hosp. Gazette, Oct. 1, 1873.

120 Loc. cit.

Local Applications.—The apparent benefit following the local

application of lotions, etc. to the arms in some cases appears to be
as much due to the generous kneading and frictions that accompany
them as to the lotions themselves. Onimus and Legros, believing the
lesion to be an excitability of the sensitive nerves at the periphery,
employed opiated embrocations, but report amelioration in one case
only.

When there are symptoms of congestion of the nerves or of neuritis,

then the proper treatment will be the application of flying blisters, or
the actual cautery very superficially applied to the points of
tenderness from time to time, so as to keep up a continual counter-
irritation. This treatment may be alternated with the application of the
galvanic current (descending, stabile, as previously mentioned) or
combined with it. As these conditions are often found in nervous
women, care should be taken lest this treatment be too vigorously
carried out.

Considerable relief has been reported from the use of alternate hot
and cold douches to the affected part—a procedure which is well
known to do good in some cases of undoubted spinal disease; the
application peripherally applied altering in some way, by the
impression conveyed to the centres, the nutrition of the spinal cord.

Tenotomy.—Tenotomy has been but little practised for the cure of

these affections. Stromeyer121 cut the short flexors of the thumb in a
case of writers' cramp without any benefit, but in a second case,
where he cut the long flexor of the thumb, the result was a cure.
Langenbeck122 quotes Dieffenbach as having performed the
operation twice without success, and states that there has been but
one observation of complete success, and that was the one of
Stromeyer. Aug. Tuppert123 has also performed this operation, and
Haupt124 advises it as a last resource.
121 “Crampe des Écrivains,” Arch. gén. de Méd., t. xiii., 1842, 3d Series, p. 97.

122 Ibid., t. xiv., 1842, 3d Series.

123 Quoted by Poore, loc. cit.

124 “Der Schreibekrampf,” rev. in Schmidt's Jahrbuch, Bd. cxv., p. 136, 1862.

Very few would be willing to repeat the experiment in a true case of

copodyscinesia after the failures above enumerated, for the
temporary rest given the muscle does not prove of any more service
than rest without tenotomy, which has failed in all the more advanced
cases, which are the only ones where tenotomy would be thought of.

Nerve-Stretching.—It is curious that no cases have been reported (at

least I have not been able to discover them) of nerve-stretching for
aggravated cases of copodyscinesia, as the operation has been
performed in several cases of local spasm of the upper extremity
following injuries to the nerves.

Von Nussbaum125 alone mentions the operation, and states that it

has been of no avail, but gives no references; he previously126
stretched the ulnar nerve at the elbow and the whole of the brachial
plexus for spasm of the left pectoral region and of the whole arm,
following a blow upon the nape of the neck; the patient made a good
recovery.
125 Aerztliches Intelligenzblatt, Munich, Sept. 26, 1882, No. 39, p. 35.

126 London Lancet, vol. ii., 1872, p. 783.

This operation, according to an editorial in the American Journal of
Neurology,127 has been performed seven times for spastic affections
of the arm with the following results: 2 cures (1 doubtful), 3 great
improvement, and 2 slight relief.
127 Am. Journ. of Neurology and Psychiatry, 1882.

This procedure would seem to be indicated in those cases of

copodyscinesia where spasms are present which have a tendency to
become tonic in their character, where other means of treatment
have failed. One such case has fallen under the writer's notice,
which, on account of its singularity and the rarity of the operation,
seems worthy of record. The patient is a physician in large practice,
and his account, fortunately, is more exact than it otherwise would
be:

