Chapter LX

OCCUPATION DISEASES DUE TO EXCESSIVELY REPEATED
MUSCULAR ACTIONS.

_Fatigue Neuroses: Scriveners’ Spasm, or Writers’ Palsy._

Under the head of occupation or fatigue neuroses it is customary to include affections characterised by spasm or paralysis of the muscles which prevent the individual performing certain muscular actions, by means of which he has hitherto earned his livelihood. The affection is met with in various occupations, usually, but not always, in those in which delicate movements--as, for example, those of the fingers--are required; hence as writing is one of the commonest of this class of occupations, it occurs as writers’ palsy. Accompanying the spasm or sudden contraction of the muscles that takes place, there is frequently pain, but there may be pain without spasm. Gowers, in his _Diseases of the Nervous System_, speaks of a motor and a sensory, or a spasmodic and neuralgic, form of scriveners’ palsy. Seventy years ago the affection was first described by Sir Charles Bell. The infirmity affects males oftener than females, and the weakness shows itself mostly between twenty and thirty years of age. While the repeated muscular movements required in writing become through fatigue the cause of the loss of power, there are other circumstances in operation, notably the inheritance of a weak nervous system, family worries, and financial difficulties. Excessive use of tobacco and intemperance in alcohol also favour its development. Since over-use of the muscles is a cause of the palsy, the malady naturally occurs in those people who earn their living by writing, _e.g._ clerks, copying-clerks particularly, and it would seem to be caused less by the amount than by the manner of writing. Steel pens have been blamed for causing scriveners’ palsy, because they have to be grasped more firmly and adjusted more exactly than quills. Doubtless the malady has become more general since their introduction, but the disease was previously not unknown in persons who only used quills. Besides, the number of people who are employed as clerks is greater now than formerly, and the conditions of life have materially altered. Quick writers do not suffer so much as slow and laborious toilers of the pen, owing to the greater range of their muscular movements. Sharp-pointed pens are more liable to cause paralysis than stub-pointed, because they have to be held more tightly, and require more and finer muscular adjustments.

Once the malady is established, it is when any muscular effort is made that the defect is observed. An individual, for example, may feel nothing wrong with his hand until he begins to write, and then the muscles that control the movements of the fingers are thrown into a state of involuntary spasm, or there is pain which prevents him writing. I have at present under my care a schoolmaster whose right arm is perfectly still, and its muscular movements normal, until he attempts to write. In the middle of writing a word the fingers will be unexpectedly thrown into a state of spasm, so that the pen is more firmly gripped than before, and yet he is unable to lift the pen off, or move it further on the paper. He has no difficulty in writing on the blackboard owing to the wider range of muscular movements of the elbow and shoulder. In scriveners’ cramp there may be, in addition to spasm and pain, violent tremor, or there may be what is still rarer, actual paralysis. When the muscles during the act of writing are thrown suddenly into a state of spasm, the individual is conscious that he is grasping the pen too tightly, but he cannot help it. Any voluntary attempt to relax his hold of the pen makes no difference so far as his ability to finish the writing is concerned. The act is accomplished slowly: the letters and figures which he makes are irregular, while the handwriting resembles that which is attempted by a person riding in a jolting carriage or on the railway. The power of writing may be lost gradually or quickly. The presence of spasm either prevents the individual writing at all, or if the spasm is intermittent and accompanied by tremor, the handwriting is jerky and rather illegible. It is the attitude assumed by the muscles in the act of writing that induces tremor, for where no effort is made there are no tremulous movements. It is an interesting fact too, as showing how the affection is limited to a distinct group of muscles concerned in a particular act, that while a person who is the subject of scriveners’ palsy cannot write, he may be able to paint quite well or even to print various letters and words. The grasp of the affected hand is usually unimpaired, or there is just the slightest loss of power. In grasping the affected hand in scriveners’ spasm, I have noticed that if there is prolonged contraction of the muscles concerned in grasping, the act is sufficient to bring on tremor. The muscles of the fingers seem to be incapable of sustaining any effort without being thrown into a state of spasm or tremor. If there is any atrophy or loss of muscle substance it is generally slight. Usually there is very little alteration in the response of the nerves and muscles to electrical stimulation. In some persons it is increased, in others it is diminished. The patients complain of the arm and hand feeling tired, and of a general sense of languor and fatigue to which they have hitherto been strangers. They are easily fatigued and retire to rest early, for they feel the need of repose, and are conscious of the benefit that comes from it. Their general health remains on the whole good. They are, however, apt to suffer in consequence if they are unable to take their accustomed out-of-door exercise, and there is a degree of mental depression that comes from the disablement caused by their infirmity. The individual feels that he cannot earn his living as he used to, and so he worries. It is not that he is overcome by pain, although in some instances this is acute and of a severe neuralgic character, especially in the muscles of the thumb, the finger, and the forearm. It is mental anxiety that drags him down.

