ICD 10
International Statistical Classification of Diseases and Related Health
Problems ICD 10. (Tenth Edition ) Geneva: World Health Organisation, 1992.
This classifies Writers' cramp and the occupation neuroses at F 48.8 in
the category of mental and behavioural disorders, in a sub section on somatization.
Occupational Neurosis
Whereas many practitioners had conceptualised writers' cramp as a disorder
caused by writing or by whatever occupation had preceded it, Gowers invoked
the German term, 'occupation neurosis'.
The term 'occupation neuroses', derived from the German ('Beschaftigungs-neurosen'),
is a convenient designation for a group of maladies in which certain symptoms
are excited by the attempt to perform some oft repeated muscular action,
commonly the one involved in the occupation of the sufferer. The symptoms
occur in the part by which the action is effected and the action is interfered
with by them. Other acts (at least in the early part of the affection) do
not excite the symptoms and are not interfered with.
With that terminology, Gowers effected a partial shift from a theory
of physical causation in peripheral tissues to the idea of functional nervous
disorder. Gowers conceptualised the symptoms as 'excited' by the act of
writing, or by other activities which appeared to be either implicated or
affected. He described his cramp subjects as governed by 'an hereditary
tendency' and as particularly susceptible to the influences of anxiety.
Gowers understood the pain to be 'referred' to the muscles,
to the bones and joints or to the position of certain nerves. The last location
was suggestive of neuralgia from which cramp differed in being 'not spontaneous,
but excited (rather than 'caused') only by the special action. Gowers distinguished
a 'motor and a sensory form' and a 'spasmodic and neuralgic form' but noted
that, in practice, these were combined. He described the characteristics
of over a hundred cases, noting that it was a 'disease easily imagined by
those who have witnessed the disorder'. He found his subjects to be of 'distinctly
'nervous' temperament, irritable, sensitive and bearing overwork and anxiety
badly'. He remarked on 'the number of sufferers enduring anxiety from family
trouble, business worry or weighty responsibilities'. He found that cramp
occasionally followed local disease or injury, ill health or a lowering
of general tone and he reported on his own difficulties in differentiating
a 'genuine' case of cramp from a feigned one, a problem which has continued
to challenge the courts and medical examiners of today. Gowers described
cramps, spasms, tremors, a lack of co-ordination, paraesthesiae, a sensation
of being swollen without visible swelling, fatigue, weakness and spread
of symptoms to the unused arm. This extension of sensory phenomena to other
limbs and body parts was attributed to an origin in the central nervous
system. Gowers also suggested that there might be a 'writing centre' and
he thought that it might be located in the cerebral cortex and that its
output was irregular or excessive.
Gowers also regarded 'true cramp' as the dystonic or spastic variety.
He considered vague pains and discomforts to be 'imagined' cramp resulting
from fear of developing it, a state of affairs for which he recommended
firm reassurance apparently with some success. Unlike Lewis in the United
States who believed them all to be successful, Gowers reported the failure
of all the common therapies, specifically immobilisation, separating tendons,
galvanic and faradic stimulation and Indian hemp. After a period of experimentation
he lit on re-education in writing style as helpful and he advocated a relaxed
hand with sweeping strokes and rhythmic movements. In contemporary terminology,
Gowers would have been seen as a behaviour therapist and as one who was
aware of his subjects' psychosocial difficulties.
Gowers located cramp among the neuroses, related it to personal characteristics
and emotional factors and made available a reasonably effective remedy in
the form of education and attention to predicament; these changes in the
management of cramp might all have been factors in decreasing its incidence,
at least at the hands of physicians who followed his regimes or subscribed
to his beliefs. Gowers' use of the term 'neurosis' has been a bone of contention
with a number of supporters of the injury theory of RSI. My belief is that
Gowers was using the term in late nineteenth century meaning, when it was
increasingly suspected of having emotional causes. At this time neuroses
were thought to be neurological disorders with functional manifestations
but competing theories about their psychogenic origins were known to those
who had read Carter, Reynolds and many others.
Gowers' selection of the observations which he made of his patients and
the questions which he asked about their circumstances were consistent with
his having knowledge of the ideogenic components and the psychosocial precipitants
of episodes of cramp.
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