Back mice is a “modern term” to designate the lumbar fibro-fatty nodules. In this treatise, Stockman just calls the nodules fibrous indurations or thickenings that have the property by certain “irritants” to swell. He describes the back mice as SEROUS EXUDATION IN FIBROUS INDURATIONS. The exudation can be partly reabsorbed and then the fibrous thickenings become less painful. According to him -and many other authors- the “mice” can be present at ANY LOCATION of the body, not just at the lumbar zone.

The painful nodules, indurations and thickenings were a common finding while palpating the patients and were known to be part of a “normal” finding of what they called “rheumatic pain” and the general term of “acute muscular rheumatism or chronic rheumatism”. (Personal note: when medical doctors were used to better palpate the patients)

The old authors were aware that the “mice” could be present at ANY fibrous structure of the body, thus causing many different pain syndromes.

I consider this treatise from Stockman a very interesting study related to “the history of the back mice studies”.

Stockman mentions that if the swollen nodule presses certain nerves it may cause excruciating pain. And that if there is a slight compression then the patient may feel numbness, prickling, and tingling (as it occurs with the back mice and the cluneal nerves).

“These hard nodules are sometimes very painful, and if they involve a nerve may cause aching and shooting pains over a wide area. Their excision gives complete relief. “

Stockman mentions the work of Balfour: “He recognized the importance of these fibrous tissue growths as the cause of chronic rheumatism, and his whole treatment was directed to getting rid of them”.

According to Stockman, one of the clear “irritant cause” to cause the swelling of the nodules is cold damp weather.

Stockman also comments that in certain women the nodules are all over the body causing a very incapacitating pain syndrome (what we now name fibromyalgia).

He also makes it clear that, on the one hand, there are the ETIOLOGIC factors that precipitate the fibrous indurations or thickenings, and once they are there, there are the EXCITING FACTORS that provoke the immediate cause of the pain and aching which are the SWELLING and TENSION of the fibrous indurations. (Personal note: Some years later, Copeman also has this hypothesis that in chronic rheumatic pain there is a “causa prima” of the nodules or indurations and then certain factors, for example, cold damp weather can precipitate the pain by the swelling and tension of the tissue and the nodules).

He presents some histological findings in 8 plates to prove that the palpable nodules, indurations or bands are fibro-fatty tissue.

He also makes the difference between acute and chronic rheumatism clear and explains the various treatments that exists by then.

He presents other authors’ studies and hypotheses such as Balfour and Scudamore. He does NOT mention the French studies about cellulite.

(Personal note: I think that many later studies that doubted the work of Stockman did not really understand his words. Despite he uses the term “inflammatory hyperplasia”, he made it clear that the pain is due to SEROUS EXUDATION AND TISSUE TENSION without inflammatory cells, except for some findings in the plates of local periarteritis and endarteritis of the small vessels.)

Notes on the work of Ralph Stockman:

Link to the original treatise: //archive.org/details/b22394680

THE CAUSES, PATHOLOGY, AND TREATMENT OF CHRONIC RHEUMATISM

By Ralph Stockman, M.D., Professor of Materia Medica and

Therapeutics in the University of Glasgow; Physician to the Western Infirmary of Glasgow

(Personal note: Stockman studied some patients and performed some biopsies of the painful fibrous indurations or nodules and concluded that the cause of what they called chronic or muscular rheumatism -as could be chronic low back pain- was related to the fibro-fatty structures of the body rather than the articular structures).

THE HISTOLOGICAL STUDIES from Stockman

The histology of these indurations was studied from a number of patients which were indurations were excised by Stockman’s surgical colleague, Dr. J. Crawford Eenton, and which were either too acutely painful to be effectively massaged or had not disappeared under prolonged treatment. They include specimens from muscle, from the subcutaneous tissue, and from periosteum.

Stockman presents 8 plates from the biopsies:

(Plates I. and II.)

Stockman findings are mainly hyperplasic fibrous edematous tissue in the fatty tissue and also some cases of inflammatory changes in the vessels walls (periarteritis and endarteritis)

Fig. 1. — Section of inflamed perimysium forming a painful swelling on the muscle ( X 140). It consists of proliferated and edematous fibrous tissue with an amorphous matrix, and at places this penetrated between the muscle fibers. In the section it is detached from the underlying muscle fibers.
Fig. 2. — Portion of same (x 550).
Fig. 3. — Section of fibrous nodule lying immediately under the skin and continuous with it ( X 75). It had been massaged for some time.
Fig. 4. — A strand of fibrous tissue lying in the subcutaneous fat, and spreading into it ( X 75). This was painful on pressure.
Fig. 6. — Section of dense subcutaneous nodule spreading into the fatty tissue (x75).
Fig. 6. — Section of a nodule that lay in the fascia (x 140). It had been massaged, but instead of dispersing it became very hard and fibrous.
Fig. 7. — Section of portion of a nodule showing periarteritis and endarteritis and numerous blood vessels (x 75). The nodule had been massaged for some time.
Fig. 8.— Section of recent periosteal nodule ( x 140). It shows the increased and edematous fibrous tissue.

Stockman makes it clear: The location of the lesions in “chronic rheumatism” are NOT the bone, synovial or cartilage tissues, rather they are the fibrous tissues

“The so-called articular structures — bone, synovial membrane and cartilage — are NOT primarily affected in chronic rheumatism, but the parts implicated are the fibrous ligaments of the joints, and more especially the aponeuroses and fibrous insertions of the muscles, fasciae, the periosteum”.

Note: Other terms to designate “chronic rheumatism”

“ Muscular Rheumatism” , “Muscular and Tendinous Rheumatism” , “Myalgia” and “Rheumatic Myositis,” (Personal note: Since 1904 in England the most used term was fibrositis, partially thanks to this work and the article from Gowers in 1904).

Regarding its etiology there are several theories about chronic rheumatism

(Personal note: by then many authors were discussing what could be the cause of the presence of the painful rheumatism)

attenuated form of acute rheumatism (Pidoux, Bristowe, Maclagan)
as a neuralgia (Senator, Osier)
special infection (Strümpell)
diathesis (Durand-Fardel)
pain from imperfect nutrition (Inman, Anstie).
connected with gout (Garrod, Hutchinson)

Stockman is aware that surpassingly very few authors refer to the presence of definite fibrous thickenings. Stockman hopes that this treatise may cast some light to the nature of chronic rheumatism and its causation.

(Personal note: This is a literal copy of Stockman’s treatise where he describes the presence of these FIBROUS INDURATIONS. Later in history his work was discredited because NO INFLAMMATORY histological signs could be found on later microscopic analysis. Personally I think he was wrong with the use of the term “inflammatory hyperplasia”; maybe a more accurate term would be a hyperplasic swelling. Nevertheless, he made it clear that there were NO inflammatory cells, except for the signs of periarteritis or endarteritis.)