Various theories have been put forward to explain writers’ palsy. According to Gowers these are--(1) weakness of groups of muscles with over-action of antagonists; (2) a reflex spasm due to stimulation of the sensory nerves in writing; (3) structural changes in those particular parts of the central nervous system that superintend the muscular movements concerned in this act. Writing is an acquired act learned by education, and it never becomes automatic. We require to concentrate our attention while writing, and so the fatigue is really as much, if not more, cerebral than muscular. Each of the above theories has its supporters, but it is difficult to make any one of them harmonise with all the facts. My own belief is that the malady is primarily central rather than peripheral. Spasm is one of the initial facts in the illness, and in writers’ palsy, as in all occupation neuroses, spasm and paresis overtake those muscles that have been trained to accomplish particular movements, especially movements of a complicated and delicate character. Altered nutrition of cerebral nerve centres is in all probability responsible for the defective muscular movements, while any pain that is felt is due to compression of the sensory nerve endings in the muscles during spasm. If there is any structural alteration in the nerve fibres it must be slight. This indicates that we are not dealing with a neuritis but a functional condition of the nerve fibres, such as occurs in neuralgia. Although the primary seat of the trouble is probably located in the cortex of the brain, there is a marked absence of headache and of impairment of intelligence. A recent author has thrown out a hint that, in cases of great nervous exhaustion and extreme fatigue, in which during life no physical signs of disease of any organs can be detected, and in which after death no gross structural changes are found, the cause in all probability resides in some obscure pathological condition of the large nerve cells in the cortex or grey matter of the brain. It is to such a condition that we are disposed to look for an explanation of the early symptoms of writers’ palsy.

Scriveners’ spasm _per se_ is distinguished from the inability to write that is observed, for example, in hemiplegic patients who have had an apoplectic stroke, by its history, the limited extent of the spasm and loss of power.

So long as the individual, the subject of scriveners’ spasm, insists upon writing, the more pronounced does his difficulty become. He must give up writing for a lengthened period if he wishes to get well. Should he, however, persist in following his occupation, the weakness may extend to other muscles, and he will then be thrown further _hors-de-combat_, a circumstance that will only tend to deepen still further his mental depression and make him more anxious with regard to his future. Feeling himself baffled, he may educate himself to write with his other hand, but in time this too may become affected. More than that, when he attempts to write with his left hand tremors may be induced in his right. In one of my patients a sudden involuntary act, such as sneezing or yawning, will sometimes induce violent tremor of the affected arm when the muscles are perfectly still. Absolute rest from the use of the pen and freedom from all worry are necessary to establish a cure, which unfortunately is readily broken by too early return to work.

_Prevention and Treatment._--All are agreed that the less cramped the handwriting and the more that shoulder muscular movement can be brought into operation, the less is the likelihood of scriveners’ spasm arising. Writing is a matter of education, hence children should be taught to use the muscles of the arm more freely. Pens should not be too fine-pointed if much writing is to be done, while the encircling of the lower part of the penholder by indiarubber obviates to some extent the necessity for taking too firm a grip of the pen. Lewis (_Twentieth Century Pract. Medicine_, vol. iii., p. 471) recommends that the pen should be held between the index and middle fingers, as this requires less muscular effort than the ordinary method, but at the best it must be admitted that this is an awkward position, and although initial difficulties can be overcome by education, it is still doubtful whether the muscular movement required under those circumstances is, after all, so very much less. Quills and stylographs may be substituted for steel pens, and, as already mentioned, the non-affected hand may be taught to write. Type for hand writing might be substituted, since this brings a new set of muscles into play, and the movements are not so fatiguing. Once symptoms of the malady begin to show themselves, absolute cessation of all handwriting is necessary. The work should cease at once, for it is in the early stages that rest is beneficial and a cure possible.

Internally, nervine tonics may be administered. Drugs as a rule do only a limited amount of good. I have got the best results from arsenic and bromides. Strychnine is recommended by some. If there is much pain such sedatives as morphia or belladonna may be required, but their use should be avoided as far as possible. Electricity, too, is worthy of a trial, especially in the voltaic rather than the faradic form, combined with massage or rubbing.

