Bursitis. Today we have definite physical therapy methods for the cure of bursitis. They are, however, wrongly employed by the average practitioner, though he possesses the apparatus. Many pitiful examples corroborating this statement could be cited, but for lack of space, I shall use of an illustration the following case only.

IF WE compare the simplicity and results of the non-surgical treatment employed in bursitis today with that of twenty years ago, at the dawn of physical therapy, we can say with regard to the latter: “Sibi gratulentur homines talem tantumque humani liberatorem doloris existere.” Even the most clever physician or surgeon did not possess any proper non-surgical method for the cure of bursitis, though such methods were employed. Among the notables surgeons that employed non-surgical methods in those days was Codman. But the methods were very poor, even dangerous and soon abandoned.

In fact, Codman 1Quoted by Brickner: “Subacromial Bursitis,” Med. Recorder., 15, January 2, 1915. himself admitted that his treatment “was a very arduous are for the surgeon and cause a good deal of complaint from the patients.” Brickner, 2Brickner, Walter: “Concerning the Non-Operative Treatment of Subacromial Bursitis,” Amer. Jour. Orthopaedic Surg., vol. 14, No.4, p. 231, April, 1916. discussing Codmans method, says, “he (Codman) seems to have abandoned both the apparatus and the “brisement force of the bursal adhesions- a procedure which is much more uncertain and more dangerous than open operation.”

Other surgeons like the just mentioned Brickner recognized for the relief of pain in bursitis, especially with lime deposit, only one method-operation. “None of my case with lime deposit,” says Brickner, 3Ibid. “has been relieved of pain except those operated upon”.

Today we have definite physical therapy methods for the cure of bursitis. They are, however, wrongly employed by the average practitioner, though he possesses the apparatus. Many pitiful examples corroborating this statement could be cited, but for lack of space, I shall use of an illustration the following case only. A man of thirty-eight, a laborer by occupation, suffered from an acute traumatic subdeltoid bursitis.

His physician, in order to relieve the pain, administered an injection of morphine and applied diathermy to the acutely inflamed shoulder. The patient felt relieved for two hours. The pain then returned with greater severity. The doctor repeated the same treatment. This was done for three days with the result that the pain grew progressively severer with every time the effect of the morphine wore off; and the patient, according to his statement, nearly became insane from the unbearable pain.

In this condition he came under my care. The treatment that I have instituted in this case, with rather rapid results, is the standard treatment which I have employed successfully in my clinics and office for a number of years, probably in 99 cases our of 100.

According to Alexander Monro: “Description of All Bursae Mucosae of the Human Body”, p.8, edited, 1788. (Obtained at the New York Academy of Medicine.) (Professor of Anatomy of University of Edinburgh) there are 140 bursae in the body: thirty-three in each of the upper extremities and thirty-seven in each of the lower extremities. Such a vast number of bursae warrants the necessity of some proper treatment of this structure in disease.

The bursa, however, most often affected is, I believe, the subdeltoid +The subacromial bursa is next in frequency, though in reality it is a part of the subdeltoid one: if the arm is abducted, the bursa is subacromial; when in contact with the side of the body is (or at least a large part of it) is subdeltoid (Codman Quoted by Da Costa: “Modern Surgery,” p. 728, 1915 edition. one, as it was the subdeltoid bursitis that most often came under my care, and was of traumatic etiology. I shall, therefore, refer to it in discussing the treatment which holds good for any other bursitis usually met with in practice and having the same etiology.

Bursitis, just as any other “itis,” has there stages: acute, subacute and chronic. For the appreciation of the methods of treatment employed, I shall refresh out knowledge, when deemed necessary, of the pathologic, physiologic, or biochemic processes that take place in these stages as well as of the physiology and biochemic effects of some of those methods. For it is the considerations of those three staples of medical science (pathology, physiology, and biochemistry) together with years of experience, that form the basis of the treatment discussed in this paper.

