A common type of irritative spasm is provided by the patient who develops a spasmodic torticollis as the result of pediculi in the hair. The spasm is of a clonic type, and is much more amenable to treatment than in those cases which present tonic contraction. The patient should lie on one side with a roll placed under the sound side of the neck, leaving the head itself without support except for that afforded by the masseur's disengaged hand. Surface stroking is soon replaced by deeper stroking over the sternomastoid and trapezius, and this, in turn, should be replaced by gentle kneading. It is important that this should be rhythmical, as every endeavour must be made to avoid causing the smallest trace of irritation. When the spasm has been relieved, or at least ameliorated, the patient may sit up. Downward neck stroking should be performed on both sides (see Figs. 131 to 133, p. 297) as a preliminary to the administration of resistive exercises to the muscles of the sound side of the neck. Success will depend on two factors - first, on the possibility or otherwise of the removal of the source of irritation, and, second, on the duration of the complaint.

Torticollis in which the spasm is of the tonic variety should be treated on similar lines. As a rule, however, treatment is used either to prepare the patient for operation or to restore the parts after operation. In the latter instance, exercises to strengthen the muscles of the opposite side are usually the most important part of treatment. Gentle massage may be used to prevent extensive cicatrisation at the site of operation.

The type of occupation spasm most frequently encountered is writer's cramp. Any occupation that entails incessant use, or rather over-use, of any muscle is liable to produce a similar spasm, particularly when the muscles concerned are engaged in the performance of some highly specialised movements which entail elaborate co-ordination. It is not uncommon for watchmakers to lose the use of their hand from spasm, and recently what might almost be called the "marcher's cramp" has been an object of great interest, but of considerable anxiety. The recruit who has "never done much walking" starts out on a route march. His heel begins to pain him, and he finishes the march on the toes of one foot. The calf then develops a most intractable spasm. It may be that the deformity produced is a pure equinus; more usually it is an equino-varus. A suitable position for treating this condition is shown in Fig. 125, p. 283. From time to time we hear of a masseur's cramp, but this can only be due to lack of skill in the exercise of his profession. Neuritis is more common, and is due to overwork. Excessive practice can produce a musician's cramp.

Of the true occupation spasms it may be said that, by means of massage and exercises, there is an almost sure hope of successful treatment. There are, however, many forms of pseudo-occupation spasms. A victim of hysteria may develop an intense writer's cramp during, or after, the composition of a "difficult" letter; while the trouble referred to above as "marcher's cramp" has frequently a large psychical element. The treatment of the "pseudo" variety of occupation spasms by massage alone is almost certainly doomed to failure. Physical remedies rarely suffice for the cure of psychical disturbance.

A true writer's cramp may extend to very serious lengths, for, when the trouble is far advanced, all power of co-ordination in the limb may be completely lost, and the patient may suffer agonising pain from cramp, though actual pain is not by any means an invariable symptom. There may be vaso-motor changes, and the appearance of the hand may even suggest serious nerve-lesion. This is, of course, a rare development. Usually the symptoms are confined to weakness, tremor, and lack of co-ordination for the movement concerned, while all other movements can be performed with perfect ease, comfort, and strength.

Massage should begin with surface stroking from wrist to shoulder for a few minutes. Then the muscles of the arm are given a short dose of kneading, which should impart a shaking movement to the muscles. Some five or six minutes from the commencement of the seance rhythmical kneading of the forearm should be undertaken; but here no shaking is allowed, at least during the early stages, as it is liable to excite spasm.

Presuming that the right arm is under treatment, the masseur next takes a firm grasp of the patient's thenar eminence with the right hand, while his own thenar rests in the patient's palm. The left hand is then placed firmly over the dorsum of the patient's hand (see Fig. 142). The hands next exert gentle intermittent pressure and subsequent relaxation, but do not change their position relatively to the patient's skin. With the closing of the masseur's fingers, however, the first carpometacarpal joint is mobilised by the right hand, while the palm is rendered fully concave by pressure from the back by the left hand. As soon as this can be accomplished freely the fingers can be flexed as well. At first no movement may be noticed, but as treatment progresses an ever-widening range of movement will be secured. It should be needless to add that every care must be taken to avoid inflicting pain or even discomfort. Full exercises of shoulder and elbow, particularly of the rhythmical swinging type, should be prescribed. Later on weight and pulley or roller exercises may be indulged in with freedom. In short, any exercise may be prescribed which does not excite the spasm, and the limb should be used with all the freedom that circumstances will allow.

Fig. 142. - Massage of the hand in treatment of writer's cramp.

As soon as it is possible to use the vibrator without exciting spasm, progress will be more rapid.

When the hand can be used with relative freedom for everything except actual writing, the patient may be presented with a thick piece of chalk, with which to practise writing very large "copper-plate" letters on a blackboard. The size of the letters is gradually reduced, and the patient is provided with a pencil. The same plan is carried out once more, and the following examples will serve as a guide. They are quoted from Graham's "Massage." "The patient is directed to make large Ill's quickly and continuously, followed by the reverse of these, making m's, so as to make him write from the upper arm and shoulder." The size is gradually decreased, and the next exercise "consists of lelele, large and rapid at first, then gradually diminishing, and later the exercise legleg, many lines at a time." A wise additional manoeuvre, when starting writing on paper, is to pad the penholder in such a manner that its bulk can be slowly reduced day by day.

Every variety of occupation cramp calls for suitable modifications of treatment. The use of massage is to enable the patient to practise exercises which alone can effect a cure.

I have found that the simple device of applying a posterior splint to the thumb so as to immobilise the interphalangeal joint has so altered the co-ordination involved in writing that a mild case has completely recovered.

I cannot refrain, however, from reference to a case in which I do not doubt that physical treatment would have failed. The patient had done much writing for many years. She was in a condition of financial anxiety when the cramp set in and, as luck would have it, was undergoing a course of psychoanalysis "to find out what it was all about." I postponed treatment for a fortnight, only to find on her reappearance that the spasm was completely cured. The analysis had reminded her of injury to her right thumb under terrifying circumstances in girlhood, at the only other time in her life when financial affairs were impressed unpleasantly upon her notice. It is possible therefore, that other cases of occupation spasm are psychical and not physical. If physical treatment fails, psychical should therefore be given trial.

A peculiar form of spasm of unknown origin is found in Parkinson's disease (paralysis agitans). The pathology of the disease has not been worked out; the symptoms may be classified, in a word, as corresponding to the advent of a premature old age. The muscles slowly lose strength and become contracted. The tendon reflexes are brisk. The arms become stiff from being kept almost motionless, the legs tend to develop contractures in the hamstrings, the shoulders become bowed, and a most distressing tremor develops in some cases, not in others. Where tremor is absent the form is known as Parkinson's disease sine agitatione.

The masseur's duty is plain. It consists of maintaining suppleness throughout the body by means of relaxed and assistive movements, and of rendering assistance to the circulation, which the patient cannot derive from nature's own means, namely, exercise. Every effort should be made to maintain and encourage voluntary movement to the uttermost. In the absence of effort in this direction the downfall is pitiably rapid, and quite unnecessarily so, as is shown by timely intervention. General massage of the whole body, chiefly of the kneading type, will be required. Abdominal massage should aim chiefly at assisting the portal circulation. Unstriped muscle seems to be unaffected by the disease, but the spread of the disease to the abdominal muscles may render defaecation difficult. Massage adapted for the relief of constipation may therefore prove of value.