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 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.





Pleural Adhesions.--Another interesting cause of pains in the arms is

the possible contraction of adhesions of the pleura and surrounding

tissues at the apices of the lungs and the spreading by continuity of

a low-grade inflammation even to the lower roots of the brachial

plexus. A certain number of cases of this kind have been reported in

which there seems to be no doubt of the diagnosis. In these, the early

symptoms were pains or aches in the arm followed by some weakness of

muscles and even some trophic disturbances. Ordinarily the condition

has been very acute as, for instance, a pneumonia when the first

symptoms were noticed. In the course of the exudation and the

contraction of the inflammatory exudate the brachial plexus is

interfered with. This, like the cases referred to the presence of a

cervical rib, emphasizes the necessity for thoroughly studying local

conditions in order to understand the meaning of painful conditions in

the arms. It is easy to say the word rheumatism, while it requires

time and careful investigation to find the real pathological factor at

work; but the difference in the value of the two diagnoses for both

patient and physician can be readily understood.





Other Conditions.--Besides these, there are the various conditions

discussed in other chapters of this section--old injuries, breaks and

dislocations, so-called sprains with laceration of tissues, and any

serious pathological condition that has affected the tissues deeply.

An old periostitis, for instance, will leave an arm rather easily

liable to the development of various painful conditions. Of course, a

tuberculous process anywhere in the arm will produce a like effect. An

arm that has had a lead neuritis will often be uncomfortable in rainy

weather for long after and a crutch palsy may, in the same way, leave

the arm sensitive. The musculo-spiral palsies that occur from lying on

the arm when drunk, or that are seen sometimes in coachmen who wrap

the reins around their arms--a Russian custom--or the nerve conditions

seen in patients who have suffered from an anesthetic nerve-pressure

disturbance, may all be at the bottom of subsequent painful

conditions, worse in rainy weather. The only sure rule is to

individualize the cases and make an exact diagnosis. The etiology will

probably suggest itself if the history is carefully taken.



In these cases the most important treatment is to disabuse the

patient's mind of the idea that there is rheumatism, or any other

constitutional ailment present, and to make him realize that the

trouble is entirely local. After this, the strengthening of the

affected muscles must, as far as possible, be secured by local

measures and exercises.





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