SUGGESTION IN TREATMENT OF SO-CALLED RHEUMATISMS
How much the treatment of these so-called chronic rheumatisms depends on suggestion, in spite of the apparent improbability of anything so materially discomforting being under the influence of the mind, is best appreciated from a consideration of the many inert materials that have been used for the cure of rheumatism. There is, of course, no more virtue in red flannel than in any other colored flannel, but many people suffer from rheumatism or rheumatic discomfort whenever they do not wear red flannel and are sure that it means much for them. Then there are all sorts of supposed electrical contrivances that do not generate an ion of electricity. They are effective only through the appeal they make to the mind. Some men wear electric belts and attribute their freedom from rheumatic pains to them. Others wear so-called electric medals or electric shields or electric insoles. Any number of people in this country wear electric rings on the little finger of one hand and get marvelous relief from it for their chronic rheumatism. Some have noted good results from even less likely objects. There are thousands in this country who carry horsechestnuts as a preventive against rheumatism, and some of [{386}] them, intelligent men and women, are persuaded it lessens their pains and aches.
In another place I have told the story of the woman who was a sufferer from rheumatism and who found great relief from carrying a horsechestnut. As her husband was also a sufferer, she wanted him to carry one, too, and when he would not, she carried one for him. It is to be hoped that her conjugal tenderness in this matter had as good an effect on him as she was sure the propinquity of the horsechestnut had on her.
The patients' occupations must be regulated by proper advice and detailed directions, and distractions of various kinds must be provided to keep their minds from becoming concentrated on certain portions of their body, emphasizing whatever discomfort is present and preventing nature's curative processes. Finally, local treatment of various kinds must be employed suitable to each individual case, that will remove all mechanical difficulties, disperse congestions, relieve fatigue and over-tiredness, and make conditions favorable for the healthy, normal use of joints and muscles.
Many painful affections of joints, sometimes complicated by immovability, are really psycho-neuroses. Sir Benjamin Brodie once said that four-fifths of the joint troubles that he saw among the better classes were hysterical. Sir James Paget thought this an exaggeration, but confessed that he saw many of them and among all classes of people. One-fifth of those that he saw in hospital and in private practice were entirely neurotic. He emphasized the fact that they must be looked for not only among women but that they are often found in men and that they are by no means confined to those who are nervously inclined, the silly young women or the foolish old women, but that they may be found in special circumstances among the most sensible people. They are often initiated by an injury which makes it quite difficult to differentiate them from real joint affections. Usually, however, there is no redness, nor swelling nor heat with them, though sometimes one of these symptoms at least may occur with the redness. The connection between the trivial accident and the large reaction is usually hard to find and causes a suspicion as to the real process at work. Often, too, there is a delay of several days or sometimes weeks after the accident before the neurosis declares itself. In the meantime it has been getting on the patient's mind.
In general, it must be remembered the patient's attitude of mind in these cases of pain around joints and in muscles is extremely important. They have furnished a goodly proportion of the patients on which quacks and charlatans have fattened. Greatrakes in the seventeenth century, Mesmer and Perkins, St. John Long, the early electrotherapeutists, the blue glass faddists, all the various liniment makers, many of the manufacturers of blood purifiers, and Eddyism and mental healing besides osteopathy in our day have all benefited these sufferers for a time and the patients have often been men and women of education and influence in their communities and have exerted their influence for the benefit of their supposed benefactors. The methods of treatment come and go. The promise of the physician or the healer and the confidence of the patient are the only factors that are common to all the supposed "cures." If people stay at home without the air and exercise they should have, if they nurse their ills and consider that they are sure to get worse, because they labor under hereditary or constitutional ailments, nothing will benefit them. [{387}] If they are convinced that their disease is only local and begin to go out to see their friends once more, a change comes over the whole aspect of their disease.