—— ——, æt. 36. Paternal uncle had a somewhat similar trouble in

right arm, father died of paralysis agitans, and one brother has
writers' cramp. From nine to twelve years of age he was considered
an expert penman, and was employed almost constantly, during
school-hours, writing copies for the scholars. At the age of eleven he
began to feel a sense of tire in right forearm and hand when writing;
soon after this the flexors of right wrist and hand began to contract
involuntarily and become rigid only when writing. He remembers
being able to play marbles well for two years after the onset of the
first symptoms. The trouble gradually increased until every motion of
the forearm became involved. At the age of nineteen he became a
bookkeeper, using his left hand, but at the end of one year this
became affected also. Since then both arms have been growing
gradually worse, and at one time exhaustion would bring on pain at
the third dorsal vertebra. At the age of thirty a period of
sleeplessness and involuntary contractions of all the muscles of the
body came on, accompanied by difficulty in articulation from
muscular inco-ordination. After persistent use of the cold douche to
spine these symptoms ameliorated, but the general muscular
twitching sometimes occurs yet, and overwork brings on spasm of
the extensors of the feet. The condition of his arms in December,
1882, was as follows: At rest the right forearm is pronated, the wrist
completely flexed and bent toward the ulnar side, the thumb is
slightly adducted, and the fingers, although slightly flexed, are
comparatively free, enabling him to use the scalpel with dexterity.
This contraction can be overcome by forcibly extending the fingers
and wrist and supinating forearm, but if the arm be now placed in
supination the following curious series of contractions occur,
occupying from one to two minutes from their commencement to
their completion: gradually the little finger partially flexes, then the
ring, middle, and fore finger follow in succession; the wrist then
slowly begins to flex and to turn toward the ulnar side, and finally the
arm pronates, in which position it will remain unless disturbed. The
contraction is accompanied by a tense feeling in the muscles, but is
painless. The left arm behaves in a somewhat similar manner, and if
this is placed in supination a gradual pronation of the arm begins;
then follows the flexion of the fingers, commencing with the little
finger and ending with the thumb; the wrist also flexes, but not as
much as the right, although the flexion of the fingers is more marked.
There is no pain on pressure over muscles or nerves. The extensor
muscles of both arms, although weaker than normal, are not
paralyzed, those of the right responding more readily to both faradic
and galvanic currents than do the left. There is no reaction of
degeneration. The flexors respond too readily, the right showing the
greatest quantitative increase.

In 1879, while abroad, his condition being essentially as above

described, he consulted Spence of Edinburgh, who as an experiment
stretched the left ulnar nerve at the elbow; immediately after the
operation the muscles were paralyzed and the arm remained quiet;
in twenty-four hours the nerve became intensely painful, and
remained so, day and night, for three weeks; this gradually subsided,
and ceased with the healing of the wound two weeks later. Forty-
eight hours after the operation the spasm of the muscles returned,
and in a short time became as bad as ever, proving the operation to
have been a failure.
An interesting point to decide in this case is whether the symptoms
point to an abnormal condition of the nerve-centres, first manifesting
itself in difficulty of writing, or whether the constant writing induced a
superexcitability (for want of a better term) of the spinal cord in a
patient markedly predisposed to nervous troubles. This last
hypothesis I believe to be the correct one.

It might be considered at first sight that the symptoms presented by

this patient were due to a paralytic condition of the extensors, and
not a spasm of the flexors, or at least that the latter was secondary
to the former. While the extensors are somewhat weaker than
normal from want of use, a careful study of the mode of onset of this
affection and the symptoms presented later prove this idea to be
erroneous.

In regard to the operation and its results, it seems that a fairer test of
the efficacy of nerve-stretching in this case would have been made if
the median and not the ulnar nerve had been stretched, as the latter
only supplies in the forearm the flexor carpi ulnaris and the inner part
of the flexor profundus digitorum, while the former supplies the two
pronators and the remainder of the flexor muscles.

Of the mode of action of this operation we are still much in the dark,
but it would seem to be indicated in any case where the contractions
are very marked and tonic in their nature—not, however, until other
means have failed to relieve.

In the ordinary forms of copodyscinesia, it is needless to say, the

operation would be unjustifiable.

Mechanical Appliances.—Most of the prothetic appliances have

been devised for the relief of writers' cramp, the other forms of
copodyscinesia having received little if any attention in this direction.
The relief obtained by their use is usually but temporary, especially if
the patient attempts to perform his usual amount of work, which is
generally the case.
These instruments are of undoubted benefit when used judiciously in
conjunction with other treatment, as by them temporary rest may be
obtained, or in some cases the weakened antagonists of cramped
muscles may be exercised and strengthened. They all, without
exception, operate by throwing the work upon another set of
muscles, and failure is almost sure to follow their use if they alone
are trusted in, as the new set of muscles sooner or later becomes
implicated in the same way that the left hand is apt to do if the whole
amount of work is thrown upon it.

To accurately describe these instruments is out of place in this

article: those wishing to study this branch of the subject more fully
are referred to the article by Debout,128 where drawings and
descriptions of the most important appliances are given.
128 “Sur les Appareils prothetiques, etc.,” Bull. de Thérap., 1860, pp. 327-377.