LITERAL DESCRIPTION FROM the fibrous induration of STOCKMAN

[…The essential pathological changes in chronic rheumatism are confined to white fibrous tissue, and as this forms so large a part of the locomotive system of the body, we find accordingly that rheumatism affects specially the aponeuroses, tendons, the sheaths of muscles and nerves, periosteum, fascia, and the fibrous ligamentous structures of the joints. The lesion consists in inflammatory hyperplasia of the connective tissue in patches, most probably the result of the action of microbes or toxins conveyed by the blood vessels, and it may be widely spread over the body, or confined to certain areas. The irritant gives rise to proliferation of the fibrous tissue with serous exudation (Personal note: he is descriving back mice) into the inflamed circumscribed parts, which are tender, painful on pressure, and, if large, they can be easily felt or seen in the muscles and fasciae, and on the sternum or other thinly covered bones. At first, they may resolve readily enough, leaving no apparent traces behind, but they tend to return on slight provocation, and if much new fibrous tissue forms in the affected area they become permanent, and often increase to a considerable size, or spread out over a large area. The older and more fibrous they become, the less tendency they have to disappear spontaneously or on treatment.

These fibrous indurations (Personal note: as Stockman called back mice) assume various forms. Sometimes, especially in the lumbar region or in the fascia lata, large portions of the aponeurosis or subcutaneous fibrous tissue become more or less uniformly thickened, with perhaps more prominent indurations at certain points. In severe cases this gives the skin a hard, inelastic, and brawny feel. More commonly, the fibrous indurations are more defined and circumscribed, varying in size from a small-shot or split-pea to an almond, or even half a walnut. The larger ones may be rounded or flattened, the smaller ones often feel like beaded chains along the fibrous edge of a muscle or aponeurosis. Very frequently, the thickening takes the form of a strand or cord running through the fascia or subcutaneous fat. Sometimes they are deeply placed in the inter-muscular septa, sometimes quite superficially in the subcutaneous tissue; in this case they may adhere to and often slightly pucker the skin. They can often be felt also as small tender projections on the surface of the ribs and other thinly covered bones.

When pressed upon they give rise to pain, and if they are vigorously rubbed they swell up in a few hours and become much more painful on pressure (Personal note: as it is described to happen with certain back mice). In the same way the fibrous hyperplasia that often results from a sprain, rupture of a muscle, dislocation, or other injury may form a purely local lesion of the same kind, which may give rise to “rheumatic” symptoms. Under the action of certain irritants (cold, damp, meteorological changes, muscular exertion, indigestion, and unknown toxins) these indurations are apt to swell and become tenser, and then they give rise to stiffness, aching, or acute pain. The local tension probably exerts pressure on the filaments of sensory nerves (Personal note: what we call cluneal nerves) ; hence these symptoms. Sudden movement of muscles, by increasing the tension or by exerting pressure on the swollen tissue, often greatly aggravates the pain or causes it to shoot excruciatingly. A branch of a nerve may be pressed upon by a nodule, or may even pass through it, hence the pain often radiates over a wide area, perhaps far from the nodule (Personal note: as back mice cause leg pain through cluneal neuropathy). If muscular movement of the part be kept up, or gentle friction be exercised over the induration, the exudation is temporarily got rid of, the tension is lessened, and the pain and aching generally pass off, usually to return again in two or three hours. One such fibrous nodule in the lumbar region is enough to cause very obstinate and painful lumbago (Personal note: as back mice do)….]

STOCKMAN’S CASE REPORT PATIENT WITH SCIATICA from plates 1 and 2

The photographs (Plate I. Figs. 1 and 2) were taken from sections of a small nodular swelling in the buttock. The patient, a 45-year-old man, had been subject to muscular rheumatism with occipital and sciatic neuralgia at frequent intervals for ten years, sometimes suffering very severely from exacerbations. The present attack had been brought on by exposure to cold while perspiring freely, and had lasted for three months. He never had any pains in his joints. On examination, a considerable number of small nodules and fibrous thickenings were found in the neck, loins, and buttocks. Many of these were very tender and painful on pressure. The nodule in the right buttock could be very distinctly felt through the skin, and gave the impression of being the size and shape of a small almond. It was very painful, and from it the sciatic pain seemed to dart down the leg. After carefully fixing its position, Dr. Eenton cut down upon it, and when exposed it was seen to consist of a swollen and slightly projecting portion of the perimysium of the gluteus medius muscle extending for about half an inch. The swelling with the adjoining portion of muscle was removed, hardened in formol-alcohol, and vertical transverse sections made from it. These show that it is a portion of the fibrous tissue sheath of the muscle, greatly hypertrophied and edematous, and consisting of white fibrous tissue and an amorphous soro-fibrinous matrix. At some places, the fibrous tissue has penetrated inwards between certain of the muscle fibers, and a few of these have partially degenerated— more likely from the action of a toxin than from pressure. Fibro-blasts are not numerous, and there is NO congregation of leucocytes in the neighborhood of the inflamed area. The small blood vessels show very distinct periarteritis and endarteritis with marked connective tissue proliferation, indicating that they also have suffered from the action of an irritant. The swelling is therefore a chronic, but still comparatively recent, localized inflammation of the perimysium.

After its removal, the sciatic pain and the aching completely disappeared.

OTHER STOCKMAN’S PLATES:

[…Some of the fibrous nodules lie immediately under the skin, with which they are continuous and to which they may give a puckered appearance. A photograph taken from a section of one of these is shown in Plate I. Fig. 3, the true skin and the dense fibrous tissue of the nodule being continuous with each other. Others lie in the subcutaneous fatty tissue, forming irregularly shaped often branching masses of fibrous tissue, or mere thin strands (Plate I. Fig. 4). They increase in size by the fibro-blasts spreading along the connective tissue of the fat cells (Plate II. Fig. 5).

After being massaged for some time, the serous exudation disappears, the tissue becomes denser and harder, and on being excised the little swelling has the feel and appearance of a piece of hard fibrous tissue, or a thin strand of the same.

Fig. 6 shows a section of such a nodule; the fibrous tissue is closely packed, the interstices have mostly disappeared, and there is an extraordinary degree of periarteritis and endarteritis, with numerous blood vessels (Plate II. Fig. 7). These hard nodules are sometimes very painful, and if they involve a nerve may cause aching and shooting pains over a wide area. Their excision gives complete relief.

