This is an interesting article about the technique of procaine infiltration as the diagnosis and treatment of fibrositis (another name for the painful fatty nodules or back mice).
The fatty painful nodules or back mice have received many names during history, personally I think that FIBROSITIS was a bad proposal from Gowers (with the stem -FIBRO- he suggested the problem was on the fibrous tissue, and the termination -ITIS he suggested that there was an inflammation, the lack of inflammatory signs in further studies led even to more confusion).
The authors made a great literature review about what was published about the entity fibrositis by the time, its problems with the diverse names, the American-British conflict, the etiopathogenic theories, the existence of the nodules, the theories about the pain mechanism, the management with the procaine injection… it is written in an excellent clear manner.
They present 5 typical medical cases from soldiers (the authors were members of the air force during WWII)
-Case 1. A 56-year-old man. Lumbar/gluteal pain.
-Case 2. A 28-year-old man. Acute lumbar pain.
-Case 3. A 23-year-old man. Stiff neck.
-Case 4. A 26-year-old man. Right iliac fossa pain.
-Case 5. A 42-year-old man. Dorsum right forearm pain.
They said that over 80 diagnosed cases were treated with good results. 7 cases failed because of a failed diagnosis.
The authors stated that procaine infiltration has a value both in DIAGNOSIS and in the TREATMENT of fibrositis.
They hypothesize that the procaine infiltration has a therapeutic action taking in consideration Gutstein-Good and Lerich’s hypothesis that the lesions are related to VASOMOTOR DISTURBANCE (of unknown cause). Procaine then may break the VICIOUS circle and allow the restoration of the vasomotor equilibrium.
Taking Gratz’s view about the pathology related to fascial adhesions, by anesthetic block, the authors hypothesize that maybe by the patient recovering movement the adhesions can break.
They were aware that the pathology was well worthy of a more extended trial.
They summarized that:
From the results they obtained in their study the use of procaine injections has a value in the DIAGNOSIS and in the TREATMENT of fibrositis. They presented a nice review about the possible etiological factors of fibrositis and discussed possible explanations why the anesthetic could have a curative effect.
Personal notes on the article:
Value of Procaine Infiltration in the Diagnosis and Treatment of Fibrositis
By E J. Moynahan and E.S. Nicholson
Free on line article
Edmund John Moynahan served in the Royal Air Force from 1936 to 1945.
The origin of the name FIBROSITIS and what it designates. The problem with the names.
Moynahan and Nicholson start saying that Gowers, in 1904, was the first one who PROPOSED the term FIBROSITIS to designate a group of conditions such as:
- “muscular rheumatism”
- “stiff neck”
- “rheumatic cephalalgia”
Controversy about “fibrositis” between British and American physicians
They were aware that fibrositis was still a condition with an indefinite etiology and pathology, and this had lead some physicians to doubt about its existence, particularly in AMERICA.
Anyway, they bet by the term “fibrositis”
Despite the American-British controversy, Moynahan and Nicholson proposed the use of the term “fibrositis” until further knowledge is done. They suggested that it was better to use a single term, as Gowers proposed.
A HIGH incidence of fibrositis according to Moynahan and Nicholson, factors that are related.
- They considered that fibrositis was one of the COMMONEST MALADIES of TEMPERATE climates.
- The referred that Hill, in 1939, pointed out that the pathology was rare in the tropical or arctic regions.
- But Davidson and Duthie, in 1939, estimated that in Scotland 75% of the 300,000 new cases of rheumatic disease were due to fibrositis. Copeman also suggested that in the B.E.F.
- It affected both sexes and in all ages (more frequent in middle and later life).
- It could be related to trauma, or occupation.
- A determining factor was exposure to damp and chill.
- The authors warn that the incidence may increase in the winter that was coming as a result of the “shelter-life” necessitated by the air raids.
