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.