Aspects of “Fibrositis”

Abstract

The conception of fibrositis, introduced in its present form by Sir William Gowers in 1904, pro-vided so ready an explanation for a number of other-wise knotty problems that it was and is widely accepted as a disease, although it has never been placed on a satisfactory pathological basis. It is true that Stockman, Brogsitter, and others have found non-inflammatory fibrotic changes and endarteritis in the subcutaneous and myo-fascial tissues, but the changes have been slight and-if we except the case of panniculitis in obese women-their relation to symptoms indefinite. The scepti-cism born of this pathological ambiguity is increased by the circumstances that many conditions formerly viewed as typical examples of fibrositis are now known to have other cause. Many cases of lum-bago, sciatica, and " brachial neuritis " (Semmes, et al., 1943; Spurling, et al., 1944; Elliott, et al.) are due to prolapse of the nucleus pulposus at the appropriate level. Other cases of lumbago are examples of spondylolisthesis, or the reverse con-dition of posterior displacement of the fifth lumbar vertebrae-conditions which depend for their recognition on improved x-ray technique. Ortho-paedic surgery has demonstrated the importance of postural strains in the production of pain in the limb girdles and back. These advances have greatly reduced the number of cases in which it is necessary to invoke a hypothetical inflammation of fibrous tissues, and it is probable that this trend will con-tinue. Nevertheless, it is still a common experience to find that cases of spondylitis, prolapsed disc, spinal tumour, and so on, have been treated as fibrositis by clinicians who are fully aware of these other diagnostic alternatives. It has appeared to me, from a review of personal mistakes of this kind, that among the factors which contribute to this confusion the most outstanding is the misinterpre-tation of tenderness as a physical sign. It is the purpose of this article to make some general obser-vations on this topic, with special reference to muscle tenderness. Diagnostic Criteria for Fibrositis Modern literature emphasizes four points in the diagnosis of fibrositis: local tenderness, repro-duction of symptoms by pressure on the tender points, the presence of nodules, and the cure of symptoms by the injection of procain into " trigger areas." A critical scrutiny of these criteria at once reveals certain pitfalls. In the first place, it is not possible to map the distribution of tender spots by palpation alone, for it is a matter of simple physics that, since tenderness is elicited by pressure, it will be most easily found where there is something firm, like bone or liga-ment, to give counter-pressure to the exploring finger. Current descriptions of the common sites of " fibrositic " tenderness are for this reason un-reliable, as can readily be demonstrated by exploring the tissues with a needle. Secondly, tenderness found by palpation does not discriminate between superficial and deep tissues, so, unless special measures are adopted, the clinician is prone to attribute any tenderness he may find to the tissues he expects to find it in. Cutaneous hyperalgesia must be excluded by testing with pin-prick. Subcutaneous tenderness must next be tested for by pinching up a roll of skin between the fingers, and is valid only if cutaneous hyperalgesia is absent. Tenderness in the deeper tissues is more difficult to judge and may require needling for its precise location. That these are not merely theo-retical considerations may be illustrated by three cases, in all of which there was tenderness in the region of the sacro-iliac joint. One had an epidural abscess at the level of the third lumbar vertebra and the tenderness was of the skin, which here received fibres from the descending branch of the third lumbar nerve. The second had a prolapse of the fourth lumbar disc, irritating the fifth lumbar nerve, which supplies the gluteus maximus-the site of the tenderness. The third had tenderness deep