Etiopathogenic factors according to the literature review
The authors were clear: THE ETIOLOGY WAS UNKNOWN
The factors that were related were:
- inclement weather
- metabolic errors
Other less common factors that were related to fibrositis:
- focal sepsis
- intestinal intoxication (Albee, 1934)
- gout (Buckley, 1938)
- electrolytic imbalance and endocrine dysfunction (Gutstein, 1938)
- allergy (Buckley, 1938)
- Fear and worry may precipitate or maintain an attack.
- psychogenic factors (Halliday, 1937; Gordon, 1939).
- chronic strain (Gratz, 1937)
- faulty posture and occupation (Wesson, 1938; Kinderová 1940)
- Wearing high heels, in women.
“Secondary fibrositis” had been related to other illnesses: (Comroe, 1940; Slocumb, 1936; Buckley, 1938)
- rheumatic fever
- “Hench et al. (1936 and 1938) pointed out that each author tends to find a cause in their own specialty”
PATHOLOGY CONSIDERATIONS according to the review
Moynahan and Nicholson said that the site of the lesion was generally believed to be the FIBROUS TISSUE.
They described the fibrous tissue, also known as connective tissue.
There were two elements of the connective tissue: the fibers and the cells.
There were two kinds of fibers: collagenous white, elastic yellow.
There were two types of cells: the fibroblast and the histiocytes.
Other cells that were found: mesenchyme cells, mast cells, plasma cells, fat cells, and pigment cells -with still unknown functions.
Stockman described an inflammatory hyperplasia of the white fibrous tissue in which fibers become swollen and there is fibroblastic proliferation with exudation of serum (according to Buckley, 1938).
Slocumb (1936) described 3 stages of the condition, in the last stage “some indurations may disappear”, other “remain painless thickenings or nodules”.
The polemic about the existence of the NODULES
Moynahan and Nicholson comment that the presence of indurations and nodules are described in fibrositis, but their existence had been doubted by some authors. (Definitely, the fibrositic nodules differ from the nodules of rheumatic fever with Poynton-Aschoff nodes).
Moynahan and Nicholson said that, in their opinion, the nodules seem to be more absent than constant in fibrositis.
The fascias role
Some authors related the backache to the post-traumatic adhesions in the fascia. They use air-injections as Gratz (1936-1937) or Carty (1936).
The vasomotor desequilibrium
Gutstein-Good (1940) suggested that there was a disturbance of the local circulation, the blood vessels would vasoconstrict (by sympathetic fibers), and this would lead to a “vasomotor desequilibrium” (Leriche (1927, 1928), Watson-Jones (1940), Moynahan (1939)). THIS WOULD OFFER AN EXPLANATION TO THE therapeutic action of the procaine injection.
The blood test was usually normal with fibrositis, which may help to differentiate it from various forms of arthritis (that can be confused).
Albee (1934) found large quantities of histamine in the stools and abnormal findings with the laevulose-tolerance test.
Hench et al. (1936-1938) have been very critical in a review about fibrositis due to the lack of proper evidence.
Symptomatology of the fibrositis syndrome
Fibrositis syndrome: “PAIN, STIFFNESS and SORENESS or TIREDNESS of the affected tissues, sometimes associated with spasm of the affected or related muscles”
The character and distribution of the pain vary with the site of the lesions.
Pain may be CONTINUOUS or INTERMITTENT. Sharp or dull. EASILY LOCATED or diffuse. Worst by movement.
“ There is fibrous tissue everywhere and everywhere can be a site of a fibrositic lesion”.
THE REFERRED PAIN MATTER
Moynahan and Nicholson comment on the work of Lewis and Kellgren, who do not agree with the works of Pollock and Davis (1935), or Morley (1937).
Gustein-Good (1940) described an “idiopathic myalgia” as a vasomotor disturbance.
The “complication” of the differential diagnosis
These statements are clear by the authors:
- The nodules can be present or absent.
- The lesions can occur ANYWHERE (so it can be confused with any painful disease).