A case in the sternum: An example was obtained from a periosteal swelling on the sternum that had all the characteristics of rheumatic periostitis. It was about half an inch in diameter, slightly raising the surface of the skin, doughy on palpation, and very tender on even slight pressure. It was incised and a small portion removed. The incision relieved the tension and lessened the pain. The patient, a 35-year-old man, had been ill for about eight weeks with severe muscular pains and slight arthritis. The swelling on the sternum had been there for three weeks or less, and many tender painful nodules were found in the loins and elsewhere. Microscopical examination showed that the swelling consisted of proliferating fibrous tissue, edematous, and containing a good many fibro-blasts, numerous blood vessels, and many newly formed or forming capillaries. At some parts, the fibrous tissue was older and denser than at others. There was an entire absence of any local leucocytic reaction, and the connective tissue in the walls of the blood vessels was greatly increased in amount. (Stockman was unable to detect any microorganisms in the tissue, but the staining methods may not have been suitable). The irritation must be due either to a toxin, or to a small local invasion of microbes…](Personal note: The old authors had the theory that the fibrous swellings had to do with certain infections, that’s why they may have thought that they could find micro-organisms foci or certain microbial toxin).

Other authors’ contribution about the fibrous indurations study:what Stockmans says about other authors:

It has long been recognized (Balfour, Scudamore, Fuller, Durand-Fardel) that chronic rheumatism is not an arthritis, but an affection of the fibrous tissue structures of the muscles, bones, and joints. Changes do not occur in the articular cartilages, or in the bones, except secondarily.

VIRCHOW and others have described the condition as it affects the fibrous tissue of muscles, but they mostly examined muscles in which the fibrous changes were much obvious than in ordinary clinical cases.

WILLIAM BALFOUR (1816): described the presence of definite fibrous thickenings in chronic rheumatism. He wrote a book on the subject, in which he describes several of his patients as having a large number of nodular tumors and thickenings which were painful to the touch, and from which pains shot to neighboring parts (Personal note: Some authors called them now trigger points). In one case, he observed that “ the fascia of the muscles and sheaths of the tendons were thickened, knotty, and puffy,” and that the origins and insertions of many muscles were painful. He recognized the importance of these fibrous tissue growths as the cause of chronic rheumatism, and his whole treatment was directed to getting rid of them. His work has been practically forgotten.

SCUDAMORE (1827): was also well aware of the fibrous tissue changes in chronic rheumatism. He described them as follows: — “bursae enlarged, thickened, and hardened, tendinous sheaths distended and thickened, and the tendons knotty at their insertions and often contracted, the aponeuroses thickened, and muscles which seem like a mass of ligament.” In a case reported on page 406 of his book he describes numerous small tumors as being present in the fascia lata of each thigh, and he often mentions periosteal nodes.

FRORIEP (1843): laid great stress on these indurations (which he called rheumatische Schwiele), and described them in detail as occurring in the connective tissue of the skin, aponeuroses, and periosteum. Froriep said that out of one hundred and fifty cases of chronic rheumatism he failed only twice to find them. Since his time Berghman, Helleday, Ewer, Hackenbruch, and Strauss have specially drawn attention to the importance of these fibrous tissue swellings as the cause of chronic rheumatic pain.

Stockman’s sentence: Judging from the almost entire absence of recent writings on the subject in his country, their importance and frequency have not been widely recognized.

Cases of the occurrence of “ rheumatic nodules ” in adults have been reported by Mahomed, Duckworth, Fowler, and Middleton, but more as curiosities than as a matter of very wide and general interest.

The Etiology — In discussing the etiology of chronic rheumatism it is necessary to differentiate between…

The original causes of the local fibrous thickenings and nodules.
The causes of the subsequent rheumatic attacks, when the fibrous indurations have become fully established, and the individual is subject to frequent and recurrent “muscular rheumatism” (chronic rheumatism), or to persistent “rheumatic neuralgia.”

The theory that the “causa prima” is an acute rheumatism:

In ACUTE RHEUMATISM: The ephemeral nodules seen in children were well known since Barlow and Warner described them in 1881, but both in children and in adults permanent fibrous indurations often remain as the result of acute rheumatism. These fibrous changes may be slight and widespread, not capable of being felt by palpation, and giving rise merely to slight stiffness in the muscles and joints, or they may be felt as small tender thickenings on the aponeuroses, tendons, and ligaments, which are often persistently aching and painful. They amay che with changes of weather, and often persist for months or permanently. Peripheral neuritis, with pain, numbness, paralysis, paresis, and wasting of muscles may also occur after acute rheumatism, and, as previously observed, it is probably a result of thickening of the fibrous nerve sheath. These are affections or sequels resulting from acute rheumatism; they are probably due to the action of toxins on the fibrous tissue, or may possibly be the result of damage produced by the actual presence of the causal microorganisms, and they differ entirely from the original disease in their nature and in the treatment required to cure them. (Personal note: They thought the microbiological toxins or agents were causing the painful nodules as a causa prima).

Scudamore says: “ The acute rheumatism very commonly produces a troublesome sequence of stiffness, debility, and aching of the limbs, most felt in the morning and at night, for which exercise and frictions should be used.”

Fuller also lays stress on this: “ After the acute or subacute symptoms have passed, tenderness and aching remain in ligaments, tendons, fasciae, and aponeurotic sheaths. They are thickened, stiff, and inapt for motion.’

Stockman often observed the formation of these indurations in adults during acute rheumatism, the following case being a fairly typical example.

STOCKMAN’S CASE REPORT with ACUTE RHEUMATISM: During an attack of acute rheumatism, and when the temperature and pulse had returned to normal conditions, the patient, a 24-year-old young man, still complained of severe pain and aching in various parts of his body on exposure to draughts, or during damp weather, or without any apparent cause. There was great tenderness at the sternal part of the first and second intercostal spaces, on the outer condyle of one humerus, on the patellae, over the instep, and elsewhere. No distinct indurations could be felt in these places, but they were slightly doughy and very painful to touch, and ached as above described. There was pain over the upper sternum on respiration. Several very painful nodules were present in both calves and on certain ribs. There was grating in the palm of the hand from tenosynovitis. His back muscles were very stiff, but no distinct indurations could be made out. On some days he was nearly free from pain, on others he suffered severely, and improvement under treatment was very tedious.

The theory that the “causa prima” could be the virus (The influenza pains):

Slight febrile attacks with pain and aching in the muscles and bones, often described as an “ influenza cold ” or a “rheumatic cold,” also cause these fibrous thickenings.

Leube thinks it is a specific infection, and possibly an attenuated form of the rheumatic virus. Dr. Newton, in reporting an epidemic of forty-three cases of “acute muscular rheumatism ” which occurred in his practice, expresses the opinion that it is identical with acute articular rheumatism. Repeated attacks of these “muscular colds,” whatever their true nature may be, bring on chronic rheumatism in time.