CHAPTER II
OLD INJURIES AND SO-CALLED RHEUMATISM
As people advance in years, it is a common experience that tissues injured years before are the source of no little discomfort and are particularly prone to be bothersome during changeable seasons and in rainy weather. A bone broken when the patient was young may twenty or thirty years later continue to give warnings of the approach of change in the weather and be a source of annoyance. A dislocation, especially if complicated in any way by considerable laceration of the tissues in the neighborhood of the luxated joint, is sure to be a source of discomfort of this kind. These painful conditions are generally more noticeable when patients are run down, or when they have been recently affected by exhausting disease of any kind, during convalescence from severe ailments or injuries, or when they are undergoing a special mental strain. These conditions, like nearly all others worse in damp weather, are sometimes grouped under the term rheumatism and have been treated by internal medication. Almost needless to say, such treatment is sure to fail or to be of only temporary anodyne benefit. As rheumatic remedies are usually coal-tar products they may even be distinctly harmful, especially for old patients. It has been shown that the salicylates, for instance, are much less rapidly eliminated in the elderly than in the young, in those with defective circulation or kidney insufficiency than in the well. Their accumulation in the system causes anemic tendencies and disturbs nervous control.
Just what is the underlying pathological condition in these cases is not easy to say. In the case of luxations with laceration of tissues there has undoubtedly been such a disturbance of venous and lymphatic circulation by the break in continuity of tissues and the resultant scar tissue, that lymphatic if not also venous congestion occurs whenever there is any circulatory disturbance. For the maintenance of normal nutrition of nerve endings a constant flow of blood past them and a proper action of the lymphatic channels to carry off waste products is essential. It is easy to understand how much these may be disturbed in the injuries under consideration. When a bone is broken there is usually laceration of the surrounding tissues. Owing to the fixation required to procure proper bony union, the circulation to the part is much more defective than usual and so the repair of torn lymph and venous vessels is not as complete as would otherwise be the case.
This seems to explain why such injuries are especially called to the attention of the patients in damp weather. It is not so much during a rain storm as some hours before it, about the time when the barometer begins to drop, that these old injuries become sensitive. Indeed, it is often said that old persons who have suffered one of these injuries earlier in life carry a barometer around with them.
Not a few of the lesions called sprains, especially those of the ankles and [{388}] wrists, though also of other joints, are often really breaks of small bones, or at least laceration of ligaments and other structures. These may long afterward prove a source of pain and discomfort, worse always in unsettled weather, or after the feet have been wet, and may seem to be due to some constitutional condition, though they are merely local. These occur more commonly in women than in men and the condition needs careful investigation and must not be put under the vague diagnosis of rheumatism, or the patient will probably not be improved by the treatment suggested. In all these cases the general condition must be looked to, and it must not be forgotten that fat may not mean health, and that increased weight may be a prominent factor in the production of symptoms in these cases, especially when individuals live a sedentary life.
There is an important therapeutic method for the prophylaxis of these conditions that has been attracting attention and yet probably not all the attention it deserves in recent years. Prof. Lucas-Championnière of the University of Paris has pointed out that when fractures and dislocations are treated by the open method with easily removable apparatus and the employment of massage within a few days after the fracture, the subsequent discomfort of these lesions is much lessened.
It seems worth while to emphasize this treatment by manipulations and massage, because it represents a psychotherapeutic factor in the treatment of these injuries. The hiding away of a limb or a joint for days and perhaps weeks, while they wonder whether it is getting better or not is most discouraging to patients. To have the physician see it, to have him declare that it is getting on well, to have the evidence of their own senses that conditions are gradually improving, is of itself a valuable factor for that satisfaction of mind which conduces to the regular functioning of tissues. Repair undoubtedly goes on better under such circumstances. Besides, the lack of constriction or at least its rather frequent periodic relaxation, the airing of the skin, the regulation of the circulation by massage and manipulation, all react upon the mind and prevent it from inhibiting trophic impulses and encourage it to stimulate them in every way.
As to the after-effects of fractures and dislocations as with regard to all this series of vague pains and aches, the patient's attitude of mind is of great importance. As they get older their aches and pains grow worse, partly because circulation is more defective and partly because they are prone to be much more in the house and the nerves of patients who are much within doors are always more sensitive than those of people who are much in the open. If their attention becomes concentrated on their pains and aches, because of lack of diversion of mind, then the condition may become a source of serious annoyance. When these painful conditions develop patients are almost sure to keep much to themselves and to nurse their ills, and consequently to increase their discomfort. The circulation to the affected parts must be stimulated by local treatment, by rubbings, by the milder liniments, by massage and manipulations, and by local hydrotherapy. Douches, as hot as can be borne, on the limb followed by cold, especially if patients are otherwise in good health, will do much to relieve the stagnant circulation.
