Psychotherapy

One now sees affections of the same kind in connection with the automobile. People who ride for many hours, especially if the riding is rapid and over a rough road and they are not used to it, are likely to develop pains and aches which they may attribute to the catching of cold or to rheumatism or to something of that kind. The muscles of the trunk are especially likely to suffer. The abdominal muscles may be quite sore and then later the lumbar muscles develop aches. The arms suffer if they are held in unusual positions because of the jolting. The discomfort may be relieved by any of the coal-tar products, though gentle rubbing with a stimulant such as soap liniment, always in the direction of the return circulation in the muscle, will help to relieve the painful condition. The salicylates are often given for these conditions and relieve the discomfort but because of their value as anodynes, which they share with the coal-tar products, and not because of any genuine antirheumatic effect.

Treatment.—Counter-irritation of various kinds, especially the milder forms, always seems to do good. The underlying therapeutic principle seems to be that the attraction of blood to the surface lessens the hyperemia or at least diverts the circulation and permits the restoration of function and encourages the reintegration of normal conditions. Rubbings are especially helpful if accompanied by rather deep pressure from the periphery of the circulation towards the center. The leg muscles must be rubbed upward, the arm muscles upward, the neck muscles downward, the trunk muscles generally in the direction of their return circulation. This would seem to indicate, as might be expected, that it is the venous circulation especially that is disturbed in the tired condition of the muscles, that a venous congestion with interference with the nutrition of nerves accounts for the aches; hence, a mechanical helping of the circulation is of benefit. There are some whose opinion is not to be put aside lightly, who think that the rubbing alone is the most important part of these external treatments and that the liniments and counter-irritants are only of secondary importance. Indeed, some consider that the tingling of the surface is mainly beneficial in making the patient feel that now that part of the body at least ought to be better.

Liniments for these conditions, however, though introduced on merely empirical grounds, are very old and have the testimony of many generations as to their therapeutic efficiency. Whenever that is the case, it is a serious question to doubt the conclusions that have been arrived at. The experience of a single generation, and, above all, of a small group or school of men, no matter how learned or how scientific they may be, is often fallacious. The experience of many generations, however, even though no good reason for the benefit derived from the treatment they suggest can be found, is almost inevitably correct. After all, though it is usually forgotten, the use of mercury, of iron, of quinin and of most of the tonics depends on nothing better than empiricism. In our day the liniments have been neglected, more perhaps than was proper, considering how many generations of physicians found them beneficial.

Where it is a neurosis rather than a real disturbance of the circulation, however, that is involved, the use of a counter-irritant, by attracting attention more and more to the part, may really do more harm than good. In nervous people it must be remembered that local neurosis may occur almost anywhere in the body and that subjective discomfort alone in these cases must not be taken to signify a pathological condition, unless the localization is such as to indicate that a particular group of muscles is affected. The differential distinction between a pure neurosis and a discomfort due to a true pathological condition in the intermuscular planes is, that in the one case a group of muscles is affected, while in the other a locality is complained of, and while local tenderness is likely to be a marked source of complaint in the neurosis it is comparatively slight as a rule in the muscular condition.

For the more chronic soreness and discomfort of muscle groups, manipulations with massage are of great importance. Undoubtedly the discomfort and soreness is due in most cases to a disturbance of the venous or lymphatic circulation of the parts. This interferes with the nutrition of nerves and leads to nerve sensitiveness from lack of nutrition, or actual nerve irritation from pressure upon sensitive nerve endings while in a state of congestion. These conditions may be relieved by gentle manipulation and by massage, provided always these measures are not painful. These encourage the circulation and very soon tend to restore functions. Just as soon as the pain of these remedial measures or of any mechano-therapy becomes noticeable, it is not likely that they are doing any good. Pain, of course, must be judged from conditions and not from the patient's complaints, which may be due to fear lest pain should be inflicted.

The main point is that local treatment, gentle, simple, yet directed with the proper therapeutic purpose so as to create a favorable expectancy in the patient's mind, will do much for these conditions, which have in many ways been the opprobrium of modern medicine. The rule has almost been to call them rheumatism, because they were worse in rainy weather. The word rheumatic instinctively calls up in most physicians' minds some cut-and-dried formula of internal medication. So these patients go the rounds of the regular practitioners in medicine taking a series of these formulae in succession and, as a rule, not getting any better. Then they go to an osteopath or to a naturapath, or some other kind of path, have some local massage and manipulations performed, which restores the circulation of the part, to some degree at least, and as a consequence they are encouraged to look for further relief. Not a few of them find the relief they look for, and it is these cured patients that in many parts of the country have insisted on securing for the osteopaths legislative recognition and actually obtained it for them in many cases, just because the regular physicians have neglected methods of cure ready to hand, but not made use of, because drugs are allowed to occupy their attention too exclusively.