True influenza is often followed by these fibrous thickenings, and sometimes in a very severe and widespread form. They are probably sequels of the changes causing the aches and pains in the bones and muscles, which are prominent symptoms in certain cases of influenza, and which are almost certainly due to local irritation of fibrous tissue by the toxin or microbe of the disease. Pitt states that fibrous nodules occur also with osteo-arthritis.

The theory that the “causa prima” could be the “sore throat”:

Stockman mantions that people who are subject to repeated attacks of sore throat often suffer from chronic muscular rheumatism, and in this case the irritating agent may be absorbed from the tonsil or pharynx. (However, people who say they have never suffered from acute rheumatism, muscular colds, influenza, or sore throat are sometimes martyrs to chronic rheumatism, and have fibrous indurations. In some patients no other cause can be assigned than a history of frequent exposure to cold and wet, or to extremes of heat and cold, accompanied often by hard muscular work. Such a person complains that he is gradually getting stiffer than he used to be, and in time chronic rheumatism develops).

The theory that the “causa prima” could be the “related to the bowel disturbance”:

Stockman mentions that possibly in some cases irritating toxins absorbed from the bowel may act as the cause. He does not think, however, that muscular rheumatism has any relationship to gout, or that it can be brought on by any particular errors of diet.

Symptoms closely resembling rheumatism occur in lead poisoning (apart from gout), and here there is increase of the connective tissue of the muscles and nerve sheaths, which probably accounts for the cramp-like and neuralgic pains.

Other theories of “causa prima” could be:

LOCAL INJURIES: Local injuries, as previously explained, may result in fibrous hyperplasia, and in the case of a joint, or an important aponeurosis or tendon, this may give rise to severe local rheumatism and varying degrees of disablement. Frequent slight trauma from over-exertion (as in athletes, gymnasts, laborers) may have the same effect. At least, these people tend to suffer from chronic rheumatism, and he had been often unable to find any other cause for it than their occupations.

ABOUT AGING: With regard to the part that age plays in the etiology, chronic rheumatism is said to be a disease of maturer years; but this is hardly correct. A slight degree of it constitutes the “ stiffness of age,” but it is not a necessary concomitant of advancing years. It is very common in adolescents and in early middle life.

Chronic rheumatism therefore is not a diathesis. It is a local affection of the fibrous tissues, and results from several preceding causes.

The Causes of Pain and Aching after the Fibrous Indurations Have Become Fully Established: the “Exciting Causes”

In discussing the pathology of chronic rheumatism, it has been already explained that the immediate cause of the pain and aching is swelling and tension of the fibrous indurations. The exciting causes are very evident, and are well known to all sufferers from the affection.

These are, in Stockman’s experience, the most frequent and obvious causes of pain and aching in chronic rheumatics, but no doubt there are others.

Weather conditions
Unusual or violent muscular exertion
Disordered primae viae
Chronic intestinal indigestion
Pharyngitis

1-Weather conditions

Cold, damp. Various meteorological conditions, damp or cold weather, lying or sitting on damp ground or on a cold seat, exposure to draughts, wet clothes, usually bring on an acute exacerbation, which may be repeated before the previous one has quite passed off, and in this way the patient may lie seldom free from aching pains. The greater part of the body may be affected, or only the part which may have been specially exposed (lumbago, pleurodynia, stiff-neck, and so on). If the person is in vigorous health, in the open air, and indulging in active exercise, frequently no evil effects follow a wetting, but one can never count on this. The rheumatic pains are most apt to ensue when leading a sedentary town life, and often on very slight exposure. The approach of rain, sudden changes in the weather, and east winds, also cause aching and pain. It is very difficult to explain the action of these different meteorological conditions.

–Longstreth says that the painful symptoms do not correspond to rain, but rather to a lowering of barometric pressure. A rapidly rising barometer is also, he says, accompanied by pain. Patients have often told him that when rain actually commences, their pains lessen, and that they can tell its approach even when in bed, so that it is not a question of exposure. It is a matter of popular knowledge that old injuries, wounds, and corns ache with changes of weather; and Weir Mitchell has found, from careful inquiries in fifty cases of old amputations, that more than half of them could foretell a change from dry to wet, or from wet to dry, or a change of wind, from the painful sensations in their stumps.

Possibly the atmospheric changes may increase or lessen the lymph pressure in the body, and so increase or lessen the tension in the new fibrous tissues. He was unable to suggest any more definite explanation, but we may remember that many plants and many domestic and wild animals show plainly by their behavior that they are conscious of impending weather changes long before these actually occur, and in the case of plants at least this must be due to some influence exerted on the cell contents, and not to the memory of previous experiences.

2- Unusual or violent muscular exertion

Chronic rheumatics are often very unwilling to take moderately violent exercise, owing to the prolonged stiffness and aching that usually follow it. A single severe wrench sometimes starts aching in a nodule or strand, and this may go on for weeks. It is apparently due to local causes, for riding brings on aching in the thighs, bicycling in the lower extremities, golfing in the arms and back, leaving in each case the other parts comparatively free. The pain can often be located in a particular induration or in more than one, to which it may return again and again; sometimes, however, it is more diffuse, and radiates.

3-Disordered primae viae

An acute indigestion brought on by a big dinner with mixed wines often starts more or less prolonged aching in certain of the fibrous tissues (lumbago, joints, etc.). The champagne and port are often specially blamed, and the aching is attributed to gout by doctor and patient alike. The real cause is probably intestinal fermentation with absorption of an irritating toxin that specially affects the fibrous indurations.

It results from over-indulgence in rich food and a consequent indigestion, rather than from any special article, and this is shown by the fact that if such a dinner is well digested and agrees well, no aching follows on it.

4-Chronic intestinal indigestion

The tongue may be clean and the appetite good, but there is flatulence, a constant tendency to slight or severe headache, and very often temporal neuralgia. As long as these symptoms last, the fibrous indurations tend to ache. Scudamore drew special attention to disordered bowel as a cause of rheumatic pain, and treated such patients with mercurial purges.

5-Pharyngitis

An attack of pharyngitis, or an “influenza cold,” also cause all the indurations throughout the body to ache, and are common causes of acuteexacerbations.

Symptomatology of “acute muscular rheumatism” versus “chronic rheumatism”:

What is ACUTE MUSCULAR RHEUMATISM?

Feverish attacks accompanied by muscular pains are often called “ acute muscular rheumatism” or “ influenza.” As it is probably a frequent, if not the most frequent, cause of inflammation of the muscle connective tissues, a short description of its symptomatology may not be out of place here. Nothing is known regarding its bacteriology, but as it is so constantly accompanied by sore throat, the idea inevitably suggests itself that the original infection is situated in the throat. This, however, is only a hypothesis. It may be due, as Leube has suggested, to an attenuated form of the microbe which is the cause of acute articular rheumatism (Personal note: It seems they did not know the virus?)

