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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.

Other bursae are not commonly seen in America. I have seen bursae over
the elbows of miners, and in one case saw one of these inflamed
so that miner's elbow became a concrete entity. This case had been
taken for an acute inflammatory arthritis with the suspicion of
tuberculosis.





Next: Painful Arm And Trunk Conditions

Previous: Muscular Pains And Aches



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