John H. Bland

The painful shoulder

The shoulder, a very common site of pain syndromes in medical practice, lends itself well to precise clinical analysis and identification of the pain-sensitive structure or structures. Once identified, rational and effective management can be applied, associated with predictably good prognosis. Early identification of the emerging specific syndrome is important in decreasing the duration of the clinical disorder and in achieving optimum return of shoulder function. Laboratory and X-ray studies are not commonly required in diagnosis and management. There are a confusing variety of names attached to the many shoulder pain syndromes; however, there are two most common categories. One is associated with severe pain but little or no limitation of shoulder movement (at least passive movement), in which the pain-sensitive structure is tendon or tendon sheath; the other is associated with both pain and limitation of active and passive motion, in which the pain-sensitive structures are capsule, bursa, and synovium as well as muscle and multiple tendons.

Anatomy and physiology of the cervical spine.

Although the lumbar spine was extensively studied from 1934 to the present, the cervical spine has received far less attention. Anatomic, physiological, biochemical, and biomechanical characteristics of the lumbar spine are often presumed to apply to the cervical spine. The differences are far too extensive to warrant such an assumed correlation. Beginning in 1955, the authors have collected 171 whole human spines and studied them anatomically, physiologically, and histologically. Reported in this article are clinically important anatomic characteristics of the nucleus pulposus, the uncinate process, nerve root exit sites, position of the motor (anterior) nerve root, relation of spinal cord volume to size and shape of the spinal canal, anatomy of the anterior and posterior spinal canal, menisci of the zygapophyseal joints, and the anatomy and clinical significance of the autonomic nervous system in the cervical spine.

Calcium, phosphorus and uric acid clearances after intravenous administration of chlorothiazide☆

Abstract The effects of intravenous chlorothiazide on the renal clearance of calcium, phosphorus and uric acid were studied in 10 normal volunteers. The results demonstrate that intravenous chlorothiazide causes a significant increase in both phosphorus and uric acid clearances and an equivocal decrease in the clearance of diffusible calcium. Since phosphaturia can also be induced by the administration of other diuretics such as mercurials and acetazolamide, this effect is neither specific nor necessarily related to the inhibition of uric acid reabsorption. The decrease in clearance of diffusible calcium seen after intravenous chlorothiazide differs from the calciuria observed after the administration of mercurials and acetazolamide. Further studies are necessary to elucidate the mechanism of action and specificity of chlorothiazide on renal handling of calcium and phosphorus.

Carpal-tunnel Syndrome in Patients with Myxedematous Arthropathy

Five patients with carpal-tunnel syndrome and with typical signs and symptoms of myxedema were found in a review of the forty-nine patients with carpal-tunnel syndrome seen in a decade at our clinic. To these were added three more such patients from a rheumatologic practice. The eight patients were treated with thyroid replacement and their carpal-tunnel syndromes disappeared while thirty-six of the other forty-four patients required surgical treatment.

Changes in metabolism of calcium, phosphorus and uric acid after oral administration of chlorothiazide

Abstract The effects of chlorothiazide, administered orally in a dose of 500 mg. every 12 hours for a period of 15 days were studied in 9 normal volunteers. Chlorothiazide had negligible effects on urinary flow. The serum concentration of calcium and phosphorus did not change significantly following the oral administration of chlorothiazide. An increase in serum uric acid was observed in all cases. The glomerular filtration rate and the urinary excretion of calcium and uric acid decreased. The plasma lactic acid tended to increase. The interpretation of these results is discussed.

Cholesterol in Connective Tissue of Joints

Lipids are present in most connective tissues. Rheumatoid arthritis (RA) patients have high synovial and low serum cholesterol concentrations and occasional cholesterol crystal deposition. To ascertain whether tritium-labeled cholesterol is transported into connective tissues, H3-cholesterol was injected into rabbit knees. It was found to enter cartilage and synovium, counts remaining above background for 40 days. Cholesterol crystals injected similarly, produced acute synovitis, lasting at least 20 days. H3-cholesterol was injected into a cholesterol-crystal-forming RA patients knee; H3-cholesterol remained in synovial fluid above background level counts for 10 days.