After exposure to damp cold and a preliminary feeling of malaise and chilliness, pain and aching are felt in the muscles and bones, and often slightly in the joints. The pain may be so severe as to prevent the patient from moving, or there may be merely a feeling of tiredness and stiffness sufficient to make any exertion unpleasant.

Neuralgia may be present in one or more nerves, and may cause severe suffering.

Often there is NO rise of temperature, or it may be very slight, there is some disturbance of appetite and digestion, and usually some deposit of urates in the urine.

There is often intense sleepiness, or a heavy dull feeling, and a sense of vague cardiac discomfort that sometimes amounts to slight faintness.

Pharyngitis or tonsillitis are very often present, but not invariably. The symptoms usually begin about eight to twelve hours after exposure to cold and wet, and they pass off in a few days. During the acute stage the fibrous tissues of the muscles, bones, and joints are distinctly painful to touch or pressure at certain places, and at these places slight doughiness or marked edematous swelling can be made out. It presents all the characteristics of a specific fever of short duration, but whether of truly rheumatic, infiuenzal, or unknown origin, it is impossible to determine definitely. It certainly bears a close resemblance to acute articular rheumatism, but the duration is shorter, and it is not controlled by salicylates with the same decisiveness and rapidity.

What is CHRONIC RHEUMATISM?

When numerous fibrous indurations have been developed throughout the body, the exciting causes previously described, especially damp and over-exertion, bring on severe attacks of muscular pain and aching, which may also involve various joints and fascie, but, instead of passing off in a few days, each attack may continue for weeks, the more acute symptoms of an exacerbation being followed by almost continual aching and stiffness. In severe cases the patient is thus never quite free from stiffness, aching, and pain, and is always liable to an increase of them on any exposure. Their severity and extent depend on the degree to which fibrous strands, thickenings, and nodules have become developed in the affected tissues. In certain patients it may recur again and again in the same part, as in the muscles of the back (lumbago), neck (stiff-neck), shoulder, legs, etc. Very often only the particular part which has been specially exposed to a draught or to severe exertion suffers, or it may be much more general, or rarely, the periosteal tissues may be chiefly affected.

The chief symptoms are pain, aching, stiffness, a readiness to feel muscular fatigue, interference with free muscular movement, and very often a want of energy and vigor.

The pain may be dull and continuous, or sharp and shooting, or a mixture of both. It is often very severe on any sudden movement which compresses the swollen indurations, as happens frequently in the lumbar region or in the deltoid, especially after the parts have been at rest.

More often, perhaps, it is a dull continuous aching or feeling of stiffness and weight, usually worst when warm in bed, or on awakening in the morning, or after resting a part for a time in one position, or after sleeping during the day.

There is a dragging feeling of fatigue, and a disinclination for muscular exertion. The aching wears off on active exertion or on vigorously rubbing the parts. All these symptoms tend to be more marked in damp weather.

The patient often has difficulty in locating the exact spot of the pain or aching, as these may radiate over a wide area, but on palpation it can be readily made out that certain places are swollen, tender, and often very painful on pressure.

The joints are not infrequently affected at the same time as the muscles, but never seriously as in acute rheumatism. One or two joints may be very slightly swollen, but usually they are merely stiff and perhaps a little painful.

Interference with the working and staying powers of the voluntary muscles is often a very marked feature.

The sudden pain often felt on movement of the muscles of the back or shoulder may be crippling in its intensity, but apart from this, the muscles are easily tired. The constant aching, stiffness, and tired feeling form a bar to active or continued exertion. The intolerable and prolonged stiffness and aching, which often ensue after athletic exercises and games, usually cause a disinclination for any exertion of the kind, and the person gradually tends to become more and more sedentary in his habits.

During an exacerbation the digestion is often out of order.

The tongue may be clean and the appetite fair, but there is often flatulence and a dull headache with temporal neuralgia. There is often almost continual slight sore throat along with these exacerbations.

If a nodule presses on or implicates a nerve, severe neuralgic pain, radiating widely and often far away from the nodule, may be present.

Occipital neuralgia is often due to a nodule in the neck, brachial neuralgia to nodules in the upper arm and sometimes to an induration close to the spinal border of the scapula, sciatica is often caused by nodules in the buttock, while temporal neuralgia is frequently present and is apparently due to swelling of the nerve sheath. Numbness, prickling, and a sense of weakness are other symptoms of implication of nerves.

Weakness of the back, aching in the fascia lata, and the symptoms that have been called “spinal irritation” are often due to these fibrous indurations. When there are many indurations, the suffering may become practically constant, with exacerbations on exposure to wet, draughts, fatigue, and indigestion.

The general health and nutrition may then be mediocre; there is a loss of energy, frequent depression of spirits, and a tired look in the face. In a case of moderate severity the patient looks quite well, is well nourished, and often works hard.

In severe cases, and especially if there is much neuralgia, digestion and nutrition are very poor, and there may be a good deal of emaciation and neurasthenia, sometimes so much that the patient is a complete invalid.

In many women who are regarded by their friends as martyrs to neuralgia, and as hopeless neurasthenics, and who have all the concomitant symptoms of these conditions, the original cause of all their ill health is found to depend on a widespread development of these fibrous thickenings throughout the body (Personal note: As it happens in what we now call fibromyalgia). In men also Stockman saw a considerable degree of neurasthenia induced, but not to the same extent as in women.

The heart and arteries do not become secondarily affected in any way, so far as he was able to judge.

Physical Examination of Stockman’s fibrous indurations (also named back mice when located in the lumbar zone).

On examining a chronic case, the indurations may sometimes be felt quite plainly and are painful on pressure, but for a satisfactory examination it is better to thoroughly smear the skin with liquid paraffin, vaseline, or some fat. The muscles of the part should be relaxed as far as possible.

[…The thumb or tips of the fingers are then passed over the skin with firm, gentle pressure, and the more superficial nodules and indurations can be readily felt. Some of the indurations are soft and ill-defined, giving the impression that they consist largely of serous exudation; others are more fibrous and hard. Some are scarcely palpable fibrous cords, often very tender along their whole extent. Occasionally, they are like a chain of small-shot or beads running along the side of a muscle or aponeurosis or under the skin. They can often be very easily felt on the periosteum of the ribs. They are tender on pressure, especially those situated just under the skin. It is difficult at first to locate them all, deep pressure is often required, but after a few days of massage they swell and become more painful on pressure, and are then much more easily detected. In very chronic cases, involving a large area of subcutaneous tissue (as in the loins or shoulder), the induration may be general, and brawny being situated just under the skin, gives the latter a resistant, brawny, and inelastic feeling…]

When the subcutaneous tissue is thickened in this way, the ordinary tactile sensibility of the skin is dulled, and even a strong faradic current can sometimes be scarcely felt.

