1816 Balfour – Cellular membrane

These are the notes of the famous English treatise published by the doctor William Balfour from Edinburgh in 1816. Despite he has been said to be the “first one” to describe the painful nodules as back mice, after reading the complete treatise, I could not find anywhere where he mentions “painful nodules”. He does mention “painful tumors” in the cellular membrane, but no nodules, -what we would call fascias- due to an effusion of certain substances. So, in a way, he does talk about back mice, but as “tumors of humor effusion in the cellular membrane” due to the “atony of the small vessels”. He theorizes that the “proximate cause of Rheumatism is impeded circulation in the capillary vessels”.

This doctor has been mentioned many times in relation to the history of the entity known as muscular rheumatism, fibrositis or fibromyalgia.

It has a free online access at //archive.org/details/b24992082

It is a book of 288 pages, with an introduction to the subject and 33 illustrative case reports.

With all these case reports (33 very extensive cases) he tried to prove his point that the painful condition of the “rheumatic patients” could be treated in “a less debilitating manner”, he mainly used PERCUSSION, FRICTION AND COMPRESSION by bandaging. (Personal note: He insisted on the “less debilitating manner” since by then it was very common to use the technique of blood-letting, which was an aggressive treatment.)

On the first page of Balfour’s book, he uses the following inspiring Latin sentence:

“Si quid novisti rectius istis, candidus imperti; si non, his utere mecum”

[If you know anything better than these maxims, frankly impart them to me; if not, then use them like me] from Horace.

Personal note: Balfour focuses his book in trying to convince the reader that “his newly discovered treatment” for rheumatic diseases is worthy to be shared with the medical community so it was a less aggressive treatment than those usually employed by then (blood-letting, blistering, leeches) and a more efficient one.

cellular membrane

He little theorizes that the primarily tissue affected in chronic and acute rheumatism is what he called the CELLULAR MEMBRANE (fascias) and aponeurosis of the muscles. Despite he did not do any biopsy, he is pretty sure of that.

In the introduction he theorizes about all the functions of the cellular membrane.

cellular membrane

Curiously, In a short letter in 1817, Balfour defends himself as a discoverer of the method of percussion since J. Johnson published a small article saying and showing oriental instruments that were used to perform percussion in the oriental countries long before Balfour’s time. Balfour argues that he did not know about these hammers.

cellular membrane 

Balfour is convinced that somehow percussion accelerates the reabsorption of the effused humor, maybe as a tonic for the atony of the capillary vessels.

cellular membrane

Apart from the book, he published some medical articles about the same subject. He repeats the same things in all of them.

  • 1815 Balfour W. Observations on the Pathology and Cure of Rheumatism. Edinb Med Surg J. 1815 Apr 1; 11(42): 168-187. PubMed PMID: 30329434; PubMed Central PMCID: PMC5743373. (This is a short article similar to the treatise from the following year).
  • 1816 Balfour W. Observations, with Cases, Illustrative of a New, Simple, and Expeditious Mode of Curing Gout. Edinb Med Surg J. 1816 Oct 1; 12 (48): 432-439. PubMed PMID: 30331410; PubMed Central PMCID: PMC5817655. (More cases of treatment with compression).
  • 1817 Balfour W. Balfour, on Rheumatism. Med Chir J Rev. 1817 Apr; 3(16): 288-290. PubMed PMID: 29257505; PubMed Central PMCID: PMC5569238. (He responds to a letter about oriental tools of percussion).
  • 1824 Balfour W. Illustrations of the Efficacy of Compression and Percussion in the Cure of Rheumatism and Sprains, Scrofulous Affections of the Joints and Spine, Chronic Pains Arising from a Scrofulous Taint in the Constitution, Lameness, and Loss of Power in the Hands from Gout, Paralytic Debility of the Extremities, General Derangement of the Nervous System; and in Promoting Digestion, with All the Secretions and Excretions. Lond Med Phys J. 1824 Jun; 51 (304): 446-462. PubMed PMID: 30494573; PubMed Central PMCID: PMC5633970. (There are 4 of these articles in the same year with cases).

NOTES on the book:

Observations with cases illustrative o a new, simple and expeditious mode, of curing Rheumatism and sprains, without in the least debilitating the system.

By William Balfour M.D.

He starts mentioning Sydenham and says that he was the first doctor to distinguish the acute from the chronic rheumatism.

Personal note: It seems that many doctors by then had to start by making this difference, somehow it had to be specified since two different entities used the same word rheumatism. And that had led to confusions. Despite that, in this treatise, Balfour treats both entities by his method of PERCUSSION, FRICTION AND COMPRESSION.

cellular membrane

He mentions some theories about the cause of what they called chronic rheumatism, from other known previous doctors such as David Macbride (1726-1778) or William Cullen (1710-1790). He mentions that Cullen related the chronic rheumatism with a State of “Atony of the blood-vessels“.

cellular membrane

cellular membrane

By then, there was always a clear distinction of what they called acute or chronic rheumatism.

