Introduction Occupation Neuroses

During the 1980s, neck and upper limb disorders apparently related to occupational factors became increasingly prevalent in sections of the Australian workforce (Ferguson, 1984). Those particularly "at risk" were female process workers, keyboard operators and machinists (National Occupational Health and Safety Commission, 1986). As the work performed by most sufferers had necessitated repetitive upper limb movements and sustained or constrained head and neck postures, these conditions became known by the collective term Repetition Strain Injuries (RSIs). According to the National Occupational Health and Safety Commission (NOHSC), RSIs were characterised by "discomfort or persistent pain in muscles, tendons and other soft tissues, with or without physical manifestations" (NOHSC, 1986). Although the definition invokes biomechanical factors in the pathogenesis of RSIs, it was stated by the NOHSC that psychosocial factors, including stress in the working environment, could also be involved in causation. The potential for diagnostic uncertainty was therefore enormous.

The difficulty in making an accurate tissue diagnosis of some RSIs quickly became apparent (Browne, Nolan and Faithfull, 1984). Often those with diffuse upper limb pain exhibited clinical features of two or more syndromes. In an editorial announcing the arrival of the "new" industrial epidemic Ferguson (1984) commented on the remarkable confusion which existed over the terminology and pathophysiology of many RSIs:
'..... the majority of cases of repetition injury are not localized syndromes but of a more diffuse disorder, apparently of muscles. The disorder, whose symptoms are those of aching, weakness and tenderness of muscles (with or without induration, swelling and heat), is variously termed muscle strain if acute or, if more chronic, occupational myalgia, myositis, myopathy, fibrositis, fibromyositis, muscular rheumatism, myofascial syndrome or tension myalgia. This syndrome has also been confused and may coexist with occupational cramp ("craft palsy"), which should be considered a major variant of repetition injury. Although ill-defined muscle aching is extraordinarily prevalent, little is known of its aetiology, pathogenesis and pathology (whether the symptom is of occupational or other origin), nor, if well-established, why it appears to persist despite prolonged rest of the affected part'.

Given the diagnostic imprecision, the lack of knowledge of pathophysiology and pathoanatomy, and the potential for confusion with pre-existing but equally ill-defined entities, it is not surprising that a debate over the true nature of RSIs ensued. This debate which concerned the diffuse cervicobrachial pain syndrome referred to by Ferguson (1984) has been essentially a struggle for ascendancy between those holding the view that it is a genuine work-related somatic problem and those denying an organic basis for the syndrome, claiming that it is primarily psychogenic (for review of the debate see Hall and Morrow, 1988; Mullally and Grigg, 1988). Important semantic, epistemological and methodological problems have already been identified in the RSI debate itself, which cast doubt on the validity of that construct (Cohen, Arroyo, Champion and Browne, 1992). The major economic, political and social dimensions of the debate have been analysed elsewhere (Reid and Reynolds, 1990; Bammer and Martin, 1992). However, the challenge of understanding the clinical presentation of diffuse cervicobrachial pain remains (Cohen et al., 1992).

Although apparently at odds, both the somatogenic and psychogenic arguments derived support from 19th century medicine in claiming that RSI is a contemporary example of conditions then known as Occupation Neuroses. On the one hand, Fry (1986) and Quintner (1991), invoking the historically earlier use of the term "neurosis", pointed out that "occupation neurosis" referred to a presumed central nervous system disorder occurring in an occupational context. By contrast Lucire (1986), the main proponent of the "psychogenic" school, and others (Ireland, 1988; Bell, 1989) considered that RSI was indeed a psychoneurosis (hysterical neurosis, conversion type). Their argument was based on the claim that the construction of "neurosis" as "any group of symptoms without localising signs for which no pathophysiological mechanism could be found or postulated" evolved into "psychoneurosis" when "the ideas, memories, experience and behaviour that accompanied such disorders were recognised and acknowledged" (Lucire, 1986).

As this paper will show, the attempt to infer psychogenesis by defining a relationship between the Occupation Neuroses and RSI is fraught with an epistemological problem, namely the failure to take into account the evolution in the construct of "neurosis" itself. The historical evolution of "nervous" diseases since the eighteenth century will be reviewed briefly. The original construct of "occupation neuroses" will be found in the neurological literature of the 19th century and its evolution traced through the early decades of this century. As theories of their organic central nervous system origin were then found to lack explanatory power by psychiatric researchers, the Occupation Neuroses acquired a psychogenic connotation which continued up until the 1980s.

Next: Evolution of the Construct of Nervous Disease

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