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Muscular Pains And Aches





Whenever exposure to cold causes a period of discomfort in almost any
organ, except the teeth and certain definite nerves (for neuralgia has
been taken out of the rheumatism group in recent years) we are sure to
hear the word rheumatism employed in connection with it. To add to the
confusion, the various "specialists" have taken to assuring their
patients that local manifestations in the eyes, in the ears, and in
the nose, for which they can find no good reason, especially if they
are worse in damp weather, are signs of the rheumatic diathesis.

Unfortunately, our supposed knowledge of the uric acid diathesis
became widely diffused, and it is not surprising in the light of the
widespread acceptance of this theory, that muscular pains of all kinds
should have the word rheumatic attached to them, and that patients are
sure that the discomfort is only one manifestation of a severe
constitutional disease, which they cannot but infer will probably make
still more serious trouble for them in years to come, since it seems
to be dependent on conditions beyond their control, such as heredity
and general constitutional traits and their special mode of nutrition,
rather than on local or passing conditions.


Local and Constitutional Conditions.--It cannot be repeated too often
that it is this persuasion as to the constitutional character of the
disease that has in recent years proved a very unfavorable suggestive
element in these cases. Patients think themselves the victims of a
serious diathesis, a deep-seated pathological condition, and attribute
a host of feelings to it that are sometimes rather seriously
disturbing but are really only sensory manifestations of various kinds
in the organs and in the skin and muscles, which would be attributed
to simple local causes--fatigue, faulty mechanical conditions,
etc.--but for the concentration of attention on them.



Individual Cases.--The careful study of these cases is thus
extremely important. They are eminently individual and not to be
grouped together. The exact diagnosis of the various conditions from
which each patient is suffering is of itself a precious factor in
psychotherapeutics. The precise recognition of the condition present
is of immediate avail in helping him to dismiss many of his symptoms,
or at least to keep him from thinking as much of them as he did before
or inevitably will if the older ideas as to the constitutional nature
of his affection are allowed to remain.

Nearly every large group of muscles in the body may be the subject of
these painful conditions. In recent years, perhaps, the muscles most
affected in this way are those that pass around the ankle and give so
much discomfort in cases of flatfoot, or beginning flatfoot
(euphemistically called weak foot), when the plantar arch is yielding.
The manifestations are not only in and around the ankle, but occur in
the calf muscles and even above the knee. These painful conditions
always develop unless the arch is supported. Until recent years it was
rare to discover a bad case of flatfoot in which the patient had not
taken many rheumatic remedies and had not come to the conclusion that
he was the subject of an incurable and probably hereditary
constitutional disease. Flatfoot is likely to cause considerable
deformity in the old, the toes becoming bent and twisted up, and the
subjects of it complain very much of their feet. Flatfoot runs in
families. When the father and mother have complained of what they
called rheumatism in their feet which got worse every year, then the
son and daughter, when they have their first manifestation, conclude
that they are inevitably bound by the stern laws of heredity.


Occupation Aches.--Flatfoot is taken, however, only as an extreme and
therefore striking illustration. Whenever a particular group of
muscles has to do an excessive amount of work, practically always
there is a development of an uncomfortable condition worse on rainy
days and therefore likely to be called rheumatic. Over-use of the arm
at any occupation, in writing, in the use of a file, at an
ironing-board, in sewing, or at anything requiring repeated movements,
will produce it almost inevitably. Especially is this true if the
occupation is carried on without such careful attention to muscular
action as enables the muscles to do their work to the best advantage.
These painful conditions are much more likely to occur in run-down
individuals of nervous temperament, above all if they have been or are
subject to worry. Men who have lost money and now have to do hard
physical work, after previously having lived sedentary lives, and
women whose previous source of support has been withdrawn and who have
to work for a daily wage after former gentle conditions of living, are
especially likely to suffer in this way. The conditions develop on a
neurotic basis or an exhausted nervous system.

Other groups of muscles may also be the subject of these painful
conditions. The large group in the loins, called the lumbar muscles,
which are so important for stooping, for the erect posture and for
lifting, are so commonly the subject of discomfort that a special name
has been applied to their affection--lumbago. In the leg the large
group of muscles supplied by the sciatic nerve are likely to be
affected, and this affection is so common in men who have to bend the
knee and flex the hip at their work that it, too, has received a
special name--sciatica. Besides the arm muscles the groups of muscles
around the shoulder girdle are often unfavorably affected and though
we have not invented a name to cover their conditions, it is so
common that we think of it as a separate entity almost in the same
manner as we think of lumbago and sciatica. In the neck the group of
muscles that rule the movements of the head, especially those at the
side may be affected and the special name of torticollis has been
given. Practically all of these affections are thought of at times as
rheumatic and the ordinary rheumatic treatment is given for them.
There is no doubt that the salicylates will relieve the pain almost at
once, but so will any other coal-tar product and phenacetin,
acetanilid or even antipyrin may be used with good effect. There is no
evidence, however, that these drugs make the underlying condition
better and, indeed, after patients have tried them for a while, unless
the affection is merely passing, they try some other physician and
perhaps are treated the same way with a different form of the drug.
These are the cases that make their way around to a number of regular
practitioners of medicine and then eventually go to some irregular or
quack and sometimes obtain relief where the regulars have failed.