_Telegraphists’ Spasm, or Cramp._

_Mal télégraphique_, or telegraphic spasm, was first described by Onimus, a Frenchman, in 1875; by Robinson in this country in 1882; and by Fulton in 1884, who described in detail the movements involved in the use of the Morse instrument. Twenty-five years ago the disease was a rarity. In the succeeding decade it was pretty prevalent. Probably it is now less frequent, owing to the telephone having been in many instances substituted for the telegraph. Dr Vivian Poore (Allbutt’s _System of Medicine_, vol. viii., p. 131) examined 400 cases of professional ailments, but he only found two patients who were telegraphists, and they had worked the Morse instrument. Telegraphists’ spasm differs in no material way from what has been described as writers’ palsy. Since it is to working the Morse machine that the largest number of cases of telegraphists’ cramp has been traced, it is necessary to remind the reader that the Morse alphabet is composed of a series of dots and dashes, and that the transmitting instrument consists of a lever surmounted at one end with a knob, which when depressed by the hand of the operator makes an electrical connection with, or completes the electrical circuit between, the transmitting apparatus at one end of the telegraph wire and the receiving apparatus at the other. On each occasion that the lever is brought down by the hand of the operator, and an electrical connection is made, a bar of soft iron in the receiving instrument becomes magnetised and attracts an armature which is fastened at one end of a lever, while an inscribing point at the other end reproduces on a slip of ribbon or paper, kept moving by clockwork, the dots and dashes made by the transmitter. As the knob is generally held between the thumb, index, and middle fingers of the right hand, the elbow meanwhile being supported, it is clear that most of the movement is made by the extensor and flexor muscles of the fingers and of the wrists, including the adductor and opposing muscles of the thumb. Since each letter, with the exception of _E_, which is a single dot, and _T_ a single dash, consists of more than one dot or dash, while some require as many as four, the amount of sustained and co-ordinated movement is necessarily very great, and as the transmission is generally very rapidly effected, the operation when repeated for a great length of time, as in the transmission of speeches delivered in Parliament, must be followed by a considerable amount of fatigue. Fulton calculated that an operator might make between thirty and forty thousand muscular contractions in one hour, and since many telegraphists work eight hours a day, the strain on their muscles is necessarily very great. While the excessive use of tobacco and alcohol doubtless favours the development of telegraphists’ spasm, as of other occupation neuroses, there is not the least doubt that cerebral fatigue and muscular overstrain are the causes of it. In America, men have not been found to be more predisposed to it than women, or _vice versâ_. Once the symptoms of the malady have shown themselves, an operator when transmitting a message may be suddenly seized with muscular cramp, so that his hand cannot be quickly enough raised, and in consequence of this involuntary spasm, the pressure on the lever by the fingers is so long maintained that what ought to have been dots become dashes, or he transmits dots and dashes in such an abnormal sequence that the message received reads quite differently to that which it was intended to send. Mistakes of this kind have a distressing mental effect upon the operator, and they tend still further to derange the functional activity of his nervous system. There may be tremor of the hand as well as cramp of the muscles, but pain as a rule is absent. The muscles respond to electrical tests and do not waste to any extent. A telegraphist feeling that the muscular spasms are unfitting him for his daily duties may train his other hand to do the work. Conscious that by this means he will retain his appointment, he becomes more cheerful, and is able to rise to some extent above his infirmity. Whenever possible, such an individual should have a lengthy respite from his labours, for muscular rest is of very great importance. The treatment of telegraphists’ spasm is the same as that described under writers’ palsy. Prevention is better than cure. Learners are encouraged to practise with both hands, and as a consequence of this ambidexterity, not only are the cases becoming fewer every year, but they are seen and treated earlier by the Post Office Medical Attendants, whose experience is, that by causing the patients to desist there and then from keying for a few months recovery invariably follows. After all, it is but a small percentage of telegraphists who have “spasm,” probably not more than 1.3 per 1000.

_Pianoforte Players’ Cramp, etc._

Pianoforte players’ cramp affects principally professionals, women more frequently than men. Like the infirmities mentioned in the preceding pages, there is muscular spasm, which may or may not be associated with pain. If the cramp is painful the individual cannot go on playing. Usually the spasm affects one or more of the fingers.

Spasmodic muscular contraction is also met with in _violin players_, in _violincellists_ especially in the fingers of the left hand that are brought down upon the strings of the instrument, and in _seamstresses_, in whom once the affection is developed any attempt at sewing is followed by cramp of the fingers, so that sewing becomes impossible. Seamstresses’ cramp bears a resemblance to shoemakers’ spasm mentioned a little further on.

Spasms of various trades have been described, _e.g._, _type-setters’_, _milkers’_ spasm, which is said to occur in the cowherds of the Tyrol, and _hammermen’s_ spasm. Workers in almost any trade, but especially those trades in which excessive muscular effort is combined with mental concentration, are liable to spasmodic seizures such as have been described, and to which in a general way the remarks already made on prevention and treatment may be said to apply.

