which I have seen, there has been evidence, more or less marked, of derangement of one or more of the muscles used in writing;" and furthermore says: "The writer's cramp of text-books, in which failure of writing is the sole symptom, I have never seen." Dr. Jacoby corroborates both of these statements; all cases, whether of writer's cramp or other artisans' cramp which he has seen, have, upon careful examination, presented evidence of peripheral disturbance sufficient to account for the failure of their work. Furthermore, the cramp was in none of them the primary and sole disturbance; and all of his patients were not only unable to perform their own special work, but were also unable to execute other work which entailed similar use of the affected muscles. It is not essential that this peripheral disorder be dependent upon a paralysis or a paresis; but it may, in very many cases, be due to a faulty innervation of single muscles or groups of muscles, which causes either a failure in their action while the other muscles still exert their functions. normally, or causes them to enter into a state of tonic contraction whenever an unusual amount of work is required of them.

The electrical examination will also, in many cases, show a difference in the reaction from that of the corresponding muscles of the sound hand-either an increased or a decreased irritability. Stress is laid upon the examination by Zuradelli, Erb, Gowers, Poore, etc.

Another indication of disordered nutrition of the muscles is fibrillary tremor; it is sometimes found at a very early stage, and even before any marked subjective symptoms are present.

Treatment.-Canstatt's words, written over forty years ago-"Much has been tried, nothing has succeeded"-could, until a few years ago, have fully expressed the results of treatment in writer's cramp. But since massage has been systematically used, the cures have far outweighed the failures. Meding, over thirty years ago, used massage empirically; Erb, in 1874, spoke of "gymnastics and massage; and Douglas Graham, in 1877, was one of the first to direct closer attention to this means of treatment.

The first reported case of cure by massage was published by Losander in 1873; but, unfortunately, another remedy was simultaneously employed-the subcutaneous injection of strychnine,-and it is not possible to ascribe the cure to massage alone. The massage treatment consisted in two

séances daily; the muscles of the thenar and hypothenar eminences, the interossei, and the lumbricales were rubbed successively. At the same time the muscles of the thumb, of the smaller finger, and of the forearm were percussed with a wooden cylinder. The patient was cured after four weeks of treatment.

The next case is one by Gottlieb. A female, æt. 52, came to him August 17, 1874; always well until 1863. She was accustomed to write nine hours a day. At this time she exposed herself to severe cold. Two years later, she suddenly became incapable of writing. The pen falls from her hand, and she is unable to resume work. Since then, the right index finger constantly refuses to act in writing, or in performing analogous work. Then the middle finger became affected; still being unable to use the thumb, she continued to write with it and the two last fingers. She then endeavored to use her left hand, and this in time became affected, but to a much lesser degree. Both hands became slightly oedematous. Thirty-seven massage séances in all were used. Complete and permanent cure.

But it was not until after Schott's publication, in 1882, that particular attention was devoted to this mode of treatment. Wolff, who claims to be the originator, is a writingmaster, and as such, according to Stein, sees many children and adults with poor handwriting. Among these, there are some with writer's cramp, who lay the blame of their poor writing to incapacity, whereas it is really due to their disease. Wolff, therefore, endeavored to cure them "by a peculiar system of writing-instruction, which he combined with massage and gymnastic exercises, passive and active, applied to the muscles of the arm." Beyond doubt, Wolff has treated and cured more cases than any other single person. But he has done absolutely nothing towards communicating this mode of treatment to others. In 1884 (N. Y. Med. Record, p. 205, Vol. I), he says, in speaking of the priority claims of the Drs. Schott: "Both gentlemen, again and again, questioned me about my method, but they never received another response to their numerous inquiries than that the same consisted in a peculiar combination of massage and gymnastics." And in a small monograph-"The Cure of Writer's Cramp, etc." (1884)-he evades description of the method. Certainly to Schott belongs the credit of having communicated it to others, and Wolff is entitled only to the thanks of the patients he has cured, and not to those of

physicians and scientists, for he has only endeavored to obscure and hamper scientific knowledge.