Their mode of action may be considered under the following heads:

I. Advantage is taken of muscles as yet unaffected, which are made

to act as splints (so to speak) to those affected, greater stability
being thus given and cramp controlled when present.

Under this head may be mentioned the simple plan of placing a

rubber band around the wrist, wearing a tight-fitting glove, or
applying Esmarch's rubber bandage with moderate firmness to the
forearm. Large cork pen-holders, by distributing the points of
resistance over a larger surface, are thus much easier to hold than
small, hard pen-holders.

Two of the instruments devised by Cazenave—one, consisting of two

rings joined together in the same plane (to which the pen-holder is
attached), and through which the index and middle fingers are thrust
as far as the distal joints; and another consisting of two rings of hard
rubber, one above the other, sufficiently large to receive the thumb,
fore and middle fingers, which are thus held rigidly in the writing
position—act in this manner, and are used when the cramp affects
the thumb or fore finger.
II. The cramp of one set of muscles is made use of to hold the
instrument, the patient writing entirely with the arm movement.

The simple plan of grasping the pen-holder in the closed hand, as

previously described, or of thrusting a short pen-holder into a small
apple or potato, which is grasped in the closed hand, occasionally
affords relief and acts in this way. The instruments of Mathieu,
Velpeau, Charrière, and one by Cazenave are based upon this
principle. The first consists of two rings rigidly joined together about
one inch apart, one above the other, through which the fore finger is
thrust, and of a semicircle against which the tip of the thumb is
pressed; the pen-holder is attached to a bar adjoining the semicircle
and rings. Velpeau's apparatus consists of an oval ball of hard
rubber carrying at one extremity the pen-holder at an angle of 45°;
the ball is grasped in the closed hand, and the pen-holder allowed to
pass between the fore and middle fingers. Charrière's instrument is a
modification of the last, having in addition to the ball a number of
rings and rests for the fixation of the fingers. The latter has also
devised an instrument consisting of a large oval ball of hard rubber;
this is grasped in the outstretched palm, which it fills, and is allowed
to glide over the paper; the pen-holder is attached to one side.
Cazenave's instrument is simply a large pen-holder with rest and
rings to fix the fingers.

III. The instrument prevents the spasm of the muscles used in

poising the hand from interfering with those used in forming the
letters.

One of the instruments devised by Cazenave acts in this way: it

consists of a small board, moving upon rollers, upon which the hand
is placed; lateral pads prevent the oscillations of the arm due to
spasmodic action of the supinators. The pen-holder is held in the
ordinary manner.

IV. The antagonistic muscles to those affected by cramp are made to

hold the instrument, while the cramped muscles are left entirely free.
But one instrument acts in this manner—viz. the bracelet invented by
Von Nussbaum,129 which consists of an oval band of hard rubber to
which the pen-holder is attached. The bracelet is held by placing the
thumb and the first three fingers within it and strongly extending
them.
129 Aerztliches Intelligenzblatt, Munich, 1883, No. 39.

The inventor claims great success by its use alone, as the weakened
muscles are exercised and strengthened and the cramped muscles
given absolute rest.

Résumé of Treatment.—In the complicated cases of copodyscinesia

rest of the affected parts, as far as the disabling occupation is
concerned, must be insisted upon: this should be conjoined with the
use of the galvanic descending stabile current, combined with
rhythmical exercise of the affected muscles and of their antagonists,
and massage. Where there is evidence of a peripheral local
congestion or inflammation, this must be attended to; for instance, if
there is congestion of the nerves, or neuritis, flying blisters or the
actual cautery should be applied over the painful spots, followed by
the galvanic current. Where there is paralysis of one or more
muscles, with evidence of interference of nerve-supply, the faradic
current may be used with advantage.

Evidences of constitutional disease should lead to the employment

of the treatment suitable for those affections.
 RÉSUMÉ OF 43 CASES OF TELEGRAPHERS' CRAMP.

Age at time of onset:

Under 20 years 7
Between 20 and 30 25
Between 30 and 40 7
Doubtful 4—43

Average age 23.94 years.

Average age of males 24.22 years.
Average age of females 20.66 years.

Average length of time before the disease appeared after the

commencement of telegraphing was—
In males 7.27 years.
In females 4 years.
The shortest period being 6 months.
The longest period being 20 years.