The commonest situations for these indurations are in the lumbar aponeurosis, the calves, fascia lata and tendinous expansions of the thigh muscles, the trapezius just above the supraspinous region, the insertion of the deltoid, the inner border of the biceps and its long head, the intercostal and pectoral muscles, the glutei, and the soles of the feet.

The fibrous tissues round the neck of the bladder, of the pharynx and esophagus, behind the sternum, all along the spinal column, and of the joints, may also be affected, giving rise to dull or acute pain in these situations. The anterior abdominal muscles are very seldom affected, those of the forearm, hand, and anterior aspect of the leg infrequently, except at the origin of the supinator longus muscle.

The symptoms arising from implication of the fibrous tissues about the bladder and thorax often cause much mental anxiety to patients. In the case of the bladder the symptoms consist in dull pain and increased frequency of micturition, but they usually pass off in a week or thereabouts. When the intercostal muscles and the fibrous tissues of the ribs and sternum are affected, each respiration may cause pain or discomfort, and if the respiration deepened or accelerated by ascending a hill or a stair, the pain may become acute, and darting or stabbing in character.

When the fibrous tissue behind the pharynx is affected, the symptoms are chiefly subjective. The patient feels as if the parts were slightly swollen, stiff, and uncomfortable, but little or nothing can be made out on inspection.

Stockman’s treatment for the fibrous indurations (what we call back mice)

Stockman’s first mentions the treatment of ACUTE MUSCULAR Rheumatism:

Stockman makes the remark that it was NOT known whether the pains in the muscles and bones are due solely to a true rheumatic infection, or whether they occur with several febrile conditions. The general treatment is that of a slight feverish attack, and recovery takes place in a few days. If the pains are widely spread over the body, rest in bed, light diet, saline purgation, mild diaphoretics (liquor ammonii acetatis, spiritus setheris nitrosi, Dover’s powder), or mild alkaline diuretics hasten recovery and give ease to the patient.

Sodium salicylate, alone, or with phenazone or phenacetin, greatly relieves the pain and aching; or, best of all; methyl salicylate may be well rubbed in locally. The salicylates, however, do not exercise the same immediate specific action that they show in acute articular rheumatism. A hot bath, followed by a copious perspiration, or a Turkish bath, with well-applied massage, if taken in time, may abort the attack.

Very often in such an attack the chief site of the pain is localized to the lumbar region, to the shoulders, neck, chest wall, or lower extremities, and in these places the actual painful area is often comparatively small and results from serous exudation.

Acute muscular rheumatism is best treated by massage, followed by passive and active movements. One thorough application of massage may result in cure, or several may be required. The parts are very tender, and the manipulations must be begun very gently by stroking so as to get rid of the exudation and relieve tension; gradually, more severe pressure can be borne, first with the palm of the hand, and then with the fist or knuckles. This is followed by passive and then by active movements appropriate for each part. The local injection of methyl salicylate, alone, or mixed with an equal part of liquid paraffin, often relieves the pain, or a 10 per cent solution of menthol in liquid paraffin may be used. Mustard leaves and other local irritants are also beneficial.

Stockman’s treatment of Chronic rheumatism

Where fibrous indurations and nodules are present, satisfactory treatment is much more difficult and prolonged. During an acute exacerbation, when the indurations swell up and cause pain and aching, these may be relieved by the measures just described. But the relief thus afforded is only temporary, and in a few hours, or as soon as treatment is stopped, the pains return, to continue for days, weeks, or indefinitely.

Besides, the patient remains liable to attacks on every exposure to cold, wet, or fatigue. To obtain permanent cure and complete relief from the recurrent attacks, the fibrous indurations must be completely dispersed, and in all but quite recent cases this is always a more or less tedious and troublesome procedure.

The only means which Stockman found to be of special value were massage and exercise, the faradic current, and the injection of solution of chromic acid into any of the fibrous nodules that are sufficiently defined to allow of this being done. Of the three, massage is the most important and the most efficacious.

1-Massage of the firbous indurations in the chronic forms (massage of back mice)

General massage is of no use. Treatment must be specially directed to any nodules and indurations that can be felt, and to parts which are painful. In many cases, especially in the lumbar region and in the fascia lata, although pain and aching are present, no special thickenings can at first be made out, but after being rubbed for a few days, certain places become swollen and painful, and the exact seat of the lesions can thus be located.

Sometimes, however, in these aponeuroses and elsewhere, the thickening is slight and widespread, it cannot be located for special treatment, and then it is more difficult to get rid of.

Frequently, too, the thickenings are deeply situated in the intermuscular septa, or in the capsules of the joints, or in the periosteum, and are not easily reached. In carrying out massage, the muscles of the part should be relaxed, the skin should be smeared with liquid paraffin, or some oleaginous substance, and, if necessary, the hairs shaved off.

At first the massage should not be too severe, as it is thus apt to irritate the indurations and to cause too much pain and subsequent stiffness. After a few days of treatment, the fibrous thickenings become more painful and defined, and in old-standing cases many of them are only then detected.

Once their number and situations are known, treatment may be directed to them more particularly. For the first week or ten days, or even a good deal longer, they are very painful when manipulated (the subcutaneous ones often exquisitely so), and hence the treatment has to be carried out judiciously; but after a time they begin to shrink in size, and become more fibrous and callous. Much more pressure can then be exerted on them, the fist or the knuckles being used, and in process of time they become quite small and hard, and ultimately disappear entirely.

The massage should be carried out daily, ten or fifteen minutes or more being devoted to each region affected; at the beginning and end about two minutes of gentle effleurage should be given, as it soothes the parts and removes serous engorgement. When the nodules are large, well-defined, and few in number, treatment can be carried out on the dry skin or through thin underclothing; but if the induration is widespread, or the nodules small and numerous, the whole part must be rubbed on the bare skin and with some lubricating material. The rubbing should not be too severe, especially at first, as the indurations become thereby very sensitive to pain, and time is lost rather than gained.

To obtain satisfactory cure, the dispersion of the indurations must be complete, otherwise relapses occur, and these are a source of much disappointment. The length of time required to effect this varies very much. Recent soft thickenings can be dispersed in from one to three weeks. A very common time is six to eight weeks; but some cases, and these are not infrequent, require treatment for six to twelve months. In such old standing cases some of the indurations are got rid of much earlier than others, and if these have been a source of aching and pain, considerable relief is afforded even by a partial cure.

Some nodules become very hard and fibrous, and fail to be dispersed by the most persistent and severe rubbing. The rapidity of dispersion also depends on other circumstances. If the nodule can be forcibly compressed against a bony part (as in the upper arm), more effective pressure can be exerted, and it is much sooner got rid of than if it lies deeply buried among fleshy muscles, or alongside the spinal column where it is difficult to reach.