Disuse, Atrophy and Pain.—I have seen a striking example of atrophy and pain due entirely to disuse in the upper part of the leg as the consequence of a fall. No bone was broken, the man was laid up for nearly a month from the wrench, and then continued to be somewhat halt for many years. After nearly twenty years his attention became concentrated on this limb and then he spared it more and more in his walking, tilting his pelvis and merely swinging that leg, until there was a difference of nearly two inches between the size of the thighs. Of course, under these circumstances any use of the limb brought fatigue and pain with it. To walk was painful, and he had some twitchings at night. There was no disturbance of sensation, however, anywhere and no reaction of degeneration. His knee jerk was slighter than on the other side, but it was present and the weakness was due to the loss of power in the muscles. It was only weak in proportion to the atrophy of the muscles. This atrophy was not trophic in the sense of any failure of nerve impulses from the central nervous system, but was due to disuse, that is, it did not come from any nervous lesion, central or peripheral, nor from any disturbance of circulation, but from the dwindling of muscles that inevitably comes when they are not employed for their proper purpose. Power to use depends on continuance of function.

All sorts of remedies had been employed in his case, but he did not improve until he was made to understand that there was no bone lesion, no lesion of nerves or muscles, and that what he needed to do was to re-exercise his muscles gently but persistently and confidently back to their normal strength. This was accomplished by exercise and resisted motion, with care never to fatigue the muscles, but at the first sign of tiredness to stop, taking up the exercises at first twice, and then three and four times a day.

As can be readily understood, these curious atrophic muscular conditions from disuse occur more frequently in the legs than in the arms. They may, however, occur in the upper extremities and are noted sometimes in the trunk. After all, certain of the stooping postures of men as they get old are due to lack of use of the large muscles at the back with consequent atrophy of them to the extent that makes standing up straight an effort very fatiguing and even painful. To attempt to straighten an old man by means of braces will lead to the development of painful conditions of tiredness if the correction is emphasized. In the arms the atrophic conditions are not so noticeable because the arms may be used without having to do the hard work required of the trunk and leg muscles in holding the man erect. It is the fear of the strain put upon them by this weight that makes the disuse continue, since there has come into the mind the thought that the muscles cannot be used to bear the weight and the burden is thrown on other muscles with unfortunate results.

Many of these atrophies from disuse are cured by mental influence of one kind or another. They are the best sources of profit and reputation of the "healers." Once the patients become persuaded that they can use a group of muscles if they will, they begin to improve, and it is only a question of six or eight weeks until they are so much better that they persuade themselves that they are as well as ever. It is easy to understand that if a person who has been lame for five to fifteen years, vainly going to physicians of all kinds, is cured by some new form of treatment, all the non-medical world is perfectly sure that there must be much in the new method of treatment.

CHAPTER IV

OCCUPATION MUSCLE AND JOINT PAINS

There is one variety of painful conditions of muscles and joints, often spoken of as muscular rheumatism or as chronic rheumatism and frequently the source of so much discomfort that patients feel that occupations must be given up, even at a great sacrifice. These deserve a special chapter. They occur in persons who have some occupation which requires them to use a particular group of muscles a great number of times during the day. They are most frequent in the arms, but they may be seen in the muscles of the neck, they occur very often in the legs and are not at all infrequent in the muscles of the trunk. Whenever a patient comes complaining of a painful condition in a particular group of muscles, careful inquiry must be made as to his occupation, with details of the movements required. These pains are, of course, as are all human discomforts, worse on rainy days and in damp seasons, so that this has come to be known as rheumatic weather. It is easy to assume without further inquiry that they are rheumatic and this has been done frequently in the past.

There is scarcely any occupation involving frequent and habitual use of muscles which may not be the source of discomfort if the actions necessary for it are done in such a way as not to use the muscles to the best mechanical advantage. In other words, there are a whole group of occupation fatigues which may take on a character of painful discomfort if the individual has not been properly trained in the use of his muscles. This refers not only to the use of muscles in the accomplishment of rather difficult tasks, but especially for those that require nice co-ordination for their accomplishment, though they may not demand the exertion of much muscular energy. In other words, what we have to deal with are rather painful occupation-neuroses than muscular fatigue in its proper sense.

Writers' Ache.—Perhaps the most typical example of these is the painful conditions that may develop in connection with writing. Writers' cramp is well known and consists in a contraction of muscles which makes it increasingly difficult to hold the pen properly for writing and may eventually make it impossible to do so. This is accompanied by a certain amount of distress, but the writer's discomfort that is much more common than writers' cramp does not occur in the fingers, but in the large group of muscles just below the elbow and may extend even to the shoulder. The pain is of a vague achy character and as it is worse on rainy days and in damp weather, the temptation to think of it as rheumatism is very great. It occurs in people who write very much and rapidly, but especially those who write in a bad position. Now that the typewriter has come in much less is heard of it than before among reporters, but it used to be common with them. There is very little hint that it is due to writing, unless one makes careful inquiries.