Left arm implicated in 21

(Not counting case with amputation of right arm) 1
Never used left arm 8
Left arm not affected, although used 12
Doubtful 1—43

Percentage with left arm implicated 63.63

No. of cases with difficulty in telegraphing only 9

No. of cases with difficulty in writing only 0
No. of cases with difficulty in telegraphing most 22
No. of cases with difficulty in writing most 11
No. of cases with difficulty in both alike 1—43
Use of tobacco or alcohol:
No effect in 14
Bad effect in 16
Good effect (in moderation) in 3
Don't use either 10—43

Flushings in arm or face during work in 22

Brittleness of nails in 5
Emotional factor present in 29
Sympathetic movements in other parts in 9
Pain in back during work in 18
Trouble in performance of other acts in 19
Pain on pressure over nerve or muscle in 13

Cramp of flexor group of muscles:

In writing only 0
In writing most 3
In telegraphing only 1
In telegraphing most 5— 9
Cramp of extensor group of muscles:
In writing only 0
In writing most 0
In telegraphing only 4
In telegraphing most 7—11
Doubtful as to character of cramp 11
No cramp 12—43

Manner of telegraphing:
Arm resting on table 22
Arm raised from table 12
Alternating one with the other 7
Doubtful 2—43

Manner of writing:
 Arm movement 13
Finger movement 6
Combination of the two 24—43

TETANUS.

BY P. S. CONNER, M.D.

Tetanus (τεινω, to stretch) is a morbid condition characterized by

tonic contraction of the voluntary muscles, local or general, with
clonic exacerbations, occurring usually in connection with a wound.
Cases of it may be classified according to cause (traumatic or
idiopathic); to age (of the new-born and of those older); to severity
(grave and mild); or to course (acute and chronic), this latter
classification being the one of greatest value.

Though known from the earliest times, it is in the civil practice of

temperate regions of comparatively rare occurrence, and even in
military surgery has in recent periods only exceptionally attacked any
considerable proportion of the wounded.
Occurring in individuals of all ages, the great majority of the subjects
of it are children and young adults. Women seem to be decidedly
less liable to it than men. That this is due to sexual peculiarity may
well be doubted, since the traumatic cases are by far the most
numerous, and females are much less often wounded than males.
The traumatisms of childbed are occasionally followed by it
(puerperal tetanus).

That race has a predisposing influence would appear to be well

established; the darker the color, the greater the proportion of
tetanics. Negroes are especially likely to be attacked with either the
traumatic or idiopathic form.

Atmospheric and climatic conditions, beyond question, act powerfully

in, if not producing at least favoring, the development of tetanus.
Places and seasons in which there is great difference between the
midday and the midnight temperature, the winds are strong, and the
air is moist, are those in which the disease is most prevalent; and it
is because of these conditions that the late spring and early autumn
are the periods of the year when cases are most often seen.1
1 In his account of the Austrian campaign of 1809, Larrey wrote: “The wounded who
were most exposed to the cold, damp air of the chilly spring nights, after having been
subjected to the quite considerable heat of the day, were almost all attacked with
tetanus, which prevailed only at the time when the Reaumur thermometer varied
almost constantly between the day and the night by the half of its rise and fall; so that
we would have it in the day at 19°, 20°, 21°, and 23° above zero (75°–84° F.), while
the mercury would fall to 13°, 12°, 10°, 9°, and 8° during the night (50°–61° F.). I had
noticed the same thing in Egypt.”

Cold has, from the time of Hippocrates, been regarded as a great

predisposing if not exciting cause, and the non-traumatic cases have
been classed together as those a frigore. It is not, however, the
exposure to simply a low temperature that is followed by the disease,
but to cold combined with dampness, and quickly succeeding to a
temperature decidedly higher, as in the cool nights coming on after
hot days in tropical regions, or in the spring and fall seasons of
temperate latitudes, or in the cold air blowing over or cold water
dashed upon a wound or the heated skin. That such cold, thus
operating, does most usually precede the attack of tetanus is
unquestionable; and it has by many been held that without it no
traumatism will be followed by the disease. Observers generally are
agreed, with Sir Thomas Watson, that “there is good reason for
thinking that in many instances one of these causes (wound and
cold) alone would fail to produce it, while both together call it forth.”

