The spastic, trembling or paralytic changes, which arise in one or more groups of muscles owing to constant fatigue and one-sided work of the upper (less often the lower) extremity, are in many instances undoubtedly accompanied by chronic inflammatory processes in the muscles or nerves of the arms or legs, which is probably due to over-fatigue of a certain group of muscles and the associated constant hyperaemia. In other instances there may not be the slightest visible sign, not even tenderness on pressure, to indicate similar or other peripheral changes. Since nervous, hereditary, and purely psychical influences often play a decided part, and signs of defective nutrition are found in distant groups of muscles (such as the eyes, tongue, larynx), and there are also sensory symptoms, we are justified in considering some of these cases as essentially central neuroses. At the same time we must not forget the possibility of a peripheral pathological-anatomical origin and in each case try to discover it by careful palpation over each possible nerve and muscle, and we must, especially in the case of muscles, take tenderness on pressure as sufficient proof.

As is well known, all kinds of craftsmen whose work is one-sided are liable to suffer from co-ordination occupation neurosis. Writers, pianists, organists, violinists, players on the zither, harp, etc., shoemakers, typists, bricklayers, sawyers, weavers, watchmakers, smiths, draughtsmen, cigar workers, laundresses, telephonists, as well as masseurs and others, have shown similar symptoms (hence the old name writer's cramp is less rational than Benedikt's now accepted title). In all the occupations where the arms are used it is especially the muscles of the hand and the flexors of the forearm which suffer from tonic cramp, tremor or paresis, but the whole group of arm muscles, as well as those of the shoulder, neck and chest, may be affected. In dancers it is generally the muscles of the big toe which are affected, in cyclists the muscles of the thigh.

The treatment of occupation neuroses by massage is now generally recognised. Of equal importance is rest for the respective muscles from fatiguing work, but especially rest from that occupation which has caused the affection, and also the use of the galvanic current over the muscles and peripheral nerves as well as the brain and spinal cord, along with attention to the general indications of the case. Many people use, in addition, gymnastics with passive and active, simple and combined movements, for which different apparatus may be used. Slow self-resisted and fully controlled exercises here play the greatest part. For my part I never use gymnastics, because rest is required in the treatment of fatigue neuroses, and also because massage, together with the unavoidable movements of daily life, is more than enough to prevent any danger from inactivity.

The technique of the treatment consists of strong effleurage over the veins along the whole extent of the affected part, as well as massage of the respective groups of muscles by effleurage, petrissage, and tapotement. In all these cases I am in the habit of giving fairly strong massage. Some authors {e.g., Eichhorst) prescribe a "cautious" (i.e., gentle) treatment. Hunerfauth uses stronger manipulations in spastic and paretic cases, gentler when tremors are present. Some masseurs lay stress on the treatment of nerves in so far as they are accessible.

All this depends on whether anatomical changes are evident; if they are, the treatment should exclusively or to a large extent be guided by them.

A co-ordination occupation neurosis is an obstinate disease which responds to treatment very slowly, and easily recurs when the onesided muscle work is resumed.

The treatment often lasts several months.

For the rare, often hereditary, primary spinal muscle spasm (= Thomson's disease, myotonia congenita) massage has been used, on Erbs advice, in combination with baths, electricity, and gymnastics.

For the curious attacks of saltatory cramp, dependent probably upon an increased reflex from the ganglia in the anterior horn of the spinal cord, the same treatment is permissible for the reason stated by Frey, that by pressure on the muscles it is possible to relieve cramp (probably by the simultaneous pressure on the nerves).

Finally, it does not seem improbable that at least some forms of tetanus may be influenced by massage between, or even possibly during, the attacks.