!sectton of I8aineolon anb elthinatoloap.

President-Dr. CHARLES W. BUCKLEY.

The Causes of Brachialgia.

By J. BARNES BURT, M.D. (Buxton).
THE CAUSES OF BRACHIALGIA.
IN this paper the term brachialgia is used with reference to pains radiating
along the nerves of the brachial plexus, just as the term sciatica is used with
reference to pains radiating along the sciatic nerve.
In England the majority of people call all cases in which pain radiates along
the nerves bf the arm brachial neuritis, even when no organic changes are
found in the nerve in any stage of the disease.
Genuine brachial neuritis in the earlier stages may begin as a brachialgia
before any microscopic changes can be found in the nerve tissues. I must,
therefore, mention the causes of brachial neuritis as among the possible causes
of brachialgia, but this paper chiefly concerns the big group of cases in which no
organic changes in the nerves are found in any stage of the disease, and for this
group the term brachialgia ought to be reserved.
RECOGNIZED CAUSES.
(1) Toxic.-Diabetes, arsenic, lead, gout, influenza.
(2) Injury.-Crutch palsy, Saturday night arm, obstetric arm, pressure
on brachial plexus, carrying of heavy weight on the shoulders, tight braces.
(3) Secondary Symptoms.-Cervical rib, osteo-arthritis cervical vertebrs,
malignant glands in axilla, syphilis of spinal meninges.
(4) Spread of inflammation from surrounding tissue into the nerves, as in
subacromial bursitis, inflammation of the shoulder-joint, spread of fibrositis
from a muscle into the tissue of the nerve.
(5) Referred pain as in certain cardiac conditions.
This long list quite fails to explain a large number of cases of brachialgia.
Several year3 ago I noticed, like several other physicians, that many
patients complaining of brachialgia had pain in the neck and scapula muscles,
and in the case of all patients consulting me for pain down the arm I have made
careful notes with regard to the condition of these muscles.
The results of this study are shown in a series of Tables made from an
analysis of my last 100 cases of brachialgia occurring in private and hospital
patients. All cases of muscle wasting and anesthesia have been excluded from
the analysis. It must be remembered that the majority of these patients have
passed through the hands of other doctors before seeing me, and hence cases,
Au-B 1 [March 6, 1924.
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 $ectton of I8alneoloap anb tlilnatolog.
President-Dr. CHARLES W. BUCKLEY.

The Causes of Brachialgia.

By J. BARNES BURT, M.D. (Buxton).
THE CAUSES OF BRACHIALGIA.
IN this paper the term brachialgia is used with reference to pains radiating
along the nerves of the brachial plexus, just as the term sciatica is used with
reference to pains radiating along the sciatic nerve.
In England the majority of people call all cases in which pain radiates along
the nerves bf the arm brachial neuritis, even when no organic changes are
found in the nerve in any stage of the disease.
Genuine brachial neuritis in the earlier stages may begin as a brachialgia
before any microscopic changes can be found in the nerve tissues. I must,
therefore, mention the causes of brachial neuritis as among the possible causes
of brachialgia, but this paper chiefly concerns the big group of cases in which no
organic changes in the nerves are found in any stage of the disease, and for this
group the term brachialgia ought to be reserved.
RECOGNIZED CAUSES.
(1) Toxic.-Diabetes, arsenic, lead, gout, influenza.
(2) Injury.-Crutch palsy, Saturday night arm, obstetric arm, pressure
on brachial plexus, carrying of heavy weight on the shoulders, tight braces.
(3) Secondary Symptoms.-Cervical rib, osteo-arthritis cervical vertebrae,
malignant glands in axilla, syphilis of spinal meninges.
(4) Spread of inflammation from surrounding tissue into the nerves, as in
subacromial bursitis, inflammation of the shoulder-joint, spread of fibrositis
from a muscle into the tissue of the nerve.
(5) Referred pain as in certain cardiac conditions.
This long list quite fails to explain a large number of cases of brachialgia.
Several years ago I noticed, like several other physicians, that many
patients complaining of brachialgia had pain in the neck and scapula muscles,
and in the case of all patients consulting me for pain down the arm I have made
careful notes with regard to the condition of these muscles.
The results of this study are shown in a series of Tables made from an
analysis of my last 100 cases of brachialgia occurring in private and hospital
patients. All cases of muscle wasting and anesthesia have been excluded from
the analysis. It must be remembered that the majority of these patients have
passed through the hands of other doctors before seeing me, and hence cases,
Au-B 1 [March 6, 1924.

