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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

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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