In the low lands of hot countries (as the East and West Indies) the
disease is very frequently met with, at times prevailing almost
epidemically; and, on the other hand, it is rare in dry elevated
regions and in high northern latitudes, as in Russia, where during a
long military and civil experience Pirogoff met with but eight cases.
Trismus nascentium would seem to be an exception to the general
rule of the non-prevalence of tetanus in places far north, since, e.g.,
it has been at different periods very common in the Hebrides and the
small islands off the southern coast of Iceland. But these localities,
from their peculiar position, are not extremely cold, and their climate
is damp and variable; so that, even if the lockjaw of infants be
accepted as a variety of true tetanus, the geographical exception
indicated is but an apparent one.

Traumatic cases are greatly more numerous than idiopathic, and no

class of wounds is free from the possibility of the supervention of
tetanus. Incised wounds are much less likely to be thus complicated
than either of the other varieties, though operation-wounds of all
sorts, minor and major, have been followed by this affection. So
frequently has it been associated with comparatively trivial injuries
that it has become a common belief that the slighter the traumatism
the greater the danger of tetanus. That this is not true the records of
military surgery abundantly show. Wounds of the lower extremity are
much graver in this respect than those of the upper. Injuries of the
hand and feet, especially roughly punctured wounds of the palmar
and plantar fasciæ (as, e.g., those made by rusty nails), have long
been regarded as peculiarly liable to develop the disease, and
accidents of this nature always give rise to the fear of lockjaw.
Though there can be no question but that more than one-half of the
cases of tetanus in civil life are associated with wounds of these
localities, yet the number of such injuries is so much greater than of
those of other parts of the body that the special liability of the
subjects of them to become tetanic may well be questioned. In this
connection it is a significant fact that during our late war of perhaps
12,000 or 13,000 wounds of the hand, only 37 were followed by
tetanus, and of 16,000 of the foot, but 57. A few years ago numerous
cases of tetanus were observed in our larger cities complicating
hand-wounds produced by the toy pistol—injuries that were often
associated with considerable laceration of the soft parts, and
generally with lodgment of the wad.

Not even the complete cicatrization of a wound altogether protects

against the occurrence of the disease, the exciting cause of which,
under such circumstances, is probably to be found in retained
foreign bodies or pent-up fluids.

ETIOLOGY.—Almost universally regarded as an affection of the central

nervous system, inducing a heightened state of the reflex irritability,
though some have maintained that the reflex excitability of the
medulla and the cord is actually lessened, how such affection is
produced is unknown; and it is an unsettled question whether it is
through the medium of the nerves or the vessels, whether by
ascending inflammation, by reflected irritation, or by the presence of
a septic element or a special micro-organism in the blood.

That the disease is due to ascending neuritis finds support in the

congested and inflamed state of the nerves leading up from the
place of injury (affecting them in whole or in part, it may be in but a
few of their fibres), and in the inflammatory changes discoverable in
the cord and its vessels. But time and again thorough and careful
investigation by experienced observers has altogether failed to
detect any alterations in the nerves or pathological changes in the
cord, other than those that might properly be attributed to the
spasms, the temperature, or the drugs administered. The symptoms
of acute neuritis and myelitis (pain, paralyses, and later trophic
changes) are not those which are present in cases of tetanus. The
evidences of inflammation of the cord are most apparent, not in that
portion of it into which the nerves from the wounded part enter, but,
as shown by Michaud, so far as the cellular changes in the gray
matter are concerned, always in the lumbar region, no matter where
the wound may be located.

