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.





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