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.





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