Gowers' Rule .—Its occurrence can be lessened to a great extent by following Sir Wm. Gowers' directions as to writing. Gowers was a parliamentary reporter before becoming a physician and he learned the difficulties of much writing and studied out the causes of the discomfort as well as of the cramp and of the best methods to avoid it. His rule is to sit on a rather high chair before a rather low table so that the elbow swings free of the table and the writing is what is called free-hand. The extent to which Gowers demands this freedom of the elbow carried may be best appreciated from his direction that the writing must be done in such a way that if a second pen were fastened to the elbow, it would write exactly the same thing that is written by the pen held in the hand. There must not be any movements of the fingers nor of the muscles of the forearm. All the movements required from writing must be accomplished from the shoulder. Just as soon as sufferers from vague aches and discomforts from much writing learn this method of writing, their aches disappear to a great extent. My own experience in the matter, when, as a medical reporter, I often wrote ten thousand words a day, taught me the value of the suggestion. During one winter I suffered so much from discomfort in the shoulder that I was sure that I had a progressive rheumatic affection. Just as soon as I learned to write properly the trouble was minimized to such a degree that I realized that it was merely a question of faulty writing. I have noted over and over again, as is true in my own case, that if there has previously been any injury in the arm, this discomfort is much more likely to develop than otherwise.

Occupation Pains and Habitual Muscle Movements.—What is true for writing is true for any habitual movement of groups of muscles requiring careful co-ordination. I have seen it in marked form in the makers of cigars and the strippers of tobacco. I have seen it in men who do much filing and whose working bench is so high, that pressure direct from their shoulders cannot be brought into play to supply any force that is needed in carrying on the filing process. If such a series of movements as filing is to be accomplished with comfort, then the arms must be held straight, the force being applied from the shoulders and not by the exertion of the muscles of the forearm, which are meant only to guide and not to supply the needed pressure. The Sloyd methods of working at benches are particularly important for workmen if they are not to develop these curious painful conditions which are due to habitual wrong use of muscles, and not to any diathesis. Any and every form of work must be looked at from this standpoint. Women often iron at a table or ironing board placed too high for them, and as a result apply the pressure necessary through their forearm muscles. If they are at all of nervous constitution they will suffer rather serious discomfort from this after a time and this will always be worse in damp weather. I have known women ready to give up because of the discomfort thus occasioned, who found that they could work without muscle discomfort for much longer periods, if the ironing board was placed low enough.

Arm and Shoulder .—The occupation aches and discomforts in the arm and shoulder are very frequent and their variety presents an interesting study in the individual and his history. I remember once having three cases present themselves at a dispensary service of the Polyclinic Hospital on the same day, all presumably suffering from rheumatism. One of them was a motorman suffering from the occupation pains that so often come to those who use their arms overmuch, and the pains seen so frequently, for instance, in baseball pitchers. These pains are always worse on rainy days and in damp weather. There is of course a large individual element as the basis of these. Why can one man pitch nearly every day all season and not suffer with his arm while another man cannot? We can no more tell the reason for this difference than we can tell why one man is right-handed and another left-handed. One individual has a store of nervous energy that serves him very well. Another has a store of nervous energy that serves him well enough for his left hand but not for his right hand. The mystery would seem to be the original endowment of nerve force according to the individual's constitution. The motorman who suffers severely from putting on the brake of a heavy car will probably never be able to continue his occupation with comfort to himself unless his sore arm is due to some temporary condition, easily recognizable.

A second of my patients with rheumatism complained of his shoulder. He had been first easily fatigued, then it was painful when he moved much, most so on rainy days, and finally he had practically lost power in it entirely. His occupation was that of finisher in a molding works. He lifted a heavy hammer many hundreds of times a day with his right arm, striking quick short blows and using mainly his deltoid muscle in the lifting process. It was just his deltoid that was affected and the nerve supply had evidently given out. The third man complained not of his right hand, but of his left and of his forearm, not his shoulder, having lost power especially on the ulnar side of his hand. He was a stonecutter, who held a chisel firmly in his left hand, grasping it mainly with the under or ulnar side of his hand, and consequently overusing the group of muscles supplied by his ulnar nerve, leaving that structure open to pathological conditions.