- There are warnings that stated that any serious disease could be confused by a wrong diagnostic of fibrositis, but the authors also point out that many times fibrositic pain has been taken as a more serious malady. Especially if the physician does not bear it in mind. (The example of a “chronic appendix pain” or “pectoral pain as angina” is explained by Lewis and Kellegren, who view that the SOMATIC AND VISCERAL PAIN are identical)
- That’s why procaine injections are a diagnostic tool in fibrositis, if the pain is not relieved by the injection, then the cause is not fibrositis.
Kellgren (1941) gave an excellent account of the differential diagnosis of sciatica using procaine injection as a tool.
Treatment by procaine infiltration
They point out that the local injections of procaine hydrochloride into the TENDER AREAS in fibrositis cases were given INSTANT and often LONG LASTING relief (Kellgren (1938); Gutstein-Good (1940); Button, (1940)).
They inject 2-3 cc of solution in the located tender spot, which gave an IMMEDIATE relief of pain and the associated tenderness or muscle spasm disappears at once. The pain disappears completely or it can return after a few hours. While pain free, the patient should be encouraged to move freely. Infiltration can be repeated if necessary.
The authors do not recommend the infiltration of large amounts of anesthetic in an area “blindly” hoping that by chance the tender spot will be infiltrated. It is better to localize the exact point by palpation.
Typical medical cases from the armed forces, Moynahan and Nicholson were army medical doctors.
Case 1. A 56-year-old man. Lumbar/gluteal pain. Pain in the right and left sacroespinalis and at the attachment of the gluteal muscles. Pain radiated to both legs. All movements limited. No neurological signs. Past history of a trauma six weeks previously. Numerous tender spots in lumbar regions were found and injected with 1-2 cc of procaine. SEVERE EXACERBATION OF THE PAIN FOLLOWED SOME HOURS AFTER INJECTION. The injection was then repeated for 3 days with complete relapse.
Case 2. A 28-year-old man. Acute lumbar pain. Patient involved in a motor accident 6 days previously. No bone injury, he was dismissed asymptomatic. While lifting his kitbag, he felt a violent pain in the left lumbar region, which caused him to collapse on the street. Examination showed 4 tender areas along the attachment of the left gluteus maximus. Pain radiated to the leg. No central nervous system signs. Few cc of procaine were injected in the areas and pain was abolished. He recovered and had no recurrences after 3 months.
Case 3. A 23-year-old man. Stiff neck. The patient presented stiff neck after a night spent in a damp air-raid shelter. All movements were limited. Pain radiated to the occipital region and down towards the left shoulder. Two tender spots were found in the trapezius about one inch to the left of the midline just below its occipital attachment. Procaine infiltration gave immediate relief.
Case 4. A 26-year-old man. Right iliac fossa pain. Attacks of pain in the right iliac fossa at intervals for 2 years, for which appendicectomy had been performed six months previously without relief. Examination showed 3 tender areas just at the right of the midline in the region of the 11th/12th dorsal vertebrae. These areas were infiltrated with procaine and the pain was abolished permanently.
Case 5. A 42-year-old man. Dorsum right forearm pain. He thought he had knocked the forearm six weeks before during evacuation from Dunkirk. On examination, two tender areas were found, one at the anterior border of the external epicondyle of the humurus, and the other deep in the brachioradialis about the level of the head of the radius. Pressure on this spot exacerbated the pain in the forearm, as did supination and pronation. Procaine was injected in both areas and pain was abolished. Another infiltration of the area led to permanent cure.
7 similar cases were failures on the diagnosis.
Published in September 2018 By Marta Cañis Parera
Moynahan EJ, Nicholson ES. Value of Procaine Infiltration in the Diagnosis and Treatment of Fibrositis. Br Med J. 1942 Jan 17; 1(4228): 65-8. PubMed PMID:20784053; PubMed Central PMCID: PMC2160464