The much more generally accepted theory of reflex neurosis is

based upon the association of the disease with “all forms of nerve-
irritation, mechanical, thermal, chemical, and pathological;” upon the
direct relation existing between the likelihood of its occurrence and
the degree of sensibility of the wounded nerve;2 in the, at times, very
short interval between the receipt of the injury and the
commencement of the tetanic symptoms; in the local spasms
unquestionably developed by nerve-pressure and injury; in the
primary affection of muscles at a distance from the damaged part; in
the already-referred-to absence of the structural lesions of
inflammation; and in the relief at times afforded by the removal of
irritating foreign bodies, the temporary cutting off of the nerve-
connection with the central organs, or the amputation of the injured
limb. But that something more than irritation of peripheral nerves is
necessary to the production of tetanus would seem to be proved by
the frequency of such irritation and the rarity of the disease; by the
not infrequent prolonged yet harmless lodgment of foreign bodies,
even sharp and angular ones, against or in nerves of high
sensibility;3 by the primary affection of the muscles about the jaws,
and not those in the neighborhood of the wound; by the almost
universal failure to produce the affection experimentally, either by
mechanical injuries or by electrical excitations; by certain well-
attested instances of its repeated outbreak in connection with a
definite locality, a single ship of a squadron, a particular ward in a
hospital, or even bed in a ward; by the usual absence of that pain
which is the ordinary effect of nerve-irritation; and by the small
measure of success which has attended operations, even when
early performed, permitting the taking away of foreign bodies
pressing upon or resting in a nerve, interrupting the connection with
the cord, or altogether removing the wound and its surroundings.
Even in the idiopathic cases—many of which, it would at first sight
appear, can be due only to reflected irritation—another explanation
of the mode of their production may, as we will see, be offered.
2 According to Gubler, the danger is greatest in wounds of parts containing numerous
Pacinian corpuscles.

3 Heller has reported a case in which a piece of lead was lodged in the sheath of the
sciatic nerve. Though chronic neuritis resulted, the wound healed perfectly. Two years
later, after exposure while drilling, the man was seized with tetanus and died of it.

The so-called humoral theory would find the exciting cause of the
disease in a special morbific agent developed in the secretions of the
unbroken skin or the damaged tissues of the wound, or introduced
from without and carried by the blood-stream to the medulla and the
cord, there to produce such cell-changes as give rise to the tetanic
movements. It finds support in the unsatisfactory character of the
neural theories; in the strong analogy in many respects of the
symptoms of the disease to the increased irritability and muscular
contractions of hydrophobia and strychnia-poisoning, or those
produced by experimental injections of certain vegetable alkaloids; in
the recent discoveries in physiological fluids, as urine and saliva, of
chemical compounds,4 and in decomposing organic matter of
ptomaïnes capable of tetanizing animals when injected into them; in
the rapidly-enlarging number of diseases known to be, or with good
reason believed to be, consequent upon the presence of peculiar
microbes; in the more easy explanation by it than upon other
theories of the ordinary irregularity and infrequency of its occurrence,
its occasional restriction within narrow limits, and its almost endemic
prevalence in certain buildings and even beds; in the extreme gravity
of acute cases and the protracted convalescence of those who
recover from the subacute and chronic forms; in the very frequent
failure of all varieties of operative treatment; and in the success of
therapeutic measures just in proportion to their power to quiet and
sustain the patient during the period of apparent elimination of a
poison or development and death of an organism.
4 Paschkie in some recent experiments found that the sulphocyanide of sodium
applied in small quantities caused a tetanic state more lasting than that caused by
 strychnia.

This theory is as yet unsupported by any positive facts. Neither

septic element nor peculiar microbe has been discovered.5 Failure
has attended all efforts to produce the disease in animals by
injecting into them the blood of tetanics. There is no testimony
worthy of acceptance of the direct transmission of the disease to
those, either healthy or wounded, coming in contact with the tetanic
patient; nor can much weight be attached to such reports as that of
Betoli of individuals being attacked with it who had eaten the flesh of
an animal dead of it.
5 Curtiss of Chicago thought that he had found a special organism, but further
investigation showed that it was present in the blood of healthy members of the family
and in the water of a neighboring pond.

The ordinary absence of fever has been thought to prove the

incorrectness of this theory, but increased body-heat is not a
symptom of rabies or strychnia-poisoning, of the tetanic state
following the injection of ptomaïnes, or of cholera—a disease very
probably dependent upon the presence and action of a bacillus.
Martin de Pedro, regarding the affection as rheumatic in character,
located it in the muscles themselves, there being produced, through
poisoning of the venous blood, a muscular asphyxia.

MORBID ANATOMY.—The pathological conditions observed upon

autopsy in the wound, the nerves, the central organs, and the
muscles, have been so various and inconstant that post-mortem
examinations have afforded little or no definite information respecting
the morbid anatomy of the disease. Many of the reported lesions
have unquestionably been dependent upon cadaveric changes or
defective preparation for microscopic study. The wound itself has
been found on the one hand healthy and in due course of
cicatrization,6 on the other showing complete arrest of the reparative
process (“the sores are dry in tetanus,” wrote Aretæus),7 or even
gangrenous, with pus-collections, larger or smaller, in its immediate
vicinity, usually in connection with retained foreign bodies.