Schott's mode of treatment consists in a combination of gymnastics and massage. The gymnastics consist of movements performed by the patient alone, and movements performed with the opposition of the operator. The first are performed by the patient during from twenty to thirty minutes; rarely for forty-five minutes. The first movements are gymnastics of the fingers-extension, flexion, abduction, and adduction, the thumb being exercised separately; thereupon the same four motions are executed at the wrist-joint, then extension and flexion of the forearm, and ultimately the arms themselves are exercised in the same manner, and are to be lifted over the head. Each single exercise is to be performed from six to twelve times. After each motion, a pause is to be observed. The opposed movements are to be carried out in the same manner, except that the operator must carefully resist their executions as though he were endeavoring to force the patient to perform a motion just the reverse of his intentions. Regularity of pressure is to be observed in this, so that the same amount of force is always used, and that the pressure does not vary in intensity from

moment to moment.

The time to be devoted to these opposed movements is the same as that for the unopposed ones. According to the intensity of the affection the exercises must be repeated two or three times daily. The massage itself consists of two parts-nerve and muscle massage. The muscle massage is effleurage* along the course of the neve trunks, the median, ulnar, and radial, going upwards to the axillary and cervical plexuses. The effleurage lasts about ten minutes. Following this is the muscle massage. This consists of petrissage,† beginning with the hand and ending at the shoulder. Duration same as last movement. One sitting a day has always proved sufficient.

Schott says in from two to three weeks improvement is noticed. The treatment must not be interrupted then, but kept up for at least six to eight weeks, which time is necessary to attain a complete cure. During the treatment, the occupation of the patient must be discontinued. Schott has

*Or stroking-the maximum of force to be applied not to exceed the deadweight of the hand.

+ Or kneading a methodical vertical pressure applied to the muscles with the fingers, hand and fist.

thus succeeded in curing all the neuroses which came under his treatment, mostly pianists, and in none of them has any return been observed."

Wolff's method, according to Stein, differs from the preceding in so far that he makes use of "a peculiar method of writing-instruction," in addition to the gymnastics and massage. "The peculiarity of the method consists in that fact, that Mr. Wolff, in consequence of years of practice and special treatment, understands how to carefully isolate those muscular groups which require a special gymnastic treatment, either with his hand or by means of rubber bands, in a way that we electro-therapeutists, even with the most minute electro-diagnostic examination, are unable to do." The accompanying illustrations give an idea as to the manner in which these bands are applied.

Wolff has certainly achieved remarkable results by his mode of treatment, and his patients are permanently cured. From 1877 to 1882, he treated in all 277 cases of writer's cramp and similar affections; 245 were writer's cramp, and of these 132 were radically cured, 22 improved, and 91 without result; 32 cases of pianist's, violinist's, telegrapher's and painter's cramp; of these 25 were cured. In all, 157 cured, 22 improved, 98 not cured. But Wolff is not alone in ob

taining good results; for Weiss, Podrazky, Zabludorosky, Schreiber and Douglas Graham all report good results in the use of massage in writer's cramp.

The results obtained by Dr. Jacoby have been excellent, and, although the number of cases is necessarily limited, still it is sufficient to show that there is no secret in the method, and that good results may be obtained by any oneall that is necessary being perseverance and thoroughness; the "peculiar" combination and the "peculiar" system of writing-instruction is not essential. Patients were examined carefully, to localize, if possible, the exact seat of the affection; cases not clearly of peripheral nature were not treated at all. Particular attention during the massage was paid to the interossei, and to all the muscles of the thumb. The massage was carried out in the manner described by Schott, the idea to be kept in mind being that, by means of the exercise and massage, the weakened muscles are to be strengthened and their nutrition improved.

In order to thoroughly manipulate the interossei and lumbricales, the hand of the patient, sitting face to face with the operator, must be taken by him into both hands, and the metacarpal bones separated from each other as much as possible, and then moved upward and downward. The small end of Granville's percuteur* will also be found very serviceable in acting upon these small and deeply-seated muscles. The larger muscles can be manipulated as described under the general head of the Technic-petrissage and massage à friction being principally applied.

The most important part of the treatment, however, consists in the active and passive movements, with and without opposition. For the active movements, the following rules must be observed by the patient. The movements are to be executed: (1st) As slowly as possible; (2d). In a certain rhythm; (3d) With a certain amount of labor; (4th) Care must be taken not to over-exert the muscles; (5th) The movements must be executed three times daily, and each movement carried out from twenty-five to two hundred times.

*This instrument consists of a strong electro-magnet operated by a portable battery. This electro-magnet works an ivory-tipped percussor, in the same manner as the tongue of an electric bell is moved. By an interruptor on the side of the instrument, the current can be made or broken at will. The ivorytipped percussor is removable, and various shaped ends may be employed.

Energetic stroking with one hand, and strong circular movements with the

other.