This is illustrated by many cases of sciatic neuralgia. If the sciatica is due to a nodule in the buttock, cure is not so difficult; but if the thickening is in the sheath or in the bed of the carefully protected nerve, it is difficult to reach, and can scarcely be cured by massage. Deeply placed nodules in the sole of the foot, in the tendo Achillis, and at the side of the spinal column, are often impossible to disperse. It is best to have an experienced rubber for some weeks at least, or until the painful stage is past and the indurations have been located. After that, treatment may be carried on by an intelligent person who is strong enough, or by the patient himself for some parts of the body. In many cases the treatment required is so prolonged, and small indurations are so often overlooked and left untreated by the masseur, that it is necessary to instruct the patient himself how to treat them when they begin to ache and give trouble.

The treatment of fibrous indurations connected with the joints is conducted on the same principles — hard massage with passive and active movements.

2-Exercises

The movements should be such as are best calculated to exercise and stretch the muscles and aponeuroses involved. They can be easily devised without apparatus, or better with the aid of a stick, dumb-bells, Indian clubs, and Sandow’s exerciser, and should be carried out for half an hour or more daily.

3-Bandaging

This treatment was described in detail by Dr. William Balfour (1816). His method was by “ friction, percussion, and compression (bandaging)”, and he applied it with great success to the treatment of rheumatism of joints, sprains, and muscular pains. He held that the frictions and hard pressure remove the tension in the aponeuroses that are the cause of the pain, and he also emphasized the value of percussion.

“ If to a tumor recently formed, the consequences of either a violent sprain or of rheumatism, compression either by friction or bandages, or both, is applied, the swelling immediately subsides, and the motion of the parts becomes free.”

“Bandages and friction produce their beneficial effects by promoting circulation in the capillaries, and absorption of effused humor.”

Scudamore says it is often impossible to effect cure or improvement in chronic rheumatism without the aid of friction and shampooing. “It tends to excite a better circulation, especially in the veins, to give more tone to the muscular fiber, to overcome rigidity of parts, to stimulate the absorption of synovial secretion or of effusion.” He does not, however, show the same practical grasp of the method, or the knowledge of details, which Balfour does.

In more recent years, Berghman, Helleday, Ewer, Hacken, Strauss, and others have insisted on the value of systematic massage in dispersing these fibrous indurations.

4- Faradism

The faradic current should be applied over each affected region for five to ten minutes daily, and should be as strong as can reasonable be borne. It is a useful adjunct to massage treatment, but it is not so powerful. Its action can be best studied in the circumscribed indurations that lie under the skin.

Probably it scarcely reaches some of the others. At first, the current renders them more painful on pressure, but then their sensitiveness is finally lessened. Presumably, therefore, it causes the serous exudation to disappear and the indurations to shrink, just as massage does. Froriep used almost exclusively the electro-magnetic current, which gradually removed the indurations in a majority of his cases, but he also employed vapor baths, dry heat, iodine ointment, and liniments as adjuvants.

For pain in the soles of the feet he used galvano-puncture. In the treatment of stiff joints, Hoffmann recommends faradism and galvanism as superior to massage, but this is contrary to Stockman’s experience.

5-Injection of chromic acid

This method is only possible where the nodule is sharply defined, and can be accurately penetrated by a hypodermic needle. Strands and diffuse thickenings cannot be so treated, as the needle passes through them, and the fluid only irritates the neighboring tissues without doing any good.

A 1 per cent solution of chromic acid in water is used, and about 5 to 8 ml are injected. The procedure usually gives rise to some aching, and occasionally to pretty sharp pain, lasting for an hour or two. The previous injection of a 1 per cent solution of cocaine hydrochloride lessens this, but extreme care must be taken that it is sterile.

The chromic acid causes the nodule to shrink, and often greatly relieves muscular or nerve pain. The nodule is not dispersed, however, and may give rise in the future to pain and aching. The injection can be repeated, if necessary, but the relief is often permanent, and occurs very rapidly. Care should be taken to inject deeply, and not throw the solution into the tissue immediately under the skin, as it may give rise there to pain and plilegmonous induration. The inflamed portion of fibrous tissue is so small that it is very easily missed, and if this occurs no relief is obtained. To obtain good results, the chromic acid must actually penetrate the inflamed tissue, and this is not always easy of accomplishment.

6-The treatment with drugs

–Mild purging agents: Where intestinal indigestion is present, and this is especially recognized in lumbago, a course of mild purging is advisable — 2 or 3 grs grey powder or blue pill, or compound rhubarb powder, in the evening, followed by a saline before breakfast.

–Potassium iodide: As regards specific remedies, Stockman could not say that any drugs are known which cause absorption of the fibrous indurations. In quite early cases Stockman mentions potassium iodide that can give relief, and Graves speaks very highly of its value in lumbago as tested in his own case, but in regularly chronic cases any benefit is not very apparent.

-Iodine ointment: Stockman used it extensively, but he questioned if it ever reached most of the indurations, or it did much good apart from the necessary rubbing in.

-Salicylic compounds (salicylates of sodium, methyl, quinine, and aspirin, salycine, etc.) given internally lessen pain during the exacerbations, and often give great relief.

Methyl salicylate, applied locally, is absorbed and relieves pain locally, and in distant parts also. Their action is not curative, however, as they cannot be expected to remove fibrous tissue.

-The same is true of phenacetin, phenazone, quinine, and all similar compounds.

OTHER OLD treatments mentioned by Stockman with more doubtful utility: Alkalies, ammonium chloride (Fuller), colchicum, arsenic (Scudamore, Hoffmann), cod-liver oil, guaiacum, actaea raceinosa, “Chelsea pensioner”.

Counter-irritants sometimes do good, but very often have no effect. Probably many of the indurations are outside the range of their action. Where the joints, tissues, or periosteum are affected superficially, blistering or painting with iodine liniments lessens pain, and causes more or less absorption of the swelling.

7-Spa treatment especially at the early stages, the advantages

-Recent cases, where the fibrous thickenings are in the early stage and still plastic, may be cured by a course of hydrotherapy, but inveterate cases only obtain temporary relief from their sufferings, which usually return in full force on the first exposure to wet and cold after their return home. The drinking, bathing, and mild general massage, suffice very efficiently to empty the bowel freely every morning, and to promote absorption of the serous exudation in the fibrous indurations.

This is sufficient to cure quite recent cases, and usually gives complete relief for a time to the aching, stiffness, and pain of chronic cases, so that the patient feels much more happy and energetic. The indurations remain, however, and on the first provocation they swell and become tender and painful again.

-The regular purgation (obtained at Harrogate for instance by the action of the sulphur water) and the consequent improvement of intestinal digestion do great good in certain cases, probably by preventing the absorption of irritating substances from the bowel.

