1938 Gutstein – Muscular rheumatism (fibrositis)

The back mice nodules have been also named muscular rheumatism during history. Another name for the back mice could be “myalgic spots”, as proposed in this article by Gutstein.

Article published by a German medical doctor from Berlin, M. Gutstein, in the British Journal in 1938.

He presents 52 cases with pains and myalgic spots in several locations. He says that almost all of his patients cured (with no recurrence at least for 3 years). He mentions the treatment briefly: general treatment (diet, rest, codeine, phenazone, aspirin, belladonna) and local treatment (special myalgic spot massage after infra-red rays).

Muscular rheumatism

He also warns that all doctors should know them since the myalgic spots may simulate visceral disease (like the ones that simulate heartache, as also mentioned by T.S. Wilson in 1936).

Gutstein is completely convinced that the lesion is settled in the muscle, he DOES NOT MENTION anything about the fatty tissue, does not even mention its existence. But the examination through palpation that he explains about the myalgic spots is exactly the same as what other authors call back mice. Nevertheless, he did NOT do BIOPSIES to confirm his theories, like Copeman and his colleagues did. Moreover, he does not mention any other studies that did biopsies.

Gutstein dislikes the term FIBROSITIS (from Gowers and Stockman) to deal with this rheumatic condition, but Copeman also did not agree with the term MUSCULAR RHEUMATISM, since Copeman was sure the pathological lesion was settled in the fibro-fatty tissue.

Many more authors as Gutstein were convinced that the lesions were related to the muscles and that’s why they name the nodulesmyalgic spots”.

He admits that he had himself suffered form rheumatism in the right arm, which helped him for this study.

In case 8, he presents a patient with knee pain and severe osteoarthritis. The patient cured after the treatment of the myalgic spots despite nothing else was done related to the osteoarthritis. (Similar cases were commented by Copeman -1949-  about certain patients with knee pain, the pain DOES NOT SEEM TO BE RELATED to the X-ray images but more to the soft tissue spots).

Notes on the article:

Diagnosis and Treatment of Muscular Rheumatism (fibrositis)

Gutstein starts saying that the rheumatic diseases seem to have importance in both the economic and the medical points of view.

The author states that a great deal of attention had been given to the articular form of rheumatism, but the non-articular rheumatic diseases have been somehow neglected.

He mentions that G. Laughton Scott said in his article “ A new treatment for fibrositis” (lipovaccine) that “fibrositis” (another form to say muscular rheumatism) was the commonest of those chronic conditions that they called rheumatic.

The term fibrositis was introduced by Gowers, and it is supposed to denote the swelling and proliferation of fibrous tissue. However, Gutstein says that “fibrositis” is a MISNOMER and should be replaced by the term muscular rheumatism.

He says that for 3 years he treated 50 cases of muscular rheumatism.

One of the things that surprised Gutstein is that most of the patients COULD NOT LOCALIZE properly their pains, they presented as referral or “heterotopic” (according to Waterston, 1935).

When examining the affected areas, the examiner will find TENDER SPOTS that Gutstein prefers to call “MYALGIC SPOTS”.


Gutstein recommends using the right thumb or the index with the third finger.

Better to press the muscle against the bone. The pain can be also compared with the symmetric spot.


  1. The tender areas correspond without exception to anatomical points: origin, insertion or course of a muscle or tendon.
  2. Pressure on a myalgic spot causes pain, which disappears after a few minutes. The character of the pain by pressure is often the same as the spontaneous pain that the patient complains about.
  3. Pressure can make the patient “give a jump”, can produce a jerking movement in another part of the body.
  4. The myalgic areas can be harder to touch than the surroundings. Well-defined nodules may or may not be felt.
  5. With the appropriate treatment, the local pain (caused by pressure) and the heterotopic pain disappear.


THESE notes were based on GUTSTEIN’s own experience.

  1. Character of the pain: a dull, very severe, agonizing pain occurring in attacks of about 2 to 3 minutes’ duration, with long intervals. The pain could not be localized. He felt it somewhere deep of the right upper arm.
  2. Spontaneous pains: they were aggravated by contraction of the muscles. He felt relief with adduction and supporting the forearm.
  3. Paresthesic sensations: sometimes it can be the only complaint. He felt enervating paresthesia in right thumb and index finger on palmar surface.
  4. Heterotopicity of pain: THE MOST ASTONISHING THING regarding myalgic spots is the fact that the patients have NO IDEA of the existence OF SUCH very painful areas of the affected muscles or tendons. And unintentionally it misleads their doctors by localizing their pains in a different area. It may be explained by the assumption that the pain follows a spinal segmental pattern.