Active and vigorous movement while the affected part is supported at skin pressure (there must be no constriction) is even more valuable than [{389}] massage, liniments or douches in the treatment of all these painful conditions of joints in which there is any scar-tissue. Wonderful results may be obtained in an old sprain of the wrist, knee and ankle by covering in the part completely (taking care to surround the limb) with strips of adhesive strapping simply laid on at skin pressure, but following exactly every fold or angle of the part, and then with the part completely covered in this way to urge immediate and constant exercise. The maintained pressure prevents any tendency to venous congestion or exudation and favors absorption of fibrous tissue, and exercise, which should be immediate, is now possible through the support furnished by the strapping. The re-assumption of normal active movement molds the old scars, strengthens the muscles and ligaments and improves the patient's general condition. The relief afforded is immediate, and the cause of relief, a simple mechanical device, is apparent. Rheumatism is forgotten as the old crutch is discarded and the patient is able to use the limb with confidence.
Recent sprains or bruises treated in this way recover perfectly and do not leave old scar tissue to be a future seat of pain.
CHAPTER III
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,
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 [{391}] 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 [{392}] 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 [{393}] 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 [{394}] 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 [{395}] 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 [{396}] 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 [{397}] 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 [{398}] 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 [{399}] 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 [{400}] 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.
CHAPTER V
PAINFUL ARM AND TRUNK CONDITIONS
Cervical Ribs.—Some interesting cases with painful conditions of the arms develop as a consequence of the presence of cervical ribs. It would be more or less naturally expected that trouble of this kind would occur early in life, but, as a matter of fact, many of the patients are well on toward thirty or even beyond middle life when the painful symptoms develop. Cases are practically always at the beginning diagnosed as rheumatism because the first symptom is likely to be pain followed by weakness. Even when this quite fruitless diagnosis is not made, the affection is often declared to be rheumatic neuritis, though it is really a traumatic neuritis and entirely a local condition, as are so many of the painful conditions spoken of as rheumatism. Usually the pain is referred to the inside of the arm and is described as resembling slight toothache at first and even severe toothache after a time. It will often be many months or even several years after the first symptoms before wasting of muscles occurs, but this practically always follows after a time and even at this stage some physicians still talk of rheumatic neuritis as affecting the trophic nerve fibers and causing the muscles to waste. Almost a differential diagnostic sign in the case of cervical ribs is that raising the arms above the head nearly always relieves the pain. Patients usually learn this for themselves because they have been tempted to place their arms in many positions in order to get relief. The reason for it is easy to understand as the elevation of the arms changes the relative position of tissues in the neck and so relieves pressure.
The direct reason for the late development of the disease is probably the ossification of the cervical rib and the pressure of this hard, bony substance upon the roots of the brachial plexus. When the disease occurs as early as the age of 30 there is likely, for some reason, to have been a preceding loss of weight. Patients are run down and then, either because there is a precocious calcification as a consequence of deterioration of tissue, or because the loss of substance in the muscles in the neighborhood makes the nerves more likely to be pressed upon, the first symptoms develop. There is only one way definitely to decide the diagnosis. That is to have a careful skiagraph, or, in case of negative results, several of them taken, in order to determine the presence or absence of cervical ribs. Not all the cases of cervical ribs give symptoms and in one recently published series of 26 cases just one-half presented symptoms and the other half did not, but all these vague cases of pain in the arm, especially if any tendency to atrophy manifests itself, should be examined from this standpoint.
Local Conditions.—The subjective symptoms in these cases often include [{401}] much more than pain. There may be numbness and the hands often feel cold, though they do not become blue. As a rule, indeed, the arms are more affected than the hands, though not infrequently one of the hands becomes more sensitive to injuries than the other and, as a rule, both hands do not heal well after injury. Even scratches take a long time to heal and slight abrasions cause skin lesions that are more or less indolent for some time before healing. Any fresh injury, even of slight degree, puts back healing much more than would ordinarily be the case. In fact, most of the so-called tendency not to heal is local rather than constitutional. When a patient complains that though his or her tissues used to heal rapidly now they are very slow to heal, it is well to think of nephritis or diabetes but it is especially important to know the local conditions.