There was just one feature in the history of all three that was the same. They did not drink alcohol to excess often, but they did take some whiskey straight every day. The easiest explanation seemed to be that there was a neuritis set up in the nerves, which their occupations caused them to use so much, and that, as a consequence, the low grade neuritis finally developed to such a condition as to make further use of the muscle supplied by the affected nerves practically impossible. Just why alcohol will select certain nerves and not others upon which to exercise its deteriorating influence and why lead usually affects an entirely different set we do not know. In the ordinary man of sedentary occupation who walks occasionally, as his only exercise, his most used nerve is his anterior peroneal. Those of us who are not used to walking much, know how soon this nerve complains of fatigue when we take some forced ambulatory effort. It is this nerve then that with most people is affected by alcohol. But any nerve that is overused will apparently be affected the same way, and as many outdoor workers take some whiskey straight pretty regularly, it is not surprising to find that some of them have an idiosyncrasy and develop a low grade alcoholic neuritis.

Alcohol, however, is not the only substance that acts thus insidiously. I was once asked to treat a painter who was suffering from intense tired feelings in his right forearm. They were always worse on rainy days, and he had been treated for rheumatism without avail. He had no signs at all of wrist-drop, there were no suspicious signs on his gums and he had never suffered from constipation or anything like lead colic. It seemed far-fetched, then, to say that his muscles were fatigued mainly because of the irritating presence of lead in the nerves supplying his right forearm. He slipped on the ice, however, and sprained his wrist, and the next day turned up with a typical lead wrist-drop. This fact of having lead poison develop shortly after an accident is not unusual, just as a sprained ankle may sometimes be the signal for an outbreak of alcoholic neuritis in the lower leg which has been preparing for some time, the accident itself being at least partially accounted for in many cases by the awkwardness of muscles with disturbed nerve supply.

Leg Occupation Pains .—What is true of the arm is also true of the leg. If a man uses his leg muscles very much and especially at any mechanical disadvantage, he usually suffers painful discomfort that is always worse on rainy days. Before the invention of the electric dental engine, dentists used to suffer from this and the profession talked about the "dentist's limp." This was also more painful in damp weather and many of them were treated for rheumatic conditions, though it was really only over-fatigue.

Neurosis and Neuritis.—There are many cases of painful conditions in the limbs where it becomes difficult to diagnose between a neurosis and a neuritis. The usual differential characteristic of tender points along the course of the nerve cannot be used in many patients with confidence, because they are prone constantly to respond to the question "is that tender" in the affirmative. Besides in a neurosis there always seems to be a hypersensitiveness of the nerves involved that may simulate the tenderness of neuritis. In a number of obscure cases I have felt that the condition was a real neuritis when the development of a corresponding condition on the other side, or relief on one side followed by development on the other, has led to the diagnosis of neurosis. Of course, a double neuritis may well occur in the same nerve on both sides of the body under certain toxic conditions. Double sciatica nearly always indicates glycosuria. Diabetes may cause double neuritis in any other much used pair of nerves. Alcoholic neuritis may manifest itself on both sides. Ordinarily, however, the transference of symptoms or their spread to the other side of the body means a neurotic condition.

In some of these cases where it has been difficult to distinguish between neuritis and neurosis, a change of occupation or some strong diversion of mind for a considerable period or a change of residence has proved the beginning of a cure. I have seen what was considered by experienced physicians to be a chronic low-grade neuritis of quite intractable form clear up completely as the result of the young woman being compelled to take up a wage-earning occupation, when it had always seemed before as though life was going to be smooth and there was no necessity for her to labor. I know of cases of so-called neuritis that had been very obstinate to treatment that were cured by Eddyite treatment. What really happened in these cases was that a group of muscles used considerably more than usual had produced a painful tired condition referred to a particular nerve. Just as soon as the mind's inhibitory action was taken off them by the persuasion that there was nothing the matter with them the patient proceeded to get well, gradually progressive use bringing back the normal trophic condition.

Discomforts of Bursae.—In any consideration of painful conditions in and around joints, especially in connection with occupations, the question of the formation and of the inflammation of bursae must be insisted upon because many of these inflammatory incidents are confused with joint affections and not infrequently treated as if they were due to constitutional disturbance. Practically everybody is familiar with housemaid's knee. Most people know that bunions are inflammations of the bursae which form over the metacarpo-phalangeal joint of the big toe whenever there is pressure and irritation of it. Very few realize, however, that frequently repeated irritations, when pressure is exerted over other joints and bony projections, will produce a bursa, and then, if the irritation continues and an opportunity for infection occurs, there is bursitis. Some of these are mistaken for other conditions and often have been thought by the patient to be serious developments of one kind or another with regard to which there has been much solicitude. An interesting case of this kind in my experience was that of an Italian organ-grinder who suffered from the occupation bursa which so often forms over the anterior superior spine of the ilium because of the frequently repeated rubbing of the hand and arm as it passes this region while turning the handle of his instrument. It had finally become inflamed, and the Italian was much disturbed and he feared that it was appendicitis.