He then makes it clear that the localization of the lesion in the chronic rheumatism was in what he called the CELLULAR SUBSTANCE or MEMBRANE (what now we would call the fascias).

Then he mentions certain considerations related to cellular membrane:

  • The cellular membrane has the function as a ligament, support tissue.
  • The cellular membrane has the function to lubricate.
  • The cellular membrane presents effusions in the sheaths of the tendons.
  • The affection of the exposure to the coldness of the cellular membrane.
  • Sprains and spasm may produce rheumatic affections since it affects the cellular membrane.

He mentions that certain treatments that were used by then may support the idea that the site of the problem was at the cellular membrane due to effusions: heat, diaphoretics, tonics… all of these remedies would lead to a decrease in the atony of the vessels of the cellular membrane, and a decrease of the congestion of the capillary network.

Then he presents 33 VERY LONG illustrative cases of rheumatic pain, where he deeply explains every symptom, treatment and outcome. He also includes certain reasoning of why his “new treatment is working”.

He starts his series of cases with himself because he suffered from left shoulder pain.

Summary notes:

-Not a single image is supported by the 288 pages of the book.

-He called the fascial layers the CELLULAR MEMBRANE.

– In the first chapter, Balfour tries to make clear his theory that the rheumatic pains are due to affections in the cellular membrane rather than in the muscular fiber. Due to atony of the vessels there is a kind of effusion of humour. (He does not go deeply on the characteristics of this humour).

He relates rheumatism to an affection of the small vessels of the cellular membrane, atony of them.

-He regarded the main treatments from that time and related their utility to the fact that somehow, they activated the “atony of the vessels”.

-He tried to be scientific in his reasoning.

He mentions crippling as a common finding in chronic rheumatism.

Some of Balfour’s statements:

“Percussion reaches every part, stimulates every vessel, and demonstrates, by its effects, the justness of our theory that the proximate cause of Rheumatism is impeded circulation in the capillary vessels”.

“If Percussion and Compression are beneficial, in proportion only as they facilitate motion (and few, I presume, will now deny this), it must be admitted that, indulgence and rest are the very food of Rheumatism (case XVIII)”.

cellular membrane

Balfour mentions old remedies related to rheumatism:

Some of the treatments he mentions are: the lancet with blood-letting (especially for acute rheumatism), Epsom salts (sulfate of magnesium), Bark, drops of laudanum (opium), purgatives, and leeches.

cellular membrane

cellular membrane

 Balfour says that, in the army, rheumatism is the most common complaint:

“After the army had toiled all day under a burning sun, and laid themselves down at night upon the cold ground, many were unable in the morning to make use of their arms.”

“But Percussion is not confined to Rheumatic affections alone. It is applicable, with the best effects, to many other complaints that occur every day. It is capable of removing, in a very short time, that general distress and uneasiness arising from an unequal distribution of the fluids, occasioned by cold, or by cold and fatigue combined.”

Balfour related the horse-riding beneficial effect as a type of percussion and friction

“If the advantage obtained by rheumatic patients from riding on horseback depended altogether on increased perspiration, then Sudorifics and the Warm Bath would, separately, prove a certain cure for Rheumatism —which we find is not universally the case. Riding on horseback has this advantage, that not only all the parts of the body are subjected to a concussive motion, but also a great part of the muscles is put in action— which, to the parts they compress, are equivalent to Friction. I know a gentleman, extremely subject to Rheumatism, who, whenever he is threatened with an attack, has recourse to a ride, which never fails to operate as a complete preventive. So powerful a corrector, indeed, of congestion, is this mode of gestation, that I firmly believe it would be of incalculable advantage in many cases of fever”.

Balfour’s notes about blood-letting:

“Many physicians are of opinion, that a very free use of the lancet in Acute Rheumatism, ensures a slow recovery, and very often Arthrodynia, or chronic pains in the joints. This opinion accords with reason and common sense. For if the proximate cause of the disease consists in debility of the parts affected, can it be supposed that a remedy directly and powerfully debilitating, can ultimately have, if carried too far, or employed unnecessarily, any other effects than that of fixing what was intended to be removed? I am far from asserting that general blood-letting is always improper in Rheumatism. Often it is advisable, sometimes necessary; but the detraction of a Scotch pint of blood, in the course of twenty-four hours, where there is no affection of the lungs or other internal organ, I call breaking down a constitution as with axes and with hammers.”

Published in May 2019 by Marta Cañis Parera