Absolute Rigidity

This may be divided into two varieties, that which is unaffected by the administration of an anaesthetic, and that which disappears under anaesthesia. These cases may again be considered under two heads - those occurring during adolescence and under the age of twenty-five, and those occurring later in life. In the former, if the rigidity persists under anaesthesia, the cause is probably either tuberculous disease or congenital peculiarity. In tuberculosis other symptoms are generally sufficient to settle the question, but it is a mistake to suppose that the rigidity of tuberculosis is always associated with pain or tenderness, as sometimes both symptoms are wanting.

It is somewhat surprising that congenital stiffness of the spine, affecting almost invariably the lumbar or dorso-lumbar region, is so little recognised, as it is not altogether rare; the importance of a proper estimate of it is obvious. The following example is sufficient to show this: Whilst a girl eight or nine years old was taking her bath her mother thought that she moved as if her back was stiff, and therefore sought advice of a medical man, who found complete immobility of the vertebras in the lumbar and lower dorsal region without any deformity. The child seemed perfectly well, had been playing hockey and other games, and showed no signs of any defect. At the same time the rigidity was naturally a cause of anxiety, and the patient was referred to me. Upon examination the lumbar spine was absolutely rigid, there was neither pain, tenderness, nor deformity; in walking there was a slightly peculiar gait, unnoticeable under ordinary circumstances. Having seen cases before of the same kind, notably one recorded in the 'Clinical Journal' of November 11, 1903, I at once suspected the cause of the condition, and, upon examining other members of the family, found the same peculiarity in two of them. The importance of recognising such a condition is clear, as failing such a recognition the temptation to err on the side of safety by treating a case of the kind as one of tuberculosis would be very strong. In a case, therefore, of stiffness of the spine without pain or deformity in a young subject, I never fail to inquire carefully into the condition of the spines of other members of the family.

In the absolute stiffness of old people, osteoarthritis or spontaneous ossification may, in the absence of other distinct indications, be assumed to be the cause, due allowance, of course, being made for the rigidity being possibly due to cured conditions (e.g. tubercle) in early life.

A Characteristic Case

In the intermediate period between adolescence and old age a variety of causes such as those enumerated in the table may account for the condition, and the clinical symptoms are generally sufficient to prevent any mistake in the diagnosis. The revelation of the x-rays in injury to the cervical spine makes it clear that fracture of the spine, principally affecting the laminae, but sometimes involving the bodies, ending in recovery, is more common than has hitherto been supposed, and that such cases are followed by stiffness, which varies, of course, according to the severity and distribution of the injury. I have at the present time a case under observation which illustrates this condition well; the patient is a man approaching 35 years of age, and the cause was a hunting accident. In persistent stiffness following injury traumatic myositis ossificans must not be overlooked as a cause, as although the disease does not, of course, affect the spine itself, the conversion of adjacent muscle into a calcified mass may cause a rigidity as firm as if the spine itself were involved. The following is a characteristic case: - A man 35 years old slipped downstairs in running to catch a train. Although a good deal shaken, he went about his business at once in the ordinary way, but was unable to resume it on the following day in consequence of the pain in his back 'across the kidneys' - he seems to have been laid up for some months, 'on and off,' but finally got sufficiently well to do what was absolutely necessary in the way of getting about - his back, however, always remained stiff, bending being difficult and in wet weather painful. For this stiffness he consulted me some three years after the accident, not having previously seen a medical man for about two years. On examination the spine was absolutely stiff over the lumbar region, the dorsal portion being supple. There was no pain, tenderness, or any visible abnormal condition, but on the right side of the lumbar spine, corresponding in outline and situation to the quad-ratus lumborum muscle, over which the erector spinae seemed harder than usual, was a mass of stony consistence, quite insensitive and absolutely fixed; the lumbar spine and the mass moved as a solid whole. The x-rays showed an opaque area corresponding to the mass mentioned, the nature of which admitted of no doubt. Nothing, of course, could be done beyond telling the patient to make the best of the situation and to get as much compensatory movement in the parts by means of exercise as was feasible. I afterwards heard that a diagnosis of malignant growth had been made, but this was obviously the result of either an imperfect examination or because the practitioner concerned had previously had no experience of such cases. These masses, resulting from traumatic myositis ossificans, are, in some respects, it is true, suggestive of a growth; indeed, operations have been proposed in some cases in consequence, but to any person familiar with the condition the mistake is not likely to occur.