A Treatment Typology for the Elderly Alcohol Abuser

Alcohol abuse is a serious, though often unrecognized and untreated, problem among the elderly. Treatment is handicapped by the clinicians frequent failure to understand all aspects of alcoholism, and by the lack of adequate treatment resources. Physical, mental and social problems complicate the situation. The Levindale Geriatric Research Center has developed a diagnostic and treatment typology which involves problems with alcohol, health, and the social support system in determining the appropriate environment and treatment resources for these patients. This method has immediate value for clinical practice, and has long‐range value as a framework for planning integrated and comprehensive treatment services.

Etiology and pathogenesis of rheumatoid arthritis and related multisystem diseases

Abstract It is now possible to construct a reasonable hypothesis for an infectious etiology and pathogenesis of RA and related multisystem rheumatic diseases. This has been done here using evidence from the clinical course and natural history of RA, recently studied animal models, the many immunologic abnormalities in these diseases, the pathologic tissue characteristics, and the few data available on efforts at direct culture of organisms. It is proposed that an infectious organism, a viable external agent, is the initiating or persistent cause of RA, and that this agent directly and indirectly results in the phenomena of immune complex disease, hypersensitivity, and autoimmunity. The organism is probably nonspecific; i.e., the disease may be initiated by various agents, such as bacteria, virus, infective particle (“L” form), phages or slow viruses (some may enter cells and compromise the genetic apparatus, resulting in synthesis of “foreign” antigen by the host cells), mycoplasma, or even physical agents. Chronic viral infection may act as an adjuvant in the patients immunologic apparatus, with consequent involvement of most tissues and organs, and so can be a multisystem disease. There are known instances of acute arthritis that closely simulates rheumatoid arthritis and that results from viral infection. Unfortunately, at present most of the supporting evidence for a clear infectious etiology of RA is circumstantial. However, the evidence is very extensive and persuasive and remains the most probable etiologic hypothesis and most promising investigative approach to these diseases that are so often disabling and tragic in their consequences.

Uric acid, calcium and phosphorus clearances in normal subjects on a low calcium, low phosphorus diet: uric acid, calcium and phosphorus clearances after calcium infusion in normal and gouty patients.

Abstract The occurrence of hyperuricemia in hyperparathyroidism 2–4 hypophosphatemia in certain cases of gout, 1 hypercalciuria, phosphaturia and uricosuria in Wilsons disease 6 and the simultaneous existence of both gout and hyperparathyroidism in the same patient, 4,8,9 suggests that calcium, phosphorus and uric acid might have relationships in common in their renal tubular transport mechanisms. If a common mechanism exists, it might be elucidated by experimentally altering metabolic handling of calcium and/or phosphorus and observing any resulting changes in uric acid metabolism. Three sets of experiments were done to test this possibility. (1) Eight normal volunteers were subjected to dietary depletion of calcium and phosphorus for 2 weeks and renal clearance studies done during the depletion period; (2) after 12 days of a calcium and phosphorus depletion diet, 6 normal subjects were infused with calcium and renal clearances done before and after; (3) after 10 days on a purine free diet 7 gouty patients were infused with calcium and renal clearances done before and after. Renal clearances for uric acid, phosphorus, calcium and endogenous creatinine were done on all subjects. Normal subjects on calcium and phosphorus depletion diets showed significant fall in clearances of both calcium and uric acid but no significant change in phosphorus clearance. Normal subjects on calcium and phosphorus depletion diet plus calcium infusion did not show the expected decrease in phosphorus clearance on hypercalcemic stimulation (suppression parathormone action); nor were uric acid clearances or serum uric acid concentrations affected. Patients with gout who had calcium infusion showed the normal decrease in phosphorus clearance after hypercalcemia but no change in uric acid clearance. It is concluded that calcium and phosphorus depletion and acute hypercalcemia do not influence uric acid clearance; hypercalcemia in gouty patients results in decrease in phosphorus clearance but does not affect uric acid clearance concomitantly. The evidence supports the concept that phosphorus, calcium and uric acid are not interrelated in their renal transport mechanisms.

A Biochemical, Histological (Light and Electron Microscopy), and Chromosomal Study of a Family with Ehler's-Danlos Syndrome.

Excerpt Though the Ehlers-Danlos syndrome has a more ancient history than the other genetic disorders of connective tissue, the basic abnormality at a molecular level remains controversial. The pr...