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 Section of Balneology and Climatology 27
A study of my notes supports these observations, only fifteen men affected
as against thirty-eight women-it is very much rarer in hospital practice than in
private practice. I had a larger proportion of cases of brachialgia in 1919,
1920, 1921, but in the last year or so they have diminished, probably because
the knitting craze is dying out.
An important point to study is the exact distribution of the pain and
tingling.
With regard to the distribution of pain, this is difficult, as most patients
appear to be unable to localize the pain to definite areas. The pain of brachialgia
is often variable in distribution and character, sometimes extending to the
elbow, at other times to the wrist; it is diffuse in character, and the whole arm
may feel tired and heavy.
Cases of brachialgia due to subacromial bursitis form an exception to the
above. Amongst my own cases 77 per cent. of the patients localized the pain
to the back of the arm and forearm.
With regard to tingling, numbness, and pins and needles, it was possible to
get more accurate answers, and the following Table has been drawn up from
thirty-four cases:
TABLE IV.-SHOWING DISTRIBUTION OF TINGLING, PINS AND NEEDLES, &CT
In all fingers Inmedian
fingers supplied by In fingers supplied by
nerve only ulnar nerve only
Group 1 ... 50 per cent. ... 10 per cent. ... 40 per cent.
2 ... 66 ,, ,, ... 30 ,, ,, ... 4
,, 3 Answers too indefinite to classify.
These figures are too small to be of very much value, but, roughly speaking,
pain confined to the back of the arm suggests subacromial bursitis, pain along
the front of the arm, most intense on the radial side, with tingling in the
fingers supplied by the median nerve, suggests the spinatus group. Pain along
the front of the arm, especially along the ulnar side, with tingling in the fingers
supplied by the ulnar nerve, suggests cervical rib.
The question now arises, how does fibrositis of the spinati muscles set up
brachialgia ? You will remember that the suprascapular nerve passing through
the suprascapular notch sends a branch along the surface of the bone to supply
the supraspinatus muscle, the nerve then winds round the spine of the scapula
to supply the infraspinatus muscle. These two muscles are bounded on two
sides by bone, on the third side by a strong aponeurosis, so firm that fibres of
the muscle rise from it. Thus, any inflammatory change in the muscle not
necessarily near the nerve exerts a definite pressure on the nerve, squeezing it
against the bone. The circulation is also interfered with. The suprascapular
nerve comes from the outer cord of the brachial plexus, which derives its fibres
from the fifth and sixth cervical nerves; and it is the pressure on the supra-
scapular nerve which gives rise to pain in the skin supplied by the musculo-
cutaneous and median nerves, viz., front of the arm, on the outer side;
hand and the tips of all fingers except the little finger.
I have shown that in many of the cases it is impossible strictly to localize
the pain in these areas but exactly the same thing occurs in neuralgia of the
fifth nerve, a small hole in an upper molar may set up a pain along the supra-
maxillary division only, the supra- and infra-maxillary, or all three branches;
it may even set up pain in the supra-orbital division without pain in any of the
other divisions.
Thus, on both anatomical and clinical grounds, I believe that the commonest
cause of brachialgia is fibrositis of the supraspinatus muscle and infraspinatus