Pleural Adhesions.—Another interesting cause of pains in the arms is the possible contraction of adhesions of the pleura and surrounding tissues at the apices of the lungs and the spreading by continuity of a low-grade inflammation even to the lower roots of the brachial plexus. A certain number of cases of this kind have been reported in which there seems to be no doubt of the diagnosis. In these, the early symptoms were pains or aches in the arm followed by some weakness of muscles and even some trophic disturbances. Ordinarily the condition has been very acute as, for instance, a pneumonia when the first symptoms were noticed. In the course of the exudation and the contraction of the inflammatory exudate the brachial plexus is interfered with. This, like the cases referred to the presence of a cervical rib, emphasizes the necessity for thoroughly studying local conditions in order to understand the meaning of painful conditions in the arms. It is easy to say the word rheumatism, while it requires time and careful investigation to find the real pathological factor at work; but the difference in the value of the two diagnoses for both patient and physician can be readily understood.
Other Conditions.—Besides these, there are the various conditions discussed in other chapters of this section—old injuries, breaks and dislocations, so-called sprains with laceration of tissues, and any serious pathological condition that has affected the tissues deeply. An old periostitis, for instance, will leave an arm rather easily liable to the development of various painful conditions. Of course, a tuberculous process anywhere in the arm will produce a like effect. An arm that has had a lead neuritis will often be uncomfortable in rainy weather for long after and a crutch palsy may, in the same way, leave the arm sensitive. The musculo-spiral palsies that occur from lying on the arm when drunk, or that are seen sometimes in coachmen who wrap the reins around their arms—a Russian custom—or the nerve conditions seen in patients who have suffered from an anesthetic nerve-pressure disturbance, may all be at the bottom of subsequent painful conditions, worse in rainy weather. The only sure rule is to individualize the cases and make an exact diagnosis. The etiology will probably suggest itself if the history is carefully taken.
In these cases the most important treatment is to disabuse the patient's mind of the idea that there is rheumatism, or any other constitutional ailment present, and to make him realize that the trouble is entirely local. After this, the strengthening of the affected muscles must, as far as possible, be secured by local measures and exercises.
CHAPTER VI
LUMBAGO AND SCIATICA
Any affection involving discomfort, pain, ache, or disability of the large muscles in the lumbar regions is likely to be called lumbago, not only by patients but by physicians. Any condition that makes it painful to use the upper part of the lower limb and especially the group of large posterior leg muscles just below the nates is called sciatica. These are commonly supposed to be typical "chronic rheumatisms." Anything in this region that is the source of discomfort on rainy days and comes especially to the working man who has been exposed to the elements, or that follows a wetting or the wearing of damp clothes, is confidently classified as a chronic rheumatic condition. Almost needless to say any such conclusion as to the heterogeneous groups of symptoms that occur in these regions, far from adding to our knowledge, rather confuses the situation. There is an assumption that we know something about them when we call these conditions either lumbago or sciatica, but unless each individual case is carefully investigated and its conditions studied so as to get at their true etiology, it is almost impossible to treat them successfully. While the general practitioner of medicine of the regular school often fails in his treatment of them, these affections are among the most fruitful sources of revenue for the irregular practitioners.
It was particularly for pains and aches in the back that St. John Long's liniment proved so efficacious about a century ago. So-called lumbago and sciatica patients were among the most frequent callers on Perkins in the days of the famous tractors and many of them received great relief. In our own time these constitute a class of patients who go from physician to physician and who finally are cured or relieved by some irregular practice which we know contains nothing especially remedial, but the advocates of which somehow succeed in persuading these patients that they must be better than before. Most old people have some aches and pains in either the lumbar muscles or the large muscles at the back of the thigh. Many of them are relieved by massage, but still more of them find relief in the rubbings and manipulations of the osteopaths, and they are great advertisers of the relief that has been afforded them and they have helped much in securing such state recognition as has come to the systems they thought curative in their cases. Eddyism has been helpful to a certain number of them. Fads of various kinds catch still others. Evidently these intractable cases deserve to be studied from the standpoint of what mental influence can do for them.