ETIOLOGY of the myalgic spots of the muscular rheumatism

In those times, some authors related the muscular rheumatism to the “filter-passing” viruses as the primary cause of rheumatoid arthritis. By then, Gutstein says that there was a lack of confirmation of this theory.

Other related factors:

1-Localized infectious focus in any part of the body: teeth, tonsils, bronchi, gall bladder, and appendix. Nevertheless, Gutstein emphasized that the teeth or the tonsils shouldn’t be removed systematically (Personal note: some desperate people did remove them).

2-Allergic conditions

3-Endocrines and electrolytes: Hypothyroidism and dysfunction of the sex glands are supposed to be related to rheumatoid arthritis. Gutstein also related it to an imbalance in the electrolytes Ca:K:Na.

4-Imbalance of the autonomic nervous system: Some authors related it to the stress (like Gordon, 1936). For example, a high pulse rate could show a sympathetic activation. Gutstein insists that the anxiety and other circumstances should be more considered by doctors. He does not agree with Halliday (1937), who related many cases to psychological factors.

5-Trauma. Sometimes it is related to traumas that took place a long time ago. That is especially true of tender spots that can be elicited over tendons near a joint.

6-Also related to high-blood pressure and localized ischemia.

Another name for muscular rheumatism could be myopathia (myalgia) rheumatica (for example myopathia trapezoidea). It can be acute, sub acute and chronic. The acute form is mainly related to acute febrile or afebrile infections.


He treated over 50 cases.

If there is a parasympathetic factor and if this is predominant: he advises belladonna and phenobarbital.

If the hyperactive sympathetic factor is predominant: gynergin (Sandoz, ergotamina) with a combination of a phenobarbital.

Thyroid medication should be carefully controlled in fat patients.

Fortnight with strict vegetarian diet (only cheese, milk, and mushrooms). Avoid common salt. Raw vegetables. With the intention of reducing Na, and increasing K and Ca.

Massage, infrared rays and diathermy. Massage less painful after the ray treatment.

CASE REPORTS: all cases cured with routine treatment

CASE 1- Myopathia trapezoido-deltoido-bicipitis: A 58-year-old man with pain in the left shoulder for the last 2 years. Myalgic spots in the trapezoid, deltoid and biceps.

CASE 2- Myopathia trapezoido-bicipitis: A 54-year-old woman. Right shoulder pain for 3 years. A well-defined area about half-a-palm its size in the trapezoid muscle cracking on pressure.

CASE 3- Myopathia trapezoido-lumbo-dorsalis: A 33-year-old man. Pain in shoulder and back for 1 1/2 years. Myalgic spots in both trapezoids, left erector spinal and right lumbo-dorsal muscles. Two tender spots were found near left sacral bone.

CASE 4-Myopathia ileo-tibialis. A 32-year-old man. He complains of severe flatulence and pain in left leg especially on standing. Myalgic spots at origin at course of M. Tensor fasciae latae and ilio-tibial tract.

CASE 5- Myopathia gluteo-ilio-tibialis: A 44-year-old man. Pain on left leg for 4 years. Plus sciatic pain for the last 2 months. Myalgic spots in left gluteus maximusilio-tibial tract and lower part of biceps femoris.

CASE 6. Myopathia genu: A 49-year-old woman. Pain in both knees for last year, hot flushes, sleeplessness. Myalgic spots along the line of semi membranous and semitendinous down to “pes anserinus”.

CASE 7. Osteoarthritis and myopathia genu. A 50-year-old woman. Left knee pain for 2 years. Myalgic spots on the internal side of the knee with severe osteoarthritis. Routine treatment and thyroidin.

CASE 8. Myopathia deltoido-brachio-radialis. Dr. Gutstein’s own case.

CASE 9. Myopathia pectoralis. A 37-year-old man. He complains about heartache. Myalgic spots in both major pectoralis muscles.

CASE 10. Myopathia cubiti. A 60 year-old-housewife. She complains of right arm pain for a month. Myalgic areas in arm.

Published in March 2019 By Marta Cañis Parera  ORCID iD icon


Gutsetein M. Diagnosis and Treatment of muscular rheumatism. The British Journal of Physical medicine 1938. 1 p302-321. ISSN 0366-2616.