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28 Burt: The Causes of Brachialqia
muscle, the result of pressure on the suprascapular nerve, and not the result of
the spread of inflammation from the muscle into the nerve.
Of course it is possible for the inflammation to spread from a muscle into
the nerve, but this event is rare and when it does occur it will explain the
wasting of these muscles.
Fibrositis of these muscles affords an exact explanation of many of those
cases of brachialgia which are associated with gout or septic foci; and it will
also explain some of those traumatic cases caused by carrying weights on the
shoulder or wearing tight braces.!
Dr. Williamson has explained these traumatic cases as being due to
pressure on the brachial plexus; I think they are far more likely to be due
to pressure on the supraspinatus.
I consider that brachialgia associated with fibrositis of the spinati muscles
forms a definite clinical entity. The cases frequently begin with stiff neck or
pain in the shoulders; this is followed by pain down the front of the arm,
chiefly on the radial side, later, tingling or pins and needles in all fingers or
fingers supplied by median nerve, most common in women and often associated
with fibrositis elsewhere. Sufferers from gout or septic infection are predisposed
to this type of brachialgia. The important diagnostic points are the condition
of the spinati muscles, the mode of onset, and distribution of the pain and
tingling.
The treatment is comparatively simple, and the much discussed question
as to the value of massage answers itself. Deep massage to the arm is
harmful, it only serves to irritate nerves already irritated. Massage applied
to the spinati muscles in most cases cures the brachialgia. Where these
muscles are too irritable to be massaged, as is generally the case in the early
stages, cataphoresis or diathermy is valuable in preparing the muscles for
massage. The final cure, however, is generally brought about by massage.
SUMMARY.
(1) In spa practice more than half the patients complaining of brachialgia
are suffering from fibrositis of the supraspinatus muscle or infraspinatus
muscle.
(2) These muscles are especially exposed to trauma and to chills.
Inflammation in these muscles will cause pressure effects on the supra-
scapular nerve, because the nerve lies on bone and the muscles it supplies
are bounded by rigid walls.
(3) Pressure effects on the suprascapular nerve will account for a large
proportion of cases of brachialgia.
DISCUSSION.
Dr. C. W. BUCKLEY (President) said that Dr. Burt had brought an important and
interesting subject before the Section, and that he agreed with most of his views on
the subject. The wearing of furs was a very important cause of fibrositis of the
shoulder; they caused undue warmth, which was relieved by throwing them back and
the result was often a severe local chill. He thought that a definite extension of
fibrositis from the muscles to the adjacent nerve trunks was more frequent than
a pressure-effect on the suprascapular nerve and bore a closer analogy to sciatica.
Teno-synovitis in the bicipital groove was a cause of brachialgia which was frequently
overlooked. In one group of cases, pain referred to the inner end of the supraspinous
1 Williamson, Brit. Med. JTourn., June, 1919.

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 Section of Balneology and Climatology 29
fossa and tenderness at the same spot was a well-marked feature. He laid stress on
the necessity for specific directions in ordering massage; the exact area to be treated
and the kind of massage to be used, should be prescribed, or the results would be
disappointing.
Dr. VINCENT COATES (Bath) said that in his opinion it was often possible to
diagnose fibrositis of the supraspinatus muscle by finding fibrositic nodules. Treatment
of these relieved the subjective symptoms in the arm and fingers.
With regard to the causation and frequency in women he considered that, arguing
on the analogy of lumbar fibrositis, it would appear that damp played a part. In this
latter condition the close approximation to the skin of garments moist with sweat to
which no air had access, was an important point. In fibrositis of the neck and supra-
scapular regions the turning up of a fur collar wet from rain produced an exactly
similar state of affairs. It was interesting to note that in pathological conditions of the
shoulder-joint one of the first muscles to waste was invariably the supraspinatus.
Dr. G. L. KERR PRINGLE referred to cases of brachialgia caused by some sub-
luxation or very slight alteration in the position of one of the cervical vertebroe. These
cases were frequently caused by hunting accidents and sometimes the alteration could
be demonstrated by X-rays. He referred specially to one case in which the pain radiated
down both arms and the X-ray showed a definite alteration in the alignment of the
cervical vertebre. After about half-a-dozen electric hot-air baths applied to the cervical
region the patient experienced a slight " click," and a second X-ray showed that the
subluxation was reduced. He was not prepared to say how far it was justifiable and
prudent to attempt to reduce these slight displacements by manipulation.

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