The indurated fibrous tissue can, however, only be removed by local and well-directed manipulations, and this is undoubtedly aided by previous hot baths (water, peat, vapor, etc.), as the parts are relaxed and rubbing is much less painful. A spa has this further advantage, that patients are content to give the necessary time for massage and electrical treatment, and have the accessory advantages of elaborate bathing appliances, and of drinking mineral water. They can also get such exercises as may be thought necessary.

The process of going chronic

-People who suffer from chronic rheumatism are often excessively sensitive to cold and damp, and develop an exaggerated fear of draughts.

-They sit in overheated, unventilated rooms, and often overclothe themselves.

-They also avoid sharp exercise, owing to the prolonged aching and stiffness from which they suffer after it, and they are apt, if they have the opportunity, to indulge unduly in hot baths, as these temporarily relieve the aching by relaxing the tissues.

All this tends to soften them, and makes them very liable to chills, and so to acquire more rheumatic thickenings.

With the disappearance of the indurations under treatment, all this should be changed, and an active muscular life and hardening regime substituted, but in a common sense way, and having regard to the patient’s age and occupation.

Balfour says in his previously mentioned treatise: “If percussion and compression are beneficial in proportion only as they facilitate motion, it must be admitted that indulgence and rest are the very food of rheumatism.”

The role of gastro-intestinal fermentation

Dietetic treatment is of no special value. The broad rule is to avoid gastro-intestinal fermentation, and this is best accomplished by a simple, ordinary mixed diet, avoiding such substances as they cause indigestion or flatulence in any particular individual. A heavy dinner with numerous wines often starts a prolonged attack, but this is due, not so much to the wines directly, as to the indigestion that they may have caused.

Total abstainers and women suffer from chronic rheumatism equally with the ordinary imbiber. In the same way, sugar and flesh meat are often forbidden to chronic rheumatics, but these are hurtful merely in so far as they cause intestinal fermentation and indigestion, which they do only in a small proportion of people.

Better to live in a dry climate

During residence in a dry, stimulating climate, the indurations may entirely disappear, and the individual ceases to suffer from his rheumatic pains. A short sojourn gives relief, but not cure. Some absorption probably takes place, and this, combined with the freedom from continual exacerbations, seems ultimately to lead to their disappearance. On the other hand, a seaside climate and a damp atmosphere increase the symptoms, and favor the conditions that give rise to chronic rheumatism.

Some affected patients hardly know any other existence than being with pain.

Stockman recommends surgical treatment if the nodules are well defined

It was previously mentioned that certain nodules, after prolonged massage, still remain very hard and fibrous, and cannot be dispersed. If a nerve passes through one of these, or is pressed upon by it, this may give rise to severe pain or continual aching. In such a case the nodule can be surgically removed. The operation is not always an easy one, as the small masses of fibrous tissue may lie pretty deep, and are then difficult to find. Before operation is attempted, they should, as a rule, be well massaged, till they become hard and defined. When they lie in the subcutaneous tissue, or attached to the skin, their removal is a very simple matter, and if their position can be accurately fixed, there is also no great difficulty in excising them from the perimysium. Their removal gives complete relief from the symptoms. Such treatment is only possible for large and well defined nodules, or where a particular one is causing extreme pain, as in most cases the thickenings are too numerous and widely spread to permit of any idea of surgical interference.

Prognosis, according to Stockman, depends on the perseveration

-The treatment must be persevered in: Some cases, mostly in young people, gradually recover without any special treatment, but the usual tendency is to get worse, and for the indurated tissue to become more fibrous and more widely spread. In cases of ordinary severity, even when the indurations are fairly numerous and widely scattered, recovery is assured if the treatment be persevered in. It requires, however, considerable resolution and determination on the part of the patient, as relapses are common, and the patient often gets discouraged.

–Some indurations disappear earlier than other: Many patients tire of the treatment, and give it up as soon as a decided improvement has occurred, but freedom from pain and aching can be counted on only if the fibrous indurations have been quite dispersed. This often requires three to twelve months of practically continuous treatment, but encouragement to go on is derived from the fact that many of them disappear much earlier than others. Soft recent nodules can often be got rid of in ten days, or disappear spontaneously. In very severe cases, where there is great induration and the patient is very stiff and crippled, recovery is hopeless, but by stretching, massage, and manipulations more freedom of movement may be obtained. When the subcutaneous tissue is much thickened and brawny, as occurs most frequently in the lumbar region, or sometimes in the neck or fascia lata, any very substantial or permanent improvement is rare. In the joints, if the fibrous tissue changes are extensive, or if the bones and cartilages have been affected by prolonged malposition or disuse, or if the muscles are greatly atrophied, the results of even prolonged treatment are disappointing. With single indurations after injury, sprains, etc., the prognosis is good.

A continued exposure to unfavorable climatic or industrial conditions may lead to the formation of fresh fibrous inflammations, but these are generally dispersed in a very short time if treated at once.

How to avoid the fibrous indurations according to Stockman (Prophylaxis)

-AVOID damp wetness: People subject to chronic rheumatism should avoid exposure to damp, and especially sitting in a draught in wet clothes.

–Prevent with massage after certain illnesses: After acute rheumatism, if any painful or aching spots remain about the fibrous tissues of the joints, periosteum, or aponeuroses, these should be thoroughly massaged until they disappear. The same course should be followed after influenza, scarlatinal rheumatism, “muscular” chills, violent muscular exertion, and stiffness from any cause.

–Treat with massage and kinesotherapy certain traumatic lesions: After dislocations, sprains, fractures, rupture of muscles, and similar injuries, local massage and faradism should be employed until the exudation has been completely absorbed. Properly devised passive and active movements are also of great value in such cases.

–Be aware in case of pharynx and tonsils chronic problems: Chronic follicular pharyngitis and chronic or acute tonsillitis should always be thoroughly treated, as muscular rheumatism seems very often to be associated with infection of the pharynx and tonsils.

–Be careful with indigestion: Digestion, and especially intestinal digestion, should be attended to, and all excesses, such as large dinners with a mixture of wines, carefully avoided.

–Long-term prophylaxis with spa, exercise and holidays: In a person who has once been cured, any return of the symptoms may be speedily overcome by a course of spa treatment, or a short course of massage. A yearly visit to a spa, or a long holiday, with plenty of outdoor exercise, is advisable, as it gets the digestion into good order and gives a feeling of fitness. When the gastro-intestinal tract is acting well, the pharynx is much less liable to infection. Regular outdoor exercise and indoor gymmastic exercises are of great value, for, as Balfour says,

“indulgence and rest are the very food of rheumatism.”

Published in May 2019 by Marta Cañis Parera