When the irregular succeeds it is always because he has done three
things. First he has persuaded the patient that it is not rheumatism,
with all the unfavorable suggestion that goes with that word, that is,
the matter with him; secondly, he has treated the local condition;
and, thirdly, he has diverted the patient's mind. Local treatment is
often the real secret of his success, though the psychotherapeutic
element is not without distinct benefit.


Mode of Occurrence.--These muscular conditions present themselves
under two forms, acute and chronic. The acute condition occurs almost
suddenly and is accompanied by spasmodic pain and acute discomfort.
Muscles go into spasm to avoid the movement that would necessarily
bring pain with it. A typical example is found in torticollis in which
the patient wakes up some morning to find a stiffness in the muscles
of his neck with limitation of movement much more pronounced on one
side, and this usually gets worse as movements are attempted during
the day. This spasmodic painful condition usually lasts for some days
and suggests all sorts of topical applications and often requires
anodyne drugs. A similar acute condition may be observed in some cases
of lumbago. In this the pain in the loins comes on suddenly, usually
during movement, often in the midst of lifting something that one has
been able to lift without difficulty before. This pain is so sudden,
so unexpected, usually comes entirely without warning and seems so
mysterious in its origin, that it is no wonder the Germans speak of it
as Hexenschuss--"witches' shot"--a remnant of the superstition that
a witch, by means of the evil eye or some other maleficent power, or
by sticking pins in a wax image of a victim that had previously been
devoted to the devil, might produce effects upon the person at the
part where the thought was directed or the pin inserted.

These painful conditions, especially when acute, are, as a rule the
consequence of exposure to dampness, or to a draft blowing directly on
the part, usually in damp and changeable weather, and often when the
patient has been sweating just before. The train of events that brings
about the painful condition is not difficult to understand. There is a
disturbance of the normal smooth-running, indeed almost frictionless,
mechanism by which muscles glide over one another. There are
practically a series of joints in all muscular groups so as to permit
just as free a play as possible of muscles over one another. Each
muscle is covered with a glistening membrane so familiar from
our dissecting room days, which secretes a substance resembling a
synovial fluid, to enable muscles to move upon each other without
friction. When, because of exposure to drafts or the evaporation of
moisture on the surface, there is a disturbance of the circulation in
these intermuscular planes, the secretion which prevents the friction
of muscle movements is disturbed. The blood is driven from the surface
and some congestion and consequent heat accumulation occurs in the
muscles, affecting particularly their contiguous layers. As a result,
the muscle surfaces are no longer smooth and the muscles now have not
as free play over one another as before. It is not surprising that,
owing to this, sensitiveness occurs and some spasm develops. This,
however, is thoroughly conservative in character since nature's idea
is to set the part at rest so as to allow the normal condition to be
restored.

This is the pathological condition that underlies these so-called
muscular rheumatisms which develop suddenly. It is important to note,
however, that these conditions develop nearly always in people who
have been over-using or wrongly using the groups of muscles which
become thus affected. The history of a torticollis patient will
usually show that there is some contortion of the muscles of the neck
familiarly practiced by him. Sometimes it will be found that the
patient has the habit of sitting on a particular easy chair in a
special relation to the light and that in order to accommodate himself
to his chair and the light in his reading, the head has to be placed
in such position that the neck muscles are constrained. It is this
that predisposes the patient to the development of the condition which
seems to be so acute and yet is really only an exacerbation of a
chronic condition. Lumbago will develop in men who have been stooping
much, especially for heavy lifting, or in women who scrub or have to
stoop much while cleaning, dusting and the like.

Some interesting muscle pains occur as a consequence of the jostling
movements of various modes of transit. They are particularly
noticeable if an uncomfortable position has been maintained for a
number of hours. People who travel on railroad trains often come with
the story that they must have caught cold on the trip for they have
been sore and achy in many of their muscles since. I have known people
who went on a crowded excursion and had to stand for several hours
confident that, standing in the drafty aisle of the car on their way
home, they had acquired rheumatism. All that had happened was
over-tiredness of muscles on the jolting train which required constant
balancing and unaccustomed muscular exertion. On board sea-going
vessels people often suffer from pains in the loins and in various
trunk muscles, due to the roll of the vessel, especially while they
are asleep. These, too, are likely to be attributed to drafts, or to
some form of rheumatism, or at least to the catching of cold. I have
even seen people sure, because of pains in their loins, that they must
be developing some kidney trouble. After a time they get used to the
swinging motion of the vessel and then their achy muscle tiredness is
relieved.

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.





Next: Occupation Muscle And Joint Pains

Previous: Old Injuries And So-called Rheumatism



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