Cervical Ribs.—Some interesting cases with painful conditions of the arms develop as a consequence of the presence of cervical ribs. It would be more or less naturally expected that trouble of this kind would occur early in life, but, as a matter of fact, many of the patients are well on toward thirty or even beyond middle life when the painful symptoms develop. Cases are practically always at the beginning diagnosed as rheumatism because the first symptom is likely to be pain followed by weakness. Even when this quite fruitless diagnosis is not made, the affection is often declared to be rheumatic neuritis, though it is really a traumatic neuritis and entirely a local condition, as are so many of the painful conditions spoken of as rheumatism. Usually the pain is referred to the inside of the arm and is described as resembling slight toothache at first and even severe toothache after a time. It will often be many months or even several years after the first symptoms before wasting of muscles occurs, but this practically always follows after a time and even at this stage some physicians still talk of rheumatic neuritis as affecting the trophic nerve fibers and causing the muscles to waste. Almost a differential diagnostic sign in the case of cervical ribs is that raising the arms above the head nearly always relieves the pain. Patients usually learn this for themselves because they have been tempted to place their arms in many positions in order to get relief. The reason for it is easy to understand as the elevation of the arms changes the relative position of tissues in the neck and so relieves pressure.

The direct reason for the late development of the disease is probably the ossification of the cervical rib and the pressure of this hard, bony substance upon the roots of the brachial plexus. When the disease occurs as early as the age of 30 there is likely, for some reason, to have been a preceding loss of weight. Patients are run down and then, either because there is a precocious calcification as a consequence of deterioration of tissue, or because the loss of substance in the muscles in the neighborhood makes the nerves more likely to be pressed upon, the first symptoms develop. There is only one way definitely to decide the diagnosis. That is to have a careful skiagraph, or, in case of negative results, several of them taken, in order to determine the presence or absence of cervical ribs. Not all the cases of cervical ribs give symptoms and in one recently published series of 26 cases just one-half presented symptoms and the other half did not, but all these vague cases of pain in the arm, especially if any tendency to atrophy manifests itself, should be examined from this standpoint.

Local Conditions.—The subjective symptoms in these cases often include {401} much more than pain. There may be numbness and the hands often feel cold, though they do not become blue. As a rule, indeed, the arms are more affected than the hands, though not infrequently one of the hands becomes more sensitive to injuries than the other and, as a rule, both hands do not heal well after injury. Even scratches take a long time to heal and slight abrasions cause skin lesions that are more or less indolent for some time before healing. Any fresh injury, even of slight degree, puts back healing much more than would ordinarily be the case. In fact, most of the so-called tendency not to heal is local rather than constitutional. When a patient complains that though his or her tissues used to heal rapidly now they are very slow to heal, it is well to think of nephritis or diabetes but it is especially important to know the local conditions.

Pleural Adhesions.—Another interesting cause of pains in the arms is the possible contraction of adhesions of the pleura and surrounding tissues at the apices of the lungs and the spreading by continuity of a low-grade inflammation even to the lower roots of the brachial plexus. A certain number of cases of this kind have been reported in which there seems to be no doubt of the diagnosis. In these, the early symptoms were pains or aches in the arm followed by some weakness of muscles and even some trophic disturbances. Ordinarily the condition has been very acute as, for instance, a pneumonia when the first symptoms were noticed. In the course of the exudation and the contraction of the inflammatory exudate the brachial plexus is interfered with. This, like the cases referred to the presence of a cervical rib, emphasizes the necessity for thoroughly studying local conditions in order to understand the meaning of painful conditions in the arms. It is easy to say the word rheumatism, while it requires time and careful investigation to find the real pathological factor at work; but the difference in the value of the two diagnoses for both patient and physician can be readily understood.

Other Conditions.—Besides these, there are the various conditions discussed in other chapters of this section—old injuries, breaks and dislocations, so-called sprains with laceration of tissues, and any serious pathological condition that has affected the tissues deeply. An old periostitis, for instance, will leave an arm rather easily liable to the development of various painful conditions. Of course, a tuberculous process anywhere in the arm will produce a like effect. An arm that has had a lead neuritis will often be uncomfortable in rainy weather for long after and a crutch palsy may, in the same way, leave the arm sensitive. The musculo-spiral palsies that occur from lying on the arm when drunk, or that are seen sometimes in coachmen who wrap the reins around their arms—a Russian custom—or the nerve conditions seen in patients who have suffered from an anesthetic nerve-pressure disturbance, may all be at the bottom of subsequent painful conditions, worse in rainy weather. The only sure rule is to individualize the cases and make an exact diagnosis. The etiology will probably suggest itself if the history is carefully taken.

In these cases the most important treatment is to disabuse the patient's mind of the idea that there is rheumatism, or any other constitutional ailment present, and to make him realize that the trouble is entirely local. After this, the strengthening of the affected muscles must, as far as possible, be secured by local measures and exercises.{402}