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.