Conditions Mistaken for Sciatica or Lumbago.—Needless to say, a large number of conditions occur which may be called sciatica or lumbago, but which are due to the most varied causes. An affection of any of the joints in this neighborhood will produce pain to which is often added tenderness and occasionally swelling, and nearly always disability. Disease of the lower part of the lumbar spine due to tuberculosis is often in its earlier stages called lumbago. Indeed, without careful investigation showing that there is a special point of tenderness, some irregular fever and that the muscles are in spasm [{403}] to protect the underlying joints from use, it is difficult to decide just what is the affection in a particular case. I have seen three physicians diagnose a one-sided tenderness and pain in muscles with disability as lumbago, when the course of the disease proved that it was tuberculosis of the sacro-iliac joint. Any of the bones or joints in this neighborhood may give rise to pain, tenderness and spasm of muscles and it is important not to make the facile diagnosis of lumbago, unless careful investigation has eliminated all underlying organic conditions.
There are other conditions not infrequently mistaken for lumbago or sciatica which are interesting. Needless to say unless they are definitely recognized there will be no relief afforded for any discomfort of a permanent character, though the coal-tar products will give temporary surcease of pain. Occasionally internal hemorrhoids produce an achy discomfort in the lower part of the back that is described as lumbago, and unless the physician is careful to investigate he may tentatively accept that diagnosis. Proper regulation of the bowels and the use of gluten suppositories will often practically cure the condition, though there will be relapses whenever constipation returns. Chronic posterior urethritis sometimes simulates painful conditions very low down in the back or in one hip or the other. Usually in that case there is a chronic inflammatory condition in the seminal vesicle on the side to which the symptoms are referred. Occasionally over-distention of the seminal vesicles, as seen in widowers who have been accustomed for many years to regular evacuation of them, may cause so much pain and disability in the region of the hip on one side as to be mistaken first for lumbago and then even for tuberculous hip joint disease. Artificial emptying of the seminal vesicle by milking through the rectum will usually afford relief. In all of these cases as soon as the exact diagnosis is made, the patient's mind is relieved of a serious burden of anxiety and it is usually not difficult to bring a great measure of relief.
Old Injuries and Discomfort.—Many of the painful conditions described as lumbago are due to old injuries, to wrenches and sprains in this region due especially to heavy lifting and to the laceration of ligaments from over-exertion.
Typhoid Spine.—Protracted cases of typhoid are sometimes followed by pain in the lumbar or sacral regions, developing usually after a slight jar or shock, sometimes after a fall or even following a severe injury, which are really the result of the physical condition of the patient. Stiffness, aching discomfort on movement and sometimes tenderness on pressure are present. Often there are associated neurotic symptoms of various kinds. This used very commonly to be considered rheumatism and occasionally one still sees cases so labeled. On the other hand, much more serious conditions, as Pott's disease, abscess of the liver, or some form of spondylitis, may be suspected. Absence of temperature is almost the rule and usually is the pathognomic differential against these. The whole condition is usually a neurosis though there may be some perispondylitis. The treatment is to increase the patient's nutrition, which has usually suffered to a marked degree, and get the mind off the condition in the back. Concentration of attention on it will make it very uncomfortable, so that even heavy doses of opiates will scarcely relieve the discomfort, and this emphasis of attention will further disturb the mind and develop neurotic [{404}] symptoms. Diversion of attention, gentle movements, plenty of air, and regulation of the functions of the body will bring about a cure.
Stooping Occupations.—Occupations are especially important in lumbago and people who have to stoop much, above all those who do hard work in a stooping position—lifting, pushing, sawing, planing, and the like—are particularly prone to suffer. Miners working where the height of the vein does not permit them to stand up are commonly subject to it. Any one who has to assume, or has the habit of assuming, a stooping posture for long hours may suffer from lumbago. Constrained position predisposes more than hard work. Tailors, though in a sedentary occupation, often suffer from it.