Pathology of the First Stage of Bursitis.- In this stage we deal with an acute inflammation, the cardinal symptoms of which, as we all know, are: rubor, tumor, calor, and door. When the bursa is located superficially, the first three symptoms are well noticed. If the inflamed bursa is situated in the deeper tissues, the signs can be detected with difficulty, if at all. The bursa is distended by fluid; thee is hyperemia and edema of the tissues surrounding it, producing pressure upon the neighboring nerve structures. This pressure is, as we know, a factor in the causation of pain. Treatment of the Acute Stage.- This consists of (1) cold applications (home treatment), and (2) galvanization (office treatment).

(1) Cold applications- To realize the importance of these applications in the acute stage, we shall consider the following physiologic process that takes place in that stage. This is increased oxidation which results in heat formation. The latter is responsible for the increased capillary pressure and edema, as shown by Landis and by Drury and Johnes (quoted by Wolf 6 Wolf, H.|: “The Physiological Basis of Wet Dressing,” Arch. Phys. Ther., X-ray, Radium, vol. 16, No.3, p. 153, March, 1935.): Landis has shown that he capillary pressure in the arterial limb in the skin of a finger is normally 32 mm. mercury and 12 mm. in the venous one, and that this pressure rises to 60 mm. and 45 mm. respectively at a temperature of 42 C.

Drury and Johnes found that edema formation is two to five times greater at 42 C. than at 16 C. Macleod points out the relation between edema and capillary pressure, stating that conditions capable of causing increased capillary pressure are likely to cause edema (“Physiology and Biochemistry in Modern Medicine.” p. 120, 4th Edition). We know now that heat brings about such a condition. It follows, therefore, that the application of heat in acute bursitis is logically and scientifically contra-indicated.

Indeed, experience has shown that the patient feels worse from the application of heat. It was also noticed by the writer that the application of heat prolongs the acute stage, while cold applications shorten it and relieve the pain. Nevertheless, some books still advocate the employment of heat in the acute stage especially in such a form as diathermy! “The early local treatment (in acute bursitis) consists of heat, particularly diathermy” (“Principles and Practice Therapy,” V.II, Chap. 6, P.54. 2nd Edition).

The cold applications are carried out in the form of a compress, the technic of which is as follows: two to three folded towels or sixteen layers of gauze are wrung out from ordinary tap water and applied to the shoulder. The compress is held in place by a spica bandage. The patient is instructed to keep it constantly wet and cool by instilling, now and them, some cold water directly into it. (An ice applied upon the compress or directly on the bare shoulder may sometimes to necessary.) The compress is changed daily and kept up for about a week or so. Experience has shown that during this time the patient is greatly relieved of his pain.

The consideration of the physiology of the cold compress will emphasize still more its importance in the acute stage. It causes a decrease in the capillary pressure and in the edema, establishing the proper circulation which is necessary for the relief of pain and repair of the injury. The compress achieves this by reducing oxidation, heat formation and creating an optimum temperature.

Such a temperature according to Starr, should range between 372 – 362 C. This temperature has proven to be so beneficial in inflammatory conditions that Starr has recommended it (and it is being used today successfully As corroborated by wolf (in his article on “The Physiological Basis of Wet DRessings” quoted above) and others.) in the treatment of gangrene of the foot. It is, however, remarkable to note that (as it has been shown) the temperature of the skin under the compress is also about 372 – 362 C.Quoted by Wolf: Ibid. Thus by applying cold compresses in the acute stage, we are bringing about that temperature which is most favorable for then relief of the pain and repair of the injury.

(2) Galvanization.- To explain the mission of this treatment in the acute stage, I shall consider the bio-chemistry of acute inflammations as well as the biochemic effect of galvanization upon the latter. In acute inflammation (as referred to by the author 8Echtman, Joseph: “Indications and Results of Ionization,” Arch. Phys. Ther., X-ray, Radium, vol. 14, pp. 489-491, August, 1933. elsewhere) a disturbance in the normal ratio of the hydrogen ion concentration and the hydroxyl (OH) ions takes place in the body fluids of the inflamed tissues: the hydroxyl ions (OH) increase. This means that the alkalinity rises. Alkali is an irritant, and when present in a relative excess becomes a factor in the causation of pain.

Joseph Echtman