_Shoemakers’ Spasm._

In Vienna and Heidelberg there have occurred on several occasions epidemics of “idiopathic tetany.” Tetany is a disease characterised by muscular spasms involving the hands and feet, and sometimes, too, the muscles of the trunk, the face, neck, eyes, and larynx. Of 399 cases of idiopathic tetany collected by Frankl-Hochwart, 174 occurred in shoemakers and 95 in tailors, mostly between the ages of sixteen and twenty-five years. The epidemics have generally prevailed during the months of March and April. Risien Russell, who alludes to this subject in Allbutt’s _System of Medicine_, vol. viii., p. 51, says that probably some general toxic condition is in operation. If so, then idiopathic tetany would be caused by something on, or in, the thread that is used, since this material is common to the two occupations, and the illness should therefore be regarded as accidental, and not as incidental, to either the trade of the shoemaker or the tailor.

_Boot and Shoe Making._

The last few decades have witnessed great changes in many trades that were formerly conducted as home industries, but perhaps in none more than in boot and shoe making. A few years ago it was no uncommon thing to find a cobbler working alone in his home, or in a small shop, assisted by one or two workmen. All boots and shoes were then handmade, the leather being cut and the pieces sewn together on the premises, so that a completely finished article was turned out by one person. The application of machinery has changed all this. It has flooded the market with ready-made boots and shoes, which, since they can be made more quickly, and in larger numbers, are cheaper than those made by hand, although not so enduring. In boot and shoe making, as in all factory production, subdivision of labour prevails. To one man is assigned the guidance of a machine which cuts the “uppers” or the “soles” of the shoes; another stitches the uppers, or “closes” them; while to yet another is given the harder task of “making” the shoe, _i.e._, of attaching the soles to the uppers. The extent to which machinery has already displaced handmade boots and shoes is depriving us of a class of workman who was capable of doing all that machinery now accomplishes, only he required much longer time. In rural districts cobblers will still be required, but their occupation in the future will be that of boot-menders rather than of boot-makers.

In reproducing the accompanying picture of one of my patients--a shoemaker--who was in the Newcastle-upon-Tyne Infirmary, I am wishful to give some literary permanence to a deformity which was very prevalent in workers in the trade a few years ago, a deformity known by the name of shoemakers’ chest, and which, as time goes on, will probably cease to exist. At his work the old type of shoemaker would sit on a low bench, with his thighs and knees tightly drawn towards each other, clasping the last with the boot upon it. His trunk would be bent down over his work, so that during the act of stitching and drawing the waxen threads through the holes made by his awl in the leather, his arms would be forcibly separated from his sides in order to tighten each stitch, while any beneficial expansion of the chest that this movement created was unfavourably counterbalanced by the increased pressure of the last upon his chest bone. As a consequence of this repeated pressure applied to the front of the chest, especially on younger men, the chest bone and ribs were driven in so as to form a deep hollow, such as is depicted in the lower part of the chest in the illustration (Fig. 89). The work, too, was sedentary, consequently the men suffered from indigestion, constipation, and piles, the latter being often aggravated by excessive indulgence in alcohol, to which shoemakers as a class were much addicted. It has sometimes been stated that they also suffered from cancer more than men engaged in other trades, but it is difficult from available statistics to prove or disprove this.

In modern boot factories, instead of the “uppers” being stitched to the “soles,” they are often riveted. When bootmaking is carried on by this process at home, the workman is often found sitting in the attitude of the shoemaker described higher up. During the act of burnishing and filing the rough edges of the boot, there is a considerable degree of pressure exercised by the heel against the front of the chest. In the bootmaking trade the men who cut out and shape the leather to be made up are known by the name of “clickers.”

Shoemakers formerly suffered from bronchitis and pulmonary phthisis in fairly large numbers, but much of this was due to the sedentary character of their occupation, their want of exercise in the open air, and their intemperate habits. The introduction of machinery, and the bringing of shoemaking under the Factory Acts, may to some extent effect an improvement in the health of shoemakers, but in many of the factories which I have visited, and where large numbers of persons are employed, the overheated rooms in which the work is carried on and the vitiated atmosphere rather predispose the workpeople to pulmonary catarrh, and tend to make the women anæmic. In addition, mercurial poisoning has been known to occur in the men employed in shoemaking factories, whose duty it is to mind the American or Blake machines. The mercury is placed in a well in the machine, to act as a lubricant, and as the metal is extremely volatile, poisoning may readily arise.

THOMAS OLIVER.